MRTMR Flashcards

Question

You are working in a colorectal clinic where you have seen several patients at risk of bowel malignancy. Which of these conditions does not warrant regular colonoscopies? A Familial Adenomatous Polyposis B Hereditary Non-Polyposis Colorectal Cancer C Family history of colonic cancer D Long standing Crohn's disease E Previous history of colorectal malignancy

Answer 1

The correct answer is: ### **C. Family history of colonic cancer** ### **Explanation:** While a **family history of colorectal cancer** increases an individual's risk, it does **not automatically warrant regular colonoscopies** unless specific high-risk criteria are met (e.g., **first-degree relative with early-onset cancer, multiple affected relatives, or known hereditary syndromes**). In contrast, the other options **do require regular colonoscopic surveillance** due to their significantly increased risk of malignancy: - **A. Familial Adenomatous Polyposis (FAP)** → **Mandatory surveillance** due to near-universal development of hundreds to thousands of adenomatous polyps with a 100% lifetime risk of colorectal cancer if untreated. - **B. Hereditary Non-Polyposis Colorectal Cancer (HNPCC/Lynch Syndrome)** → **High lifetime risk (up to 80%) of colorectal cancer**, requiring **colonoscopy every 1–2 years starting at age 20–25**. - **D. Long-standing Crohn’s disease** → **Increased risk of colorectal cancer after 8–10 years of disease**, especially with extensive colonic involvement (similar to ulcerative colitis). - **E. Previous history of colorectal malignancy** → **High risk of recurrence/metachronous cancers**, requiring **regular surveillance (e.g., colonoscopy at 1, 3, and 5 years post-resection)**. ### **Conclusion:** A **general family history of colorectal cancer (C)** alone does not necessitate routine colonoscopies unless additional risk factors are present (e.g., **early age at diagnosis or multiple affected relatives**). The other conditions (A, B, D, E) are well-established high-risk scenarios requiring **regular endoscopic surveillance**. Those with a strong family history of colonic cancer are advised to undergo genetic testing. In the absence of a genetic condition (such as FAP or Lynch syndrome), a colonoscopy is advised between the ages of 35 and 45. Further routine colonoscopy is only indicated in the presence of polyps or other suspicious pathology. Genetic conditions like FAP or HNPCC (aka Lynch syndrome) are associated with high risk of bowel cancer and hence managed with annual colonoscopies. Patients with IBD are also at higher risk of colonic malignancy, though the exact risk depends on a variety of factors (age, duration and severity of illness, sites affected, etc.) The screening usually starts 10 years after onset of the condition with routine colonoscopies every 1 to 5 years (depending on the risk). Previous history of colorectal malignancy also predisposes to a subsequent cancer and requires screening every few years.

Answer 2

Correct Answer: Cecum Explanation: The cecum is the most insidious site for colon cancer because: • Tumors in the cecum and ascending colon can grow large before causing symptoms due to the wide lumen and liquid stool content. • Patients often present late with iron deficiency anemia from chronic occult bleeding rather than obstructive symptoms. • Right-sided colon cancers are often diagnosed at advanced stages compared to left-sided tumors, which cause earlier symptoms like obstruction or altered bowel habits. Why Not the Other Options? • Ascending Colon – Similar to the cecum, but cecal tumors are usually more insidious. • Descending Colon – Left-sided tumors tend to present earlier with obstruction, tenesmus, or rectal bleeding. • Transverse Colon – Intermediate presentation, but not as silent as the cecum. • Sigmoid Colon – More common site for cancer, but presents earlier with obstructive symptoms due to narrower lumen. Conclusion: Cancers in the cecum grow silently for a long time, making it the most insidious site for colon cancer.

Answer 3

Giardia lamblia, also known as Giardia intestinalis and Giardia duodenalis, is a flagellated, anaerobic protozoon, which is an important cause of persistent diarrhoea or malabsorption. Giardia has an outer membrane that makes it possible to retain life even when outside of the host body which can make it tolerant to chlorine disinfection. There are multiple transmission methods including drinking infected water, which is the most common method of transmission for this parasite. It is also common in day-care centers (among children) where poor/undeveloped hygiene practices lead to feco-oral transmission. Suspect diarrhea when : • Acute diarrhea lasts more than a week • Traveller's diarrhea that has not resolved in over 10 days, and the symptoms started after return, with associated weight loss. • Diarrhea in day-care centers/ palliative care facilities. Investigation is usually via stool microscopy OC&P (ova, cysts and parasites).

Answer 4

Pathognomonic of Paget's disease is the presence of large, pale, vacuolated cells (Paget cells) in the rete pegs of the epithelium. Paget's disease may be confused with superficial spreading melanoma. Differentiation from pagetoid intrepithelial melanoma is based on the presence of S-100 antigen immunostaining in melanoma and carcinoembryonic antigen immunostaining in Paget's disease. Surgical therapy for Paget's disease may involve lumpectomy or mastectomy, depending on the extent of involvement of the nipple-areolar complex and the presence of DCIS or invasive cancer in the underlying breast parenchyma. None of the above

Answer 5

Glucagonoma syndrome is a rare syndrome, with a classic presentation of the "4 D's": diabetes, dermatitis, deep vein throm-bosis, and depression. It is also characterised by a severe catabolic state with weight loss, depletion of fat and protein stores, and associated vitamin deficiencies. The characteristic skin lesion, a necrolytic migrating erythema, is noted in approximately two thirds of patients and often appears before other symptoms of the syndrome

Answer 6

D Tolcapone • Levodopa is the single most effective agent in the treat- ment of PD.The effects of levodopa result from its decarboxylation to DA. In clinical practice, levodopa is almost always administered in combination with a peripherally acting inhibitor of AADC, such as carbidopa or benserazide, drugs that do not penetrate well into the CNS. If levodopa is administered alone, the drug is largely decarboxylated by enzymes in the intestinal mucosa and other peripheral sites so that relatively little unchanged drug reaches the cerebral circulation, and probably less than 1% penetrates the CNS. • Dopamine receptor agonists are proposed to have the potential to modify the course of PD by reducing endogenous release of DA as well as the need for exogenous levodopa, thereby reducing free-radical formation. Two orally administered DA receptor agonists are commonly used for treatment of PD: ropinirole and pramipexole.Ropinirole,pramipexole and rotigotine may produce hallucinosis or confusion, similar to that observed with levodopa, and may cause nausea and orthostatic hypotension. They should be initiated at low dose and titrated slowly to minimize these effects. • COMT inhibitors block this peripheral conversion of levodopa to 3-O-methylDOPA, increasing both the plasma t1/2 of levodopa and the fraction of each dose that reaches the CNS.The COMT inhibitors tolcapone and entacapone reduce significantly the "wearing off" symptoms in patients treated with levodopa/carbidopa. Common adverse effects of both agents include nausea, orthostatic hypotension, vivid dreams, confusion, and hallucinations. An important adverse effect associated with tolcapone is hepatotoxicity. • Selective MAO-B inhibitors are used for the treatment of PD: selegiline and rasagiline. These agents selectively and irreversibly inactivate MAO-B. Both agents exert modest beneficial effects on the symptoms of PD. Selegiline can lead to the development of stupor, rigidity, agitation, and hyperthermia when administered with the analgesic meperidine • Amantadine, an antiviral agent used for the prophylaxis and treatment of influenza A, has antiparkinsonian activity. Amantadine appears to alter DA release in the striatum, has anticholinergic properties, and blocks NMDA glutamate receptors. It is used as initial therapy of mild PD. It also may be helpful as an adjunct in patients on levodopa with dose-related fluctuations and dyskinesias. Dizziness, lethargy, anticholinergic effects, and sleep disturbance, as well as nausea and vomiting, side effects are mild and reversible. • Antimuscarinic drugs currently used in the treatment of PD include trihexyphenidyl and benztropine mesylate, as well as the antihistaminic diphenhydramine hydrochloride, which also interacts at central muscarinic receptors. The biological basis for the therapeutic actions of muscarinic antagonists is not completely understood. Adverse effects result from their anticholinergic properties. Most troublesome are sedation and mental confusion. All anti- cholinergic drugs must be used with caution in patients with narrow-angle glaucoma, and in general anticholinergics are not well tolerated in the elderly

Answer 7

Acute inflammation has three major components: • Dilation of small vessels leading to an increase in blood flow • Increased permeability of the microvasculature enabling plasma proteins and leukocytes to leave the circulation; and • Emigration of leukocytes from the microcirculation, their accumulation in the focus of injury, and their activation to eliminate the offending agent Granuloma formation is a feature of chronic inflammation.

Answer 8

This is a Bouchard node. The hard, bony growths in the PIP joint are exostoses, and are usually asymptomatic. They can occasionally cause finger tip deviation. Usually, Bouchard nodes are indicative of severe systemic osteoarthritis.

Answer 9

C. Torsion of a testicular or epididymal appendage characteristically affects boys just before puberty, possibly because of enlargement of the hydatid in response to gonadotropins. A hydatid of Morgagni is an embryological remnant found on the upper pole of the testis or epididymis. The pain often increases over a day or two. Occasionally, the torted hydatid can be felt or seen (blue dot sign). Excision of the appendage leads to rapid resolution of symptoms.

Answer 10

The correct answer is: E. Inflammation mediated by Th1 and Th17 cytokines Explanation: Ulcerative colitis (UC) is an idiopathic chronic inflammatory condition of the colon, and although the exact cause remains unclear, the pathogenesis is believed to involve a dysregulated immune response to intestinal flora in genetically susceptible individuals. The disease mechanism in UC is primarily associated with inflammatory responses mediated by Th2 and Th17 cells, though more recent research also highlights the role of Th1 and Th17 cytokines particularly in the broader category of IBD (including Crohn’s disease). • Th17 cells produce interleukin-17 (IL-17), a cytokine implicated in the recruitment of neutrophils and promotion of inflammation. • Th1 cells release interferon-gamma (IFN-γ), contributing to cellular immunity and inflammation. This immune-mediated inflammatory response leads to mucosal damage in the colon, characteristic of ulcerative colitis. The other options describe mechanisms associated with different immune conditions: • A. IgE antibodies – typical of type I hypersensitivity (e.g., allergies). • B. Antibody-mediated cellular dysfunction – seen in diseases like myasthenia gravis. • C. Antibody-mediated phagocytosis and opsonization – related to type II hypersensitivity. • D. Antigen-antibody complex deposition – hallmark of type III hypersensitivity (e.g., systemic lupus erythematosus).

Answer 11

The correct answer is: C. Endoplasmic reticulum Explanation: Döhle bodies are small, pale blue, cytoplasmic inclusions found in neutrophils. They are remnants of rough endoplasmic reticulum (RER) and are often seen in conditions involving increased neutrophil turnover or toxic granulation, such as in systemic inflammatory response syndrome (SIRS), sepsis, burns, or after administration of certain medications. These inclusions indicate accelerated neutrophil production in the bone marrow, with immature or toxic changes. Here’s why the other options are incorrect: • A. Mitochondria – do not form cytoplasmic inclusions like Döhle bodies. • B. Lysosomes – may contribute to toxic granules but not Döhle bodies. • D. Nucleus – Döhle bodies are cytoplasmic, not nuclear. • E. None of the above – incorrect because they specifically originate from RER.

