MRCS RECALLS Flashcards

Question

What is the age incidence of torsion testicular appendage?

Answer 1

Blue dot sign on the upper pole of testis due to ischaemia of testicular appendage

Answer 2

(1) painful swollen testis not improved by testicular elevation (2) normal place testis

Answer 3

Urgent scrotal exploration + evacuation

Answer 4

< 60 yrs — chlamydia > 60 yrs — E.coli

Answer 5

+ epididymo- orchitis—- post urological procedure + orchitis— infection ( viral or parotid)

Answer 6

(1) Fever (2) Dysuria (3) Urethral discharge (4) Unilateral scrotal pain + tender swollen testis

Answer 7

Drug of choice = ciprofloxacilin + Doxycycline

Answer 8

(1) With RCC (2) After long standing (3) Lt > Rt (4) Bag of worms in the scrotum

Answer 9

After long standing

Answer 10

A bag of worms

Answer 11

(1) Conservative, (2) Surgical —- + indication = affects fertility + procedure = testicular veins ligation via inguinal approach

Answer 12

affects fertility

Answer 13

testicular veins ligation via inguinal approach

Answer 14

Sperm granuloma

Answer 15

Painful scrotal swelling post vasectomy

Answer 16

Paratesticular tumour

Answer 17

Distal part of spermatic cord

Answer 18

Bimodal age = 4 months - 16 yrs

Answer 19

Liability for L.N spread in 30 - 50 % of patients

Answer 20

30 - 50% of patients

Answer 21

1. Urethral injuries + Bulbar urethral injuries + Membranous urethral injuries 2. Bladder rupture

Answer 22

Bulbar urethral injury

Answer 23

Straddle injury (i.e., falling astride, such as bicycle riders)

Answer 24

Mnemonic; F/BUP 1. Full bladder 2. Blood in meatus 3. Urine retention 4. Perineal haematoma

Answer 25

Ascending cystourethrogram OR Alternative: IV urography

Answer 26

1. Suprapubic catheter 2. Urethral catheter is contraindicated

Answer 27

Urethral catheter is contraindicated

Answer 28

With pelvic fractures

Answer 29

Mnemonic → F/BUP F: Full bladder B: Blood in meatus U: Perineal hematoma P: PR → High or non-palpable prostate.

Answer 30

Ascending cystourethrography OR Intravenous urography

Answer 31

Suprapubic catheterization Urethral catheterization is contraindicated.

Answer 32

Urethral catheterization is contraindicated.

Answer 33

(1) with pelvic fractures (2) Bladder rupture may occur without trauma after neglected desire of urination, especially after stressful conditions.

Answer 34

Mnemonic → FRESH F: Free fluid intra-abdominally R: Retention E: Empty bladder S: Suprapubic pain H:Haematoma

Answer 35

Ascending cystourethrogram OR IV urography.

Answer 36

(1) Extraperitoneal: Conservative. (2) Intraperitoneal: Laparotomy for fear of peritonitis

Answer 37

(1) Retroperitoneal organs, (2) on the upper part of the posterior abdominal wall (3) In the paravertebral gutter (4) Opposite— last thoracic vertebra (T12) — upper 3 lumbar vertebrae (L1-L3) (4) The Rt kidney is 0.5 inches lower than the Lt because of liver on the Rt

Answer 38

Bean shaped

Answer 39

- 2 ends (poles): upper and lower; the upper end is nearer to the median plane than the lower. - 2 borders: lateral convex border and + medial concave border presenting the hilum at its middle. - 2 surfaces: anterior (related to adjacent organs) and posterior (applied to the posterior abdominal wall).

Answer 40

The upper end of the (1) both kidneys is nearer to the median plane(midline) than the lower end. (2) left kidney is opposite the — 11th rib + upper border of T12; (3) right kidney is opposite the — 11th space + lower border of T12.

Answer 41

- Lt kidney opposite → upper border of L3 + 6.5cm above iliac crest - Rt Kidney opposite → lower border of L3 + 5cm above iliac crest

Answer 42

Opposite the (1) 11th space (ICS) (2) lower border of T12

Answer 43

Opposite the (1) 11th rib (2) upper border of T12

Answer 44

6.5 cm above iliac crest ## Footnote None

Answer 45

(1) Opposite the lower border of L3, (2) 5 cm above iliac crest

Answer 46

Risk of pneumothorax during nephrectomy

Answer 47

Lower border of L3

Answer 48

5cm above iliac crest

Answer 49

Hilum at its middle.

Answer 50

- Both Kidneys → the middle of the medial border of the Kidney - Lt Kidney → L1( mnemonic; Lt one L1) → the centre of the hilum lies opposite the lower border of L1 spine, 2 inches from the median plane - Rt Kidney → L1-L2 (mostly L2)

Answer 51

+ In nephrolithotomy: pelvis of the ureter (posterior surface) is opened + in radical nephrectomy: renal vein (anterior surface) is opened

Answer 52

Pelvis of the ureter (posterior surface)

Answer 53

Renal vein (anterior surface)

Answer 54

1. True capsule (Fibrous capsule) 2. Fatty capsule (Perinephric fat) 3. False capsule (Zucker candle fascia or Gerota's fascia)

Answer 55

Fibrous capsule

Answer 56

Perinephric fat

Answer 57

Zucker candle fascia or Gerota's fascia

Answer 58

1.Collagen 2.Elastic fibres

Answer 59

Closely invests or surrounds the kidneys

Answer 60

Fascia transversalis

Answer 61

2 layers: (1) Fused above the kidney, (2) Remain separate below to allow ptosis of the kidney

Answer 62

1. Encloses both kidneys and suprarenal glands 2. Opens inferiorly

Answer 63

Can be stripped off easily

Answer 64

Adipose (fatty) tissue

Answer 65

Both: (1) kidneys (2) suprarenal glands

Answer 66

Inferiorly

Answer 67

The kidneys are supplied with blood via the renal arteries, which arise directly distal or inferior to the abdominal aorta, immediately distal to the origin of the superior mesenteric artery. Due to the anatomical position of the abdominal aorta (slightly to the left of the midline), the right renal artery is longer, and crosses the vena cava posteriorly. The renal artery arises perpendicularly from the abdominal aorta just immediately below or distal to the branching of the superior mesenteric artery, roughly at the level of the intervertebral disc between the L1 and L2 vertebrae. +The right renal artery, which is slightly longer and higher up than the left one, courses posterior to the inferior vena cava, renal vein, head of the pancreas and second part of the duodenum. +The left renal artery courses more horizontally and posterior to the renal vein, the body of the pancreas and the splenic vein. The renal artery enters the kidney via the renal hilum. At the hilum level, the renal artery forms an anterior and a posterior division, which carry 75% and 25% of the blood supply to the kidney, respectively. Five segmental arteries originate from these two divisions. The avascular plane of the kidney (line of Brodel) is an imaginary line along the lateral and slightly posterior border of the kidney, which delineates the segments of the kidney supplied by the anterior and posterior divisions. It is an important access route for both open and endoscopic surgical access of the kidney, as it minimises the risk of damage to major arterial branches. Note: The renal artery branches are anatomical end arteries – there is no communication between vessels. This is of crucial importance; as trauma or obstruction in one arterial branch will eventually lead to ischaemia and necrosis of the renal parenchyma supplied by this vessel.

