Surgery Flashcards

Question

4-w after acute attack Persisting abdominal pain Epigastric mass-\> early satiety

Answer 1

?Pancreatic pseudocyst

Answer 2

Infection-\> abscess Obstruction of duodenum or common bile duct

Answer 3

Persistently raised amylase +/- deranged LFTs USS/CT

Answer 4

\<6cm: spontaneous resolution \>6cm: Endoscopic cyst-gastrostomy Percutaenous drainage under US/CT

Answer 5

Alcohol: 70% Genetic: CF, HH Immune: lymphoplasmacytic sclerosing pancreatitis (raised IgG4) TGs raised Structural: obstruction by tumour, pancreas divisum

Answer 6

Sentinal loop Focal dilated proximal jejunal loop in the LUQ Acute pancreatitis

Answer 7

Pancreatic calcification

Answer 8

Chronic pancreatitis (DM) (pancreatic pseudocyst)

Answer 9

Pseudocyst DM Pancreatic cancer Pancreatic swelling-\> biliary obstruction Splenic vein thrombosis

Answer 10

Raised glucose Reduced faecal elastase= indicative of reduced exocrine function LFTs USS: pseudocyst AXR: speckled pancreatic clacifications CT: pancreatic calcifications

Answer 11

serum amylase level is not routinely raised, is not diagnostic in chronic pancreatitis, and testing should therefore not be performed.

Answer 12

1/3rd die within 10y

Answer 13

No EToH or smoking Reduced fat and increased carb diet

Answer 14

Analgesia: NSAIDS/paracetamol first line. ?weak opiate (codeine phospohate) if not effective. May need additional pain relief in primary care e.g. coeliac plexus block. Enzyme supplementation e.g. Creon Cobalamin/thiamine supplementation ADEK vitamins DM Rx (Octreotide: somatostatin analgoe that inhibits pancreatic enzyme secretions)

Answer 15

DM Osteoporosis

Answer 16

Unremitting pain Weight loss Duct blockage

Answer 17

Distal pancreatectomy: Whipple's Pancreaticojejunostomy: drainage Endoscopic stenting

Answer 18

Manage at appropriate level e.g. ITU if severe Constant reassessment: Hourly TPR, UO Daily FBC, U+Es, Ca, glucose, amylase

Answer 19

ABC approach Aggressive fluid resus: keep UO \>30ml/h Catheter+/- CVP Pancreatic rest: NBM NGT if vomiting TPN may be required Analagesia: pethidine or buprenorphine ± intravenous (IV) benzodiazepines. Morphine is relatively contra-indicated because of possible spastic effect on the sphincter of Oddi. Antibiotics: Not routinely given, use if suspected infection or before ERCP Penems often used, but use to treat specific infections Mx complications

Answer 20

ARDS: O2 therapy or ventilation Raied glucose: insulin sliding scale Ca EToH withdrawal: chlordiazepoxide

Answer 21

Diagnostic Can be used if pancreatitis with dilated ducts secondary to gallstones. ERCP and sphincterectomy -\> reduces complications

Answer 22

Infected pancreatic necrosis Pseudocyst or abscess Unsure re dx

Answer 23

Laparotomy + necrosectomy (pancreatic debridement) Laparotomy + peritoneal lavage Laparostomy: abdomen left open with sterile packs in ITU

Answer 24

~8% of the population \>40 years Incidence increasing Slight increased incidence in females 90% of gallstones remain asymptomatic

Answer 25

Fair Fat Female Forty Fertile

Answer 26

Phopsholipids: lecithin Bile pigments (broken down Hb) Cholesterol

Answer 27

Mixed stones: 75% Cholesterol stones: 20% Pigment stones: 5%

Answer 28

Lithogenic bile: Admirand's triangle Biliary sepsis GB hypomotility-\> stasis: pregnancy, OCP, TPN, fasting

Answer 29

A delicate balacnce exists between the levels of bile acids, phospholipids and cholesterol When this balance is disrupted, especially when there is supersaturation with cholesterol, there is predisoposition to the formation of lithogenic bile and the conseuqent development of cholesterol-type gallstones. This is because when cholesterol supersaturates it tends to crystallise and in the presence of enucleating factors can be a nidus for stone formation

Answer 30

Cholsterol

Answer 31

According to Admirand's triangle: decreased bile salts decreased lecithin increased cholesterol

Answer 32

Female OCP/pregnancy Increasing age High fat diet + obesity Racial e.g. American Indian tribes Loss of terminal ileum (reduction in bile salt reabsorption)

Answer 33

Calcium bilirubinate

Answer 34

Haemolysis

Answer 35

Pigment stones

Answer 36

Mixed stones

Answer 37

In the gallbladder: Biliary colic Acute cholecystitis +/- empyema Chronic cholecystitis Mucocele Carcinoma Mirizzi's syndrome In the CBD: Obstructive jaundice Pancreatitis Cholangitis In the gut: Gallstone ileus

Answer 38

Mirizzi's syndrome is a rare complication in which a gallstone becomes impacted in the cystic duct or neck of the gallbladder causing compression of the common bile duct (CBD) or common hepatic duct, resulting in obstruction and jaundice. The obstructive jaundice can be caused by direct extrinsic compression by the stone or from fibrosis caused by chronic cholecystitis (inflammation). A cholecystocholedochal fistula can occur

Answer 39

Gallbladder spasm against a stone impacted in the neck of the gallbladder: Hartmann's pouch Less commonly, the stone may be in the CBD

Answer 40

a spheroid or conical pouch at the junction of the neck of the gallbladder and the cystic duct.

Answer 41

?Biliary colic | (if stone is in the CBD)

Answer 42

Cholecystitis/other gallstone disease Pancreatitis Bowel perforation

Answer 43

Same work up as cholecystitis Urine: Bilirubin, urobilinogen, Hb

Answer 44

Bloods: FBC, U+E, amylase, LFTs, G+S, clotting CRP

Answer 45

AXR: 10% of gallstones are radio-opaque Erect CXR: ?perforation USS: stones: acoustic shadow dilated ducts \>6mm Inflamed GB: wall oedema

Answer 46

bile duct dilated and or liver function tests abnormal and USS has not detected CBD stones

Answer 47

If MRCP does not allow diagnosis to be made

Answer 48

Conservative: Rehydrate and NBM Opioid analgesia: morphine 5-10mg/2h max High recurrence rate therefore surgical management is favoured NB asymptomatic gallbladder stones do not need treatment Surgical: Laparoscopic cholecystectomy: Urgent (within 1w of diagnosis in those with acute cholecystitis) Elective at 6-12w Percutaenous choleystotomy

Answer 49

Management of gallbladder empyema when: surgery is contraindicated at presentation and conservative management is unsuccessful. Reconsider lap chole for people whho have had percutaenous cholecystotomy once they are well enough for surgery

Answer 50

Offer bile duct clearance and lap chole to people with symptomatic or asymptomatic CBD stones Clear the bile duct: surgically at the time of lap chole or with ERCP before or at time of surgery If the bile duct cannot be cleared with ERCP, use bilirary stenting to achieve drainage as a definitive measure until definitive clearance

Answer 51

Stone or sludge impaction in Hartmann's pouch leading to chemical and or bacterial inflammation 5% are acalculous: sepsis, burns, DM

Answer 52

Resolution +/- recurrence Gangrene and rarely perf Chronic cholecystitis Empyema

Answer 53

?Acute cholecystitis

Answer 54

?Acute cholecystitis

Answer 55

2 fingers over the GB and ask patient to breath in Pain and breath catch, must be -ve on the left

Answer 56

May be palpable in acute cholecystitis Mass of adherent omentum and bowel

Answer 57

Hyperaesthesia below the right scapula

Answer 58

Bilirubin, urobilinogen

Answer 59

FBC: raised WCC U+E: dehydration from vomiting Amylase, LFTs, G+S, clotting, CRP

Answer 60

AXR: gallstone, porcelain GB Erect CXR: perforation USS: stones, acoustic shadow Dilated ducts \>6mm Inflamed GB: wall oedema MRCP if dilated ducts seen on USS

Answer 61

Porcelain gallbladder is an uncommon manifestation of chronic cholecystitis, characterized by intramural calcification of the gallbladder wall [1]. The term "porcelain gallbladder" is used to describe the bluish discoloration and brittle consistency of the gallbladder wall seen in this condition [

Answer 62

Admit Conservative: NBM Fluid resuscitation Analgesia: paracetamol, diclofenac, codeine, naproxen, IM pethidine Abx: cef and met 80-90% settle over 24-48h Deterioration may be suggestive of perforation/empyema Surgical: May be elective surgery at 6-12w (once inflammation has reduced) Or if \<72h can perform lap chole in acute phase

Answer 63

Think ?GB empyema Percutaenous drainage via cholecystotomy may be indicated

Answer 64

Flatulent dyspepsia ?Chronic cholecystitis

Answer 65

PUD IBS Hiatus hernia Chronic pancreatitis

Answer 66

AXR: porcelain GB US: stones, fibrotic, shrunken GB MRCP

Answer 67

Medical: bile salts (not very effective) Surgical: Elective cholecystectomy ERCP first if USS shows dilated ducts and stones

Answer 68

Neck of the GB blocked by stone but contents remain sterile Can be very large-\> palpable mass May become infected--\> empyema

Answer 69

Rare Associated with gallstones and gallbladder polyps May see porcelain GB Incidental Ca found in 0.5-1% of lap choles

Answer 70

Large stone \>2.5cm erodes from GB into duodenum through a cholecysto-duodenal fistula 2o to inflammation May impact in the distal ileum leading to obstruction Rigler's triad

Answer 71

Pneumobilia SBO Gallstone in RLQ

Answer 72

Rigler triad consists of three findings seen in gallstone ileus: pneumobilia small bowel obstruction gallstone, usually in the right iliac fossa Rigler triad should not be confused with Rigler sign or the Hoffman-Rigler sign.

Answer 73

Gastric outlet obstruction due to gallstone

Answer 74

30% stones 30% Ca head of the pancreas 30% other

Answer 75

LNs @ porta hepatis: TB, Ca Inflammatory: PBC, PSC Drugs: OCP, sulfonylureas, fluclox Neoplastic: cholangiocarcinoma Mirizzi's syndrome

Answer 76

Obstructive jaundice Itch due to bile salts

Answer 77

Noticable at ~50mM Seen at tongue frenulum first

Answer 78

Dark Raised bilirubin Reduced urobilinogen

Answer 79

FBC: raised WCC in cholangitis U+Es: hepatorenal syndrome LFTs: raised conjugated bilirubin, ++ ALP, +AST/ALT Clotting: reduced VitK--\> Raised INR G+S: may need ERCP Immune: AMA, ANCA, ANA

Answer 80

AXR: may visualise stone Pneumobilia suggests gas forming infection USS: DIlated ducts \>6mm Stones (95% accurtate) Tumour MRCP or ERCP PTC: percutaneous transhepatic colangiography

Answer 81

Percutaneous transhepatic cholangiography (PTHC or PTC) or percutaneous hepatic cholangiogram is a radiologic technique used to visualize the anatomy of the biliary tract. A contrast medium is injected into a bile duct in the liver, after which X-rays are taken.

Answer 82

Pneumobilia May be suggestive of a gas forming infection

Answer 83

Conservative: Monitor LFTs, stone passage may lead to resolution Vits ADEK Analgesia Cholestyramine Interventional: If no resolution, worsening LFTs or cholangitis ERCP with sphincterectomy and stone extraction Surgical: Open/lap stone removal with T tube placement T tube cholangiogram 8d later to confirm stone removal Delayed cholecystectomy to prevent recurrence

Answer 84

Cholestyramine is a bile acid sequestrant. It works by helping the body remove bile acids, which can lower cholesterol levels in the blood. The medicine is also used to relieve itching that's caused by a bile duct blockage

Answer 85

Charcot's triad Reynolds pentad

Answer 86

Fever/rigors RUQ pain Jaundice

Answer 87

Charcot's tirad Shock Confusion

Answer 88

Cef and met 1st ERCP 2nd: open or lap stone removal with T tube drain

Answer 89

Smoking Inflammation: chronic pancreatitis Nutrition: high fat diet EtOH DM

Answer 90

90% are ductal adenocarcinomas Present late, metastasise early Direct extension to local structures, lymphatics, haematogenously to liver and lungs

Answer 91

60% in head 25% in body 15% in tail

Answer 92

?Pancreatic carcinoma

Answer 93

Pancreatic adenocarcinoma (Thrombophlebitis migrans) Splenomegaly due to PV thrombosis leading to portal HTN

Answer 94

In the presence of painless obstructive jaundice, a palpable gall bladder is unlikely to be due to stones

Answer 95

Cause unlikely to be gallstones, gallstones form over an extended period of time resulting in a shrunken, fibrotic gall bladder that does not easily distend, this is less likely to be palpable on examination In contrast, the gallbladder is more enlarged in pathologies that cause obstruction of the biliary tree over longer periods of time e.g. pancreatic malgiancny leading to passive distension from back pressure

Answer 96

Cholestatic LFTs Ca 19-9 Raised Ca

Answer 97

USS: pancreatic mass, dilated ducts, hepatic mets, guide biopsy EUS: better than CT/MRI for staging CXR: mets Laparoscopy: mets, staging

Answer 98

Shows anatomy Allows stenting Biopsy of peri-ampullary lesions

Answer 99

\<2% Mean survival \<6m

Answer 100

Sx: fit, nomets, tumour \<3cm (\<10% patients) Whipple's pancreaticoduodenectomy Distal pancreatectomy Post-op chemo delays progression Palliation: Endoscopic/percutaneous stenting of CBD Paliative bypass surgery: cholecystojejunosostomy, gastrojejunostomy Pain relief: may need coeliac plexus block

Answer 101

30-60 y/o 15% associated with MEN1

Answer 102

Insulinoma

Answer 103

Gastrinoma (Zollinger-Ellison)

Answer 104

Glucagonoma

Answer 105

Necrolytic migratory erythema Characteristic rash of glucagonoma

Answer 106

VIPoma/ Verner-Morrison/ WDHA syndrome

Answer 107

Inhibits glucagon and insulin release Inhibits pancreatic enzyme secretion

Answer 108

Somatostatinoma

Answer 109

Ectopic pancreas

Answer 110

Pancreas divisum

Answer 111

Annular pancreas

Answer 112

Pancreas divisum

Answer 113

Annular pancreas

Answer 114

Typically occuring cholangiocarcinoma at confluence of right and left hepatic ducts

Answer 115

Rare bile duct tumour Adenocarcinoma [Klatskin tumour[

Answer 116

Klatskin tumour

Answer 117

PSC UC Choledocholithiasis Hep B/C Choledochal cysts Lynch 2 Flukes

Answer 118

?Cholangiocarcinoma

Answer 119

Cholestatic LFTs CA19-9

Answer 120

Poor Px Palliative stenting

Answer 121

Zoonotic infection by Echinococcus granulosus Occurs in sheep-rearing communities Parasite penetrates the portal system and infects the liver---\> calcified cyst

Answer 122

?Hydatid cyst

Answer 123

Eosinophilia CT

Answer 124

Rx: albendazole Sx: cystectomy for large cysts

Answer 125

Informed consent Assess risk vs benefits Optimise fitness of patient Check anaesthesia/analgesia type with anaesthetist

Answer 126

Operative fitness: cardiorespiratory comorbidities Pills Consent History: MI, asthma, HTN, jaundice, complications of anaesthesia, DVT Ease of intubation: neck arthritis, dentures, loose teeth Clexane: DVT prophylaxis Site: correct and marked

Answer 127

Balance risk of haemorrhage with risk of thrombosis Avoid epidural, spinal and regional blocks

Answer 128

Continue as usual Post-op give IV or via NGT if unable to tolerate orally

Answer 129

Stop 4w before major/leg sx Restart 2w post-op if mobile

Answer 130

Continue as normal

Answer 131

FBC U+Es G+S Clotting Glucose

Answer 132

LFTs: liver disease, EtOH, jaundice TFT: thyroid disease Electrophoresis if from risk background

Answer 133

CXR: cardiorespiratory disease/symptoms, \>65 y/o Echo: poor LV function,?murmurs ECG: HTN, Hx of cardiac disease, \>55y Cardiopulmonary exercise testing PFT: known pulmonary disease or obesity

Answer 134

Flexion and extension views, in RA/AS

Answer 135

1: Normally healthy 2: Mild systemic disease 3: Severe systemic disease that limits activity 4: Systemic disease which is a constant threat to life 5: Moribund, not expected to survive 24h even with operation

Answer 136

\>2h for clear fluids \>6h for solids

Answer 137

May be needed in left-sided operations Not usually needed in right-sided procedures Necessity is controversial

Answer 138

Liquid bowel contents spilling during Sx Electrolyte disturbance Dehydration Increased rate of post-op anastamotic leak

Answer 139

Gi Sx Joint replacement

Answer 140

15-60 mins before Sx

Answer 141

Picloax: picosulfate and Mg citrate Klean-prep: macrogol

Answer 142

Cef 1.5g and met 500mg IV

Answer 143

Cef and Met TDS

Answer 144

Co-amoxiclav 1.2g IV TDS

Answer 145

Low risk: early mobilisation Medium risk: early mobilisation + TEDs + 20mg enoxaparin High: early mobilisation + TEDS + 40mg enoxaparin and intermittent compression boots perioperatievely

Answer 146

Increased risk of post-operative complications

Answer 147

Sx leads to the release of stress hormones which antagonise insulin Patients are NBM Increased risk of infection Coexistant IHD and PVD

Answer 148

Urine dipstick: proteinuria Venous glucose U+Es: K

Answer 149

Put patient first on list and inform surgeon and anaesthetist Some centres prefer to use GKI infusions (mixture of glucose, insulin and potassium) Sliding scale is not always necessary for minor ops, if in doubt, liase with diabetes specialist nurse

Answer 150

Stop long acting insulin the night before Omit AM insulin if sx if in the morning Start sliding scale

Answer 151

5% Dextroes with 20mmol KCl 125ml/hr Infusion pump with c50u actrapid Check CPG hourly and adjust insulin rate

Answer 152

Continue sliding scale until tolerating food Switch to SC regimen around meal

Answer 153

If glucose control poor (fasting glucose \>10mM) treat as IDDM Omit oral hypoglycaemics on the AM of Sx Eating post-op: resume oral hypoglycaemics with meal Not eating post-op: check fasting glucose on AM of surgery, start insulin sliding scale. Consult specialist team about restrting PO Rx

Answer 154

Usually no problem Patient may be briefly insulin-dependant post-op Monitor CPGs

Answer 155

Poor wound healing Infection Adrenal crisis

Answer 156

Need to increase steroids to cope with stress Consider cover if high-dose steroids have been received within the past year

Answer 157

Hydrocortisone 50-100mg IV with pre-med then 6-8 hourly for 3d Usual pre-operative steroids +25 mg hydrocortisone @ induction +100 mg day-1 for 48 – 72h

Answer 158

As for major but only for 24h

Answer 159

Best to avoid operating Use ERCP instead

Answer 160

Patients with obstructive jaundice have increased risk of post-op renal failure, need to maintain a good UO Coagulopathy Increased infection risk---\> cholangitis

Answer 161

Avoid morphine in pre-med due to possible spastic effect on the sphincter of Oddi Check clotting and consider pre-op vit K Give 1L NS pre-op unless CCF-\> moderate diuresis Catheterise to monitor UO Abx prophlyaxis

Answer 162

Hourly UO monitoring NS titrated to output

Answer 163

Intensive monitoring of fluid status Consider CVP and frusemide if poor output despite NS

Answer 164

Risk of haemorrhage vs risk of thrombosis Consultant surgeon, anaesthetist and haemotologist Very minor surgery can be undertaken without stopping warfarin if INR \<3.5 Avoid spinal, epidural and regional blocks In general continue aspirin/clopidogrel unless risk of bleeding is high, in which case stop 7d before surgery

Answer 165

Stop warfarin 5d pre-op, need INR \<1.5 Restart next day

Answer 166

Need bridging with LMWH Stop warfaring 5d pre-op and start LMWH Stop LMWH 12-18h pre-op Restart LMWH 6h post-op Restart warfarin next day Stop LMWH when INR \>2

Answer 167

Discontinue warfarin Vit K 5mg slow IV Request FFP or PCC (prothrombin complext concentrate) to cover surgery

Answer 168

Basal atelectasis Aspiration Chest infection

Answer 169

CXR PFTs Physio Quit smoking at least 4w prior to surgery

Answer 170

Hypnosis, analgesia, muscle relaxation

Answer 171

Induction Muscle relaxation Airway control Maintenance End of anaesthesia

Answer 172

IV propofol

Answer 173

Depolarising: suxamethonium Non-depolarising: vecuronium , atracurium

Answer 174

ET tube LMA

Answer 175

Usually volatile agent added to NO2/O2 mix e.g. halothan, enflurane

Answer 176

Change inspired gas to 100% O2 Reverse paralysis: neostigmine and atropine (prevents muscarinic side effects)

Answer 177

Anxiolytics and Amnesia: temazepam Analgesics: opioids, NSAIDs, paracetamol Anti-emetics: ondansteron 4mg/ metoclopramide 10mg Antacids: lansoprazole Anti-sialogue: glycopyrolate (reduces secretion) Antibiotics

Answer 178

May be used for minor procedures or if unsuitable for GA Nerve or spinal blocks Use long-acting agents e.g. bupivacaine

Answer 179

Local infection Clotting abnormality

Answer 180

Cardiorespiratory depression

Answer 181

Oro-pharyngeal injury with laryngoscope Oesophageal intubation

Answer 182

Urinary retention Pressure necrosis Nerve palsies

Answer 183

Corneal abrasion No cough---\> atelectasis + pneumonia

Answer 184

Rare complication precipitated by halothane or suxamethonium AD inheritance Rapid rise in temperature and masseter spasm Rx: dantrolene and cooling

Answer 185

Rare Possible triggers: antibiotics colloid NM blockers

Answer 186

Pain-\> autonomic acitvation--\> arteriolar constriction-\> reduced wound perfusion--\> impaired wound healing Pain-\> decreased mobilisation-\> increased VTE and decreased function Pain-\> decreased respiratory excursion and decreased cough--\> atelectasis and pneumonia Humanitarian considerations

Answer 187

Give regular doses at fixed intervals Consider best route: PO if possible PCA (patient-controlled) should be considered: morphine, fentanyl Follow stepwise approach Liaise with acute pain service

Answer 188

Epidural e.g. bupivacaine

Answer 189

Infiltrate wound edge with LA Infiltrate major regional nerves with LA

Answer 190

Decreased SE as drugs more localised First line for major bowel resection Caution: respiratory depression, neurogenic shock (reduced BP)

Answer 191

Non-opiod +/- adjuvants Weak opiod + non-opioid +/- adjuvants Strong opiod + non-opioid +/- adjuvants

Answer 192

Paracetamol NSAIDs: ibuprofen, diclofenac

Answer 193

Codeine Dihydrocodeine Tramadol

Answer 194

Morphine Oxycodone Fentanyl

Answer 195

Enhanced recovery after surgery Commonly employed in colorectal and orthopaedic surgery

Answer 196

Optimisie pre-op preparation for surgery Avoid iatrogenic problems e.g. ileus Minimise adverse physiological/immunological responses to surgery: (raised cortisol, reduced insulin) (hypercoagulbility) (immunosuppression) Increase speed of recover and return to function Recognise abnormal recovery and allow early intervention

Answer 197

Optimisation: Aggressive physiological optimisation e.g. Hydration, BP, anaemia, DM, co-morbidities Smoking cessation \>4w before surgery Admission on day of surgery, avoidance of prolonged fast Carb loading prior to surgery Fully informed patient encouraged to participate in recovery

Answer 198

Short-acting anaesthetic agents Epidural use Minimally invasive technqiues Avoid drains and NGTs where possible

Answer 199

Aggressive Rx of pain and nausea Early mobilisation and PT Early resumption of oral intake Early discontinuation of IV fluids Remove drains and urinary catheters ASAP

Answer 200

Immediate (\<24h) Early (1d-1m) Late (\>1m)

Answer 201

\<24h Intubation leading to oropharyngeal trauma Surgical trauma to local structures Primary or reactive haemorrhage

Answer 202

1d-1m Secondary haemorrhage VTE Urinary retention Atelectasis and pneumonia Wound infection and dehiscence Antibitoic associated colitis

Answer 203

\>1m Scarring Neuropathy Failure or recurrence

Answer 204

Primary Reactive Secondary

Answer 205

Continuous bleeding starting during surgery

Answer 206

Bleeding at the end of surgery or early post-op 2o to increased CO and BP

Answer 207

Bleeding \>24h post op Usually due to infection

Answer 208

Drugs: opioids, epidural/spinal, anti-AChM Pain: sympathetic activation leading to sphincter contraction Psychogenic: hospital environment

Answer 209

Male Increasing age Neuropathy e.g. DM, EtOH BPH Surgery type: hernia and anorectal

Answer 210

Conservative: Privacy, ambulation, void to running taps or in hot bath, analgesia Catheterise +/- gent 2.5mg/kg IV stat TWOC: if failed may be sent home with silicone catheter and urology output f/up

Answer 211

Occurs after nearly every GA Mucus plugging + absorption of distal air---\> collapse

Answer 212

Pre-op smoking Anaesthetic: increases mucus production, reduced mucociliary clearance Pain inhibitng respiratory excursion and cough

Answer 213

?Pulmonary atelectasis

Answer 214

Analgesia to aid coughing Chest PT

Answer 215

5-7d post-op S. aureus and coliforms

Answer 216

Clean Clean/cont Contaminated Dirty

Answer 217

Incision of uninfected skin without opening viscus

Answer 218

Intraoperative beach of viscus (not colon)

Answer 219

Breach of viscus and spillage or opening of colon

Answer 220

Site already contaminated- faeces, urine, trauma

Answer 221

Pre-operative Operative Post-operative

Answer 222

Increasing age Comorbidities e.g. DM Pre-existing infection e.g. appendix perf Patient colonisation e.g. MRSA

Answer 223

Op classification and wound infection risk Duration Technical: pre-op Abx, asepsis

Answer 224

Contamination to wound from staff

Answer 225

Regular wound dressing Abx Abscess drainage

Answer 226

Wound dehiscence

Answer 227

Pre-op Op Post-op

Answer 228

Increasing age Smoking Obesity, malnutrition, cachexia Comorbidities e.g. DM, uraemia, chronic cough, Cancer Drugs: steroids, chemo, RTx

Answer 229

Length and orientation of incision Closure technique: follow Jenkin's rule Suture material

Answer 230

It is a rule for closure of the abdominal wound. It states that for a continuous suture, the length of suture used should be at least four times the length of the wound with sutures 1cm apart and with 1cm bites of the wound edge (More recent research has shown that the optimal ratio may in fact be 6:1)

Answer 231

Increased IAP e.g. prolonged ileus leading to distension Infection Haematoma/seroma formation

Answer 232

Replace abdo contents and cover with sterile soaked gauze IV Abx: cef and met Opioid analgesia Call senior and arrange theatre Repair: wash bowel, debride wound edge, close with deep non-absorbable sutures e.g. nylon May require VAC dressing or grafting

Answer 233

Conversion to open: 5% CBD injury: 0.3% Bile leak Retained stones needing ERCP Fat intolerance/ loose stools

Answer 234

Haematoma/seroma formation: 10% Intra-abdominal injury (laparoscopic) Infection Urinary retention

Answer 235

Recurrence (\<2%) Ischaemic orchitis (0.5%) Chronic groin pain/paraesthesia (5%)

Answer 236

Abscess formation Fallopian tube trauma Right hemicolectomy e.g. for carcinoid, caecal necrosis

Answer 237

Ileus AAC (acute acalculous cholecystitis) Anastomotic leak Enterocutaneous fistulae Abdominal or pelvic abscess

Answer 238

Adhesions leading to obstruction Incisional hernia

Answer 239

Bowel handling Anaesthesia Electrolyte imbalance

Answer 240

?post-op ileus

Answer 241

IV fluids and NGT TPN if prolonged

Answer 242

Anal incontinence Stenosis Anal fissure

Answer 243

Short gut syndrome (\<250cm)

Answer 244

Malabsorption disorder caused by the surgical removal of a large portion of the small intestine

Answer 245

?Small gut syndrome May also have complications caused by malabsorption in vitamin absoprtion e.g. anaemia, hyperkeratosis, easy brusing, muscle spasms, poor blood clotting and bone pain

Answer 246

Gastric dilatation 2o to gastric ileus: prevent with NGT Thrombocytosis-\> VTE Infection: encapsulated organisms

Answer 247

Thrombosis and embolisation Anastomotic leak Graft infection

Answer 248

Gut ischaemia Renal failure Aorto-enteric fistula Anterior spinal syndrome Emboli: distal ischaemia--\> trash foot

Answer 249

Arm lymphoedema Skin necrosis Seroma

Answer 250

Sepsis Uroma: extravasation or urine

Answer 251

Urinary incontinence Erectile dysfunction Retrograde ejaculation Prostatitis

Answer 252

Wound haematoma--\> tracheal obstruction Recurrent laryngeal nerve trauma-\> hoarse voice - transient in 1.5% - permanent in 0.5% Damage to R nerve more common due to it being more medial Hypoparathyroidism---\> hypocalcaemia Thyroid storm Hypothyroidism

Answer 253

Stenosis Mediastinitis Surgical emphysema

Answer 254

Mal/non-union Osteomyelitis AVN Compartment syndrome

Answer 255

Deep infection VTE Dislocation Nerve injury: sciatic, SGN Leg length discrepancy

Answer 256

Pneumo/haemothorax Infection: mediastinitis, empyema

Answer 257

Early 0-5d Delayed \>5d

Answer 258

0-5d post-op Blood transfusion Physiological: SIRS from trauma, 0-1d Pulmonary atelectasis: 24-48hr Infection: UTI, superficial thrombophlebitis, cellulitis Drug reaction

Answer 259

\>5d post-op Pneumonia VTE: 5-10d Wound infection: 5-7d Anastomotic leak: 7d Collection: 5-20d

Answer 260

Obs, notes and drug chart Wound Abdo + DRE Legs Chest Lines Urine Stool

Answer 261

Urine: dip, MC+S Bloods: FBC, CRP, cultures +/- LFTs Cultures: wound swabs, CVP tip for culture CXR

Answer 262

Anaesthesia-\> atelectasis Pain-\> reduced cough Sx-\> immunosuppression

Answer 263

Chest physio: encourage coughing Good analgesia Abx

Answer 264

?Collection

Answer 265

Pelvic: 4-10d post-op Subphrenic: present 7-21d post-op Paracolic gutters Lesser sac Hepatorenal recess (Morrison's space) Small bowel (interloop spaces)

Answer 266

Hepatorenal recess

Answer 267

FBC, CRP, cultures USS, CT Diagnostic lap

Answer 268

Abx Drainage/washout

Answer 269

Acute infection of subcutaneous connective tissue

Answer 270

Beta haemolytic strep and staph aureus

Answer 271

Cellulitis

Answer 272

Benpen IV Pen V and fluclox PO

Answer 273

Out-pouching of tubular structure

Answer 274

Composed of complete wall e.g. Meckel's

Answer 275

Composed of mucosa only (pharyngeal, colonic)

Answer 276

Symptomatic diverticulosis

Answer 277

Inflammation of diverticula

Answer 278

30% have diverticulosis by 60 years F\>M

Answer 279

Associated with increased intraluminal pressure: low fibre diet has no osmotic effect to keep stool wet Mucosa herniates through muscularis propria at points of weakness i.e. where perforating arteries enter Most commonly located in the sigmoid colon

Answer 280

Hiatus hernia Cholelithiasis Diverticular disease ?Obesity

Answer 281

Altered bowel habit +/- left sided colic, relieved by defecation Nausea Flatulance

Answer 282

?Diverticular disease

Answer 283

High fibre diet Mebeverine may help Elective resection for chronic pain

Answer 284

Inspissated faeces-\> obstruction of diverticulum Think in elderly patient with previous history of constipation

Answer 285

Abdominal pain and tenderness Typically LIF Localised peritonitis Pyrexia

Answer 286

Diverticulitis

Answer 287

FBC Raised WCC Raised CRP/ESR Amylase G+S/x-match

Answer 288

Erect CXR: ?perforation AXR: fluid level/air in bowel wall Contrast CT Gastrograffin enema

Answer 289

Flexi sig Colonscopy (not used in acute attack)

Answer 290

Hinchey grading

Answer 291

Localised para-colonic abscess- surgery rarely needed

Answer 292

Large abscess extending into pelvis May resolve without surgery

Answer 293

Generalised purulent peritonitis Surgery needed

Answer 294

Generalised faecal peritonitis Surgery needed

Answer 295

Can be treated at home with bowel rest (fluids only) and abx- some conflicting evidence about use of abx in uncomplicated diverticular disease.. (augmentin +/- met)

Answer 296

Unwell Fluids can't be tolerated Pain can't be controlled

Answer 297

NBM IV fluids Analgesia: paracetamol Antibiotics: cef and met Most cases settle

Answer 298

Have been identified as risk factors for perforation

Answer 299

Perforation Large haemorrhage Stricture leading to obstruction

Answer 300

Harmann's to resect diseased bowel

Answer 301

Perforation Haemorrhage Abscess Fistulae Strictures

Answer 302

?Perforation

Answer 303

CXR: free air under the diaphragm Rx: Hartmann's

Answer 304

?Haemorrhage

Answer 305

Mesenteric angiography or colonoscopy

Answer 306

Usually stops spontaneously May need transfusion Colonoscopy +/- diathermy/adrenaline Embolisation Resection

Answer 307

Abx + CT/US guided drainage

Answer 308

Enterocolic Colovaginal Colovesicular

Answer 309

?Colovesciular fistula

Answer 310

Colon may heal with fibrous strictures

Answer 311

Resection (usually with primary anastomosis) Stenting

Answer 312

Simple Closed loop Strangulated

Answer 313

1 obstructing point + no vascular compromise May be partial or complete

Answer 314

Bowel obstructed at two points Left CRC with competent ileocaecal valve. Volvulus Gross distension can lead to perforation

Answer 315

Compromised blood supply Localised, constant pain + peritonism Fever and raised WCC

Answer 316

Adhesions: 60% Hernia

Answer 317

Colorectal neoplasia (60%) Diverticular stricture (20%) Volvulus 5%

Answer 318

Non-mechanical Mechanical

Answer 319

Paralytic ileus

Answer 320

Post-op Peritonitis Pancreatitis or any localised inflammation Posions/drugs: anti-AChM Pseudo-obstruction Metabolic: hypokalaemia, hyponatraemia, hypomagnesia, uraemia Mesenteric ischaemia

Answer 321

Intestinal pseudo-obstruction is a clinical syndrome caused by severe impairment in the ability of the intestines to push food through. It is characterized by the signs and symptoms of intestinal obstruction without any lesion in the intestinal lumen.[1] Clinical features can include abdominal pain, nausea, severe distension, vomiting, dysphagia, diarrhea and constipation, depending upon the part of the gastrointestinal tract involved.[2] The condition can begin at any age and it can be a primary condition (idiopathic or inherited) or caused by another disease (secondary).[3] It can be chronic[4] or acute.[5]

Answer 322

Intraluminal Intramural Extramural

Answer 323

Impacted matter: faeces, worms, bezoars Intussuception Gallstones

Answer 324

Benign stricutre: IBD, Sx, ischaemic colitis, diverticulitis, RTx Neoplasia Congenital atresia

Answer 325

Hernia Adhesions Volvulus (sigmoid, caecal, gastric) Extrinsic compression: pseudocyst, abscess, haematoma, tumour e.g. ovarian, congenital bands e.g. Ladds

Answer 326

Ladd's bands, sometimes called bands of Ladd, are fibrous stalks of peritoneal tissue that attach the cecum to the abdominal wall and create an obstruction of the duodenum. This condition is found in malrotation of the intestine.

Answer 327

Abdominal pain: Colicky, central but level depends on gut region, constant/localised pain suggest strangulation or impending perforation Distension: with lower bowel involvement Vomiting: early in high, late or absent in low Absolute constipation

Answer 328

?Bowel obstruction

Answer 329

Of flatus and faeces

Answer 330

Tachycardia: hypovolaemia, strangulation Dehydration, hypovolaemia Fever: suggests inflammatory disease or strangulation Surgical scars Hernias Mass: neoplastic or inflammatory Bowel sounds: increased in mechanical obstruction, reduced in ileus PR: empty rectum, rectal mass, hard impacted stool, blood from higher pathology

Answer 331

Mechanical obstruction

Answer 332

FBC: raised WCC U+Es: dehydration, electrolyte abnormalities Amylase: ++ in strangulation/perforation VBG: raised lactate in strangulation G+S, clotting: may need Sx

Answer 333

Erect CXR AXR +/- erect film for fluid levels CT: can show transition point

Answer 334

Look for mechanical obstruction: no free flow Follow through or enema Follow through may relive mild mechanical obstruction, usually adhesional

Answer 335

Can be used in some cases Risk of perforation May be used to therapeutically stent

Answer 336

Both small and large bowel may be visible No clear transition point

Answer 337

Diameter \>3 Central Valvulae coniventes: completely across LB gas absent Many loops Many, short fluid levels

Answer 338

\>6cm (caecum \>9cm) Peripheral loccation Haustra- partially across LB gas present in rectum Few loops Few, long fluid levels

Answer 339

Ileal remnant of vitellointestinal duct Joins yoke sac to midgut lumen

Answer 340

A true diverticulum 2 inches long 2ft from ileocaecal vavle on antimesenteric border 2% of population 2% symptomatic Contain ectopic gastric or pancreatic tissue

Answer 341

Rectal bleeding from gastric mucosa Diverticulitis mimicking appendicitis Intussuception Volvulus Malignant change: adenocarcinoma Raspberry tumour: musoca protruding at umbilicius: vitello-intestinal fistula Littre's hernia

Answer 342

Meckels diverticulum

Answer 343

Littre hernia is a hernia containing a Meckel's diverticulum. Also known as a persistent omphalomesenteric duct hernia. It is most frequently encountered in the inguinal region.

Answer 344

Tc pertechnecate scan +ve in 70% (detects gastric mucosa)

Answer 345

Surgical resection

Answer 346

Portion of the intestine (the intussuception) is invaginated into its own lumen (the intussuscipiens)

Answer 347

Hypertrophied Peyer's patch Meckel's HSP Petuz-Jeghers Lymphoma

Answer 348

6-12mo Colicky abdo pain: episodic incosolable crying, drawing up legs +/- bilious vomiting Redcurrent jelly stools Sausage shaped abdominal mass

Answer 349

Intussuception

Answer 350

Rarely occurs If it does, consider neoplasm as a lead point

Answer 351

Resuscitate and X-match, NGT US + reduction by air enema Sx if irreducible

Answer 352

URTI/viral infeciotn-\> enlargement of mesenteric LNs= pain tenderness and fever

Answer 353

Post URTI Headache + photophobia Higher temperature Tenderness is more generalised Lymphocytosis

Answer 354

Auricle External auditory meatus

Answer 355

Tympanic: malleus, incus and stapes

Answer 356

Semicircular canals, vestibule, cochlea

Answer 357

Quantify loss and determine its nature

Answer 358

Headphones deliver tones at different frequencies and strengths Patient indicates when sound appears and disappears Mastoid vibrator- bone conduction threshold Threshold at different frequences are plotted to give an audiogram

Answer 359

Measures stiffness of the ear drum Evaluates middle ear function

Answer 360

Mid ear fluid or perforation

Answer 361

+/- mid ear pressure

Answer 362

Auditory stimulus with measurement of elicited brain response by surface electrode Used for neonatal screening if otoacoustic emission test negative

Answer 363

Watery discharge Itch Pain and tragal tenderness

Answer 364

?Otitis externa

Answer 365

Moisture e.g. swimming Trauma e.g. fingernails Absence of wax Hearing aid

Answer 366

Pseudomonas Staph aureus

Answer 367

Conservative: remove precipitating factors Medical: Analgesia e.g. paracetamol or ibuprofen Treat inflammation: Topical acetic acid For more severe cases consider topical antibitoic +/- corticosteroid Surgical: ?Cleaning of ear if required

Answer 368

Betamethasone

Answer 369

Betamethasone with neomycin Hydrocortisone with gentamicin

Answer 370

Consider clotrimazole

Answer 371

If perf can lead to ototoxicity

Answer 372

Malignant otitis externa

Answer 373

Life-threatening infection which can lead to skull osteomyletitis Look for tenderness of mastoid process

Answer 374

Admit for IV abx +/- surgical debridement

Answer 375

Malignant OE

Answer 376

Painful haemorrhagic blisters on deep meatal skin and tympanic membrane Associated with influenza infection

Answer 377

Influenza infection

Answer 378

Bullous myringitis

Answer 379

Earache (referred pain from auriculo temporal nerve) Facial pain Joint-clicking/popping Teeth-grinding (bruxism) Stress (associated with depression)

Answer 380

?TMJ dysfunction

Answer 381

NSAIDs stabilising orthodontic occlusal prostheses

Answer 382

Acute OME Chronic Chronic suppurative OM

Answer 383

Acute phase OM

Answer 384

Effusion after symptom regression

Answer 385

Effusion \>3mo if bilateral or \>6mo if unilateral

Answer 386

Ear discharge with hearing loss and evidence of central drum perforation

Answer 387

Usually children post viral UTI Rapid onset ear pain, tugging Irrritability, anorexia, vomiting Purulent discharge if perforation

Answer 388

Paracetamol Amoxicillin: may used delayed presecription

Answer 389

Intratemporal Intracranial Systemic

Answer 390

OME Perforation of TM Mastoidis Facial N. palsy

Answer 391

Meningitis/encephalitis Brain abscess Sub/epidural abscess

Answer 392

Bacteraemia Septic arthritis IE

Answer 393

Should be started if symptoms not improving within 4d of onset of symptoms or signficiant worsening of symptoms Safety net

Answer 394

OME Retracted, dull TM Fluid level

Answer 395

Flat tympanogram

Answer 396

Usually resolves spontaenously Consider grommets if persistent hearing loss SE: infections and tympanosclerosis

Answer 397

Chronic suppurative OM

Answer 398

Chronic suppurative OM

Answer 399

Aural toilet Abx/steroid ear drops

Answer 400

Cholesteatoma

Answer 401

Middle-ear inflammation-\> destruction of mastoid air cells and abscess formation

Answer 402

?Mastoiditis

Answer 403

IV Abx Myringotomy and mastoidectomy

Answer 404

Locally destructive expansion of stratified squamous epithelium within the middle ear

Answer 405

Congenital Acquired: secondary to attic perforation in chronic suppurative OM

Answer 406

?Cholesteatoma

Answer 407

Cholesteatoma Pearly white with surrounding inflammation

Answer 408

Deafness (ossicle destruction) Meningitis Cerebral abscess

Answer 409

Sensation of sound without external sound stimulation

Answer 410

Specific General Drugs

Answer 411

Meniere's Acoustic neuroma Otosclerosis Noise-induced Head injury Hearing loss e.g. presbyacusis

Answer 412

Loss of hearing that gradually occurs in most individuals as they grow older

Answer 413

Raised BP Anaemia

Answer 414

Aspirin Aminoglycosides Loop diuretics ETOH

Answer 415

Character: constant or pulsatile Unilateral (acoustic neuroma) FHx: otoscleoris Alleviating/exacerbating factors e.g. worse at night Associations: Vertigo: Meniere's, acoustic neuroma Deafness: Meniere's, acoustic neuroma Causes e.g. head injury, noise, drugs, Fhx

Answer 416

Hereditary disorder causing progressive deagness due to bone overgrowth in the inner ear

Answer 417

Otoscopy Tuning fork tests Pulse and BP

Answer 418

Audiometry and tympanogram MRI if unilateral to exclude acoustic neuroma

Answer 419

Treat underlying causes Psych support: tinnitus retraining therapy Hypnotics at night may help

Answer 420

The illusion of movement

Answer 421

Peripheral/vestibular Central Drugs

Answer 422

Meniere's BPPV Labyrinthitis

Answer 423

Acoustic neuroma MS Vertebrobasilar insufficiency Stroke Head injury Inner ear syphillis

Answer 424

Gentamicin Loop diuretics Metronidazole Co-trimoxazole

Answer 425

Is it true vertigo or light-headedness: which way are things moving: spinning/whirling when not moving (vertigo), sense of imbalance or staggering when walking (disequilibirium), light headedness (presyncope), dizziness caused by hyperventilation Timespan Associated symptoms: n/v, hearing loss, tinnitus, nystagmus

Answer 426

Condition of involuntary eye movement can be physiological or pathological

Answer 427

Hearing Cranial nerve Cerebellar and gait Rombergs +ve= vestibular or proprioception Hallpike manouvre Audiometry, calorimetry, LP, MRI

Answer 428

Vertigo Tinnitus Hearing loss

Answer 429

Dilatation of endolymph spaces of membranous labyrinth (endolymphatic oedema)

Answer 430

?Meniere's

Answer 431

Medical: Symptomatic reliefe: prochlorperazine (if severe) or betahistine or cyclizine Surgical: Gentamicin instillation via grommets Saccus decompression

Answer 432

Vestibular neuronitis/viral labyrinthistis

Answer 433

Cyclizine Improvement in days

Answer 434

Displacement of otoliths in semicircular canals Common after head injury

Answer 435

Geotropic nystagmus with the problem ear down Predominantly rotatory fast phase toward undermost ear Latency (a few seconds) Limited duration (\< 20 s) Reversal upon return to upright position Response decline upon repetitive provocation

Answer 436

Begins as a slow pursuit movement followed by a fast rapid, resetting phase Named by direction of the fast phase Right or left beating (horizontal nystagmus) Up-beating or down-beating (vertical) Or direction changing If the movements are not horizontal or vertical then the nystagmus is rotational (clockwise or counter-clockwsie) Can also have visual evoked nystagamus (VER)- implies central lesion

Answer 437

Idiopathic Head injury Otosclerosis Post-viral

Answer 438

Hallpike manoeuvre-\> upbeat torsional nystagmus

Answer 439

Self-limiting Epley manoeuvre Betahistine

Answer 440

Primary there is usually abnormality on examination Secondary is normal looking ear

Answer 441

OE/OM FB Barotrauma Rarely: OME Ramsay hunt Perichorditis Cellulitis Relapsing polychondritis etc.

Answer 442

Can be classified on basis of nerve territory e.g. Trrigeminal TMJ problems Facial: CPA lesions etc Glossopharyngeal: tumours in PNS/pharynx Vagus: tumours in pharynx/larynx, GORD Spinal nerves: arthritis/tumours

Answer 443

Mandible Midline Sternocleidomastoid

Answer 444

Sternocleidomastoid Trapezius Clavicle

Answer 445

Peritonsillar abscess

Answer 446

In the trachea Cuffed below the vocal cords Attached to oxygen Secured

Answer 447

A: protection and patency B: respiratory failure, increase FRC, decreased WOB, secretion management, to facilitate bronchoscopy C: minimise oxygen consumption and optimise O2 delivery D: unresponsive to pain, prevent brain injury E: temperature control

Answer 448

Children: croup, inhaled FB, tracheitis, abscess (retropharyngeal, peritonsillar), anaphylaxis, epiglottits, laryngomalacia, VC dysfunction, subglottic stenosis, laryngeal web, laryngeal tumours, tracheomalacia, choanal atresia, tracheal stenosis Adults: anaphylaxis, laryngitis, epiglottits/supraglottitis, FB, abscess, laryngospasm, tumour

Answer 449

Insipiratory NB: stridor can be biphasic if obstruction is at the level of the glottis

Answer 450

Strep Staph HiB Pseudomonas Moraxella catarrhalis TB

Answer 451

?Epiglottis/supraglottits

Answer 452

Airway prep Lateral neck XR Bloods +/- cultures

Answer 453

IV antibiotics: usually 3rd gen cephalosporin Steroids Intubation +/- cricothyroidotomy c trachy if airway obstructed

Answer 454

ABCDE Appropriate area e.g. A&E resus Adrenaline (1:1000) nebulised Steroids: budenoside nebs + IV dex O2 Intubation if needed Cricothyroidotomy either needle or surgical

Answer 455

Through cricothyroid membrane inbetween thyroid cartilage and cricoid Can be done with large bore cannulae or surgically

Answer 456

1. External compresion: 90% anterior, 10% posterior, lean forward and distal part of nose, spit anything that enters mouth 2. Packing: Anterior: merocel (nasal tampon)/ Rapid rhino 48hrs After removal cauterise and give naseptin cream (NB contain peanut oil) Posterior packing: urinary catheter, insert until tip seen at back of mouth, inflate balloon slowly, don't let go of catheter 3. Cautery using silver nitrate 4. Theatre Surgical ligation of the sphenopalantine artery

Answer 457

AKA Kiesselbach's plexus Kiesselbach's plexus, which lies in Kiesselbach's area, Kiesselbach's triangle, or Little's area, is a region in the anteroinferior part of the nasal septum where four arteries anastomose to form a vascular plexus. The arteries are:[1] Anterior ethmoidal artery and posterior ethmoidal artery (both from the ophthalmic artery) Sphenopalatine artery (terminal branch of the maxillary artery) Greater palatine artery (from the maxillary artery) Septal branch of the superior labial artery (from the facial artery) 90% of nosebleeds occur here due to the drying effect of air

Answer 458

Age \>50y Nasal obstruction Facial pain Hearing loss Proptosis/double vision Lymphadenopathy, weight loss

Answer 459

?Nasopharyngeal carcinoma as high incidence

Answer 460

Think nasopharyngeal carcinoma as RF

Answer 461

Shouldn't happen ?NAI

Answer 462

Young children Immunocompromised Cholesteatoma

Answer 463

Strep pneumonia, pyogenes, staph, pseudomonas, HiB

Answer 464

?Mastoiditis

Answer 465

Mastoiditis

Answer 466

?Mastoiditis

Answer 467

FBC, CRP, blood cultures Ear swab CT/MRI Audiogram

Answer 468

High dose broad specrutm IV Abx Analgesia Emergency mastoidectomy for cholesteatoma and mastoid oteitits or intracranial spread or not improving

Answer 469

N+V Tinnitus Hearing loss Feeling of aural fullness Headaches Visual changes Weakness Numbness

Answer 470

Periorbital cellulitis

Answer 471

?Periorbital cellulitis

Answer 472

Orbital also presents with painful eye movements, proptosis, opthalmoplegia, visual impairment, chemosis

Answer 473

Usually idiopathic

Answer 474

Short-course high dose steroids (+/- PPI cover) With repeat audiogram F/U

Answer 475

Benign slow-growing tumour of the vestibular nerve (vestibular schwanomma)

Answer 476

?Acoustic neuroma

Answer 477

5th trigeminal causing facial numbness and tingling Facial nerve can also be affected If very large can compress the brainstem or cuse raised ICP

Answer 478

Cerebellopontine angle

Answer 479

Watchful waiting with MRI/audiogram Stereotactic radiotherapy

Answer 480

Loss of hearing Damage to other cranial nerves esepcially the 7th

Answer 481

Bell's palsy

Answer 482

Bell's palsy

Answer 483

UMN lesions have forehead sparing as frontalis receives innervation from both hemispheres) For it to be true Bell's it must not have forehead sparing

Answer 484

As LD can lead to facial nerve palsy

Answer 485

Short term high dose (60-80mg) steroids + eye care (drops with taping at night)

Answer 486

Incomplete lesions have better prognosis

Answer 487

Submandibular space infection Aggressive and rapidly spreading cellulits from which patients can become quickly septic with compromised airway

Answer 488

Ludwig's angina

Answer 489

IV Abx with anaerobe cover Close monitoring Airway +++

Answer 490

Impaired conduciton anywhere between auricle and round window

Answer 491

External canal obstruciton TM perforation Ossicle defects Inadequate eustachian tube ventilation of midddle air

Answer 492

Wax Pus FB

Answer 493

Trauma Infection

Answer 494

Otosclerosis Infection Trauma

Answer 495

Defects of cochlea, cochlear nerve or brain

Answer 496

Aminoglycosides Vancomycin

Answer 497

Meningitis Measles Mumps Herpes

Answer 498

Meniere's Trauma MS CPA lesions e.g. acoustic neuroma Low B12

Answer 499

Benign slow-growing tumour of superior vestibular nerve

Answer 500

?Acoustic neuroma

Answer 501

Acoustic neuromas

Answer 502

Acoustic neuromas

Answer 503

Dancing eyes Seen in large tumours due to compression of the flocculi in CPA syndrome

Answer 504

Tumours within nerve cannaliculi: unilateral SNHL, tinnitus or disequilibirium Tumours extending into the CPA may present with disequilibrium and ataxia With brainstem extension, midfacial and corneal hypesthesia, hydrocephalies and other CN palsies become more prevalent | (speech discrimination out of proportion to hearing loss and difficulty talking on the telephone are frequent accompaniements)

Answer 505

Meningioma Cerebellar astrocytoma Mets

Answer 506

AD condition characterised by fixation of the stapes at the oval window F\>M 2:1

Answer 507

Otosclerosis

Answer 508

Age-related hearing loss i.e. presbyacussis

Answer 509

Anomalies of pinna, external auditory canal, TM or ossicles Congenital cholesteatoma Pierre-Robin

Answer 510

AD: Waardenburgs: SNHL, heterochromia + telecanthus AR: Alports (SNHL + haematuria), Jewell-Lange-Nielson X-Linked: Alports Infections: CMV, rubella, HSV, toxo, GBS Ototoxic drugs

Answer 511

Anoxia CP Kernicterus Infeciton: meningitis

Answer 512

OM/OME Infection: meningitis, measles Head injury

Answer 513

1st and 2nd branchial arches form auricle while 1st branchial groove forms external auditory canal Malfusion leads to accessory tags/auricles and preauricular pits, fistulae or sinuses Sinuses may get infected

Answer 514

Blunt trauma leading to subperichondrial haematoma Can lead to ischaemic necrosis of cartilage and subsequent fibrosis to cauliflower ears

Answer 515

Aspiration and firm packing to auricle contour

Answer 516

Smooth, symmetrical bony narrowing of external canals

Answer 517

Bony hypertrophy due to cold exposure e.g. from swimming/surfing Asymptomatic unless narrowing occludes the canal leading to conductive deafness

Answer 518

OM Trauma Barotrauma FB

Answer 519

Seasonal Perennial

Answer 520

T1HS Ig-E mediated inflammation from allergen exposure leading to mediator relesase from mast cells Allergens include pollen, house dust mites

Answer 521

?Allergic rhinosinusitis

Answer 522

?Allergic rhinosinusitis

Answer 523

Extends from the nasal bones and surrounding parts of the maxilla and frontal bone Supported by the central septal cartilage and its lateral processes At the apex there are two major alar cartilages Near the maxilla there are smaller minor alar cartilages

Answer 524

Comprises two paired nasal cavities which extend and expand supero-posteriorly from the anterior nares Nasal septum separates left and right Hard palate makes up the floor of the cavities and separates them from the oral cavity Posterior nares open posteriorly into the nasopharynx

Answer 525

Vestibular: just inside nostrils Respiratory: ciliated epithelium making up the bulk of the cavity walls Olfactory: specialised olfactory epithelium on the roofs of the cavities

Answer 526

Superior middle and inferior conchae

Answer 527

The maxilla

Answer 528

Narrow air passages known as the superior, middle and inferior meatus

Answer 529

Sphenopalatine formaen and is found on the postero-lateral wall of the superior meatus

Answer 530

The spheno-ethmoidal recess

Answer 531

Ethmoidal Sphenoidal Maxillary Frontal

Answer 532

Collection of specialised ethmoidal air cells in the respiratory region of the nose Openings in the bulla ethmoidalis on the lateral wall of the middle meatus Cells between medial and lateral plates of the ethmoid labyrinths

Answer 533

Posterior to the nasal cavity within the sphenoid bone Openings in the posterior wall of the spheno-ethmoidal recess Immediately antero-inferior to the pituitary fossa

Answer 534

Beyond the lateral walls of the nasal cavity within the maxillae Openings in the hiatus semilunaris floor on the lateral wall of the middle meatus Drain at the apex- prone to filling with fluids that are hard to drain

Answer 535

Superior to the nasal cavities within the frontal bone Openings in the hiatus semilunaris roof on the lateral wall of the middle meatus Drains through the frontonasal duct to the ethmoidal infundibulum

Answer 536

Carries tears from the corner of the eye opening in the inferior meatus, inerfo-anterior to the hiatus semilunaris

Answer 537

Internal and external carotid arteries

Answer 538

Sphenopalantine artery Greater palantine artery Anterior and posterior ethmoidal arteries

Answer 539

Terminal branch of the maxillary artery- branch of external carotid Enters the cavity through the sphenopalatine formaen Gives lateral branches supplying most of the lateral wall and medial branches to medial wall

Answer 540

Branch of maxillary artery: branch of external carotid Enters the anterior floor of the nasal cavity through the incisive canal and supplies the anterior septum and floor Anastomoses with septal branches of the sphenopalatine artery

Answer 541

Ophthalmic artery Internal carotid

Answer 542

Through the cribiform plate

Answer 543

Anterior: anastomoses with branches of the sphenopalatine artery and terminates as the external nasal artery Posterior division supplies the upper lateral and medial walls

Answer 544

Ophthalmic and maxillary division of V

Answer 545

Parasympathetic fibres of the facial nerve: arise form the pterygopalatine ganglion and run with V2 fibres

Answer 546

Temporal Zygomatic Buccal Mandibular Cervical

Answer 547

Ophthalmic Maxillary Mandibular

Answer 548

Superior orbital fissure Foramen rotundum Foramen ovale

Answer 549

Two key branches: ethmoidal nerves Anterior branch: travels with anterior ethmoidal artery and supplies the anterior medial and lateral walls before terminating as the external nasal nerve Posterior branch supplies the ethmoidal air cells and does not enter the nasal cavity

Answer 550

Lateral branches supply the lateral wall Nasopalantine nerve supplies the medial wall before terminating in the oral muscoa

Answer 551

Skin-prick testing to find allergnes RAST

Answer 552

Allergen avoidance: regulalry washing bedding, avoid pollen Rx: 1st Line: PRN: Oral antihistamine e.g. cetirazine, desloratidine or intranasal e.g. azelastine Preventative: intranasal corticosteroid e.g. beclometasone (if nasal blockage or polyps) or oral antihistamine 2nd line: Intranasal steroid + antihistamine (oral) 3rd line: Zafirlukast (leukotriene antag) 4th line: Immunotherapy: to induce desensitisation to allergen Oral corticosteroids can be considered for severe symptoms

Answer 553

Pseudoephedrine, otrivine

Answer 554

Viruses-\> mucosal oedema and decreased mucosal ciliary actions leading to mucus retention and secondary bacterial infection

Answer 555

Pneumococcus, Haemophilus, Moraxella

Answer 556

S. aureus, anaerobes

Answer 557

Majority are bacterial infection 2o to viral 5% due to dental root infections Diving/swimming in infected water Anatomical variation may leave individuals susceptile e.g. deviated septum, nasal polyps Systmic disease e.g. PCD/Kartagener's

Answer 558

?Bacterial sinusitis

Answer 559

Nasendoscopy +/- CT

Answer 560

Bed-rest, decongestants, analgesia Nasal douching and topical steroids Abx of uncertain benefit

Answer 561

Usually a structural or drainage problem Stop smoking and fluticasone nasal spray Functional endoscopic sinus sx if medical therapy fails

Answer 562

Mucoceles-\> pyoceles Orbital cellulitis/abscess Ostemoyelitis e.g. staph in frontal bone Intracranial infection e.g. meningitis, encephalitis, abscess, CVST

Answer 563

Middle turbinates Middle meatus Ethmoids

Answer 564

?Nasal polyps

Answer 565

?Nasal polyps

Answer 566

Allergic/non-allergic rhinitis CF Aspirin hypersensitvity Asthma

Answer 567

May be a sign of rare but sinister pathology e.g. Nasopharyngela Ca Glioma Lymphoma Neuroblastoma Sarcoma CT + histology

Answer 568

Rare in \<10, must consider neoplastic disease or CF

Answer 569

Drugs: Betamethasone for 2/7 Short course of oral steroids Endoscopic polypectomy

Answer 570

Afferent defect

Answer 571

Total CNII lesion

Answer 572

RAPD- Marcus Gunn pupil

Answer 573

Optic neuritis Optic atrophy Retinal disease

Answer 574

Efferent defect

Answer 575

3rd nerve palsy

Answer 576

Pupil sparing as the visceral constrictive fibres run on the outisde of the nerve so are spared in vascular aetiologies

Answer 577

"surgical third"

Answer 578

?3rd nerve palsy

Answer 579

DM (75% pupil sparing) Temporal arteritis SLE MS Cavernous sinus thrombosis Amyloid PCA aneurysm Tumour

Answer 580

Weber syndrome= midbrain stroke

Answer 581

Rostral midbrain

Answer 582

Oculomotor nucleus (somatic fibres)- eye movements Edinger-Westphal nucleus (visceral fibres)- pupillary constriciton

Answer 583

Passes between the posterior cerebral and superior cerebellar arteries and then through the cavernous sinus and out through the superior orbital fissure

Answer 584

Superior branch- levator palpebrae Inferior branch- MR, IR and IO muscles and carries the visceral fibres

Answer 585

3rd nerve palsy ptosis 'down and out' pupil dilated pupil

Answer 586

Mydriatics e.g. tropicamide Iris trauma Acute glaucoma CN3 compression: tumour, coning

Answer 587

Holmes-Adie pupil

Answer 588

Holmes-Adie pupil

Answer 589

Damage to postganglionic parasympathetic fibres Idiopathic: may have viral aetiology

Answer 590

Homes-Adie pupil

Answer 591

Holmes-Adie syndrome

Answer 592

Swiss opthalmologist

Answer 593

Ptosis: partial (superior tarsal muscle) Enophthalmos Anhydrosis Small pupil

Answer 594

Horner's syndrome

Answer 595

Central Pre-ganglionic Post-ganglionic

Answer 596

MS Wallenberg's Lateral Medullary Syndrome

Answer 597

Argyll-Robertson

Answer 598

Accomodates but doens't react

Answer 599

DM Quaternary syphillis

Answer 600

?Optic atrophy/opticneuropathy

Answer 601

MS and glaucoma

Answer 602

Congenital Alcohol and other toxins Compression Vascular Inflammatory Sarcoid Infection Oedema Neoplastic infiltration

Answer 603

Leber's hereditary optic neuropathy Hereditary motor and sensory neuropathy/ Charcot Marie Tooth Friedrich's ataxia Wolfram (DIDMOAD) Retinitis pigmentosa

Answer 604

Leber's hereditary optic neuropathy Mitochondrial disease

Answer 605

Ethambutol Pb B12 deficiency

Answer 606

Neoplasia: optic glioma, pituitary adenoma Glaucoma Paget's

Answer 607

DM, GCA, thromboembolic

Answer 608

MS, Devic's, DM

Answer 609

Neuromyelitis optica (NMO), also known as Devic's disease or Devic's syndrome, is a heterogeneous condition consisting of the simultaneous inflammation and demyelination of the optic nerve (optic neuritis) and the spinal cord (myelitis). It can be monophasic or recurrent.

Answer 610

Herpes zoster, TB, syphillis

Answer 611

Papilloedema

Answer 612

Cornea Anterior chamber (aqueous humours) Uvea (Iris, ciliary body, choroid plexus) Posterior chamber Lens Vitreous humour

Answer 613

Obicularis oculi- closes the eyelids, innervated by CN7 (Bell's palsy) Levator palpebrae- opens the eyelid, innervated by CN3 (Horner's)

Answer 614

Mucus membrane covering the eyeball Semi-transparent hence the white colouring Starts at the edge of the cornea (imbus) and loops forward to form the inner surface of the eyelid.

Answer 615

Accessory tear glands located within the eyelid and the conjunctiva Lacrimal gland itself is primarily responsible for reflexive tearing.

Answer 616

Compromising the canalicular tear-drainage pathway.