Answer 12

The correct answer is: E. Stretch injury from the fracture displacement Explanation: This patient presents with a classic radial nerve palsy: • Wrist drop (inability to extend the wrist), • Loss of extension of fingers and thumb, • Numbness in the first dorsal web space (a key sensory distribution of the superficial branch of the radial nerve). The radial nerve travels in the radial (spiral) groove of the humerus, making it particularly vulnerable to injury in mid-shaft humeral fractures. Among the listed mechanisms: • Stretch injury from fracture displacement is the most common mechanism of radial nerve palsy in this context. The nerve gets stretched or entrapped by the displaced bone fragments, not necessarily cut or compressed. • Laceration by fracture fragment (A) is possible but less common than stretch injuries in closed fractures. • Direct blow (B) and crush injuries (C) might cause nerve injury but are less likely in this typical scenario. • Vascular injury (D) is unrelated to the specific nerve symptoms described.

Answer 13

The correct answer is: A. Frank-Starling law Explanation: The Frank-Starling law of the heart states that the stroke volume of the heart increases in response to an increase in the volume of blood filling the heart (the end-diastolic volume). This is due to the increased stretch of the ventricular myocardium, which optimizes the alignment of actin and myosin filaments, resulting in a stronger contraction. In simpler terms: the more the heart fills with blood during diastole, the greater the force of contraction during systole, up to a physiological limit. This ensures that the heart pumps out all the blood it receives, maintaining balance between venous return and cardiac output. Here’s why the others are incorrect: • B. Laplace law: Describes the relationship between pressure, wall tension, and radius in hollow organs. • C. Poiseuille law: Governs flow through a cylindrical vessel based on radius, viscosity, and pressure. • D. Bernoulli principle: Relates pressure and velocity in fluid dynamics.

Answer 14

The correct answer is: A. Comedo Explanation: Ductal carcinoma in situ (DCIS) is a non-invasive breast cancer confined to the ductal system. Among its various histological subtypes, the comedo type is considered the most aggressive and most likely to progress to invasive ductal carcinoma if left untreated. Comedo DCIS is characterized by: • High nuclear grade, • Central necrosis (often calcified and visible on mammography), • Rapid proliferation. The other types—micropapillary, papillary, and cribriform—tend to be lower grade and less likely to become invasive, though all forms of DCIS carry some risk. E. All of the above is incorrect because not all subtypes carry the same risk; comedo specifically stands out as the highest-risk histologic type for progression.

Answer 15

The correct answer is: A. She should ask the patient to be on the lookout for perioral tingling, ringing in the ears or excessive drowsiness. Explanation: Lignocaine toxicity can develop in case of accidental intravascular injection or loosening of a tourniquet during regional block. Symptoms include drowsiness, headache, perioral tingling, tinnitus and anxiety. Toxicity can lead to seizures, cardiovascular collapse, arrhythmias, and apnoea. If this develops, initial treatment should always follow ABC protocol - intubation may be necessary and IV fluids should be started. Treatment is mainly symptomatic and inotropic support may be needed. Incident Reports must always be filled when any avoidable error occurs in the hospital. These are used to document any problems faced in the workplace, including statements of how the problem came about and what corrective actions were taken. This is a standard procedure in hospitals in the UK. While it is crucial to monitor patients for signs of local anaesthetic systemic toxicity (LAST)—which includes symptoms like perioral tingling, tinnitus, metallic taste, dizziness, and in severe cases, seizures or cardiovascular collapse—it is not appropriate to rely on the patient to self-monitor for these signs, especially if they are sedated, anxious, or not medically trained. The appropriate course of action includes: • B. Informing nursing staff to closely observe the patient for any signs of toxicity. • C. Preparing for emergency management, including IV fluids and ICU transfer if needed. • D. Informing the anaesthetics team, as advanced airway support or lipid emulsion therapy may be required. • E. Completing an incident report, which is essential for patient safety, documentation, and reflective learning.

Answer 16

The correct answer is: D. Hypercalcemia Explanation: Massive transfusion—typically defined as the replacement of a patient’s total blood volume within 24 hours or transfusion of more than 10 units of packed red blood cells—can lead to several complications. Let’s review them: • A. Hypothermia – Stored blood is cold, and large volumes can cause hypothermia if not warmed properly. • B. Coagulopathy – Due to dilutional effects and consumption of clotting factors and platelets. • C. Hyperkalemia – Stored red cells can leak potassium, especially in older blood, which can lead to elevated serum potassium levels. • D. Hypercalcemia – This is not a complication. In fact, the opposite is true: hypocalcemia may occur because citrate used in blood products binds to calcium, reducing ionized calcium levels. So, hypercalcemia is not a complication—that makes D the correct answer here. Complications from a single transfusion It includes: • Incompatibility, haemolytic transfusion reaction; • Febrile transfusion reaction • Allergic reaction • Infection • Bacterial infection (usually due to faulty storage) • Hepatitis • HIV • Malaria • Air embolism • Thrombophlebitis • Transfusion-related acute lung injury (usually from FFP). Complications from massive transfusion: • Coagulopathy • Hypocalcaemia • Hyperkalaemia • Hypokalaemia • Hypothermia. Ref: Bailey & Love's Short Practice of Surgery, 27th Edition, Chapter 2.

Answer 17

The correct answer is: E. A, B, and C Explanation: To determine equivalent oral doses of different opioids from subcutaneous morphine, you need to consider both opioid equivalence and bioavailability. Step 1: Calculate the total daily oral morphine equivalent. • Subcutaneous morphine has higher bioavailability than oral morphine. • The usual conversion ratio is: subcutaneous morphine : oral morphine = 1 : 2. • So, 120 mg/day subcutaneous morphine = ~240 mg/day oral morphine. Step 2: Match oral alternatives. Let’s break down the options: • A. 40 mg immediate release morphine every 4 hours: • 6 doses/day → 40 mg × 6 = 240 mg/day oral morphine. Correct. • B. 120 mg sustained release oxycodone OD: • Oral oxycodone is approximately 1.5–2 times as potent as oral morphine. • So 120 mg oxycodone ≈ 180–240 mg morphine. Correct. • C. 16 mg sustained release hydromorphone BD: • Oral hydromorphone is ~5–7 times as potent as oral morphine. • 16 mg BD = 32 mg/day hydromorphone × 5–7 = 160–224 mg morphine. Correct. So, all three regimens are reasonable equivalents to 240 mg/day oral morphine, making the best answer: E. A, B, and C

Answer 18

The correct answer is: E. All of the above Explanation: Farabeuf’s triangle is an important anatomical landmark in neck surgery, particularly in vascular and lymph node dissections. It is bounded by: • Medially: Common facial vein • Laterally: Internal jugular vein (IJV) • Superiorly: Hypoglossal nerve (cranial nerve XII) Within or near this triangle, you’ll also find: • Jugulodigastric lymph node (a prominent lymph node in the upper deep cervical chain), • And the carotid bifurcation, which makes this area surgically significant. So, each structure listed: • IJV (A) – forms the lateral boundary, • Common facial vein (B) – forms the medial boundary, • Hypoglossal nerve (C) – forms the superior boundary, • Jugulodigastric node (D) – is located near/within this triangle, are indeed all related to Farabeuf’s triangle. Hence, the answer is E. All of the above.

Answer 19

The correct answer is: B. Glossopharyngeal nerve Explanation: This is a classic case of referred otalgia (ear pain) in a patient with acute tonsillitis. The glossopharyngeal nerve (cranial nerve IX) provides sensory innervation to: • The posterior third of the tongue, • The tonsils, • The oropharynx, • And importantly, the middle ear via the tympanic branch (Jacobson’s nerve). Because of this shared sensory pathway, inflammation or infection in the tonsillar region (as in tonsillitis) can refer pain to the ear, even if the ear exam is normal. Let’s rule out the others: • A. Facial nerve – primarily motor to muscles of facial expression; not involved in oropharyngeal sensation. • C. Hypoglossal nerve – motor to the tongue; no sensory role. • D. Lesser palatine nerve – sensory to soft palate, but not connected to the ear. • E. Superior laryngeal nerve – branch of the vagus nerve; sensory to the larynx above vocal cords, not the ear. So, glossopharyngeal nerve is responsible for the referred ear pain in tonsillitis.

Answer 20

The correct answer is: B. Avulsion of ureter Explanation: Percutaneous nephrolithotomy (PCNL) is a minimally invasive surgical procedure used to remove kidney stones through a small incision in the back. While it is generally safe, several complications can occur: Common complications of PCNL include: • A. Renal parenchymal haemorrhage – due to vascular injury during access or dilation. • C. Rupture of the collecting system – can occur with high-pressure irrigation or traumatic instrumentation. • D. Sepsis – due to bacteria released from infected stones or urine. • E. Pneumothorax – especially if upper pole access is attempted through the 10th or 11th intercostal space. B. Avulsion of ureter – This is not a complication of PCNL. It is typically associated with ureteroscopic procedures, especially when retrieving large or impacted stones, or during forceful stent placement. So, avulsion of the ureter is not a known risk of PCNL, making B the correct answer.

Answer 21

The correct answer is: D. Lymphangiosarcoma Explanation: This clinical scenario is classic for Stewart-Treves syndrome, which refers to the development of lymphangiosarcoma, a rare but aggressive malignant vascular tumor arising in the setting of chronic lymphoedema, often following mastectomy with axillary lymph node dissection and/or radiotherapy. Key features include: • History of breast cancer treatment (mastectomy + irradiation). • Long-standing lymphoedema in the upper limb. • Development of purple patches, nodules, or plaques on the edematous limb. • May be mistaken for bruises or hematomas initially. Let’s rule out other options: • A. Lymphoedema – is the predisposing condition but not the diagnosis in this case. • B. Thrombophlebitis – usually involves tender cords and erythema over veins. • C. DVT – uncommon in the upper limb and doesn’t present with nodules or purple patches. • E. Granulomas – are more associated with chronic inflammatory or infectious conditions, not post-radiation malignancy. Lymphangiosarcoma is a surgical emergency, as it is highly malignant and often necessitates radical surgery (like limb amputation) and/or chemotherapy.

Answer 22

The correct answer is: D. Diffuse axonal injury (DAI) Explanation: Diffuse axonal injury is a severe form of traumatic brain injury caused by shearing forces during rapid acceleration-deceleration, such as in high-speed motor vehicle accidents. It leads to widespread microscopic damage to axons, especially at the grey-white matter junction, corpus callosum, and brainstem. Key clues in this case: • High-impact trauma (car crash), • Persistent GCS of 3 despite resuscitation, • Normal CT scan initially (DAI may not show up clearly on CT; MRI is more sensitive), • No evidence of major hemorrhage or mass lesion. Why others are incorrect: • A. Concussion – usually has transient symptoms and GCS should improve. • B. Subarachnoid haemorrhage – would likely be visible on CT. • C. Intraventricular bleed – also visible on CT. • E. Alcohol induced coma – possible, but persistent GCS of 3 after resuscitation in trauma makes DAI more likely. So, the clinical picture fits diffuse axonal injury, making D the most likely diagnosis.

