Examinations Flashcards

Question

Types of thyroid cancer and surgical management

Answer 1

Papillary- 70%- in kids, lymphatic spread (90% have mets at Px), <1cm hemi + thyroid suppression, >1cm total + level 6 neck dissection + radioiodine ablation Follicular- 20%- 50 yo, Haematogenous spread, difficult to differentiate from adenoma- therefore hemithyroidectomy, if cancer for total + level 6 + radioiodine ablation therapy Medullary Ca- 5%- Parafollicular C cells, calcitonin producing- MEN 2 association!, Total thyroidectomy + level 6 neck dissection + F/U calcitonin for lifelong Anaplastic- <5%, elderly, worse prognosis- 1 year, direct spread. Surgery indicated for debulking +- chemo/radio Lymphoma

Answer 2

MEN 1- Pituitary adenoma, primary hyperparathyroidism, pancreatic islet cell tumour MEN2a- Phaeochromocytoma, Medullary thyroid Ca, Primary hyperPTH MEN 2b- Phaeochromcytoma, medullary thyroid ca, marfanoid habitus, neuromas

Answer 3

Standards- skin/subcutaneous lesions Lymphadenopathy Anterior triangle- congential- thyroglossal cysts Acquired- thyroid swellings, carotid artery aneurysms, carotid body tumours, pharyngeal pouches, parotid/submandibular swellings, BRANCHIAL Cyst- failure of obliteration of branchial arches- young adults Posterior triangle- Congenital- cystic hygromas-lymphangioma (lymphatic system blockage) Acquried- lipoma, subclavian artery aneurysm, cervical ribs

Answer 4

``` Level 1- submental/submandibular Level 2- upper 1/3 of IJV Level 3- middle 1/3 of IJV Level 4- Lower 1/3 of IJV Level 5- Posterior triangle Level 6- pretracheal/prethyroid ```

Answer 5

Removal of levels 1-5 +- 6 | +- removal of accessory nerve/SCM/IJV

Answer 6

Retromandibular vein + post auricular

Answer 7

Pertrosal sinus | Lingual/pharyngeal, sup and middle thyroid and facial vein drain into it

Answer 8

Drains laryngeal veins Some small thyroid veins Ends up in EJV/subclavian vein Variable in nature

Answer 9

Hx and exam Bloods- FBC, UEs, CRP, LFTs, Ca, Coag, RF and autoAbs- sjorgrens- anti Ro/La USS +- FNA Sialogram- anatomy of duct and can be theraputic

Answer 10

Infective- viral- mumps/HIV, bacterial- staph/TB Inflam- Sjorgrens Drugs- Alcohol/COCP Neoplastic Sialectasis- stones Metabolic- bulaemia, cushings, cirrhosis Mimics- lumps and bumps- cyst, lipoma, CNVII neuroma, masseter hypertrophy

Answer 11

Benign- Pleomorphic adenomas- 80%, slow growing, 5th decade of life Warthin's tunmours- men, 7th decade Variable- mucoepidermoid carcinoma- commonest paediatric Malignant-Adenoic cystic carcinoma- commonest, 6th decade Adenocarcinoma Lymphoma

Answer 12

UMN- bilateral innervation of levator palpabrae Can raise eyebrows CVA/MND LMN- hemiparesis of face Bells palsy-?viral Trauma Ramsay Hunt syndrome- Shingles- HZV- vesicles in ear canal Tumour- parotid/extrinsic pressure intracranially/ acoustic neuroma Infection

Answer 13

Automimmune disease classically presenting 5th decade of women with dry eyes and mouth, characterised by periductal lymphocytes primary and secondary (RA and SLE) 1 in 6 go on to develop lymphoma

Answer 14

Dx- schmirer's test- hyposecretion in eyes AutoAbs- Anti Ro, La and RF Biopsy of salivary glands Rx- C- tear replacements, good oral hygiene M- immunosuppression/steroids S- Lacrimal punctum diathermy

Answer 15

Viral- influenza, adenovirus, rhinovirus- EBV/Infectious mononeucleosis Bacterial- Hi, Strep pneumoniae, GAS/GBS

Answer 16

Need 3 or more to justify Abx treatment Exudate on tonsils Fever above 38 No cough Anterior lymphadenopathy

Answer 17

Recurrent tonsilities | >5 episodes in two consecutive years

Answer 18

``` Sepsis Airway obstruction Quinsy Acute otitis media Recurrent ```

Answer 19

Anterior-from little's area- Klessielbachs plexus Post Woodruffs plexus ``` Causes Infective- rhinits Trauma Neoplastic On anticoagulation Clotting abnormalities Substance abuse ```

Answer 20

C- pinch bridge of nose for 20 mins, rapid rhino if unsuccessful M- Resuscitate, reverse anticoagulation, FFP/cryo, nasceptin post bleed, adrenaline spray S- cautery, embolisation/ligation Culprit vessels are often- sphenopalatine, post/ant ethmoidal, maxillary