Answer 617

Nasal absorption of drugs can have profound effects. hence why squeezing the medial canthus during administration of eye drops can help mitigate htis

Answer 618

White fibrous outer layer of the eyeball, continuous with the cornea anteriorly and the optic nerve sheath posteriorly

Answer 619

Between cornea and the iris

Answer 620

Between the iris and the lens

Answer 621

Extends from the lens to the retina

Answer 622

Posterior viterous detachment usually benign but can cause retinal tears

Answer 623

Posterior chamber, flowing through the pupil into the anterior chamber where it drains into the venous circulation via the Canal of schlemm

Answer 624

Avascular receiving its nutrition from tears on the outside and aqueous fluid internally with peripheral blood vessels

Answer 625

Epithelium Bowman's layer (belfry) Stroma Descemet's membrane (deep) Endothelium

Answer 626

Corneal stroma

Answer 627

Angle formed by the inner cornea and the root of the iris Location of the Schlemms canal

Answer 628

Iris Ciliary body (secretes aqueous fluid and controls the shape of the lens) Choroid plexus

Answer 629

Capsule Nucleus Cortex

Answer 630

Described by where they occur I.e. nucleur, cortical, subcapsular

Answer 631

Causes the zonule ligaments holding the lens in place to relax Allowing the lens to become rounder

Answer 632

Difficulty focusing on nearby objects

Answer 633

Pigmented area of the retina responsible for central vision Within the macula lies the fovea (susceptible to injury during retinal detachments)

Answer 634

Frontal Sphenoid (greater wing) Ethmoid Lacrimal Palatine Maxillary Zygomatic

Answer 635

Orbital apex

Answer 636

Lacrimal and Frontal divisions of V1 Trochlear nerve Superior division fo the oculomotor nerve Abducens Nasociliary branch of V1 Inferior division of III

Answer 637

Ethmoid Mose likely to perforate from an eroiding sinus infection in children

Answer 638

Diplopia when looking in the affected direction

Answer 639

Ptosis Anhydrosis Miosis Enophthalmos Loss of ciliospinal reflex

Answer 640

The ciliospinal reflex (pupillary-skin reflex) consists of dilation of the ipsilateral pupil in response to pain applied to the neck, face, and upper trunk. If the right side of the neck is subjected to a painful stimulus, the right pupil dilates (increases in size 1-2mm from baseline). This reflex is absent in Horner's syndrome and lesions involving the cervical sympathetic fibers. The enhanced ciliospinal reflex in asymptomatic patients with cluster headache is due to preganglionic sympathetic mechanisms.

Answer 641

Excessive dilataion of the pupil

Answer 642

6th nerve palsy

Answer 643

Vasculopathic Tumour False localising sign i.e. raised ICP

Answer 644

SO Causes eye depression and intorsion Looking towards nose: more up down Looking laterally: more rotational

Answer 645

Nasal upshoot

Answer 646

4th nerve palsy

Answer 647

Vasculopathic Tumour Congenital Trauma

Answer 648

As the fibres controlling pupillary constriction run on the external surface of the nerve

Answer 649

=Idiopathic intracranial HTN

Answer 650

Vision Sensation Appearance Discharge

Answer 651

Blurred Distorted Diplopia Field defect/scotoma Floaters/flashes

Answer 652

Irritation Pain Itching Photophobia FB

Answer 653

Red: ?distribution Lump Puffy lids

Answer 654

Watering Sticking Stringy

Answer 655

Inspect A-P Is acuity affected Is the globe painful Pupils equal and reactive? Corena: intact, cloudy? Use fluorescein

Answer 656

Photophobia Poor vision Corneal fluorescein staining Abnromal pupil

Answer 657

?Acute glaucoma

Answer 658

?Acute glaucoma

Answer 659

The eclipse sign using an oblique flashlight has been well described as a tool to detect shallow anterior chamber. A beam of light shone from the temporal aspect of the cornea towards the root of nose produces a semicircular shadow of the iris in the nasal area. The width of the semicircular shadow gives an indication of the depth of the anterior chamber. A shallow anterior chamber produces a broader shadow compared to an anterior chamber of normal depth as it is the eclipse of the light.

Answer 660

?Anterior uveitis

Answer 661

?Acute closed angle glauocma

Answer 662

?Conjunctivitis

Answer 663

Site: Lids Conjunctiva Sclera Cornea Anterior chamber

Answer 664

Lids: Ectropion, entropion, FB, trichiasis Conjunctiva: Sub cojunctival haemorrhage Sclera: Perforation Cornea: Foreign body Abrasion Anterior chamber; Acute glaucoma

Answer 665

Lids: Blepharitis, Chalazion Conjunctiva: Allergic conjunct Sclera: Chemical burn, episcleritis, scleritis Anterior chamber: Iritis/uveitis

Answer 666

Lids: Perioribital cellulitis, orbital cellulitis Conjunctiva: Conjunctivitis Cornea: Keratitis Ant chamber: Endophthalmitis

Answer 667

Anterior uveitis

Answer 668

Blocked drainage of aqueous from anterior chamber vis the canal of Schlemm Pupilar dilatation worsens the blockage IOP rises from 15-20--\> 60mmHg

Answer 669

Hypermetropia Shallow anterior chamber Female FHx Increased age Drugs: anticholinergics sympathomimetics TCAs Anti-histmaines

Answer 670

Acute closed angle glaucoma

Answer 671

Acute cloesd angle glaucoma

Answer 672

Tonometry: raised IOP, usually \>40mmHg

Answer 673

Refer to ophthalmology Lie the person flat Pilocarpine eye drops (2% blue, 4% brown) (miosis opens blockage) Acetazolamide 500mg IV stat: reduces aqueous formation Analgesia +/- antiemetic

Answer 674

Reduce intraocular pressure Ease symptoms Prevent development/further progression of glaucoma

Answer 675

Laser iridotomy to allow aqueous humour to freely flow into posterior chamber.

Answer 676

Inflammation of uvea (iris, ciliary body and choroid) If just iris and ciliary body= anterior uveitis

Answer 677

?Acute uveitis

Answer 678

Anterior uveitis

Answer 679

Seronegative arthritits: AS, psoriatic, Reiter's Stills'/JIA IBD Sarcoidosis Behcet's Infections: TB, leprosy, syphilis, HSV, CMV, toxo

Answer 680

Refer to ophthalmology Prednisolone Cyclopentolate drops: dilates pupil and prevents adhesions between the iris and lens

Answer 681

Inflammation below conjunctiva in the episclera

Answer 682

Episcleritis

Answer 683

Usually idiopathic May complicate RA or SLE

Answer 684

Topical or systemic NSAIDs

Answer 685

Conjunctivitis

Answer 686

Vasculitis of the sclera

Answer 687

Wegener's RA SLE Vasculitis

Answer 688

RFTs as may be first presentation of Wegner's

Answer 689

Scleromalacia leading to globe perforation

Answer 690

Refer to specialist Most need corticosteroids or immunosuppressants

Answer 691

Conjunctivitis

Answer 692

Viral Bacterial Allergic

Answer 693

Chloramphenicol 0.5% ointment

Answer 694

Anti-histamine drops e.g. emedastine

Answer 695

Nasopharynx Oropharynx Laryngopharynx

Answer 696

From the posterior nares to the soft palate

Answer 697

From the soft palate to the superior margin of the epiglottis

Answer 698

From the superior margin of the epiglottis to the oesophagus

Answer 699

In various fascial layers: superficial fascia which surrounds the anterior neck and is innervated by CNVII Deep fascia: surrounds rest of the neck, several different layers

Answer 700

Investing layer: surrounds all structures within the neck Carotid sheaths: laterally surrounds the neurovascular components Pre-treacheal layer: ventrally, surrounds the viscera Pre-vertebral layer: dorsally: surrounds the vertebrae and associated muscles

Answer 701

2 vascular compartments: bilaterally, covered by the carotid sheath Visceral compartment: ventrally: covered by the pre-tracheal fascia Vertebral compartment: dorsally: covered by the pre-vertebral fascia

Answer 702

Internal jugular vein Common carotid Vagus nerve

Answer 703

Contains the pharynx, larynx, trachea, oesophagus and thyroid gland

Answer 704

Contains the vertebral column and associated deep muscles

Answer 705

Superior thyroid: supplies thyroid gland Ascending pharygneal: small posterior branch supplying around the pharynx Lingual: anterior branch to the tongue Facial: supplies the front of the face, soft palate and submandibular glands Occipital: supplies the posterior scalp Posterior auricular: ssupplies the ear Terminates at the parotid gland, bifurcating into two terminal branches: Superficial temporal: supplies the parotid gland, lateral face and temple region Maxillary: supplies numerous structures around the maxilla and mandible

Answer 706

At the superior margin of the thyroid cartilage

Answer 707

Supra and infrahyoid (strap)

Answer 708

Digastric: both insert on the medial hyoid: anterior belly (innervated by nerve to mylohyoid (of V3), posterior belly (arises from mastoid process and innervated by CNVII Stylohyoid: arses from the base of the sytloid process and inserts on the lateral hyoid (CNVII)

Answer 709

Omohyoid Sternohyoid Thyrohyoid Sternothyroid

Answer 710

Depress the mandible or raise the hyoid

Answer 711

Depress the hyoid or fix the hyoid so that the suprahyoid muscles can act

Answer 712

Superior: from the pterygomandibular raphe to the pharyngeal tubercle Middle: from the hyoid bone Inferior: from the thyroid cartilage All overlap to make up the pharyngeal walls

Answer 713

Vagus nerve

Answer 714

Stylopharyngeus Salpingopharyngeus Palatopharyngeus All innervated by vagus except stylopharyngeus which is innervated by the glossopharyngeal

Answer 715

Stylopharyngeus

Answer 716

Epithelial breach w/o keratitis Cause: trauma

Answer 717

?Corneal abrasion

Answer 718

Slit lamp: fluorescein stains defect green

Answer 719

Chloramphenicol ointment for infection prohpylaxis

Answer 720

Bacterial, herpetic, fungal, protozoa, vasculitic (RA)

Answer 721

Corneal ulcer

Answer 722

Herpes simplex keratitis

Answer 723

Dendritic ulcer Herpes simplex keratitis

Answer 724

Protozoal infection affecting contact lens wearers in swimming pools

Answer 725

Acanthomoeba

Answer 726

?Corneal ulcer

Answer 727

Contact lens wearers

Answer 728

Fluorescein on slit lamp

Answer 729

Refer to specialist who will Take smears and cultures Abx drops, oral/topical aciclovir Cyclopegics/mydriatics to ease photophobia NB steroids may worsen symptoms

Answer 730

Scarring and visual loss

Answer 731

VZV of CNV1 20% of all shingles

Answer 732

?Opthalmic shingles

Answer 733

Nose-tip zoster due to involvement of nasociliary branch Increased risk of globe involvement as nasociliary involvement also supplies globe

Answer 734

Ophthalmic shingles

Answer 735

Hutchinson's sign Nose tip zoster due to involvement of nasociliary branch Increased risk of globe involvement as nasociliary branch also supplies globe

Answer 736

Headache associated? GCA Eye movements hurt? Optic neuritis Lights/flashes preceding visual loss? Retinal detachment Like curtain descending? TIA/GCA Poorly controlled DM? Vitreous bleed from new vessels

Answer 737

Optic nerve damage due to occlusion of posterior ciliary arteries, etiher by inflammation or atheroma Pale/swollen optic disc

Answer 738

Arteritic: GCA Non-arteritic: HTN, DM, raised lipids, smoking

Answer 739

?Optic neuritis

Answer 740

MS (45-80% \>15y) DM Drugs: ethambutol, chloramphenicol Vitamin deficiency Infection: Zoster, Lyme disease

Answer 741

High dose IV methyl predniosolone for 72h Then oral pred for 11/7

Answer 742

New vessles: DM Retinal tears/detachment/trauma

Answer 743

Optic neuritis

Answer 744

?Viterous haemrorrhage

Answer 745

Viterous haemorrhage

Answer 746

Can obscure vision-\> no red reflex Difficulty visualising retina

Answer 747

Vitrectomy may be performed in dense VH Usually undergoes spontaneous absorption

Answer 748

Central retinal artery occlusion

Answer 749

GCA Thromboembolism: clot, infective, tumour

Answer 750

If seen \<6h aim is to increas retinal blood flow by reducing IOP: Ocular massage, surgical removal of aqueous, local and systemic antihypertensives

Answer 751

Retinal vein occlusion

Answer 752

Retinal artery occlusion Pale retina with cherry red macula

Answer 753

Arteriosclerosis, raised BP, DM, polycythaemia

Answer 754

?Central Retinal vein occlusion

Answer 755

?Central Retinal vein occlusion

Answer 756

Stormy sunset apperaance Torutous dilated vessels Haemorrhages Cotton wool spots Central retinal vein occlusion

Answer 757

Glaucoma Neovascularisation

Answer 758

Possibel improvement for 6mo-1 year

Answer 759

?Retinal vein branch occlusion

Answer 760

Central retinal artery branches off the ophthalmic artery

Answer 761

The choroid

Answer 762

Retina supplied by retinal artery Fovea supplied by the vascular choroid that surrounds the eye Thus in retinal artery occlusion the retinal blood supply is compromised and becomes pale and swollen, while the central fovea appears reddish as the choroid colour shows throguh

Answer 763

Retinal ischaemia-\> VEGF release and neovascularisation Treated with anti-VEGFR monoclonal

Answer 764

Holes/tears in retina which allow fluid to separate sensory retina from retinal pigmented epithelium. May be secondary to cataract surgery, trauma, DM

Answer 765

?Retinal detachment

Answer 766

Grey, opalescent retina ballooning forwards ?Retinal detachment

Answer 767

Urgent surgery Vitrectomy and gas tamponade with laser coagulation to secure the retina

Answer 768

Vascular: TIA, migraine MS Subacute glaucoma Papilloedema

Answer 769

Diabetic retinopathy ARMD Cataracts Open-angle glaucoma

Answer 770

Genetic retinal disease: retinitis pigmentosa HTN Optic atrophy

Answer 771

Smoking Increasing age Genetic factors

Answer 772

Dry: geographic atrophy and Wet: subretinal neovascularisation

Answer 773

Amsler grid

Answer 774

Optic coherence tomography Used to give high resolution images of the retina

Answer 775

Intravitreal inhibitors e.g. Bevacizumab Ranibizumab Antioxidant vitamines (C,E) and zinc may help ARMD

Answer 776

Intravitreal VEGF inhibitors

Answer 777

Tobacco-alcohol amyblopia

Answer 778

Vitamins may help

Answer 779

Depends on susceptibility of patients retina and optic nerve to raised IOP damage IOP \>21mmHg: reduced blood flow and damage to optic nerve leading to optic disc atrophy + cupping

Answer 780

Chronic simple glaucoma

Answer 781

Chronic Simple Glaucoma

Answer 782

Optic neuropathy +/- pressure (pressure is not part of definition)

Answer 783

\>35y Afro-carribean FHx Drugs: steroids Comorbidities: DM, HTN, migraines Myopia Screening

Answer 784

Chronic simple glaucoma

Answer 785

Trachoma Cataracts Glaucoma Keratomalacia: vitamin A deficiency Onchoceriasis Diabetic retinopathy

Answer 786

Life long F/U Set target pressure related to degree of damage Medical therapy first line 1st line: Prostaglandin analogue Latanoprost, travoprost 2nd line: Beta blockers: timolol, betaxalol muscarinic alpha agonsts e.g. brominidine, apraclonidine Carbonic anyhdrase inhibitors: dorzolamide, drops, acetazolmide PO Miotics Non-medical options include laser trabeculoplasty, generally if drugs fail

Answer 787

Increase aqueous outflow via the uveoscleral route

Answer 788

Reduce aqueous secretion by inhibiting beta=adrenoreceptors on the ciliary body

Answer 789

Reduce aqueous secretion by ciliary body

Answer 790

Reduce aqueous secretion and increase outflow through trabecular meshwork

Answer 791

Open up the drainage channels in the trabecular meshwork by ciliary muscle contraction

Answer 792

Caution in asthma/heart failure

Answer 793

Change in eye colour and lash lengthening

Answer 794

Leading cause of blindness up to 60y 30% have ocular probelms at presentation Good BP and sugar control reduces diabetic retinopathy

Answer 795

Cataract: DM accelerates cataract formation, lens absorbs glucose which is converted to sorbitol by aldose reducatse Retinopathy: Microangiopathy-\> occlusion Occlusion-\> ischaemia and new vessel formation in retina: bleed-\> viterous haemorrhage, carry fibrous tissue with them-\> retinal detachment Occlusion also leads to cotton wool spots (ischaemia Vascular leakage-\> oedema and lipid exudates Rupture of micro-aneurysms-\> blot haemorrhage

Answer 796

All diabetics should be screened annually Fundus photogrophay Refer those with maculopathy, NPDR and pDR to opathlmologist

Answer 797

Fluorescein angiography

Answer 798

Good BP and glycaemic control Rx concurrent disease: HTN, dyslipidaemia, renal disease, smoking, anaemia Laser photocoagulation: maculopathy: focal or grid, proliferative disease: pan-retinal

Answer 799

CNII and VI In diabetic CNIII the pupil may be spared as its nerve fibres run peripherally and receive blood from plial vessels

Answer 800

Background retinopathy: leakage Pre-proliferative retinopathy: ischaemia Proliferative retinoapthy Maculopathy

Answer 801

Background DM retinopathy

Answer 802

Microaneurysms

Answer 803

Haemorrhages

Answer 804

Yellow lipid patches

Answer 805

Pre-proliferative retinopathy (ischaemia)

Answer 806

Proliferative Retinopathy

Answer 807

Maculopathy

Answer 808

Diabetic maculopathy

Answer 809

Upper 3rd of nose has bony support Lower 2/3rd and septum are cartilaginous

Answer 810

Time of injury LOC CSF rhinorrhoea Epistaxis Previous nose injury Obstruction Consider facial# check for teech malocclusion, diplopia (orbital floor#)

Answer 811

Cartilaginous injury won't show and radiographs don't alter management

Answer 812

Exclude septal haematoma Re-examine after 1w once swelling reduced Reduction under GA with post-op splinting best within 2w

Answer 813

Septal necrosis and nasal collapse if untreated as cartilage blood supply comes from the mucosa Boggy swelling and nasal obstruction Needs evacuation under GA with packing and suturing

Answer 814

Septal haematoma

Answer 815

80% unknown Trauma: nose picking/fractures Local infection: URTI Pyogenic granuloma: overgrowth of tissues on Little's area due to irritation or hormonal factors Osler-Weber-Rendu/HHT Coagulopathy: Warfarin, NSAIDs, haemophilia, thrombocytopenia, vWD, EToH Neoplasm

Answer 816

Wear PPE Assess for shock and manage accordingly If bleeding not controlled, remove clots with suction or by blowing and try to visualise bleeding through rhinoscopy

Answer 817

Don't pick nose Sit upright, out of sun Avoid bending, lifting or straining Sneeze through mouth No hot food or drink Avoid EtOH and tobacco

Answer 818

Autosomal dominant with 5 genetic subtypes

Answer 819

Osler-Weber-Rendu/HHT

Answer 820

Osler-Weber-Rendu/HHT

Answer 821

Tonsillitis

Answer 822

Viruses (consider EBV)

Answer 823

Viruses (EBV) GAS: pyogenes Staph Moraxella

Answer 824

Swabbing superficial bacteria is irrelevant and can lead to overdiagnosis Analgesia: ibuprofen/paracetamol +/- diffiam gargle Consider Abx only if ill, use Centor criteria: Pen V 250mg QDS (125mg TDS in children) or erythromycin for 5/7

Answer 825

EBV-\> maculopapular rash

Answer 826

Fever \>38 by history Tender anterior cervical adenopathy Tonsilar exudates Absence of cough

Answer 827

0-1: no Abx (risk of strep infection \<10%) 2: consider rapid Ag test + Rx if +ve 3: Abx

Answer 828

Recurrent tonsilitis if all of the below criteria are met: Caused by tonsilitis 5+ epsidoes/y Symptoms \>1y Episodes are disabling and prevent normal functioning Quinsy Suspicion of carcinoma: unilateral enlargement or ulceration

Answer 829

Cold steel Cautery

Answer 830

Reactive haemorrhage Tonsillar gag may damage teeth, TMJ or posterior pharyngeal wall Mortality is 1/30000

Answer 831

EBV tonsillitis

Answer 832

Strep tonsillitis

Answer 833

Admit IV Abx I&D under LA or tonsillectomy under GA

Answer 834

?Retropharyngeal absceess

Answer 835

Lateral neck XR show soft tissue swelling CT skull and thorax

Answer 836

IV Abx I&D

Answer 837

Lemierre's syndrome

Answer 838

Fusobacterium necrophorum

Answer 839

IV Abx: pen G, clindamycin, metronidazole

Answer 840

Scarlet fever

Answer 841

Start Pen V/G and notify HPA

Answer 842

Carditis Arthritis Subcutaenous nodules Erythema marginatum Sydenham's chorea

Answer 843

?Post-streptococcal GN

Answer 844

Phonation Positive thoracic pressure including auto-PEEP Respiration Prevention of aspiriation

Answer 845

Usually viral and self-limiting 2o bacterial infection may develop

Answer 846

?Laryngitis

Answer 847

Supportive, Pen V if necessary

Answer 848

Laryngeal papilloma

Answer 849

Recurrent laryngeal nerve palsy

Answer 850

Supplies all of the intrinsic muscles of the larynx except cricothyroideus Exterior branch of superior laryngeal nerve Responsible for ab and adduction of the vocal folds

Answer 851

30% are cancers: larynx, thyroid, oesophagus, hypopharynx, bronchus 25% iatrogenic: para-/thyroidectomy, carotid endarterectomy Other: aortic aneurysm, bulbar/pseudobulbar palsy

Answer 852

Smoking, EtoH

Answer 853

?Laryngeal SCC

Answer 854

spasm of the jaw muscles, causing the mouth to remain tightly closed, typically as a symptom of tetanus. Origin

Answer 855

Laryngoscopy + biopsy MRI staging

Answer 856

Based on stage RTx Laryngectomy

Answer 857

Patients have a permanent tracheostomy - speech valve - electrolarynx - oesophageal speech Regular f/u for recurrence

Answer 858

Laryngomalacia

Answer 859

Laryngomalacia

Answer 860

Laryngomalacia

Answer 861

?Epiglottits

Answer 862

Haemophilus GAS

Answer 863

Don't examine Consult anaesthetist and ENT O2 + nebulised adrenaline IV dexamethasone Cefotaxime Take to theatre for airway securing

Answer 864

Encourage cough Back slaps Needle cricothyrotomy if necessary FB in bronchus can only be excluded through bronchoscopy

Answer 865

?Subglottic stenosis

Answer 866

Prolonged intubation Congential abnormalities

Answer 867

Inflammatory oedema from entrapment of CNVII in narrow facial canal Probably of viral origin 75% of facial palsy

Answer 868

Bell's palsy

Answer 869

Serology: borrelia or VZV Abs MRI: SOL, stroke, MS LP

Answer 870

Protect eye: dark glasses, artifical tears, tape closed at night Give high dose prednisolone within 72h: 60mg/d PO for 5/7 followed by tapering Valaciclovir if ?zoster, otherwise antivirals don't help Plastic surgery if no recovery

Answer 871

Aberrant neural connections: Synkinesis e.g. blinking causes up-turning of mouth Crocodile tears: eating stimulates unilateral lacrimation rather than salivation

Answer 872

Incomplete paralysis usually recovers completely within weeks With complete lesions, 80% get full recovery but the remainder may have delayed or permanent neurological/cosmetic abnormalities

Answer 873

American neurologist James Ramsay Hunt in 1907

Answer 874

Reactivation of VZV in geniculate ganglion of CNVII

Answer 875

Ramsay Hunt Syndrome

Answer 876

Zoster sine herpete

Answer 877

Valaciclovir and prednisolone within first 72h

Answer 878

Rxed within 72h: 75% recovery Otherwise: 1/3 full, 1/3 partial, 1/3 poor

Answer 879

Bilateral symptoms (Lyme, GBS, leukaemia, sarcoid) UMN signs: sparing of frontalis and obicularis oculi Other CN palsies (also seen in 8% of Bell's) Limb weakness Rahses

Answer 880

Ramsay Hunt Snydrome

Answer 881

Intracranial Intratemporal Infratemporal Systemic

Answer 882

Vascular, MS, SOL: motor cortex= UMN signs. Brainstem nuclei= LMN signs Cerebellopontine angle lesion: may be accompanied by 5th, 6th and 8th CN palsy

Answer 883

Otitis media Cholesteatoma Ramsay Hunt

Answer 884

Parotid tumours Trauma

Answer 885

Peripheral neuropathy e.g. GBS (demyelinating) or DM, Lyme, HIB, Sarcoid (axonal) Pseudopalsy e.g. MG, botulism

Answer 886

Motor: innervates the muscles of facial expression, the posterior belly of digastric, the stylohyoid and stapedius muscles Sensory: nil Special sensory: taste sensation to anterior 2/3rds of the tongue PNS: supplies the submandibular, sublingual, nasal, palatine, lacrimal and pharyngeal glands

Answer 887

Facial nerve

Answer 888

Arises in the pons, begins as two roots a large motor and small sensory root (intermediate nerve is the part of the facial nerve that arises from the sensory root) The two roots travel through the internal acoustic meatus, a 1cm opening in the petrous part of the temporal bone Leaves the internal acoustic meatus and enters the facial canal where: The two roots fuse to form the facial nerve. The nerve forms the geniculate ganglion The nerve gives rise to the greater petrosal nerve, the nerve to staepdius and the chorda tympani Exits via the facial canal, posterior to the styloid process of the temporal bone

Answer 889

Branch of facial nerve, PNS fibres to glands

Answer 890

Facial nerve branch Motor fibres to stapedius muscle

Answer 891

Branch of the facial nerve, special sensory fibres to the anterior 2/3rds of the tongue

Answer 892

Sensory and autonomic innervation Sensory innervation is supplied by the auriculotemporal nerve (V3) Parasympathetic innervation begins with CNIX which then synapses with the otic ganglion. The auriculotemporal nerve then carries fibres from the otic ganglion to the parotid Sympathetic innervation originates from the superior cervical ganglion.

Answer 893

First branch is the posterior aruicular nerve- provides motor innervation to some of the muscles around the ear, immediately dital to this it sends branches to the posterior belly of digastric and the stylohyoid muscle Main trunk, now termed the motor root continuse anteriorly and inferiorly to the parotid (which it does not innervate) Within the parotid gland, the nerve splits into its 5 terminal branches TZBMC

Answer 894

Branch of the facial nerve Ascends in front of the mastoid process and innervates the intrinsic and extrinsic muscles of the outer ear

Answer 895

Innervates the frontalis, obicularis oculi and corrugator supercili

Answer 896

Innervates obicularis ori

Answer 897

Innervates the obicularis oris, buccinator and zygomaticus

Answer 898

Innervates the mentalis muscle

Answer 899

Innervates the platysma

Answer 900

?Cataracts

Answer 901

Age: \>75% of \>65 DM Steroids Congenital: Idiopathic Infeciton: rubella Metabolic: Wilson's, galactosaemia Myotonic dystrohpy

Answer 902

Visual acuity DIlated fundoscopy Tonometry Blood glucose to exclude DM

Answer 903

Conservative: glasses Medical: mydriatic drops and sunglasses may give some relief Sx: Consider if symptoms affect lifestyle or driving Day case surgery Pacoemulsion and lens implant

Answer 904

1% risk of serious complication Anterior uveitis/iritis VH Retinal detachment Secondary glaucoma Endophthalmitis (blindness in 0.1%) Post op capsule thickening is common and treated with laser capsulotomy Post-op eye irritation is common and requires drops

Answer 905

Outer pigmented layer in contact with the choroid Inner sensory layer in contact with vitreous At the centre is the fovea

Answer 906

?Optic atrophy

Answer 907

?Papilloedema and optic neuritis

Answer 908

Colour Contour Cup: physiological- 1/3rd. Cup widening and deepening seen in glaucoma

Answer 909

Normal retina

Answer 910

Optic atrophy

Answer 911

Retinitis pigmentosa Various modes of inheritance Mostly AR, AD has best prognosis X-linked has worst prognosis Affects 1/2000

Answer 912

?Retinitis pigmentosa

Answer 913

?Retinitis pigmentosa

Answer 914

Classic Retinitis pigmentosa, with mid-peripheral bony spicules, baring of RPE, vessel attenuation, and sparing of central macula

Answer 915

DM retinopathy post laser treatment

Answer 916

Friedrich's ataxia Refsum's disease Kearns-Sayre syndrome Usher's syndrome

Answer 917

Herediatry type differs from non-hereditary type AD mutations of RB gene Patients typically have on mutant allele in every retinal cell, if the other alleles mutates-\> retinoblastoma 2 HIT hypothesis

Answer 918

5% occur with pineal or other tumour Increased risk of osteosarcoma and rhabdomyosarcoma

Answer 919

?Retinoblastoma

Answer 920

Leucokoria ?Retinoblastoma

Answer 921

Stye or horeolum externum

Answer 922

Hordeolum externum (stye)

Answer 923

Chalazion or hoedolum internum

Answer 924

Hordeolum internum/ Chalazion

Answer 925

Chronic inflammation of the eyelid

Answer 926

?Blepharitis

Answer 927

Seborrhoic dermatitis Staphs

Answer 928

Clean crusts of lashes with warm soaks May need fusidic acid drops

Answer 929

Blepharitis

Answer 930

Lid inversion-\> corneal irritation Degeneration of the lower lid fascia

Answer 931

Low lid eversion-\> watering and exposure keratitis Associated with ageing and facial N. palsy

Answer 932

Intrinisc LPS weakness

Answer 933

Congenital Senile MG Myotonic dystrophy

Answer 934

3rd Nerve palsy Horner's (partial) Mechanical: xanthelasma, trauma

Answer 935

Difficulty in lid closure over the globe which may lead to exposure keratitis

Answer 936

Exophthalmos Facial palsy Injury

Answer 937

Lubricate eyes Temporary tarsorrhaphy may be needed if corneal ulcers develop

Answer 938

Yellow vascular nodules either side of the cornea

Answer 939

Pinguecula

Answer 940

Similar to pinguecula but grows over the cornea-\> reduced vision Benign growth of conjunctiva Associated with dusty, wind-blown life styles, sun exposure

Answer 941

Infection spreading locally e.g from paranasal sinuses, eyelid or external eye Staphs, pneumococcus, GAS

Answer 942

Orbital cellulitis

Answer 943

Orbital cellulitis

Answer 944

IV Abx: Cefuroxime (20mg/kg/8h IV)

Answer 945

Local extension-\> meningitis and cavernous sinus thrombosis Blindness due to optic nerve pressure

Answer 946

May fallow carotid aneurysm rupture with reflex of blood into cavernous sinus Spontaneous/trauma

Answer 947

Carotico-cavernous fistula

Answer 948

Carotid-cavernous fistula

Answer 949

Protrusion of one or both eyes

Answer 950

Graves: 25-50%, increased in smoker's, anti-TSH Abs-\> retro-orbital inflammation and lymphocyte infiltration leading to swelling Orbital cellulitis Trauma

Answer 951

Idiopathic orbital inflammatory disease Vasculitis- Wegener's Neoplasm: lymhpoma, optic glioma, capillary haemangioma, metastatic Carotico-cavernous fistula

Answer 952

Keith-Wagener Classification

Answer 953

1. Tortuosity and silver wiring 2. AV nipping 3. Flame haemorrhages and soft/cotton wool spots 4. Papilloedema Grades 3 and 4= malignant HTN

Answer 954

A. Earliest sign of hypertension showing only generalized narrowing of the arterioles with no change in the vessel wall thickness or reflex. B. Grade II hypertension showing generalized narrowing plus focal constriction and grade I arteriolar sclerosis with widening of the reflex stripe. C. Grade III hypertension showing generalized narrowing, focal constriction, hemorrhages, and exudate, and grade I arteriolar sclerosis with widening of the light reflex. D. Grade IV hypertension showing generalized narrowing, focal constriction, hemorrhages, and exudates and edema of the disc with grade I arteriolar sclerosis

Answer 955

TB, sarcoid, toxoplasmosis, leprosy, brucella

Answer 956

SLE, reactive arthritis, IBD

Answer 957

RA, vasculitis, SLE, IBD

Answer 958

Ank spond IBD Sarcoid

Answer 959

Dermatomyositis

Answer 960

Keratoconjuncitivities SIcca/ Sjogren's

Answer 961

Infective endocarditis As a consequence of microemboli

Answer 962

Boat shaped haemorrhage with pale centre Roth spot Infective endocarditis

Answer 963

Kayser-Fleischer Rings Wilson's

Answer 964

Exophthalmos Grave's disease

Answer 965

Corneal calcification Hyperparathyroidism

Answer 966

CMV retinitis Pizza-pie fundus + flames

Answer 967

HIV retinopathy Cotton wool spots

Answer 968

Anti-muscarinics Sympathomimetics

Answer 969

Eye examination Prevention of snechiae in anterior uveitis/iritis

Answer 970

May lead to acute glaucoma if shallow anterior chamber

Answer 971

Anti-muscarinic Tropicamide -3h Cyclopentolate- 24h

Answer 972

Pupil dilatation and loss of light reflex Cyclopegia-\> blurred vision

Answer 973

Muscarinic agonist

Answer 974

Acute closed-angle galucoma

Answer 975

Anaesthetic used to permit examination of a painful eye

Answer 976

Topical anti-histamines used in ophthalmology

Answer 977

Eye lubricants

Answer 978

Disorders of the size and shape of the eye

Answer 979

Short-sightedness

Answer 980

Eye is too long, distant objects are focussed too far forward Genetic or excessive close work in early decades

Answer 981

Concave lenses

Answer 982

Cornea or lens doesn't have the same degree of curvature in horizontal and vertical planes Image of object is distorted longitudinally or vertically

Answer 983

Long-sightedness

Answer 984

Eye is too short When the eye is relaxed and not accomodating, objects are focussed behind the retina Contraction of ciliary muscles to focus image-\> tiredness of gage and psosible a convergent squint in children

Answer 985

Convex lenses

Answer 986

With age, the lens becomes stiff and less easy to deform Start at about 40y and are complete by 60y Use convex lenses to correct

Answer 987

Convergent squint May be idiopathic or due to hypermetropia

Answer 988

Divergent squint common in older children, often divergent

Answer 989

Corneal reflection: should fall centrally and symmetrically on each cornea Cover test: movement of uncovered eye to take up fixation demonstrates manifest squint

Answer 990

Optical: correct refractive errors Orthoptic: patching good eye encourages use of squinting eye Operation: e.g. resection and recession of rectus muscles

Answer 991

Paralytic squint

Answer 992

Cover each eye in turn, whichever eye sees the outer image is malfunctioning

Answer 993

Diplopia most on looking in direction of pull of paralysed muscle

Answer 994

CNIII lesion

Answer 995

Medical: DM, MS, infarction Surgical: raised ICP, cavernous sinus thrombosis, posterior communicating artery aneurysm

Answer 996

?CNVI palsy

Answer 997

Peripheral: DM (30%), trauma (30%)- nerve exits posterior of brainstem, compression Central: MS, vascular, SOL

Answer 998

?CNVI palsy

Answer 999

Peripheral: DM, compression, trauma Central: MS, vascular, SOL

Answer 1000

Record acuity of both eyes Take detailed Hx of event If unable to open injured eye, instill LA e.g. tetracaine

Answer 1001

XR orbit if metal suspected Fluorescein may show corneal abrasions

Answer 1002

Chloramphenicol drops 0.5% to prevent infection, usually with coag negative staph Eye patch Cycloplegic drops may reduce pain e.g. tropicamide, cyclopentolate

Answer 1003

Blood in anterior chamber- hyphaema Small amounts clear spontaneously but some may need evacuation Complicated by corneal staining and glaucoma Keep IOP down and monitor

Answer 1004

Blunt injury-\> sudden increase in orbital pressure with herniation of orbital contents into maxillary sinus

Answer 1005

?Orbital blowout fracture

Answer 1006

Alkaline solutions are particulary damaging due to saponification Mx with copious irrigation and specialist referral

Answer 1007

Blood or retinal detachment

Answer 1008

Retinal detachment VH Diabetic retinopathy/ HTN Old retinal branch vein occlusion Syneresis (degenerative opacities in the vitreous)

Answer 1009

Either from intraocular or intracerebral pathology Headached, NV: migraine Flashes and floater= retinal detachment

Answer 1010

May be caused by hazy ocular media- cataract, corneal oedema, acute glaucoma

Answer 1011

Acute glaucoma

Answer 1012

Migrainous

Answer 1013

Antazoline: antihistamine drops Cromoglycate: inhibits mast cell degranulation

Answer 1014

?Seasonal allergic/ perenial allergic conjuncitivites

Answer 1015

Olopatadine (anti-histamine and mast cell stabiliser)

Answer 1016

Iatrogenic FBs: contact lenses, prostheses, sutures Removal of FB, mast cell stabilisers

Answer 1017

Giant papillary conjunctivitis

Answer 1018

Remove the allergen responsible where possible General measures: cold compress, artificial tears, oral antihistamine (loratadine 10mg/pd PO) Eye drops: Antihistamines: antazoline, azelastine Mast cell stabilisers: cromoglycate, lodoxamide Steroids: dexamethasone (NB of inducing glaucoma) NSAIDs: Diclofenac

Answer 1019

Caused by Chlamydia trachomatis (A, B, C) Spread by flies Inflammatory reaction under the lids-\> scarring-\> entropion-\> eyelashes scratching cornea-\> ulceration-\> blindness

Answer 1020

Tetracycline 1% +/- PO

Answer 1021

Caused by microfilariae or nematode Onchocerca volvulus Spread by flies Fly bites-\> microfilariae infeciton-\> invade the eye-\> inflammation-\> fibrosis-\> corneal opacities and synechiae

Answer 1022

Ivermectin

Answer 1023

Vitamin A deficiency

Answer 1024

?Vitamin A deficiency

Answer 1025

Vitamin A/palmitate reverses early corneal changes

Answer 1026

Olfactory and optic

Answer 1027

The midbrain, comes from the posterior side of the midbrain and has the longest intracranial length

Answer 1028

Midbrain-pontine junction

Answer 1029

Pontine medulla junction

Answer 1030

Posterior to the olive in the medulla oblongata

Answer 1031

Anterior to the olive in the medulla oblongata

Answer 1032

III IV V1 VI

Answer 1033

Special visceral sensory: smell

Answer 1034

Special somatic sensory (Vision)

Answer 1035

General somatic motor: skeletal muscles General visceral motor: pupillary sphincter (autonomic)

Answer 1036

General sensory motor: SO

Answer 1037

General somatic sensory: scalp, forehead and nose

Answer 1038

General somatic sensory: cheeks, lower eye lid, nasal mucosa, upper lip, upper teeth, palate

Answer 1039

General somatic sensory: anterior 2/3rd tongue, skin over mandible and lower teeth Special visceral motor: Muscles of mastication

Answer 1040

General somatic motor: LR

Answer 1041

General somatic sensory: sensation to part of external ear Special visceral sensory: taste from anterior 2/3rds of tongue and soft palate General somatic motor: muscles of facial expression General visceral motor: lacrimal, submandibular, sublingual glands and mucous glands of mouth and nose

Answer 1042

Special somatic sensory: hearing and balance

Answer 1043

General somatic sensory: posterior 1/3rd of the tongue, external ear and middle ear cavity General visceral sensory: carotid body and sinus Special visceral sensory: taste from posterior 1/3rd of tonuge General visceral motor: parotid gland Special visceral motor: stylopharyngeus

Answer 1044

General somatic sensory: external ear, larynx, pharynx General visceral motor: larynx, pharynx and thoracic and abdominal viscera Special visceral sensory: taste from epiglottis region of tongue General visceral motor: smooth muscles of the pharynx larynx and most of the GIT Special visceral motor: most muscles of the pharynx and larynx

Answer 1045

General somatic motor: trapezius and sternocleidomastoid Special visceral motor: few fibres run with CNX to visceral

Answer 1046

Intrinsic and extrinsic tongue muscles (except palatoglossus)

Answer 1047

CNX Only muscle of the tongue not innervated by XII

Answer 1048

Peripheral olfactory processes (in the olfactory mucosa) Central processes that return the information to the brain

Answer 1049

Enters the cranial cavity through the cribiform plate of the ethmoid bone Once in the cranial cavity the fibres enter the olfacory bulb which lies in the olfactory groove in the anterior cranial fossa. Pass posteriorly to the olfactory tract As the tract reaches the anterior perforated substance it divides into lateral and medial stria Lateral stria carries axons to the primary olfactory cortex Medial stria carry axons to the olfactory bulb on the other side

Answer 1050

Through the optic canal, a passage in the sphenoid bone running along the middle cranial fossa in close proximity to the pituitary gland

Answer 1051

Within the middle cranial fossa the optic nerves from each eye unite to form the optic chiasm At the optic chiasm the nerves cross over and form the optic tracts Each tract travels to its corresponding cerebral hemisphere to reach the lateral geniculate nucleus, a relay system in the thalamus where the fibres synpase Axons from the LGN carry information via optic radiation The upper optic radiation carries fibres from the superior retinal quadrants (corresponding to the inferior visual field quadrants), travelling through the parietal lobe to reach the visual cortex The lower optic radiation carries fibres from the inferior retinal quadrants (superior visual field quadrants) and travels through the temporal lobe via Meyer's loop.

Answer 1052

Originates from the anterior branch of the midbrain, moving anteriorly Passes below the posterior cerebral artery and above the superior cerebellar artery Pierces the dura mater and enters the cavernous sinus Within the cavernous sinus it receives sympathetic branches from the internal carotid plexus, that travel within its sheath Leaves the cranial cavity via the superior orbital fissure, where it divides into the superior and inferior branches

Answer 1053

SR and LPS Sympathetic fibres run with the superior branch to innervate the superior tarsal muscle

Answer 1054

IR, MR IO PNS fibres run to the ciliary ganglion which ultimately innervates the sphincter pupillae and ciliary muscles

Answer 1055

. As the fibres from the trochlear nucleus cross in the midbrain before they exit, the trochlear neurones innervate the contralateral superior oblique.

Answer 1056

The trochlear nucleus is unique in that its axons run dorsally and cross the midline before emerging from the brainstem posteriorly. Thus a lesion of the trochlear nucleus affects the contralateral eye. Lesions of all other cranial nuclei affect the ipsilateral side. Also the only CN to emerge from the posterior of the brainstem

Answer 1057

Depress and intort the eyeball- down and in

Answer 1058

Only the mandibular branch of CN V has motor fibres. It innervates the muscles of mastication: medial pterygoid, lateral pterygoid, masseter and temporalis. The mandibular nerve also supplies other 1st pharyngeal arch derivatives: anterior belly of digastric, tensor veli palatini and tensor tympani.

Answer 1059

The post-ganglionic neruones of the PNS ganglia travel with branches of the trigeminal but the trigeminal nerve is not part of the cranial outflow of PNS supply

Answer 1060

Originates from three sensory nuclei (mesencephalic, principal sensory, spinal nuceli) and one motor nucleus extending from the midbrain to the medulla At the level of the pons, the sensory nuclei merge to form a sensory root The motor nucleus continues to form a motor root In the middle cranial fossa the sensory root expands into the trigeminal ganglion which is located lateral to the cavernous sinus. In a depression of the temporal bone- the trigeminal cave Trigeminal gives rise to V1, V2, V3. Motor root passes inferiorly to the sensory root and its fibres are only carried in V3

Answer 1061

Gives rise to 3 terminal branches, frontal, lacrimal and nasociliary which innervate the skin and mucous membrane of derivatives of the frontonasal prominence Also provides PNS supply to the lacrimal gland from the pterygopalatine ganglion (facial nerve derivative) travel with V2 then join the lacrimal branch of V1 providing PNS innervation to the lacrimal gland

Answer 1062

Afferent: V1 Efferent: facial nerve

Answer 1063

Sensory PNS: initially carries post ganglionic fibres from the pterygopalatine ganglion (VII derivative) and travel with the zygomatic branch of V2 then join the lacrimal branch of V1 Nasal glands: PNS fibres are also carried to the mucous glands of the nasal mucosa travelling with branches of V2

Answer 1064

Carried by V3 Muscles of mastication: medial and lateral pterygoids, massester, temporalis Anterior belly of digastric and mylohyoid muscles Tensor veli palatini Tensory tympani PNS: post ganglionic fibres from the submandibular ganglion travel with the lingual nerve to innervate submandibular and sublingual glands Parotid gland: post ganglionic fibres from the otic ganglion (derived from CN IX) travel with the auriculotemporal branch of V3 to innervate the parotid gland

Answer 1065

Vestibular and cochlear portions of the VIII are functionally discrete so orignate from different nuclei in the brain Vestibular: vesitublar nuclei complex in the pon and medulla Cochlear: from the ventral and dorsal cochlear nuclei in the inferior cerebellar peduncle. Combine in the pons, nerve emerges from the brain at the CPA and exits the cranium via the internal acoustic meatus of the temporal bone. Splits distal to the internal acoustic meatus.

Answer 1066

Basilar skull fracture can cause damage to VIII in the internal acoustic meatus producing symptoms of vestibular and cochlear nerve damage.

Answer 1067

Arises from the medulla oblongata Leaves the cranium via the jugular foramen at which point the tympanic nerve arises. Immediately outside the jugular foramen lie two ganglia known as the superior and inferior (or petrous) ganglia that contain the cell bodies of the sensory fibres in the glossopharyngeal nerve. Descends to give innervation to stylopharyngeus and the carotid sinus nerve which provides sensation to the carotid sinus and body.

Answer 1068

Afferent= CNIX Efferent= CNX

Answer 1069

Originates from the medulla and exits via the jugular foramen Within the cranium the auricular branch arises which supplies sensation to the posterior part of the external auditory canal and external ear

Answer 1070

Passes into carotid sheath, travelling inferiorly with the internal jugular vein and common carotid. Right vagus passes anterior to the subclavian artery and posterior to the sternoclavicular joint, entering the thorax Left vagus passes inferiorly between the left common carotid and the left subclavian arteries, posterior to the sternoclavicular joint.

Answer 1071

Pharyngeal branches: motor innervation to the muscles of the pharynx and soft palate Superior laryngelal nerve: internal and external branches, external innervate the cricothyroid muscle, the internal providing sensory innervation to the laryngopharynx and superior part of the larynx Recurrent laryngeal nerve (on the right only) hooks underneath the subclavian artery and ascends to the larynx, innervating the majority of the intrinsic muscles of the larynx

Answer 1072

Right vagus forms the posterior vagal trunk The left forms the anterior vagal trunk Branches from these trunks contribute to the oesophageal plexus Two other branches arise: the left recurrent laryngeal nerve (hooks under the arch of the aorta) Cardiac branches Vagal trunks enter the abdomen via the oesophageal hiatus

Answer 1073

Dysphonia Aphonia

Answer 1074

Spinal portion arises from neurones of the upper SC (C1-C5/C6) of the spinal nerve roots. Coalesce to form the spinal part of the accessory nerve which then runs superiorly to enter the cranium via the foramen magnum It travels to the posterior cranial fossa to reach the jugular foramen where it meets the cranial portion of the accessory nerve before exiting the skull. Descends along the internal carotid to reach sternocleidomastoid which it innervates. Extracranial course is relatively superficial leaving it vulnerable to damage.

Answer 1075

Much smaller and arises from the lateral aspect of the medulla. Leaves the cranium via the jugular foramen where it briefly contacts the spinal part of the accessory nerve. Immediately after leaving the skull, the cranial portion combines with the vagus at the inferior ganglion of the vagus. The fibres are then distributed through the vagus nerve.

Answer 1076

Iatrogenic e.g. cervical LN biopsy or cannulation of the IJV. Clinical features include muscle wasting and partial paralysis of the sternocleidomastoid, resulting in the inability to rotate the head or weakness in shrugging the shoulders. Damage to the muscles may also result in an asymmetrical neckline.

Answer 1077

Accessory nerve palsy Asymmetrical neck line

Answer 1078

All muscles of the tongue except palatoglossus (innervated by the vagus nerve)

Answer 1079

Genioglossus Hypoglossus Styloglossus [Palatoglossus- vagus nerve]

Answer 1080

Superior longitudinal Inferior longitudinal Transverse Vertical

Answer 1081

Can be supranuclear (UMN), nuclear, or infranuclear (LMN) UMN: tongue will deviate away from injured side. Only seen during the initial days after the injury, after which it will not deviate. Infranuclear lesions lead to parlaysis of the hpyoglossal nerve leading to atrophy of muscles of the tonuge, tongue will be deviated **TOWARDS** lesion. Due to weaker geniglossal muscle.

Answer 1082

Damage to facial and trigemnial nerve dysfunction as a consequence of damage to the brainstem following arteriosclerosis of the vertebrobasilar artery

Answer 1083

?Cartoid dissection

Answer 1084

Extrinsic, palatoglossus (Vagus)

Answer 1085

Right subclavian arises from the brachiocephalic trunk Left subclavian directly from the arota

Answer 1086

When they cross the lateral edge of the first 1 rib and enter the axilla

Answer 1087

Passes through the axilla underneath pectoralis minor enclosed in the axillary sheath At the humeral surgical neck the posterior and anterior circumflex humeral arteries arise Circle posteriorly around the humerus to supply the shoulder region The subscapsular artery also arises here (largest brach of the axillary artery) At the level of the teres major the axillary artery becomes the brachial artery

Answer 1088

At the lower margin of teres major

Answer 1089

Axillary artery aneurysm

Answer 1090

Immediately distal to teres major gives the profunda brachii- deep artery of the arm which travels along the posterior surface of the humerus in the radial groove, supplying the posterior aspect of the arm Brachial artery descends down the arm immediately posterior to the median nerve, as it crosses the cubital fossa underneath brachialis it terminates by bifurcating into the radial and ulnar arteries

Answer 1091

Radial- posterior aspect of the forearm Ulnar- anterior Areteries anastomose by forming the superficial palmar arch and the deep palmar arch

Answer 1092

The cephalic and basilic veins

Answer 1093

Basilic vein originates from the dorsal venous network of the hand ascending the medial aspect of the upper limb. At the border of teres major the vein moves deep into the arm where it combines with brachial veins to form the axillary vein The cephalic vein arises from the dorsal venous network of the ascending ascending on the anterolateral aspect of the upper limb, passing anteriorly at the elbow. At the shoulder the cephalic vein travels between the delotid and pec major muscles in the deltopectoral groove and enters the axilla via the clavipectoral triangle. It terminates here by joining the axillray vein. At the elbow the cephalic and basilic veins are connected by the median cubital vein

Answer 1094

Paired veins that accompany and lie either side of an artery Brachial veins are the largest in size and are situated either side of the brachial artery These are vena comitantes Perforating veins run between the deep and superficail veins of the upper limb, connecting the two systems

Answer 1095

Long thoracic nerve (winged scapula) Or the thoracodorsal nerve

Answer 1096

Continuation of the EIA which becomes the femoral artery when it crosses under the inguinal ligament and enters the femoral triangle In the femoral triangle the profunda femoris artery arises from the posterolateral aspect. It travels posteriorly giving off three main branches: Lateral femoral circumflex: wraps around the anterior, lateral side of the femur supplying muscles in the lateral side of the thigh Medial circumflex artery: wraps around the posterior side of the femur supplying the head and neck (avascular necorsis in intracapsular #) Perforating branches: 3/4 arteries that perforate the adductor magnus After exiting the femoral triangle the femoral artery continues down the anterior surface of the thigh via the adductor canal. The adductor canal ends at the adductor hiatus at which point the femoral artery enters the posterior compartment of the thigh proximal to the knee

Answer 1097

Superior border: inguinal ligament Lateral border: sartorius Medial border: medial border of adductor longus Anteriorly the roof of the femoral triangle is the fascia lata Posteriorly the base is formed by pectineus, ilopsoas and adductor longus muscles.

Answer 1098

Femoral nerve: innervates the anterior compartment of the thigh Femoral artery Femoral vein Empty space Lymph canal Contained in the femoral sheath

Answer 1099

Midway between the pubic symphysis and ASIS

Answer 1100

Obturator artery arises from the IIA in the pelvic region, descends via the obturator canal to enter the medial thigh bifurcating into the canal. Gluteal region is largely supplied by the superior and inferior gluteal arteries which exit the pelvis via the GSF. The IGA also contirbutes to the vasculature of the posterior thigh

Answer 1101

Both exit the GSF SGA superior to piriformis IGA inferior to piriformis

Answer 1102

Popliteal artery descends down the posterior thigh giving off genicular branches that supply the knee joint. Moves through the popliteal fossa between gastrocnemius and popliteus. At the lower border of popliteus it terminates by dividing into anterior and posterior tibial artery. Posterior tibial continues inferiorly along the surface of the deep muscles accompanying the tibial nerve entering the sole of the foot via the tarsal tunnel. During the descent of the posterior tibial the fibular artery arises which moves laterally penetrating the lateral compartment of the leg. The anterior tibial artery passes anteriorly between the tibia and fibular through a gap in the interoesseous membrane. Moving inferiorly down the leg and into the foot where it becomes dorsalis pedis.

Answer 1103

Aneurysm of the popliteal artery has consequences for other contents of the popliteal fossa. The tibial nerve is particularly susceptible to compression from the popliteal artery Major features are absent/weakened plantar fleixion, paraesthesia of the foot and posterolateral leg. Can be detected through obvious expansile pulsatile mass and an arterial bruit

Answer 1104

Dorsalis pedis- continuation of the anterior tibial artery Posterior tibial enters through the sole of the foot through the tarsal tunnel and supplies the lateral and medial plantar surfaces

Answer 1105

be palpated as it enters the femoral triangle, midway between the anterior superior iliac spine of the pelvis, and the pubis synthesis (the mid-inguinal point).

Answer 1106

Dorsum of the foot in the fist intermetatarsal space, lateral to the tendon of the great toe

Answer 1107

Behind and below the medial malleolus

Answer 1108

In the midline in the popliteal fossa with gentle knee flexion

Answer 1109

Dorsal arch drains mainly into the superficial veins, some penetrate deep into the leg forming the anterior tibial vein. On the plantar aspect of the foot the medial and lateral plantar veins arise and combine to form the posterior tibial and fibular vein. The posterior tibial vein accompanies the posterior tibial artery, entering the leg posteriorly to the medial malleolus. On the posterior surface of the knee the anterior tibial, posterior tibial and fibular veins unite to form the popliteal vein which enters the thigh through the adductor canal

Answer 1110

The popliteal vein becomes the femoral vein once it enters the thigh and is situated anteriorly. The profunda femoris vein is the other main venous structure. Empties into the distal section of the femoral vein. The femoral vein leaves the thigh to become the EIV

Answer 1111

Two major veins, the great and small saphenous Great saphenous is formed by the dorsal venous arch of the foot. Ascends on the medial side of the leg, passing anteriorly to the medial malleolus and posterior to the medial condyle at the knee. As the vein moves up the leg it receives tributaries from other small superficial veins, and terminates by draining into the femoral vein immediately inferior to the inguinal ligament. The small saphenous vein moves up the posterior side of the leg, passing posterior to the lateral malleolus along the border of the calcaneal tendon. It moves between the two heads of gastrocnemius and empties into the popliteal vein in the popliteal fossa

Answer 1112

2.5cm below and 2.5cm lateral to the pubic tubercle

Answer 1113

5% of males \>50 years have intermittent claudication

Answer 1114

Ankle artery pressure \<50mmHg (toe \<30) And either: persistent rest pain requiring analgesia for \>2w or Ulceration or gangrene

Answer 1115

Atherosclerosis: typically asymptomatic until 50% stenosis Vasculitis and fibromuscular dysplasia are v rare causes

Answer 1116

Endothelial injury: haemodynamic, HTN, raised lipids Chronic inflammation: lipid-laden foam cells produce GFs, cytokines, ROS and MMPs-\> lymphocyte and SMC recruitment SM proliferation: conversion of fatty streak to atherosclerotic plaque

Answer 1117

Arteriosclerosis= general arterial hardening Atherosclerosis= arterial hardening specifically due to atheroma

Answer 1118

Fibrous cap: SM cells, lymphocytes, collagen Necrotic centre: cell debris, cholesterol, Ca, foam cells

Answer 1119

Smoking BP DM Hyperlipiademia Reduced exercise

Answer 1120

FH and PMHx Male Increased age Genetic

Answer 1121

IHD: 90% Carotid stenosis; 15% AAA Renovascular disease DM microvascular disease

Answer 1122

Intermittent claudication

Answer 1123

Superifical femoral disease (commonest)

Answer 1124

Iliac disease (internal or common)

Answer 1125

Fontaine 3 or 4 Rest pain Especially at night, usually felt in the foot Patient hangs foot out of bad Due to reduced CO and loss of gravity Ulceration Gangrene

Answer 1126

?Critical limb ischaemia

Answer 1127

Aortoiliac occlusive disease Atherosclerotic occlusion of abdominal aorta and iliacs

Answer 1128

Buttock claudication and wasting Erectile dysfunction Absent femoral pulses

Answer 1129

Thromboangitis obliterans

Answer 1130

Buerger's disease

Answer 1131

Buerger's Disease Thrombangitis obliterans

Answer 1132

?Chornic limb ischaemia

Answer 1133

The vascular angle, which is also called Buerger's angle, is the angle to which the leg has to be raised before it becomes pale, whilst in supine decubitus. In a limb with a normal circulation the toes and sole of the foot, stay pink, even when the limb is raised by 90 degrees.

Answer 1134

Chronic limb iscahemia

Answer 1135

\>90= normal 20-30= ischaemia \<20= severe ischaemia

Answer 1136

Pale-\> reactive hyperaemia due to accumulation of deoxygenated blood in dilated capillaries

Answer 1137

Fontaine or Rutherford

Answer 1138

1. Asymptomatic 2. Intermittent claudication a \>200m b \<200m 3. Iscahemic rest pain 4. Ulceration/ gangrene

Answer 1139

1. Mild claudication 2. Moderate claudication 3. Severe claudication 4. Ischaemic rest pain 5. Minor tissue loss 6. Major tissue loss

Answer 1140

ABPI Doppler Walk test Bloods Imaging Other: ECG

Answer 1141

Normal: triphasic Mild stenosis: biphasic Severe stenosis: monophasic

Answer 1142

Calcification: CRF, DM

Answer 1143

Asymptomatic Fontaine 1

Answer 1144

Fontaine 2 Claudication

Answer 1145

Fontaine 3 Rest pain

Answer 1146

Ulceration and gangrene Fontaine 4

Answer 1147

Due to calcification of vessels: mediasclerosis Use toe pressure with small cuff, \<30mmHg is the cut off

Answer 1148

Walk on treadmill @ certain speed and incline to establish maximum claudication distance ABPI measured before and after, 20% reduction is signifcant

Answer 1149

FBC + U+Es: anaemia, renovascular disease Lipids and glucose ESR: arteritis G+S: possible procedure

Answer 1150

Assess site, extent and distal run-off Colour duplex US CT/MR angiogram with gadolinium contrast Digital subtraction angiography: invasive, not commonly used for Dx only but used when performing therapeutic angioplasty or stenting

Answer 1151

Look for evidence of coronary artery pathology

Answer 1152

Most patients with claudication can be managed conservatively Increase exercise and employ exercise programs Stop smoking Weight loss Foot care

Answer 1153

1/3 improve 1/3 stay the same 1/3 deteriorate

Answer 1154

Modification of cardiovascular risk fators: BP, lipis, DM Beta blockers don't worsen intermittent caludication but use with caution Parenteral prostanoids reduces pain in patients unfit for surgery Antiplatelet drugs: clopidogrel/aspirin Peripheral vasodilators: naftidrofuryl oxalate

Answer 1155

BP medication may initially worsen pain of claudication but improve LT CV risk However, 25% of patients with PAD also have RAS so ACEI should be used with caution

Answer 1156

Percutaneous transluminal angioplasty Good for short stenosis in big vessels e.g. iliacs, SFA Lower risk for patient as performed under LA Improved inflow can reduce pain but restoration of foot pulses is required for Rx of ulceration/gangrene

Answer 1157

V. short claudication distance e.g. \<100m Symptoms greatly affecting patients QoL Development of rest pain NB pre-op assessment as patient likely to have cardiorespiratory co-morbidities

Answer 1158

Need good proximal supply and distal run-off Saphenous vein grafts are preferred below the IL More distal grafts have increased rates of thrombosis

Answer 1159

Anatomical: fem-pop, fem-distal, aortobifemoral Extra-anatomical: axillo-femoral, bifemoral, fem-fem crossover

Answer 1160

Endarterectomy Sympathectomy: chemical or surgical Amputation

Answer 1161

50% alive w/o amputation 25% will have had major amputation 25% dead (usually MI or stroke)

Answer 1162

1/3 complete autonomy 1/3 partial autonomy 1/3 dead

Answer 1163

Ischaemia \<14d

Answer 1164

Worsening symptoms and signs \<14d

Answer 1165

Ischaemia stable for \>14d

Answer 1166

Limb not threatened

Answer 1167

Limb threatened, loss of limb unless intervention within 6hrs

Answer 1168

Requires amputation

Answer 1169

Thrombosis in situ: 60% Embolism: 30% Graft/stent occlusion Trauma Aortic dissection

Answer 1170

A previously stenosed vessel with plaque rupture, usually incomplete iscahemia

Answer 1171

80% from LA in AF Valvular disease Can be iatrogenic/surgery Cholesterol in long bone # Paradoxical via PFO Typically lodge at femoral bifurcation causing complete limb ischaemia

Answer 1172

Pale Pulseless Perishingly cold Painful Paraesthesia Paralysis

Answer 1173

Thrombotic cause

Answer 1174

Embolic acute limb iscahemia

Answer 1175

Bloods: FBC, U+E, INR, G+S, CK ECG Imaging: CXR, Duplex doppler

Answer 1176

SENIOR NBM Rehydration: IV fluids Analgesia: morphine + metoclopramide Abx if signs of infection Unfractionated heparin IV: prevent extension If occlusion is complete: urgent surgery If incomplete: angiogram + observe for deterioriation

Answer 1177

Not performed if there is complete occlusion as it introduces delay If occlusion is incomplete, pre-op angio will guide any distal bypass

Answer 1178

1. Embolectomy 2. Thrombolysis 3. Other options

Answer 1179

Under LA or GA Wire fed through embolus Fogarty catheter fed over the top Balloon inflated and catheter withdrawn removing the embolism Send embolism for histology to exclude atrial myxoma Adequacy can be confirmed by on-table angiography

Answer 1180

Consider if embolectomy unsuccessful E.g. local injection of TPA

Answer 1181

Emergency reconstruction Amputation

Answer 1182

Anticoagulate: IV heparin-\> warfarin ID embolic source: ECG, echo, US aorta, femoral and pop Complications

Answer 1183

Reperfusion injury: Local swelling-\> compartment syndrome Acidosis and arrhythmia 2o to raised K ARDS GI oedema-\> endotoxic shock Chronic pain syndromes

Answer 1184

Emergency reconstruction if complete occlusion Angiography and angioplasty Thrombolysis Amputation

Answer 1185

Turbulent flow-\> reduced shear stress at carotid bifurcation promoting atherosclerosis and plaque formation Plaque rupture-\> complete occlusion or distal emboli Causes 15-25% of CVA/TIA

Answer 1186

?Carotid artery disease

Answer 1187

Duplex carotid Doppler MRA

Answer 1188

Aspirin or clopidogrel Control RFs Surgical: endarterectomy Symptomatic \>70% benefit (5% stroke risk per year) \>50% benefit if low risk Performed within 2w of presentation Asymptomatic: \>60% benefit if low risk

Answer 1189

ECST vs optimal medical therapy NASCET

Answer 1190

Stroke or death: 3% HTN: 60% Haematoma MI Nerve injury

Answer 1191

Hypoglossal: ipsilateral tongue deviation Great auricular: numb ear lobe Recurrent larygneal: hoarse voice, bovine cough

Answer 1192

Less invasive: reduced hospital stay, reduced infection, reduced CN injury Concern over increased stroke risk, esp. in pts \>70y Meta-analysis shows no sig difference in mortality vs CEA

Answer 1193

Abnormal dilatation of a blood vessel \>50% of its normal diameter

Answer 1194

Dilatation of a blood vessel involving all layers of the wall and that is \>50% of its normal diameter Two different morphologies: Fusiform e.g. AAA Saccular: e.g. Berry aneurysm

Answer 1195

The shape of an aneurysm is described as being fusiform or saccular, which helps to identify a true aneurysm. The more common fusiform-shaped aneurysm bulges or balloons out on all sides of the blood vessel. A saccular-shaped aneurysm bulges or balloons out only on one side.

Answer 1196

Collection of blood around a vessel wall that communicates with the vessel lumen Usually iatrogenic e.g. puncture, cannulation

Answer 1197

Vessel dilatation caused by blood splaying apart the media to form a channel within the vessel wallt

Answer 1198

Lumen Intima Media Advenititia

Answer 1199

ADPKD-\> Berry aneurysms Marfan's, Ehlers Danlos

Answer 1200

Atherosclerosis Trauma e.g. penetrating trauma Inflammatory: Takayasu's, HSP, Kawasaki Infection: Mycotic- SBE Tertiary syphillis (esp. thoracic)

Answer 1201

Rupture Thrombosis Distal embolisation Pressure: DVT, oesophagus, nutcracker syndrome Fistula (IVC, intestine)

Answer 1202

Nutcracker syndrome is a vascular compression disorder, and refers to the compression of the left renal vein between the superior mesenteric artery (SMA) and aorta. This can lead to renal venous hypertension, resulting in rupture of thin-walled veins into the collecting system with resultant haematuria.