Answer 23

The correct answer is: E. It has no role in infectious diseases — this statement is false. Explanation: This technique is a special staining method. It detects a specific antigen using a specific antibody which is labelled with a dye and, when bound to its target antigen, is seen as a coloured stain. It determines cell type and differentiation and site of origin. The method has a role in the selection of treatment and in the prediction of prognosis. It also has a role in infections. There are antibodies to many infectious agents such as cytomegalovirus (CMV), Epstein-Barr virus (EBV), herpes virus and hepatitis B. Immunohistochemistry (IHC) is a powerful diagnostic tool that uses antibodies to detect specific antigens in tissue sections, making it valuable in both pathology and research. Let’s review each statement: • A. This is just a special staining method – True, though “just” understates its importance; IHC is a special stain using antibody-antigen interaction. • B. It relies on the use of a specific antibody – True, that’s fundamental to IHC. • C. It helps to determine cell type and differentiation – True, it’s commonly used to distinguish tumour subtypes (e.g., lymphoma vs carcinoma). • D. It has a role in the determination of treatment and prognosis – True, e.g., HER2 in breast cancer affects treatment decisions. • E. It has no role in infectious diseases – False. IHC can detect pathogens (like CMV, HSV, tuberculosis, fungi) in tissue by targeting their antigens, and is especially useful when cultures are negative or slow. Thus, E is the false statement, and therefore the correct answer.

Answer 24

The correct answer is: D. Transduction Explanation: NSAIDs (Non-Steroidal Anti-Inflammatory Drugs) primarily act at the transduction phase of the pain pathway. Here’s how it works: Pain Pathway Steps: 1. Transduction – Conversion of a noxious stimulus (e.g., thermal or chemical from a burn) into an electrical signal at the peripheral nerve ending. NSAIDs act here by inhibiting cyclooxygenase (COX) enzymes, reducing prostaglandin production, which in turn lowers nociceptor sensitivity. 2. Transmission – The signal travels via peripheral nerves to the spinal cord and then the brain. 3. Modulation – The central nervous system modulates the pain signal through inhibitory or excitatory pathways. 4. Perception – Conscious awareness and interpretation of pain in the brain. So, NSAIDs reduce the generation of pain signals at the site of injury, specifically during transduction.

Answer 25

B. Q-angle Explanation: The Q-angle (Quadriceps angle) is a clinical measurement used to assess the alignment and biomechanics of the knee, particularly in relation to the patella and quadriceps muscle pull. The patellar ligament is the anterior ligament of the knee joint. Laterally, it receives the medial and lateral patellar retinaculum, aponeurotic expansions of the vastus medialis and lateralis and overlying deep fascia. The retinacula make up the joint capsule of the knee on each side of the patella and play an important role in maintaining alignment of the patella relative to the patellar articular surface of the femur. The oblique placement of the femur and/or line of pull of the quadriceps femoris muscle relative to the axis of the patellar tendon and tibia, assessed clinically as the Q-angle, favors lateral displacement of the patella. Key points about the Q-angle: • It represents the angle formed by: 1. A line drawn from the anterior superior iliac spine (ASIS) to the center of the patella. 2. A line from the center of the patella to the tibial tuberosity. • It reflects the lateral force vector applied by the quadriceps muscle on the patella. • Normal Q-angle: • Males: ~13° • Females: ~18° (due to wider pelvis) • Increased Q-angle can predispose to patellar subluxation/dislocation, especially laterally. Clinical relevance: This measurement is important in assessing patellofemoral pain syndrome, knee malalignment, and risk of patellar dislocation. Thus, the correct answer is B. Q-angle.

Answer 26

The correct answer is: A. Meckel’s diverticulum Explanation: In older children, the incidence of a pathologic lead point is up to 12%, and Meckel diverticulum is found to be the most common lead point for intussusception. However, other causes, such as intestinal polyps, an inflamed appendix, submucosal haemorrhage associated with Henoch-Schönlein purpura, a foreign body, ectopic pancreatic or gastric tissue, and intestinal duplication, must also be considered. Intussusception is a condition in which a segment of the intestine “telescopes” into an adjacent distal segment, leading to obstruction, ischemia, and bleeding. It is most common in infants and young children, presenting with: • Intermittent colicky abdominal pain • “Red currant jelly” stools (blood and mucus) • Palpable abdominal mass Pathological lead points: In most cases (especially under 2 years), intussusception is idiopathic and may be associated with Peyer’s patches hypertrophy (after viral infections). However, when a pathological lead point is identified, the most common cause in children is: • A. Meckel’s diverticulum – A remnant of the vitelline duct, often located in the ileum, and may contain ectopic gastric or pancreatic tissue. Other less common lead points include: • Polyps (B) – e.g., juvenile polyps, more common in older children. • Lymphoma (C) – more typical in older children and adolescents. • Duplication cyst (D) – rare congenital anomalies of the gut. So, the most common lead point in children is Meckel’s diverticulum.

Answer 27

B. Bohr effect Explanation: The Bohr effect describes the rightward shift of the oxygen-haemoglobin dissociation curve in response to a decrease in pH (acidosis) or an increase in carbon dioxide (CO₂). This shift facilitates the release of oxygen from haemoglobin in tissues where it is most needed (e.g., active muscles producing CO₂ and H⁺). Key features of the Bohr effect: • Lower pH (more acidic) → rightward shift • Increased CO₂ → rightward shift • Promotes oxygen unloading in tissues. Let’s look at the other options: • A. Haldane effect – Describes how oxygenation of blood in the lungs displaces CO₂ from haemoglobin, enhancing CO₂ removal. • C. Pasteur effect – Refers to the inhibition of glycolysis by oxygen. • D. Rebound effect – A general term not specific to respiratory physiology. • E. Breuer effect – Possibly referring to the Hering–Breuer reflex, which prevents lung overinflation. Thus, the Bohr effect is the best explanation for the rightward shift due to a fall in pH.

Answer 28

The correct answer is: C. Internal thoracic artery Explanation: In coronary artery bypass grafting (CABG), the preferred and most durable conduit is the internal thoracic artery (ITA)—specifically the left internal thoracic artery (LITA). Reasons: • Superior long-term patency rates compared to vein grafts. • Resistant to atherosclerosis. • Most commonly anastomosed to the left anterior descending artery (LAD), which is often the most critical artery in terms of myocardial perfusion. The other options: • A. Great saphenous vein – Frequently used as a secondary conduit, especially for multiple grafts, but has lower patency than ITA. • B. Short saphenous vein – Rarely used due to smaller size and variable anatomy. • D. Radial artery – A good alternative arterial conduit, used when additional arterial grafts are needed. • E. Axillary vein – Not used for CABG. So, the internal thoracic artery is the gold standard conduit for CABG. In earlier coronary artery bypass operations, a suitable length of great saphenous vein was anastomosed at one end to the ascending aorta and at the other to the appropriate coronary vessel distal to the site of blockage. The vein, of course, must be turned upside down so that any valves in the chosen segment do not obstruct the arterial flow. Current opinion now often favours the use of the internal thoracic artery, particularly for the left anterior descending artery; the proximal end remains intact at its subclavian origin and the cut lower end is anastomosed to the coronary vessel. Three or four coronary arteries may be bypassed in the same patient utilizing both internal thoracic arteries and vein grafts or free arterial segments (such as from the radial artery).

Answer 29

The correct answer is: A. Recurrent inflammation Explanation: The most important and common reason to remove a thyroglossal duct cyst is recurrent infection or inflammation. These cysts often present in childhood or adolescence as a midline neck swelling that may become tender, enlarge, or drain during episodes of infection. Why the others are incorrect: • B. Malignancy – While possible, malignancy in a thyroglossal cyst (usually papillary carcinoma) is rare (~1%). • C. Aberrant tissues – Thyroglossal cysts may contain ectopic thyroid tissue, but this alone isn’t a primary reason for removal. • D. Hyperthyroidism – Unrelated; thyroglossal cysts typically don’t secrete thyroid hormones. Surgical removal: The standard procedure is the Sistrunk operation, which involves excising the cyst, the tract, and the central portion of the hyoid bone to reduce recurrence.

Answer 30

The correct answer is: D. Lies in the middle third of a line between the intertragic notch of the auricle and the midpoint of the philtrum Explanation: The parotid (Stensen’s) duct is about 5 cm long, not 1 cm. It arises from the anterior border of the parotid gland, passes over the masseter muscle, and then pierces the buccinator muscle to open opposite the second upper molar tooth, not the first lower molar (which is the submandibular duct’s location). Importantly, it lies in the middle third of a line drawn from the intertragic notch (just below the ear) to the midpoint of the philtrum of the upper lip, which is a classic anatomical landmark used in clinical assessment and procedures involving the duct. Let’s quickly go through the other options: • A refers to the submandibular (Wharton’s) duct, not the parotid duct. • B is incorrect; the opening is opposite the second upper molar, not the first lower. • C is incorrect; the duct is approximately 5 cm long. • E is incorrect; the parotid duct does not run between the mylohyoid and hyoglossus—that’s the course of the submandibular duct.

Answer 31

The correct answer is: B. Female gender Explanation: Female gender is not considered a risk factor for ischaemic heart disease (IHD); in fact, pre-menopausal women are relatively protected due to the cardioprotective effects of estrogen. However, this protection diminishes after menopause, and the risk eventually becomes similar to that in men. Here’s how the other options relate to IHD risk: • A. Obesity: Increases risk due to its association with hypertension, diabetes, and dyslipidemia. • C. Advancing age: A well-established non-modifiable risk factor. • D. Reduced physical activity: A modifiable risk factor. • E. Smoking: A major modifiable risk factor that damages vascular endothelium and accelerates atherosclerosis.

Answer 32

The correct answer is: **B. Medulla** The **vagus nerve (CN X)** and the **hypoglossal nerve (CN XII)** nuclei are located in the **medulla oblongata** of the brainstem. - The **dorsal motor nucleus of the vagus** and the **nucleus ambiguus** (which contributes motor fibers to the vagus nerve) are found in the medulla. - The **hypoglossal nucleus** (which controls tongue movement via CN XII) is also located in the medulla. ### Breakdown of the other options: - **A. Pons** – Contains nuclei for CN V, VI, VII, and VIII, but not X or XII. - **C. Cerebrum** – Not part of the brainstem; does not contain cranial nerve nuclei. - **D. Midbrain** – Contains nuclei for CN III and IV, but not X or XII. - **E. Any of the above** – Incorrect, as only the medulla houses these nuclei. Thus, damage to the **medulla** can affect the vagus and hypoglossal nerve nuclei.