Answer 68

A branch of the abdominal aorta at L1/L2 (mostly L2)

Answer 69

- Left renal vein is longer than the right renal vein. - Rt renal artery is longer than the left renal artery.

Answer 70

Renal artery passes behind renal vein.

Answer 71

Right renal artery passes behind the IVC.

Answer 72

L1/L2 (mostly L2)

Answer 73

- The left renal vein is longer than the right renal vein. - The right renal artery is longer than the left renal artery

Answer 74

The renal vein passes in front of the renal artery.

Answer 75

1. renal artery 2. aorta.

Answer 76

The renal vein passes behind the superior mesenteric artery.

Answer 77

Lumber region (loin)

Answer 78

Between redial artery and cephalic vein

Answer 79

Rib resection may be needed in Lt kidney operations

Answer 80

Due to 1st/ relation of the Rt kidney to the (1) Biliary duct (2) 2nd part of the duodenum (3) Ampulla of Vater 2nd/ short Rt renal vein

Answer 81

From the tip of the transverse process of L1 (sacroiliac joint) to L5 (tip of ischial spine)

Answer 82

1. At the pelvic-ureteric junction 2. In front of the tip of the transverse process of L1

Answer 83

Postero-superior angle of the urinary bladder

Answer 84

Stone impaction, e.g., vesicoureteric stone.

Answer 85

25 - 30 cm

Answer 86

Each ureter descends vertically behind the peritoneum of the posterior abdominal wall opposite the tips of transverse processes of lower 4 lumbar vertebrae (the same course in both ♂ & ♀).

Answer 87

Retroperitoneal

Answer 88

Tips of transverse process of lower 4 lumbar vertebrae (L2-L5)

Answer 89

• Medial border of psoas major & genito-femoral nerve on it. • Tips of transverse processes of the lower 4 lumbar vertebrae (L2-L5)

Answer 90

Mnemonic; 3 • 3rd part of duodenum • 3 arteries - Rt Gonadal vessels: gonadal vessels are medial to ureter then cross anterior then become lateral to the pelvic brim - Rt colic - Rt ileocolic • 3 structures related to the mesentry - its root - SMA - coils of ileum

Answer 91

Mnemonic; MAL

Answer 92

. Three arteries: (1) Left gonadal, which becomes lateral to it at the pelvic brim; (2) Upper left colic; (3) Lower left colic. . It passes behind the fossa intersigmoidae . Sigmoid mesocolon . Coils of sigmoid colon

Answer 93

Inferior mesentric artery (IMA)

Answer 94

It enters the pelvis by crossing in front of the bifurcation of the common iliac artery at the sacroiliac joint or pelvic inlet brim.

Answer 95

It enters the pelvis by crossing in front of the bifurcation of the common iliac artery at the sacroiliac joint or pelvic inlet (brim).

Answer 96

It runs downwards and backwards on the side of the pelvic wall until it reaches the ischial spine with the following relations: - Anterior: peritoneum (it is retro-peritoneal). - Posterior: internal iliac vessels. - Lateral: obturator nerve & vessels and the umbilical artery.

Answer 97

It runs downwards and backwards on the side of the pelvic wall until it reaches the ischial spine with the following relations: - Anterior: peritoneum (it is retro-peritoneal). - Posterior: internal iliac vessels. - Lateral: obturator nerve & vessels and the umbilical artery. At the level of the ischial spine ,it curves antero-medially crossing over the levator ani muscle to open into the postero-superior angle of the urinary bladder. Here its course is different in M & F: - in M: it is crossed by the vas deferens from lateral to medial. - in F: it crosses posterior to the uterine artery 2 cm lateral to the cervix

Answer 98

At the level of the ischial spine ,it curves antero-medially crossing over the levator ani muscle to open into the postero-superior angle of the urinary bladder. Here its course is different in M & F: - in M: it is crossed by the vas deferens from lateral to medial. - in F: it crosses posterior to the uterine artery 2 cm lateral to the cervix

Answer 99

At the level of the ischial spine ,it curves antero-medially crossing over the levator ani muscle to open into the postero-superior angle of the urinary bladder. Here its course is different in M & F: - in M: it is crossed by the vas deferens from lateral to medial. - in F: it crosses posterior to the uterine artery 2 cm lateral to the cervix

Answer 100

In males, it is crossed by the vas deferens from lateral to medial. In females, it crosses posterior to the uterine artery 2 cm lateral to the cervix.

Answer 101

It is crossed by the vas deferens from lateral to medial.

Answer 102

It crosses posterior to the uterine artery 2 cm lateral to the cervix.

Answer 103

The ureter passes behind the uterine artery, which can be injured during ovarian excision or hysterectomy.

Answer 104

Runs in an oblique course in the bladder wall.

Answer 105

Blood Supply: (Segmental) - UPPER 1⁄2 ➔ renal artery. - MIDDLE 1⁄2 ➔ gonadal, aorta & common iliac, internal iliac - LOWER 1⁄2 ➔ vesical in male & uterine & vaginal in female & middle rectal in both

Answer 106

Renal artery.

Answer 107

Gonadal, aorta & common iliac.

Answer 108

Vesical in male & uterine & vaginal in female & middle rectal in both.

Answer 109

Vesical artery.

Answer 110

Uterine & vaginal.

Answer 111

Middle rectal.

Answer 112

Base of the bladder.

Answer 113

The base of the bladder.

Answer 114

It runs in front of: 1. Tips of the transverse processes of lumbar vertebrae. 2. Iliosacral joint. 3. Ischial spine.

Answer 115

1st/Anatomical site: + Lies on psoas major. + Seen crossing: (1) The bifurcation of common iliac. (2) The ischial spine. 2nd/It is not an artery: since the pulsations are not continuous but peristalsis. 3rd/It is not Psoas minor: • Psoas Minor: Flat shining tendon. • Ureter: white cord-like (tubular). 4th/It is not a colon: • Colon: Blood vessels run circular. • Ureter: Blood vessels run longitudinally.

Answer 116

The stone.

Answer 117

Abdominal ureter should be mobilized medially. Pelvic ureter should be mobilized laterally (receives its blood supply from lateral side).

Answer 118

The ureter remains attached to the undersurface of the peritoneum when the latter is reflected at surgery.

Answer 119

Renal stones are likely to get impacted through constriction sites → ureteric colic (begins in loin & radiates to groin).

Answer 120

Pain radiates to external genitalia.

Answer 121

Gynaecomastia

Answer 122

Group.A - β haemolytic streptococci which is Streptococcus pyogenes

Answer 123

Methicillin-resistant Staphylococcus aureus

Answer 124

Antibiotic-resistant Staphylococcus aureus, a major nosocomial pathogen that spreads by hands. (usually of nursing or medical staph)

Answer 125

Mnemonic; N/BAG (1) Nose (2) Buttocks (3) Armpits (4) Groin

Answer 126

MRSA lives harmlessly on the skin, i.e.,asymptomatic.

Answer 127

Contact, especially from the hands of nurses or medical staff.

Answer 128

1st/ Asymptomatic, discovered only during screening. 2nd/ Mild cases may include - pain - reddness - swelling - pus 3rd/ Severe cases may include - fever > 38C - chills, - aches, - dizziness, and - confusion.