Answer 21

Intro- expose, 45o on couch, chaperone Inspect- hands by side, above head, pressed into hips 6Ss, peau d'orange, nipple changes, discharge, tethering (astley cooper ligaments), lymphoedema Palpate- pain?, temp, SEC FFP TR, good then bad, clock face, axillary LNs, suprclavicular LNs, nipple discharge Complete- Liver, lung, brain and bone, post op N palsies- long thoracic, intercostobrachial, thoracodorsal Triple assessment- Mammogram/USS + biopsy

Answer 22

15-25 yo- Fibroadenomas 25-40- Cyclical nodularity and mastalgia 35-55- cystic disease, duct ectasia, periductal mastitis, hyperplasia

Answer 23

Benign- fibroadenomas, intraductal papillomas, lipomas Malignant- Lobular/Ductal carcinomas in situ Ductal carcinoma- 80% Lobular- 10% Medullary/mucinous/tubular/papillary carcinomas

Answer 24

Paget's disease involves the nipple | Eczema rarely involves the nipple

Answer 25

Patient flat in bed Inspect- hands- nails, flap, dupytren's Wrists- pulse, tatoos, exoriations Face- eyes, mouth Neck- LNs Chest- gynaecomastia, spider naevi Abdomen- 6Ss, distention, visible perastalsis, pulsatations, scars!! Pain? Temp Palpation- 9 regions- soft for guarding, deep for masses Liver, Spleen, Kidneys, Aorta Percuss- Liver spleen, shifting dullness Auscultate- bruits- bowel sounds, renal, iliac, aortic Peripheral oedema Complete- Inguinal LNs, Hernial orifices, Exeternal genitalia, preg test/urine dip, DRE/PV exam, fluid and stool charts

Answer 26

Related to exess oestrogen:testosterone levels Dilated BVs, fill from inside out >5 is pathognomic

Answer 27

``` Pathological swelling of the distal phalanges 1- Congestion 2- Loss of angulation 3- Increase AP angle 4- drumsticking ```

Answer 28

``` Idiopathic 2o Endocarditis/ cyanotic heart disease Lung ca/Pulmonary fibrosis/COPD/Bronchiectasis GI cancer/IBD/Coeliac Thyroid acropatchy ```

Answer 29

Intramural- foreign body/food bolus Mural-Oesophageal ca, oesophagitis, GORD, strictures, pharyngeal pouches, achalasia, oesophageal webs Extramural- thyroid/lung ca/retrosternal goitre/hilar lymphadenopathy MND/stroke Traumatic

Answer 30

Chronic IDA deficiency leads to oesophagea webs Dysphagia to solids more than liquids Propsenity to go on and become SqCC

Answer 31

Any mass- skin/subcutaneous/lipoma/ AAA/epigastric herniation/ epigastric hernia/panceratic pseudopolyps, pancreatic ca/gastric ca/ lymphadenopathy

Answer 32

``` Physiology- Ridele's lobe Infective- hepatitides/CMV, malaria, TB/abscess Cancer- 1/2/lymphoma/leukaemia Cirrhosis- alcohol, wilson's, amyloid Vascular- RHF, Budd chiari ```

Answer 33

Heptaic vein obstruction Due to thrombosis/ cancer Clin feats of abdominal pain, hepatomegaly, jaundice, ascites

Answer 34

Fibrosis of the liver secondary to long term damage, causing decrease function of the liver ``` Aetiology- alcohol Viral, bacterial, protozoan Autoimmune heptatitis NAFLD RHF Sarcoid Wilson's/Alpha 1 antitrypsin PBC and PSC ```

Answer 35

PBC- fat women forty, anti AMA PSC- UC association, pANCA

Answer 36

Pre hepatic- splenic/portal vein thrombosis Hepatic- cirrhosis/liver ca Post hepatic- Budd chiari/ RHF

Answer 37

Engorged and dilated periumbilical veins that form part of the portal system and become dilated due to porto-systemic shunting Due to either Portal HTN or IVC blockage

Answer 38

Transudate- SAAG >1.1/Protein <30, Hypoalbunaemia- Liver failure, nephrotic, starvation Increased venous pressure- Heart failure, Portal htn, budd chiari, pregnancy, volume overload Exudate (increased permeability)- Malignancy, infective, pancreatitis Peritoneal radiation, pancreatitis, peritonitis, peritoneal mets

Answer 39

``` Treat underlying cause C- salt and fluid restriction M- spironolactone S- pacacentesis TIPSS Liver transplat ```

Answer 40

FFISH Filtering of encapsulated organisms- s.pneuomnia, n.menigitidis, Hi Immunological- Ab production and opsonisation S- storage of platelets Haematopoesis in fetus F- reticuloendothelial system- filtering RBCs/WBCs/Platelts

Answer 41

``` Infective- HIV/abscess/TB/malarial Leukaemia and lymphoma (CML/NHL/myelofibrosis) Sickle cell and thalassaemia Splenic thrombosis/budd chiari syndrome RA/Sarcoid ```

Answer 42

ADPCKD- Adult, 5th decade, chronic renal failure/haematuria, good response to dialysis, 40% have berry aneurysms Infantile- ARPCKD, Renal mass and poor renal function, hepatic fibrosis, liver transplant needed

Answer 43