Answer 33

The correct answer is: **D. CLL (Chronic Lymphocytic Leukemia)** **Smudge cells** (also called **basket cells**) are a hallmark finding in **CLL**. They are fragile, ruptured lymphocytes that appear as smudged or broken cells on a peripheral blood smear due to their fragility during slide preparation. ### Why not the other options? - **A. CML (Chronic Myeloid Leukemia)** – Typically shows **myeloid precursors** (e.g., myelocytes, metamyelocytes) and **basophilia**, not smudge cells. - **B. AML (Acute Myeloid Leukemia)** – Presents with **myeloblasts** and **Auer rods**, not smudge cells. - **C. ALL (Acute Lymphoblastic Leukemia)** – Shows **lymphoblasts**, which are larger and more uniform, not smudge cells. - **E. Hodgkin's lymphoma** – Diagnosed by **Reed-Sternberg cells** in lymph nodes, not smudge cells in peripheral blood. ### Key Point: Smudge cells are most characteristic of **CLL**, where they result from the fragility of malignant B lymphocytes (CD5+/CD19+/CD23+). A high smudge cell count may correlate with disease burden.

Answer 34

D. It is designed to answer: “What standard does this service achieve?” Explanation: A clinical audit is a quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria and the implementation of change. The key elements involve: • Measuring current practice against a predetermined standard • Identifying areas for improvement • Implementing necessary changes • Re-auditing to assess the effect of changes Let’s review the other options: • A: Incorrect. While audits assess current care, they are also about improving care, not just judging it. • B: Incorrect. Randomisation is a feature of clinical trials, not audits. • C: Incorrect. Clinical audits may involve existing interventions, but this isn’t the defining feature. • E: Incorrect. An audit must compare current service against a set standard, not just describe it.

Answer 35

Descending thoracic aorta commences at the lower border of T4 vertebra, where the arch of the aorta ends. At first to the left of the midline, the vessel slants gradually to the midline and leaves the posterior mediastinum at the level of T12 vertebra by passing behind the diaphragm between the crura (i.e. behind the median arcuate ligament). It gives off nine pairs of posterior intercostal arteries, a pair of subcostal arteries, bronchial arteries, esophageal vessels and a few small pericardial and phrenic branches.

Answer 36

The correct answer is: B. Chronic, compensated respiratory acidosis Here’s why: Let’s interpret the blood gases step by step: • pH: 7.37 — This is within the normal range, but on the acidic side, suggesting compensation. • PaCO₂: 10 kPa — This is very high, indicating respiratory acidosis. • HCO₃⁻: 31 mmol/L — This is elevated, indicating renal compensation by retaining bicarbonate to buffer the acidosis. • PaO₂: 10 kPa — Slightly low, consistent with COPD. Conclusion: This patient with known COPD has: • A high PaCO₂, consistent with chronic CO₂ retention. • A normal pH, maintained by a raised bicarbonate, indicating the kidneys have compensated. • This is a typical picture of chronic, compensated respiratory acidosis. Other options: • A: Acute respiratory acidosis would show low pH without time for renal compensation. • C: In acute-on-chronic, you’d usually see a drop in pH due to the acute element. • D: Respiratory alkalosis would show low PaCO₂. • E: Metabolic acidosis would present with low HCO₃⁻ and low pH.

Answer 37

Solution Lobectomy. Patients with potentially resectable tumors require careful assessment of their functional status and ability to tolerate either lobectomy or pneumonectomy. The surgeon should first estimate the likelihood of pneumonectomy, lobectomy, or possibly sleeve resection, based on the CT images. A sequential process of evaluation then unfolds. A patient's history is the most important tool for gauging risk. Specific questions regarding performance status should be routinely asked. If the patient can walk on a flat surface indefinitely, without oxygen and without having to stop and rest secondary to dyspnea, he will be very likely to tolerate lobectomy. If the patient can walk up two lights on stairs (up two standard levels), without having to stop and rest secondary to dyspnea, he will likely tolerate pneumonectomy. Finally, nearly all patients, except those with carbon dioxide (CO2 ) retention on arterial blood gas analysis, will be able to tolerate periods of single-lung ventilation and wedge resection.

Answer 38

The correct answer is: B. The underlying pathology involves all layers of the bowel wall Here’s why: This patient presents with: • Left iliac fossa (LIF) pain • Fresh rectal bleeding • Longstanding constipation • No systemic symptoms like weight loss These features are most consistent with diverticular disease, likely diverticulitis or bleeding from a colonic diverticulum. Key facts about diverticular disease: • Pathology: Diverticula are mucosal herniations through the muscular layer at points of weakness — typically where vessels penetrate the bowel wall. So, A is true. • Layers involved: Diverticula are not full-thickness defects — they are false diverticula, involving mucosa and submucosa only, not all bowel layers. So, B is not true. • Common location: Most often in the sigmoid and descending colon. So, C is true. • Epidemiology: Common in Western populations, linked with low-fibre diets. So, D is true. • Rectum: Almost never affected due to stronger longitudinal muscle layer. So, E is true. Therefore: B is not true, making it the correct answer to the “not true” question.

Answer 39

The correct answer is: A. Hereditary spherocytosis Here’s why: Intravascular hemolysis occurs when red blood cells (RBCs) are destroyed within the blood vessels, leading to the release of free hemoglobin into the plasma. Let’s examine each option: • A. Hereditary spherocytosis: • This is primarily a cause of extravascular hemolysis, where spherocytes are removed by the spleen. • It does not typically cause intravascular hemolysis, hence this is the correct answer to the “except” question. • B. Prosthetic heart valves: • Can cause mechanical destruction of RBCs in circulation — a classic cause of intravascular hemolysis. • C. Thrombotic vessel (e.g., microangiopathic hemolytic anemia): • RBCs get sheared as they pass through narrowed or damaged vessels — another cause of intravascular hemolysis. • D. Marathon running: • Known to cause foot strike hemolysis, a mild form of intravascular hemolysis due to mechanical trauma. • E. All of the above: • Incorrect, as A is not a cause of intravascular hemolysis. Summary: Hereditary spherocytosis causes extravascular, not intravascular, hemolysis — making A the correct choice.

Answer 40

Solution Descending thoracic aorta commences at the lower border of T4 vertebra, where the arch of the aorta ends. At first to the left of the midline, the vessel slants gradually to the midline and leaves the posterior mediastinum at the level of T12 vertebra by passing behind the diaphragm between the crura (i.e. behind the median arcuate ligament). It gives off nine pairs of posterior intercostal arteries, a pair of subcostal arteries, bronchial arteries, esophageal vessels and a few small pericardial and phrenic branches.

Answer 41

• Strength of association in a cohort study is evaluated by Relative risk (RR), Attributable risk (AR) and Population attributable risk (PAR) • Relative risk (RR) = Incidence among exposed/ Incidence among non-exposed • Interpretation of RR: Incidence of lung disease among exposed IS SO MANY TIMES HIGHER as compared to that among non-exposed • Attributable risk (AR) = (Incidence among exposed - Incidence among non- exposed) / Incidence among exposed × 100 • Interpretation of AR: So much disease can be attributed to exposure • Population attributable risk (PAR) = (Incidence among total - Incidence among non- exposed) / Incidence among total × 100 • Interpretation of PAR: If risk factor is modified or eliminated, there will be so much annual reduction in incidence of disease in the given population

Answer 42

The structures passing through the foramen magnum include: the medulla oblongata; meninges; spinal parts of the accessory nerves; meningeal branches of the upper cervical nerves; the vertebral arteries; and the anterior and posterior spinal arteries. The correct answer is: D. The medulla oblongata and the spinal accessory nerve Explanation: The foramen magnum is the largest opening in the base of the skull and serves as a passage for several critical structures: • The medulla oblongata, which continues as the spinal cord. • The spinal root of the accessory nerve (cranial nerve XI), which ascends through the foramen magnum to join its cranial component before exiting the skull via the jugular foramen. • Vertebral arteries and meninges also pass through. This question links to the clinical scenario: the inability to shrug the shoulder suggests spinal accessory nerve (CN XI) damage, which innervates the trapezius muscle. Compression or traction injury from carrying a heavy backpack could lead to this. Other nerves listed pass through different foramina: • Facial nerve (VII): stylomastoid foramen. • Hypoglossal nerve (XII): hypoglossal canal. • Optic nerve (II): optic canal. • Vestibulocochlear nerve (VIII): internal acoustic meatus.

Answer 43

Dexamethasone (Option b) is commonly used to reduce cerebral edema and manage symptoms in patients with brain metastases, providing relief from blurring of vision, headaches, and nausea.

Answer 44

It is a T cell lymphoma affecting the skin which can evolve into generalized lymphoma.tumor of CD4 + helper T cells that home to the skin. Clinically, the cutaneous lesions of mycosis fungoides typically progress through three somewhat distinct stages, an inflammatory premycotic phase, a plaque phase, and a tumor phase. Histologically, the epidermis and upper dermis are infiltrated by neoplastic T cells, which often have a cerebriform appearance due to marked infolding of the nuclear membrane. Late disease progression is characterized by extracutaneous spread, most commonly to lymph nodes and bone marrow.

Answer 45

Fall on an outstretched hand can result in scaphoid fracture. The most common symptom is pain and tenderness over the anatomic snuffbox. The pain is often mild with no noticeable deformity or swelling. The pain may even improve in the days and weeks after the fracture. Although X-rays are the primary imaging tool, these fractures may not show up on them. Therefore, if suspected clinically, immobilisation with a thumb splint should be done till repeat X-rays after 2 weeks show healing (thus making the fracture more noticeable).

Answer 46

Answer: A - Cecum Explanation: Cecal (right-sided) colon cancers, including those in the ascending colon, are often termed “insidious” because they tend to grow larger before presenting with symptoms. This is due to the larger diameter of the right colon and the more liquid nature of the fecal content, which delays the onset of obstructive symptoms. As a result, patients may not notice changes in bowel habits early. Symptoms like anemia (from chronic blood loss) and fatigue are often the first signs, rather than pain or obstruction, making them harder to detect early. In contrast, left-sided cancers (like those in the sigmoid and descending colon) more often present earlier with changes in bowel habit, obstruction, or bleeding due to the smaller lumen and more formed stool.

Answer 47

Hypoglossal nerve is a part of the anterior triangle of the neck. Nerves within the posterior triangle of the neck are: • Accessory nerve • Phrenic nerve • Three trunks of the brachial plexus • Branches of the cervical plexus: Supraclavicular nerve, transverse cervical nerve, great auricular nerve, lesser occipital nerve

Answer 48

Hormones that use the adenylyl-cyclase cAMP second messenger system are: • ACTH • Angiotensin II on epithelial cells • Calcitonin Catecholamines on beta receptor • CRH • FSH • Glucagon • HCG • LHI • PTH • Secretin • Somatostatin • TSH • Vasopressin V2 receptor on epithelial cells TRH stands for Thyrotropin Releasing Hormone which predominantly uses the phosphoinositol second messenger system.

Answer 49

Emphysema is defined by irreversible enlargement of the airspaces distal to the terminal bronchiole, accompanied by destruction of their walls. Based on the segments of the respiratory units that are involved, emphysema is subdivided into four major types: • Centriacinar • Panacinar • Paraseptal • Irregular. Centriacinar emphysema is the most common form, constituting more than 95% of clinically significant cases. It occurs predominantly in heavy smokers with COPD.