Answer 1203

50% of patients with popliteal aneurysm also have AAA AAA is more common than popliteal aneurysm

Answer 1204

Popliteal aneurysm

Answer 1205

Thrombosis and distal embolism-\> acute limb ischaemia

Answer 1206

Embolectomy or fem-distal bypass

Answer 1207

Elective grafting + tie off vessel

Answer 1208

Prevalence: 5% \>50y Mortality: 10,000 deaths/yr M\>F 3:1

Answer 1209

Dilatation of abdominal aorta \>3cm 90% infrarenal 30% involving iliac arteries

Answer 1210

AAA Rupture

Answer 1211

Bloods: FBC, clotting screen, renal function and liver function Cross match if sx ESR and or CRP if an inflammatory cause suspected AXR: calcification may be seen Abdo US: screening and monitoring CT/MRI: gold standard Angiography: won't show true extent of aneurysm due to endoluminal thrombus but useful to delineate relationship of renal arteries

Answer 1212

AAA Calcified

Answer 1213

Manage CV RFs esp BP UK small aneurysm trial suggested that AAA \<5.5cm in maximum diameter can be monitored by US \<4cm: yearly monitoring 4.5-5cm: 6 monthly monitoring

Answer 1214

Aim to treat aneurysm before it ruptures Elective mortality: 5%, emergency mortality: 50%

Answer 1215

Symptomatic: back pain= imminent rupture Diameter \>5.5cm Expanding \>1cm per year Causing complications e.g. emboli

Answer 1216

EVAR has reduced perioperative mortality No reduction in mortality by 5 years due to fatal endograft failures EVAR not better than medical Rx in unfit patients EVAR requires that the aneurysm should have an adequate 1.2cm neck below the renal arteries for stent fixation, currently 65% with AAA are suitable for endovascular repair.

Answer 1217

MASS trial revealed 50% reduction in aneurysm-related mortality in males aged 65-74 screened with US. UK- one time screen at 65y

Answer 1218

Raised BP Smoker Female Strong FHx

Answer 1219

?AAA rupture

Answer 1220

ABC High flow O2 2x large bore cannulae: Give fluid if shocked but keep SBP\<100mHg (permissive hypotension) Instigate major haemorrhage protocol Call vascular surgeon, anaesthetist and warn theatre Abx prophylaxis: cef+met Analgesia Urinary catheter + CVP line If stable + Dx uncertain: US or CT may be feasible Take to theatre, clamp neck, insert dacron graft

Answer 1221

100% without surgery 50% with surgery

Answer 1222

Blood splays apart the laminar planes of the media to form a channel within the aortic wall

Answer 1223

Atherosclerosis and HTN cause 90% Minority caused by underlying CTD e.g. Marfan's, Ehlers Danlos Vit CD

Answer 1224

?Aortic dissection

Answer 1225

Distal: sequential occlusion of branches Left hemiplegia Unequal arm pulses and BP Paraplegia Anuria Proximal propagation: AR, tamponade Rupture into pericardial, pleural or peritoneal cavities commonest cause of death

Answer 1226

Type A: proximal 70% involves ascending aorta +/- descending Higher mortality due to probable cardiac involvement Usually require Sx Type B: distal 30% Involves descending only, distal to left subclavian artery Usually managed conservatively

Answer 1227

ECG: exclude MI TTE/TOE can be used in haemodynamically unstable pts CT/MRI not suitable for unstable paitents

Answer 1228

ABC Bloods: X-match 10u, FBC, U+E, clotting, amylase ECG: 20% show ischaemia due to involvement of the coronary ostia Ix: CXR, CT/MRI, TOE if haemodynamically unstable Treat: Analgesia Reduce SBP (labetalol or esmolol) 100-110mmHg Type A: open repair, acute mortality \<25% Type B: conservative, sx if persistent pain or complications, consider TEVAR if uncomplicated

Answer 1229

Death of tissue from poor vascular supply

Answer 1230

Wet: tissue death + infection Dry: tissue death only Pregangrene: tissue on brink of gangrene

Answer 1231

Wet gangrene

Answer 1232

Dry gangrene

Answer 1233

Pregangrene

Answer 1234

Clostridium perfringes myositis

Answer 1235

DM Trauma Malignancy

Answer 1236

Gas gangrene

Answer 1237

Debridement: may need amputation Benzylpenicllin and metronidazole Hyperbaric O2

Answer 1238

Involves aerobes and anaerobes Can progress rapidly to nec fasc and myositis

Answer 1239

Synergistic gangrene Chronic undermining burrowing ulcer (also known as Meleney gangrene, or Meleney's ulcer) is a cutaneous condition that is a postoperative, progressive bacterial gangrene.[1]:269 It is seen in immunocompromised individuals, mostly after post abdominal surgery and rapidly spreads to involve a large area.[citation needed]

Answer 1240

Synergistic gangrene Fournier gangrene is a type of necrotizing fasciitis or gangreneaffecting the perineum.

Answer 1241

Take cultures Debridement Benzlpenicllin +/- clindamycin

Answer 1242

Tortuous dilated veins of the superficial venous system

Answer 1243

One-way flow from superifical-\> deep venous system maintained by valves Valve failure-\> increased pressure in superficial veins-\> varicosity

Answer 1244

SFJ: 3cm below and 3cm lateral to pubic tubercle SPJ: popliteal fossa Perforators: draining GSV

Answer 1245

Idiopathic: congenitally weak valves Prolonged standing, pregnancy, obesity, OCP, FHx Congenital valve absence (v. rare)

Answer 1246

Valve destruction-\> reflux: DVT, thrombophlebitis Obstruction: DVT, foetus, pelvic mass Constipation AVM Overactive pumps e.g. cyclists Klippel-Trenaunay: PWS, varicose veins, limb hypertrophy

Answer 1247

Torniquet Start 3cm below and 3cm lateral to pubic tubercle Lift patient's leg as high as comfortable and milk leg to empty veins. Once varicosities are empty place thumb or torniquet over SFJ Ask patient to stand while pressure is maintained If varicosities rapidly fill, suggests the incompetent perforator veins lie below the SFJ Now repeat moving down 3cm each time, when varicosities do not refill, the incompetent perforator is above the torniquet but below the previous one.

Answer 1248

Varicose veins

Answer 1249

Varicose veins

Answer 1250

Venous stars

Answer 1251

Haemosiderin deposition Varicose veins

Answer 1252

Venous eczema Varicose veins

Answer 1253

Lipodermatosclerosis Varicose veins

Answer 1254

Atrophie blanche Venous eczema

Answer 1255

Venous ulcer

Answer 1256

Duplex ultrasonography: anatomy, presence of incompetence, caused by obstruction or reflux Sx: FBC, U&E, clotting, G+S, CXR, ECG

Answer 1257

Bleeding Pain Ulceration Superficial thrombophlebitis Severe impact on QoL

Answer 1258

CEAP classification

Answer 1259

Chronic venous disease can be classified according to Clinical signs (1-6 + Symptomatic or Asymptomatic) i.e. 1S or 4A Etiology Anatomy Pathophysiology

Answer 1260

Treat any contributing factors: lose weight, relieve constipation Education: avoid prolonged standing, regular walks Class II Graduated compression stockings: symptomatic relief and slows progression Skin care: maintain hydration with emollients and treat ulcers rapidly

Answer 1261

Small below knee varicosities not involving GSV or SSV

Answer 1262

Local or GA Injection scleropathy: 1% Na tetradecyl sulphate Endovenous laser or radiofrequency ablation Post-operatively: Compression bandage for 24h Compression stockings for 1m

Answer 1263

SFJ incompetence Major perforator incompetence Symptomatic: ulceration, skin changes, pain

Answer 1264

Trendelenberg: SFJ ligation SSV ligation: popliteal fossa LSV stripping: no longer performed due to risk of saphenous nerve damage Multiple avulsions Perforator ligation: Cockett's operation Subfascial endoscopic perforator surgery

Answer 1265

Bandage tightly Elevate for 24h Discharge with compression stockings and instruct to walk daily

Answer 1266

Haematoma (esp. groin) Wound sepsis Damage to cutaneous nerve e.g. long saphenous Superficial thrombophlebitis DVT Recurrence: may approach 50%

Answer 1267

Interruption in the continuity of an epithelial surface

Answer 1268

Venous Arterial Neuropathic Traumatic Systemic disease Neoplastic

Answer 1269

?Venous ulcer

Answer 1270

Arterial ulcer

Answer 1271

Arterial ulcer

Answer 1272

Neuropathic ulcer

Answer 1273

Neuropathic ulcer

Answer 1274

Osteomyelitis Development of SCC in ulcer (Marjolin's)

Answer 1275

Development of SCC in ulcer

Answer 1276

ABPI if possible Duplex ultrasonography Biopsy may be necessary to look for malignant change

Answer 1277

Refer to leg ulcer community clinic Focus on prevention: graduated compression stockings, venous uclers Optimise risk factors: nutrition, smoking

Answer 1278

Analgesia Bed Rest and Elevate leg 4 layer graded compression bandage if ABPI \>0.8 Pentoxyfylline PO: increases microcirculatory blood flow, improves healing rates

Answer 1279

Increased venous pressure: RHF Venous insufficiency Drugs e.g. nifedipine Reduced oncotic pressure: Nephrotic syndrome Hepatic failure Protein losing enteropathy Lymphoedema Myxoedema: hyper/hypothyroidism

Answer 1280

Venous insufficiency DVT Infection or inflammation Lymphoedema

Answer 1281

Collection of interstitial fluid due to blockage or absence of lymphatics

Answer 1282

Congenital absence of lymphatics May or may not be familial

Answer 1283

Congenital: evident from birth Praecox: after birth but \<35 Tarda: \>35

Answer 1284

Familial AD subtype of congenital lymphoedema: F\>M

Answer 1285

Fibrosis; e.g. post RTx Infiltration: Ca: prostate, lymphoma Filariasis Infection: TB Trauma: block dissection of lymphatics

Answer 1286

Doppler US Lymphoscintigraphy CT/MRI

Answer 1287

Conservative: Skin care, compression stockings, physio, treat or prevent comorbid infections Surgical: debulking

Answer 1288

DVTs occur in 25-50% of surgical patients

Answer 1289

Virchow's triad Blood: Surgery-\> increased plt and fibrinogen Dehydration Malignancy Increased age Blood flow: Sx Immobility Obesity Vessel wall: damage to veins: esp. pelvic veins Previous VTE

Answer 1290

Cellulitis Ruptured Baker's cyst

Answer 1291

D-dimers: sensitive but not specific Compression US: clot will be incompressible Thrombophilia screen if no precipitating factors, recurrent DVT or family Hx

Answer 1292

Assess probability using Well's Score Low probability: perform D-dimers -ve= excludes DVT +ve= compression US Medium/high probability: compression USS

Answer 1293

Well's score

Answer 1294

Active cancer Paralysis, paresis or recent plaster immobilisation of legs Recently bedridden for \>3d or major sx within last 12w Localised tenderness along the distribution of the deep venous system Entire leg is swollen Calf swelling by more than 3cm compared with asymptomatic leg (10cm below the tibial tuberosity) Piiting oedema (greater than on the asymptomatic leg) Pitting oedema Collateral superficial veins Perviously documented DVT Subtract two points if an alternative cause is considered more likely than DVT \>2= likely, \<2 unlikely

Answer 1295

Antiocagulate: Therapeutic LMWH: enoxaparin 1.5mg/kg/24h SC Start warfrain Stop LMWH when INR 2.5 Duration depends on cause

Answer 1296

5mg OD for 2 days, measure INR on day 3 subsequent doses depend on INR

Answer 1297

Should be taken at the same time each day

Answer 1298

Graduated compression stockings to prevent post-phlebitic syndrome

Answer 1299

Pre-op VTE risk assessment TED stockings Aggressive optimisation esp. hydration Stop OCP 4w pre-op

Answer 1300

Minimise length of sx Use minimal access surgery where possible Intermittent pneumatic compression boots

Answer 1301

LMWH Early mobilisation Good analgesia Physio Adequate hydration

Answer 1302

Previous lung disease Atelectasis, aspiration, pneumonia LVF PE Pneumothorax (e.g. due to CVP line insertion) Pain-\> hypoventilation

Answer 1303

FBC, ABG CXR ECG

Answer 1304

Sit up, give O2, monitor SpO2 Rx cause

Answer 1305

Post renal: Most common cause- blocked/malsited catheter, acute urinary retention Pre-renal: Hypovolaemia Renal: NSAIDs, gentamicin

Answer 1306

Blocked or malsited catheter

Answer 1307

Inadequate fluid replacement

Answer 1308

Information: Operation history, obs chart: UO Drugs chart: nephrotoxins Examination: Assess fluid status Examine for palpable bladder Inspect drips, drains, stomas, CVP Action Flush with 50ml NS and aspirate back Fluid challenge

Answer 1309

Obstruction Ileus Emetic drugs e.g. opioids

Answer 1310

Consider NGT, AXR and ondansetron 4mg IV TDS

Answer 1311

What was the pre-op level Common causes: SIADH: pain, nausea, opioids, stress Overadministration of IV fluids

Answer 1312

Tilt bed head down give O2 Assess fluid status

Answer 1313

Cardiogenic: MI, fluid overload Hypovolaemia: inadequate replacement of fluids losses, haemorrhage Obstructive: PE Distributive: sepsis, neurogenic shock

Answer 1314

Fluid challenge 250-500ml fluid challenge STAT

Answer 1315

Return to theatre

Answer 1316

Fluid challenge, start Abx

Answer 1317

Nadr infusion

Answer 1318

Continue anti-hypertensives during peri-operative period

Answer 1319

Pain Urinary retention Previous HTN

Answer 1320

Rx cause May use labetalol 50mg IV every 5 mins (200mg max)

Answer 1321

An area of skin that is mainly supplied by a single spinal nerve

Answer 1322

T4 T4 at teat pore

Answer 1323

T7 at bottom of sternum

Answer 1324

T10 at belly butTEN

Answer 1325

L4 to the floor

Answer 1326

Series of sounds used to examine cranial nerve function Each tests a specific muscle and nerve pair

Answer 1327

Levator palatini: responsible for palatal elevation Nerve required: CNX

Answer 1328

Glossus muscles CNXII

Answer 1329

Perioral muscles CNVII

Answer 1330

ischaemic optic neuropathy (e.g. temporal arteritis or atherosclerosis) occlusion of central retinal vein occlusion of central retinal artery vitreous haemorrhage retinal detachment

Answer 1331

Posterior vitreous detachment

Answer 1332

Retinal detachment

Answer 1333

Vitreous haemorrhage

Answer 1334

Acute angle closure glaucoma

Answer 1335

Anterior uveitis

Answer 1336

Conjunctivitis

Answer 1337

Subconjunctival haemorrhage

Answer 1338

Oral antiviral treatment for 7-0 days, ideally started within 72h Oral corticosteroids may reduce duration of pain Ophthalmology review

Answer 1339

Viral conjunctivitis

Answer 1340

Allergic conjunctivitis

Answer 1341

Dry macular degeneration

Answer 1342

Wet macular degeneration

Answer 1343

Dry macular degneration

Answer 1344

Used to treat wet macular degeneration Anti-VEGF

Answer 1345

keratoconjunctivitis sicca (most common) episcleritis (erythema) scleritis (erythema and pain) corneal ulceration keratitis Iatrogenic steroid-induced cataracts chloroquine retinopathy

Answer 1346

Acute angle closure glaucoma is associated with hypermetropia, where as primary open-angle glaucoma is associated with myopia

Answer 1347

Anhydrosis of the face, arm and trunk= central Anhydrosis of the face= preganglionic No anhydrosis= post-ganglionic

Answer 1348

Stroke Syringomelia MS Tumour Encephalitis

Answer 1349

Pancoast Thyroidectomy Trauma Cervical rib

Answer 1350

Carotid artery dissection Carotid aneurysm CVST Cluster headache

Answer 1351

Retinal detachment

Answer 1352

Causes of papilloedema space-occupying lesion: neoplastic, vascular malignant hypertension idiopathic intracranial hypertension hydrocephalus hypercapnia Rare causes include hypoparathyroidism and hypocalcaemia vitamin A toxicity

Answer 1353

Papilloedema

Answer 1354

Pit- upper, cranipharyngioma- lower Bitemporal hemianopia, upper quadrant defect Unilateral peripheral visual field loss Right homonymous hemianopia Remember: the homonymous hemianopia is always on the same side as the paresis.

Answer 1355

upper quadrant defect \> lower quadrant defect = inferior chiasmal compression, commonly a pituitary tumour lower quadrant defect \> upper quadrant defect = superior chiasmal compression, commonly a craniopharyngioma

Answer 1356

Retinitis pigmentosa primarily affects the peripheral retina resulting in tunnel vision Features night blindness is often the initial sign tunnel vision due to loss of the peripheral retina (occasionally referred to as funnel vision) fundoscopy: black bone spicule-shaped pigmentation in the peripheral retina, mottling of the retinal pigment epithelium Associated diseases Refsum disease: cerebellar ataxia, peripheral neuropathy, deafness, ichthyosis Usher syndrome abetalipoproteinemia Lawrence-Moon-Biedl syndrome Kearns-Sayre syndrome Alport's syndrome

Answer 1357

Smoking is the most important modifiable risk factor for the development of thyroid eye disease

Answer 1358

unexplained deterioration in vision awareness of change in intensity or quality of colour vision in one or both eyes history of eye suddenly 'popping out' (globe subluxation) obvious corneal opacity cornea still visible when the eyelids are closed disc swelling

Answer 1359

Ankylosing spondylitis is associated with anterior uveitis. The history of pain and photophobia combined with the examination findings of a red eye confirm the diagnosis Note that the pupil in this image is dilated - this is not a typical finding at diagnosis but may reflect the fact that cycloplegic drops are commonly given to patients for pain relief

Answer 1360

10-21 mmHg

Answer 1361

Hot compresses + mechanical removal of lid debris

Answer 1362

Blepharitis

Answer 1363

Blepharitis

Answer 1364

softening of the lid margin using hot compresses twice a day mechanical removal of the debris from lid margins - cotton wool buds dipped in a mixture of cooled boiled water and baby shampoo is often used\* artificial tears may be given for symptom relief in people with dry eyes or an abnormal tear film

Answer 1365

This is Hutchinson's sign which is strongly predictive for ocular involvement.

Answer 1366

Anterior ischemic optic neuropathy

Answer 1367

Anterior ischaemic optic neuropathy

Answer 1368

Dacryocystitis is infection of the lacrimal sac Features watering eye (epiphora) swelling and erythema at the inner canthus of the eye Management is with systemic antibiotics. Intravenous antibiotics are indicated if there is associated periorbital cellulitis

Answer 1369

2 years A newborn's visual acuity is only about 6/200. This improves to 6/60 at 3 months but does no reach adult levels until about 2 years of age. The table below summarises the vision tests which may be performed when assessing children: AgeTest BirthRed reflex 6 weeksFix and follow to 90 degrees (e.g. Red ball 90cm away) 3 monthsFix and follow to 180 degrees No squint 12 monthsCan pick up 'hundreds and thousands' with pincer grip \> 3 yearsLetter matching test \> 4 yearsSnellen charts Ishihara plates for colour vision

Answer 1370

Whilst a hypopyon can of course be seen in anterior uveitis the combination of a normal pupillary reaction and contact lens use make a diagnosis of keratitis more likely.

Answer 1371

Left sided ectropion

Answer 1372

Diabetic retinopathy

Answer 1373

Hyperventilation to induce hypocapnia may be used in the emergency setting to reduce intracranial pressure

Answer 1374

olmes-Adie pupil is a benign condition most commonly seen in women. It is one of the differentials of a dilated pupil. Overview unilateral in 80% of cases dilated pupil once the pupil has constricted it remains small for an abnormally long time slowly reactive to accommodation but very poorly (if at all) to light Holmes-Adie syndrome association of Holmes-Adie pupil with absent ankle/knee reflexes

Answer 1375

Central retinal vein occlusion - sudden painless loss of vision, severe retinal haemorrhages on fundoscopy

Answer 1376

Latanoprost Brimonidine Pilocarpine

Answer 1377

homonymous quadrantanopias: PITS (Parietal-Inferior, Temporal-Superior)

Answer 1378

optical coherence tomography: provide cross-sectional views of the macula if neovascularisation is present fluorescein angiography is performed

Answer 1379

If left untreated this patient may develop a corneal ulcer. The definitive management of entropion is surgical although eye lubricants and tape (to pull the eyelid outwards) may be used whilst awaiting surgery.

Answer 1380

Right superior quadranopia Lower bitemporal hemianopia Right inferior quadranopia

Answer 1381

ankylosing spondylitis reactive arthritis ulcerative colitis, Crohn's disease Behcet's disease

Answer 1382

Argyll-Robertson pupil is one of the classic pupillary syndrome. It is sometimes seen in neurosyphilis and is often said to be the prostitute's pupil - accommodates but doesn't react. Another mnemonic used for the Argyll-Robertson Pupil (ARP) is Accommodation Reflex Present (ARP) but Pupillary Reflex Absent (PRA) Features small, irregular pupils no response to light but there is a response to accommodate Causes diabetes mellitus syphilis

Answer 1383

Central retinal artery occlusion The pale retina is the most obvious sign in this slide.

Answer 1384

Increases uveoscleral outflow

Answer 1385

MS Longstanding papilloedema Raised IOP Retinal damage e.g. choroiditis, retinitis pigmentosa Ischaemia Toxins: tobacco ambylopia, quinine, methanol, arsenic, lead Nutritional: vitamin B1, B2, B6 and B12 deficiency

Answer 1386

Friedrich's ataxia Mitochondrial disorders DIDMOAD (cranial DI, DM, OA, deafness- Wolfram's)

Answer 1387

The Holmes-Adie pupil is unilateral, rather than bilateral, in 80% of patients

Answer 1388

Brimonidine Latanoprost Dorzolamide

Answer 1389

papilloedema glaucoma retinitis pigmentosa choroidoretinitis optic atrophy secondary to tabes dorsalis hysteria

Answer 1390

Beta-carotene has been found to increase the risk of lung cancer and hence antioxidant dietary supplements are not recommended for smokers.

Answer 1391

Occipital cortex The macula sparing suggests the lesion is most likely to be in the occipital cortex rather than the optic tract. Optic chiasm This patient has a pituitary tumour causing compression of the optic chiasm and bitemporal hemianopia. The sweating and headaches are consistent with acromegaly. Retina This is a common presentation of retinitis pigmentosa. Extensive pigmentation would normally be noted on fundoscopy.

Answer 1392

Hypocalcaemia, rather than hypercalcaemia, predisposes to cataract formation.

Answer 1393

Majority age related UV light Systemic diabetes mellitus steroids infection (congenital rubella) metabolic (hypocalcaemia, galactosaemia) myotonic dystrophy, Down's syndrome Ocular trauma uveitis high myopia topical steroids

Answer 1394

Marfan's: upwards Homocystinuria: downwards Ehlers-Danlos Trauma Uveal tumours Autosomal recessive ectopia lentis

Answer 1395

A key way to discriminate between scleritis and episcleritis is the presence of pain. Keratoconjunctivitis sicca is usually bilateral and associated more with dryness, burning and itch

Answer 1396

Central retinal vein occlusion - sudden painless loss of vision, severe retinal haemorrhages on fundoscopy This appearance is sometimes compared to a cheese and tomato pizza.

Answer 1397

Organic= osteoid (40%) Collagent Type 1 Resists tension, twisting and bending Inroganice (60%) Calcium hydroxapatite Resits compressive forces

Answer 1398

Woven bone: disorganised bone that forms the embryonic skeleton and fracture callus Lamellar bone: mature bone that can be of two types: Cortical/compact= dense outer layer Cancellous/trabecular: porous central layer

Answer 1399

Direct ossification of mesenchymal bone models formed during embryonic development Skull bones, mandible and clavicle

Answer 1400

Mesenchyme-\> cartilage-\> bone Most bones ossify this way

Answer 1401

Reactive phase Reparative phase Remodelling phase

Answer 1402

Injury-48h Bleeding into #site-\> haematoma Inflammation-\> cytokine, GF and vasoactive mediator release-\> recruitment of leukocytes and fibroblasts-\> granulation tissue

Answer 1403

2d-2w Proliferation of osteoblasts and fibroblasts-\> cartilage and woven bone production-\> callus formation Consolidation-\> endochondral ossificaiton of woven bone-\> lamellar bone

Answer 1404

1w-7y Remodelling of lamellar bone to cope with mechanical forces applied to it Follows Wolff's law

Answer 1405

Form follows function Wolff's law, developed by the German anatomist and surgeon Julius Wolff (1836–1902) in the 19th century, states that bone in a healthy person or animal will adapt to the loads under which it is placed.[1] If loading on a particular bone increases, the bone will remodel itself over time to become stronger to resist that sort of loading.[2][3] The internal architecture of the trabeculae undergoes adaptive changes, followed by secondary changes to the external cortical portion of the bone,[4] perhaps becoming thicker as a result. The inverse is true as well: if the loading on a bone decreases, the bone will become less dense and weaker due to the lack of the stimulus required for continued remodeling.[5] This reduction in bone density (osteopenia) is known as stress shielding and can occur as a result of a hip replacement (or other prosthesis).[6] The normal stress on a bone is shielded from that bone by being placed on a prosthetic implant.

Answer 1406

Double healing time Adult LL Diaphyseal Open

Answer 1407

Diaphysis= shaft Metaphysis: growth plate region (physis- growth plate) Epiphysis Atrciular cartilage over joint surfaces

Answer 1408

Medullary cavity Endosteum Cortical bone Periosteum

Answer 1409

Traumatic Stress Pathological

Answer 1410

Direct e.g. assualt with metal bar Indirect e.g. FOOSH-\> #clavicle Avulsion

Answer 1411

Bone fatigue due to repetitive strain E.g. foot #s in marathon runners

Answer 1412

Normal forces but disease bone Local- tumours General: osteoporosis, Cushing's Pagets

Answer 1413

Radiographs must be orthogonal request AP and lat films Need images of joint above and below #

Answer 1414

Demographics Pattern Anatomical Intra/extra-articular Deformity Soft tissues Specific #classification/type

Answer 1415

Transverse Oblique Spiral Multifragmentary Crush Greenstick Avulsion

Answer 1416

Translation Angulation or tilt Rotation Impaction (shortening) Describe distal relative to proximal

Answer 1417

Open or closed Neurovascular status Compartment syndrome

Answer 1418

Resuscitation Reduction Restriction Rehabilitation

Answer 1419

Follow ATLS guidelines Trauma series in 1o survey: C-spine, chest and pelvis usually assessed in 2o survey Assess neurovascular status and look for dislocations Consider reduction and splinting before imaging when: reduced pain, reduced bleeding, risk of neurovascular imaging XR once stable

Answer 1420

To reduce pain To reduce bleeding To reduce risk of neurovascular injury

Answer 1421

Analgesia Assess: NV status, soft tissues, photograph Antisepsis: wound swab, copious irrigation, cover with betadine-soaked dressign Alignment: align # and splint Anti-tetanus: check status Abx: fluxclox 500mg IV/IM and benpen 600mg IV/IM Or augmentin 1.2g IV

Answer 1422

Debridement and fixation in theatre

Answer 1423

Clostridium perfrigens Wound infections and gas gangrene +/- shock and renal failure

Answer 1424

Debride, benpen, clindamycin

Answer 1425

1. Wound \<1cm in length 2. Wound \>1cm with minimal soft tissue damage 3. Extensive soft tissue damage

Answer 1426

Displaced #s should be reduced unless no effect on outcome e.g. ribs Aim for anatomical reduction, especially if articular surfaces involved Alignment is more important than opposition

Answer 1427

Manipulation/closed reduction Traction Open reduction and internal fixation

Answer 1428

Under local, regional or general anaesthetic Traction to disimpact Manipulation to align

Answer 1429

Not typically used now Employed to overcome contraction of large muscles e.g. femoral #s Skeletal traction vs skin traction

Answer 1430

Accurate reduction weighed up vs risks of surgery Intra-articular #s Open #s 2 #s on 1 limb Failure in conservative mx Bilateral identical fractures

Answer 1431

Interfragmentary strain hypothesis dictates that tissue is formed at site dependent on strain it experiences Fixation reduces strain -\> bone formation Fixation also reduces pain, increases stability and ability to function

Answer 1432

Non-rigid Plaster Functional bracing Continuous traction Ex-fix Internal fixation

Answer 1433

Slings Elastic supports

Answer 1434

POP In first 24-48h use back-slab or split cast due to risk of compartment syndrome

Answer 1435

Joints free to move but bone shafts supported in cast segments

Answer 1436

Collar and cuff sling

Answer 1437

Fragments held in position by pins/wires which are then connected to an external frame Intervention is away from field of injury Useful in open #s, burns, tissue loss to allow wound access and reduce infection risk However there is a risk of pin-site infections

Answer 1438

Pins, plates, screws, IM nails Usually perfect anatomical alignement Increased stability Aid early mobilisation

Answer 1439

Immobility-\> reduced muscle and bone mass, joint stiffness Need to maximise return to function to reduce later morbidity

Answer 1440

PT: exercises to improve mobility OT: splints, mobility aids, home modification Social services: meals on wheels, home help

Answer 1441

Tissue damage: Haemorrhage and shock Infection Muscle damage-\> rhabdomyolysis Anaesthesia: Anaphylaxis Damage to teeth Aspiration Prolonged bed rest: Chest infection, UTI Pressure sores and muscle wasing DVT, PE Decreased bone mineral density

Answer 1442

Neurovascular damage Visceral damage

Answer 1443

Compartment syndrome Infection (worse if associated with metalwork) Fat embolism-\> ARDS

Answer 1444

Problems with union AVN Growth disturbance Post-traumatic osteoarthritis Complex regional pain syndromes Myositis ossificans

Answer 1445

far most common type, nonhereditary myositis ossificans (commonly referred to simply as "myositis ossificans", as in the remainder of this article), calcifications occur at the site of injured muscle, most commonly in the arms or in the quadriceps of the thighs. ## Footnote The term myositis ossificans traumatica is sometimes used when the condition is due to trauma.[1][2] Also Myositis ossificans circumscripta is another synonym of myositis ossificans traumatica refers to the new extraosseous bone that appears after traum

Answer 1446

The second condition, myositis ossificans progressiva (also referred to as fibrodysplasia ossificans progressiva) is an inherited affliction, autosomal dominant pattern, in which the ossification can occur without injury, and typically grows in a predictable pattern. Although this disorder can be passed to offspring by those afflicted with FOP, it is also classified as nonhereditary, as it is most often attributed to a spontaneous genetic mutation upon conception.

Answer 1447

Myositis ossificans

Answer 1448

Severance is rare, stretching over bone edge commoner Seddon classification describes three types of injury

Answer 1449

Descrbie neurological damage post # Neuropraxia Axonotmesis Neurotmesis

Answer 1450

Temprorary interruption of conduction without loss of axonal continuity

Answer 1451

Disruption of nerve axon-\> distal Wallerian degeneration Connective tissue framework of nerve is preserved Regeneration occurs and recovery is possible

Answer 1452

Wallerian degeneration is a process that results when a nerve fiber is cut or crushed, in which the part of the axon separated from the neuron's cell body degenerates distal to the injury. This is also known as anterograde or orthograde degeneration.

Answer 1453

Disruption of the entire nerve fibre Surgery is required and recovery is not usually complete

Answer 1454

Axillary nerve Numb chevron Weak abduction

Answer 1455

Radial nerve Waiter's tip

Answer 1456

Ulnar nerve Claw hand

Answer 1457

Sciatic nerve Foot drop

Answer 1458

Fibular nerve Foot drop

Answer 1459

Osteofascial membranes divide limbs into separate comparments of muscles Oedema following # can lead to an increase in compartment pressure, this reduces venous drainage increasing compartment pressure further If compartment pressure \> capillary pressure-\> ischaemia Muscle infarction-\> Rhabdomyolsis and ATN Fibrosis-\> Volkman's ischaemic contractrue

Answer 1460

?Compartment syndrome

Answer 1461

Elevate limb Remove all bandages and split/remove cast Fasciotomy

Answer 1462

Union takes longer than expected

Answer 1463

fails to unite

Answer 1464

Ischaemia: poor blood supply or AVN Infection Increased interfragmentary strain Interposition of tissue between fragments Intercurrent disease: e.g. malignancy or malnutrition

Answer 1465

Hypertrophic: bone end is rounded, dense and sclerotic Atrophic: bone looks osteopenic

Answer 1466

Optimise biology: infection, blood supply, bone graft, BMPs Optimise mechanics: ORIF

Answer 1467

#healed in an imperfect position poor position and or function e.g. gunstock deformity

Answer 1468

Cubitus varus (varus means a deformity of a limb in which part of it is deviated towards the midline of the body) is a common deformity in which the extended forearm is deviated towards midline of the body. Cubitus varus is often referred to as "Gunstock deformity", due to the crooked nature of the healing. A common cause is the supracondylar fracture of humerus.

Answer 1469

Form of myositis ossificans Calcification of the superior attachment of MCL at the knee following traumatic injury

Answer 1470

Pellegrini-Stieda disease 􀁸 form of MO 􀁸 Calcification of the superior attachment of MCL @ the knee following traumatic injury.

Answer 1471

=Reflex Sympathetic Dystrophy, Sudek's atrophy Complex disorder of pain, sensory abnormalities, abnormal blood flow, sweating and trophic changes in superficial or deep tissues No evidence of nerve injury

Answer 1472

Injury: #s, carpal tunnel release, ops for Dupuytren's Zoster, MI, Idiopathic

Answer 1473

Complex Regional Pain Syndrome Type 1 (Reflex Sympathetic Dystrophy, Sudek''s atrophy)

Answer 1474

Pain caused by something that wouldn't normally cause pain

Answer 1475

Usually self-limiting Refer to pain team Amitryptilline, gabapentin Sympathetic nerve blocks can be tried

Answer 1476

Persistent pain following an injury caused by nerve lesions

Answer 1477

Damage to the physis can result in abnormal bone growth Salter-Harris classification categorises growth plate injuries

Answer 1478

Used to classify growth plate injuries 1. Straight across 2. Above 3. Lower 4. Through 5. Crush

Answer 1479

e.g. SUFE Normal growth with good reduction

Answer 1480

Union across physis may interfere with bone growth

Answer 1481

Crush-\> physis injury-\> growth arrest

Answer 1482

Junction of the medial 2/3 and lateral 1/3 After the # the lateral end of the clavicle is displaced inferiorly be the weight of the arm and medially by pectoralis major Medial end is pulled superiorly by sternocleidomastoid FOOSH

Answer 1483

Serratus anterior muscle originates from ribs 2-8 and attaches to the costal face of the scapula pulling it against the ribcage This is innervated by the LTN If the LTN becomes damaged the scapula protrudes out of the back when pushing with the arm.

Answer 1484

Greater tubercle is located laterally on the humerus Serves as attachment site for 3 of the rotator cuff muscles, supraspinatus, infraspinatus, teres minor.

Answer 1485

Subscapularis

Answer 1486

Initiator of abduction up to first 25

Answer 1487

External rotators of the shoulder Infraspinatus acting when the arm is in neutral and teres minor when the arm is in 90% of abduction

Answer 1488

Main internal rotator of the shoulder Largest and strongest cuff muslce

Answer 1489

SITS Supraspinatus: abduction Infraspinatus: external rotation Teres minor: external rotation (when arm is abducted to 90 deg) Subscapularis: internal rotation

Answer 1490

Trochlea articulates with ulnar: located medially and extends onto the posterior of the bone Capitulum articulates with the radius

Answer 1491

Usually caused by a force from behind the ulna Proximal shaft of the ulna is fractured and the head of the radius dislocates anteriorly at the elbow

Answer 1492

Monteggia fracture The Monteggia fracture is a fracture of the proximal third of the ulna with dislocation of the head of the radius. It is named after Giovanni Battista Monteggia.[1][2] Fall on an outstretched hand with the forearm in excessive pronation (hyper-pronation injury). The Ulna fractures in the proximal one-third of the shaft due to extreme dislocation. Depending on the impact and forces applied in each direction, degree of energy absorption determines pattern, involvement of the radial head and whether or not open soft tissue occurs. Direct blow on back of upper forearm would be a very uncommon cause. In this context, isolated ulnar shaft fractures are most commonly seen in defence against blunt trauma (e.g. nightstick injury). Such an isolated ulnar shaft fracture is not a Monteggia fracture.[citation needed] It is called a 'nightstick fracture'.

Answer 1493

Galeazzi’s Fracture – A fracture to the distal radius, with the ulna head dislocating at the distal radio-ulnar joint.

Answer 1494

Most common types of radial fracture Fall onto an outstretched hand causing a fracture of the distal radius. Structures distal to the fracture (wrist and hand are displaced posteriorly to produce the dinner fork deformity)

Answer 1495

Most common type of radial fracture FOOSH causing a fracture of the distal radius. Structures distal to the fracture (wrist and hand are displaced posteriorly to produce the dinner fork deformity)

Answer 1496

Smith’s Fracture – A fracture caused by falling onto the back of the hand. It is the opposite of a Colles’ fracture, as the distal fragment is now placed anteriorly.

Answer 1497

Smith’s Fracture – A fracture caused by falling onto the back of the hand. It is the opposite of a Colles’ fracture, as the distal fragment is now placed anteriorly.

Answer 1498

Scaphoid Lunate Triquetrum Pisiform Trapezium Trapezoid Capitate Hamate

Answer 1499

Scaphoid and lunate FOOSH

Answer 1500

Classical clinical features is pain and tenderness in the anatomical snuffbox Fracture needs to be reduced quickly as the blood supply to the proximal part of the bone can be cut off leading to an avascular necrosis

Answer 1501

Occurs when there is hyperextension at the wrist Associated with damage to the median nerve

Answer 1502

A fracture of the 5th metacarpal neck Usually caused by a clenched fist striking a hard object The distal part of the fracture is displaced posteriorly producing shortening of the affected finger

Answer 1503

Boxer's fracture

Answer 1504

Fracture of the 1st metacarpal base extending into the carpometacarpal joint It is caused by hyperabduction of the thumb

Answer 1505

Bennet's fracture

Answer 1506

Supraspinatus and infraspinatus both innervated by suprascapular Teres minor innervated by axillary nerve Subscapularis upper and lower subscapular nerve

Answer 1507

Abduction (upper limb away from midline in coronal plane) The first 0-15 degrees of abduction is produced by the supraspinatus. The middle fibres of the deltoid are responsible for the next 15-90 degrees. Past 90 degrees, the scapula needs to be rotated to achieve abduction – that is carried out by the trapezius and serratus anterior.

Answer 1508

Acromioclavicular joint dislocation

Answer 1509

Most of the flexor and extensor muscles in the forearm have a common tendinous origin. The flexor muscles originate from the medial epicondyle, and the extensor muscles from the lateral. Sportspersons can develop an overuse strain of the common tendon – which results in pain and inflammation around the area of the affected epicondyle. Typically, tennis players experience pain in the lateral epicondyle from the common extensor origin. Golfers experience pain in the medial epicondyle from the common flexor origin.

Answer 1510

Scaphoid, lunate, triqeutrum

Answer 1511

80/100,000 50% \>80 y F\>M 3:1

Answer 1512

Old= osteoporosis with minor trauma e.g. fall Young= major trauma

Answer 1513

Age Steroids Hyper para/thyroidism Alcohol and cigarettes Thin (BMI \<22) Testosterone low Early menopause Renal/ liver failure Ersoive/inflammatory bone disease e.g. RA, myeloma Dietary Ca low/malabsorption DM

Answer 1514

Mechanism RFs for osteoporosis/pathological # Premorbid mobility Premorbid independence Comorbidities MMSE

Answer 1515

Shortened and externally rotated

Answer 1516

Resuscitate: dehydration, hypothermia Analgesia: M + M Assess neurovascular status of limb Imaging: AP and lateral films Prep for theatre

Answer 1517

Anaesthetist and book theatre Bloods: FBC, U+Es, clotting, X-match (2u) CXR DVT prophylaxis: TEDS, LMWH ECG Films: orthogonal XR Get consent

Answer 1518

Ask for AP and lateral film Look at Shenton's lines Intra or extracapsular Displaced or non-displaced Osteopenic?

Answer 1519

Shenton's line is formed by the medial edge of the femoral neck and the inferior edge of the superior pubic ramus Loss of contour of Shenton's line is a sign of a fractured neck of femur IMPORTANT NOTE: Fractures of the femoral neck do not always cause loss of Shenton's line

Answer 1520

Capsule envelopes the femoral head and neck Subcapital, transcervical and basicervical fractures are intracapsular hip fractures Intertrochanteric and subtrochanteric fractures do not involve the neck of the femur

Answer 1521

Most of the bloody suppply to the femoral head ariseses from the lateral femoral circumflex artery which gives rise to the retinacular vessels. These run posteriorly until they reach the cartilaginous border of the femoral head. The obturator artery gives rise to the vessels within the ligemantum teres (artery of ligamentum teres) An ascending branch of the medial femoral circumflex artery supplies the greater trochanter and anastomoses with the lateral femoral circumflex artery

Answer 1522

Capsular attaches proximally to the acetabular margin and distally to the intertrochanteric line If retinacular vessels are damaged theres is a risk of AVN of the femoral head -\> pain, stiffness and OA

Answer 1523

Intracapsular: Subcapital, transcervical, basicervical Extracapsular: Intertrochanteric, subtrochanteric

Answer 1524

Garden Classification

Answer 1525

1. Incomplete # undisplaced 2. Complete fracture, undisplaced 3. Complete fracture, partially dispalced 4. Complete fracture, completely dispalced

Answer 1526

Depends on Garden classification 1,2. ORIF with cancellous screws 3,4. \<55: ORIF with screws, FU in OPD and do arthroplasty if AVN develops (30%) 55-75: THR \>75: hemiarthroplasty Mobilises: cemented Thompson's Non-mobiliser: uncemented Austin Moore

Answer 1527

ORIF with DHS

Answer 1528

Involve OT and physios Discharge when mobilisation and social circumstances permit

Answer 1529

AVN of femoral head in displaced #s (30%) Non/malunion Infection OA

Answer 1530

30% mortality at 1y 50% never regain pre-morbid functioning \>10% unable to return to premorbid residence Majority will have some residual pain or disability

Answer 1531

FOOSH Most common elderly females with osteoporosis Dinner fork deformity

Answer 1532

Colles fracture

Answer 1533

Examine for neurovascular injury as median nerve and radial artery lie close If there is much displacement: reduction Under haematoma block, IV regional anaesthesia or GA Disimpact and correct angulation Position: ulnar deviation + some wrist flexion Apply dorsal backslab: provide 3- point pressure Re-XR: satisfactory position No: ortho review and consider MUA +/- K wires Yes: home with clinic follow up witihin 48h for completion of POP 6w in POP + physio If comminuted: intra-articular or redisplaces: surgical fixation with ex-fix, Kirschner-wries or ORIF and plates

Answer 1534

Median nerve injury Frozen shoulder/adhesive capsulitis Tendon rupture especially EPL Carpal tunnel syndrome Mal/nonunion Sudek's atrophy/CRPS

Answer 1535

Smith's/Reverse Colle's

Answer 1536

Barton's fracture

Answer 1537

Barton fractures are fractures of the distal radius. It is also sometimes termed the dorsal type Barton fracture to distinguish it from the volar type or reverse Barton fracture. Barton fractures extend through the dorsal aspect to the articular surface but not to the volar aspect. Therefore, it is similar to a Colles fracture. There is usually associated dorsal subluxation/dislocation of the radiocarpal joint.

Answer 1538

Scaphoid fracture

Answer 1539

Request scaphoid XR view If clinical hx and exam suggest a scaphoid fracture it should be initially treated even if the XR is normal as # may take 10d to become apparent Place wrist in scaphoid blaster (beer glass position) If initial XR is negative F/U in clinic in 10d for repeat XR Fracture visible-\> plaster for 6 w No visible fracture but clinically tender-\> 2w No visible fracture not tender, no plaster

Answer 1540

Galleazi fracture

Answer 1541

Unstable: adults: ORIF, children: MUA and above elbow plaster Fractures of forearm should be plastered in most stable position Proximal: supination Distal: pronation Mid-shaft: neutral

Answer 1542

Anterior Posterior

Answer 1543

95% of shoulder dislocations Direct trauma or falling on hand Humeral head dislocates antero-inferiorly

Answer 1544

Caused by direct trauma or muscle contraction (electrocution, epileptics)

Answer 1545

Anterior shoulder dislocation

Answer 1546

Posterior dislocation Lightbulb sign: internally rotated humeral head takes on a rounded appearance

Answer 1547

Bankart lesion Hill-Sachs lesion

Answer 1548

Damage to anteroinferior glenoid labrum

Answer 1549

Cortical depression in the posteriolateral part of the humeral head following impaction against the glenoid rim during anterior dislocaiton Occurs in 35-40% of anterior dislocaiton

Answer 1550

Hill Sachs

Answer 1551

Bankart Lesion

Answer 1552

?Shoulder dislocation

Answer 1553

Assess for neurovascular deficit: especially axillary nerve- sensation over chevron area before and after reduction Occurs in 5% XR: AP and transcapular view Reduction under sedation Rest arm in a sling for 3-4w Physio

Answer 1554

Hippocratic Kocher's

Answer 1555

Longitudinal traction with arm in 30 degree abduction and counter traction at the axilla

Answer 1556

External rotation of adducted arm, anterior movement, internal rotation

Answer 1557

Recurrent dislocation 90% of patietns \<20y with traumatic dislocation Axillary nerve injury

Answer 1558

Traumatic Unilateral dislocations with a Bankart lesion often require Surgery Mostly young patients: 15-30y Surgery involves a Bankart repair

Answer 1559

Atraumatic Multidirectional Bilateral shoulder dislocation is treated with Rehabilitation but may require Inferior capsular shift

Answer 1560

Entrapment of supraspinatus tendon and subacromial bursa between acromion and greater tuberosity of humerus -\> subacromial bursitis and or supraspinatus tendonitis

Answer 1561

Impingement syndrome/ painful arc

Answer 1562

The patient is examined while sitting with their shoulder flexed to 90° and their elbow flexed to 90°. The examiner grasps and supports proximal to the wrist and elbow to ensure maximal relaxation, the examiner and the patient then quickly rotate the arm internally.[4][5] Pain located below the acromioclavicular joint with internal rotation is considered a positive test result

Answer 1563

Plain radiographs may see bony spurs US MRI arthrogram

Answer 1564

Conservative: rest, PT Medical: NSAIDs, subacromial bursa steroid +/- LA injeciton Surgical: arthoroscopic acromioplasty

Answer 1565

Impingement Supraspinatus tear or partial tear AC joint OA

Answer 1566

Frozen shoulder: adhesive capsulitis

Answer 1567

Freezing Frozen Unfreezing

Answer 1568

Conservative: rest, PT Medical: NSAIDs, subacromial bursa steroid +/- LA injection

Answer 1569

Painful arc

Answer 1570

Degeneration, a sudden jolt or fall

Answer 1571

Shoulder tip pain Full range of passive movement Inability to abduct the arm Active abduction possible following passive abduction to 90 degrees Lowering the arm beneath this -\> sudden drop: drop-arm sign

Answer 1572

A positive test is determined by the patient’s inability to smoothly control the lowering of their arm or the inability to hold the arm in 90 degrees of abduction. In a positive test that starts above 90 degrees of abduction, the patient will tend to have difficulty controlling the movement around 90 degrees of abduction. There may or may not be pain reported. Pain alone is not a positive test.

Answer 1573

Open or arthroscopic repair

Answer 1574

Supracondylar fracture of the humerus

Answer 1575

Extension: commonest type Flexion

Answer 1576

Gartland Type 1: non-displaced Type 2: angulated with intact posterior cortex Type 3: displaced with no cortical contact

Answer 1577

Supracondylar fracture (extension type)

Answer 1578

Supracondylar fracture flexion type

Answer 1579

Ensure there is no neurovascular damage: if radial pulse absent or damage to brachial artery suspected, take urgently to theatre for reduciton +/- on table angiogram. Median nerve is also vulnerable Restore the anatomy: no displacement-\> flex the arm as fully as possible and apply a collar and cuff for 3w. Triceps acts as sling to stabilise fragments. Displacement: MUA + fixation with K wires + collar and cuff with arm flexed for 3w

Answer 1580

Neurovascular injury Compartment syndrome Gunstock deformity

Answer 1581

Brachial artery Radial nerve Median nerve All vulnerable to injury: esp anterior ossesus branch of the median nerve which supplies the deep forearm flexors (FPL, lateral half of FDP and pronator quadratus)

Answer 1582

Monitor closely during the first 24h Pain on passive extension of the fingers (stretches flexor compartment) is early sign Mx: try extension of the elbow though surgical Rx may be needed Volkmann's ischaemic contracture can result-\> fibrosis of flexors-\> claw hand

Answer 1583

Valgus, varus and rotational deformities in the coronal plane do not remodel and can lead to cubitus varus deformity aka Gunstock deformity

Answer 1584

The correct answer is a lipoma. Epidermoid cysts are common cutaneous cysts that result from the proliferation of epidermal cells within a circumscribed space of the dermis. They can occur at any age and are typically asymptomatic. On physical examination they are typically firm, round nodules of various sizes and a central punctum may be present. Cystic hygromas are congenital lymphatic lesions that are typically found in the neck and axilla region with a predilection for the left side. The majority present by 2 years of age. On physical examination, cystic hygromas are often soft, painless and transilluminate brightly. Branchial cleft cysts are congenital epithelial cysts that develop due to failure of obliteration of the second branchial cleft in embryonic development. They typically present by early adulthood. On physical examination, they are typically smooth, painless, and do not transilluminate. Deep cervical abscesses typically occur following a source of infection such as recent dental work, upper respiratory tract infections, neck or oral cavity trauma. They can occur at any age. On physical examination, the patient typically presents with a painful and tender swelling that may be hot to touch. The patient may also have other signs of infection such as fever, chills, aches, and pains.

Answer 1585

Reactive lymphadenopathy

Answer 1586

Thyroid swelling

Answer 1587

Thyroglossal cyst

Answer 1588

Pharyngeal pouch

Answer 1589

Cystic hygroma

Answer 1590

Branchial cyst

Answer 1591

Cervical rib

Answer 1592

Carotid aneurysm

Answer 1593

Mirror image nuclei = Reed-Sternberg cells Reed-Sternberg cells are diagnostic of Hodgkin's lymphoma. Patient's present with large, non-tender, rubbery lymph nodes. 25% will have constitutional upset with fever, night sweats, weight loss, lethargy and pruritus. An exam favourite, but lesser seen symptom is alcohol induced lymph node pain.

Answer 1594

Hodgkin's lymphoma is a malignant proliferation of lymphocytes characterised by the presence of the Reed-Sternberg cell. It has a bimodal age distributions being most common in the third and seventh decades

Answer 1595

Around in 1% of adults in the UK have nasal polyps. They are around 2-4 times more common in men and are not commonly seen in children or the elderly. Associations asthma\* (particularly late-onset asthma) aspirin sensitivity\* infective sinusitis cystic fibrosis Kartagener's syndrome Churg-Strauss syndrome Features nasal obstruction rhinorrhoea, sneezing poor sense of taste and smell Unusual features which always require further investigation include unilateral symptoms or bleeding. Management all patients with suspected nasal polyps should be referred to ENT for a full examination topical corticosteroids shrink polyp size in around 80% of patients

Answer 1596

The association of asthma, aspirin sensitivity and nasal polyposis

Answer 1597

A cholesteatoma consists of squamous epithelium that is 'trapped' within the skull base causing local destruction. It is most common in patients aged 10-20 years. Main features ## Footnote foul smelling discharge hearing loss Other features are determined by local invasion: vertigo facial nerve palsy cerebellopontine angle syndrome Otoscopy 'attic crust' - seen in the uppermost part of the ear drum Management patients are referred to ENT for consideration of surgical removal

Answer 1598

Adrenaline 500 mcg 0.5ml 1 in 1000 200mg Hydrocortisone 10mg Chlorphenamine

Answer 1599

This lady likely has acute otitis externa. The NICE Clinical Knowledge summary suggests that inflammation is more likely to be severe if there is: a red, oedematous ear canal which is narrowed and obscured by debris conductive hearing loss discharge regional lymphadenopathy cellulitis spreading beyond the ear fever This lady has some features of inflammation with a red swollen ear canal and reduced hearing. NICE recommend that for mild cases (mild discomfort and/or pruritus; no deafness or discharge), consider prescribing topical acetic acid 2% spray. When features of more severe inflammation are present, such as in this case, they advise 7 days of a topical antibiotic with or without a topical steroid. Taking swabs from the ear is not useful routinely as virtually all bacteria detected are sensitive to the high concentrations of antibiotic in topical medications. However, this should be done if there is no response to an initial course of treatment or infections are recurrent. All patients should be advised to use simple analgesia if needed and to avoid getting water into the ear until the infection has resolved.

Answer 1600

Audiograms are usually the first-line investigation that is performed when a patient complains of hearing difficulties. They are relatively easy to interpret as long as some simple rules are followed: ## Footnote anything above the 20dB line is essentially normal (marked in red on the blank audiogram below) in sensorineural hearing loss both air and bone conduction are impaired in conductive hearing loss only air conduction is impaired in mixed hearing loss both air and bone conduction are impaired, with air conduction often being 'worse' than bone

Answer 1601

features of marked systemic upset secondary to the acute sore throat unilateral peritonsillitis a history of rheumatic fever an increased risk from acute infection (such as a child with diabetes mellitus or immunodeficiency) patients with acute sore throat/acute pharyngitis/acute tonsillitis when 3 or more Centor criteria are present

Answer 1602

Vertebrobasilar ischaemia

Answer 1603

Given that his symptoms are unilateral it is important he is referred to ENT for a full examination.

Answer 1604

Black hairy tongue is relatively common condition which results from defective desquamation of the filiform papillae. Despite the name the tongue may be brown, green, pink or another colour. Predisposing factors poor oral hygiene antibiotics head and neck radiation HIV intravenous drug use The tongue should be swabbed to exclude Candida Management tongue scraping topical antifungals if Candida

Answer 1605

Have CXR findings that suggest lung cancer Are aged 40 and over with unexplained haemoptysis

Answer 1606

People over 40 with 2 or more of: cough fatigue shortness of breath chest pain weight loss appetite loss

Answer 1607

People aged 40 and over with any of persistent or recurrent chest infection finger clubbing supraclavicular lymphadenopathy or persistent cervical lymphadenopathy chest signs consistent with lung cancer thrombocytosis

Answer 1608

Globus pharyngis (also known as globus hystericus) is the persistent sensation of having a 'lump in the throat', when there is none. Symptoms are often intermittent and relieved by swallowing food or drink. Swallowing of saliva is often more difficult.

Answer 1609

Oesophagitis

Answer 1610

Oesophageal cancer

Answer 1611

Systemic sclerosis

Answer 1612

Myasthenia gravis

Answer 1613

Globus hystericus

Answer 1614

Papillary carcinoma is the most common subtype and may cause lymph node metastasis (mass separate from the gland itself) that is rare with follicular tumours. Anaplastic carcinoma would cause more local symptoms and would be rare in this age group

Answer 1615

Papillary carcinoma

Answer 1616

Follicular carcinoma of thyroid

Answer 1617

Anaplastic carcinoma

Answer 1618

Medullary carcinoma

Answer 1619

This man has acute necrotizing ulcerative gingivitis with systemic upset. Treatment should be commenced whilst he is awaiting to see a dentist. Paracetamol + oral metronidazole + chlorhexidine mouthwash

Answer 1620

All mouth ulcers persisting for greater than 3 weeks should be sent to oral surgery as a 2 week wait referral. 2 week wait referrals to oral surgery should be done in all of the following cases: Unexplained oral ulceration or mass persisting for greater than 3 weeks Unexplained red, or red and white patches that are painful, swollen or bleeding Unexplained one-sided pain in the head and neck area for greater than 4 weeks, which is associated with ear ache, but does not result in any abnormal findings on otoscopy Unexplained recent neck lump, or a previously undiagnosed lump that has changed over a period of 3 to 6 weeks Unexplained persistent sore or painful throat Signs and symptoms in the oral cavity persisting for more than 6 weeks, that cannot be definitively diagnosed as a benign lesion The level of suspicion should be higher in patients who are over 40, smokers, heavy drinkers and those who chew tobacco or betel nut (areca nut).

Answer 1621

Tympanic membrane perforation is a relatively common complication from trauma to the skull. It is important to distinguish this from sensorineural hearing loss resulting from a base of skull fracture. Rinne's test her shows that there is a conductive hearing loss in the affected ear. Weber's test confirms that there is no sensorineural hearing loss on the right.

Answer 1622

Loss of corneal reflex - think acoustic neuroma

Answer 1623

Otagia can be due to a primary or secondary cause. Primary otalgia is a result of pathology within the ear where as secondary otalgia occurs due to referred pain from an external source. Referred otalgia can occurs due to one of five neural pathways (cranial nerve V, cranial nerve VII, cranial nerve IX, cranial nerve X, and via the second and third spinal segments, C2 and C3). Therefore, many parts of the head and neck can refer pain back to the ears. Otalgia in the absence of any ear signs is a red flag for head and neck malignancy and must be investigated further. In this case the otalgia is likely to be explained by referred pain from the pharynx, and the pharynx must be assess for malignancy, particular due to the age of the gentleman and the risk factor profile.

Answer 1624

?Nasopharyngeal carcinoma Squamous cell carcinoma of the naasopharynx Associated with EBV infection

Answer 1625

Sjogren's syndrome Most patients with Sjogren's present in the post menopausal years. Multi-system involvement is common. Sarcoidosis Sarcoid occurs bilaterally in 70% of cases and facial nerve involvement is recognised. Treatment is conservative in most cases although individuals with facial nerve palsy will usually receive steroids with good effect. Viral parotitis In a young adult with parotid swelling and pancreatitis/orchitis/reduced hearing/meningoencephalitis suspect mumps.

Answer 1626

Benign pleomorphic adenoma or benign mixed tumour

Answer 1627

Warthin tumor (papillary cystadenoma lymphoma or adenolymphoma)

Answer 1628

Monomorphic adenoma

Answer 1629

Haemangioma

Answer 1630

Mucoepidermoid carcinoma

Answer 1631

Adenoid-cystic carcinoma

Answer 1632

Mixed parotid tumour

Answer 1633

Acinic cell carcinoma

Answer 1634

Adenocarcinoma

Answer 1635

Plain x-rays may be used to exclude calculi Sialography may be used to delineate ductal anatomy FNAC is used in most cases Superficial parotidectomy may be either diagnostic or therapeutic depending upon the nature of the lesion Where malignancy is suspected the primary approach should be definitive resection rather than excisional biopsy CT/ MRI may be used in cases of malignancy for staging primary disease

Answer 1636

Sarcoidosis

Answer 1637

Parotid manifestation of HIV infection

Answer 1638

A monoamine oxidase inhibitor combined with pseudoephedrine could potentially cause a hypertensive crisis.

Answer 1639

This girl has marked systemic upset and should be treated with antibiotics. A 7 or 10 day course of antibiotics is appropriate to ensure eradication of possible Streptococcus infection. Phenoxymethylpenicillin is the first-line antibiotic choice in the BNF

Answer 1640

When he presented initially with the perforation this boy was given amoxicillin which is consistent with NICE guidelines. There is no indication for continuing the antibiotics if the ear is dry. If there is still a perforation when the boy is reviewed in 4 weeks time (i.e. 6 weeks since the perforation occurred) then ENT referral should be considered.

Answer 1641

no treatment is needed in the majority of cases as the tympanic membrane will usually heal after 6-8 weeks. It is advisable to avoid getting water in the ear during this time it is common practice to prescribe antibiotics to perforations which occur following an episode of acute otitis media. NICE support this approach in the 2008 Respiratory tract infection guidelines myringoplasty may be performed if the tympanic membrane does not heal by itself

Answer 1642

Motion sickness - hyoscine \> cyclizine \> promethazine

Answer 1643

Management the BNF recommends hyoscine (e.g. transdermal patch) as being the most effective treatment. Use is limited due to side-effects non-sedating antihistamines such as cyclizine or cinnarizine are recommended in preference to sedating preparation such as promethazine

Answer 1644

Osler Weber Rendu HHT

Answer 1645

2= possible diagnosis 3 or more= definite diagnosis Epistaxis: spontaneous and recurrent nosebleeds Telangiectasis: multiple at characteristic sites: lips, oral cavity, fingers, nose Visceral lesions: e.g. GI, pulmonary AVM, hepatic AVM, spinal AVM Fhx of first degree relative with HHT

Answer 1646

The chest x-ray shows multiple pulmonary nodules representing arteriovenous malformations, the largest in the right mid-zone. The CT scan shows multiple hepatic arteriovenous malformations

Answer 1647

Management ## Footnote ENT assessment is required to confirm the diagnosis patients should inform the DVLA. The current advice is to cease driving until satisfactory control of symptoms is achieved acute attacks: buccal or intramuscular prochlorperazine. Admission is sometimes required prevention: betahistine may be of benefit

Answer 1648

This patient has classical symptoms of benign paroxysmal positional vertigo. A positive Dix-Hallpike manoeuvre is an appropriate next step and would help support the diagnosis. The change in blood pressure on standing is not significant.

Answer 1649

After using topical decongestants for prolonged periods increasing doses are needed to provide the same effect, a phenomenon known as tachyphylaxis.

Answer 1650

Trigeminal neuralgia

Answer 1651

Cluster headache

Answer 1652

Temporal arteritis

Answer 1653

This patient has a unilateral nasal polyp. Polyps due to rhinosinusitis are usually bilateral so it is important to refer this gentleman to be seen by an ENT doctor to exclude malignancy. If small bilateral nasal polyps are seen these can be treated in primary care with a saline nasal douche and intranasal steroids, but if they are causing significant obstruction patients should be referred to ENT.

Answer 1654

This is a case of otitis media. Although 50% of these cases are viral, and 60% improve without antibiotics, guidelines would advocate treatment after a delay of 2-3 days if there is no improvement in symptoms. Especially in this case, where the gentleman has a temperature and therefore evidence of systemic involvement. Therefore, advising regular paracetamol is not correct in this case. Erythromycin is a useful alternative to patients who are penicillin allergic, and especially as a syrup in children (as it costs less that some alternatives!) but would not be first line in someone who can take penicillin. Penicillin V is the first line antibiotic for tonsillitis due to amoxicillin having the potential to cause a rash in cases of glandular fever. However, it is not generally used in otitis media. Amoxicillin is the correct first line medication for treating otitis media at 500mg TDS for 7 days. Co-amoxiclav is used as a second line agent if amoxicillin doesn't work, but wouldn't be used first line according to current guidelines.

Answer 1655

The spreading erythema is an indication for oral antibiotics. Flucloxacillin is first-line.

Answer 1656

This man has sudden sensorineural hearing loss, which in the vast majority of cases is idiopathic. There is some evidence that high dose steroids (60mg/day) for seven days improves prognosis, so all patients should start treatment as soon as possible. ENT assessment should be arranged as soon as possible to allow pure tone audiometry testing and to arrange an MRI to exclude an acoustic neuroma. Intra-tympanic steroids can also be given if there is no response to oral steroids. Aciclovir is not routinely recommended as there is no evidence of benefit.

Answer 1657

Although patients often give a history of bending prior to disc prolapse the normal straight leg raising makes this diagnosis less likely.

Answer 1658

Facet joint

Answer 1659

Spinal stenosis

Answer 1660

Ankle XR only reqired if there is any pain in malleolar zone + 1 of: Bony tenderness at lateral malleolar zone Bony tenderness at the medial malleolar zone Inability to walk four weight bearing steps immediately after the injury and in the ED

Answer 1661

A typical buckle fracture is shown in this radiograph. This is a common fracture pattern in children due to the pliable nature of the bone. Buckle, or torus, fractures are incomplete fractures of the shaft of a long bone that is characterised by bulging of the cortex. They typically occur in children aged 5-10 years. As they are typically self-limiting they do not usually require operative intervention and can sometimes be managed with splinting and immobilisation rather than a cast.

Answer 1662

Chondromalacia patellae

Answer 1663

Osgood-Schlatter disease | (tibial apophysitis)

Answer 1664

Osteochondritis dissecans

Answer 1665

Patellar subluxation

Answer 1666

Patellar tendonitis

Answer 1667

The radiograph shows a fracture involving the palmar surface of the distal radius, with minimal dorsal angulation and no disruption of the dorsal cortex. The growth plate appears normal.

Answer 1668

Complete fracture

Answer 1669

Toddlers fracture

Answer 1670

Plastic deformity

Answer 1671

Greenstick fracture

Answer 1672

Buckle fracture

Answer 1673

Osteogenesis imperfecta

Answer 1674

Collagen is normal quality but insufficient quantity

Answer 1675

Poor collagen quantity and quality

Answer 1676

Collagen poorly formed, normal quantity

Answer 1677

Sufficient collagen quantity but poor quality

Answer 1678

Osteopetrosis

Answer 1679

This is a classic presentation of spinal stenosis. Whilst peripheral arterial disease is an obvious differential the characteristic relieving factors of the pain and normal vascular examination point away from this diagnosis.