Answer 129

1. Redness (rubor), 2. Pain (dolor), 3. Heat (calor), 4. Swelling (tumor), 5. Pus

Answer 130

The bacterial virulence is related to toxin & enzyme production.

Answer 131

All pathogens are facultative anaerobes except Clostridium; Bacteroids are obligate anaerobes.

Answer 132

Immediately start the rabies vaccine & give anti-rabies serum.

Answer 133

Bacteroides fragilis is a gram-negative obligate anaerobe bacillus of the gut.

Answer 134

It is involved in 90% of anaerobic potential infections.

Answer 135

Lactobacillus is a gram-positive facultative anaerobe bacteria (bacilli) present in the vagina & GIT.

Answer 136

It produces lactic acid making its environment acidic.

Answer 137

Proteus mirabilis is gram-negative and associated with UTI in (1) long term catheterization, and (2) stag horn-stone.

Answer 138

T.B mycobacterium is common in immune-suppressed patients.

Answer 139

Risk of wound infection can be decreased by: 1. Administration of prophylactic antibiotics. 2. Iodophor impregnated drapes.

Answer 140

< 6 months = CMV > 6 months = EBV

Answer 141

- Non sickler = staph.aureus - Sickler = salmonella

Answer 142

Streptococcus Pneumoni

Answer 143

Staphylococcus infections especially staphylococcus aureus

Answer 144

Advancing soft tissue infection associated with fascial necrosis.

Answer 145

It is uncommon but can be fatal, especially in immunosuppressed individuals, such as those with diabetes.

Answer 146

It is caused by polymicrobial flora (aerobic and anaerobic), with MRSA also being seen.

Answer 147

Streptococcus is the commonest isolated pathogen, accounting for 15% of cases.

Answer 148

It is a form of necrotising fasciitis that is (1) superficial (2) located in the trunk.

Answer 149

Necrotizing fasciitis affecting the perineum, where muscles are spared.

Answer 150

E. coli, mixed flora, and Bacteroids, which produce verotoxin.

Answer 151

Blisters and crepitations, along with general constitutional manifestations.

Answer 152

Aggressive surgical debridement is required.

Answer 153

Diarrhoea that occurs after broad-spectrum antibiotics, such as Ciprofoxacin, Cephalosporins, Ampicillin, and Clindamycin.

Answer 154

It is caused by the overgrowth of Clostridium difficile due to the inhibition of normal flora.

Answer 155

(1) Stool analysis for Cl. difficile toxins (2) Colonoscopy showing elevated yellow-white plaques (pseudomembrane).

Answer 156

(1) Electrolyte disturbance, (2) paralytic ileus, (3) toxic megacolon, (4) endotoxic shock, and (5) bowel perforation.

Answer 157

Metronidazole (oral) or Vancomycin (oral). For severe cases, Metronidazole (IV) and Vancomycin (oral) are used.

Answer 158

I) Superficial fascia 1. Camper's fascia — Superficial fatty layer 2. Scarpaes fascia — Deep membranous layer II) No deep fascia III) Muscles 1st/ Lateral muscles - External oblique muscle and aponeurosis - Internal oblique muscle and aponeurosis - Transversus abdominis muscle and aponeurosis 2nd/ Medial muscles: divided by arcuate line into +Above arcuate line — (a) Anterior rectus sheath (1) External oblique aponeurosis (2) Anterior leaflet of internal oblique aponeurosis — (b) Rectus abdominis muscle — (c) Posterior rectus sheath — (1) Posterior leaflet of internal oblique aponeurosis (2) Transversus abdominis muscle aponeurosis +Below arcuate line — (a) Anterior rectus sheath — All 3 lateral muscles (1) External oblique aponeurosis (2) Internal oblique aponeurosis (3) Transversus abdominis aponeurosis — (b) Rectus abdominis muscle — (c) Fascia transversalis . no posterior rectus sheath . fascia transversalis only presents posteriorto the rectus abdominis e.g., in pfannensteil incision 3rd/Posterior muscle - Quadratus lumborum muscle — alone ( unilateral) action: lateral flexion of vertebral column — Together (bilateral) action: depression of thoracic cage IV) Fascia transversalis V) Extraperitoneal fat — between transversalis fascia and parietal peritoneum VI) Parietal peritoneum

Answer 159

1. Anterior rectus sheath: - External oblique - Anterior leaflet of internal oblique 2. Rectus abdominis muscle 3. Posterior rectus sheath: - Posterior leaflet of internal oblique - Transversus abdominis

Answer 160

1. Anterior rectus sheath: - All three flat muscles (EOM, IOM, TAM) 2. Rectus abdominis muscle 3. Fascia transversalis ## Footnote No posterior rectus sheath; fascia transversalis only present posteriorly to the rectus abdominis.

Answer 161

Extraperitoneal fat is located between the transversalis fascia and the parietal peritoneum.

Answer 162

(1) Camper's fascia → Superficial fatty layer (2) Scarpa's fascia → Deep membranous layer

Answer 163

Camper's fascia

Answer 164

Scarpa's fascia

Answer 165

No deep fascia

Answer 166

1) External oblique muscle and aponeurosis 2) Internal oblique muscle and aponeurosis 3) Transversus abdominis muscle and aponeurosis

Answer 167

Midway between the umbilicus and symphysis pubis

Answer 168

Divides the abdominal wall muscles: Above arcuate line - Anterior rectus sheath formed of external oblique and anterior leaflet of internal oblique; Below arcuate line - Anterior rectus sheath formed of all three lateral muscles; No posterior rectus sheath but fascia transversalis only present posterior especially in Pfannenstiel incision.

Answer 169

It is a protrusion of a tissue or an organ through the wall of the cavity in which it is normally contained

Answer 170

The defect is in the linea alba.

Answer 171

The defect is in the Linea alba, whatever - supra-umbilical, and - infra-umbilical.

Answer 172

(1) Females, (2) multiparity, and (3) obesity.

Answer 173

(1) Between external and internal oblique muscles, (2) lateral to rectus abdominis, (3) at the level of arcuate line.

Answer 174

Through the greater sciatic foramen.

Answer 175

Through the lesser sciatic foramen.

Answer 176

Through the superior and inferior lumbar triangle.

Answer 177

- Laterally: external oblique, - Medially: latissimus dorsi, - Inferiorly: iliac crest.

Answer 178

(1) Through obturator foramen (2) Behind pectineus muscle

Answer 179

- Intestinal obstruction - Pain → Site → region of obturator nerve distribution; → Associated with → leg groin pain; → radiation → Ipsilateral knee

Answer 180

The defect is usually repaired from within the abdomen.

Answer 181

Sites of previous surgical incisions.

Answer 182

(1) Wound infection (2) Haematoma

Answer 183

Jenkins rule should be used in which bites taken at (1) 1 cm interval (2) 1 cm from the wound edge

Answer 184

- Indication → to minimize the following post midline laparotomy (1) wound dehiscence or (2) incisional hernia - Technique → Bites taken at 1 cm (1) interval (2) from wound edge

Answer 185

To minimize wound dehiscence or incisional hernia following midline incision.

Answer 186

Bites taken at 1cm (1) intervals (2) from the wound edge.

Answer 187

Littre's hernia = Meckel's diverticulum.

Answer 188

Resection of diverticulum + Mesh repair.

Answer 189

Mnemonic; A= A Amyand hernia = Appendix.

