Upper Limb

1. A 43 year old man is stabbed outside a nightclub. He suffers a transection of his median nerve just as it leaves the
brachial plexus. Which of the following features is least likely to ensue?
A. Ulnar deviation of the wrist
B. Complete loss of wrist flexion
C. Loss of pronation
D. Loss of flexion at the thumb joint
E. Inability to oppose the thumb
Answer: B

Loss of the median nerve will result in loss of function of the flexor muscles. However, flexor carpi ulnaris will still function and
produce ulnar deviation and some residual wrist flexion. High median nerve lesions result in complete loss of flexion at the thumb
joint.

Median nerve

The median nerve is formed by the union of a lateral and medial root respectively from the lateral (C5,6,7) and medial (C8 and
T1) cords of the brachial plexus; the medial root passes anterior to the third part of the axillary artery. The nerve descends lateral
to the brachial artery, crosses to its medial side (usually passing anterior to the artery). It passes deep to the bicipital aponeurosis
and the median cubital vein at the elbow.
It passes between the two heads of the pronator teres muscle, and runs on the deep surface of flexor digitorum superficialis (within
its fascial sheath).
Near the wrist it becomes superficial between the tendons of flexor digitorum superficialis and flexor carpi radialis, deep to
palmaris longus tendon. It passes deep to the flexor retinaculum to enter the palm, but lies anterior to the long flexor tendons
within the carpal tunnel.

Branches
Region Branch
Upper arm No branches, although the nerve commonly communicates with the musculocutaneous nerve
Forearm Pronator teres
Flexor carpi radialis
Palmaris longus
Flexor digitorum superficialis
Flexor pollicis longus
Flexor digitorum profundus (only the radial half)
Distal Palmar cutaneous branch
forearm
Hand Motor supply (LOAF)
(Motor)
 Lateral 2 lumbricals
 Opponens pollicis
 Abductor pollicis brevis
 Flexor pollicis brevis

Hand  Over thumb and lateral 2 ½ fingers

(Sensory)  On the palmar aspect this projects proximally, on the dorsal aspect only the distal regions are innervated
with the radial nerve providing the more proximal cutaneous innervation.

Patterns of damage
Damage at wrist

 e.g. carpal tunnel syndrome

 paralysis and wasting of thenar eminence muscles and opponens pollicis (ape hand deformity)
 sensory loss to palmar aspect of lateral (radial) 2 ½ fingers

Damage at elbow, as above plus:

 unable to pronate forearm

1
  weak wrist flexion
 ulnar deviation of wrist

Anterior interosseous nerve (branch of median nerve)

 leaves just below the elbow

 results in loss of pronation of forearm and weakness of long flexors of thumb and index finger

2. A 24 year old man falls and sustains a fracture through his scaphoid bone. From which of the following areas does the
scaphoid derive the majority of its blood supply?
A. From its proximal medial border
B. From its proximal lateral border
C. From its proximal posterior surface
D. From the proximal end
E. From the distal end

Answer: E
The blood supply to the scaphoid enters from a small non articular surface near its distal end. Transverse fractures through the
scaphoid therefore carry a risk of non union.

Scaphoid bone

The scaphoid has a concave articular surface for the head of the capitate and at the edge of this is a crescentic surface for the
corresponding area on the lunate.
Proximally, it has a wide convex articular surface with the radius. It has a distally sited tubercle that can be palpated. The
remaining articular surface is to the lateral side of the tubercle. It faces laterally and is associated with the trapezium and trapezoid
bones.
The narrow strip between the radial and trapezial surfaces and the tubercle gives rise to the radial collateral carpal ligament. The
tubercle receives part of the flexor retinaculum. This area is the only part of the scaphoid that is available for the entry of blood
vessels. It is commonly fractured and avascular necrosis may result.

3. A 56 year old man requires long term parenteral nutrition and the decision is made to insert a PICC line for long term
venous access. This is inserted into the basilic vein at the region of the elbow. As the catheter is advanced, into which
venous structure is the tip of the catheter most likely to pass from the basilic vein?
A. Subclavian vein
B. Axillary vein
C. Posterior circumflex humeral vein
D. Cephalic vein
E. Superior vena cava
Answer: B
The basilic vein drains into the axillary vein and although PICC lines may end up in a variety of fascinating locations the axillary
vein is usually the commonest site following from the basilic. The posterior circumflex humeral vein is encountered prior to the
axillary vein. However, a PICC line is unlikely to enter this structure because of its angle of entry into the basilic vein.

Basilic vein

The basilic and cephalic veins both provide the main pathways of venous drainage for the arm and hand. It is continuous with the
palmar venous arch distally and the axillary vein proximally.

Path

 Originates on the medial side of the dorsal venous network of the hand, and passes up the forearm and arm.
 Most of its course is superficial.
 Near the region anterior to the cubital fossa the vein joins the cephalic vein.
 Midway up the humerus the basilic vein passes deep under the muscles.
 At the lower border of the teres major muscle, the anterior and posterior circumflex humeral veins feed into it.
 Joins the brachial veins to form the axillary vein.

2
Theme: Nerve injury

A. Ulnar nerve
B. Musculocutaneous nerve
C. Radial nerve
D. Median nerve
E. Axillary nerve
F. Intercostobrachial nerve

What is the most likely nerve injury for the scenario given? Each option may be used once, more than once or not at all.

4. A 23 year old man is involved in a fight outside a nightclub and sustains a laceration to his right arm. On examination
he has lost extension of the fingers in his right hand.

Answer: Radial nerve

The radial nerve supplies the extensor muscle group.

5. A 40 year old lady trips and falls through a glass door and sustains a severe laceration to her left arm. Amongst her
injuries it is noticed that she has lost the ability to adduct the fingers of her left hand.

Answer: Ulnar nerve

The interossei are supplied by the ulnar nerve.

6. A 28 year old rugby player injures his right humerus and on examination is noted to have a minor sensory deficit
overlying the point of deltoid insertion into the humerus.

Answer: Axillary nerve

This patch of skin is supplied by the axillary nerve

Brachial plexus
Origin Anterior rami of C5 to T1
Sections of the plexus  Roots, trunks, divisions, cords, branches
 Mnemonic:Real Teenagers Drink Cold Beer

Roots  Located in the posterior triangle

 Pass between scalenus anterior and medius

Trunks  Located posterior to middle third of clavicle

 Upper and middle trunks related superiorly to the subclavian artery
 Lower trunk passes over 1st rib posterior to the subclavian artery

Divisions Apex of axilla

Cords Related to axillary artery

7. A 21 year old man is stabbed in the antecubital fossa. A decision is made to surgically explore the wound. At operation
the surgeon dissects down onto the brachial artery. A nerve is identified medially, which nerve is it likely to be?
A. Radial
B. Recurrent branch of median
C. Anterior interosseous
D. Ulnar
3
 E. Median
Answer: E

8. A man sustains a laceration between the base of the little finger and wrist. Several weeks after the injury there is loss
of thumb adduction power. Which nerve is most likely to have been injured?
A. Superficial ulnar nerve
B. Deep ulnar nerve
C. Median nerve
D. Radial nerve
E. Recurrent branch of median nerve
Answer: B

Ulnar nerve injury at wrist

Branches of the ulnar nerve in the wrist and hand

At the wrist the ulnar nerve divides into superficial and deep branches. The superficial branch lies deep to the palmaris brevis. It
divides into two; to produce digital nerves, which innervate the skin of the medial third of the palm and the palmar surface of one
and a half fingers.
The deep branch arises from the nerve on the flexor retinaculum lateral to the pisiform bone. It passes posteriorly between the
abductor and short flexor of the little finger supplying them, and supplying and piercing the opponens digiti minimi near its origin
from the flexor retinaculum, turns laterally over the distal surface of the Hook of the Hamate bone. It eventually passes between
the two heads of adductor pollicis with the deep palmar arch and ends in the first dorsal interosseous muscle. In the palm the deep
branch also innervates the lumbricals and interosseous muscles.

9. A 25 year old man is stabbed in the upper arm. The brachial artery is lacerated at the level of the proximal humerus,
and is being repaired. A nerve lying immediately lateral to the brachial artery is also lacerated. Which of the following
is the nerve most likely to be?
A. Ulnar nerve
B. Median nerve
C. Radial nerve
D. Intercostobrachial nerve
E. Axillary nerve
Answer: B
The brachial artery begins at the lower border of teres major and terminates in the cubital fossa by branching into the radial and
ulnar arteries. In the upper arm the median nerve lies closest to it in the lateral position. In the cubital fossa it lies medial to it.

Brachial artery

The brachial artery begins at the lower border of teres major as a continuation of the axillary artery. It terminates in the cubital
fossa at the level of the neck of the radius by dividing into the radial and ulnar arteries.
Relations
Posterior relations include the long head of triceps with the radial nerve and profunda vessels intervening. Anteriorly it is
overlapped by the medial border of biceps.
It is crossed by the median nerve in the middle of the arm.
In the cubital fossa it is separated from the median cubital vein by the bicipital aponeurosis.
The basilic vein is in contact at the most proximal aspect of the cubital fossa and lies medially.

10. What is the course of the median nerve relative to the brachial artery in the upper arm?
A. Medial to anterior to lateral
B. Lateral to posterior to medial
C. Medial to posterior to lateral
D. Medial to anterior to medial
E. Lateral to anterior to medial
Answer: E
Relations of median nerve to the brachial artery:
Lateral -> Anterior -> Medial
4
The median nerve descends lateral to the brachial artery, it usually passes anterior to the artery to lie on its medial side. It passes
deep to the bicipital aponeurosis and the median cubital vein at the elbow. It enters the forearm between the two heads of the
pronator teres muscle.

A 22 year old falls over and lands on a shard of glass. It penetrates the palmar aspect of his hand, immediately lateral to
the pisiform bone. Which of the following structures is most likely to be injured?

A. Palmar cutaneous branch of the median nerve

B. Lateral tendons of flexor digitorum superficialis
C. Ulnar artery
D. Flexor carpi radialis tendons
E. Lateral tendons of flexor digitorum profundus
Answer: C
The ulnar nerve and artery are at most immediate risk in this injury.

Hand

Anatomy of the hand

Bones  8 Carpal bones
 5 Metacarpals
 14 phalanges

Intrinsic Muscles 7 Interossei - Supplied by ulnar nerve

 3 palmar-adduct fingers
 4 dorsal- abduct fingers

Intrinsic muscles Lumbricals

 Flex MCPJ and extend the IPJ.

 Origin deep flexor tendon and insertion dorsal extensor hood mechanism.
 Innervation: 1st and 2nd- median nerve, 3rd and 4th- deep branch of the ulnar nerve.

Thenar eminence  Abductor pollicis brevis

 Opponens pollicis
 Flexor pollicis brevis

Hypothenar eminence  Opponens digiti minimi

 Flexor digiti minimi brevis
 Abductor digiti minimi

11. A motorcyclist is involved in a road traffic accident. He suffers a complex humeral shaft fracture which is plated. Post
operatively he complains of an inability to extend his fingers. Which of the following structures is most likely to have
been injured?
A. Ulnar nerve
B. Radial nerve
C. Median nerve
D. Axillary nerve
E. None of the above
Answer: B

5
Mnemonic for radial nerve muscles: BEST: B rachioradialis; E xtensors; S upinator; T riceps. The radial nerve is responsible for
innervation of the extensor compartment of the forearm.
Radial nerve

Continuation of posterior cord of the brachial plexus (root values C5 to T1)

Path

 In the axilla: lies posterior to the axillary artery on subscapularis, latissimus dorsi and teres major.
 Enters the arm between the brachial artery and the long head of triceps (medial to humerus).
 Spirals around the posterior surface of the humerus in the groove for the radial nerve.
 At the distal third of the lateral border of the humerus it then pierces the intermuscular septum and descends in front of
the lateral epicondyle.
 At the lateral epicondyle it lies deeply between brachialis and brachioradialis where it then divides into a superficial and
deep terminal branch.
 Deep branch crosses the supinator to become the posterior interosseous nerve.

Regions innervated

Motor (main nerve)  Triceps

 Anconeus
 Brachioradialis
 Extensor carpi radialis

Motor (posterior  Extensor carpi ulnaris

interosseous branch  Extensor digitorum
 Extensor indicis
 Extensor digiti minimi
 Extensor pollicis longus and brevis
 Abductor pollicis longus

Sensory The area of skin supplying the proximal phalanges on the dorsal aspect of the hand is supplied by the
radial nerve (this does not apply to the little finger and part of the ring finger)

Muscular innervation and effect of denervation

Anatomical Muscle affected Effect of paralysis
location
Shoulder Long head of triceps Minor effects on shoulder stability in abduction
Arm Triceps Loss of elbow extension
Forearm Supinator Weakening of supination of prone hand and elbow flexion in mid
Brachioradialis prone position
Extensor carpi radialis longus and
brevis

12. A 48 year old lady is undergoing an axillary node clearance for breast cancer. Which of the structures listed below are
most likely to be encountered during the axillary dissection?
A. Cords of the brachial plexus
B. Thoracodorsal trunk
C. Internal mammary artery
D. Thoracoacromial artery
E. None of the above
Answer: B
Beware of damaging the thoracodorsal trunk if a latissimus dorsi flap reconstruction is planned.

The thoracodorsal trunk runs through the nodes in the axilla. If injured it may compromise the function and blood supply to
latissimus dorsi, which is significant if it is to be used as a flap for a reconstructive procedure.

Axilla

Boundaries of the axilla

6
Medially Chest wall and Serratus anterior
Laterally Humeral head
Floor Subscapularis
Anterior aspect Lateral border of Pectoralis major
Fascia Clavipectoral fascia

Content:
Long thoracic nerve (of Bell) Derived from C5-C7 and passes behind the brachial plexus to enter the axilla. It lies on the
medial chest wall and supplies serratus anterior. Its location puts it at risk during axillary surgery
and damage will lead to winging of the scapula.
Thoracodorsal nerve and Innervate and vascularise latissimus dorsi.
thoracodorsal trunk
Axillary vein Lies at the apex of the axilla, it is the continuation of the basilic vein. Becomes the subclavian
vein at the outer border of the first rib.
Intercostobrachial nerves Traverse the axillary lymph nodes and are often divided during axillary surgery. They provide
cutaneous sensation to the axillary skin.
Lymph nodes The axilla is the main site of lymphatic drainage for the breast.

13. 53 year old lady is recovering following a difficult mastectomy and axillary nodal clearance for carcinoma of the
breast. She complains of shoulder pain and on examination has obvious winging of the scapula. Loss of innervation to
which of the following is the most likely underlying cause?
A. Latissimus dorsi
B. Serratus anterior
C. Pectoralis minor
D. Pectoralis major
E. Rhomboids
Answer: B

Winging of the scapula is most commonly the result of long thoracic nerve injury or dysfunction. Iatrogenic damage during the
course of the difficult axillary dissection is the most likely cause in this scenario. Damage to the rhomboids may produce winging
of the scapula but would be rare in the scenario given.

Long thoracic nerve

 Derived from ventral rami of C5, C6, and C7 (close to their emergence from intervertebral foramina)
 It runs downward and passes either anterior or posterior to the middle scalene muscle
 It reaches upper tip of serratus anterior muscle and descends on outer surface of this muscle, giving branches into it
 Winging of Scapula occurs in long thoracic nerve injury (most common) or from spinal accessory nerve injury (which
denervates the trapezius) or a dorsal scapular nerve injury

14. A 23 year old man falls and slips at a nightclub. A shard of glass penetrates the skin at the level of the medial
epicondyle, which of the following sequelae is least likely to occur?
A. Atrophy of the first dorsal interosseous muscle
B. Difficulty in abduction of the the 2nd, 3rd, 4th and 5th fingers
C. Claw like appearance of the hand
D. Loss of sensation on the anterior aspect of the 5th finger
E. Partial denervation of flexor digitorum profundus
Answer: C
Injury to the ulnar nerve in the mid to distal forearm will typically produce a claw hand. This consists of flexion of the 4th and 5th
interphalangeal joints and extension of the metacarpophalangeal joints. The effects are potentiated when flexor digitorum
profundus is not affected, and the clawing is more pronounced.More proximally sited ulnar nerve lesions produce a milder clinical
picture owing to the simultaneous paralysis of flexor digitorum profundus (ulnar half). This is the 'ulnar paradox', due to the more
proximal level of transection the hand will typically not have a claw like appearance that may be seen following a more distal
injury. The first dorsal interosseous muscle will be affected as it is supplied by the ulnar nerve.

Ulnar nerve

Origin:C8, T1
Supplies (no muscles in the upper arm)
 Flexor carpi ulnaris
 Flexor digitorum profundus
7
  Flexor digiti minimi
 Abductor digiti minimi
 Opponens digiti minimi
 Adductor pollicis
 Interossei muscle
 Third and fourth lumbricals
 Palmaris brevis

Path
 Posteromedial aspect of ulna to flexor compartment of forearm, then along the ulnar. Passes beneath the flexor carpi
ulnaris muscle, then superficially through the flexor retinaculum into the palm of the hand.

Branch Supplies
Articular branch Flexor carpi ulnaris
Medial half of the flexor digitorum profundus
Palmar cutaneous branch (Arises near the middle of the Skin on the medial part of the palm
forearm)
Dorsal cutaneous branch Dorsal surface of the medial part of the hand
Superficial branch Cutaneous fibres to the anterior surfaces of the medial one and one-
half digits
Deep branch Hypothenar muscles
All the interosseous muscles
Third and fourth lumbricals
Adductor pollicis
Medial head of the flexor pollicis brevis

Effects of injury
Damage at the wrist  Wasting and paralysis of intrinsic hand muscles (claw hand)
 Wasting and paralysis of hypothenar muscles
 Loss of sensation medial 1 and half fingers

Damage at the elbow  Radial deviation of the wrist

 Clawing less in 3rd and 4th digits

15. A 43 year old lady is due to undergo an axillary node clearance as part of treatment for carcinoma of the breast.
Which of the following fascial layers will be divided during the surgical approach to the axilla?
A. Sibsons fascia
B. Pre tracheal fascia
C. Waldayers fascia
D. Clavipectoral fascia
E. None of the above
Answer: D
The clavipectoral fascia is situated under the clavicular portion of pectoralis major. It protects both the axillary vessels and nodes.
During an axillary node clearance for breast cancer the clavipectoral fascia is incised and this allows access to the nodal stations.
The nodal stations are; level 1 nodes inferior to pectoralis minor, level 2 lie behind it and level 3 above it. During a Patey
Mastectomy surgeons divide pectoralis minor to gain access to level 3 nodes. The use of sentinel node biopsy (and stronger
assistants!) have made this procedure far less common.

16. A 23 year old climber falls and fractures his humerus. The surgeons decide upon a posterior approach to the middle
third of the bone. Which of the following nerves is at greatest risk in this approach?
A. Ulnar
B. Antebrachial
C. Musculocutaneous
D. Radial
E. Intercostobrachial
Answer: D
8
The radial nerve wraps around the humerus and may be injured during a posterior approach. An IM nail may be preferred as it
avoids the complex dissection needed for direct bone exposure.

Theme: Nerve injury

A. Median nerve
B. Ulnar nerve
C. Radial nerve
D. Posterior interosseous nerve
E. Anterior interosseous nerve
F. Musculocutaneous nerve
G. Axillary nerve
H. Brachial Trunks C5-6
I. Brachial trunks C6-7
J. Brachial Trunks C8-T1

Please select the most likely lesion site for each scenario. Each option may be used once, more than once or not at all.

17. A 42 year old teacher is admitted with a fall. An x-ray confirms a fracture of the surgical neck of the humerus. Which
nerve is at risk?
Answer: Axillary nerve

The Axillary nerve winds around the bone at the neck of the humerus. The axillary nerve is also at risk during shoulder
dislocation.
18. A 32 year old window cleaner is admitted after falling off the roof. He reports that he had slipped off the top of the
roof and was able to cling onto the gutter for a few seconds. The patient has Horner's syndrome.

Answer: Brachial
Trunks C8-T1

The patient has a Klumpke's paralysis involving brachial trunks C8-T1. Classically there is weakness of the hand intrinsic
muscles. Involvement of T1 may cause a Horner's syndrome. It occurs as a result of traction injuries or during delivery.
19. A 32 year old rugby player is hit hard on the shoulder during a rough tackle. Clinically his arm is hanging loose on the
side. It is pronated and medially rotated.

Answer: Brachial
Trunks C5-6
The patient has an Erb's palsy involving brachial trunks C5-6.

20. Which of the following nerves is responsible for innervation of the triceps muscle?
A. Radial
B. Ulnar
C. Axillary
D. Median
E. None of the above
Answer: A
To remember nerve roots and their relexes:
1-2 Ankle (S1-S2)
3-4 Knee (L3-L4)
5-6 Biceps (C5-C6)
7-8 Triceps (C7-C8)

The radial nerve innervates all three heads of triceps, with a separate branch to each head.

Triceps

Origin  Long head- infraglenoid tubercle of the scapula.

 Lateral head- dorsal surface of the humerus, lateral and proximal to the groove of the radial nerve
 Medial head- posterior surface of the humerus on the inferomedial side of the radial groove and both of
the intermuscular septae

Insertion  Olecranon process of the ulna. Here the olecranon bursa is between the triceps tendon and olecranon.
9
  Some fibres insert to the deep fascia of the forearm, posterior capsule of the elbow (preventing the
capsule from being trapped between olecranon and olecranon fossa during extension)

Innervation Radial nerve

Blood Profunda brachii artery
supply
Action Elbow extension. The long head can adduct the humerus and and extend it from a flexed position
Relations The radial nerve and profunda brachii vessels lie between the lateral and medial heads

21. Which of the following muscles inserts onto the lesser tuberostiy of the the humerus?
A. Subscapularis
B. Deltoid
C. Supraspinatus
D. Teres minor
E. Infraspinatus

Answer: A

With the exception of subscapularis which inserts into the lesser tuberosity, the muscles of the rotator cuff insert into the greater
tuberosity.

Shoulder joint
 Shallow synovial ball and socket type of joint.
 It is an inherently unstable joint, but is capable to a wide range of movement.
 Stability is provided by muscles of the rotator cuff that pass from the scapula to insert in the greater tuberosity (all except
sub scapularis-lesser tuberosity).

Glenoid labrum
 Fibrocartilaginous rim attached to the free edge of the glenoid cavity
 Tendon of the long head of biceps arises from within the joint from the supraglenoid tubercle, and is fused at this point to
the labrum.
 The long head of triceps attaches to the infraglenoid tubercle

Fibrous capsule
 Attaches to the scapula external to the glenoid labrum and to the labrum itself (postero-superiorly)
 Attaches to the humerus at the level of the anatomical neck superiorly and the surgical neck inferiorly
 Anteriorly the capsule is in contact with the tendon of subscapularis, superiorly with the supraspinatus tendon, and
posteriorly with the tendons of infraspinatus and teres minor. All these blend with the capsule towards their insertion.
 Two defects in the fibrous capsule; superiorly for the tendon of biceps. Anteriorly there is a defect beneath the
subscapularis tendon.
 The inferior extension of the capsule is closely related to the axillary nerve at the surgical neck and this nerve is at risk in
anteroinferior dislocations. It also means that proximally sited osteomyelitis may progress to septic arthritis.

Movements and muscles

Flexion Anterior part of deltoid
Pectoralis major
Biceps
Coracobrachialis
Extension Posterior deltoid
Teres major
Latissimus dorsi
Adduction Pectoralis major
Latissimus dorsi
Teres major
Coracobrachialis
Abduction Mid deltoid
Supraspinatus
Medial rotation Subscapularis
Anterior deltoid
Teres major
10
 Latissimus dorsi
Lateral rotation Posterior deltoid
Infraspinatus
Teres minor

Important anatomical relations

Anteriorly Brachial plexus
Axillary artery and vein
Posterior Suprascapular nerve
Suprascapular vessels
Inferior Axillary nerve
Circumflex humeral vessels

22. Which of the following nerves is not contained within the posterior triangle of the neck?
A. Accessory nerve
B. Phrenic nerve
C. Greater auricular nerve
D. Ansa cervicalis
E. Lesser occiptal nerve
Answer: D

Ansa cervicalis is a content of the anterior triangle of the neck.

Posterior triangle of the neck

Boundaries
Apex Sternocleidomastoid and the Trapezius muscles at the Occipital bone
Anterior Posterior border of the Sternocleidomastoid
Posterior Anterior border of the Trapezius
Base Middle third of the clavicle

Contents
Nerves  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

Vessels  External jugular vein

 Subclavian artery

Muscles  Inferior belly of omohyoid

 Scalene

Lymph  Supraclavicular
nodes  Occipital

23. A 73 year old lady suffers a fracture at the surgical neck of the humerus. The decision is made to operate. There are
difficulties in reducing the fracture and a vessel lying posterior to the surgical neck is injured. Which of the following
is this vessel most likely to be?
A. Axillary artery
B. Brachial artery
C. Thoracoacromial artery
D. Transverse scapular artery
E. Posterior circumflex humeral artery
Answer: E

The circumflex humeral arteries lie at the surgical neck and is this scenario the posterior circumflex is likely to be injured. The
11
thoracoacromial and transverse scapular arteries lie more superomedially. The posterior circumflex humeral artery is a branch of
the axillary artery.

24. Which of the structures listed below lies posterior to the carotid sheath at the level of the 6th cervical vertebra?
A. Hypoglossal nerve
B. Vagus nerve
C. Cervical sympathetic chain
D. Ansa cervicalis
E. Glossopharyngeal nerve
Answer: C

The carotid sheath is crossed anteriorly by the hypoglossal nerves and the ansa cervicalis. The vagus lies within it. The cervical
sympathetic chain lies posteriorly between the sheath and the prevertebral fascia.

Common carotid artery

The right common carotid artery arises at the bifurcation of the brachiocephalic trunk, the left common carotid arises from the
arch of the aorta. Both terminate at the level of the upper border of the thyroid cartilage (the lower border of the third cervical
vertebra) by dividing into the internal and external carotid arteries.

Left common carotid artery

This vessel arises immediately to the left and slightly behind the origin of the brachiocephalic trunk. Its thoracic portion is 2.5- 3.5
cm in length and runs superolaterally to the sternoclavicular joint.

In the thorax
The vessel is in contact, from below upwards, with the trachea, left recurrent laryngeal nerve, left margin of the oesophagus.
Anteriorly the left brachiocephalic vein runs across the artery, and the cardiac branches from the left vagus descend in front of it.
These structures together with the thymus and the anterior margins of the left lung and pleura separate the artery from the
manubrium.

In the neck
The artery runs superiorly deep to sternocleidomastoid and then enters the anterior triangle. At this point it lies within the carotid
sheath with the vagus nerve and the internal jugular vein. Posteriorly the sympathetic trunk lies between the vessel and the
prevertebral fascia. At the level of C7 the vertebral artery and thoracic duct lie behind it. The anterior tubercle of C6 transverse
process is prominent and the artery can be compressed against this structure (it corresponds to the level of the cricoid).
Anteriorly at C6 the omohyoid muscle passes superficial to the artery.
Within the carotid sheath the jugular vein lies lateral to the artery.

Right common carotid artery

The right common carotid arises from the brachiocephalic artery. The right common carotid artery corresponds with the cervical
portion of the left common carotid, except that there is no thoracic duct on the right. The oesophagus is less closely related to the
right carotid than the left.

Summary points about the carotid anatomy

Path
Passes behind the sternoclavicular joint (12% patients above this level) to the upper border of the thyroid cartilage, to divide into
the external (ECA) and internal carotid arteries (ICA).

Relations

 Level of 6th cervical vertebra crossed by omohyoid

 Then passes deep to the thyrohyoid, sternohyoid, sternomastoid muscles.
 Passes behind the carotid tubercle (transverse process 6th cervical vertebra)-NB compression here stops haemorrhage.
 The inferior thyroid artery passes posterior to the common carotid artery.
 Then : Left common carotid artery crossed by thoracic duct, Right common carotid artery crossed by recurrent laryngeal
nerve

12
25. A 45 year old man presents with a lipoma located posterior to the posterior border of the sternocleidomastoid muscle,
approximately 4cm superior to the middle third of the clavicle. During surgical excision of the lesion troublesome
bleeding is encountered. Which of the following is the most likely source?
A. Internal jugular vein
B. External jugular vein
C. Common carotid artery
D. Vertebral artery
E. Second part of the subclavian artery
Answer: B

The external jugular vein runs obliquely in the superficial fascia of the posterior triangle. It drains into the subclavian vein. During
surgical exploration of this area the external jugular vein may be injured and troublesome bleeding may result. The internal
jugular vein and carotid arteries are located in the anterior triangle. The third, and not the second, part of the subclavian artery is
also a content of the posterior triangle

26. Which of the following upper limb muscles is not innervated by the radial nerve?
A. Extensor carpi ulnaris
B. Abductor digit minimi
C. Anconeus
D. Supinator
E. Brachioradialis
Answer: B

Abductor digiti minimi is innervated by the ulnar nerve

27. Which of the following forms the floor of the anatomical snuffbox?
A. Radial artery
B. Cephalic vein
C. Extensor pollicis brevis
D. Scaphoid bone
E. Cutaneous branch of the radial nerve
Answer: D

The scaphoid bone forms the floor of the anatomical snuffbox. The cutaneous branch of the radial nerve is much more
superficially and proximally located.

Anatomical snuffbox

Posterior border Tendon of extensor pollicis longus

Anterior border Tendons of extensor pollicis brevis and abductor pollicis longus
Proximal border Styloid process of the radius
Distal border Apex of snuffbox triangle
Floor Trapezium and scaphoid
Content Radial artery

28. A 32 year old lady complains of carpal tunnel syndrome. The carpal tunnel is explored surgically. Which of the
following structures will lie in closest proximity to the hamate bone within the carpal tunnel?
A. The tendon of abductor pollicis longus
B. The tendons of flexor digitorum profundus
C. The tendons of flexor carpi radialis longus
D. Median nerve
E. Radial artery
Answer: B

The carpal tunnel contains nine flexor tendons: Flexor digitorum profundus, Flexor digitorum superficialis, Flexor pollicis longus
The tendon of flexor digitorum profundus lies deepest in the tunnel and will thus lie nearest to the hamate bone.

Carpal bones
No tendons attach to: Scaphoid, lunate, triquetrum (stabilised by ligaments)

13
29. A 45 year man presents with hand weakness. He is given a piece of paper to hold between his thumb and index finger.
When the paper is pulled, the patient has difficulty maintaining a grip. Grip pressure is maintained by flexing the
thumb at the interphalangeal joint. What is the most likely nerve lesion?
A. Posterior interosseous nerve
B. Deep branch of ulnar nerve
C. Anterior interosseous nerve
D. Superficial branch of the ulnar nerve
E. Radial nerve
Answer: B
This is a description of Froment's sign, which tests for ulnar nerve palsy. It mainly tests for the function of adductor pollicis. This
is supplied by the deep branch of the ulnar nerve. Remember the anterior interosseous branch, which innervates the flexor pollicis
longus (hence causing flexion of the thumb IP joint), branches off more proximally to the wrist.

30. A 10 year old by falls out of a tree has suffers a supracondylar fracture. He complains of a painful elbow and forearm.
There is an obvious loss of pincer movement involving the thumb and index finger with minimal loss of sensation. The
most likely nerve injury is to the:

A. Ulnar nerve
B. Radial nerve
C. Anterior interosseous nerve
D. Axillary nerve damage
E. Median nerve damage above the elbow
Answer: C

The anterior interosseous nerve is a motor branch of the median nerve just below the elbow. When damaged it classically causes:
Pain in the forearm, Loss of pincer movement of the thumb and index finger (innervates the long flexor muscles of flexor pollicis
longus & flexor digitorum profundus of the index and middle finger), Minimal loss of sensation due to lack of a cutaneous branch
A 32 year old attends neurology clinic complaining of tingling in his hand. He has radial deviation of his wrist and there is
mild clawing of his fingers, with the 3rd and 4th digits being relatively spared. What is the most likely lesion?

A. Ulnar nerve damage at the wrist

B. Ulnar nerve damage at the elbow
C. Radial nerve damage at the elbow
D. Median nerve damage at the wrist
E. Median nerve damage at the elbow
Answer: B

At the elbow the ulnar nerve lesion affects the flexor carpi ulnaris and flexor digitorum profundus.

31. A 23 year old man is involved in a fight and is stabbed in his upper arm. The ulnar nerve is transected. Which of the
following muscles will not demonstrate compromised function as a result?
A. Flexor carpi ulnaris
B. Medial half of flexor digitorum profundus
C. Palmaris brevis
D. Hypothenar muscles
E. Pronator teres
Answer: E

M edial lumbricals, A dductor pollicis, F lexor digitorum profundus/Flexor digiti minimi, I nterossei, A bductor digiti minimi and
opponens
Innervates all intrinsic muscles of the hand (EXCEPT 2: thenar muscles & first two lumbricals - supplied by median nerve)
Pronator teres is innervated by the median nerve. Palmaris brevis is innervated by the ulnar nerve

32. Which of the structures listed below overlies the cephalic vein?
A. Extensor retinaculum
B. Bicipital aponeurosis
C. Biceps muscle
D. Antebrachial fascia
E. None of the above
14
 Answer: E
The cephalic vein is superficially located in the upper limb and overlies most the fascial planes. It pierces the coracoid membrane
(continuation of the clavipectoral fascia) to terminate in the axillary vein. It lies anterolaterally to biceps.

Cephalic vein

Path

 Dorsal venous arch drains laterally into the cephalic vein

 Crosses the anatomical snuffbox and travels laterally up the arm
 At the antecubital fossa connected to the basilic vein by the median cubital vein
 Pierces deep fascia of deltopectoral groove to join axillary vein

33. A 22 year old man is involved in a fight. He sustains a laceration to the posterior aspect of his wrist. In the emergency
department the wound is explored and the laceration is found to be transversely orientated and overlies the region of
the extensor retinaculum, which is intact. Which of the following structures is least likely to be injured in this
scenario?

A. Dorsal cutaneous branch of the ulnar nerve

B. Tendon of extensor indicis
C. Basilic vein
D. Superficial branch of the radial nerve
E. Cephalic vein
Answer: B

The extensor retinaculum attaches to the radius proximal to the styloid, thereafter it runs obliquely and distally to wind around the
ulnar styloid (but does not attach to it). The extensor tendons lie deep to the extensor retinaculum and would therefore be less
susceptible to injury than the superficial structures.

Extensor retinaculum

The extensor rentinaculum is a thickening of the deep fascia that stretches across the back of the wrist and holds the long extensor
tendons in position.
Its attachments are:

 The pisiform and hook of hamate medially

 The end of the radius laterally

Structures related to the extensor retinaculum

Structures superficial to the retinaculum  Basilic vein

 Dorsal cutaneous branch of the ulnar nerve
 Cephalic vein
 Superficial branch of the radial nerve

Structures passing deep to the extensor  Extensor carpi ulnaris tendon

retinaculum  Extensor digiti minimi tendon
 Extensor digitorum and extensor indicis tendon
 Extensor pollicis longus tendon
 Extensor carpi radialis longus tendon
 Abductor pollicis longus and extensor pollicis brevis tendons

Beneath the extensor retinaculum fibrous septa form six compartments that contain the extensor muscle tendons. Each
compartment has its own synovial sheath.
The radial artery
The radial artery passes between the lateral collateral ligament of the wrist joint and the tendons of the abductor pollicis longus
and extensor pollicis brevis.

15
34. A man has an incision sited than runs 8cm from the deltopectoral groove to the midline. Which of the following is not
at risk of injury?
A. Cephalic vein
B. Shoulder joint capsule
C. Axillary artery
D. Pectoralis major
E. Trunk of the brachial plexus
Answer: B
This region will typically lie medial to the joint capsule. The diagram below illustrates the plane that this would transect and as it
can be appreciated the other structures are all at risk of injury.

Pectoralis major muscle

Origin From the medial two thirds of the clavicle, manubrium and sternocostal angle
Insertion Crest of the greater tubercle of the humerus
Nerve supply Lateral pectoral nerve
Actions Adductor and medial rotator of the humerus

Theme: Nerve Injury

A. Median nerve
B. Ulnar nerve
C. Radial nerve
D. Musculocutaneous nerve
E. Axillary nerve
F. Anterior interosseous nerve
G. Posterior interosseous nerve

For each scenario please select the most likely underlying nerve injury. Each option may be used once, more than once or not at
all.

35. A 19 year old student is admitted to A&E after falling off a wall. He is unable to flex his index finger. An x-ray
confirms a supracondylar fracture.

Answer : Median nerve

This median nerve is at risk during a supracondylar fracture.
36. A well toned weight lifter attends clinic reporting weakness of his left arm. There is weakness of flexion and supination
of the forearm.
Answer: Musculocutaneous nerve
Mucocutaneous nerve compression due to entrapment of the nerve between biceps and brachialis. Elbow flexion and
supination of the arm are affected. This is a rare isolated injury.
37. An 18 year old girl sustains an Holstein-Lewis fracture. Which nerve is at risk?

Answer: Radial nerve

Proximal lesions affect the triceps. Also paralysis of wrist extensors and forearm supinators occur. Reduced sensation of
dorsoradial aspect of hand and dorsal 31/2 fingers. Holstein-Lewis fractures are fractures of the distal humerus with radial
nerve entrapment.

38. A 35 year old farm labourer is injures the posterior aspect of his hand with a mechanical scythe. He severs some of his
extensor tendons in this injury. How many tunnels lie in the extensor retinaculum that transmit the tendons of the
extensor muscles?
A. One
B. Three
C. Four
D. Five
E. Six
Answer: E
There are six tunnels, each lined by its own synovial sheath.

The radial artery

The radial artery passes between the lateral collateral ligament of the wrist joint and the tendons of the abductor pollicis longus

16
and extensor pollicis brevis.

39. A 23 year old man is injured during a game of rugby. He suffers a fracture of the distal third of his clavicle, it is a
compound fracture and there is evidence of arterial haemorrhage. Which of the following vessels is most likely to be
encountered first during subsequent surgical exploration?
A. Posterior circumflex humeral artery
B. Axillary artery
C. Thoracoacromial artery
D. Sub scapular artery
E. Lateral thoracic artery
Answer: C
The thoracoacromial artery arises from the second part of the axillary artery. It is a short, wide trunk, which pierces the
clavipectoral fascia, and ends, deep to pectoralis major by dividing into four branches.

Thoracoacromial artery
The thoracoacromial artery (acromiothoracic artery; thoracic axis) is a short trunk, which arises from the forepart of the axillary
artery, its origin being generally overlapped by the upper edge of the Pectoralis minor. Projecting forward to the upper border of
the Pectoralis minor, it pierces the coracoclavicular fascia and divides into four branches: pectoral, acromial, clavicular, and
deltoid.

Branch Description

Pectoral Descends between the two Pectoral muscles, and is distributed to them and to the breast, anastomosing with the
branch intercostal branches of the internal thoracic artery and with the lateral thoracic.

Acromial Runs laterally over the coracoid process and under the Deltoid, to which it gives branches; it then pierces that
branch muscle and ends on the acromion in an arterial network formed by branches from the suprascapular,
thoracoacromial, and posterior humeral circumflex arteries.
Clavicular Runs upwards and medially to the sternoclavicular joint, supplying this articulation, and the Subclavius
branch

Deltoid Arising with the acromial, it crosses over the Pectoralis minor and passes in the same groove as the cephalic vein,
branch between the Pectoralis major and Deltoid, and gives branches to both muscles.

40. 68 year old man falls onto an outstretched hand. Following the accident he is examined in the emergency department.
On palpating his anatomical snuffbox there is tenderness noted in the base. What is the most likely injury in this
scenario?
A. Rupture of the tendon of flexor pollicis
B. Scaphoid fracture
C. Distal radius fracture
D. Rupture of flexor carpi ulnaris tendon
E. None of the above
Answer: B

A fall onto an outstretched hand is a common mechanism of injury for a scaphoid fracture. This should be suspected clinically if
there is tenderness in the base of the anatomical snuffbox. A tendon rupture would not result in bony tenderness.

41. Which of the following structures passes through the quadrangular space near the humeral head?
A. Axillary artery
B. Radial nerve
C. Axillary nerve
D. Median nerve
E. Transverse scapular artery
Answer: C

The quadrangular space is bordered by the humerus laterally, subscapularis superiorly, teres major inferiorly and the long head of
triceps medially. It lies lateral to the triangular space. It transmits the axillary nerve and posterior circumflex humeral artery.

17
42. Which of the following structures separates the ulnar artery from the median nerve?
A. Brachioradialis
B. Pronator teres
C. Tendon of biceps brachii
D. Flexor carpi ulnaris
E. Brachialis
Answer: B

It lies deep to pronator teres and this separates it from the median nerve.

43. A 32 year old motorcyclist is involved in a road traffic accident. His humerus is fractured and severely displaced. At
the time of surgical repair the surgeon notes that the radial nerve has been injured. Which of the following muscles is
least likely to be affected by an injury at this site?
A. Extensor carpi radialis brevis
B. Brachioradialis
C. Abductor pollicis longus
D. Extensor pollicis brevis
E. None of the above
Answer: E
The radial nerve supplies the extensor muscles, abductor pollicis longus and extensor pollicis brevis (the latter two being
innervated by the posterior interosseous branch of the radial nerve).

44. Which muscle is responsible for causing flexion of the interphalangeal joint of the thumb?
A. Flexor pollicis longus
B. Flexor pollicis brevis
C. Flexor digitorum superficialis
D. Flexor digitorum profundus
E. Adductor pollicis
Answer: A

There are 8 muscles:

1. Two flexors (flexor pollicis brevis and flexor pollicis longus)
2. Two extensors (extensor pollicis brevis and longus)
3. Two abductors (abductor pollicis brevis and longus)
4. One adductor (adductor pollicis)
5. One muscle that opposes the thumb by rotating the CMC joint (opponens pollicis).

Flexor and extensor longus insert on the distal phalanx moving both the MCP and IP joints.

45. An 18 year old man is stabbed in the axilla during a fight. His axillary artery is lacerated and repaired. However, the
surgeon neglects to repair an associated injury to the upper trunk of the brachial plexus. Which of the following
muscles is least likely to demonstrate impaired function as a result?
A. Palmar interossei
B. Infraspinatus
C. Brachialis
D. Supinator brevis
E. None of the above
Answer: A

The palmar interossei are supplied by the ulnar nerve. Which lies inferiorly and is therefore less likely to be injured.

46. A 23 year old man is involved in a fight, during the dispute he sustains a laceration to the posterior aspect of his right
arm, approximately 2cm proximal to the olecranon process. On assessment in the emergency department he is unable
to extend his elbow joint. Which of the following tendons is most likely to have been cut?
A. Triceps
B. Pronator teres
C. Brachioradialis
D. Brachialis
E. Biceps
Answer: A

The triceps muscle extends the elbow joint. The other muscles listed all produce flexion of the elbow joint.

18
47. Which of the following muscles does not attach to the radius?
A. Pronator quadratus
B. Biceps
C. Brachioradialis
D. Supinator
E. Brachialis
Answer: E
The brachialis muscle inserts into the ulna. The other muscles are all inserted onto the radius.

Radius
Bone of the forearm extending from the lateral side of the elbow to the thumb side of the wrist

Upper end

 Articular cartilage- covers medial > lateral side

 Articulates with radial notch of the ulna by the annular ligament
 Muscle attachment- biceps brachii at the tuberosity

Shaft

Muscle attachment-
Upper third of the body Supinator, Flexor digitorum superficialis, Flexor pollicis longus
Middle third of the body Pronator teres
Lower quarter of the body Pronator quadratus , tendon of supinator longus
Lower end

 Quadrilateral
 Anterior surface- capsule of wrist joint
 Medial surface- head of ulna
 Lateral surface- ends in the styloid process

Posterior surface: 3 grooves containing:

1. Tendons of extensor carpi radialis longus and brevis

2. Tendon of extensor pollicis longus
3. Tendon of extensor indicis

48. Which of the following is not an intrinsic muscle of the hand?

A. Opponens pollicis
B. Palmaris longus
C. Flexor pollicis brevis
D. Flexor digiti minimi brevis
E. Opponens digiti minimi
Answer: B

Mnemonic for intrinsic hand muscles

'A OF A OF A'

A dductor pollicis (thenar muscles)

O pponens digiti minimi
F lexor digiti minimi brevis A bductor pollicis brevis
A bductor digiti minimi (hypothenar muscles) O pponens pollicis
F lexor pollicis brevis

Palmaris longus originates in the forearm.

19
49. A 28 year old man lacerates the posterolateral aspect of his wrist with a knife in an attempted suicide. On arrival in
the emergency department the wound is inspected and found to be located over the lateral aspect of the extensor
retinaculum (which is intact). Which of the following structures is at greatest risk of injury?
A. Superficial branch of the radial nerve
B. Radial artery
C. Dorsal branch of the ulnar nerve
D. Tendon of extensor carpi radialis brevis
E. Tendon of extensor digiti minimi
Answer: A

The superficial branch of the radial nerve passes superior to the extensor retinaculum in the position of this laceration and is at
greatest risk of injury. The dorsal branch of the ulnar nerve and artery also pass superior to the extensor retinaculum n but are
located medially.

50. Transection of the radial nerve at the level of the axilla will result in all of the following except:
A. Loss of elbow extension.
B. Loss of extension of the interphalangeal joints.
C. Loss of metacarpophalangeal extension.
D. Loss of triceps reflex.
E. Loss of sensation overlying the first dorsal interosseous.
Answer: B
51. Which of the following muscls cause shoulder abduction
A. Teres major
B. Pectoralis major
C. Coracobrachialis
D. Supraspinatus
E. Latissimus dorsi
Answer: D

Supraspinatus is an abductor of the shoulder.

52. Which of the following structures is not closely related to the brachial artery?
A. Ulnar nerve
B. Median nerve
C. Cephalic vein
D. Long head of triceps
E. Median cubital vein
Answer: C
The cephalic vein lies superficially and on the contralateral side of the arm to the brachial artery. The relation of the ulnar nerves
and others are demonstrated in the image below:

53. The following statements relating to the musculocutaneous nerve are true except?
A. It arises from the lateral cord of the brachial plexus
B. It provides cutaneous innervation to the lateral side of the forearm
C. If damaged then extension of the elbow joint will be impaired
D. It supplies the biceps muscle
E. It runs beneath biceps
Answer: C

It supplies biceps, brachialis and coracobrachialis so if damaged then elbow flexion will be impaired.

Musculocutaneous nerve
 Branch of lateral cord of brachial plexus

Path

 It penetrates the Coracobrachialis muscle

 Passes obliquely between the Biceps brachii and the Brachialis to the lateral side of the arm
 Above the elbow it pierces the deep fascia lateral to the tendon of the Biceps brachii
 Continues into the forearm as the lateral cutaneous nerve of the forearm

20
Innervates

 Coracobrachialis
 Biceps brachii
 Brachialis

54. Which ligament keeps the head of the radius connected to the radial notch of the ulna?
A. Annular (orbicular) ligament
B. Quadrate ligament
C. Radial collateral ligament of the elbow
D. Ulnar collateral ligament
E. Radial collateral ligament
Answer: A

The annular ligament connects the radial head to the radial notch of the ulna. This is illustrated below:

55. A 38 year old man presents to the clinic with shoulder weakness. On examination he has an inability to initiate
shoulder abduction. Which of the nerves listed below is least likely to be functioning normally?
A. Suprascapular nerve
B. Medial pectoral nerve
C. Axillary nerve
D. Median nerve
E. Radial nerve
Answer: A
Suprascapular nerve
The suprascapular nerve arises from the upper trunk of the brachial plexus. It lies superior to the trunks of the brachial plexus and
passes inferolaterally parallel to them. It passes through the scapular notch, deep to trapezius. It innervates both supraspinatus and
infraspinatus and initiates abduction of the shoulder. If damaged, patients may be able to abduct the shoulder by leaning over the
affected side and deltoid can then continue to abduct the shoulder.
56. Which of the following vessels provides the greatest contribution to the arterial supply of the breast?
A. External mammary artery
B. Thoracoacromial artery
C. Internal mammary artery
D. Lateral thoracic artery
E. Subclavian artery

Answer: C

60% of the arterial supply to the breast is derived from the internal mammary artery. The external mammary and lateral thoracic
arteries also make a significant (but lesser) contribution. This is of importance clinically in performing reduction mammoplasty
procedures.

Breast

The breast itself lies on a layer of pectoral fascia and the following muscles:
1. Pectoralis major
2. Serratus anterior
3. External oblique

Breast anatomy
Nerve supply Branches of intercostal nerves from T4-T6.
Arterial supply  Internal mammary (thoracic) artery
 External mammary artery (laterally)
 Anterior intercostal arteries
 Thoraco-acromial artery

Venous drainage Superficial venous plexus to sub clavian, axillary and intercostal veins.

21
Lymphatic drainage  70% Axillary nodes
 Internal mammary chain
 Other lymphatic sites such as deep cervical and supraclavicular fossa (later in disease)

57. A baby is found to have a Klumpke's palsy post delivery. Which of the following is most likely to be present?
A. Loss of flexors of the wrist
B. Weak elbow flexion
C. Pronation of the forearm
D. Adducted shoulder
E. Shoulder medially rotated
Answer: A

Features of Klumpkes Paralysis: Claw hand (MCP joints extended and IP joints flexed), Loss of sensation over medial aspect of
forearm and hand, Horner's syndrome, Loss of flexors of the wrist

A C8, T1 root lesion is called Klumpke's paralysis and is caused by delivery with the arm extended.

58. With respect to the basilic vein, which statement is false?

A. Its deep anatomical location makes it unsuitable for use as an arteriovenous access site in fistula surgery
B. It originates from the dorsal venous network on the hand
C. It travels up the medial aspect of the forearm
D. Halfway between the shoulder and the elbow it lies deep to muscle
E. It joins the brachial vein to form the axillary vein
Answer: A

It is used in arteriovenous fistula surgery during a procedure known as a basilic vein transposition.

A 78 year old man is lifting a heavy object when a feels a pain in his forearm and is unable to continue. He has a swelling
over his upper forearm. An MRI scan shows a small cuff of tendon still attached to the radial tuberosity consistent with a
recent tear. Which of the following muscles has been injured?

A. Pronator teres
B. Supinator
C. Aconeus
D. Brachioradialis
E. Biceps brachii
Answer: E
Biceps inserts into the radial tuberosity. Distal injuries of this muscle are rare but are reported and are clinically more important
than more proximal ruptures.

59. Which of the following is a branch of the third part of the axillary artery?
A. Superior thoracic
B. Lateral thoracic
C. Dorsal scapular
D. Thoracoacromial
E. Posterior circumflex humeral
Answer: E
The other branches include :Subscapular, Anterior circumflex humeral
Axilla
Boundaries of the axilla
Medially Chest wall and Serratus anterior
Laterally Humeral head
Floor Subscapularis
Anterior aspect Lateral border of Pectoralis major
Fascia Clavipectoral fascia

Content:
Long thoracic nerve (of Bell) Derived from C5-C7 and passes behind the brachial plexus to enter the axilla. It lies on the
medial chest wall and supplies serratus anterior. Its location puts it at risk during axillary surgery
22
 and damage will lead to winging of the scapula.
Thoracodorsal nerve and Innervate and vascularise latissimus dorsi.
thoracodorsal trunk
Axillary vein Lies at the apex of the axilla, it is the continuation of the basilic vein. Becomes the subclavian
vein at the outer border of the first rib.
Intercostobrachial nerves Traverse the axillary lymph nodes and are often divided during axillary surgery. They provide
cutaneous sensation to the axillary skin.
Lymph nodes The axilla is the main site of lymphatic drainage for the breast.

Theme: Nerve lesions

A. Intercostobrachial
B. Median
C. Axillary
D. Radial
E. Ulnar
F. Musculocutaneous
G. Brachial plexus upper cord
H. Brachial plexus lower cord

Please select the most likely nerve injury for the scenarios given. Each option may be used once, more than once or not at all.

60. A 23 year old rugby player sustains a Smiths Fracture. On examination opposition of the thumb is markedly
weakened.

Answer: Median
This high velocity injury can often produce significant angulation and displacement. Both of these may impair the function of
the median nerve with loss of function of the muscles of the thenar eminence
61. A 45 year old lady recovering from a mastectomy and axillary node clearance notices that sensation in her armpit is
impaired.

Answer: Intercostobrachial
The intercostobrachial nerves are frequently injured during axillary dissection. These nerves traverse the axilla and supply
cutaneous sensation.
62. An 8 year old boy falls onto an outstretched hand and sustains a supracondylar fracture. In addition to a weak radial
pulse the child is noted to have loss of pronation of the affected hand.

Answer: Median
This is a common injury in children. In this case the angulation and displacement have resulted in median nerve injury.

63. Froment's test which muscle function is tested?

A. Flexor pollicis longus
B. Adductor pollicis longus
C. Abductor pollicis brevis
D. Adductor pollicis
E. Opponens pollicis
Answer: D

Nerve signs
Froment's sign

 Assess for ulnar nerve palsy

 Adductor pollicis muscle function tested
 Hold a piece of paper between their thumb and index finger. The object is then pulled away. If ulnar nerve palsy, unable
to hold the paper and will flex the flexor pollicis longus to compensate (flexion of thumb at interphalangeal joint).

 More sensitive than Tinel's sign Phalen's test

 Hold wrist in maximum flexion and the test is
positive if there is numbness in the median nerve  Assess carpal tunnel syndrome
distribution.
23
  Tap the median nerve at the wrist and the test is Tinel's sign
positive if there is tingling/electric-like sensations
over the distribution of the median nerve.  Assess for carpal tunnel syndrome
Theme: Cutaneous innervation

A. Ulnar nerve
B. Fifth cervical spinal segment
C. Radial nerve
D. Musculocutaneous nerve
E. Median nerve
F. None of these

Please select the source of innervation for the region described. Each option may be used once, more than once or not at all.

64. The skin on the palmar aspect of the thumb

Answer: Median nerve
The median nerve supplies cutaneous sensation to this region.

65. The nail bed of the index finger

Answer: Median nerve
66. The skin overlying the medial aspect of the palm
Answer: Ulnar nerve

67. From which of the following foramina does the opthalmic branch of the trigeminal nerve exit the skull?
A. Foramen ovale
B. Foramen rotundum
C. Foramen spinosum
D. Superior orbital fissure
E. Foramen magnum
Answer: D
Mnemonic:Standing Room Only -Exit of branches of trigeminal nerve from the skull
V1 -Superior orbital fissure
V2 -foramen Rotundum
V3 -foramen Ovale

The opthalmic branch of the trigeminal nerve exits the skull through the superior orbital fissure.

Trigeminal nerve
The trigeminal nerve is the main sensory nerve of the head. In addition to its major sensory role, it also innervates the muscles of
mastication.

Distribution of the trigeminal nerve

Sensory  Scalp
 Face
 Oral cavity (and teeth)
 Nose and sinuses
 Dura mater

Motor  Muscles of mastication

 Mylohyoid
 Anterior belly of digastric
 Tensor tympani
 Tensor palati

Autonomic connections (ganglia)  Ciliary

 Sphenopalatine
 Otic
 Submandibular

24
Path
 Originates at the pons
 Sensory root forms the large, crescentic trigeminal ganglion within Meckel's cave, and contains the cell bodies of
incoming sensory nerve fibres. Here the 3 branches exit.
 The motor root cell bodies are in the pons and the motor fibres are distributed via the mandibular nerve. The motor root
is not part of the trigeminal ganglion.

Branches of the trigeminal nerve

Ophthalmic nerve Sensory only
Maxillary nerve Sensory only
Mandibular nerve Sensory and motor

Sensory
Ophthalmic Exits skull via the superior orbital fissure
Sensation of: scalp and forehead, the upper eyelid, the conjunctiva and cornea of the eye, the nose (including
the tip of the nose, except alae nasi), the nasal mucosa, the frontal sinuses, and parts of the meninges (the dura
and blood vessels).
Maxillary Exit skull via the foramen rotundum
nerve Sensation: lower eyelid and cheek, the nares and upper lip, the upper teeth and gums, the nasal mucosa, the
palate and roof of the pharynx, the maxillary, ethmoid and sphenoid sinuses, and parts of the meninges.
Mandibular Exit skull via the foramen ovale
nerve Sensation: lower lip, the lower teeth and gums, the chin and jaw (except the angle of the jaw), parts of the
external ear, and parts of the meninges.

Motor
Distributed via the mandibular nerve.
The following muscles of mastication are innervated:
 Masseter
 Tensor veli palatini  Temporalis
 Mylohyoid  Medial pterygoid
 Anterior belly of digastric  Lateral pterygoid
 Tensor tympani
Other muscles innervated include:
68. 42 year old lady has had an axillary node clearance for breast malignancy. Post operatively she reports weakness of
the shoulder. She is unable to push herself forwards from a wall with the right arm and the scapula is pushed out
medially from the chest wall. What is the most likely nerve injury?
A. C5, C6
B. C8, T1
C. Axillary nerve
D. Long thoracic nerve
E. Spinal accessory nerve

Answer: D
The patient has a winged scapula caused by damage to the long thoracic nerve (C5,6,7) during surgery. The long thoracic nerve
innervates serratus anterior. Serratus anterior causes pushing out of the scapula during a punch.

NB winging of the scapular laterally may indicate trapezius muscle weakness. Innervated by the spinal accessory nerve.

69. A 36 year old male is admitted for elective surgery for a lymph node biopsy in the supraclavicular region. Post
operatively the patient has difficulty shrugging his left shoulder. What nerve has been damaged?
A. Phrenic nerve
B. Axillary nerve
C. C5, C6 lesion
D. C8, T1 lesion
E. Accessory nerve

Answer: E
The accessory nerve lies in the posterior triangle and may be injured in this region. Apart from problems with shrugging the
shoulder, he may also have difficulty lifting his arm above his head.
25
70. Which of the following muscles is supplied by the musculocutaneous nerve?
A. Brachialis
B. Latissimus dorsi
C. Flexor carpi ulnaris
D. Teres minor
E. Triceps
Answer: A
Mnemonic Muscles innervated by the musculocutaneous nerve BBC: Biceps brachii, Brachialis, Coracobrachialis

71. A 17 year old male presents to the clinic. He complains of difficulty using his left hand. It has been a persistent
problem since he sustained a distal humerus fracture as a child. On examination there is diminished sensation
overlying the hypothenar eminence and medial one and half fingers. What is the most likely nerve lesion?
A. Anterior interosseous nerve
B. Posterior interosseous nerve
C. Ulnar nerve
D. Median nerve
E. Radial nerve
Answer: C

This sensory deficit pattern is most consistent with ulnar nerve injury.

72. A 72 year old male with end stage critical ischaemia is undergoing an axillo-femoral bypass. What structure is not
closely related to the axillary artery?
A. Posterior cord of the brachial plexus
B. Scalenus anterior muscle
C. Pectoralis minor muscle
D. Axillary vein
E. Lateral cord of the brachial plexus
Answer: B

The axillary artery is the continuation of the subclavian artery. It is surrounded by the cords of the brachial plexus (from
whichthey are named). The axillary vein runs alongside the axillary artery throughout its length.

73. Which of the following carpal bones is a sesamoid bone in the tendon of flexor carpi ulnaris?
A. Triquetrum
B. Lunate
C. Pisiform
D. Scaphoid
E. Capitate

Answer: C

This small bone has a single articular facet. It projects from the triquetral bone at the ulnar aspect of the wrist where most regard it
as a sesamoid bine lying within the tendon of flexor carpi ulnaris.

74. A 70 year old man falls and fractures his scaphoid bone. The fracture is displaced and the decision is made to insert a
screw to fix the fracture. Which of the following structures lies directly medial to the scaphoid?
A. Lunate
B. Pisiform
C. Trapezoid
D. Trapezium
E. None of the above

Answer: A
The lunate lies medially in the anatomical plane. Fractures of the scaphoid that are associated with high velocity injuries may
cause associated lunate dislocation.

Scaphoid bone
The scaphoid has a concave articular surface for the head of the capitate and at the edge of this is a crescentic surface for the
corresponding area on the lunate.
Proximally, it has a wide convex articular surface with the radius. It has a distally sited tubercle that can be palpated. The
remaining articular surface is to the lateral side of the tubercle. It faces laterally and is associated with the trapezium and trapezoid
bones.
The narrow strip between the radial and trapezial surfaces and the tubercle gives rise to the radial collateral carpal ligament. The
26
tubercle receives part of the flexor retinaculum. This area is the only part of the scaphoid that is available for the entry of blood
vessels. It is commonly fractured and avascular necrosis may result.

75. A 73 year old lady is hit by a car. She suffers a complex fracture of the distal aspect of her humerus with associated
injury to the radial nerve. Which of the following movements will be most impaired as a result?
A. Elbow extension
B. Elbow flexion
C. Shoulder abduction
D. Wrist extension
E. None of the above

Answer: D

The triceps will not be affected so elbow extension will be preserved. Loss of wrist extension will be the most obvious effect.

76. An 18 year old man develops a severe spreading sepsis of the hand. The palm is explored surgically and the flexor
digiti minimi brevis muscle is mobilised to facilitate drainage of the infection. Which of the following structures is not
closely related to this muscle?
A. The hook of hamate
B. Median nerve
C. Superficial palmar arterial arch
D. Digital nerves arising from the ulnar nerve
E. None of the above

Answer: B

The flexor digiti minimi brevis originates from the Hamate, on its undersurface lie the ulnar contribution to the superficial palmar
arterial arch and digital nerves derived from the ulnar nerve. The median nerve overlies the flexor tendons.

77. A 22 year old man develops an infection in the pulp of his little finger. What is the most proximal site to which this
infection may migrate?
A. The metacarpophalangeal joint
B. The distal interphalangeal joint
C. The proximal interphalangeal joint
D. Proximal to the flexor retinaculum
E. Immediately distal to the carpal tunnel

Ansewr: D

The 5th tendon sheath extends from the little finger to the proximal aspect of the carpal tunnel. This carries a significant risk of
allowing infections to migrate proximally.

78. Which of the following muscles is not innervated by the deep branch of the ulnar nerve?
A. Adductor pollicis
B. Hypothenar muscles
C. All the interosseous muscles
D. Opponens pollicis
E. Third and fourth lumbricals
Answer: D

Which of the following structures lie between the lateral and medial heads of the triceps muscle?