Answer 1680

Age \<20 or \>50 Hx of previous malignancy Night pain History of trauma Systemicallly unwell e.g. weight loss fever Altered neurology Incontinence or constipation

Answer 1681

Lumbricals (third and fourth) Opponens pollicis Abductor pollicis brevis Flexor pollicis brevis

Answer 1682

Psoas abscess is a collection within the psoas muscle. It is commonly missed or diagnosed late due to its numerous differential diagnoses and a high index of suspicion is required in those with risk factors. The psoas muscle extends from T12 - L5 caudally, inserting on the lesser trochanter of the femur. It can be of primary origin or a result of spread from local sources such as pyelonephritis or inflammatory bowel disease. Left untreated it can lead to septicaemia and multi organ failure. The most common causative organism is staphylococcus or streptococcus and risk factors for developing a primary abscess are related to causes of immunosupression such as HIV, cancer and diabetes. Being an intravenous drug user, previous surgery and tuberculosis also predispose to the condition. Pain is usually non specific initially but increases over several days. It is worth suspecting if there is no history of trauma or injury. Fever may be present but not always. Psoas irritation is evidenced when the position of comfort is the patient lying on their back with slightly flexed knees. Inability to weight bear or pain when moving the hip is usually evident. Investigations should include bloods to evidence infection and a complete septic screen if systemic inflammatory response syndrome criteria are met. Plain radiographs are not useful for identifying an abscess although are useful for ruling out differentials. CT abdomen may identify the abscess but MRI is the gold standard. Management is with antibiotic therapy +/- drainage. Alongside managing any predisposing risk factors if appropriate.

Answer 1683

\>20mmHg is abnormal \>40mmHg is diagnostic

Answer 1684

This is essentially prompt and extensive fasciotomies In the lower limb the deep muscles may be inadequately decompressed by the inexperienced operator when smaller incisions are performed Myoglobinuria may occur following fasciotomy and result in renal failure and for this reason these patients require aggressive IV fluids Where muscle groups are frankly necrotic at fasciotomy they should be debrided and amputation may have to be considered Death of muscle groups may occur within 4-6 hours

Answer 1685

More common in women than men RA DM

Answer 1686

Tirgger finger

Answer 1687

Steroid injeciton is successful in the majority Surgery may be reserved for patients who have not responded to steroid injections

Answer 1688

This describes the typical patient with a Baker's cyst. They are more likely to develop in patients with arthritis or gout and following a minor trauma to the knee. Foucher's sign describes the increase in tension of the Baker's cyst on extension of the knee. A DVT (deep vein thrombosis) needs to be considered because it can mimic a Baker's cyst. A DVT can also co-exist with a Baker's cyst and a low threshold for ultrasound should be considered.

Answer 1689

Osteoarthritis of the knee

Answer 1690

Infrapatellar bursitis: Clergyman's knee

Answer 1691

Prepatellar bursitis: Housemaid's knee

Answer 1692

?Collateral ligament injury

Answer 1693

Meniscal lesion

Answer 1694

Anatomical neck fractures are rare, those that are displaced by \>1cm carry a risk of avascular necrosis to the humeral head

Answer 1695

Glenohumeral dislocation Acromioclavicular dislocation: clavicle loses all attachment with scapula Sternoclavicular dislocation (uncommon)

Answer 1696

Anterior Inferior Posterior Superior

Answer 1697

Anterior dislocation

Answer 1698

The trough line sign is a sign of posterior shoulder dislocation on AP films. In posterior dislocation, the anterior aspect of the humeral head becomes impacted against the posterior glenoid rim. With sufficient force, this causes a compression fracture on the anterior aspect of the humeral head. This compression fracture is analogous to the Hill-Sachs compression fracture seen with anterior shoulder dislocation of the glenohumeral joint. Frontal radiographs reveal two nearly parallel lines in the superomedial aspect of the humeral head.

Answer 1699

Trough sign

Answer 1700

An inferior shoulder dislocation is the least common form of shoulder dislocation. The condition is also called luxatio erecta because the arm appears to be permanently held upward or behind the head, in fixed abduction.

Answer 1701

Luxatio erecta (inferior shoulder disloccation)

Answer 1702

Ulnar nerve

Answer 1703

Lateral epicondylitis (tennis elbow)

Answer 1704

Medial epicondylitis (golfer's elbow)

Answer 1705

Radial tunnel syndrome

Answer 1706

Cubital tunnel syndrome

Answer 1707

Olecranon bursitis

Answer 1708

De Quervain's tenosynovitis is a common condition in which the sheath containing the extensor pollicis brevis and abductor pollicis longus tendons is inflamed. It typically affects females aged 30 - 50 years old

Answer 1709

De Quervain's tenosynovitis

Answer 1710

Management analgesia steroid injection immobilisation with a thumb splint (spica) may be effective surgical treatment is sometimes required

Answer 1711

Loss of dorsiflexion and eversion suggests a common peroneal nerve lesion as opposed to an L5 radiculopathy (in L5 radiculopathy, eversion tends to be spared while sensory involvement tends to be greater). This is before the recent risk factor of knee surgery is considered, making common peroneal nerve palsy the more obvious answer. NB common peroneal palsy spares inversion whilst l5 radiculopathy will have weakness of ankle inversion

Answer 1712

Common peroneal nerve palsy

Answer 1713

Greater trochanteric pain syndrome is now the preferred term for trochanteric bursitis. Whilst the x-ray shows joint space narrowing this is not an uncommon finding. Osteoarthritis would also be less likely given the palpable nature of the pain and relatively short duration of symptoms.

Answer 1714

Inflammatory arthritis

Answer 1715

Referred lumbar spine pain

Answer 1716

Greater trochanteric pain syndrome (Trochanteric bursitis)

Answer 1717

Meralgia paraesthetica

Answer 1718

Avascular necrosis

Answer 1719

Pubic symphysis dysfunction

Answer 1720

Transient idiopathic osteoporosis

Answer 1721

The x-ray shows calcification of the supraspinatus tendon consistent with prolonged inflammation. On examination the patient exhibits the classical 'painful arc' associated with this condition.

Answer 1722

Most commonly idiopathic. Associations include: ## Footnote spina bifida cerebral palsy Edward's syndrome (trisomy 18) oligohydramnios arthrogryposis

Answer 1723

Gradual swelling of the knee is suggestive of effusion which often occurs due to meniscal injury. Tenderness over the medial joint line suggests a medial meniscus tear. An ACL or PCL tear would more commonly present with rapid joint swelling due to bleeding within the joint capsule (haemarthrosis). Isolated MCL injuries rarely cause a large effusion. In addition, the lack of laxity on the valgus stress test makes an MCL injury less likely.

Answer 1724

Ruptured ACL

Answer 1725

Ruptured posterior cruciate ligament

Answer 1726

Rupture of medial collateral ligament

Answer 1727

Menisceal tear

Answer 1728

Chondromalacia patellae

Answer 1729

Dislocation of the patella

Answer 1730

Fractured patella

Answer 1731

Tibial plateau fracture

Answer 1732

Schatzker system

Answer 1733

Type 1: Vertical split of lateral condyle Fracture through dense bone, usually in the young, may be undisplaced or condylar fragment may be pushed in feriorly Type 2: Vertical split of the lateral condyle combined with an adjacent load bearing part of the condyle The wedge fragment (which may be of variable size), is displaced laterally; the joint is widened. Untreated, a valgus deformity may develop Type 3: Depression of the articular surface with intact condylar rim The split does not extend to the edge of the plateau. Depressed fragments may be firmly embedded in subchondral bone, the joint is stable Type 4 Fragment of the medial tibial condyle Two injuries are seen in this category; (1) a depressed fracture of osteoporotic bone in the elderly. (2) a high energy fracture resulting in a condylar split that runs from the intercondylar eminence to the medial cortex. Associated ligamentous injury may be severe Type 5 Fracture of both condyles Both condyles fractured but the column of the metaphysis remains in continuity with the tibial shaft Type 6 Combined condylar and subcondylar fractures High energy fracture with marked comminution

Answer 1734

Anticoagulation will worsen compartment syndrome.

Answer 1735

Dupuytren's contracture has a prevalence of about 5%. It is more common in older male patients and around 60-70% have a positive family history Specific causes include: manual labour phenytoin treatment alcoholic liver disease trauma to the hand

Answer 1736

Schober's test \<5cm is suggestive of ankylosing spondylitis. This is an indication of reduced lumbar flexion. Schober's test is performed by identifying L5, and then marking 10cm above and 5cm below this point whilst the patient is stood upright. The patient is then asked to bend forwards to touch their toes whilst keeping their knees straight. If the distance between the points does not increase by 5cm (or the distance between the points originally marked is not more than 20cm in total), then it can be said that there is reduced flexion of the lumbar spine, which is a sign of ankylosing spondylitis. Thoracic kyphosis is an associated spinal deformity, alongside neck hyperextension. This may be referred to by some as the 'question mark' appearance. Aortic valve incompetence is associated with \<3% of cases.

Answer 1737

Apical fibrosis Anterior uveitis Aortic regurgitation Achilles tendonitis AV node block Amyloidosis and cauda equina syndrome peripheral arthritis (25%, more common if female)

Answer 1738

Resus and Mx life threatening injuries first X-match Assess neurovascular status: especially distal pulses If open Abx and ATT Take to theatre urgently for debridement, washout and stabilisation Fixation methods: Intramedullary nail External fixation Plates and screws MUA with fixed traction for 3-4 months

Answer 1739

Hypovolaemic shock Neurovascular: SFA: swelling and check pulses Sciatic nerve Compartment syndrome Respiratory complications: Fat embolism ARDS Pneumonia

Answer 1740

Typically twisting inversion injury Strains anterior talofibular part of LCL Medial deltoid ligament strains are rare May be associated with malleolar avulsion fractures

Answer 1741

Relation of fibula # to joint line

Answer 1742

A: below joint line B: at joint line C: above joint line

Answer 1743

Weber's B and C represent possible injury to the syndesmotic ligaments between tib and fib -\> instability

Answer 1744

Weber Classification 􀁸 Relation of fibula # to joint line 􀁸 A: below joint line 􀁸 B: at joint line 􀁸 C: above joint line 􀁸 Weber’s B and C represent possible injury to the syndesmotic ligaments between tib and fib → instability

Answer 1745

Boot or below knee POP

Answer 1746

Below knee POP

Answer 1747

Closed reduction and POP if anatomical reduction achieved ORIF if closed reduction fails

Answer 1748

Mechanism Swelling: immediate vs overnight Pain/tenderness: joint line vs medial/lateral margins Locking: meniscal tear Giving way: instability following lgt injury

Answer 1749

= haemarthrosis. # or torn cruciates

Answer 1750

= effusion Meniscus or other ligamentous injury

Answer 1751

Meniscal tear

Answer 1752

Collateral ligaments

Answer 1753

Spontaneous bleeding: Coagulopathy: warfarin, haemophilia

Answer 1754

Trauma ACL injury: 80% Patella dislocation: 10% Meniscal injury: outer third where it is vascularised (10%) Osteophyte #

Answer 1755

MCL Medial meniscus ACL

Answer 1756

Full examination of acutely swollen knee after injury is difficult Take XR to ensure no #s: fluid level indicates a lipohaemarthrosis and indicates either a # or torn cruciate If no #-\> RICE + later re-examination If meniscal or cruciate injury suspected-\> MRI

Answer 1757

Direct vision of inside of knee joint by arthroscope Can examine knee under anaesthesia (reduced muscle tone) Meniscal tears can be trimmed or repaired

Answer 1758

Conservative: Rest PT to strengthen quads and hamstrings Not enough stability for many sports Surgical: Gold-standard is autograft repair Usually semintendonosus +/- gracillis (can use patella tendon) Tendon threaded through heads of tibia and femur and held using screws

Answer 1759

Softening of articular cartilage-\> fraying and fissuring of smooth surface-\> underlying bone exposure Subchondral bone becomes sclerotic with cysts Proliferation and ossification of cartilage in unstressed areas-\> osteophytes Capsular fibrosis-\> stiff joints

Answer 1760

Septic Crystal Trauma

Answer 1761

Loss of joint space Osteophytes Subchondral cysts Subchondral sclerosis Deformity

Answer 1762

CRP may be elevated Ca, PO4, ALP all normal

Answer 1763

MDT: GP, physio, OT, dietician, orthopod Conservative: Lifestyle: reduce weight, increase exercise PT: muscle strengthening OT: walking aids, supportive footwear, home modifications Medical: Analgesia: paracetamol + topical NSAIDs e.g. voiltarel Tramadol Joint injeciton: LA and steroids Surgical: Arthroscopic washout Realignment osteotomy: small area of bone cut out, useful in younger patients with medial knee OA. High tibial valgus osteotomy redistributes weight to lateral part of joint Arthroplasty Arthrodesis Novel techniques

Answer 1764

Soft tissue injury-\> dysfunction of whole spine-\> muscle spasm-\> pain May have inciting event e.g. lifting Young patients with no sinister features

Answer 1765

Conservative: Max 2d bed rest Education: keep active, how to lift/stoop PT Psychoscoial issues Warmth Medical: Analgesia: paracetamol +/- NSAIDS +/- codeine Muscle relaxant: low-dose diazepam (used ST)

Answer 1766

Herniation of nucleeus pulposus through annulus fibrosus

Answer 1767

L5 (L4/L5 disc) S1 (L5/S1 disc)

Answer 1768

=?Disc prolapse

Answer 1769

?Disc herniation

Answer 1770

Pain on straight leg raise ?Radiculopathy

Answer 1771

Lateral herniation= radiculopathy Central herniatoin= cauda equina syndrome

Answer 1772

L4/L5 root compression

Answer 1773

L5/S1-\> S1 root compression

Answer 1774

MRI (emergency if cauda equina)

Answer 1775

Brief rest, analgesia and mobilisation effective in \>90% Conservative: Brief rest Mobilisation/PT Medical: analgesia, transforaminal steroid injection Surgical: discectomy or laminectomy may be needed in cauda equina syndrome, continuing pain or muscle weakness

Answer 1776

Commonest procedure for disc prolapse Microscopic resection of the protruding nucleus pulposus Posterior approach with patient in prone position May be performed endoscopically

Answer 1777

Displacement of one lumbar vertebra on another Usually forward Usually L5 on S1

Answer 1778

Spondylolisthesis

Answer 1779

Congenital malformation Spondylosis osteoarthritis

Answer 1780

Spondylolisthesis

Answer 1781

Plain radiography

Answer 1782

Corset Nerve release Spinal fusion

Answer 1783

Developmental predisposition +/- facet joint OA-\> generalised narrowing of lumbar spinal canal

Answer 1784

Spinal claudicaiton

Answer 1785

Corsets NSAIDs Epidural steroid injection Canal decompression surgery

Answer 1786

Spine of a person with lordosis curves significantly inward at lower back

Answer 1787

Abnormally rounded upper back (more than 50 deg of curvature)

Answer 1788

Sideways curve to the spine, often S-shaped or C-shaped

Answer 1789

Idiopathic condition in which bony centres of children/adolescents become temporarily softened due to osteonecrosis Bone hardens in new deformed position

Answer 1790

Initially: increased denisty/sclerosis then: patchy appearance

Answer 1791

Self-limiting skeletal disorder of childhood. Vertebrae grow unevenly in respect to the saggital plane. (posterior angle greater than anterior angle) Uneven growth results in wedging shape of vertebrae causing kyphosis.

Answer 1792

Scheueurmann's disease Autosomal dominant Vertebral tenderness and kyphosis XR: wedge-shaped thoracic vertebra

Answer 1793

Rare bone disorder of the foot found in young children (3-5). Caused by the navicular bone temporarily losing its blood supply. Undergoes avascular necrosis. Pain in mid-tarsal region-\> limp

Answer 1794

Kohler's disease

Answer 1795

Kienböck's disease is a disorder of the wrist. It is named for Dr. Robert Kienböck, a radiologist in Vienna, Austria who described osteomalacia of the lunate in 1910.[1] It is breakdown of the lunate bone, a carpal bone in the wrist that articulates with the radius in the forearm. Specifically, Kienböck's disease is another name for avascular necrosis[2](death and fracture of bone tissue due to interruption of blood supply) with fragmentation and collapse of the lunate. This has classically been attributed to arterial disruption, but may also occur after events that produce venous congestion with elevated interosseous pressure.

Answer 1796

Kienboch's disease Lunate bone 􀁸 Adults 􀁸 Pain over lunate, esp. on active movement 􀁸 Impaired grip

Answer 1797

Freiberg disease, also known as a Freiberg infraction, is a form of avascular necrosis in the metatarsal. It generally develops in the second metatarsal, but can occur in any metatarsal. Physical stress causes repeated microfractures where the middle of the metatarsal meets the growth plate. These restrict circulation to the end of the metatarsal, causing the necrosis. It is an uncommon condition, occurring most often in young women, athletes, and those with abnormally long metatarsals. Approximately 80% of those diagnosed are women.[1]

Answer 1798

Friedberg's disease 2nd/3rd metatarsal heads Around puberty Forefoot pain worse with pressure

Answer 1799

Panner disease is an osteochondrosis of the capitellum of the elbow. It causes pain and stiffness in the affected elbow and may limit extension. On radiographs, the capitulum may appear irregular with areas of radioluceny. Treatment is symptomatic, with a good prognosis. It is primarily seen in children between five and ten years old. The disease is named after the Danish radiologist Hans Jessen Panner

Answer 1800

Panner's disease Capitulum of humerus

Answer 1801

Legg–Calvé–Perthes disease (LCPD) is a childhood hip disorder initiated by a disruption of blood flow to the ball of the femur called the femoral head. Due to the lack of blood flow, the bone dies (osteonecrosis or avascular necrosis) and stops growing. Over time, healing occurs by new blood vessels infiltrating the dead bone and removing the necrotic bone which leads to a loss of bone mass and a weakening of the femoral head.[1] The bone loss leads to some degree of collapse and deformity of the femoral head and sometimes secondary changes to the shape of the hip socket. It is also referred to as idiopathic avascular osteonecrosis of the capital femoral epiphysis of the femoral head since the cause of the interruption of the blood supply of the head of the femur in the hip joint is unknown.

Answer 1802

Legg-Calve-Perthes Disease of right hip

Answer 1803

Tibial tuberosity apophysitis + patellar tendonitis Seen in children 10-14y/o M\>F 3:1 Associated with physical activity Pain below knee especially on quad contraction

Answer 1804

Osgood-Shlatter's

Answer 1805

Osgood-Shlatters

Answer 1806

Singind Larsen's disease

Answer 1807

Tranction tendinopathy with calcification of proximal attachment of patellar tendon 􀁸 Children 8-10yrs

Answer 1808

Sinding Larsen's disease Tranction tendinopathy with calcification of proximal attachment of patellar tendon 􀁸 Children 8-10yrs

Answer 1809

Calcaneal apophysitis 8-13 years Pain behind heel and limp

Answer 1810

Sever's disease

Answer 1811

Piece of bone overlying catrilage dissects off into the joint space Commonly knee (medial femoral condyle), also elbow, hip and ankle Young adult/adolescent Pain, swelling, locking, reduced ROM

Answer 1812

Osteochondritis dissecans

Answer 1813

Osteochondritis Dissecans

Answer 1814

or dislocation SCD, thalassaemia SLE Gaucher's Drugs: steroids, NSAIDs

Answer 1815

Natural swelling of bone for attachment of a muscle

Answer 1816

Connective tissue between tendon or ligament and bone. There are two types of entheses: Fibrous entheses and fibrocartilaginous entheses.

Answer 1817

A trimalleolar fracture is a fracture of the ankle that involves the lateral malleolus, the medial malleolus, and the distal posterior aspect of the tibia, which can be termed the posterior malleolus. The trauma is sometimes accompanied by ligament damage and dislocation.[1]

Answer 1818

A bimalleolar fracture is a fracture of the ankle that involves the lateral malleolus and the medial malleolus. Studies have shown[1] that bimalleolar fractures are more common in women, people over 60 years of age, and patients with existing comorbidities.[1]

Answer 1819

Ulnar (medial border): tendon of extensor pollicis longus Radial (lateral) border: tendons of abductor pollicis longus and extensor pollicis brevis Proximal border: styloid process of the radius Floor: carpal bones: scaphoid and trapezium Roof: skin

Answer 1820

Radial artery Superficial branch of radial nerve Cephalic vein

Answer 1821

Lateral border: medial border of brachioradialis Medial border: lateral border of pronator teres Superior border: line between the epicondyles of the humerus

Answer 1822

Lateral to medial: Radial Nerve Biceps Tendon Brachial Artery Median Nerve

Answer 1823

Formed by two layers: a deep carpal arch and a superficial flexor retinaculum Carpal arch: Concave on palmar side Formed laterally by the scaphoid and trapezium tubercles Formed medially by the hook of hamate and pisiform Flexor retinaculum: Thick connective tissue Turns the carpal arch into the carpal tunnel Originates on the lateral side and inserts on the medial side of the carpal arch

Answer 1824

9 tendons and median nerve

Answer 1825

1 FPL own sheath 4 FDP + 4 FDS shared sheath

Answer 1826

Median nerve 1 FPL 4 FDP 4 FDS

Answer 1827

4 sides and a base with an opening at the apex Apex: lateral border of first rib, superior border of scapula and posterior border of clavicle Lateral wall: intertubercular groove of the humerus Medial wall: serratus anterior and thoracic wall Anterior wall: pec major and pec minor and subclavius Posterior wall: subscap, teres major, lat dorsi

Answer 1828

3 routes Main route: into the upper limb, immediately inferiorly and laterally Another via the quadrangular space: gap in the posterior wall of the axilla Clavipectoral triangle: opening in the anterior wall of the axilla bounded by pectoralis major, deltoid and clavicle

Answer 1829

Axillary artery Axillary vein Brachial plexus Biceps brachii and coarcobrachialis Axillary lymph nodes

Answer 1830

Pec major, minor, serratus anterior, subclavius

Answer 1831

Adducts and medially rotates the upper limb Draws scapula anteroinferiorly

Answer 1832

Lateral and medial pectoral nerves

Answer 1833

Stabilises the scapula by drawing it anteroinferiorly against the thoracic wall

Answer 1834

Medial pectoral nerve

Answer 1835

Rotates the scapula allowing the arm to be raised over 90 Holds scapula against the ribcage

Answer 1836

Anchors and depresses the clavicle

Answer 1837

Nerve to subclavius

Answer 1838

Extrinsic: originate from the torso and attach to bones of the shoulder Intrinsic: originate from scapula or clavicle and attach to the humerus

Answer 1839

Deltoid, teres major Rotator cuff muscles

Answer 1840

Anterior fibres flex arm at the shoulder Posterior fibres extend arm at the shoulder Middle fibres are the major abductor of the arm, taking over from supraspinatus which abducts the first 15 degrees

Answer 1841

Axillary nerve

Answer 1842

Adducts at the shoulder and internally rotates arm

Answer 1843

Lower subscapular nerve

Answer 1844

Rhomboid Levator scapulae

Answer 1845

Into a superficial and deep layer

Answer 1846

Trapezius Lat dorsi

Answer 1847

Elevate scapula and rotate it during abduction of the arm. Middle fibres retract scapula Lower fibres pull the scapula inferiorly

Answer 1848

Accessory nerve

Answer 1849

Extends, adducts and medially rotates the upper limb

Answer 1850

Levator scapulae Rhomboids

Answer 1851

Biceps brachii Brachialis Coarcobrachialis

Answer 1852

Supination of forearm Flexes arm at elbow and at the shoulder

Answer 1853

Musculocutaneous nerve

Answer 1854

Flexion of the arm at the shoulder and weak adduciton

Answer 1855

Musculocutaneous nerve

Answer 1856

Flexion at the elbow

Answer 1857

Musculocutanous nerve

Answer 1858

Rupture of biceps tendon

Answer 1859

Extension of the arm at the elbow

Answer 1860

Radial nerve

Answer 1861

Superficial Intermediate Deep

Answer 1862

Flexion at wrist and fingers, pronation

Answer 1863

Flexor carpi ulnaris Palmaris Longus Flexor carpi radialis Pronator teres

Answer 1864

Flexion and adduciton at wrist

Answer 1865

Ulnar nerve

Answer 1866

Flexion at wrist NB this muscle is absent in 15% of the population

Answer 1867

Median nerve

Answer 1868

Flexion and adduction at the wrist

Answer 1869

Median nerve

Answer 1870

Pronation of the forearm

Answer 1871

Median nerve

Answer 1872

Flexor digitorum superficialis

Answer 1873

Flexes the metacarpophalangeal joints and PIP at the 4 fingers and flexes the wrist

Answer 1874

FDP FPL Pronator quadratus

Answer 1875

Flex the DIP of the fingers (only)

Answer 1876

Medial half is innervated by the ulnar nerve Lateral half innervated by median nerve

Answer 1877

Flexes the interphalangeal joint and MCP of the thumb

Answer 1878

Median nerve (anterior interosseus branch)

Answer 1879

Pronates the forearm

Answer 1880

Median nerve (ant interosseus)

Answer 1881

Deep and superficial

Answer 1882

Extensor carpi radialis brevis and longus, extensor digitorum, extensor carpi ulnaris, extensor digitis minimi, brachioradialis, anconeus

Answer 1883

Flexes forearm

Answer 1884

Radial nerve

Answer 1885

Supinator APL EPB EPL Extensor indices

Answer 1886

Supinates the forearm

Answer 1887

The extrinsic muscles are located in the anterior and posterior compartments of the forearm. They control crude movements and produce a forceful grip. The intrinsic muscles of the hand are located within the hand itself. They are responsible for the fine motor functions of the hand.

Answer 1888

Median nerve

Answer 1889

Opponens polllicis Abductor Pollicis brevis Flexor pollicis brevis

Answer 1890

Ulnar nerve

Answer 1891

Opponens digiti minimi Abductor digiti minimi Flexor digiti minimi brevis

Answer 1892

Flex at the MCP joint and extend at the IP joints

Answer 1893

Medial two: ulnar nerve Lateral two: median nerve

Answer 1894

Abduct the fingers at the MCP

Answer 1895

Ulnar nerve

Answer 1896

Adducts the fingers at the MCP

Answer 1897

Palmaris brevis Adductor pollicis Both innnervated by ulnar nerve

Answer 1898

Wrinkles the skin of the hypothenar eminence and deepens the curvature of the hand

Answer 1899

Adductor of the thumb

Answer 1900

DDH Transient synovitis Septic arthritis Perthes SUFE JIA/Still's Disease

Answer 1901

Congenital hip deformity in which the femoral head is or can be completely/partially displaced

Answer 1902

Fhx Breech presentation Oligohydramnios

Answer 1903

Maintain abduction Double nappies Pavlik harness Plaster hip spica Open reduction: derotation varus osteotomy

Answer 1904

Transient synovitis

Answer 1905

Transient Synovitis

Answer 1906

PMN and ESR/CRP normal -ve blood cultures May need joint aspiraiton and culture

Answer 1907

Rest and analgesia Settles over 2-3d

Answer 1908

Osteochondritis of the femoral head 2o to AVN

Answer 1909

Perthes' disease

Answer 1910

XR normal intially increased density of femoral head Femoral head becomes fragmented and irregular Flattening and sclerosis is seen

Answer 1911

Detected early and \< half femoral head affected- bed rest and traction More severe: maintain hip in abduction with plaster Femoral or pelvic osteotomy

Answer 1912

Postero-inferior displacement of femoral head epiphysis 10-15 years Fat and sexually undeveloped tall annd thin

Answer 1913

Reduce and pin ephiphysis

Answer 1914

In situ pinning as epihpyseal reduction risks AVN

Answer 1915

Chondrolysis: breakdown of articular cartilage Increased risk with surgery

Answer 1916

**Staph** Strep E Coli Pseudomonas Salmonella (SCD)

Answer 1917

Salmonella

Answer 1918

Vascular disease Trauma SCD Immunosuppression e.g. DM Children: rich blood supply to growth plate therefore usually affects the metaphysis

Answer 1919

Raised ESR/CRP Raised WCC +ve blood cultures in 60% XR changes take 10-14d MRI is sensitive and specific

Answer 1920

Changes take 10-14d Haziness and reduecd bone density Sub-periosteal reaction Sequestrum and involucrum

Answer 1921

IV Abx: vanc and cefotaxime until MCS known Drain abscess and remove sequestra Analgesia

Answer 1922

Usually radiolucent except prostate is sclerotic Usually axial skeleton (contains red marrow) Present with pain or pathological fracture

Answer 1923

Lung Thyroid Breast Kidney Prostate

Answer 1924

Fibrous dysplasia

Answer 1925

McCune Albright's

Answer 1926

0-30 F\>M Increased fracture risk Long bones, rib, skull Mono-ostotic

Answer 1927

Simple bone cyst

Answer 1928

Fibrous dysplasia Ground glass appearance

Answer 1929

Simple bone cyst Well-defined lytic lesion

Answer 1930

Fibrous dysplasia Simple bone cyst Aneurysmal bone cyst Fibrous cortical defect and non-ossifying fibroma

Answer 1931

Aneurysmal bone cyst

Answer 1932

Fibrous cortical defect

Answer 1933

Fibrous cortical defect

Answer 1934

Osteochondroma Enchondroma/Chondromas Chondroblastoma

Answer 1935

Osteochondroma (exostosis)

Answer 1936

Enchondromas/chondromas

Answer 1937

Multiple enchondromas

Answer 1938

Enchondromatosis and multiple soft tissue haemangiomas

Answer 1939

Chondroblastoma

Answer 1940

Osteochondroma

Answer 1941

Enchondroma

Answer 1942

Chondroblastoma

Answer 1943

Have risk of malignant transformation

Answer 1944

Ollier disease

Answer 1945

Marfucci syndrome

Answer 1946

Chondrosarcoma

Answer 1947

Chondrosarcoma

Answer 1948

Chondrosarcoma

Answer 1949

Osteoma Osteoid osteoma Osteoblastoma Giant Cell tumour/osteoclastoma

Answer 1950

Gardner syndrome

Answer 1951

Gardner syndrome

Answer 1952

Osteoid osteoma

Answer 1953

Osteoid osteoma

Answer 1954

Osteoblastoma

Answer 1955

Giant Cell Tumour/osteocalstoma

Answer 1956

Osteoclastoma (Giant cell tumour)

Answer 1957

Osteosarcoma Ewing's Sarcoma

Answer 1958

Osteosarcoma

Answer 1959

Osteosarcoma (Codman triangle)

Answer 1960

Ewing's sarcoma

Answer 1961

Ewing's Sarcoma

Answer 1962

Between scalenus anterior and medius

Answer 1963

Under the clavicle, medial to the coracoid process

Answer 1964

Direct e.g. shoulder girdle #, penetrating or iatrogenic injury. Indirect: e.g. avulsion or traction injuries

Answer 1965

Leffert Classification

Answer 1966

1. Open 2. Closed: a supraclavicular b infraclavicular 3. Radiation induced 4. Obstetric a upper b lower c mixed

Answer 1967

Erb's palsy (high brachial plexus injury)

Answer 1968

Klumpke's paralysis

Answer 1969

Posterior interosseus nerve affected Site: #around elbow or forearm e.g. head of radius Loss of extension of CMC (finger drop) No sensory loss

Answer 1970

Site: #shaft of humerus where N is in radial groove Wrist drop Loss of sensation to dorsum of thumb Triceps functions nromally

Answer 1971

High radial nerve injury

Answer 1972

Axilla e.g. crutches or saturday night palsy Paralysis of triceps and wrist drop

Answer 1973

Elbow: cubital tunnel Wrist: Guyon's canal

Answer 1974

The ulnar canal or ulnar tunnel (also known as Guyon's canal or tunnel) is a semi-rigid longitudinal canal in the wrist that allows passage of the ulnar artery and ulnar nerve into the hand

Answer 1975

Ulnar nerve lesion

Answer 1976

Can't cross fingers for luck Froment's sign

Answer 1977

Can't flex index finger IPJs Can't flex terminal thumb phalanx Loss of sensation in median distribution

Answer 1978

Typically affects abductor pollicis brevis

Answer 1979

Posterior triangle LN biopsy

Answer 1980

Posterior approach to hip

Answer 1981

Legs in Lloyd davies position

Answer 1982

Lloyd-Davies position is a medical term referring to a common position for surgical procedures involving the pelvis and lower abdomen. The majority of colorectal and pelvic surgery is conducted with the patient in the Lloyd-Davies position. It is also known as the Trendelenburg position with legs apart.

Answer 1983

Axillary node clearance

Answer 1984

Pelvic cancer surgery

Answer 1985

During thyroid surgery

Answer 1986

During carotid endaterectomy

Answer 1987

During upper limb fracture repairs

Answer 1988

During thoracic surgery e.g. pneumonectomy, oesophagectomy

Answer 1989

During difficult thyroid surgery

Answer 1990

During colonic resections/gynaecological surgery

Answer 1991

Use of verres needle to establish pneumoperitoneum

Answer 1992

A Veress needle is a spring-loaded needle used to create pneumoperitoneum for laparoscopic surgery. Of the three general approaches to laparoscopic access, the Veress needle technique is the oldest and most traditional.

Answer 1993

Failure to delineate Calot's triangle carefully and careless use of diathermy

Answer 1994

Hepatobiliary triangle bordered by the cystic duct inferiorly, common hepatic duct medially and the inferior surface of the liver superiorly. Cystic artery lies within the triangle which is used to locate it during a laparoscopic cholecystectomy

Answer 1995

Always at risk during parotidectomy

Answer 1996

When ligating splenic hilum

Answer 1997

During re-do open hernia surgery

Answer 1998

During liver mobilisation

Answer 1999

Susceptibility to hypokalaemia (\<4 in cardiac patients)

Answer 2000

SIADH following cranial surgery causing hyponatraemia

Answer 2001

Fluid sequestration and loss of electrolytes

Answer 2002

Loss of lung volume makes patients very sensitive to fluid overload

Answer 2003

Generalised sepsis causing mediastinitis or peritonitis depending on site of leak

Answer 2004

May follow any type of sx and in addition to direct cardiac effects, the decreased CO may compromsie grafts etc.

Answer 2005

CT scanning +luminal contrast

Answer 2006

Gastrograffin enema

Answer 2007

U+E Amylase

Answer 2008

Echocardiogram if no pleural window made

Answer 2009

When considering acid-base disorders in post-operative patients, it is important to consider the potential side effects related to the specific procedure. In this case, this gentleman has an ileostomy for a stoma bag to drain bowel contents post-operatively. These patients may develop significant volume depletion, electrolyte and acid-base disturbances (metabolic acidosis) if the ileostomy output increases or if dietary intake is disrupted or altered. Hence, it is important to monitor fluid balance including stoma output in these patients.

Answer 2010

Tumours located in the rectum can be surgically resected with either an anterior resection or an abdomino-perineal excision of rectum (APER). The technical aspects governing the choice between these two procedures can be complex to appreciate and the main point to appreciate for the exam is that involvement of the sphincter complex or very low tumours require APER. In the rectum a 2cm distal clearance margin is required and this may also impact on the procedure chosen. In addition to excision of the rectal tube an integral part of the procedure is a meticulous dissection of the mesorectal fat and lymph nodes (total mesorectal excision/ TME).

Answer 2011

In rectal cancer surgery involvement of the cirumferential resection margin carries a high risk of disease recurrence. Because the rectum is an extraperitoneal structure (until you remove it that is!) it is possible to irradiate it, something which cannot be offered for colonic tumours. This has a major impact in rectal cancer treatment and many patients will be offered neoadjuvent radiotherapy (both long and short course) prior to resectional surgery. Patients with T1 and 2 /N0 disease on imaging do not require irradiation and should proceed straight to surgery. Patients with T4 disease will typically have long course chemo radiotherapy. Those with T3 , N0 tumours may be offered short course radiotherapy prior to surgery. Patients presenting with large bowel obstruction from rectal cancer should not undergo resectional surgery without staging as primary treatment (very different from colonic cancer). This is because rectal surgery is more technically demanding, the anastomotic leak rate is higher and the danger of a positive resection margin in an unstaged patient is high. Therefore patients with obstructing rectal cancer should have a defunctioning loop colostomy.

Answer 2012

Right hemicolectomy Ileo-colic

Answer 2013

Left hemicolectomy Colo-colon

Answer 2014

High anterior resection Colo-rectal

Answer 2015

Anterior resection (TME) Colo-rectal

Answer 2016

Anterior resection (Low TME) Colo-rectal +/- defunctioning stoma

Answer 2017

In the emergency setting where the bowel has perforated the risk of an anastomosis is much greater, particularly when the anastomosis is colon-colon. In this situation an end colostomy is often safer and can be reversed later. When resection of the sigmoid colon is performed and an end colostomy is fashioned the operation is referred to as a Hartmans procedure. Whilst left sided resections are more risky, ileo-colic anastomoses are relatively safe even in the emergency setting and do not need to be defunctioned.

Answer 2018

60-74 years Every 2 years to all men and women

Answer 2019

16% reduction

Answer 2020

5/10 will have normal exam 4/10 will have polyps which may be removed due to premalignant potential 1/10 will have cancer

Answer 2021

The correct answer is Loop ileostomy Colonic resections with an anastomosis below the peritoneal reflection may have an anastomotic leak rate (both clinical and radiological) of up to 15%. Therefore most surgeons will defunction such an anastomosis to reduce the clinical severity of an anastomotic leak. A loop ileostomy will achieve this end point and is relatively easy to reverse. End ileostomy Following a sub total colectomy the immediate surgical options include an end ileostomy or ileorectal anastomosis. In the emergency setting an ileorectal anastomosis would be unsafe. The correct answer is Loop colostomy Large bowel obstruction resulting from carcinoma should be resected, stented or defunctioned. The first two options typically apply to tumours above the peritoneal reflection. Lower tumours should be defunctioned with a loop colostomy and then formal staging undertaken prior to definitive surgery. An emergency attempted rectal resection carries a high risk of involvement of the circumferential resection margin and is not recommended

Answer 2022

Bringing of lumen or visceral contents onto the skin With bowel stomas, the method and site will be determined by the bowel affected. In practice small bowel stomas should be spouted so that their irritant contents are not in contact with the skin Colonic stomas do not need to be spouted

Answer 2023

Gastric decompression or fixation Feeding Commonly sited in the epigastrium

Answer 2024

Seldom used as very high output May be used following emergency laparotomy with planned early closure Any location according to need

Answer 2025

Usually performed for feeding purposes and sited in the proximal bowel Usually LUQ

Answer 2026

Defunctioning of colon e.g. following rectal cancer surgery Does not decompress colon if ileocaecal valve competent Usually RIF

Answer 2027

Usually folllowing complete excision of colon or where ileo-colic anastomosis is not planned May be used to defunciton colon but reversal is more difficult Usually RIF

Answer 2028

Where a colon is diverted or resected and anastomosis is not primarly achievable or desirable Either L or RIF

Answer 2029

To defunction a distal segment of colon Since both lumens are present, the distal lumen acts as a vent May be located in any region of the abdomen depending on colonic segment used

Answer 2030

Stoma of last resort where loop colostomy is not possible RIF

Answer 2031

To decompress a distal segment of bowel following colonic diversion or resection Where closure of a distal resection margin is not safe or achievable May be located in any region of the abdomen according to clinical need

Answer 2032

This patient had toxic megacolon secondary to underlying ulcerative colitis - note the dilated transverse colon. The abdomen demonstrates a markedly dilated transverse colon (9 cm) with impression of slight dilatation of the descending colon with some 'thumb printing' in the wall. No free subphrenic gas is seen. They went on to have a subtotal colectomy

Answer 2033

This man's tumour is in the rectum and sigmoid colon. Therefore, removing only the colon (left hemicolectomy or pancolectomy) is not a valid management option. For tumours that are in the distal 8cm of the rectum, an abdominoperoneal resection is the option of choice. In this procedure, the anus, rectum and distal sigmoid are removed and the remaining sigmoid is brought out to the surface as a permanent colostomy. For tumours in the proximal part of the rectum (as in this case), an anterior resection is performed and after removal of the tumour, the remaining sigmoid is anastomosed to the lower rectum. The approach is anterior (through the abdominal wall), giving the procedure its name. Once upon a time the procedure was done with a posterior approach (posterior resection), but this has fallen out of favour.

Answer 2034

More than 90% of colorectal cancers are adenocarcinomas

Answer 2035

older patients chronic constipation Chagas disease neurological conditions e.g. Parkinson's disease, Duchenne muscular dystrophy psychiatric conditions e.g. schizophrenia

Answer 2036

all ages adhesions pregnancy

Answer 2037

Rigid sigmoidoscopy with rectal tube insertion

Answer 2038

Usually operative R hemicolectomy often needed

Answer 2039

Simoid (80%) Caecal (20%)

Answer 2040

Small bowel obstruction is clearly visible on this film (note the valvulae conniventes, mucosal folds, that cross the full width of the bowel) secondary to caecal volvulus. Note the left nephrostomy tube in-situ.

Answer 2041

Carcinoma of the splenic flexure requires a left hemicolectomy. This patient should be defunctioned-definitive surgery should wait until staging is completed. A loop ileostomy will not satisfactorily decompress an acutely obstructed colon. Low rectal cancers that are obstructed should not usually be primarily resected. The obstructed colon that would be used for anastomosis would carry a high risk of anastomotic dehisence. In addition, as this is an emergency presentation, staging may not be completed, an attempted resection may therefore compromise the circumferential resection margin, with an associated risk of local recurrence Low rectal cancer is usually treated with a low anterior resection. Contraindications to this include involvement of the sphincters (unlikely here) and poor sphincter function that would lead to unsatisfactory function post resection. Most colorectal surgeons defunction resections below the peritoneal reflection as they have an intrinsically high risk of anastomotic leak. A loop ileostomy provides a safe an satisfactory method of defunctioning these patients. A contrast enema should be performed prior to stoma reversal.

Answer 2042

Wound dehiscence is a post-operative complication in which a wound ruptures along the surgical incision site. In this case, deep dehiscence has occurred as bowel can be seen protruding. This is an emergency and senior help should be called for immediately. Non-urgent senior review should be considered for superficial dehiscence. Applying pressure with dry gauze is inappropriate immediate management for this patient. However, a large sterile swab soaked in 0.9% saline can be used while waiting for senior help to arrived. Packing the wound can be considered for superficial dehiscence but is an inappropriate immediate management for this patient. Sepsis six protocol is a possibility and the patient's vital signs should be recorded after senior help has been called for.

Answer 2043

\>40 with unexplained weight loss and abdo pain \>50 with unexplained rectal bleeding \>60 with IDA or change in bowel habit Tests show occult blood in faeces

Answer 2044

\>50 with unexplained abdo pain or weight loss \<60 with change in bowel habit or IDA \>60 who have anaemia even in absence of IDA

Answer 2045

Rectal or abdo mass UNexplained anal mass or ulceration \<50 with rectal bleeding and any of: abdo pain change in bowel habit weight loss IDA

Answer 2046

sporadic (95%) hereditary non-polyposis colorectal carcinoma (HNPCC, 5%) familial adenomatous polyposis (FAP, \<1%)

Answer 2047

HNPCC, an autosomal dominant condition, is the most common form of inherited colon cancer. Around 90% of patients develop cancers, often of the proximal colon, which are usually poorly differentiated and highly aggressive. Currently seven mutations have been identified, which affect genes involved in DNA mismatch repair leading to microsatellite instability. The most common genes involved are: MSH2 (60% of cases) MLH1 (30%)

Answer 2048

at least 3 family members with colon cancer the cases span at least two generations at least one case diagnosed before the age of 50 years

Answer 2049

A haemoglobin of 58 g/L will need to be corrected prior to surgery and this will only be achieved in such a short time frame by arranging a blood transfusion. Iron transfusions or oral iron supplements would be recommended over a longer time frame of weeks to months had this been detected earlier.

Answer 2050

Vocal cord check

Answer 2051

Consider methylene blue to identiffy gland

Answer 2052

Radioactive marker/patent blue dye

Answer 2053

Several methods have been described that vary from a high fat diet the evening before that includes heavy cream or ice cream.8 and 9 Some have advocated for enteral fat to continue during the intraoperative period via a nasogastric tube, nasoduodenal feeding tube, gastrostomy tube, or feeding jejunostomy.8 and 9 This will create a high-volume flow of chyle and allow the surgeon to identify the thoracic duct clearly.

Answer 2054

Will require alpha and beta blockade

Answer 2055

Will require covering with octreotide

Answer 2056

Bowel preparation

Answer 2057

Lugols iodine/ medical therapy

Answer 2058

Location of cancer (averages) rectal: 40% sigmoid: 30% descending colon: 5% transverse colon: 10% ascending colon and caecum: 15%

Answer 2059

3rd most common in UK Second most common cause of cancer deaths

Answer 2060

Tumour confined to mucosa (90%)

Answer 2061

Tumour invading bowel wall (70% 5y survival)

Answer 2062

LN metastases (45%)

Answer 2063

Distant mets (6%)

Answer 2064

Arthritis: pauciarticular, asymmetric Erythema nodosum Episcleritis Osteoporosis

Answer 2065

Polyarticular symmetric arthritis Uveitis Pyoderma gangrenosum Clubbing PSC

Answer 2066

three dense lines converging towards the site of obstruction (Frimann Dahl's sign) in keeping with sigmoid volvulus.

Answer 2067

Tx Primary tumour cannot be assessed T0 No evidence of primary tumour Tis Carcinoma in situ: intraepithelial or invasion of lamina propria T1 Tumour invades submucosa T2 Tumour invades muscularis propria T3 Tumour invades through the muscularis propria into the pericolorectal tissues T4a Tumour penetrates to the surface of the visceral peritoneum T4b Tumour directly invades or is adherent to other organs or structures

Answer 2068

NX Regional lymph nodes cannot be assessed N0 No regional lymph node metastasis N1 Metastasis in 1-3 regional lymph nodes N1a Metastasis in 1 regional lymph node N1b Metastasis in 2-3 regional lymph nodes N1c Tumour deposit(s) in the subserosa, mesentery, or non-peritonealised pericolic or perirectal tissues without regional nodal metastasis N2 Metastasis in 4 or more lymph nodes N2a Metastasis in 4-6 regional lymph nodes N2b Metastasis in 7 or more regional lymph nodes

Answer 2069

M0 No distant metastasis M1 Distant metastasis M1a Metastasis confined to 1 organ or site (eg, liver, lung, ovary, non-regional node) M1b Metastases in more than 1 organ/site or the peritoneum

Answer 2070

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

Answer 2071

Carried on chromosome 17 Linked to developing breast cancer (60%) risk. Associated risk of developing ovarian cancer (55% with BRCA 1 and 25% with BRCA 2).

Answer 2072

Autosomal dominant Develop colonic cancer and endometrial cancer at young age 80% of affected individuals with get colonic and or endometrial cancer High risk individuals may be identified using the Amsterdam criteria

Answer 2073

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

Answer 2074

This lady is an arteriopath as evidenced by her past medical history. The pain she describes - severe, central and worse after eating, with associated diarrhoea is classic of mesenteric ischaemia - worse when the gut is working to digest food. The most appropriate investigation to confirm the diagnosis would be a magnetic resonance angiogram of the mesenteric vasculature.

Answer 2075

Mesenteric ischaemia is primarily caused by arterial embolism resulting in infarction of the colon. It is more likely to occur in areas such as the splenic flexure that are located at the borders of the territory supplied by the superior and inferior mesenteric arteries.

Answer 2076

Mesenteric ischaemia

Answer 2077

Increasing age AF other causes of emboli e.g. endocarditis CV disease risk factors Cocaine

Answer 2078

Loop ileostomy is a method to divert bowel contents away from a distal anastomosis. It is often indicated in rectal cancers. Reversal of the ileostomy restores bowel continuity and improves the patient's overall quality of life.

Answer 2079

Pain on passing faeces accompanied by bleeding post-defaecation is suggestive of a diagnosis of fissure in ano. Thrombosed haemorrhoids may also present with painful PR bleeding but in this scenario a fissure is more likely. This young lady has a background of Crohn's disease and that patients with Crohn's disease are more susceptible to fissure formation. Rectal cancer can present with rectal bleeding but would be unlikely in a 36-year-old. Recto-uterine fistulas typically cause faecal incontinence rather than bleeding. A perianal abscess would cause perianal pain and may be accompanied by pyrexia.

Answer 2080

The pectinate line (dentate line) is a line which divides the upper two thirds and lower third of the anal canal. Developmentally, this line represents the hindgut-proctodeum junction.

Answer 2081

This is a clinical picture of severe sepsis (i.e. sepsis with one or more organ dysfunction) and clearly points to an intra-abdominal origin as other sources of infection are unremarkable. The ABG is consistent with sepsis but has also impaired renal function (creatinine 331 µmol/L) and therefore intravenous contrast would be unwise due to the risk of developing contrast nephropathy. As such a CT abdomen would not be advisable and a CT angiogram is not warranted as there isn't any suspicion of haemorrhage. An anastomotic leak is unlikely as the patient's abdomen would be peritonitic. Plain abdominal x-ray would not detect a source of infection and an MRI is not going to be possible 4 days post-operative due to the use of metal surgical clips. The best modality would therefore be ultrasound abdomen as this would be able to detect an intra-abdominal collection.

Answer 2082

In patients with fulminant UC a sub total colectomy is the safest treatment option. The rectum will be left in situ as resection of the rectum in these acutely unwell patients carries an extremely high risk of complications. Severe rectal Crohns that has developed complications such as haemorrhage and multiple fistulae is usually best managed with proctectomy. Although a diverting stoma may reduce the risk of local sepsis it is unlikely to reduce the bleeding. She is keen to conserve a rectum, however, an ileoanal pouch in this setting is unwise. In patients with UC where medical management is not successful, surgical resection may offer a chance of cure. Those patients wishing to avoid a permanent stoma may be considered for an ileoanal pouch. However, this procedure is only offered in the elective setting.

Answer 2083

Longstanding UC is associated with a risk of malignant transformation. Dysplastic transformation of the colonic epithelium with associated mass lesions is an absolute indication for a proctocolectomy.

Answer 2084

Emergency presentations of poorly controlled colitis that fails to respond to medical therapy should usually be managed with a subtotal colectomy. Excision of the rectum is a procedure with a higher morbidity and is not generally performed in the emergency setting. An end ileostomy is usually created and the rectum either stapled off and left in situ, or, if the bowel is very oedematous, may be brought to the surface as a mucous fistula.

Answer 2085

Anastomotic dehiscence Pouchitis Poor physiological function with seepage and soiling

Answer 2086

Restorative options in UC include an ileoanal pouch. This procedure can only be performed whilst the rectum is in situ and cannot usually be undertaken as a delayed procedure following proctectomy.

Answer 2087

Surgical resection of Crohns disease does not equate with cure, but may produce substantial symptomatic improvement. Indications for surgery include complications such as fistulae, abscess formation and strictures. Extensive small bowel resections may result in short bowel syndrome and localised stricturoplasty may allow preservation of intestinal length. Staging of Crohns will usually involve colonoscopy and a small bowel study (e.g. MRI enteroclysis).

Answer 2088

Severe perianal and / or rectal Crohns may require proctectomy. Ileoanal pouch reconstruction in Crohns carries a high risk of fistula formation and pouch failure and is not recommended.

Answer 2089

Terminal ileal Crohns remains the commonest disease site and these patients may be treated with limited ileocaecal resections. Terminal ileal Crohns may affect enterohepatic bile salt recycling and increase the risk of gallstones.

Answer 2090

This man most likely has a ruptured abdominal aortic aneurysm and is showing signs of shock. This carries a very high mortality and he should therefore be taken immediately to theatre. Diagnosing a ruptured abdominal aortic aneurysm requires a high index of suspicion and if suspected, it is inappropriate to waste time on imaging. Whilst it is important to gain intravenous access and treat shock, systolic blood pressure should be maintained \<100mmHg to avoid rupturing any contained leak.

Answer 2091

As this patient has established cardiovascular disease he should be taking a statin, regardless of the baseline cholesterol. The 2010 NICE guidelines on clopidogrel changed the previous advice that all patients with established cardiovascular disease should be taking aspirin, unless there is a contraindication. NICE propose that clopidogrel is now used first-line following an ischaemic stroke and also in peripheral arterial disease.

Answer 2092

Treat comorbidites All patients with established CVD should be taking a statin Clopidogrel should be used first line in patients with PAD in preference to aspirin Exercise training has been shown to ahve significant benefits Severe PAD or critical limb iscahemia may be treated by: Angioplasty Stenting Bypass surgery Other drugs that are licensed for PAD include naftidrofuryl oxalate: vasodilator sometimes used for patients with poor QoL Cilostazol: PDE III inhibitor with both antiplatelet and vasodilator effects (not recommended by NICE)

Answer 2093

T1- the tumour is confined to the submucosa T2- the tumour has grown into (but not through) the muscularis propria T3- the tumour has grown into (but not through) the serosa T4- the tumour has penetrated through the serosa and the peritoneal surface. If extending directly into other nearby structures (such as other parts of the bowel or other organs/body structures) it is classified as T4a. If there is perforation of the bowel, it is classified as T4b.

Answer 2094

N0- no lymph nodes contain tumour cells N1- there are tumour cells in up to 3 regional lymph nodes N2- there are tumour cells in 4 or more regional lymph nodes

Answer 2095

Metastases M0- no metastasis to distant organs M1- metastasis to distant organs

Answer 2096

Oesophageal adenocarcinoma is associated with GORD or Barrett's

Answer 2097

TPN associated jaundice

Answer 2098

Oesophageal cancer is the eighth most common cancer worldwide and the thirteenth most common in the UK. It is 20 times more common in China but its incidence is rising in the western world. Risk factors include smoking, alcohol and obesity. In addition, squamous cell carcinoma is linked to achalasia and coeliac disease, while adenocarcinoma occurs in the setting of Barrett's oesophagus. Flexible upper GI endoscopy is the diagnostic investigation of choice and a minimum of eight biopsies should be obtained. CT is an acceptable staging modality and should be used routinely to identify metastatic disease. However, it requires the use of intravenous and oral contrast (unlike the options given above). Endoscopic ultrasound provides superior axial resolution to CT and is the most accurate way of determining the depth of spread of a malignant tumour through the oesophageal wall. PET is not routinely used as a staging modality in oesophageal carcinoma.

Answer 2099

Right upper quadrant tenderness and bilious fluid in the intra-abdominal drain would suggest a bile leak following the cholecystectomy. As the patient is apyrexial and normotensive an intra-abdominal collection or haemorrhage would be unlikely. A perforation is a recognised complication of a laparoscopic cholecystectomy however the patient would normally develop peritonitis, as oppose to localised right upper quadrant tenderness. Finally, an ileus would not causes right upper quadrant pain or bilious fluid in the drain.

Answer 2100

Subcutaneous (surgical) emphysema which is a known complication of laparoscopic surgery. If the anterior chest wall is affected air can outline the pectoralis major muscle, giving rise to the 'ginkgo leaf' sign.

Answer 2101

This radiograph demonstrates subcutaneous (surgical) emphysema which is a known complication of laparoscopic surgery. If the anterior chest wall is affected air can outline the pectoralis major muscle, giving rise to the 'ginkgo leaf' sign.

Answer 2102

General risks of anaesthetic Vasovagal reaction e.g. bradycardia in response to abdominal distension Extra-peritoneal gas insufflation: surgical emphysema Trauma to GIT Injury to BVs: Common iliacs, deep IEA

Answer 2103

Overview associated with H. pylori infection in 95% of cases good prognosis if low grade then 80% respond to H. pylori eradication Features paraproteinaemia may be present

Answer 2104

The dominant differential diagnosis should be of pancreatic adenocarcinoma in this setting. Glucagonomas are very rare and may be associated with a bullous rash. Diarrhoea, abdominal pain and multiple ulcers should raise the suspicion of Zollinger Ellison syndrome cause by gastrinoma. These episodes are due to hypoglycaemia. Insulinomas are normally solitary tumours and may not be seen by radiological imaging. Resection is the treatment of choice.

Answer 2105

Investigation ## Footnote ultrasound has a sensitivity of around 60-90% high resolution CT scanning is the investigation of choice if the diagnosis is suspected

Answer 2106

Purtscher retinopathy is a hemorrhagic and vasoocclusive vasculopathy, which, in 1912, was first described as a syndrome of sudden blindness associated with severe head trauma. These patients had findings of multiple white retinal patches and retinal hemorrhages that were associated with severe vision loss Since its original description, Purtscher retinopathy has been associated with traumatic injury, primarily blunt thoracic trauma and head trauma, and numerous nontraumatic diseases. Purtscher-like retinopathy is seen in diverse conditions, including acute pancreatitis; fat embolization; amniotic fluid embolization; preeclampsia; hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome; and vasculitic diseases, such as lupus.

Answer 2107

Characteristic fundus findings of Purtscher retinopathy. Multiple cotton-wool spots surround the optic nerve after blunt thoracic trauma.

Answer 2108

Melanoma Scwhwannomas

Answer 2109

SCLC Gastric cancer Neuroblastome

Answer 2110

Reynolds Pentad (jaundice, right upper quadrant pain, fever/rigors, shock and altered mental status) is associated with ascending cholangitis. This patient would need adequate resuscitation before further investigation of biliary tree with USS/MRCP for common bile duct stones +/- ERCP.

Answer 2111

Whilst Barrett's oesophagus increases the risk of oesophageal adenocarcinoma, achalasia increases the risk of squamous cell carcinoma of the oesophagus.

Answer 2112

Palmar cutaneous branch of the median nerve travels superficially to the flexor retinaculum

Answer 2113

F\>M 1o/ idiopathic 2o Water: pregnancy, hypothyroidism Radial: # Inflamation: RA/gout Soft tissue swelling: lipomas, acromegaly, amyloidosis Toxic: DM, EtOH

Answer 2114

Carpal tunnel syndrome

Answer 2115

Reduced sensation over lateral 3.5 fingers Reduced 2 point touch discrimination: early sign of irreversible damage Wasting of thenar eminence: late sign of irreversible damage Phalen's Flexing Tinnel's Tapping

Answer 2116

The patient is asked to hold their wrist in complete and forced flexion (pushing the dorsal surfaces of both hands together) for 30–60 seconds. The lumbricals attach in part to the flexor digitorum profundus tendons. As the wrist flexes, the flexor digitorum profundus contracts in a proximal direction, drawing the lumbricals along with it. In some individuals, the lumbricals can be "dragged" into the carpal tunnel with flexor digitorum profundus contraction. As such, Phalen's maneuver can moderately increase the pressure in the carpal tunnel via this mass effect, pinching the median nerve between the proximal edge of the transverse carpal ligament and the anterior border of the distal end of the radius. By compressing the median nerve within the carpal tunnel, characteristic symptoms (such as burning, tingling or numb sensation over the thumb, index, middle and ring fingers) conveys a positive test result and suggests carpal tunnel syndrome. Because not all individuals will draw the lumbricals into the carpal tunnel with this maneuver, this test cannot be perfectly sensitive or specific for carpal tunnel syndrome

Answer 2117

This test is performed by having the patient maintain full wrist and finger extension for two minutes. The reverse Phalen's test significantly increases pressure in the carpal tunnel within 10 seconds of the change in wrist posture and the carpal tunnel pressure has the tendency to increase throughout the test's duration. In contrast, the change in carpal tunnel pressure noted in the standard Phalen's test is modest and plateaus after 20 to 30 seconds.

Answer 2118

Tinel's sign is a way to detect irritated nerves. It is performed by lightly tapping (percussing) over the nerve to elicit a sensation of tingling or "pins and needles" in the distribution of the nerve. It takes its name from French neurologist Jules Tinel (1879–1952).[1][2][3] For example, in carpal tunnel syndrome where the median nerve is compressed at the wrist, Tinel's sign is often "positive" causing tingling in the thumb, index, middle finger and the radial half of the fourth digit. Tinel's sign is sometimes referred to as "distal tingling on percussion" or DTP. This distal sign of regeneration can be expected during different stage of somatosensory recovery.[4] Although most frequently associated with carpal tunnel syndrome, Tinel's sign is a generalized term, and can also be positive in tarsal tunnel syndrome, or in ulnar nerve impingement at the wrist (Guyon's canal syndrome), where it affects the other (ulnar) half of the fourth digit and the fifth digit.

Answer 2119

Not usually performed Nerve conduction studies USS

Answer 2120

Conservative: Mx of underlying cause Wrist splints: neutral position, especially at night Medical: Local steroid injections Surgical: Carpal tunnel decompression by division of the flexor retinacuum

Answer 2121

Scar formation: high risk for hypertrophied or keloid Scar tenderness: up to 40% Nerve injury: palmar cutaneous branch of the median nerve; motor branch to the thenar muscles Failure to relieve symptoms

Answer 2122

Pronator syndrome Anterior interossesous syndrome

Answer 2123

Entrapment of the median nerve between two heads of pronator teres

Answer 2124

Compression of the anterior interosseous branch of the median nerve by deep head of pronator teres Muscle weakness only: pronator quadratus, FPL, radial half of FDP

Answer 2125

Progressive, painless fibrotic thickening of palmar fascia

Answer 2126

M\>F Middle age/elderly Skin puckering and tethering Fixed flexion contracture of ring and little fingers. Often bilateral and symmetrical MCP and IP joint flexion

Answer 2127

Dupuytren's conracture

Answer 2128

Bent penis: Peyronies AIDS DM FH: D Idiopathic: commonest Booze: ALD Epilepsy (+ epilepsy meds- phenytoin) Reidel's thyroiditis and other fibromatoses e.g. Ledderhose disease, Retroperitoneal fibrosis Smoking

Answer 2129

Peyronie's disease or Peyronie disease (/peɪroʊˈniː/), also known as induratio penis plastica (IPP)[1] or chronic inflammation of the tunica albuginea (CITA), is a connective tissue disorder involving the growth of fibrous plaques[2] in the soft tissue of the penis affecting an estimated 5% of men.[3] Specifically, scar tissue forms in the tunica albuginea, the thick sheath of tissue surrounding the corpora cavernosa causing pain, abnormal curvature, erectile dysfunction, indentation, loss of girth and shortening.[4][5][6][7] A variety of treatments have been used, but none have been especially effective.

Answer 2130

Plantar fascial fibromatosis, also known as Ledderhose's disease, Morbus Ledderhose, and plantar fibromatosis, is a relatively uncommon[1] non-malignant thickening of the feet's deep connective tissue, or fascia. In the beginning, where nodules or cords start growing along tendons of the foot[citation needed], the disease is minor. Eventually, however, the cords thicken, the toes stiffen and bend, and walking becomes painful. The disease is named after Dr. Georg Ledderhose, a German surgeon who described the condition for the first time in 1894.[2][3] A similar disease is Dupuytren's disease, which affects the hand and causes bent hand or fingers.

Answer 2131

Conservative: PT/ exercise Fasciectomy: e.g. when hand can't be placed flat on table Z-shaped scars prevent contracture However can damage ulnar nerve, usually recurs

Answer 2132

Skin contracture: old laceration or burn Tendon fibrosis, trigger finger Ulnar N palsy

Answer 2133

Tendon nodule which catches on proximal side of tendon sheath-\> triggering on forced extension-\> fixed flexion deformity Usually ring and middle fingers Associated with RA Rx: steroid injection or sx

Answer 2134

Smooth multilocular cystic swellings Mucoid degeneration of joint capsule or tendon sheath May be in communication with joint capsules/tendons

Answer 2135

50% disappear spontaneously Aspiration +/- steroid and hyaluronidase injection Sx excision

Answer 2136

Lipoma Fibroma Sebaceous cyst

Answer 2137

Meralgia paraesthetica

Answer 2138

Chondromalacia patellae

Answer 2139

Baker's cyst

Answer 2140

In medicine, Clarke's test is a component of knee examination which may be used to test for patellofemoral pain syndrome, or anterior knee pain. It is not a standard part of the knee examination but is used to diagnose anterior knee pain where the history indicates this as the likely pathology. The patient is asked to actively contract the quadriceps muscle while the examiner's hand exerts pressure on the superior pole of the patella, so trying to prevent the proximal movement of the patella. While it can produce some discomfort even in normal people, the reproduction of the symptoms suggest pain of patello-femoral origin.[1]

Answer 2141

Baker's cyst

Answer 2142

Hallux valgus

Answer 2143

Hallux valgus

Answer 2144

Morton's metatarsalgia/Neuroma

Answer 2145

This is typical of plantar fasciitis which is the most common cause of heel pain in adults. Pain in Achilles tendonitis is at the calcaneal insertion of the tendon or further up the tendon depending on the area affected. Thompson's test excludes rupture of the tendon. S1 radiculopathy would cause sensory loss along the lateral aspect of the foot and may lead to reduced dorsiflexion of the foot. Morton's neuroma is a thickening of the tissue around the nerve usually between the 3rd and 4th toes. Pain tends to be on the ball of the foot. Subcalcaneal bursitis presents with pain at the point of Achilles tendon insertion, and on the back and bottom of the heal. Plantar fasciitis is more common and would give the specific area of tenderness mentioned.

Answer 2146

The Thompson test is diagnostic for a complete tear of the Achilles tendon. The Thompson Test: When the tendon is intact, and the calf is squeezed, the ankle will plantar flex . The test is positive when the right ankle doesn't plantar flex when the calf is squeezed,

Answer 2147

Plantar fasciitis Pain usually worse around the medial calcaneal tuberosity Mx: Rest feet where possible Wear shoes with good arch support and cushioned heels Insoles and heel pads may be helpful

Answer 2148

Rapid joint swelling is suggestive of haemoarthrosis which can occur due to ACL or PCL rupture. The mechanism of injury suggests rupture of the ACL. A positive Lachman tests is also very suggestive of an ACL injury. An LCL injury most commonly occurs due to direct blows to the medial aspect of the leg which puts strain on the LCL ligament. The classical symptoms would be a slow developing joint effusion and lateral joint line tenderness. Similarly, an MCL injury most commonly occurs due to direct blows to the lateral aspect of the leg which results in strain on the MCL ligament. The classical symptoms would be a slow developing joint effusion and medial joint line tenderness. Meniscal tears often occur due to twisting injuries. They are associated with delayed knee swelling and joint locking.