Answer 190

The antimesentric border of part of the small intestine wall is herniated to outside through a hernial sac and intrapped in hernia

Answer 191

One inguinal obstruction as luminal patency is preserved.

Answer 192

The antimesentric border of part of the small intestine wall

Answer 193

Mnemonic; (M)aydl = W Two W-shaped bowel loops within its sac.

Answer 194

With any organ.

Answer 195

Type of direct inguinal hernia; has two parts each is on either side of the inferior epigastric artery.

Answer 196

Downward → Forward →Medially

Answer 197

(1) At the external oblique muscle (2) Above pubic tubercle

Answer 198

(1) At fascia transversalis (2) 1/2 inch above midpoint of inguinal ligament (3) lateral to inferior epigastric vessels.

Answer 199

- Sternal → xiphoid process - Costal → lower costal cartilages

Answer 200

Central tendon

Answer 201

- Central part → Phrenic nerve ( C3,4,5) sensory and motor (Mnemonic; C3,4,5 keep the diaphragm alive) - Peripheral part → lower 6 thoracic nerves

Answer 202

Mnemonic; C3,4,5 keep the diaphragm alive Phrenic nerve (C3,4,5) motor and sensory

Answer 203

Lower 6 Thoracic nerves

Answer 204

Mnemonic; (V)ery (P)owerful/ (O)n (V)esting/ ATA

Answer 205

Congenital diaphragmatic hernia

Answer 206

1. Bochdäleck hernia 2. Morgagni hernia

Answer 207

Pleuroperitoneal membrane

Answer 208

Septum transversum

Answer 209

Posterior left

Answer 210

Anterior right

Answer 211

> Complications

Answer 212

< Complications

Answer 213

Mnemonic; Bochdaleck=Bad Bad prognosis

Answer 214

(1) Cyanosis (2) Chest examination → Left side → ↓air entry on the Lt side → Right side → displaced apex beat to the Rt (3) Abdominal examination → scaphoid abdomen

Answer 215

(1) Recurrent chest infection (2) Chest examination → Left side → ↓air entry on the Lt side → Right side → displaced apex beat to the Rt (3) Abdominal examination → scaphoid abdomen

Answer 216

Mnemonic; BEX (1) X-rays, (2) Barium study, (3) Echocardiogram

Answer 217

Mnemonic; BEX (1) X-rays, (2) Barium study, (3) Echocardiogram

Answer 218

A type of congenital diaphragmatic hernia.

Answer 219

A type of congenital diaphragmatic hernia.

Answer 220

Abdominal incision with (1) Reduction of contents (2) Closure of diaphragm

Answer 221

Abdominal incision with (1) Reduction of contents (2) Closure of diaphragm

Answer 222

+ Floor of popliteal fossa (1) Popliteal surface of the femur, (2) posterior ligament of knee joint (3) popliteus muscle + Roof of popliteal fossa Superficial and deep fascia + Contents (according to the EMRCS) (1) Popliteal artery and vein (2) Small saphenous vein (3) Common peroneal nerve (4) Tibial nerve (5) Posterior cutaneous nerve of the thigh (6) Genicular branch of the obturator nerve (7) Lymph nodes + Clinical notes In total knee replacement or knee surgery, the popliteal artery is - the deepest structure amongst the contents of the popliteal fossa ↓ - directly applied to bone ↓ - worry about it in any knee surgery especially in the popliteal fossa

Answer 223

CT Contraindication: metallic prosthesis

Answer 224

MRI ## Footnote Contraindication: Claustrophobia May 2022 A patient had trauma to his ankle. Xray revealed no fracture. Ankle pain persists. The most appropriate investigation is: A.Stress Xray B.CT C.MRI D.Bone scan E.Repeat Xray The correct answer is C.MRI MRI is done for any ligamentous soft tissue injury or ankle sprain with persistent pain not improving with whatsoever

Answer 225

+ 1st 24 hrs → MRI + After 24 hrs → CT

Answer 226

<1cm wound

Answer 227

>1cm wound with moderate soft tissue damage

Answer 228

>1cm wound with extensive soft tissue damage

Answer 229

Open reduction + external fixation with inadequate soft tissue coverage

Answer 230

Immediate vascular repair if <6hrs; Amputation if >6hrs

Answer 231

Internal fixation due to the risk of infection

Answer 232

Closed reduction

Answer 233

Not an emergency: Open reduction, fixation with a cast, internal fixation (nail or plate)

Answer 234

Nailing is better where there are adequate stumps of bone on both sides of the fracture

Answer 235

Plates are better when the fracture is adjacent to joints with short stumps

Answer 236

A complication causing dyspnea and respiratory failure with tachypnea and rash following orthopedic surgeries.

Answer 237

A systemic complication of fracture management.

Answer 238

A complication associated with long bone fractures causing vascular injury and bleeding (e.g., femur fracture causing hematoma).

Answer 239

Blood accumulation around the joint after trauma causing joint swelling. ## Footnote Spontaneous hemarthrosis may be seen in patients with Hemophilia A (factor 8 deficiency).

Answer 240

Also known as Sudeck's atrophy or sympathetic dystrophy, it involves sympathetic overactivity at the fracture site leading to shiny, swollen, and erythematous skin.

Answer 241

Absent distal pulsation after fixation of the fracture, managed by removal of the cast and revision of surgery.

Answer 242

A condition treated by 4 compartments fasciotomy through 2 incisions.

Answer 243

A term used when the bone does not heal properly due to improper alignment or early removal of the cast.

Answer 244

Permanent failure of bone healing due to poor blood supply, excessive movement, or infection of the joint causing pseudoarthrosis on X-ray.

Answer 245

Def: Ischemia and necrosis at the fracture site causing stiffness and pain. Liable sites include (Mnemonic; FSTK على أغنية نجاح الموجي وفريد شوقي بتاع فستك نو يا فستك نو) 1) neck femur, 2) scaphoid, 3) talus, and 4) knee.

Answer 246

Idiopathic avascular necrosis of femoral epiphysis leading to flattened femoral head.

Answer 247

Idiopathic

Answer 248

6 years Males

Answer 249

(1) Antalgic gait (2) Limping (3) Shortening (4) Catterall staging: 1 → Clinical and histological features only. 2 → Sclerosis without affection of articular surface. 3 → Affection of femoral head. 4 → Affection of acetabulum.

Answer 250

A system to classify the severity of Perth's disease.

Answer 251

1 → Clinical and histological features only. 2 → Sclerosis without affection of articular surface. 3 → Affection of femoral head. 4 → Affection of acetabulum.

Answer 252

- X-ray shows (1) flattened femoral head and (2) crescent sign. - If X-ray is normal, bone scan is better than MRI. - U/S and specific tests like Ortolani test and Barlow test are also used.

Answer 253

Flattened femoral head

Answer 254

Dysplasia of acetabulum resulting in recurrent dislocation of femoral head.

Answer 255

(1) Neonate: Breach delivery, (2) Missed or delayed: limited movement on extreme range of motion (ROM). (3) Female gender

Answer 256

(1) Antalgic gait, (2) limping, (3) shortening, (4) prominent skin crease.

Answer 257

(1) U/S (2) Specific tests - Ortolani test - Barlow test

Answer 258

Recurrent femoral head dislocation

Answer 259

Slipping of the femoral head.