A. Radial nerve
B. Median nerve
C. Ulnar nerve
D. Axillary nerve
E. Medial cutaneous nerve of the forearm
Answer: A

27
The radial nerve runs in its groove on between the two heads. The ulnar nerve lies anterior to the medial head. The axillary nerve
passes through the quadrangular space. This lies superior to lateral head of the triceps muscle and thus the lateral border of the

79. Into which of the following structures does the superior part of the fibrous capsule of the shoulder joint insert?
A. The surgical neck of the humerus
B. The body of the humerus
C. The bicipital groove
D. Immediately distal to the greater tuberosity
E. The anatomical neck of the humerus

Answer: E

The shoulder joint is a shallow joint, hence its great mobility. However, this comes at the expense of stability. The fibrous capsule
attaches to the anatomical neck superiorly and the surgical neck inferiorly

80. Damage to the posterior cord of the brachial plexus will not result in any of the following except:
A. Klumpkes palsy
B. Anaesthesia overlying the lateral aspect of the forearm
C. A warm sweaty hand on the affected side
D. Loss of flexion of the arm
E. Anaesthesia overlying the posterior surface of the arm

Answer: E

The radial nerve gives cutaneous branches which supply the forearm posteriorly and the arm laterally. Division of the posterior
cord will impair the upper level of cutaneous sensation. However, the lateral cutaneous nerve of the forearm arises from the
musculocutaneous nerve and would be unaffected. Loss of sympathetic function would not result in a sweaty hand. Klumpkes
palsy occurs when the lower roots are C8-T1 are damaged.

81. A woman develops winging of the scapula following a Patey mastectomy. What is the most likely cause?
A. Division of pectoralis minor to access level 3 axillary nodes
B. Damage to the brachial plexus during axillary dissection
C. Damage to the long thoracic nerve during axillary dissection
D. Division of the thoracodorsal trunk during axillary dissection
E. Damage to the thoracodorsal trunk during axillary dissection

Answer: C

The serratus anterior muscle is supplied by the long thoracic nerve which runs along the surface of serratus anterior and is liable to
injury during nodal dissection. Although pectoralis minor is divided during a Patey mastectomy (now seldom performed) it is rare
for this alone to produce winging of the scapula.

Which of the following is not closely related to the capitate bone?

A. Lunate bone
B. Scaphoid bone
C. Ulnar nerve
D. Hamate bone
E. Trapezoid bone
Answer: C
The ulnar nerve and artery lie adjacent to the pisiform bone. The capitate bone articulates with the lunate, scaphoid, hamate and
trapezoid bones, which are therefore closely related to it.

Capitate bone
This is the largest of the carpal bones. It is centrally placed with a rounded head set into the cavities of the lunate and scaphoid
bones. Flatter articular surfaces are present for the hamate medially and the trapezoid laterally. Distally the bone articulates
predominantly with the middle metacarpal.

82. An injury to the spinal accessory nerve will affect which of the following movements?
A. Lateral rotation of the arm
28
 B. Adduction of the arm at the glenohumeral joint
C. Protraction of the scapula
D. Upward rotation of the scapula
E. Depression of the scapula
Answer: D
The spinal accessory nerve innervates trapezius. The entire muscle will retract the scapula. However, its upper and lower fibres act
together to upwardly rotate it.

83. A 23 year old man falls over whilst intoxicated and a shard of glass transects his median nerve at the proximal border
of the flexor retinaculum. His tendons escape injury. Which of the following features will not be present?
A. Weakness of thumb abduction
B. Loss of sensation on the dorsal aspect of the thenar eminence
C. Loss of power of opponens pollicis
D. Adduction and lateral rotation of the thumb at rest
E. Loss of power of abductor pollicis brevis

Answer: B
The median nerve may be injured proximal to the flexor retinaculum. This will result in loss of flexor pollicis brevis, opponens
pollicis and the first and second lumbricals. When the patient is asked to close the hand slowly there is a lag of the index and
middle fingers reflecting the impaired lumbrical muscle function. The sensory changes are minor and do not extend to the dorsal
aspect of the thenar eminence.
Abductor pollicis longus will contribute to thumb abduction (and is innervated by the posterior interosseous nerve) and therefore
abduction will be weaker than prior to the injury.

84. A 23 year old man falls and injures his hand. There are concerns that he may have a scaphoid fracture as there is
tenderness in his anatomical snuffbox on clinical examination. Which of the following forms the posterior border of
this structure?
A. Basilic vein
B. Radial artery
C. Extensor pollicis brevis
D. Abductor pollicis longus
E. Extensor pollicis longus

Answer: E

Its boundaries are extensor pollicis longus, medially (posterior border) and laterally (anterior border) by the tendons of abductor
pollicis longus and extensor pollicis brevis.

85. A 28 year old man is stabbed outside a nightclub in the upper arm. The median nerve is transected. Which of the
following muscles will demonstrate impaired function as a result?
A. Palmaris brevis
B. Second and third interossei
C. Adductor pollicis
D. Abductor pollicis longus
E. Abductor pollicis brevis

Answer: E

Palmaris brevis - Ulnar nerve

Palmar interossei- Ulnar nerve
Adductor pollicis - Ulnar nerve
Abductor pollicis longus - Posterior interosseous nerve
Abductor pollicis brevis - Median nerve

The median nerve innervates all the short muscles of the thumb except the adductor and the deep head of the short flexor.
Palmaris and the interossei are innervated by the ulnar nerve.

29
Which of the following is not a branch of the posterior cord of the brachial plexus?

A. Thoracodorsal nerve
B. Axillary nerve
C. Radial nerve
D. Lower subscapular nerve
E. Musculocutaneous nerve
Answer: E
Mnemonic branches off the posterior cord: S ubscapular (upper and lower), T horacodorsal, A xillary, R adial

The musculocutaneous nerve is a branch off the lateral cord.

86. A 56 year old machinist has his arm entrapped in a steel grinder and is brought to the emergency department. On
examination, he is unable to extend his metacarpophalangeal joints and abduct his shoulder. He has weakness of his
elbow and wrist. What has been injured?
A. Ulnar nerve
B. Axillary nerve
C. Medial cord of brachial plexus
D. Lateral cord of brachial plexus
E. Posterior cord of brachial plexus
Answer: E
The posterior cord gives rise to:
 Radial nerve ((innervates the triceps, brachioradialis, wrist extensors, and finger extensors)
 Axillary nerve (innervates deltoid and teres minor)
 Upper subscapular nerve (innervates subscapularis)
 Lower subscapular nerve (innervates teres major and subscapularis)
 Thoracodorsal nerve (innervates latissimus dorsi)

This is a description of a posterior cord lesion. Remember that the posterior cord gives rise to the axillary and radial nerve.

Cords of the brachial plexus

The brachial plexus cords are described according to their relationship with the axillary artery. The cords pass over the 1st rib near
to the dome of the lung and pass beneath the clavicle immediately posterior to the subclavian artery.

Lateral cord: Anterior divisions of the upper and middle trunks form the lateral cord. Origin of the lateral pectoral nerve (C5, C6,
C7)

Medial cord: Anterior division of the lower trunk forms the medial cord. Origin of the medial pectoral nerve (C8, T1), the medial
brachial cutaneous nerve (T1), and the medial antebrachial cutaneous nerve (C8, T1)

Posterior cord. Formed by the posterior divisions of the 3 trunks (C5-T1). Origin of the upper and lower subscapular nerves (C7,
C8 and C5, C6, respectively) and the thoracodorsal nerve to the latissimus dorsi (also known as the middle subscapular nerve, C6,
C7, C8), axillary and radial nerve

87. A motor cyclist is involved in a road traffic accident causing severe right shoulder injuries. He is found to have an
adducted, medially rotated shoulder. The elbow is fully extended and the forearm pronated. Which is the most likely
diagnosis?
A. C8, T1 root lesion
B. C5, C6 root lesion
C. Radial nerve lesion
D. Ulnar nerve lesion
E. Axillary nerve lesion

Answer: B

Erbs Palsy C5, C6 lesion

The features include:Waiter's tip position

 Loss of shoulder abduction (deltoid and supraspinatus paralysis)

 Loss of external rotation of the shoulder (paralysis of infraspinatus and teres major)
 Loss of elbow flexion (paralysis of biceps, brachialis and brachioradialis)
 Loss of forearm supination (paralysis of Biceps)
30
The motorcyclist has had an Erb's palsy (C5, C6 root lesion). This is commonly known to be associated with birth injury when a
baby has a shoulder dystocia.

88. A 23 year old man has a cannula inserted into his cephalic vein. Through which structure does the cephalic vein pass?
A. Interosseous membrane
B. Triceps
C. Pectoralis major
D. Clavipectoral fascia
E. Tendon of biceps
Answer: D
The cephalic vein is a favored vessel for arteriovenous fistula formation and should be preserved in patients with end stage renal
failure. The cephalic vein penetrates the calvipectoral fascia (but not the pectoralis major) prior to terminating in the axillary vein.

89. Which of the following is not a muscle of the rotator cuff?

A. Subscapularis
B. Teres minor
C. Supraspinatus
D. Infraspinatus
E. Deltoid
Answer: E
Deltoid may abduct the shoulder and is not a rotator cuff muscle.

Muscles of the rotator cuff

Muscle Innervation
Supraspinatus muscle Suprascapular nerve
Infraspinatus muscle Suprascapular nerve
Teres minor muscle Axillary nerve
Subscapularis muscle Superior and inferior subscapular nerves

90. A 32 year old man is stabbed in the neck and the inferior trunk of his brachial plexus is injured. Which of the
modalities listed below is least likely to be affected?
A. Initiating abduction of the shoulder
B. Abduction of the fingers
C. Flexion of the little finger
D. Sensation on the palmar aspect of the little finger
E. Gripping a screwdriver

Answer: A

Inferior trunk of brachial plexus. C8 and T1 rootsContributes to ulnar nerve and part of median nerve. The inferior trunk of the
brachial plexus is rarely injured. Nerve roots C8 and T1 are the main contributors to this trunk. Therefore an injury to this site will
most consistently affect the ulnar nerve. The inferior trunk also contributes to the median nerve by way of the posterior division
and therefore some impairment of grip is almost inevitable.

91. As it exits the axilla the radial nerve lies on which of the following muscles?
A. Supraspinatus
B. Infraspinatus
C. Teres major
D. Deltoid
E. Pectoralis major
Answer: C

The radial nerve passes through the triangular space to leave the axilla. The superior border of this is bounded by the teres major
muscle to which the radial nerve is closely related.

31
92. A 62 year old man presents with arm weakness. On examination he has a weakness of elbow extension and loss of
sensation on the dorsal aspect of the first digit. What is the site of the most likely underlying defect?
A. Axillary nerve
B. Median nerve
C. Ulnar nerve
D. Radial nerve
E. Musculocutaneous nerve
Answer:D

The long head of the triceps muscle may be innervated by the axillary nerve and therefore complete loss of triceps muscles
function may not be present even with proximally sited nerve lesions.

From which of the following structures does the long head of the triceps muscle arise?

A. Coracoid process
B. Acromion
C. Infraglenoid tubercle
D. Coraco-acromial ligament
E. Coraco-humeral ligament
Answer: C

The long head arises from the infraglenoid tubercle. The fleshy lateral and medial heads are attached to the posterior aspect of the

93. A 58 year old lady presents with a mass in the upper outer quadrant of the right breast. Which of the following
statements relating to the breast is untrue?
A. The internal mammary artery provides the majority of its arterial supply
B. Nipple retraction may occur as a result of tumour infiltration of the clavipectoral fascia
C. The internal mammary artery is a branch of the subclavian artery
D. Up to 70% of lymphatic drainage is to the ipsilateral axillary nodes
E. None of the above
Answer: B

Nipple retraction is a feature of breast malignancy. However, it is typically caused by tumour infiltration of Coopers Ligaments
that run through the breast and surround the lobules. The clavipectoral fascia encases the axillary contents. The lymphatic
drainage of the breast is to the axilla and also to the internal mammary chain. The breast is well vascularised and the internal
mammary artery is a branch of the subclavian artery.

Theme: Nerve injury

A. Median nerve
B. Ulnar nerve
C. Radial nerve
D. Anterior interosseous nerve
E. Posterior interosseous nerve
F. Axillary nerve
G. Musculocutaneous nerve

Please select the nerve at risk of injury in each scenario. Each option may be used once, more than once or not at all.

94. A 43 year old typist presents with pain at the dorsal aspect of the upper part of her forearm. She also complains of
weakness when extending her fingers. On examination triceps and supinator are both functioning normally. There is
weakness of most of the extensor muscles. However, there is no sensory deficit.

Answer: Posterior interosseous nerve

The radial nerve may become entrapped in the "arcade of Frohse" which is a superficial part of the supinator muscle which
overlies the posterior interosseous nerve. This nerve is entirely muscular and articular in its distribution. It passes postero-
inferiorly and gives branches to extensor carpi radialis brevis and supinator. It enters supinator and curves around the lateral
and posterior surfaces of the radius. On emerging from the supinator the posterior interosseous nerve lies between the
superficial extensor muscles and the lowermost fibres of supinator. It then gives branches to the extensors.

95. A 28 year teacher reports difficulty with writing. There is no sensory loss. She is known to have an aberrant Gantzer
muscle.
32
 Answer: Anterior interosseous nerve

Anterior interosseous lesions occur due to fracture, or rarely due to compression. The Gantzer muscle is an aberrant accessory
of the flexor pollicis longus and is a risk factor for anterior interosseous nerve compression. Remember loss of pincer grip and
normal sensation indicates an interosseous nerve lesion.

96. A 35 year tennis player attends reporting tingling down his arm. He says that his 'funny bone' was hit very hard by a
tennis ball. There is weakness of abduction and adduction of his extended fingers.

Answer: Ulnar nerve

The ulnar nerve arises from the medial cord of the brachial plexus (C8, T1 and contribution from C7). The nerve descends
between the axillary artery and vein, posterior to the cutaneous nerve of the forearm and then lies anterior to triceps on the
medial side of the brachial artery. In the distal half of the arm it passes through the medial intermuscular septum, and
continues between this structure and the medial head of triceps to enter the forearm between the medial epicondyle of the
humerus and the olecranon. It may be injured at this site in this scenario.

97. A 53 year old lady presents with pain and discomfort in her hand. She works as a typist and notices that the pain is
worst when she is working. She also suffers symptoms at night. Her little finger is less affected by the pain. Which of
the nerves listed below is most likely to be affected?
A. Radial
B. Median
C. Ulnar
D. Anterior interosseous nerve
E. Posterior interosseous nerve
Answer: B

The most likely diagnosis here is carpal tunnel syndrome, the median nerve is compressed in the wrist and symptoms usually
affect the fingers and wrist either at night or when the hand is being used (e.g. as a typist).

98. A 24 year female is admitted to A&E with tingling of her hand after a fall. She is found to have a fracture of the
medial epicondyle. What is the most likely nerve lesion?
A. Ulnar nerve
B. Radial nerve
C. Median nerve
D. Axillary nerve
E. Cutaneous nerve
Answer: A

The radial nerve is located near the lateral epicondyle.

A 43 year old lady is undergoing an axillary node clearance for breast cancer. The nodal disease is bulky. During
clearance of the level 3 nodes there is suddenly brisk haemorrhage. The most likely vessel responsible is:

A. Thoracoacromial artery
B. Cephalic vein
C. Thoracodorsal trunk
D. Internal mammary artery
E. Posterior circumflex humeral artery

Answer: A

The thoracoacromial artery pierces the pectoralis major and gives off branches within this space. The level 3 axillary nodes lie
between pectoralis major and minor.Although the thoracodorsal trunk may be injured during an axillary dissection it does not lie
within the level 3 nodes.

99. A 73 year old lady with long standing atrial fibrillation develops a cold and pulseless white arm. A brachial embolus is
suspected and a brachial embolectomy is performed. Which of the following structures is at greatest risk of injury
during this procedure?
A. Radial nerve
B. Cephalic vein

33
 C. Ulnar nerve
D. Median nerve
E. None of the above
Answer: D
The median nerve lies close to the brachial artery in the antecubital fossa. This is the usual site of surgical access to the brachial
artery for an embolectomy procedure. The median nerve may be damaged during clumsy application of vascular clamps to the
artery.

100.Which of the following fingers is not a point of attachment for the palmar interossei?
A. Middle finger
B. Little finger
C. Ring finger
D. Index finger
E. None of the above

Answer: A

101.A 6 year old sustains a supracondylar fracture of the distal humerus. There are concerns that the radial nerve may
have been injured. What is the relationship of the radial nerve to the humerus at this point?
A. Anterolateral
B. Anteromedial
C. Posterolateral
D. Posteromedial
E. Immediately anterior
Answer: A

The radial nerve lies anterolateral to the humerus in the supracondylar area.

102.The following are true of the ulnar nerve except:

A. It innervates the palmar interossei
B. Derived from the medial cord of the brachial plexus
C. Supplies the muscles of the thenar eminence
D. Supplies the medial half of flexor digitorum profundus
E. Passes superficial to the flexor retinaculum
Answer: C

These are supplied by the median nerve and atrophy of these is a feature of carpal tunnel syndrome

103.Which muscle is responsible for causing flexion of the distal interphalangeal joint of the ring finger?
A. Flexor digitorum superficialis
B. Lumbricals
C. Palmar interossei
D. Flexor digitorum profundus
E. Flexor digiti minimi brevis
Answer: D

Flexor digitorum superficialis and flexor digitorum profundus are responsible for causing flexion. The superficialis tendons insert
on the bases of the middle phalanges; the profundus tendons insert on the bases of the distal phalanges. Both tendons flex the
wrist, MCP and PIP joints; however, only the profundus tendons flex the DIP joints.

104.Which of the following muscles lies medial to the long thoracic nerve?
A. Serratus anterior
B. Latissimus dorsi
C. Pectoralis major
D. Pectoralis minor
E. None of the above

34
 Lower Limb
1. A 25 year old man is stabbed in the groin and the area, which lies within the femoral triangle is explored. Which
structure forms the lateral wall of the femoral triangle?
A.Adductor longus
B. Pectineus
C. Adductor magnus
D.Sartorius
E. Conjoint tendon
Answer: D
The sartorius forms the lateral wall of the femoral triangle (see below).

Femoral triangle anatomy

Boundaries

Superiorly Inguinal ligament

Laterally Sartorius
Medially Adductor longus
Floor pectineus and adductor longus muscles medially and iliopsoas muscle laterally.
Roof  Fascia lata and Superficial fascia
 Superficial inguinal lymph nodes (palpable below the inguinal ligament)
 Great saphenous vein

Contents

 Femoral vein (medial to lateral)

 Femoral artery-pulse palpated at the mid inguinal point
 Femoral nerve
 Deep and superficial inguinal lymph nodes
 Lateral cutaneous nerve
 Great saphenous vein
 Femoral branch of the genitofemoral nerve

2. Which of the following is not contained within the deep posterior compartment of the lower leg?
A. Tibialis posterior muscle
B. Posterior tibial artery
C. Tibial nerve
D. Sural nerve
E. Flexor hallucis longus

Answer: D

The deep posterior compartment lies anterior to soleus. The sural nerve is superficially sited and therefore not contained within it.

Lower limb- Muscular compartments

Anterior compartment

Muscle Nerve Action

Tibialis anterior Deep peroneal nerve Dorsiflexes ankle joint, inverts foot
Extends lateral four toes, dorsiflexes
Extensor digitorum longus Deep peroneal nerve
ankle joint
Peroneus tertius Deep peroneal nerve Dorsiflexes ankle, everts foot

Extensor hallucis longus Deep peroneal nerve Dorsiflexes ankle joint, extends big toe

35
Posterior and peroneal compartments

Muscle Nerve Action

Everts foot, assists in plantar
Peroneus longus Superficial peroneal nerve
flexion
Peroneal compartment
Peroneus brevis Superficial peroneal nerve Plantar flexes the ankle joint
Plantar flexes the foot, may
Gastrocnemius Tibial nerve
Superficial posterior also flex the knee
compartment
Soleus Tibial nerve Plantar flexor

Flexor digitorum longus Tibial Flexes the lateral four toes

Deep posterior compartment Flexor hallucis longus Tibial Flexes the great toe

Tibialis posterior Tibial Plantar flexor, inverts the foot

3. A 20 year old lady presents with pain on the medial aspect of her thigh. Investigations show a large ovarian cyst.
Compression of which of the nerves listed below is the most likely underlying cause?
A. Sciatic
B. Genitofemoral
C. Obturator
D. Ilioinguinal
E. Femoral cutaneous

Answer: C

The cutaneous branch of the obturator nerve is frequently absent. However, the obturator nerve is a recognised contributor to
innervation of the medial thigh and large pelvic tumours may compress this nerve with resultant pain radiating distally.

Obturator nerve

The obturator nerve arises from L2, L3 and L4 by branches from the ventral divisions of each of these nerve roots. L3 forms the
main contribution and the second lumbar branch is occasionally absent. These branches unite in the substance of psoas major,
descending vertically in its posterior part to emerge from its medial border at the lateral margin of the sacrum. It then crosses the
sacroiliac joint to enter the lesser pelvis, it descends on obturator internus to enter the obturator groove. In the lesser pelvis the
nerve lies lateral to the internal iliac vessels and ureter, and is joined by the obturator vessels lateral to the ovary or ductus
deferens.

Supplies

 Medial compartment of thigh

 Muscles supplied: external obturator, adductor longus, adductor brevis, adductor magnus (not the lower part-sciatic
nerve), gracilis
 The cutaneous branch is often absent. When present, it passes between gracilis and adductor longus near the middle part
of the thigh, and supplies the skin and fascia of the distal two thirds of the medial aspect.

Obturator canal

 Connects the pelvis and thigh: contains the obturator artery, vein, nerve which divides into anterior and posterior
branches.

36
4. A 22 year old man suffers a compound fracture of the tibia. During attempted surgical repair the deep peroneal nerve
is divided. Which of the following muscles will not be affected as a result?
A. Tibialis anterior
B. Peroneus longus
C. Extensor hallucis longus
D. Extensor digitorum longus
E. Peroneus tertius
Answer: B
Peroneus longus is innervated by the superficial peroneal nerve (L4, L5, S1).

Deep peroneal nerve

Origin From the common peroneal nerve, at the lateral aspect of the fibula, deep to peroneus longus
Nerve root values L4, L5, S1, S2
Course and relation  Pierces the anterior intermuscular septum to enter the anterior compartment of the lower leg
 Passes anteriorly down to the ankle joint, midway between the two malleoli

Terminates In the dorsum of the foot

Muscles innervated  Tibialis anterior
 Extensor hallucis longus
 Extensor digitorum longus
 Peroneus tertius
 Extensor digitorum brevis

Cutaneous Web space of the first and second toes

innervation
Actions  Dorsiflexion of ankle joint
 Extension of all toes (extensor hallucis longus and extensor digitorum longus)
 Eversion of the foot

After its bifurcation past the ankle joint, the lateral branch of the deep peroneal nerve innervates the extensor digitorum brevis and
the extensor hallucis brevis
The medial branch supplies the web space between the first and second digits.

5. Which of the following forms the medial wall of the femoral canal?
A. Pectineal ligament
B. Adductor longus
C. Sartorius
D. Lacunar ligament
E. Inguinal ligament
Answer: D
Femoral canal

The femoral canal lies at the medial aspect of the femoral sheath. The femoral sheath is a fascial tunnel containing both the
femoral artery laterally and femoral vein medially. The canal lies medial to the vein.

Borders of the femoral canal

Laterally Femoral vein
Medially Lacunar ligament
Anteriorly Inguinal ligament
Posteriorly Pectineal ligament

Contents

 Lymphatic vessels
 Cloquet's lymph node

Physiological significance
Allows the femoral vein to expand to allow for increased venous return to the lower limbs.
37
Pathological significance
As a potential space, it is the site of femoral hernias. The relatively tight neck places these at high risk of strangulation.

6. You decide to take an arterial blood gas from the femoral artery. Where should the needle be inserted to gain the
sample?
A. Mid point of the inguinal ligament
B. Mid inguinal point
C. 2cm inferomedially to the pubic tubercle
D. 2cm superomedially to the pubic tubercle
E. 3cm inferolaterally to the deep inguinal ring

Answer: B

The mid inguinal point in the surface marking for the femoral artery.

7. A 34 year old man is shot in the postero- inferior aspect of his thigh. Which of the following lies at the most lateral
aspect of the popliteal fossa?
A. Popliteal artery
B. Popliteal vein
C. Common peroneal nerve
D. Tibial nerve
E. Small saphenous vein

Answer: C

The contents of the popliteal fossa are (from medial to lateral): Popliteal artery; Popliteal vein; Tibial nerve
Common peroneal nerve
The sural nerve is a branch of the tibial nerve and usually arises at the inferior aspect of the popliteal fossa. However, its anatomy
is variable.

Popliteal fossa
Boundaries of the popliteal fossa
Laterally Biceps femoris above, lateral head of gastrocnemius and plantaris below
Medially Semimembranosus and semitendinosus above, medial head of gastrocnemius below
Floor Popliteal surface of the femur, posterior ligament of knee joint and popliteus muscle
Roof Superficial and deep fascia

Contents

 Popliteal artery and vein

 Small saphenous vein
 Common peroneal nerve
 Tibial nerve
 Posterior cutaneous nerve of the thigh
 Genicular branch of the obturator nerve
 Lymph nodes

8. A 76 year old man complains of symptoms of claudication. The decision is made to measure his ankle brachial
pressure index. The signal from the dorsalis pedis artery is auscultated with a hand held doppler device. This vessel is
the continuation of which of the following?
A. Posterior tibial artery
B. Anterior tibial artery
C. Peroneal artery
D. Popliteal artery
E. None of the above

Answer: B

The dorsalis pedis is a continuation of the anterior tibial artery.

38
Foot- anatomy

Arches of the foot

The foot is conventionally considered to have two arches.

 The longitudinal arch is higher on the medial than on the lateral side. The posterior part of the calcaneum forms a
posterior pillar to support the arch. The lateral part of this structure passes via the cuboid bone and the lateral two
metatarsal bones. The medial part of this structure is more important. The head of the talus marks the summit of this arch,
located between the sustentaculum tali and the navicular bone. The anterior pillar of the medial arch is composed of the
navicular bone, the three cuneiforms and the medial three metatarsal bones.
 The transverse arch is situated on the anterior part of the tarsus and the posterior part of the metatarsus. The cuneiforms
and metatarsal bases narrow inferiorly, which contributes to the shape of the arch.

Intertarsal joints
Sub talar joint Formed by the cylindrical facet on the lower surface of the body of the talus and the posterior facet on
the upper surface of the calcaneus. The facet on the talus is concave anteroposteriorly, the other is
convex. The synovial cavity of this joint does not communicate with any other joint.
Talocalcaneonavicular The anterior part of the socket is formed by the concave articular surface of the navicular bone,
joint posteriorly by the upper surface of the sustentaculum tali. The talus sits within this socket
Calcaneocuboid joint Highest point in the lateral part of the longitudinal arch. The lower aspect of this joint is reinforced by
the long plantar and plantar calcaneocuboid ligaments.
Transverse tarsal joint The talocalcaneonavicular joint and the calcaneocuboid joint extend accross the tarsus in an irregular
transverse plane, between the talus and calcaneus behind and the navicular and cuboid bones in front.
This plane is termed the transverse tarsal joint.
Cuneonavicular joint Formed between the convex anterior surface of the navicular bone and the concave surface of the the
posterior ends of the three cuneiforms.
Intercuneiform joints Between the three cuneiform bones.
Cuneocuboid joint Between the circular facets on the lateral cuneiform bone and the cuboid. This joint contributes to the
tarsal part of the transverse arch.
A detailed knowledge of the joints is not required for MRCS Part A. However, the contribution they play to the overall structure of
the foot should be appreciated

Muscles of the foot

Muscle Origin Insertion Nerve Action
supply
Abductor Medial side of the calcaneus, flexor Medial side of the Medial Abducts the great toe
hallucis retinaculum, plantar aponeurosis base of the proximal plantar
phalanx nerve
Flexor Medial process of the calcaneus, plantar Via 4 tendons into the Medial Flexes all the joints of the
digitorum eponeurosis. middle phalanges of plantar lateral 4 toes except for the
brevis the lateral 4 toes. nerve interphalangeal joint.
Abductor From the tubercle of the calcaneus and from Together with flexor Lateral Abducts the little toe at the
digit the plantar aponeurosis digit minimi brevis plantar metatarsophalangeal joint
minimi into the lateral side of nerve
the base of the
proximal phalanx of
the little toe
Flexor From the medial side of the plantar surface Into the proximal Medial Flexes the metatarsophalangeal
hallucis of the cuboid bone, from the adjacent part of phalanx of the great plantar joint of the great toe.
brevis the lateral cuneiform bone and from the toe, the tendon nerve
tendon of tibialis posterior. contains a sesamoid
bone
Adductor Arises from two heads. The oblique head Lateral side of the Lateral Adducts the great toe towards
hallucis arises from the sheath of the peroneus base of the proximal plantar the second toe. Helps maintain
longus tendon, and from the plantar surfaces phalanx of the great nerve the transverse arch of the foot.
of the bases of the 2nd, 3rd and 4th toe.
metatarsal bones. The transverse head arises
from the plantar surface of the lateral 4
metatarsophalangeal joints and from the
deep transverse metatarsal ligament.
Extensor On the dorsal surface of the foot from the Via four thin tendons Deep Extend the
digitorum upper surface of the calcaneus and its which run forward peroneal metatarsophalangeal joint of
39
brevis associated fascia and medially to be the medial four toes. It is
inserted into the unable to extend the
medial four toes. The interphalangeal joint without
lateral three tendons the assistance of the lumbrical
join with hoods of muscles.
extensor digitorum
longus.

Detailed knowledge of the foot muscles are not needed for the MRCS part A

Nerves in the foot

Lateral plantar nerve

Passes anterolaterally towards the base of the 5th metatarsal between flexor digitorum brevis and flexor accessorius. On the
medial aspect of the lateral plantar artery. At the base of the 5th metatarsal it splits into superficial and deep branches.

Medial plantar nerve

Passes forwards with the medial plantar artery under the cover of the flexor retinaculum to the interval between abductor hallucis
and flexor digitorum brevis on the sole of the foot.

Plantar arteries
Arise under the cover of the flexor retinaculum, midway between the tip of the medial malleolus and the most prominent part of
the medial side of the heel.

 Medial plantar artery. Passes forwards medial to medial plantar nerve in the space between abductor hallucis and flexor
digitorum brevis.Ends by uniting with a branch of the 1st plantar metatarsal artery.
 Lateral plantar artery. Runs obliquely across the sole of the foot. It lies lateral to the lateral plantar nerve. At the base of
the 5th metatarsal bone it arches medially across the foot on the metatarsals

Dorsalis pedis artery

This vessel is a direct continuation of the anterior tibial artery. It commences on the front of the ankle joint and runs to the
proximal end of the first metatarsal space. Here is gives off the arcuate artery and continues forwards as the first dorsal metatarsal
artery. It is accompanied by two veins throughout its length. It is crossed by the extensor hallucis brevis

9. A 67 year old man is due to undergo a revisional total hip replacement using a posterior approach. After dividing
gluteus maximus in the line of its fibres there is brisk arterial bleeding. Which of the following vessels is likely to be
responsible?
A. Profunda femoris artery
B. External iliac artery
C. Internal iliac artery
D. Obturator artery
E. Inferior gluteal artery

Answer: E

The inferior gluteal artery runs on the deep surface of the gluteus maximus muscle. It is a branch of the internal iliac artery. It is
commonly divided during the posterior approach to the hip joint.

Hip joint

 Head of femur articulates with acetabulum of the pelvis

 Both covered by articular hyaline cartilage
 The acetabulum forms at the union of the ilium, pubis, and ischium
 The triradiate cartilage (Y-shaped growth plate) separates the pelvic bones
 The acetabulum holds the femoral head by the acetabular labrum
 Normal angle between femoral head and femoral shaft is 130o

Ligaments

40
  Transverse ligament: joints anterior and posterior ends of the articular cartilage
 Head of femur ligament (ligamentum teres): acetabular notch to the fovea. Contains arterial supply to head of femur in
children.

Extracapsular ligaments

 Iliofemoral ligament: inverted Y shape. Anterior iliac spine to the trochanteric line
 Pubofemoral ligament: acetabulum to lesser trochanter
 Ischiofemoral ligament: posterior support. Ischium to greater trochanter.

Blood supply
Medial circumflex femoral and lateral circumflex femoral arteries (Branches of profunda femoris)

2 anastomoses: Cruciate and the trochanteric anastomoses (provides most of the blood to the head of the femur) Hence the need
for hemiarthroplasty when there is a displaced femoral head fracture. These anastomoses exist between the femoral artery or
profunda femoris and the gluteal vessels.

10. Which of the following nerves passes through the greater and lesser sciatic foramina?
A. Pudendal nerve
B. Sciatic nerve
C. Superior gluteal nerve
D. Inferior gluteal nerve
E. Posterior cutaneous nerve of the thigh
Answer: A
Structures passing through the lesser and greater sciatic foramina (medial to lateral): PIN

 Pudendal nerve
 Internal pudendal artery
 Nerve to obturator internus

The pudendal nerve originates from the ventral rami of the second, third, and fourth sacral nerves (S2, S3, S4). It passes between
the piriformis and coccygeus muscles and exits the pelvis through the the greater sciatic foramen. It crosses the spine of the
ischium and reenters the pelvis through the lesser sciatic foramen. It passes through the pudendal canal. The pudendal nerve gives
off the inferior rectal nerves. It terminates into 2 branches: perineal nerve, and the dorsal nerve of the penis or the dorsal nerve of
the clitoris.

Greater sciatic foramen

Contents
Nerves  Sciatic Nerve
 Superior and Inferior Gluteal Nerves
 Internal Pudendal Nerve
 Posterior Femoral Cutaneous Nerve
 Nerve to Quadratus Femoris
 Nerve to Obturator internus

Vessels  Superior Gluteal Artery and vein

 Inferior Gluteal Artery and vein
 Internal Pudendal Artery and vein

Piriformis
The piriformis is a landmark for identifying structures passing out of the sciatic notch

 Above piriformis: Superior gluteal vessels

 Below piriformis: Inferior gluteal vessels, sciatic nerve (10% pass through it, <1% above it) and posterior cutaneous
nerve of the thigh

41
Greater sciatic foramen boundaries
Anterolaterally Greater sciatic notch of the ilium
Posteromedially Sacrotuberous ligament
Inferior Sacrospinous ligament and the ischial spine
Superior Anterior sacroiliac ligament

Contents of the lesser sciatic foramen

 Tendon of the obturator internus

 Pudendal nerve
 Internal pudendal artery and vein
 Nerve to the obturator internus

11. A 65 year old man with long standing atrial fibrillation develops an embolus to the lower leg. The decision is made to
perform an embolectomy, utilising a trans popliteal approach. After incising the deep fascia, which of the following
structures will the surgeons encounter first on exploring the central region of the popliteal fossa?
A. Popliteal vein
B. Common peroneal nerve
C. Popliteal artery
D. Tibial nerve
E. None of the above

Answer: D
The tibial nerve lies superior to the vessels in the inferior aspect of the popliteal fossa. In the upper part of the fossa the tibial
nerve lies lateral to the vessels, it then passes superficial to them to lie medially. The popliteal artery is the deepest structure in the
popliteal fossa.

12. A 43 year old lady presents with varicose veins and undergoes a saphenofemoral disconnection, long saphenous vein
stripping to the ankle and isolated hook phlebectomies. Post operatively she notices an area of numbness superior to
her ankle. What is the most likely cause for this?
A. Sural nerve injury
B. Femoral nerve injury
C. Saphenous nerve injury
D. Common peroneal nerve injury
E. Superficial peroneal nerve injury

Answer: C

The sural nerve is related to the short saphenous vein. The saphenous nerve is related to the long saphenous vein below the knee
and for this reason full length stripping of the vein is no longer advocated.

Saphenous vein

Long saphenous vein

This vein may be harvested for triple or quadruple bypass surgery

 Originates at the 1st digit where the dorsal vein merges with the dorsal venous arch of the foot
 Passes anterior to the medial malleolus and runs up the medial side of the leg
 At the knee, it runs over the posterior border of the medial epicondyle of the femur bone
 Then passes laterally to lie on the anterior surface of the thigh before entering an opening in the fascia lata called the
saphenous opening
 It joins with the femoral vein in the region of the femoral triangle at the saphenofemoral junction

Tributaries

 Medial marginal, superficial epigastric, superficial iliac circumflex and superficial external pudendal veins

42
Short saphenous vein

 Originates at the 5th digit where the dorsal vein merges with the dorsal venous arch of the foot, which attaches to the
great saphenous vein.
 It passes around the lateral aspect of the foot (inferior and posterior to the lateral malleolus) and runs along the posterior
aspect of the leg (with the sural nerve)
 Passes between the heads of the gastrocnemius muscle, and drains into the popliteal vein, approximately at or above the
level of the knee joint.

13. A 34 year old man undergoes excision of a sarcoma from the right buttock. During the procedure the sciatic nerve is
sacrificed. Which of the following will not occur as a result of this process?
A. Loss of extension at the knee joint
B. Foot drop
C. Inability to extend extensor hallucis longus
D. Loss of sensation to the posterior aspect of the thigh
E. Loss of sensation to the posterior aspect of the lower leg

Answer: A

Extension of the knee joint is caused by the obturator and femoral nerves.

Sciatic nerve

Origin Spinal nerves L4 - S3

Articular Branches Hip joint
Muscular branches in upper leg  Semitendinosus
 Semimembranosus
 Biceps femoris
 Part of adductor magnus

Cutaneous sensation  Posterior aspect of thigh

 Gluteal region
 Entire lower leg (except the medial aspect)

Terminates At the upper part of the popliteal fossa by dividing into the tibial and peroneal nerves

 The nerve to the short head of the biceps femoris comes from the common peroneal part of the sciatic and the other
muscular branches arise from the tibial portion.
 The tibial nerve goes on to innervate all muscles of the foot except the extensor digitorum brevis (which is innervated by
the common peroneal nerve).

14. A 24 year old lady is stabbed in the buttock. Following the injury the wound is sutured in the emergency department.
Eight weeks later she attends the clinic, as she walks into the clinic room she has a waddling gait and difficulty with
thigh abduction. On examination she has buttock muscle wasting. Which nerve has been injured?
A. Superior gluteal nerve
B. Obturator nerve
C. Sciatic nerve
D. Femoral nerve
E. Inferior gluteal nerve
Answer: A

Damage to the superior gluteal nerve will result in a Trendelenberg gait.

Trendelenberg test
Injury or division of the superior gluteal nerve results in a motor deficit that consists of weakened abduction of the thigh by
gluteus medius, a disabling gluteus medius limp and a compensatory list of the body weakened gluteal side. The compensation
results in a gravitational shift so that the body is supported on the unaffected limb.
When a person is asked to stand on one leg the gluteus medius usually contracts as soon as the contralateral leg leaves the floor,
preventing the pelvis from dipping towards the unsupported side. When a person with paralysis of the superior gluteal nerve is
43
asked to stand on one leg, the pelvis on the unsupported side descends, indicating that the gluteus medius on the affected side is
weak or non functional ( a positive Trendelenberg test).

15. A 73 year old lady presents with symptoms of faecal incontinence. On examination she has weak anal sphincter
muscles. What are the main nerve root values of the nerves supplying the external anal sphincter?
A. S2,3
B. L5, S1
C. S4,5
D. S5
E. S2,3,4
Answer: E
The external anal sphincter is innervated by the inferior rectal branch of the pudendal nerve, this has root values of S2, 3 and the
perineal branch of S4.

Anal sphincter

 Internal anal sphincter composed of smooth muscle continuous with the circular muscle of the rectum. It surrounds the
upper two- thirds of the anal canal and is supplied by sympathetic nerves.
 External anal sphincter is composed of striated muscle which surrounds the internal sphincter but extends more distally.
 The nerve supply of the external anal sphincter is from the inferior rectal branch of the pudendal nerve (S2 and S3) and
the perineal branch of the S4 nerve roots.

16. A 72 year old man has a fall. He is found to have a fractured neck of femur and goes on to have a left hip
hemiarthroplasty. Two months post operatively he is found to have an odd gait. When standing on his left leg his
pelvis dips on the right side. There is no foot drop. What is the cause?
A. Sciatic nerve damage
B. L5 radiculopathy
C. Inferior gluteal nerve damage
D. Previous poliomyelitis
E. Superior gluteal nerve damage

Answer: E

This patient has a trendelenburg gait caused by damage to the superior gluteal nerve causing weakness of the abductor muscles.
Classically a patient is asked to stand on one leg and the pelvis dips on the opposite side. The absence of a foot drop excludes the
possibility of polio or L5 radiculopathy.

Gluteal region

Gluteal muscles

 Gluteus maximus: inserts to gluteal tuberosity of the femur and iliotibial tract
 Gluteus medius: attach to lateral greater trochanter
 Gluteus minimis: attach to anterior greater trochanter
 All extend and abduct the hip

Deep lateral hip rotators

 Piriformis
 Gemelli
 Obturator internus
 Quadratus femoris

Nerves
Superior gluteal nerve (L5, S1)  Gluteus medius
 Gluteus minimis
 Tensor fascia lata

Inferior gluteal nerve Gluteus maximus

44
Damage to the superior gluteal nerve will result in the patient developing a Trendelenberg gait. Affected patients are unable to
abduct the thigh at the hip joint. During the stance phase, the weakened abductor muscles allow the pelvis to tilt down on the
opposite side. To compensate, the trunk lurches to the weakened side to attempt to maintain a level pelvis throughout the gait
cycle. The pelvis sags on the opposite side of the lesioned superior gluteal nerve.

17. Which of the following structures lies posterior to the femoral nerve in the femoral triangle?
A. Adductor longus
B. Pectineus
C. Psoas major
D. Iliacus
E. None of the above
Answer: D

The iliacus lies posterior to the femoral nerve in the femoral triangle. The femoral sheath lies anterior to the iliacus and pectineus
muscles.

Femoral nerve

Root values L2, 3, 4

Innervates  Pectineus
 Sartorius
 Quadriceps femoris
 Vastus lateralis/medialis/intermedius

Branches  Medial cutaneous nerve of thigh

 Saphenous nerve
 Intermediate cutaneous nerve of thigh

Path
Penetrates psoas major and exits the pelvis by passing under the inguinal ligament to enter the femoral triangle, lateral to the
femoral artery and vein.

Mnemonic for femoral nerve supply

(don't) M I S V Q Scan for PE

M edial cutaneous nerve of the thigh
I ntermediate cutaneous nerve of the thigh
S aphenous nerve
V astus
Q uadriceps femoris
S artorius
PE ectineus

18. Which of the following ligaments contains the artery supplying the head of femur in children?
A.Transverse ligament
B. Ligamentum teres
C. Iliofemoral ligament
D.Ischiofemoral ligament
E. Pubofemoral ligament

Answer: B

19. A 68 year old man with critical limb ischaemia is undergoing a femoro-distal bypass graft. During mobilisation of the
proximal part of the posterior tibial artery which of the following is at greatest risk of injury?
A. Tibial nerve
B. Sciatic nerve
C. Saphenous nerve
D. Common peroneal nerve
E. Medial superior genicular artery
45
 Answer: A

The tibial nerve is closely related to the posterior tibial artery. The tibial nerve crosses the vessel posteriorly approximately 2.5cm
distal to its origin. At its origin the nerve lies medial and then lateral after it crosses the vessel as described.

Posterior tibial artery

 Larger terminal branch of the popliteal artery

 Terminates by dividing into the medial and lateral plantar arteries
 Accompanied by two veins throughout its length
 Position of the artery corresponds to a line drawn from the lower angle of the popliteal fossa, at the level of the neck of
the fibula, to a point midway between the medial malleolus and the most prominent part of the heel

Relations of the posterior tibial artery

Proximal to distal
Anteriorly Tibialis posterior
Flexor digitorum longus
Posterior surface of tibia and ankle joint
Posterior Tibial nerve 2.5 cm distal to its origin
Fascia overlying the deep muscular layer
Proximal part covered by gastrocnemius and soleus
Distal part covered by skin and fascia

20. Which of the following structures lies deepest in the popliteal fossa?
A. Popliteal artery
B. Popliteal vein
C. Tibial nerve
D. Common peroneal nerve
E. Popliteal lymph nodes

Answer: A
From superficial to deep:
The common peroneal nerve exits the popliteal fossa along the medial border of the biceps tendon. Then the tibial nerve lies
lateral to the popliteal vessels to pass posteriorly and then medially to them. The popliteal vein lies superficial to the popliteal
artery, which is the deepest structure in the fossa.

21. An intravenous drug user develops a false aneurysm and requires emergency surgery. The procedure is difficult and
the femoral nerve is inadvertently transected. Which of the following muscles is least likely to be affected as a result?
A. Sartorius
B. Vastus medialis
C. Pectineus
D. Quadriceps femoris
E. Adductor magnus
Answer: E

Adductor magnus is innervated by the obturator and sciatic nerve. The pectineus muscle is sometimes supplied by the obturator
nerve but this is variable. Since the question states least likely, the correct answer is adductor magnus

22. Which of the following structures does not pass posteriorly to the medial malleolus?
A. Posterior tibial artery
B. Tibial nerve
C. Tibialis anterior tendon
D. Tendon of flexor digitorum longus
E. Tendon of flexor hallucis longus
Answer: C

Mnemonic for structures posterior to the medial malleolus: Tom Dick And Nervous Harry: T ibialis posterior tendon; flexor
Digitorum longus; A rtery; N erve; H allucis longus

46
Medial malleolus

The following structures pass posterior to medial malleolus (in order):

 Tibialis posterior tendon

 Flexor digitorum longus tendon
 Posterior tibial artery
 Tibial nerve
 Tendon of flexor hallucis longus

23. A 44 year old man has a malignant melanoma and is undergoing a block dissection of the groin. The femoral triangle
is being explored for intra operative bleeding. Which of the following forms the medial border of the femoral triangle?
A. Femoral artery
B. Biceps femoris
C. Adductor longus
D. Sartorius
E. Adductor magnus
Answer: C

Vastus medialis forms the lateral border of the adductor canal. The sartorius muscles forms the roof of the adductor canal.
Adductor longus forms the medial boundary of the femoral triangle (see below).

24. The foramen marking the termination of the adductor canal is located in which of the following?
A.Adductor longus
B. Adductor magnus
C. Adductor brevis
D.Sartorius
E. Semimembranosus
Answer: B

The foramen marking the distal limit of the adductor canal is contained within adductor magnus. The vessel passes through this
region to enter the popliteal fossa.

Adductor canal

 Also called Hunter's or subsartorial canal

 Immediately distal to the apex of the femoral triangle, lying in the middle third of the thigh. Canal terminates at the
adductor hiatus.

Contents

 Saphenous nerve
 Superficial femoral artery
 Superficial femoral vein

Borders
Laterally Vastus medialis muscle
Posteriorly Adductor longus, adductor magnus
Roof Sartorius

25. A 24 year old motor cyclist is involved in a road traffic accident. He suffers a tibial fracture which is treated with an
intra medullary nail. Post operatively he develops a compartment syndrome. Surgical decompression of the anterior
compartment will relieve pressure on all of the following muscles except?
A. Peroneus brevis
B. Peroneus tertius
C. Extensor digitorum longus
D. Tibialis anterior
E. None of the above
47
 Answer: A
The anterior compartment contains: Tibialis anterior, Extensor digitorum longus, Peroneus tertius, Extensor hallucis longus,
Anterior tibial artery, All the muscles are innervated by the deep peroneal nerve.

26. A 42 year old lady is reviewed in the outpatient clinic following a routine surgical procedure. She complains of
diminished sensation at the lateral aspect of her foot. Which of the following nerves is likely to be affected?
A. Sural
B. Superficial peroneal
C. Deep peroneal
D. Medial plantar
E. Lateral Plantar

Answer: A

The sural nerve supplies the lateral aspect of the foot. It runs alongside the short saphenous vein and may be injured in short
saphenous vein surgery.

Foot- Cutaneous sensation

Region Nerve
Lateral plantar Sural
Dorsum (not 1st web space) Superficial peroneal
1st Web space Deep peroneal
Extremities of toes Medial and lateral plantar nerves
Proximal plantar Tibial
Medial plantar Medial plantar nerve
Lateral plantar Lateral plantar nerve

27. A sprinter attends A&E with severe leg pain. He had forgotten to warm up and ran a 100m sprint race. Towards the
end of the race he experienced pain in the posterior aspect of his thigh. The pain worsens, localising to the lateral
aspect of the knee. The sprinter is unable to flex the knee. What structure has been injured?
A.Anterior cruciate ligament
B. Posterior cruciate ligament
C. Semimembranosus tendon
D.Semiteninosus tendon
E. Biceps femoris tendon

Answer: E
The biceps femoris is commonly injured in sports that require explosive bending of the knee as seen in sprinting, especially if the
athlete has not warmed up first. Avulsion most commonly occurs where the long head attaches to the ischial tuberosity. Injuries to
biceps femoris are more common than to the other hamstrings.

Biceps femoris

The biceps femoris is one of the hamstring group of muscles located in the posterior upper thigh. It has two heads.

Long head

Origin Ischial tuberosity

Insertion Fibular head
Action Knee flexion, lateral rotation tibia, extension hip
Innervation Tibial nerve (L5, S1, S2)
Arterial supply Profunda femoris artery, inferior gluteal artery, and the superior muscular branches of popliteal artery

Short head

Origin Lateral lip of linea aspera, lateral supracondylar ridge of femur

Insertion Fibular head
Action Knee flexion, lateral rotation tibia
Innervation Common peroneal nerve (L5, S1, S2)
Arterial supply Profunda femoris artery, inferior gluteal artery, and the superior muscular branches of popliteal artery

48
28. The sciatic nerve lies deep to the following structures except:
A. Gluteus maximus
B. The femoral cutaneous nerve
C. Long head of biceps femoris
D. Gluteus medius
E. Branch of the inferior gluteal artery

Answer: D

The gluteus medius does not extend around to the sciatic nerve.

Sciatic nerve

Origin Spinal nerves L4 - S3

Articular Branches Hip joint
Muscular branches in upper leg  Semitendinosus
 Semimembranosus
 Biceps femoris
 Part of adductor magnus

Cutaneous sensation  Posterior aspect of thigh

 Gluteal region
 Entire lower leg (except the medial aspect)

Terminates At the upper part of the popliteal fossa by dividing into the tibial and peroneal nerves

 The nerve to the short head of the biceps femoris comes from the common peroneal part of the sciatic and the other
muscular branches arise from the tibial portion.
 The tibial nerve goes on to innervate all muscles of the foot except the extensor digitorum brevis (which is innervated by
the common peroneal nerve).

29. A 72 year old lady is suspected of having a femoral hernia. At which of the following sites is it most likely to be
identifiable clinically?
A.Mid inguinal point
B. Above and medial to the pubic tubercle
C. Below and lateral to the pubic tubercle
D.Mid point of the inguinal ligament
E. 3 cm superomedially to the superficial inguinal ring

Answer: C

Femoral hernias exit the femoral canal below and lateral to the pubic tubercle. Femoral hernia occur mainly in women due to their
difference in pelvic anatomy. They are at high risk of strangulation and therefore should be repaired.

30. Which of the following represents the root values of the sciatic nerve?
A. L4 to S3
B. L1 to L4
C. L3 to S1
D. S1 to S4
E. L5 to S1
Answer: A

31. The common peroneal nerve, or its branches, supply the following muscles except:
A. Peroneus longus
B. Tibialis anterior
C. Extensor hallucis longus
D. Flexor digitorum brevis
E. Extensor digitorum longus
Answer: D
49
Flexor digitorum is supplied by the tibial nerve.

Common peroneal nerve

Derived from the dorsal divisions of the sacral plexus (L4, L5, S1 and S2).

This nerve supplies the skin and fascia of the anterolateral surface of the leg and the dorsum of the foot. It also innervates the
muscles of the anterior and peroneal compartments of the leg, extensor digitorum brevis as well as the knee, ankle and foot joints.

It is laterally placed within the sciatic nerve. From the bifurcation of the sciatic nerve it passes inferolaterally in the lateral and
proximal part of the popliteal fossa, under the cover of biceps femoris and its tendon. To reach the posterior aspect of the fibular
head. It ends by dividing into the deep and superficial peroneal nerves at the point where it winds around the lateral surface of the
neck of the fibula in the body of peroneus longus, approximately 2cm distal to the apex of the head of the fibula. It is palpable
posterior to the head of the fibula.

Branches
In the thigh Nerve to the short head of biceps
Articular branch (knee)
In the popliteal fossa Lateral cutaneous nerve of the calf
Neck of fibula Superficial and deep peroneal nerves

32. An 83 year old lady presents with a femoral hernia and undergoes a femoral hernia repair. Which of the following
forms the posterior wall of the femoral canal?
A.Pectineal ligament
B. Lacunar ligament
C. Inguinal ligament
D.Adductor longus
E. Sartorius

Answer: A

33. Which of the following structures does not pass behind the lateral malleolus?
A. Peroneus brevis tendon
B. Sural nerve
C. Short saphenous vein
D. Peroneus longus tendon
E. Tibialis anterior tendon
Answer: E
Tibialis anterior tendon passes at the medial malleolus.

Structures posterior to the lateral malleolus and superficial to superior peroneal retinaculum: sural nerve and short
saphenous vein
Structures posterior to the lateral malleolus and deep to superior peroneal retinaculum:peroneus longus tendon and
peroneus brevis tendon

The calcaneofibular ligament is attached at the lateral malleolus

34. Theme: Nerve lesions

A. Iliohypogastric nerve
B. Ilioinguinal nerve
C. Lateral cutaneous nerve of the thigh
D. Femoral nerve
E. Saphenous nerve
F. Genitofemoral nerve

Please select the most likely nerve implicated in the situation described. Each option may be used once, more than once or not at
all.

50
A 42 year old woman complains of a burning pain of her anterior thigh which worsens on walking. There is a positive tinel
sign over the inguinal ligament.
Answer: Lateral cutaneous nerve of the thigh

The lateral cutaneous nerve supplies sensation to the anterior and lateral aspect of the thigh. Entrapment is commonly due to intra
and extra pelvic causes. Treatment involves local anaesthetic injections.

A 29 year old woman has had a Pfannenstiel incision. She has pain over the inguinal ligament which radiates to the lower
abdomen. There is tenderness when the inguinal canal is compressed.

Answer: Ilioinguinal nerve

A 22 year man is shot in the groin. On examination he has weak hip flexion, weak knee extension, and impaired
quadriceps tendon reflex, as well as sensory deficit in the anteromedial aspect of the thigh.

Answer: Femoral nerve

This is a classical description of a femoral nerve injury.

Nerve lesions during surgery

A variety of different procedures carry the risk of iatrogenic nerve injury. These are important not only from the patients
perspective but also from a medicolegal standpoint.

The following operations and their associated nerve lesions are listed here:

 Posterior triangle lymph node biopsy and accessory nerve lesion.

 Lloyd Davies stirrups and common peroneal nerve.
 Thyroidectomy and laryngeal nerve.
 Anterior resection of rectum and hypogastric autonomic nerves.
 Axillary node clearance; long thoracic nerve, thoracodorsal nerve and intercostobrachial nerve.
 Inguinal hernia surgery and ilioinguinal nerve.
 Varicose vein surgery- sural and saphenous nerves.
 Posterior approach to the hip and sciatic nerve.
 Carotid endarterectomy and hypoglossal nerve.

There are many more, with sound anatomical understanding of the commonly performed procedures the incidence of nerve lesions
can be minimised. They commonly occur when surgeons operate in an unfamiliar tissue plane or by blind placement of
haemostats (not recommended).

35. A 23 year old man is stabbed in the groin, several structures are injured and the adductor longus muscle has been
lacerated. Which of the following nerves is responsible for the innervation of adductor longus?
A.Femoral nerve
B. Obturator nerve
C. Sciatic nerve
D.Common peroneal nerve
E. Ilioinguinal nerve
Answer: B

The adductors are innervated by the obturator nerve

Adductor longus
Origin Anterior body of pubis
Insertion Middle third of linea aspera
Action Adducts and flexes the thigh, medially rotate the hip
Innervation Anterior division of obturator nerve (L2, L3, L4)

36. Which of the following muscles does not recieve any innervation from the sciatic nerve?
A. Semimembranosus
B. Quadriceps femoris
C. Biceps femoris
D. Semitendinosus
51
 E. Adductor magnus
Answer: B

The sciatic nerve is traditionally viewed as being a nerve of the posterior compartment. It is known to contribute to the innervation
of adductor magnus (although the main innervation to this muscle is from the obturator nerve). The quadriceps femoris is nearly
always innervated by the femoral nerve.

37. The following are true of the femoral nerve except:

A. It is derived from L2, L3 and L4 nerve roots
B. It supplies sartorius
C. It supplies quadriceps femoris
D. It gives cutaneous innervations via the saphenous nerve
E. It supplies adductor longus
Answer: E

Adductor longus is supplied by the obturator nerve.

38. Which of the following is true in relation to the sartorius muscle?

A. Innervated by the deep branch of the femoral nerve
B. Inserts at the fibula
C. It is the shortest muscle in the body
D. Forms the Pes anserinus with Gracilis and semitendinous muscle
E. Causes extension of the knee
Answer: D

It is innervated by the superficial branch of the femoral nerve. It is a component of the pes anserinus.

Sartorius

 Longest strap muscle in the body

 Most superficial muscle in the anterior compartment of the thigh

Origin Anterior superior iliac spine

Insertion Medial surface of the of the body of the tibia (upper part). It inserts anterior to gracilis and semitendinosus
Nerve Supply Femoral nerve (L2,3)
Action  Flexor of the hip and knee, slight abducts the thigh and rotates it laterally
 It assists with medial rotation of the tibia on the femur. For example it would play a pivotal role in
placing the right heel onto the left knee ( and vice versa)

Important The middle third of this muscle, and its strong underlying fascia forms the roof of the adductor canal , in which
relations lie the femoral vessels, the saphenous nerve and the nerve to vastus medialis.

39. Theme: Nerve lesions

A. Sciatic nerve
B. Peroneal nerve
C. Tibial Nerve
D. Obturator nerve
E. Ilioinguinal nerve
F. Femoral nerve
G. None of the above

Please select the most likely nerve injury for the scenario given. Each option may be used once, more than once or not at all

A 56 year old man undergoes a low anterior resection with legs in the Lloyd-Davies position. Post operatively he complains
of foot drop.
Answer: Peroneal nerve
Positioning legs in Lloyd- Davies stirrups can carry the risk of peroneal nerve neuropraxia if not done carefully.

52
A 23 year old man complains of severe groin pain several weeks after a difficult inguinal hernia repair.
Answer: Ilioinguinal nerve
The ilioinguinal nerve may have been entrapped in the mesh causing a neuroma.
A 72 year old man develops a foot drop after a revision total hip replacement.
Answer: Sciatic nerve
This may be done by a number of approaches, in this scenario a posterior approach is the most likely culprit.

40. Which muscle is supplied by the superficial peroneal nerve?

A. Peroneus tertius
B. Sartorius
C. Adductor magnus
D. Peroneus brevis
E. Gracilis
Answer: D
Superficial peroneal nerve

Supplies

 Lateral compartment of leg: peroneus longus, peroneus brevis (action: eversion and plantar flexion)
 Sensation over dorsum of the foot (except the first web space, which is innervated by the deep peroneal nerve)

Path

 Passes between peroneus longus and peroneus brevis along the length of the proximal one third of the fibula
 10-12 cm above the tip of the lateral malleolus, the superficial peroneal nerve pierces the fascia
 6-7 cm distal to the fibula, the superficial peroneal nerve bifurcates into intermediate and medial dorsal cutaneous nerves

41. Which of the following structures separates the posterior cruciate ligament from the popliteal artery?
A.Oblique popliteal ligament
B. Transverse ligament
C. Popliteus tendon
D.Biceps femoris
E. Semitendinosus
Answer: A

The posterior cruciate ligament is separated from the popliteal vessels at its origin by the oblique popliteal ligament. The
transverse ligament is located anteriorly.

Knee joint

The knee joint is a synovial joint, the largest and most complicated. It consists of two condylar joints between the femure and tibia
and a sellar joint between the patella and the femur. The tibiofemoral articular surfaces are incongruent, however, this is improved
by the presence of the menisci. The degree of congruence is related to the anatomical position of the knee joint and is greatest in
full extension.

Knee joint compartments

Tibiofemoral  Comprise of the patella/femur joint, lateral and medial compartments (between femur condyles and
tibia)
 Synovial membrane and cruciate ligaments partially separate the medial and lateral compartments

Patellofemoral  Ligamentum patellae

 Actions: provides joint stability in full extension

53
Fibrous capsule
The capsule of the knee joint is a complex, composite structure with contributions from adjacent tendons.

Anterior The capsule does not pass proximal to the patella. It blends with the tendinous expansions of vastus medialis
fibres and lateralis
Posterior These fibres are vertical and run from the posterior surface of the femoral condyles to the posterior aspect of the
fibres tibial condyle
Medial fibres Attach to the femoral and tibial condyles beyond their articular margins, blending with the tibial collateral
ligament
Lateral fibres Attach to the femur superior to popliteus, pass over its tendon to head of fibula and tibial condyle

Bursae

Anterior  Subcutaneous prepatellar bursa; between patella and skin

 Deep infrapatellar bursa; between tibia and patellar ligament
 Subcutaneous infrapatellar bursa; between distal tibial tuberosity and skin

Laterally  Bursa between lateral head of gastrocnemius and joint capsule

 Bursa between fibular collateral ligament and tendon of biceps femoris
 Bursa between fibular collateral ligament and tendon of popliteus

Medially  Bursa between medial head of gastrocnemius and the fibrous capsule
 Bursa between tibial collateral ligament and tendons of sartorius, gracilis and semitendinosus
 Bursa between the tendon of semimembranosus and medial tibial condyle and medial head of gastrocnemius

Posterior Highly variable and inconsistent

Ligaments

 Medial collateral ligament: Medial epicondyle femur to medial tibial condyle: valgus stability
 Lateral collateral ligament: Lateral epicondyle femur to fibula head: varus stability
 Anterior cruciate ligament: Anterior tibia to lateral intercondylar notch femur: prevents tibia sliding anteriorly
 Posterior cruciate ligament: Posterior tibia to medial intercondylar notch femur: prevents tibia sliding posteriorly
 Patellar ligament: Central band of the tendon of quadriceps femoris, extends from patella to tibial tuberosity

Menisci
Medial and lateral menisci compensate for the incongruence of the femoral and tibial condyles.
Composed of fibrous tissue.
Medial meniscus is attached to the tibial collateral ligament.
Lateral meniscus is attached to the loose fibres at the lateral edge of the joint and is separate from the fibular collateral ligament.
The lateral meniscus is crossed by the popliteus tendon.

Nerve supply
The knee joint is supplied by the femoral, tibial and common peroneal divisions of the sciatic and by a branch from the obturator
nerve. Hip pathology pain may be referred to the knee.

Blood supply
Genicular branches of the femoral artery, popliteal and anterior tibial arteries all supply the knee joint.

42. A 25 year old man undergoes an excision of a pelvic chondrosarcoma, during the operation the obturator nerve is
sacrificed. Which of the following muscles is least likely to be affected as a result?
A. Adductor longus
B. Pectineus
C. Adductor magnus
D. Sartorius
E. Gracilis
Answer: D

Sartorius is supplied by the femoral nerve. In approximately 20% of the population, pectineus is supplied by the accessory
obturator nerve.