Answer 2149

L5 lesion features = loss of foot dorsiflexion + sensory loss dorsum of the foot

Answer 2150

This example describes an injury of the humerus with associated radial nerve damage. The radial nerve is most susceptible to damage from a fracture of the shaft of the humerus. Supracondylar fracture of humerus is most commonly associated with ulnar nerve damage. Fracture of the proximal humerus is most commonly associated with axillary nerve damage. Colle's fracture and Smith's fracture are fractures of the distal radius. These fractures are not in keeping with the upper limb examination findings.

Answer 2151

ponseti method: manipulation and progressive casting starting sooon after birth (6-10w). Achilles tenotomy required in around 85% of cases Night-time braces applied until child is 4 years old

Answer 2152

L3 nerve root compression

Answer 2153

L4 nerve root compression

Answer 2154

L5 nerve root compression

Answer 2155

S1 nerve root compression

Answer 2156

Femoral nerve stretch test (Mackiewicz sign[1]) - for the FNST the patient lies prone, the knee is passively flexed to the thigh and the hip is passively extended; the test is positive if the patient experiences anterior thigh pain. This test is usually strongly positive in patients with protrusions at L2–L3 and L3–L4, slightly positive or negative in L4–L5 disc protrusions and negative in cases with a lumbosacral protrusion.

Answer 2157

The therapist raises the leg, keeping the knee straight. The therapist moves the ankle into a dorsiflexed position which lengthens the nerve. If there are no neural symptoms (tingling, shooting pain or tight, restricted feeling throughout the back of the leg), then the therapist may ask the patient to raise the head to further increase the stretch.

Answer 2158

Lateral epicondylitis: worse on resisted wrist extension/supination whilst elbow extended

Answer 2159

Buckle, or torus, fractures are incomplete fractures of the shaft of a long bone that is characterised by bulging of the cortex. They typically occur in children aged 5-10 years. As they are typically self-limiting they do not usually require operative intervention and can sometimes be managed with splinting and immobilisation rather than a cast.

Answer 2160

Inverted and plantar flexed foot Usually diagosed on newborn exam M \> F 2:1 1:1000 births Idiopathic most commonly Associated with spina bifida, cerebal palsy, Edward's, oligohydramnios, arthrogryposis

Answer 2161

This is a femoral nerve stretch test

Answer 2162

Morton's neuroma

Answer 2163

Morton's neuroma

Answer 2164

Total water: 60% of 70kg= 42l 2/3rds intracellular: 28l 1/3rd extracellular: 14l Plasma 3l Interstitial 10l Transcellular 1l

Answer 2165

Osmotic pressure Hydrostatic pressure

Answer 2166

Pressure which needs to be applied to prevent the inflow of water across a semipermeable membrane i.e. the ability of a solute to attract water Oncotic pressure: form of osmotic pressure exerted by proteins

Answer 2167

Pressure exerted by a fluid at equilibrium due to the force of gravity

Answer 2168

Driven by differences in osmotic pressure only

Answer 2169

Determined by Starling's forces: capillary and interstitial oncotic pressure capillary and interstitial hydrostatic pressure Filtration coefficient (capillary permeability)

Answer 2170

The four Starling’s forces are: hydrostatic pressure in the capillary (Pc) hydrostatic pressure in the interstitium (Pi) oncotic pressure in the capillary (pc ) oncotic pressure in the interstitium (pi ) The balance of these forces allows calculation of the net driving pressure for filtration. Net Driving Pressure = [( Pc - Pi ) - ( pc - pi )]

Answer 2171

Reduction in ECF e.g. bowel obstruction-\> reduced fluid reabsorption-\> 3rd space loss Peritonitis-\> ascites-\> 3rd space loss

Answer 2172

0.5ml/kg/h ~30ml/h

Answer 2173

1.5-2 mmol/kg/d= 100mmol/d

Answer 2174

1mmol/kg/d= 60mmol/d

Answer 2175

3L dex-saline with 20mM K in each bag (i.e. Hartmann's) or 1l NS + 2l dex with 20mM K in each bag Each bag over 8h= 125ml/hr

Answer 2176

Vomiting and diarrhoea NGT Drains Fever (+500ml for each oC) Tachypnoea High-output stomas

Answer 2177

RV preload and depends on venous return and CO

Answer 2178

Increased circualting volume Reduced CO i.e. pump failure

Answer 2179

Reduced circulating volume

Answer 2180

5-10 cm H2O

Answer 2181

Single reading is not as useful as serial measurements before and after fluid challenge Unchanged- hypovolaemic Increase that reverses after 30 mins: euvolaemic Sustained raise \>5cm: overload/failure Passive leg raising may be more useful than fluid challenge in determining the response to fluids. Sustained increase in CVP suggests heart failure

Answer 2182

NS 5% dextrose Dextrose-Saline Hartmann's

Answer 2183

0.9% NaCL= 9g/L 15mM NaCL pH: 5-6 Use normal daily fluid requirements + replace losses

Answer 2184

Contains 50g dextrose/l Used for normal daily fluid requirements

Answer 2185

Contains 4% dextrose= 4-g/l 0.18% NaCl= 31mM Used for normal daily fluid requirements

Answer 2186

Na 131mM Cl: 111mM K: 5mM Ca 2.2mM Lactate/HCO3: 29mM

Answer 2187

Resuscitation in trauma patients Maintenance

Answer 2188

The Parkland formula is a burn formula used to estimate the amount of replacement fluid required for the first 24 hours in a burn patient so as to ensure they remain hemodynamically stable.[1] The milliliter amount of fluid required for the first 24 hours -usually Ringer's lactate- is four times the product of the body weight and the burn percentage (i.e. body surface area affected by burns).[2] The first half of the fluid is given within 8 hours from the burn incident, and the remaining over next 16 hours. Only area covered by second-degree burns or greater is taken into consideration, as first-degree burns do not cause hemodynamically significant fluid shift to warrant fluid replacement.[3] The Parkland formula is mathematically expressed as:[2] V = 4 ⋅ m ⋅ ( A ⋅ 100 ) {\displaystyle V=4\cdot m\cdot (A\cdot 100)} where mass is in kilograms (kg), area as a percentage of total body surface area, and volume is in milliliters (mL). For example, a person weighing 75 kg with burns to 20% of his or her body surface area would require 4 x 75 x 20 = 6,000 mL of fluid replacement within 24 hours. The first half of this amount is delivered within 8 hours from the burn incident, and the remaining fluid is delivered in the next 16 hours.[4]

Answer 2189

pH=6.5 but Harmann's is an alkalinising solution Lactate is not an acid in itself it's a conjugate base Lactate metabolised in liver -\> HCO3 production

Answer 2190

Give 1l NS-\> 210ml remaining IV Give 1L D5W-\> 70ml remaining IV Acidosis or electrolyte disturbances Fluid overload

Answer 2191

Contain large molecular weight molecules e.g. gelatin, dextrans Idea is to preserve oncotic pressure and thus remain intravascular

Answer 2192

Synthetic: Gelofusin Volpex Haemaccel Voluven Natural: Albumin Blood

Answer 2193

Can interfere with cross-matching therefore take blood for cross matching before using Anaphylaxis Volume overload

Answer 2194

Hx: balance chart, surgery, other losses, thirsty Impression: drowsy, alert Inspect: drips, drains, stomas, catheter Examination

Answer 2195

IV volume Tissue perfusion End-organ perfusion

Answer 2196

CRT HR BP lying and standing JVP

Answer 2197

Skin turgor Oedema: ankle, pulmonary, ascites Mucus membranes

Answer 2198

UO, raised U + Cr Consciousness Lactate

Answer 2199

The pulmonary wedge pressure or PWP, or cross-sectional pressure (also called the pulmonary arterial wedge pressure or PAWP, pulmonary capillary wedge pressure or PCWP, pulmonary venous wedge pressure or PVWP, or pulmonary artery occlusion pressure or PAOP), is the pressure measured by wedging a pulmonary catheter with an inflated balloon into a small pulmonary arterial branch.[1] Physiologically, distinctions can be drawn among pulmonary artery pressure, pulmonary capillary wedge pressure, pulmonary venous pressure and left atrial pressure, but not all of these can be measured in a clinical context.[2] Noninvasive estimation techniques have been proposed. Essentially an indirect measure of left atrial pressure

Answer 2200

Raised ADH, raised aldosterone, raised cortisol-\> Na and H2O conservation Increased K: tissue damage, transfusion, stress hormones

Answer 2201

Use UO (aim \>30ml/h) to guide fluid replacement, may need to reduce maintenance fluids to 2l for first 24h post op Avoid K supplementation for first 24h post op

Answer 2202

RAS activation-\> Na and H2O retention Avoid fluids with Na-\> 5% dextrose

Answer 2203

Patients have significant third space losses of both water and electrolytes Likely to need significantly more than standard daily requirments

Answer 2204

0.9% NS with 20-40mm KCL added to each bag Titrate rate of fluid therapy to clinical findings on serial examination Serial U+Es guide electrolyte replacement

Answer 2205

Inflammation- significant fluid shift into the abdomen Patients require aggressive fluid resuscitiation and maintenance Inser urinary catheter and consider CVP monitoring 0.9% NS with 20-40mm KCL Keep UO \>30 Serial U+Es guide electrolyte replacement

Answer 2206

Na: 130mM Cl: 110mM K: 10mM HCO3: 30mM Normal output: 10-15ml/Kg/d= 700ml/d High output= 1000ml/d Ileum will adapt to limit fluid and electrolyte losses

Answer 2207

0.9% saline and KCl Daily requirements + replace losses titrated to UO Serial U+Es guide electrolyte replacement

Answer 2208

\>1000ml/d

Answer 2209

Antimotility: loperamide, codeine phosphate Antisecretory: omeprazole

Answer 2210

Post-renal: Commonest cause, blocked/malsited catheter or acute urinary retention Pre-renal: hypovolaemia Renal: NSAIDs, gentamicin Anuria normally= blocked or malsited catheter Oliguria: inadeqauate fluid replacement

Answer 2211

Collect info: Op Hx, Obs chart, drug chart Examine patient: fluid status, palpable bladder, inspect drips, drains etc. Action: flush with 50mL NS, fluid challenge

Answer 2212

Life-threatening metabolic complication of refeeding via any route after prolonged period of starvation

Answer 2213

Reduced carbs-\> catabolic state, reduced insulin, fat and protein catabolism and depletion of intracellular PO4 Refeeding: increased insuin in response to carbs and increased cellular PO4 uptake Result is hypophosphataemia which can lead to: rhabdo respiratory insufficiency arrhythmias shock seizures

Answer 2214

KPMG (all reduced)

Answer 2215

Malignancy AN Alcoholism GI surgery Starvation

Answer 2216

Identify and monitor at-risk patients Liaise with dietician

Answer 2217

Identify at risk patients in advance Parenteral and oral PO4 supplementation Rx complications

Answer 2218

Clinically: Hx: weight loss, diet Examination: skin fat, dry hair, pressure sores, chelitis, Weight and BMI (\<20) Anthropometric Skin-fold thickness Arm circumference Ix Albumin Transthyretin (prealbumin) Phosphate

Answer 2219

per kg: 20-40kCal Carbs: 2g Fat: 3g Protein 0.5-1g Nitrogen: 0.2-0.4g

Answer 2220

PO is best, consider semi-solid diet if risk of aspiration Other options include NGT PEG Jejunostomy Build up feeds gradually to prevent diarrhoea

Answer 2221

jejunostomy feeding

Answer 2222

Oral supplements Polymeric e.g. osmolite, jevity. Intact proteins, starches and long chain FAs Disease specific: e.g. redcued branch chain AAs in hepatic encephalopathy Elemental e.g. simple AAs and oligo/monosaccharides, require minimal digestion and used if abormal GIT e.g. in Crohn's

Answer 2223

Catabolic: sepsis, burns, major Sx Coma/ITU Malnutrition Dysphagia: stricture, stroke

Answer 2224

Nasal trauma Malposition or tube blockage

Answer 2225

Feed intolerance-\> diarrhoea Electrolyte imbalance Aspiration Refeeding syndrome

Answer 2226

May be total or used to supplement enteral feeding Combined with H2O to deliver total daily requirements

Answer 2227

Prolonged obstruction or ileus (\>7d) High output fistula Short bowel syndrome Severe Crohn's Severe malnutrition Severe pancreatitis Unable to swallow e.g. oesophageal Ca

Answer 2228

Delivered centrally as high osmolality is toxic to veins ST: CV catheter LT: Hickmann or PICC line Sterility is essential, use line only for PN

Answer 2229

Standard: weight, fluid balance and urine glucose daily. Zn, MG weekly Initially: blood glucose, FBC, U+E, PO4 daily. LFTs 3/w Once stable: blood glucose, FBC, U+E +PO4, 3/w LFTs weekly

Answer 2230

2000kCal: 50% fat, 50% carbs 10-14g nitrogen Vitamins, minerals and trace elements

Answer 2231

Line related: Pneumothorax/haemothorax Cardiac arrythmia Line sepsis Central venous thrombosis: PE or SVCO Feed-related: Villous atrophy of GIT Electrolyte disturbance: refeeding syndrome, hypercapnea from excessive CO2 production Hyperglycaemia and reactive hypoglycaemia Line sepsis: increased risk with TPN Vitamin and mineral deficiencies Liver disease: Fatty liver is usually a more long term complication of TPN, though over a long enough course it is fairly common. The pathogenesis is due to using linoleic acid (an omega-6 fatty acid component of soybean oil) as a major source of calories.[10][11] TPN-associated liver disease strikes up to 50% of patients within 5–7 years, correlated with a mortality rate of 2–50%. Onset of this liver disease is the major complication that leads TPN patients to requiring an intestinal transplant

Answer 2232

Facet for attachment of the posterior cruciate ligament – Found on the medial wall of the intercondylar fossa, it is a large rounded flat face, where the posterior cruciate ligament of the knee attaches

Answer 2233

Found on the lateral wall of the intercondylar fossa, it is smaller than the facet on the medial wall, and is where the anterior cruciate ligament of the knee attaches.

Answer 2234

Proximal end On the posterolateral surface

Answer 2235

Talus and calcaneus

Answer 2236

Transmit forces from the tibia to calcaneus

Answer 2237

Navicular: articulates with the talus posteriorly, the cuneiform bones anteriorly and the cuboid bone laterally. Attachment on plantar surface for the attachment of tibialis posterior

Answer 2238

Cuboid and three cuneiforms

Answer 2239

Acetabulum Fibrocartilaginous collar Iliofemoral, pubofemoral and ischiofemoral ligaments also provide a degree of stability

Answer 2240

Flexion Extension Abduction Adduction Lateral rotation Medial rotation

Answer 2241

Knee flexion, knee flexion relaxes the hamstring muscles and increases the range of flexion

Answer 2242

Hilton's law, espoused by John Hilton in a series of medical lectures given in 1860–1862,[1] is the observation that in the study of anatomy, the nerve supplying the muscles extending directly across and acting at a given joint also innervate the joint.[2] For example, the musculocutaneous nerve supplies the elbow joint of humans with pain and proprioception fibres. It also supplies coracobrachialis, biceps brachii, brachialis, and the forearm skin close to the insertion of each of those muscles.

Answer 2243

Extension Flexion Lateral rotation Medial rotation

Answer 2244

Lateral ligament is weaker than medial ligament Lateral ligament resists inversion

Answer 2245

Term used to describe a bimalleolar or trimalleolar fracture ## Footnote Forced eversion pulls on the medial ligaments, producing an avulsion fracture of the medial malleolus. The talus moves laterally, breaking off the lateral malleolus. The tibia is then forced anteriorly, shearing off the distal and posterior part against the talus.

Answer 2246

Pott's (trimalleolar fracture)

Answer 2247

Address problems in 1o survey in ABCDE order

Answer 2248

Check for airway compromsie: Ask pt question Stridor Orofacial inury or burns Visualise airway and use suction if necessar Manoeuvres to open airway: Jaw thrust Adjuncts if compromsie/potential compromised NPA: gag reflex present OPA: no gag refelex (stop tongue swallowing) Emergency airways: Needle circothyroidotomy or surgical cric Definitive airways: no risk of aspiration ETT Tracheostomy

Answer 2249

Maintain in-line cervical support to keep neck stable Place pt in hard collar and sandbags with tape

Answer 2250

Start 15l O2 via non-rebreathe mask (Hudson) Inspection of chest RR and chest expansion Position of trachea Breath sounds, vocal resonance Perucssion ABG

Answer 2251

Tension pneumothorax

Answer 2252

Insert large bore venflon into 2nd ICS MCL Insert ICD later

Answer 2253

Convert to closed wounds by covering with damp occlusive dressing stuck down on both sides

Answer 2254

Two large bore cannulae: 14G/16G in each ACF FBC, U+E, X-match (6U), clotting, VBG Assess: Inspection: pale, sweaty, active bleeding Vascular status: BP, HR, JVP, heart sounds, cardiac monitoring End-orgna: consciousness, UO Sites of haemorrhage: CAP: use pelvic binder Floor Mx: if haemodynamic compromsie give 2l warm Hartmann's stat Consider further colloid/blood Inesrt CVP and catheter (after PR) to guide resus

Answer 2255

Use UO, lactate, BP

Answer 2256

Usually \<20% loss Slow fluid response to maintenance if haemodynamically stable

Answer 2257

20-40% loss On-going losses or inadequate resus

Answer 2258

Exsanguinating haemorrhage-\> theatre Consider non-haemorrhagic shock: tamponade, pnuemothorax

Answer 2259

AVPU or GCS PEARL

Answer 2260

Completely undress patient Perform leg roll and PR: feel for high riding prostate (urethral rupture) Look for bleeding Prevent hypothermia

Answer 2261

Repate primary survery again

Answer 2262

Allergies Medications PMHx Last ate/ drunk Events

Answer 2263

Head to toe Examine every system

Answer 2264

Trauma series: C spine: lat and peg CXR Pelvis FAST (focusseed assessment with sonogrpahy in trauma) CT: when patient is stable

Answer 2265

Lateral AP Open-mouth Peg view

Answer 2266

Need C7-T1 junction visualised May need swimmer's view with abducted arm

Answer 2267

Anterior vertebral bodies Anterior vertebral canal Posterior vertebral canal Tips of spinous processes

Answer 2268

Shapes of bodies Laminae Processes

Answer 2269

IV discs should be equal height

Answer 2270

Width of soft tissue shadow anterior to upper vertebrae should be 50% of vertebral width

Answer 2271

C-spine systematic approach - Normal Lateral 1 Coverage - All vertebrae are visible from the skull base to the top of T2 (T1 is considered adequate) - If T1 is not visible then a repeat image with the patient's shoulders lowered or a 'swimmer's' view may be necessary Alignment - Check the Anterior line (the line of the anterior longitudinal ligament), the Posterior line (the line of the posterior longitudinal ligament), and the Spinolaminar line (the line formed by the anterior edge of the spinous processes - extends from inner edge of skull) - GREEN = Anterior line - ORANGE = Posterior line - RED = Spinolaminar line Bone - Trace the cortical outline of all the bones to check for fractures Note: The spinal cord (not visible) lies between the posterior and spinolaminar lines

Answer 2272

-spine systematic approach - Normal Lateral 2 Disc spaces - The vertebral bodies are spaced apart by the intervertebral discs - not directly visible with X-rays. These spaces should be approximately equal in height Pre-vertebral soft tissue - Some fractures cause widening of the pre-vertebral soft tissue due to pre-vertebral haematoma - Normal pre-vertebral soft tissue (asterisks) - narrow down to C4 and wider below - Above C4 ≤ 1/3rd vertebral body width - Below C4 ≤ 100% vertebral body width Note: Not all C-spine fractures are accompanied by pre-vertebral haematoma - lack of pre-vertebral soft tissue thickening should NOT be taken as reassuring Edge of image - Check other visible structures

Answer 2273

C-spine systematic approach - Normal AP Coverage - The AP view should cover the whole C-spine and the upper thoracic spine Alignment - The lateral edges of the C-spine are aligned (red lines ) Bone - Fractures are often less clearly visible on this view than on the lateral Spacing - The spinous processes (orange) are in a straight line and spaced approximately evenly Soft tissues - Check for surgical emphysema Edges of image - Check for injury to the upper ribs and the lung apices for pneumothorax

Answer 2274

C-spine normal anatomy - Open mouth view This view is considered adequate if it shows the alignment of the lateral processes of C1 and C2 (red circles) The distance between the peg and the lateral masses of C1 (asterisks) should be equal on each side Note: In this image the odontoid peg is fully visible which is not often achievable in the context of trauma due to difficulty in patient positioning

Answer 2275

C2 odontoid peg fracture - Lateral view The C2 bone 'ring' is incomplete due to a fracture The odontoid peg is displaced posteriorly

Answer 2276

C2 'hangman' fracture - Lateral view Loss of alignment at C2/C3 with anterior displacement of C2 (large arrow) Following the cortical outline of C2 (white line) reveals discontinuity due to a fracture

Answer 2277

Bilateral perched facets - Lateral view (Same patient as image below) Loss of alignment of all three lines at C5/C6 with 'perching' of the C5 facet on the C6 facet (ring) No fracture is visible The pre-vertebral soft tissue is widened due to a haematoma Bilateral perched facets - AP view (Same patient as image above) There is widening of space between the C5 and C6 spinous processes (SP) with loss of normal alignment Again no fracture is demonstrated Note The spinal canal lies between the posterior (Orange) and spinolaminar (Red) lines Derangement of the spinal canal due to this injury results in a high incidence of spinal cord injury

Answer 2278

NEXUS criteria

Answer 2279

Focal neurologic deficit Midline spinal tenderness Altered level of consciousness Intoxication present Distracting injury If no to all of the above, C-spine can be cleared clinically

Answer 2280

Examine for brusing or deformity Palpate for deformity and tenderness Ensure pain-free active movement

Answer 2281

Patient doesn't meet criteria for clinical clearance

Answer 2282

Radiograph initially: clear if normal radiograph and clinical exam CT C-spine if abnormal radiograph or clinical exam

Answer 2283

By degree of blood loss There is a correlation clinically between volume loss and clinical manifestation

Answer 2284

1: 0-15% loss: 750ml 2: 15-30% loss 750-1500ml 3: 30-40% loss 1500-2000,l 4: \>40% loss \>2000ml

Answer 2285

Disruption of symapthetic nervous system

Answer 2286

Spinal anaesthesia Hypoglycaemia Cord inury above T5 Closed head injuries

Answer 2287

Hypotension Bradycardia Warm extremities

Answer 2288

Vasopressors: vasopressors and noradrenaline Atropine: reverse bradycardia

Answer 2289

Acute spinal cord transection Loss of all voluntary and reflex activity below the level of injury

Answer 2290

?Spinal shock

Answer 2291

Airway obstruction Tension pneumothorax Open pneumothorax (sucking) Massive haemothorax Flail chest Cardiac tamponade

Answer 2292

Accumulation of \>1.5l of blood in chest cavity Usually caused by disruption of hilar vessels

Answer 2293

Massive haemothorax

Answer 2294

X-match 6u Large-bore chest drain with heparinised saline for autotransfusion Thoracotamy if \>1.5ml or \>200ml/h

Answer 2295

Massive haemothorax

Answer 2296

Anterior or lateral # of \>2 adjacent ribs in 2 places Flail segment moves paradoxically with respiration Reduced oxygenation: due to underlying pulmonary contusion and reduced ventilation of affected segment

Answer 2297

CXR/CT chest: pulmonary contusion (white) Serial ABGs: Reduced PaO2:FiO2 ratio

Answer 2298

O2 Good analgesia: PCA, epidural Persistant respiratory failure: PPV

Answer 2299

Flail chest

Answer 2300

Disruption of myocardium or great vessles-\> blood in pericardium-\> reduced filing and contraction-\> shock Usually results from penetrating trauma

Answer 2301

Cardiac tamponade

Answer 2302

Seen in Cardiac tamponade: Raised JVP/distended neck veins Reduced BP Muffled heart sounds

Answer 2303

Seen in cardiac tamponade SBP fall of \>10mmHg on inspiration Normally during inspiration, systolic blood pressure decreases ≤10 mmHg.,[1] and pulse rate goes up slightly. This is because inspiration makes intra-thoracic pressure more negative relative to atmospheric pressure. The negative pressure in the thorax increases venous return, so more blood flows into the right side of the heart. However, the decrease in intra-thoracic pressure also expands the compliant pulmonary vasculature. This increase in pulmonary blood capacity pools the blood in the lungs, and decreases pulmonary venous return, so flow is reduced to the left side of the heart. Also, the increased systemic venous return to the right side of the heart expands the right heart and directly compromises filling of the left side of the heart. Reduced left-heart filling leads to a reduced stroke volume which manifests as a decrease in systolic blood pressure. The decrease in systolic blood pressure leads to a faster heart rate due to the baroreceptor reflex, which stimulates sympathetic outflow to the heart. Although it might be tempting to expect during inspiration that the increased volume of the right ventricle causes the septum to bulge dramatically into the left ventricle, this is unlikely under normal physiologic conditions, as there is still a large pressure gradient between the right and left ventricles during inspiration. However, during cardiac tamponade, this is the case. Here, pressure equalizes between all of the chambers of the heart.[4] This means that there is a zero-sum game, and as the right ventricle gets more volume, it can push the septum into the left ventricle and therefore reduce the volume of the left ventricle. This additional loss of volume of the left ventricle that only occurs with equalization of the pressures (as in tamponade) allows for the further reduction in volume, so cardiac output is reduced, leading to a further decline in BP. However, in situations where the left ventricular pressure remains higher than the pericardial sac (most frequently from coexisting disease with an elevated left ventricular diastolic pressure), there is no pulsus paradoxus

Answer 2304

Raised JVP on inspiration Seen in Cardiac tamponade amongst other conditiosn Ordinarily the JVP falls with inspiration due to reduced pressure in the expanding thoracic cavity and the increased volume afforded to right ventricular expansion during diastole. Kussmaul sign suggests impaired filling of the right ventricle due to a poorly compliant myocardium or pericardium. This impaired filling causes the increased blood flow to back up into the venous system, causing the jugular vein distension (JVD) and is seen clinically in the internal jugular veins becoming more readily visible.

Answer 2305

US: FAST or TTE CXR: enlarged pericardium CVP \>12mmHg ECG: low voltage QRS with electrical alternans

Answer 2306

Cardiac tamponade

Answer 2307

Massive pericardial effusion Massive pericardial effusion produces a triad of… Low voltage Tachycardia Electrical alternans Electrical alternans is… when consecutive, normally-conducted QRS complexes alternate in height. produced by the heart swinging backwards and forwards within a large fluid-filled pericardium. Patients with this ECG pattern need to be immediately assessed for clinical and echocardiographic evidence of tamponade.

Answer 2308

Pericardiocentesis: spinal needle in R subxiphoid space aiming at 45o towards R tip of left scapula Thoracotamy may be needed

Answer 2309

Usually 5th-9th ribs of upper 4 ribs= high energy trauma

Answer 2310

Rib# Sternal# Pulmonary contusion Myocardial contusion Contained aortic disruption Diaphragmatic injury Oesophageal disruption Trachoebronchial disruption

Answer 2311

Pneumothorax Lacerate thoracic or abdominal viscera

Answer 2312

Good analgesia NSAIDs + opioids Intrapleural analgesia Intercostal block

Answer 2313

Usually MVA driver vs steering wheel Risk of mediastinal injury

Answer 2314

Analgesia, admit, observe Cardiac monitor Troponin: rule out myocardial contusion

Answer 2315

Usually due to rapid deceleration injury or shock waves May-\> ARDS

Answer 2316

?Pulmonary contusion

Answer 2317

CXR: opacification Serial ABGs: reduced PaO2: FiO2 ratio

Answer 2318

O2, ventilate if necessary

Answer 2319

?Myocardial contusion

Answer 2320

Bed rest, cardiac monitoring, Rx arrythmias

Answer 2321

?Contained aortic disruption

Answer 2322

Diaphragmatic injury

Answer 2323

Oesophageal disruption

Answer 2324

Tracheobronchial disruption

Answer 2325

Penetrating: All require exploration as tract may be deeper than it appears Blunt: Have a high index of suspicion for taking to theatre

Answer 2326

Urine dip: Heamturia suggests injury to renal tract FAST scan Diagnostic peritoneal lavage

Answer 2327

Replacing DPL in most centres Check for fluid in abdomen, pelvis and pericardium Can be extended to look for pneumothoraces

Answer 2328

Perihepatic space (Morrison's pouch) Perisplenic space Pericardium Pelvis 90% sensitive

Answer 2329

Insert urinary catheter and NGT (decompression to minimise risk of injury) Midline incision through skin and fascia @ 1/3rd distance from umbilicus to pubic symphysis (arcuate line) Carefully dissect to peritoneum and insert a urinary catheter Instil 10ml/kg warmed Hartman's Drain fluid back into bag and send sample to lab +ve= \>100,000 RBCs/mm, bile/intestinal contents

Answer 2330

98% sensitive for intra-abdominal haemorrhage Useful if FAST unavailable May be better for identifying injury to hollow viscus Unable to identify retroperitoneal injury

Answer 2331

Unexplained shock Peritonism: rigid or silent abdomen Evisceration: bowel or omentum Radiological evidence of intraperitoneal gas Radiological evidence of ruptured diaphragm Gunshot wounds +VE DPL or CT

Answer 2332

Early Mx of abdominal trauma should focus on damge control to limit physiological stress Control haemorrhage: ligation and packing Control contamination: stabilise in ITU

Answer 2333

Shoulder tip pain 2o to blood in peritoneal cavity Left Kehr's is classic symptom of ruptured spleen

Answer 2334

1: capsular tear 2: tear + parenchymal injury 3: tear up to hilum 4: complete fracture

Answer 2335

Haemodynamically unstable: laparotomy Stable 1-3: observation in HDU Stable 4: consider laparotomy: suture lac or partial/complete splenectomy

Answer 2336

Conservative if capsule is intact Suture laceration Partial hepatectomy Packing

Answer 2337

Resection may be required

Answer 2338

Often associated with pelvic injury Intraperitoneal rupture requires laparoscopic repair with urethral and suprapubic drainage Extraperitoneal rupture can be treated conservatively with urethral drainage Give prophylactic Abx

Answer 2339

Anterior Posterior

Answer 2340

Injury to spongy urethra (penile + bulbar) Occur following straddling injuries or instrumentation

Answer 2341

Membranous urethra Occur following pelvic #s

Answer 2342

?Urethral injury

Answer 2343

Retrograde urethrogram

Answer 2344

Suprapubic catheter Surgical repair

Answer 2345

Contained aortic dissection

Answer 2346

Pneumomediastinum

Answer 2347

Head injury alone or in combination with other injuries is the commonest cause of trauma death (50%)

Answer 2348

Occcurs at time of injury and is a result of direct or indirect injury to brain tissue Diffuse: Concusison/ mild TBI: temporary reduction in brain function. Headache, confusion, visual symptoms, amnesia Diffuse axonal injury: Shearing forces disrupt axons. May lead to coma and persistent vegetative state. Autonomic dysfunction: fever, HTN, seating Focal: Contusion e.g. coup and contra-coup, may have focal neurological deficit Intracranial haemorrhage: EDH, SDH, SAH, ICH and laceration

Answer 2349

Occurs after 1o injury Hypoxia Hypercapnoea Hypotension Raised ICP Infection

Answer 2350

Cranium is a rigid box. Therfore total volume of intracranial contents must remain constant if ICP is not to change. Increase in a volume of one constitutent leads to a compensatory reduciton in another e.g. CSF, bloods (especially venous) These mechanisms can compensate for a volume change of around 100ml before ICP increases As autoregulation feails, ICP raipidly-\> herniation

Answer 2351

CBF proportion to CPP x radius of vessels CPP= MABP-ICP Raised ICP-\> reduced CPP-\> Reduced CBF Reduced CBF-\> autoregulatory-\> vasodilation-\> increased volume-\> increased ICP Need to prevent or attenuate this vicious cycle by ventilating to normocapnoea IV fluid to normovolaemia Mannitol bolus acutely

Answer 2352

Ventilate to low normocapnia [end - tidal CO2 of 30 mmHg, 4.0KPa]. This equates to a PaCO2 of approximately 4.5KPa in normal individuals. This minimises the risk of cerebral vasodilation (high PaCO2) and cerebral vasoconstriction (low PaCO2)

Answer 2353

HTN Bradycardia Irregular breathing Imminent herniation

Answer 2354

Unilateral or bilateral pupil dilation in association with GCS \<8 Progressive hypertension and bradycardia in association with GCS \<8

Answer 2355

LOC Amnesia: anterograde worse N+V Fits Focal neurology Mechanisms Drugs e.g. antiplatelets, warfarin

Answer 2356

Age: children and elderly Co-morbidities: epilepsy, CVA, dementia, mental illness Occupation

Answer 2357

Superficial Partial thickness Full thickness

Answer 2358

Erythema Painful e.g. sunburn

Answer 2359

Heal within 2-3w if not complicated Superficial: No loss of dermis Painful Blisters Deep: Loss of dermis but adnexae remain Healing from adenexae e.g. follicles V painful

Answer 2360

Complete loss of dermis Charred, waxy, white, skin Anaesthetic Heal from edges-\> scar

Answer 2361

Infection: loss of barrier funciton, necrotic tissue, SIRS Hypovolaemia: loss of fluid in skin and increased capillary permeability Metabolic distrubance: raised K, raised myoglobin, Raised Hb-\> AKI Compartment syndrome: circumferential burns Peptic ulcers: Curling's ulcers Pulmonary: laryngeal oedema, CO poisoning, ARDS Renal and hepatic impariment

Answer 2362

VTE Pressure sores

Answer 2363

Scarring Contractures Psychological problems

Answer 2364

Head and neck: 9% Arms: 9% Torso 18% front and back Legs: 18% each Perineum 1% Palms 1% May also use Lund and Browder charts

Answer 2365

Based on ATLS principles Specific concerns with burns: secure airway, manage fluids, prevent infection

Answer 2366

Examine for respiratory burns: soot in oral or nasal cavity, burnt nasal hairs, hoarse voice/stridor Flexible laryngoscopy can be helpful Conider early intubation and dexamethasone

Answer 2367

100% O2 Exclude constricting burns Look for signs of CO poisoning e.g. headache, N+V, confusion, cherry red appearance ABG: COHb level, SpO2 unreliable if CO poisoning

Answer 2368

Fluids losses may be huge 2x large bore cannulae in each ACF Bloods: FBC, U+E, G+S, X match Start 2l warmed Hartmann's immediately. Formula guide additional fluid requirements in burns patients

Answer 2369

1st 24h 4x weight (kg) x % burn=ml Hartmann's in 24h Replace fluid from time of burn Give half in 1st 8h Best guide is UO: 30-50ml

Answer 2370

Muir and Barclay, relates to albumin as fluid replacement Parkland formula is preferred by British Burns Association

Answer 2371

Analgesia: morphine Dress partial thickness burns: biological e.g. cadaveric skin synthetic cream e.g. flamazine \*silver sulfadiazine + sterile film Full thickness burns: tangential excision debridement, split thickness skin grafts Circumferential burns may require escharotomy to prevent compartment syndrome Anti-tetanus toxoid Consider prophylactic Abx esp. pseudomonas

Answer 2372

Core (rectal) T \<35

Answer 2373

Radiation: 60% Conduction: 15% direct contatct, primary means is cold water immersion Convection: 15% Evaporation: 10%

Answer 2374

1o: environental exposure 2o: change in temperature set point e.g. age-related, hypothyroidism, autonomic neuropathy

Answer 2375

32-35 deg Shivering Tachycardia Vasoconstriction Apathy

Answer 2376

28-32 deg Dysrhythmia, bradycardia, hypotension J waves Reduced reflexes, dilated pupils, reduced GCS

Answer 2377

\<28 deg VT-\> VF-\> cardiogenic shock Apnoea Non-reactive pupils Coagulopathy Oliguria Pulmonary oedema

Answer 2378

Rectal/ear temperature FBC, U+E, glucose TFTs, blood gas ECG: J waves between QRS and T wave, arrythmias

Answer 2379

Cardiac monitor Warm IVI 0.9% saline Urinary catheter Consider Abx for prevention of pneumonia routine if temp \<32 and \>65 Slowly rewarm: reheating too qucikly-\> peripheral vasodilation and shock Aim for 0.5 deg /hr Passive external: blankets, warm drinks Active external: warm water or warmed air Active internal: mediastinal lavage and CPB (severe hypothermia only)

Answer 2380

Arrhythmias Pneumonia Coagulopathy ARF

Answer 2381

25cm long mucscular tube (40cm from GOJ to lips) Starts at level of cricoid cartilage (C6) Lies in the visceral compartment of the neck Runs in posterior mediastinum and passes through right crus of diaphragm at T10 Continues before entering the cardia

Answer 2382

Right crus T10

Answer 2383

Level of cricoid Posterior to left main bronchus and aortic arch LOS

Answer 2384

Into 3rds reflecting change in musculature from striated to mixed to smooth

Answer 2385

Where the oesophagus changes from squamous epithelium to gastric columnar aka squamocolumnar junction

Answer 2386

Concious difficulty in swallowing

Answer 2387

Complete inability to swallow

Answer 2388

Painful swallowing

Answer 2389

Considered from the point of its chronciity to be acute, chronic, or progressive

Answer 2390

Inflammatory Neurological/motility disorders Mechanical obstruction

Answer 2391

Tonsillitis, pharyngitis Oesophagitis: GORD, candida Oral candidiasis Apthous ulcers

Answer 2392

Local: Achalasia Diffuse oesophageal spasm Nutcracker oesophagus Bulbar/pseudobulbar palsy (CVA, MND) Systemic: Systemic sclerosis/CREST MG

Answer 2393

Luminal: FB Large food bolus Mural: Benign stricutre: Web, oesophagitis, Trauma (e.g. OGD) Malignant stricture: pharynx, oesopgaus, gastric Pharyngeal pouch Extra mural: Retrosternal goitre Rolling hiatus hernia Lung Ca Mediastinal LNs e.g. lymphoma Thoracic aortic aneurysm

Answer 2394

Upper GI endoscopy Ba swallow Manometry

Answer 2395

Degeneration of myenteric plexus (Auerbach's)-\> decresed peristalsis with failure of LOS to relax

Answer 2396

1o/idiopathic: commonest 2o: Chagas (T. cruzi)

Answer 2397

?Achalasia

Answer 2398

Oesophageal SCC in 3-5%

Answer 2399

Ba swallow: dialted tapering oesophagus, Brid's beak Manometry: failure of relaxation and reduced peristalsis CXR: widened mediatsinum, double heart border OGD: exclude malignancy

Answer 2400

Oesophageal achalasia Bird's beak

Answer 2401

Medical: CCBs, nitrates Interventional: botox injection, endoscopic balloon dilatation Surgery: Heller's cardiomyotomy eith peroral, endoscopic

Answer 2402

Pharyngeal pouch Outpouching between crico and thyropharyngeal components of the inferior pharyngeal constrictor at an area of weakness known as Killian's dehiscence Defect usually occurs posteriorly but swelling usually bulges to left side of neck Food debris-\> pouch expansion-\> oesophageal compression-\> dysphagia

Answer 2403

Pharyngeal Pouch (Zenker's diverticulum)

Answer 2404

Excision Endoscopic stapling

Answer 2405

Intermittent severe chest pain +/i dysphagia Barium swallow shows corkscrew appearance Diffuse esophageal spasm (DES) is a condition characterized by uncoordinated contractions of the esophagus, which may cause difficulty swallowing (dysphagia) or regurgitation. In some cases, it may causes symptoms such as chest pain, similar to heart disease. The cause of DES remains unknown. Certain abnormalities on x-ray imaging are commonly observed in DES, such as a "corkscrew" or "rosary bead esophagus", although these findings are not unique to this condition. Specialized testing called manometry can be performed to evaluate the motor function of the esophagus, which can help identify abnormal patterns of muscle contraction within the esophagus that are suggestive of DES. The treatment of DES consists primarily of medications, such as acid suppressing agents (like proton pump inhibitors), calcium channel blockers, hyoscine butylbromide, or nitrates. In only extremely rare cases, surgery may be considered. People with DES have higher incidences of gastroesophageal reflux disease (GERD) and anxiety.

Answer 2406

Diffuse oesophageal spasm

Answer 2407

DOS Pathology Aetiology is unknown but may be related to loss of inhibitory neurones in the distal oesophagus. Radiographic features Fluoroscopy only 60% of barium swallows will be abnormal \<5% will show "corkscrew oesophagus" or "rosary bead oesophagus" where normal peristalsis is interrupted by many tertiary (non-propulsive) contractions occurring in the distal oesophagus nonperistaltic contractions, pushing contrast in two directions, can be seen (sometimes the only feature) 5 sacculations and pseudodivertucula may be seen 5

Answer 2408

Intermittent dysphagai +/- chest pain Increased contraction pressure with normal peristalsis Nutcracker esophagus, or hypertensive peristalsis, is a disorder of the movement of the esophagus characterized by contractions in the smooth muscle of the esophagus in a normal sequence but at an excessive amplitude or duration. Nutcracker esophagus is one of several motility disorders of the esophagus, including achalasia and diffuse esophageal spasm. It causes difficulty swallowing, or dysphagia, to both solid and liquid foods, and can cause significant chest pain; it may also be asymptomatic. Nutcracker esophagus can affect people of any age, but is more common in the sixth and seventh decades of life. The diagnosis is made by an esophageal motility study (esophageal manometry), which evaluates the pressure of the esophagus at various points along its length. The term "nutcracker esophagus" comes from the finding of increased pressures during peristalsis, with a diagnosis made when pressures exceed 180 mmHg; this has been likened to the pressure of a mechanical nutcracker. The disorder does not progress, and is not associated with any complications; as a result, treatment of nutcracker esophagus targets control of symptoms only.[1][2]

Answer 2409

Severe IDA-\> hyperkeratinsiation of upper 3rd of oesophagus-\> web formation Premalignant: 20% risk of SCC

Answer 2410

Iatrogenic (85-90%): endoscopy, biopsy, dilatation Violent emesis: Boerhaave's syndrome Carcinoma Caustic ingestion Trauma: surgical emphysema +/- pneumothorax

Answer 2411

?Oesophageal rupture

Answer 2412

PPI NGT Abx

Answer 2413

ABC PPI ABx ANtifunglas Debridement and formation of oesophagocutaneous fistula with T-tube

Answer 2414

This patient has severe pain which will likely need an opiate to settle. IV morphine titrated in 1-2mg boluses until comfortable would be a sensible first choice. Regular paracetamol would also be sensible as this would be opioid sparing, however this would not be the first choice for initially managing severe acute pain.

Answer 2415

nitially peripherally acting drugs such as paracetamol or non-steroidal anti-inflammatory drugs (NSAIDs) are given. If pain control is not achieved, the second part of the ladder is to introduce weak opioid drugs such as codeine or dextropropoxyphene together with appropriate agents to control and minimise side effects. The final rung of the ladder is to introduce strong opioid drugs such as morphine. Analgesia from peripherally acting drugs may be additive to that from centrally-acting opioids and thus, the two are given together.

Answer 2416

Severe pain and may need controlling with strong analgesics with local anaesthetic blocks and peripherally acting drugs Second rung on postoperative pain ladder is restoration of oral route and strong opioids may no longer be required with adequate analgesia obtained using combinations of peripherally acting agents and weak opioids Final step is when pain can be controlled with peripherally acting agents alone

Answer 2417

Infiltration of a wound with a long-acting local anaesthetic such as Bupivacaine Analgesia for several hours Further pain relief can be obtained with repeat injections or by infusions via a thin catheter Blockade of plexuses or peripheral nerves will provide selective analgesia in those parts of the body supplied by the plexus or nerves Can either be used to provide anaesthesia for the surgery or specifically for postoperative pain relief Especially useful where a sympathetic block is needed to improve postoperative blood supply or where central blockade such as spinal or epidural blockade is contraindicated.

Answer 2418

Provides excellent analgesia for surgery in the lower half of the body and pain relief can last many hours after completion of the operation if long-acting drugs containing vasoconstrictors are used.

Answer 2419

Hypotension Sensory and motor block Nausea Urinary retention

Answer 2420

An indwelling epidural catheter inserted. This can then be used to provide a continuous infusion of analgesic agents. It can provide excellent analgesia. They are still the preferred option following major open abdominal procedures and help prevent post operative respiratory compromise resulting from pain.

Answer 2421

- Disadvantages of epidurals is that they usually confine patients to bed, especially if a motor block is present. In addition an indwelling urinary catheter is required. Which may not only impair mobility but also serve as a conduit for infection. They are contraindicated in coagulopathies.

Answer 2422

In this technique an ultrasound is used to identify the correct muscle plane and local anaesthetic (usually bupivicaine) is injected. The agent diffuses in the plane and blocks many of the spinal nerves. It is an attractive technique as it provides a wide field of blockade but does not require the placement of any indwelling devices. There is no post operative motor impairment. For this reason it is the preferred technique when extensive laparoscopic abdominal procedures are performed. They will then provide analgesia immediately following surgery but as they do not confine the patient to bed, the focus on enhanced recovery can begin sooner.

Answer 2423

The main disadvantage is that their duration of action is limited to the half life of the local anaesthetic agent chosen. In addition some anaesthetists do not have the USS skills required to site the injections.

Answer 2424

Morphine Pethidine Tramadol Buprenorphine Methadone Diamorphine Fentanyl Hydromorphone Oxycodone Used for severe pain arising from deep or visceral structures

Answer 2425

Short half life and poor bioavailability. Metabolised in the liver and clearance is reduced in patients with liver disease, in the elderly and the debilitated Side effects include nausea, vomiting, constipation and respiratory depression. Tolerance may occur with repeated dosages

Answer 2426

Synthetic opioid which is structurally different from morphine but which has similar actions. Has 10% potency of morphine. Short half life and similar bioavailability and clearance to morphine. Short duration of action and may need to be given hourly. Pethidine has a toxic metabolite (norpethidine) which is cleared by the kidney, but which accumulates in renal failure or following frequent and prolonged doses and may lead to muscle twitching and convulsions. Extreme caution is advised if pethidine is used over a prolonged period or in patients with renal failure.

Answer 2427

Codeine Dihydrocodeine

Answer 2428

Inhibits prostaglandin synthesis. Analgesic and antipyretic properties but little anti-inflammatory effect It is well absorbed orally and is metabolised almost entirely in the liver Side effects in normal dosage and is widely used for the treatment of minor pain. It causes hepatotoxicity in over dosage by overloading the normal metabolic pathways with the formation of a toxic metabolite.

Answer 2429

Analgesic and anti-inflammatory actions Inhibition of prostaglandin synthesis by the enzyme Cyclooxygenase which catalyses the conversion of arachidonic acid to the various prostaglandins that are the chief mediators of inflammation. All NSAIDs work in the same way and thus there is no point in giving more than one at a time. . NSAIDs are, in general, more useful for superficial pain arising from the skin, buccal mucosa, joint surfaces and bone. Relative contraindications: history of peptic ulceration, gastrointestinal bleeding or bleeding diathesis; operations associated with high blood loss, asthma, moderate to severe renal impairment, dehydration and any history of hypersensitivity to NSAIDs or aspirin.

Answer 2430

First line: Amitriptyline (Imipramine if cannot tolerate) or pregabalin Second line: Amitriptyline AND pregabalin Third line: refer to pain specialist. Give tramadol in the interim (avoid morphine) If diabetic neuropathic pain: Duloxetine

Answer 2431

Diabetic patients have greater risk of complications. Poorly controlled diabetes carries high risk of wound infections. Patients with diet or tablet controlled diabetes may be managed using a policy of omitting medication and checking blood glucose levels regularly. Diabetics who are poorly controlled or who take insulin will a require variable rate intravenous insulin infusion. Potassium supplementation should also be given. Diabetic cases should be operated on first.

Answer 2432

The decision of whether to start a women on the combined oral contraceptive pill is now guided by the UK Medical Eligibility Criteria (UKMEC). This scale categorises the potential cautions and contraindications according to a four point scale, as detailed below: UKMEC 1: a condition for which there is no restriction for the use of the contraceptive method UKMEC 2: advantages generally outweigh the disadvantages UKMEC 3: disadvantages generally outweigh the advantages UKMEC 4: represents an unacceptable health risk

Answer 2433

more than 35 years old and smoking less than 15 cigarettes/day BMI \> 35 kg/m^2\* family history of thromboembolic disease in first degree relatives \< 45 years controlled hypertension immobility e.g. wheel chair use carrier of known gene mutations associated with breast cancer (e.g. BRCA1/BRCA2)

Answer 2434

more than 35 years old and smoking more than 15 cigarettes/day migraine with aura history of thromboembolic disease or thrombogenic mutation history of stroke or ischaemic heart disease breast feeding \< 6 weeks post-partum uncontrolled hypertension current breast cancer major surgery with prolonged immobilisation

Answer 2435

if mobility significantly reduced for \>= 3 days or if expected to have ongoing reduced mobility relative to normal state plus any VTE risk factor (see below)

Answer 2436

if total anaesthetic + surgical time \> 90 minutes or if surgery involves pelvis or lower limb and total anaesthetic + surgical time \> 60 minutes or if acute surgical admission with inflammatory or intra-abdominal condition or if expected to have significant reduction in mobility or if any VTE risk factor present (see below)

Answer 2437

Dabigatran Fondaparinux LMWH Rivaroxaban Apixaban

Answer 2438

dabigatran, started 14 hours after surgery fondaparinux, started 6 hours after surgery LMWH, started 6-12 hours after surgery rivaroxaban, started 6-10 hours after surgery. apixaban

Answer 2439

Unlike low molecular weight heparins that do not require monitoring unfractionated heparin does require monitoring, this is done by measuring the APTT.

Answer 2440

Activates antithrombin III. Forms a complex that inhibits thrombin, factors Xa, IXa, Xia and XIIa

Answer 2441

Activates antithrombin III. Forms a complex that inhibits factor Xa

Answer 2442

Anti-factor Xa (although routine monitoring not required)

Answer 2443

immune mediated - antibodies form against complexes of platelet factor 4 (PF4) and heparin these antibodies bind to the PF4-heparin complexes on the platelet surface and induce platelet activation by cross-linking FcγIIA receptors usually does not develop until after 5-10 days of treatment despite being associated with low platelets HIT is actually a prothrombotic condition features include a greater than 50% reduction in platelets, thrombosis and skin allergy treatment options include alternative anticoagulants such as lepirudin and danaparoid

Answer 2444

Hyperkalaemia ?through inhibition of aldosterone secretion

Answer 2445

The BNF states that for elective procedures, where an antiplatelet effect is not needed, clopidogrel should be discontinued 7 days before surgery. The indication for clopidogrel is important, and if related to cardiovascular disease, discontinuation of clopidogrel therapy should only be considered after discussion with the patients cardiologist.

Answer 2446

Clopidogrel is an antiplatelet agent used in the management of cardiovascular disease. It was previously used when aspirin was not tolerated or contraindicated but there are now a number of conditions for which clopidogrel is used in addition to aspirin, for example in patients with an acute coronary syndrome. Following the 2010 NICE technology appraisal clopidogrel is also now first-line in patients following an ischaemic stroke and in patients with peripheral arterial disease.

Answer 2447

Antagonist of P2Y12 adenosine diphosphate R, inhibiting platelet activaton

Answer 2448

Clopidogrel belongs to a class of drugs known as thienopyridines which have a similar mechanism of action. Other examples include: prasugrel ticagrelor ticlopidine

Answer 2449

May make clopidogrel less effecive Generally this seems to be with omeprazole and esomeprazole Other PPIs such as lansoprazole are ok

Answer 2450

Hypocalaceamia CCF Infections Hyperkalaemia

Answer 2451

NICE recommends that patients who will undergo an elective hip replacement have both mechanical and pharmacological methods of venous thromboembolism (VTE) prophylaxis. TED stockings should be administered and the patient should wear them once they have been admitted. As long as there are not contraindications, such as bleeding risk, pharmacological VTE prophylaxis is administered after surgery. Dalteparin sodium, a low molecular weight heparin, is started 6 hours after surgery. Other pharmacological methods can also be used.

Answer 2452

This is a case of post-operative pyrexia which is a very common finding for junior doctors on a surgical firm. This questions tests the ability to know the common causes of post-operative pyrexia and the time frames they are likely to occur within. From the given vignette it is testing the user to identify a clinically stable patient with no evidence of focal infection (CRP commonly raised post-op, chest likely collapsed bilaterally following a general anaesthesia) but who presents with an isolated temperature spike. These findings are in keeping with post-surgical inflammation/atelectasis given the stable picture. It is importan to be able to clinically synthesise the history, examination and clinical picture (I.e. 24 hours post TURP - a relatively low risk procedure) and be guided by this in further management instead of performing blanket investigations (i.e. CXR, blood cultures) for an isolated temperature spike 24 hours post-op. Chest physiotherapy with mobilisation and breathing exercises would help manage post-op lung atelectasis which is a very common post-op complication; especially within the first 24 hours. If the patient were to become unwell (I.e. infective symptoms, further temperature spikes, development of SIRS) they would then need further review and investigations based on the clinical picture. Benign temperature spikes in the first 24 hours after surgery due to atelectasis is a common presentation. Treatment involves mobilisation, chest physiotherapy and saline nebulisers for excessive secretions. Ongoing temperature spikes or infective symptoms would warrant further investigation.

Answer 2453

The Royal College of Anaesthetists recommend that patients should have no food for 6 hours before the induction of general anaesthesia. Patients should be allowed to drink water or other clear fluids until 2 hours before the induction of general anaesthesia. This is to reduce the likelihood of pulmonary aspiration of gastric contents.

Answer 2454

Hepatotoxicity Myocardial depression Malignant hyperthermia

Answer 2455

Laryngospasm

Answer 2456

Although packed red cells have a higher haematocrit than blood, transfusion of two units or more can result in fluid overload. Therefore, furosemide should be prescribed to be given between every other unit, if two or more units are given. Paracetamol can be used if there is a non-haemolytic febrile reaction to the transfusion. Cetirizine and hydrocortisone are used in cases of an anaphylactic reaction to the transfusion. Platelets may be given in cases of major haemorrhage, alongside packed red cells.

Answer 2457

Used for transfusion in chronic anaemia and cases where infusion of large volumes of fluid may result in cardiovascular compromise. Product obtained by centrifugation of whole blood.

Answer 2458

Usually administered to patients who are thrombocytopaenic and are bleeding or require surgery. It is obtained by low speed centrifugation.

Answer 2459

Prepared by high speed centrifugation and administered to patients with thrombocytopaenia.

Answer 2460

Prepared from single units of blood. Contains clotting factors, albumin and immunoglobulin. Unit is usually 200 to 250ml. Usually used in correcting clotting deficiencies in patients with hepatic synthetic failure who are due to undergo surgery. Usual dose is 12-15ml/Kg-1. It should not be used as first line therapy for hypovolaemia.

Answer 2461

Formed from supernatant of FFP. Rich source of Factor VIII and fibrinogen. Allows large concentration of factor VIII to be administered in small volume.

Answer 2462

Removal of all plasma from a blood unit and substitution with: Sodium chloride Adenine Anhydrous glucose Mannitol Up to 4 units of SAG M Blood may be administered. Thereafter whole blood is preferred. After 8 units, clotting factors and platelets should be considered.

Answer 2463

Stop Warfarin 2. Vitamin K (reversal within 4-24h) IV takes 3-6h to work (at least 5mg) Oral can take 24h to be clinically effective 3. FFP Used less commonly now as first line 30ml/kg need to give at least 1l fluid in 70kg person (therfore not appropriated in fluid overload Need blood group Only used if human prothrombin complex is not available 4. Human prothrombin complex (reversal within 1 hour) Bereplex 50u/kg Rapid action but factor 6 short t1/2, therefore give with vit K

Answer 2464

This patient is an orally controlled diabetic and therefore is unlikely to need a sliding scale regimen unless it is particularly major surgery, which an incision and drainage is not. If the patient was undergoing significant surgery, then they would usually be admitted the night before, and commenced on a variable rate infusion. Delaying surgery is not normally advised unless there are significant contraindications. This type of surgery is likely to be a day case and therefore she can continue on her normal metformin regimen.

Answer 2465

this should raise the possibility of polycythaemia rubra vera which may cause an iron-deficiency secondary to bleeding.

Answer 2466

A small subset of the population has an autosomal dominant mutation, leading to a lack of the specific acetylcholinesterase in the plasma which acts to break down suxamethonium, terminating its muscle relaxant effect. Therefore, the effects of suxamethonium are prolonged and the patient needs to be mechanically ventilated and observed in ITU until the effects of suxamethonium wear off. Opioid toxicity causes respiratory depression but is unlikely to be extreme enough to cause no respiratory effort in the monitored conditions of an anaesthetic. Misplacement of the endotracheal tube would cause hypoxia with a respiratory acidosis soon after intubation and potentially a pneumothorax ipsilaterally with collapse contralaterally. A propofol overdose would cause a fall in blood pressure. Malignant hyperpyrexia would manifest with a rise in temperature, rise in blood pressure, muscle spasm, type II respiratory failure and metabolic acidosis and arrhythmias.

Answer 2467

Depolarising neuromuscular blocker Inhibits action of acetylcholine at the neuromuscular junction Degraded by plasma cholinesterase and acetylcholinesterase Fastest onset and shortest duration of action of all muscle relaxants Produces generalised muscular contraction prior to paralysis Adverse effects include hyperkalaemia, malignant hyperthermia and lack of acetylcholinesterase

Answer 2468

Non depolarising neuromuscular blocking drug Duration of action usually 30-45 minutes Generalised histamine release on administration may produce facial flushing, tachycardia and hypotension Not excreted by liver or kidney, broken down in tissues by hydrolysis Reversed by neostigmine

Answer 2469

Non depolarising neuromuscular blocking drug Duration of action approximately 30 - 40 minutes Degraded by liver and kidney and effects prolonged in organ dysfunction Effects may be reversed by neostigmine

Answer 2470

Non depolarising neuromuscular blocker Onset of action approximately 2-3 minutes Duration of action up to 2 hours Effects may be partially reversed with drugs such as neostigmine

Answer 2471

An ASA (American Society of Anesthesiologists) score is an indicator of a patient's fitness for surgery. A patient is classified as ASA 2 if they have a mild systemic disease without any functional limitations. Examples include (but not limited to): current smoker, social alcohol drinker, pregnancy, obesity (30 \< BMI \< 40), well-controlled diabetes mellitus or hypertension, and mild lung disease.

Answer 2472

ASA IV recent (\< 3 months) of Myocardial infarction, Cerebrovascular accidents, ongoing cardiac ischaemia or severe valve dysfunction, severe reduction of ejection fraction, sepsis, DIC, ARD or ESRD not undergoing regularly scheduled dialysis

Answer 2473

ruptured abdominal/thoracic aneurysm, massive trauma, intra-cranial bleed with mass effect, ischaemic bowel in the face of significant cardiac pathology or multiple organ/system dysfunction

Answer 2474

A declared brain-dead patient whose organs are being removed for donor purposes

Answer 2475

G+S X-match 2-6u dependant on local protocols G+S

Answer 2476

This patient has just left theatre and will require fluids. Oral fluids should be initiated as soon as possible but if a patient is unable to drink then maintenance fluids should be prescribed through the IV route. Sodium chloride is a recommended fluid to be used for maintenance. Maintenance fluids should be prescribed at a rate of 30 ml/kg/24hr. Amount: 75 kg X 30 ml = 2250 mL in a 24 hour period Rate: 2500 / 24 = 93.75 ml/hr. Initially prescribe 500 ml and then reassess the patients fluid status and ability to drink. So prescribe 500 ml at a rate of 100 ml/hr.

Answer 2477

3mg/kg Available pre-mixed with adrenaline which increases the duration of aciton and reduces blood loss secondary to vasoconstriction Should never be used near extremities due to risk of ischaemia

Answer 2478

Slik Novafil Prolene Ethilon

Answer 2479

Vicryl Dexon PDS

Answer 2480

Patients who are not actively bleeding and have a platelet count of \> 80x10^9/L do not require any immediate management of their ITP pre-operatively and can be monitored intra-operatively. When treatment is required urgently this normally involves corticosteroids +/- IVIG. Eltrombopag is used in chronic ITP but requires 10-14 days to have an outcome on platelet count. Finally, cryoprecipitate and fresh frozen plasma are not indicated for the treatment of ITP.

Answer 2481

Drugs used to increase blood pressure in intra-operative hypotension can be broadly divided into those which are predominantly vasopressors and those which are positive inotropes (although there is a significant overlap). In this case, the patient has a normal heart rate and therefore a vasopressor such as metaraminol would be the most sensible choice. Metaraminol is primarily an alpha 1-adrenergic receptor agonist which causes systemic arteriole vasoconstriction, thereby increasing mean arterial blood pressure. Phenylephrine and metaraminol have dominant actions on alpha 1 receptors. Therefore these drugs are most suitably classed as vasopressors. Dobutamine is a powerful beta 1 receptor agonist which acts on the myocardium to increase myocardial contractility and heart rate. Doputamine is therefore most suitably named a positive inotrope. It is important to remember that there is often a significant overlap in properties of these agents, and noradrenaline, dopamine, and adrenaline have mixed alpha 1 and beta 1 receptor agonist properties and are therefore both positive inotropes and vasopressors.

Answer 2482

In general, warfarin is usually stopped 5 days before planned surgery, and once the person's international normalized ration (INR) is less than 1.5 surgery can go ahead. Warfarin is usually resumed at the normal dose on the evening of surgery or the next day if haemostasis is adequate.

Answer 2483

Sepsis or surgery causing an acute exacerbation of chronic insufficiency Adrenal haemorrahge e.g. Waterhouse-Friedrichsen Steroid withdrawal

Answer 2484

100mg IM or IV 1L NS infused over 30-5mins or with dextrose if hypogylcaemic Continue hydrocortisone 6 hourly until patient is stable. No fludrocortisone is necessary because high cortisol exerts weak MC action Oral replacement may begin after 24h and reduced to maintenance over 3-4d

Answer 2485

12/100000 (increassing due to increased Barret/s) 50-70y M\>F 5:1 Iran, Transkei, China

Answer 2486

EtOH Smoking Achalasia GORD-\> Barrett;s Plummer Vinson Fatty Diet Reduced Vit A and C Nitrosamine exposure

Answer 2487

65% adenocarcinoma 35% SCC

Answer 2488

Adenocarcinoma

Answer 2489

Oesopageal carcinoma

Answer 2490

Likely Upper 3rd

Answer 2491

Direct extension, lymphatics and blood 75% of patients have mets at diagnosis

Answer 2492

Bloods: FBC: anaemia LFTs: hepatic mets, albumin Dx: Upper GI endsocopy: biopsy Ba swallow, not often used, apple core stricture Staging: CT EUS Laparoscopy/mediastinoscopy: mets

Answer 2493

Apple core appearance Oesophageal carcinoma

Answer 2494

􀁸 Tis: carcinoma in situ 􀁸 T1: submucosa 􀁸 T2: muscularis propria (circ / long) 􀁸 T3 adventicia 􀁸 T4: adjacent structures 􀁸 N1: regional nodes 􀁸 M1: distant mets

Answer 2495

Upper GI surgeon and gastro Radiologist Pathologist Oncologist Specialist nurses Macmillan nurses Palliative care

Answer 2496

Only 25-30% have resectable tumours May be offered neo-adjuvant chemo before surgery to downstage tumour e.g. cisplatin + 5FU Approaches@ Ivor-Lewis McKeown Hiatal

Answer 2497

2 stage approach In the Ivor Lewis esphagectomy, the esophageal tumor is removed through an abdominal incision and a right thoracotomy (a surgical incision of the chest wall). The esophagogastric anastomosis (reconnection between the stomach and remaining esophagus) is located in the upper chest.