Answer 50

Colles' fracture is a transverse fracture of the radius just above the wrist, with dorsal displacement of the distal fragment. X-ray findings demonstrate a transverse fracture of the distal radius, and often the ulna styloid process is broken off. The distal fragment is: • shifted and tilted backwards (dorsally) • shifted and tilted radially • impacted, and reduction should aim to reverse these changes. Rupture of the extensor pollicis longus tendon may occur as a late complication. Most Colles' fractures are treated in plaster for six weeks, but in young patients it may be necessary to restore normal alignment by internal fixation especially when cosmetic appearances or type of occupation may be adversely affected by residual deformity or loss of movement.

Answer 51

C. Dermoid cysts arise from cystic change in epithelial remnants left behind at lines of embryological fusion. They are usually found in the midline of the scalp, neck and lower jaw. Treatment is by excision.

Answer 52

With the hypercalcemia combined with the normal albumin and PTH levels, the 2 main differentials in this patient are primary hyperparathyroidism and familial hypocalciuric hypercalcemia. Therefore, the most useful next step to differentiate between these two disorders is 24-h urinary calcium, which will be low in familial hypocalciuric hypercalcemia and high in primary hyperparathyroidism. Obtaining serum calcium values from first-degree relatives in the absence of a family history can be helpful. Ref: Afzal M, Kathuria P. Familial Hypocalciuric Hypercalcemia. [Updated 2020 Jul 20]. In: StatPearls [Internet].

Answer 53

D. This wound is an example of healing by first intention. • When the injury involves only the epithelial layer, the principal mechanism of repair is epithelial regeneration, also called primary union or healing by first intention. One of the simplest examples of this type of wound repair is the healing of a clean, uninfected surgical incision approximated by surgical sutures. • Wounding causes the rapid activation of coagulation pathways, which results in the formation of a blood clot on the wound surface • Within 24 hours, neutrophils are seen at the incision margin, migrating toward the fibrin clot. • Within 24 to 48 hours, epithelial cells from both edges have begun to migrate and proliferate along the dermis yielding a thin but continuous epithelial layer that closes the wound. • By day 3, neutrophils have been largely replaced by macrophages, and granulation tissue progressively invades the incision space. • By day 5, neovascularization reaches its peak as granulation tissue fills the incisional space. • During the second week, there is continued collagen accumulation and fibroblast proliferation. • By the end of the first month, the scar comprises a cellular connective tissue largely devoid of inflammatory cells and covered by an essentially normal epidermis. • Carefully sutured wounds have approximately 70% of the strength of normal skin, largely because of the placement of sutures. • Wound strength reaches approximately 70% to 80% of normal by 3 months but usually does not substantially improve beyond that point.

Answer 54

C. Chemotherapy has developed an increasing role over the past two decades in the treatment of head and neck SCCs. For early-stage patients, treatment consists of either radiation therapy or surgery, with chemotherapy having little to no role in the treatment. It is never used as a primary single-modality treatment for head and neck cancers with an intent to cure. For patients with advanced metastatic or recurrent disease, chemotherapy can be used in the palliative setting to inhibit tumor growth for a limited effective period. Its main role is in the treatment of locoregionally advanced stage III/IV cancer. A second role of chemotherapy in this group of patients is for organ preservation. Patients with an advanced primary T stage are best served by total laryngectomy. For advanced-stage unresectable tumors, concurrent chemoradiation therapy, compared with radiation therapy alone, has shown an improved locoregional control with a questionable overall survival benefit. Ref: Yeh SA. Radiotherapy for head and neck cancer. Semin Plast Surg. 2010;24®:127-136. doi:10.1055/s-0030-1255330

Answer 55

70-75% of the breast's drainage is laterally and superiorly into the axillary lymph nodes. Axillary LNs have 3 surgical levels: • Level 1: below the pectoralis minor • Level 2: behind the pectoralis minor • Level 3: between the upper border of pectoralis minor and lower border of the clavicle. Most of the remaining drainage is to the parasternal nodes, deep in the anterior thoracic wall. Some drainage is also covered by lateral branches of the posterior intercostal nodes

Answer 56

C Von Willebrand disease is the most common inherited bleeding disorder of humans. The bleeding tendency is usually mild and often goes unnoticed until some hemostatic stress, such as surgery or a dental procedure, reveals its presence. It is usually transmitted as an autosomal dominant disorder, but rare autosomal recessive variants also exist. Type 1 and type 3 von Willebrand disease are associated with quantitative defects in vWF. Type 2 von Willebrand disease is characterized by qualitative defects in vWF Patients with von Willebrand disease have defects in platelet function despite having normal platelet counts. Because a deficiency of VWF decreases the stability of factor VIII, type 1 and type 3 von Willebrand disease are associated with a prolonged PTT. Persons with types 1 or 2 von Willebrand disease facing hemostatic challenges (dental work, surgery) can be treated with desmopressin (which stimulates vWF release), infusions of plasma concentrates containing factor VIll and vWF, or with recombinant VWF.

Answer 57

E S/c oxycodone dose = s/c morphine dose/2 = 60 mg/day Breakthrough dose = 1/6th of daily dose = 6 mg oxycodone (or) 12 mg morphine prn (every 4 hours) Oral oxycodone dose = oral morphine dose/2 s/c morphine dose = oral morphine dose/ 2

Answer 58

D Fibrocystic breast disease, also known as fibroadenosis or fibrosclerosis, is an aberration of normal development and involution of the breast (ANDI). Symptoms vary widely, and include some combination of breast nodularity, tender lumps, cysts, and pain. Symptoms are usually cyclical and peak in the premenstrual phase (luteal phase). The upper outer quadrant is most often affected. This condition is not considered a disease, but a part of a natural physiological process caused by cumulative exposure to hormones. This is supported by the fact that it is rarely seen before 30 years, with incidence peaking in the pre-menopausal years and decreasing after menopause. It is not a malignant condition and is only considered premalignant if associated with the presence of atypia.

Answer 59

The biceps tendon inserts at the neck of the fibula in the lateral aspect of the back of the knee. Here, the common peroneal nerve winds around the neck of the fibula before dividing into superficial and deep branches. Therefore it is at risk of injury here. Piriformis m. Sciatic nerve Long head of biceps femoris Semimembranosus and semitendinosus m. Tibial nerve Common peroneal nerve Ref: Image from Sehmbi, Herman & Shah, Ushma. (2013). Ultrasound-guided Approaches to Sciatic Nerve Block. International Journal of Perioperative Ultrasound and Applied Technologies. 2. 135-137. 10.5005/jp-journals-10027-1052.

Answer 60

B Diagnostic peritoneal lavage (DPL) is a test used to assess the presence of blood or contaminants in the abdomen. A gastric tube is placed to empty the stomach and a urinary catheter is inserted to drain the bladder. A cannula is inserted below the umbilicus, directed caudally and posteriorly. The cannula is aspirated for blood (>10 mL is deemed as positive) and, following this, 1000 mL of warmed Ringer's lactate solution is allowed to run into the abdomen and is then drained out via the same route. The presence of >100000 red cells/uL or >500 white cells/uL is deemed positive (this is equivalent to 20 mL of free blood in the abdominal cavity), as is the presence of vegetable fiber or a raised amylase level. In penetrating trauma, a minimum of one tenth of the above would be regarded as evidence of peritoneal penetration or intraperitoneal injury.

Answer 61

O negative is the universal donor group. O negative blood can be transfused in anyone since it does not have any antibodies.

Answer 62

Syringomyelia patients may present with sensory disturbance, weakness of the hands, loss of pain and temperature sensation, asymmetrical abdominal reflexes or progressive kyphoscoliosis. It is associated with Arnold-Chiari malformation and spinal cord tumours. Where syringomyelia is associated with an Arnold- Chiari malformation and scoliosis, a posterior cranial fossa decompression should be carried out first to resolve the syringomyelia. The scoliosis may then be corrected at a later date.

Answer 63

Patients with scaphoid fractures will typically present following a fall on an outstretched hand. The patient exhibits several common symptoms including pain in the anatomical snuff box, between the tendons of the abductor pollicis longus, and decreased grip strength. When pain occurs in the anatomical snuff box after trauma, the injury should be treated as a scaphoid fracture until proven otherwise; initial x-rays may not reveal the fracture in up to 25% of cases.

Answer 64

JVP has 3 Upward deflections and 2 downward deflections. Upward deflections: • a wave = atrial contraction; • c wave = ventricular contraction; • v wave = atrial venous filling. Downward deflections: • x wave = atrium relaxes and tricuspid valve moves down; • y wave = ventricular filling

Answer 65

A Temporal lobe infarct - homonymous superior quadrantanopia Right lobe = Left visual field = Left homonymous superior quadrantanopia Visual field defects: 1. Monocular blindness: Lesions of the optic nerve (Relative afferent pupillary defect +) and structures anterior to it (diseases of the eyeball) 2. Bitemporal homonymous hemianopia: Lesion of optic chiasm eg. Pituitary tumours 3. Homonymous hemianopia: Lesions of the optic tract and radiating fibres leaving the lateral geniculate body. Eg. Stroke, Neoplasms. Left homonymous hemianopia = Left visual field loss = Right sided lesion They are often associated with contralateral hemiparesis 1. Homonymous superior quadrantanopia: Temporal lobe lesions (inferior optic radiating fibres) AKA Pie in the Sky (Remember: Temples reach into the sky) Seen in temporal lobe strokes (MCA territory strokes) and can be associated with audio-visual hallucinations, seizures, aphasia, or memory disturbances. Visual loss is contralateral to the side of the lesion. 1. Homonymous inferior quadrantanopia: Parietal lobe lesions (superior optic radiations) AKA Pie on the Floor (Remember: Parties happen on the floor) Seen in parietal lobe strokes/neoplasms - lesion contralateral to visual defect Dominant lobe lesion: associated with agnosia, agraphia, acalculia Non-dominant lobe: associated with contralateral hemi-neglect 1. Homonymous hemianopia with macular sparing: Occipital lobe lesions Macular region is spared because it is represented at the tip of the occipital cortex, where there is dual blood supply from MCA and PCA

Answer 66

DDH (developmental dysplasia of the hip) is a disorder that is due to abnormal development of acetabulum with or without hip dislocation. Early diagnosis and management will prevent long term complications like persistent dislocation and early hip osteoarthritis. The following are the risk factors for DDH: female sex, first-born infant, breech positioning in the third trimester, swaddling, postmaturity, LGA, conditions causing limited in utero space, and family history. Unilateral involvement in 63% and 64% involves the left side due to in utero most frequent fetal positioning (left occipitoanterior). The left hip of the fetus is adducted against the mother's lumbosacral spine. If hip examination in a newborn reveals abnormalities, then a US scan is requested. The timing of the scan is at 4-6 weeks, to reduce splint age in children that do not require it, as the majority of lax capsules will tighten up by this stage.

Answer 67

Actinomyces israelii is a gram positive bacillus and a normal colonizer of the mouth, vagina and colon. It is an anaerobe that causes a large continuously growing mass with intense fibrosis and multiple sinus tracts. Listeria monocytogenes, Bacillus cereus and Corynebacterium difficile are gram positive, aerobic bacilli. Pseudomonas aeruginosa is a gram negative aerobic bacillus that mainly affects immunocompromised hosts.