54
43. Which nerve supplies the 1st web space of the foot?
A. Popliteal nerve
B. Superficial peroneal nerve
C. Deep peroneal nerve
D. Tibial nerve
E. Saphenous nerve
Answer: C
The first web space is innervated by the deep peroneal nerve.
44. Which of the following structures does not pass behind the piriformis muscle in the greater sciatic foramen?
A.Sciatic nerve
B. Posterior cutaneous nerve of the thigh
C. Inferior gluteal artery
D.Obturator nerve
E. None of the above
Answer: D
The obturator nerve does not pass through the greater sciatic foramen.

45. A 78 year old lady falls over in her nursing home and sustains a displaced intracapsular fracture of the femoral neck.
A decision is made to perform a hemi arthroplasty through a lateral approach. Which of the following vessels will be
divided to facilitate access?
A.Saphenous vein
B. Superior gluteal artery
C. Superficial circumflex iliac artery
D.Profunda femoris artery
E. Transverse branch of the lateral circumflex artery
Answer: E
During the Hardinge style lateral approach the transverse branch of the lateral circumflex artery is divided to gain access.

46. A 72 year old lady with osteoporosis falls and sustains an intracapsular femoral neck fracture. The fracture is
completely displaced. Which of the following vessels is the main contributor to the arterial supply of the femoral head?
A.Deep external pudendal artery
B. Superficial femoral artery
C. External iliac artery
D.Circumflex femoral arteries
E. Superficial external pudendal artery
Answer: D

The vessels which form the anastomoses around the femoral head are derived from the medial and lateral circumflex femoral
arteries. These are usually derived from the profunda femoris artery.

47. The following statements relating to the ankle joint are true except?
A. Three groups of ligaments provide mechanical stability
B. The sural nerve lies medial to the Achilles tendon at its point of insertion
C. Eversion of the foot occurs at the sub talar joint
D. The flexor hallucis longus tendon is the most posterior structure at the medial malleolus
E. The saphenous nerve crosses the ankle joint.

Answer: B

The sural nerve lies behind the distal fibula. Inversion and eversion are sub talar movements. The structures passing behind the
medial malleolus from anterior to posterior include: tibialis posterior, flexor digitorum longus, posterior tibia vein, posterior tibial
artery, nerve, flexor hallucis longus.

Ankle joint: The ankle joint is a synovial joint composed of the tibia and fibula superiorly and the talus inferiorly.

Ligaments of the ankle joint

 Deltoid ligament (medially)

55
  Lateral collateral ligament
 Talofibular ligaments (both anteriorly and posteriorly)

The calcaneofibular ligament is separate from the fibrous capsule of the joint. The two talofibular ligaments are fused with it.

The components of the syndesmosis are

 Antero-inferior talofibular ligament

 Postero-inferior talofibular ligament
 Inferior transverse talofibular ligament
 Interosseous ligament

Movements at the ankle joint

 Plantar flexion (55 degrees)

 Dorsiflexion (35 degrees)
 Inversion and eversion movements occur at the level of the sub talar joint

Nerve supply: Branches of deep peroneal and tibial nerves.

48. A 19 year old man is playing rugby when he suddenly notices a severe pain at the posterolateral aspect of his right
thigh. Which of the following muscle groups is most likely to have been injured?
A.Semimembranosus
B. Semitendinosus
C. Long head of biceps femoris
D.Gastrocnemius
E. Soleus
Answer: C

The biceps femoris is the laterally located hamstring muscle. The semitendinosus and semimembranosus are located medially.
Rupture of gastrocnemius and soleus may occur but is less common.

49. A 22 year old man is involved in a fight and is stabbed in the posterior aspect of his right leg. The knife passes into the
popliteal fossa. He sustains an injury to his tibial nerve. Which of the following muscles is least likely to be
compromised as a result?
A. Tibialis posterior
B. Flexor hallucis longus
C. Flexor digitorum brevis
D. Soleus
E. Peroneus tertius
Answer: E

Peroneus tertius is innervated by the deep peroneal nerve.

Tibial nerve
Begins at the upper border of the popliteal fossa and is a branch of the sciatic nerve. Root values: L4, L5, S1, S2, S3

Muscles innervated: Popliteus, Gastrocnemius, Soleus, Plantaris, Tibialis posterior, Flexor hallucis longus and Flexor digitorum
brevis. Terminates by dividing into the medial and lateral plantar nerves.

50. At which of the following anatomical locations does the common peroneal nerve bifurcate into the superficial and deep
peroneal nerves?
A. Immediately anterior to the linea aspera
B. At the lateral aspect of the neck of the fibula
C. Within the substance of tibialis anterior muscle
D. At the inferomedial aspect of the popliteal fossa
56
 E. Under the medial head of gastrocnemius

Answer: B

The common peroneal nerve bifurcates at the neck of the fibula (where it is most likely to be injured).

51. A 48 year old motor cyclist sustains a complex lower limb fracture in a motor accident. For a time the popliteal artery
is occluded and eventually repaired. Subsequently he develops a compartment syndrome and the anterior and
superficial posterior compartments of the lower leg are decompressed. Unfortunately, the operating surgeon neglects
to decompress the deep posterior compartment. Which of the following muscles is least likely to be affected as a
result?
A. Flexor digitorum longus
B. Plantaris
C. Tibialis posterior
D. Flexor hallucis longus
E. None of the above
Answer: B
The plantaris muscle lies within the superficial posterior compartment of the lower leg.

52. A 23 year old lady is undergoing a trendelenberg procedure for varicose veins. During the dissection of the
saphenofemoral junction, which of the following is most liable to injury?
A. Superficial circumflex iliac artery
B. Superficial circumflex iliac vein
C. Femoral artery
D. Femoral nerve
E. Deep external pudendal artery

Answer: E
The deep external pudendal artery runs under the long saphenous vein close to its origin and may be injured. It is at greatest risk
of injury during the flush ligation of the saphenofemoral junction. Provided an injury is identified and vessel ligated, injury is
seldom associated with any serious adverse sequelae.

53. A 52 year female post hysterectomy attends clinic. She reports pain and reduced sensation over the medial aspect of
her thigh. Clinically thigh adduction is weak. What is the most likely nerve injury?
A.Obturator nerve
B. Sciatic nerve
C. Femoral nerve
D.L3 cord compression
E. Deep peroneal nerve
Answer: A

The obturator nerve supplies sensation to the medial aspect of the thigh and causes adduction and internal rotation of the thigh.
Injury occurs during pelvic or abdominal surgery.
L3 cord compression is unlikely.

54. With regard to the sciatic nerve which statement is false?

A. It is derived from L4 to S3
B. It contains nerve roots from the posterior division of the lumbosacral plexus only
C. It divides to give the tibial nerve and common peroneal nerve
D. It provides cutaneous sensation to the posterior aspect of the thigh
E. It provides cutaneous sensation to the entire lower leg with the exception of its medial aspect

Answer: B

It is derived from both anterior and posterior divisions of the lumbosacral plexus. The sciatic nerve is the longest and widest nerve
in the human body. It is particularly susceptible to trauma in the posterior approach to the hip.

55. Which of the following is a content of the adductor canal?

A.Saphenous nerve
B. Sural nerve
C. Femoral nerve
D.Profunda branch of the femoral artery
57
 E. Saphenous vein
Answer: A

It contains the saphenous nerve and the superficial branch of the femoral artery.

56. A 56 year old lady with metastatic breast cancer develops an oestolytic deposit in the proximal femur. One morning
whilst getting out of bed she notices severe groin pain. X-rays show that the lesser trochanter has been avulsed. Which
muscle is the most likely culprit?
A. Vastus lateralis
B. Psoas major
C. Piriformis
D. Gluteus maximus
E. Gluteus medius

Answer: B

The psoas major inserts into the lesser trochanter and contracts when raising the trunk from the supine position. When oestolytic
lesions are present in the femur the lesser trochanter may be avulsed.

Psoas Muscle

Origin
The deep part originates from the transverse processes of the five lumbar vertebrae, the superficial part originates from T12 and
the first 4 lumbar vertebrae.
Insertion
Lesser trochanter of the femur.
Innervation
Anterior rami of L1 to L3.
Action
Flexion and external rotation of the hip. Bilateral contraction can raise the trunk from the supine position.

57. A 34 year old man is injured by farm machinery and sustains a laceration at the superolateral aspect of the popliteal
fossa. The medial aspect of biceps femoris is lacerated. Which of the following underlying structures is at greatest risk
of injury?
A. Gracilis
B. Sural nerve
C. Nerve to semimembranosus
D. Popliteal artery
E. Common peroneal nerve

Answer: E

The common peroneal nerve lies under the medial aspect of biceps femoris and is therefore at greatest risk of injury. The tibial
nerve may also be damaged in such an injury (but is not listed here). The sural nerve branches off more inferiorly.

58. A laceration to the upper lateral margin of the popliteal fossa may injure which of the following nerves?
A.Common peroneal nerve
B. Sural nerve
C. Sciatic nerve
D.Saphenous nerve
E. Tibial nerve
Answer: A

The sural nerve exits at the lower latero-medial aspect of the fossa and is more at risk in short saphenous vein surgery. The tibial
nerve lies more medially and is even less likely to be injured in this location.

59. An elderly lady falls and lands on her hip. On examination her hip is tender to palpation and x-rays are taken. There
are concerns that she may have an intertrochanteric fracture. What is the normal angle between the femoral neck and
the femoral shaft?
58
 A.90o
B. 105o
C. 80o
D.130o
E. 180o
Answer: D

The normal angle between the femoral head and shaft is 130o. Changes to this angle may occur as a result of disease or pathology
and should be investigated.

60. An 18 year old athlete attends orthopaedic clinic reporting pain and swelling over the medial aspect of the knee joint.
The pain occurs when climbing the stairs, but is not present when walking on flat ground. Clinically there is pain over
the medial, proximal tibia and the McMurray test is negative. What is the most likely cause of this patient's
symptoms?
A. Anterior cruciate ligament tear
B. Prepatellar bursitis
C. Medial meniscus injury
D. Pes Anserinus Bursitis
E. Fracture of tibia
Answer: D
Pes anserinus: GOOSE'S FOOT: Combination of sartorius, gracilis and semitendinous tendons inserting into the anteromedial
proximal tibia. Pes Anserinus Bursitis is common in sportsmen due to overuse injuries. The main sign is of pain in the medial
proximal tibia. As the McMurray test is negative, medial meniscal injury is excluded.

61. Which of the following nerves innervates the long head of the biceps femoris muscle?
A.Inferior gluteal nerve
B. Tibial nerve
C. Superior gluteal nerve
D.Common peroneal nerve
E. Obturator nerve
Answer: B

The short head of biceps femoris, which may occasionally be absent, is innervated by the common peroneal component of the
sciatic nerve. The long head is innervated by the tibial nerve.

62. Which of the following bones is related to the cuboid at its distal articular surface?
A.All metatarsals
B. 5th metatarsal
C. Calcaneum
D.Medial cuneiform
E. 3rd metatarsal
Answer: B

The cuboid is located at the lateral aspect of the foot between the calcaneus posteriorly and the 4th and 5th metatarsals distally.

63. A 40-year-old man presents with pain in his lower back and 'sciatica' for the past three days. He describes bending
down to pick up a washing machine when he felt 'something go'. He now has severe pain radiating from his back down
the right leg. On examination he describes paraesthesia over the anterior aspect of the right knee and the medial
aspect of his calf. Power is intact and the right knee reflex is diminished. The femoral stretch test is positive on the
right side. Which nerve or nerve root is most likely to be affected?
A. Common peroneal nerve
B. Lateral cutaneous nerve of the thigh
C. L5
D. L3
E. L4

Answer: E

59
Prolapsed disc
A prolapsed lumbar disc usually produces clear dermatomal leg pain associated with neurological deficits.
Features

 Leg pain usually worse than back

 Pain often worse when sitting

The table below demonstrates the expected features according to the level of compression:

L3 nerve root compression Sensory loss over anterior thigh

Weak quadriceps
Reduced knee reflex
Positive femoral stretch test
L4 nerve root compression Sensory loss anterior aspect of knee
Weak quadriceps
Reduced knee reflex
Positive femoral stretch test
L5 nerve root compression Sensory loss dorsum of foot
Weakness in foot and big toe dorsiflexion
Reflexes intact
Positive sciatic nerve stretch test
S1 nerve root compression Sensory loss posterolateral aspect of leg and lateral aspect of foot
Weakness in plantar flexion of foot
Reduced ankle reflex
Positive sciatic nerve stretch test

Management

 Similar to that of other musculoskeletal lower back pain: analgesia, physiotherapy, exercises
 Persistent symptoms, muscular weakness, bladder or bowel dysfunction are indications for urgent MRI scanning to
delineate the disease extent to allow surgical planning
 Plain spinal x-rays have no useful role in establishing the extent of disk disease

64. Onto which of the following structures does the anterior cruciate ligament insert?
A.Posterolateral aspect of the lateral femoral condyle
B. Posteromedial aspect of the lateral femoral condyle
C. Posterolateral aspect of the medial femoral condyle
D.Posteromedial aspect of the medial femoral condyle
E. None of the above

Answer: B

The anterior cruciate ligament is attached to the anterior intercondylar area of the tibia. Is then passes posterolaterally to insert into
the posteromedial aspect of the lateral femoral condyle.

65. A 40 year old lady presents with varicose veins, these are found to originate from the short saphenous vein. As the vein
is mobilised close to its origin which of the following structures is at greatest risk of injury?
A.Sciatic nerve
B. Sural nerve
C. Common peroneal nerve
D.Tibial nerve
E. Popliteal artery

Answer; B

The sural nerve is closely related and damage to this structure is a major cause of litigation. The other structures may all be injured
but the risks are lower.

60
66. A 72 year old man with non reconstructible arterial disease is undergoing an above knee amputation. The posterior
compartment muscles are divided. Which of the following muscles does not lie in the posterior compartment of the
thigh?
A. Biceps femoris
B. Quadriceps femoris
C. Semitendinosus
D. Semimembranosus
E. None of the above

Answer: B

The quadriceps femoris lies in the anterior compartment.

Compartments of the thigh

Formed by 3 septae passing from the femur to the fascia lata.

Compartment Nerve Muscles Blood supply
 Iliacus
 Tensor fasciae latae
Anterior compartment Femoral  Sartorius Femoral artery
 Quadriceps femoris

 Adductor longus/magnus/brevis
 Gracilis
Medial compartment Obturator Profunda femoris artery and obturator artery
 Obturator externus

 Semimembranosus
 Semitendinosus
Posterior compartment Sciatic Branches of Profunda femoris artery
 Biceps femoris

Which of the following structures is not closely related to the posterior tibial artery?

F. Soleus posteriorly
G. Tibial nerve medially
H. Deep peroneal nerve laterally
I. Flexor hallucis longus postero-inferiorly
J. Popliteus

Answer: C

The deep peroneal nerve lies in the anterior compartment. The tibial nerve lies medially. At its termination it lies deep to the
flexor retinaculum.

67. A 30 year old man presents with back pain and the surgeon tests the ankle reflex. Which of the following nerve roots
are tested in this manoeuvre?
A. S3 and S4
B. L4 and L5
C. L3 and L4
D. S1 and S2
E. S4 only

Answer: D

Ankle reflex

61
The ankle reflex is elicited by tapping the Achilles tendon with a tendon hammer. It tests the S1 and S2 nerve roots. It is typically
delayed in L5 and S1 disk prolapses.

68. Which of the following structures is not closely related to the piriformis muscle?
A. Superior gluteal nerve
B. Sciatic nerve
C. Inferior gluteal artery
D. Inferior gluteal nerve
E. Medial femoral circumflex artery
Answer: E
Nerve supply of lateral hip rotators

Piriformis: ventral rami S1, S2

Obturator internus: nerve to obturator internus
Superior gemellus: nerve to obturator internus
Inferior gemellus: nerve to quadratus femoris
Quadrator femoris: nerve to quadrator femoris

The piriformis muscle is an important anatomical landmark in the gluteal region. The following structures are closely related:

 Sciatic nerve
 Inferior gluteal artery and nerve
 Superior gluteal artery and nerve

The medial femoral circumflex artery runs deep to quadratus femoris.

Gluteal muscles

 Gluteus maximus: inserts to gluteal tuberosity of the femur and iliotibial tract
 Gluteus medius: attach to lateral greater trochanter
 Gluteus minimis: attach to anterior greater trochanter
 All extend and abduct the hip

Deep lateral hip rotators

 Piriformis
 Gemelli
 Obturator internus
 Quadratus femoris

Nerves
Superior gluteal nerve (L5, S1)  Gluteus medius
 Gluteus minimis
 Tensor fascia lata

Inferior gluteal nerve Gluteus maximus

Damage to the superior gluteal nerve will result in the patient developing a Trendelenberg gait. Affected patients are unable to
abduct the thigh at the hip joint. During the stance phase, the weakened abductor muscles allow the pelvis to tilt down on the
opposite side. To compensate, the trunk lurches to the weakened side to attempt to maintain a level pelvis throughout the gait
cycle. The pelvis sags on the opposite side of the lesioned superior gluteal nerve.

69. A 77 year old man with symptoms of intermittent claudication is due to have his ankle brachial pressure indices
measured. The vessel is impalpable. Which of the following tendinous structures lies medial to it, that may facilitate its
identification?
A.Extensor digitorum longus tendon
B. Peroneus tertius tendon
C. Extensor hallucis longus tendon
D.Extensor digitorum brevis tendon
62
 E. Flexor digitorum longus tendon
Answer: C

The extensor hallucis longus tendon lies medial to the dorsalis pedis artery.

70. The integrity of which muscle is assessed by the Trendelenberg test?

A. Sartorius
B. Quadratus femoris
C. Semimembranosus
D. Gluteus medius
E. Piriformis

Answer: D

71. A 78 year old man presents with symptoms consistent with intermittent claudication. To assess the severity of his
disease you decide to measure his ankle brachial pressure index. To do this you will identify the dorsalis pedis artery.
Which of the following statements relating to this vessel is false?
A.It originates from the peroneal artery
B. It is crossed by the tendon of extensor hallucis brevis
C. Two veins are usually closely related to it
D.It passes under the inferior extensor retinaculum
E. The tendon of extensor hallucis longus lies medial to it.

Answer: A

The dorsalis pedis artery is a direct continuation of the anterior tibial artery.

72. Which of the following statements relating to the knee joint is false?
A.It is the largest synovial joint in the body
B. When the knee is fully extended all ligaments of the knee joint are taut
C. Rupture of the anterior cruciate ligament may result in haemarthrosis
D.The posterior aspect of the patella is extrasynovial
E. The joint is innervated by the femoral, sciatic and obturator nerves
Answer: D

The posterior aspect is intrasynovial and the knee itself comprises the largest synovial joint in the body. It may swell considerably
following trauma such as ACL injury. Which may be extremely painful owing to rich innervation from femoral, sciatic and ( a
smaller) contribution from the obturator nerve. During full extension all ligaments are taut and the knee is locked.

73. Which of the following does not exit the pelvis through the greater sciatic foramen?
A. Superior gluteal artery
B. Internal pudendal vessels
C. Sciatic nerve
D. Obturator nerve
E. Inferior gluteal nerve

Answer: D

The obturator nerve exits through the obturator foramen.

74. A 78 year old man is undergoing a femoro-popliteal bypass graft. The operation is not progressing well and the
surgeon is complaining of poor access. Retraction of which of the following structures will improve access to the
femoral artery in the groin?
A.Quadriceps
B. Adductor longus
C. Adductor magnus
D.Pectineus
E. Sartorius
Answer: E

63
At the lower border of the femoral triangle the femoral artery passes under the sartorius muscle. This can be retracted to improve
access.

75. A builder falls off a ladder whilst laying roof tiles. He sustains a burst fracture of L3. The MRI scan shows complete
cord transection at this level as a result of the injury. Which clinical sign will not be present?
A. Flaccid paralysis of the legs
B. Extensor plantar response
C. Sensory loss in the legs
D. Incontinence
E. Loss of patellar tendon reflex
Answer: B

In lower motor neuron lesions everything is reduced

The main purpose of this question is to differentiate the features of an UMN lesion and a LMN lesion. The features of a LMN
lesion include:

 Flaccid paralysis of muscles supplied

 Atrophy of muscles supplied.
 Loss of reflexes of muscles supplied.
 Muscles fasciculation

For lesions below L1 LMN signs will occur. Hence in an L3 lesion, there will be loss of the patella reflex but there will be no
extensor plantar reflex.

Spinal cord

 Located in a canal within the vertebral column that affords it structural support.
 Rostrally is continues to the medulla oblongata of the brain and caudally it tapers at a level corresponding to the L1-2
interspace (in the adult), a central structure, the filum terminale anchors the cord to the first coccygeal vertebra.
 The spinal cord is characterised by cervico-lumbar enlargements and these, broadly speaking, are the sites which
correspond to the brachial and lumbar plexuses respectively.

There are some key points to note when considering the surgical anatomy of the spinal cord:

 During foetal growth the spinal cord becomes shorter than the spinal canal, hence the adult site of cord termination at the
L1-2 level.
 Due to growth of the vertebral column the spine segmental levels may not always correspond to bony landmarks as they
do in the cervical spine.
 The spinal cord is incompletely divided into two symmetrical halves by a dorsal median sulcus and ventral median
fissure. Grey matter surrounds a central canal that is continuous rostrally with the ventricular system of the CNS.
 The grey matter is sub divided cytoarchitecturally into Rexeds laminae.
 Afferent fibres entering through the dorsal roots usually terminate near their point of entry but may travel for varying
distances in Lissauers tract. In this way they may establish synaptic connections over several levels
 At the tip of the dorsal horn are afferents associated with nociceptive stimuli. The ventral horn contains neurones that
innervate skeletal muscle.

The key point to remember when revising CNS anatomy is to keep a clinical perspective in mind. So it is worth classifying
the ways in which the spinal cord may become injured. These include:

 Trauma either direct or as a result of disc protrusion

 Neoplasia either by direct invasion (rare) or as a result of pathological vertebral fracture
 Inflammatory diseases such as Rheumatoid disease, or OA (formation of osteophytes compressing nerve roots etc.
 Vascular either as a result of stroke (rare in cord) or as complication of aortic dissection
 Infection historically diseases such as TB, epidural abscesses.

The anatomy of the cord will, to an extent dictate the clinical presentation. Some points/ conditions to remember:

64
  Brown- Sequard syndrome-Hemisection of the cord producing ipsilateral loss of proprioception and upper motor neurone
signs, plus contralateral loss of pain and temperature sensation. The explanation of this is that the fibres decussate at
different levels.
 Lesions below L1 will tend to present with lower motor neurone signs

76. A 66 year old man with peripheral vascular disease is undergoing a below knee amputation. In which of the lower leg
compartments does peroneus brevis lie?
A. Lateral compartment
B. Anterior compartment
C. Superficial posterior compartment
D. Deep posterior compartment
E. None of the above

Answer: A

The interosseous membrane separates the anterior and posterior compartments. The deep and superficial compartments are
separated by the deep transverse fascia. The peroneus brevis is part of the lateral compartment.

77. A 70 year old man is due to undergo an arterial bypass procedure for claudication and foot ulceration. The anterior
tibial artery will form the site of the distal arterial anastomosis. Which of the following structures is not closely related
to it?
A. Interosseous membrane
B. Deep peroneal nerve
C. Tibialis posterior
D. Extensor hallucis longus
E. Dorsalis pedis artery
Answer: C
As an artery of the anterior compartment, the anterior tibial artery is closely related to tibialis anterior.

Anterior tibial artery

 Begins opposite the distal border of popliteus

 Terminates in front of the ankle, continuing as the dorsalis pedis artery
 As it descends it lies on the interosseous membrane, distal part of the tibia and front of the ankle joint
 Passes between the tendons of flexor digitorum and flexor hallucis longus distally
 It is related to the deep peroneal nerve, it lies anterior to the middle third of the vessel and lateral to it in the lower third

78. Which of the following muscles does not cause lateral rotation of the hip?
A. Obturator internus
B. Quadratus femoris
C. Gemellus inferior
D. Piriformis
E. Pectineus
Answer: E

Mnemonic lateral hip rotators: P-GO-GO-Q (top to bottom): Piriformis, Gemellus superior, Obturator internus, Gemellus inferior,
Obturator externus, Quadratus femoris. Pectineus adducts and medially rotates the femur.

79. Which of the following structures does not pass anterior to the lateral malleolus?
A. Anterior tibial artery
B. Extensor digitorum longus
C. Tibialis anterior
D. Peroneus brevis
E. Peroneus tertius
Answer: D
Peroneus brevis passes posterior to the lateral malleolus.

80. Which of the following statements relating to sartorius is untrue?

A. It is supplied by the femoral nerve
B. It forms the lateral boundary of the femoral triangle
C. The middle third forms the roof of the adductor canal
65
 D. It is a flexor of the hip and knee
E. It inserts into the medial femoral condyle

Ansewr: E

It inserts into the medial aspect of the upper part of the tibia.

81. Which of the following structures are not closely related to the adductor longus muscle?
A. Long saphenous vein
B. Tendon of iliacus
C. The profunda branch of the femoral artery
D. Pectineus muscle
E. Femoral nerve
Answer: B

Femoral triangle:Adductor longus medially; Inguinal ligament superiorly; Sartorius muscle laterallyAdductor longus forms the
medial border of the femoral triangle. It is closely related to the long saphenous vein which overlies it and the profunda branch of
the femoral artery. The femoral nerve is related to it inferiorly. However, the tendon of iliacus inserts proximally and is not in
contact with adductor longus.

82. Which of the following muscles is not within the posterior compartment of the lower leg?
A. Peroneus brevis
B. Flexor digitalis longus
C. Soleus
D. Popliteus
E. Flexor hallucis longus
Answer: A
Peroneus brevis lies in the lateral compartment.

83. Which of the following actions will be impaired?

A.Extension of the great toe
B. Adduction of the thigh
C. Flexion of the knee joint
D.Extension of the knee joint
E. Eversion of the foot
Answer: D

The femoral nerve supplies the quadriceps muscle which is responsible for extension at the knee joint.

84. Which of the following structures are at risk of direct injury following a fracture dislocation of the femoral condyles?
A.Popliteal artery
B. Sciatic nerve
C. Plantaris muscle
D.Tibial artery
E. Tibial nerve
Answer: A

The heads of gastrocnemius will contract to pull the fracture segment posteriorly. The popliteal artery lies against the bone and
may be damaged or compressed.

66
 Abdomen
85. A 56 year old man is undergoing a radical nephrectomy via a posterior approach. Which of the following
structures is most likely to be encountered during the operative approach?

A. 8th rib
B. 10th rib

C. 6th rib
D. 12th rib

E. 9th rib

Answer: D

The 11th and 12th ribs lie posterior to the kidneys and may be encountered during a posterior approach. A
pneumothorax is a recognised complication of this type of surgery.

Renal anatomy

Each kidney is about 11cm long, 5cm wide and 3cm thick. They are located in a deep gutter alongside the projecting
verterbral bodies, on the anterior surface of psoas major. In most cases the left kidney lies approximately 1.5cm higher
than the right. The upper pole of both kidneys approximates with the 11th rib (beware pneumothorax during
nephrectomy). On the left hand side the hilum is located at the L1 vertebral level and the right kidney at level L1-2.
The lower border of the kidneys is usually alongside L3.

The table below shows the anatomical relations of the kidneys:

Relations
Relations Right Kidney Left Kidney
Posterior Quadratus lumborum, diaphragm, psoas major, Quadratus lumborum, diaphragm, psoas major,
transversus abdominis transversus abdominis
Anterior Hepatic flexure of colon Stomach, Pancreatic tail
Superior Liver, adrenal gland Spleen, adrenal gland

Fascial covering
Each kidney and suprarenal gland is enclosed within a common and layer of investing fascia that is derived from the
transversalis fascia into anterior and posterior layers (Gerotas fascia).

Renal structure
Kidneys are surrounded by an outer cortex and an inner medulla which usually contains between 6 and 10 pyramidal
structures. The papilla marks the innermost apex of these. They terminate at the renal pelvis, into the ureter.
Lying in a hollow within the kidney is the renal sinus. This contains:
1. Branches of the renal artery
2. Tributaries of the renal vein
3. Major and minor calyces's
4. Fat

Structures at the renal hilum

The renal vein lies most anteriorly, then renal artery (it is an end artery) and the ureter lies most posterior.

67
86. A 44 year old lady is undergoing an abdominal hysterectomy and the ureter is identified during the ligation
of the uterine artery. At which site does it insert into the bladder?

A. Posterior
B. Apex

C. Anterior
D. Base

E. Superior aspect of the lateral side

Answer: D

The ureters enter the bladder at the upper lateral aspect of the base of the bladder. They are about 5cm apart from each
other in the empty bladder. Internally this aspect is contained within the bladder trigone.

Ureter
 25-35 cm long
 Muscular tube lined by transitional epithelium
 Surrounded by thick muscular coat. Becomes 3 muscular layers as it crosses the bony pelvis
 Retroperitoneal structure overlying transverse processes L2-L5
 Lies anterior to bifurcation of iliac vessels
 Blood supply is segmental; renal artery, aortic branches, gonadal branches, common iliac and internal
iliac
 Lies beneath the uterine artery

87. A 6 month old child is brought to the surgical clinic because of non descended testes. What is the main
structure that determines the descent path of the testicle?
A. Processus vaginalis
B. Cremaster
C. Mesorchium
D.Inguinal canal
E. Gubernaculum

Answer: E
The gubernaculum is a ridge of mesenchymal tissue that connects the testis to the inferior aspect of the scrotum. Early
in embryonic development the gubernaculum is long and the testis are located on the posterior abdominal wall. During
foetal growth the body grows relative to the gubernaculum, with resultant descent of the testis.

Testicular embryology
Until the end of foetal life the testicles are located within the abdominal cavity. They are initially located on the
posterior abdominal wall on a level with the upper lumbar vertebrae (L2). Attached to the inferior aspect of the testis
is the gubernaculum testis which extends caudally to the inguinal region, through the canal and down to the superficial
skin. Both the testis and the gubernaculum are extra-peritoneal.
As the foetus grows the gubernaculum becomes progressively shorter. It carries the peritoneum of the anterior
abdominal wall (the processus vaginalis). As the processus vaginalis descends the testis is guided by the
gubernaculum down the posterior abdominal wall and the back of the processus vaginalis into the scrotum. By the
third month of foetal life the testes are located in the iliac fossae, by the seventh they lie at the level of the deep
inguinal ring. The processus vaginalis usually closes after birth, but may persist and be the site of indirect hernias. Part
closure may result in development of cysts on the cord.

68
88. A 28 year old man requires a urethral catheter to be inserted prior to undergoing a splenectomy. Where is
the first site of resistance to be encountered on inserting the catheter?
a. Bulbar urethra
b. Membranous urethra
c. Internal sphincter
d. Prostatic urethra
e. Bladder neck

Answer: B

The membranous urethra is the least distensible portion of the urethra. This is due to the fact that it is surrounded by
the external sphincter.

Urethral anatomy
Female urethra
The female urethra is shorter and more acutely angulated than the male urethra. It is an extra-peritoneal structure and
embedded in the endopelvic fascia. The neck of the bladder is subjected to transmitted intra-abdominal pressure and
therefore deficiency in this area may result in stress urinary incontinence. Between the layers of the urogenital
diaphragm the female urethra is surrounded by the external urethral sphincter, this is innervated by the pudendal
nerve. It ultimately lies anterior to the vaginal orifice.

Male urethra
In males the urethra is much longer and is divided into four parts.

Pre-prostatic Extremely short and lies between the bladder and prostate gland.It has a stellate lumen and is
urethra between 1 and 1.5cm long.Innervated by sympathetic noradrenergic fibres, as this region is
composed of striated muscles bundles they may contract and prevent retrograde ejaculation.
Prostatic urethra This segment is wider than the membranous urethra and contains several openings for the
transmission of semen (at the midpoint of the urethral crest).
Membranous Narrowest part of the urethra and surrounded by external sphincter. It traverses the perineal
urethra membrane 2.5cm postero-inferior to the symphysis pubis.
Penile urethra Travels through the corpus songiosum on the underside of the penis. It is the longest urethral
segment.It is dilated at its origin as the infrabulbar fossa and again in the gland penis as the
navicular fossa. The bulbo-urethral glands open into the spongiose section of the urethra 2.5cm
below the perineal membrane.
The urothelium is transitional in nature near to the bladder and becomes squamous more distally.

89. A 23 year old man undergoes an orchidectomy. The right testicular vein is ligated; into which structure
does it drain?
A. Right renal vein
B. Inferior vena cava
C. Common iliac vein
D. Internal iliac vein
E. External iliac vein

Answer: B

The testicular venous drainage begins in the septa and these veins together with those of the tunica vasculosa converge
on the posterior border of the testis as the pampiniform plexus. The pampiniform plexus drains to the testicular vein.
The left testicular vein drains into the left renal vein. The right testicular vein drains into the inferior vena cava.
69
Scrotal and testicular anatomy

Spermatic cord
Formed by the vas deferens and is covered by the following structures:
Layer Origin
Internal spermatic fascia Transversalis fascia
Cremasteric fascia From the fascial coverings of internal oblique
External spermatic fascia External oblique aponeurosis

Contents of the cord

Vas deferens Transmits sperm and accessory gland secretions
Testicular artery Branch of abdominal aorta supplies testis and epididymis
Artery of vas deferens Arises from inferior vesical artery
Cremasteric artery Arises from inferior epigastic artery
Pampiniform plexus Venous plexus, drains into right or left testicular vein
Sympathetic nerve fibres Lie on arteries, the parasympathetic fibres lie on the vas
Genital branch of the genitofemoral nerve Supplies cremaster
Lymphatic vessels Drain to lumbar and para-aortic nodes

Scrotum

 Composed of skin and closely attached dartos fascia.

 Arterial supply from the anterior and posterior scrotal arteries
 Lymphatic drainage to the inguinal lymph nodes
 Parietal layer of the tunica vaginalis is the innermost layer

Testes

 The testes are surrounded by the tunica vaginalis (closed peritoneal sac). The parietal layer of the tunica
vaginalis adjacent to the internal spermatic fascia.
 The testicular arteries arise from the aorta immediately inferiorly to the renal arteries.
 The pampiniform plexus drains into the testicular veins, the left drains into the left renal vein and the right
into the inferior vena cava.
 Lymphatic drainage is to the para-aortic nodes.

90. A 21 year old man has an inguinal hernia and is undergoing a surgical repair. As the surgeons approach
the inguinal canal they expose the superficial inguinal ring. Which of the following forms the lateral edge of
this structure?
A.Inferior epigastric artery
B. Conjoint tendon
C. Rectus abdominis muscle
D.External oblique aponeurosis
E. Transversalis fascia

Answer: D

The external oblique aponeurosis forms the anterior wall of the inguinal canal and also the lateral edge of the
superficial inguinal ring. The rectus abdominis lies posteromedially and the transversalis posterior to this.

Inguinal canal

Location

70
  Above the inguinal ligament
 The inguinal canal is 4cm long

Boundaries of the inguinal canal

Floor  External oblique aponeurosis
 Inguinal ligament
 Lacunar ligament

Roof  Internal oblique

 Transversus abdominis

Anterior wall External oblique aponeurosis

Posterior wall  Transversalis fascia
 Conjoint tendon

Laterally  Internal ring

 Fibres of internal oblique

Medially  External ring

 Conjoint tendon

Contents
Males Spermatic cord and ilioinguinal nerve As it passes through the canal the spermatic cord has 3
coverings:

 External spermatic fascia from external oblique

aponeurosis
 Cremasteric fascia
 Internal spermatic fascia

Females Round ligament of uterus and

ilioinguinal nerve

Related anatomy of the inguinal region: the boundaries of Hesselbachs triangle

91. A 67 year old man is undergoing a transurethral resection of a bladder tumour using diathermy. Suddenly
during the procedure the patients leg begins to twitch. Stimulation of which of the following nerves is the
most likely cause?
A.Femoral
B. Pudendal
C. Sciatic
D.Obturator
E. Gluteal

Answer: D

The obturator nerve is most closely related to the bladder.

Obturator nerve

The obturator nerve arises from L2, L3 and L4 by branches from the ventral divisions of each of these nerve roots. L3
forms the main contribution and the second lumbar branch is occasionally absent. These branches unite in the
71
substance of psoas major, descending vertically in its posterior part to emerge from its medial border at the lateral
margin of the sacrum. It then crosses the sacroiliac joint to enter the lesser pelvis, it descends on obturator internus to
enter the obturator groove. In the lesser pelvis the nerve lies lateral to the internal iliac vessels and ureter, and is joined
by the obturator vessels lateral to the ovary or ductus deferens.

Supplies

 Medial compartment of thigh

 Muscles supplied: external obturator, adductor longus, adductor brevis, adductor magnus (not the lower part-
sciatic nerve), gracilis
 The cutaneous branch is often absent. When present, it passes between gracilis and adductor longus near the
middle part of the thigh, and supplies the skin and fascia of the distal two thirds of the medial aspect.

Obturator canal

 Connects the pelvis and thigh: contains the obturator artery, vein, nerve which divides into anterior and
posterior branches.

92. A 45 year old lady is undergoing a Whipples procedure for carcinoma of the pancreatic head. The bile duct
is transected. Which of the following vessels is mainly responsible for the blood supply to the bile duct?
A.Cystic artery
B. Hepatic artery
C. Portal vein
D.Left gastric artery
E. None of the above

Answer: B

The bile duct has an axial blood supply which is derived from the hepatic artery and from retroduodenal branches of
the gastroduodenal artery. Unlike the liver there is no contribution by the portal vein to the blood supply of the bile
duct. Damage to the hepatic artery during a difficult cholecystectomy is a recognized cause of bile duct strictures.

Gallbladder
 Fibromuscular sac with capacity of 50ml
 Columnar epithelium

Relations of the gallbladder

Anterior Liver
Posterior  Covered by peritoneum
 Transverse colon
 1st part of the duodenum

Laterally Right lobe of liver

Medially Quadrate lobe of liver

Arterial supply: Cystic artery (branch of Right hepatic artery)

Venous drainage: Cystic vein

Nerve supply: Sympathetic- mid thoracic spinal cord, Parasympathetic- anterior vagal trunk

72
Common bile duct

Origin: confluence of cystic and common hepatic ducts

Relations:

At origin  Medially - Hepatic artery

 Posteriorly- Portal vein

Distally  Duodenum - anteriorly

 Pancreas - medially and laterally
 Right renal vein – posteriorly

Arterial supply Branches of hepatic artery and retroduodenal branches of gastroduodenal artery

Calot's triangle

Medially Common hepatic duct

Inferiorly Cystic duct
Superiorly Inferior edge of liver
Contents Cystic artery

93. 7 year old boy presents with right iliac fossa pain and there is a clinical suspicion that appendicitis is
present. From which of the following embryological structures is the appendix derived?
A. Vitello-intestinal duct
B. Uranchus
C. Foregut
D. Hindgut
E. Midgut

Answer: E
The appendix is derived from the midgut

It is derived from the midgut which is why early appendicitis may present with periumbilical pain.

Appendix

 Location: Base of caecum.

 Up to 10cm long.
 Mainly lymphoid tissue (Hence mesenteric adenitis may mimic appendicitis).
 Caecal taenia coli converge at base of appendix and form a longitudinal muscle cover over the appendix. This
convergence should facilitate its identification at surgery if it is retrocaecal and difficult to find (which it can
be when people start doing appendicectomies!)
 Arterial supply: Appendicular artery (branch of the ileocolic).
 It is intra peritoneal.

McBurney's point: 1/3 of the way along a line drawn from the Anterior Superior Iliac Spine to the Umbilicus
6 Positions:

 Retrocaecal 74%
 Pelvic 21%
 Postileal
 Subcaecal
 Paracaecal
 Preileal
73
94. A 34 year old man presents to the surgical clinic 8 months following a laparotomy for a ruptured spleen. He
complains of a nodule in the centre of his laparotomy wound. This is explored surgically and a stitch
granuloma is found and excised. From which of the following cell types do granulomata arise?
A. Polymorpho nucleocytes
B. Plasma cells
C. Reed- Sternberg cells
D. Platelets
E. Macrophages

Answer: E
Granulomas are organised collections of macrophages
Macrophages give origin to granulomas.

Chronic inflammation

Overview
Chronic inflammation may occur secondary to acute inflammation. In most cases chronic inflammation occurs as a
primary process. These may be broadly viewed as being one of three main processes:

 Persisting infection with certain organisms such as Mycobacterium tuberculosis which results in delayed type
hypersensitivity reactions and inflammation.
 Prolonged exposure to non-biodegradable substances such as silica or suture materials which may induce an
inflammatory response.
 Autoimmune conditions involving antibodies formed against host antigens.

Acute vs. Chronic inflammation

Acute inflammation Chronic inflammation
Changes to existing vascular structure and increased permeability of Angiogenesis predominates
endothelial cells
Infiltration of neutrophils Macrophages, plasma cells and lymphocytes
predominate
Process may resolve with: Healing by fibrosis is the main result

 Suppuration
 Complete resolution
 Abscess formation
 Progression to chronic inflammation
 Healing by fibrosis

Granulomatous inflammation
A granuloma consists of a microscopic aggregation of macrophages (with epithelial type arrangement =epitheliod).
Large giant cells may be found at the periphery of granulomas.

Mediators
Growth factors released by activated macrophages include agents such as interferon and fibroblast growth factor (plus
many more). Some of these such as interferons may have systemic features resulting in systemic symptoms and signs,
which may be present in individuals with long standing chronic inflammation.

The finding of granulomas is pathognomonic of chronic inflammation,

74
95. A 53 year old man is undergoing a radical gastrectomy for carcinoma of the stomach. Which of the
following structures will need to be divided to gain access to the coeliac axis?
A.Lesser omentum
B. Greater omentum
C. Falciform ligament
D.Median arcuate ligament
E. Gastrosplenic ligament

Answer: A

The lesser omentum will need to be divided. During a radical gastrectomy this forms one of the nodal stations that will
need to be taken.

Coeliac axis

The coeliac axis has three main branches.

 Left gastric
 Hepatic: branches-Right Gastric, Gastroduodenal, Right Gastroepiploic, Superior Pancreaticoduodenal,
Cystic.
 Splenic: branches- Pancreatic, Short Gastric, Left Gastroepiploic

It occasionally gives off one of the inferior phrenic arteries.

Relations
Anteriorly Lesser omentum
Right Right coeliac ganglion and caudate process of liver
Left Left coeliac ganglion and gastric cardia
Inferiorly Upper border of pancreas and renal vein

96. A 17 year old lady presents with right iliac fossa pain and diagnosed as having acute appendicitis. You take
her to theatre to perform a laparoscopic appendicectomy. During the procedure the scrub nurse distracts
you and you inadvertently avulse the appendicular artery. The ensuing haemorrhage is likely to be supplied
directly from which of the following vessels?
A.Inferior mesenteric artery
B. Superior mesenteric artery
C. Ileo-colic artery
D.Internal iliac artery
E. None of the above

Answer: C

The appendicular artery is a branch of the ileocolic artery.

97. A 63 year old man who smokes heavily presents with dyspepsia. He is tested and found to be positive for
helicobacter pylori infection. One evening he has an episode of haematemesis and collapses. What is the
most likely vessel to be responsible?
A. Portal vein
B. Short gastric arteries
C. Superior mesenteric artery
75
 D. Gastroduodenal artery
E. None of the above

Answer: D

He is most likely to have a posteriorly sited duodenal ulcer. These can invade the gastroduodenal artery and present
with major bleeding. Although gastric ulcers may invade vessels they do not tend to produce major bleeding of this
nature.

Gastroduodenal artery
Supplies
Pylorus, proximal part of the duodenum, and indirectly to the pancreatic head (via the anterior and posterior superior
pancreaticoduodenal arteries)

Path
Most commonly arises from the common hepatic artery of the coeliac trunk
Terminates by bifurcating into the right gastroepiploic artery and the superior pancreaticoduodenal artery

98. Which of the following nerves is responsible for the cremasteric reflex?
A.Lateral femoral cutaneous nerve
B. Femoral nerve
C. Obturator nerve
D.Genitofemoral nerve
E. None of the above

Answer: D

The motor and sensory fibres of the genitofemoral nerve are tested in the cremasteric reflex. A small contribution is
also played by the ilioinguinal nerve and thus the reflex may be lost following an inguinal hernia repair.

Genitofemoral nerve

Supplies
- Small area of the upper medial thigh

Path
- Arises from the first and second lumbar nerves
- Passes obliquely through Psoas major, and emerges from its medial border opposite the fibrocartilage between the
third and fourth lumbar vertebrae.
- It then descends on the surface of Psoas major, under cover of the peritoneum
- Divides into genital and femoral branches.
- The genital branch passes through the inguinal canal, within the spermatic cord, to supply the skin overlying the skin
and fascia of the scrotum. The femoral branch enters the thigh posterior to the inguinal ligament, lateral to the femoral
artery. It supplies an area of skin and fascia over the femoral triangle.

 It may be injured during abdominal or pelvic surgery, or during inguinal hernia repairs.

99. A 73 year old lady is admitted with brisk rectal bleeding. Despite attempts at resuscitation the bleeding
proceeds to cause haemodynamic compromise. An upper GI endoscopy is normal. A mesenteric angiogram

76
 is performed and a contrast blush is seen in the region of the sigmoid colon. The radiologist decides to
embolise the vessel supplying this area. At what spinal level does it leave the aorta?
A.L2
B. L1
C. L4
D.L3
E. T10

Answer: D
The inferior mesenteric artery leaves the aorta at L3. It supplies the left colon and sigmoid. It's proximal continuation
to communicate with the middle colic artery is via the marginal artery.

Levels

Transpyloric plane
Level of the body of L1

 Pylorus stomach
 Left kidney hilum (L1- left one!)
 Right hilum of the kidney (1.5cm lower than the left)
 Fundus of the gallbladder
 Neck of pancreas
 Duodenojejunal flexure
 Superior mesenteric artery
 Portal vein
 Left and right colic flexure
 Root of the transverse mesocolon
 2nd part of the duodenum
 Upper part of conus medullaris
 Spleen

Can be identified by asking the supine patient to sit up without using their arms. The plane is located where the lateral
border of the rectus muscle crosses the costal margin.

Anatomical planes
Subcostal plane Lowest margin of 10th costal cartilage
Intercristal plane Level of body L4 (highest point of iliac crest)
Intertubercular plane Level of body L5

Common level landmarks

Inferior mesenteric artery L3
Bifurcation of aorta into common iliac arteries L4
Formation of IVC L5 (union of common iliac veins)
Diaphragm apertures  Vena cava T8
 Oesophagus T10
 Aortic hiatus T12

100. 43 year old man is undergoing a right hemicolectomy and the ileo-colic artery is ligated. From which of
the following vessels is is derived?
A.Inferior mesenteric artery
B. Superior mesenteric artery
77
 C. Coeliac axis
D.Aorta
E. None of the above

Answer: B

The ileocolic artery is a branch of the SMA and supplies the right colon and terminal ileum. The transverse colon is
supplied by the middle colic artery. As veins accompany arteries in the mesentery and are lined by lymphatics, high
ligation is the norm in cancer resections. The ileo-colic artery branches off the SMA near the duodenum.

Colon anatomy

The colon is about 1.5m long although this can vary considerably.
Components:

 Ascending colon
 Transverse colon
 Descending colon
 Sigmoid colon

Arterial supply
Superior mesenteric artery and inferior mesenteric artery: linked by the marginal artery.
Ascending colon: ileocolic and right colic arteries
Transverse colon: middle colic artery
Descending and sigmoid colon: left colic artery

Venous drainage
From regional veins (that accompany arteries) to superior and inferior mesenteric vein

Lymphatic drainage
Initially along nodal chains that accompany supplying arteries, then para-aortic nodes.

Embryology
Midgut- Second part of duodenum to 2/3 transverse colon
Hindgut- Distal 1/3 transverse colon to anus

Peritoneal location
The right and left colon are part intraperitoneal and part extraperitoneal. The sigmoid and transverse colon are
generally wholly intraperitoneal. This has implications for the sequelae of perforations, which will tend to result in
generalised peritonitis in the wholly intra peritoneal segments.

101. A 53 year old man is undergoing a distal pancreatectomy for trauma. Which of the following vessels is
responsible for the arterial supply to the tail of the pancreas?
A.Splenic artery
B. Pancreaticoduodenal artery
C. Gastric artery
D.Hepatic artery
E. Superior mesenteric artery

Answer: A

78
Pancreatic head is supplied by the pancreaticoduodenal artery. Pancreatic tail is supplied by branches of the splenic
artery
There is an arterial "watershed" in the supply between the head and tail of the pancreas. The head is supplied by the
pancreaticoduodenal artery and the tail is supplied by branches of the splenic artery.

Pancreas

The pancreas is a retroperitoneal organ and lies posterior to the stomach. It may be accessed surgically by dividing the
peritoneal reflection that connects the greater omentum to the transverse colon. The pancreatic head sits in the
curvature of the duodenum. It's tail lies close to the hilum of the spleen, a site of potential injury during splenectomy.

Relations
Posterior to the pancreas
Pancreatic head Inferior vena cava
Common bile duct
Right and left renal veins
Superior mesenteric vein and artery
Pancreatic neck Superior mesenteric vein, portal vein
Pancreatic body- Left renal vein
Crus of diaphragm
Psoas muscle
Adrenal gland
Kidney
Aorta
Pancreatic tail Left kidney

Anterior to the pancreas

Pancreatic head 1st part of the duodenum
Pylorus
Gastroduodenal artery
SMA and SMV(uncinate process)
Pancreatic body Stomach
Duodenojejunal flexure
Pancreatic tail Splenic hilum

Superior to the pancreas

Coeliac trunk and its branches common hepatic artery and splenic artery

Grooves of the head of the pancreas

2nd and 3rd part of the duodenum

Arterial supply

 Head: pancreaticoduodenal artery

 Rest: splenic artery

Venous drainage

 Head: superior mesenteric vein

 Body and tail: splenic vein

Ampulla of Vater
79
  Merge of pancreatic duct and common bile duct
 Is an important landmark, halfway along the second part of the duodenum, that marks the anatomical
transition from foregut to midgut (also the site of transition between regions supplied by coeliac trunk and
SMA)>

102. Surgical occlusion of which of these structures, will result in the greatest reduction in hepatic blood
flow?
A.Portal vein
B. Common hepatic artery
C. Right hepatic artery
D.Coeliac axis
E. Left hepatic artery

Answer: A

The portal vein transports 70% of the blood supply to the liver, while the hepatic artery provides 30%. The portal vein
contains the products of digestion. The arterial and venous blood is dispersed by sinusoids to the central veins of the
liver lobules; these drain into the hepatic veins and then into the IVC. The caudate lobe drains directly into the IVC
rather than into other hepatic veins.

Liver

Structure of the liver

Right lobe  Supplied by right hepatic artery
 Contains Couinard segments V to VIII (-/+Sg I)

Left lobe  Supplied by the left hepatic artery

 Contains Couinard segments II to IV (+/- Sg1)

Quadrate lobe  Part of the right lobe anatomically, functionally is part of the left
 Couinard segment IV
 Porta hepatis lies behind
 On the right lies the gallbladder fossa
 On the left lies the fossa for the umbilical vein

Caudate lobe  Supplied by both right and left hepatic arteries

 Couinard segment I
 Lies behind the plane of the porta hepatis
 Anterior and lateral to the inferior vena cava
 Bile from the caudate lobe drains into both right and left hepatic ducts

Detailed knowledge of Couinard segments is not required for MRCS Part A

 Between the liver lobules are portal canals which contain the portal triad: Hepatic Artery, Portal Vein,
tributary of Bile Duct.

Relations of the liver

Anterior Postero inferiorly

Diaphragm Oesophagus
Xiphoid process Stomach
Duodenum
Hepatic flexure of colon
80
 Right kidney
Gallbladder
Inferior vena cava

Porta hepatis
Location Postero inferior surface, it joins nearly at right angles with the left sagittal fossa, and separates the caudate
lobe behind from the quadrate lobe in front
Transmits  Common hepatic duct
 Hepatic artery
 Portal vein
 Sympathetic and parasympathetic nerve fibres
 Lymphatic drainage of the liver (and nodes)

Ligaments
Falciform ligament  2 layer fold peritoneum from the umbilicus to anterior liver surface
 Contains ligamentum teres (remnant umbilical vein)
 On superior liver surface it splits into the coronary and left triangular ligaments

Ligamentum teres Joins the left branch of the portal vein in the porta hepatis
Ligamentum venosum Remnant of ductus venosus

Arterial supply: Hepatic artery

Venous: Hepatic veins and Portal vein

Nervous supply: Sympathetic and parasympathetic trunks of coeliac plexus

103. A 23 year old man presents with appendicitis. A decision is made to perform an appendicectomy. The
operation commences with a 5cm incision centered on McBurneys point. Which of the following structures
will be encountered first during the dissection?
A. External oblique aponeurosis
B. Internal oblique muscle
C. Transversalis fascia
D. Rectus sheath
E.Peritoneum

Answer: A

The external oblique will be encountered first in this location. The rectus sheath lies more medially.
The external oblique muscle is the most superficial of the abdominal wall muscles. It originates from the 5th to 12th
ribs and passes inferomedially to insert into the linea alba, pubic tubercle and anterior half of the iliac crest. It is
innervated by the thoracoabdominal nerves (T7-T11) and sub costal nerves.

Abdominal wall

The 2 main muscles of the abdominal wall are the rectus abdominis (anterior) and the quadratus lumborum (posterior).
The remaining abdominal wall consists of 3 muscular layers. Each muscle passes from the lateral aspect of the
quadratus lumborum posteriorly to the lateral margin of the rectus sheath anteriorly. Each layer is muscular
posterolaterally and aponeurotic anteriorly.

81
Muscles of abdominal wall
External  Lies most superficially
oblique  Originates from 5th to 12th ribs
 Inserts into the anterior half of the outer aspect of the iliac crest, linea alba and pubic
tubercle
 More medially and superiorly to the arcuate line, the aponeurotic layer overlaps the rectus
abdominis muscle
 The lower border forms the inguinal ligament
 The triangular expansion of the medial end of the inguinal ligament is the lacunar ligament.

Internal oblique  Arises from the thoracolumbar fascia, the anterior 2/3 of the iliac crest and the lateral 2/3 of
the inguinal ligament
 The muscle sweeps upwards to insert into the cartilages of the lower 3 ribs
 The lower fibres form an aponeurosis that runs from the tenth costal cartilage to the body
of the pubis
 At its lowermost aspect it joins the fibres of the aponeurosis of transversus abdominis to
form the conjoint tendon.

Transversus  Innermost muscle

abdominis  Arises from the inner aspect of the costal cartilages of the lower 6 ribs , from the anterior
2/3 of the iliac crest and lateral 1/3 of the inguinal ligament
 Its fibres run horizontally around the abdominal wall ending in an aponeurosis. The upper
part runs posterior to the rectus abdominis. Lower down the fibres run anteriorly only.
 The rectus abdominis lies medially running from the pubic crest and symphysis to insert
into the xiphoid process and 5th, 6th and 7th costal cartilages. The muscles lies in a
aponeurosis as described above.
 Nerve supply: anterior primary rami of T7-12

Surgical notes
During abdominal surgery it is usually necessary to divide either the muscles or their aponeuroses. During a midline
laparotomy it is desirable to divide the aponeurosis. This will leave the rectus sheath intact above the arcuate line and
the muscles intact below it. Straying off the midline will often lead to damage to the rectus muscles, particularly below
the arcuate line where they may often be in close proximity to each other.

104. A 23 year old man is undergoing an inguinal hernia repair. The surgeons mobilise the spermatic cord
and place it in a hernia ring. A small slender nerve is identified superior to the cord. Which of the following
nerves is it most likely to be?

A. Iliohypogastric nerve
B. Pudendal nerve
C. Femoral branch of the genitofemoral nerve

D. Ilioinguinal nerve

E. Obturator nerve

Answer: D

The ilioinguinal nerve passes through the inguinal canal and is the nerve most commonly identified during hernia
surgery. The genitofemoral nerve splits into two branches, the genital branch passes through the inguinal canal within
the cord structures. The femoral branch of the genitofemoral nerve enters the thigh posterior to the inguinal ligament,
lateral to the femoral artery. The iliohypogastric nerve pierces the external oblique aponeurosis above the superficial
inguinal ring.

82
Ilioinguinal nerve

Arises from the first lumbar ventral ramus with the iliohypogastric nerve. It passes inferolaterally through the
substance of psoas major and over the anterior surface of quaratus lumborum. It pierces the internal oblique muscle
and passes deep to the aponeurosis of the external oblique muscle. It enters the inguinal canal and then passes through
the superficial inguinal ring to reach the skin.

Branches

 To supply those muscles of the abdominal wall through which it passes.

 Skin and fascia over the pubic symphysis, superomedial part of the femoral triangle, surface of the scrotum,
root and dorsum of penis or labum majus in females.

105. A 45 year old man is undergoing a low anterior resection for a carcinoma of the rectum. Which of the
following fascial structures will need to be divided to mobilise the mesorectum from the sacrum and
coccyx?
A. Denonvilliers fascia
B. Colles fascia
C. Sibsons fascia
D. Waldeyers fascia
E. None of the above

Answer: D
Fascial layers surrounding the rectum:

 Anteriorly lies the fascia of Denonvilliers

 Posteriorly lies Waldeyers fascia

Waldeyers fascia separates the mesorectum from the sacrum and will need to be divided.

Rectum

The rectum is approximately 12 cm long. It is a capacitance organ. It has both intra and extraperitoneal components.
The transition between the sigmoid colon is marked by the disappearance of the tenia coli.The extra peritoneal rectum
is surrounded by mesorectal fat that also contains lymph nodes. This mesorectal fatty layer is removed surgically
during rectal cancer surgery (Total Mesorectal Excision). The fascial layers that surround the rectum are important
clinical landmarks, anteriorly lies the fascia of Denonvilliers. Posteriorly lies Waldeyers fascia.

Extra peritoneal rectum

 Posterior upper third

 Posterior and lateral middle third
 Whole lower third

Relations
Anteriorly (Males) Rectovesical pouch
Bladder
Prostate
Seminal vesicles
Anteriorly (Females) Recto-uterine pouch (Douglas)
Cervix
Vaginal wall
Posteriorly Sacrum
83
 Coccyx
Middle sacral artery
Laterally Levator ani
Coccygeus

Arterial supply
Superior rectal artery

Venous drainage
Superior rectal vein

Lymphatic drainage

 Mesorectal lymph nodes (superior to dentate line)

 Internal iliac and then para-aortic nodes
 Inguinal nodes (inferior to dentate line)

106. A 73 year old lady is admitted with acute mesenteric ischaemia. A CT angiogram is performed and a
stenotic lesion is noted at the origin of the superior mesenteric artery. At which of the following levels does
this branch from the aorta?
A. L1
B. L2
C. L3
D. L4
E.L5
Answer: A

The SMA leaves the aorta at L1. It passes under the neck of the pancreas prior to giving its first branch the inferior
pancreatico-duodenal artery.

 Branches off aorta at L1

 Supplies small bowel from duodenum (distal to ampulla of vater) through to mid transverse colon
 Takes more oblique angle from aorta and thus more likely to recieve emboli than coeliac axis

Relations of superior mesenteric artery

Superiorly Neck of pancreas
Postero-inferiorly Third part of duodenum
Uncinate process
Posteriorly Left renal vein
Right Superior mesenteric vein

Branches of the superior mesenteric artery

 Inferior pancreatico-duodenal artery

 Jejunal and ileal arcades
 Ileo-colic artery
 Right colic artery
 Middle colic artery

84
107. 72 year old man is undergoing an open abdominal aortic aneurysm repair. The aneurysm is located in a
juxtarenal location and surgical access to the neck of aneurysm is difficult. Which of the following
structures may be divided to improve access?
A.Cisterna chili
B.Transverse colon
C.Left renal vein
D.Superior mesenteric artery
E. Coeliac axis

Answer: C

The left renal vein will be stretched over the neck of the anuerysm in this location and is not infrequently divided. This
adds to the nephrotoxic insult of juxtarenal aortic surgery as a supra renal clamp is also often applied. Deliberate
division of the Cisterna Chyli will not improve access and will result in a chyle leak. Division of the transverse colon
will not help at all and would result in a high risk of graft infection. Division of the SMA is pointless for a juxtarenal
procedure.

Abdominal aorta

Abdominal aortic topography

Origin T12
Termination L4
Posterior relations L1-L4 Vertebral bodies
Anterior relations Lesser omentum
Liver
Left renal vein
Inferior mesenteric vein
Third part of duodenum
Pancreas
Parietal peritoneum
Peritoneal cavity
Right lateral relations Right crus of the diaphragm
Cisterna chyli
Azygos vein
IVC (becomes posterior distally)
Left lateral relations 4th part of duodenum
Duodenal-jejunal flexure
Left sympathetic trunk

108. Your consultant decides to perform an open inguinal hernia repair under local anaesthesia. Which of
the following dermatomal levels will require blockade?
A. T10
B. T12
C. T11
D. S1
E. S2

Answer: B

109. A 53 year old man presents with an inguinal hernia. Which of the following surface landmarks may be
used to identify the location of the deep inguinal ring?
A. Mid point of the inguinal ligament
B. The mid inguinal point
C. The pubic tubercle
D. The medial edge of external oblique
85
 E. 2cm supero medially to the femoral artery
Answer: A

Surface marking of deep inguinal ring = midpoint of inguinal ligament

The surface markings of the deep inguinal ring are a commonly examined topic and should be memorised. The surface
marking is the midpoint of the inguinal ligament. The mid inguinal point is the surface marking for the femoral artery.
The pubic tubercle marks the site of the superficial inguinal ring.

110. At which level is the hilum of the left kidney located?

A. L1
B. L2
C. T12
D. T11
E. L3

Answer: A
Remember L1 ('left one') is the level of the hilum of the left kidney. This is commonly tested in the mrcs exam.

111. You are assisting in an open right adrenalectomy for a large adrenal adenoma. The consultant is
distracted and you helpfully pull the adrenal into the wound to improve the view. Unfortunately this is
followed by brisk bleeding. The vessel responsible for this is most likely to be:
A. Portal vein
B. Phrenic vein
C. Right renal vein
D. Superior mesenteric vein
E. Inferior vena cava

Answer: E
It drains directly via a very short vessel. If the sutures are not carefully tied then it may be avulsed off the IVC. An
injury best managed using a Satinsky clamp and a 6/0 prolene suture.