Answer 2498

Three stage Abdominal + R thoractomoy and left neck incision Used for lesions higher in the oesophagus Cervical anastomosis

Answer 2499

Stage dependant 15% 5y

Answer 2500

Majority of patients Laser coagulation Alcohol injeciton and reduce ascites (spironolactone) Stenting and secretion reduction e.g. hyoscine patch Analgesia e.g. fentanyl patch RTx: external or brachytherapy Referral: palliative care team Macmillan nurses Px: 5y \<5% Median: 4mo

Answer 2501

Leiomyoma Lipoma Haemangioma Benign polyps

Answer 2502

LOS dysfunciton-\> reflux of gastric contents-\> oesophogaitis

Answer 2503

Hiatus hernia Smoking EtOH Obesity Pregnancy Drugs: anti-AChM, nitrates, CCBs, TCAs Iatrogenic: Heller's myotomy

Answer 2504

Oesophageal: Retrosternal pain: heartburn Related to meals Worse lying down and stooping Relieved by antacids Belching Regurgitation Acid brash, water brash Odynophagia Extra-oesophageal Nocturnal asthma Chronic cough Laryngitis, sinusitis

Answer 2505

Oesophagitis Ulceration: rarely-\> haematemesis, melaena, reduced Fe Benign stricture: dysphagia Barrett's oesophagus: intestinal metaplasia of squamous epithelium-\> dysplasia-\> adenocarcinoma Oesophageal adenocarcinoma

Answer 2506

Isolated symptoms don't need Ix Bloods: FBC CXR: hiatus hernia may be seen OGD if fulfil criteria Ba swallow: hiatus hernia, dysmotility 24h pH testing + manometry

Answer 2507

Hiatus hernia retrocardiac opacity with air-fluid level

Answer 2508

If \>55yrs Persistent symptoms despite Rx Anaemia Loss of weight Anorexia Recent onset progressive symptoms Melaena Swallowing difficulty

Answer 2509

Los Angeles grade A to D Grade A: one or more mucosal breaks no longer than 5 mm, none of which extends between the tops of the mucosal folds. Grade B: one or more mucosal breaks more than 5 mm long, none of which extends between the tops of two mucosal folds. Grade C: mucosal breaks that extend between the tops of two or more mucosal folds but which involve \<75% of the mucosal circumference Grade D: mucosal breaks which involve ≥75% of the mucosal circumference

Answer 2510

Conservative: Reduce weight Raise head of bed Small regular meals \>3h before bed Stop smoking and EtOH Avoid hot drinks and spicy food Stop drugs: NSAIDs, anti-AChM, nitrates, CCB, TCAs Medical: OTC antacids: Gaviscon, Mg Triscillate 1. Full dose PPI for 102mo Lansoprazole 30mg OD 2. No response-\> double dose PPI BD 3. No response add H2RA: Ranitidine 300mg Control, low dose acid suppression PRN Step down to lowest effective dose Surgical: Nissen fundoplication

Answer 2511

Severe symptoms Refractory to medical therapy Confirmed reflux

Answer 2512

Aim: prevent reflux Repair diaphragm Can be open or lap Mobilise gastric fundus and wrap around lower oesophagus Close any diaphragamtic hiatus

Answer 2513

Gas-bloat syndrome: inability to belch/vomit Dysphagia if wrap too tight

Answer 2514

Lap insertion of magnetic bead band With the patient under general anaesthesia, an implant is placed so that it encircles the distal oesophagus at the gastro-oesophageal junction. The implant is then secured in place. The implant consists of a ring of interlinked titanium beads, each with a weak magnetic force which holds the beads together to keep the distal oesophagus closed. When the patient swallows, the magnetic force is overcome, allowing the ring to open. After swallowing, magnetic attraction brings the beads together and the distal oesophagus is again closed. MRI is contra-indicated after this procedure. NICE currently recommends that the evidence on the safety and efficacy of laparoscopic insertion of a magnetic bead band for GORD is limited in quantity. Therefore, this procedure should only be used with special arrangements for clinical governance, consent and audit, or for research

Answer 2515

Patients with documented NSAID induced ulcer who must consitinue with NSAIDs Patients with severe reflux oesophagitis Patients with complicated reflux disease

Answer 2516

Sliding (80%) Rolling (15) Mixed (5%)

Answer 2517

80% GOJ slides up into chest Often associated with GORD

Answer 2518

Think Rolling/ paraoesophageal hiatus hernia

Answer 2519

GOJ remains in abdomen but bulge of stomach rolls into chest alongside oesophagus LOS remains intact so GORD uncommon Can lead to strangulation

Answer 2520

CXR: gas bubble and fluid level in chest Ba swallow OGD: assess for oesphagitis 24pH and manometry to exclude dysmotility or achalasia

Answer 2521

Lose weight Treat reflux Surgery if intractable symptoms despite medical Rx Should repair rolling hernia due to risk of strangulation (even if asymptomatic)

Answer 2522

Hiatus hernia

Answer 2523

Duodenal ulcer

Answer 2524

Gastric ulcer

Answer 2525

H. pylori NSAIDs, steroids Smoking EtOH Stress GU Cushing's ulcers: head injury Curling's ulcers: burns

Answer 2526

Punched out ulcers Usualy background of chronic inflammation DU: 4x commoner than GU, 1st part of duodenum GU: lesser curvature of gastric antrum

Answer 2527

Haemorrhage: Haematemesis or melaeana IDA Perforation: peritonitis Gastric outflow obstruction Vomiting, colic, distension Malignancy: Incresed risk with H. pylori infection Actual malignant transformation probably doesn't occur

Answer 2528

Bloods: FBC, urea (raised in UGI haemorrhage) C13 breath test or stool antigen test (C13 as test of eradication) OGD: Stop PPIs 2w before Biopsy ulcers to check for malignancy (only necessary with gastric) Gasrtin levels if Zollinger-Ellison suspected

Answer 2529

Conservative: Lose weight Stop smoking and reduce EtOH Avoid hot drinks and spicy food Stop drugs: NSAIDs, steroids OTC antacids Medical: OTC antacids: Gaviscon, Mgtriscillate Aimed at H pylori eradication: PAC500 or PMC250 If not H. pylroi induced: PPI

Answer 2530

PPI: lansoprazole mg/BD 1g amoxicllin BD Clarithromycin 500BD

Answer 2531

PPI Metronidazole Clarithromycin

Answer 2532

Lansoprazole 30mg/d

Answer 2533

300mg nocte

Answer 2534

No acid- no ulcer Acid secretion is stimulated by gastrin from antral G cells and vagus nerve

Answer 2535

Rarely used Vagotomy Antrectomy with vagotomy Subtotal gastrectomy with Roux en Y

Answer 2536

Reduce acid secretion directly and via reduced gastrin Prevents pyloric sphincter relaxation Must be combined with pyloroplasty (widening of pylorus) or gastroenterostomy

Answer 2537

Vagus nerve only denervated where it supplies lower oesophagus and stomach Pylorus left intact

Answer 2538

Distal half of stomach removed Anastomosis: Billroth 1: directly to duodenum Billroth 2: to small bowel loop with duodenal stump oversown

Answer 2539

Ca: increased risk of gastric Ca Reflux or billious vomiting (improves with time) Abdominal fullness Stricture Stump leakage

Answer 2540

Dumping syndrome: Abdo distension, flushing, N/v, fainting, sweating Early: osmotic hypovolaemia Late: reactive hypoglycaemia Blind loop syndrome: malbasorption, diarrhoea Overgrowth of bacteria in duodenal stump Vitamin deficiency: Reduced parietal cells-\> B12 deficiency Bypassing proximal SB-\> Fe and folate deficiency Osteoporosis Weight loss: malabsroption of reduced calorie intake

Answer 2541

pH \<4 for \>4hrs

Answer 2542

Perforated duodenal ulcer is commonest 1st part of duodenum: highest acid concentration Anterior perforation-\> air under diaphragm Posterior perforation can erode into GDA-\> bleed 3/4 of duodenum is retroperitoneal therefore no air under diaphragm if perforated Perforated GU Perforated Gastric Ca

Answer 2543

Perforated peptic ucler

Answer 2544

Pancreatitis Acute cholecystitis AAA MI

Answer 2545

Bloods; FBC, U+E, amylase, CRP, G+S, clotting ABG: mesenteric ischaemia Urine dipstick Erect CXR: must be erect for 15 minutes first Air under diaphragm seen in 70% False positive in Chilaiditi's sign AXR: Rigler's: aire on both sides of bowel wall

Answer 2546

Chilaiditi syndrome is a rare condition when pain occurs due to transposition of a loop of large intestine (usually transverse colon) in between the diaphragm and the liver, visible on plain abdominal X-ray or chest X-ray.

Answer 2547

Chest X-ray showing obvious Chilaiditi's sign, or presence of gas in the right colic angle between the liver and right hemidiaphragm.

Answer 2548

Subdiaphragmatic air

Answer 2549

ABC: NBM Aggressive fluid resusc: urinary catheter +/- CVP line Analgesia: 5-10mg/2h max +/- cyclizine Abx: cef and met NGT Conservative: May be considered if patient is not peritonitic Careful monitorig, fluid + Abx Omentum may seal perforation preventing operation in 50% Surgical: Laparotomy DU: abdominal washout and omental patch repair GU: excise ulcer and repair defect Partial/gastrectomy may be required Send specimen for histo: exclude Ca Test and treat: 90% perforated PU associated with H. pylori

Answer 2550

Late complication of PUD-\> fibrotic stricturing Gastric Ca

Answer 2551

Gastric outlet obstruction

Answer 2552

ABG: hypochloraemic, hypokalaemic metabolic alkalosis AXR: dilated gastric air bubble, air flud level, collapsed distal bowel OGD Contrast meal

Answer 2553

Correct metabolic abnormality: 0.9% NS and KCl Benign: Endoscopic balloon dilatation Pyloroplasty or gastroenterostomy Malignant: Stenting Resection

Answer 2554

Test feed: palpate mass and see peristalsis Hypochloraemic hypokalaemic metabolic alkalosis USS

Answer 2555

Resus and correct metabolic abnormality NGT Ramstedt pyloromyotomy: divide muscularis propria

Answer 2556

23/100000 50y/o M\>F Increased in Japan, Eastern Europe, China, SAm

Answer 2557

Atrophic gastritis (intestinal metaplasia): pernicious anaemia/AI gatritis. H. pylori Diet: high in nitrates: smoked pickled salted. Metabolised to carcinogenic nitrosamines in GIT Smoking Blood group A Low SEC Familial: cadherin abnormality Partial gastrectomy

Answer 2558

Mainly adenocarcinomas Usually located on gastric antrum H. pylroi may -\> MALTOMA

Answer 2559

By depth of invasion: Early gastric Ca: mucosa or submucosa Late gastric cancer: muscularis propria breached Microscopic appearanace: Intestinal: bulky glandular tumours, heaped ulceration Diffuse: infiltravive with signet ring morphology

Answer 2560

4 basic tissue layers: Mucosa Submucosa Muscularis Serosa

Answer 2561

Myenteric plexus

Answer 2562

Submucosal plexus

Answer 2563

Bormann Classification

Answer 2564

Polypoid/fungating Excavating Ulcerating and raised Linitis plastica: leather bottle like thickening with flat rugae

Answer 2565

Gastric Ca

Answer 2566

Anaemia Epigastric mass Jaundice Ascites Hepatomegaly Virchow's node (Troisier's sign) Acanthosis nigricans

Answer 2567

Perforation Upper GI bleed Gastric outlet obstruction: succession splash

Answer 2568

Succussion splash is a sloshing sound heard through the stethoscope during sudden movement of the patient on abdominal auscultation. It reflects the presence of gas and fluid in an obstructed organ, as in gastric outlet obstruction. Physical examination can show an abdominal succussion splash, which is elicited by placing the stethoscope over the upper abdomen and rocking the patient back and forth at the hips. Retained gastric material greater than three hours after a meal will generate a splash sound and indicate the presence of a hollow viscus filled with both fluid and gas. An example would be a gastric outflow obstruction as pyloric stenosis, with abdominal succussion splash

Answer 2569

Within stomach: linitis plastica Direct invasion: pancreas Lymphatic: Virchow's node Blood: liver and lung Transcoelomic: Ovaries: Krukengerg tumour Sister Mary Joseph nodule: umbilical mets

Answer 2570

Transcoelomic spread to ovaries associated with gastric Ca and signet ring morphology

Answer 2571

Palpable node bulging in the umbilicus

Answer 2572

Sister Mary Joseph Nodule

Answer 2573

Virchow's node (or signal node) is a lymph node in the left supraclavicular fossa (the area above the left clavicle). It takes its supply from lymph vessels in the abdominal cavity. The finding of an enlarged, hard node (also referred to as Troisier's sign) has long been regarded as strongly indicative of the presence of cancer in the abdomen, specifically gastric cancer, that has spread through the lymph vessels. It is sometimes called the signal node or sentinel node for the same reason. Despite this, the concept is not directly related to the sentinel node procedure sometimes used in cancer surgery, and it is also unrelated to the "sentinel gland" of the greater omentum.[citation needed] It is named after Rudolf Virchow (1821–1902), the German pathologist who first described the gland and its association with gastric cancer in 1848.[1] The French pathologist Charles Emile Troisier noted in 1889 that other abdominal cancers, too, could spread to the node

Answer 2574

Bloods: FBC: anaemia LFTs and clotting Imaging: CXR: mets USS: liver mets Gastroscopy and biopsy Ba meal Staging: Endoluminal US CT/MRI Diagnostic laparoscopy

Answer 2575

Medical palliation: Analgesia e.g. fentanyl patch PPI Secretion control CTx: epirubicin, 5FU, cisplatin Palliative care team package Surgical palliation Pyloric stenting Bypass procedures Curative surgery Can be resected endoscopically Partial or total gastrectomy with roux en Y to prevent bile reflux Spleen and part of pancreas may be removed

Answer 2576

In general surgery, a Roux-en-Y anastomosis, or Roux-en-Y, is a surgically created end-to-side anastomosis, most commonly performed for weight loss or to remove a malignancy. Typically, it is between stomach and small bowel that is distal (or further down the gastrointestinal tract) from the cut end. The name is derived from the surgeon who first described it (César Roux)[1] and the stick-figure representation. Diagrammatically, the Roux-en-Y anastomosis looks a little like the letter Y. Typically, the two upper limbs of the Y represent (1) the proximal segment of stomach and the distal small bowel it joins with and (2) the blind end that is surgically divided off, and the lower part of the Y is formed by the distal small bowel beyond the anastomosis. Roux-en-Ys are used in several operations and collectively called Roux operations.[1] When describing the surgery, the Roux limb is the efferent or antegrade limb that serves as the primary recipient of food after the surgery, while the hepatobiliary or afferent limb that anatamoses with the biliary system serves as the recipient for biliary secretions, which then travel through the residual stomach from the liver and into the Roux limb to aid digestion. The altered anatomy can contribute to indigestion following surgery

Answer 2577

5y 10% Sx: 20-50%

Answer 2578

Benign polyps: adenomas Leiomyoma Lipoma Haemangioma Schwannoma

Answer 2579

Lymphoid Carcinoid GIST

Answer 2580

Gastrointestinal stromal tumour Commonest mesenchymal tumour of the GIT \>50% occur in the stomach

Answer 2581

M=F 60y Increased with NF1

Answer 2582

Airse from intestinal cells of cajal located in muscularis propria Pacemaker cells On OGD: well demarcated spherical ams with central punctum

Answer 2583

Mass effects: abdo pain, obstruction Ulceration: bleeding

Answer 2584

Size Extra-gastric location Raised mitotic index

Answer 2585

Medical: Unresectable, recurrent or metastatic disese Imatinib: seletive RtkI Surgical: Resection

Answer 2586

Diverse group of neuroendocrine tumours of enterochromaffin cell origin May secrete multiple horomones 10% occur in stomach

Answer 2587

Atrophic gastritis-\> reduced acid produciton-\> raised gastrin-\> ECL hyperplasia-\> carcinoid tumour Gastrinomas may also-\> carcinoid

Answer 2588

Gastric lymphoma

Answer 2589

Most commonly MALToma due to chronic H. pylori gastritis H. pylroi eradication can be curative

Answer 2590

Gastrin-secreting tumour (gastrinoma) most commonly found in the small intestine or pancreas Increased gastrin-\> raised HCL-\> PUD + chronic diarrhoea Diahrroea is a consequence of pancreatic enzymes ECL proliferation can -\> carcinoid tumours 60-90% of gastrinomas are malignant 25% associated with MEN1

Answer 2591

ZE syndrome

Answer 2592

Raised gastrin with raised ++HCl (pH\<2) MRI/CT Somatostatin R scintigraphy

Answer 2593

High dose PPI Sx: Tumour resection May do subtotal gastrectomy wtih Roux en Y

Answer 2594

Sustained weight loss Symptom improvement: sleep apnoea Mobility HTN DM

Answer 2595

All criteria must be met: BMI \>40 or \>35 with significant co-morbidities that could improve with weight Failure of non-surgical mx to achieve and maintain clinically beneficail weight loss for 6m Fit for Sx and anaesthesia Integrated programm providing guidance on diet, physical activity, psychosocial concerns and lifelong medical monitoring Well informed and motivated patient If BMI \>50 sx is first line Rx

Answer 2596

Laparoscopic gastric banding Roux-en-Y Gastric Bypass

Answer 2597

Inflatable silicone band around proximal stomach-\> small pre-stomach pouch Limits food intake Slows digestions At 1y 46% mean XS weight loss

Answer 2598

Oesophagojejunostomy allows bypass of stomach, duodenum and proximal jejunum Alters secretion of hormones influencing glucose regulation and perception of hunger/satiety Greater weight loss and lower reoperation rates

Answer 2599

Dumping syndrome Wound infection Hernias Malabsorption Diarrhoea Mortality: 0.5%

Answer 2600

Signet ring cells

Answer 2601

Acalculous cholecystitis

Answer 2602

Sodium valproate induced pancreatitis is more common in young adults and tends to occur within the first few months of treatment. Asymptomatic elevation of the amylase level is seen in up to 10% of patients

Answer 2603

Azathioprine Mesalazine (\*pancreatitis is 7 times more common in patients taking mesalazine than sulfasalazine) Didanosine Bendroflumethiazide Furosemide Pentamidine Steroids VPA

Answer 2604

Lipase The serum amylase may rise and fall quite quickly and lead to a false negative result. Should the clinical picture not be concordant with the amylase level then serum lipase or a CT Scan should be performed.

Answer 2605

A subcapital fracture is the commonest type of intracapsular fracture of the proximal femur. The intertrochanteric line is the line connecting the greater and lesser trochanters. Any fracture proximal to that line is classed as intracapsular, while any fracture distal is classed as extracapsular. Since the blood supply is threatened in intracapsular fractures, as a general rule: ## Footnote Intracapsular femoral fracture - hemiarthroplasty extracapsular femoral fracture - dynamic hip screw A hemiarthroplasty is favoured over a total hip replacement in this situation as the patient is: frail, with a background of chronic health problems no history of hip osteoarthritis

Answer 2606

Protrusion of a viscus or part of a viscus through the walls of its containing cavity into an abnromal position

Answer 2607

Sac can be returned to the abdominal cavity either spontaneously or with manipulation

Answer 2608

Sac cannot be returned despite pressure or maniupulation

Answer 2609

Blood supply of contents is compromised due to pressure at the neck of the hernia

Answer 2610

Part of the sac is formed by bowel e.g. caecum or sigmoid, take care when excising sac

Answer 2611

Herniating double loop of bowel. Strangulated portion may reside as a single loop inside the abdomen

Answer 2612

Maydl's hernia

Answer 2613

Herniating double loop of bowel. Strangulated portion may reside as a single loop inside the abdomen

Answer 2614

Hernia sac containing strangulated Meckel's diverticulum

Answer 2615

Only part of circumference of bowel is within sac. Most commonly seen with femoral hernias. Can strangulate without obstructing

Answer 2616

Inguinal hernia containing strangulated appendix

Answer 2617

Simultaneous direct and indirect hernia

Answer 2618

Excivision of hernial sac

Answer 2619

Suture repair of hernia defect

Answer 2620

Mesh repair of hernial defect

Answer 2621

3% of adults will require hernioplasty 4% of male neonates will have hernia M\>F 9:1 (due to testes descent) Majority present in 50s

Answer 2622

Commoner on R (?damage to ilioinguinal N and appendicectomy-\> muscle weakness) 5% are bilateral 8-15% present as emergency with strangulation/obstruction

Answer 2623

Congenital Acquired

Answer 2624

Patent processus vaginalis Should obliterate following descent of the testes If it stays patent, it may fill with Fluid-\> hydrocele Bowel/omentum-\> indirect hernia

Answer 2625

Mainly things which raise IAP Chronic cough: COPD, asthma Prostatism Constipation Severe muscular effort e.g. heavy lifting Previous incision/repair Ascites/ obesity Appendicectomy

Answer 2626

Indirect Direct

Answer 2627

Indirect (80%), commoner in young

Answer 2628

Congenital patent processus vaginalis Emerge through deep ring Same 3 coverings as cord and descend into the scrotum Can strangulate

Answer 2629

20%: commoner in elderly Acquired Emerge through Hesselbach's triangle Can acquire internal and external spermatic fascia Rarely descend into the scrotum Rarely strangulate

Answer 2630

Inguinal ligament as base Inferior epigastric vessels as the lateral border Lateral border of rectus sheath as medial border FC Hesselbach: German anatomist and surgeon

Answer 2631

Hesselbach's triangle

Answer 2632

Skin Camper's fascia: fatty Scarpa's fascia: membranous External olbique Internal oblique Nerves and vessels Transversus abdominis Transversalis fascia Pr-peritoneal fat Parietal peritoneum

Answer 2633

1.5cm above femoral pulse or mid-point of inguinal ligament (ASIS-\> PT)

Answer 2634

Ilioinguinal N and spermatic cord in males Ilioinguinal nerve, genital branch of genitofemoral nerve and round ligament of uterus in females

Answer 2635

Enters canal directly through the anterior wall, does not pass through the deep ring Exits through the superficial ring

Answer 2636

Supplies skin at the root of the penis and the scrotum and small area of skin on the upper thigh

Answer 2637

3 layers of fascia: External spermatic: from external oblique Cremasteric: from internal oblique Internal spermatic: from transversalis fascia 3 arteries: Testicular: from aorta Cremasteric: from inferior epigastric Artery of vas: from inferiror vesciular artery 3 veins: Pampiniform plexus-\> R drains into IVC, left to left renal Cremasteric vein Vein of vas 2 nerves: Nerve to cremaster from genito-femoral nerve Sympathetic fibres from T10-T11 ilioinguinal N (is on the cord) 3 other structures: Vas deferens Lymphatics of the testes-\> para aortic nodes Obliterated processus vaginalis

Answer 2638

External speramtic fascia: from external oblique Cremasteric fascia: from internal oblique Internal spermatic fascia: from transversalis fascia

Answer 2639

Testicular: from aorta Cremasteric: from inferior epigastric Artery of vas: from the inferior vesicular arteries

Answer 2640

Pampiniform plexus-\> R-\> IVC, L-\> LRV Cremasteric vein Vein of vas

Answer 2641

Ilioinguinal on the cord Nerve to cremaster: from genitofemoral nerve Sympathetic fibres from T10-T11

Answer 2642

Vas deferens Lymphatics of the testes (drain to para-aortic nodes) Obliterated processus vaginalis

Answer 2643

Arise from EIA immediately superior to inguinal ligament Can be seen passing deep to the posterior wall Sac arising laterally= indirect Sac arising medially= direct

Answer 2644

4cm long Floor: inguinal ligament Roof: arching fibres of the internal olbique and transversus abdominis Anterior: external oblique aponeurosis and internal oblique for lateral 3rd Posterior: transveralis fascia and conjoint tendon for medial 3rd Laterally: deep ring Medially: pubic tubercle

Answer 2645

Combined insertion of internal oblique and trasnversus abdominis into pubic crest and pectineal line

Answer 2646

Below arcuate line

Answer 2647

US if Dx in doubt

Answer 2648

Indirect inguinal hernia

Answer 2649

Inguinal hernia ?direct

Answer 2650

Reducible? Ever episodes of obstruction/strangulation Predisposing factors: cough, straining, lifting Occupation and social circumstances

Answer 2651

Non-surgical: Rx RFs: cough, constipation Lose weight Truss Surgical: Tension-free mesh (e.g. Lichenstein repair) better cf. suture repair (\<2% vs 10% recurrence) Open approach can be done under LA or GA Lap approach allows bilateral repair and improved cosmesis. Also preferred for recurrent hernias 1o unilateral repairs should be open Children only require sac excision (herniotomy)

Answer 2652

Haematoma/seroma formation (10%) Intra-abdominal injury (lap) Infection: 1% Urinary retention

Answer 2653

Recurrence (\<2%) Iscaehmic orchitis: 0.5% Chronic groin pain/paraesthesia: 5%

Answer 2654

Protrusion of viscus through the femoral canal

Answer 2655

F\>M **Inguinal hernias are still more comon in F** Middle aged and elderly

Answer 2656

Acquired: raised intra-abdominal pressure Femoral canal larger in females due to shape of pelvis and changes in its configuration due to childbirth

Answer 2657

?Femoral hernia

Answer 2658

50% risk of strangulation within 1m Require urgent surgery Elective or Emergency

Answer 2659

Lockwood Approach Low incision over hernia with herniotomy and herniorrhaphy: suture inguinal ligament to pectineal ligament

Answer 2660

High approach in inguinal region to allow inspection and resection of non-viable bowel Then herniotomy and herniorrhaphy Vertical incision

Answer 2661

In the femoral triangle, femoral artery vein and lymphatics are enclosed within femoral sheath Sheath is contiuous superiorly with transversalis fascia Each structure has its own compartment Most medial compartment is the femoral canal

Answer 2662

Anterior: inguinal ligaemnt Posterior: pectineal ligament (ligament of Cooper and pectineus) Medially: lacunar ligament and pubic bone Laterally: femoral vein Contents: fat and Cloquet's node

Answer 2663

Cloquet's node (or gland) is a lymph node[1][2] found in the inguinal region. It is named for French surgeon Jules Germain Cloquet.[3][4] It can be considered the superiormost deep inguinal lymph nodes or inferiormost external iliac lymph nodes.[

Answer 2664

Hernia arising through a previously acquired defect

Answer 2665

6% of surgical incisions

Answer 2666

Pre-operative Intra-operative Post-operative

Answer 2667

Increased age Obesity or malnutirtion Comorbidities: DM, renal failure, malignancy Drugs: steroids, chemo, RTx

Answer 2668

Surgical technique/skill (major factor) Too small suture bites Inappropriate suture material Incision type e.g. midline Placing drains through wounds

Answer 2669

Raised IAP: chronic cough, post-op ileus, straining Infection Haematoma

Answer 2670

Sx not appropriate for all patients Must balance risk of operation and recurrence with risk of obstruction/strangulation and patient choice Usually broad-necked, therefore low risk of strangulation

Answer 2671

Conservative: Manage RFs e.g. constipation, cough Weight loss Elasticated corset or truss Surgical: Pre-op: Optimise cardiorespiratory funciton Encourage weight loss Nylon mesh repair: open or lap

Answer 2672

Congenital 3% of LBs Defect in umbilical scar

Answer 2673

Afro-caribbean Trisomy 21 Congenital hypothyroidism

Answer 2674

Usually resolves by 2-3y Mesh repair if no closure Can recur in adults: pregnancy or gross ascites

Answer 2675

Acquired: middle aged obese men Defect through linea alba just above or below umbilicus Small defect-\> omentum, often strangulates

Answer 2676

Chronic cough Straining

Answer 2677

Mayo (double breast linea alba with sutures)/ mesh repair

Answer 2678

Young M\>F Pea-sized swelling caused by defect in linea alba above umbilicus Usually contains omentum: can strangulae

Answer 2679

Mesh repair

Answer 2680

Hernia through linea semilunaris Hernia lies between layers of abdo wall Palpable mass more likely to be colon Ca

Answer 2681

Old aged F\>M Sac protrudes through obturator foramen Pain on inner aspect of thigh or knee Frequently present obstructed/strangulated

Answer 2682

Middle-aged M\>F Typically following loin incisions Hernia through superior/inferior lumbar triangles

Answer 2683

Hernia through LSF Usually presents as SBO + gluteal mass

Answer 2684

Hernia through GSF Usually presents as SBO + gluteal mass

Answer 2685

12cm Sacral promontory to levator ani muscle 3 tenia coli fuse around the rectum to form a continuous muscle layer

Answer 2686

4cm Levator ani muscle to anal verge Upper 2/3rd of the canal: lined by columnar epithelium Insensate Superior rectal artery and vein Internal iliac nodes Lower 1/rd of the canal: Lined by squamous epithelium Sensate Middle and inferior rectal arteries and veins Superficial inguinal nodes

Answer 2687

Squamomucosal junciton between columnar epithelium of upper 2/3rd of anal canal and lower 1/3rd which is lined by squamous epihtelium

Answer 2688

Where anal canal becomes true skin

Answer 2689

Internal External

Answer 2690

Thickening of rectal smooth muscle Involuntary control

Answer 2691

Three rings of skeltal muscle: deep, superficial, subcutaenous Voluntary control

Answer 2692

Deep segment of external sphincter which is continuous with puborectalis muscle (part of levator ani) Palpable on PR: 5cm from anus Demarcates junction between the anal canal and rectum Must be preserved to maintain continence

Answer 2693

Subcutaneous bleeding from a burst venule caused by straining or passage of hard stool Also called an external pile: misnomer

Answer 2694

Perianal haematoma

Answer 2695

Analgesia and spontaenous resolution Evacuation under LA

Answer 2696

Proctalgia fugax

Answer 2697

Reassurance GTN cream

Answer 2698

Commonly seen in MSM HPV Syphillis

Answer 2699

HPV Rx: podophyllin paint, cryo, surgical excision

Answer 2700

Syphillis Rx: penicllin

Answer 2701

50% idiopathic Poor hygiene Haemorrhoids Anal fissure Anal fistula Fungi, worms Crohn's Neoplasia

Answer 2702

Disrupted and dilated anal cushions

Answer 2703

Anal cushion: mass of spongy vascular tissue Positioned at 3, 7, and 11 o' clock where the three major arteries that feed the vascular plexuses feed the anal canal Gravity, straining-\> engorgement and enlargement of anal cushions Hard stool disrupts connective tissue around cushions Cushions protrude and can be damaged by hard stool-\> bright red capillary bleeding Haemorrhoids arise above dentate line therefore **NOT PAINFUL** May be gripped by anal sphincter-\> thrombosis, strangulated piles are acutely painful. May ulcerate or infarct

Answer 2704

Constipation with prolonged straining Venous congestion may contribute Pregnancy, abdominal tumour, portal HTN

Answer 2705

Grade 1: never prolapse 2nd: prolapse on defecation but spontaneously reduce 3rd: prolapse on defecation but require digital reduction 4th: remain permanently prolapsed

Answer 2706

Haemorrhoids

Answer 2707

Full abdo exam palpating for masses Inspect perianal area: masses, recent bleeding DRE: can't palpate piles unless thrombosed Rigid sig to ideitify higher rectal pathology Proctoscopy: also allows Rx

Answer 2708

Perianal haematoma Fissure Abscess Tumour (must exclude in all cases)

Answer 2709

Conservatve: Increase fibre and fluid intake Stop straining at stool Medical: Topical preparations: anusol (hydrocortisone), topical analgesics Laxatives: lactulose, fybogel Interventional: Injection scleropathy Barron's banding Cryotherapy Infrared coagulation Bipolar diathermy Surgical: Haemorrhoidectomy

Answer 2710

Injection sclerosant (5% phenol in Almond oil) Injection above dentate line SE: impotence, prostatisi

Answer 2711

Haemorrhoid intervention: thrombosis and separation SE: bleeding, infection

Answer 2712

Watery discharge3 post procedure

Answer 2713

Band ligation

Answer 2714

Haemorrhoidectomy: Excision of piles and ligation of vascular perdicles Lactulose and metronidazole 1w pre-op Discharge with laxatives post-op Haemorrhoid artery ligation can also be used

Answer 2715

Bleeding Stenosis

Answer 2716

Analgesia Ice-packs Stool softeners Bed rest with elevate foot of bed Pain usually resolves in 2-3w Hamoerrhoidectomy is not usually necessary

Answer 2717

Tear of squamous epithelial lining in lower anal canal

Answer 2718

Mostly trauma 2o to the passage of hard stool Associated with constipation Spasm of internal anal sphincter contributes to pain and ischaemia-:\> poor healing Commoner in women Rarer causes often lead to multiple +/- lateral fissures: crohn's, herpes, anal ca

Answer 2719

Anal fissure

Answer 2720

PR often impossible Midline ulcer seen, usually posteriorly at 6 o'clock May be anterior May be a mucosal tag: sentinal pile, usually at 6 o'clock Groin LNs suggest complicating factor e.g. HIV

Answer 2721

Anal fissure with sentinal skin pile

Answer 2722

Conservative: Soaks in warm bath Toileting and dietary advice Medicals: Lactulose + fybogel Topical: resolution in 75: lignocaine, GTN, diltiazem Botulinum injeciton Surgical: Lateral partial sphincterectomy

Answer 2723

Lateral partial sphincterectomy Division of internal anal sphincter at 3 o'clock Pre-op anorectal US and mannometry Lord's operation is no longer used due to high rates of incontinence (anal dilatation under anaesthesia)

Answer 2724

Minor feacal/flatus incontinence Perianal abscess

Answer 2725

Abnromal connection between ano-rectal canal and the skin

Answer 2726

Usually occurs 2o to perianal sepsis Blockage of intramuscular glands-\> abscess Abscess discharges to form a fistula

Answer 2727

Crohn's Diverticular disease Rectal Ca Immunosuppression

Answer 2728

Parks Classificaiton inter-sphincteric (~70%): fistula crosses the intersphincteric space and does not cross the external sphincter trans-sphincteric (25%): fistula crosses from the intersphincteric space, through the external sphincter and into the ischiorectal fossa supra-sphincteric (5%): fistula passes superiorly into the intersphincteric space, and over the top of the puborectalis muscle then descending through the iliococcygeus muscle into the ischiorectal fossa and then skin extra-sphincteric (1%): fistula crosses from perineal skin through the ischiorectal fossa and levator ani muscle complex into the rectum (i.e. is outside the external anal sphincter)

Answer 2729

Determines the path of an anal fistula tract Internal opening of the fistula is dependant on where the fistula is located relative to the anal clock and the transverse anal line If the internal opening is anterior to the transverse anal line, there will be a usually simple direct radial fistulous tract If the internal opening is posterior to the transverse anal line, there will be a tortusous and often more complex fistulous tract that enters posteriorly in the midline (6 o'clock) Exception: anterior fistulas lying more than 3cm from the anus which may have a curved track that opens into the posterior midline of the anal canal

Answer 2730

?anal fistula

Answer 2731

anal fistula

Answer 2732

MRI Endoanal US

Answer 2733

Extent of fistula must be delineated by probing the fistula @ EUA Approach varies dependant on whether the fistula is high or low

Answer 2734

Fistulotomy and excision Laid open to heal by 2o intention

Answer 2735

Fistulotomy could damage the anorectal ring Suture: a seton: passed through fistula and gradually tightened over months. Stimulates fibrosis of tract. Scar tissue holds sphincter together

Answer 2736

Anal gland blockage-\> infection-\> abscess e.g. E. Coli, bacteroides May develop from skin infections e.g. sebaceous gland or hair follcile Staphs

Answer 2737

Crohn's DM Malignancy

Answer 2738

Perianal: 45% discrete local red swelling close to the anal verge Ischiorectal \<30%: systemic upset, extremely painful on DRE Intersphincteric/intermuscular: \>20% Pelvirectal/supralevator: 5% Systemic upset bladder irritaiton

Answer 2739

?Peri-anal abscess

Answer 2740

Abx may suffice if instigated early Most cases require EUA with I&D Wound packed Heals by second intention Daily dressing for 7-10d Look for anal fistula which complicates 30% of abscesses

Answer 2741

Primary intention: healing of clean wound without tissue loss, i.e. edges brought together Secondary intention: wound allowed to granulate, resulting in broader scar Teritary intention: intially, cleaned debrided, purposely left open.

Answer 2742

Pilonoidal: nest of hair Sinus: blind ending tract, lined either by epithelial or granulation tissue which opens onto an epithelial surface

Answer 2743

Hair works way beneath skin-\> foreign body reaction-\> abscess formation usually occurs in the natal cleft

Answer 2744

M\>F 4:1 Mediterranean, Middle east, Asians Often overweight with poor personal hygiene Occupation with lots of sitting

Answer 2745

Pilonidal sinus

Answer 2746

Conservative: Hygiene advice Shave/remove hair from affected area Surgical: I&D of abscesses Elective sinus excision: methylene blue to outline tract. Recurrence in 4-15%

Answer 2747

Relatively uncommon 250-300 caes per year in UK

Answer 2748

80% are SCCs, others: melanomas, adenocarcinomas Anal margin tumours Anal canal tumours

Answer 2749

Well differentatied keratinising lesions Common in men Good Px

Answer 2750

Arise above dentate line Poorly differentiated, non-keratinising Commoner in women Worse prognosis

Answer 2751

Above dentate line-\> internal iliac nodes Below dentate line-\> inguinal nodes

Answer 2752

HPV 16, 18, 31, 33 is important factor Increased incidence in MSM Increased incidence if perianal warts

Answer 2753

Anal carcinoma

Answer 2754

70% have sphincter involvement at presentation Important RED FLAG

Answer 2755

Palpable lesion in only 25%, +/- palpable inguinal nodes

Answer 2756

FBC: ACD Endoanal US Rectal EUA and biopsy CT/MRI to assess pelvic spread

Answer 2757

ChemoRTx: most patients. 50% 5y Sx: reserved for Tumours that fail to respond GI obstruction Small anal margin tumours without sphincter involvement

Answer 2758

Protrusion of rectal tissue through the anal canal

Answer 2759

Type 1: mucosal prolapse Partial prolapse of redundant mucosa Commoner in children, especially in CF Essentially large piles, same Rx Type 2: Full thickness prolapse Commoner cf. type 1 Usually elderly females with poor O+G hx

Answer 2760

Rectal prolapse

Answer 2761

Visibile prolapse: brought out on straining +/- excoriation and ulceration Reduced sphincter tone on PR Associated with uterovaginal prolapse

Answer 2762

Sigmoidoscopy to exclude proximal lesions Anal manometry Endoanal US MRI

Answer 2763

Phenol injection Rubber band ligation Delorme's procedure

Answer 2764

A Delorme's procedure aims to repair the prolapse. This operation involves the surgeon remov- ing some of the prolapsed lining of the rectum (mucosa) and reinforcing the muscle of the rectum by placating stitches. This is done via the anus. No external incision is needed.

Answer 2765

Conservative: Pelvic floor exercises Stool softeners Sx: Abdominal appraoach: Rectopexy, lap or open. Mobilised rectum fixed to sacrum with mesh Perineal appraoch: Delorme's procedure

Answer 2766

35% benign 65% malignant (2% of GI malignancies)

Answer 2767

Lipoma Leiomyoma Neurofibroma Haemangioma Adenomatous polyps (FAP, Peutz-Jehgers)

Answer 2768

Adenocarcinoma (40% of malignant tumours) Carcinoid (40%) Lymphoma (especially with coeliac disease: EATL) Gastrointestinal stromal tumours

Answer 2769

Often non-specific symptoms so present late N/V, obstruction Weight loss and abdominal pain Bleeding Jaundice from biliary obstruction or liver mets

Answer 2770

AXR: SBO Ba follow through CT Endocscopy: Push enteroscopy Capsule enteroscopy

Answer 2771

Diverse group of neuroendocrine tumours of enterochromaffin cell origin capable of producing 5HT May be derived from foregut: resp tract Midgut: stomach, ileum, appendix Hindgut: colorectum

Answer 2772

5HT Vasoactive intestinal peptide Gastrin Glucagon Insulin ACTH Hindgut tumours rarely secrete 5HT

Answer 2773

Bypass of FPM and is strongly associated with metastatic disease

Answer 2774

10% with MEN1

Answer 2775

Appendix: 45% Ileum: 30% Colorectum: 20% Stomach: 10% Elsewhere in GIT Bronchus: 10% Cosider all as malignant

Answer 2776

Flushing: paroxysmal, upper body +/- wheals Intestinal: diarrhoea Valve fibrosis: TR and PS whEEze: bronchoconstriction Hepatic involvement: bypassed FPM Tryptophan deficiency: pellagra (3Ds)

Answer 2777

Appendicits Intussuception or obstruction Abdominal pain

Answer 2778

Increased urine 5-hydroxyindoleacetic acid: 5HT metabolite Raised plasma chromogranin A CT/MRI: find primary

Answer 2779

Symptoms: octreotide or loperamide Curative: tumours are very yellow Give octerotide to avoid carcinoid crisis

Answer 2780

Tumour outgrows blood supply or is handled too much-\> massive mediator release Leads to vasodilatoin, hypotension, bronchoconstriction, hyperglycaemia

Answer 2781

High-dose octreotide

Answer 2782

Median survival is 5-8y ~3y if mets present

Answer 2783

Inflammation of the vermiform appendix ranging from oedema to ischaemic necrosis and perforation

Answer 2784

Incidence: 6% lifetime incidence, commonest surgical emergency Rare \<2y. Maximal peak during childhood, decreases thereafter

Answer 2785

Obstruction of the appendix: faceolith most commonly lymphoid hyperplasia post-infection Tumour e.g. caecal Ca, carcinoid Worms e.g. Ascaris lumbicoides, Schisto Gut organisms-\> infection behind obstruction Leads to oedema, ischaemia, necrosis, perforation Peritonitis Abscess Appendiceal mass

Answer 2786

Early inflammation-\> appendiceal irritation: Visceral pain is not well localised cf. somatic pain Nociceptive info travels in the sympathetic afferent fibres that supply the viscus Pain is refrred to the dermatome corresponding toth e spinal cord level of these sympathetic fibres Append= midgut= lesser splanch (T10/11)= umbilical pain Late inflammation-\> parietal peritoneum irritation Pain localised to RIF

Answer 2787

Colicky abdominal pain. Central-\> localised in RIF. Worse with movement Anorexia Nausea (vomiting is rarely prominent) Constipation/diarrhoea

Answer 2788

Appendicits

Answer 2789

Low grade pyrexia: 37.5-38,5 Increased HR, shallow breathing Foetor oris Guarding and tenderness @ McBurney's point: +ve cough/percussion tenderness Appendix may be palpable in RIF Pain PR suggests pelvic appendix

Answer 2790

Acute appendicits

Answer 2791

1/3rd from ASIS to the umbilicus

Answer 2792

Blumberg's sign, also referred to as rebound tenderness, is a clinical sign that is elicited during physical examination of a patient's abdomen by a doctor or other health care provider. It is indicative of peritonitis. It refers to pain upon removal of pressure rather than application of pressure to the abdomen.

Answer 2793

Pressure in LIF-\> more pain RIF Appendicits

Answer 2794

Pain on extending the hip: retrocaecal appenidix

Answer 2795

Flexion + internal rotation of R hip-\> pain Appendix lying close to obturator internus

Answer 2796

Surgical: Cholecystitis Diverticulitis Meckel's diverticulitis Gynae: Cyst accident: torsion, rupture, haemorrhage Salpingitis/PID Medical: Mesenteric adenitis UTI Crohn's

Answer 2797

Dx is primarily clinical Bloods: FBC, CRP, amylase, G+S. clotting Urile: Sterile pyruia may indicate bladder irritation Ketones: anorexia Exclude UTI **Beta HCG** Imaging: USS: exclude gynae path. Visualise inflamed appendix CT: can be used Diagnostic lap

Answer 2798

Fluids Abx: cef 1.5mg + met 500g IV TDS Analgesia: paracetamol, NSAIDs, codeine phosphate Certain dx-\> appendicectomy Uncertain dx-\> active observation

Answer 2799

cef 1.5g met 500g IV TDS

Answer 2800

Appendix mass Apppendix abscess Perforation

Answer 2801

Inflammed appendix with adherent covering of omentum and small bowel

Answer 2802

Initially: Abx and NBM Resolution of mass-\> interval appendicectomy Exclude a colonic tumour: colonoscopy

Answer 2803

Results if appendix mass doesn't resolve Mass enlarges, patient deterioirates

Answer 2804

Abx + NBM CT guided percutaneous drainage If no resolution, sx may involve right hemicolectomy

Answer 2805

Commoner if faecolith present and in young children (as dx is often delayed) Deteriorating patient with peritonitis

Answer 2806

100-200/100,000 30s F\>M

Answer 2807

Concordance= 10% Smoking protective TH2 mediated

Answer 2808

50-100,000 20s F\>M

Answer 2809

Concordance= 70% Smoking increases risk TH1/Th17 mediated

Answer 2810

Found in rectum and colon +/- backwash ileitis Contiguous No strictures

Answer 2811

Found mouth to anus, especially terminal ileum Skip lesions Strictures present

Answer 2812

Mucosal inflammation Shallow and broad ulceration No fibrosis No granulomas Marked pseudopolyps No fistulae

Answer 2813

Transmural inflammation Deep, thin, serpiginious ulceration-\> cobblestone mucosa Marked fibrosis Granulomas present Minimal pseudopolyps Fistulae present

Answer 2814

Fever, malaise, anorexia, weight loss in active disease

Answer 2815

Fever Tender, distended abdomen

Answer 2816

Apthous ulcers Glossitis Abdominal tenderness RIF mass Perianal abscesses, fistulae, tags Anal/rectal strictures

Answer 2817

Skin Eyes Joints HPB Other

Answer 2818

Clubbing Erythema nodosum Pyoderma gangrenosum (esp. UC)

Answer 2819

Iritis Conjunctivitis Episcleritis Scleritis

Answer 2820

Arthritis (non-deforming, asymmetrical) Sacroilitis Ank spond

Answer 2821

PSC and cholangiocarcinoma (esp. UC) Gallstones (esp. Crohn's) Fatty liver

Answer 2822

Amyloidosis Oxalate renal stones (esp. Crohn's)

Answer 2823

Toxic megacolon Bleeding Malignancy Cholangiocarcinoma Strictures-\> obstruction Venous thrombosis

Answer 2824

Diameter \>6cm Risk of perforation

Answer 2825

CRC in 15% with pancolitis for 20y Cholangiocarcinoma also a risk

Answer 2826

Fistulae Strictures-\> obstruction Abscesses Malabsorption Toxic megacolon and Ca may occur although this is less common than in UC

Answer 2827

Entero-enteric/colonic-\> diarrhoea Enterovescial-\> frequency, UTI Enterovaginal Perianal-\> pepperpot anus

Answer 2828

Abdominal Anorectal

Answer 2829

Fat-\> steatorrhoea, gallstones B12-\> megaoloblastic anaemia Vit D-\> osteomlacia Protein-\> oedema

Answer 2830

Bloods Stool Imaging Ileocolonoscopy and regional biopsy

Answer 2831

FBC: reduced Hb, raised WCC LFT: reduced albumin Raised CRP/ESR Blood cultures

Answer 2832

MCS: exclude campy, shigella, salmonella CDT: C d.iff may complicate or mimic

Answer 2833

AXR: megacolon (\>6cm) CXR: perforation CT Ba/gastrograffin enema: Lead pipe: no haustra Thumbprinting: mucosal thickening Pseudopolyps: regenerating mucosal island

Answer 2834

Baron Score

Answer 2835

Lead pipe colon UC

Answer 2836

Dilated transverse colon noted. The abdomen demonstrates markedly dilated transverse colon (9 cm) with impression of slight dilatation of the descending colon with some" thumb printing" in the wall (consistent with mucosal inflammation in the clinical circumstances). No free subphrenic gas is seen. UC

Answer 2837

n endoscopic scoring system devised for ulcerative colitis, which has been used in clinical practice as the modified Baron score: • Normal—normal mucosa; inactive disease. • Mild—erythema; decreased vascular pattern. • Moderate—marked erythema; loss of vascular pattern; mucosal friability. • Severe—spontaneous bleeding; ulceration.

Answer 2838

Truelove and Witts criteria

Answer 2839

Bowel movements PR bleeding Pyrexia (\>37.8) HR (\>90) Anaemia ESR

Answer 2840

\<4 bm Small PR bleeding No pyrexia HR \<90 Anaemia not present ESR \<30

Answer 2841

4-6bm Between mild and severe PR bleed No pyrexia No HR \>90 No anaemia ESR \<30

Answer 2842

?6 bm Large PR bleed Pyrexic \>37.8 HR \>90bpm Hb \<10.5 ESR \>30

Answer 2843

Resus: admit, IV hydration, NBM IV hydrocortisone 100mg QDS + PR (can consider adding IV ciclosporin if not improvement) Transfuse if required Thromboprophlyaxis Monitoring Abx not routinely recommended may be used in megacolon, peforation, uncertain Dx

Answer 2844

Bloods: FBC, ESR, CRP, U+E Vitals and stool chart Twice daily examination +/- AXR

Answer 2845

Perforation Bleeding Toxic megacolon VTE

Answer 2846

Switch to oral prednisolone and a 5-ASA (e.g. mesalazine) Taper pred after full remission

Answer 2847

Rescue therapy On day 3: stool freq \>8, or CRP \>45 Predicts 85% chance of needing a colectomy during admission Medical: ciclosporin, infliximab or visilzumab (anti T cell) Surgical

Answer 2848

1st line: 5-asas e.g. mesalazine 2nd line: oral pred

Answer 2849

Mainly used for left-sided disease Proctitis: suppositories More proximal disese: enemas or foams 5 ASA +/- steroids (pred or budenoside)

Answer 2850

Can add pred to 5-ASA Oral tacrolimus can be added Steroid sparing agents include: azathioproine or mercaptopurine Infliximab: steroid-dependant patients

Answer 2851

1st line: 5-ASA PO: sulfasalzine or mesalazine Topical can be used in proctitis 2nd line: Azathioprine or mercaptopurine Relapsed on ASA or are steroid dependent. Give 6-mercaptopurine if azathioprine intolerant 3rd line: Infliximab/ adalimumab

Answer 2852

Toxic megacolon Perforation Massive haemorrhage Failure to respond to medical Rx

Answer 2853

20% require surgery at some stage 30% with colitis require surgery within 5y

Answer 2854

Total/subtotal colectomy with end ileostomy +/- mucus fistula Followed after 3m by either completion proctectomy and ileal pouch anal anastomosis or end ileostomy. Or ileorectal anastomosis Panproctocolectomy and permanent end ileostomy Acute colitis op mortality: 7% (30% if perforated)

Answer 2855

Chronic symptoms despite medical therapy Carcinoma or high grade dysplasia

Answer 2856

Panproctocolectomy with end ileostomy or ileal pouch anal anastomosis Total colectomy with IRA (ileorectal anastomosis)

Answer 2857

Abdominal: SBO Anastomotic stricture Pelvic abscess Stoma: Retraction Stenosis Prolapse Dermatitis Pouch: Pouchitis Reduced female fertility Faecal leakage

Answer 2858

Metronidazole and cipro

Answer 2859

Bloods Stool Imaging Endoscopy

Answer 2860

FBC: anaemia, raised WCC LFT: hypoalbuminaemia Raised CRP/ESR Haematinics: Fe B12 folate Blood cultures

Answer 2861

MCS: exclude campy, shigella, salmonella CDT

Answer 2862

AXR: obstruction, sacroileitis CXR: perforation MRI: assess pelvic disease and fistula. Assess disease severity Small bowel follow thourgh or enterocylsis: Skip lesions Rose-thorn ulcers Cobllestoning: ulceration and mural oedema String sign of Kantor: narrow terminal ileum Endoscopy: Ileocolonsocopy and regional biopsy Wireless capsule endoscopy Small bowel enteroscopy

Answer 2863

FBC LFT CRP/ESR

Answer 2864

Temperature (increased) HR (increased) ESR (raised) CRP (raised) WCC (raised Albumin (reduced)

Answer 2865

Narrow terminal ileus

Answer 2866

String sign of Kantor

Answer 2867

ABC, NBM, IV hydration Hydrocortisone IV + PR if rectal disease Abx: metronidazole PO or IV Thromboprophylaxis: LMWH Dietician review: Elemental diet Consider TPN Monitoring: vitals and stool chart, daily examination

Answer 2868

Switch to oral pred 40mg/d

Answer 2869

Rescue therapy Methotrexate +/- infliximab Surgical

Answer 2870

High fibre diet Vitamin supplements

Answer 2871

1st line: prednisolone 2nd line: budenoside or sulfasalazine Add on treatment Consider azathioprine or mercaptopurine addition to pred or budenoside Consider adding methotrexate in those unable to tolerate azathioprine or in whom TPMT activity is deficient Biologic: Infliximab/ adalimumab

Answer 2872

Occurs in 50% Ix: MRI and EUA Rx: oral abx: metronidazole immunosuppression +/- infliximab Local surgery +/- seton insertion

Answer 2873

1st line: azathioprine or mercaptopurine 2nd line: methotrexate 3rd line: infliximab/adalimumab

Answer 2874

50-80% need \>1 operation in their life Never curative Should be as conservative as possible

Answer 2875

Failure to respond to medical Rx Intestinal obstruction or perforation Massive haemorrhage

Answer 2876

Abscess or fistula Perianal disease Chronic ill health Carcinoma

Answer 2877

Limited resection e.g. ileocaecal Stricturoplasty Defunction distal disease with temproray loop ileostomy

Answer 2878

Stoma complications Enterocutaneous fistulae Anastamotic leak or stricture

Answer 2879

\<1-2m small bowel

Answer 2880

Steatorrhoea ADEK and B12 malabsorption Bile acid depletion-\> gall stones Hyperoxaluria-\> renal stones

Answer 2881

Dietician Supplements or TPN Loperamide

Answer 2882

ABC Drip and suck IV fluids: aggressive as patient may be v dehydrated NGT: decompress upper GIT, stops vomiting, prevents aspiration Catheterise: moinotr UO

Answer 2883

Analgesia: may require strong opioid Abx: cef + met if strangulation or peforation Gastrograffin study: oral or via NGT Consider need for parenteral nutrition

Answer 2884

Regular clinical examination is necessary to ensure that the patient is not deteriorating Change in distension, pain or tenderness, HR or RR Repeat imaging and bloods Non-operative mx succesful in 80% of patients with SBO without peritonitis Pts with LBO are more likely to need sx

Answer 2885

Closed loop obstruction Obstructing neoplasm Strangulation/perforation-\> sepsis/peritonitis Failure of conservative mx (up to 72h)

Answer 2886

Aim to treat cause Typically involves resection of obstructing lesion Colon has not been cleaned, therefore most surgeons utilise a proximal ostomy post-resection Patients with substantial comorbidity or unresectable tumours may be offered bypass procedures Endoscopically placed expanding metal stents offer palliation or a bridge to surgery allowing optimisation

Answer 2887

Must consent patient for possible resection +/- stoma SBO: adhesiolysis LBO: Hartman's Colectomy and 1o anastomosis and on table lavage Palliative bypass procedure Transverse loop colostomy or loop ileostomy Caecostomy

Answer 2888

Long mesentry with narrow base predisposes to torsion Usally due to sigmoid elongation 2o to chronic constipation Increased risk in neuropsych patients: MS, PD, psychiatric as disease Rx interferes with intestinal motility Leads to closed loop obstruction

Answer 2889

Sigmoid volvulus

Answer 2890

Sigmoid volvulus Coffee bean sign

Answer 2891

Ahaustral wall and the lower end pointing to the pelvis

Answer 2892

Often relieved by sigmoidoscopy and flatus tube insertion Monitor for signs of bowel ischaemia Sigmoid colectomy occassionally required: failed endoscopic decompression bowel necrosis Often recurs: elective sigmoidectomy may be needed

Answer 2893

Associated with congenital malformation where caecum is not fixed in the RIF Only 10% of patients can be detorsed with colonoscopy therefore typically requires sx Right hemi with 1o ileocolic anastomosis Caecostomy

Answer 2894

Caecal volvulus Despite the varying positions of the distended cecum, the plain radiographic features of a caecal volvulus are characteristic, and the caput caecum can typically be identified. The colonic haustral pattern is generally maintained in contradistinction to a sigmoid volvulus although some effacement may be present if ischemia develops.

Answer 2895

Vomiting-\> retching with regurgitation of saliva Pain Failed attempts to pass an NGT

Answer 2896

Congenital: Bands Rolling/paraoesophageal hernia Py Sten Acquired Gastric/oesophageal sx Adhesions

Answer 2897

Gastric dilatation Double fluid level on erect films

Answer 2898

Endoscopic manipulation Emergency laparotomy

Answer 2899

Paralytic ileus

Answer 2900

Post-op Peritonitis Pancreatitis or any localised inflammation Poisons/Drugs: AntiAChM e.g. TCAs Pseudo-obstruction Metabolic: hypokalaemia, hyponatraemia, hypomagnesaemia, uraemia Mesenteric ischaemia

Answer 2901

Reduced bowel handling Laparoscopic approach Peritoneal lavage after peritonitis Unstarched gloces

Answer 2902

Conservative drip and suck Mx Correct any underlying causes e.g. drugs, metabolic abnormalities Consider need for parenteral nutrition Exclude mechanical cause if protracted

Answer 2903

Colonic pseudo-obstruction/ Ogilvie's syndrome

Answer 2904

Aetiology unknown Associated with elderly, cardiorespiratory disorders, pelvic sx e.g. hip arthroplasty, trauma

Answer 2905

Gastrograffin enema to exclude mechanical cause

Answer 2906

Neostigmine: anti-cholinesterase Colonoscopic decompression: 80% successful

Answer 2907

3rd commonest cancer 2nd commonest cause of cancer death Age: peak in 60s Sex: rectal Ca commoner in men Geo: Western disease

Answer 2908

Benign precursors to CRC Characterised by dysplastic epithelium Malignant potential increases with size, dysplasia and villous component

Answer 2909

Tubular: small, pedunculated, tubular glands Villous: large, sessile, covered by villi Tubulovillous: mixture

Answer 2910

Typically asymptomatic Large polyps can bleed-\> IDA Villous adenomas can lead to hypokalaemia and hypoproteinaemia

Answer 2911

Negative regulator of beta-catenin (component of WNT pathway) APC binds to and promotes beta catenin degradation mutAPC leads to increased beta catenin-\> incrased tx of genes that promote cell proliferation Proliferation-\> mutation of other genes which promote growth and prevent apoptosis e.g. KRAS (proto-oncogen) p53 (TSG)

Answer 2912

First hit: mutation of one APC copy Second hit: mutation of second APC copy-\> adenoma formation Additional mutations in adenoma-\> malignant transformation

Answer 2913

Diet: reduced fibre, increased refined carbs IBD: CRC in 15% with pancolitis for 20y Familial: FAP, HNPCC, Peutz-Jehgers Smoking Genetics: one 1st degree relaticve= 1/10 risk (no relative 1/50) NSAIDs/Aspirin: protective

Answer 2914

95% adenocarcinoma Others: lymphoma, GIST, carcinoid

Answer 2915

Rectum: 35% Sigmoid: 25% Caecum and ascending colong: 20% Transverse: 10% Descending: 5%

Answer 2916

Rectosigmoidal

Answer 2917

Local Lymphatic Blood (liver, lungs) Transcoelomic

Answer 2918

Altered bowel habit PR mass (60%) Obstruction (25%) Bleeding/mucus PR Tenesmus old man

Answer 2919

Right sided CRC

Answer 2920

Anaemia Weight loss Abdominal pain Old man

Answer 2921

Abdominal mass perforation haemorrhage fistula

Answer 2922

Palpable mass: per abdomen or PR Perianal fistulae Hepatomegaly Anaemia Signs of obstruction

Answer 2923

Managing anticoagulation peri-operatively is challenging and depends on the reasons for and agent used to anti-coagulate. Each patient should have a venous thromboembolic risk assessment undertaken to consider risk factors for thromboembolism versus bleeding. In this scenario the patient is at high risk of thromboembolic disease (previous CVA, known AF) but also significant bleeding due to major abdominal surgery. Therefore the best option is a shorter acting anticoagulant (e.g. low molecular weight heparin) given at treatment dose whilst withholding warfarin. This would then be withheld the evening before surgery, and mechanical prophylaxis used.

Answer 2924

The history here (sudden onset respiratory distress after a penicillin-containing antibiotic) is of anaphylaxis. Giving 0.5mg IM adrenaline 1:1000 as Resuscitation Council UK guidelines for anaphylaxis is the most sensible option.

Answer 2925

Rapid onset of anaesthesia Pain on IV injection Rapidly metabolised with little accumulation of metabolites Proven anti emetic properties Moderate myocardial depression Widely used especially for maintaining sedation on ITU, total IV anaesthesia and for daycase surgery

Answer 2926

Extremely rapid onset of action making it the agent of choice for rapid sequence of induction Marked myocardial depression may occur Metabolites build up quickly Unsuitable for maintenance infusion Little analgesic effects

Answer 2927

May be used for induction of anaesthesia Has moderate to strong analgesic properties Produces little myocardial depression making it a suitable agent for anaesthesia in those who are haemodynamically unstable May induce state of dissociative anaesthesia resulting in nightmares

Answer 2928

Has favorable cardiac safety profile with very little haemodynamic instability No analgesic properties Unsuitable for maintaining sedation as prolonged (and even brief) use may result in adrenal suppression Post operative vomiting is common

Answer 2929

For elective total hip replacement surgery NICE recommend commencing a low molecular weight heparin 6-12 hours after surgery.

Answer 2930

* Cataract surgery (reduces the risk of endophthalmitis) * Appendicectomy * Colorectal surgery * Caesarean section * Abdominal/vaginal hysterectomy * Transurethral resection of the prostate * Arthroplasty * Hip fracture * 3rd/4th degree perineal tear repair

Answer 2931

* Tonsillectomy * Inguinal hernia repair * Laparoscopic removal of ectopic pregnancy * Assisted delivery (e.g. forceps) * Evacuation of incomplete miscarriage

Answer 2932

Atlantoaxial subluxation is a rare complication of rheumatoid arthritis, but important as it can lead to cervical cord compression. Anteroposterior and lateral cervical spine radiographs preoperatively screen for this complication, ensuring the patient goes to surgery in a C-spine collar and the neck is not hyperextended on intubation. Radiographs of the hands are useful in diagnosis, but not necessary pre-operatively. CT scanning of the cervical spine is not necessary for screening pre-operatively, but may be useful is any abnormalities are picked up.

Answer 2933

In patients with no clinical signs or documentation of heart failure a 500 ml prescription of normal saline delivered STAT is the recommended fluid challenge. You must remember to reassess the patient to decide whether to prescribe another 500 mls. 250 mlx of 0.9% Normal Saline would be appropriate in patients with evidence of heart failure. This does not put as much strain on their physiology and risk the patient devoting worsening cardiac failure.

Answer 2934

In the UK the GIFTASUP guidelines (see reference below) were devised to try and provide some consensus guidance as to how intravenous fluids should be administered. A decade ago it was a commonly held belief that little harm would occur as a result of excessive administration of normal saline and many oliguric post operative patients received enormous quantities of IV fluids. As a result they developed hyperchloraemic acidosis. With greater understanding of this potential complication the use of electrolyte balanced solutions (Ringers lactate/ Hartmans) is now favored over normal saline. In addition to this solutions of 5% dextrose and dextrose/saline combinations are now generally not recommended for surgical patients.

Answer 2935

Chest x-rays are now not routinely recommended before surgery. Patients over the age of 65 may need an ECG before major surgery. Patients with renal disease may need a full blood count and an ECG depending on their ASA grade even before intermediate surgery. Patients with hypertension do not need any specific investigations pre-operation. Patients with diabetes may need an ECG before intermediate surgery.

Answer 2936

25mg hydrocortisone at induction, then resume normal medication post-operatively

Answer 2937

Usual dose pre-operatively Then 25mg hydrocortisone at induction followed by 25mg IV every 8 hours for 24h Continue normal pre-operative dose afterwards

Answer 2938

Usual dose of steroids preoperatively 50mg IV hydrocortisone at induction Followed by 50mg IV evey 8h for 48-72h. Continue infusion until patient has started light eating, then restart normal pre-operative dose

Answer 2939

sepsis or surgery causing an acute exacerbation of chronic insufficiency (Addison's, Hypopituitarism) adrenal haemorrhage eg Waterhouse-Friderichsen syndrome (fulminant meningococcemia) steroid withdrawal

Answer 2940

Hydrocortisone 100mg IM or IV 1L NS over 30-60 mins + dextrose if hypoglycaemic Cotninue hydrocortisone 6hly until patient is stable Oral replacement may begin after 24h and be reduced to maintenance over 3-4d

Answer 2941

Usually administered via fine bore naso gastric feeding tube Complications relate to aspiration of feed or misplaced tube May be safe to use in patients with impaired swallow Often contra indicated following head injury due to risks associated with tube insertion

Answer 2942

Avoids problems of feed pooling in stomach (and risk of aspiration) Insertion of feeding tube more technically complicated (easiest if done intra operatively) Safe to use following oesophagogastric surgery

Answer 2943

Surgically sited feeding tube May be used for long term feeding Low risk of aspiration and thus safe for long term feeding following upper GI surgery Main risks are those of tube displacement and peritubal leakage immediately following insertion, which carries a risk of peritonitis

Answer 2944

Combined endoscopic and percutaneous tube insertion May not be technically possible in those patients who cannot undergo successful endoscopy Risks include aspiration and leakage at the insertion site

Answer 2945

The definitive option in those patients in whom enteral feeding is contra indicated Individualised prescribing and monitoring needed Should be administered via a central vein as it is strongly phlebitic Long term use is associated with fatty liver and deranged LFT's

Answer 2946

The diagnosis is of an acute haemolytic transfusion reaction, normally due to ABO incompatibility. Haemolysis of the transfused cells occurs causing the combination of shock, haemoglobinaemia and loin pain. This may subsequently lead to disseminated intravascular coagulation. A Coomb's test should confirm haemolysis. Other tests for haemolysis include: unconjugated bilirubin, haptoglobin, serum and urine free haemoglobin. Note that delayed haemolytic reactions are normally associated with antibodies to the Rh system and occur 5-10 days after transfusio

Answer 2947

Day surgery is suitable theoretically for any procedure in which GA time is \<1hr severe dementia severe learning disabilities ASA III and above (unless conditions can be optimised and stabilised pre-operatively) BMI (body mass index) 32 kg/m^2 and above diabetes type I (if sliding scale commenced) infection at the site of surgery social factors uncontrolled pain or nausea expected post-operatively

Answer 2948

Flumazenil Flumazenil antagonises the effects of benzodiazepines by competition at GABA binding sites. Since may benzodiazepines have longer half lives than flumazenil patients still require close monitoring after receiving the drug. An agent which is associated with hepatotoxicity Halothane Halothane is hepatotoxic. Despite this it remains in mainstream use. It should be avoided in patients with hepatic dysfunction, and scavengers should be used in theatres as accumulation of the drug may be injurious to theatre staff. The correct answer is Propofol Propofol is rapidly metabolised and has mild/ moderate anti emetic properties. It is the agent of choice in most day case operations for this reason.