Answer 68

Staghorn calculi associated with Proteus infections are often composed of struvite (Option c). Struvite stones can form in alkaline urine and are frequently associated with urinary tract infections.

Answer 69

Lesion will potentially metastasize to: Inguinal lymph nodes

Answer 70

The caudate lobe consists of 3 portions: • The Spiegel lobe - Couinaud's segment I • The paracaval portion - Couinaud's segment IX • The caudate process

Answer 71

The long thoracic nerve (of Bell) is formed directly from the C5, C6 and C7 roots. It travels posteriorly to the C8 and T1 roots, and superficially over the serratus anterior muscle in the medial axilla where it is vulnerable to damage during axillary dissection. Damage to the long thoracic nerve leads to winging of the scapula. The brachial plexus with its main branches is shown in schematic in the image below. The three posterior divisions form the posterior cord. The medial and lateral cords form the median nerve. The C8 and T1 anterior division continues as the medial cord. A. From the superior trunk C5, C6 and C7 roots. The superior trunk gives off the suprascapular nerve, and the nerve to subclavius. The long thoracic nerve is formed directly from the B. From all three posterior divisions The long thoracic nerve is formed directly from the C5, C6 and C7 roots. The posterior divisions all unite to form the posterior cord, which gives off the upper and lower subscapular nerves, and thoracodorsal nerve and the axillary nerve before terminating as the radial nerve. C. From the medial and lateral cords The medial and lateral cords form the median nerve, with the lateral cord terminating as the musculocutaneous nerve and the medial cord terminating as the ulnar nerve. They do not contribute to the long thoracic nerve. D. From the C8 and T1 roots The long thoracic nerve is formed from the C5, C6 and C7 roots, not the C8 and T1 roots. The C8 and T1 roots contribute to the median and ulnar nerves, supplying the intrinsic muscles of the hand (via the ulnar nerve), and the thenar muscles and lateral two lumbricals (via the median nerve).

Answer 72

The surgical neck of the humerus is above the deltoid tuberosity and the anatomical neck of the humerus represents the fused epiphyseal plate. The lateral attachment of the glenohumeral joint capsule attaches to the anatomical neck of the humerus. The medial attachment of the joint capsule is the glenoid and the labrum.

Answer 73

A greenstick fracture is a partial thickness fracture where only cortex and periosteum are interrupted on one side of the bone, while they remain uninterrupted on the other side. Paediatric fracture patterns Bending force Plastic deformation of ulna Greenstick Buckle (torus) fracture radius There is a difference between buckle fracture and greenstick fractures. Buckle fractures (also called torus) are defined as a compression of the bony cortex on one side with the opposite cortex remaining intact. In contrast, a greenstick fracture the opposite cortex is not intact.

Answer 74

Isolated IgA deficiency is a common immunodeficiency caused by impaired differentiation of naïve B lymphocytes to IgA-producing plasma cells. The molecular basis of this defect in most patients is unknown; defects in a receptor for a B cell-activating cytokine, BAFF, have been described in some patients. Most individuals with IgA deficiency are asymptomatic. Because IgA is the major antibody in mucosal secretions, mucosal defenses are weakened, and infections occur in the respiratory, gastrointestinal, and urogenital tracts. Symptomatic patients commonly present with recurrent sinopulmonary infections and diarrhea. IgA-deficient patients have a high frequency of respiratory tract allergy and a variety of autoimmune diseases, particularly SLE and rheumatoid arthritis. When transfused with blood containing normal IgA, some patients develop severe, even fatal, anaphylactic reactions, because the IgA behaves like a foreign antigen.

Answer 75

B Creatinine is a by-product of muscle metabolism and is cleared from the body fluids almost entirely by glomerular filtration. Therefore, creatinine clearance can also be used to assess GFR. Because measurement of creatinine clearance does not require intravenous infusion into the patient, this method is much more widely used than inulin clearance for estimating GFR clinically. However, creatinine clearance is not a perfect marker of GFR because a small amount of it is secreted by the tubules, so the amount of creatinine excreted slightly exceeds the amount filtered. There is normally a slight error in measuring plasma creatinine that leads to an overestimation of the plasma creatinine concentration; fortuitously, these two errors tend to cancel each other. Therefore, creatinine clearance provides a reasonable estimate of GFR.

Answer 76

While all the listed pathogens are known food-borne pathogens, Listeria monocytogenes can manifest in a variety of illnesses, including meningitis, infectious abortion, perinatal septicemia, and encephalitis. Often, it is the cause of stillbirths or deaths of infants soon after birth. Surviving infants usually develop meningitis, which can be fatal or result in permanent mental retardation. Although Listeria can be inactivated by pasteurisation, it is of particular concern because it usually infects and multiplies in the cheese AFTER pasteurisation has taken place. The rich moisture content of soft cheese makes it an ideal breeding ground for this bacteria. It is for this reason that pregnant women are told to avoid soft cheeses like Brie, Camembert, Feta and Gorgonzola cheeses.

Answer 77

E Causes of raised conjugated bilirubin in infants/neonates: • Dubin Johnson syndrome • Rotor syndrome • Galactosemia • Biliary atresia • Alagille syndrome • Choledochal cyst • Primary sclerosing cholangitis • TORCH infections Causes of raised unconjugated bilirubin in infants/ neonates: • Physiological jaundice • Haemolytic conditions including G6PD deficiency • Polycythaemia • Gilbert syndrome • Crigler-Najjar syndrome

Answer 78

D Closed reduction is indicated for greenstick fractures with severe angulation deformity. In children less than 5 years of age, an angulation in the AP view > 10° (or > 30° in the lateral view) is considered unacceptable, and closed reduction must be performed. Following closed reduction, the distal radius fracture must be immobilized with a cast for about 3 weeks to stabilize the fracture site and allow the fracture to heal. A follow-up x-ray must be performed after 3-5 days in children younger than 5 years and after 7-10 days in older children.

Answer 79

The clinical picture is that of polycythemia and the patient is likely to have renal cell carcinoma.It is a paraneoplastic syndrome. Some cancer-bearing individuals develop signs and symptoms that cannot readily be explained by the anatomic distribution of the tumor or by the elaboration of hormones indigenous to the tissue from which the tumor arose; these are known as paraneoplastic syndromes. These occur in about 10% of persons with cancer.

Answer 80

Breast carcinoma can be managed with either breast conservation surgery or mastectomy. The decision on which surgery is suitable depends on several factors. Multifocal tumours are best managed with mastectomy. Solitary tumours may be suitable for wide local excision if they are of an appropriate size and location. Peripheral tumours can be managed with breast conservative surgery with better cosmetic results. Central tumours usually result in loss of tissue volume and may do better with mastectomy and use of implants/flaps for reconstruction. Tumour size is not a firm indicator for the choice of surgery. The decision will depend on tumour size relative to the breast size. A 4cm tumour in a smaller breast may need mastectomy but can be managed with conservative surgery in a larger breast.

Answer 81

The right coronary artery supplies the AV node in 85-90% of the population via the AV nodal branch

Answer 82

A CT scan of the abdomen and pelvis exposes a patient to 10 mSv of radiation, equivalent to 4.5 years of background radiation and associated with a 1 in 2000 increased lifetime additional risk of fatal cancer.

Answer 83

C The scalp consists of skin (normally hair bearing) and subcutaneous tissue that cover the neurocranium from the superior nuchal lines on the occipital bone to the supra-orbital margins of the frontal bone The scalp is composed of five layers, the first three of which are connected intimately and move as a unit (e.g., when wrinkling the forehead and moving the scalp). Each letter in the word scalp serves as a memory key for one of its five layers: • Skin: thin, except in the occipital region, contains many sweat and sebaceous glands and hair follicles. It has an abundant arterial supply and good venous and lymphatic drainage. • Connective tissue: forms the thick, dense, richly vascularized subcutaneous layer that is well supplied with cutaneous nerves. • Aponeurosis (epicranial aponeurosis): the broad, strong, tendinous sheet that covers the calvaria and serves as the attachment for muscle bellies converging from the forehead and occiput (occipitofrontalis muscle) and from the temporal bones on each side (temporoparietalis and superior auricular muscles). • Loose areolar tissue: a sponge-like layer including potential spaces that may distend with fluid as a result of injury or infection. This layer allows free movement of the scalp proper (the first three layers-skin, connective tissue, and epicranial aponeurosis) over the underlying calvaria. • Pericranium: a dense layer of connective tissue that forms the external periosteum of the neurocranium. It is firmly attached but can be stripped from the crania of living persons, except where the pericranium is continuous with the fibrous tissue in the cranial The occipitofrontalis muscles move the scalp, wrinkle the forehead, and raise the eyebrows. The frontal belly is innervated by temporal branches of the facial nerve [VIl] and the posterior belly by the posterior auricular branch.

Answer 84

D Triple assessment represents clinical, radiological, and pathological assessment of a breast lesion with independant scoring of the three aspects of assessment based on degree of suspicion of malignancy. Scoring is given from 1 (definitely benign) to 5 (very likely to be malignant). Clinical assessment is prefixed with 'P', radiological assessment with 'M'(Mammogram) or 'U'(Ultrasonogram), and histopathological assessment with 'C' (cytology) or 'B'(Core biopsy). Histopathological grading differs slightly from the other two; C1 indicated inadequate sample or a dry tap, requiring a follow up core biopsy. B5 score is further divided into B5a (DCIS) and B5b (invasive carcinoma).

Answer 85

Normal urine output in adults 0.5ml/kg/h So, 70 × 0.5 = 35 mL

Answer 86

Expressive aphasia is most often seen in lesions of Broca's area (Brodmann area 44) located in the inferio-lateral frontal cortex. These lesions are usually due to thrombus in the superior part of the MCA which supplies this area.

Answer 87

B Lung capacity or total lung capacity (TLC) is the volume of air in the lungs upon the maximum effort of inspiration. Among healthy adults, the average lung capacity is about 6 liters. The volume of air that makes up the TLC can be calculated by directly measuring the lung volumes at different phases of the respiratory cycle and by measuring the remaining volume of air in the lungs after maximum exhalation. This relationship calculates as the total lung capacity equaling the sum of functional residual capacity and the inspiratory capacity or as the equation: TLC = FRC + IC. The FRC is only measurable by plethysmography, nitrogen gas washout, or helium gas dilution methods, or using computed tomography (CT). Once the FRC gas volume is measured and the RV is determined, the following additional equations that can be used to calculate the TLC; the sum of the four lung volumes: TLC = RV + ERV + IRV + TV or the sum of vital capacity and the residual volume: TLC = VC + RV.

Answer 88

E You should inform the patient who will be doing the operation and be honest about your experience. As the consultant plans to remain in theatre to supervise the procedure you should also inform the patient of this. All alternative management options should be mentioned. In any case non-operative management is always an option provided the patient understands any associated risks with such an option. Risk of anaphylaxis with loca; anaesthesia always needs to be Even though the procedure is to be performed under a local anaesthetic the site still needs to be marked before the operation to act as an additional check to prevent wrong site surgery, which would be a never event. At least three patient identifiers need to be put on the form. Commonly this is the patient's name, date of birth and hospital or NHS number.