Answer 260

Adolescent obese children.

Answer 261

(1) Antalgic gait (2) Limping (3) Shortening (4( Limited internal rotation of the hip. May 2022 A 12-year-old overweight child presented with obvious limping and limited internal rotation. He denies any history of trauma. What is the most accurate diagnosis? A.Perthes disease B.Slipped upper femoral epiphysis C.Developmental dysplasia of the hip D.Septic arthritis E.Osteoarthritis The correct answer is B.Slipped upper femoral epiphysis

Answer 262

Molten ice cream cone.

Answer 263

A congenital disorder of type 1 collagen resulting in abnormal (1) bone formation and (2) mineralization

Answer 264

(1) irregular patches of ossification, (2) wormian bones, and (3) multiple fractures.

Answer 265

An autosomal recessive disorder of osteoclasts resulting in harder bone formation. ## Footnote Characterized by a lack of differentiation between bone cortex and medulla.

Answer 266

A congenital deformity in which (1) the ankle is dropped and inverted, (2) occurring bilaterally in 50% of cases and (3) more common in males.

Answer 267

(1) physiotherapy, (2) bracing, (3) casting, and (4) tendoachilis release.

Answer 268

Joint disease due to breakdown of cartilage and bone.

Answer 269

1. Previous joint injury and fractures 2. Mechanical stress on the joint 3. Obesity

Answer 270

Mnemonic; SCON 1. Subchondral sclerosis 2. Cyst formation 3. Osteophyte 4. Narrow joint space

Answer 271

1. Exercise + reduce weight 2. Steroids + Intra-articular steroids 3. Heat application + Physiotherapy

Answer 272

Arthroscope or joint replacement.

Answer 273

Necrobiotic granuloma ## Footnote It is an autoimmune inflammatory disorder affecting hand and wrist joints in females mainly after rest.

Answer 274

Deposition of urate crystals in joints causing arthritis. ## Footnote 90% idiopathic, 10% diuretics related.

Answer 275

(1) Idiopathic 90% (2) Diuretics related 10%

Answer 276

Metatarsophalangeal joint of big toe.

Answer 277

(1) Joint pain (2) Renal affection (3) Tophi of ear lobule

Answer 278

Aspirate showing (1) Negative birefringence, (2) Needle shaped crystals.

Answer 279

(1) Negative birefringence, (2) Needle shaped crystals.

Answer 280

NSAIDS + Colchicine.

Answer 281

Deposition of Ca pyrophosphate crystals in joints causing arthritis. ## Footnote Associated with hyperparathyroidism, hemochromatosis, and Wilson disease.

Answer 282

(1) Hyperparathyroidism (2) Haemochromatosis (3) Wilson disease

Answer 283

(1) Joint pain (2) Renal affection (3) Tophi of ear lobule

Answer 284

Aspirate showing (1) Positive birefringence, (2) Rhomboidal shaped crystals.

Answer 285

(1) Positive birefringence, (2) Rhomboidal shaped crystals.

Answer 286

Elevated transferrin level may be used as an indicator for pseudogout as it's related to hemochromatosis disease.

Answer 287

(1) Reduced bone density (2) Normal mineralization. ## Footnote Common in post-menopausal females, and associated with steroids, smoking, alcohol, and frequent fractures.

Answer 288

(1) post menopausal females (2) steroids (3) smoking (4) alcohol

Answer 289

Frequent fractures

Answer 290

Normal (1) Alkaline phosphatase (2) Calcium (3) Phosphorus

Answer 291

Uncontrolled bone turnover caused by disorder in osteoclasts and osteoblasts.

Answer 292

(1) Frequent fractures (2) Thickened bone

Answer 293

Skull X-ray shows thickened calvarium.

Answer 294

Thickened calvarium.

Answer 295

(1) predispose to osteosarcoma (2) Deafness due to skull thickening

Answer 296

Decreased mineralization of bone due to calcium deficiency.

Answer 297

Vit.D (1) deficiency (2) resistance

Answer 298

Therapeutic trial of vit.D

Answer 299

osteomalacia

Answer 300

Bony lesions caused by the spread of a tumor. ## Footnote Commonly associated with breast cancer and bronchus cancer.

Answer 301

Anterior rami of spinal nerves L2-L3 and part of L4

Answer 302

Anterior rami of L4-L5

Answer 303

Root value of the lumbosacral plexus (anterior rami of L4-L5)+ anterior rami of S1-S3 and part of S4

Answer 304

- The femoral nerve is the largest branch of lumbar plexus - It carries contributions from the dorsal division of the anterior (ventral) rami of L2 to L4 segments of spinal cord.

Answer 305

It forms in the abdomen within the substance of psoas major muscle. It lies in the groove between the psoas major and iliacus muscles outside femoral sheath It passes through (i.e.,penetrates) psoas major muscle then emerges from its lateral border to reach the anterior compartment of the thigh It descends posterolaterally through the pelvis to the midpoint of the inguinal ligament It leaves the abdomen by passing under or behind the inguinal ligament and through the gap between the inguinal ligament and superior margin of the pelvis to enter the femoral triangle ,on the anteromedial aspect of the thigh, lateral to the femoral vessels. It has a short course of about 2.5 cm below the inguinal ligament. It ends by dividing into anterior and posterior divisions 2.5 cm below the inguinal ligament

Answer 306

it is lateral to the femoral artery.

Answer 307

+ It innervates all muscles in the anterior compartment of the thigh (mnemonic;ISQ) (1) Iliopsoas (2) Sartorius (3) Quadriceps femoris muscles 1. Vastus lateralis 2. Vastus intermedius 3. Vastus medialis 4. Rectus femoris + In the abdomen, gives rise to branches that innervate the iliacus and Pectineus muscles.

Answer 308

It gives rise to branches that innervate the iliacus and pectineus muscles.

Answer 309

It innervates skin over the (1) anterior aspect of the thigh, (2) anteromedial side of the knee, (3) medial side of the leg, and (4) medial side of the foot through its branch, the Saphenous Nerve.

Answer 310

it is one of the two branches of the anterior division of the femoral nerve distal the inguinal ligament, the other branch is the intermediate (anterior) cutaneous nerve of the thigh

Answer 311

(1) arises from the femoral nerve distal to the inguinal ligament (2) travels along the sartorius (3) pierces through the deep fascia (4) becomes superficial at the upper 1/3rd of the thigh

Answer 312

provides cutaneous innervation to the medial thigh

Answer 313

(1) intermediate (anterior) femoral cutaneous nerve (2) anterior cutaneous nerve of the thigh

Answer 314

innervates anterior thigh

Answer 315

a purely sensory nerve that arises from the femoral nerve

Answer 316

(1) It descends in the femoral triangle and accompanies the femoral artery and femoral vein in the adductor canal(Hunter's canal). (2) It then travels on the posteromedial border of the knee and at this exact point it is accompanied by saphenous vein and could be injured by placement of the posteromedial portal(used to visualise posterior cruciate ligament and posterior horn of lateral meniscus) (3) pierces through the medial deep fascia of the knee(fascia lata) between sartorius and gracilis muscles to become subcutaneous. (4) It travels superficially down the + anteromedial lower leg + ankle over the medial malleolus + 1st metatarsal head + dorsum of the foot