``` Think kidney functions HTN, HF Peripheral oedema 2o hyperparathyroidism Osteoporosis, hypocalcaemia Anaemia Uraemia leading to puritus, peripheral uropathy, gout ```

Answer 44

Inflammatory bowel disease with an autoimmune and genetic component Faecal calprotectin

Answer 45

``` Non smokers Colonic and rectal disease Continous Submucosal inflammation Pseudopolyps and cryptal abscess ``` Thumbprinting and lead piping on barium enema

Answer 46

``` Cancer PSC Toxic megacolon Perforation Obstruction ```

Answer 47

``` Smokers Any part of GI tract Skip lesions Transmural ulceration with cobblestone pattern Granulomas Fistulas and strictures ```

Answer 48

Fistulas Strictures Obstruction Infection

Answer 49

Mouth Ulcers and Perianal skin tags- Crohns ``` IBD in general Eyes- Iritis and uveitis Arthritis Ank spon Skin- erythema nodosum and pyoderma gangrenosum ```

Answer 50

C- diet altering, stop smoking M- Steroids, azathioprine, infliximab S- segmental resections, strictuloplasty, fistulotomies- setons, open

Answer 51

C- dietary changes M- steroids, sulfasalazine S- Proctocolectomy +- end ileostomy +- ileoanal pouch (curative)

Answer 52

Medical management not working | Complications

Answer 53

Sinus is a blinding ending epithelial lined tract | Fistula is an abnormal connection between 2 epithelial lined surfaces

Answer 54

The level of anorectal fistula denotes the level of the anorectal abscess Subcutaneous fistula = perianal abscess Intersphincteric fistula = intersphincteric abscess High anal fisutal = ischiorectal abscess Low anal fistula = ischiorectal abscess Pelvirectal fistula = supralevator abscess

Answer 55

``` Full Hx and exam Bloods- IV Abx for infection IBD investigations/DM investigations MRI Proctoscopy/sigmoidoscopy ``` Surgery- do not explore fistulas acutely- just drain abscess In post acute phase Subcutaneous/Low anal fistulas- Laid open High anal/interspincteric- setons Complicated fistulas may need fistulotomy +- flap

Answer 56

9 till 3- normal course | 3 till 9 abnormal course

Answer 57

Lanz medial to lateral | Gridiron is along Langer's lines

Answer 58

Inspect- expose + chaperone, standing 6Ss, cough Palpate- pain?, temp SECFFPTR Cough Can patient reduce it- reducible when lying Reduce and cover superficial and deep ring Auscultate ``` Complete LNs ContraL Scrotal examination Abdo exam ```

Answer 59

``` Expose, standing chaperone Inspect- 6Ss, cough impulse? Pain, temp? Palpate- SEC FFP TR Can you get above lump- if not do hernia exam Define anatomy- separate to testis? Feel testis and epipdyimis + vas Complete- LN, contraL side ```

Answer 60

``` Inguinal hernia Femoral hernia Saphena Varix Undescended testis Femoral Artery A Lymphadenopathy Skin lesions ```

Answer 61

Abnormal protusion of a tissue or organ through the wall of its normal cavity

Answer 62

Open vs Lap herniotomy and herniorrhapy Lichentstein's- uses mesh to reinforce defect Shouldice- if infection concerns, 4 layers of opposing muscle

Answer 63

In women- as increase stretch of femoral canal during pregnancy- increased venous return Also fat regression during menopause- more space Lockwood's repair- low repair of reducible femoral hernia McVedy's high repair of irreducible femoral hernia