Answer 2949

More typical of conditiosn such as mesenteric adenitis rather than appendicitis

Answer 2950

Maximum normal diameter= 35mm Valvulae conniventes extend all the way across

Answer 2951

Maximum normal diamter= 55mm Haustra extend about a third of the way acrosS

Answer 2952

Renal colic

Answer 2953

CT KUB is most sensitive and specific diagnostic test

Answer 2954

Stones \<5mm will pass within 4w of symptom onset More intensive and urgent treatment required in presence of ureteric obstruciton, renal developmental abnormality or previous renal transplant. Ureteric obstruction due to stones + infection is a surgical emergency.

Answer 2955

Lithotripsy

Answer 2956

Ureteroscopy

Answer 2957

Percutaneous nephrolithotomy

Answer 2958

Manage expectantly

Answer 2959

A shock wave is generated external to the patient, internally cavitation bubbles and mechanical stress lead to stone fragmentation. The passage of shock waves can result in the development of solid organ injury. Fragmentation of larger stones may result in the development of ureteric obstruction. The procedure is uncomfortable for patients and analgesia is required during the procedure and afterwards.

Answer 2960

A ureteroscope is passed retrograde through the ureter and into the renal pelvis. It is indicated in individuals (e.g. pregnant females) where lithotripsy is contraindicated and in complex stone disease. In most cases a stent is left in situ for 4 weeks after the procedure.

Answer 2961

In this procedure access is gained to the renal collecting system. Once access is achieved, intra corporeal lithotripsy or stone fragmentation is performed and stone fragments removed.

Answer 2962

For patients (adults and children) who have sustained a head injury with no other indications for a CT head scan and who are having warfarin treatment, perform a CT head scan within 8 hours of the injury. A provisional written radiology report should be made available within 1 hour of the scan being performed.

Answer 2963

Anal fissures are longitudinal or elliptical tears of the squamous lining of the distal anal canal. If present for less than 6 weeks they are defined as acute, and chronic if present for more than 6 weeks. Around 90% of anal fissures occur on the posterior midline

Answer 2964

Topical steroids have been shown in studies to be of little benefit in treating anal fissures

Answer 2965

Intestinal obstruction

Answer 2966

Urinary retention

Answer 2967

Ovarian cancer

Answer 2968

In this setting Staphylococcus aureus Infection is the most likely cause. In the UK between 2010 and 2011 the commonest cause of wound infection was enterobacter infections (usually following cardiac or colonic surgery). 23% of infections were due to Staph aureus, which fits the scenario above. Infection with the other organisms including strep pyogenes was much rarer.

Answer 2969

Post operative stridor in patients who have undergone neck surgery is a life threatening emergency. Using an ABCDE approach, this patient has potentially compromised airway and breathing. Each patient undergoing head and neck surgery is returned to the ward with a suture blade. In the event of a post operative bleed. If a bleed occurs, the pressure behind the suture line increases and the trachea becomes compressed resulting in stridor. Therefore 3 is the answer becuase immediate removal of the pressure will relieve the stridor. Senior assistance will be required as this patient will require further surgery for haemostasis. Intubation will improve this patients airway and breathing, however taken in the clinical context removal of the compression is the correct answer. For those individuals who chose 1, this is not anaphylaxis. There are no predisposing factors in the question. Moreover to treat anaphylaxis you prescribe 1:1000 intramuscular adrenaline not 1:10,000. Nebulised hypertonic saline will not be of any use in this patient.

Answer 2970

GCS \< 13 on admission GCS \< 15 2h after admission Suspected open or depressed skull fracture Suspected skull base fracture (panda eyes, Battle's sign, CSF from nose/ear, bleeding ear) Focal neurology Vomiting \> 1 episode Post traumatic seizure Coagulopathy

Answer 2971

Persistent GCS \< 8 or = 8 Unexplained confusion \> 4h Reduced GCS after admission Progressive neurological signs Incomplete recovery post seizure Penetrating injury Cerebrospinal leak

Answer 2972

If a c-spine injury is suspected a 3 view c-spine x-ray is indicated. CT c-spine is preferred if: - Intubated - GCS \<13 - Normal x-ray but continued concerns regarding c-spine injury

Answer 2973

The low bicarbonate points to a metabolic acidosis - highly suggestive of mesenteric ischaemia.

Answer 2974

Any elderly gentleman that presents with back pain needs a ultrasound scan to exclude a AAA before any other diagnosis is considered, especially if they have haemodynamic instability.

Answer 2975

Abdominal wall (rectus sheath) haematoma can occur following trauma, either directly to the abdominal wall or iatrogenic trauma from surgery, or can be spontaneous following excessive straining of the rectus muscle. This can occur during prolonged valsalva manoeuvres experienced with strenuous excesses or, in this case, coughing.

Answer 2976

Diffuse oseophagea spasm

Answer 2977

Midline incision

Answer 2978

Paramedian incision

Answer 2979

Battle insicsion

Answer 2980

Gridiron incision

Answer 2981

Pfannenstiel's

Answer 2982

Rutherford Morrison

Answer 2983

Fitz-Hugh Curtis syndrome

Answer 2984

Boas' or Boas's sign is hyperaesthesia (increased or altered sensitivity) below the right scapula can be a symptom in acute cholecystitis (inflammation of the gallbladder).[1] It is one of many signs a medical provider may look for during an abdominal examination.[2] Originally this sign referred to point tenderness in the region to the right of the 10th to 12th thoracic vertebrae.[3] It is less than 7% sensitive.[4][5]

Answer 2985

Classically, Murphy's sign is tested for during an abdominal examination; it is performed by asking the patient to breathe out and then gently placing the hand below the costal margin on the right side at the mid-clavicular line (the approximate location of the gallbladder). The patient is then instructed to inspire (breathe in). Normally, during inspiration, the abdominal contents are pushed downward as the diaphragm moves down (and lungs expand). If the patient stops breathing in (as the gallbladder is tender and, in moving downward, comes in contact with the examiner's fingers) and winces with a 'catch' in breath, the test is considered positive. In order for the test to be considered positive, the same maneuver must not elicit pain when performed on the left side.

Answer 2986

This is a case of Kartagener's syndrome. The primary problem is of immotile cilia syndrome. When associated with situs inversus Kartagener's syndrome is diagnosed. This is a case of Lynch syndrome HNPCC. It is transmitted in an autosomal dominant fashion. This is a case MEN type IIb. It is associated with phaeochromocytomas and is transmitted in an autosomal dominant pattern if inherited. All MEN II tend to have medullary carcinoma of the thyroid as a presenting feature

Answer 2987

Fibre supplementation has been shown to be as effective as injection sclerotherapy in some studies

Answer 2988

The patients social history suggests they have worked in an environment serving alcohol for many years, though this does not mean they were a heavy drinker the raised gamma-glutamyl transpeptidase alludes to this. As a result of heavy drinking the patient has a degree of liver cirrhosis and therefore portal hypertension. This has caused raised venous pressure in the veins of the abdomen. This explains why a source of the bleeding is difficult to identify during the operation, as is typical of extensive venous bleeds. Arterial bleeds are pulsatile in nature and tend to clearly spout from their source. Thrombocytopenia - Would be shown by a low platelet count in the pre-operative full blood count. Disseminated intravascular coagulation - This would cause a prolonged PT and APTT Haemophilia A - This would cause a prolonged APTT Bud Chiari Syndrome - This could also be a cause of portal hypertension, though it is far rarer than cirrhosis. Von Willebrand Disease would be important to rule out in a patient such as this. As it is relatively common, and PT and APTT can both be norm

Answer 2989

Arterial pH and lactate Arterial phase CT scanning is the most sensitive test

Answer 2990

Immediate laparotomy and resection of affected segments, in acute embolic events SMA embolectomy may be needed.

Answer 2991

This patient has an asymptomatic inguinal hernia. Studies looking at conservative management tend to find that many patients become symptomatic and eventually have surgery anyway. As this patient is medically fit most clinicians would refer for surgical repair.

Answer 2992

CT imaging of the head is currently the primary investigation of choice for detecting clinical important brain injuries in the acute setting. For safety, logistic and resource reasons MRI is not the investigation of choice in this setting. NICE recommends that patients who are taking warfarin who suffer a head injury should receive a CT head scan within 8 hours, even without further indications. If the patient has any indications for a CT head scan within 1 hour, this would obviously take precedence.

Answer 2993

NICE recommends that patients who suffer a head injury with loss of consciousness or amnesia, and who are aged over 65 years old, should have a CT head scan within 8 hours. If the patient had an indication for a CT head scan within 1 hour, obviously this would take precedence. The indications for CT head scan within 1 hour and within 8 hours, are found below.

Answer 2994

Infection with human papilloma virus 16 is a risk factor for the development of intra epithelial dysplasia of the anal skin with subsequent increased risk of invasive malignancy.

Answer 2995

The correct answer is Staphylococcus epidermidis This tends to colonise plastic devices and forms a biofilm which allows colonisation with other bacterial agents. It is notoriously difficult to eradicate once established and the usual treatment is removal of the device. -coli and bacteroides This is likely to be Fournier's Gangrene. A number of agents are implicated. E-coli and bacteroides are the most commonly isolated organisms. The key point is that both aerobic and anaerobic organisms must be present and only A has this option. Streptococcus viridians This is the most common organism affecting previously abnormal heart valves

Answer 2996

NICE recommend the following regarding postoperative wound cleansing: Use sterile saline for wound cleansing up to 48 hours after surgery. Advise patients that they may shower safely 48 hours after surgery. Use tap water for wound cleansing after 48 hours if the surgical wound has separated or has been surgically opened to drain pus.

Answer 2997

Air leak Damage to the lung substance may produce an air leak. Air leaks will manifest themselves as a persistent pneumothorax that fails to settle despite chest drainage. When suction is applied to the chest drainage system, active and persistent bubbling may be seen. Although an anastomotic leak may produce a small pneumothorax, a large volume air leak is more indicative of lung injury. Portal vein thrombosis Such marked intra-abdominal sepsis may well produce coagulopathy and the risk of portal vein thrombosis. Chyle leak Damage to the lymphatic duct may occur during this procedure and some surgeons administer a lipid rich material immediately prior to surgery to facilitate its identification in the event of iatrogenic damage.

Answer 2998

you can also see the Hx which risk factors do the patient present with. CAD risks are more likely for mes ischemia. This particular pt has afib, a strong risk for emboli. dec in blood flow (eg decomp CHF, prolonged shock, dehydration) accompanied w abd pain and bloody diarrhea, will point to ischemic colitis.

Answer 2999

The correct answer is Non-seminomatous testicular cancer A raised alpha-feto protein level excludes a seminoma

Answer 3000

The CT shows multiple dilated loops of small bowel. CT is more sensitive than radiographs and will also demonstrate the cause in around 80% of cases. There are variable criteria for maximal small bowel obstruction, but 3.5 cm is a conservative estimate of dilated bowel. Note the protrusion of small bowel through the inguinal ring

Answer 3001

phimosis recurrent balanitis balanitis xerotica obliterans paraphimosis

Answer 3002

Voiding symptoms: weak or intermittenet flow, straining, hesitancy, terminal dribbling, incomplete emptying Storage symptoms: urgency, frequency, urgency incontinence and nocturia Post micturition: Dribbling Cx: UTI, retention, obstructive uropathy

Answer 3003

Watchful waiting Rx: Alpha 1 antagonists 5 alpha reductase inhibitor Medical therapy of prostatic symptoms trial: (MTOPS) advocated combination therapy Sx: TURP

Answer 3004

Tamsulosin Afluzosin

Answer 3005

Decrease smooth muscle tone (prostate and bladder)

Answer 3006

Considered first line Improve symptoms in 40% of men

Answer 3007

Dizziness Postural hypotension Dry mouth Depression

Answer 3008

Block the conversion of testosterone to DHT (testosterone known to induce BPH)

Answer 3009

unlike alpha-1 antagonists causes a reduction in prostate volume and hence may slow disease progression. This however takes time and symptoms may not improve for 6 months. They may also decrease PSA concentrations by up to 50%

Answer 3010

ED Reduced libido Ejaculation problems Gynaecomastia

Answer 3011

Tip of the 9th costal cartilage

Answer 3012

Half way between the umbilicus and pubic crest

Answer 3013

L1 vertebra 9th Costal cartilage

Answer 3014

Pylorus Fundus of the gallbladder Origin of SMA Duodojejunal junction Neck of pancreas Hila of kidneys Formation of portal vein

Answer 3015

L4/L5 Also location of bifurcation of the aorta

Answer 3016

CCF Cirrhosis Lymphoreticular disease Budd Chiari Amyloid

Answer 3017

Hepatitis Biliary tract obstruction Cholangitis Portal pyaemia

Answer 3018

2o mets Macronodular cirrhosis Polycystic disease Primary HCC

Answer 3019

Extensive 2o mets Cirrhosis Localised swellings: Reidel's lobe Hydatid cyst Liver abscess

Answer 3020

LUQ to RIF mass Notch Moves with respiration Dull to precussion Cannot get above it Not ballotable

Answer 3021

Polycystic kidneys

Answer 3022

Look- location, parastomal hernia Stoma: stoma itself, colour, surface ect. Bag + contents and surroundings Abdomen Ask to inspect perineum Palpate around and inside the stoma: need gloves and KY jelly Site Calibre Number of lumens Funcitoning Healthy

Answer 3023

Paraumbilical are crescenteric Umbilical are hemispherical

Answer 3024

There will be no palpable defect in diverification whereas with hernia, can palpate defect

Answer 3025

Bright fresh rectal bleeding- visible with proctoscope: haemorrhoids Dark mixed in bleeding: upper GI/right colon

Answer 3026

= defunctioning Pathology taken out

Answer 3027

Loop ileostomy

Answer 3028

Loop ileostomy: - High output stoma + easy to make, easy to reverse Loop colostomy: - Tend to prolapse - Harder to reverse + Not high output

Answer 3029

Feeding tube: into jejunum, can be guided under radiology Used in high output stomas Longer term than NGT

Answer 3030

LT use can lead to oesophageal stenosis

Answer 3031

Decreasing pressure up to knee Compress blood upwards Used in combination with calf exercises

Answer 3032

?Pelvic malignancy

Answer 3033

Megarectum i.e. constipation

Answer 3034

Larynx is barrier to weaning from ventilation. Easier to wean from LT ITU ventilation or patients with elective maxfax sx

Answer 3035

Central venous O2: if \>75% patient adequately filled

Answer 3036

Abdomen due to risk of fistula Can be used following breast sx etc

Answer 3037

Aortobifemoral bypass graft

Answer 3038

Access to retroperitoneal iliac artery

Answer 3039

Thoracolaparotomy Used for approaches to aort above the renal artery

Answer 3040

Access to carotid for carotid endarterectomy

Answer 3041

Femorofemoral crossover graft

Answer 3042

Access axillary artery with cross over to both femorals

Answer 3043

Blockage in aorta or iliacs

Answer 3044

= long saphenous vein harvest scar.

Answer 3045

Greater than two weeks duration (otherwise acute) Rest pain or tissue loss Ankle pressure of less than 40mmHg or \<0.6ABPI

Answer 3046

1 popliteal aneurysm 50% chance of having another 1 popliteal aneurysm 10% chance of infrarenal aneurysm

Answer 3047

Small aneurysm trial showed that sureillance is safe for patients under 5.5cm

Answer 3048

Can be due to an additional cervical rib, can be due to overgrowth of scalene, can be due to prolonged abudction e.g. violinists, cellists Can be classified as: Venous: upper limb DVT and long term swelling: heparinise Arterial: raynauds, claudication, embolisation Neurological: pain, radiculopathy

Answer 3049

0-15 15-30 30-40 Game

Answer 3050

Autlogous saphenous vein

Answer 3051

First due to exposure to acid

Answer 3052

Pain Swelling Crepitus Deformity Adjacent structural injury: nerves/vessels/ligament/tendons

Answer 3053

Translation (lateral): proximal/distal. ant/post. medial/lateral Angulation: internal/external rotation. dorsal/volar/ varus/valgus

Answer 3054

Monoplanar (i.e. in one plane) Multiplaner e.g. circular ext fixation

Answer 3055

When there is extensive soft tissue injury or complex periarticular fracture.

Answer 3056

100% of external fixators are infected. Pins get infected but controllable, prevents infection in the bone. Allows control of infection

Answer 3057

Immediate Early Late under these, local and general

Answer 3058

General (early or late): Fat embolus DVT Infection Prolonged immobility: UTI Specific: Neurovascular injuery Muscle/tissue injury Non/malunion Compartment synrome Local infection Degenerative change Reflex sympathetic dystrophy AVN Growth disturbance

Answer 3059

Weight bearing views

Answer 3060

Coming down the stairs is like 5x your body weight. If you lose 5kg- like reducing 25kg of strain on knee

Answer 3061

Pain in all ranges of movement with a normal shoulder xray. (mostly external rotation is limited)

Answer 3062

Adductor weakness/rupture Leg length discrepancy Prosthesis failure Infection

Answer 3063

Red flag, require cystoscopy

Answer 3064

Doesn't exclude underlying cause May mean presentation is earlier

Answer 3065

Cyclophosphamide

Answer 3066

Micro and macroscopic

Answer 3067

Upper UT: Kidney stones TCC of renal pelvis RCC Inury to kidney: tear Medical causes e.g. nephritis... TB Ureter: luminal: stone mural: tumour e.g. malignant stricture or urothelial Lower urinary tract Bladder: stone, tumour, injury to bladder Prostate: distended veins over large prostate, prostatitis, prostate cancer Urethra Testes

Answer 3068

Bladder Ca

Answer 3069

Cyclophosphamide

Answer 3070

All frank haematuria Persistent haematuria with dysuria in the absence of UTI Micro/macrohaematuria with LUTS Female retention with pain and haematuria

Answer 3071

Renal bladder/ USS

Answer 3072

CT urogram

Answer 3073

Noninvasive Differentiates between cyst and solid (tumour) Any evidence of hydronephrosis

Answer 3074

Examination of KUB before and after IV contrast material. Cotrol CT, 5 and 15 min scans. Picks up urothelial filling defects. Instead of IV pyelogram

Answer 3075

Non contrast CT scan of the kidneys, ureturs and bladder Dx of renal stones which show up as white within the urinary trract Taken at 2.5mm cuts

Answer 3076

Scan used to further evaluate renal tumours Non contrast: look for fat in tumour (to ensure not angiomyolipoma) Arterial: contrast enhancement Venous phase Examines location of tumour, size, renal vein involvement, any LNs or distant mets. Always comment on presence/absence/state of contralateral kidney

Answer 3077

Smokers Occupational exposure to chemicals/dyes History of persistent dysuria History of phenacitin abuse Hx of pelvic Rtx Cyclophosphamide exposure

Answer 3078

TURBT R/V stage and grade

Answer 3079

Allows examination of bladdder under blue light Red patch shows TCC in situ Enhances view

Answer 3080

CIS Ta: confined to mucosa T1: in the lamina propria T2: in the muscularis propria T3: into perivesical fat

Answer 3081

Mucosa Submucosa Muscularis propria Pervivesical fat

Answer 3082

Intravescial immunotherapy: BCG Close cystoscopic surveillance Ultimately radical cystectomy

Answer 3083

Present with bladder pain and dysruia If untreated for 2y: 50% develop invasive TCC Treated with intravesical BCG with radical cystectomy for those who fail to respond

Answer 3084

Nephroureterectomy (kidney, ureteur and cuff of bladder) Ureteroscopy and laser for low grade tumours in unfit patients/solitary kidneys

Answer 3085

Urine carries malignant cells down to bladder 20-40% incidence of bladder TCC

Answer 3086

Usually an incidental finding on abdo USS

Answer 3087

Haematuria Loin pain Palpable mass Late presentaiton

Answer 3088

Stauffer syndrome is a constellation of signs and symptoms of liver dysfunction that arise due to presence of renal cell carcinoma, and, more rarely, in connection with other malignant neoplasms, though the specific pathogenesis is currently unknown. It is named for Dr. Maurice Stauffer, a gastroenterologist at the Mayo Clinic in Rochester, MN. The hepatic abnormalities are not due to tumor infiltration of the liver or intrinsic liver disease; they instead reflect the presence of a paraneoplastic syndrome.[1] Stauffer syndrome causes abnormal liver function tests, especially those that reflect the presence of cholestasis, i.e. abnormal bile flow. Hepatosplenomegaly may also be observed. The symptoms and signs resolve if the renal cell carcinoma (or another associated tumor) is successfully ablated

Answer 3089

High clacium LFTs (stauffer syndrome)

Answer 3090

Stage 1 \<7cm Stage 2: \>7cm Stage 3: Invading into renal vein or into Gerota's fascia Stage IV: to other organs/LNs

Answer 3091

Fascia covering kidney

Answer 3092

Treated conservatively: active surveillance, total/partial nephrectomy, radiofrequency ablation or cryotherapy AKA Small renal mass (SRM)

Answer 3093

Radical nephrectomy: lap or open Lap unless massive

Answer 3094

Solitary Bilateral renal mass Renal impairment

Answer 3095

85% calcium 15% combination or uric acid (radiolucent) cystine and struvite Struvite stones: combination of Mg, NH3 and P: occur in infected urine

Answer 3096

Urease producing bacteria: Staghorn calculi are composed of struvite (MAP, magnesium ammonium phosphate) and are usually seen in the setting of recurrent urinary tract infection with urease producing bacteria (e.g. Proteus, Klebsiella, Pseudomonas and Enterobacter).

Answer 3097

Indication for admission

Answer 3098

Rectal diclofenac

Answer 3099

\<5mm have an 80% chance of passing spontaneously

Answer 3100

Storage symptoms: Weak stream Straining Hesitancy Terminal dribbling Incomplete emptying Voiding: Urgency Frequency Nocturia Incontinence Post micturition dribbling

Answer 3101

Treatment: alpha blockers: relax neck of bladder e.g. alfusoin, tamsulosin 5 alpha reductase inhibitor e.g. finasteride (takes 6m) Can be used in combination: combidart Surgical: TURP Enulceation of prostate If very large: open prostatectomy (Millin's prostatectomy) Freyer's prostatectomy (transvesicular) used if patient has a stone with the prostate

Answer 3102

DRE PSA Flow rate US prostate (MRI is used more and more) Bone scan if ?mets

Answer 3103

\<1 hour To prevent turp syndrome

Answer 3104

Can be biopsied transrectally or transperineal. Stage 1: confined to periphery Stage 2: in both lobes May not be palpable Stage 3: multiple and palpable LN Stage 4: in contiguous organs Palpable

Answer 3105

Active surveillance Hormone treatment RTx/Brachytherapy Sx: radical prostatectomy Cryotherapy/HIFU

Answer 3106

10d Seen same day Painless enlarging lump in body of testes

Answer 3107

Inguinal: The inguinal orchiectomy is a necessary procedure if testicular cancer is suspected. While it is possible to remove a testicle through an incision in the scrotum, this is not done when cancer is suspected because it disrupts the natural lymphatic drainage patterns. Testicular cancer usually spreads into the lymph nodes inside the abdomen in a predictable manner. Cutting the skin in the scrotum may disrupt this and cancer may spread to the inguinal lymph nodes, making surveillance and subsequent operations more difficult.

Answer 3108

Chemo BEP/CHOP may need retroperitoneal LN dissection One of the problems is retrograde ejaculation so need to consent

Answer 3109

Used for irrigation/haematuria/post TURP/TURBT Coude tipped, allow irrigation to prevent clot causing outflow obstruction

Answer 3110

Used to size them Green is the smallest

Answer 3111

Hollow tube: urine drains through and around Ureter stops peristalsing and dilates- can allow the uretur to become suitable for ureteroscopy

Answer 3112

Antegrade: from above Retrograde: from below

Answer 3113

Inspection or urethra and bladder under LA

Answer 3114

Inspection of urethra and bladder under GA

Answer 3115

Contrast examination of ureter

Answer 3116

Under GA: obstructed ureter

Answer 3117

Percutaenous nephrolithotomy (insertion of a scope directly into the kidney to laser stones in the kdiney): GA

Answer 3118

Removal of non functioning kidney: lap or open

Answer 3119

Removal of kidney for cancer: kidney/perinephric fat and adrenal gland

Answer 3120

Bloods: FBC: Hb LFTs: mets Tumour marker: CEA Imaging: CXR: lung mets USS liver: mets CT and MRI: staging, MRI best for rectal Ca and liver mets Endoanal US: staging rectal tumours Ba/gastrograffin enema: apple-core lesion Endoscopy + biopsy: Flexi sig: 65% of tumors accessible Colonoscopy

Answer 3121

Apple-core sign CRC

Answer 3122

Dukes (Sir Cuthbert Dukes: St Mary's Pathologist)

Answer 3123

A: confined to bowel wall :90% B: through bowel wall but no LNs: 60% C: Regional LNs: 30% D: Distant mets: \<10% 5ys

Answer 3124

Tis: carcinoma in situ T1: submucosa T2: muscularis propria T3: subserosa T4: through serosa to adjacent organs N1: 1-3 nodes N2: \>4 nodes

Answer 3125

Grading from low to high based on cell morphology Dysplasia, mitotic index, hyperchromatism

Answer 3126

MDT Confirm Dx Stage with CT or MRI 60% amenable to radical Sx

Answer 3127

Use ERAS pathway Pre-operative bowel prep (except R sided lesions) e.g. Kleen Prep (macrogol: osmotic laxative) the day before and phosphate enema in the AM Consent for stoma Stoma nurse consult for siting

Answer 3128

Excision depends on lymphatic drainage which follows the arterial supply Mobility of bowel and blood supply at cut ends is also important Hartmann's often used if obstruction Laparoscopic approach is the standard of care

Answer 3129

\>40y reporting rectal bleeding with change in bowel habit persisting for \>6w \>60 with retal bleeding for \>6w without change in bowel habit \>60 with change in bowel habit without rectal bleeding Of any age with right lower abdominal mass consistent with involvement of large bowel Of any age with palpable rectal mass (intraluminal and not pelvic, if pelvic requires referral to uro or gynae) Men of any age with unexplained IDA and Hb \<11 Non-menstruating women with unexplained IDA and Hb \<10

Answer 3130

Neoadjuvant RTx may be used to reduced local recurrence and increase 5y survival Anterior resection AP resection + total mesorectal excision

Answer 3131

Tumour 4-5cm from anal verge Defunction with loop ileostomy

Answer 3132

\<4cm from anal verge

Answer 3133

For tumours of the middle and lower third Aims to reduce recurrence Increased anastomotic leak and feacal incontinence

Answer 3134

High anterior resection or sigmoid colectomy

Answer 3135

Left hemicolectomy

Answer 3136

Extended right hemicolectomy

Answer 3137

Right hemicolectomy

Answer 3138

Local exision: e.g. transanal endoscopic microsurgery Bypass surgery: palliation Hepatic resection: if single lobe mets Stenting: palliation or bridge to surgery in obstruction CTx

Answer 3139

Adjuvant 5-FU for Duke's C reduces mortality by 25% i.e. LN +ve patients High grade tumour Palliation of metastatic disease

Answer 3140

Introduced in 2006 60-75y Home FOB every 2y: 1/50 have +ve FOB Colonoscopy if +ve: 1/10 have Ca Lindholm et al BJS: screening reduced risk of dying from CRC by 25%

Answer 3141

Introduced inn 2011/12 One off screen at 55 Atkin et al Lancet: Reduced CRC incidence by 33% Reduced CRC mortality by 43%

Answer 3142

Autosomal dominant APC gene on 5q21

Answer 3143

Familial Adenomatous Polyposis

Answer 3144

Attenuated FAP

Answer 3145

FAP variant Thyroid tumours Osteomas of the mandible, skull and long bones Dental abnormalities: supernumerary teeth Epidermal cysts

Answer 3146

Variant of FAP In addition: CNS tumours medullo and glioblastomas

Answer 3147

Prophylactic colectomy before 20y Total colectomy + IRA: requires life long stump surveillance Proctocolectomy: IPAA Remain at risk of Ca in stomach and duodenum, require endoscopic screening

Answer 3148

AD Mutation of MMR enzymes e.g. MSH2 on Chr 2p Commonest cause of hereditary CRC: 3% of all CRC

Answer 3149

HNPCC right sided CRC

Answer 3150

CRC + gastric, endometrial, prostate, breast

Answer 3151

1 is familial colon cancer 2 is associated with other Ca of the GIT and reproductive tissue

Answer 3152

Amsterdam II criteria 3 or more relatives with an associated cancer (CRC, endometrial, small intestine, uretur or renal pelvis) 2 or more successive generations involved At least 1 diagnosed \<50y/o 1 should be a first degree relative of the other 2 FAP should be exluded Tumours should be verified via pathologic examination

Answer 3153

AD STK11 mutation

Answer 3154

Peutz-Jehgers

Answer 3155

Peutz Jehgers

Answer 3156

Inflammatory pseudopolyps Hyperplastic polyps Hamartomatous Neoplastic

Answer 3157

Regnerating islands of mucosa in UC

Answer 3158

Piling up of goblet cells and absorptive cells Serrated surface architecture No malignant potential

Answer 3159

Hyperplastic polyps

Answer 3160

Hamartomous polyps

Answer 3161

Juvenile polyp

Answer 3162

Neoplastic polyps

Answer 3163

Juvenile polyposis

Answer 3164

Cowden syndrome

Answer 3165

Arterial Non occlusive Venous Other

Answer 3166

Thrombotic (35%), embolic (35%)

Answer 3167

Splanchnic vasoconstriction e.g. 2o to shock

Answer 3168

Trauma, vasculitis, strangulation

Answer 3169

Arterial (70%) (non-occlusive-20%, VT- 5%)

Answer 3170

Acute severe abdominal pain +/- PR bleed Rapid hypovolaemia-\> shock No abdominal signs

Answer 3171

?acute mesenteric ischaemia

Answer 3172

Bloods: Raised Hb: plasma loss Raised WCC Raised amylase Persistent metabolic acidosis: raised lactate Imaging: AXR- gasless abdomen Arteriography/CT/MRI angio

Answer 3173

Septic peritonitis SIRS-\> MODS

Answer 3174

Fluids Abx: gent + met LMWH Laparotomy: resect necrotic bowel

Answer 3175

Atheroma + low flow state e.g. LVF

Answer 3176

Chronic small bowel ischaemia

Answer 3177

Mx: angioplasty

Answer 3178

Follows low flow in IMA territory

Answer 3179

?Chronic large bowel ischaemia

Answer 3180

Raised WCC Ba enema: thumb-printing MR angiography

Answer 3181

May-\> peritonitis and septic shock Strictures in the LT

Answer 3182

Usually conservative: fluids and Abx Angioplasty and endovascular stenting

Answer 3183

Rectal: haemorrhoids, fissure Diverticulitis Neoplasm

Answer 3184

Important: Rectal: haemorrhoids, fissure Diverticulitis Neoplasm Other: IBD Infection: shigella, campylobacter, C diff Polyps Large upper GI bleed (15% of lower GI bleeds) Angio: dysplasic, ischaemic colitis, HHT

Answer 3185

Colonic ischaemia

Answer 3186

FBC, U+E, LFT, x-match, clotting, amylase Stool: MCS Imaging: AXR erect CXR Angiography: necessary if no source on endoscopy Endoscopy

Answer 3187

1st: Rigid proctoscopy/sigmoidoscopy 2nd: OGD 3rd: colonoscopy: difficult in major bleeding

Answer 3188

ABC Urinary catheter Abx if evidence of sepsis or perf PPI if upper GI bleed Keep bed bound: need to pass stool may be large bleed-\> collapse Stool chart Diet: keep on clear fluids (allows colonoscopy) Surgery: only if unremitting, massive bleed

Answer 3189

Submucosal AV malformation 70-90% occur in right colon Can affect anywhere in GIT

Answer 3190

Elderly Fresh PR bleeding

Answer 3191

Exlcude other dx: PR, Ba enema, colonoscopy Mesenteric angiorgraphy or CT angiography Tc-labelled RBC scan: indentify active bleeding

Answer 3192

Embolisation Endoscopic laser electrocoagulation Resection

Answer 3193

Soft Subcutaneous Imprecise margin Fluctuant

Answer 3194

Non-surgical Surgical excision

Answer 3195

Dercum's disease/Adiposis dolorosa Familial Mutliple Lipomatosis Madelung's Disease Bannayan-Zonana Syndrome

Answer 3196

Multiple painful lipomas Associated with peripheral neuropathy Obese, postmenopausal women Dercum's disease was first described at Jefferson Medical College by neurologist Francis Xavier Dercum in 1892

Answer 3197

is a rare condition that is characterized by multiple lipomas on the trunk and extremities. As the name suggests, FML is diagnosed when multiple lipomatosis occurs in more than one family member, often over several generations. The lipomas associated with FML are usually painless, but may impact quality of life as they can be numerous and large.[1][2] Although the condition appears to be passed down through families in an autosomal dominant manner, the underlying genetic cause is currently unknown.[3]Treatment is based on the signs and symptoms present in each person. Surgical excision may be necessary if the tumors interfere with movement and/or daily life.[1][2

Answer 3198

Benign symmetric lipomatosis (also known as Benign symmetric lipomatosis of Launois–Bensaude, Madelung's disease, multiple symmetric lipomatosis, and cephalothoracic lipodystrophy) is a cutaneous condition characterized by extensive symmetric fat deposits in the head, neck, and shoulder girdle area.[1] The German surgeon Otto Wilhelm Madelung was the first to give a detailed description of the disorder. This condition is very rare, with an estimated incidence rate of 1 in 25,000, and affects males up to 30 times more frequently than females.[2] The cause of the disease remains unknown, but its incidence strongly correlates with alcohol abuse; abstinence from alcohol prevents disease progression. Defects in the adrenergic-stimulated lipolysis and accumulation of embryological brown fat have also been reported. Cosmetic disfigurement due to the fat deposition in the cervicothoracic region results in a "pseudoathletic appearance", resembling the Italian statue Warrior of Capestrano and carvings of Queen of Punt (Egypt).[3] Traditionally the treatment is mainly surgical, consisting of the removal of the lipomas, although recent study has proposed liposuction and phosphatidylcholine injection as possible alternatives.[4]

Answer 3199

Madelung's disease

Answer 3200

Multiple lipomas Macrocephaly Haemangiomas AD

Answer 3201

Sebaceous cyst

Answer 3202

Epidermal cyst: arise from hair follicle infundibulum Trichilemmal cyst/Wen Arise from hair follicle epithelium Often multiple May be AD

Answer 3203

Sebaceous cyst

Answer 3204

Infection: pus discharge Ulceration Calcification

Answer 3205

Cock's Peculiar Tumour

Answer 3206

Non-surgical or with excision

Answer 3207

Cock's peculiar tumour

Answer 3208

Bursae Cystic protrusion from synovial cavity of arthritic joint

Answer 3209

Non-surgical: Aspiration followed by 3w of immobilisation Surgical excision: Recurrence can be 50% Risk of neurovascular damage

Answer 3210

Seborrhoeic keratosis

Answer 3211

Seborrheic keratosis

Answer 3212

Nonsurgical

Answer 3213

Seborrheic keratosis

Answer 3214

Neurofibroma

Answer 3215

Neurofibroma

Answer 3216

Surgical excision only indicated if malignant growth suspected Local regrowth is common

Answer 3217

Excision and diathermy to control bleeding

Answer 3218

Pyogenic granuloma NB neither pyogenic nor a granuloma

Answer 3219

Possibly associated with previous trauma More common in pregnancy

Answer 3220

Curettage with diathermy at the bases

Answer 3221

Pyogenic granuloma

Answer 3222

Dermoid cyst

Answer 3223

Dermoid cyst

Answer 3224

Congenital/inclusion: Developmental inclusion of epidermis along lines of skin fusion Midline of neck and nose Medial and lateral ends of eyebrows Acquired/implantation: Implantation of epidermis in dermis Often 2o to trauma e.g. piercing

Answer 3225

CT to establish extent Surgical excision

Answer 3226

Surgical excision

Answer 3227

Have you always had it Trauma

Answer 3228

Dermatofibroma

Answer 3229

Dermatofibroma

Answer 3230

Melanoma, BCC Requires excision and histology

Answer 3231

Keratoacanthoma

Answer 3232

Typically regress As it cannot be clinically differentaited from SCC with reliability they require surgical treatment

Answer 3233

F\>M: 1.5:1 10000/yr and 2000 deaths/yr Increased 80% over past 20y

Answer 3234

Asymmetry Border: irregular Colour: \>1 Diameter: \>6m Evolving/elevation

Answer 3235

Sunlight especially intesnse exposure in early years Low Fitzpatrick skin type Increased no of common moles +ve FH Increased age Immunosuppression

Answer 3236

Superficial spreading Lentigo maligna melanoma Acral lentiginous Nodular melanoma Amelanotic

Answer 3237

Superficail spreading

Answer 3238

Superficial spreading melanoma

Answer 3239

Superficial spreading melanoma

Answer 3240

Lentigo maligna melanoma

Answer 3241

Lentigo Maligna melanoma

Answer 3242

Acral lentiginous MM

Answer 3243

Melanonychia: important sign of subungual melanoma

Answer 3244

Acral lentigionous melanoma

Answer 3245

Nodular melanoma

Answer 3246

Nodular Melanoma

Answer 3247

Amelanotic melanoma

Answer 3248

Amelanotic melanoma

Answer 3249

Breslow depth Clark's staging

Answer 3250

Thickness of tumour to deepest point of dermal invasion \<1mm= \>75% 5ys 4mm= 50% 5ys

Answer 3251

MM Stratifies depth by 5 anatomical levles Stage 1: epidermis Stage 5: SC fat

Answer 3252

Excision and 2o margin excision depending on Breslow depth +/- lymphadenectomy +/- adjuvant chemo: may use isolated limb perfusion

Answer 3253

Male sex (more tumours on trunk cf. females) Increased mitosis Satellite lesions

Answer 3254

Squamous cell carcinoma

Answer 3255

Sun exposure: scalp, face, ears, lower leg May arise in chronic ulcers: Marjolin's ulcer Xeroderma pigmentosa

Answer 3256

Xeroderma pigmentosa Increased risk of SCC skin

Answer 3257

Solar/actinic keratosis-\> Bowen's-\> SCC LN spread is rare

Answer 3258

Actinic keratosis

Answer 3259

Actinic keratoses

Answer 3260

Cautery Cryotherapy 5-FU Imiquimod Photodynamic phototherapy

Answer 3261

Bowen's disease= SCC in situ

Answer 3262

Bowen's disease

Answer 3263

Low-grade malignancy-\> very rarely metastasies Locally invasvie

Answer 3264

Ecision: Mohs- complete circumferential margin assessment using frozen section histology Cryo/radio may be used

Answer 3265

85% of neck lumps are LNs: especially if present \<3w Infection: EBV, tonsilitis, HIV Ca: lymphoma or mets 8% are goitres 7% other e.g. sebaceous cyst or lipoma

Answer 3266

Clinical assessment Imaging: USS Cyto/histology: aspiration or biopsy

Answer 3267

Anterior margin of SCM Midline Ramus of the mandible Roof: investing fascia Floor: prevertebral fascia

Answer 3268

Carotid artery aneurysm Tortuous carotid artery Carotid body tumour

Answer 3269

Branchial cysts Laryngocele Goitre Parotid tumour: lump in postero superior area

Answer 3270

Mental process Ramus of the mandible Line between the two angles of the mandible

Answer 3271

Salivary stone Sialadenitis Salivary tumour

Answer 3272

Posterior margin of SCM Anterior margin of trapezius Middle 1/3rd of clavicle

Answer 3273

LNs Cervical ribs Pharyngeal pouch Cystic hygromas Pancoast's tumours

Answer 3274

Thyroglossal cyst Dermoid cyst

Answer 3275

Thyroid isthmus mass Ectopic thyroid tissue

Answer 3276

Embryological remnant 2nd branchial cleft

Answer 3277

Branchial cysts

Answer 3278

Branchial cyst

Answer 3279

Med: Abx for infection Sclerotherapy with OK-432 can be used Sx: Definitive Rx May be difficult due to proximity of carotids

Answer 3280

Branchial sinus or fistula

Answer 3281

Carotid body tumour Very rare Located @ carotid bifurcation Detect pO2, pCO2 and H+

Answer 3282

Chemodectoma

Answer 3283

Doppler or angio: splaying of bifurcation

Answer 3284

Extirpation by vascular surgeon

Answer 3285

Laryngocele

Answer 3286

Dermoid Cyst

Answer 3287

Thyroglossal cyst

Answer 3288

Thyroglossal cyst

Answer 3289

Infected thyroglossal cyst

Answer 3290

Overdevelopment of transverse process of C7 Occur in 1:150

Answer 3291

Cervical rib

Answer 3292

Cervical rib

Answer 3293

Zenker's diverticulum

Answer 3294

Killian's dehiscence (also known as Killian's triangle, Laimer triangle, Laimer-Killian triangle, or Laimer-Haeckermann area) is a triangular area in the wall of the pharynx between the thyropharyngeal and cricopharyngeus of the inferior constrictor of the pharynx

Answer 3295

It is a pseudodiverticulum as it doesn't involve the muscle

Answer 3296

Zenker's diverticulum/Pharyngeal pouch

Answer 3297

Barium swallow

Answer 3298

Excision and cricopharyngeal myotomy Endoscopic stapling

Answer 3299

Cystic hygroma

Answer 3300

Cystic hygroma

Answer 3301

Cystic hygroma

Answer 3302

Excision or hypertonic saline sclerosant May recur

Answer 3303

Pagets disease differs from eczema of the nipple in that it involves the nipple primarily and only latterly spreads to the areolar (the opposite occurs in eczema).

Answer 3304

Amoebic abscesses will tend to present in a similar fashion to other pyogenic liver abscesses. They should be considered in any individual presenting from a region where Entamoeba histiolytica is endemic. Treatment with metronidazole usually produces a marked clinical response.

Answer 3305

A large hyperechoic lesion in the presence of normal AFP is likely to be a haemangioma. An HCC of equivalent size will almost always result in rise in AFP.

Answer 3306

Liver cell adenoma

Answer 3307

Haemangioma

Answer 3308

Mecenchymal hamartomas

Answer 3309

Amoebic abscess

Answer 3310

Liver abscess

Answer 3311

Polycystic liver disease

Answer 3312

Cystadenoma

Answer 3313

Hyatid cysts

Answer 3314

This is typical for a benign adenoma.Benign adenomas often have a lipid rich core that is readily identifiable on CT scanning. In addition the nodules are often well circumscribed.

Answer 3315

Phaeochromocytoma

Answer 3316

During the first stages of treatment, goserelin may cause a transient increase in symptoms of prostatic cancer. This is known as the 'flare effect' and is caused by an initial increase in luteinizing hormone production prior to receptor down-regulation. Flutamide, a synthetic antiandrogen, can be used preemptively to attenuate the tumour flare through its antagonistic effects at androgen receptors. The new onset back pain in this patient is significant and demands further investigation of spinal metastasis.

Answer 3317

This man is malnourished, although he is likely to require surgery it is best for him to be nutritionally optimised first. As he may have reduced surface area for absorption and has a localised perforation TPN is likely to be the best feeding modality.

Answer 3318

The combination of low platelet counts and raised FDP in this setting make DIC the most likely diagnosis.

Answer 3319

Lithotripsy

Answer 3320

Ureteroscopy

Answer 3321

Percutaneous nephrolithotomy

Answer 3322

Manage expectantly

Answer 3323

Topical diltiazem Theme from January 2013 Exam Initial therapy should be with pharmacological agents to relax the sphincter and facilitate healing. This is particularly true in females presenting for the first time

Answer 3324

Aortic injuries that do not die at the scene may have a contained haematoma. Clinical signs are subtle and the diagnosis may not be apparent on clinical examination. Without prompt treatment the haematoma usually bursts and the patient dies.

Answer 3325

Takayasu's arteritis most commonly affects young Asian females. Pulseless peripheries are a classical finding. The CNS symptoms may be variable.

Answer 3326

Takayasu's arteritis

Answer 3327

Gleason score

Answer 3328

Diclofenac

Answer 3329

Diclofenac

Answer 3330

high fluid intake low animal protein, low salt diet (a low calcium diet has not been shown to be superior to a normocalcaemic diet) thiazides diuretics (increase distal tubular calcium resorption)

Answer 3331

cholestyramine reduces urinary oxalate secretion pyridoxine reduces urinary oxalate secretion

Answer 3332

allopurinol urinary alkalinization e.g. oral bicarbonate

Answer 3333

Increased CV risk, likely to be substituted for other NSADIs e.g. naproxen

Answer 3334

Pregnancy and frank haematuria, especially if there is a history of placenta previa or prior caesarean section, should indicate this diagnosis. There is invasive placental implantation into the myometrium, which can rarely extend into the bladder causing severe bleeding.

Answer 3335

APKD is associated with liver cysts (70%), berry aneurysms (25%) and pancreatic cysts (10%). Patients may have a renal mass, hypertension, renal calculi and macroscopic haematuria.

Answer 3336

Renal vein thrombosis is a common feature of renal cell carcinoma as it invades the renal vein. Other features include PUO, left varicocele and paraneoplastic endocrine effects due to erythropoietin factor, renin, ACTH and PTH like substance.

Answer 3337

The symptoms are typical for sialolithiasis. The stones most commonly form in the submandibular gland and therefore may occlude Whartons duct. Stensens duct drains the parotid gland.

Answer 3338

Only 8% of salivary gland tumours affect the sub mandibular gland Of these 50% are malignant (usually adenoid cystic carcinoma) Diagnosis usually involves fine needle aspiration cytology Imaging is with CT and MRI In view of the high prevalence of malignancy, all masses of the submandibular glands should generally be excised.

Answer 3339

Excision 50% are malignant

Answer 3340

The correct answer is Radiotherapy Radiotherapy is routine following breast conserving surgery. Without irradiation the local recurrence rates are approximately 40%.

Answer 3341

he correct answer is Endocrine therapy using letrozole Elderly patients may be managed using endocrine therapy alone. Eventually most will escape hormonal control. In post menopausal women oestrogens are produced by the peripheral aromatization of androgens and aromatase inhibitors are therefore the most popular agent in this age group.

Answer 3342

The combination of a grade 3 tumour and axillary nodal metastasis in a young female would attract a recommendation for chemotherapy. Some may also add herceptin (if they are HER 2 positive).

Answer 3343

Multifocal tumour Central tumour Large lesion in small breast DCIS \>4cm

Answer 3344

Solitary lesion Peripheral tumour Small lesion in large breast DCIS \<4cm

Answer 3345

Whole breast RTx recommended in all those with WLE Offered for T3-T4 tumours in women who've had a mastecomty and those with four or more +ve axillary nodes

Answer 3346

Aromatase inhibotrs e.g. anastrozaloe This is because the process of aromatisation accounts for most oestrogen production

Answer 3347

Heart disorders

Answer 3348

Poor specificity and sensitivity around 33% of men with PSA 4-10 will have prostate cancer. Increases to 0% in PSA10-20 Around 20% with prostate cancer have normal PSA PSA levels increase with age

Answer 3349

BPH Prostatitis and UTI (NICE recommend that PSA test should be postponed for at least 1m) Ejaculation Vigorous exercise Urinary retention Insturmentaiton of the urinary tract (DRE)

Answer 3350

Stag-horn calculi are composed of struvite and form in alkaline urine (ammonia producing bacteria therefore predispose)

Answer 3351

The lesion is unlikely to be a desmoid cyst as these are seldom located either at this site or in this age group. In addition they do not contain hair. Sebaceous cysts will usually have a punctum and contain a cheesy material. Epidermoid cysts contain keratin plugs.

Answer 3352

Adenocarcinoma of the oesophagus

Answer 3353

Peptic stricture

Answer 3354

This mans age, presenting symptoms and normal tumour markers make a seminoma the most likely diagnosis. Epididymo-orchitis does not produce irregular mass lesions which are painless.

Answer 3355

Teratoma or other nonseminomatous germ cell tumours

Answer 3356

Cryptorchidism Infertility FHx Klinfelter's Mumps orchtitis

Answer 3357

Consistency Number Fixation Symmetry Tenderness Face and scalp for infection or neoplasm Chest exam: infection or neoplasm Breast examinatoin Formal full ENT examination Rest of RES

Answer 3358

Symptoms form the lumps e.g. EtOH induced pain General symptoms e.g. fever, malaise, weight loss Systemic disease: PMH, previous operations Social Hx: Ethnic origin, HIV RFs

Answer 3359

Lymphoma and leukaemia infection Sarcoid Tumours

Answer 3360

Bacterial Tonsilitis, dental abscess TB Bartonella henselae Viral: EBV HIV Protozoal Toxoplasmosis

Answer 3361

FBC, ESR, film (atypical lymhpocytes0 TFTs, serum ACE Monospot test, HIV test Radiological: US CT scan Path FNAC Excision biopsy

Answer 3362

Scar confined to wound margins Across flexor surfaces and skin creases Appear soon after injury and regress spontaneously Ang age: commonly 8-20y M=F All races

Answer 3363

Hypertrophic scar

Answer 3364

Scar extends beyond wound margins Earlobes, chin, neck, shoulder, chest Appear months after injury and continue to grow Puberty to 30y F\>M Black and hispanic

Answer 3365

Keloid scar

Answer 3366

Infection Trauma Burns Tension Certain body areas

Answer 3367

Mechanical-pressure therapy Topical silicone gel sheets Intralesional steroid and LA injections Revision of scar with closure by direct suturing

Answer 3368

Migrates from its origin at the foramen caecum at the base of the tonuge Passes behind the hyoid bone Lies anterior to 3rd and 4th tracheal rings in the pretracheal fascia Leaves behind the thyroglossal cyst which atrophies Ectopic thyroid tissue can be found anywhere aloing this descent

Answer 3369

Lingual thyroid Thyroglossal cyst Ectopic thyroid tissue

Answer 3370

Simple colloid goitre: endemic iodine deficiency, sporadic: autoimmune, hereditary, goitrogens e.g. sulphonylureas Grave's Thyroditis: Hashimoto's De Quervain's, Subacute lymphocytic

Answer 3371

Multinodular colloid goitre (commonest) Multiple cysts Multiple adenomas

Answer 3372

Dominant nodule in multinodular goitre Adenoma: hot or cold Cyst Malignancy

Answer 3373

TFTs FBC, Ca, LFTs, eSR Antibodies: anti-TPO, TSH Ix: CXR High resolution US Radionucleotide Tc or I scan Histology or cytology (FNAC can't distinguish adneoma vs follicular Ca). Biopsy Laryngoscopy: Important pre-op to assess vocal cords

Answer 3374

Mechanical obstruction Malignancy Marred beauty Medical Rx failure Mediastinal extension

Answer 3375

Swellling/pain related to food: calculi Malaise, fever, mumps Dry eyes/mouth: Sjogrens (Sicca, Mickulicz)

Answer 3376

Parotitis Sjogrens Sarcoid Amyloid ALL CLD Anorexia or bulimia

Answer 3377

Tumours Stones

Answer 3378

Mumps, Coxsackie A, HIV

Answer 3379

Staph aureus Associated with calculi and poor oral hygiene

Answer 3380

Recurrent unilateral swelling and pain Worse on eating Red, tender, swollen gland (80%) submandibular

Answer 3381

Plain XR or sialography

Answer 3382

Gland excision

Answer 3383

Deflection of ear outwards

Answer 3384

Malignancy

Answer 3385

80% in parotid (80% superficial) 80% are pleomorphic adneomas

Answer 3386

Benign 1st: pleomorphic adneoma 2nd: adenolymphoma (Warthin's) Malignant (CN7 palsy and fast growing) 1st: Mucoepidermoid 2nd: Adenoid cystic

Answer 3387

ENT exam US +/- CT FNAC

Answer 3388

Commonest salivary gland neoplasm (80%) Presentation: 90% in parotid Occur in middle age F\>M Benign and slow growing Histo: different tissue types Rx: superficial parotidectomy

Answer 3389

Benign soft cystic tumour Older men Rx: enucleation

Answer 3390

One of the commonest malignant salivary tumours Highly malignant and often incurable Rapid growth Hard, fixed mass Pain Facial palsy

Answer 3391

Superificial or radical parotidectomy Facia lata face lift for facial palsy

Answer 3392

Facial palsy Salivary fistula Frey's syndrome

Answer 3393

Gustatory sweating Redness and sweating skin over parotid area Occurs in relation to food (inc. thinking) Auriculotemporal branch of CNV3 carrries sympathetic fibres to sweat glands over parotid area and parasympathetic fibres to the parotid Reinervation of divided sympathetic nerves by fibres from the secretomotory branch or auriculotemporal branch of CN V3

Answer 3394

Affects 1/10 women 20,000 cases per year in the UK Commonest cause of cancer death in females 15-54 Second commonest caues of cancer deaths overall

Answer 3395

Familial Oestrogen exposure Other factors

Answer 3396

10% Ca breast is familial One first degree relative = 2x risk 5% assodiated with BRCA mutations BRCA1-\> 80% breast, 40% ovarian BRCA2- 80% bresat

Answer 3397

Early menarche, late menopause HRT, OCP First child \>35y/o Obesity

Answer 3398

Proliferative breast disease with atypia Previous Ca breast Increased age (v. rare \<30) Breast feeding is protective

Answer 3399

Invasive ductal carcinoma

Answer 3400

Non-inavsive pre-malignant condition Microcalcificaiton on mammography 10x increased risk of invasive Ca

Answer 3401

Commonest (70%) of cancers Feels hard (scirrhous)

Answer 3402

Invasive lobular

Answer 3403

Colloid/mucinous

Answer 3404

Inflammatory breast ca

Answer 3405

Phyllodes tumour

Answer 3406

Direct extension-\> muscle and or skin Lymph-\> p'eau d'oange and arm oedema Blood: Bones- bone pain, #, raised Ca Lungs: dyspnoea, pleural effusion Liver- abdo pain, hepatic impairment Brain: headache, seizures

Answer 3407

Inflammatory breast cancer with peau d'orange

Answer 3408

50-70y/o women. Every 3 years. Being extended as a trial to some women aged 47-73

Answer 3409

Reduce breast Ca deaths by 25% 10% false negative rate

Answer 3410

Lump: commonest presentation Usually painless 50% in UOQ +/- axillary nodes Skin changes: Paget's disease of skin: persistent eczema Peau d'orange Nipple: Discharge Inversion Mets: Pathological #s SOB Abdo pain Seizures May present through screening

Answer 3411

Hx and clinical examination Radiology \<35y: US \>35y: US + mammography Pathology Solid lump- core biopsy Cystic lump: FNAC (18g needle) Reassure if clear fluid Send cytology if bloody fluid Core biopsy residual mass Core biospy if +ve cytology

Answer 3412

Bloods: FBC, LFTs, ESR, bone profile Imaging: help staging CXR Liver USS CT scan Breast MRI Bone scan and PET/CT May need wire-guided excision biopsy

Answer 3413

Stage 1: Confined to breast, mobile, no LNs Stage 2: Stage 1 and nodes in ipsilateral axilla Stage 3: Stage 2 + fixation to muscle but not chest wall. LNs matted and fixed and large skin involvement Stage 4: Complete fixation to chest wall + mets

Answer 3414

Tis (no palpable tumour): CIS T1 \<2cm: no skin fixation T2: 2-5cm, skin fixation T3: 5-10cm, ulceration + pectoral fixation T4: \>10cm, chest wall extension, skin involved N1: mobile nodes N2: fixed nodes

Answer 3415

Manage in MDT with individual approach Oncologist Breast sx Breastcare nures Radiologist Histopathologist Try to enroll in a trial Factors: age, fitness, wishes, clinical stage 1-2: surgical 3-4: palliation

Answer 3416

To gain local control

Answer 3417

WLE- conservation surgery Mastectomy- removal of whole breast

Answer 3418

WLE + LN biopsy

Answer 3419

Mastectomy

Answer 3420

Same survival but WLE has increased recurrence rates

Answer 3421

SN= first node that a section of breast drains to If clinically -ve axillary LNs, no need for further dissection if SN is clear

Answer 3422

Blue dye/ radiocolloid injected into tumour Visual inspection/gamma probe at surgery to ID SN SN removed and sent for frozen section If node +ve-\> axillary clearance or RTx

Answer 3423

2 RCTs compared No differences in overall or disease-free surivival Reduced morbidity with SNB alone: lymphoedema Pain numbness

Answer 3424

Axillary sampling: Removal of lower nodes. Clearance or DXT if +ve Axillary clearance: Can be done to various levels

Answer 3425

?Axillary clearance

Answer 3426

Haematoma, seroma Frozen shoulder LTN palsy Lymphoedema

Answer 3427

Nottingham Prognostic Index

Answer 3428

Predicts survival and risk of relapse Guides appropriate adjuvant systemic therapy 0.2 x tumour size + histo grade + nodal status

Answer 3429

Bloom-Richardson system

Answer 3430

RTx CTx Endocrine therapy

Answer 3431

Post-WLE: reduces local recurrence Post-mastecomty: only if high risk of local recurrence. Large, poorly differentiated, node +ve Axillary: node +ve disease Palliation: bone pain

Answer 3432

Pre-menopasual Node High grade Recurrent tumours

Answer 3433

5-FU Epirubicin Cyclophosphamide

Answer 3434

Cardiac toxicity

Answer 3435

Used in ER or PR +ve disease: reduces recurrence, increases survival 5y of adjuvant therapy

Answer 3436

SERM antagonist @ breast Agonist at uterus

Answer 3437

Menopausal symptoms Endometrial Ca

Answer 3438

Aromatse inhibitor-\> reduced oestrogen Better cf. tamoxifen if post-men (ATAC trial)

Answer 3439

Menopausal symptoms

Answer 3440

If pre-menopausal and ER +ve may consider ovarian ablation or GnRH anlogues

Answer 3441

Tamoxifen if ER +ve Chemo for relapse Her 2 +ve tumours may respond to trastuzumab Supportive Bone pain: DXT, bisphosphonates, analgeisa Brain: occassional surgery, DXT, steroids, AEDs Lymphoedema: decongestion, compression

Answer 3442

Offered either at 1o sx or delayed procedure Implants: silastic or saline inflatable

Answer 3443

Latissimus dorsi myocutaneous flap (LDMF) Transverse recturs abdominis myocutaneous flap (TRAM)

Answer 3444

Pedicled flap: skin, fat, muscle and blood supply Supplied by thoracodorsal A via subscapular A Usually used with an implant

Answer 3445

Gold standard Pedicled (inf. epigastric A) or free: attached to internal thoracic artery No implant necessary and combined tummy tuck Risk of abdominal hernia

Answer 3446

Poor circulation: smokers, obese, PVD, DM

Answer 3447

Lat dorsi myocutaneous flap Usually used with implant

Answer 3448

Transverse rectus abdominis myocutaneous flap

Answer 3449

Amastia: complete absence of breast and nipple Hypoplasia more common, some asymmetry normal Accessory nipples: can occur anywhere along the milk line. Present in 1%

Answer 3450

Occurs in 30% of boys at puberty Hormone secreting tumours e.g. sex-cord testicular CLD: hypogonadism and reduced E2 metabolism Drugs: sprionolactone, digoxin, cimetidine

Answer 3451

Cyclical mastalgia

Answer 3452

Non-cyclical mastalgia

Answer 3453

Conservative: Reassurance, better fitting bra Medical: Topical diclofenac Evening primrose oil 2nd line: Danazol (anti-gonadotrophin) is licesnsed for severe pain

Answer 3454

Acute mastitis Fat necrosis Duct ectasia (dilatation) Periductal mastitis

Answer 3455

Benign mammary dysplasia Cystic disease Ductal papilloma

Answer 3456

Fibroadenoma Phyllodes tumour

Answer 3457

Acute mastitis

Answer 3458

Fluclox alone in early stages Fluclox and I+D if abscess

Answer 3459

Fat necrosis

Answer 3460

Analgesia No F/U necessary

Answer 3461

Duct ectasia

Answer 3462

Periductal mastitis

Answer 3463

Need to distinguish from Ca Surgical duct excision if mass present or discharge troublesome Close f/u

Answer 3464

Broad-spectrum abx

Answer 3465

Benign mammary dysplasia Aberration of normal development and involution: Fibroadenosis Cyst formation Epitheliosis Papillomatosis

Answer 3466

Cystic disease

Answer 3467

Duct papilloma

Answer 3468

Triple assessment Reassurance Analgesia Good bra +/- Evening primrose oil Danazol

Answer 3469

Aspiration: green-brown fluid Persistence or blood-\> triple assessment

Answer 3470

Triple assessment Excise due to incresaed risk of Ca

Answer 3471

Fibroadenoma

Answer 3472

Fibroadenoma

Answer 3473

Pnyllodes tumour

Answer 3474

1%/y (10x risk) in ipsilateral breast

Answer 3475

WLE + RTx Extensive or multifocal: mastectomy + reconstruction + SNB

Answer 3476

x10 in both breasts

Answer 3477

Bilateral prophylactic mastectomy or close watching with mammographic screening

Answer 3478

usually underlying invasive or DCIS breast cancer Mastectomy + radio +/- CTx

Answer 3479

Evidence obtained from systematic review of all relevant randomised controlled trials

Answer 3480

Evidence derived from at least one properly designed randomised controlled trial

Answer 3481

Evidence derived from well designed pseudo-randomised controlled trials (e.g. alternate allocation) or historical controls

Answer 3482

Evidence derived from case series or case reports

Answer 3483

Panel or expert opinion

Answer 3484

The intercostobrachial nerves are frequently injured during axillary dissection. These nerves traverse the axilla and supply cutaneous sensation.

Answer 3485

This is a common injury in children. In this case the angulation and displacement have resulted in median nerve injury.

Answer 3486

Application of below knee plaster cast to include the midfoot Theme from 2008 Exam These distal injuries are generally managed conservatively. Conservative management will involve a below knee cast, this will need to extend to the midfoot. It can be substituted for an aircast boot once radiological union is achieved.

Answer 3487

Although, this is a potentially unstable injury operative fixation in this age group generally gives poor results owing to poor quality bone. A below knee cast should be applied in the first instance. If this fails to provide adequate control it can be extended above the knee.

Answer 3488

Weber classification Related to the level of the fibular fracture. Type A is below the syndesmosis Type B fractures start at the level of the tibial plafond and may extend proximally to involve the syndesmosis Type C is above the syndesmosis which may itself be damaged A subtype known as a Maisonneuve fracture may occur with spiral fibular fracture that leads to disruption of the syndesmosis with widening of the ankle joint, surgery is required.

Answer 3489

Theme from September 2012 Exam Theme from September 2013 Exam Nasopharyngeal cancer is strongly associated with wood work. Most cases require an occupational exposure of greater than 10 years and are adenocarcinomas on histology. Most cases are ethmoidal in origin

Answer 3490

Plasma components

Answer 3491

Loss of one blood volume in 24h or loss of 50% of circulating blood volume in 3 hours. Bloods loss of 150ml is also included

Answer 3492

7% of total adult bodweight 5 litres

Answer 3493

Hypothermia Hypocalcaemia Hyperkalaemia Delayed TRs TRALI Coaglopathy

Answer 3494

Blood is refrigerated Hypothermic blood impairs homeostasis Shifts Bohr curve to the left

Answer 3495

Both FFP and plt contain citrate anticoagulant, this may chelate calcium

Answer 3496

Plasma of red cells stored for 4-5w contains 5-10mmol K+

Answer 3497

Occurs as a result of leucocyte antibodies in transfused plasma Aggregation and degranulation of leucocytes in lung tissue accounts for lung injury

Answer 3498

Anticipate once circulating blood transfused 1 blood volume usually drops plt to \<100 1 bv will both dilute and not replace clotting factors Fibrinogen concentration halves per 0.75 blood volume tranfused

Answer 3499

This lady is most likely to have a colovesical fistula complicating diverticular disease of the sigmoid colon. In addition she may also have developed a diverticular stricture resulting in large bowel obstruction. A locally advanced tumour of the sigmoid colon may produce a similar clinical picture. The best investigation of this acute surgical patient is an abdominal CT scan, this will demonstrate the site of the disease and also supply regional information such as organ involvement and other local complications such as a pericolic abscess. A barium enema would require formal bowel preparation and this is contra indicated where large bowel obstruction is suspected. A flexible sigmoidoscopy is unlikely to be helpful and the air insufflated at the time of endoscopy may make the colonic distension worse. A cystogram would provide only very limited information.