Answer 317

Supplies sensation to the skin of the (1) anteromedial lower leg (2) ankle over the medial malleolus (3) 1st metatarsal head (4) a part of the arch of the foot medially (5) dorsum of the foot medially

Answer 318

from the femoral nerve (L2-L3) and is purely sensory

Answer 319

(1) deep thigh ache (2) Paraesthesia in the cutaneous distribution of nerve (3) knee pain

Answer 320

Posterior surface of ventral rami of L2-L3

Answer 321

Purely sensory and Supplies the (1) Lower lateral quadrant of the gluteal region (2) anterior and lateral thigh and (3) lateral knee

Answer 322

The nerve emerges from the lateral border of psoas muscle, anterior to the iliac crest, and passes between iliacus and iliac fascia crossing the iliacus. Enters the thigh posterior or under the lateral end inguinal ligament , medial to the anterior superior iliac spine (ASIS). From there, it becomes superficial and innervates the lateral thigh. The most common site of impingement is under the inguinal ligament.It pierces the fascia lata 10 cm inferior to the ASIS and divides into two branches: • Anterior branch supplies skin and fascia of the anterolateral surface of the knee • Smaller posterior branch supplies the skin and fascia on the lateral part of the upper leg between the greater trochanter and distal 1/3rd of the thigh

Answer 323

meralgia paraesthetica

Answer 324

Sacral plexus

Answer 325

posterior femoral cutaneous nerve

Answer 326

More common in men

Answer 327

innervates the skin to the posterior (1) thigh (2) leg (2) perineum

Answer 328

Mnemonic; SCOPA (1) Surgery (2) tight Clothing, (3) Obesity, (4) Pregnancy (5) tense Ascites,

Answer 329

(1) It presents with paraesthesia & numbness in the upper lateral thigh on the affected side. (2) Symptoms are worsened by standing and relieved by sitting (3) Examination reproduces the pain by compression below the anterior superior iliac spine (ASIS) and hip extension. The motor examination is intact.

Answer 330

May 2022 Question (21) A 45-year-old man presents with fever and pain in his right loin and groin. A soft swelling was noted in his femoral triangle. Diagnosis of a psoas abscess was made. Which of the following statements is most accurate regarding psoas major? 十 A.It arises from the lateral borders of the bodies of T12 to L5 B.It extends the hip C.It inserts into the greater trochanter of the femur D.It is innervated from T12 and LI E.It passes posterior to the capsule of the hip joint Answer A.It arises from the lateral borders of the bodies of T12 to L5

Answer 331

The obturator nerve originates from lumbosacral plexus as anterior (ventral) division of ventral rami L2 to L4 segments of spinal cord. L3 is main segment and L2 is occasionally absent

Answer 332

May 2022 Q19 A 25-year-old man sustains a twisting injury while playing football. He develops immediate swelling of the knee, and he cannot continue the game. Six months later, he is still not able to play football. His knee feels unsteady and tends to give way. On examination, he has a full range of knee motion. There is a positive anterior draw test and a small effusion. What is the most likely structure damaged? 十 A. Anterior cruciate ligament B. Lateral collateral ligament C.Medial collateral ligament D.Oblique popliteal ligament E.Posterior cruciate ligament Answer A.Anterior cruciate ligament (ACL) May 2022 Q20 During a game of football, Andrew experienced a twisted injury. The next day emergency house officer found a positive patellar tap. He cannot extend his knee. What is your diagnosis? 十 A.Anterior cruciate ligament injury B.Knee Dislocation C.Dislocated patella D.Bucket handle meniscal tear E.Lateral collateral ligament injury Answer D.Bucket handle meniscal tear

Answer 333

The obturator nerve originates from lumbosacral plexus as anterior (ventral) division of ventral rami L2 to L4 segments of spinal cord. L3 is main segment and L2 is occasionally absent The femoral nerve is the largest branch of lumbar plexus It carries contributions from the dorsal division of the anterior (ventral) rami of L2 to L4 segments of spinal cord.

Answer 334

FOR READING ONLY Bucket-handle menisceal tear: One of the types of menisceal tears, the meniscus separates around its circumference, and the inner margin becomes displaced, often folding over on itself Appearance: The tear is named for its resemblance to the handle on a bucket, with the torn portion of the meniscus folding over like a handle Mechanism of injury: Meniscus tears, including bucket-handle tears, often occur after twisting injuries, such as planting the knee and foot forcefully and turning too quickly.

Answer 335

The branches of the obturator nerve unite in the substance of psoas major It descends vertically along the posterior abdominal wall, Emerges from the medial border of the passes through the pelvic cavity, and enters the thigh by passing through the obturator canal.

Answer 336

(1) all muscles in the medial compartment of the thigh, except the part of the adductor magnus muscle that originates from the ischium and the pectineus muscle. (2) obturator externus muscle

Answer 337

Obturator externus muscle

Answer 338

It innervates skin on the medial side of the upper thigh.(upper medial thigh)

Answer 339

The sciatic nerve is the largest nerve of the body and carries contributions from L4 to S3.

Answer 340

The sciatic nerve divides into the common fibular nerve and the tibial nerve.

Answer 341

A march fracture, also known as a metatarsal stress fracture, is a type of stress fracture that occurs in the metatarsal bones of the foot, often due to repetitive stress or overuse

Answer 342

The common fibular nerve carries posterior divisions of L4 to S2.

Answer 343

The tibial nerve carries anterior divisions of L4 to S3.

Answer 344

The sciatic nerve innervates all muscles in the posterior compartment of the thigh, the part of the adductor magnus originating from the ischium, and all muscles in the leg and foot.

Answer 345

The sciatic nerve innervates skin on the lateral side of the leg and the lateral side and sole of the foot.

Answer 346

A syndesmosis is a type of fibrous joint where two parallel bones are connected by ligaments or an interosseous membrane, providing stability and allowing slight movement. The distal tibiofibular syndesmosis, located in the ankle, is a key example, and injuries to this area are often referred to as "high ankle sprains".

Answer 347

Used for ankle fractures Type A ankle fractures— below syndesmosis Type B ankle fractures— at the level of or (trans) syndesmosis Type C ankle fractures— above syndesmosis

Answer 348

The superior gluteal nerve innervates the gluteus medius and minimus muscles, and the tensor fasciae lata muscle.

Answer 349

The superior gluteal nerve carries contributions from the anterior rami of L4 to S1.

Answer 350

- Comminuted distal tibial fracture needing external fixation between tibia and calcaneum by delta frame ## Footnote - occurs at the bottom of the tibia(shinbone)which is the tibial plafond,i.e.,tibial articular surface - involves the weight-bearing surface of the ankle joint -is a saparate injury

Answer 351

The inferior gluteal nerve leaves the pelvis through the greater sciatic foramen inferior to the piriformis muscle.

Answer 352

Spiral distal fibula fracture + disturbed syndesmosis

Answer 353

The inferior gluteal nerve supplies the gluteus maximus.

Answer 354

Treated like type C Denise Weber classification (1) open reduction (2) internal fixation (3) syndesmosis reconstruction

Answer 355

They are terminal sensory branches that descend into the upper thigh from the lumbar plexus.

Answer 356

After a blow to the posterior surface of the ankle

Answer 357

The ilio-inguinal nerve originates from the superior part of the lumbar plexus.