Answer 64

``` Umbilical Paraumbilical Brainstem Littre's- meckel's diverticulum Amyand- appendix Richter's- one side of bowel wall Hiatus Epigastric Spigelian- through semilunaris ```

Answer 65

Hernia- cant get above them Separate to testis- varicocele, epidymitis, epidyimal cyst, spermatocele Cant separate from testis- hydrocele, cancer, orchitis, haematocele

Answer 66

Undescended- premature stopping of descent down gubernaculum Retractile Ectopic Complications- torsion, tumour (seminoma risk is 30x normal), infertility

Answer 67

Wait till 1 year then orchidoplexy Or orchidectomy Or GnRH/bhCG may encourage descent

Answer 68

Fluid collection within tunica vaginalis Can also include Vas deferens 1o- patent processus vaginalis 2o- tumour, torsion, infection

Answer 69

C- in 1o can wait till 1 year old as it may resolve Scrotal support Analgesia S- aspiration, phenol injection Lord's plication- sac incised and plicated behind testis Jaboulay's plication- sac incised and partially excised

Answer 70

Viral- mumps, infectious mononeucleosis | Bacterial- e.coli vs chlamydia

Answer 71

Dilated and tortous pampiniform plexus seen on standing 98% on the left- Left testicular vein drain into left renal Colon compresses/left RCC Treat if symptomatic Emobilisation Ligation

Answer 72

Leydig cell tumours- can cause precocious puberty | Sertoli cell tumours- gynaecomastia

Answer 73

Seminomas- 30-40 yo, 40%, produce Beta HCG only Teratomas- contain all 3 elements of the germ layer, 30%, produce AFP and BHCG Mixed- 20% Lymphoma

Answer 74

Staging= TNM or Royal Marsden Bloods + LDH + AFP +BHCG Scrotal USS CT CAP Orchidectomy via inguinal approach Chemo for seminomas and teratomas DTx for seminomas

Answer 75

Expose abdomen full, take off bag Sheets/chaperone Insepct- site, bag and contents, spout vs flush, Lumens, mucosa (inflammed/ulcerated), scars, old stoma sites Complications- prolapse/reactraction/stenosis/hernia Excoriations Rectal opening? Pain Temp Palpate- lumen, parastomal hernia, stoma bag in 1 or 2 pieces Auscultate Completion- abdo exam

Answer 76

Ileostomy vs colostomy End vs loop End ileostomy- panprotcocolectomy End colostomy- colonic resections- AP/Hartmann's Loop ileostomy- protect distal anastomosis Loop colostomy- diversion pre chemo/DTx/palliative

Answer 77

PEG feeding Diversion to protect distal anastomosis Emergency/planned resections

Answer 78

``` 4Ss + MDE Scars, sinus, symmetry, swellings Muscle wasting Deformity Erythema ```

Answer 79

Look- 4S MDE Feel- tenderness, stepping off, cervical rib, LNs, thyroid? Move- + examine with downward pressure on neck whilst slight ear to shoulder- exaggerates intervertebral foramen stenosis symptoms Special- looking for thoracic outlet syndrome Roos- arm abducted and ext rotated, hand flex/exten for 3 mins Adson's- palpate pulse and abduct +extend and ext rotation + turn head to same sign

Answer 80

Expose + chaperone Look Feel- pain, temp, stepping, chest expansion Move- cervical as standard, thoracic in chair, lumbar Specials- Schober's find PSIS- 5cm above and 10cm below, forward flex, should increase by 5cm Sciatic nerve stretch- dorsiflex worsens it and, knee flex and hip flex worsens it Femoral nerve stretch test Pelvic compression- pain if ank spond Lhermitte's- c spine flexion Beevor's sign- T6-12 spinal injury, lying supine, arms above head, flexes c spine, umbilicul deviates away from affected side Abdo reflex- umbilicus twitch Complete- LNs, Full NVI + vascular exam, QOL and sleep, dress, imaging

Answer 81

Shoulder exam- standing, expose neck and elbow and shoulder 4S MDE Walk and arm swing Feel- around joint + axilla for lymphadenopathy Move- active and passive + stabilise scapula (push down on shoulder) Global fnx- arms behind head, arms behind back Power- supraspinatus lift off test, deltoid resistance, internal rotation, subscap lift off test Specials- Jobes- supraspinatus Neers- pronation and forward flexion Scapula winging Whilst on couch supine- multidirectional instability Complete- LN, NVI, above and below, QOL &sleep, dress, imaging

Answer 82

``` Look- expose to shoulder and wrist Arm carrying angle? 4S MDE Pain Temp Feel- lat/medial epicondyle and olecranon Radial head whilst supinating/pronating Rhemuatoid nodule Ulnar N Move Complete-NVI, above and below, LN, QOL, Sleep, Dress, Imaging ```

Answer 83

Look- Expose, above and below, walk and turn Trendelenburg's whilst standing- hold their hands- abductor weakness 4S MDE Pain Temp Feel- whilst lying- fem head, trochanter, adductor longus insertion, ischial tuberosity Crepitus LN Apparent leg length- xiphi to medial malleolus- abductor or adductor deformities True leg length- ASIS to medial malleolus- femoral shaft/tibial deformity Move- Thomas's test- fixed flexion deformity Extend (whilst pronated) All others, active and passive Complete- NVI, above and below, LN, QOL, Sleep, Dress, Imaging

Answer 84

``` Look- expose above and below, walk + standing 4S MDE Pain Temp Feel- joint line measure quads effusion test synovial thickening test (RA)-lift patella Flexion deformity ``` Move- SLR, flex/extension Special- Ant/post draw Post sag test Collateral ligs McMurray's- medial meniscus- externally rotate +aduct Lateral meniscus- internal rotate in adduct Patella tests- move it, push down and contract femur (OA), apprehension- displace lat and flex knee Complete- LN, NVI, above and below, QOL and sleep, Dress, imaging

Answer 85

``` Inspect- above and below exposed Ask to walk- perform all ankle movements Standing inspect and in chair Look between toes and on heel and plantar surface Inspect shoes 4S MDE ``` Pain Temp Feel- Soft tissues and bones, squeeze metatarsals Move- ankle and subtalar, midtarsal, toes Special- tenosynovitis- plantarflex and invert/evert Simmonds test Tinnel tarsal tunnel Complete- NVI, above and below, LN, QOL sleep, dress, imaging

Answer 86