Adrenal gland anatomy

Anatomy

Location Superomedially to the upper pole of each kidney

Relationships of the right Diaphragm-Posteriorly, Kidney-Inferiorly, Vena Cava-Medially, Hepato-renal pouch
adrenal and bare area of the liver-Anteriorly
Relationships of the left Crus of the diaphragm-Postero- medially, Pancreas and splenic vessels-Inferiorly,
adrenal Lesser sac and stomach-Anteriorly
Superior adrenal arteries- from inferior phrenic artery, Middle adrenal arteries - from
Arterial supply aorta, Inferior adrenal arteries -from renal arteries
Venous drainage of the Via one central vein directly into the IVC
right adrenal
Venous drainage of the left Via one central vein into the left renal vein
adrenal

112. An enthusiastic surgical registrar undertakes his first solo splenectomy. The operation is far more
difficult than anticipated and the registrar leaves a tube drain to the splenic bed at the end of the
procedure. Over the following 24 hours approximately 500ml of clear fluid has entered the drain.
Biochemical testing of the fluid is most likely to reveal:
A.Elevated creatinine
B. Elevated triglycerides
86
 C. Elevated glucagon
D.Elevated amylase
E. None of the above

Answer: D

During splenectomy the tail of the pancreas may be damaged. The pancreatic duct will then drain into the splenic bed,
amylase is the most likely biochemical finding. Glucagon is not secreted into the pancreatic duct.

Splenic anatomy

The spleen is the largest lymphoid organ in the body. It is an intraperitoneal organ, the peritoneal attachments
condense at the hilum where the vessels enter the spleen. Its blood supply is from the splenic artery (derived from the
coeliac axis) and the splenic vein (which is joined by the IMV and unites with the SMV).

 Embryology: derived from mesenchymal tissue

 Shape: clenched fist
 Position: below 9th-12th ribs
 Weight: 75-150g

Relations

 Superiorly- diaphragm
 Anteriorly- gastric impression
 Posteriorly- kidney
 Inferiorly- colon
 Hilum: tail of pancreas and splenic vessels
 Forms apex of lesser sac (containing short gastric vessels)

113. A 56 year old lady is referred to the colorectal clinic with symptoms of pruritus ani. On examination a
polypoidal mass is identified inferior to the dentate line. A biopsy confirms squamous cell carcinoma. To
which of the following lymph node groups will the lesion potentially metastasise?
A. Internal iliac
B. External iliac
C. Mesorectal
D. Inguinal
E.None of the above

Answer: D

Lesions distal to the dentate line drain to the inguinal nodes. Occasionally this will result in the need for a block
dissection of the groin.

114. A 72 year old man develops a hydrocele which is being surgically managed. As part of the procedure
the surgeons divide the tunica vaginalis. From which of the following is this structure derived?
A.Peritoneum
B. External oblique aponeurosis
C. Internal oblique aponeurosis
D.Transversalis fascia
87
 E. Rectus sheath

Answer: A

The tunica vaginalis is derived from peritoneum, it secretes the fluid that fills the hydrocele cavity.

115. A 43 year old lady is donating her left kidney to her sister and the surgeons are harvesting the left
kidney. Which of the following structures will lie most anteriorly at the hilum of the left kidney?
A.Left renal artery
B. Left renal vein
C. Left ureter
D.Left ovarian vein
E. Left ovarian artery

Answer: B

The renal veins lie most anteriorly, then artery and ureter lies posteriorly.

Renal arteries
 The right renal artery is longer than the left renal artery
 The renal vein/artery/pelvis enter the kidney at the hilum

Relations

 Right: Anterior- IVC, right renal vein, the head of the pancreas, and the descending part of the duodenum.
 Left:Anterior- left renal vein, the tail of the pancreas.

Branches

 The renal arteries are direct branches off the aorta (upper border of L2)
 In 30% there may be accessory arteries (mainly left side). Instead of entering the kidney at the hilum, they
usually pierce the upper or lower part of the organ.
 Before reaching the hilum of the kidney, each artery divides into four or five segmental branches (renal vein
anterior and ureter posterior); which then divide within the sinus into lobar arteries supplying each pyramid
and cortex.
 Each vessel gives off some small inferior suprarenal branches to the suprarenal gland, the ureter, and the
surrounding cellular tissue and muscles.

116. A 56 year old lady is due to undergo a left hemicolectomy for carcinoma of the splenic flexure. The
surgeons decide to perform a high ligation of the inferior mesenteric vein. Into which of the following does
this structure usually drain?
A. Portal vein
B. Inferior vena cava
C. Left renal vein
D. Left iliac vein
E. Splenic vein
Answer: E
Beware of ureteric injury in colonic surgery.

The IMV drains into the splenic vein.

Left colon
88
Position

 As the left colon passes inferiorly its posterior aspect becomes extraperitoneal, and the ureter and gonadal
vessels are close posterior relations that may become involved in disease processes
 At a level of L3-4 (variable) the left colon becomes the sigmoid colon and wholly intraperitoneal once again
 The sigmoid colon is a highly mobile structure and may even lie of the right side of the abdomen
 It passes towards the midline, the taenia blend and this marks the transition between sigmoid colon and upper
rectum.

Blood supply

 Inferior mesenteric artery

 However, the marginal artery (from the right colon) contributes and this contribution becomes clinically
signifi cant when the IMA is divided surgically (e.g. During AAA repair)

117. Which of the following statements relating to quadratus lumborum is false?

A.Causes flexion of the thoracic spine
B.Causes the rib cage to be pulled down
C.Innervated by anterior primary rami of T12 and L1-3
D.Attached to the iliac crest
E. Inserts into the 12th rib
Answer: A

The rectus abdominis causes flexion of the thoracic spine.

Attached to the medial iliac crest and iliolumbar ligament.

Inserts: 12th rib
Action: pulls the rib cage inferiorly. Lateral flexion.
Nerve supply: anterior primary rami of T12 and L1-3

118. A 67 year old man is undergoing an angiogram for gastro intestinal bleeding. The radiologist advances
the catheter into the coeliac axis. At what spinal level does this vessel typically arise from the aorta?
A.T10
B. L3
C. L4
D.T12
E. None of the above
Answer: D

The coeliac axis lies at T12, it takes an almost horizontal angle off the aorta. It has three major branches.

Abdominal aortic branches

Branches Level Paired Type

Inferior phrenic T12 (Upper border) Yes Parietal
Coeliac T12 No Visceral
Superior mesenteric L1 No Visceral
Middle suprarenal L1 Yes Visceral
Renal L1-L2 Yes Visceral
Gonadal L2 Yes Visceral
Lumbar L1-L4 Yes Parietal
Inferior mesenteric L3 No Visceral
Median sacral L4 No Parietal
89
Common iliac L4 Yes Terminal

119. During a radical gastrectomy for carcinoma of the stomach the surgeons remove the omentum. What is
the main source of its blood supply?
A.Ileocolic artery
B. Superior mesenteric artery
C. Gastroepiploic artery
D.Middle colic artery
E. Inferior mesenteric artery
Answer: C

The vessels supplying the omentum are the omental branches of the right and left gastro-epiploic arteries. The colonic
vessels are not responsible for the arterial supply to the omentum. The left gastro-epiploic artery is a branch of the
splenic artery and the right gastro-epiploic artery is a terminal branch of the gastroduodenal artery.

Omentum

 The omentum is divided into two parts which invest the stomach. Giving rise to the greater and lesser
omentum. The greater omentum is attached to the inferolateral border of the stomach and houses the gastro-
epiploic arteries.
 It is of variable size but is less well developed in children. This is important as the omentum confers
protection against visceral perforation (e.g. Appendicitis).
 Inferiorly between the omentum and transverse colon is one potential entry point into the lesser sac.
 Several malignant processes may involve the omentum of which ovarian cancer is the most notable.

120. A 45 year old man has a long fermoral line inserted to provide CVP measurements. The catheter passes
from the common iliac vein into the inferior vena cava. At which of the following vertebral levels will this
occur?
A.L5
B.L4
C.S1
D.L3
E. L2
Answer: A

The common iliac veins fuse with the IVC at L5.

Inferior vena cava

Origin

 L5

Path

 Left and right common iliac veins merge to form the IVC.
 Passes right of midline
 Paired segmental lumbar veins drain into the IVC throughout its length
 The right gonadal vein empties directly into the cava and the left gonadal vein generally empties into the left
renal vein.
 The next major veins are the renal veins and the hepatic veins
 Pierces the central tendon of diaphragm at T8

90
  Right atrium

Relations

Anteriorly Small bowel, first and third part of duodenum, head of pancreas, liver and bile duct, right common iliac
artery, right gonadal artery
Posteriorly Right renal artery, right psoas, right sympathetic chain, coeliac ganglion

Levels

Level Vein
T8 Hepatic vein, inferior phrenic vein, pierces diaphragm
L1 Suprarenal veins, renal vein
L2 Gonadal vein
L1-5 Lumbar veins
L5 Common iliac vein, formation of IVC

121. What is the nerve root value of the external urethral sphincter?
A.S4
B. S1, S2, S3
C. S2, S3, S4
D.L3, L4, L5
E. L5, S1, S2
Answer: C

The external urethral sphincter is innervated by branches of the pudendal nerve, therefore the root values are S2, S3,
S4.

122. A 32 year old man is undergoing a splenectomy. Division of which of the following will be necessary
during the procedure?
A. Left crus of diaphragm
B. Short gastric vessels
C. Gerotas fascia
D. Splenic flexure of colon
E. Marginal artery

Answer: B

During a splenectomy the short gastric vessels which lie within the gastrosplenic ligament will need to be divided. The
splenic flexure of the colon may need to be mobilised. However, it will almost never need to be divided, as this is
watershed area that would necessitate a formal colonic resection in the event of division.

123. Two teenagers are playing with an airgun when one accidentally shoots his friend in the abdomen. He is
brought to the emergency department. On examination there is a bullet entry point immediately to the
right of the rectus sheath at the level of the 1st lumbar vertebra. Which of the following structures is most
likely to be injured by the bullet?
A.Head of pancreas
B. Right ureter
C. Right adrenal gland
D.Fundus of the gallbladder
E. Gastric antrum

91
 Answer: D
The fundus of the gallbladder lies at this level and is the most superficially located structure.

124. Which of the following anatomical planes separates the prostate from the rectum?
A.Sibsons fascia
B. Denonvilliers fascia
C. Levator ani muscle
D.Waldeyers fascia
E. None of the above
Answer: B

The Denonvilliers fascia separates the rectum from the prostate. Waldeyers fascia separates the rectum from the
sacrum

Prostate gland

The prostate gland is approximately the shape and size of a walnut and is located inferior to the bladder. It is separated
from the rectum by Denonvilliers fascia and its blood supply is derived from the internal iliac vessels. The internal
sphincter lies at the apex of the gland and may be damaged during prostatic surgery, affected individuals may
complain of retrograde ejaculation.

Summary of prostate gland

Arterial supply Inferior vesical artery (from internal iliac)
Venous drainage Prostatic venous plexus (to paravertebral veins)
Lymphatic Internal iliac nodes
drainage
Innervation Inferior hypogastric plexus
Dimensions  Transverse diameter (4cm)
 AP diameter (2cm)
 Height (3cm)

Lobes  Posterior lobe: posterior to urethra

 Median lobe: posterior to urethra, in between ejaculatory ducts
 Lateral lobes x 2
 Isthmus

Zones  Peripheral zone: subcapsular portion of posterior prostate. Most prostate cancers are
here
 Central zone
 Transition zone
 Stroma

Relations
Anterior Pubic symphysis
Prostatic venous plexus
Posterior Denonvilliers fascia
Rectum
Ejaculatory ducts
Lateral Venous plexus (lies on prostate)
Levator ani (immediately below the puboprostatic ligaments)

92
125. A 56 year old lady is undergoing an adrenalectomy for Conns syndrome. During the operation the
surgeon damages the middle adrenal artery and haemorrhage ensues. From which of the following
structures does this vessel originate?
A.Aorta
B. Renal artery
C. Splenic artery
D.Coeliac axis
E. Superior mesenteric artery
Answer: A

The middle adrenal artery is usually a branch of the aorta, the lower adrenal artery typically arises from the renal
vessels.

126. A 24 year old man falls and lands astride a manhole cover. He suffers from a injury to the anterior
bulbar urethra. Where will the extravasated urine tend to collect?
A.Lesser pelvis
B. Connective tissue of the scrotum
C. Deep perineal space
D.Ischiorectal fossa
E. Posterior abdominal wall

Answer: B

This portion of the urethra is contained between the perineal membrane an the membranous layer of the superficial
fascia. As these are densely adherent to the ischiopubic rami, extravasated urine cannot pass posteriorly because the 2
layers are continuous around the superficial transverse perineal muscles.

Lower genitourinary tract trauma

 Most bladder injuries occur due to blunt trauma

 85% associated with pelvic fractures
 Easily overlooked during assessment in trauma
 Up to 10% of male pelvic fractures are associated with urethral or bladder injuries

Types of injury

Urethral injury  Mainly in males

 Blood at the meatus (50% cases)
 There are 2 types:

i.Bulbar rupture
- most common
- straddle type injury e.g. bicycles
- triad signs: urinary retention, perineal haematoma, blood at the meatus
ii. Membranous rupture
- can be extra or intraperitoneal
- commonly due to pelvic fracture
- Penile or perineal oedema/ hematoma
- PR: prostate displaced upwards (beware co-existing retroperitoneal haematomas
as they may make examination difficult)

- Investigation: ascending urethrogram

- Management: suprapubic catheter (surgical placement, not percutaneously)

93
External genitalia injuries (i.e.,  Secondary to injuries caused by penetration, blunt trauma, continence- or
the penis and the scrotum) sexual pleasure-enhancing devices, and mutilation

Bladder injury  rupture is intra or extraperitoneal

 presents with haematuria or suprapubic pain
 history of pelvic fracture and inability to void: always suspect bladder or
urethral injury
 inability to retrieve all fluid used to irrigate the bladder through a Foley
catheter indicates bladder injury
 investigation- IVU or cystogram
 management: laparotomy if intraperitoneal, conservative if
extraperitoneal

127. A 73 year old man presents with symptoms of mesenteric ischaemia. As part of his diagnostic work up a
diagnostic angiogram is performed .The radiologist is attempting to cannulate the coeliac axis from the
aorta. At which of the following vertebral levels does this is usually originate?
A. T10
B. L2
C. L3
D. T8
E. T12
Answer: E

Coeliac trunk branches:

Left Hand Side (LHS): Left gastric, Hepatic, Splenic

The coeliac axis branches off the aorta at T12.

Coeliac axis

Relations

Anteriorly Lesser omentum

Right Right coeliac ganglion and caudate process of liver
Left Left coeliac ganglion and gastric cardia
Inferiorly Upper border of pancreas and renal vein

128. During a liver resection a surgeon performs a pringles manoeuvre to control bleeding. Which of the
following structures will lie posterior to the epiploic foramen at this level?
A. Hepatic artery
B. Cystic duct
C. Greater omentum
D. Superior mesenteric artery
E. Inferior vena cava
Answer: E
Bleeding from liver trauma or a difficult cholecystectomy can be controlled with a vascular clamp applied at the
epiploic foramen.

The epiploic foramen has the following boundaries:

Anteriorly: (in the free edge of the lesser omentum): Bile duct to the right, portal vein behind and hepatic artery to the
left.

94
Posteriorly: Inferior vena cava
Inferiorly:1st part of the duodenum
Superiorly: Caudate process of the liver

129. Which of the following is not considered a major branch of the descending thoracic aorta?
A.Bronchial artery
B. Mediastinal artery
C. Inferior thyroid artery
D.Posterior intercostal artery
E. Oesophageal artery

Answer: C

The inferior thyroid artery is usually derived from the thyrocervical trunk, a branch of the subclavian artery.

Thoracic aorta

Origin T4
Terminates T12
Relations  Anteriorly (from top to bottom)-root of the left lung, the pericardium, the oesophagus, and the
diaphragm
 Posteriorly-vertebral column, azygos vein
 Right- hemiazygos veins, thoracic duct
 Left- left pleura and lung

Branches  Lateral segmental branches: Posterior intercostal arteries

 Lateral visceral: Bronchial arteries supply bronchial walls and lung excluding the alveoli
 Midline branches: Oesophageal arteries

130. During a right hemicolectomy the caecum is mobilised. As the bowel is retracted medially a vessel is
injured, posterior to the colon. Which of the following is the most likely vessel?
A.Right colic artery
B. Inferior vena cava
C. Aorta
D.External iliac artery
E. Gonadal vessels

Answer: E

The gonadal vessels and ureter are important posterior relations that are at risk during a right hemicolectomy.

Caecum

Location  Proximal right colon below the ileocaecal valve

 Intraperitoneal

Posterior relations  Psoas

 Iliacus
 Femoral nerve
 Genitofemoral nerve
 Gonadal vessels

Anterior relations Greater omentum

Arterial supply Ileocolic artery
Lymphatic drainage Mesenteric nodes accompany the venous drainage
95
The caecum is the most distensible part of the colon and in complete large bowel obstruction with a competent
ileocaecal valve the most likely site of eventual perforation.

131. A 66 year old man is undergoing a left nephro-ureterectomy. The surgeons remove the ureter, which of
the following is responsible for the blood supply to the proximal ureter?
A.Branches of the renal artery
B. External iliac artery
C. Internal iliac artery
D.Direct branches from the aorta
E. Common iliac artery
Answer: A

The proximal ureter is supplied by branches from the renal artery.

132. Which of the following is not a content of the porta hepatis?

A. Portal vein
B. Hepatic artery
C. Cystic duct
D. Hepatic lymph nodes
E. None of the above

Answer: C
The cystic duct lies outside the porta hepatis and is an important landmark in laparoscopic cholecystectomy. The
structures in the porta hepatis are:

 Portal vein
 Hepatic artery
 Common hepatic duct

These structures divide immediately after or within the porta hepatis to supply the functional left and right lobes of the
liver.
The porta hepatis is also surrounded by lymph nodes, that may enlarge to produce obstructive jaundice and
parasympathetic nervous fibres that travel along vessels to enter the liver.

133. A man is stabbed in the abdomen during a fight. He is brought to the emergency department. On
examination there is a laceration in the anterior abdominal wall immediately lateral to the left rectus
abdominis muscle on a level with the upper border of the first lumbar vertebra. Which of the following
structures is most likely to have been injured?

A. Head of the pancreas

B. Gastric antrum

C. Spleen

D. Right lobe of the liver

E. Superior mesenteric artery

Answer: C

The spleen is the most likely target in this instance.

134. A surgeon is due to perform a laparotomy for perforated duodenal ulcer. An upper midline incision is
to be performed. Which of the following structures is the incision most likely to divide?
A.Rectus abdominis muscle
96
 B.External oblique muscle
C.Linea alba
D.Internal oblique muscle
E. None of the above

Answer: C

Upper midline abdominal incisions will involve the division of the linea alba. Division of muscles will not usually
improve access in this approach and they would not be routinely encountered during this incision.

Abdominal incisions

Theme in January 2012 exam

Midline incision  Commonest approach to the abdomen

 Structures divided: linea alba, transversalis fascia, extraperitoneal fat, peritoneum (avoid
falciform ligament above the umbilicus)
 Bladder can be accessed via an extraperitoneal approach through the space of Retzius

Paramedian  Parallel to the midline (about 3-4cm)

incision  Structures divided/retracted: anterior rectus sheath, rectus (retracted), posterior rectus
sheath, transversalis fascia, extraperitoneal fat, peritoneum
 Incision is closed in layers

Battle  Similar location to paramedian but rectus displaced medially (and thus denervated)
 Now seldom used

Kocher's Incision under right subcostal margin e.g. Cholecystectomy (open)

Lanz Incision in right iliac fossa e.g. Appendicectomy
Gridiron Oblique incision centered over McBurneys point- usually appendicectomy (less cosmetically
acceptable than Lanz
Gable Rooftop incision
Pfannenstiel's Transverse supra pubic, primarily used to access pelvic organs
McEvedy's Groin incision e.g. Emergency repair strangulated femoral hernia
Rutherford Extraperitoneal approach to left or right lower quadrants. Gives excellent access to iliac vessels
Morrison and is the approach of choice for first time renal transplantation.

135. A 59 year old man is undergoing an extended right hemicolectomy for a carcinoma of the hepatic
flexure of the colon. The surgeons divide the middle colonic vein close to its origin. Into which of the
following structures does this vessel primarily drain?
A.Superior mesenteric vein
B. Portal vein
C. Inferior mesenteric vein
D.Inferior vena cava
E. Ileocolic vein

Answer: A

97
The middle colonic vein drains into the SMV, if avulsed during mobilisation then dramatic haemorrhage can occur
and be difficult to control.

Transverse colon

 The right colon undergoes a sharp turn at the level of the hepatic flexure to become the transverse colon.
 At this point it also becomes intraperitoneal.
 It is connected to the inferior border of the pancreas by the transverse mesocolon.
 The greater omentum is attached to the superior aspect of the transverse colon from which it can easily be
separated. The mesentery contains the middle colic artery and vein. The greater omentum remains attached to
the transverse colon up to the splenic flexure. At this point the colon undergoes another sharp turn.

Relations
Superior Liver and gall-bladder, the greater curvature of the stomach, and the lower end of the spleen
Inferior Small intestine
Anterior Greater omentum
Posterior From right to left with the descending portion of the duodenum, the head of the pancreas, convolutions of
the jejunum and ileum, spleen

136. A 23 year old man is stabbed in the chest approximately 10cm below the right nipple. In the emergency
department a abdominal ultrasound scan shows a large amount of intraperitoneal blood. Which of the
following statements relating to the likely site of injury is untrue?
A.Part of its posterior surface is devoid of peritoneum.
B. The quadrate lobe is contained within the functional right lobe.
C. Its nerve supply is from the coeliac plexus.
D.The hepatic flexure of the colon lies posterio-inferiorly.
E. The right kidney is closely related posteriorly.

Answer: B

The right lobe of the liver is the most likely site of injury. Therefore the answer is B as the quadrate lobe is
functionally part of the left lobe of the liver. The liver is largely covered in peritoneum. Posteriorly there is an area
devoid of peritoneum (the bare area of the liver). The right lobe of the liver has the largest bare area (ans is larger
thant the left lobe).

137. Which of the following nerves passes through the greater sciatic foramen and innervates the perineum?
A. Pudendal
B. Sciatic
C. Superior gluteal
D. Inferior gluteal
E. Posterior cutaneous nerve of the thigh
Answer: A
3 divisions of the pudendal nerve:

 Rectal nerve
 Perineal nerve
 Dorsal nerve of penis/ clitoris

All these pass through the greater sciatic foramen.

The pudendal nerve innervates the perineum. It passes between piriformis and coccygeus medial to the sciatic nerve.

98
Gluteal region

Gluteal muscles

 Gluteus maximus: inserts to gluteal tuberosity of the femur and iliotibial tract
 Gluteus medius: attach to lateral greater trochanter
 Gluteus minimis: attach to anterior greater trochanter
 All extend and abduct the hip

Deep lateral hip rotators

 Piriformis
 Gemelli
 Obturator internus
 Quadratus femoris

Nerves
Superior gluteal nerve (L5, S1)  Gluteus medius
 Gluteus minimis
 Tensor fascia lata

Inferior gluteal nerve Gluteus maximus

Damage to the superior gluteal nerve will result in the patient developing a Trendelenberg gait. Affected patients are
unable to abduct the thigh at the hip joint. During the stance phase, the weakened abductor muscles allow the pelvis to
tilt down on the opposite side. To compensate, the trunk lurches to the weakened side to attempt to maintain a level
pelvis throughout the gait cycle. The pelvis sags on the opposite side of the lesioned superior gluteal nerve.

138. A 53 year old man is undergoing a left hemicolectomy for carcinoma of the descending colon. From
which embryological structure is this region of the gastrointestinal tract derived?

A. Vitellino-intestinal duct

B. Hind gut

C. Mid gut

D. Fore gut

E. Woolffian duct

Answer: B

The left colon is embryologically part of the hind gut. Which accounts for its separate blood supply via the IMA.

139. You excitedly embark on your first laparoscopic cholecystectomy and during the operation the
anatomy of Calots triangle is more hostile than anticipated. Whilst trying to apply a haemostatic clip you
avulse the cystic artery. This is followed by brisk haemorrhage. From which source is this most likely to
originate ?
A.Right hepatic artery
B. Portal vein
C. Gastroduodenal artery
D.Liver bed
99
 E. Common hepatic artery

Answer: A

The cystic artery is a branch of the right hepatic artery. There are recognised variations in the anatomy of the blood
supply to the gallbladder. However, the commonest situation is for the cystic artery to branch from the right hepatic
artery.

140. A 43 year old man suffers a pelvic fracture which is complicated by an injury to the junction of the
membranous urethra to the bulbar urethra. In which of the following directions is the extravasated urine
most likely to pass?
A.Posteriorly into extra peritoneal tissues
B. Laterally into the buttocks
C. Into the abdomen
D.Anteriorly into the connective tissues surrounding the scrotum
E. None of the above

Answer: D

The superficial perineal pouch is a compartment bounded superficially by the superficial perineal fascia, deep by the
perineal membrane (inferior fascia of the urogenital diaphragm), and laterally by the ischiopubic ramus. It contains the
crura of the penis or clitoris, muscles, viscera, blood vessels, nerves, the proximal part of the spongy urethra in males,
and the greater vestibular glands in females.
When urethral rupture occurs as in this case the urine will tend to pass anteriorly because the fascial condensations
will prevent lateral and posterior passage of the urine.

Urogenital triangle

The urogenital triangle is formed by the:

 Ischiopubic inferior rami

 Ischial tuberosities

A fascial sheet is attached to the sides, forming the inferior fascia of the urogenital diaphragm.

It transmits the urethra in males and both the urethra and vagina in females. The membranous urethra lies deep this
structure and is surrounded by the external urethral sphincter.

Superficial to the urogenital diaphragm lies the superficial perineal pouch. In males this contains:

 Bulb of penis
 Crura of the penis
 Superficial transverse perineal muscle
 Posterior scrotal arteries
 Posterior scrotal nerves

In females the internal pudendal artery branches to become the posterior labial arteries in the superficial perineal
pouch.

141. Which of the following statements relating to the gastroduodenal artery is untrue?
100
 A.It runs posterior to the 1st part of the duodenum
B. It originates from the common hepatic artery
C. The bile duct is a close relation
D.The portal vein is closely related anteriorly
E. It terminates as the gastro-epiploic and superior pancreaticoduodenal artery

Answer: D

The portal vein is located posteriorly and then separated from the artery by the pancreas. The anatomy of this artery is
important as it is a site of bleeding in posteriorly sited duodenal ulcers. At laparotomy for bleeding from this vessel,
the relation of the bile duct should be remembered less it be caught inadvertently in a stitch.

Gastroduodenal artery

Supplies
Pylorus, proximal part of the duodenum, and indirectly to the pancreatic head (via the anterior and posterior superior
pancreaticoduodenal arteries)

Path
Most commonly arises from the common hepatic artery of the coeliac trunk
Terminates by bifurcating into the right gastroepiploic artery and the superior pancreaticoduodenal artery

142. Through which of the following foramina does the genital branch of the genitofemoral nerve exit the
abdominal cavity?
A. Superficial inguinal ring
B. Sciatic notch
C. Obturator foramen
D. Femoral canal
E. Deep inguinal ring

Answer: E

The genitofemoral nerve divides into two branches as it approaches the inguinal ligament. The genital branch passes
anterior to the external iliac artery through the deep inguinal ring into the inguinal canal. It communicates with the
ilioinguinal nerve in the inguinal canal (though this is seldom of clinical significance).

143. A 63 year old lady is diagnosed as having an endometrial carcinoma arising from the uterine body. To
which nodal region will the tumour initially metastasise?
A.Para aortic nodes
B. Iliac lymph nodes
C. Inguinal nodes
D.Pres sacral nodes
E. Mesorectal lymph nodes

Answer: B

Tumours of the uterine body will tend to spread to the iliac nodes initially. When the tumour is expanding to cross
different nodal margins this is of considerable clinical significance if nodal clearance is performed during a Wertheims
type hysterectomy.

Lymphatic drainage of the uterus and cervix

101
  The uterine fundus has a lymphatic drainage that runs with the ovarian vessels and may thus drain to the para-
aortic nodes. Some drainage may also pass along the round ligament to the inguinal nodes.
 The body of the uterus drains through lymphatics contained within the broad ligament to the iliac lymph
nodes.
 The cervix drains into three potential nodal stations; laterally through the broad ligament to the external iliac
nodes, along the lymphatics of the uterosacral fold to the presacral nodes and posterolaterally along
lymphatics lying alongside the uterine vessels to the internal iliac nodes.

144. Which of the following structures is not located in the superficial perineal space in females?
A.Posterior labial arteries
B. Pudendal nerve
C. Superficial transverse perineal muscle
D.Greater vestibular glands
E. None of the above

Answer: B

The pudendal nerve is located in the deep perineal space and then branches to innervate more superficial structures.

145. Which of the following is not a branch of the hepatic artery?

A.Pancreatic artery
B.Cystic artery
C.Right gastric artery
D.Superior Pancreaticoduodenal artery
E. Right Gastroepiploic artery

Answer: A

The pancreatic artery is a branch of the splenic artery.

146. A 56 year old man is undergoing a nephrectomy. The surgeons divide the renal artery. At what level do
these usually branch off the abdominal aorta?
A.T9
B. L2
C. L3
D.T10
E. L4

Answer: B

The renal arteries usually branch off the aorta on a level with L2.

147. A 22 year old man presents with appendicitis. At operation the appendix is retrocaecal and difficult to
access. Division of which of the following anatomical structures should be undertaken?
A.Ileocolic artery
B. Mesentery of the caecum
C. Gonadal vessels
D.Lateral peritoneal attachments of the caecum
E. Right colic artery

Answer: D

The commonest appendiceal location is retrocaecal. Those struggling to find it at operation should trace the tenia to
the caecal pole where the appendix is located. If it cannot be mobilised easily then division of the lateral caecal
peritoneal attachments (as for a right hemicolectomy) will allow caecal mobilisation and facilitate the procedure.

102
148. A 56 year old man is left impotent following an abdomino-perineal excision of the colon and rectum.
What is the most likely explanation?
A.Psychosexual issues related to an end colostomy
B. Damage to the sacral venous plexus during total mesorectal excision
C. Damage to the left ureter during sigmoid mobilisation
D.Damage to the hypogastric plexus during mobilisation of the inferior mesenteric artery
E. Damage to the internal iliac artery during total mesorectal excision

Answer: D

Autonomic nerve injury is the most common cause.

Nerve lesions during surgery

A variety of different procedures carry the risk of iatrogenic nerve injury. These are important not only from the
patients perspective but also from a medicolegal standpoint.

The following operations and their associated nerve lesions are listed here:

 Posterior triangle lymph node biopsy and accessory nerve lesion.

 Lloyd Davies stirrups and common peroneal nerve.
 Thyroidectomy and laryngeal nerve.
 Anterior resection of rectum and hypogastric autonomic nerves.
 Axillary node clearance; long thoracic nerve, thoracodorsal nerve and intercostobrachial nerve.
 Inguinal hernia surgery and ilioinguinal nerve.
 Varicose vein surgery- sural and saphenous nerves.
 Posterior approach to the hip and sciatic nerve.
 Carotid endarterectomy and hypoglossal nerve.

There are many more, with sound anatomical understanding of the commonly performed procedures the incidence of
nerve lesions can be minimised. They commonly occur when surgeons operate in an unfamiliar tissue plane or by
blind placement of haemostats (not recommended).

149. A 73 year old man is due to undergo a radical prostatectomy for carcinoma of the prostate gland. To
which of the following lymph nodes will the tumour drain primarily?
A.Para aortic
B.Internal iliac
C.Superficial inguinal
D.Meso rectal
E. None of the above
Answer: B

The prostate lymphatic drainage is primarily to the internal iliac nodes and also the sacral nodes. Although internal
iliac is the first site.

150. A 28 year old man has sustained a non salvageable testicular injury to his left testicle. The surgeon
decides to perform an orchidectomy and divides the left testicular artery. From which of the following does
this vessel originate?
A.Abdominal aorta
B. Internal iliac artery
C. Inferior epigastric artery
D.Inferior vesical artery
E. External iliac artery

103
 Answer: A

The testicular artery is a branch of the abdominal aorta.

151. A 44 year old man is stabbed in the back and the left kidney is injured. A haematoma forms, which of
the following fascial structures will contain the haematoma?
A.Waldeyers fascia
B. Sibsons fascia
C. Bucks fascia
D.Gerotas fascia
E. Denonvilliers fascia
Answer: D

152. Which of the following structures is not directly related to the right adrenal gland?
A. Diaphragm posteriorly
B. Bare area of the liver anteriorly
C. Right renal vein
D. Inferior vena cava
E. Hepato-renal pouch
Answer: C

The right renal vein is very short and lies more inferiorly.

153. Mobilisation of the left lobe of the liver will facilitate surgical access to which of the following?
A.Abdominal oesophagus
B. Duodenum
C. Right colic flexure
D.Right kidney
E. Pylorus of stomach

Answer: A

The fundus of the stomach is a posterior relation. The pylorus lies more inferolaterally. During a total gastrectomy
division of the ligaments holding the left lobe of the liver will facilitate access to the proximal stomach and abdominal
oesophagus. This manoeuvre is seldom beneficial during a distal gastrectomy.

154. A 32 year old man presents with an inguinal hernia and undergoes an open surgical repair. The
surgeons decide to place a mesh on the posterior wall of the inguinal canal to complete the repair, which of
the following structures will lie posterior to the mesh?
A. Transversalis fascia
B. External oblique
C. Rectus abdominis
D. Obturator nerve
E. None of the above
Answer: A

Inguinal canal walls: 'MALT: 2M, 2A, 2L, 2T':

Starting from superior, moving around in order to posterior:

Superior wall (roof): 2 Muscles:Internal oblique, transversus abdominis
Anterior wall: 2 Aponeuroses: Aponeurosis of external oblique, Aponeurosis of internal oblique
Lower wall (floor): 2 Ligaments: Inguinal Ligament, Lacunar Ligament Posterior wall: 2Ts: Transversalis fascia,
Conjoint Tendon
104
This is actually quite a straightforward question. It is simply asking for the structure that forms the posterior wall of
the inguinal canal. This is composed of the transversalis fascia, the conjoint tendon and more laterally the deep
inguinal ring.

155. A 22 year old man is involved in a fight outside a nightclub. He is stabbed in the back, on the left side,
approximately 3cm below the 12th rib in the mid scapular line. The structure most likely to be injured first
as a result is the:
A.Spleen
B. Left kidney
C. Left adrenal gland
D.Left ureter
E. None of the above

Answer: B

The left kidney lies in this location and is the most likely structure to be injured. The Spleen lies more superiorly, and
the left adrenal and ureter are unlikely to be injured in isolation.

156. A 23 year old man is undergoing an hernia repair and the mesh is to be sutured to the inguinal
ligament. From which of the following does the inguinal ligament arise?
A. Transversus abdominis fascia
B. Internal oblique
C. Rectus sheath
D. Rectus abdominis muscle
E. External oblique aponeurosis

Answer: E

The inguinal ligament is formed by the external oblique aponeurosis. It runs from the pubic tubercle to the anterior
superior iliac spine.

Abdominal wall

The 2 main muscles of the abdominal wall are the rectus abdominis (anterior) and the quadratus lumborum (posterior).
The remaining abdominal wall consists of 3 muscular layers. Each muscle passes from the lateral aspect of the
quadratus lumborum posteriorly to the lateral margin of the rectus sheath anteriorly. Each layer is muscular
posterolaterally and aponeurotic anteriorly.

157. A 56 year old man is undergoing a high anterior resection. Which of the following structures is at
greatest risk of injury in this procedure?
A.Superior mesenteric artery
B. Left ureter
C. External iliac vein
D.External iliac artery
E. Inferior vena cava

Answer: B

A careless surgeon may damage all of these structures. However, the structure at greatest risk and most frequently
encountered is the left ureter.

105
158. A 42 year old lady undergoes a difficult cholecystectomy and significant bleeding is occurring. The
surgeons place a vascular clamp transversely across the anterior border of the epiploic foramen. Which of
the following structures will be occluded in this manoeuvre?

A. Cystic artery
B. Cystic duct

C. Left gastric artery

D. Portal vein
E. None of the above
Answer: D

During liver surgery bleeding may be controlled using a Pringles manoeuvre, this involves placing a vascular clamp
across the anterior aspect of the epiploic foramen. The portal vein, hepatic artery and common bile duct are occluded.

159. A 56 year old lady undergoes a Hartmans style resection of the sigmoid colon, with ligation of the
vessels close to the colon. Which of the following vessels will be responsible to supplying the rectal stump
directly?
A.Superior mesenteric artery
B. Middle colic artery
C. Superior rectal artery
D.Inferior mesenteric artery
E. External iliac artery

Answer: C

This question is addressing the blood supply to the rectum. Which is supplied by the superior rectal artery. High
ligation of the IMA may compromise this structure. However, the question states that during the Hartmans procedure
the vessels were ligated close to the bowel. Implying that the superior rectal was preserved.

160. On inspecting the caecum, which of the following structures is most likely to be identified at the point at
which all the tenia coli converge?
A.Gonadal vessels
B. Appendix base
C. Appendix tip
D.Ileocaecal valve
E. Ileocolic artery

Answer: B

The tenia coli converge at the base of the appendix.

161. Which of the following structures lies most posteriorly at the porta hepatis?
A. Cystic artery
B. Common hepatic artery
C. Left hepatic artery
D. Portal vein
E. Common bile duct

Answer: D

106
The portal vein is the most posterior structure at the porta hepatis.The common bile duct is a continuation of the
common hepatic duct and is formed by the union of the common hepatic duct and the cystic duct.

162. A 76 year old man is undergoing an abdominal aortic aneurysm repair. The surgeons occlude the aorta
with two clamps, the inferior clamp being placed at the point of aortic bifurcation. Which of the following
vertebral bodies will lie posterior to the clamp at this level?
A. L1
B. T10
C. L4
D. L5
E. L2

Answer: C

The aorta bifurcates at L4. An important landmark that is tested frequently.

163. Which of the following statements relating to the greater omentum is false?
A.It is less well developed in children under 5.
B. It has no relationship to the lesser sac.
C. It contains the gastroepiploic arteries.
D.Has an attachment to the transverse colon.
E. It may be a site of metastatic disease in ovarian cancer.

Answer: B

It is connected with the lesser sac and the transverse colon. This plane is entered when performing a colonic resection.
It is a common site of metastasis in many visceral malignancies.

164. A 48 year old man with newly diagnosed hypertension is found to have a phaeochromocytoma of the
left adrenal gland and is due to undergo a laparoscopic left adrenalectomy. Which of the following
structures is not directly related to the left adrenal gland?
A.Crus of the diaphragm
B. Lesser curvature of the stomach
C. Splenic hilum
D.Pancreas
E. Splenic artery
Answer: C

The splenic hilum lies more laterally and is therefore not a direct relation of the left adrenal gland.

Adrenal gland anatomy

Anatomy

Location Superomedially to the upper pole of each kidney

Relationships of the right Diaphragm-Posteriorly, Kidney-Inferiorly, Vena Cava-Medially, Hepato-renal pouch
adrenal and bare area of the liver-Anteriorly
Relationships of the left Crus of the diaphragm-Postero- medially, Pancreas and splenic vessels-Inferiorly,
adrenal Lesser sac and stomach-Anteriorly
Superior adrenal arteries- from inferior phrenic artery, Middle adrenal arteries - from
Arterial supply aorta, Inferior adrenal arteries -from renal arteries
Venous drainage of the Via one central vein directly into the IVC
right adrenal
Venous drainage of the left Via one central vein into the left renal vein
adrenal

107
165. An 18 year old boy is undergoing an appendicectomy for appendicitis. At which of the following
locations is the appendix most likely to be found?
A.Pre ileal
B. Pelvic
C. Retrocaecal
D.Post ileal
E. None of the above

Answer: C

Most appendixes lie in the retrocaecal position. If a retrocaecal appendix is difficult to remove then mobilisation of the
right colon significantly improves access.

166. A 56 year old man is undergoing a pancreatectomy for carcinoma. During resection of the gland which
of the following structures will the surgeon not encounter posterior to the pancreas itself?
A.Left crus of the diaphragm
B. Superior mesenteric vein
C. Common bile duct
D.Portal vein
E. Gastroduodenal artery

Answer: E

The gastroduodenal artery lies anterior to the pancreas.

167. A 55 year old man is admitted with a brisk haematemesis. He is taken to the endoscopy department and
an upper GI endoscopy is performed by the gastroenterologist. He identifies an ulcer on the posterior
duodenal wall and spends an eternity trying to control the bleeding with all the latest haemostatic
techniques. He eventually asks the surgeons for help. A laparotomy and anterior duodenotomy are
performed, as the surgeon opens the duodenum a vessel is spurting blood into the duodenal lumen. From
which of the following does this vessel arise?
A.Left gastric artery
B. Common hepatic artery
C. Right hepatic artery
D.Superior mesenteric artery
E. Splenic artery

Answer: B

The vessel will be the gastroduodenal artery, this arises from the common hepatic artery.

168. Which of the following is not a content of the rectus sheath?

A.Pyramidalis
B.Superior epigastric artery
C.Inferior epigastric vein
D.Internal iliac artery
E. Rectus abdominis

Answer: D

108
The rectus sheath also contains:
superior epigastric vein
inferior epigastric artery

169. Which of the following vessels does not drain directly into the inferior vena cava?
A.Superior mesenteric vein
B.Right common iliac
C.Right hepatic vein
D.Left hepatic vein
E. Right testicular vein

Answer: A

The superior mesenteric vein drains into the portal vein. The right and left hepatic veins drain into it directly, this can
account for major bleeding in more extensive liver shearing type injuries.

170. A 17 year old male has a suspected testicular torsion and the scrotum is to be explored surgically. The
surgeon incises the skin and then the dartos muscle. What is the next tissue layer that will be encountered
during the dissection?
A.Visceral layer of the tunica vaginalis
B. Cremasteric fascia
C. Parietal layer of the tunica vaginalis
D.External spermatic fascia
E. Internal spermatic fascia
Answer: D

The layers that will be encountered are (in order):

1. Skin; 2. Dartos fascia and muscle; 3. External spermatic fascia; 4. Cremasteric muscle and fascia; 5. Internal
spermatic fascia; 6. Parietal layer of the tunica vaginalis

The layers of the spermatic cord and scrotum are a popular topic in the MRCS exam.

171. A 19 year old man undergoes an open inguinal hernia repair. The cord is mobilised and the deep
inguinal ring identified. Which of the following structures forms its lateral wall?
A.External oblique aponeurosis
B.Transversalis fascia
C.Conjoint tendon
D.Inferior epigastric artery
E. Inferior epigastric vein
Answer: B

The transversalis fascia forms the superolateral edge of the deep inguinal ring. The epigastric vessels form its
inferomedial wall.

172. A 34 year old lady presents with symptoms of faecal incontinence. Ten years previously she gave birth
to a child by normal vaginal delivery. Injury to which of the following nerves is most likely to account for
this process?
A.Genitofemoral
B. Ilioinguinal
C. Pudendal
D.Hypogastric autonomic nerve
E. Obturator

109
 Answer: C

Damage to the pudendal nerve is classically associated with faecal incontinence and it is for this reason that sacral
neuromodulation is a popular treatment for the condition. Injury to the hypogastric autonomic nerves is an aetiological
factor in the development of constipation.

Pudendal nerve

The pudendal nerve arises from nerve roots S2, S3 and S4 and exits the pelvis through the greater sciatic foramen. It
re-enters the pelvis through the lesser sciatic foramen. It travels inferior to give innervation to the anal sphincters and
external urethral sphincter. It also provides cutaneous innervation to the region of perineum surrounding the anus and
posterior vulva.

Traction and compression of the pudendal nerve by the foetus in late pregnancy may result in late onset pudendal
neuropathy which may be part of the process involved in the development of faecal incontinence.

173. A 56 year old man undergoes an abdomino-perineal excision of the rectum. He is assessed in the
outpatient clinic post operatively. His wounds are well healed. However, he complains of impotence. Which
of the following best explains this problem?
A. Sciatic nerve injury
B. Damage to the internal iliac artery
C. Damage to the hypogastric nerve plexus
D. Damage to the vas
E. Damage to the genitofemoral nerve

Answer: C

Autonomic supply to the penis is via the hypogastric plexus of nerves. These may be damaged during mobilisation of
the proximal rectum from the sacrum and result in impotence post operatively. The addition of radiotherapy greatly
increases the risks of impotence following surgery.

Penile erection

Physiology of erection
Autonomic  Sympathetic nerves originate from T11-L2 and parasympathetic nerves from S2-4 join to form
pelvic plexus.
 Parasympathetic discharge causes erection, sympathetic discharge causes ejaculation and
detumescence.

Somatic Supplied by dorsal penile and pudendal nerves. Efferent signals are relayed from Onufs nucleus (S2-4)
nerves to innervate ischiocavernosus and bulbocavernosus muscles.

Autonomic discharge to the penis will trigger the veno-occlusive mechanism which triggers the flow of arterial blood
into the penile sinusoidal spaces. As the inflow increases the increased volume in this space will secondarily lead to
compression of the subtunical venous plexus with reduced venous return. During the detumesence phase the arteriolar
constriction will reduce arterial inflow and thereby allow venous return to normalise.

Priapism
Prolonged unwanted erection, in the absence of sexual desire, lasting more than 4 hours.

Classification of priaprism

110
Low flow priaprism Due to veno-occlusion (high intracavernosal pressures).

 Most common type

 Often painful
 Often low cavernosal flow
 If present for >4 hours requires emergency treatment

High flow priaprism Due to unregulated arterial blood flow.

 Usually presents as semi rigid painless erection

Recurrent priaprism Typically seen in sickle cell disease, most commonly of high flow type.

Causes

 Intracavernosal drug therapies (e.g. for erectile dysfunction>

 Blood disorders such as leukaemia and sickle cell disease
 Neurogenic disorders such as spinal cord transection
 Trauma to penis resulting in arterio-venous malformations

Tests

 Exclude sickle cell/ leukaemia

 Consider blood sampling from cavernosa to determine whether high or low flow (low flow is often hypoxic)

Management

 Ice packs/ cold showers

 If due to low flow then blood may be aspirated from copora or try intracavernosal alpha adrenergic agonists.
 Delayed therapy of low flow priaprism may result in erectile dysfunction.

174. Which of the following is not a branch of the descending abdominal aorta?
A. Inferior mesenteric artery
B. Inferior phrenic artery
C. Superior mesenteric artery
D. Superior phrenic artery
E. Renal artery
Answer: D
Mnemonic for the Descending abdominal aorta branches from diaphragm to iliacs:

'Prostitutes Cause Sagging Swollen Red Testicles [in men] Living In Sin':

Phrenic [inferior]
Celiac
Superior mesenteric
Suprarenal [middle]
Renal
Testicular ['in men' only]
Lumbars
Inferior mesenteric
Sacral

111
 
The superior phrenic artery branches from the aorta in the thorax.
 Abdominal aortic branches

Branches Level Paired Type

Inferior phrenic T12 (Upper border) Yes Parietal
Coeliac T12 No Visceral
Superior mesenteric L1 No Visceral
Middle suprarenal L1 Yes Visceral
Renal L1-L2 Yes Visceral
Gonadal L2 Yes Visceral
Lumbar L1-L4 Yes Parietal
Inferior mesenteric L3 No Visceral
Median sacral L4 No Parietal
Common iliac L4 Yes Terminal

175. A 23 year old man is admitted with a suspected ureteric colic. A KUB style x-ray is obtained. In which
of the following locations is the stone most likely to be visualised?
A.The tips of the transverse processes between L2 and L5
B. The tips of transverse processes between T10-L1
C. At the crest of the ilium
D.Over the S3 foramina
E. Over the sacrococcygeal joint

Answer: A

The ureter lies anterior to L2 to L5 and stones may be visualised at these points, they may also be identified over the
sacro-iliac joints.

176. A 55 year old man is due to undergo a radical prostatectomy for carcinoma of the prostate gland.
Which of the following vessels directly supplies the prostate?
A.External iliac artery
B.Common iliac artery
C.Internal iliac artery
D.Inferior vesical artery
E. None of the above
Answer: D

The arterial supply to the prostate gland is from the inferior vesical artery, it is a branch of the prostatovesical artery.
The prostatovesical artery usually arises from the internal pudendal and inferior gluteal arterial branches of the
internal iliac artery.

177. From which of the following embryological structures is the ureter derived?
A. Uranchus
B. Wolffian duct
C. Vitello-intestinal duct
D. Mesonephric duct
E. Cloaca

Answer: D

The ureter develops from the mesonephric duct.

112
178. A 56 year old man is having a long venous line inserted via the femoral vein into the right atrium for
CVP measurements. The catheter is advanced through the IVC. At which of the following levels does this
vessel enter the thorax?
A.L2
B.T10
C.L1
D.T8
E. T6
Answer: D

The IVC passes through the diaphragm at T8.

179. A 62 year old man is undergoing a left hemicolectomy for carcinoma of the descending colon. The
registrar commences mobilisation of the left colon by pulling downwards and medially. Blood soon appears
in the left paracolic gutter. The most likely source of bleeding is the:
A.Marginal artery
B. Left testicular artery
C. Spleen
D.Left renal vein
E. None of the above
Answer: C

The spleen is commonly torn by traction injuries in colonic surgery. The other structures are associated with bleeding
during colonic surgery but would not manifest themselves as blood in the paracolic gutter prior to incision of the
paracolonic peritoneal edge.

180. A 53 year old man with a chronically infected right kidney is due to undergo a nephrectomy. Which of
the following structures would be encountered first during a posterior approach to the hilum of the right
kidney?
A.Right renal artery
B. Ureter
C. Right renal vein
D.Inferior vena cava
E. Right testicular vein
Answer: B

The ureter is the most posterior structure at the hilum of the right kidney and would therefore be encountered first
during a posterior approach.

Which of the following regions of the male urethra is entirely surrounded by Bucks fascia?

A. Preprostatic part
B. Prostatic part
C. Membranous part
D. Spongiose part
E. None of the above

Answer: D
Bucks fascia is a layer of deep fascia that covers the penis it is continuous with the external spermatic fascia and the
penile suspensory ligament. The membranous part of the urethra may partially pass through Bucks fascia as it passes
into the penis. However, the spongiose part of the urethra is contained wholly within Bucks fascia.

113
181. 48 year old lady is undergoing a left sided adrenalectomy for an adrenal adenoma. The superior
adrenal artery is injured and starts to bleed, from which of the following does this vessel arise?
A.Left renal artery
B. Inferior phrenic artery
C. Aorta
D.Splenic
E. None of the above
Answer: B

182. Theme: Abdominal pain

 Appendicitis
 Threatened miscarriage
 Ectopic pregnancy
 Irritable bowel syndrome
 Mittelschmerz
 Pelvic inflammatory disease
 Adnexial torsion
 Endometriosis
 Degenerating fibroid

Please select the most likely cause of abdominal pain for the clinical scenario given. Each option may be used once,
more than once or not at all.

A. An 18 year-old girl presents to the Emergency Department with sudden onset sharp, tearing pelvic pain
associated with a small amount of vaginal bleeding. She also complains of shoulder tip pain. On
examination she is hypotensive, tachycardic and has marked cervical excitation.

Answer: Ectopic pregnancy. The history of tearing pain and haemodynamic compromise in a women of child
bearing years should prompt a diagnosis of ectopic pregnancy.

B. A 25 year-old lady presents to her GP complaining of a two day history of right upper quadrant pain,
fever and a white vaginal discharge. She has seen the GP twice in 12 weeks complaining of pelvic pain
and dyspareunia.

Answer:pelvic inflammatory disease. The most likely diagnosis is pelvic inflammatory disease. Right upper
quadrant pain occurs as part of the Fitz Hugh Curtis syndrome in which peri hepatic inflammation occurs.

C. A 16 year old female presents to the emergency department with a 12 hour history of pelvic discomfort.
She is otherwise well and her last normal menstrual period was 2 weeks ago. On examination she has a
soft abdomen with some mild supra pubic discomfort.

Answer: Mittelschmerz. Mid cycle pain is very common and is due to the small amount of fluid released
during ovulation. Inflammatory markers are usually normal and the pain typically subsides over the next 24-
48 hours.

Gynaecological causes of abdominal pain

A number of women will present with abdominal pain and subsequently be diagnosed with a gynaecological disorder.
In addition to routine diagnostic work up of abdominal pain, all female patients should also undergo a bimanual
vaginal examination, urine pregnancy test and consideration given to abdominal and pelvic ultrasound scanning.
When diagnostic doubt persists a laparoscopy provides a reliable method of assessing suspected tubulo-ovarian

114
pathology.

Differential diagnoses of abdominal pain in females

Diagnosis Features Investigation Treatment
Mittelschmerz Usually mid cycle pain. Full blood count- Conservative
Often sharp onset. usually normal
Little systemic disturbance. Ultrasound- may
May have recurrent episodes. show small quantity
Usually settles over 24-48 hours. of free fluid
Endometriosis 25% asymptomatic, in a further Ultrasound- may Usually managed medically, complex
25% associated with other pelvic show free fluid disease will often require surgery and
organ pathology. Laparoscopy will some patients will even require formal
Remaining 50% may have usually show lesions colonic and rectal resections if these
menstrual irregularity, infertility, areas are involved
pain and deep dyspareurina.
Complex disease may result in
pelvic adhesional formation with
episodes of intermittent small
bowel obstruction.
Intra-abdominal bleeding may
produce localised peritoneal
inflammation.
Recurrent episodes are common.
Ovarian torsion Usually sudden onset of deep Ultrasound may show Laparoscopy
seated colicky abdominal pain. free fluid
Associated with vomiting and Laparoscopy is
distress. usually both
Vaginal examination may reveal diagnostic and
adnexial tenderness. therapeutic
Ectopic Symptoms of pregnancy without Ultrasound showing Laparoscopy or laparotomy is
gestation evidence of intra uterine no intra uterine haemodynamically unstable. A
gestation. pregnancy and beta salphingectomy is usually performed.
Present as an emergency with HCG that is elevated
evidence of rupture or impending May show intra
rupture. abdominal free fluid
Open tubular ruptures may have
sudden onset of abdominal pain
and circulatory collapse, in other
the symptoms may be more
prolonged and less marked.
Small amount of vaginal
discharge is common.
There is usually adnexial
tenderness.
Pelvic Bilateral lower abdominal pain Full blood count- Usually medical management
inflammatory associated with vaginal Leucocytosis
disease discharge. Pregnancy test
Dysuria may also be present. negative (Although
Peri-hepatic inflammation infection and
secondary to Chlamydia (Fitz pregnancy may co-
Hugh Curtis Syndrome) may exist)
produce right upper quadrant Amylase - usually
discomfort. normal or slightly
Fever >38o raised
High vaginal and
urethral swabs

115
183. An 80 year old lady with a caecal carcinoma is undergoing a right hemicolectomy performed through a
transverse incision. The procedure is difficult and the incision is extended medially by dividing the rectus
sheath. Brisk arterial haemorrhage ensues. From which of the following does the damaged vessel originate?
A.Internal iliac artery
B.External iliac artery
C.Superior vesical artery
D.Inferior vesical artery
E. None of the above
Answer: B

The vessel damaged is the epigastric artery. This originates from the external iliac artery (see below).

Epigastric artery
The inferior epigastric artery arises from the external iliac artery immediately above the inguinal ligament. It then
passes along the medial margin of the deep inguinal ring. From here it continues superiorly to lie behind the rectus
abdominis muscle.

184. A 73 year old man has a large abdominal aortic aneurysm. During a laparotomy for planned surgical
repair the surgeons find the aneurysm is far more proximally located and lies near the origin of the SMA.
During the dissection a vessel lying transversely across the aorta is injured. What is this vessel most likely
to be?
A.Left renal vein
B.Right renal vein
C.Inferior mesenteric artery
D.Ileocolic artery
E. Middle colic artery

Answer: A

The left renal vein runs across the surface of the aorta and may require deliberate ligation during juxtarenal aneurysm
repair.

Abdominal aorta
Origin T12
Termination L4
Posterior relations L1-L4 Vertebral bodies
Anterior relations Lesser omentum
Liver
Left renal vein
Inferior mesenteric vein
Third part of duodenum
Pancreas
Parietal peritoneum
Peritoneal cavity
Right lateral relations Right crus of the diaphragm
Cisterna chyli
Azygos vein
IVC (becomes posterior distally)
Left lateral relations 4th part of duodenum
Duodenal-jejunal flexure
Left sympathetic trunk

116
185. A 18 year old man presents with an indirect inguinal hernia and undergoes surgery. The deep inguinal
ring is exposed and held with a retractor at its medial aspect. Which structure is most likely to lie under the
retractor?
A. Ureter
B. Inferior epigastric artery
C. Internal iliac vein
D. Femoral artery
E. Lateral border of rectus abdominis
Answer: B

Boundaries of the deep inguinal ring:

 Superolaterally - transversalis fascia

 Inferomedially - inferior epigastric artery

The deep inguinal ring is closely related to the inferior epigastric artery. The inferior epigastric artery forms part of the
structure referred to as Hesselbach's triangle.

186. In a patient with a carcinoma of the distal sigmoid colon, what is the most likely source of its blood
supply?
A.Ileocolic artery
B. External iliac artery
C. Internal iliac artery
D.Superior mesenteric artery
E. Inferior mesenteric artery

Answer: E

During a high anterior resection of such tumours, the inferior mesenteric artery is ligated. Note that the branches
(mainly middle rectal branch) of the internal iliac artery are important in maintaining vascularity of the rectal stump
and hence the integrity of the anastomoses.

187. A patient is due to undergo a right hemicolectomy for a carcinoma of the caecum. Which of the
following vessels will require high ligation to provide optimal oncological control?
A.Middle colic artery
B. Inferior mesenteric artery
C. Superior mesenteric artery
D.Ileo-colic artery
E. None of the above

Answer: D

The ileo - colic artery supplies the caecum and would require high ligation during a right hemicolectomy. The middle
colic artery should generally be preserved when resecting a caecal lesion.
This question is essentially asking you to name the vessel supplying the caecum. The SMA does not directly supply
the caecum, it is the ileocolic artery which does this.

Caecum

Location  Proximal right colon below the ileocaecal valve

 Intraperitoneal

Posterior relations  Psoas

117
  Iliacus
 Femoral nerve
 Genitofemoral nerve
 Gonadal vessels

Anterior relations Greater omentum

Arterial supply Ileocolic artery
Lymphatic drainage Mesenteric nodes accompany the venous drainage

The caecum is the most distensible part of the colon and in complete large bowel obstruction with a competent
ileocaecal valve the most likely site of eventual perforation.

188. A 72 year old man is undergoing a repair of an abdominal aortic aneurysm. The aorta is cross clamped
both proximally and distally. The proximal clamp is applied immediately inferior to the renal arteries. Both
common iliac arteries are clamped distally. A longitudinal aortotomy is performed. After evacuating the
contents of the aneurysm sac a significant amount of ongoing bleeding is encountered. This is most likely to
originate from:
A.The coeliac axis
B. Testicular artery
C. Splenic artery
D.Superior mesenteric artery
E. Lumbar arteries

Answer: E

The lumbar arteries are posteriorly sited and are a common cause of back bleeding during aortic surgery. The other
vessels cited all exit the aorta in the regions that have been cross clamped.

Abdominal aortic branches

Branches Level Paired Type

Inferior phrenic T12 (Upper border) Yes Parietal
Coeliac T12 No Visceral
Superior mesenteric L1 No Visceral
Middle suprarenal L1 Yes Visceral
Renal L1-L2 Yes Visceral
Gonadal L2 Yes Visceral
Lumbar L1-L4 Yes Parietal
Inferior mesenteric L3 No Visceral
Median sacral L4 No Parietal
Common iliac L4 Yes Terminal

The superficial inguinal ring is traversed by which of the following nerves?

A. Subcostal
B. Iliohypogastric
C. Ilioinguinal
D. Obturator
E. Pudendal

Answer: C

118
Ilioinguinal nerve entrapment may be a cause of neuropathic pain following inguinal hernia surgery.
The ilioinguinal nerve passes through the superfical inguinal ring and is routinely encountered when exploring the
inguinal canal during hernia surgery. The iliohypogastric nerve pierces the aponeurosis of the external oblique muscle
superior to the superficial inguinal ring.

Ilioinguinal nerve

Arises from the first lumbar ventral ramus with the iliohypogastric nerve. It passes inferolaterally through the
substance of psoas major and over the anterior surface of quaratus lumborum. It pierces the internal oblique muscle
and passes deep to the aponeurosis of the external oblique muscle. It enters the inguinal canal and then passes through
the superficial inguinal ring to reach the skin.

Branches

 To supply those muscles of the abdominal wall through which it passes.

 Skin and fascia over the pubic symphysis, superomedial part of the femoral triangle, surface of the scrotum,
root and dorsum of penis or labum majus in females.

189. A 63 year old man undergoes a radical cystectomy for carcinoma of the bladder. During the procedure
there is considerable venous bleeding. What is the primary site of venous drainage of the urinary bladder?
A.Vesicoprostatic venous plexus
B. Internal iliac vein
C. External iliac vein
D.Gonadal vein
E. Common iliac vein

Answer: A

The urinary bladder has a rich venous plexus surrounding it, this drains subsequently into the internal iliac vein. The
vesicoprostatic plexus may be a site of considerable venous bleeding during cystectomy.

Bladder
The empty bladder is contained within the pelvic cavity. It is usually a three sided pyramid. The apex of the bladder
points forwards towards the symphysis pubis and the base lies immediately anterior to the rectum or vagina.
Continuous with the apex is the medial umbilical ligament, during development this was the site of the uranchus.
The inferior aspect of the bladder is retroperitoneal and the superior aspect covered by peritoneum. As the bladder
distends it will tend to separate the peritoneum from the fascia of tansversalis. For this reason a bladder that is
distended due to acute urinary retention may be approached with a suprapubic catheter that avoids entry into the
peritoneal cavity.
The trigone is the least mobile part of the bladder and forms the site of the ureteric orifices and internal urethral
orifice. In the empty bladder the ureteric orifices are approximately 2-3cm apart, this distance may increase to 5cm in
the distended bladder.

Arterial supply
The superior and inferior vesical arteries provide the main blood supply to the bladder. These are branches of the
internal iliac artery.

Venous drainage
In males the bladder is drained by the vesicoprostatic venous plexus. In females the bladder is drained by the
vesicouterine venous plexus. In both sexes this venous plexus will ultimately drain to the internal iliac veins.

Lymphatic drainage
119
Lymphatic drainage is predominantly to the external iliac nodes, internal iliac and obturator nodes also form sites of
bladder lymphatic drainage.

Innervation
Parasympathetic nerve fibres innervate the bladder from the pelvic splanchnic nerves. Sympathetic nerve fibres are
derived from L1 and L2 via the hypogastric nerve plexuses. The parasympathetic nerve fibres will typically cause
detrusor muscle contraction and result in voiding. The muscle of the trigone is innervated by the sympathetic nervous
system. The external urethral sphincter is under concious control. During bladder filling the rate of firing of nerve
impulses to the detrusor muscle is low and receptive relaxation occurs. At higher volumes and increased intra vesical
pressures the rate of neuronal firing will increase and eventually voiding will occur.