Answer 89

Glucose, amino acids and bicarbonate are reabsorbed along sodium in the early portion of the proximal convoluted tubule. Glucose is removed from the urine by secondary active transport. It is filtered at a rate of approximately 100 mg/min (80 mg/dL of plasma × 125 mL/min). Essentially all of the glucose is reabsorbed, and no more than a few milligrams appear in the urine per 24h. The amount reabsorbed is proportional to the amount filtered and hence to the plasma glucose level (PG) times the GFR up to the transport maximum (TmG). When the TmG is exceeded, the amount of glucose in the urine rises. The TmG is about 375 mg/min in men and 300 mg/min in women.

Answer 90

C Risk factors for torsion include undescended testis, testicular tumor, and a "bell-clapper" deformity-poor gubernacular fixation of the testicles to the scrotal wall. The diagnosis is made by clinical history and examination, but can be supported by a Doppler ultrasound, which typically shows decreased intratesticular blood flow relative to the contralateral testis. Immediate surgical exploration can salvage an ischemic testis. More than 80% of testes can be salvaged if surgery is performed within 6 hours; this rate decreases to <20% as time lapses beyond 12 hours. At the time of surgery, the contralateral testes must also be explored and fixed to the dartos fascia due to the possibility that the same anatomic defect allowing torsion exists on the contralateral side.

Answer 91

E The cavernous sinus lies on either side of the body of the sphenoid. Anteriorly, the ophthalmic veins drain into the sinus and communicate with the anterior facial vein, which drains the face and upper lip - the infection spreads from this locus.

Answer 92

E The major effects of glucagon on glucose metabolism are : • breakdown of liver glycogen (glycogenolysis) and • increased gluconeogenesis in the liver. Both of these effects greatly enhance the availability of glucose to the other organs of the body. Most other effects of glucagon occur only when its concentration rises well above the maximum normally found in the blood. Perhaps the most important effect is that glucagon activates adipose cell lipase, making increased quantities of fatty acids available to the energy systems of the body. Glucagon in high concentrations also • enhances the strength of the heart; • increases blood flow in some tissues, especially the kidneys; • enhances bile secretion; and • inhibits gastric acid secretion. These effects of glucagon are probably of much less importance in the normal function of the body compared with its effects on glucose.

Answer 93

B Paroxysmal nocturnal hemoglobinuria (PNH) is a disease that results from acquired mutations in the phosphatidylinositol glycan complementation group A gene (PIGA), an enzyme that is essential for the synthesis of certain membrane-associated complement regulatory proteins. It is the only hemolytic anemia caused by an acquired genetic defect. PNH blood cells are deficient in three GPI-linked proteins that regulate complement activity: CD55, CD59 and C8 binding protein.Red cells deficient in GPI-linked factors are abnormally susceptible to lysis or injury by complement. This manifests as intravascular hemolysis. The tendency for red cells to lyse at night is explained by a slight decrease in blood pH during sleep, which increases the activity of complement. Thrombosis is the leading cause of disease-related death in individuals with PNH. About 5% to 10% of patients eventually develop acute myeloid leukemia or a myelodysplastic syndrome, indicating that PNH may arise in the context of genetic damage to hematopoietic stem cells.PNH is diagnosed by flow cytometry. The cardinal role of complement activation in PNH pathogenesis has been proven by therapeutic use of a monoclonal antibody called Eculizumab that prevents the conversion of C5 to C5a. This inhibitor not only reduces the hemolysis and attendant transfusion requirements, but also lowers the risk of thrombosis by up to 90%. The drawbacks to C5 inhibitor therapy are its high cost and an increased risk of serious or fatal meningococcal infection.

Answer 94

The correct matches for the clinical manifestations of syphilis are as follows: - **A. Chancre - primary syphilis** → **Correct** (Painless ulcer at the site of inoculation) - **B. Condyloma lata - secondary syphilis** → **Correct** (Broad, flat, wart-like lesions in moist areas) - **C. Gumma - tertiary syphilis** → **Correct** (Granulomatous lesions in late-stage syphilis) - **D. Lymphadenopathy - primary syphilis** → **Correct** (Regional lymphadenopathy near the chancre) - **E. Palmar rash - secondary syphilis** → **Correct** (Copper-red maculopapular rash involving palms and soles) Since all the given options are correctly matched, **none are wrong** based on the choices provided. However, if the question implies that one of them is mismatched (which it doesn't seem to be), then **all are correct**. If this is a trick question expecting you to pick the "wrong" one when none are wrong, the best answer is that **none are mismatched**. But if forced to choose, recheck the wording—sometimes "lymphadenopathy" is more prominent in **secondary syphilis** (generalized) compared to primary (localized). So **D** could be argued as *partially incorrect* if strictly referring to **generalized lymphadenopathy**, which occurs in secondary, not primary syphilis. ### Final Answer: **D (Lymphadenopathy - primary syphilis)** is the *least accurate* because while **local lymphadenopathy** occurs in primary syphilis, **generalized lymphadenopathy** is a feature of **secondary syphilis**. (But strictly, the question has no wrong matches unless interpreted this way.)

Answer 95

D Raynaud's disease is characterized by excess arterial and arteriolar constriction within the peripheral circulation. Therefore, a reduction in the sympathetic-mediated tone of these vessels via a pre-ganglionic sympathectomy is a reasonable option to treat this disorder. The salivary glands are influenced to a much greater extent by the parasympathetic rather than the sympathetic division of the autonomic nervous system. Increased parasympathetic activity increases the flow rate in the salivary glands but less time is allowed for the duct cell secretion of potassium into the salivary fluid. Consequently, the potassium content of the saliva is reduced. Noradrenaline is the neurotransmitter released by the majority of postganglionic sympathetic neurons. Genital erection and ejaculation requires coordinated activity from both divisions of the autonomic nervous system. The sympathetic fibres from 111 to L2 govern ejaculation whereas genital erection is mediated by parasympathetic innervation arising from the sacral region of the spinal cord. A lesion at the T10 level would therefore affect both erection and ejaculation. 'Dry orgasm', where the patient can generate and maintain an erection but is unable to ejaculate, can be a side effect of drugs such as beta-blockers. The parasympathetic innervation of the heart is almost exclusively restricted to the atria and structures therein, including the sinoatrial node (SAN). Increased parasympathetic activity reduces the slope of the pacemaker potential in the SAN, resulting in a reduced heart rate—a negative chronotropic action

Answer 96

The sinus tarsi is a cavity that lies between the calcaneum and talus in the foot.

Answer 97

D During inspiration, a greater pressure is required to inflate the lungs to a given volume than that is required to achieve the same volume during the expiratory phase. This is the phenomenon of hysteresis and reflects the fact that work must be done during inspiration to overcome resistive forces such as the resistance of the airways and pulmonary tissue. Approximately 30% of airway resistance is located in the nose, pharynx, and larynx, and the remaining 70% of airway resistance is generated by the trachea and subsequent airway divisions. As the lungs inflate, increased radial traction is exerted on the airways, allowing them to expand such that radial traction is directly proportional to lung volume. The relationship between laminar flow and pressure is one of direct proportionality. However, during conditions of turbulent flow, pressure is indeed proportional to the square of the flow rate. Note: a full understanding of airway resistance and airflow involves consideration of several key principles of physics including Poiseuille's and Bernoull's laws, and is a complex issue.

Answer 98

The drainage of a small amount of bile after T tube removal may occur transiently. In this scenario, the best course of action is to await spontaneous resolution.

Answer 99

Best Diagnostic Method in this case would be CT pulmonary angiography (Option e) to assess pulmonary embolism.

Answer 100

D This patient's x-ray shows a fracture of the neck of the second metatarsal and callus formation. The metatarsal bones are common sites for stress fractures, which are typically caused by repetitive, high-intensity activity and/or by a sudden increase in the intensity of physical activity, as seen with this army recruit. Such stress to the bone can increase the level of bone resorption to a degree that overwhelms the bone's ability to adapt to the stress, resulting in multiple microfractures that coalesce over time to form a larger break in the bone cortex. Risk factors for stress fractures include ill-fitting footwear (this patient is using his brother's old boots that may not fit him properly), decreased bone density (e.g., osteoporosis), and severe caloric restriction (e.g., in anorexia nervosa). Other important sites for stress fractures are the tibia (most common site), calcaneum, and navicular bone.

Answer 101

B The "ulnar paradox" is described as the worsening of the ulnar claw hand the more distal the injury to the ulnar nerve is. While the ulnar claw is most pronounced in a lesion at the wrist, ulnar nerve injuries at the elbow do not lead to any flexion at the distal IP joints of the ring and little fingers. So, here, the ulnar claw only consists of hyperextension at the MCP joints and flexion at the proximal IP joints. This produces a much less evident claw hand. In the low lesion, the hand muscles are weak but the long flexors in the forearm are unaffected (FDP) leading to a more pronounced flexure at the wrist. However, in the high lesion, both are affected and so, the clawing is mild.

Answer 102

The elevated serum amylase in this clinical background is a key marker for pancreatitis. The normal GGT and ALP suggest that the liver and bile ducts are not primarily involved. The slightly elevated bilirubin may be a secondary effect or could be associated with pancreatitis.

Answer 103

E External intercostal • Most superficial • Attached from the inferior margin of rib above to the superior margin of the one below. • Most active during inspiration • Moves ribs superiorly Internal intercostals • Between external and innermost intercostals • Attached from the lateral edge of the costal groove above to the superior edge of the rib below. • Most active in expiration • Moves ribs inferiorly Innermost intercostals • Least distinct and have the same orientation as internal intercostals. • Attach from the medial surface of the costal groove above to the deep surface of the rib below. • Most evident in the lateral thoracic wall • The intercostal space neurovascular bundles pass in a plane between the internal and innermost intercostals. Subcostales • On the same plane as innermost intercostals. • Span multiple ribs (attach from internal surface of one rib to the second or third next rib) • Goes from the angle off ribs above to more medially below • May help depress ribs Transversus thoraces • Deep surface of anterior thoracic wall • Same plane as innermost intercostals • Originate from the posterior part of the xiphoid process, inferior part of the body of the sternum and costal cartilages of the lower true ribs and go superolaterally to the lower borders of the costal cartilages of ribs 3 to 6. • Lie deep to the internal thoracic vessels and secure these vessels to the anterior thoracic wall.