``` 60% stance, 40% swing phase Stance phase- heel strike Foot flat Mid stance Toe off ```

Answer 87

``` Shuffling- parkinsons High stepping- Common peroneal deformity Antalgic- one side affected Ataxic gait/broad gait- cerebellar Trendelenburg- duck waddling ```

Answer 88

Chronic systemic inflammatory disorder with an autoimmune component that primarlary affects the joints 4:1 women to men, <1% of population

Answer 89

Symmetrical polyarthropathy and joint deformity EMS ``` Extra-articular Skin- rheumatoid nordules/erythema nodosum CVS- pericardial effusion/pericarditis Eyes- uveitis/episcleritis Kidneys- amyloidosis Lungs- pulmonary fibrosis Neuro- carpal tunnel Felty's pancytopenia, splenomeglay, lymphadenopathy ```

Answer 90

HX and exam Bloods- FBC, UEs, CRP, ESR RF, ANA, HLA D4 LESS (swelling, erosions, subluxation) American college of rheumatologist criteria EMS, >3 joint groups involved, hand joints, symmetrical, rheumatoid nodules, RF +ve, erosions on xrays

Answer 91

``` C- hot and cold packs, patient education, weight loss, OT/PT M- WHO Ladder, steroids Methotrexate Sulfasalzine Infliximab S- athroplasty/athrodesis/synovectomy ```

Answer 92

Seronegative spondyloarthropathy, presenting mainly with EMS back pain in young men RF negative HLA B27 +ve

Answer 93

Intra articular feats- back pain, stiffness, decrease function, fractures, tendon inflammation Extra-articular- myocarditis, ant uveitis, pulmonary fibrosis, cauda equina HLA B27 positive SI joint fusion Bamboo spine with bridging osteophytes Sacroilitis on MRI

Answer 94

C- lifestyle changes, OT and PT M- WHO, steroids, infliximab S- osteotomy, athroplasty/desis

Answer 95

Osteitis deformans Abnormal osteoblast and clast activity with unknown aetiology 3 phases Osteolytic then mixed then blastic

Answer 96

Bone pain and weakness CNV and 8 defects Eythema around sites- due to increased vascularity ``` #s and OA HF due to increased vascularity 2o hyperpth Hypercalcaemia osteosarcoma conversion in 1% ```

Answer 97

Bloods- raised ALP,normal Ca/PTH/TFTs Urinary hydroxproline- collagen breakdwon Imaging

Answer 98

C- lifestyle and PT/OT M- WHO, bisphosphonates- decrease bone turnover, calcitonin- inhibt osteoclast activity S- standard

Answer 99

``` Trauma Rotator cuff tears Adhesive capsulitis OA Bursitis Septic Neoplastic MI- referred ```

Answer 100

Frozen shoulder, idiopathic decreased ROM and pain External rotation is normally worse affected Stiffness that leads to underuse and glenoid adhesions C- physio M- R/O rotator cuff tear and infection Steroid injections/analgesic ladder S- MUA/athroscopic release

Answer 101

Compression of supraspinatus tendon as it passess through the subacromial space Painful arc from 60-120 and anterior shoulder instability

Answer 102

Subacromial bursitis Trauma/overuse Bony spur from ACJ

Answer 103

MRI- identify rotator cuff pathology C- pt/limit activity M- WHO, steroid injection S- rotator cuff repair, subacromial decompression

Answer 104

Flexion deformity of PIPJs/DIPJs Seen in RA and charcot marie tooth disease Treated by tendon transfer/arthrodesis

Answer 105

Bunions etc Promience of 1st MT head Due to chronic forefoot splaying Rx- buinionectomy and realignment osteotomy

Answer 106

Talipes equinovarus platar flex, add, inverted ankle Congenital deformity Treat by plaster/splinting Surgical correction- tibialis ant lengthening

Answer 107

Neuropathic arthropathy Progressive destruction of a weight bearing joint to peripheral neuropathy Leads to skin breakdown and ulceration as well

Answer 108

Look- elbows exposed on pillow 4S and MDE OA signs- Bouchards- prox and Herbeden's- distal, CMJ squaring RA signs- ulnar deviation, rheumatoid nodules, swan necking/boutonniaires/z thumbing ``` Pain Temp Feel CRT, dupytrens, nodules, bimanual palpation/mcp squeeze sensation ``` Move- all joint actions, passive and active ROM- prayer and reverse prayer, fist, spread fingers, oppose, pronate and supinate Thumb power Digit power- bullhorns Special- Tinnels, Phalens, finklesteins (dequervain's tenosynovitis), pincer grip stuff, two point descrimination Complete- NVI< above joint, LN, QOL and sleep, Dress, imaging

Answer 109

Fibrotic disease of the palmar and digital fascia Seen more often in white old males with diabetes Smoking and infection risk factors

Answer 110

Peyronie's disease- fibrosis of corpus callosum | Ledderhose's disease- plantar fascia fibrosis

Answer 111

Indications for op when flexure contracture >30o Pain and increasing disability C- lifestyle mods M- WHO S- fasciotomy, fasciectomy, dermatofasciectomy +- flap, amputation

Answer 112