A 60 year old female is undergoing a Whipples procedure for adenocarcinoma of the pancreas. As the surgeons
begin to mobilise the pancreatic head they identify a large vessel passing inferiorly over the anterior aspect of
the pancreatic head. What is it likely to be?

A. Superior mesenteric artery

B. Coeliac axis
C. Inferior mesenteric artery
D. Aorta
E. Left gastric artery

Answer: A

The superior mesenteric artery arises from the aorta and passes anterior to the lower part of the pancreas. Invasion of
this structure is a relative contra indication to resectional surgery.

190. An 18 year old man is undergoing an orchidectomy via a scrotal approach. The surgeons mobilise the
spermatic cord. From which of the following is the outermost layer of this structure derived?
A.Internal oblique aponeurosis
B. External oblique aponeurosis
C. Transversalis fascia
D.Rectus sheath
E. Campers fascia

Answer: B

The outermost covering of the spermatic cord is derived from the external oblique aponeurosis.This layer is added as
the cord passes through the superficial inguinal ring.

191. A 53 year old male presents with a carcinoma of the transverse colon. Which of the following structures
should be ligated close to their origin to maximise clearance of the tumour?
A.Superior mesenteric artery
B. Inferior mesenteric artery
C. Middle colic artery
D.Ileo-colic artery
E. Superior rectal artery

Answer: C

The middle colic artery supplies the transverse colon and requires high ligation during cancer resections. It is a branch
of the superior mesenteric artery.

192. Which of the following structures does not lie posterior to the right kidney?

120
 A.Psoas major
B. Transversus abdominis
C. Quadratus lumborum
D.Medial artcuate ligament
E. 10th rib

Answer: E

The 10th rib lies more superior. The 12th rib is a closer relation posteriorly.

193. A 73 year old lady presents with a femoral hernia. Which of the following structures forms the lateral
wall of the femoral canal?
A.Pubic tubercle
B.Femoral vein
C.Femoral artery
D.Conjoint tendon
E. Femoral nerve

Answer: B

The canal exists to allow for the physiological expansion of the femoral vein, which lies lateral to it.

Femoral canal

The femoral canal lies at the medial aspect of the femoral sheath. The femoral sheath is a fascial tunnel containing
both the femoral artery laterally and femoral vein medially. The canal lies medial to the vein.

Borders of the femoral canal

Laterally Femoral vein

Medially Lacunar ligament
Anteriorly Inguinal ligament
Posteriorly Pectineal ligament
Contents

 Lymphatic vessels
 Cloquet's lymph node
Physiological significance
Allows the femoral vein to expand to allow for increased venous return to the lower limbs.

Pathological significance
As a potential space, it is the site of femoral hernias. The relatively tight neck places these at high risk of
strangulation.

194. How many unpaired branches leave the abdominal aorta to supply the abdominal viscera?
A.One
B. Two
C. Three
D.Four
E. Five

Answer: C

121
There are three unpaired branches to the abdominal viscera. These include the coeliac axis, the SMA and IMA.
Branches to the adrenals, renal arteries and gonadal vessels are paired. The fourth unpaired branch of the abdominal
aorta, the median sacral artery, does not directly supply the abdominal viscera.

195. A 78 year old man develops a carcinoma of the scrotum. To which of the following lymph node groups
may the tumour initially metastasise?
A.Para aortic
B. Obturator
C. Inguinal
D.Meso rectal
E. None of the above

Answer: C

The scrotum is drained by the inguinal nodes.

196. An 22 year old soldier is shot in the abdomen and amongst his various injuries is a major disruption to
the abdominal aorta. There is torrential haemorrhage and the surgeons decide to control the aorta by
placement of a vascular clamp immediately inferior to the diaphragm. Which of the following vessels may
be injured in this maneouvre?
A.Inferior phrenic arteries
B. Superior phrenic arteries
C. Splenic artery
D.Renal arteries
E. Superior mesenteric artery
Answer: A

As the first branches of the abdominal aorta the inferior phrenic arteries are at greatest risk. The superior phrenic
arteries lie in the thorax. The potential space at the level of the diaphragmatic hiatus is a potentially useful site for
aortic occlusion. However, leaving the clamp applied for more than about 10 -15 minutes usually leads to poor
outcomes.

197. Which of the following statements relating to the gallbladder is untrue?

A.The fundus is usually intra peritoneal
B. Arterial supply is from the cystic artery
C. The cystic artery is usually located in Calots triangle
D.Calots triangle may rarely contain an aberrant hepatic artery
E. Cholecystokinin causes relaxation of the gallbladder

Answer: E

CCK causes gallbladder contraction.

198. A 25 year old man is being catheterised, prior to a surgical procedure. As the catheter enters the
prostatic urethra which of the following changes will occur?
A. Resistance will increase significantly
B. Resistance will increase slightly
C. It will lie horizontally
D. Resistance will decrease
E. It will deviate laterally
Answer: D

The prostatic urethra is much wider than the membranous urethra and therefore resistance will decrease. The prostatic
urethra is inclined vertically.

122
199. Which of the following nerves is the primary source of innervation to the anterior scrotal skin?
A.Genital branch of the genitofemoral nerve
B. Pudendal nerve
C. Ilioinguinal nerve
D.Femoral branch of the genitofemoral nerve
E. Obturator nerve

Answer: C

The pudendal nerve may innervate the posterior skin of the scrotum. The anterior innervation of the scrotum is
primarily provided by the ilioinguinal nerve. The genital branch of the genitofemoral nerve provides a smaller
contribution.

Scrotal sensation
The scrotum is innervated by the ilioinguinal nerve and the pudendal nerve. The ilioinguinal nerve arises from L1 and
pierces the internal oblique muscle. It eventually passes through the superficial inguinal ring to innervate the anterior
skin of the scrotum.The pudendal nerve is the principal nerve of the perineum. It arises in the pelvis from 3 nerve
roots. It passes through both greater and lesser sciatic foramina to enter the perineal region. The perineal branches pass
anteromedially and divide into posterior scrotal branches. The posterior scrotal branches pass superficially to supply
the skin and fascia of the perineum. It cross communicates with the inferior rectal nerve.

200. The transversalis fascia contributes to which of the following?

A. Pectineal ligament
B. Deep inguinal ring
C. Cremaster muscle and fascia
D. Inguinal ligament
E. External spermatic fascia
Answer: B

The internal spermatic fascia (derived from transversalis fascia) invests:

Ducuts deferens
Testicular vessels
The principal outpouching of the transversalis fascia is the internal spermatic fascia. The mouth of the outpouching is
the deep inguinal ring.

201. A 73 year old lady is admitted with right iliac fossa pain. A plain abdominal x-ray is taken and the
caecal diameter measured. Which of the following caecal diameters are pathological?
A.4cm
B. 5cm
C. 6cm
D.7cm
E. 10cm

Answer: E

8 cm is still within normal limits. However, caecal diameters of 9 and 10 are pathological and should prompt further
investigation.

Right colon

Ileocaecal valve

123
  Entry point of the terminal ileum to the caecum
 An important colonoscopic landmark
 The ileocaecal valve is not always competent and this may allow partial decompression of an obstructed colon
Appendix

 At the base of the caecum the taenia coalesce to mark the base of the appendix
 This is a reliable way of locating the appendix surgically and is a constant landmark
 The appendix has a small mesentery (the mesoappendix) and in this runs the appendiceal artery, a branch of
the ileocolic artery.

The posterior aspect of the right colon is extra peritoneal and the anterior aspect intraperitoneal.

Relations

 Posterior :Iliacus, Iliolumbar ligament, Quadratus lumborum, Transverse abdominis, Diaphragm at the tip of
the last rib; Lateral cutaneous, ilioinguinal, and iliohypogastric nerves; the iliac branches of the iliolumbar
vessels, the fourth lumbar artery, gonadal vessels, ureter and the right kidney.

 Superior: Right kidney which is embedded in the perinephric fat

 Medial: Mesentery which contains the ileocolic artery that supplies the right colon and terminal ileum. A
further branch , the right colic artery, also contributes to supply the hepatic flexure and proximal transverse
colon. Medially these pass through the mesentery to join the SMA. This occurs near to the head of the
pancreas and care has to be taken when ligating the ileocolic artery near to its origin in cancer cases for fear of
impinging on the SMA.

- Anterior: Coils of small intestine, the right edge of the greater omentum, and the anterior abdominal wall.

Nerve supply: Parasympathetic fibres of the vagus nerve (CN X)

Arterial supply: Ileocolic artery and right colic artery, both branches of the SMA. While the ileocolic artery is almost
always present, the right colic can be absent in 5-15% of individuals.

202. Which of the following options in relation to the liver is true?

A. Ligamentum venosum is an anterior relation of the liver
B. The portal triad comprises the hepatic artery, hepatic vein and tributary of the bile duct
C. The liver is completely covered by peritoneum
D. There are no nerves within the porta hepatis
E. The caudate lobe is superior to the porta hepatis
Answer: E
'VC goes with VC'

The ligamentun Venosum and Caudate is on same side as Vena Cava [posterior].
Ligamentum venosum is posterior to the liver. The portal triad contains the portal vein rather than the hepatic vein.
There is the 'bare area of the liver' created by a void due to the coronary ligament layers being widely separated. There
are sympathetic and parasympathetic nerves in the porta hepatis.

203. The following statements regarding the rectus abdominis muscle are true except:
A. It runs from the symphysis pubis to the xiphoid process
B. Its nerve supply is from the ventral rami of the lower 6 thoracic nerves
C. It has collateral supply from both superior and inferior epigastric vessels
124
 D. It lies in a muscular aponeurosis throughout its length
E. It has a number of tendinous intersections that penetrate through the anterior layer of the muscle

Answer: D

The aponeurosis is deficient below the arcuate line.

Rectus abdominis: Arises from 5th, 6th, 7th costal cartilages.
Inserts into the pubis.
The muscle lies in the rectal sheath, which also contains the superior & inferior epigastric artery and vein.
Action: flexion of thoracic and lumbar spine.
Nerve supply: anterior primary rami of T7-12

204. A 42 year old male sustains a back injury resulting in the compression of the conus medullaris. Which
of the dematomes below is most likely to be affected by this process?
A.S1
B.L1
C.S3
D.L3
E. L5
Answer: C
The perineum is innervated by S3 and S4, S2 runs down the posterior aspect of the leg and would also be affected.

205. During liver mobilisation for a cadaveric liver transplant the hepatic ligaments will require
mobilisation. Which of the following statements relating to these structures is untrue?
A.Lesser omentum arises from the porta hepatis and passes the lesser curvature of the stomach
B. The falciform ligament divides into the left triangular ligament and coronary ligament
C. The liver has an area devoid of peritoneum
D.The coronary ligament is attached to the liver
E. The right triangular ligament is an early branch of the left triangular ligament

Answer: E

The right triangular ligament is a continuation of the coronary ligament.

Physiology
1. There is decreased secretion of which one of the following hormones in response to major surgery:
A. Insulin
B. Cortisol
C. Renin
D. Anti diuretic hormone
E. Prolactin
Answer: A
Endocrine parameters reduced in stress response: Insulin, Testosterone, Oestrogen
Insulin is often released in decreased quantities following surgery.

Stress response: Endocrine and metabolic changes: Surgery precipitates hormonal and metabolic changes causing the stress
response. Stress response is associated with: substrate mobilization, muscle protein loss, sodium and water retention, suppression
of anabolic hormone secretion, activation of the sympathetic nervous system, immunological and haematological changes. The
hypothalamic-pituitary axis and the sympathetic nervous systems are activated and there is a failure of the normal feedback
mechanisms of control of hormone secretion.

A summary of the hormonal changes associated with the stress response: Increased: Growth hormone, Cortisol, Cortisol,
Renin, Adrenocorticotrophic hormone (ACTH), Aldosterone, Prolactinm, Antidiuretic hormone, Glucagon. Decreased: Insulinm
Testosterone, Oestrogen. No Change: Thyroid stimulating hormone, Luteinizing hormone, Follicle stimulating hormone

Sympathetic nervous system: Stimulates catecholamine release. Causes tachycardia and hypertension
125
Pituitary gland: ACTH and growth hormone (GH) is stimulated by hypothalamic releasing factors, corticotrophin releasing
factor (CRF) and somatotrophin (or growth hormone releasing factor). Perioperative increased prolactin secretion occurs by
release of inhibitory control. Secretion of thyroid stimulating hormone (TSH), luteinizing hormone (LH) and follicle stimulating
hormone (FSH) does not change significantly. ACTH stimulates cortisol production within a few minutes of the start of surgery.
More ACTH is produced than needed to produce a maximum adrenocortical response.

Cortisol: Significant increases within 4-6h of surgery (>1000 nmol litre-1). The usual negative feedback mechanism fails and
concentrations of ACTH and cortisol remain persistently increased. The magnitude and duration of the increase correlate with the
severity of stress and the response is not abolished by the administration of corticosteroids. The metabolic effects of cortisol are
enhanced: Skeletal muscle protein breakdown to provide gluconeogenic precursors and amino acids for protein. synthesis in the
liver. Stimulation of lipolysis'. Anti-insulin effect'. Mineralocorticoid effects. Anti-inflammatory effects

Growth hormone: Increased secretion after surgery has a minor role. Most important for preventing muscle protein breakdown
and promote tissue repair by insulin growth factors

Alpha Endorphin: Increased

Antidiuretic hormone: An important vasopressor and enhances haemostasis. Renin is released causing the conversion of
angiotensin I to angiotensin II, which causes the secretion of aldosterone from the adrenal cortex. This increases sodium
reabsorption at the distal convoluted tubule

Insulin: Release inhibited by stress. Occurs via the inhibition of the alpha cells in the pancreas by the α2-adrenergic inhibitory
effects of catecholamines. Insulin resistance by target cells occurs later. The perioperative period is characterized by a state of
functional insulin deficiency

Thyroxine (T4) and tri-iodothyronine (T3): Circulating concentrations are inversely correlated with sympathetic activity and
after surgery there is a reduction in thyroid hormone production, which normalises over a few days.

Metabolic effect of endocrine response

Carbohydrate metabolism: Hyperglycaemia is a main feature of the metabolic response to surgery.Due to increased increase in
glucose production and a reduction in glucose utilization. Catecholamines and cortisol promote glycogenolysis and
gluconeogenesis. Initial failure of insulin secretion followed by insulin resistance affects the normal responses. The proportion of
the hyperglycaemic response reflects the severity of surgery. Hyperglycaemia impairs wound healing and increase infection rates

Protein metabolism: Initially there is inhibition of protein anabolism, followed later, if the stress response is severe, by enhanced
catabolism. The amount of protein degradation is influenced by the type of surgery and also by the nutritional status of the patient.
Mainly skeletal muscle protein is affected. The amino acids released form acute phase proteins (fibrinogen, C reactive protein,
complement proteins, a2-macroglobulin, amyloid A and ceruloplasmin) and are used for gluconeogenesis. Nutritional support has
little effect on preventing catabolism

Lipid metabolism: Increased catecholamine, cortisol and glucagon secretion, and insulin deficiency, promotes lipolysis and ketone
body production.

Salt and water metabolismADH causes water retention, concentrated urine, and potassium loss and may continue for 3 to 5 days
after surgery. Renin causes sodium and water retention

Cytokines: Glycoproteins. Interleukins (IL) 1 to 17, interferons, and tumour necrosis factor. Synthesized by activated
macrophages, fibroblasts, endothelial and glial cells in response to tissue injury from surgery or trauma. IL-6 main cytokine
associated with surgery. Peak 12 to 24 h after surgery and increase by the degree of tissue damage Other effects of cytokines
include fever, granulocytosis, haemostasis, tissue damage limitation and promotion of healing.

Modifying the response: Opioids suppress hypothalamic and pituitary hormone secretion. At high doses the hormonal response
to pelvic and abdominal surgery is abolished. However, such doses prolong recovery and increase the need for postoperative
ventilatory support. Spinal anaesthesia can reduce the glucose, ACTH, cortisol, GH and epinephrine changes, although cytokine
responses are unaltered. Cytokine release is reduced in less invasive surgery. Nutrition prevents the adverse effects of the stress
response. Enteral feeding improves recovery. Growth hormone and anabolic steroids may improve outcome. Normothermia
decreases the metabolic response

A. The intrinsic pathway is the main pathway in coagulation

126
 B. Heparin inhibits the activation of Factor 8
C. The activation of factor 8 is the point when the intrinsic and the extrinsic pathways meet
D. Tissue factor released by damaged tissue initiates the extrinsic pathway
E. Thrombin converts plasminogen to plasmin
Answer: D
The extrinsic pathway is the main path of coagulation. Heparin inhibits the activation of factors 2,9,10,11. The activation of factor
10 is when both pathways meet. Thrombin converts fibrinogen to fibrin. During fibrinolysis plasminogen is converted to plasmin
to break down fibrin.

Coagulation cascade: Two pathways lead to fibrin formation

Intrinsic pathway (components already present in the blood): Minor role in clotting. Subendothelial damage e.g. collagen.
Formation of the primary complex on collagen by high-molecular-weight kininogen (HMWK), prekallikrein, and Factor 12.
Prekallikrein is converted to kallikrein and Factor 12 becomes activated. Factor 12 activates Factor 11 . Factor 11 activates Factor
9, which with its co-factor Factor 8a form the tenase complex which activates Factor 10

Extrinsic pathway (needs tissue factor released by damaged tissue): Tissue damage. Factor 7 binds to Tissue factor. This
complex activates Factor 9. Activated Factor 9 works with Factor 8 to activate Factor 10

Common pathway: Activated Factor 10 causes the conversion of prothrombin to thrombin. Thrombin hydrolyses fibrinogen
peptide bonds to form fibrin and also activates factor 8 to form links between fibrin molecules

Fibrinolysis: Plasminogen is converted to plasmin to facilitate clot resorption

 Intrinsic pathway: Increased APTT: Factors 8,9,11,12

 Extrinsic pathway :Increased PT: Factor 7
 Common pathway: Increased APTT & PT: Factors 2,5,10
 Vitamin K dependent:Factors 2,7,9,10

2. Which of the following is not secreted by the parietal cells?

A. Hydrochloric acid
B. Mucus
C. Magnesium
D. Intrinsic factor
E. Calcium
Answer: B
Chief of Pepsi cola = Chief cells secrete PEPSInogen. Parietal cells: secrete HCl, Ca, Na, Mg and intrinsic factor. Chief cells:
secrete pepsinogen. Surface mucosal cells: secrete mucus and bicarbonate

Gastric secretions
A working knowledge of gastric secretions is important for surgery because peptic ulcers are common, surgeons frequently
prescribe anti secretory drugs and because there are still patients around who will have undergone acid lowering procedures
(Vagotomy) in the past.

Gastric acid: Is produced by the parietal cells in the stomach. pH of gastric acid is around 2 with acidity being maintained by the
H+/K+ ATP ase pump. As part of the process bicarbonate ions will be secreted into the surrounding vessels. Sodium and chloride
ions are actively secreted from the parietal cell into the canaliculus. This sets up a negative potential across the membrane and as a
result sodium and potassium ions diffuse across into the canaliculus.Carbonic anhydrase forms carbonic acid which dissociates
and the hydrogen ions formed by dissociation leave the cell via the H+/K+ antiporter pump. At the same time sodium ions are
actively absorbed. This leaves hydrogen and chloride ions in the canaliculus these mix and are secreted into the lumen of the
oxyntic gland.

Phases of gastric acid secretion: There are 3 phases of gastric secretion: 1. Cephalic phase (smell / taste of food): 30% acid
produced. Vagal cholinergic stimulation causing secretion of HCL and gastrin release from G cells; 2. Gastric phase (distension of
stomach ): 60% acid produced. Stomach distension/low H+/peptides causes Gastrin release; 3. Intestinal phase (food in
duodenum): 10% acid produced. High acidity/distension/hypertonic solutions in the duodenum inhibits gastric acid secretion via
enterogastrones (CCK, secretin) and neural reflexes. Regulation of gastric acid production: Factors increasing production
include:Vagal nerve stimulation. Gastrin release. Histamine release (indirectly following gastrin release) from enterchromaffin
like cells. Factors decreasing production include: Somatostatin (inhibits histamine release). Cholecystokinin. Secretin.

127
 Source Stimulus Actions
Gastrin G cells in Distension of stomach, Increase HCL, pepsinogen and IF secretion, increases gastric
antrum of the extrinsic nerves motility, trophic effect on gastric mucosa
stomach Inhibited by: low
antral pH, somatostatin
CCK I cells in upper Partially digested Increases secretion of enzyme-rich fluid from pancreas, contraction
small intestine proteins and of gallbladder and relaxation of sphincter of Oddi, decreases gastric
triglycerides emptying, trophic effect on pancreatic acinar cells, induces satiety
Secretin S cells in upper Acidic chyme, fatty Increases secretion of bicarbonate-rich fluid from pancreas and
small intestine acids hepatic duct cells, decreases gastric acid secretion, trophic effect on
pancreatic acinar cells
VIP Small intestine, Neural Stimulates secretion by pancreas and intestines, inhibits acid and
pancreas pepsinogen secretion
Somatostatin D cells in the Fat, bile salts and Decreases acid and pepsin secretion, decreases gastrin secretion,
pancreas and glucose in the decreases pancreatic enzyme secretion, decreases insulin and
stomach intestinal lumen glucagon secretion
inhibits trophic effects of gastrin, stimulates gastric mucous
production

3. A 45 year old male is diagnosed with carcinoma of the head of the pancreas. He reports that his stool sticks to the
commode and will not flush away. Loss of which of the following enzymes is most likely to be responsible for this
problem?
A. Lipase
B. Amylase
C. Trypsin
D. Elastase
E. None of the above
Answer: A
Loss of lipase is one of the key features in the development of steatorrhoea which typically consists of pale and offensive stools
that are difficult to flush away.

Pancreatic cancer: Adenocarcinoma. Risk factors: Smoking, diabetes, Adenoma, Familial adenomatous polyposis. Mainly occur
in the head of the pancreas (70%). Spread locally and metastasizes to the liver. Carcinoma of the pancreas should be differentiated
from other periampullary tumours with better prognosis

Clinical features: Weight loss. Painless jaundice. Epigastric discomfort (pain usually due to invasion of the coeliac plexus is a
late feature). Pancreatitis. Trousseau's sign: migratory superficial thrombophlebitis
Investigations: USS: May miss small lesions. CT Scanning (pancreatic protocol). If unresectable on CT then no further staging
needed.. PET/CT for those with operable disease on CT alone. ERCP/ MRI for bile duct assessment. Staging laparoscopy to
exclude peritoneal disease.

Management: Head of pancreas: Whipple's resection (SE dumping and ulcers). Newer techniques include pylorus preservation
and SMA/ SMV resection. Carcinoma body and tail: poor prognosis, distal pancreatectomy if operable. Usually adjuvent
chemotherapy for resectable disease. ERCP and stent for jaundice and palliation.Surgical bypass may be needed for duodenal
obstruction.

4. Which of the following is not well absorbed following a gastrectomy?

A. Vitamin c
B. Zinc
C. Vitamin B12
D. Copper
E. Molybdenum
Answer: C
Vitamin B12. The others are unaffected
Post gastrectomy syndrome:
Rapid emptying food from stomach into the duodenum: diarrhoea, abdominal pain, hypoglycaemia
Complications: Vitamin B12 and iron malabsorption, osteoporosis
Treatment: High protein, low carbohydrate diet. Replace B12/Fe/Ca

Gastric emptying: The stomach serves both a mechanical and immunological function. Solid and liquid are retained in the
stomach during which time repeated peristaltic activity against a closed pyloric sphincter will cause fragmentation of food bolus
material. Contact with gastric acid will help to neutralise any pathogens present. The amount of time material spends in the

128
 stomach is related to its composition and volume. For example a glass of water will empty more quickly than a large meal. The
presence of amino acids and fat will all serve to delay gastric emptying.

Controlling factor: Neuronal stimulation of the stomach is mediated via the vagus and the parasympathetic nervous system will
tend to favor an increase in gastric motility. It is for this reason that individuals who have undergone truncal vagotomy will tend to
routinely require either a pyloroplasty or gastro-enterostomy as they would otherwise have delayed gastric emptying. The
following hormonal factors are all involved: Delay emptying: Gastric inhibitory peptide, Cholecystokinin and Enteroglucagon.
Increase emptying :Gastrin.

Diseases affecting gastric emptying: All diseases that affect gastric emptying may result in bacterial overgrowth, retained food
and eventually the formation of bezoars that may occlude the pylorus and make gastric emptying even worse. Fermentation of
food may cause dyspepsia, reflux and foul smelling belches of gas.

Iatrogenic: Gastric surgery can have profound effects on gastric emptying. As stated above any procedure that disrupts the vagus
can cause delayed emptying. Whilst this is particularly true of Vagotomy this operation is now rarely performed. Surgeons are
divided on the importance of vagal disruption that occurs during an oesophagectomy and some will routinely perform a
pyloroplasty and other will not.
When a distal gastrectomy is performed the type of anastomosis performed will impact on emptying. When a gastro-enterostomy
is constructed, a posterior, retrocolic gastroenterostomy will empty better than an anterior one.

Diabetic gastroparesis: This is predominantly due to neuropathy affecting the vagus nerve. The stomach empties poorly and
patients may have episodes of repeated and protracted vomiting. Diagnosis is made by upper GI endoscopy and contrast studies,
in some cases a radio nucleotide scan is needed to demonstrate the abnormality more clearly. In treating these conditions drugs
such as metoclopramide will be less effective as they exert their effect via the vagus nerve. One of the few prokinetic drugs that do
not work in this way is the antibiotic erythromycin.

Malignancies: Obviously a distal gastric cancer may obstruct the pylorus and delay emptying. In addition malignancies of the
pancreas may cause extrinsic compression of the duodenum and delay emptying. Treatment in these cases is by gastric
decompression using a wide bore nasogastric tube and insertion of a stent or if that is not possible by a surgical gastroenterostomy.
As a general rule gastroenterostomies constructed for bypass of malignancy are usually placed on the anterior wall of the stomach
(in spite of the fact that they empty less well). A Roux en Y bypass may also be undertaken but the increased number of
anastomoses for this in malignant disease that is being palliated is probably not justified.

Congenital Hypertrophic Pyloric Stenosis: This is typically a disease of infancy. Most babies will present around 6 weeks of
age with projectile non bile stained vomiting. It has an incidence of 2.4 per 1000 live births and is more common in males.
Diagnosis is usually made by careful history and examination and a mass may be palpable in the epigastrium (often cited seldom
felt!). The most important diagnostic test is an ultrasound that usually demonstrates the hypertrophied pylorus. Blood tests may
reveal a hypochloraemic metabolic alkalosis if the vomiting is long standing. Once the diagnosis is made the infant is resuscitated
and a pyloromyotomy is performed (usually laparoscopically). Once treated there are no long term sequelae.

5. Which vitamin is involved in the formation of collagen?

A. Vitamin A
B. Vitamin B
C. Vitamin C
D. Vitamin D
E. Vitamin E
Answer: C
Vitamin C is needed for the hydroxylation of proline during collagen synthesis.

Collagen: One of the major connective tissue proteins. Composed of 3 polypeptide strands that are woven into a helix. Numerous
hydrogen bonds exist within molecule to provide additional strength. Many sub types but commonest sub type is I (90% of bodily
collagen). Vitamin c is important in establishing cross links

Collagen Diseases: Osteogenesis imperfect. Ehlers Danlos

Osteogenesis imperfecta: 8 Subtypes: Defect of type I collagen. In type I the collagen is normal quality but insufficient quantity.
Type II- poor quantity and quality. Type III- Collagen poorly formed, normal quantity. Type IV- Sufficient quantity but poor
quality. Patients have bones which fracture easily, loose joint and multiple other defects depending upon which sub type they
suffer from
Ehlers Danlos: Multiple sub types. Abnormality of types 1 and 3 collagen. Patients have features of hypermobility. Individuals
are prone to joint dislocations and pelvic organ prolapse. In addition to many other diseases related to connective tissue defects

129
6. A 56 year old man has long standing chronic pancreatitis and develops pancreatic insufficiency. Which of the following
will be absorbed normally?
A. Fat
B. Protein
C. Folic acid
D. Vitamin B12
E. None of the above
Answer: C
Pancreatic lipase is required for digestion of fat, Proteases facilitate protein and B12 absorption. Folate digestion is independent of
the pancreas.

Pancreatic juice: Alkaline solution pH 8. 1500ml/day. Composition: acinar secretion (ENZYMES: trypsinogen, procarboxylase,
amylase, lecithin) and ductile secretion (HCO, Na+, water). Pancreatic juice action: Trypsinogen is converted via enterokinase to
active trypsin in the duodenum. Trypsin then activates the other inactive enzymes.

7. A 56 year old male presents to the acute surgical take with severe abdominal pain. He is normally fit and well. He has
no malignancy. The biochemistry laboratory contacts the ward urgently, his corrected calcium result is 3.6 mmol/l.
What is the medication of choice to treat this abnormality?

A. IV Pamidronate
B. Oral Alendronate
C. Dexamethasone
D. Calcitonin
E. IV Zoledronate
Answer: A
IV Pamidronate is the drug of choice as it most effective and has long lasting effects. Calcitonin would need to be given with
another agent, to ensure that the hypercalcaemia is treated once its short term effects wear off. IV zoledronate is preferred in
scenarios associated with malignancy.

Management of hypercalcaemia: Free Ca is affected by pH (increased in acidosis) and plasma albumin concentration. ECG
changes include: Shortening of QTc interval. Urgent management is indicated if: Calcium > 3.5 mmol/l, reduced consciousness,
severe abdominal pain.
Pre renal failure

Management: Airway Breathing Circulation, Intravenous fluid resuscitation with 3-6L of 0.9% Normal saline in 24h, After
hydration, give frusemide (to encourage excretion of Ca), Medical therapy (usually if Corrected calcium >3.0mmol/l)

Bisphosphonates:Analogues of pryrophosphate. Prevent osteoclast attachment to bone matrix and interfere with osteoclast
activity. Inhibit bone resorption.

Agents

Drug Side effects Notes

IV Pamidronate pyrexia, leucopaenia Most potent agent
IV Zoledronate response lasts 30 days Used for malignancy associated hypercalcaemia

Calcitonin: Quickest onset of action however short duration (tachyphylaxis) therefore only given with a second agent.
Prenisolone: May be given in hypercalcaemia related to sarcoidosis, myeloma or vitamin D intoxication.

8. An over enthusiastic medical student decides to ask you questions about ECGs. Rather than admitting your dwindling
knowledge on this topic, you bravely attempt to answer her questions! One question is what segment of the ECG
represents ventricular repolarization?
A. QRS complex
B. Q-T interval
C. P wave
D. T wave
E. S-T segment

Answer: D
The T wave represents ventricular repolarization. The common sense approach to remembering this, is to acknowledge that
ventricular repolarization is the last phase of cardiac contraction and should therefore correspond the the last part of the ECG.

130
 The normal ECG
P wave: Represents the wave of depolarization that spreads from the SA node throughout the atria. Lasts 0.08 to 0.1 seconds (80-
100 ms) . The isoelectric period after the P wave represents the time in which the impulse is traveling within the AV node . P-R
interval: Time from the onset of the P wave to the beginning of the QRS complex. Ranges from 0.12 to 0.20 seconds in duration.
Represents the time between the onset of atrial depolarization and the onset of ventricular depolarization. QRS complex:
Represents ventricular depolarization. Duration of the QRS complex is normally 0.06 to 0.1 seconds. ST segment: Isoelectric
period following the QRS. Represents period which the entire ventricle is depolarized and roughly corresponds to the plateau
phase of the ventricular action potential. T wave: Represents ventricular repolarization and is longer in duration than
depolarization. A small positive U wave may follow the T wave which represents the last remnants of ventricular repolarization.
Q-T interval: Represents the time for both ventricular depolarization and repolarization to occur, and therefore roughly estimates
the duration of an average ventricular action potential. Interval ranges from 0.2 to 0.4 seconds depending upon heart rate. At high
heart rates, ventricular action potentials shorten in duration, which decreases the Q-T interval. Therefore the Q-T interval is
expressed as a "corrected Q-T (QTc)" by taking the Q-T interval and dividing it by the square root of the R-R interval (interval
between ventricular depolarizations). This allows an assessment of the Q-T interval that is independent of heart rate. Normal
corrected Q-Tc interval is less than 0.44 seconds.

9. The oxygen-haemoglobin dissociation curve is shifted to the right in which of the following scenarios?
A. Hypothermia
B. Respiratory alkalosis
C. Low altitude
D. Decreased 2,3-DPG in transfused red cells
E. Chronic iron deficiency anaemia
Answer: E
Mnemonic to remember causes of right shift of the oxygen dissociation curve:
CADET face RIGHT: C O2. A cidosis. 2,3-DPG. E xercise. T emperature

The curve is shifted to the right when there is an increased oxygen requirement by the tissue. This includes: Increased
temperature. Acidosis. Increased DPG: it is found in erythrocytes and is increased during glycolysis. It binds to the Hb molecule,
thereby releasing oxygen to tissues. DPG is increased in conditions associated with poor oxygen delivery to tissues, such as
anaemia and high altitude.

Oxygen transport: Almost all oxygen is transported within erythrocytes. It has limited solubility and only 1% is carried as
solution. Therefore the amount of oxygen transported will depend upon haemoglobin concentration and its degree of saturation.

Haemoglobin: Globular protein composed of 4 subunits. Haem consists of a protoporphyrin ring surrounding an iron atom in its
ferrous state. The iron can form two additional bonds; one with oxygen and the other with a polypeptide chain. There are two
alpha and two beta subunits to this polypeptide chain in an adult and together these form globin. Globin cannot bind oxygen but is
able to bind to carbon dioxide and hydrogen ions, the beta chains are able to bind to 2,3 diphosphoglycerate. The oxygenation of
haemoglobin is a reversible reaction. The molecular shape of haemoglobin is such that binding of one oxygen molecule facilitates
the binding of subsequent molecules.

Oxygen dissociation curve: The oxygen dissociation curve describes the relationship between the percentage of saturated
haemoglobin and partial pressure of oxygen in the blood. It is not affected by haemoglobin concentration. Chronic anaemia causes
2, 3 DPG levels to increase, hence shifting the curve to the right. Bohr effect: Shifts to left = for given oxygen tension there is
increased saturation of Hb with oxygen i.e. Decreased oxygen delivery to tissues. Shifts to right = for given oxygen tension there
is reduced saturation of Hb with oxygen i.e. Enhanced oxygen delivery to tissues

Shifts to Left = Lower oxygen delivery: HbF, methaemoglobin, carboxyhaemoglobin; low [H+] (alkali); low pCO2; low 2,3-
DPG.
low temperature
Shifts to Right = Raised oxygen delivery: raised [H+] (acidic); raised pCO2; raised 2,3-DPG*; raised temperature

10. A 73 year old lady is admitted for a laparoscopic cholecystectomy. During her pre-operative assessment it is noted that
she is receiving furosemide for the treatment of hypertension. Where is the site of action of this diuretic?
A. Proximal convoluted tubule
B. Descending limb of the loop of Henle
C. Ascending limb of the loop of Henle
D. Distal convoluted tubule
E. Collecting ducts
Answer: C

131
Action of furosemide = ascending limb of the loop of Henle
Furosemide and bumetanide are loop diuretics that act by inhibiting the Na-K-Cl cotransporter in the thick ascending limb of the
loop of Henle, reducing the absorption of NaCl.
Diuretic agents: The diuretic drugs are divided into three major classes, which are distinguished according to the site at which
they impair sodium reabsorption: loop diuretics in the thick ascending loop of Henle, thiazide type diuretics in the distal tubule
and connecting segment; and potassium sparing diuretics in the aldosterone - sensitive principal cells in the cortical collecting
tubule.
In the kidney, sodium is reabsorbed through Na+/ K+ ATPase pumps located on the basolateral membrane. These pumps return
reabsorbed sodium to the circulation and maintain low intracellular sodium levels. This latter effect ensures a constant
concentration gradient.

Physiological effects of commonly used diuretics

Site of action Diuretic Carrier or channel Percentage of filtered sodium
inhibited excreted
Ascending limb of loop of Henle Frusemide Na+/K+ 2Cl - carrier Upt to 25%
Distal tubule and connecting Thiazides Na+Cl- carrier Between 3 and 5%
segment
Cortical collecting tubule Spironolactone Na+ channel Between 1 and 2%

11. A 45 year old man is referred to the breast clinic with gynaecomastia. He takes the drugs listed below. Which is least
likely to be the cause of his symptoms?
A. Spironolactone
B. Carbimazole
C. Chlorpromazine
D. Cimetidine
E. Methyldopa
Answer: B
Mnemonic for drugs causing gynaecomastia: DISCO: D igitalis, I soniazid, S pironolactone, C imentidine, O estrogen
Mnemonic for causes of gynaecomastia: METOCLOPRAMIDE: M etoclopramide. E ctopic oestrogen, T rauma skull/tumour
breast, testes, O rchitis, C imetidine, Cushings, L iver cirrhosis, O besity, P araplegia
R A, A cromegaly, M ethyldopa, I soniazid, D igoxin, E thionamide. Carbimazole is not associated with gynaecomastia.

GynaecomastiaGynaecomastia describes an abnormal amount of breast tissue in males and is usually caused by an increased
oestrogen:androgen ratio. It is important to differentiate the causes of galactorrhoea (due to the actions of prolactin on breast
tissue) from those of gynaecomastia

Causes of gynaecomastia: physiological: normal in puberty. Syndromes with androgen deficiency: Kallman's, Klinefelter's.
Testicular failure: e.g. Mumps. Liver disease. Testicular cancer e.g. Seminoma secreting hCG. Ectopic tumour secretion.
Hyperthyroidism. Haemodialysis. Drugs: see below

Drug causes of gynaecomastia: spironolactone (most common drug cause). Cimetidine. Digoxin. Cannabis. Finasteride.
Oestrogens, anabolic steroids. Very rare drug causes of gynaecomastia: Tricyclics. Isoniazid. Calcium channel blockers.
Heroin. Busulfan Methyldopa

12. 43 year old lady is recovering on the intensive care unit following a Whipples procedure. She has a central venous line
in situ. Which of the following will lead to the "y" descent on the waveform trace?
A. Ventricular contraction
B. Emptying of the right atrium
C. Emptying of the right ventricle
D. Opening of the pulmonary valve
E. Cardiac tamponade
Answer: B
JVP
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

The 'y' descent represents the emptying of the atrium and the filling of the right ventricle.

Cardiac physiology: The heart has four chambers ejecting blood into both low pressure and high pressure systems. The pumps
generate pressures of between 0-25mmHg on the right side and 0-120 mmHg on the left. At rest diastole comprises 2/3 of the
cardiac cycle. The product of the frequency of heart rate and stroke volume combine to give the cardiac output which is typically
5-6L per minute.

132
Detailed descriptions of the various waveforms are often not a feature of MRCS A (although they are on the syllabus). However,
they are a very popular topic for surgical physiology vivas in the oral examination.

Electrical properties: Intrinsic myogenic rhythm within cardiac myocytes means that even the denervated heart is capable of
contraction. In the normal situation the cardiac impulse is generated in the sino atrial node in the right atrium and conveyed to the
ventricles via the atrioventricular node. The sino atrial node is also capable of spontaneous discharge and in the absence of
background vagal tone will typically discharge around 100x per minute. Hence the higher resting heart rate found in cardiac
transplant cases. In the SA and AV nodes the resting membrane potential is lower than in surrounding cardiac cells and will
slowly depolarise from -70mV to around -50mV at which point an action potential is generated. Differences in the depolarisation
slopes between SA and AV nodes help to explain why the SA node will depolarise first. The cells have a refractory period during
which they cannot be re-stimulated and this period allows for adequate ventricular filling. In pathological tachycardic states this
time period is overridden and inadequate ventricular filling may then occur, cardiac output falls and syncope may ensue.
Parasympathetic fibres project to the heart via the vagus and will release acetylcholine. Sympathetic fibres release nor adrenaline
and circulating adrenaline comes from the adrenal medulla. Noradrenaline binds to β 1 receptors in the SA node and increases the
rate of pacemaker potential depolarisation.

Cardiac cycle
Mid diastole: AV valves open. Ventricles hold 80% of final volume. Outflow valves shut. Aortic pressure is high. Late diastole:
Atria contract. Ventricles receive 20% to complete filling. Typical end diastolic volume 130-160ml. Early systole: AV valves
shut. Ventricular pressure rises. Isovolumetric ventricular contraction. AV Valves bulge into atria (c-wave). Aortic and pulmonary
pressure exceeded- blood is ejected. Shortening of ventricles pulls atria downwards and drops intra atrial pressure (x-descent).
Late systole: Ventricular muscles relax and ventricular pressures drop. Although ventricular pressure drops the aortic pressure
remains constant owing to peripheral vascular resistance and elastic property of the aorta. Brief period of retrograde flow that
occurs in aortic recoil shuts the aortic valve. Ventricles will contain 60ml end systolic volume. The average stroke volume is 70ml
(i.e. Volume ejected). Early diastole: All valves are closed. Isovolumetric ventricular relaxation occurs. Pressure wave associated
with closure of the aortic valve increases aortic pressure. The pressure dip before this rise can be seen on arterial waveforms and is
called the incisura. During systole the atrial pressure increases such that it is now above zero (v- wave). Eventually atrial pressure
exceed ventricular pressure and AV valves open - atria empty passively into ventricles and atrial pressure falls (y -descent ). The
negative atrial pressures are of clinical importance as they can allow air embolization to occur if the neck veins are exposed to air.
This patient positioning is important in head and neck surgery to avoid this occurrence if veins are inadvertently cut, or during
CVP line insertion.

Mechanical properties: Preload = end diastolic volume; Afterload = aortic pressure. It is important to understand the principles
of Laplace's law in surgery. It states that for hollow organs with a circular cross section, the total circumferential wall tension
depends upon the circumference of the wall, multiplied by the thickness of the wall and on the wall tension. The total luminal
pressure depends upon the cross sectional area of the lumen and the transmural pressure. Transmural pressure is the internal
pressure minus external pressure and at equilibrium the total pressure must counterbalance each other. In terms of cardiac
physiology the law explains that the rise in ventricular pressure that occurs during the ejection phase is due to physical change in
heart size. It also explains why a dilated diseased heart will have impaired systolic function.
Starlings law: Increase in end diastolic volume will produce larger stroke volume. This occurs up to a point beyond which cardiac
fibres are excessively stretched and stroke volume will fall once more. It is important for the regulation of cardiac output in
cardiac transplant patients who need to increase their cardiac output.

Baroreceptor reflexes: Baroreceptors located in aortic arch and carotid sinus. Aortic baroreceptor impulses travel via the vagus
and from the carotid via the glossopharyngeal nerve. They are stimulated by arterial stretch. Even at normal blood pressures they
are tonically active.Increase in baroreceptor discharge causes: Increased parasympathetic discharge to the SA node, Decreased
sympathetic discharge to ventricular muscle causing decreased contractility and fall in stroke volume, Decreased sympathetic
discharge to venous system causing increased compliance and Decreased peripheral arterial vascular resistance

Atrial stretch receptors: Located in atria at junction between pulmonary veins and vena cava.Stimulated by atrial stretch and are
thus low pressure sensors. Increased blood volume will cause increased parasympathetic activity.Very rapid infusion of blood will
result in increase in heart rate mediated via atrial receptors: the Bainbridge reflex. Decreases in receptor stimulation results in
increased sympathetic activity this will decrease renal blood flow-decreases GFR-decreases urinary sodium excretion-renin
secretion by juxtaglomerular apparatus-Increase in angiotensin II. Increased atrial stretch will also result in increased release of
atrial natriuretic peptide.

13. Which of the following are not characteristic features of central chemoreceptors in the control of ventilation?
A. They are located in the medulla oblongata
B. They are stimulated primarily by venous hypercapnia
C. They are relatively insensitive to hypoxia
D. They are less sensitive to changes in arterial pH than other ventillatory receptors
E. During acute hypercapnia the carotid receptors will be stimulated first
Answer: B

133
They are stimulated by arterial carbon dioxide. It takes longer to equilibrate than the peripheral chemoreceptors located in the
carotid. They are less sensitive to acidity due to the blood brain barrier.

Control of ventilation: Control of ventilation is coordinated by the respiratory centres, chemoreceptors, lung receptors and
muscles. Automatic, involuntary control of respiration occurs from the medulla. The respiratory centres control the respiratory
rate and the depth of respiration.

Respiratory centres

Medullary respiratory centre: Inspiratory and expiratory neurones. Has ventral group which controls forced voluntary
expiration and the dorsal group controls inspiration. Depressed by opiates.
Apneustic centre: Lower pons, Stimulates inspiration - activates and prolongs inhalation, Overridden by pneumotaxic control to
end inspiration, Pneumotaxic centre:Upper pons, inhibits inspiration at a certain point. Fine tunes the respiratory rate, Levels of
PCO2 most important in ventilation control, Levels of O2 are less important. Peripheral chemoreceptors: located in the
bifurcation of carotid arteries and arch of the aorta. They respond to changes in reduced pO2, increased H+ and increased pCO2 in
ARTERIAL BLOOD. Central chemoreceptors: located in the medulla. Respond to increased H+ in BRAIN INTERSTITIAL
FLUID to increase ventilation. NB the central receptors are NOT influenced by O2 levels. Lung receptors include: Stretch
receptors: respond to lung stretching causing a reduced respiratory rate. Irritant receptors: respond to smoke etc causing
bronchospasm. J (juxtacapillary) receptors

14. A 32 year old man has a glomerular filtration rate of 110ml / minute at a systolic blood pressure of 120/80. If his blood
pressure were to fall to 100/70 what would glomerular filtration rate be?
A. 110ml / minute
B. 100ml/ minute
C. 55ml/ minute
D. 25ml/ minute
E. 75ml/ minute
Answer: A

The proposed drop in blood pressure falls within the range within which the kidney autoregulates its blood supply. GFR will
therefore remain unchanged.

Each nephron is supplied with blood from an afferent arteriole that opens onto the glomerular capillary bed. Blood then flows to
an efferent arteriole, supplying the peritubular capillaries and medullary vasa recta. The kidney receives up to 25% of resting
cardiac output.

Control of blood flow:The kidney is able to autoregulate its blood flow between systolic pressures of 80- 180mmHg so there is
little variation in renal blood flow. This is achieved by myogenic control of arteriolar tone, both sympathetic input and hormonal
signals (e.g. renin) are responsible.

Glomerular structure and function: Blood inside the glomerulus has considerable hydrostatic pressure. The basement
membrane has pores that will allow free diffusion of smaller solutes, larger negatively charged molecules such as albumin are
unable to cross. The glomerular filtration rate (GFR) is equal to the concentration of a solute in the urine, times the volume of
urine produced per minute, divided by the plasma concentration (assuming that the solute is freely diffused e.g. inulin). In clinical
practice creatinine is used because it is subjected to very little proximal tubular secretion. Although subject to variability, the
typical GFR is 125ml per minute. Glomerular filtration rate = Total volume of plasma per unit time leaving the capillaries and
entering the bowman's capsule. Renal clearance = volume plasma from which a substance is removed per minute by the kidneys

Substances used to measure GFR have the following features:1. Inert; 2. Free filtration from the plasma at the glomerulus (not
protein bound); 3. Not absorbed or secreted at the tubules; 4. Plasma concentration constant during urine collection

Examples: inulin, creatinine

GFR = urine concentration (mmol/l) x urine volume (ml/min)

plasma concentration (mmol/l)

The clearance of a substance is dependent not only on its diffusivity across the basement membrane but also subsequent tubular
secretion and / or reabsorption. So glucose which is freely filtered across the basement membrane is usually reabsorbed from
tubules giving a clearance of zero.

134
Tubular function: Reabsorption and secretion of substances occurs in the tubules. In the proximal tubule substrates such as
glucose, amino acids and phosphate are co-transported with sodium across the semi permeable membrane. Up to two thirds of
filtered water is reabsorbed in the proximal tubules. This will lead to increase in urea concentration in the distal tubule allowing
for its increased diffusion. Substances to be secreted into the tubules are taken up from the peritubular blood by tubular cells.
Solutes such as paraaminohippuric acid are cleared with a single passage through the kidneys and this is why it is used to measure
renal plasma flow. Ions such as calcium and phosphate will have a tubular reabsorption that is influenced by plasma PTH levels.
Potassium may be both secreted and re-absorbed and is co-exchanged with sodium.

Loop of Henle: Approximately 60 litres of water containing 9000mmol sodium enters the descending limb of the loop of Henle in
24 hours. Loops from the juxtamedullary nephrons run deep into the medulla. The osmolarity of fluid changes and is greatest at
the tip of the papilla. The thin ascending limb is impermeable to water, but highly permeable to sodium and chloride ions. This
loss means that at the beginning of the thick ascending limb the fluid is hypo osmotic compared with adjacent interstitial fluid. In
the thick ascending limb the reabsorption of sodium and chloride ions occurs by both facilitated and passive diffusion pathways.
The loops of Henle are co-located with vasa recta, these will have similar solute compositions to the surrounding extracellular
fluid so preventing the diffusion and subsequent removal of this hypertonic fluid. The energy dependent reabsorption of sodium
and chloride in the thick ascending limb helps to maintain this osmotic gradient.

15. Which of the following does not stimulate insulin release?

A. Gastrin
B. Atenolol
C. Protein
D. Secretin
E. Vagal cholinergic action
Answer: B
Beta blockers inhibit the release of insulin. Stimulation of insulin release:Glucose, Amino acid, Vagal cholinergic,
Secretin/Gastrin/CCK, Fatty acids, Beta adrenergic drugs.

Insulin is an Anabolic hormone. Synthesis: Pro-insulin is formed by the rough endoplasmic reticulum in pancreatic beta cells.
Then pro-insulin is cleaved to form insulin and C-peptide. Insulin is stored in secretory granules and released in response to Ca.
Function: Secreted in response to hyperglycaemia, Glucose utilisation and glycogen synthesis, Inhibits lipolysis, Reduces muscle
protein loss

16. A 63 year old female is referred to the surgical clinic with an iron deficiency anaemia. Her past medical history
includes a left hemi colectomy but no other co-morbidities. At what site is most dietery iron absorbed?
A. Stomach
B. Duodenum
C. Proximal ileum
D. Distal ileum
E. Colon
Ansewr: B
Iron is best absorbed from the proximal small bowel (duodenum and jejunum) in the Fe 2+ state. Iron is transported across the
small bowel mucosa by a divalent membrane transporter protein (hence the improved absorption of F2 2+. The intestinal cells
typically store the bound iron as ferritin. Cells requiring iron will typically then absorb the complex as needed.

Iron metabolism: absorption Duodenum and upper jejunum; About 10% of dietary iron absorbed; Fe2+ (ferrous iron) much
better absorbed than Fe3+ (ferric iron); Ferrous iron is oxidized to form ferric iron, which is combined with apoferritin to form
ferritin; Absorption is regulated according to body's need; Increased by vitamin C, gastric acid; Decreased by proton pump
inhibitors, tetracycline, gastric achlorhydria, tannin (found in tea). Transport: In plasma as Fe3+ bound to transferrin.
Storage:Ferritin (or haemosiderin) in bone marrow. Excretion: Lost via intestinal tract following desquamation
Distribution in body
Total body iron:4g; Haemoglobin: 70%; Ferritin and haemosiderin: 25%; Myoglobin: 4%; Plasma iron: 0.1%

17. Which of the following drugs increases the rate of gastric emptying in the vagotomised stomach?
A. Ondansetron
B. Metoclopramide
C. Cyclizine
D. Erythromycin
E. Chloramphenicol
Answer: D
Vagotomy seriously compromises gastric emptying which is why either a pyloroplasty or gastro-enterostomy is routinely
performed at the same time.
135
Chloramphenicol has no effect on gastric emptying. Ondansetron slows gastric emptying slightly. Metoclopramide increases the
rate of gastric emptying but its effects are mediated via the vagus nerve.

18. Which of the following haemodynamic changes is not seen in hypovolaemic shock?
A. Decreased cardiac output
B. Increased heart rate
C. Reduced left ventricle filling pressures
D. Reduced blood pressure
E. Reduced systemic vascular resistance
Answer: E
Cardiogenic Shock: e.g. MI, valve abnormality

increased SVR (vasoconstriction in response to low BP); increased HR (sympathetic response); decreased cardiac; output;
decreased blood pressure

Hypovolaemic shock: blood volume depletion e.g. haemorrhage, vomiting, diarrhoea, dehydration, third-space losses during
major operations; increased SVR; increased HR; decreased cardiac output
decreased blood pressure

Septic shock: occurs when the peripheral vascular dilatation causes a fall in SVR . Similar response may occur in anaphylactic
shock, neurogenic shock. reduced SVR; increased HR; normal/increased cardiac output; decreased blood pressure; SVR will
typically increase

Shock:Shock occurs when there is insufficient tissue perfusion. The pathophysiology of shock is an important surgical topic and
may be divided into the following aetiological groups:Septic, Haemorrhagic, Neurogenic, Cardiogenic, Anaphylactic

Septic shock: Septic shock is a major problem and those patients with severe sepsis have a mortality rate in excess of 40%. In
those who are admitted to intensive care mortality ranges from 6% with no organ failure to 65% in those with 4 organ failure.
Sepsis is defined as an infection that triggers a particular Systemic Inflammatory Response Syndrome (SIRS). This is
characterised by body temperature outside 36 oC - 38 o C, HR >90 beats/min, respiratory rate >20/min, WBC count >12,000/mm3
or < 4,000/mm3. Patients with infections and two or more elements of SIRS meet the diagnostic criteria for sepsis. Those with
organ failure have severe sepsis and those with refractory hypotension -septic shock. During the septic process there is marked
activation of the immune system with extensive cytokine release. This may be coupled with or triggered by systemic circulation
of bacterial toxins. These all cause endothelial cell damage and neutrophil adhesion. The overall hallmarks are thus those of
excessive inflammation, coagulation and fibrinolytic suppression.

The surviving sepsis campaign highlights the following key areas for attention: Prompt administration of antibiotics to cover all
likely pathogens coupled with a rigorous search for the source of infection. Haemodynamic stabilisation. Many patients are
hypovolaemic and require aggressive fluid administration. Aim for CVP 8-12 cm H2O, MAP >65mmHg. Modulation of the septic
response. This includes manoeuvres to counteract the changes and includes measures such as tight glycaemic control, use of
activated protein C and sometimes intravenous steroids.In surgical patients, the main groups with septic shock include those with
anastomotic leaks, abscesses and extensive superficial infections such as necrotising fasciitis. When performing surgery the aim
should be to undertake the minimum necessary to restore physiology. These patients do not fare well with prolonged surgery.
Definitive surgery can be more safely undertaken when physiology is restored and clotting in particular has been normalised.

Haemorrhagic shock: The average adult blood volume comprises 7% of body weight. Thus in the 70 Kg adult this will equate to
5 litres. This changes in children (8-9% body weight) and is slightly lower in the elderly.
The table below outlines the 4 major classes of haemorrhagic shock and their associated physiological sequelae:

Parameter Class I Class II Class III Class IV

Blood loss ml <750ml 750-1500ml 1500-2000ml >2000ml
Blood loss % <15% 15-30% 30-40% >40%
Pulse rate <100 >100 >120 >140ml
Blood pressure Normal Decreased Decreased Decreased
Respiratory rate 14-20 20-30 30-40 >35
Urine output >30ml 20-30ml 5-15ml <5ml
Symptoms Normal Anxious Confused Lethargic

Decreasing blood pressure during haemorrhagic shock causes organ hypoperfusion and relative myocardial ishaemia. The cardiac
index gives a numerical value for tissue oxygen delivery and is given by the equation: Cardiac index= 13.4 - [Hb] - SaO2 + 0.03
PaO2. Where Hb is haemoglobin concentration in blood and SaO2 the saturation and PaO2 the partial pressure of oxygen. Detailed
knowledge of this equation is required for the MRCS Viva but not for part A, although you should understand the principle.

In patients suffering from trauma the most likely cause of shock is haemorrhage. However, the following may also be the cause or
136
occur concomitantly:Tension pneumothorax, Spinal cord injury, Myocardial contusion, Cardiac tamponade. When assessing
trauma patients it is worth remembering that in order to generate a palpable femoral pulse an arterial pressure of >65mmHg is
required. Once bleeding is controlled and circulating volume normalised the levels of transfusion should be to maintain a Hb of 7-
8 in those with no risk factors for tissue hypoxia and Hb 10 for those who have such risk factors.

Neurogenic shock: This occurs most often following a spinal cord transection, usually at a high level. There is resultant
interruption of the autonomic nervous system. The result is either decreased sympathetic tone or increased parasympathetic
tone, the effect of which is a decrease in peripheral vascular resistance mediated by marked vasodilation. This results in
decreased preload and thus decreased cardiac output (Starlings law). There is decreased peripheral tissue perfusion and shock is
thus produced. In contrast with many other types of shock peripheral vasoconstrictors are used to return vascular tone to normal.

Cardiogenic shock: In medical patients the main cause is ischaemic heart disease. In the traumatic setting direct myocardial
trauma or contusion is more likely. Evidence of ECG changes and overlying sternal fractures or contusions should raise the
suspicion of injury. Treatment is largely supportive and transthoracic echocardiography should be used to determine evidence of
pericardial fluid or direct myocardial injury. The measurement of troponin levels in trauma patients may be undertaken but they
are less useful in delineating the extent of myocardial trauma than following MI. When cardiac injury is of a blunt nature and is
associated with cardiogenic shock the right side of the heart is the most likely site of injury with chamber and or valve rupture.
These patients require surgery to repair these defects and will require cardiopulmonary bypass to achieve this. Some may require
intra aortic balloon pump as a bridge to surgery.

Anaphylactic shock: Anaphylaxis may be defined as a severe, life-threatening, generalised or systemic

hypersensitivity reaction. Anaphylaxis is one of the few times when you would not have time to look up the dose of a medication.
The Resuscitation Council guidelines on anaphylaxis have recently been updated. Adrenaline is by far the most important drug in
anaphylaxis and should be given as soon as possible. The recommended doses for adrenaline, hydrocortisone and chlorphenamine
are as follows:

Adrenaline Hydrocortisone Chlorphenamine

< 6 months 150 mcg (0.15ml 1 in 1,000) 25 mg 250 mcg/kg
6 months - 6 years 150 mcg (0.15ml 1 in 1,000) 50 mg 2.5 mg
6-12 years 300 mcg (0.3ml 1 in 1,000) 100 mg 5 mg
Adult and child 12 years 500 g (0.5ml 1 in 1,000) 200 10 g

Adrenaline can be repeated every 5 minutes if necessary. The best site for IM injection is the anterolateral aspect of the middle
third of the thigh.Common identified causes of anaphylaxis:food (e.g. Nuts) - the most common cause in children, drugs, venom
(e.g. Wasp sting)

19. A 25 year old man is undergoing respiratory spirometry. He takes a maximal inspiration and maximally exhales.
Which of the following measurements will best illustrate this process?
A. Functional residual capacity
B. Vital capacity
C. Inspiratory capacity
D. Maximum voluntary ventilation
E. Tidal volume
Answer: B
The maximum voluntary ventilation is the maximal ventilation over the course of 1 minute.

Tidal volume (TV) Is the volume of air inspired and expired during each ventilatory cycle at rest. It is normally 500mls in males
and 340mls in females. Inspiratory reserve volume (IRV) Is the maximum volume of air that can be forcibly inhaled following a
normal inspiration. 3000mls. Expiratory reserve volume (ERV): Is the maximum volume of air that can be forcibly exhaled
following a normal expiration. 1000mls.Residual volume (RV): Is that volume of air remaining in the lungs after a maximal
expiration: RV = FRC - ERV. 1500mls. Functional residual capacity (FRC) Is the volume of air remaining in the lungs at the
end of a normal expiration. FRC = RV + ERV. 2500mls. Vital capacity (VC) Is the maximal volume of air that can be forcibly
exhaled after a maximal inspiration. VC = TV + IRV + ERV. 4500mls in males, 3500mls in females. Total lung capacity (TLC)
Is the volume of air in the lungs at the end of a maximal inspiration. TLC = FRC + TV + IRV = VC + RV. 5500-
6000mls. Forced vital capacity (FVC) The volume of air that can be maximally forcefully exhaled.

20. Which of the following does not decrease the functional residual capacity?
A. Obesity
B. Pulmonary fibrosis
C. Muscle relaxants
D. Laparoscopic surgery
E. Upright position
Answer: E

137
Increased FRC: Erect position, Emphysema, Asthma. Decreased FRC: Pulmonary fibrosis, Laparoscopic surgery, Obesity,
Abdominal swelling, Muscle relaxants

When the patient is upright the diaphragm and abdominal organs put less pressure on the lung bases, allowing for an increase in
the functional residual capacity (FRC). Other causes of increased FRC include: Emphysema, Asthma.
In addition to those listed above, causes of reduced FRC include: Abdominal swelling, Pulmonary oedema, Reduced muscle tone
of the diaphragm, Age

21. Which of the following is the main site of dehydroepiandrosterone release?

A. Posterior pituitary
B. Zona reticularis of the adrenal gland
C. Zona glomerulosa of the adrenal gland
D. Juxtaglomerular apparatus of the kidney
E. Zona fasciculata of the adrenal gland
Answer: B
Adrenal cortex mnemonic: GFR - ACD
DHEA possesses some androgenic activity and is almost exclusively released from the adrenal gland.

Renin-angiotensin-aldosterone system

Adrenal cortex (mnemonic GFR - ACD): Zona glomerulosa (on outside): mineralocorticoids, mainly aldosterone; Zona
fasciculata (middle): glucocorticoids, mainly cortisol; Zona reticularis (on inside): androgens, mainly dehydroepiandrosterone
(DHEA)

Renin: Released by JGA cells in kidney in response to reduced renal perfusion, low sodium; Hydrolyses angiotensinogen to form
angiotensin I

Factors stimulating renin secretion: Low BP; Hyponatraemia; Sympathetic nerve stimulation; Catecholamines; Erect posture

Angiotensin: ACE in lung converts angiotensin I --> angiotensin II; Vasoconstriction leads to raised BP; Stimulates thirst;
Stimulates aldosterone and ADH release

Aldosterone: Released by the zona glomerulosa in response to raised angiotensin II, potassium, and ACTH levels; Causes
retention of Na+ in exchange for K+/H+ in distal tubule

22. Secretions from which of the following will contain the highest levels of potassium?
A. Rectum
B. Small bowel
C. Gallbladder
D. Pancreas
E. Stomach
Answer: A

The rectum has the potential to generate secretions rich in potassium. This is the rationale behind administration of resins for
hyperkalaemia and the development of hypokalaemia in patients with villous adenoma of the rectum.