Answer 104

E • The use of sirolimus in renal transplant patients is associated with a dose-dependent increase in serum cholesterol and triglycerides that may require treatment. Although immunotherapy with sirolimus per se is not considered nephrotoxic, patients treated with cyclosporine plus sirolimus have impaired renal function compared to patients treated with cyclosporine alone. Lymphocele, a known surgical complication associated with renal transplantation, is increased in a dose-dependent fashion by sirolimus, requiring close postoperative follow-up. • The major side effect of azathioprine is bone marrow suppression, including leukopenia (common), thrombocytopenia (less common), or anemia (uncommon). Other important adverse effects include increased susceptibility to infections (especially varicella and herpes simplex viruses), hepatotoxicity, alopecia, Gl toxicity, pancreatitis, and increased risk of neoplasia. • The principal adverse reactions to cyclosporine therapy are renal dysfunction and hypertension; tremor, hirsutism, hyperlipidemia, and gum hyperplasia also are frequently encountered. Hypertension occurs in about 50% of renal transplant and almost all cardiac transplant patients. Hyperuricemia may lead to worsening of gout, increased P-glycoprotein activity, and hypercholesterolemia • Extensive glucocorticoid use often results in disabling and life-threatening adverse effects. These effects include growth retardation in children, avascular necrosis of bone, osteopenia, increased risk of infection, poor wound healing, cataracts, hyperglycemia, and hypertension. The advent of combined glucocorticoid/calcineurin inhibitor regimens has allowed reduced doses or rapid withdrawal of steroids, resulting in lower steroid-induced morbidities.

Answer 105

E The largest branch of the femoral artery in the thigh is the deep artery of the thigh (profunda femoris artery), which originates from the lateral side of the femoral artery in the femoral triangle and is the major source of blood supply to the thigh.The deep artery of the thigh has lateral and medial circumflex femoral branches and three perforating branches.

Answer 106

The blood supply to the breast is chiefly from the lateral thoracic artery (from the axillary) and the internal thoracic also known as the internal mammary artery (from the subclavian). It also receives a contribution from the pectoral branch of the thoracoacromial artery, and the second to sixth intercostal arteries. A. Contains a maximum of 15 main lactiferous ducts that drain separately at the nipple The breast comprises 15-20 lobules, each of which has a separate lactiferous duct which then confluence to open at the nipple. C. In this age group is best visualised by a combination of crainiocaudal and true mediolateral mammograms The standard views taken on a mammogram are cranio-caudal (CC) and mediolateral oblique (MLO) (not truly mediolateral). D. Is a modified sebaceous gland The breast is considered to be a modified apocrine sweat gland. E. Predominantly drains to the internal thoracic nodes Most (> 75%) of the lymph from the breast drains to the axillary lymph nodes. Lymph from the medial aspect of the breast drains to the parasternal (internal thoracic) nodes or across to the opposite breast. Lymph from the inferior aspect of the breast drains to the inferior phrenic nodes Ref: Gray's Anatomy for Students 4th Edition, Chapter 3

Answer 107

E The arterial supply to the structures in the orbit, including the eyeball, is by the ophthalmic artery . This vessel is a branch of the internal carotid artery, given off immediately after the internal carotid artery leaves the cavernous sinus. The ophthalmic artery passes into orbit through the optic canal with the optic nerve. The central retinal artery, a branch of ophthalmic artery, which enters the optic nerve, proceeds down the centre of the nerve to the retina, and is clearly seen when viewing the retina with an ophthalmoscope-occlusion of this vessel or of the parent artery leads to blindness.

Answer 108

The described maneuver is the **anterior drawer test**, which is used to assess the integrity of the **anterior cruciate ligament (ACL)** of the knee. ### Key points: - **Positioning**: The hip is partially flexed, and the knee is flexed to **30 degrees**. - **Action**: The examiner stabilizes the thigh and pulls the lower leg **anteriorly**. - **Positive test**: Excessive anterior tibial translation (the tibia moves forward abnormally) suggests **ACL injury**. ### Why not the other options? - **A & B (LCL/MCL)**: These are tested with **varus/valgus stress tests**, not the anterior drawer. - **C (PCL)**: The **posterior drawer test** assesses the PCL by pushing the tibia backward. - **E (Achilles tendon)**: This is not involved in knee stability; it’s a tendon of the ankle. ### Correct Answer: **D - Anterior cruciate ligament of knee**

Answer 109

D Hypertrophic scars and keloids both occur due to excess collagen production in a healing wound. Hypertrophic scars usually have scar tissue confined to the wound thickness and usually occur only after full thickness dermal injuries. They can contract. Histopathology shows nodules of randomly arranged fibrils with a surface of parallel collagen fibres. They can regress with time. Once excised, they do not recur. Keloids have scar tissue growing beyond the margins of the wound. These rarely regress over time and can occur after trivial injuries as well. They can recur after excision. The histopathology does not show any nodules.

Answer 110

E Major abdominal surgery is a risk factor for the development of abdominal compartment syndrome. This is a major cause of mortality in major surgery, especially emergency surgery or multiple injuries. Clinical features are all consequences of raised intra-abdominal pressure - abdominal distension, oliguria due to impaired renal perfusion, cardiac and respiratory embarrassment due to elevated pressure on the heart and diaphragm, etc. Measurement of intra-abdominal pressure by measuring the intravesical pressure through the indwelling catheter will help in making the diagnosis. An intra-abdominal pressure of more than 25 mm Hg is a poor prognostic indicator, implying that the patient requires immediate abdominal decompression. Some surgeons prefer to leave the abdomen open after a major abdominal surgery, covered with a plastic mesh (Bogota bag). Definitive surgery is carried out later. This condition has a high mortality of about 60%.

Answer 111

A Laparoscopy is done to look for undescended testis, most commonly in the deep inguinal ring. The most common location of ectopic testis is superficial perineal pouch. When no testis, testicular vessels or vas is found laparoscopically, usually in utero torsion of testis is assumed. This is labelled as vanishing testis. Agenesis of unilateral testis is very very rare. As testis is present on one side and genitalia are normal, there is no need for karyotyping. Ref: Bailey & Love's Short Practice of Surgery, 27th Edition, Chapter 80

Answer 112

Oesophagitis due to Candida albicans is relatively common in patients taking steroids (especially transplant recipients) or those undergoing cancer chemotherapy. It may present with dysphagia or odynophagia. There may be visible thrush in the throat. Endoscopy shows numerous white plaques that cannot be moved, unlike food residues . Biopsies are diagnostic. In severe cases, a barium swallow may show dramatic mucosal ulceration and irregularity that is surprisingly similar to the appearance of esophageal varices. Treatment is with a topical antifungal agent.

Answer 113

MEN Type II. The mutations listed each affect a tumor suppressor gene. Somatic mutations in P53, PTEN and NF1 are frequent in gliomas in general, and syndromes involving germline mutation in these genes predispose to these and other tumours. HNPCC is associated with a number of distinct gene mutations affecting DNA mismatch repair, and collectively these mutations also confer increased risk of glioma. Certain menin gene mutations confer risk of risk of pituitary adenoma (MEN Type I- pituitary, parathyroid, pancreas). MEN Type Il is associated with medullary thyroid cancer, pheochromocytoma and parathyroid tumours.

Answer 114

A Mongolian spot is a congenital blue grey macule found on the sacral skin. Pigmentation initially deepens and then regresses completely by age 7 years. Thanks for helping Vinayak with the diagnosis. He is less worried now.

Answer 115

B The golden hour refers to the period of time after trauma in which life and limb saving procedures may be applied to change the outcome. This is mostly applicable to injuries that would cause 'early stage death'. Mortality from trauma is broadly divided into 3 phases:- • Immediate phase deaths - These are usually instantaneously fatal and result in mortality at the site of accident/trauma. Eg. Aortic rupture, brainstem transection/high cervical transection, irreversible brain injury, exsanguination etc. (as in options A and D) • Early phase deaths - These injuries are fatal if not adequately managed in a timely manner. Injuries of this type must be managed within the 'golden hour' to save life or limb. Eg. compartment syndrome, secondary CNS damage, major blood loss etc. • Late phase deaths - These occur weeks to months after the initial trauma and their severity will depend on the initial management provided. Eg. MODS/Sepsis (as in option C)

Answer 116

Pancreas divisum : The most common variation in pancreatic ductal anatomy characterized by the dorsal pancreatic duct directly entering the minor papilla. It can be associated with abdominal pain and idiopathic pancreatitis. It can lead to a cystic dilatation of the distal dorsal duct aka a santorinicele.

Answer 117

A normal flow volume loop is often described as a 'triangle on top of a semi circle' Flow volume loops are the most suitable way of assessing compression of the upper airway

Answer 118

A From the first part of the subclavian artery, the internal thoracic artery (formerly the internal mammary) passes vertically downwards about 1 cm lateral to the border of the sternum. It gives off two anterior intercostal arteries in each intercostal space. At the costal margin it divides into the superior epigastric and musculophrenic arteries. The internal thoracic artery is accompanied by two venae comitantes that empty into the brachiocephalic vein.

Answer 119

D In patients with chronic wasting diseases, disseminated intravascular coagulation, mucin-producing metastatic carcinomas (eg, of lung, stomach, or pancreas), or chronic infections (eg, tuberculosis, pneumonia, osteomyelitis), large thrombotic vegetations may form on valves and produce significant emboli to the brain, kidneys, spleen, mesentery, extremities, and coronary arteries. These vegetations tend to form on congenitally abnormal cardiac valves or those damaged by rheumatic fever. Half of patients with disseminated intravascular coagulation have noninfective endocarditis, suggesting a relationship between the two conditions. The vegetations are usually small and form along the lines of valve closure and contain fibrin and platelets, they are therefore referred to as sterile vegetations as they lack evidence of micro-organisms of inflammatory cells, differentiating them from infective endocarditis vegetations. They can release systemic emboli. Diagnosis is most common at autopsy.

Answer 120

C Three broadly stated conditions, first described by Rudolf Virchow in 1862, contribute to VTE formation: stasis of blood flow, endothelial damage, and hypercoagulability. Of these risk factors, relative hypercoagulability appears most important in cases of spontaneous VTE, or so-called idiopathic VTE, whereas stasis and endothelial damage likely play a greater role in secondary VTE, or so-called provoked VTE, occurring in association with transient risk factors such as immobilisation, surgical procedures, and trauma.

Answer 121

E Subcostal plane • Corresponds to a line drawn joining the lower most bony point of the rib cage, usually 10th costal cartilage • Body of the L3 vertebra; the origin of the inferior mesenteric artery and 3rd part of the duodenum lie on this plane

Answer 122

C The Ho:YAG laser has replaced the Nd:YAG laser for the treatment of superficial bladder cancer. Treatments are performed at different frequencies, energy per pulse and power and show peri- and postoperative complication rates lower when compared to conventional transurethral resection. In urology, this laser has also been employed to treat upper urinary tract tumors with settings similar to the ones employed during bladder ablation. Diode lasers have been largely employed on prostatic tumors with very good results in terms of complications and tumor recurrence. CO lasers are better for superficial tissue ablation and are more useful in penile carcinoma and for removal of hemangiomas

Answer 123

Carcinoembryonic antigen (CEA) and calcitonin are used for follow up in medullary carcinoma thyroid.

Answer 124

A The most frequent cause of spontaneous subarachnoid hemorrhage is rupture of a saccular ("berry") aneurysm in a cerebral artery. Saccular aneurysms are found in about 2% of the population according to recent data from community-based radiologic studies. About 90% of saccular aneurysms are found near major arterial branch points in the anterior circulation; multiple aneurysms exist in 20% to 30% of cases based on autopsy series.

MRTMR Flashcards

(150 cards)