``` NVI infection, flap necrosis, haematoma 10% reocurrence Scar contracture Wound breakdown ```

Answer 113

Mucinous filled cyst near joint/tnedon | 70% on dorsum of wrist

Answer 114

Difficult in extending finger from flexed position Trapping of flexor tendons 1o idiopathic/congenital 2o trauma, infection, inflammation- DM/RA/renal disease/amyloidosis Narrowing of the tendon sheath leads to increase friction and inflam=> downward spiral Tendon become stuck in A1 Night splinting Steroid injection of sheath Surgical division of A1

Answer 115

Patient on bed, trousers off, shirt unbuttoned Inspect- skin, nails, ulcers (BEDS), scars, venous guttering Chronic venous congestion? Pain Temp Palpate CRT and pulses (radial, brachial, carotid, aorta, femoral, popliteal, DP and PT) Odema Buerger's (Lift leg off- not angle of pallor<20 is severe PAD + reactive hyperaemia when placing leg off bed) Allen's test Auscultat- carotid, aorta, femoral and iliac Completion- ABPI, varicose vein exam, cardiac exam, distal NVI, BP/HR, Doppler + further investigations

Answer 116

Inspect- 6Ss, Chronic venous insufficiency- haemosiderin deposits, lipodermatosclerosis, venous eczema Ulcers, Sacrs (groin/popliteal fossa, small and multiple) Pain Temp Palpate- SECFFRTR, Saphena varix Tap test Trendelenberg test- milk and empty varicosities/ occlude SFJ and stand up Tourniquet test- same as above but use tourniquet to find incompetency level Perthes disease- deep venous incompetence- calf raises with tourniquet- painful Doppler has replaced this- place over SFJ/SPJ, squeeze calf- one whoosh is ok, two is bad Auscultate femoral As Complete- abdo exam, ABPI, investigations, dress patient

Answer 117

pulseslness, pale, perishingly cold, parasthetsia, paralysis, painful

Answer 118

Intermittent claudication on exertion, + cvs risk factors Fontaine's critertia 1- asymptomatic 2a- intermittent claudication on walking >200m 2b- intermittent claudication on walking <200m 3- rest pain/nocturnal pain 4- gangrenous/necrosis

Answer 119

>1,3- calcified vessels-?diabetic 0.9-1.3- normal <0.9- moderate critical disease <0.5- severe critical disease

Answer 120

Typically have pain from the back radiating down the lateral aspect of the leg (tensor fascia lata), often have symptoms on initial movement or symptoms that are relieved by sitting rather than standing- flexed position on spine Narrowing of spinal canal or of neural foramina

Answer 121

Acute generally less than 14 days Can be acute on chronic Acute more likely to be an embolic event

Answer 122

Abnormal dilation of abdominal aortic artery- >4.5cm

Answer 123

<1% when <5.5cm, 5.5-6.5cm= 10% Monitoring once >3cm- annual US 4.5-5.5 cm every 3 months Referral for op if Symptomatic >5.5cm >1cm growth in 1 year

Answer 124

Proximal subclavian artery lesion Leading to ischaemic arm symptom and brain symp on exercise Vertebral artery reverses flow to compensate

Answer 125

Compression of Subclavian NAV at clavicle/1 st rib area

Answer 126

Congenital- cervical rib Acquire-#/scalene hypertrophy Neoplastic compression

Answer 127

Roo's/Adson's test USS CT

Answer 128

Digital vasospasm with 3 clear transition stages White- ischaemic Blue- cyanotic Red- Hyperaemic

Answer 129

``` 1o- idiopathic 2o- RA/scleroderma Traumatic/chronic use Athersclorotic B blockers Polycythaemia ```

Answer 130

C- warm gloves, avoid precipitants M- nifedipine S- sympathectomy- either digital or thorascopic T1-3

Answer 131

If occlusion 50-99% and surgery done within 2 weeks of event ASymptomatic, <75yo and >70% occlusion

Answer 132

Virchow's triad- damage, stasis, hypercoagulable 75% are silent Homan's sig- pain on dorsiflexion?

Answer 133

C- early mobilisation, compression stockings, hydrate, flowtrons M- LMWH, IVT, stop COCP 4 weeks prior to op S- Avoid GA, vena cava filters

Answer 134

Post DVT syndrome/congenital abscence of valves/AVM Leading to increased venous pressure in superfiscial veins Test with Perthe's test

Answer 135

Tortous dilated superfiscial veins 1o 2o- DVT, pregnancy, overuse, long standing, klippel-trenaunary syndrome

Answer 136

``` C-weight loss, compression stockings S- sclerotherapy Multiple stab avulsions High ligation Low ligation Vein stripping Laser/radiofrequency ablations ```

Answer 137

``` Age Time Street remember Year Current location DOB WW2 Prime minister Identify 2 people Count backwards Remember street ```

Answer 138