Answer 358

Its terminal branches innervate skin on the medial side of the upper thigh and adjacent parts of the perineum.

Answer 359

Simmonds Thompson test

Answer 360

The genitofemoral nerve passes anteroinferiorly through the psoas major muscle.

Answer 361

The genital branch innervates anterior aspects of the perineum.

Answer 362

Between talus and calcaneum

Answer 363

The femoral branch innervates skin over the upper central part of the anterior thigh.

Answer 364

Autoimmune inflammation of the spine joints

Answer 365

(1) Inflammatory bowel disease,especially.UC (2) Anterior uveitis (3) Psoriasis (4) HLA B27

Answer 366

(1) Back pain (2) Stiffness

Answer 367

Fracture of vertebrae after me mechanical stress

Answer 368

(1) Mechanical stress (2) After a fall during sport

Answer 369

(1) Conservative - excercise -steroids (2) Surgical fixation or correction

Answer 370

Displacement of one vertebra after spondylolysis affecting 1) L5 mainly 2) Sacral vertebrae

Answer 371

1) L5 mainly 2) Sacral vertebrae

Answer 372

Prominent sacrum

Answer 373

(1) Conservative - excercise -steroids (2) Surgical fixation or correction

Answer 374

Narrowing of the spinal canal ↓ Pressure on the spinal cord

Answer 375

Pain relieved by exercise,e.g., walking uphill or riding a bicycle

Answer 376

(1) Conservative - excercise -steroids (2) Surgical fixation or correction

Answer 377

Degeneration of the facet joint of vertebrae

Answer 378

1) heavy work 2) obesity

Answer 379

1) Increased during day and relieved at the end of it 2) Improved by NSAIDs

Answer 380

Failure of development of the 1) Spine 2) Spinal cord

Answer 381

(1) spina bifida occulta (2) Meningocele (3) Myelomeningocele

Answer 382

A birth mark of hairy patch over the vertebral column

Answer 383

A sac containing CSF only

Answer 384

A sac containing CSF + spinal cord

Answer 385

Myelomeningocele

Answer 386

Folic acid supplementation during pregnancy

Answer 387

Surgical repair

Answer 388

Sural nerve

Answer 389

Structures that pass behind the medial malleolus beneath the flexor retinaculum (medial to lateral) + (ant to post) [Mnemonic;Tom Does Very Nice Hat] DEEP POSTERIOR COMPARTMENT WITHOUT PERONEAL NERVE * Tibialis posterior tendon. * Flexor digitorum longus. * Posterior tibial vessels. * Tibial nerve. * Flexor hallucis longus. * Synovial sheaths of all the tendons.

Answer 390

Structures that pass behind the medial malleolus beneath the flexor retinaculum (medial to lateral) [Mnemonic;Tom Does Very Nice Hat] DEEP POSTERIOR COMPARTMENT WITHOUT PERONEAL NERVE * Tibialis posterior tendon. * Flexor digitorum longus. * Posterior tibial vessels. * Tibial nerve. * Flexor hallucis longus. * Synovial sheaths of all the tendons.

Answer 391

Structures that pass behind the medial malleolus beneath the flexor retinaculum (medial to lateral) [Mnemonic; Tom Does Very Nice Hat] DEEP POSTERIOR COMPARTMENT WITHOUT PERONEAL NERVE * Tibialis posterior tendon. * Flexor digitorum longus. * Posterior tibial vessels. * Tibial nerve. * Flexor hallucis longus. * Synovial sheaths of all the tendons.

Answer 392

ACCORDING TO MRCS IV BOOK:- Anterior leg compartment muscles Mnemonic; Tiny Elegant Fire (or pain) Extinguishers (1) Tibialis anterior, (2) Extensor hallucis longus, (3) Fibularis (peroneus) tertius, (4) Extensor digitorum longus

Answer 393

From medial to lateral (1) beginning of great saphenous vein and lower part of Saphenous nerve (both are anterior to medial malleolus) (3) superficial peroneal nerve

Answer 394

From medial to lateral (1) beginning of great saphenous vein (2) lower part of Saphenous nerve (3) superficial peroneal nerve للمراجعه بعد الامتحان

Answer 395

From medial to lateral (1) beginning of great saphenous vein (2) lower part of Saphenous nerve

Answer 396

Superficial peroneal nerve

Answer 397

(1) peroneus longus (2) peroneus brevis (3) short saphenous vein (4) sural nerve

Answer 398

(1) Sciatic nerve Sciatic nerve passes just beneath gluteus maximus muscle and long head of biceps femoris on the posterior surface of the thigh so it might be injured during posterior hip (2) Inferior gluteal artery

Answer 399

Tibial nerve

Answer 400

Common peroneal nerve

Answer 401

Common peroneal nerve ##Footnote Lloyd Davi’s position is often needed in surgical procedures causing compression of common peroneal nerve

Answer 402

Peroneal artery

Answer 403

Mnemonic;الكبير(teres major) شايل الصغير(teres minor) This means teres major (lower border of quadrangular space and medial or upper triangular space) is carrying the teres minor(upper border of quadrangular space and medial or upper triangular space)

Answer 404

Superior gluteal nerve, artery, vein.

Answer 405

Mnemonic; PIN+ obturator internus muscle (1) Pudendal nerve, (2) Internal pudendal vessels. (3) Nerve to obturator internus (4) Obturator internus muscle tendon,

Answer 406

Mnemonic; PIN (1) Sciatic nerve (10% pass through it, < 1% above it) (2) Inferior gluteal nerve, artery, vein, (3) Pudendal nerve, (4) Internal pudendal artery and vein, (5) Posterior femoral cutaneous nerve, (6) Nerve to obturator internus and Gemellus superior muscles, (7) Nerve to quadratus femoris and Gemellus inferior muscles.

Answer 407

The femoral triangle is a wedge-shaped depression formed by muscles in the upper thigh at the junction between the anterior abdominal wall and the lower limb.

Answer 408

base — inguinal ligament, medial border — medial margin of the adductor longus muscle, lateral margin — medial margin of the sartorius muscle.

Answer 409

Mnemonic; PIA 1) iliopsoas muscle, 2) pectineus muscle, 3) adductor longus muscle.

Answer 410

The apex of the femoral triangle - points inferiorly - continuous with the adductor canal.

Answer 411

The femoral artery and vein pass inferiorly through the adductor canal and become the popliteal vessels behind the knee.

Answer 412

Mnemonic; NAV 1) femoral nerve, 2) femoral artery, 3) femoral vein, 4) lymphatic vessels.

Answer 413

1) in the femoral triangle 2) just inferior to the inguinal ligament, 3) midway between the anterior superior iliac spine and the pubic symphysis.

Answer 414

Mnemonic;(teres minor) شايل الصغير(teres major) الكبير This means teres major below is carrying teres minor above

Answer 415

The phrenic nerve originates from the anterior rami of cervical spinal roots C3, C4 and C5 . This can be remembered using the limerick “C3, 4 and 5 keep the diaphragm alive”. Spinal root C4 provides the main contribution, with lesser contributions from C3 and C5 and some communicating fibres from the cervical plexus.

Answer 416

The phrenic nerve originates from anterior rami of cervical spinal roots C3, C4 and C5 . This can be remembered using the limerick “C3, 4 and 5 keep the diaphragm alive”. Spinal root C4 provides the main contribution, with lesser contributions from C3 and C5 and some communicating fibres from the cervical plexus.