Potassium secretions: Salivary glands: Variable may be up to 60mmol/L; Stomach: 10 mmol/L; Bile:5 mmol/L; Pancreas: 4-5
mmol/L; Small bowel: 10 mmol/L; Rectum:30 mmol/L. These values provide average figures only and the exact composition
varies depending upon the existence of disease, serum aldosterone levels and serum pH.
A key point to remember for the exam is that gastric potassium secretions are low. Hypokalaemia may occur in vomiting, usually
as a result of renal wasting of potassium, not because of potassium loss in vomit.

23. What is the typical stroke volume in a resting 70 Kg man?

A. 10ml
B. 150ml
C. 125ml
D. 45ml
E. 70ml
Answer: E
138
Stroke volumes range from 55-100ml.
The stroke volume equates to the volume of blood ejected from the ventricle during each cycle of cardiac contraction. The
volumes for both ventricles are typically equal and equate roughly to 70ml for a 70Kg man. It is calculated by subtracting the end
systolic volume from the end diastolic volume. Factors affecting stroke volume: Cardiac size, Contractility, Preload, Afterload

24. A patient loses 1.6L fresh blood from their abdominal drain. Which of the following will not decrease?
A. Cardiac output
B. Renin secretion
C. Firing of carotid baroreceptors
D. Firing of aortic baroreceptors
E. Blood pressure
Answer: B
Renin secretion will increase as systemic hypotension will cause impairment of renal blood flow. Although the kidney can
autoregulate its own blood flow over a range of systemic blood pressures a loss of 1.6 L will usually produce an increase in renin
secretion.

25. Release of vasopressin from the pituitary will result in which of the following?
A. Vasoconstriction of the afferent glomerular arteriole
B. Increased permeability of the mesangial cells to glucose
C. Reduced permeability of the inner medullary portion of the collecting duct to urea
D. Increased secretion of aldosterone from the macula densa
E. Increased water permeability of the distal tubule cells of the kidney
Answer: E
ADH (vasopressin) results in the insertion of aquaporin channels in apical membrane of the distal tubule and collecting ducts.

26. Which of the following hormones is mainly responsible for sodium - potassium exchange in the salivary ducts?
A. Vasopressin
B. Angiotensin I
C. Aldosterone
D. Somatostatin
E. Cholecystokinin
Answer: C
Aldosterone is responsible for regulating ion exchange in salivary glands. It acts on a sodium / potassium ion exchange pump.It is
a mineralocorticoid hormone derived from the zona glomerulosa of the adrenal gland.

Anatomy of the parotid gland

Location: Overlying the mandibular ramus; anterior and inferior to the ear. Salivary duct: Crosses the masseter, pierces the
buccinator and drains adjacent to the 2nd upper molar tooth (Stensen's duct). Structures passing through the gland: Facial nerve
(Mnemonic: The Zebra Buggered My Cat; Temporal Zygomatic, Buccal, Mandibular, Cervical). External carotid artery.
Retromandibular vein. Auriculotemporal nerve .
Relations:Anterior: masseter, medial pterygoid, superficial temporal and maxillary artery, facial nerve, stylomandibular
ligament. Posterior: posterior belly digastric muscle, sternocleidomastoid, stylohyoid, internal carotid artery, mastoid process,
styloid process
Arterial supply: Branches of external carotid artery. Venous drainage: Retromandibular vein. Lymphatic drainage: Deep
cervical nodes. Nerve innervation:Parasympathetic-Secretomotor. Sympathetic-Superior cervical ganglion. Sensory- Greater
auricular nerve. Parasympathetic stimulation produces a water rich, serous saliva. Sympathetic stimulation leads to the production
of a low volume, enzyme-rich saliva.

27. In a 70 Kg male, what proportion of total body fluid will be contributed by plasma?
A. 50%
B. 5%
C. 35%
D. 65%
E. 25%
Answer: B
70 Kg male = 42 L water (60% of total body weight)
Body fluid compartments comprise intracellular and extracellular compartments. The latter includes interstitial fluid, plasma and
transcellular fluid. Typical figures are based on the 70 Kg male.

Body fluid volumes

Compartment Volume in litres Percentage of total volume
Intracellular 28 L 60-65%
Extracellular 14 L 35-40%
Plasma 3L 8%
139
 Interstitial 10 L 24%
Transcellular 1L 3%

28. A 23 year old man is undergoing an inguinal hernia repair under local anaesthesia. The surgeon encounters a bleeding
site which he manages with diathermy. About a minute or so later the patient complains that he is able to feel the
burning pain of the heat at the operative site. Which of the following nerve fibres is responsible for the transmission of
this signal?
A. A α fibres
B. A β fibres
C. B fibres
D. C fibres
E. None of the above
Answer: D
Slow transmission of mechanothermal stimuli is transmitted via C fibres.
A α fibres transmit information relating to motor proprioception, A β fibres transmit touch and pressure and B fibres are
autonomic fibres.
Somatic pain: Peripheral nociceptors are innervated by either small myelinated fibres (A-gamma) fibres or by unmyelinated C
fibres. The A gamma fibres register high intensity mechanical stimuli. The C fibres usually register high intensity
mechanothermal stimuli.

29. What is the approximate volume of pancreatic secretions in a 24 hour period?

A. 100ml
B. 200ml
C. 500ml
D. 1500ml
E. 3000ml
Answer: D
Typically the pancreas secretes up to 1.5L per day.

30. A 34 year old lady has just undergone a parathyroidectomy for primary hyperparathyroidism. The operation is
difficult and all 4 glands were explored. The wound was clean and dry at the conclusion of the procedure and a suction
drain inserted. On the ward she becomes irritable and develops respiratory stridor. On examination her neck is soft
and the drain empty. Which of the following treatments should be tried initially?
A. Administration of intravenous calcium gluconate
B. Administration of intravenous lorazepam
C. Removal of the skin closure on the ward
D. Direct laryngoscopy
E. Administration of calcichew D3 orally
Answer: A
Exploration of the parathyroid glands may result in impairment of the blood supply. Serum PTH levels can fall quickly and
features of hypocalcaemia may ensue, these include neuromuscular irritability and laryngospasm. Prompt administration of
intravenous calcium gluconate can be lifesaving. The absence of any neck swelling and no blood in the drain would go against a
contained haematoma in the neck (which should be managed by removal of skin closure).

Calcium homeostasis: Calcium ions are linked to a wide range of physiological processes. The largest store of bodily calcium is
contained within the skeleton. Calcium levels are primarily controlled by parathyroid hormone, vitamin D and calcitonin.
Parathyroid hormone (PTH): Increase calcium levels and decrease phosphate levels. Increases bone resorption. Immediate
action on osteoblasts to increase ca2+ in extracellular fluid. Osteoblasts produce a protein signaling molecule that activate
osteoclasts which cause bone resorption. Increases renal tubular reabsorption of calcium. Increases synthesis of 1,25(OH)2D
(active form of vitamin D) in the kidney which increases bowel absorption of Ca2+. Decreases renal phosphate reabsorption
1,25-dihydroxycholecalciferol (the active form of vitamin D):Increases plasma calcium and plasma phosphate. Increases renal
tubular reabsorption and gut absorption of calcium. Increases osteoclastic activity. Increases renal phosphate reabsorption
Calcitonin:Secreted by C cells of thyroid. Inhibits intestinal calcium absorption. Inhibits osteoclast activity Inhibits renal tubular
absorption of calcium
Both growth hormone and thyroxine also play a small role in calcium metabolism.

Theme: Interpretation of aterial blood gas results

A. pH 7.19, pCO2 10.2, pO2 16 (FiO2 85%), Bicarbonate 23.8, Base excess -2.2 mmol
B. pH 7.57, PaCO2 3.5, Pa O2 24.5 (FiO2 85%), Bicarbonate 23.5, Base excess +1.8 mmol
C. pH 7.14, PaCO2 7.4, PaO2 8.9 (FiO2 40%), Bicarbonate 14 mmol, Base excess -10.6
D. pH 7.36, PaCO2 7.3, PO2 8.9 (FiO2 40%), Bicarbonate 30.2, Base excess 5.3
140
E. pH 7.32, PCO2 3.8, PaO2 22.2 (FiO2 40%), Bicarbonate 19.1, Base excess -7.9

Which of the following arterial blood gases fit with the description below?

31. Acute respiratory acidosis

pH 7.19, pCO2 10.2, pO2 16 (FiO2 85%), Bicarbonate 23.8, Base excess -2.2 mmol
32. Metabolic acidosis with a compensatory respiratory alkalosis
pH 7.32, PCO2 3.8, PaO2 22.2 (FiO2 40%), Bicarbonate 19.1, Base excess -7.9
33. Chronic respiratory acidosis with a compensatory metabolic alkalosis
pH 7.36, PaCO2 7.3, PO2 8.9 (FiO2 40%), Bicarbonate 30.2, Base excess 5.3

In advanced life support training, a 5 step approach to arterial blood gas interpretation is advocated.
1. How is the patient?
2. Is the patient hypoxaemic? The Pa02 on air should be 10.0-13.0 kPa
3. Is the patient acidaemic (pH <7.35) or alkalaemic (pH >7.45)?
4. What has happened to the PaCO2? If there is acidaemia, an elevated PaCO2 will account for this
5. What is the bicarbonate level or base excess? A metabolic acidosis will have a low bicarbonate level and a low base excess
(< -2 mmol). A metabolic alkalosis will have a high bicarbonate and a high base excess (> +2 mmol)

34. Cortisol is predominantly produced by which of the following?

A. Zona fasciculata of the adrenal
B. Zona glomerulosa of the adrenal
C. Zona reticularis of the adrenal
D. Adrenal medulla
E. Posterior lobe of the pituitary
Answer: A
Relative Glucocorticoid activity: Hydrocortisone = 1; Prednisolone = 4; Dexamethasone = 25
Cortisol is produced by the zona fasciculata of the adrenal gland.

Cortisol: Glucocorticoid; Released by zona fasiculata of the adrenal gland; 90% protein bound; 10% active; Circadian rhythm:
High in the mornings; Negative feedback via ACTH. Actions: Glycogenolysis; Glucaneogenesis; Protein catabolism; Lipolysis;
Stress response; Anti-inflammatory; Decrease protein in bones; Increase gastric acid; Increases neutrophils/platelets/red blood
cells; Inhibits fibroblastic activity

35. Which of the following is not an intravenous colloid?

A. Gelofusine
B. Dextran 40
C. Human albumin solution
D. Hydroxyethyl starch
E. Bicarbonate 8.4%
Answer: E
Bicarbonate is a crystalloid

Pre operative fluid management: fluid management has been described in the British Consensus guidelines on IV fluid
therapy for Adult Surgical patients (GIFTASUP)

The Recommendations include: Use Ringer's lactate or Hartmann's when a crystalloid is needed for resuscitation or replacement
of fluids. Avoid 0.9% N. Saline (due to risk of hyperchloraemic acidosis) unless patient vomiting or has gastric drainage. Use
0.4%/0.18% dextrose saline or 5% dextrose in maintenance fluids. It should not be used in resuscitation or as replacement fluids.
Adult maintenance fluid requirements are: Na 50-100 mmol/day and K 40-80 mmol/day in 1.5-2.5L fluid per day. Patients for
elective surgery should NOT be nil by mouth for >2 hours (unless has disorder of gastric emptying). Patients for elective surgery
should be given carbohydrate rich drinks 2-3h before. Ideally this should form part of a normal pre op plan to facilitate recovery.
Avoid mechanical bowel preparation. If bowel prep is used, simultaneous administration of Hartmann's or Ringer's lactate should
be considered. Excessive fluid losses from vomiting should be treated with a crystalloid with potassium replacement. 0.9% N.
Saline should be given if there is hypochloraemia. Otherwise Hartmann's or Ringer lactate should be given for
diarrhoea/ileostomy/ileus/obstruction. Hartmann's should also be given in sodium losses secondary to diuretics. High risk patients
should receive fluids and inotropes. An attempt should be made to detect pre or operative hypovolaemia using flow based
measurements. If this is not available, then clinical evaluation is needed i.e. JVP, pulse volume etc. In Blood loss or infection
causing hypovolaemia should be treated with a balanced crystalloid or colloid (or until blood available in blood loss). A critically
ill patient is unable to excrete Na or H20 leading to a 5% risk of interstitial oedema. Therefore 5% dextrose as well as colloid
should be given. Give 200mls of colloid in hypovolaemia, repeat until clinical parameters improve.

141
Theme: Electrolyte disorders

A. Hypotonic hypovolaemic hyponatraemia

B. Hypotonic hypervolaemic hyponatraemia
C. Pseudohyponatraemia
D. Syndrome of inappropriate ADH secretion (SIADH)
E. Hypertonic hyponatraemia
F. Over administration 5% dextrose

Please select the most likely reason for hyponatraemia for each scenario given. Each option may be used once, more than once or
not at all.

36. A 73 year old man presents to pre operative clinic for an elective total hip replacement. He is on frusemide for
hypertension. He is found to have the following blood results: Na 120; Urine Na 10 (low); Serum osmolality 280
(normal)
Answer: Hypotonic hypovolaemic hyponatraemia

The blood results reflect extra-renal sodium loss. The body is trying to preserve the sodium by not allowing any sodium
into the urine (hence the low Na in the urine). Note with renal sodium loss the Urinary sodium is high.

37. A 67 year old man presents to pre operative clinic for an elective hernia repair. He is on frusemide for heart
failure. He is found to have the following blood results: Na 120; Urine Na 35 (high); Urine osmolality 520 (high);
Serum osmolality 265 (low)
Answer: Syndrome of inappropriate ADH secretion (SIADH)

This blood picture fits with SIADH. SIADH causes retention of fluid from the urine (concentrated urine) into the blood
vessels, therefore diluting the fluid in the blood vessels (low osmolality). Management involves removing the cause and
fluid restriction.

38. A 77 year old man presents to pre operative clinic for a total knee replacement. He is on frusemide for
hypertension. He is known to have multiple myeloma. He is found to have the following blood results:
Na 120; Serum osmolality 280 (normal); Urine osmolallity normal; Urine Na normal

Answer: Pseudohyponatraemia
Hyperlipidaemia and multiple myeloma are known to cause a pseudohyponatraemia.
SIADH: Low serum osmolalityHigh/Normal urine osmolality

Hyponatraemia
This is commonly tested in the MRCS (despite most surgeons automatically seeking medical advice if this occurs!). The most
common cause in surgery is the over administration of 5% dextrose.
Hyponatraemia may be caused by water excess or sodium depletion. Causes of pseudohyponatraemia include hyperlipidaemia
(increase in serum volume) or a taking blood from a drip arm. Urinary sodium and osmolarity levels aid making a diagnosis.

Classification
 Urinary sodium > 20 mmol/l: Sodium depletion, renal loss
Patient often hypovolaemic; Diuretics (thiazides); Addison's; Diuretic stage of renal failure; SIADH (serum osmolality
low, urine osmolality high, urine Na high); Patient often euvolaemic. Mnemonic: Syndrome of INAPPropriate Anti-
Diuretic Hormone: In creased; Na (sodium); PP (urine)

 Urinary sodium < 20 mmol/l Sodium depletion, extra-renal loss

Diarrhoea, vomiting, sweating. Burns, adenoma of rectum (if villous lesion and large

 Water excess (patient often hypervolaemic and oedematous)Secondary hyperaldosteronism: CCF, cirrhosis; Reduced
GFR: renal failure; IV dextrose, psychogenic polydipsia

Management
Symptomatic Hyponatremia: Acute hyponatraemia with Na <120: immediate therapy. Central Pontine Myelinolisis, may occur
from overly rapid correction of serum sodium. Aim to correct until the Na is > 125 at a rate of 1 mEq/h. Normal saline with
frusemide is an alternative method. The sodium requirement can be calculated as follows:
(125 - serum sodium) x 0.6 x body weight = required mEq of sodium

142
39. A 53 year old man is on the intensive care unit following an emergency abdominal aortic aneurysm repair. He develops
abdominal pain and diarrhoea and is profoundly unwell. His abdomen has no features of peritonism. Which of the
following arterial blood gas pictures is most likely to be present?
A. pH 7.45, pO2 10.1, pCO2 3.2, Base excess 0, Lactate 0
B. pH 7.35, pO2 8.0, pCO2 5.2, Base excess 2, Lactate 1
C. pH 7.20, pO2 9.0, pCO2 3.5, Base excess -10, Lactate 8
D. pH 7.29, pO2 8.9, pCO2 5.9, Base excess -4, Lactate 3
E. pH 7.30, pO2 9.2 pCO2 4.8, Base excess -2, lactate 1
Answer: C
This man is likely to have a metabolic acidosis secondary to a mesenteric infarct.
Disorders of acid- base balance are often covered in the MRCS part A, both in the SBA and EMQ sections.

Metabolic acidosis: This is the most common surgical acid - base disorder. Reduction in plasma bicarbonate levels. Two
mechanisms:1. Gain of strong acid (e.g. diabetic ketoacidosis); 2. Loss of base (e.g. from bowel in diarrhoea)
Classified according to the anion gap, this can be calculated by: (Na+ + K+) - (Cl- + HCO3-).
If a question supplies the chloride level then this is often a clue that the anion gap should be calculated. The normal range = 10-18
mmol/L

Normal anion gap ( = hyperchloraemic metabolic acidosis): Gastrointestinal bicarbonate loss: diarrhoea,
ureterosigmoidostomy, fistula; Renal tubular acidosis; Drugs: e.g. acetazolamide; Ammonium chloride injection; Addison's
disease

Raised anion gap: Lactate: shock, hypoxia; Ketones: diabetic ketoacidosis, alcohol; Urate: renal failure; Acid poisoning:
salicylates, methanol

Metabolic acidosis secondary to high lactate levels may be subdivided into two types: Lactic acidosis type A: (Perfusion disorders
e.g.shock, hypoxia, burns) or Lactic acidosis type B: (Metabolic e.g. metformin toxicity)

Metabolic alkalosis: Usually caused by a rise in plasma bicarbonate levels. Rise of bicarbonate above 24 mmol/L will typically
result in renal excretion of excess bicarbonate. Caused by a loss of hydrogen ions or a gain of bicarbonate. It is due mainly to
problems of the kidney or gastrointestinal tract

Causes: Vomiting / aspiration (e.g. Peptic ulcer leading to pyloric stenosis, nasogastric suction); Diuretics; Liquorice,
carbenoxolone; Hypokalaemia; Primary hyperaldosteronism; Cushing's syndrome; Bartter's syndrome; Congenital adrenal
hyperplasia

Mechanism of metabolic alkalosis: Activation of renin-angiotensin II-aldosterone (RAA) system is a key factor; Aldosterone
causes reabsorption of Na+ in exchange for H+ in the distal convoluted tubule; ECF depletion (vomiting, diuretics) --> Na+ and Cl-
loss --> activation of RAA system --> raised aldosterone levels; In hypokalaemia, K+ shift from cells --> ECF, alkalosis is caused
by shift of H+ into cells to maintain neutrality

Respiratory acidosis: Rise in carbon dioxide levels usually as a result of alveolar hypoventilation: Renal compensation may
occur leading to Compensated respiratory acidosis

Causes: COPD; Decompensation in other respiratory conditions e.g. Life-threatening asthma / pulmonary oedema; Sedative
drugs: benzodiazepines, opiate overdose

Respiratory alkalosis: Hyperventilation resulting in excess loss of carbon dioxide; This will result in increasing pH

Causes: Psychogenic: anxiety leading to hyperventilation; Hypoxia causing a subsequent hyperventilation: pulmonary embolism,
high altitude; Early salicylate poisoning*; CNS stimulation: stroke, subarachnoid haemorrhage, encephalitis; Pregnancy
*Salicylate overdose leads to a mixed respiratory alkalosis and metabolic acidosis. Early stimulation of the respiratory centre leads
to a respiratory alkalosis whilst later the direct acid effects of salicylates (combined with acute renal failure) may lead to an
acidosis

40. A 48 year old women suffers blunt trauma to the head and develops respiratory compromise. As a result she develops
hypercapnia. Which of the following effects is most likely to ensue?
A. Cerebral vasoconstriction
B. Cerebral vasodilation
C. Cerebral blood flow will remain unchanged
143
 D. Shunting of blood to peripheral tissues will occur in preference to CNS perfusion
E. None of the above
Answer: B
Hypercapnia will tend to produce cerebral vasodilation. This is of considerable importance in patients with cranial trauma as it
may increase intracranial pressure.

Pressure within the cranium is governed by the Monroe-Kelly doctrine. This considers the skull as a closed box. Increases in mass
can be accommodated by loss of CSF. Once a critical point is reached (usually 100- 120ml of CSF lost) there can be no further
compensation and ICP rises sharply. The next step is that pressure will begin to equate with MAP and neuronal death will occur.
Herniation will also accompany this process. The CNS can autoregulate its own blood supply. Vaso constriction and dilatation of
the cerebral blood vessels is the primary method by which this occurs. Extremes of blood pressure can exceed this capacity
resulting in risk of stroke. Other metabolic factors such as hypercapnia will also cause vasodilation, which is of importance in
ventilating head injured patients. The brain can only metabolise glucose, when glucose levels fall, consciousness will be impaired.

41. A patient is seen in clinic complaining of abdominal pain. Routine bloods show:Na+ 142 mmol/l; K+ 4.0 mmol/l;
Chloride 104 mmol/l; Bicarbonate 19 mmol/l; Urea 7.0 mmol/l; Creatinine 112 µmol/l. What is the anion gap?
A. 4 mmol/L
B. 14 mmol/L
C. 20 mmol/L
D. 21 mmol/L
E. 23 mmol/L

Answer: E

The anion gap may be calculated by using (sodium + potassium) - (bicarbonate + chloride)
= (142 + 4.0) - (104 + 19) = 23 mmol/L

42. A surgeon is considering using lignocaine as local anasthesia for a minor procedure. Which of the following best
accounts for its actions?
A. Blockade of neuronal acetylcholine receptors
B. Blockade of neuronal nicotinic receptors
C. Blockade of neuronal sodium channels
D. Blockade of neuronal potassium channels
E. Blockade of neuronal calcium channels
Answer: C
Lignocaine blocks sodium channels. They will typically be activated first, hence the pain some patients experience on
administration.

Local anaesthetic agents

Lidocaine: An amide; Local anaesthetic and a less commonly used antiarrhythmic (affects Na channels in the axon); Hepatic
metabolism, protein bound, renally excreted; Toxicity: due to IV or excess administration. Increased risk if liver dysfunction or
low protein states. Note acidosis causes lidocaine to detach from protein binding.; Drug interactions: Beta blockers, ciprofloxacin,
phenytoin; Features of toxicity: Initial CNS over activity then depression as lidocaine initially blocks inhibitory pathways then
blocks both inhibitory and activating pathways. Cardiac arrhythmias. Increased doses may be used when combined with
adrenaline to limit systemic absorption.

Cocaine: Pure cocaine is a salt, usually cocaine hydrochloride. It is supplied for local anaesthetic purposes as a paste. It is
supplied for clinical use in concentrations of 4 and 10%. It may be applied topically to the nasal mucosa. It has a rapid onset of
action and has the additional advantage of causing marked vasoconstriction. It is lipophillic and will readily cross the blood brain
barrier. Its systemic effects also include cardiac arrhythmias and tachcardia. Apart from its limited use in ENT surgery it is
otherwise used rarely in mainstream surgical practice.

Bupivicaine: Bupivacaine binds to the intracellular portion of sodium channels and blocks sodium influx into nerve cells, which
prevents depolarization. It has a much longer duration of action than lignocaine and this is of use in that it may be used for topical
wound infiltration at the conclusion of surgical procedures with long duration analgesic effect. It is cardiotoxic and is therefore
contra indicated in regional blockage in case the tourniquet fails. The co-administration of adrenaline concentrates it at the site of
action and allows the use of higher doses.

Prilocaine: Similar mechanism of action to other local anaesthetic agents. However, it is far less cardiotoxic and is therefore the
agent of choice for intravenous regional anaesthesia e.g. Biers Block.

All local anaesthetic agents dissociate in tissues and this contributes to their therapeutic effect. The dissociation constant shifts in
tissues that are acidic e.g. where an abscess is present and this reduce the efficacy.

144
Doses of local anaesthetics
Agent Dose plain Dose with adrenaline
Lignocaine 3mg/Kg 7mg/Kg
Bupivicane 2mg/Kg 2mg/Kg
Prilocaine 6mg/Kg 9mg/Kg
These are a guide only as actual doses depend on site of administration, tissue vascularity and co-morbidities.

43. A 22 year old man suffers a blunt head injury. He is drowsy and has a GCS of 7 on admission. Which of the following
is the major determinant of cerebral blood flow in this situation?
A. Systemic blood pressure
B. Mean arterial pressure
C. Intra cranial pressure
D. Hypoxaemia
E. Acidosis
Answer: C

Hypoxaemia and acidosis may both affect cerebral blood flow. However, in the traumatic situation increases in intracranial
pressure are far more likely to occur especially when GCS is low. This will adversely affect cerebral blood flow.
Cerebral blood flow: CNS autoregulates its own blood supply
Factors affecting the cerebral pressure include; systemic carbon dioxide levels, CNS metabolism, CNS trauma, CNS pressure. The
PaCO2 is the most potent mediator
Acidosis and hypoxaemia will increase cerebral blood flow but to a lesser degree
Cerebral perfusion pressure may increase in patients with head injuries and this can result in impaired blood flow
Intra cerebral pressure governed by Monroe-Kelly Doctrine which considers brain as closed box, changes in pressure are offset by
loss of CSF. When this is no longer possible ICP rises

44. Which main group of receptors does dobutamine bind to?

A. α-1
B. α-2
C. ß-1
D. ß-2
E. D-1
Answer: C
Dobutamine is a sympathomimetic with both alpha- and beta-agonist properties; it displays a considerable selectivity for beta1-
cardiac receptors.

Inotrope and its receptor:Adrenaline: α-1, α-2, β-1, β-2; Noradrenaline : α-1,( α-2), (β-1), (β-2); Dobutamine: β-1, (β 2);
Dopamine : (α-1), (α-2), (β-1), D-1,D-2. Minor receptor effects in brackets

Effects of receptor binding: α-1, α-2:vasoconstriction; β-1:increased cardiac contractility and HR; β-2:vasodilatation; D-1:renal
and spleen vasodilatation; D-2:inhibits release of noradrenaline

45. Which of the following is responsible for the release and synthesis of calcitonin?
A. Parathyroid glands
B. Anterior pituitary
C. Thyroid gland
D. Posterior pituitary
E. Adrenal glands
Answer: C
Calcitonin has the opposite effect of PTH and is release from the thyroid gland.

46. What is the half life of insulin in the circulation of a normal healthy adult?
A. Less than 30 minutes
B. Between 1 and 2 hours
C. Between 2 and 3 hours
D. Between 4 and 5 hours
E. Over 6 hours
Answer: A

Insulin is degraded by enzymes in the circulation. It typically has a half life of less than 30 minutes. Abnormalities of the
clearance of insulin may occur in type 2 diabetes.

145
47. Which of the following statements about blood clotting is untrue?
A. Platelet adhesion to disrupted endothelium is dependent upon von Willebrand factor
B. Protein C is a vitamin K dependent substance
C. The bleeding time provides an assessment of platelet function
D. The prothrombin time tests the extrinsic system
E. Administration of aprotinin during liver transplantation surgery prolongs survival
Answer: E

Although aprotinin reduces fibrinolysis and thus bleeding, it is associated with increased risk of death and was withdrawn in 2007.
Protein C is dependent upon vitamin K and this may paradoxically increase the risk of thrombosis during the early phases of
warfarin treatment.

Theme: Management of vomiting

A. Ondansetron
B. Metoclopramide
C. Cyclizine
D. Erythromycin
E. Cisapride
F. Haloperidol

Please select the most appropriate drug for the given scenario. Each option may be used once, more than once or not at all.

48. A 78 year old manwith diabetes develops autonomic gastropathy and persistant a troublesome vomiting.
Answer: Erythromycin
Unlike metoclopramide the effects of erythromycin on gastric empyting are not mediated via the vagus nerve.
49. A drug which blocks the chemoreceptor trigger zone in the area postrema.
Answer: Ondansetron
5 HT3 blockers are most effective for many types of nausea for this reason.
50. A 48 year old man with oesphageal varices has a profuse haemorrhage on the ward.
Answer: Metoclopramide
Intravenous metoclopramide causes increased oesophageal pressure and this may temporarily slow the rate of
haemorrhage whilst more definitive measures are instigated.

Vomiting
Reflex oral expulsion of gastric (and sometimes intestinal) contents - reverse peristalsis and abdominal contraction The vomiting
centre is in part of the medulla oblongata and is triggered by receptors in several locations: Labyrinthine receptors of ear (motion
sickness); Overdistention receptors of duodenum and stomach; Trigger zone of CNS - many drugs (e.g., opiates) act here ; Touch
receptors in throat; Sensory innervation rich, both extrinsic and intrinsic

51. Which of the following cell types is least likely to be found in a wound 1 week following injury?
A. Macrophages
B. Fibroblasts
C. Myofibroblasts
D. Endothelial cells
E. Neutrophils
Answer: C
Myofibroblasts are differentiated fibroblasts composed, in which the cytoskeleton contains actin filaments. These cell types
facilitate wound contracture and are the hallmark of a mature wound.

Phases of wound healing

Phase Key features Cells Timeframe

 Vasospasm in adjacent vessels
Seconds/
Haemostasis  Platelet plug formation and generation of fibrin rich clot Erythrocytes
Minutes

 Neutrophils migrate into wound (function impaired in

diabetes).
Neutrophils, fibroblasts
Inflammation  Growth factors released, including basic fibroblast Days
and macrophages
growth factor and vascular endothelial growth factor.
 Fibroblasts replicate within the adjacent matrix and

146
 migrate into wound.
 Macrophages and fibroblasts couple matrix regeneration
and clot substitution.

 Platelet derived growth factor and transformation growth

factors stimulate fibroblasts and epithelial cells.
 Fibroblasts produce a collagen network. Fibroblasts, endothelial
Regeneration Weeks
 Angiogenesis occurs and wound resembles granulation cells, macrophages
tissue.

 Longest phase of the healing process and may last up to

one year (or longer).
 During this phase fibroblasts become differentiated
(myofibroblasts) and these facilitate wound contraction. 6 weeks to 1
Remodelling Myofibroblasts
year
 Collagen fibres are remodelled.
 Microvessels regress leaving a pale scar.

52. The blood - brain barrier is not highly permeable to which of the following?
A. Carbon dioxide
B. Barbituates
C. Glucose
D. Oxygen
E. Hydrogen ions
Answer: E
The blood brain barrier is relatively impermeable to highly dissociated compounds.

Cerebrospinal fluid: The CSF fills the space between the arachnoid mater and pia mater (covering surface of the brain). The total
volume of CSF in the brain is approximately 150ml. Approximately 500 ml is produced by the ependymal cells in the choroid
plexus (70%), or blood vessels (30%). It is reabsorbed via the arachnoid granulations which project into the venous sinuses.

Circulation: 1. Lateral ventricles (via foramen Munro); 2. 3rd ventricle; 3. Cerebral aqueduct (aqueduct Sylvius); 4. 4th ventricle
(via foramina of Magendie and Luschka); 5. Subarachnoid space; 6. Reabsorbed into venous system via arachnoid granulations in
superior sagittal sinus

Composition: Glucose: 50-80mg/dl; Protein: 15-40 mg/dl; Red blood cells: Nil; White blood cells: 0-3 cells/ mm3

53. A 43 year old presents to the urology clinic complaining of impotence.Which of the following will occur in response to
increased penile parasympathetic stimulation?
45. Detumescence
46. Ejaculation
47. Erection
48. Vasospasm of the penile branches of the pudendal artery
49. Contraction of the smooth muscle in the epididymis and vas deferens
Answer: C
Parasympathetic stimulation causes erection. Sympathetic stimulation will produce ejaculation, detumescence and vasospasm of
the pudendal artery. It will also cause contraction of the smooth muscle in the epididymis and vas to convey the ejaculate.

Autonomic: Sympathetic nerves originate from T11-L2 and parasympathetic nerves from S2-4 join to form pelvic plexus.
Parasympathetic discharge causes erection, sympathetic discharge causes ejaculation and detumescence. Somatic nerves
Supplied by dorsal penile and pudendal nerves. Efferent signals are relayed from Onufs nucleus (S2-4) to innervate
ischiocavernosus and bulbocavernosus muscles.

Autonomic discharge to the penis will trigger the veno-occlusive mechanism which triggers the flow of arterial blood into the
penile sinusoidal spaces. As the inflow increases the increased volume in this space will secondarily lead to compression of the
subtunical venous plexus with reduced venous return. During the detumesence phase the arteriolar constriction will reduce arterial
inflow and thereby allow venous return to normalise.

Priapism: Prolonged unwanted erection, in the absence of sexual desire, lasting more than 4 hours.

Classification of priaprism
147
Low flow priaprism Due to veno-occlusion (high intracavernosal pressures): Most common type; Often painful; Often low
cavernosal flow; If present for >4 hours requires emergency treatment
High flow priaprism:Due to unregulated arterial blood flow. Usually presents as semi rigid painless erection
Recurrent priaprism Typically seen in sickle cell disease, most commonly of high flow type.

Causes: Intracavernosal drug therapies (e.g. for erectile dysfunction>; Blood disorders such as leukaemia and sickle cell disease;
Neurogenic disorders such as spinal cord transection; Trauma to penis resulting in arterio-venous malformations

Tests: Exclude sickle cell/ leukaemia; Consider blood sampling from cavernosa to determine whether high or low flow (low flow
is often hypoxic)

Management: Ice packs/ cold showers; If due to low flow then blood may be aspirated from copora or try intracavernosal alpha
adrenergic agonists.Delayed therapy of low flow priaprism may result in erectile dysfunction.

54. In class II haemorrhagic shock in a 70Kg male, one would not expect to find?
A. Blood loss greater than 750ml
B. Tachycardia
C. Decreased blood pressure
D. Urine output less than 20ml
E. Anxiety
Answer: D
Urine output in class II shock (assuming 70Kg adult) is typically between 20 and 30ml.

Theme: Acid - base disorders

A. pH 7.64 pO2 10.0 kPa pCO2 2.8 kPa HCO3 20

B. pH 7.25 pO2 8.9 pCO2 3.2 HCO3 10
C. pH 7.20 pO2 6.2 pCO2 8.2 HCO3 27
D. pH 7.60 pO2 8.2 pCO2 5.8 HCO3 40
E. pH7.45 pO2 7.2 pCO2 2.5 HCO3 24

Please match the diagnosis with the arterial blood gas result. Each option may be used once, more than once or not at all.

55. Pulmonary embolus

The correct answer is pH7.45 pO2 7.2 pCO2 2.5 HCO3 24

A combination of hypoxia and respiratory alkalosis should suggest a pulmonary embolus. The respiratory alkalosis is due
to hyperventilation associated with the pulmonary embolism.
56. Ureterosigmoidostomy

Answer: pH 7.25 pO2 8.9 pCO2 3.2 HCO3 10

There is acidosis. To compensate the patient will attempt to reduce the pH level in the blood by hyperventilating, hence
the low CO2 level .

57. Peptic ulcer causing pyloric stenosis

Answer: pH 7.60 pO2 8.2 pCO2 5.8 HCO3 40

58.Which of the following best accounts for the action of PTH in increasing serum calcium levels?
A.Activation of vitamin D to increase absorption of calcium from the small intestine.
B.Direct stimulation of oestoclasts to absorb bone with release of calcium.
C.Stimulation of phosphate absorption at the distal convoluted tubule of the kidney.
D.Decreased porosity of the vessels at Bowmans capsule to calcium.
E.Vasospasm of the afferent renal arteriole thereby reducing GFR and calcium urinary loss.
Answer: A
PTH increases the activity of 1-α-hydroxylase enzyme, which converts 25-hydroxycholecalciferol to 1,25-
dihydroxycholecalciferol, the active form of vitamin D.
Osteoclasts do not have a PTH receptor and effects are mediated via osteoblasts.

Parathyroid hormone is secreted by the chief cells of the parathyroid glands. It acts to increase serum calcium concentration by
stimulation of the PTH receptors in the kidney and bone. PTH has a plasma half life of 4 minutes.
148
Effects of PTH
Bone:Binds to osteoblasts which signal to osteoclasts to cause resorption of bone and release calcium. Kidney:Active
reabsorption of calcium and magnesium from the distal convoluted tubule. Decreases reabsorption of phosphate. Intestine via
kidney:Increases intestinal calcium absorption by increasing activated vitamin D. Activated vitamin D increases calcium
absorption.

59. Which of the following drugs does not cause syndrome of inappropriate anti diuretic hormone release?
45. Haloperidol
46. Carbamazepine
47. Amitriptylline
48. Cyclophosphamide
49. Methotrexate
Answer: E
Drugs causing SIADH: ABCD:A nalgesics: opioids, NSAIDs; B arbiturates; C yclophosphamide/ Chlorpromazine/
Carbamazepine; D iuretic (thiazides)

60. Which of the following changes are not typically seen in established dehydration?
A. Rising haematocrit
B. Urinary sodium <20mmol/ litre
C. Metabolic acidosis
D. Decreased serum urea to creatinine ratio
E. Hypernatraemia
Answer: D
Diagnosing dehydration can be complicated, laboratory features include:Hypernatraemia; Rising haematocrit; Metabolic acidosis;
Rising lactate; Increased serum urea to creatinine ratio; Urinary sodium <20 mmol/litre; Urine osmolality approaching
1200mosmol/kg

61. A 67 year old male is admitted to the surgical unit with acute abdominal pain. He is found to have a right sided
pneumonia. The nursing staff put him onto 15L O2 via a non rebreathe mask. After 30 minutes the patient is found
moribund, sweaty and agitated by the nursing staff. An arterial blood gas reveals: pH:7.15; pCO2:10.2; pO2:8;
Bicarbonate:32; Base excess:5.2. What is the most likely cause for this patients deterioration?
A. Acute respiratory alkalosis secondary to hyperventilation
B. Over administration of oxygen in a COPD patient
C. Metabolic acidosis secondary to severe pancreatitis
D. Metabolic alkalosis secondary to hypokalaemia
E. Acute respiratory acidosis secondary to pneumonia
Answer: B
This patient has an acute respiratory acidosis, however this is on a background of chronic respiratory acidosis (due to COPD) with
a compensatory metabolic alkalosis (the elevated bicarbonate is the main clue to the chronic nature of the respiratory acidosis).
This blood gas picture is typical in a COPD patient who has received too much oxygen; these patients lose their hypoxic drive for
respiration, therefore retain CO2 and subsequently hypoventilate leading to respiratory arrest. If the bicarbonate was normal, then
the answer would be acute respiratory acidosis secondary to pneumonia.

62. Which of the following statements relating to the pharmacology of warfarin is untrue?
45. Interferes with clotting factors 2,7,9 and 10
46. It may not be pharmacologically active for up to 72 hours
47. The half life of warfarin is 40 hours
48. Warfarin has a large volume of distribution
49. It is metabolized in the liver
Answer: D
Factors 2,7,9,10 affected
Warfarin interferes with fibrin formation by affecting carboxylation of glutamic acid residues in factors 2,7,9 and 10. Factor 2 has
the longest half life of approximately 60 h, therefore it can take up to 3 days for warfarin to be fully effective. Warfarin has a
small volume of distribution as it is protein bound. Warfarin is an oral anticoagulant which inhibits the reduction of vitamin K to
its active hydroquinone form, which in turn acts as a cofactor in the formation of clotting factor II, VII, IX and X (mnemonic =
1972) and protein C

Factors that may potentiate warfarin: Liver disease; P450 enzyme inhibitors, e.g.: amiodarone, ciprofloxacin; Cranberry juice;
Drugs which displace warfarin from plasma albumin, e.g. NSAIDs; Inhibit platelet function: NSAIDs

149
Side-effects: Haemorrhage; Teratogenic; Skin necrosis: when warfarin is first started biosynthesis of protein C is reduced. This
results in a temporary procoagulant state after initially starting warfarin, normally avoided by concurrent heparin administration.
Thrombosis may occur in venules leading to skin necrosis.

63. Which of the following does not cause an increased anion gap acidosis?
A. Uraemia
B. Paraldehyde
C. Diabetic ketoacidosis
D. Ethylene glycol
E. Acetazolamide
Answer: E

Causes if increased anion acidosis: MUDPILES : M – Methanol; U – Uraemia; D - DKA/AKA; P - Paraldehyde/phenformin; I

- Iron/INH; L - Lactic acidosis; E - Ethylene glycol; S - Salicylates

64. Which one of the following is least associated with thrombocytopenia?

A. Heparin therapy
B. Rheumatoid arthritis
C. Infectious mononucleosis
D. Liver disease
E. Pregnancy
Answer: B
Rheumatoid arthritis, unlike systemic lupus erythematous, is generally associated with a thrombocytosis. In some cases of Felty's
syndrome thrombocytopaenia may be seen secondary to hypersplenism. This however represents a small percentage of patients
with rheumatoid arthritis. Causes of severe thrombocytopenia: ITP; DIC; TTP; haematological malignancy. Causes of
moderate thrombocytopenia: heparin induced thrombocytopenia (HIT); drug-induced (e.g. quinine, diuretics, sulphonamides,
aspirin, thiazides); alcohol; liver disease; hypersplenism; viral infection (EBV, HIV, hepatitis); pregnancy; SLE/antiphospholipid
syndrome; vitamin B12 deficiency

65. Which of the following will increase the volume of pancreatic exocrine secretions?
A. Octreotide
B. Cholecystokinin
C. Aldosterone
D. Adrenaline
E. None of the above
Answer: B
Cholecystokinin will often increase the volume of pancreatic secretions.

66. Where is the majority of iron found in the body?

A. Bone
B. Haemoglobin
C. Ferritin and haemosiderin
D. Myoglobin
E. Plasma iron
Answer: B
Approximately 70% of body iron is found bound to haemoglobin.

67. A 44 year old man recieves a large volume transfusion of whole blood. The whole blood is two weeks old. Which of the
following best describes its handling of oxygen?
A. It will have a low affinity for oxygen
B. Its affinity for oxygen is unchanged
C. It will more readily release oxygen in metabolically active tissues than fresh blood
D. The release of oxygen in metabolically acitve tissues will be the same as fresh blood
E. It will have an increased affinity for oxygen
Answer: E

Stored blood has less 2,3 DPG and therefore has a higher affinity for oxygen, this reduces its ability to release it at metabolising
tissues.

68. Which of the following does not occur during the physiological response to surgery?
A. Glycogenolysis

150
 B. Increased acute phase proteins
C. Increased cortisol production
D. Bronchoconstriction
E. Release of nitric oxide by vessels

Answer: D

Response to surgery
Sympathetic nervous system: Noradrenaline from sympathetic nerves and adrenaline from adrenal medulla; Blood diverted from
skin and visceral organs; bronchodilatation, reduced intestinal motility, increased glucagon and glycogenolysis, insulin reduced;
Heart rate and myocardial contractility are increased

Acute phase response: TNF-α, IL-1, IL-2, IL-6, interferon and prostaglandins are released; Excess cytokines may cause SIRS

Cytokines increase the release of acute phase proteins

Endocrine response: Hypothalamus, pituitary, adrenal axis. Increases ACTH and cortisol production:increases protein
breakdown and increases blood glucose levels Aldosterone increases sodium reabsorption. Vasopressin increases water
reabsorption and causes vasoconstriction

Vascular endothelium: Nitric oxide produces vasodilatation. Platelet activating factor enhances the cytokine response.
Prostaglandins produce vasodilatation and induce platelet aggregation

69. A 43 year old lady undergoes a day case laparoscopic cholecystectomy. The operation is more difficult than anticipated
and a drain is placed to the operative site. Whilst in recovery the patient loses 1800ml of frank blood into the drain.
Which of the following will not occur?
A. Release of aldosterone via the Bainbridge reflex
B. Reduced urinary sodium excretion
C. Increase in sympathetic discharge to ventricular muscle
D. Fall in parasympathetic discharge to the sino atrial node
E. Decreased stimulation from atrial pressure receptors
Answer: A

The Bainbridge reflex is the increase in heart rate mediated via atrial stretch receptors that occurs following a rapid infusion of
blood.

70. Which of the following statements are not typically true in hypokalaemia?
A. It may occur as a result of mechanical bowel preparation
B. Chronic vomiting may increase renal potassium losses
C. It may be associated with aciduria
D. It may cause hyponatraemia
E. It often accompanies acidosis
Answer: E
Potassium depletion occurs either through the gastrointestinal tract or the kidney. Chronic vomiting in itself is less prone to induce
potassium loss than diarrhoea as gastric secretions contain less potassium than those in the lower GI tract. If vomiting produces a
metabolic alkalosis then renal potassium wasting may occur as potassium is excreted in preference to hydrogen ions. The converse
may occur in potassium depletion resulting in acid urine.

Hyperkalaemia Plasma potassium levels are regulated by a number of factors including aldosterone, acid-base balance and
insulin levels. Metabolic acidosis is associated with hyperkalaemia as hydrogen and potassium ions compete with each other for
exchange with sodium ions across cell membranes and in the distal tubule. ECG changes seen in hyperkalaemia include tall-tented
T waves, small P waves, widened QRS leading to a sinusoidal pattern and asystole

Causes of hyperkalaemia: Acute renal failure; Drugs*: potassium sparing diuretics, ACE inhibitors, angiotensin 2 receptor
blockers, spironolactone, ciclosporin, heparin** Metabolic acidosis; Addison's; Tissue necrosis/rhabdomylosis: burns, trauma;
Massive blood transfusion. Foods that are high in potassium: Salt substitutes (i.e. Contain potassium rather than sodium);
Bananas, oranges, kiwi fruit, avocado, spinach, tomatoes

*beta-blockers interfere with potassium transport into cells and can potentially cause hyperkalaemia in renal failure patients -
remember beta-agonists, e.g. Salbutamol, are sometimes used as emergency treatment

**both unfractionated and low-molecular weight heparin can cause hyperkalaemia. This is thought to be caused by inhibition of
aldosterone secretion
151
71. Approximately what proportion of salivary secretions is provided by the submandibular glands?
A. 10%
B. 70%
C. 40%
D. 90%
E. 20%
Answer: B
Although they are small, the submandibular glands provide the bulk of salivary secretions and contribute 70%, the sublingual
glands provide 5% and the remainder from the parotid.

Relations of the submandibular gland

Superficial:Platysma, deep fascia and mandible, Submandibular lymph nodes, Facial vein (facial artery near mandible), Marginal
mandibular nerve, Cervical branch of the facial nerve. Deep:Facial artery (inferior to the mandible), Mylohoid muscle, Sub
mandibular duct, Hyoglossus muscle, Lingual nerve, Submandibular ganglion, Hypoglossal nerve. Submandibular duct
(Wharton's duct): Opens lateral to the lingual frenulum on the anterior floor of mouth. 5 cm length. Lingual nerve wraps around
Wharton's duct. As the duct passes forwards it crosses medial to the nerve to lie above it and then crosses back, lateral to it, to
reach a position below the nerve.

Innervation: Sympathetic innervation- Superior Cervical ganglion via the Lingual nerve. Parasympathetic innervation-
Submandibular ganglion Arterial supply: Branch of the Facial artery. The facial artery passes through the gland to groove its
deep surface. It then emerges onto the face by passing between the gland and the mandible. Venous drainage: Anterior Facial
vein (lies deep to the Marginal Mandibular nerve). Lymphatic drainage: Deep cervical and jugular chains of nodes.

72. Which is not a cause of hyperuricaemia?

A. Severe psoriasis
B. Lesch-Nyhan syndrome
C. Hyperthyroidism
D. Diabetic ketoacidosis
E. Alcohol
Answer: C
Mnemonic of the drugs causing hyperuricaemia as a result of reduced excretion of urate: 'Can't leap': C iclosporin; A lcohol; N
icotinic acid; T hiazides; L oop diuretics; E thambutol; A spirin; P yrazinamide

Hyperuricaemia:Increased levels of uric acid may be seen secondary to either increased cell turnover or reduced renal excretion
of uric acid. Hyperuricaemia may be found in asymptomatic patients who have not experienced attacks of gout. Hyperuricaemia
may be associated with hyperlipidaemia and hypertension. It may also be seen in conjunction with the metabolic syndrome
Increased synthesis: Lesch-Nyhan disease; Myeloproliferative disorders; Diet rich in purines; Exercise; Psoriasis; Cytotoxics.
Decreased excretion: Drugs: low-dose aspirin, diuretics, pyrazinamide; Pre-eclampsia; Alcohol; Renal failure; Lead.

73. A 20 year old man is hit in the face and occludes his airway. Which of the following stimuli and receptor groups would
the most potently activated as a result?
A. Receptors in the apneustic centre
B. Hypoxia of centrally located chemoreceptors
C. Hypoxia of peripherally located chemoreceptors
D. Hypercapnia of the carotid bodies
E. Hypoxia in the aortic arch receptors
Answer: D
The carotid bodies are the most vascular site and hypercapnia the most potent stimulus.

74. Which of the following statements relating to low molecular weight heparins is false?
A. They act via inhibition of Factor Xa
B. Large doses may be used prior to commencing cardiopulmonary bypass
C. They have a highly predictable pharmacokinetic profile
D. They are derivatives of unfractionated heparin
E. They have a molecular mass in the range of 3000-10000Da
Answer: B
As they are not easily reversed they are unsuitable for this purpose.

Heparin: Causes the formation of complexes between antithrombin and activated thrombin/factors 7,9,10,11 & 12

152
Advantages of low molecular weight heparin: Better bioavailability; Lower risk of bleeding; Longer half life; Little effect on
APTT at prophylactic dosages; Less risk of HIT. Complications: Bleeding; Osteoporosis; Heparin induced thrombocytopenia
(HIT): occurs 5-14 days after 1st exposure; Anaphylaxis. In surgical patients that may need a rapid return to theatre administration
of unfractionated heparin is preferred as low molecular weight heparins have a longer duration of action and are harder to reverse.

75. A 43 year old lady presents with urinary incontinence. At which of the following locations is Onufs nucleus likely to be
found?
A. Medulla oblongata
B. Anterior horn of L5 nerve roots
C. Micturition centre in the Pons
D. Anterior horn of S2 nerve roots
E. None of the above
Answer: D
Onufs nucleus is located in the anterior horn of S2 and is the origin of neurones to the external urethral sphincter.

Urinary incontinence: Involuntary passage of urine. Most cases are female (80%). It has a prevalence of 11% in those aged
greater than 65 years. The commonest variants include:Stress urinary incontinence (50%); Urge incontinence (15%); Mixed (35%)

Males: Males may also suffer from incontinence although it is a much rarer condition in men. A number of anatomical factors
contribute to this. Males have 2 powerful sphincters; one at the bladder neck and the other in the urethra. Damage to the bladder
neck mechanism is a factor in causing retrograde ejaculation following prostatectomy. The short segment of urethra passing
through the urogenital diaphragm consists of striated muscle fibres (the external urethral sphincter) and smooth muscle capable of
more sustained contraction. It is the latter mechanism that maintains continence following prostatectomy.

Females: The sphincter complex at the level of bladder neck is poorly developed in females. As a result the external sphincter
complex is functionally more important, its composition being similar to that of males. Innervation is via the pudendal nerve and
the neuropathy that may accompany obstetric events may compromise this and lead to stress urinary incontinence.

Innervation: Somatic innervation to the bladder is via the pudendal, hypogastric and pelvic nerves. Autonomic nerves travel in
these nerve fibres too. Bladder filling leads to detrusor relaxation (sympathetic) coupled with sphincter contraction. The
parasympathetic system causes detrusor contraction and sphincter relaxation. Overall control of micturition is centrally mediated
via centres in the Pons.

Stress urinary incontinence: 50% of cases, especially in females. Damage (often obstetric) to the supporting structures
surrounding the bladder may lead to urethral hypermobility. Other cases due to sphincter dysfunction, usually from neurological
disorders (e.g. Pudendal neuropathy, multiple sclerosis).

Urethral mobility:Pressure not transmitted appropriately to the urethra resulting in involuntary passage of urine during episodes of
raised intra-abdominal pressure.

Sphincter dysfunction: Sphincter fails to adapt to compress urethra resulting in involuntary passage of urine. When the sphincter
completely fails there is often to continuous passage of urine.

Urge incontinence: In these patients there is sense of urgency followed by incontinence. The detrusor muscle in these patients is
unstable and urodynamic investigation will demonstrate overactivity of the detrusor muscle at inappropriate times (e.g. Bladder
filling). Urgency may be seen in patients with overt neurological disorders and those without. The pathophysiology is not well
understood but poor central and peripheral co-ordination of the events surrounding bladder filling are the main processes.

Assessment: Careful history and examination including vaginal examination for cystocele.
Bladder diary for at least 3 days
Consider flow cystometry if unclear symptomatology or surgery considered and diagnosis is unclear.
Exclusion of other organic disease (e.g. Stones, UTI, Cancer)

Management: Conservative measures should be tried first; Stress urinary incontinence or mixed symptoms should undergo 3
months of pelvic floor exercise. Over active bladder should have 6 weeks of bladder retraining.
Drug therapy for women with overactive bladder should be offered with oxybutynin if conservative measures fail.
In women with detrusor instability who fail non operative therapy a trial of sacral neuromodulation may be considered, with
conversion to permanent implant if good response. Augmentation cystoplasty is an alternative but will involve long term
intermittent self catheterisation.
In women with stress urinary incontinence a urethral sling type procedure may be undertaken. Where cystocele is present in
association with incontinence it should be repaired particularly if it lies at the introitus.

NICE guidelines: Initial assessment urinary incontinence should be classified as stress/urge/mixed. At least 3/7 bladder diary if
153
unable to classify easily. Start conservative treatment before urodynamic studies if a diagnosis is obvious from the history.
Urodynamic studies if plans for surgery. Stress incontinence: Pelvic floor exercises 3/12, if fails consider surgery. Urge
incontinence: Bladder training >6/52, if fails for oxybutynin (antimuscarinic drugs) then sacral nerve stimulation. Pelvic floor
exercises offered to all women in their 1st pregnancy.

76. Which of the following is associated with reduced lung compliance?

A. Older age
B. Emphysematous type COPD
C. Decline in pulmonary blood flow
D. Adopting a vertical posture
E. Adjusting a ventilator to maintain high lung volumes

Answer: E

Increased lung compliance = Older age, COPD

Lung compliance is a measure of the ease of expansion of the lungs and thorax, determined by pulmonary volume and elasticity.
A high degree of compliance indicates a loss of elastic recoil of the lungs, as in old age or emphysema. This increased lung
compliance is due to loss of supportive tissue around the airways. While a normal lung has a high passive elastic recoil, the sick
lung has a decreased elasticity (i.e. decreased transpulmonary pressure) which leads to increased lung compliance.
Decreased compliance means that a greater change in pressure is needed for a given change in volume, as in atelectasis,
pulmonary fibrosis, pneumonia, or lack of surfactant.

77. Which of the following statements relating to alveolar ventilation is untrue?

A. Anatomical dead space is measured by helium dilution

B. Physiological dead space is increased in PE
C. Alveolar ventilation is defined as the volume of fresh air entering the alveoli per minute
D. Anatomical dead space is increased by noradrenaline
E. Type 2 pneumocytes in the alveoli secrete surfactant
Answer: A
Anatomical dead space is measured by Fowlers method.
A patient inhales 100% oxygen to empty the conducting zone gases of nitrogen and then exhales through a mouthpiece which
analyses the nitrogen concentration at the mouth. Initially the exhaled gases contain no nitrogen as this is dead space gas; the
nitrogen concentration will increase
as the alveolar gases are exhaled. Nitrogen which is measured following the breath of 100% oxygen must then have come only
from gas exchanging areas of the lung and not dead space.

Alveolar ventilation: Minute ventilation is the total volume of gas ventilated per minute.
MV (ml/min)= tidal volume x Respiratory rate (resps/min).

Dead space ventilation describes the volume of gas not involved in exchange in the blood. There are 2 types:

1. Anatomical dead space: 150mls: Volume of gas in the respiratory tree not involved in gaseous exchange: mouth,
pharynx, trachea, bronchi up to terminal bronchioles. Measured by Fowlers method. Increased by:Standing, increased
size of person, increased lung volume and drugs causing bronchodilatation e.g. Adrenaline
2. Physiological dead space: normal 150 mls, increases in ventilation/perfusion mismatch e.g. PE, COPD, hypotension

Volume of gas in the alveoli and anatomical dead space not involved in gaseous exchange. Alveolar ventilation is the volume of
fresh air entering the alveoli per minute. Alveolar ventilation = minute ventilation - Dead space volume

77. Which opioid receptor does morphine attach to?

A. mu
B. alpha
C. sigma
D. beta
E. kappa
Answer: A
Pethidine and other conventional opioids attach to this receptor.

Opioids: Combine to specific opiate receptors in the CNS (periaqueductal grey matter, limbic system, substantia gelatinosa).
Morphine attaches to mu1 receptors

78. Which of the following inhibits the secretion of insulin?

154
 A. Adrenaline
B. Glucagon
C. Gastrin
D. Arginine
E. Vagal cholinergic activity
Answer: A

Inhibition of insulin release: Alpha adrenergic drugs, Beta blockers, Sympathetic nerves

79. What is measured to obtain renal plasma flow?

A. Creatinine
B. Para-amino hippuric acid (PAH)
C. Inulin
D. Glucose
E. Protein

Answer: B

amount of PAH in urine per unit time

Renal plasma flow =
difference in PAH concentration in the renal artery or vein

Normal value = 660ml/min

80. Which of the following is not a cause of hypercalcaemia?

A. Thiazides
B. Antacids
C. Coeliac disease
D. Sarcoidosis
E. Zolinger-Ellison syndrome
Answer: C
Mnemonic for the causes of hypercalcaemia: CHIMPANZEES: C alcium supplementation; H yperparathyroidism; I
atrogentic (Drugs: Thiazides); M ilk Alkali syndrome; P aget disease of the bone; A cromegaly and Addison's Disease; N
eoplasia; Z olinger-Ellison Syndrome (MEN Type I); E xcessive Vitamin D; E xcessive Vitamin A; S arcoidosis
Patients with coeliac disease tend to develop hypocalcaemia due to malabsorption of calcium by the bowel.

Main causes: Malignancy; Primary hyperparathyroidism. Less common: Sarcoidosis (extrarenal synthesis of calcitriol );
Thiazides, lithium; Immobilisation; Pagets disease; Vitamin A/D toxicity; Thyrotoxicosis; MEN; Milk alkali syndrome. Clinical
features: “Stones, bones, abdominal moans, and psychic groans”

81. Which of the following surgical procedures will have the greatest long term impact on a patients calcium metabolism?
A. Distal gastrectomy
B. Cholecystectomy
C. Extensive small bowel resection
D. Sub total colectomy
E. Gastric banding for obesity

Answer: C
Calcium is mainly absorbed from the small bowel and this will have a direct long term impact on calcium metabolism and
increase the risk of osteoporosis. Gastric banding and distal gastrectomy may affect a patients dietary choices but any potential
deleterious nutritional intake may be counteracted by administration of calcium supplements orally. Only 10% of calcium is
absorbed from the colon so that a sub total colectomy will only have a negligible effect.

82. A 52-year-old woman with a history of gastrectomy reports lethargy and a sore tongue. Blood tests are reported as
follows: Hb:10.7 g/dl; MCV:121 fl; Plt:177 * 10^9/l; WBC:5.4 * 10^9/l. What is the most likely cause?
A. Vitamin B12 deficiency
B. Vitamin C deficiency
C. Iron deficiency anaemia
D. Anaemia of chronic disease
E. Vitamin E deficiency
Answer: A
A history of gastrectomy and a macrocytic anaemia should indicate a diagnosis of B12 deficiency.
Vitamin B12 is mainly used in the body for red blood cell development and also maintenance of the nervous system. It is absorbed
after binding to intrinsic factor (secreted from parietal cells in the stomach) and is actively absorbed in the terminal ileum. A small
amount of vitamin B12 is passively absorbed without being bound to intrinsic factor.
155
Causes of vitamin B12 deficiency: pernicious anaemia; post gastrectomy; poor diet; disorders of terminal ileum (site of
absorption): Crohn's, blind-loop etc. Features of vitamin B12 deficiency: macrocytic anaemia; sore tongue and mouth;
neurological symptoms: e.g. Ataxia; neuropsychiatric symptoms: e.g. Mood disturbances. Management: if no neurological
involvement 1 mg of IM hydroxocobalamin 3 times each week for 2 weeks, then once every 3 months. If a patient is also deficient
in folic acid then it is important to treat the B12 deficiency first to avoid precipitating subacute combined degeneration of the cord

83. A 43 year old lady is diagnosed with primary hyperparathyroidism. Her serum PTH levels are elevated. An endocrine
surgeon performs a parathyroidectomy. How long will it take for the serum PTH levels to fall if the functioning
adenoma has been successfully removed?
A. 6 hours
B. 24 hours
C. 2 hours
D. 1 hour
E. 10 minutes
Answer: E
PTH has a very short half life usually less than 10 minutes. Therefore a demonstrable drop in serum PTH should be identified
within 10 minutes of removing the adenoma. This is useful clinically since it is possible to check the serum PTH intraoperatively
prior to skin closure and explore the other glands if levels fail to fall.

84. Which of the following statements relating to abnormal coagulation is false?

A. Warfarin affects the synthesis of factor 2,7,9,10
B. The prothrombin time is prolonged in Haemophilia A
C. Cholestatic jaundice can cause vitamin K deficiency
D. Disseminated intravascular coagulation is associated with thrombocytopenia
E. Massive transfusion is associated with reduced levels of factor 5 and 8

Answer: B

In haemophilia A the APTT is prolonged and there is reduced levels of factor 8:C. The bleeding time and PT are normal.
Cholestatic jaundice prevents the absorption of the fat soluble vitamin K. Massive transfusion (>10u blood or equivalent to the
blood volume of a person) puts the patient at risk of thrombocytopaenia, factor 5 and 8 deficiency.

Abnormal coagulation
Heparin: Prevents activation factors 2,9,10,11; Warfarin: Affects synthesis of factors 2,7,9,10; DIC: Factors 1,2,5,8,11; Liver
disease: Factors 1,2,5,7,9,10

Interpretation blood clotting test results

Disorder APTT PT Bleeding time

Haemophilia Increased Normal Normal
von Willebrand's disease Increased Normal Increased
Vitamin K deficiency Increased Increased Normal

85. Which of the following physiological changes do not occur following tracheostomy?
A. Alveolar ventilation is increased.
B. Anatomical dead space is reduced by 50%.
C. Work of breathing is increased.
D. Proportion of ciliated epithelial cells in the trachea may decrease.
E. Splinting of the larynx may lead to swallowing difficulties.
Answer: C
Work of breathing is decreased which is one reasons it is popular option for weaning ventilated patients. Humdified air in this
setting helps to reduce the viscosity of mucous that forms.