Answer 3500

Hinchey classificaiton

Answer 3501

Howell- Jolly bodies Pappenheimer bodies Target cells Irregular contracted erythrocytes

Answer 3502

Takayasus arteritis may be divided into acute systemic phases and the chronic pulseless phase. In the latter part of the disease process the patient may complain of symptoms such as upper limb claudication. In the later stages of the condition the vessels will typically show changes of intimal proliferation, together with band fibrosis of the intima and media.

Answer 3503

Takyasu's arteritis

Answer 3504

Buergers disease

Answer 3505

Giant cell arteritis

Answer 3506

Polyarteritis nodosa

Answer 3507

Wegeners granulomatosis

Answer 3508

FOOSH 1. Transverse fracture of the radius 2. 1 inch proximal to the radio-carpal joint 3. Dorsal displacement and angulation Colles' fracture (dinner fork deformity)

Answer 3509

Smith's fracture (reverse Colles' fracture)

Answer 3510

Bennet's fracture

Answer 3511

Bennet's Fracture

Answer 3512

Monteggia's fracture

Answer 3513

Galeazzi fracture

Answer 3514

Pott's fracture

Answer 3515

Barton's fracture

Answer 3516

Magnesium is required for both PTH secretion and its action on target tissues. Hypomagnesaemia may both cause hypocalcaemia and render patients unresponsive to treatment with calcium and vitamin D supplementation. Magnesium is the fourth most abundant cation in the body. The body contains 1000mmol, with half contained in bone and the remainder in muscle, soft tissues and extracellular fluid. There is no one specific hormonal control of magnesium and various hormones including PTH and aldosterone affect the renal handling of magnesium. Magnesium and calcium interact at a cellular level also and as a result decreased magnesium will tend to affect the permeability of cellular membranes to calcium, resulting in hyperexcitability. Submit answer

Answer 3517

Nocturnal diarrhoea and incontinence are typical of inflammatory bowel disease.

Answer 3518

These are features of anal cancer. Anal cancers arise from the cutaneous epithelium and are therefore typically squamous cell. They are usually sensitive to chemoradiotherapy.

Answer 3519

This is the typical presentation of SRUS. These patients require careful diagnostic work up to elicit the underlying cause of their altered bowel habit. The histological appearances of solitary rectal ulcers are characteristic and extensive collagenous deposits are often seen. This is usually termed fibromuscular obliteration.

Answer 3520

Axillary nerve The Axillary nerve winds around the bone at the neck of the humerus. The axillary nerve is also at risk during shoulder dislocation.

Answer 3521

The patient has a Klumpke's paralysis involving brachial trunks C8-T1. Classically there is weakness of the hand intrinsic muscles. Involvement of T1 may cause a Horner's syndrome. It occurs as a result of traction injuries or during delivery.

Answer 3522

The patient has an Erb's palsy involving brachial trunks C5-6.

Answer 3523

This is another site of sudden deceleration injury. Given the large amount of free fluid, if it were blood, then a greater degree of haemodynamic instability would be expected.

Answer 3524

Duodeno-jejunal flexure disruption. This is another site of sudden deceleration injury. Given the large amount of free fluid, if it were blood, then a greater degree of haemodynamic instability would be expected.

Answer 3525

Brown to black, poorly defined, velvety hyperpigmentation of the skin. Usually found in body folds such as the posterior and lateral folds of the neck, the axilla, groin, umbilicus, forehead, and other areas. The most common cause of acanthosis nigricans is insulin resistance, which leads to increased circulating insulin levels. Insulin spillover into the skin results in its abnormal increase in growth (hyperplasia of the skin). In the context of a malignant disease, acanthosis nigricans is a paraneoplastic syndrome and is then commonly referred to as acanthosis nigricans maligna. Involvement of mucous membranes is rare and suggests a coexisting malignant condition

Answer 3526

nfection with enterobius is extremely common. Pruritus is the main symptom, as there is a lack of tissue invasion it is rare for individuals to have any signs of systemic sepsis.

Answer 3527

Infection with Ascaris lumbricoides usually occurs after individuals have visited places like sub Saharan Africa or the far east. Unlike ancyclostoma duodenale infection there is usually evidence of both worms and eggs in the stool. The absence of pruritus makes enterobius less likely. The presence of coughing may be due to the migration of the larva through the lungs.

Answer 3528

Ancylostoma duodenale

Answer 3529

Enterobiasis

Answer 3530

Ascariasis

Answer 3531

Strongyloidiasis

Answer 3532

Cryptosporidium

Answer 3533

Giardiasis

Answer 3534

Luminal Mural Extramural

Answer 3535

Stones Blood clots Sloughed papilla

Answer 3536

Congenital/acquired stricture Tumour: renal, ureteric, bladder Neuromuscular dysfunction

Answer 3537

Prostatic enlargement Abdo/pelvic mass/tumour Retroperitoneal fibrosis

Answer 3538

Loin pain-\> groin

Answer 3539

Bladder outflow obstruction precedes severe suprapubic pain with distended palpable bladder

Answer 3540

Flank pain Renal pain (may be polyuric)

Answer 3541

Frequency, hesitancy, poor stream, terminal dribbling, overflow incontinence Distended, palpable bladder +/- large prostate PR

Answer 3542

Bloods: FBC, U+E Urine: dip, MC+S Imaging: USS- hydronephrosis/hydrouretur Anterograde/retrograde ureterograms (allow therapeutic drainage) Radionucleotide imaging: renal function CT/MRI

Answer 3543

Nephrostomy Ureteric stent

Answer 3544

Urethral or suprapubic catheter- may be a large post-obstructive diuresis

Answer 3545

Common: Infection Haematuria Trigonal irritation Encrustation Rare: Obstruction Ureteric rupture Stent migration

Answer 3546

Trauma: instrumentation, pelvic fractures Infection e.g. gonorrhoea CTx Balanatitis xerotica obliterans

Answer 3547

Voiding difficulty Hesitancy Strangury Poor stream Terminal dribbling Pis en deux

Answer 3548

Urinary urgency shortly after voiding

Answer 3549

PR: exclude prostatic cause Palpate urethra through penis Examine meatus

Answer 3550

Urodynamcs: reduced peak flow, increased micturition time Urethroscopy and cystoscopy Retrograde urethrogram

Answer 3551

Internal urethrotomy Dilatation Stent

Answer 3552

Acute retention on a chronic background may go unnoticed for days due to lack of pain Se Cr may be up to 1500uM Renal function should return to normal over days although some background impairment may remain

Answer 3553

Hyperkalaemia Metabolic acidosis Post-obstructive diuresis Na and HCO3 losing nephropathy Infection

Answer 3554

Kidneys produce a lot of urine in the acute phase after relief of obstruction Must keep up with losses to avoid dehydration

Answer 3555

Diuresis-\> loss of Na and HCO3 May require replacement with 1.26% NaHCO3

Answer 3556

Obstructive Neurological Myogenic

Answer 3557

BPH Urethral stricture Clots, stones Constipation

Answer 3558

Increased smooth muscle tone (alpha adrenergic) Post-op pain Drugs

Answer 3559

Interruption of sensory or motor innervation pelvic sx, ms, dm, spinal injury/compression

Answer 3560

Over-distension of the bladder Post-anaesthesia High EtOH intake

Answer 3561

Acute urinary retention

Answer 3562

Blood: FBC, U+E, PSA (prior to PR) Urine: dip, MC+S Imaging: US- bladder volume, hydropnephrosis Pelvic XR

Answer 3563

Conservative: analgesia, privacy, walking, running water or hot bath Catheterise: Use correct catheter (e.g. 3 way if clots) +/- STAT gent cover Hourly UO + replace: post-obstruction diuresis Tamsulosin: redcued risk of recatheterisation after retention TWOC after 24-72h: can be d/c and have OPD f/U. More likely to be successful if predisposing factor and lower residual volume

Answer 3564

Failed TWOC Impaired renal function Elective

Answer 3565

High pressure Low pressure

Answer 3566

High detrusor pressure @ end of micturition Typically bladder outflow obstruction-\> bilateral hydronpehrosis and impaired renal function

Answer 3567

Low detrusor pressure @ end of micturition Large volume retention with very compliant bladder Kidney able to excrete urine No hydronephrosis therefore normal renal function

Answer 3568

?Chronic urinary retention

Answer 3569

Catheterise if: renal impairment, pain, infection Hourly UO and replace post-obstruction diuresis Consider TURP before TWOC

Answer 3570

Avoid catheterisation if possible due to risk of introducing infection Early TURP: often do poorly due to poor detrusor function. Need CISC or permanent catheter

Answer 3571

Reduceed UTIs Reduced stricture formation TWOC w/o catheter removal Pt preference: increased comfort Maintain sexual function

Answer 3572

More complex: need skills Serious cx can occur

Answer 3573

Known or suspected bladder carcinoma Undiagnosed haematuria Previous lower abdominal surgery: adhesions of small bowel to abdominal wall

Answer 3574

Clean intermittent self-catheterisation Alternative to indwelling catheter in AUR and CUR Also useful in pts who fail to void after TURP

Answer 3575

Beetroot Rifampicin Porphyria PV bleed

Answer 3576

General Renal Uretur Bladder Prostate Urethra

Answer 3577

HSP Bleeding diathesis

Answer 3578

Infarct Trauma inc. stones Infection Neoplasm GN Polycystic kidneys

Answer 3579

Stone Tumour

Answer 3580

Infection Stones Tumour Exercise

Answer 3581

BPH Prostatitis Tumour

Answer 3582

Infection Stones Trauma Tumour

Answer 3583

Renal/systemic, bladder

Answer 3584

Bladder stone Schistosomiasis

Answer 3585

Timing Painful or painless Obstructive symptoms Systemic symptoms

Answer 3586

Bloods: FBC, U+E. clotting Urine: dip, MC+S, cytology Imaging: Renal US IVU Flexible cystoscopy and biopsy CT/MRI Renal angiography

Answer 3587

Idiopathic retroperitoneal fibrosis Inflammatory AAAs Perianeurysmal RPF RPF 2o to malignancy e.g. lymphoma

Answer 3588

Autoimmune vasculitis Fibrinoid necrosis of vasa vasorum Affects aorta and small/medium sized retroperitoneal vessels Ureters are embedded in dense, fibrous tissue-\> bilateral obstruction

Answer 3589

Drugs: beta blockers, bromocriptine, methysergide, methyldopa AI disease: thyroiditis, SLE, ANCA+ vasculitis Smoking Asbestos

Answer 3590

?Para-aortitis

Answer 3591

Blood: raised U and Cr, raised ESR/CRP, reduced Hb US: bialteral hydronephrosis + medial ureteric deviation CT/MRI: peri-aortic mass Biopsy to exclude cancer

Answer 3592

Relieve obstruction: retrograde stent placement Ureterolysis: dissection of uretur from retroperitoneal tissue +/- immunosuppression

Answer 3593

Lifetime incidence: 15% Young men: peak age 20-40y. Sex M\>F 3:1

Answer 3594

Increased concentration of urinary solute Reduced urine volume Urinary stasis

Answer 3595

Pelviureteric junction Crossing the iliac vessels at the pelvic brim Under the vas or uterine artery Vesicoureteric junction

Answer 3596

Calcium oxalate

Answer 3597

Proteus infection (staghorn calculi)

Answer 3598

Calcium oxalate: 75% Struvite: 15% Urate: 5% (radiolucent) Cystine: 1% (faint)

Answer 3599

Dehydration Hypercalcaemia: 1o HPT, immobilisation Increased oxalate excretion: tea, strawberries UTIs Hyperuricaemia: gout Urinary tract abnromalities e.g. bladder diverticulae Drugs: frusemide, thiazides

Answer 3600

Severe loin pain radiating to the groin Associated with n/v Patient cannot lie still

Answer 3601

?Urolithiasis

Answer 3602

Urine: dip- haematuria. MC+S Blood: FBC, U+E, Ca, PO4, urate Imaging: KUB XR USS- hydronephrosis CT KUB: gold standard IVU Functional scans

Answer 3603

99% of stones visualised

Answer 3604

600x radiation dose of KUB IV contrast injected and control, immediate and serial films taken until taken at level of obstruction Abnormal findings: Failure of flow to the bladder Standing column of contrast Clubbing of the calcyces Delayed, dense nephrogran- no flow from kidney

Answer 3605

Contrast allergy Severe asthma Meformin Pregnancy

Answer 3606

DMSA: dimeracptosuriccinic acid DTPA: diethylenetriamene penta-acetic acid MAG-3

Answer 3607

Drink plenty Treat UTI rapidly Reduce oxalate intake: chocolate, tea, strawberries

Answer 3608

Analgesia: diclofenac 75mg PO/IM or 100mg PR Opioids if NSAIDs CI e.g. pethidine Fluids: IV if unable to tolerate PO Abx if infection e.g. cefuroxime 1.5mg IV TDS

Answer 3609

\<5mm in lower 1/3 of uretur 90-95% pass spontaneously Can discharge patient with analgesia Sieve urine to collect stone for OPD analysis

Answer 3610

Stone 5-10mm Stone expected to pass

Answer 3611

CCB or alpha antag: nifedipine or tamsulosin +/- pred Most pass within 48h, 80% within 30d

Answer 3612

Low likelihood of spontaneous passage e.g. \>10mm Pesistent obstuciton Renal insufficeincy Infection

Answer 3613

Extracorporeal shockwave lithotripsy Ureterorenoscopy + Dormier basket removal Percutaneous nephrolithotomy Lap or Open surgery

Answer 3614

Location and size of stone

Answer 3615

PNL or URS 2nd line: SWL

Answer 3616

SWL 2nd line: URS, PNL

Answer 3617

URS or SWL

Answer 3618

URS 2nd line: SWL

Answer 3619

URS or SWL

Answer 3620

Stones \<20mm in kidney or proximal uretur

Answer 3621

Renal injury may-\> raised BP

Answer 3622

Pregnancy AAA Bleeding diathesis

Answer 3623

Stone \>10mm in distal uretur or if SWL failed Stone \>20mm in renal pelvis

Answer 3624

Stone \>20mm in renal pelvis e.g. staghorn calculus: do DMSA first

Answer 3625

Surgical emergency Percutaneous nephrostomy or ureteric stent IVAbx: cefurime, 1.5g IV TDS

Answer 3626

90% of renal cancer 55y/o Sex: M\>F 2:1

Answer 3627

Obesity Smoking HTN Dialysis (15% of patients develop RCC) 4% heritable e.g. VHL syndrome

Answer 3628

Adenocarcinoma from proximal renal tubular epithleium Subtypes: Clear cell (glycogen): 70-80% Papillary: 15% Chromophobe: 5% Collecting duct 1%

Answer 3629

50% incidental finding

Answer 3630

Haematuria, loin pain, loin mass

Answer 3631

EPO-\> polycythaemia PTHrP-\> hypercalcaemia Renin-\> HTN ACTH-\> Cushing's syndrome Amyloidosis Deranged LFTs

Answer 3632

Direct: renal vein Lymphatic Haematogenous: bone, liver and lung

Answer 3633

Blood: polycythaemia, ESR, U+E, ALP, Ca Urine: dip, cytology Imaging: CXR- cannonball mets US: mass IVU: filling defect CT/MRI

Answer 3634

Confined to kidney Involves perinephric fat but not Garota's fascia Spread into renal vein Spread to adjacent/distant organs

Answer 3635

Medical: reserved for patients with poor px Temsirolimus (mTOR inhibitor) Surgical: Radical nephrectomy Consider partial if small tumour or 1 kidney

Answer 3636

2nd commonest renal cancer 50-80y M\>F: 4:1

Answer 3637

Smoking Amine exposure (rubber industry) Cyclophosphamide

Answer 3638

Highly malignant Locations: bladder (50%), uretur, renal pelvis

Answer 3639

Painless haematuria Frequency, urgency, dysuria Urinary tract obstruction

Answer 3640

Urine cytology CT/MRI IVU: pelviceal filling defect

Answer 3641

Nephouretectomy Regular f/up: 50% develop bladder tumours

Answer 3642

Nephroblastoma

Answer 3643

Wilms Aniridia GU abnormaltities Retardation

Answer 3644

Cysts: very common Renal papillary adenomas Oncocytoma: eosinophilic cells with numerous mitochondria Angiomyolipoma: seen in tubeorus sclersosis

Answer 3645

SCC associated with chronic infected staghorn calculi

Answer 3646

Commonly require nephrectomy to exclude malignancy

Answer 3647

1:5000/y M\>F 4:1

Answer 3648

TCC account for 90% SCCs: associated with schistosomiasis Adenocarcinoma

Answer 3649

Low-grade: 80% Non-invasive, generally not life-threatening High recurrence rate High grade: 20% Invasive and life-threatening High recurrence rates

Answer 3650

Smoking Amine exposure (rubber industry) Previous renal TCC Chronic cystitis Schistosomiasis (SCC) Urechral remnants (adenocarcinomas): embryological remnants of communication between umbilicus and bladder Pelvic irradiation

Answer 3651

?bladder tumour

Answer 3652

80% confined to mucosa 20% penetrate muscle (increased moratlity) Tis: carcinoma in situ, not fetlt at EUA Ta: confined to epithelium, not felt at EUA T1: tumour in lamina propria: not felt T2: superficial muscle involved: rubbery thickness T3: deep muscle involved: mobile mass T4: invasion of prostate, uterus, vag: fixed mass

Answer 3653

Local-\> pelvic structures Lymph-\> iliac and para-aortic nodes Haem-\> bones, liver and lungs

Answer 3654

Grade 1: well differentiated Grade 2: intermediate Grade 3: poorly differentiated

Answer 3655

Urine: dip (sterile pyuria), cytology IVU: filling defects Cystoscopy with biopsy- diagnostic Bimanual EUA helps to assess spread CT/MRI helps stage

Answer 3656

Depends on histological grade and the presence of dissemination

Answer 3657

80% of all patients diathermy via transurethral cystoscopy/TURBT Intravesicular chemo: mitomycin C Intravesicular immunotherapy: BCG

Answer 3658

Radical cystectomy with ileal conduit is gold standard RTx: worse 5ys but preserves bladder: salvage cystectomy can be performed Adjuvant chemo: M-VAC Neoadjuvant chemo may have a role

Answer 3659

Palliate CT/RTx Long-term catheterisation Urinary diversions

Answer 3660

Massive haemorrhage Cystectomy-\> sexual and urinary malfunction

Answer 3661

Up to 70% of bladder tumours recur, therefore intensive F/U is required Hx, ex and regular cystoscopy High risk tumours: every 3m for 2y then ever 6m Low risk: @9m then yearly

Answer 3662

Depends on age and stage Non invasive: 95% 5ys T2: 40-50% T3: 25% T4 \<1y

Answer 3663

70% @60y 90% @80y

Answer 3664

Benign nodular or diffuse hyperplasia of stromal and epithelial cells Affects inner (transitional) layer of prostate (cf. Ca)-\> urethral compression DHT produced from testosteroe in stromal cells by 5-a reductase enzyme DHT-induced GFs-\> raised stromal cells and reduced epithelial cell death

Answer 3665

Storage symptoms: nocturia, frequency, urgency, overflow incontinence Voiding symptoms: hesitancy, straining, poor stream/flow + terminal dribbling, strangury, incomplete emptying Bladder stones: 2o to stasis UTI: 2o to satasis

Answer 3666

PR: smoothly enlarged prostate Definable median sulcus Bladder not usually palpable unless acute-on-chronic obstruction

Answer 3667

Bloods: U+E, PSA Urine: dip, MC+S Imaging: transrectal US +/- biopsy Urodynamics: pressure/flow cystometry Voiding diary

Answer 3668

Reduce caffeine, EtOH Double voiding Bladder training: hold on-\> increase time between boiding

Answer 3669

Useful in mild disease while awaiting TURp 1st line: alpha blockers: tamsulosin, doxazosin 2nd line: 5alpha reductase inhibitors: finasterid

Answer 3670

Tamsulosin, doxazosin Relax prostate smooth muscle SE: drowsiness, reduced BP, depression, ED, weight gain, extra-pyramidal signs

Answer 3671

Finasteride Inhibit conversion of testosterone to DHT Preferred if significantly enlarged prostate SE: secreted in semen, ED

Answer 3672

`Symptoms affect QoL Cx of BPH

Answer 3673

TURP TUIP Transurethral electrovaporisation of prostate Laser prostatectomy Open retropubic prostatectomy

Answer 3674

Cystoscopic resection of lateral and middle lobes \<14% become impotent

Answer 3675

Transurethral incision of prostate (TUIP) less destrction than TURP so less risk to sexual function Similar benefits if small prostate (\<30g)

Answer 3676

Reduced ED and retrograde ejaculation Similar efficacy as TURP

Answer 3677

Used for very large prostates \>100g

Answer 3678

TUR syndrome: absorption of large quantity of fluids-\> hyponatraemia Haemorrhage

Answer 3679

Haemorrhage Infection Clot retention: requires bladder irrigation

Answer 3680

Retrograde ejaculation: common ED: 10% Incontinence: 10% Urethral stricture Recurrence

Answer 3681

Commonest male cancer 3rd commonest cause of male cancer death 80% of men \>80y Increased in blacks

Answer 3682

Adenocarcinoma Peripheral zone of prostate

Answer 3683

Prostate Ca

Answer 3684

Hard irregular prostate on PR Loss of midline sulcus

Answer 3685

Local: seminal vesicles, bladder, rectum lymph: para-aortic nodes Haemo: sclerotic bony lesions

Answer 3686

Bloods: PSA, U+E, acid and ALP, Ca Imaging: XR chest and spine transrectal US + biopsy Bone scan Staging MRI: contrast enhancing magnetic nanoparticles increases detection of affected nodes

Answer 3687

Proteloytic enzyme used in liquefaction of ejaculate Not specific for prostate Ca: increases with age, PR, TURP and prostatitis \>4ngml: 40-90% sensitivie, 60-90% specific. Only 1 in 3 will have cancer Normal in 30% of small cancers

Answer 3688

Gleason Grade Score 2 worst affected areas Sum is inversely proportional to px

Answer 3689

Tis: carcinoma in situ T1: incidental finding on TURP or raised PSA T2: intracapsular tumour with deformation of prostate T3: extraprostatic extension T4: fixed to pelvis + invading neighbouring structures N1-4: 1 or more LNs involved M1: distant mets e.g. spine

Answer 3690

Help determine whether to pursue radical Rx Age Pre-Rx PSA tumour stage Tumour grade

Answer 3691

Difficult to know which tumours are indolent and will not lead to mortality before something else Radical therapy associated with significant morbidity

Answer 3692

Close monitoring with DRE and PSA

Answer 3693

Radical prostatectomy (+ gosrelin if node +ve) Performed laparoscopically with robot Only improves survival vs active monitoring if \<75y Brachytherapy: implantation of palladium seeds

Answer 3694

ED, urinary incontinence, death

Answer 3695

Performed laparoscopically Only improves survival vs active monitoring if \<75y

Answer 3696

Used for metastatic or node +ve diseae LHRH analgoues e.g. gosrelin: inhibits pituitay gonadotrophins-\> reduce testosterone Anti-andrognes: e.g. cyporterone actetate, flutamide

Answer 3697

TURP for obstruction Analgesia RTx for bone mets/cord compression

Answer 3698

Population based screening not recommended in UK PSA not an accurate tumour marker ERSPC trial showed small mortality benefit, PLCO trial showed no benefit Must balance mortality benefit with harm caused by over diagnosis and over treatment of indolent cancers

Answer 3699

S. faecalis E. coli Chlamydia

Answer 3700

Prostatitis

Answer 3701

Blood: FBC, U+E, CRP Urine dip: MC+S

Answer 3702

Fluoroquinolone for 4 w Analgesia e.g. levofloxacin 500mg/d for 28d

Answer 3703

Usually caused by prostatic enlargement Urge incontinence or dribbling may result from partial retention Retention may lead to overflow (palpable bladder after voiding) TURP and pelvic surgery may weaken external urethral sphincter

Answer 3704

Stress: Leakage from incompetent sphincter when raiesd IAP Loss of small amounts of urine when coughing Pelvic floor weakness Urge/OAB can't hold urine May have precipitatnt Dx: urodynamic studies

Answer 3705

Check PR: faecal impaction Palpable bladder after voiding: retention with overflow DM CNS: MS, parkinson's, stroke, spinal trauma Diuretics Stress: Pelvic floor exercises Ring pessary Duloxetine Surgery: tension free vaginal tape Urge: Bladder training Weight loss Anti-AChM: tolterodine, imipramine

Answer 3706

3% at birth 1% at 1y Unilateral 4x commoner cf. bilateral: should have genetic testing if bilateral Commoner in prems: incidence up to 30%

Answer 3707

Testes remain in abdomen (retroperitoneal) until 7m Gubernaculum connects inferior pole of testis to scrotum Testes descend through inguinal canal to scrotum with an out-pouching of peritoneum: processus vaginalis

Answer 3708

Complete absence of testis from scrotum Anorchism= absence of both testes

Answer 3709

Normal development but excessive cremasteric reflex Testicle often found at external inguinal ring Will descend, no Rx required

Answer 3710

Found anywhere along normal path of descent Testis and scrotum are usually under-developed Often associated with patent processus vaginalis

Answer 3711

Found outside line of descent Usually in superior inguinal pouch (anterior to external oblique aponeurosis) Abdominal, perineal, penile, femoral triangle

Answer 3712

Infertility 10x risk of malignancy (remains after surgery) Increased risk of trauma Increased risk of torsion Associated with hernias (90%) or UT abnormalities

Answer 3713

Restores potential for spermatogensis Make ca surveillance easier

Answer 3714

Orchidopexy by Dartos Pouch Procedure Perform before 2y Mobilisation of testis and cord Removal of patent processus testicle brought through a hole made in the dartos muscle to lie in a subcutaneous pouch Dartos prevents retraction

Answer 3715

Beta-HCG may be tried if testis is in inguinal canal

Answer 3716

Usually 2o to some exertion or minor trauma Occurs because testicles don't have a large bare area to attach to scrotal wall: Tunica vaginalis invests whole of testicle Free hanging clapper-bell testicle can twist on its mesentry

Answer 3717

?Testicular torsion

Answer 3718

Testicular torsion

Answer 3719

Epididymo-orchtiis: older patient, UTI symptoms, more gardual onset Torted Hydatid of Morgagni: remnant of mullerian duct, younger patient, less pain. Tiny ble dot visible on scrotum tumour Trauma Strangulated hernia Appendicitis

Answer 3720

Doppler US may demonstrate absence of flow must not delay surgical exploration

Answer 3721

Surgical emergency: 4-6h window from onset of pain to salvage testis Inform senior NBM IV access: analgesia, bloods: FBC, U+E, G+S, clotting Sx: consent for possible orchidectomy, bilateral orchidopexy: suture testes to scrotum if no torsion found and epidydiom-orchtitis dx- take fluid for bacteriology and rx with abx

Answer 3722

Inguinoscrotal hernia

Answer 3723

Epididymal cyst

Answer 3724

Varicocele Sperm granuloma Epidydimitis

Answer 3725

Tumour Orchitis haematocele

Answer 3726

Epididymal cyst

Answer 3727

Varicocele (dilated veins of pampiniform plexus)

Answer 3728

1o: left side commoner, drain into LRV 2o: left renal tumour has tracked down renal vein-\> testicular vein obstruction

Answer 3729

Conservative: scrotal support Surgical: clipping the testicular vein (open or lap)

Answer 3730

Sperm granuloma

Answer 3731

US testicle to exclude tumour

Answer 3732

May resolve spontaneously: surgery- Lord's repair: plication of the sac Jaboulay's repair: eversion of the sac Aspiration: usually recur so not 1st line Send fluid for cytology and MC+S

Answer 3733

haematocele

Answer 3734

STI: chlamydia, gonorrhoea Ascending UTI: E. Coli Mumps

Answer 3735

Epididymo-orchitis

Answer 3736

Positive Prehn's sign indicates there is pain relief with lifting the affected testicle, which points towards epididymitis

Answer 3737

Blood: FBC, CRP Urine: dip, MC+S (first catch) Urethral swab and STI screen US: may be needed to exclude abscess

Answer 3738

May-\> infertility

Answer 3739

Bed rest Analgesia Scrotal support Abx: doxy or cipro Drain abscess if present

Answer 3740

Commonest male malignancies from 15-44y Whites \> blacks 5:1

Answer 3741

Testicular tumours

Answer 3742

Undescended testis: 10% occur in this group Infant hernia Infertility

Answer 3743

Germ Cell Sex-cord Stromal lymphoma/leukaemia

Answer 3744

Germ cell (95%)

Answer 3745

Pure Seminomas (40%) Non-seminomas (inc. mixed): (60%) Mixed Teratoma Yolk sac Choriocarcinoma

Answer 3746

Beta HCG and or AFP

Answer 3747

Choriocarcinoma

Answer 3748

Leydig cell Sertoli cell Both mostly benign

Answer 3749

Androgens or oestrogens

Answer 3750

Oestrogens

Answer 3751

Royal Marsden Staging

Answer 3752

1. Disease only in testis 2. Para-aortic nodes involved (below diaphragm) 3. Supra and infra-diaphragmatic LNs involved 4. Extra-lymphatic spread: lungs, liver

Answer 3753

Tuour markers: useful for monitoring Raised AFP and hCG in 90% of teratomes Raised hCG in 15% of seminomas Normal AFP in pure seminomas Scrotum US Staging: CXR, CT NB: percutaneous needle biopsy should not be performed due to risk of seeding along the needle tract

Answer 3754

Semen can be cryopreserved

Answer 3755

Inguinal orchidectomy + RTx Groin incision allows cord clamping to prevent seeding

Answer 3756

Inguinal orchidectomy + RTx + chemo (BEP) Bleomycin, etoposide, cisPlatin

Answer 3757

Inguinal orchidecctomy and surveillance

Answer 3758

Orchidectomy + chemo + para-aortic LN dissection

Answer 3759

Orchidectomy + chemo

Answer 3760

Typically within 18-24m Repeat CT scanning and tumour markers

Answer 3761

Stage 1: 98% 5ys Stage 2: 85% Stage 4: 60%

Answer 3762

Acute inflammation of foreskin and glans

Answer 3763

Strep, staph, candida

Answer 3764

DM Young children with tight foreskin

Answer 3765

Hygiene advice Abx Circumcision

Answer 3766

Foreskin occludes the meatus

Answer 3767

Gentle retraction Steroid creams Circumcision

Answer 3768

Dyspareunia, infection

Answer 3769

Circumcision

Answer 3770

Thickening of foreskin and glans-\> phimosis + meatal narrowing

Answer 3771

Tight foreskin is retracted and becomes irreplaceable Reduced venous return-\> oedema and swelling of the glans Can rarely lead to ischaemia

Answer 3772

Catheterisation, masturbation, intercourse

Answer 3773

Manual reduction: use ice and lignocaine jelly May require glans aspiration or dorsal slit

Answer 3774

Developmental abnormality of the position of the urethral opening Opens on ventral surface of penis

Answer 3775

Developmental abnormality of the position of the urethral opening Opens on the dorsal surface

Answer 3776

1:100,000/y in UK commoner in far east and africa

Answer 3777

V. rare if circumcised RFs: HPV, chronic irritation

Answer 3778

Erythroplasia of Querat-\> Penile CIS SCC

Answer 3779

Penile cancer

Answer 3780

Medical: early growths with no urethral invovlement: DXT and iridium wires Surgical: Amputation required if urethral involvement LN dissection

Answer 3781

In an IVDU with back pain and pyrexia have a high suspicion for osteomylelitis. The most likely organism is staph aureus and the cervical spine is the most common region affected. TB tends to affect the thoracic spine and in other causes of osteomyelitis the lumbar spine is affected.

Answer 3782

Rectal diversion may result in proctitis.

Answer 3783

Fissure in ano

Answer 3784

Crohns disease

Answer 3785

Ulcerative colitis

Answer 3786

Rectal cancer

Answer 3787

This patient has an extensive disease process and lobular cancers are notorious for being multifocal. In this case a mastectomy is the safest next step.

Answer 3788

The imaging and biopsy results are not concordant. At this stage an excision biopsy is the safest option

Answer 3789

Retroperitoneal air is more likely with a duodenal injury. As it is largely retroperitoneal. A handlebar type injury is the commonest cause and the pancreas should be carefully inspected as it too may be injured. It would be unusual for the ileum to be injured in this type of scenario as it is mobile.

Answer 3790

1. Small bowel injury is the most common type of injury in this scenario. The enteric contents will tend to result in a large amount of intra abdominal fluid.

Answer 3791

Tracheobronchial tree injury

Answer 3792

Cardiac contusion

Answer 3793

Transient aplastic crisis in SCD following parvovirus B19 infection

Answer 3794

Chronic testicular pain is seen in more than 5% of patients

Answer 3795

Failure rate: 1/2000 Simple operation, can be done under LA, go home after a couple of hours Doesn't work immediately. Requires semen analysis 2 weeks following procedure before a man can hvae unprotected sex

Answer 3796

Bruising Haematoma Infection Sperm ganuloma Chronic testicular pain (affects 5-30% of men)

Answer 3797

1/200 fail Usually done laparoscopically under GA Day case Many different techniques

Answer 3798

Increased risk of ectopic if sterilisation fails General Cx of GA/lap

Answer 3799

head + neck = 9% Each arm= 9% Each anterior part of leg= 9% Each posterior part of leg= 9% Ant chest= 9% Post chest= 9% Ant abdo and post abdo= 9% each

Answer 3800

Lund and Browder chart

Answer 3801

Parkland formula: volume= total body surface area of the burn x weight (kg) x 4 Half of the fluid is administered in the first 8h

Answer 3802

Comedo necrosis is a feature of high nuclear grade ductal carcinoma in situ. It is has a high risk of being associated with foci of invasion.

Answer 3803

Mucinous carcinomas comprise 2-3% of all breast cancers. They are one of the special type of carcinomas. These have a better prognosis that tumours of Non Special Type (NST) and axillary nodal disease is rare in this group

Answer 3804

Paget's is associated with DCIS or invasive carcinoma.Unlike eczema of the nipple which predominantly affects the areolar region, Pagets will usually affect the nipple first and then spread to the areolar area. Diagnosis is made by punch biopsy.

Answer 3805

Mitral stenosis is the commonest cause of cardiac abnormality occurring in pregnant women. Mitral stenosis is becoming less common in the UK population, however should be considered in women from countries were there is a higher incidence of rheumatic heart disease. Mitral stenosis causes a mid diastolic murmur which may be difficult to auscultate unless the patient is placed into the left lateral position. These patients are at risk of atrial fibrillation (up to 40%), which can also contribute to rapid decompensation. Physiological changes in pregnancy may cause an otherwise asymptomatic patient to suddenly deteriorate. Balloon valvuloplasty is the treatment of choice.

Answer 3806

Aortic dissection is associated with the 3rd trimester of pregnancy, connective tissue disorders (Marfan's, Ehlers- Danlos) and bicuspid valve. Patients may complain of a tearing chest pain or syncope. Clinically they may be hypertensive. The right coronary artery may become involved in the dissection, causing myocardial infarct in up to 2% cases (hence ST elevation in the inferior leads). An aortic regurgitant murmur may be auscultated.

Answer 3807

0.3 This is critical limb ischaemia. Values of 0.3 are typical in this setting and urgent further imaging is needed. Debridement of necrosis prior to improving arterial inflow carries a high risk of limb loss.

Answer 3808

0.5 Hyperaemia may occur in association with severe vascular disease and is referred to surgically as a "sunset foot". ABPI is usually higher than 0.3, but seldom greater than 0.5. Especially when associated with hyperaemic changes and ulceration. Urgent further imaging and risk factor modification is needed.

Answer 3809

\>1.2 Type 2 diabetes may have vessel calcification. This will result in abnormally high ABPI readings. Pain of this nature in diabetics is usually neuropathic and if a duplex scan is normal then treatment with an agent such as duloxetine is sometimes helpful.

Answer 3810

Rectal intussceception Rectal intussceception (internal rectal prolapse) typically presents with symptoms of obstructed defecation. The pathology is best demonstrated by a defecating procotogram rather than barium enema.

Answer 3811

Hyponatraemia: dilutional Fluid overload Glycine toxicity Mx: fluid restriction and the treatment of cx associated with the hyponatraemia

Answer 3812

The correct answer is Benign oesophageal stricture Children with tracheo-oesophageal fistulas will commonly develop oesophageal strictures following repair. These may require regular dilations throughout childhood.

Answer 3813

CVP 18mmHg

Answer 3814

Early: exudative phase of injury with associated oedema Late stage: repair and consists of fibroproliferative changes Subsequent scarring may rseult in poor lung function

Answer 3815

Transient increases in transpulmonary pressure designed to open up collapsed airless alveoli Primarily used in ARDS Multiple methods have been described 40cmH20 for 40-60 seconds 3 consecutive sighs/min with a plateau pressure of 45cmH2O 2 minutes of peak pressure of 50cmH2O and PEEP above upper inflection point (obese/trauma patients may require \>60-70cmH2O) long slow increase in inspiratory pressure up to 40 cmH2O (RAMP) stepped increase in pressure (e.g. Staircase Recruitment Manoeuvre) Proning can also be considered a recruitment manoeuvre, and other recruitment manoeuvres are more more effective in the prone position

Answer 3816

Dextran 40 and 70 have higher incidence of anaphylaxis than either gelatins or starches. 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.

Answer 3817

Adhesive capsulitis Frozen shoulder passes through an initial painful stage followed by a period of joint stiffness. With physiotherapy the problem will usually resolve although it may take up to 2 years to do so.

Answer 3818

Rotator cuff tear Rotator cuff tears are common in elderly people and may occur following minor trauma or as a result of long standing impingement. Tears greater than 2cm should generally be repaired surgically.

Answer 3819

Parsonage - Turner syndrome This is a peripheral neuropathy that may complicate viral illnesses and usually resolves spontaneously.

Answer 3820

Median median Ulnar

Answer 3821

he correct answer is Torn meniscus Theme from September 2012 Exam Twisting sporting injuries followed by delayed onset of knee swelling and locking are strongly suggestive of a menisceal tear. Arthroscopic menisectomy is the usual treatment.

Answer 3822

The correct answer is Anterior cruciate ligament rupture This is common in footballers as the football boot studs stick to the ground and high twisting force is applied to a flexed knee. Rapid joint swelling also supports the diagnosis.

Answer 3823

Venous insufficiency Venous ulcers are usually associated with features of venous insufficiency. These include haemosiderin deposition and varicose veins. Neuropathic ulcers will tend to present at sites of pressure, which is not typically at the medial malleolus.

Answer 3824

Chronic obliterative arterial disease Painful ulcers associated with a low ABPI are usually arterial in nature. The question does not indicate that features of chronic venous insufficiency are present. Patients may have mild pitting oedema as many vascular patients will also have ischaemic heart disease and elevated right heart pressures. The absence of more compelling signs of venous insufficiency makes a mixed ulcer less likely.

Answer 3825

Pilar cyst Pilar cysts may contain foul smelling cheesy material and are surrounded by the outer part of a hair follicle. Because of their histological appearances they are more correctly termed pilar cysts than sebaceous cysts.

Answer 3826

Ulnar nerve The interossei are supplied by the ulnar nerve.

Answer 3827

Nottingham Prognostic Index

Answer 3828

Tumour size x 0.2 + LN score + grade score

Answer 3829

Chondromalacia patellae A teenage girl with knee pain on walking down the stairs is characteristic for chondromalacia patellae (anterior knee pain). Most cases are managed with physiotherapy.

Answer 3830

Dislocated patella A patella dislocation is a common cause of haemarthrosis and many will spontaneously reduce when the leg is straightened. In the chronic setting physiotherapy is used to strengthen the quadriceps muscles.

Answer 3831

Osgood Schlatters disease Athletic boys and girls may develop this condition in their teenage years. It is caused by multiple micro fractures at the point of insertion of the tendon into the tibial tuberosity. Most cases settle with physiotherapy and rest.

Answer 3832

Pain/pins and needles in thumb, index, middle finger e.g. at night Patient flicks hand to obtain relief Weakness of thumb abduction Wasting of thenar eminence Tinel's sign: tapping causes paraesthesia) Phalen's sign

Answer 3833

Myxoedema Edema premnestrually DM Idiopathic Acromegaly Neoplasm Trauma Rheumatoid arthritis Amyloidoisis Pregnancy

Answer 3834

Anti-androgen treatment such as cyproterone acetate should be co-prescribed when starting gonadorelin analogues due to the risk of tumour flare. This phenomenon is secondary to initial stimulation of luteinising hormone release by the pituitary gland resulting in increased testosterone levels. The BNF advises starting cyproterone acetate 3 days before the gonadorelin analogue.

Answer 3835

Anterior Peroneal compartment Superficial posterior compartment Deep posterior compartment

Answer 3836

Tibialis anterior EDL Peroneus tertius EHL

Answer 3837

Deep pernoeal nerve

Answer 3838

Superficial peroneal nerve

Answer 3839

Tibial nerve

Answer 3840

Peroneus longus Peroneus brevis

Answer 3841

Gastrocnemius Soleus

Answer 3842

FDL FHL Tibialis posterior

Answer 3843

Dorsiflexis ankle Inverts foot

Answer 3844

Extends lateral 4 toes, dorsiflexes ankle joint

Answer 3845

Dorsiflexes ankle, everts foot

Answer 3846

Dorsiflexes ankle joint, extends big toe

Answer 3847

Everts foot, assits in plantar flexion

Answer 3848

Plantar flexes the ankle joint

Answer 3849

Plantar flexes the foot, may also flex the knee

Answer 3850

Plantar flexor

Answer 3851

Flexes lateral four toes

Answer 3852

Flexes the great toe

Answer 3853

Plantar flexor, inverts the foot

Answer 3854

Sudden arterial embolus will affect the axillary artery in up to 30% cases. Because of the acute nature of the condition there is no time for the development of a collateral circulation so the limb is usually pale and painful. Emboli occur usually occur as a result of atrial fibrillation. Fast atrial fibrillation can cause syncope and an acute embolus.

Answer 3855

The correct answer is Intraductal papilloma Intraductal papilloma usually cause single duct discharge. The fluid is often clear, although it may be blood stained. If the fluid is tested with a labstix (little point in routine practice) then it will usually contain small amounts of blood. A microdocechtomy may be performed.

Answer 3856

Smoking Exposure to aniline dyes int he printing and textile industry Rubber manufacture Cyclophosphamide

Answer 3857

Schistosomiasis BCG treatment Smoking

Answer 3858

Epididymo-orchitis: acute pain and swelling after urological intervention. To differentiate from testicular torsion there is usually pyrexia and positive urine dipstick.

Answer 3859

Orchitis Orchitis may be associated with mumps viral infections.

Answer 3860

Endocrine parameters reduced in stress response: ## Footnote Insulin Testosterone Oestrogen

Answer 3861

GH Cortisol Renin ACTH Aldosterone Prolactin ADH Glucagon

Answer 3862

Papillary carcinoma Papillary thyroid cancer is the most common type of thyroid cancer and are the more common in females (M:F=1:3). Papillary tumours are more likely to develop lymphatic spread than follicular tumours.

Answer 3863

Fasciotomy The delay is the significant factor here. These injuries often have neurovascular compromise and inactivity now places him at risk of developing complications. In compartment syndrome the loss of arterial pulsation occurs late.

Answer 3864

Discharge home with futura splint and fracture clinic appointment This could well be a scaphoid fracture and should be temporarily immobilised pending further review. A futura splint will immobilise better than an arm sling for this problem.

Answer 3865

Gustilo and Anderson Classification System

Answer 3866

Grade 1: Low energy wound \<1cm Grade 2: \>1cm wound with moderate soft tissue damage Grade 3: High energy wound \>1cm with extensive soft tissue damage A: adeqate soft tissue coverage B: inadequate soft tissue coverage C: associated arterial injury

Answer 3867

Squamous cell carcinoma The risk of squamous cell carcinoma of the oesophagus is increased in people with achalasia. The condition often presents late and has a poor prognosis.

Answer 3868

is a narrowing of the lower esophagus that can cause difficulty swallowing (dysphagia). The narrowing is caused by a ring of mucosal tissue (which lines the esophagus) or muscular tissue.[1] A Schatzki ring is a specific type of "esophageal ring", and Schatzki rings are further subdivided into those above the esophagus/stomach junction (A rings),[2] and those found at the squamocolumnar junction in the lower esophagus (B rings).[3] Patients with Schatzki rings can develop intermittent difficulty swallowing or, more seriously, a completely blocked esophagus. The ring is named after the German-American physician Richard Schatzki.

Answer 3869

Deep coma of known aetiology. Reversible causes excluded No sedation Normal electrolytes

Answer 3870

Fixed pupils which do not respond to sharp changes in intensity of incident light No corneal reflex Absent VOR (no eye movements following the slow injection of at least 50ml of ice-cold water in each ear in turn- caloric test) No response to supraorbital pressure No cough reflex to bronchial stimulat or gagging response to pharyngeal stimulation No observed repiratory effort in response to disconnection of the ventilator for ~5 minutes,

Answer 3871

Streptococcus bovis Streptococcus bovis septicaemia is associated with carcinoma of the colon. It also can also cause endocarditis.

Answer 3872

Acute bacterial tonsillitis Theme from April 2012 Exam In acute tonsillitis the tonsils will often meet in the midline and may be covered with a membrane. Individuals who are systemically well are unlikely to have diptheria.

Answer 3873

A combination of pharyngitis and tonsillitis is often seen in glandular fever. Antibiotics containing penicillin may produce a rash when given in this situation, leading to a mistaken label of allergy.

Answer 3874

Retroperitoneal fibrosis Retroperitoneal fibrosis is an uncommon condition and its aetiology is poorly understood. In a significant proportion the ureters are displaced medially. In most retroperitoneal malignancies they are displaced laterally. Hypertension is another common finding. A CT scan will often show a para-aortic mass

Answer 3875

Pseudomyxoma peritonei Pseudomyxoma is classically associated with mucin production and the appendix is the commonest source. Pseudomyxoma peritoneii- Curative treatment is peritonectomy (Sugarbaker procedure) and heated intra peritoneal chemotherapy.

Answer 3876

Cryoprecipitate Blood product made from plasma Usually transfused as 6 unit pool Indications include massive haemorrhage and uncontrolled bleeding due to haemophilia Composition AgentQuantity Factor VIII100IU Fibrinogen250mg von Willebrand factorVariable Factor XIIIVariable

Answer 3877

Oslers nodes 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.

Answer 3878

Squamous cell carcinoma 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.

Answer 3879

Duodenal atresia Proximally sited atresia will produce high volume vomits which may or may not be bile stained. Abdominal distension is characteristically absent. Whilst under resuscitated children may be a little dehydrated they are seldom severely ill. The presence of Trisomy 21 (palmar and eye signs) increases the likelihood of duodenal atresia.

Answer 3880

The correct answer is Transfer to regional burn centre once stabilised This women has been resuscitated and requires transfer for specialist management

Answer 3881

Escharotomy He requires an escharotomy as this will be contributing to impaired ventilation

Answer 3882

A cystogram involves passing radiopaque dye into the bladder, then performing radiographs to assess the course of the bladder contents. This provides evidence of whether there is any radiopaque fluid that has escaped the bladder and is free in the abdominal cavity.

Answer 3883

Bladder rupture A pelvic fracture and lower abdominal peritonism should raise suspicions of bladder rupture (especially as this man cannot pass urine).

Answer 3884

Membranous urethral rupture A pelvic fracture and highly displaced prostate should indicate a diagnosis of membranous urethral rupture.

Answer 3885

Bulbar rupture: Most common Straddle type injury e.g. bicycles Triad signs: urinary retention, perineal haematoma, blood at the meatus Membarnous rupture: Can be extra or intraperitoneal Commonly due to pelvic fracture Penile or perineal oedema/haematoma PR: prostate displaced upwards (beware coexisiting retroperitoneal haematomas as they make examination difficult)

Answer 3886

Platelets are stored at room temperature and must be used soon after collection. This places them at increased risk of culturing gram positive organisms. Iatrogenic infection with gram negative organisms is more likely with packed red cells as these are stored at 4 degrees. Infections with blood products of this nature are both rare.

Answer 3887

Acromioclavicular dislocation Acromioclavicular joint (ACJ) dislocation normally occurs secondary to direct injury to the superior aspect of the acromion. Loss of shoulder contour and prominent clavicle are key features. Note; rotator cuff tears rarely occur in the second decade.

Answer 3888

Glenohumeral dislocation A Hill-Sachs lesion is when the cartilage surface of the humerus is in contact with the rim of the glenoid. About 50% of anterior glenohumeral dislocations are associated with this lesion.

Answer 3889

Mondor's disease (also known as "Mondor's syndrome of superficial thrombophlebitis"[1]) is a rare condition which involves thrombophlebitis of the superficial veins of the breast and anterior chest wall. It sometimes occurs in the arm or penis.[2] In axilla, this condition is known as axillary web syndrome.[3] Patients with this disease often have abrupt onset of superficial pain, with possible swelling and redness of a limited area of their anterior chest wall or breast. There is usually a lump present, which may be somewhat linear and tender. Because of the possibility of the lump being from another cause, patients are often referred for mammogram and/or breast ultrasound.[4]

Answer 3890

abdominal pain peripheral neuropathy (mainly motor) fatigue constipation blue lines on gum margin (only 20% of adult patients, very rare in children)

Answer 3891

Pyoderma gangrenosum Associated with inflammatory bowel disease/RA Can occur at stoma sites Erythematous nodules or pustules which ulcerate Submit answer

Answer 3892

Respiratory Neurological Petechial rash (tends to occur after the first 2 symptoms)

Answer 3893

Angiomyolipoma This patient has tuberous sclerosis. This is associated with angiomyolipoma, which is present in 60-80% patients. It is a benign lesion.

Answer 3894

Uric acid Chemotherapy and cell death can increase uric acid levels. In this acute setting the uric acid stones are unlikely to be coated with calcium and will therefore be radiolucent.

Answer 3895

Cystine Cystine stones are associated with an inherited metabolic disorder.

Answer 3896

Solitary rectal ulcer

Answer 3897

Loss of plasma proteins is the most common cause of oedema developing in this time frame.

Answer 3898

Indirect measure of left atrial pressure and thus filling pressure of the left heart. When combined with measurements of SVR and CO it is possible to accurately classify the potential cause of shock

Answer 3899

Derived from aortic pressure, RAP and CO SVR= 80(mean aortic pressure-mean right atrial pressure)/CO

Answer 3900

\<5: hypovolaemia

Answer 3901

\>18: suggestive of overload e.g. cardiogenic pulmonary oedema

Answer 3902

Roux-en-Y portojejunostomy This child has biliary atresia. The aim is to avoid liver transplantation (however, most will come to transplant in time).

Answer 3903

Bendroflumethiazide may help prevent the formation of calcium based renal stones. It may however theoretically increase the risk of urate based stones

Answer 3904

Vomiting Thoracic pain Subcutaneous emphysema Commonly presents in middle aged men with a background of alcohol abuse

Answer 3905

Proximal aortic dissection An inferior myocardial infarction and AR murmur should raise suspicions of an ascending aorta dissection rather than an inferior myocardial infarction alone. Also the history is more suggestive of a dissection. Other features may include pericardial effusion, carotid dissection and absent subclavian pulse.

Answer 3906

ynamic hip screw The blood supply to the femoral head may be intact and the fracture should heal with compression type devices such as gamma nails or dynamic hip screws. The latter device being the most commonly performed therapeutic intervention.

Answer 3907

Hemiarthroplasty Hemiarthroplasty is offered to older, less mobile individuals compared to fracture reduction and fixation in younger patients.

Answer 3908

Total hip replacement This patient has pre-existing joint disease, good level of activity and a relatively high life expectancy, therefore THR is preferable to hemiarthroplasty.

Answer 3909

Calculated figure wich provides an estimate of the metabolic componenet of acid-base balance Defined as the amount of H+ ions that would be required to return the pH of the blood to 7.35 if the pCO2 were adjusted to normal BE \>+3: metabolic alkalsois BE \< -3= metabolic acidosis

Answer 3910

Persistent urachus A patent urachus will present with umbilical urinary discharge. The skin may become macerated if not properly cared for. The discharge is most likely to be present when intra-abdominal pressure is raised. It is associated with posterior urethral valves.

Answer 3911

Omphalitis Infection from omphalitis may spread rapidly and cause severe sepsis especially in immunologically compromised, premature neonates.

Answer 3912

Persistent vitello-intestinal duct A persistent vitello-intestinal duct may allow the persistent and ongoing discharge of small bowel content from the umbilicus. This fluid may be very irritant to the surrounding skin.

Answer 3913

Imatinib Imatinib is licensed for treatment of GIST in the United Kingdom for this situation. The guidance from the National Institute of Clinical evidence is that patients be reviewed at 12 weeks after initiating therapy.

Answer 3914

Malabsorption of bile salts is a common cause of diarrhoea following ileal resection. A normal small bowel study and CRP effectively excludes active Crohns disease and therefore immunomodulator drugs are not appropriate.

Answer 3915

Warthins tumours are most common in elderly smokers. They have a relatively benign and indolent course. They are usually well circumscribed as illustrated below:

Answer 3916

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.

Answer 3917

1-2cm depending on site and pathological features

Answer 3918

2-3cm depending on site and pathological features

Answer 3919

Although etomidate is widely used in emergency settings due to its favourable haemodynamic profile and cerebroprotective effects, it is associated with depressed corticosteroid synthesis by inhibition of 11-beta-hydroxylase. Adrenal suppression can increase mortality, especially in the post-operative recovery period.

Answer 3920

Thiopentone

Answer 3921

McKeown oesophagectomy He requires a total (3 stage oesophagectomy). This is also called a McKeown oesophagectomy. Ivor Lewis type resections are concluded in the mid third of the oesophagus and would not adequately treat this disease

Answer 3922

Ivor Lewis oesophagectomy This requires an Ivor Lewis oesophagectomy with resection of the distal oesophagus and an intrathoracic anastomosis

Answer 3923

Proximal aortic dissections are generally managed with surgical aortic root replacement. The proximal origin of the dissection together with chest pain (which may occur in all types of aortic dissection) raises concerns about the possibility of coronary ostial involvement (which precludes stenting). There is no role for attempted suture repair in this situation.

Answer 3924

Breast cyst Lesions such as breast cysts compress the underlying fat and produce a radiolucent area (halo sign). If symptomatic these cysts should be aspirated.

Answer 3925

Lobular carcinoma in situ has a low association with invasive malignancy. It is seldom associated with microcalcification and therefore MRI is the best tool for determining disease extent. Resection of in situ disease is not generally recommended and most surgeons would simply pursue a policy of close clinical and radiological follow up.

Answer 3926

Risedronate and calcium supplements The osteoporosis guidelines state if a postmenopausal woman has a fracture she should be put on bisphosphonates (there is no need for a DEXA scan).

Answer 3927

Exploration and parathyroidectomy This patient has primary hyperparathyroidism and nephrolithiasis, which is an indication for parathyroidectomy.

Answer 3928

Intravenous fluid (0.9% N.Saline) This patient needs rehydration due to hypercalcaemia. An intravenous bisphosphonate is indicated if the Ca is above 3.

Answer 3929

Mammary duct ectasia

Answer 3930

A unilateral dilated pupil is a classic sign of transtentorial herniation. The medial aspect of the temporal lobe (uncus) herniates across the tentorium and causes pressure on the ipsilateral oculomotor nerve, interrupting parasympathetic input to the eye and resulting in a dilated pupil. In addition the brainstem is compressed. As the ipsilateral oculomotor nerve is being compressed, craniotomy (rather than Burr Holes) should be made on the ipsilateral side.

Answer 3931

Surgical time \>1hr Height of bag \>70cm Resected \>60h Large blood loss Perforation Large amount of fluid used Poorly controlled CHF

Answer 3932

The right sided midline defect is referring to herniation through the foramen of Morgagni, 60% of Morgagni hernias contain transverse colon whereas Bochdalek hernias tend to be left sided, containing stomach.

Answer 3933

Fracture of the radial head is common in young adults. It is usually caused by a fall on the outstretched hand. On examination, there is marked local tenderness over the head of the radius, impaired movements at the elbow, and a sharp pain at the lateral side of the elbow at the extremes of rotation (pronation and supination).

Answer 3934

Galeazzi fractures occur after a fall on the hand with a rotational force superimposed on it. On examination, there is bruising, swelling and tenderness over the lower end of the forearm. X- Rays reveal a displaced fracture of the radius and a prominent ulnar head due to dislocation of the inferior radio-ulnar joint.

Answer 3935

Oesophageal atresia This child has 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.

Answer 3936

Magnesium ammonium phosphate

Answer 3937

Medial: pituitary fossa, Sphenoid sinus Lateral: temporal lobe

Answer 3938

Lateral wall from top to bottom Oculomotor nerve Trochlear nerve V1 V2 Contents of the sinus: from medial to lateral Internal carotid artery and sympathetic plexus Abducens nerve

Answer 3939

Cavernous sinus syndrome

Answer 3940

Dumping syndrome, which can be divided into early and late, may occur following gastric surgery. It occurs as a result of a hyperosmolar load rapidly entering the proximal jejunum. Osmosis drags water into the lumen, this results in lumen distension (pain) and then diarrhoea. Excessive insulin release also occurs and results in hypoglycaemic symptoms.

Answer 3941

Osteopetrosis is an autosomal recessive condition. It is commonest in young adults. They may present with symptoms of anaemia or thrombocytopaenia due to decreased marrow space. Radiology reveals a lack of differentiation between the cortex and the medulla described as marble bone. These bones are very dense and brittle.

Answer 3942

Perthes' disease should be suspected in boys over 4 years old presenting with a limp. Early disease can be missed on x-ray. MRI is increasingly replacing bone scans as the second line investigation of choice

Answer 3943

Acquired haemophilia Factor 8 acquired disorder. The elderly, pregnancy, malignancy and autoimmune conditions are associated with acquired haemophilia. Prolonged APTT is key to the diagnosis. Management involves steroids.

Answer 3944

Scheuermann's disease

Answer 3945

Spondylolysis

Answer 3946

Spondylolisthesis

Answer 3947

Diaphragmatic rupture A lateral blunt injury during a road traffic accident is a common cause of diaphragmatic rupture. Diagnosis is usually evident on chest x-ray. CXR changes include non visible diaphragm, bowel loops in the hemithorax and displacement of the mediastinum. In most cases direct surgical repair is the best option.

Answer 3948

Aorta rupture He has a deceleration injury, with persistent hypotension (contained haematoma). This should indicate aorta rupture. Widened mediastinum may not always be present on a chest x-ray. A CT angiogram will provide clearer evidence of the extent of injury. The presence of persistent hypotension, from a early stage is more consistent with haematoma than a tension pneumothorax in which it occurs as a final periarrest phenomena.

Answer 3949

Bennett's fracture

Answer 3950

Thyroglossal cyst This is the procedure for excision of the cyst and its associated track. Excision must be complete and thus a small segment of the hyoid bone is removed to gain access to the upper part of the cyst tract.

Answer 3951

Pleomorphic adenoma of the parotid The histological features are as described with a classic biphasic (mixed stromal and epithelial elements), although benign local recurrence can complicate incomplete excision. As this is a benign lesion direct extension into the facial nerve is unlikely to occur. Facial nerve injury can happen during repeat parotid surgery.

Answer 3952

IV terlipressin Rectal varices are a recognised complication of portal hypertension. In the first instance they can be managed with medical therapy to lower pressure in the portal venous system. TIPSS may be considered. Whilst band ligation is an option, attempting to inject these in same way as haemorroids would carry a high risk of precipitating further haemorrhage.

Answer 3953

Angiography of mesenteric artery This women is actively bleeding and mesenteric angiography may localise the bleeding. Colonoscopy in this situation is seldom helpful or successful.

Answer 3954

A 68-year-old man with ulcerative colitis is admitted with an exacerbation. You are called to see him because he is having brisk PR bleeding. He has been on Intravenous hydrocortisone for 5 days. The gastroenterologists have done an OGD to exclude a duodenal ulcer, this was normal.

Answer 3955

Cowden disease

Answer 3956

MYH associated polyposis

Answer 3957

Giant cell tumour Giant cell tumours on x-ray have a 'soap bubble' appearance. They present as pain or pathological fractures. They commonly metastasize to the lungs.

Answer 3958

Osteomalacia Hypocalcemia and low urinary calcium are biochemical features of osteomalacia.

Answer 3959

A Ewings sarcoma is most common in males between 10-20 years. It can occur in girls. A lytic lesion with a lamellated or onion type periosteal reaction is a classical finding on x-rays. Most patients present with metastatic disease with a 5 year prognosis between 5-10%.

Answer 3960

In most units a crystalloid such as Hartmans (Ringers lactate) is administered initially. Controversy does remain and some units do prefer colloid. Should this leak in the interstial tissues this may increase the risk of oedema.

Answer 3961

: \>15% total body area burns in adults (\>10% children) The main aim of resuscitation is to prevent the burn deepening Most fluid is lost 24h after injury First 8-12h fluid shifts from intravascular to interstitial fluid compartments Therefore circulatory volume can be compromised. However fluid resuscitation causes more fluid into the interstitial compartment especially colloid (therefore avoided in first 8-24h) Protein loss occurs

Answer 3962

Parkland formula (crystalloid only) Total fluid requirement in 24h= 4ml x total burn surface area x bodyweight (kg) 1/2 in first 8 hours. Aim for urine output of 0.5-1ml/kg/hr in adults (increase rate of fluid to achieve this) Starting point of resus is time of injury

Answer 3963

Colloid infusion is begun at a rate of 0.5ml x total burn surface area x bodyweight Maintenance crystalloid is continued at rate of 1.5ml x total burn SA x weight Colloids used include albumin and FFP Antioxidants may be used to minimise inflammatory cascade High tension electrical injuries and inhalational injuries require more fluid.

Answer 3964

Meckels diverticulum This scenario should raise suspicion for Meckels as these may contain ectopic gastric mucosa which may secrete acid with subsequent bleeding and ulceration

Answer 3965

Internal fixation, especially if young

Answer 3966

Hemiarthroplasty

Answer 3967

Internal fixation if possible Hip aryhoplasty if not

Answer 3968

Hemiarthroplasty

Answer 3969

Dynamic hip screw

Answer 3970

Intramedulllary device

Answer 3971

Dynamic hip screw Extracapsular fractures should be treated surgically. Since the blood supply to the femoral head is not compromised joint replacement is not usually warranted

Answer 3972

Intramedullary device Intramedullary device is normally recommended for reverse oblique, transverse or subtrochanteric fractures.

Answer 3973

Hemiarthroplasty non cemented prosthesis This patient warrants a hemiarthroplasty due to reduced mobility and older age. The anterolateral approach is recommended in the SIGN guidelines. In this case most surgeons would not use a cemented prosthesis.

Answer 3974

Atracurium Atracurium is degraded by a process of ester hydrolysis. This uses non specific plasma esterases. Suxamethonium 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. Suxamethonium Suxamethonium is extremely rapidly metabolised, acetylcholinesterases degrade the drug within minutes. In patients who lack this enzyme the drug may last far longer.

Answer 3975

Air filled sac that communicates with the larynx Can be congenital or acquired (e.g. due to high pressure- COPD) If it is limited to the paraglottic space it presents with stridor and hoarseness. If it protrudes through the thyrohyoid membrane it presents as a reducible lump in the anterior triangle of the neck which recurs with coughing, sneezing, etc.

Answer 3976

Abnormal connection between two epithelial surfaces. AV fistula which is a connection between two endothelial surfaces

Answer 3977

Petit hernia (lumbar hernia)

Answer 3978

Grynfelt hernia

Answer 3979

Elevated left hemidiaphragm Left lower lobe atelectasis Left pleural effusion

Answer 3980

Incomplete tear of supraspinatus Chronic supraspinatus tendonitis Subacromial bursitis Crack fracture of the greater tuberosity

Answer 3981

Full can test against resistance- weakness +/- supraspinatus lesion or tear dependent on degree of weakness Empty can test force, assess for weakness or pain impingement= painful arc

Answer 3982

Pancreatic head, common bile duct and gallbladder, distal stomach and some of the duodenum. 3 anastomoses: hepato-jejnostomy, pancreatic jejunostomy and a gastrojejunostomy

Answer 3983

Saphena varix will demonstrate a fluid thrill when the greater saphenous vein is tapped distally

Answer 3984

3-5cm below the costal margin Anterior rectus sheath exposed and divided along the line of excision exposing the rectus muscles which may then be divdided, taking care to enure haemostasis when branches of the superior epigastric vessels are sacrificed. Incision is extended through the lateral abdominal wall muscles which are split to allow better access. 8th and 9th intercostal nerves lie between the IO and transversus muscles. 8th nerve often sacrificed. Incision is deepened through the posterior rectus sheath and peritoneum.

Surgery Flashcards

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