Answer 417

The phrenic nerve arises at the lateral border of scalenus anterior muscle

Answer 418

The phrenic nerve descends inferiorly and obliquely with the internal jugular vein + posterolateral to the internal jugular vein + over the the anterior surface sclenus anterior muscle + beneath or deep to the prevertebral layer of deep cervical fascia(in other texts,the phrenic nerve is superficial to the deep cervical fascia) It then runs vertically downwards on the cervical pleura to enter the thoracic cavity behind the 1st costal cartilage

Answer 419

The phrenic nerve descends inferiorly and obliquely with the internal jugular vein + posterolateral to the internal jugular vein + over the the anterior surface sclenus anterior muscle + beneath or deep to the prevertebral layer of deep cervical fascia(in other texts,the phrenic nerve is superficial to the deep cervical fascia) It then runs vertically downwards on the cervical pleura to enter the thoracic cavity behind the 1st costal cartilage

Answer 420

The medial relations of the phrenic nerve as it enters the neck involve its proximity to the internal jugular vein and the scalenus anterior muscle. The phrenic nerve travels medially, crossing the anterior surface of the scalenus anterior muscle and lying (posterolateral) to the internal jugular vein,i.e.,the phrenic nerve in both sides is:- (1) anterior to the scalenus anterior (2) posterolateral to the internal jugular veins Elaboration: Origin and Course: The phrenic nerve originates from the cervical plexus (C3-C5) and descends vertically in the neck, lying on the anterior surface of the anterior scalene muscle. Relationship to Internal Jugular Vein: The phrenic nerve travels adjacent to and posterolateral to the internal jugular vein as it descends in the neck. Crossing the Scalenus Anterior: The phrenic nerve passes over the anterior surface of the scalenus anterior muscle, a key landmark in the neck. Thoracic Entry: After crossing the scalenus anterior, the phrenic nerve continues its descent and enters the thorax posterior to the subclavian vein.

Answer 421

The phrenic nerve is posterolateral to the internal jugular vein

Answer 422

Anterior to scalenus anterior muscle

Answer 423

Beneath or deep to the prevertebral layer of deep cervical fascia

Answer 424

Prevertebral layer ##Footnote The phrenic nerve beneath or deep to the prevertebral layer of deep cervical fascia

Answer 425

It runs vertically downwards on the cervical pleura to enter the thoracic cavity behind the 1st costal cartilage

Answer 426

It runs vertically downwards on the cervical pleura to enter the thoracic cavity behind the 1st costal cartilage

Answer 427

When the phrenic nerve enters the thoracic cavity.

Answer 428

The distribution of the phrenic nerve on the diaphragm is best seen on the inferior surface

Answer 429

It passes anteriorly over the lateral part of the subclavian artery

Answer 430

Via the superior thoracic aperture

Answer 431

It descends anteriorly along the the Rt lung root

Answer 432

Courses along the pericardium of the Rt atrium of the heart

Answer 433

IVC opening at T8

Answer 434

Inferior surface

Answer 435

Passés anteriorly over the medial part of the left subclavian artery

Answer 436

Descends anterior to the Lt lung root

Answer 437

Crosses the aortic arch and bypasses the vagus nerve

Answer 438

Inferior surface

Answer 439

- 1st structure to be punctured — epidural fat - 1st ligament to be punctured — supraspinous ligament - last ligament punctured — ligamentum flavum - strongest ligament— ligamentum flavum - last structure punctured— arachnoid matter - site reached by LP — arachnoid space

Answer 440

Mnemonic; FPTS 1) Frontal 2) Parietal 3) Squamous part of temporal 4) Greater wing of sphenoid

Answer 441

For the compensation,we look at PCO2+HCO3:- ↓ (1) Compensated — ↑PCO2+ ↑HCO3 or ↓PCO2+ ↓HCO3 both PCO2 and HCO3 are in the samed direction (2) Partially compensated —- abnormal PH (4) Fully or completely compensated— normal PH (5) Uncompensated—- ↑PCO2+ normal HCO3 or normal PCO2+↑HCO3 ↓PCO2+ normal HCO3 or normal PCO2+ ↓HCO3 One value is normal and the other is low or high (6) Mixed — ↑PCO2+ ↓HCO3 or↓PCO2+↑HCO Values are in the opposite direction

Answer 442

Hyperchloraemic metabolic acidosis

Answer 443

Mnemonic;HARDUPS (1) Hyperalimentation/hyperventilation (2) **A**cetazolamide,**A**mmonium chloride injection,**A**ddison's disease (3) **R**enal tubular acidosis (4) **D**iarrhoea,fistula-causing gastrointestinal bicarbonate loss (5) **U**reteral diversion(uretrosigmoidostomy)-causing gastrointestinal bicarbonate loss (6) **P**ancreatic fistula/**P**arentral saline (7)**S**pironolactone

Answer 444

Mnemonic;MUDPILES (1) **M**ethanol,**M**etformin(Renal failure),**M**esentric ischaemia or infarction (2) **U**raemia,i.e.,urate(renal failure or CKD) (3) **D**iabeti ketoacidosis,AKA,alcohol (4) **P**ropylene glycol/**P**araldehyde/**P**henformin,**P**aracetamol (5) **I**soniazide/**I**ron,**I**nfections,**I**nborn errors of metabolism (6) **L**actic acidosis,i.e.,lactate(shock,hypoxia,burn,sepsis) (7) **E**thylene glycol,**E**thanol (8) **S**alycilates-Aspirin ***N.B:Mesentric ischaemia or infarction is associated with lactic acidosis and metabolic acidosis late in its biochemical presentation***

Answer 445

Mnemonic;HYP/HL (1) **Hypo**albuminaemia (2) **Hyper**calcaemia (3) **Hyper**magnesaemia (4) **Hyper** γ-globulinaemia (5) **Hyper**viscosity (6) **H**alide(bromide or iodide)intoxication (7) **L**ithium intoxication

Answer 446

(1) Lactic acidosis type A:Perfusion disorders e.g.,shock,hypoxia,burn (2) Lactic acidosis type B:Metabolic e.g.,Metformin toxicity

Answer 447

Rise in plasma bicarbonate levels

Answer 448

Mnemonic:VAD/PHCL/CBC Problems of the kidney or gastrointestinal tract (1) **V**omiting/**A**spiration(e.g., peptic ulcer leading to pyloric stenosis,nasogastric suction) (2) **D**iuretics (3) **P**rimary hyperaldosteronism (4)**H**ypokalaemia (5) **C**arbenoxolone,**L**iquorice (6) **C**ushing syndrome (7) **B**artter's syndrome (8) **C**ongenital adrenal hyperplasia

Answer 449

* COPD * Decompensation in other respiratory conditions e.g. Life-threatening asthma / pulmonary oedema * Sedative drugs: benzodiazepines, opiate overdose(e.g.,morphine)

Answer 450

Mnemonic:CHEAP (1) **C**NS stimulation:stroke,subarachnoid haemorrhage,encephalitis (2) **H**ypoxia causing hyperventilation:**H**igh altitude,pulmonary embolism (3) **E**arly salycilate poisoning (4) Psychogenic:**A**nxiety leading to hyperventilation (5) **P**regnancy