Trachea: Location:C6 vertebra to the upper border of T5 vertebra (bifurcation). Arterial and venous supply:Inferior thyroid
arteries and the thyroid venous plexus. Nerve:Branches of vagus, sympathetic and the recurrent nerves

Relations in the neck: Anterior(Superior to inferior): Isthmus of the thyroid gland, Inferior thyroid veins, Arteria thyroidea ima
(when that vessel exists), Sternothyroid, Sternohyoid, Cervical fascia, Anastomosing branches between the anterior jugular veins;
Posterior: Oesophagus. Laterally: Common carotid arteries, Right and left lobes of the thyroid gland, Inferior thyroid arteries,
Recurrent laryngeal nerves

156
Relations in the thorax: Anterior: Manubrium sterni, the remains of the thymus, the aortic arch, left common carotid arteries,
and the deep cardiac plexus; Lateral: In the superior mediastinum, on the right side is the pleura and right vagus; on its left side
are the left recurrent nerve, the aortic arch, and the left common carotid and subclavian arteries.

86. A 34 year old man presents with a peptic ulcer. Which of the following is responsible for the release of gastric acid?
A. Chief cells
B. Parietal cells
C. Brunners Glands
D. G Cells
E. None of the above
Answer: B

Parietal cells are responsible for the release of gastric acid. Brunners glands are found in the duodenum.

87. Which of the following does not lead to relaxation of the lower oesophageal sphincter?
A. Metoclopramide
B. Botulinum toxin type A
C. Nicotine
D. Alcohol
E. Theophylline
Answer: A
Metoclopramide acts directly on the smooth muscle of the LOS to cause it to contract.
Theophylline is a phosphodiesterase inhibitor (mimics action of prostaglandin E1) which causes relaxation of the LOS.

Peristalsis: Circular smooth muscle contracts behind the food bolus and longitudinal smooth muscle propels the food through the
oesophagus. Primary peristalsis spontaneously moves the food from the oesophagus into the stomach (9 seconds). Secondary
peristalsis occurs when food, which doesn't enter the stomach, stimulates stretch receptors to cause peristalsis. In the small
intestine each peristalsis waves slows to a few seconds and causes mixture of chime. In the colon three main types of peristaltic
activity are recognised (see below)

Colonic peristalsis
Segmentation contractions: Localised contractions in which the bolus is subjected to local forces to maximise mucosal
absorption. Antiperistaltic contractions towards ileum: Localised reverse peristaltic waves to slow entry into colon and
maximise absorption. Mass movement: Waves migratory peristaltic waves along the entire colon to empty the organ prior to the
next ingestion of food bolus

88. Which of the following is not released from the islets of Langerhans?
A. Pancreatic polypeptide
B. Glucagon
C. Secretin
D. Somatostatin
E. Insulin
Answer: C
Secretin is released from mucosal cells in the duodenum and jejunum.
Hormones released from the islets of Langerhans: Beta cells:Insulin (70% of total secretions); Alpha cells:Glucagon; Delta
cells:Somatostatin; F cells:Pancreatic polypeptide

89. Which of the following is not classically seen in coning resulting from raised intra cranial pressure?
A. Coma
B. Hypotension
C. Unreactive mid sized pupils
D. Cheyne Stokes style respiratory efforts
E. Bradycardia
Answer: B
Cushings triad: Widening of the pulse pressure; Respiratory changes; Bradycardia
Due to raised ICP systemic hypertension is usually seen. Compression of the respiratory centre will typically result in Cheyne
Stokes style respiration.

157
Coning: The cranial vault is a confined cavity apart from infants with a non fused fontanelle. Rises in ICP may be accommodated
by shifts of CSF. Once the CSF shifting has reached its capacity ICP will start to rise briskly. The brain autoregulates its blood
supply, as ICP rises the systemic circulation will display changes to try and meet the perfusion needs of the brain. Usually this will
involve hypertension. As CSF rises further, the brain will be compressed, cranial nerve palsies may be seen and compression of
essential centres in the brain stem will occur. When the cardiac centre is involved bradycardia will often develop.

90. Control of ventilation. Which statement is false?

A. Peripheral chemoreceptors are located in the bifurcation of the carotid arteries and arch of the aorta
B. Central chemoreceptors respond to changes in O2
C. The respiratory centres control the rate and depth of respiration
D. Involuntary control of respiration is from the medulla and pons
E. Irritant receptors cause bronchospasm
Answer: B
Central chemoreceptors: Respond to increased H+ in BRAIN INTERSTITIAL FLUID to increase ventilation.

91. A 54 year old lady has her serum calcium measured. Assuming her renal function is normal, what proportion of
calcium filtered at the glomerulus will be reabsorbed by the renal tubules?

A. 5%
B. 15%
C. 25%
D. 50%
E. 95%
Answer: E
Most filtered calcium is reabsorbed (95%) a rare disorder of familial hypercalcemic calciurea may affect this proportion.

91. Which of the following does not cause hyperkalaemia?

A. Haemolysis
B. Burns
C. Familial periodic paralysis
D. Type 4 renal tubular acidosis
E. Severe malnutrition
Answer: E
'Machine' - Causes of Increased Serum K+: M - Medications - ACE inhibitors, NSAIDS; A - Acidosis - Metabolic and
respiratory; C - Cellular destruction - Burns, traumatic injury; H - Hypoaldosteronism, haemolysis; I - Intake – Excessive; N -
Nephrons, renal failure; E - Excretion - Impaired

Familial periodic paralysis has subtypes associated with hyper and hypokalaemia.

92. Which of the following statements is true of glucagon?

A. Produced in response to hyperglycaemia
B. Released by beta cells
C. Inhibits gluconeogenesis
D. Produced in response to an increase of amino acids
E. Composed of 2 alpha polypeptide chains linked by hydrogen bonds
Answer: D
Glucagon is a protein comprised of a single polypeptide chain.
Produced by alpha cells of pancreatic islets of Langerhans in response to hypoglycaemia and amino acids.
It increases plasma glucose and ketones.

Glucagon, the hormonal antagonist to insulin, is released from the alpha cells of the Islets of Langerhans in the pancreas. It will
result in an increased plasma glucose level.Stimulation: Decreased plasma glucose; Increased catecholamines; Increased plasma
amino acids; Sympathetic nervous system; Acetylcholine; Cholecystokinin. Inhibition: Somatostatin; Insulin; Increased free fatty
acids and keto acids; Increased urea

93. A 28 year old man undergoes a completion right hemicolectomy for treatment of a 5cm appendiceal carcinoid. As part
of his follow up he is due to undergo 24 hour urine collection for 5-HIAA. Which of the following causes an elevated 5-
HIAA in a 24-hour urine collection?
A. Isoniazid
B. Oranges
C. Flucloxacillin
D. Amiodarone

158
 E. Beef
Answer: A
It is important to be aware of what can falsely elevate 5-HIAA to avoid diagnosing carcinoid syndrome incorrectly. These include:
Food: spinach, cheese, wine, caffeine, tomatoes. Drugs: Isoniazid, Monoamine oxidase inhibitors

Carcinoid syndrome: Carcinoid tumours secrete serotonin; Originate in neuroendocrine cells mainly in the intestine (midgut-
distal ileum/appendix); Can occur in the rectum, bronchi; Hormonal symptoms mainly occur when disease spreads outside the
bowel
Clinical features: Onset: years. Flushing face. Palpitations. Tricuspid stenosis causing dyspnea. Asthma. Severe diarrhoea
(secretory, persists despite fasting)
Investigation: 5-HIAA in a 24-hour urine collection. Scintigraphy. CT scan
Treatment: Octreotide; Surgical removal

94. A 52 year old man develops septic shock following a Hartmans procedure for perforated diverticular disease. He is
started on an adrenaline infusion. Which of the following is least likely to occur?
A. Peripheral vasoconstriction
B. Coronary artery vasospasm
C. Gluconeogenesis
D. Lipolysis
E. Tachycardia
Answer: B
Its cardiac effects are mediated via β 1 receptors. The coronary arteries which have β 2 receptors are unaffected.

Adrenaline
Fight or Flight response: Catecholamine (phenylalanine and tyrosine); Neurotransmitter and hormone; Released by the adrenal
glands; Effects on α 1 and 2, β 1 and 2 receptors; Main effect on alpha 1 receptors in skeletal muscle-causing vasodilation;
Increase cardiac output and total peripheral resistance; This leads to vasoconstriction in the skin and kidneys causing a narrow
pulse pressure

Actions: α adrenergic receptors: Inhibits insulin secretion by the pancreas. Stimulates glycogenolysis in the liver and muscle.
Stimulates glycolysis in muscle

β adrenergic receptors: Stimulates glucagon secretion in the pancreas. Stimulates ACTH. Stimulates lipolysis by adipose tissue

95. Intra cranial pressure is governed by the principles of the Monroe-Kellie doctrine. To which of the following does this
concept not apply?
A. A 2 month old child
B. A 2 year old child
C. A 5 year old child
D. A 10 year old child
E. An adult
Answer: A

The Monroe-Kelly Doctrine assumes that the cranial cavity is a rigid box. In children with non fused fontanells this is not the case.

Pressure within the cranium is governed by the Monroe-Kelly doctrine. This considers the skull as a closed box. Increases in mass
can be accommodated by loss of CSF. Once a critical point is reached (usually 100- 120ml of CSF lost) there can be no further
compensation and ICP rises sharply. The next step is that pressure will begin to equate with MAP and neuronal death will occur.
Herniation will also accompany this process. The CNS can autoregulate its own blood supply. Vaso constriction and dilatation of
the cerebral blood vessels is the primary method by which this occurs. Extremes of blood pressure can exceed this capacity
resulting in risk of stroke. Other metabolic factors such as hypercapnia will also cause vasodilation, which is of importance in
ventilating head injured patients. The brain can only metabolise glucose, when glucose levels fall, consciousness will be impaired.

96. Which of the following is not caused by cortisol in the stress response?
A. Anti-inflammatory effects
B. Hypoglycaemia
C. Skeletal muscle protein breakdown
D. Stimulation of lipolysis
E. Mineralocorticoid effects
Answer: B
An 'anti insulin' effect occurs leading to hyperglycaemia.

97. Which of the following features does not put a patient at risk of refeeding syndrome?
159
 A. BMI < 16 kg/m2
B. Alcohol abuse
C. Thyrotoxicosis
D. Chemotherapy
E. Diuretics

Answer: C

Diuretics increase the risk of re-feeding syndrome through a process of increasing the risk of depletion of key electrolytes.

Refeeding syndrome describes the metabolic abnormalities which occur on feeding a person a starved state. The metabolic
consequences include: Hypophosphataemia; Hypokalaemia; Hypomagnesaemia; Abnormal fluid balance
These abnormalities can lead to organ failure.

Re-feeding problems: If patient not eaten for > 5 days, aim to re-feed at < 50% energy and protein levels

High risk for re-feeding problems: If one or more of the following: BMI < 16 kg/m2; Unintentional weight loss >15% over 3-6
months; Little nutritional intake > 10 days; Hypokalaemia, Hypophosphataemia or hypomagnesaemia prior to feeding (unless
high). If two or more of the following: BMI < 18.5 kg/m2; Unintentional weight loss > 10% over 3-6 months; Little nutritional
intake > 5 days; PMH alcohol abuse or drug therapy including insulin, chemotherapy, diuretics, antacids

Prescription: Start at up to 10 kcal/kg/day increasing to full needs over 4-7 days; Start immediately before and during feeding:
oral thiamine 200-300mg/day, vitamin B co strong 1 tds and supplements; Give K+ (2-4 mmol/kg/day), phosphate (0.3-0.6
mmol/kg/day), magnesium (0.2-0.4 mmol/kg/day)

98. Which of the following statements relating to the regulation of renal blood flow is untrue?
A. In a healthy 70Kg male, the glomerular filtration rate will be the same at a systolic blood pressure of 120mmHg as a
systolic blood pressure of 95 mmHg
B. Over 90% of the blood supply to the kidney is distributed to the cortex
C. The kidney receives approximately 25% of the total cardiac output at rest
D. A decrease in renal perfusion pressure will cause the juxtaglomerular cells to secrete renin
E. Systolic blood pressures of less than 65mmHg will cause the mesangial cells to secrete aldosterone
Answer: E

The kidney autoregulates its blood supply over a range of systolic blood pressures. Drop in arterial pressure is sensed by the
juxtaglomerular cells and renin is released leading to the activation of the renin-angiontensin system. Mesangial cells are
contractile cells that are located in the tubule and have no direct endocrine function.

99. 39 year old lady undergoes a laparoscopic cholecystectomy as a daycase. The operation is more difficult than
anticipated and the surgeon places a drain to the liver bed. In recovery 1.5 litres of blood is seen to enter the drain.
Which of the following substances is the first to be released in this situation?
A. Angiotensinogen
B. Renin
C. Angiotensin I
D. Angiotensin II
E. Aldosterone
Answer: B
The decrease in blood pressure will be sensed by the juxtaglomerular cells in the kidney. This will cause renin secretion.

100.Which of the following drugs causes hyperkalaemia?

A. Heparin
B. Ciprofloxacin
C. Salbutamol
D. Levothyroxine
E. Codeine phosphate
Answer: A
Both unfractionated and low-molecular weight heparin can cause hyperkalaemia. This is thought to be caused by inhibition of
aldosterone secretion. Salbutamol is a recognised treatment for hyperkalaemia.

101.A 25-year-old man who has been morbidly obese for the past five years is reviewed in the surgical bariatric clinic. In
this patient, release of which of the following hormones would increase appetite?
A. Leptin
B. Thyroxine
160
 C. Adiponectin
D. Ghrelin
E. Serotonin
Answer: D
Obesity hormones: leptin decreases appetite. Ghrelin increases appetite. Whilst thyroxine can increase appetite it does not fit
with the clinical picture being described.
Leptin: Leptin is thought to play a key role in the regulation of body weight. It is produced by adipose tissue and acts on satiety
centres in the hypothalamus and decreases appetite. More adipose tissue (e.g. in obesity) results in high leptin levels. Leptin
stimulates the release of melanocyte-stimulating hormone (MSH) and corticotrophin-releasing hormone (CRH). Low levels of
leptin stimulates the release of neuropeptide Y (NPY)

Ghrelin: Where as leptin induces satiety, ghrelin stimulates hunger. It is produced mainly by the fundus of the stomach and the
pancreas. Ghrelin levels increase before meals and decrease after meals

102.Which of the following bony complications is not linked to excess glucocorticoids?

A. Avascular necrosis
B. Vertebral body collapse
C. Increased susceptibility to osteomyelitis from strep viridans
D. Decreased absorption of calcium from the gut
E. Growth retardation in children
Answer: C
This infection is not typical of steroid excess, although general increased susceptibilty to infections is.

103.A 54-year-old woman is admitted to the Surgical Admissions Unit with abdominal pain. Blood tests taken on admission
show the following: Magnesium: 0.40 mmol/l. Which one of the following factors is most likely to be responsible for this
result?
A. Excessive resuscitation with intravenous saline
B. Digoxin therapy
C. Diarrhoea
D. Hypothermia
E. Rhabdomyolysis
Answer: C
Cause of low magnesium: Diuretics; Total parenteral nutrition; Diarrhoea; Alcohol; Hypokalaemia, hypocalcaemia
Features: Paraesthesia; Tetany; Seizures; Arrhythmias; Decreased PTH secretion --> hypocalcaemia; ECG features similar to
those of hypokalaemia. Exacerbates digoxin toxicity

104.A 43 year old man has a nasogastric tube inserted. The nurse takes a small aspirate of the fluid from the stomach and
tests the pH of the aspirate. What is the normal intragastric pH?
45. 0.5
46. 2
47. 4
48. 5
49. 6

Answer: B
The intragastric pH is usually 2. Administration of proton pump inhibitors can result in almost complete abolition of acidity

105.Which of the following is the equivalent of cardiac preload?

A. End diastolic volume
B. Stroke volume
C. Systemic vascular resistance
D. Mean arterial pressure
E. Peak systolic arterial pressure
Answer: A

Preload is the same as end diastolic volume. When it is increased slightly there is an associated increase in cardiac output (Frank
Starling principle). When it is markedly increased e.g. over 250ml then cardiac output falls.

106.A 73 year old female is referred to the surgical clinic with an iron deficiency anaemia. As part of the diagnostic work
up the doctor requests a serum ferritin level. Which of the conditions listed is most likely to lead to a falsely elevated
result?
A. Locally perforated sigmoid colonic adenocarcinoma

161
 B. Colonic angiodysplasia
C. Dieulafoy lesion of the stomach
D. Transitional cell carcinoma of the bladder
E. Endometrial adenocarcinoma
Answer: A

A locally perforated colonic tumour will typically cause an intense inflammatory response and if peritonitis is not present
clinically then at the very least a localised abscess. This inflammatory process is the most likely (from the list) to falsely raise the
serum ferritin level. Angiodysplasia and dieulafoy lesions are mucosal arteriovenous malformations and unlikely to result in
considerable inflammatory activity.

Ferritin: Ferritin is an intracellular protein that binds iron and stores it to be released in a controlled fashion at sites where iron is
required. Because iron and ferritin are bound the total body ferritin levels may be decreased in cases of iron deficiency anaemia.
Measurement of serum ferritin levels can be useful in determining whether an apparently low haemoglobin and microcytosis is
truly caused by an iron deficiency state.
Ferritin is an acute phase protein and may be synthesised in increased quantities in situations where inflammatory activity is
ongoing. Falsely elevated results may therefore be encountered clinically and need to be taken in context of the clinical picture
and full blood count results.

107.Which of the following is least likely to cause a prolonged prothrombin time?

A. Cholestatic jaundice
B. Disseminated intravascular coagulation
C. Prolonged antibiotic treatment
D. Liver disease
E. Acquired factor 12 deficiency
Answer: E
Vitamin K deficiency results from cholestatic jaundice and prolonged antibiotic therapy. Acquired factor 12 deficiency causes
prolonged APTT.

108.Which statement about peristalsis is true?

A. Longitudinal smooth muscle propels the food bolus through the oesophagus
B. Secondary peristalsis occurs when there is no food bolus in the oesophagus
C. Food transfer from the oesophagus to the stomach is 4 seconds
D. Circular smooth muscle is not involved in peristalsis
E. Peristalsis only occurs in the oesophagus
Answer: A

109.24 year old man is injured in a road traffic accident. He becomes oliguric and his renal function deteriorates. Which of
the options below would favor acute tubular necrosis over pre renal uraemia?
A. No response to intravenous fluids
B. Urinary sodium < 20mmol/L
C. Bland coloured urinary sediment
D. Increased urine specific gravity
E. None of the above
Answer: A

In acute tubular necrosis there is no response to intravenous fluids because the damage occurs from within the renal system rather
than as a result of volume depletion.

Acute renal failure: Pre renal failure vs. acute tubular necrosis: Prerenal uraemia - kidneys retain sodium to preserve volume
Pre-renal uraemia Acute tubular necrosis
Urine sodium < 20 mmol/L > 30 mmol/L
Fractional sodium excretion* < 1% > 1%
Fractional urea excretion** < 35% >35%
Urine:plasma osmolality > 1.5 < 1.1
Urine:plasma urea > 10:1 < 8:1
Specific gravity > 1020 < 1010
Urine 'bland' sediment brown granular casts
Response to fluid challenge Yes No

162
 *fractional sodium excretion = (urine sodium/plasma sodium) / (urine creatinine/plasma creatinine) x 100
**fractional urea excretion = (urine urea /blood urea ) / (urine creatinine/plasma creatinine) x 100

110.Which of the following is not an effect of cholecystokinin?

A. It causes gallbladder contraction
B. It increases the rate of gastric emptying
C. It relaxes the sphincter of oddi
D. It stimulates pancreatic acinar cells
E. It has a trophic effect on pancreatic acinar cells
Answer:B

It decreases the rate of gastric emptying.

111.Which part of the jugular venous waveform is associated with the closure of the tricuspid valve?
A. a wave
B. c wave
C. x descent
D. y descent
E. v wave

Answer: B

JVP: {C} wave - {c}losure of the tricuspid valveThe c wave of the jugular venous waveform is associated with the closure of the
tricuspid valve.

112.Which one of the following serum proteins is most likely to increase in a patient with severe sepsis?
A. Transferrin
B. Transthyretin
C. Ferritin
D. Albumin
E. Cortisol binding protein
Answer: C

Ferritin can be markedly increased during acute illness. The other parameters tend to decrease during an acute phase response.
Acute phase proteins: CRP; procalcitonin; ferritin; fibrinogen; alpha-1 antitrypsin; caeruloplasmin; serum amyloid A;
haptoglobin; complement

During the acute phase response the liver decreases the production of other proteins (sometimes referred to as negative acute
phase proteins). Examples include:albumin; transthyretin (formerly known as prealbumin); transferrin; retinol binding protein;
cortisol binding protein

Theme: Critical care

B. Hypovolaemia
C. Normal
D. Cardiogenic shock
E. Septic shock

For each of the scenarios outlined in the tables below, please select the most likely diagnosis from the list. Each option may be
used once, more than once or not at all.

113.A 45 year old man is admitted to the intensive care unit following a laparotomy. He has a central line, pulmonary artery
catheter and arterial lines inserted. The following results are obtained:

Pulmonary artery occlusion pressure: Low; Cardiac output: Low; Systemic vascular resistance:High

Answer: Hypovolaemia
Cardiac output is lowered in hypovolaemia due to decreased preload.
163
114.A 75 year old man is admitted to the intensive care unit following a laparotomy. He has a central line, pulmonary
artery catheter and arterial lines inserted. The following results are obtained: Pulmonary artery occlusion
pressure:High; Cardiac output: Low; Systemic vascular resistance:High

Answer: Cardiogenic shock

In cardiogenic shock pulmonary pressures are often high. This is the basis for the use of venodilators in the treatment of
pulmonary oedema.

115.A 22 year old lady is admitted to the intensive care unit following a laparotomy. She has a central line, pulmonary
artery catheter and arterial lines inserted. The following results are obtained: Pulmonary artery occlusion pressure:
Low; Cardiac output: High; Systemic vascular resistance: Low

Answer: Septic shock

Decreased SVR is a major feature of sepsis. A hyperdynamic circulation is often present. This is the reason for the use of
vasoconstrictors.
Pulmonary artery occlusion pressure monitoring: The pulmonary artery occlusion pressure is an indirect measure of left atrial
pressure, and thus filling pressure of the left heart. The low resistance within the pulmonary venous system allows this useful
measurement to be made. The most accurate trace is made by inflating the balloon at the catheter tip and "floating" it so that it
occludes the vessel. If it is not possible to occlude the vessel in this way then the measurement gained will be the pulmonary
artery end diastolic pressure. Interpretation of PAOP(mmHg): Normal: 8-12; Low:<5: Hypovolaemia; Low with pulmonary
oedema: <5:ARDS; High: >18:Overload. When combined with measurements of systemic vascular resistance and cardiac output
it is possible to accurately classify patients.
Systemic vascular resistance: Derived from aortic pressure, right atrial pressure and cardiac output.
SVR=80(mean aortic pressure-mean right atrial pressure)/cardiac output

116.A 73 year old man has an arterial line in situ. On studying the trace the incisura can be seen. What is the physiological
event which accounts for this process?
A. Atrial repolarisation
B. Mitral valve closure
C. Ventricular repolarisation
D. Elastic recoil of the aorta
E. Tricuspid valve closure

Answer: D

It is the temporary rise in aortic pressure occurring as a result of elastic recoil.

117.A 72-year-old woman is admitted to the acute surgical unit with profuse vomiting. Admission bloods show the
following: Na+: 131 mmol/l; K+:2.2 mmol/l; Urea: 3.1 mmol/l; Creatinine:56 µmol/l; Glucose: 4.3 mmol/l. Which one of
the following ECG features is most likely to be seen?
A. Short PR interval
B. Short QT interval
C. Flattened P waves
D. J waves
E. U waves

Answer: E

Hypokalaemia - U waves on ECG

J waves are seen in hypothermia whilst delta waves are associated with Wolff Parkinson White syndrome.

ECG features in hypokalemia: U waves; Small or absent T waves (occasionally inversion); Prolonged PR interval; ST
depression; Long QT interval. Mnemonic: In Hypokalaemia, U have no Pot and no T, but a long PR and a long QT!

118.Which of the following secretions contains the highest composition of potassium?

A. Bile
B. Small bowel
C. Pancreatic juice
D. Gastric juice
E. Saliva
Answer: E

164
Of the secretions shown above, saliva has the greatest composition of potassium. The exact amount secreted will depend upon
aldosterone levels. Potassium composition of secretions: Saliva:20-60 mmol/L; Gastric juice:5-10 mmol/L; Bile:5-8 mmol/L;
Pancreatic juice:4-5 mmol/L; Small bowel:4-10 mmol/L

119.The oxygen-haemoglobin dissociation curve is shifted to the left in:

A. With decreased 2,3-DPG in transfused red cells
B. Respiratory acidosis
C. High altitude
D. Pyrexia
E. Haemolytic anaemia

Answer: A

S shaped curve. The curve is shifted to the left when there is a decreased oxygen requirement by the tissue. This
includes:1.Hypothermia; 2. Alkalosis; 3. Reduced levels of DPG: DPG is found in erythrocytes and is reduced in non exercising
muscles, i.e. when there is reduced glycolysis. 4. Polycythaemia

120.A homeless 42 year old male had an emergency inguinal hernia repair 24 hours previously. He has a BMI of 15. He has
been put on a feeding regime of 35 kcal/kg/day with no additional medications. The nursing staff contact you as he has
become confused and unsteady. On examination the patient is disorientated to place, has diplopia and nystagmus.
What is the most likely diagnosis?
45. Cerebellar stroke
46. Acute dystonic reaction
47. Refeeding syndrome
48. Parkinsonism
49. Wernickes encephalopathy
Answer: E
Triad of Wernicke encephalopathy: Acute confusion, Ataxia, Opthalmoplegia
This patient has received a carbohydrate rich diet without any thiamine or vitamin B co strong replacement. This has led to
Wernickes encephalopathy, which classically presents with confusion, ataxia and opthalmoplegia. Characteristically it is
associated with chronic alcoholism, however it is also known to occur post bariatric surgery.

121.A 22 year old lady receives intravenous morphine for acute abdominal pain. Which of the following best accounts for
its analgesic properties?
45. Binding to δ opioid receptors in the brainstem
46. Binding to δ opioid receptors at peripheral nerve sites
47. Binding to β opioid receptors within the CNS
48. Binding to α opioid receptors within the CNS
49. Binding to µ opioid receptors within the CNS

Answer: E

Morphine: Strong opiate analgesic. It is a pro- type narcotic drug and its effects mediated via the µ opioid receptor. Its clinical
effects stem from binding to these receptor sites within the CNS and gastrointestinal tract. Unwanted side effects include nausea,
constipation, respiratory depression and, if used long term, addiction.
It may be administered orally or intravenously. It can be reversed with naloxone.

122.Which one of the following reduces the secretion of renin?

A. Erect posture
B. Adrenaline
C. Hyponatraemia
D. Hypotension
E. Beta-blockers
Answer: E
Renin is secreted by juxtaglomerular cells and hydrolyses angiotensinogen to produce angiotensin I
Factors stimulating renin secretion: Low BP; Hyponatraemia; Sympathetic nerve stimulation; Catecholamines; Erect posture.
Factors reducing renin secretion: drugs: beta-blockers, NSAIDs

123.Which of the following stimulates prolactin release?

A. Leutinising hormone

165
 B. Dopamine
C. Thyrotropin releasing hormone
D. Oestrogen
E. Follicle stimulating hormone
Answer: C

TRH stimulates prolactin release. Dopamine suppresses the release of prolactin. Prolactin: is a peptide hormone released from the
anterior pituitary. It is under tonic dopamine inhibition, thyrotropin releasing hormone has a stimulatory effect on release.
Prolactin release stimulates milk production but also reduces gonadal activity. It decreases GnRH pulsatility at the hypothalamic
level and to a lesser extent, blocks the action of LH on the ovary or testis.

124.Which of the following statements are not typically true in hypokalaemia?

A. It may occur as a result of mechanical bowel preparation
B. Chronic vomiting may increase renal potassium losses
C. It may be associated with aciduria
D. It may cause hyponatraemia
E. It often accompanies acidosis
Answer: E

Potassium depletion occurs either through the gastrointestinal tract or the kidney. Chronic vomiting in itself is less prone to induce
potassium loss than diarrhoea as gastric secretions contain less potassium than those in the lower GI tract. If vomiting produces a
metabolic alkalosis then renal potassium wasting may occur as potassium is excreted in preference to hydrogen ions. The converse
may occur in potassium depletion resulting in acid urine.

Potassium and hydrogen can be thought of as competitors. Hyperkalaemia tends to be associated with acidosis because as
potassium levels rise fewer hydrogen ions can enter the cells

Hypokalaemia with alkalosis: Vomiting, Diuretics, Cushing's syndrome, Conn's syndrome (primary hyperaldosteronism)
Hypokalaemia with acidosis: Diarrhoea, Renal tubular acidosis, Acetazolamide, Partially treated diabetic ketoacidosis

Theme: Vitamin deficiency

A. Vitamin A
B. Vitamin B1
C. Vitamin B12
D. Vitamin B3
E. Vitamin C
F. Vitamin K
G. Vitamin D

Please select the vitamin deficiency most closely associated with the situation described. Each option may be used once, more
than once or not at all.

125.A 3 year old child presents with Rickets

Answer: Vitamin D
Vitamin D is needed to help mineralise bone. When this is deficient, mineralisation is inadequate and deformities mayt result.

126.A 44 year old lady presents with jaundice. Following a minor ward based surgical procedure she develops troublesome
and persistent bleeding.

Answer: Vitamin K
Patients who are jaundiced usually have impaired absorption of vitamin K. This can result in loss of the vitamin K dependent
clotting factors and troublesome bleeding.

127.A 69 year old man who has been living in sheleted accomodation for many months, with inadequate nutrition notices
that his night vision is becoming impaired.

Answer: Vitamin A
Loss of vitamin A will result in impaire rhodopsin synthesis and poor night vision.

Vitamin deficiency
166
A: Night blindness, Epithelial atrophy, Infections. B1:Beriberi; B2:Dematitis and photosensitivity; B3:Pellagra; B12:Pernicious
anaemia; C:Poor wound healing, Impaired collagen synthesis. D:Rickets (Children), Osteomalacia (Adults). K:Clotting disorders

128.Which of the following statements is true with regards to gastric secretions?

A. During the cephalic phase 40% of the total gastric secretion occurs
B. Histamine release stimulates acid secretion in the stomach
C. Secretin stimulates gastric acid secretion
D. Intrinsic factor combines with B1 in the stomach
E. G cells are only present in the gastric mucosa
Answer: B

Histamine is released from enterochromaffin cells in the stomach mucosa which stimulates acid secretion.
Intrinsic factor combines with B12 to prevent acid digestion in the stomach.
G cells can be found in the duodenum and jejunum

129.A 55 year old man undergoes a laparotomy and repair of incisional hernia. Which of the following hormones is least
likely to be released in increased quantities following the procedure?
A. Insulin
B. ACTH
C. Glucocorticoids
D. Aldosterone
E. Growth hormone
Answer: A
Insulin and thyroxine are often have reduced levels of secretion in the post operative period. This, coupled with increased
glucocorticoid release may cause difficulty in management of diabetes in individuals with insulin resistance.

130.Which of the following is not a major function of the spleen in adults?

A. Iron reutilisation
B. Storage of platelets
C. Storage of monocytes
D. Haematopoeisis in haematological disorders
E. Storage red blood cells

Answer: E

The reservoir function of the spleen is less marked in humans than other animals (e.g. pigs) and in normal individuals it can
sequester between 5 and 10% of the red cell mass. The other stated processes are major splenic functions and this accounts for the
answer provided.

Spleen: Embryology: derived from mesenchymal tissue. Shape: orange segment. Position: below 9th-12th ribs. Weight: 75-150g

Relations: Superiorly- diaphragm. Anteriorly- gastric impression. Posteriorly- kidney. Inferiorly- colon. Hilum: tail of pancreas
and splenic vessels (splenic artery divides here, branches pass to the white pulp transporting plasma). Forms apex of lesser sac
(containing short gastric vessels)

Contents: White pulp: immune function. Contains central trabecular artery. The germinal centres are supplied by arterioles called
penicilliary radicles. Red pulp: filters abnormal red blood cells

Function: Filtration of abnormal blood cells and foreign bodies such as bacteria. Immunity: IgM. Production of properdin, and
tuftsin which help target fungi and bacteria for phagocytosis. Haematopoiesis: up to 5th month gestation or in haematological
disorders. Pooling: storage of 40% platelets. Iron reutilization. Storage red blood cells-animals, not humans. Storage monocytes

Disorders of the spleen

Massive splenomegaly: Myelofibrosis. Chronic myeloid leukaemia. Visceral leishmaniasis (kala-azar). Malaria. Gaucher's
syndrome. Other causes (as above plus): Portal hypertension e.g. secondary to cirrhosis. Lymphoproliferative disease e.g. CLL,
Hodgkin's. Haemolytic anaemia. Infection: hepatitis, glandular fever. Infective endocarditis. Sickle-cell*, thalassaemia
Rheumatoid arthritis (Felty's syndrome)
*the majority of adults patients with sickle-cell will have an atrophied spleen due to repeated infarction

131.Which one of the following is associated with increased lung compliance?

A. Kyphosis
B. Pulmonary oedema
C. Emphysema
167
 D. Pulmonary fibrosis
E. Pneumonectomy
Answer: C

Respiratory physiology: lung compliance: Lung compliance is defined as change in lung volume per unit change in airway
pressure. Causes of increased compliance: Age. Emphysema (this is due to loss alveolar walls and associated elastic tissue).
Causes of decreased compliance: pulmonary oedema, pulmonary fibrosis, pneumonectomy, kyphosis

132.Which of the following areas is predominantly concerned with thermoregulation?

A. Hypothalamus
B. Anterior pituitary
C. Cerebellum
D. Brain stem
E. Temporal lobe
Answer: A
The hypothalamus is primarily concerned with thermoregulation. It may relay to the cerebral cortex to induce behavioural
adaptation to facilitate the thermoregulatory process.

Thermoregulation: The hypothalamus is the main centre for thermoregulation. Peripheral and central thermoreceptors relay to
this region. Central chemoreceptors play the main role in maintenance of core temperature. Hypothalamus may initiate
involuntary motor responses to raise body temperature (e.g.shivering). It will also stimulate the sympathetic nervous system to
produce peripheral vasoconstriction and release of adrenaline from the adrenal medulla. Heat loss is governed by behavioural
responses and by autonomic responses including peripheral vasodilation. Heat loss can be maintained within the thermoneutral
zone (25 to 30 degrees) although the absolute value depends upon atmospheric humidity. Sepsis results in the release of cytokines
that reset the thermoregulatory centre resulting in fever.

133.Which of the following drugs does not interfere with the measurement of cortisol levels?
A. Dexamethasone
B. Prednisolone
C. Hydrocortisone IV
D. Hydrocortisone PO
E. Hydrocortisone IM
Asnwer: A
Dexamethasone can be given as glucorticoid replacement during testing for addisons or adrenal insufficiency as it does not
interfere with cortisol levels. For example if you have a patient with polymyalgia rheumatica and they are on longterm
prednisolone, you can replace the prednisolone with dexamethasone to undertake a short synacthen test.

134.An elderly lady who presented with weight loss and malabsorption was found to have amyloid of the small bowel. On
presentation she was found to have osteomalacia and was hypocalcaemic. Over the past seven days she has received
total parenteral nutrition with adequate calcium replacement. Despite this she remained hypocalcaemic. Deficiency of
which of the following electrolytes is most likely to account for this process?
A. Magnesium
B. Potassium
C. Sodium
D. Phosphate
E. None of the above
Answer: A
Patients with malabsorption may develop magnesium deficiency, although her TPN feeds may have contained magnesium it may
not have been sufficient to correct her losses. Sodium, phosphate and potassium would not have this effect on serum calcium.

Combined deficiency of magnesium and calcium: Magnesium is required for both PTH secretion and its action on target
tissues. Hypomagnesaemia may both cause hypocalcaemia and render patients unresponsive to treatment with calcium and
vitamin D supplementation. Magnesium is the fourth most abundant cation in the body. The body contains 1000mmol, with half
contained in bone and the remainder in muscle, soft tissues and extracellular fluid. There is no one specific hormonal control of
magnesium and various hormones including PTH and aldosterone affect the renal handling of magnesium. Magnesium and
calcium interact at a cellular level also and as a result decreased magnesium will tend to affect the permeability of cellular
membranes to calcium, resulting in hyperexcitability.

135.A 19 year old man is attacked outside a club and beaten with a baseball bat. He sustains a blow to the right side of his
head. He is brought to the emergency department and a policy of observation is adopted. His glasgow coma score
deteriorates and he becomes comatose. Which of the following haemodynamic parameters is most likely to be present?
168
 A. Hypertension and bradycardia
B. Hypotension and tachycardia
C. Hypotension and bradycardia
D. Hypertension and tachycardia
E. Normotension and bradycardia
Answer: A
Hypertension and bradycardia are seen prior to coning. The brain autoregulates its blood supply by controlling systemic blood
pressure.

Head injury: Patients who suffer head injuries should be managed according to ATLS principles and extra cranial injuries should
be managed alongside cranial trauma. Inadequate cardiac output will compromise CNS perfusion irrespective of the nature of the
cranial injury.

Types of traumatic brain injury

Extradural haematoma:Bleeding into the space between the dura mater and the skull. Often results from acceleration-
deceleration trauma or a blow to the side of the head. The majority of extradural haematomas occur in the temporal region where
skull fractures cause a rupture of the middle meningeal artery.
Features: Raised intracranial pressure. Some patients may exhibit a lucid interval

Subdural haematoma:Bleeding into the outermost meningeal layer. Most commonly occur around the frontal and parietal lobes.
May be either acute or chronic. Risk factors include old age and alcoholism. Slower onset of symptoms than a extradural
haematoma.

Subarachnoid haemorrhage:Usually occurs spontaneously in the context of a ruptured cerebral aneurysm but may be seen in
association with other injuries when a patient has sustained a traumatic brain injury

Pathophysiology: Primary brain injury may be focal (contusion/ haematoma) or diffuse (diffuse axonal injury). Diffuse axonal
injury occurs as a result of mechanical shearing following deceleration, causing disruption and tearing of axons. Intra-cranial
haematomas can be extradural, subdural or intracerebral, while contusions may occur adjacent to (coup) or contralateral (contre-
coup) to the side of impact. Secondary brain injury occurs when cerebral oedema, ischaemia, infection, tonsillar or tentorial
herniation exacerbates the original injury. The normal cerebral auto regulatory processes are disrupted following trauma rendering
the brain more susceptible to blood flow changes and hypoxia. The Cushings reflex (hypertension and bradycardia) often occurs
late and is usually a pre terminal event

Management: Where there is life threatening rising ICP such as in extra dural haematoma and whilst theatre is prepared or
transfer arranged use of IV mannitol/ frusemide may be required. Diffuse cerebral oedema may require decompressive
craniotomy. Exploratory Burr Holes have little management in modern practice except where scanning may be unavailable and to
thus facilitate creation of formal craniotomy flap. Depressed skull fractures that are open require formal surgical reduction and
debridement, closed injuries may be managed non operatively if there is minimal displacement. ICP monitoring is appropriate in
those who have GCS 3-8 and normal CT scan. ICP monitoring is mandatory in those who have GCS 3-8 and Abnormal CT scan.
Hyponatraemia is most likely to be due to syndrome of inappropriate ADH secretion. Minimum of cerebral perfusion pressure of
70mmHg in adults. Minimum cerebral perfusion pressure of between 40 and 70 mmHg in children.

Interpretation of pupillary findings in head injuries

Pupil size Light response Interpretation

Unilaterally dilated Sluggish or fixed 3rd nerve compression secondary to tentorial herniation

Bilaterally dilated Sluggish or fixed Poor CNS perfusion; Bilateral 3rd nerve palsy

Unilaterally dilated or equal Cross reactive (Marcus - Gunn) Optic nerve injury
Opiates; Pontine lesions; Metabolic encephalopathy
Bilaterally constricted May be difficult to assess

Unilaterally constricted Preserved Sympathetic pathway disruption

136.Which of the following drugs does not cause pseudohaematuria?

A. Rifampicin
169
 B. Quinine
C. Noradrenaline
D. Levodopa
E. Phenytoin
Answer: C
Rifampicin, phenytoin, levodopa, methyldopa, and quinine all cause pseudohaematuria.

Causes of haematuria: Trauma Injury to renal tract. Renal trauma commonly due to blunt injury (others penetrating injuries).
Ureter trauma rare: iatrogenic. Bladder trauma: due to RTA or pelvic fractures. Infection: Remember TB. Malignancy :Renal
cell carcinoma (remember paraneoplastic syndromes): painful or painless. Urothelial malignancies: 90% are transitional cell
carcinoma, can occur anywhere along the urinary tract. Painless haematuria. Squamous cell carcinoma and adenocarcinoma: rare
bladder tumours. Prostate cancer. Penile cancers: SCC. Renal disease:Glomerulonephritis. Stones: Microscopic haematuria
common. Structural abnormalities: Benign prostatic hyperplasia (BPH) causes haematuria due to hypervascularity of the
prostate gland, Cystic renal lesions e.g. polycystic kidney disease, Vascular malformations, Renal vein thrombosis due to renal
cell carcinoma. Coagulopathy: Causes bleeding of underlying lesions. Drugs: Cause tubular necrosis or interstitial nephritis:
aminoglycosides, chemotherapy. Interstitial nephritis: penicillin, sulphonamides, and NSAIDs. Anticoagulants. Benign: Exercise.
Gynaecological: Endometriosis: flank pain, dysuria, and haematuria that is cyclical. Iatrogenic: Catheterisation, Radiotherapy;
cystitis, severe haemorrhage, bladder necrosis. Pseudohaematuria

137.A 74-year-old woman with thyroid cancer is admitted due to shortness of breath. What is the best investigation to
assess for possible compression of the upper airways?
A. Arterial blood gases
B. Forced vital capacity
C. Transfer factor
D. Peak expiratory flow rate
E. Flow volume loop
Answer: E
Flow volume loop is the investigation of choice for upper airway compression.
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

138.Which of the following statements relating to cerebrospinal fluid is untrue?

A. The choroid plexus is only present in the lateral ventricles
B. Total CSF volume is 100-150ml
C. CSF pressure is usually 10-15mmHg
D. The cerebral aqueduct connects the third and fourth ventricles
E. The foramen of Luschka are paired and lie laterally in the fourth ventricle
Answer: A
The choroid plexus lies in all ventricles.

139.Which substance can be used to achieve the most accurate measurement of the glomerular filtration rate?
A. Glucose
B. Protein
C. Inulin
D. Creatine
E. Para-amino hippuric acid
Answer: C
Creatinine declines with age due to decline in renal function and muscle mass. Glucose, protein (amino acids) and PAH are
reabsorbed by the kidney.

140.A 45 year old man sustains a closed head injury. He is initially alert, however, his level of consciousness deteriorates
on arrival at hospital. An intra cranial pressure monitor is inserted. What is the normal intracranial pressure?
A. 35 - 45mm Hg
B. 45 - 55mm Hg
C. <15mm Hg
D. 25 - 35mm Hg
E. 25 - 30 mm Hg
Answer: C
The normal intracranial pressure is between 7 and 15 mm Hg. The brain can accommodate increases up to 24 mm Hg, thereafter
clinical features will become evident.

141.A 55-year-old man with a history of type 2 diabetes mellitus, bipolar disorder and chronic obstructive pulmonary
disease has bloods taken during a pre operative assessment of an inguinal hernia repair:Na+:125 mmol/l; K+:3.8

170
 mmol/l; Bicarbonate:24 mmol/l; Urea:3.7 mmol/l; Creatinine:92 µmol/l Due to his smoking history a chest x-ray is
ordered which is reported as normal. The Consultant asks you what is the most likely cause for the hyponatraemia?
A. Metformin
B. Lithium
C. Carbamazepine
D. Sodium valproate
E. Pioglitazone
Answer: C
SIADH - drug causes: carbamazepine, sulfonylureas, SSRIs, tricyclics
Lithium can cause diabetes insipidus but this is generally associated with a high sodium. Lithium only tends to cause raised
antidiuretic hormone levels following a severe overdosage.

Syndrome of inappropriate antidiuretic hormone (SIADH): causes: Malignancy: especially small cell lung cancer. Also:
pancreas, prostate. Neurological: stroke; subarachnoid haemorrhage; subdural haemorrhage; meningitis/encephalitis/abscess.
Infections: tuberculosis; pneumonia. Drugs: sulfonylureas; SSRIs, tricyclicsl; carbamazepine; vincristine; cyclophosphamide.
Other causes: positive end-expiratory pressure (PEEP); porphyrias

142.A 39 year old lady has recurrent attacks of biliary colic. What is the approximate volume of bile to enter the duodenum
per 24 hours?
A. 500 mL
B. 50 mL
C. 100 mL
D. 2000 mL
E. 150 mL
Answer: A
Between 500 mL and 1.5 L of bile enters the small bowel daily. Most bile salts are recycled by the enterohepatic circulation.
When the gallbladder contracts the lumenal pressure is approximately 25cm water, which is why biliary colic may be so painful.

Bile: is produced at a rate of between 500ml and 1500mL per day. Bile is composed of bile salts, bicarbonate, cholesterol, steroids
and water. There are three main factors regulating bile flow; hepatic secretion, gall bladder contraction and sphincter of oddi
resistance. Bile salts are absorbed in the terminal ileum (and recycled to the liver). Over 90% of all bile salts are recycled in this
way, such that the total pool of bile salts is recycled up to six times a day. Primary bile salts: Cholate and chenodeoxycholate.
Secondary bile salts: Formed by bacterial action on primary bile salts. These are deoxycholate and lithocholate. Of these
deoxycholate is reabsorbed, whilst lithocholate is insoluble and excreted. Pathophysiology of gallstones: Bile salts have a
detergent action. They aggregate to form micelles and these have a lipid centre in which fats may be transported. Excessive
quantities of cholesterol cannot be transported in this way and will tend to precipitate, resulting in the formation of cholesterol rich
gallstones.

143.At which of the following sites is the most water absorbed?

A. Right colon
B. Left colon
C. Stomach
D. Jejunum
E. Duodenum

Water absorption in the gastrointestinal tract predominantly occurs in the small bowel (jejunum and ileum). The colon is an
important site of water absorption, however, its overall contribution is relatively small. The importance of the colonic component
to water absorption may increase following extensive small bowel resections.

Water absorption: During a 24 hours period the average person will ingest up to 2000 ml of liquid orally. In addition a further
8000ml of fluid will enter the small bowel as gastrointestinal secretions. Intestinal water absorption is a passive process and is
related to solute load. In the jejunum the active absorption of glucose and amino acids will create a concentration gradient that
water will flow across. In the ileum most water is absorbed by a process of facilitated diffusion (with sodium). Approximately
150ml of water enters the colon daily, most is absorbed, the colon can adapt to, and increase this amount following resection.

144.Which of the following is not a characteristic of the proximal convoluted tubule in the kidney?
A. Up to 95% of filtered amino acids will be reabsorbed at this site
B. It is a risk of damage in a patient with compartment syndrome due to a tibial fracture
C. It is responsible for absorbing more than 50% of filtered water
D. Its secretory function is most effective at low systolic blood pressures (typically less than 100mmHg)

171
 E. Glucose is reabsorbed by a process of facilitated diffusion
Answer: D
The proximal convoluted tubule may undergo necrosis in situations such as compartment syndrome. It is responsible for
reabsorbing up to two thirds of filtered water. Low systolic blood pressures (below the renal autoregulatory range) are a risk factor
for acute tubular necrosis. Within the autoregulatory range the absolute value of systolic BP has little effect.

145.Which of the following does not cause a normal anion gap acidosis?
45. Pancreatic fistula
46. Acetazolamide
47. Uraemia
48. Ureteric diversion
49. Renal tubular acidosis

Answer: C

Normal Gap Acidosis: HARDUP: H - Hyperalimentation/hyperventilation ; A - Acetazolamide ; R - Renal tubular acidosis; D -

Diarrhoea; U - Ureteral diversion; P - Pancreatic fistula/parenteral saline. Uraemia will typically cause a high anion gap acidosis.
It is one of the unmeasured anions.

146.Which one of the following would cause a rise in the carbon monoxide transfer factor (TLCO)?
A. Emphysema
B. Pulmonary embolism
C. Pulmonary haemorrhage
D. Pneumonia
E. Pulmonary fibrosis
Answer: C
Transfer factor: raised: asthma, haemorrhage, left-to-right shunts, polycythaemia. low: everything else
Where alveolar haemorrhage occurs the TLCO tends to increase due to the enhanced uptake of carbon monoxide by intra-alveolar
haemoglobin.

Transfer factor: The transfer factor describes the rate at which a gas will diffuse from alveoli into blood. Carbon monoxide is
used to test the rate of diffusion. Results may be given as the total gas transfer (TLCO) or that corrected for lung volume (transfer
coefficient, KCO)
Causes of a raised TLCO Causes of a lower TLCO

 asthma  pulmonary fibrosis

 pulmonary haemorrhage (Wegener's, Goodpasture's)  pneumonia
 left-to-right cardiac shunts  pulmonary emboli
 polycythaemia  pulmonary oedema
 hyperkinetic states  emphysema
 male gender, exercise  anaemia
 low cardiac output

KCO also tends to increase with age. Some conditions may cause an increased KCO with a normal or reduced TLCO

 pneumonectomy/lobectomy
 scoliosis/kyphosis
 neuromuscular weakness
 ankylosis of costovertebral joints e.g. ankylosing spondylitis

147.Release of somatostatin from the pancreas will result in which of the following?
A. Decrease in pancreatic exocrine secretions
B. Contraction of the gallbladder
C. Increase in the rate of gastric emptying
D. Increased synthesis of growth hormone
E. Increased insulin release
Answer: A
Octreotide reduces exocrine pancreatic secretions so is used to treat high output pancreatic fistulae (though parenteral feeding is
most effective). Other uses include variceal bleeding and treatment of acromegaly.
Inhibits growth hormone and insulin release (when released from pancreas).
Somatostatin is also released by the hypothalamus causing a negative feedback response on growth hormone.

172
Somatostatin: is produced in the D cells of the pancreatic islets. It is also produced in the gut (enterochromaffin cells) and is
found in brain tissue. Those substances that stimulate insulin release will also induce somatostatin secretion. It is an inhibitor of
growth hormone, it also delays gastric emptying and reduces gastrin secretion.
It reduces pancreatic exocrine secretions and may be used therapeutically to treat pancreatic fistulae.
Somatostatinomas are rare pancreatic endocrine tumours and will result in the clinical manifestations of diabetes mellitus,
gallstones and steatorrhoea.

148.A 34 year old lady develops septic shock and features of the systemic inflammatory response syndrome as a
complication of cholangitis. Which of the following is not a typical feature of this condition?
A. Body temperature less than 36oC or greater than 38oC
B. Respiratory rate >20
C. Lactate <4 mmol/L
D. High levels of tumour necrosis factor α
E. WCC >12,000 mm3
Answer: C

Septic shock will typically result in end organ hypoperfusion and as a result lactate levels will often be high. In the surviving
sepsis campaign it is suggested that elevated lactate levels are an independent indicator for vasopressor support in patient with
sepsis. The WCC may be paradoxically low in severe sepsis, although it is most often elevated.

149.Which of the following stimulates gastric acid secretion?

A. Cholecystokinin
B. Gastric inhibitory peptide
C. Secretin
D. Histamine
E. Somatostatin
Answer: D
Gastrin: From G cells: stimulates gastric acid production. Pepsin: Digestion of protein, secretion occurs simultaneously with
gastrin. Secretin: From mucosal cells in the duodenum and jejunum: inhibits gastric acid, stimulates bile and pancreatic juice
production. Gastric inhibitory peptide: (produced in response to fatty acids) inhibits gastrin release and acid secretion from
parietal cells. Cholecystokinin: From mucosal cells in the duodenum and jejunum (produced in response to fatty acids) inhibits
acid secretion from parietal cells, causes gallbladder contraction and relaxation of sphincter of Oddi. Somatostatin: From D cells

150.Which of the following statements relating to gastric acid secretions are untrue?
A. In parietal cells carbonic anhydrase generates hydrogen ions which are then actively secreted
B. The cephalic phase is abolished following truncal vagotomy
C. The intestinal phase accounts for 60% of gastric acid produced
D. Histamine acts in a paracrine manner on H2 receptors
E. H2 receptor antagonists will not completely abolish gastric acid production
Answer: C

The intestinal phase of gastric acid secretion accounts for only 10% of gastric acid produced.

151.A 22 year old man is undergoing a daycase excision of a sebaceous cyst. He is needle phobic and as the surgeon
approaches with the needle the patient begins to hyperventilate. He soon develops circumoral parasthesia and
muscular twitching. Which of the following is the most likely explanation for this event?
A. Temporal lobe epilepsy
B. Reduction in ionised calcium levels
C. Increase in ionised calcium levels
D. Fall in serum PTH levels
E. Rise in serum PTH levels
Answer: B
50% of plasma calcium is ionised. Hyperventilation will induce a state of alkalosis which will lower ionised plasma calcium
levels.

152.Which of the following inhibits gastric acid secretion?

A. Histamine
B. Nausea
C. Calcium
D. Parasympathetic vagal stimulation

173
 E. Gastrin
Answer: B

Nausea inhibits gastric secretion via higher cerebral activity and sympathetic innervation.

153.73 year old lady is diagnosed with hyperaldosteronism. From which of the following structures is aldosterone released?
A. Zona fasciculata of the adrenal gland
B. Juxtaglomerular apparatus of the kidney
C. Zona reticularis of the adrenal gland
D. Adrenal medulla
E. Zona glomerulosa of the adrenal cortex
Answer: E
Aldosterone serves to conserve sodium and water. It is produced in the zona glomerulosa of the adrenal cortex.

Adosterone is secreted by the zona glomerulosa of the adrenal cortex. It is a mineralocorticoid hormone. Secretion is regulated by
the renin- angiotensin system, and by plasma levels of sodium and potassium. Aldosterone conserves sodium by stimulating the
reabsorption of sodium in the distal nephron in exchange for potassium. Lack of aldosterone release will result in hyperkalaemia
and hyponatraemia.

154.A 43 year old lady is admitted with cholestasis secondary to a stone impacted at the level of the ampulla of vater.
Which of the following tests is most likely to be predictive of bleeding diathesis at the time of ERCP in this particular
case?
A. Bleeding time
B. Prothrombin time
C. APTT
D. Platelet count
E. Factor I levels
Answer: B
PT: Vitamin K dependent factors 2, 7, 9, 10. APTT: Factors 8, 9, 11, 12

Jaundice will impair the production of vitamin K dependent clotting factors. This is most accurately tested by measuring the
prothrombin time. APTT can be affected by vitamin K deficiency (due to factor 9 deficiency), however this occurs to a lesser
extent and is normally associated with severe liver disease. The bleeding time is a measure of platelet function.

155.Which of the following mechanisms best accounts for the release of adrenaline?
A. Release from the adrenal medulla in response to increased angiotensin 1 levels
B. Release from the zona fasiculata from the adrenal gland in response to increased sympathetic discharge
C. Release from the adrenal medulla in response to increased noradrenaline levels
D. Release from the adrenal medulla in response to sympathetic stimulation from the splanchnic nerves
E. None of the above
Answer: D
The adrenal gland releases adrenaline in response to increased sympathetic discharge from preganglionic sympathetic fibres of the
splanchnic nerves. These cause the chromafin cells of the medulla to release adrenaline (which is preformed) by exocytosis.

156.The acute phase response to injury does not include:

A. Pyrexia
B. Decreased albumin
C. Hepatic sequestration of cations
D. Increased transferrin
E. Increased serum amyloid A
Answer: D

The acute phase response includes: Acute phase protein.Reduction of transport proteins (albumin, transferrin); Hepatic
sequestration cations; Pyrexia; Neutrophil leukocytosis; Increased muscle proteolysis; Changes in vascular permeability

157. Which of the following statements relating to blood transfusions in surgical patients is false?
A. Packed red cells typically have a haematocrit of between 55 and 75%
174
 B. Clotting factor activity in whole blood decreases in samples stored for longer than 7 days
C. After 3 weeks of storage blood has a pH of 6.9
D. Gamma irradiated blood products are not required routinely
E. Patients should be transfused to achieve a target haemoglobin of 10 g/dl and a haematocrit of 30%
Answer: E
Patients can generally be managed without transfusion as long as the Hb is 7 or greater. The exact level depends upon patient
factors such as co-morbidities. Old blood functions less effectively and should not be used during massive transfusions.

Whole blood fractions

Packed red cells: Used for transfusion in chronic anaemia and cases where infusion of large volumes of fluid may result in
cardiovascular compromise. Product obtained by centrifugation of whole blood. Platelet rich plasma: Usually administered to
patients who are thrombocytopaenic and are bleeding or require surgery. It is obtained by low speed centrifugation. Platelet
concentrate: Prepared by high speed centrifugation and administered to patients with thrombocytopaenia. Fresh frozen plasma:
Prepared from single units of blood. Contains clotting factors, albumin and immunoglobulin.Unit is usually 200 to 250ml. Usually
used in correcting clotting deficiencies in patients with hepatic synthetic failure who are due to undergo surgery. Usual dose is 12-
15ml/Kg-1. It should not be used as first line therapy for hypovolaemia. Cryoprecipitate: Formed from supernatant of FFP. Rich
source of Factor VIII and fibrinogen. Allows large concentration of factor VIII to be administered in small volume. SAG-
Mannitol Blood: Removal of all plasma from a blood unit and substitution with: Sodium chloride, Adenine, Anhydrous glucose,
Mannitol. Up to 4 units of SAG M Blood may be administered. Thereafter whole blood is preferred. After 8 units, clotting factors
and platelets should be considered.

Cell saver devices

These collect patients own blood lost during surgery and then reinfuse it. There are two main types: Those which wash the blood
cells prior to reinfusion. These are more expensive to purchase and more complicated to operate. However, they reduce the risk
of reinfusing contaminated blood back into the patient. Those which do not wash the blood prior to reinfusion.
Their main advantage is that they avoid the use of infusion of blood from donors into patients and this may reduce risk of blood
borne infection. It may be acceptable to Jehovah's witnesses. It is contraindicated in malignant disease for risk of facilitating
disease dissemination.

Blood products used in warfarin reversal

In some surgical patients the use of warfarin can pose specific problems and may require the use of specialised blood products
Immediate or urgent surgery in patients taking warfarin (1) (2):
1. Stop warfarin. 2. Vitamin K (reversal within 4-24 hours): IV takes 4-6h to work (at least 5mg). Oral can take 24 hours to be
clinically effective. 3. Fresh frozen plasma: Used less commonly now as 1st line warfarin reversal: 30ml/kg-1. Need to give at
least 1L fluid in 70kg person (therefore not appropriate in fluid overload). Need blood group. Only use if human prothrombin
complex is not available. 4. Human Prothrombin Complex (reversal within 1 hour): Bereplex 50 u/kg. Rapid action but factor 6
short half life, therefore give with vitamin K

158.Which of the following statements relating the fluid physiology of a physiologically normal 70 Kg adult male is
false?
A. He will have more water per unit of body weight than a female of similar weight
B. Plasma will comprise 25% of his body weight
C. Interstitial fluid will account for up to 14% of body weight
D. Approximately 65% of total body water is intracellular
E. 60% of his body weight is composed of water
Answer: B
The 60-40-20 rule: 60% total body weight is water; 40% of total body weight is intracellular fluids; 20% of body weight is
extracellular fluids

Plasma typically accounts for 4-6% of body weight in healthy individuals.

Males typically have more water per unit weight than females, as females have a higher fat content.

159.A 17 year old lady with long standing anorexia nervosa is due to undergo excision of a lipoma. Which of the
following nutritional deficiencies is most likely to be implicated in poor collagen formation as the wound heals?
A. Deficiency of copper
B. Deficiency of iron
C. Deficiency of ascorbic acid
D. Deficiency of phosphate
E. None of the above

175
 Answer: C
Vitamin C is involved in the cross linkage of collagen and impaired wound healing is well described in cases of vitamin C
deficiency.

160.A 45 year old man is undergoing a small bowel resection. The anaesthetist decides to administer an intravenous
fluid which is electrolyte rich. Which of the following most closely matches this requirement?
A. Dextrose / Saline
B. Pentastarch
C. Gelofusine
D. Hartmans
E. 5% Dextrose with added potassium 20mmol/ L
Answer: D
Hartmans solution is the most electrolyte rich. However, both pentastarch and gelofusine have more macromolecules.
Composition of commonly used intravenous fluids mmol-1

Na K Cl Bicarbonate Lactate
Plasma 137-147 4-5.5 95-105 22-25 -
0.9% Saline 153 - 153 - -
Dextrose / saline 30.6 - 30.6 - -
Hartmans 130 4 110 - 28

Recommendations for intra operative fluid management: Intra operative fluids are recommended to optimise cardiac stroke
volume. Patients undergoing non elective orthopaedic or abdominal surgery should receive IV fluids for the 1st 8h post
operatively. This may be supplemented by a low dose dopexamine infusion in selected cases.

161.A 16 year old girl develops pyelonephritis and is admitted in a state of septic shock. Which of the following is not
typically seen in this condition?
A. Increased cardiac output
B. Increased systemic vascular resistance
C. Oliguria may occur
D. Systemic cytokine release
E. Tachycardia
Answer: B

Septic shock:occurs when the peripheral vascular dilatation causes a fall in SVR. Similar response may occur in anaphylactic
shock, neurogenic shock

162.A man is admitted after a period of prolonged self, induced starvation. Naso gastric feeding is planned. Which of
the following is least likely to occur?
A. Hypokalaemia
B. Increased risk of cardiac arrhythmias
C. His haemoglobin will have decreased affinity for oxygen
D. Hypophosphataemia
E. None of the above
Answer: C
The process of starvation may lower DPG levels, in practice this is unlikely to occur early as it is generated during glycolysis.
Altered metabolism in starvation may be more acidotic and this would also tend to impair oxygen carriage.

163.Where does spironolactone act in the kidney?

A. Glomerulus
B. Proximal convoluted tubule
C. Descending limb of the loop of Henle
D. Ascending limb of the loop of Henle
E. Distal convoluted tubule
Answer: E

Potassium-sparing diuretics may be divided into the epithelial sodium channel blockers (amiloride and triamterene) and
aldosterone antagonists (spironolactone and eplerenone). Amiloride is a weak diuretic which blocks the epithelial sodium channel
in the distal convoluted tubule. Usually given with thiazides or loop diuretics as an alternative to potassium supplementation.
Spironolactone is an aldosterone antagonist which acts act in the distal convoluted tubule. Indications: ascites: patients with
cirrhosis develop a secondary hyperaldosteronism. Relatively large doses such as 100 or 200mg are often used; heart failure;
nephrotic syndrome; Conn's syndrome
176
 164. Which receptor does noradrenaline mainly bind to?
B. α 1 receptors
C. α 2 receptors
D. β 1 receptors
E. β 2 receptors
F. G receptors
Answer: A

Noradrenaline is the precursor of adrenaline. It is a powerful α 1 stimulant (although it will increase myocardial contractility).
Infusions will produce vasoconstriction and an increase in total peripheral resistance. It is the inotrope of choice in septic shock.