``` Orientation Registration- remember 3 items Attention- world backwards, serial 7s Recall- 3 items Language name 2 items Repeat phrase- no ifs and buts Follow written instructions Wrist sentence Copy picture- interlocking pentagons ```

Answer 139

Inspect- general, facial assymetry, dyskinesias, speech 1- smell changes 2- visual acuity, snellen charts, ishihara charts, visual fields, Pupils (PERLA), fundoscopy 3/4/6- H 5- sensation in opthalmic/maxillary/mandibulary regions, muscles of mastication/temporalis, corneal reflex 7- taste on anterior 2/3s of tongue, facial expression 8- Whisper test, Rinne's and weber's 9/10- Swallow, gag, baby hippopotamus, inspect palate 11- traps and scm 12- tongue inspetion and protusion

Answer 140

Inspect The Patient Really Carefully Inspect- front/back, gait, wasting, romberg's Cerebellar signs- Dysdiado/Ataxia/Nystagmus/Intention tremor/Speech sluring/hypotonia ``` Pain Temo Tone- upper + lower (clonus + knee lift) Power- upper and lower Reflexes Coordination Sensation- pain, temp, light touch, proprioception, vibration, 2 point discrimination ```

Answer 141

``` C5- shoulder abduction C5/6- elbow flexion C7/8 elbow extension C8- Thumb flexion/MCPJ extension T1- finger Abd ``` ``` L2- hip flexion L3/4- knee flexion L4/5- ankle dorsi flexion L5- big toe dorsi S1/2- ankle plantar flexion ```

Answer 142

Biceps- C5/6 Triceps is C7/8 Ankle is S1/2 Knee is L3/4

Answer 143

``` Congenital Degenerative OA Infective Inflam- Ank spond Metabolic- osteoporosis Neuro- spinal canal stenosis/prolapsed disc/spinal haematoma (post LP) Neoplastic Function Renal calculi AAA Pancreatitis Trauma ```

Answer 144

Normally posterolater herniation of the nucleus propulus through the anulus fibrosis 90% happening and L4/5 and L5/S1 Dysfunction occurs first- injury of fibrosis INstability- disc reabsoprtion and loss of height Restabilisation- osteophyte formation and progressive stenosis

Answer 145

``` Fever, weight loss, shocked Bilateral radiculopathy Bladder/bowel dysfnx Preceeding trauma Saddle anaesthesia Incontinence ```

Answer 146

CES suspected- bilateral radiculopathy, no other red flags CES Incomplete- bilateral + altered bladder/bowel symptoms CES Complete- painless retention, no sensation on defecation, absent anal tone

Answer 147

Neurosurgical emergency Nerve ischaemia at 6 hours Requires surgical decompression Reasonable recovery if done within 24 hours of onset of symptoms

Answer 148

``` <1 hour If GCS <13 on initial assessment in ED GCS <15 2 hours after injury Open/depressed skull fracture Focal neurology >2 focal vomiting episodes >30 mins of retrograde amnesia Seizures ```

Answer 149

``` GCS<8/ >2 points deterioration Progressive neurology Open injury CSF leak Seizure without full recovery ```

Answer 150

Prevent 2o brain injuries- normotension, normoxia, normocapnia, normal ICP Tier 1- elevate head to 45o, hyperventilate Tier 2- increase sedation, induce hypothermia, mannitol Tier 3- barbituate coma, burr hole/decompressive craniotomy

Answer 151

>5mm midline shift on CT Intercerebral haematoma with >40cm Depressed/open skull #

Answer 152

Stroke- haemorrhagic Trauma SAH Spontaneous

Answer 153

Old Hypertensive/blood dysacrias Aneurysm/AVM Cocaine/amphetamines

Answer 154

``` Idiopathic Aneurysmal- berry (ADPKD) AVM Endocarditis Blood dysacrias ```

Answer 155

CT Head- 96% sensitivity if done before 6 hours | LP at 12 hours for bili levels

Answer 156

CTA/MRA Catheter angio Rx- Interventional coiling Operative clipping

Answer 157

Global or focal neurological deficit 2o to vascular cause lasting >24 hours

Answer 158

Age, FHx, HTN, hypercholestrolaemia, AF, anticoagulants, protein C deficiency, diabetes, poor diet, obestiy, smoking

Answer 159

Produced in choroid plexus Absorbed by arachnoid villi 150mls circulating, 480mls produced a day

Answer 160

CSF production and absorption balance ``` Leads to increased head size/headaches RICP Memory problems Focal neurology Seizures Coma ```

Answer 161

Increased production- choroid papilloma Decreased absorption- sinus thrombosis/NPH Obstruction of flow- thalamic/cerebellar tumours

Answer 162

Furosemide and decrease secretions Serial anterior fontanelle taps/LPs VP shunt Vatrial shunt Vpleural shunt

Answer 163

Immunocomprimised Genetic- Li fraumeni FHx Radiation exposure

Answer 164

Gliomas- 70% Astrocytomas, oligodendromas, ependyomas Lymphomas 3%

Answer 165

Menigiomas Pituitary Cerebllopontin- acoustic neuromas

Answer 166

Lung (60%) and breast (20%)

Answer 167

Gliomas- large singular brain lesion with central area of necrosis and enhancing ring Mets- small, multiple, disproportionately excessive peri-orbital oedema

Answer 168

Depends on grade for gliomas 1- surgical resection +- radio- curative 2- Debulking and chemo- v likely for grade jump, 35% survival at 5 years 3- debulking + chemo + DTx- 2 year median survival 4- debulking + chemo + DTx- 10 month median survival Mets- NSCLC- poor prognosis Breast Ca- full resection gives good prognosis

Answer 169

Sitting, hands on pillows Look for 4S, MDE Pain Temp Palpate- sensation- 1st web space and dorsal forearm Motor- EPL, EDC, EI and EDM, Elbow extension, Supination Special- global and fine function Complete

Answer 170

C5-T1 Off posterior cord of brachial plexus Through triangular interval Spiral groove- between medial and lateral heads of triceps Behind lateral epicondyle Splits into PIN- around neck of radius and through 2 heads of supinator SRN- goes beneath brachioradialis

Answer 171

High- wrist drop | Low MCPJ drop

Answer 172

Sitting, pillow Inspect- 4S MDE Sensation- thenar eminence, 3.5 digital nerves Motor- pronation, finger flexion, oppens pollicis, APB, FPL Special- Tinnel, phalens, global and fine assessment

Answer 173

Roots are C6-T1 Comes off median and lateral cords of the brachial plexus Runs with brachial artery to the antecubital fossa Medial to brachial artery here Under PT and then under FDS Gives AIN under PT- supplies FPL/FDP/PQ Gives off palmar cutaneous branch before carpal tunnel After carpal tunnel gives off recurrent motor branch Digital cutaneous branch

Answer 174

Sitting, pillow Inspect- 4S MDE Palpate- sensation over hypothenar eminence, medial 1.5 digital nerves Motor- FCU, FDP, hand movements- DIPJ flexion of little finger, PAD DAB, Froment's test (Adductor policis weakness) Special- Tinnel's, cubital tunnel syndrome- flexion and adduction of elbows

Answer 175

C8 and T1- medial cord of brachial plexus Posteromedial aspect of the humerus and pierces intramuscular septum Through cubital tunnel (arching fibres of FCU retinaculum) Between the two heads of FCU Runs in anterior compartment of the forearm beneath FCU Gives off dorsal sensory branch- dorsal ulna sensation of the hand Through Guyon's canal Giving off a deep motor branch and superfiscial sensory branch

Answer 176

Claw Further the Paw the worse the claw Think opposite of interossei Ulna paradox High ulna defect leads to less of claw as paralysis of FDP

Answer 177

Congenital bicuspid aortic valve Rheumatic fever Endocarditis SOBOE/palpitations/exertional chest pain, LVF/syncope Ejection systolic murmur in aortic region radiating to carotid Slow rising pulse and forceful apex beat

Answer 178

Congential bicuspid, rehum f, endocarditis/aortic root pathology-aneurysm/marfans Early diastolic murmur in aortic region exertional dysponea Collapsing pulse

Answer 179

Rheum fever/endocarditis SOBOE/palpitations/AF Diastolic murmur in mitral region

Answer 180

Commonest valvular abnormality in the world Rheum/MI/myxomatous degeneration SOBOE/palpitations Pansystolic murmur to axilla/apex beat displacement

Answer 181

``` HTN Hypercholestrolaemia DM FHx Smoking Obesity ```

Answer 182

Autosomal dominant damage to the FBN1 gene which leads to lack of fibrillin Connective tissue disorder Long limbs, hypermobile, high palate, pes excavatum, lens disloaction Aortic aneurysms, mitral prolapse, aortic dissections Pneumothoraces

Answer 183

Inspect and expose Hands- clubbing, tar staining, xanthomas, marfanoid Endocarditis hands- splinter haemorrhages, janeway's, olser nodes (painful) eyes- xanthomas, mouth- central cyanosis, Chest- scars, pes, pulsatations, pacemakers Pulses- collapsing and radio-radial delay JVP Carotids palpate- heaves and thrills apex beat auscultate + manouvers +bruits Complete- auscultate lung bases, peripheral oedema and pulses, vein graft scars? BP ECG Echo PVD exam

Answer 184

Inspect- hands, eyes, mouth, co2 retention flap Palpate- pulse, JVP, LN, trachea, chest expansion, focal fremitus Auscultate Percuss ``` Peripheral oedema DVT O2 sats and resp rate Peak flow Temp Sputum ```

Answer 185

Small cell lung cancers Neuroendocrine cells- smoking association, quick mets Nonsmall cell Sqcc, adenocarcinoma, large cell

Answer 186

Local Lymphatic Mets- liver, brain, bone, adrenals, ContraL Neuroendocrine disorders Sqcc- PTHrP SCLC- SIADH, Cushings