165. A 47 year old lady is diagnosed as suffering from a phaeochromocytoma. From which of the following amino acids
are catecholamines primarily derived?
A. Aspartime
B. Glutamine
C. Arginine
D. Tyrosine
E. Alanine
Answer: D

Catecholamine hormones are derived from tyrosine, it is modified by a DOPA decarboxylase enzyme to become dopamine and
thereafter via two further enzymic modifications to noradrenaline and finally adrenaline.

Adrenal medulla The chromaffin cells of the adrenal medulla secrete the catecholamines noradrenaline and adrenaline. The
medulla is innervated by the splanchnic nerves; the preganglionic sympathetic fibres secrete acetylcholine causing the chromaffin
cells to secrete their contents by exocytosis.
Phaeochromocytomas are derived from these cells and will secrete both adrenaline and nor adrenaline.

Adrenal cortex: Three histologically distinct zones are recognised:

Zone Location Hormone Secreted

Zona glomerulosa Outer zone Aldosterone
Zona fasiculata Middle zone Glucocorticoids
Zona reticularis Inner zone Androgens

The glucocorticoids and aldosterone are mostly bound to plasma proteins in the circulation. Glucocorticoids are inactivated and
excreted by the liver.

165. Where are the arterial baroreceptors located?

A. Carotid sinus and aortic arch
B. Carotid sinus only
C. Superior vena cava
D. External carotid artery
E. None of the above
Answer: A

They lie in the carotid sinus and aortic arch.

166. Which one of the following cells secretes the majority of tumour necrosis factor in humans?
A. Neutrophils
B. Macrophages
C. Natural killer cells
D. Killer-T cells
E. Helper-T cells
Answer: B
Tumour necrosis factor (TNF) is a pro-inflammatory cytokine with multiple roles in the immune system. TNF is secreted
mainly by macrophages and has a number of effects on the immune system, acting mainly in a paracrine fashion: activates
macrophages and neutrophils, acts as costimulator for T cell activation, key mediator of bodies response to Gram negative
septicaemia, similar properties to IL-1, anti-tumour effect (e.g. phospholipase activation)
TNF-alpha binds to both the p55 and p75 receptor. These receptors can induce apoptosis. It also cause activation of NFkB.
Endothelial effects include increase expression of selectins and increased production of platelet activating factor, IL-1 and
177
 prostaglandins. TNF promotes the proliferation of fibroblasts and their production of protease and collagenase. It is thought
fragments of receptors act as binding points in serum. Systemic effects include pyrexia, increased acute phase proteins and
disordered metabolism leading to cachexia. TNF is important in the pathogenesis of rheumatoid arthritis - TNF blockers (e.g.
infliximab, etanercept) are now licensed for treatment of severe rheumatoid

167. Which of the following is responsible for the rapid depolarisation phase of the myocardial action potential?
A. Rapid sodium influx
B. Rapid sodium efflux
C. Slow efflux of calcium
D. Efflux of potassium
E. Rapid calcium influx
Answer: A
Myocardial action potential

Phase Description Mechanism

Rapid sodium influx
0 Rapid depolarisation
These channels automatically deactivate after a few ms
1 Early repolarisation Efflux of potassium
2 Plateau Slow influx of calcium
3 Final repolarisation Efflux of potassium
Resting potential is restored by Na+/K+ ATPase
Restoration of ionic
4 There is slow entry of Na+ into the cell decreasing the potential difference until the
concentrations
threshold potential is reached, triggering a new action potential
NB cardiac muscle remains contracted 10-15 times longer than skeletal muscle

Conduction velocity
Atrial conduction Spreads along ordinary atrial myocardial fibres at 1 m/sec
AV node 0.05 m/sec
conduction
Ventricular Purkinje fibres are of large diameter and achieve velocities of 2-4 m/sec (this allows a rapid and
conduction coordinated contraction of the ventricles

168. Which of the following is not a feature of normal cerebrospinal fluid?

A. It has a pressure of between 10 and 15 mmHg.
B. It usually contains a small amount of glucose.
C. It may normally contain up to 5 red blood cells per mm3.
D. It may normally contain up to 3 white blood cells per mm3.
E. None of the above
It should not contain red blood cells.
Answer: C
169. Which of the following is not an effect of somatostatin?
A. It stimulates pancreatic acinar cells to release lipase
B. It decreases gastric acid secretion
C. It deceases gastrin release
D. It decreases pepsin secretion
E. It decreases glucagon release
Answer: A
It inhibits pancreatic enzyme secretion.
170. Which of the following is the least likely to increase acid secretion in the stomach?
A. Calcium
B. Alcohol
C. Caffeine
D. Pear
E. None of the above Answer: D
Pathology
1. A 38 year old lady presents with a recent episode of renal colic. As part of her investigations the following results are
obtained: Corrected Calcium: 3.84 mmol/l; PTH: 88pg/ml (increased). Her serum urea and electrolytes are normal.
What is the most likely diagnosis?
A. Carcinoma of the bronchus
B. Secondary hyperparathyroidism
C. Primary hyperparathyroidism
D. Tertiary hyperparathyroidism

178
E. Carcinoma of the breast

Answer: C
In this situation the most likely diagnosis is primary hyperparathyroidism. The question mentions that serum urea and
electrolytes are normal, which makes tertiary hyperparathyroidism unlikely.
In exams primary hyperparathyroidism is stereotypically seen in elderly females with an unquenchable thirst and an
inappropriately normal or raised parathyroid hormone level. It is most commonly due to a solitary adenoma
Causes of primary hyperparathyroidism: 80%: solitary adenoma; 15%: hyperplasia; 4%: multiple adenoma; 1%: carcinoma
Features - 'bones, stones, abdominal groans and psychic moans' Polydipsia, polyuria; Peptic
ulceration/constipation/pancreatitis; Bone pain/fracture; Renal stones; Depression; Hypertension. Associations; Hypertension;
Multiple endocrine neoplasia: MEN I and II
Investigations: Raised calcium, low phosphate; PTH may be raised or normal; Technetium-MIBI subtraction scan. Treatment;
Parathyroidectomy, if imaging suggests target gland then a focused approach may be used

Theme: Head and neck lumps

A. Branchial cyst
B. Cystic hygroma
C. Carotid body tumour
D. Lymphadenopathy
E. Adenolymphoma of the parotid
F. Pleomorphic adenoma of the parotid
G.Submandibular tumour
H.Thyroglossal cyst
I. Thoracic outlet syndrome
J. Submandibular gland calculus
Please select the most likely lesion to account for the clinical scenario given. Each option may be used once, more than once or
not at all.

2. A 60 year old Tibetan immigrant is referred to the surgical clinic with a painless neck swelling. On examination it is
located on the left side immediately anterior to the sternocleidomastoid muscle. There are no other abnormalities to find
on examination.
Answer: The correct answer is Carotid body tumour
Carotid body tumours typically present as painless masses. They may compress the vagus or hypoglossal nerves with symptoms
attributable to these structures. Over 90% occur spontaneously and are more common in people living at high altitude. In
familial cases up to 30% may be bilateral. Treatment is with excision.

3. A 40 year old women presents as an emergency with a painful mass underneath her right mandible. The mass has
appeared over the previous week with the pain worsening as the lump has increased in size. On examination there is a
4cm mass underneath her mandible, there is no associated lymphadenopathy.
Answer: Submandibular gland calculus
The sub mandibular gland is the most common site for salivary calculi. Patients will usually complain of pain, which is worse
on eating. When the lesion is located distally the duct may be laid open and the stone excised. Otherwise the gland will require
removal.

179
4. A 73 year old male smoker is referred to the clinic by his GP. On examination he has a 3cm soft mass immediately
anterior to his ear. It has been present for the past five years and is otherwise associated with no symptoms.
Answer: Adenolymphoma of the parotid
Warthins tumours (a.k.a. adenolymphoma) are commoner in older men (especially smokers). They are the second commonest
benign tumour of the parotid gland, they may be bilateral. They are soft and slow growing and relatively easy to excise.
Pleomorphic adenomas typically present in females aged between 40 - 60 years.

The table below gives characteristic exam question features for conditions causing neck lumps:

Reactive By far the most common cause of neck swellings. There may be a history of local infection or a
lymphadenopathy generalised viral illness
Lymphoma Rubbery, painless lymphadenopathy
The phenomenon of pain whilst drinking alcohol is very uncommon
There may be associated night sweats and splenomegaly
Thyroid swelling May be hypo-, eu- or hyperthyroid symptomatically
Moves upwards on swallowing
Thyroglossal cyst More common in patients < 20 years old
Usually midline, between the isthmus of the thyroid and the hyoid bone
Moves upwards with protrusion of the tongue
May be painful if infected
Pharyngeal pouch More common in older men
Represents a posteromedial herniation between thyropharyngeus and cricopharyngeus muscles
Usually not seen, but if large then a midline lump in the neck that gurgles on palpation
Typical symptoms are dysphagia, regurgitation, aspiration and chronic cough
Cystic hygroma A congenital lymphatic lesion (lymphangioma) typically found in the neck, classically on the left side
Most are evident at birth, around 90% present before 2 years of age
Branchial cyst An oval, mobile cystic mass that develops between the sternocleidomastoid muscle and the pharynx
Develop due to failure of obliteration of the second branchial cleft in embryonic development
Usually present in early adulthood
Cervical rib More common in adult females
Around 10% develop thoracic outlet syndrome
Carotid aneurysm Pulsatile lateral neck mass which doesn't move on swallowing

5. A 12 year old child is admitted with a 12 hour history of colicky right upper quadrant pain. On examination the child is
afebrile and is jaundiced. The abdomen is soft and non tender at the time of examination. What is the most likely cause?
A. Infectious hepatitis
B. Acute cholecystitis
C. Cholangitis
D. Hereditary spherocytosis
E. Gilberts syndrome

Answer: D
The child is most likely to have hereditary spherocytosis. In these individuals there may be disease flares precipitated by acute
illness. They form small pigment stones. These may cause biliary colic and some may require cholecystectomy.

Hereditary Spherocytosis: Most common disorder of the red cell membrane, it has an incidence of 1 in 5000. The abnormally
shaped erythrocytes are prone to splenic sequestration and destruction. This can result in hyperbilirubinaemia, jaundice and
splenomegaly. In older patients an intercurrent illness may increase the rate of red cell destruction resulting in more acute
symptoms.
Severe cases may benefit from splenectomy.

180
6. A 2 day old baby is noted to have voiding difficulties and on closer inspection is noted to have hypospadias. Which of the
following abnormalities is most commonly associated with the condition?
A. Cryptorchidism
B. Diaphragmatic hernia
C. Ventricular - septal defect
D. Bronchogenic cyst
E. Atrial septal defect

Answer: A
Hypospadias most commonly occurs as an isolated disorder. Associated urological abnormalities may be seen in up to 40% of
infants, of these cryptorchidism is the most frequent (10%).
Hypospadias: The urethral meatus opens on the ventral surface of the penis. There is also a ventral deficiency of the foreskin.
The uretral meatus may open more proximally in the more severe variants. However, 75% of the openings are distally located.
The incidence is 1 in 300 male births.

Features include: Absent frenular artery; Ventrally opened glans; Skin tethering to hypoplastic urethra; Splayed columns of
spongiosum tissue distal to the meatus; Deficiency of the foreskin ventrally
Management: No routine cultural circumcisions; Urethroplasty; Penile reconstruction. The foreskin is often utilised in the
reconstructive process. In boys with very distal disease no treatment may be needed.

Theme: Liver lesions

A. Cystadenoma
B. Hyatid cyst
C. Amoebic abscess
D. Mesenchymal hamartoma
E. Liver cell adenoma
F. Cavernous haemangioma

Please select the most likely lesion for the scenario given. Each option may be used once, more than once or not at all.

7. A 38 year old lady presents with right upper quadrant pain and nausea. She is otherwise well and her only medical
therapy is the oral contraceptive pill which she has taken for many years with no ill effects. Her liver function tests are
normal. An ultrasound examination demonstrates a hyperechoic well defined lesion in the left lobe of the liver which
measures 14 cm in diameter.
Answer: Cavernous haemangioma
Cavernous haemangioma often presents with vague symptoms and signs. They may grow to considerable size. Liver function
tests are usually normal. The lesions are typically well defined and hyperechoic on ultrasound. A causative link between OCP
use and haemangiomata has yet to be established, but is possible.

8. A 37 year old lady presents with right upper quadrant pain and nausea. She is otherwise well and her only medical
therapy is the oral contraceptive pill which she has taken for many years with no ill effects. Her liver function tests and
serum alpha feto protein are normal. An ultrasound examination demonstrates a 4cm non encapsulated lesion in the
right lobe of the liver which has a mixed echoity and heterogeneous texture.
Answer: Liver cell adenoma
Liver cell adenomas are linked to OCP use and 90% of patients with liver cell adenomas have used the OCP. Liver function
tests are often normal. The lesions will typically have a mixed echoity and heterogeneous texture.

9. A 38 year old shepherd presents to the clinic with a 3 month history of malaise and right upper quadrant pain. On
examination he is mildly jaundiced. His liver function tests demonstrate a mild elevation in bilirubin and transaminases,
his full blood count shows an elevated eosinophil level. An abdominal x-ray is performed by the senior house officer and
demonstrates a calcified lesion in the right upper quadrant of the abdomen.
Answer: Hyatid cyst

181
 Hyatid disease is more common in those who work with sheep or dogs. Liver function tests may be abnormal and an
eosinophilia is often present. Plain radiographs may reveal a calcified cyst wall.

Benign liver lesions

Haemangioma: Most common benign tumours of mesenchymal origin. Incidence in autopsy series is 8%. Cavernous
haemangiomas may be enormous. Clinically they are reddish purple hypervascular lesions. Lesions are normally separated from
normal liver by ring of fibrous tissue. On ultrasound they are typically hyperechoic
Liver cell adenoma: 90% develop in women in their third to fifth decade. Linked to use of oral contraceptive pill. Lesions are
usually solitary. They are usually sharply demarcated from normal liver although they usually lack a fibrous capsule. On
ultrasound the appearances are of mixed echoity and heterogeneous texture. On CT most lesions are hypodense when imaged
prior to administration of IV contrast agents. In patients with haemorrhage or symptoms removal of the adenoma may be
required
Mesenchymal hamartomas: Congential and benign, usually present in infants. May compress normal liver
Liver abscess: Biliary sepsis is a major predisposing factor. Structures drained by the portal venous system form the second
largest source. Common symptoms include fever, right upper quadrant pain. Jaundice may be seen in 50. Ultrasound will
usually show a fluid filled cavity, hyperechoic walls may be seen in chronic abscesses
Amoebic abscess: Liver abscess is the most common extra intestinal manifestation of amoebiasis. Between 75 and 90% lesions
occur in the right lobe. Presenting complaints typically include fever and right upper quadrant pain. Ultrasonography will
usually show a fluid filled structure with poorly defined boundaries. Aspiration yield sterile odourless fluid which has an
anchovy paste consistency. Treatment is with metronidazole
Hyatid cysts: Seen in cases of Echinococcus infection. Typically an intense fibrotic reaction occurs around sites of infection.
The cyst has no epithelial lining. Cysts are commonly unilocular and may grow to 20cm in size. The cyst wall is thick and has
an external laminated hilar membrane and an internal enucleated germinal layer. Typically presents with malaise and right upper
quadrant pain. Secondary bacterial infection occurs in 10%. Liver function tests are usually abnormal and eosinophilia is present
in 33% cases. Ultrasound may show septa and hyatid sand or daughter cysts. Percutaneous aspiration is contra indicate
Treatment is by sterilisation of the cyst with mebendazole and may be followed by surgical resection. Hypertonic swabs are
packed around the cysts during surgery
Polycystic liver disease: Usually occurs in association with polycystic kidney disease. Autosomal dominant disorder.
Symptoms may occur as a result of capsular stretch
Cystadenoma: Rare lesions with malignant potential. Usually solitary multiloculated lesions. Liver function tests usually
normal. Ultrasonography typically shows a large anechoic, fluid filled area with irregular margins. Internal echos may result
from septa. Surgical resection is indicated in all cases

10. A 72 year old man presents with symptoms and signs of benign prostatic hyperplasia. Which of the following structures
is most likely to be enlarged on digital rectal examination?
A. Posterior lobe of the prostate
B. Median lobe of the prostate
C. Right lateral lobe of the prostate
D. Left lateral lobe of the prostate
E. Anterior lobe of the prostate
Answer: B
Carcinoma of the prostate typically occurs in the posterior lobe. The median lobe is usually enlarged in BPH. The anterior lobe
has little in the way of glandular tissue and is seldom enlarged.

Benign Prostatic Hyperplasia: Prostatic enlargement occurs in many elderly men . >90% of men aged over 80 will have at
least microscopic evidence of benign prostatic hyperplasia. Pathology: As part of the hyperplastic process increase in both
stromal and glandular components are seen. The changes are most notable in the central and periurethral region of the gland.
Presentation: The vast majority of men will present with lower urinary tract symptoms. These will typically be: Poor flow.
Nocturia. Hesitancy. Incomplete and double voiding. Terminal dribbling. Urgency. Incontinence. Investigation: Digital rectal
examination to assess prostatic size and morphology. Urine dipstick for infections and haematuria. Uroflowmetry (a flow rate of
>15ml/second helps to exclude BOO). Bladder pressure studies may help identify detrusor failure and whilst may not form part
of first line investigations should be included in those with atypical symptoms and prior to redo surgery. Bladder scanning to
demonstrate residual volumes. USS if high pressure chronic retention. Management: Lifestyle changes such as stopping
smoking and altering fluid intake may help those with mild symptoms. Medical therapy includes alpha blockers and 5 alpha
reductase inhibitors.

182
 The former work quickly on receptor zones located at the bladder neck. Cardiovascular side effects are well documented. The
latter work on testosterone metabolising enzymes. Although they have a slower onset of action, the 5 alpha reductase inhibitors
may prevent acute urinary retention. Surgical therapy includes transurethral resection of the prostate and is the treatment of
choice in those with severe symptoms and those who fail to respond to medical therapy. More tailored bladder neck incision
procedures may be considered in those with small prostates. Retrograde ejaculation may occur following surgery. The change in
the type of irrigation solutions used has helped to minimise the TURP syndrome of electrolyte disturbances.
11. A 58 year old man has been suffering from mechanical back pain for several years. One morning he awakes from sleep
and feels a sudden onset of pain in his back radiating down his left leg. Which of the following events is most likely to
account for his symptoms?
A. Prolapse of inner annulus fibrosus
B. Prolapse of outer annulus fibrosus
C. Prolapse of nucleus pulposus
D. Rupture of the ligamentum flavum
E. None of the above

Answer: C
The symptoms would be most likely the result of intervertebral disk prolapse. In disk prolapse the nucleus pulposus is the
structure which usually herniates. Intervertebral discs: Consist of an outer annulus fibrosus and an inner nucleus pulposus.
The anulus fibrosus consists of several layers of fibrocartilage. The nucleus pulposus contains loose fibres suspended in a
mucoprotein gel with the consistency of jelly. The nucleus of the disc acts as a shock absorber. Pressure on the disc causes
posterior protrusion of the nucleus pulposus. Most commonly in the lumbrosacral and lower cervical areas. The discs are
separated by hyaline cartilage. There is one disc between each pair of vertebrae, except for C1/2 and the sacrococcygeal
vertebrae.

Theme: Paediatric neck masses

A. Cystic hygroma
B. Thyroglossal cyst
C. Rhabdomyosarcoma
D. Branchial cyst
E. Dermoid cyst

Please select the most likely underlying diagnosis for the situation that is described. Each option may be used once, more than
once, or not at all.

12. A 2 year old boy is brought to the clinic by his mother who has noticed that he has developed a small mass. On
examination a small smooth cyst is identified which is located above the hyoid bone. On ultrasound the lesion appears to
be a heterogenous and multiloculated mass.
Answer: Dermoid cyst
Dermoid cysts are usually multiloculated and heterogeneous. Most are located above the hyoid and their appearances on
imaging differentiate them from thyroglossal cysts.

13. A 22 month old baby is brought to the clinic by her mother who is concerned that she has developed a swelling in her
neck. On examination she has a soft, lesion located in the posterior triangle that transilluminates.
Answer: Cystic hygroma
Cystic hygromas are soft and transilluminate. Most are located in the posterior triangle.

14. A 3 year old boy is brought to the clinic by his mother who has noticed a mass in his neck. On examination he has a
smooth mass located on the lateral aspect of his anterior triangle, near to the angle of the mandible. On ultrasound it has
a fluid filled, anechoic, appearance.
Answer: The correct answer is Branchial cyst
Branchial cysts are usually located laterally and derived from the second branchial cleft. Unless infection has occurred they will
usually have an anechoic appearance on ultrasound.

183
 Neck Masses in Children
Thyroglossal cyst: Located in the anterior triangle, usually in the midline and below the hyoid (65% cases). Derived from
remnants of the thyroglossal duct. Thin walled and anechoic on USS (echogenicity suggests infection of cyst)
Branchial cyst: Six branchial arches separated by branchial clefts. Incomplete obliteration of the branchial apparatus may result
in cysts, sinuses or fistulae. 75% of branchial cysts originate from the second branchial cleft. Usually located anterior to the
sternocleidomastoid near the angle of the mandible. Unless infected the fluid of the cyst has a similar consistency to water and
is anechoic on USS
Dermoids: Derived from pleuripotent stem cells and are located in the midline. Most commonly in a suprahyoid location. They
have heterogeneous appearances on imaging and contain variable amounts of calcium and fat
Thyroid gland: True thyroid lesions are rare in children and usually represent thyroglossal cysts or tumours like lymphoma
Lymphatic malformations: Usually located posterior to the sternocleidomastoid. Cystic hygroma result from occlusion of
lymphatic channels. The painless, fluid filled, lesions usually present prior to the age of 2. They are often closely linked to
surrounding structures and surgical removal is difficult. They are typically hypoechoic on USS
Infantile haemangioma: May present in either triangle of the neck. Grow rapidly initially and then will often spontaneously
regress. Plain x-rays will show a mass lesion, usually containing calcified phleboliths. As involution occurs the fat content of
the lesions increases
Lymphadenopathy: Located in either triangle of the neck. May be reactive or neoplastic. Generalised lymphadenopathy
usually secondary to infection in children (very common)

15. An unusually tall 43 year old lady presents to the surgical clinic with bilateral inguinal hernias. She develops chest pain
and collapses. As part of her investigations a chest x-ray shows evidence of mediastinal widening. What is the most likely
underlying diagnosis?
A. Pulmonary embolus
B. Aortic dissection
C. Tietze syndrome
D. Boerhaaves syndrome
E. Myocardial infarct
Answer:
B
Marfans syndrome may present with a variety of connective tissue disorders such as bilateral inguinal hernia. They are at high
risk of aortic dissection, as in this case. Aortic dissection: More common than rupture of the abdominal aorta. 33% of patients
die within the first 24 hours, and 50% die within 48 hours if no treatment received. Associated with hypertension: Features of
aortic dissection: tear in the intimal layer, followed by formation and propagation of a subintimal hematoma. Cystic medial
necrosis (Marfan's). Most common site of dissection: 90% occurring within 10 centimetres of the aortic valve

Stanford Classification: Type A: Ascending aorta/ aortic root: Surgery- aortic root replacement. Type: B: Descending aorta:
Medical therapy with antihypertensives. DeBakey classification: Type I:Ascending aorta, aortic arch, descending aorta; Type
II: Ascending aorta only; Type III: Descending aorta distal to left subclavian artery. Clinical features: Tearing, sudden onset
chest pain (painless 10%). Hypertension or Hypotension. A blood pressure difference greater than 20 mm Hg. Neurologic
deficits (20%)
Investigations: CXR: widened mediastinum, abnormal aortic knob, ring sign, deviation trachea/oesophagus. CT (spiral). MRI.
Angiography (95% of patients diagnosed). Management: Beta-blockers: aim HR 60- bpm and systolic BP 100-120 mm Hg.
Urgent surgical intervention: type A dissections. This will usually involve aortic root replacement.

16. A 72 year old man has just undergone an emergency repair for a ruptured abdominal aortic aneurysm. Pre operatively
he was taking aspirin, clopidogrel and warfarin. Intra operatively he received 5000 units of unfractionated heparin prior
to application of the aortic cross clamp. His blood results on admission to the critical care unit are as follows:
Full blood count: Hb: 8 g/dl; Platelets: 40 * 109/l; WBC: 7.1 * 109/l. His fibrin degradation products are measured and
found to be markedly elevated. Which of the following accounts for these results?
A. Anastomotic leak
B. Disseminated intravascular coagulation
C. Heparin induced thrombocytopenia
D. Adverse effect of warfarin
E. Adverse effects of antiplatelet agents

Answer: B
The combination of low platelet counts and raised FDP in this setting maked DIC the most likely diagnosis.

Disseminated intravascular coagulation – Diagnosis: Under homeostatic conditions, coagulation and fibrinolysis are coupled.
The activation of the coagulation cascade yields thrombin that converts fibrinogen to fibrin; the stable fibrin clot being the final
product of hemostasis. The fibrinolytic system breaks down fibrinogen and fibrin. Activation of the fibrinolytic system

184
 generates plasmin (in the presence of thrombin), which is responsible for the lysis of fibrin clots. The breakdown of fibrinogen
and fibrin results in polypeptides (fibrin degradation products). In a state of homeostasis, the presence of plasmin is critical, as it
is the central proteolytic enzyme of coagulation and is also necessary for fibrinolysis.

In DIC, the processes of coagulation and fibrinolysis are dysregulated, and the result is widespread clotting with resultant
bleeding. Regardless of the triggering event of DIC, once initiated, the pathophysiology of DIC is similar in all conditions. One
critical mediator of DIC is the release of a transmembrane glycoprotein (tissue factor =TF). TF is present on the surface of many
cell types (including endothelial cells, macrophages, and monocytes) and is not normally in contact with the general circulation,
but is exposed to the circulation after vascular damage. For example, TF is released in response to exposure to cytokines
(particularly interleukin 1), tumor necrosis factor, and endotoxin. This plays a major role in the development of DIC in septic
conditions. TF is also abundant in tissues of the lungs, brain, and placenta. This helps to explain why DIC readily develops in
patients with extensive trauma. Upon activation, TF binds with coagulation factors that then triggers the extrinsic pathway (via
Factor VII) which subsequently triggers the intrinsic pathway (XII to XI to IX) of coagulation.

Fibrin degradation products are often raised.

Disorder Prothrombin time APTT Bleeding time Platelet count
Warfarin administration Prolonged Normal Normal Normal
Aspirin administration Normal Normal Prolonged Normal
Heparin Often normal (may be prolonged) Prolonged Normal Normal
DIC Prolonged Prolonged Prolonged Low

17. A 53 year old man from Hong Kong presents with symptoms of fatigue, weight loss and recurrent epistaxis. Clinical
examination reveals left sided cervical lymphadenopathy and oropharyngeal examination reveals an ulcerated mass in
the naso pharynx. Which of the following viral agents is most commonly implicated in the development of this condition?
A. Cytomegalovirus
B. Epstein Barr virus
C. Coxsackie virus
D. Herpes simplex virus
E. None of the above

Answer: B
The clinical scenario is most typical for nasopharyngeal carcinoma. An association with previous Epstein Barr Virus is well
established. Infection with the other viruses listed is not a recognised risk factor for the development of the
condition.Nasopharyngeal carcinoma: Squamous cell carcinoma of the nasopharynx. Rare in most parts of the world, apart
from individuals from Southern ChinaAssociated with Epstein Barr virus infection. Presenting features: Systemic: Cervical
lymphadenopathy. Local: Otalgia, Unilateral serous otitis media, Nasal obstruction, discharge and/ or epistaxis, Cranial nerve
palsies e.g. III-VI. Imaging: Combined CT and MRI. Treatment: Radiotherapy is first line therapy.

18. An 18 year old male presents with lethargy, night sweats and on examination is found to have left supraclavicular
lymphadenopathy. A surgical registrar performs a left supraclavicular lymph node biopsy. The pathologist identifies
Reed- Sternberg cells on the subsequent histology sections, what is the most likely diagnosis?
A. Metastatic gastric cancer
B. Hodgkins lymphoma
C. Non Hodgkins lymphoma
D. Tuberculosis
E. None of the above

Answer: B
Reed-Sternberg cells are characteristic histological cell type found in Hodgkins disease. Lymphadenopathy:
Lymphadenopathy in the neck, axillae, groins and abdomen. Need to note: solitary/multiple, defined/indistinct,
hard/rubbery/soft, tender/painless

Causes of lymphadenopathy: Mnemonic: Hodgkins disease: H aematological: Hodgkins lymphoma, NHL, Leukaemia; O
ncological: metastases; D ermatopathic lympadenitis; G aucher's disease; K awasaki disease; I nfections: TB, glandular fever,
Syphilis; N iemann Pick disease; S erum sickness; D rug reaction (phenytoin); I mmunological (SLE); S arcoidosis; E
ndocrinological (Hyperthyroidism); A ngioimmunoplastic lymphadenopathy; S LE; E osinophilic granulomatosis

19. Which of the following lesions is least likely to occur in the presence of severe atrophic gastritis?
A. Duodenal ulcer
B. Gastric cancer
C. Gastric polyp
D. Iron deficiency anaemia
185
E. Pernicious anaemia

Answer: A
Due the absence of acid a duodenal ulcer is unlikely to occur.

Gastric cancer: Overview: There are 700,000 new cases of gastric cancer worldwide each year. It is most common in Japan
and less common in western countries. It is more common in men and incidence rises with increasing age. The exact cause of
many sporadic cancer is not known, however, familial cases do occur in HNPCC families. In addition, smoking and smoked or
preserved foods increase the risk. Japanese migrants retain their increased risk (decreased in subsequent generations). The
distribution of the disease in western countries is changing towards a more proximal location (perhaps due to rising obesity).

Pathology: There is some evidence of support a stepwise progression of the disease through intestinal metaplasia progressing to
atrophic gastritis and subsequent dysplasia, through to cancer. The favoured staging system is TNM. The risk of lymph node
involvement is related to size and depth of invasion; early cancers confined to submucosa have a 20% incidence of lymph node
metastasis. Tumours of the gastro-oesophageal junction are classified: Type 1: True oesophageal cancers and may be associated
with Barrett's oesophagus. Type 2: Carcinoma of the cardia, arising from cardiac type epithelium or short segments with
intestinal metaplasia at the oesophagogastric junction. Type 3: Sub cardial cancers that spread across the junction. Involve
similar nodal stations to gastric cancer. Groups for close endoscopic monitoring: Intestinal metaplasia of columnar type.
Atrophic gastritis. Low to medium grade dysplasia. Patients who have previously undergone resections for benign peptic ulcer
disease (except highly selective vagotomy).

Table: Referral to endoscopy

Patients of any age with dyspepsia and Patients without dyspepsia Worsening dyspepsia
any of the following
Chronic gastrointestinal bleeding Dysphagia Barretts oesophagus
Dysphagia Unexplained abdominal pain Intestinal metaplasia
or weight loss
Weight loss Vomiting Dysplasia
Iron deficiency anaemia Upper abdominal mass Atrophic gastritis
Upper abdominal mass Jaundice Patient aged over 55 years with unexplained
or persistent dyspepsia

Staging: CT scanning of the chest abdomen and pelvis is the routine first line staging investigation in most centres.
Laparoscopy to identify occult peritoneal disease. PET CT (particularly for junctional tumours). Treatment: Proximally sited
disease greater than 5-10cm from the OG junction may be treated by sub total gastrectomy. Total gastrectomy if tumour is <5cm
from OG junction. For type 2 junctional tumours (extending into oesophagus) oesophagogastrectomy is usual. Endoscopic sub
mucosal resection may play a role in early gastric cancer confined to the mucosa and perhaps the sub mucosa (this is debated).
Lymphadenectomy should be performed. A D2 lymphadenectomy is widely advocated by the Japanese, the survival advantages
of extended lymphadenectomy have been debated. However, the overall recommendation is that a D2 nodal dissection be
undertaken. Most patients will receive chemotherapy either pre or post operatively. Prognsis: (UK Data) by percentage 5 year
survival: All RO resections: 54%; Early gastric cancer: 91%; Stage 1: 87%; Stage 2: 65%; Stage 3: 18%
Operative procedure: Total Gastrectomy , lymphadenectomy and Roux en Y anastomosis: General anaesthesia.
Prophylactic intravenous antibiotics. Incision: Rooftop. Perform a thorough laparotomy to identify any occult disease. Mobilise
the left lobe of the liver off the diaphragm and place a large pack over it. Insert a large self retaining retractor e.g. omnitract or
Balfour (take time with this, the set up should be perfect). Pack the small bowel away. Begin by mobilising the omentum off the
transverse colon. Proceed to detach the short gastric vessels. Mobilise the pylorus and divide it at least 2cm distally using a
linear cutter stapling device. Continue the dissection into the lesser sac taking the lesser omentum and left gastric artery flush at
its origin.
The lymph nodes should be removed en bloc with the specimen where possible.
Place 2 stay sutures either side of the distal oesophagus. Ask the anaesthetist to pull back on the nasogastric tube. Divide the
distal oesophagus and remove the stomach. The oesphago jejunal anastomosis should be constructed. Identify the DJ flexure
and bring a loop of jejunum up to the oesophagus (to check it will reach). Divide the jejunum at this point. Bring the divided
jejunum either retrocolic or antecolic to the oesophagus. Anastamose the oesophagus to the jejunum, using either interrupted 3/0
vicryl or a stapling device. Then create the remainder of the Roux en Y reconstruction distally.
Place a jejunostomy feeding tube. Wash out the abdomen and insert drains (usually the anastomosis and duodenal stump). Help
the anaesthetist insert the nasogastric tube (carefully!). Close the abdomen and skin. Enteral feeding may commence on the first
post-operative day. However, most surgeons will leave patients on free NG drainage for several days and keep them nil by
mouth.

20. A 28 year old man develops an acute paronychia and subsequent spreading sepsis. The tissue exudate has a higher
protein content than normal tissue because?

186
A. Breakdown of tissue cells release protein
B. Capillary walls are more permeable
C. Increased blood flow transports more protein into the area
D. Intracapillary pressure is raised
E. Plasma cells release gamma globulin

Answer: B
The increased permeability allows the exudation of plasma proteins.

Acute inflammation: Inflammation is the reaction of the tissue elements to injury. Vascular changes occur, resulting in the
generation of a protein rich exudate. So long as the injury does not totally destroy the existing tissue architecture, the episode
may resolve with restoration of original tissue architecture.
Vascular changes: Vasodilation occurs and persists throughout the inflammatory phase. Inflammatory cells exit the circulation
at the site of injury. The equilibrium that balances Starlings forces within capillary beds is disrupted and a protein rich exudate
will form as the vessel walls also become more permeable to proteins. The high fibrinogen content of the fluid may form a
fibrin clot. This has several important immunomodulatory functions.

Sequelae: Resolution: Typically occurs with minimal initial injury. Stimulus removed and normal tissue architecture results.
Organisation:Delayed removed of exudate. Tissues undergo organisation and usually fibrosis. Suppuration:Typically
formation of an abscess or an empyema. Sequestration of large quantities of dead neutrophils. Progression to chronic
inflammation: Coupled inflammatory and reparative activities. Usually occurs when initial infection or suppuration has been
inadequately managed
Causes: Microbacterial infections e.g. Viruses, exotoxins or endotoxins released by bacteria. Chemical agents. Physical agents
e.g. Trauma. Hypersensitivity reactions. Tissue necrosis. Presence of neutrophil polymorphs is a histological diagnostic
feature of acute inflammation

21. As a busy surgical trainee on the colorectal unit you are given the unenviable task of reviewing the unit's histopathology
results for colonic polyps. Which of the polyp types described below has the greatest risk of malignancy?
A. Hyperplastic polyp
B. Tubular adenoma
C. Villous adenoma
D. Hamartomatous polyp
E. Serrated polyp

Answer: C
Villous adenomas carry the highest risk of malignant transformation. Hyperplastic polyps carry little in the way of increased
risk. Although, patients with hamartomatous polyp syndromes may have a high risk of malignancy, the polyps themselves have
little malignant potential.

Colonic Polyps: May occur in isolation of greater numbers as part of the polyposis syndromes. In FAP greater than 100 polyps
are typically present. The risk of malignancy in association with adenomas is related to size and is the order of 10% in a 1cm
adenoma. Isolated adenomas seldom give risk of symptoms (unless large and distal). Distally sited villous lesions may produce
mucous and if very large electrolyte disturbances may occur.
Follow up of colonic polyps: Low risk: 1 or 2 adenomas <1cm. No follow up or re-colonoscopy at 5 years. Moderate risk: 3
or 4 small adenomas or 1 adenoma >1cm. Re-scope at 3 years. High risk: >5 small adenomas or >3 with 1 of them >1cm. Re
scope at 1 year. It is important to stratify patients appropriately and ensure that a complete colonoscopy with good views was
performed.
Segmental resection or complete colectomy should be considered when: 1. Incomplete excision of malignant polyp; 2.
Malignant sessile polyp; 3. Malignant pedunculated polyp with submucosal invasion; 4. Polyps with poorly differentiated
carcinoma; 5. Familial polyposis coli. Screening from teenager up to 40 years by 2 yearly sigmoidoscopy/colonoscopy.
Panproctocolectomy and Ileostomy or Restorative Panproctocolectomy. Rectal polypoidal lesions may be amenable to trans
anal endoscopic microsurgery.

22. A 23 year old man presents to the surgical clinic with an inguinal hernia. On examination he has a small direct hernia.
However, you also notice that he has pigmented spots around his mouth, on his palms and soles. In his history he
underwent a reduction of an intussusception aged 12 years. Which of the following lesions is most likely to be identified
if a colonoscopy were performed?
A. Hamartomas
B. Tubulovillous adenoma
C. Colorectal cancer
D. Crohns disease

187
E. Hyperplastic polyps

Answer: A
He is most likely to have Peutz-Jeghers syndrome which is associated with Hamartomas.

Peutz-Jeghers syndrome: Peutz-Jeghers syndrome is an autosomal dominant condition characterised by numerous benign
hamartomatous polyps in the gastrointestinal tract. It is also associated with pigmented freckles on the lips, face, palms and
soles. Around 50% of patients will have died from a gastrointestinal tract cancer by the age of 60 years.
Genetics: Autosomal dominant. Responsible gene encodes serine threonine kinase LKB1 or STK11. Features: Hamartomatous
polyps in GI tract (mainly small bowel). Pigmented lesions on lips, oral mucosa, face, palms and soles. Intestinal obstruction
e.g. intussusception (which may lead to diagnosis). Gastrointestinal bleeding. Management: Conservative unless complications
develop

23. A 56 year old surgeon has been successfully operating for many years. Over the past few weeks she has begun to notice
that her hands are becoming blistering and weepy. A latex allergy is diagnosed. Which of the following pathological
processes accounts for this scenario?
A. Type 1 hypersensitivity reaction
B. Type 2 hypersensitivity reaction
C. Type 4 hypersensitivity reaction
D. Type 3 hypersensitivity reaction
E. None of the above
Answer:
C
Hypersensitivity reactions: ACID: type 1 –Anaphylactic; type 2 –Cytotoxic; type 3 --Immune complex type 4 --Delayed
hypersensitivity
Contact dermatitis of a chronic nature is an example of a type 4 hypersensitivity reaction. Type 4 hypersensitivity reactions are
cell mediated rather than antibody mediated.

Hypersensitivity reactions: The Gell and Coombs classification divides hypersensitivity reactions into 4 types

Type I Type II Type III Type IV

Description Anaphylactic Cytotoxic Immune complex Delayed type
Mediator IgE IgG, IgM IgG, IgM T-cells
Antigen Exogenous Cell surface Soluble Tissues
Response time Minutes Hours Hours 2-3 days
Examples Asthma Autoimmune haemolytic anaemia Serum sickness Graft versus host disease
Hay fever Pemphigus SLE Contact dermatitis
Goodpasture's Aspergillosis

24. A 56 year old motorcyclist is involved in a road traffic accident and sustains a displaced femoral shaft fracture. Not
other injuries are identified on the primary or secondary surveys. The fracture is treated with closed, antegrade
intramedullary nailing. The following day the patient becomes increasingly agitated and confused. On examination he is
pyrexial, hypoxic SaO2 90% on 6 litres O2, tachycardic and normotensive. Systemic examination demonstrates a non
blanching petechial rash present over the torso. What is the most likely explanation for this?
A. Pulmonary embolism with paradoxical embolus
B. Fat embolism
C. Meningococcal sepsis
D. Alcohol withdrawl
E. Chronic sub dural haematoma

Answer: B
This man has a recent injury and physical signs that would be concordant with fat embolism syndrome. Meningococcal sepsis is
not usually associated with hypoxia initially. Pulmonary emboli are not typically associated with pyrexia. Fat embolism:
Cardiothoracic:Early persistent tachycardia. Tachypnoea, dyspnoea, hypoxia usually 72 hours following injury. Pyrexia.
Dermatological: Red/ brown impalpable petechial rash (usually only in 25-50%). Subconjunctival and oral haemorrhage/
petechiae. CNS: Confusion and agitation. Retinal haemorrhages and intra-arterial fat globules on fundoscopy. Imaging: May be
normal. Fat emboli tend to lodge distally and therefore CTPA may not show any vascular occlusion, a ground glass appearance
may be seen at the periphery. Treatment: Prompt fixation of long bone fractures. Some debate regarding benefit Vs. risk of
medullary reaming in femoral shaft/ tibial fractures in terms of increasing risk (probably does not). DVT prophylaxis. General
supportive care

25. Which of these tumour markers is most helpful in identifying an individual with hepatocellular carcinoma?
A. Serum AFP
188
B. Serum CA19-9
C. CEA
D. Beta HCG
E. CA125

Answer: A
Hepatocellular carcinoma is commonly diagnosed with imaging and an elevated alpha fetoprotein. Biopsy may seed the tumour
and should be avoided. Up to 80% of hepatocellular carcinoma arise in cirrhotic livers.

The most common primary liver tumours are cholangiocarcinoma and hepatocellular carcinoma. Overall metastatic disease
accounts for 95% of all liver malignancies making the primary liver tumours comparatively rare.
Primary liver tumours include: Cholangiocarcinoma. Hepatocellular carcinoma. Hepatoblastoma. Sarcomas (Rare).
Lymphomas. Carcinoids (most often secondary although primary may occur)

Hepatocellular carcinoma: These account for the bulk of primary liver tumours (75% cases). Its worldwide incidence reflects
its propensity to occur on a background of chronic inflammatory activity. Most cases arise in cirrhotic livers or those with
chronic hepatitis B infection, especially where viral replication is actively occurring. In the UK it accounts for less than 5% of
all cancers, although in parts of Asia its incidence is 100 per 100,000.
The majority of patients (80%) present with existing liver cirrhosis, with a mass discovered on screening ultrasound.
Diagnosis: CT/ MRI (usually both) are the imaging modalities of choice. a-fetoprotein is elevated in almost all cases. Biopsy
should be avoided as it seeds tumours cells through a resection plane. In cases of diagnostic doubt serial CT and aFP
measurements are the preferred strategy. Treatment: Patients should be staged with liver MRI and chest, abdomen and pelvic
CT scan. The testis should be examined in males (testicular tumours may cause raised AFP). PET CT may be used to identify
occult nodal disease. Surgical resection is the mainstay of treatment in operable cases. In patients with a small primary tumour
in a cirrhotic liver whose primary disease process is controlled, consideration may be given to primary whole liver resection and
transplantation.Liver resections are an option but since most cases occur in an already diseased liver the operative risks and
post-operative hepatic dysfunction are far greater than is seen following metastectomy. These tumours are not particularly
chemo or radiosensitive however, both may be used in a palliative setting. Tumour ablation is a more popular strategy.
Survival: Poor, overall survival is 15% at 5 years.

Cholangiocarcinoma: This is the second most common type of primary liver malignancy. As its name suggests these tumours
arise in the bile ducts. Up to 80% of tumours arise in the extra hepatic biliary tree. Most patients present with jaundice and by
this stage the majority will have disease that is not resectable. Primary scelerosing cholangitis is the main risk factor. In
deprived countries typhoid and liver flukes are also major risk factors. Diagnosis: Patients will typically have an obstructive
picture on liver function tests. CA 19-9, CEA and CA 125 are often elevated. CT/ MRI and MRCP are the imaging methods of
choice. Treatment: Surgical resection offers the best chance of cure. Local invasion of peri hilar tumours is a particular
problem and this coupled with lobar atrophy will often contra indicate surgical resection. Palliation of jaundice is important,
although metallic stents should be avoided in those considered for resection. Survival: Is poor, approximately 15% 5 year
survival.

26. A 39 year old man has suffered from terminal ileal Crohns disease for the past 20 years. Which condition is he least
likely to develop?
A. Gallstones
B. Malabsorption
C. Pyoderma gangrenosum
D. Amyloidosis
E. Feltys syndrome

Answer: E
Felteys syndrome: Rheumatoid disease, Splenomegaly and Neutropenia
Feltys syndrome is associated with rheumatoid disease. Individuals with long standing crohns disease are at risk of gallstones
because of impairment of the enterohepatic recycling of bile salts. Formation of entero-enteric fistulation may produce
malabsorption. Amyloidosis may complicate chronic inflammatory states.

Crohns disease: Crohns disease is a chronic transmural inflammation of a segment(s) of the gastrointestinal tract and may be
associated with extra intestinal manifestations. Frequent disease patterns observed include ileal, ileocolic and colonic disease.
Peri-anal disease may occur in association with any of these. The disease is often discontinuous in its distribution. Inflammation
may cause ulceration, fissures, fistulas and fibrosis with stricturing. Histology reveals a chronic inflammatory infiltrate that is
usually patchy and transmural.

Ulcerative colitis Vs Crohns

Crohn's disease Ulcerative colitis
Distribution Mouth to anus Rectum and colon
189
 Macroscopic Cobblestone appearance, apthoid ulceration Contact bleeding
changes
Depth of disease Transmural inflammation Superficial inflammation
Distribution Patchy Continuous
pattern
Histological Granulomas (non caseating epithelioid cell aggregates Crypt abscesses, Inflammatory cells in the
features with Langhans' giant cells) lamina propria

Extraintestinal manifestations of Crohns

Related to disease extent Unrelated to disease extent
Aphthous ulcers (10%) Sacroiliiitis (10-15%)
Erythema nodosum (5-10%) Ankylosing spondylitis (1-2%)
Pyoderma gangrenosum (0.5%) Primary sclerosing cholangitis (Rare)
Acute arthropathy (6-12%) Gallstones (up to 30%)
Ocular complications (up to 10%) Renal calculi (up to 10%)

Theme: Renal stones

A. Calcium oxalate
B. Uric acid
C. Cystine
D. Struvite
E. Calcium phosphate

Please select the most likely stone type for each of the following urinary tract stone scenarios. Each option may be used once,
more than once or not at all.

27. A 73 year old lady is undergoing chemotherapy for treatment of acute leukaemia. She develops symptoms of renal colic.
Her urine tests positive for blood. A KUB x-ray shows no evidence of stones.
Answer: Uric acid
Chemotherapy and cell death can increase uric acid levels. In this acute setting the uric acid stones are unlikely to be coated
with calcium and will therefore be radiolucent.

28. A 16 year old boy presents with renal colic. His parents both have a similar history of the condition. His urine tests
positive for blood. A KUB style x-ray shows a relatively radiodense stone in the region of the mid ureter.
Answer: Cystine
Cystine stones are associated with an inherited metabolic disorder.

29. A 43 year old lady with episodes of recurrent urinary tract sepsis presents with a staghorn calculus of the left kidney.
Her urinary pH is 7.3. A KUB x-ray shows a faint outline of the calculus.
Answer: Struvite
Chronic infection with urease producing enzymes can produce an alkaline urine with formation of struvate stone.
Renal stones: Calcium oxalate: Hypercalciuria is a major risk factor (various causes). Hyperoxaluria may also increase risk
Hypocitraturia increases risk because citrate forms complexes with calcium making it more soluble. Stones are radio-opaque
(though less than calcium phosphate stones). Hyperuricosuria may cause uric acid stones to which calcium oxalate binds
Percentage of all calculi: 85%

Cystine: Inherited recessive disorder of transmembrane cystine transport leading to decreased absorption of cystine from
intestine and renal tubule. Multiple stones may form. Relatively radiodense because they contain sulphur. Percentage of all
calculi 1%. Uric acid: Uric acid is a product of purine metabolism. May precipitate when urinary pH low. May be caused by
diseases with extensive tissue breakdown e.g. malignancy. More common in children with inborn errors of metabolism.
Radiolucent. Percentage of all calculi: 5-10%. Calcium Stone type Urine acidity Mean
phosphate: May occur in renal tubular acidosis, high urinary pH urine pH
increases supersaturation of urine with calcium and phosphate. Calcium phosphate Normal- alkaline >5.5
Renal tubular acidosis types 1 and 3 increase risk of stone Calcium oxalate Variable 6
formation (types 2 and 4 do not). Radio-opaque stones Uric acid Acid 5.5
(composition similar to bone). Percentage of all calculi 10%. Struvate Alkaline >7.2
Struvite: Stones formed from magnesium, ammonium and
Cystine Normal 6.5
phosphate. Occur as a result of urease producing bacteria (and
are thus associated with chronic infections). Under the alkaline conditions produced, the crystals can precipitate. Slightly radio-
opaque. Percentage of all calculi: 2-20%>

190
 Effect of urinary pH on stone formation: Urine pH will show individual variation (from pH 5-7). Post prandially the pH falls
as purine metabolism will produce uric acid. Then the urine becomes more alkaline (alkaline tide). When the stone is not
available for analysis the pH of urine may help to determine which stone was present.

30. A 64 year old man presents to the clinic with right upper quadrant discomfort. He has never attended the hospital
previously and is usually well. He has just retired from full time employment as a machinist in a PVC factory. CT
scanning shows a large irregular tumour in the right lobe of his liver. Which of the following lesions is the most likely?
A. Liposarcoma
B. Angiosarcoma
C. Hamartoma
D. Hyatid liver disease
E. Benign angioma

Answer: B
Angiosarcoma of the liver is a rare tumour. However, it is linked to working with vinyl chloride, as in this case. Although
modern factories minimise the exposure to this agent, this has not always been the case.

Occupational cancers accounted for 5.3% cancer deaths in 2005. In men the main cancers include: Mesothelioma. Bladder
cancer. Non melanoma skin cancer. Lung cancer. Sino nasal cancer. Occupations with high levels of occupational tumours
include: Construction industry. Working with coal tar and pitch. Mining. Metalworkers. Working with asbestos (accounts for
98% of all mesotheliomas). Working in rubber industry. Shift work has been linked to breast cancer in women (Health and
safety executive report RR595).
The latency between exposure and disease is typically 15 years for solid tumours and 20 for leukaemia. Many occupational
cancers are otherwise rare. For example sino nasal cancer is an uncommon tumour, 50% will be SCC. They are linked to
conditions such as wood dust exposure and unlike lung cancer is not strongly linked to cigarette smoking. Another typical
occupational tumour is angiosarcoma of the liver which is linked to working with vinyl chloride. Again in the non occupational
context this is an extremely rare sporadic tumour.

31. A 32 year old man is involved in a house fire and sustains extensive partial thickness burns to his torso and thigh. Two
weeks post operatively he develops oedema of both lower legs. The most likely cause of this is:
A. Iliofemoral deep vein thrombosis
B. Venous obstruction due to scarring
C. Hypoalbuminaemia
D. Excessive administration of intravenous fluids
E. None of the above

Answer: C
Loss of plasma proteins is the most common cause of oedema developing in this time frame.

Extensive burns: Haemolysis due to damage of erythrocytes by heat and microangiopathy. Loss of capillary membrane
integrity causing plasma leakage into interstitial space. Extravasation of fluids from the burn site causing hypovolaemic shock
(up to 48h after injury)- decreased blood volume and increased haematocrit. Protein loss. Secondary infection e.g.
Staphylococcus aureus. ARDS. Risk of Curlings ulcer (acute peptic stress ulcers). Danger of full thickness circumferential
burns in an extremity as these may develop compartment syndrome
Healing: Superficial burns: keratinocytes migrate to form a new layer over the burn site. Full thickness burns: dermal scarring.
Usually need keratinocytes from skin grafts to provide optimal coverage.

32. What is the diagnostic marker for carcinoid syndrome?

A. B-HCG
B. Histamine
C. Chromogranin A
D. 5-Hydroxyindoleacetic acid
E. 5-Hydroxytryptamine

Answer: D
Urinary measurement of 5- HIAA is an important part of clinical follow up.

Carcinoid syndrome: Carcinoid tumours secrete serotonin. Originate in neuroendocrine cells mainly in the intestine (midgut-
distal ileum/appendix). Can occur in the rectum, bronchi. Hormonal symptoms mainly occur when disease spreads outside the
bowel
Clinical features: Onset: years. Flushing face. Palpitations. Tricuspid stenosis causing dyspnea. Asthma. Severe diarrhoea
(secretory, persists despite fasting). Investigation: 5-HIAA in a 24-hour urine collection. Scintigraphy. CT scan. Treatment:
Octreotide. Surgical removal.

191
33. A 42 year old man from Southern India presents with chronic swelling of both lower legs, they are brawny and
indurated with marked skin tophic changes. Which of the following organisms is the most likely origin of this disease
process?
A. Loa loa
B. Wuchereria bancrofti
C. Trypanosoma cruzi
D. Trypanosoma gambiense
E. None of the above

Answer: B
W. Bancrofti is the commonest cause of filariasis leading to lymphatic obstruction. Infection with Loa loa typically occurs in the
African sub continent and usually results in generalised sub cutaneous infections without lymphatic obstruction. Trypanosomal
infections would not produce this clinical picture.

Wuchereria bancrofti: Parasitic filarial nematode. Accounts for 90% of cases of filariasis. Usually diagnosed by blood smears.
Usually transmitted by mosquitos. Treatment is with diethylcarbamazine.

34. A 45 year old lady has recently undergone a thyroidectomy for treatment of medullary thyroid cancer. Which of the
following tumour markers is used clinically to screen for recurrence?
a. Free T3
b. Thyroglobulin
c. Calcitonin
d. Free T4
e. Thyroid stimulating hormone
Answer: C
Calcitonin is clinically utilised to screen for medullary thyroid cancer recurrence. Thyroid function testing does not form part of
either diagnosis or follow up from a malignancy perspective. However, routine assessment of TSH may be needed in patients on
thyroxine.

Papillary carcinoma: Commonest sub-type. Accurately diagnosed on fine needle aspiration cytology. Histologically they may
demonstrate psammoma bodies (areas of calcification) and so called 'orphan Annie' nuclei. They typically metastasise via the
lymphatics and thus laterally located apparently ectopic thyroid tissue is usually a metastasis from a well differentiated papillary
carcinoma.
Follicular carcinoma: Are less common than papillary lesions. Like papillary tumours they may present as a discrete nodule.
Although they appear to be well encapsulated macroscopically there invasion on microscopic evaluation. Lymph node
metastases are uncommon and these tumours tend to spread haematogenously. This translates into a higher mortality rate.
Follicular lesions cannot be accurately diagnosed on fine needle aspiration cytology and thus all follicular FNA's will require at
least a hemi thyroidectomy.
Anaplastic carcinoma: Less common and tend to occur in elderly females. Disease is usually advanced at presentation and
often only palliative decompression and radiotherapy can be offered.
Medullary carcinoma: These are tumours of the parafollicular cells ( C Cells) and are of neural crest origin. The serum
calcitonin may be elevated which is of use when monitoring for recurrence. . They may be familial and occur as part of the
MEN -2A disease spectrum. Spread may be either lymphatic or haematogenous and as these tumours are not derived primarily
from thyroid cells they are not responsive to radioiodine.
Lymphoma: These respond well to radiotherapy. Radical surgery is unnecessary once the disease has been diagnosed on biopsy
material. Such biopsy material is not generated by an FNA and thus a core biopsy has to be obtained (with care!).

35. A 22 year old man is kicked in the head during a rugby match. He is temporarily concussed, but then regains
consciousness. Half an hour later he develops slurred speech, ataxia and loses consciousnesses. On arrival in hospital he
is intubated and ventilated. A CT Scan is performed which shows an extradural haematoma. What is the most likely
cause?
A. Basilar artery laceration
B. Middle meningeal artery laceration
C. Laceration of the sigmoid sinus
D. Laceration of the anterior cerebral artery
E. Laceration of the middle cerebral artery

Answer: B
The most likely vessel from those in the list to cause an acute extra dural haemorrhage is the middle meningeal artery. The
anterior and middle cerebral arteries may cause acute sub dural haemorrhage. Acute sub dural haemorrhages usually take
slightly longer to evolve than acute extra dural haemorrhages.

192
 Middle meningeal artery: Middle meningeal artery is typically the third branch of the first part of the maxillary artery, one of
the two terminal branches of the external carotid artery. After branching off the maxillary artery in the infratemporal fossa, it
runs through the foramen spinosum to supply the dura mater (the outermost meninges) . The middle meningeal artery is the
largest of the three (paired) arteries which supply the meninges, the others being the anterior meningeal artery and the posterior
meningeal artery. The middle meningeal artery runs beneath the pterion. It is vulnerable to injury at this point, where the skull is
thin. Rupture of the artery may give rise to an extra dural hematoma. In the dry cranium, the middle meningeal, which runs
within the dura mater surrounding the brain, makes a deep indention in the calvarium. The middle meningeal artery is intimately
associated with the auriculotemporal nerve which wraps around the artery making the two easily identifiable in the dissection of
human cadavers and also easily damaged in surgery.

36. Which of the following is not characteristic of a granuloma?

A. Altered macrophages
B. Fused macrophages
C. Epithelioid cells
D. Mixture of chronic inflammatory cells
E. Polymorphnuclear leucocytes, cellular debris and fibrin
Answer:
E
These are typical components of an abscess cavity. Polymorphonuclear leucocytes may be found in a granuloma if there is a
focus of suppuration.

Chronic inflammation: it may occur secondary to acute inflammation.In most cases chronic inflammation occurs as a primary
process. These may be broadly viewed as being one of three main processes: Persisting infection with certain organisms such as
Mycobacterium tuberculosis which results in delayed type hypersensitivity reactions and inflammation. Prolonged exposure to
non-biodegradable substances such as silica or suture materials which may induce an inflammatory response. Autoimmune
conditions involving antibodies formed against host antigens.

Acute vs. Chronic inflammation: Acute inflammation: Infiltration of neutrophils. Changes to existing vascular structure and
increased permeability of endothelial cells. Process may resolve with: Suppuration. Complete resolution. Abscess formation.
Progression to chronic inflammation. Healing by fibrosis. Chronic inflammation: Angiogenesis predominates. Macrophages,
plasma cells and lymphocytes predominate. Healing by fibrosis is the main result

Granulomatous inflammation: A granuloma consists of a microscopic aggregation of macrophages (with epithelial type
arrangement =epitheliod). Large giant cells may be found at the periphery of granulomas.

Mediators: Growth factors released by activated macrophages include agents such as interferon and fibroblast growth factor
(plus many more). Some of these such as interferons may have systemic features resulting in systemic symptoms and signs,
which may be present in individuals with long standing chronic inflammation.

37. A 42 year old man presents with a painless lump in the left testicle that he noticed on self examination. Clinically there is
a firm nodule in the left testicle, ultrasound appearances show an irregular mass lesion. His serum AFP and HCG levels
are both within normal limits. What is the most likely diagnosis?
A. Yolk sack tumour
B. Seminoma
C. Testicular teratoma
D. Epididymo-orchitis
E. Adenomatoid tumour

Answer: B This mans age, presenting symptoms and normal tumour markers make a seminoma the most likely diagnosis.
Epididymo-orchitis does not produce irregular mass lesions which are painless.

Testicular cancer: Testicular cancer is the most common malignancy in men aged 20-30 years. Around 95% of cases of
testicular cancer are germ-cell tumours. Germ cell tumours may essentially be divided into Seminoma and Non seminomatous
germ cell tumours

Seminoma: Key features: Commonest subtype (50%). Average age at diagnosis = 40. Even advanced disease associated with 5
year survival of 73% AFP usually normal. Tumour markers: HCG elevated in 10% seminomas. Lactate dehydrogenase;
elevated in 10-20% seminomas (but also in many other conditions). Pathology: Sheet like lobular patterns of cells with
substantial fibrous component. Fibrous septa contain lymphocytic inclusions and granulomas may be seen.

Non seminomatous germ cell tumours (42%): Teratoma, Yolk sac tumour, Choriocarcinoma and Mixed germ cell tumours
(10%): Key features Younger age at presentation =20-30 years. Advanced disease carries worse prognosis (48% at 5 years).
193
 Retroperitoneal lymph node dissection may be needed for residual disease after chemotherapy. Tumour markers: AFP
elevated in up to 70% of cases. HCG elevated in up to 40% of cases. Other markers rarely helpful. Pathology: Heterogenous
texture with occasional ectopic tissue such as hair

Risk factors for testicular cancer: Cryptorchidism. Infertility. Family history. Klinefelter's syndrome. Mumps orchitis.
Features: A painless lump is the most common presenting symptom. Pain may also be present in a minority of men. Other
possible features include hydrocele, gynaecomastia. Diagnosis: Ultrasound is first-line. CT scanning of the chest/ abdomen and
pelvis is used for staging. Tumour markers (see above) should be measured. Management: Orchidectomy (Inguinal approach).
Chemotherapy and radiotherapy may be given depending on staging. Abdominal lesions >1cm following chemotherapy may
require retroperitoneal lymph node dissection.. Prognosis is generally excellent: 5 year survival for seminomas is around 95% if
Stage I. 5 year survival for teratomas is around 85% if Stage I

Benign disease
Epididymo-orchitis: Acute epididymitis is an acute inflammation of the epididymis, often involving the testis and usually
caused by bacterial infection. Infection spreads from the urethra or bladder. In men <35 years, gonorrhoea or chlamydia are the
usual infections. Amiodarone is a recognised non infective cause of epididymitis, which resolves on stopping the drug..
Tenderness is usually confined to the epididymis, which may facilitate differentiating it from torsion where pain usually affects
the entire testis.
Testicular torsion: Twist of the spermatic cord resulting in testicular ischaemia and necrosis. Most common in males aged
between 10 and 30 (peak incidence 13-15 years). Pain is usually severe and of sudden onset.. Cremasteric reflex is lost and
elevation of the testis does not ease the pain. Treatment is with surgical exploration. If a torted testis is identified then both testis
should be fixed as the condition of bell clapper testis is often bilateral.
38. A baby is born by normal vaginal delivery at 39 weeks gestation. Initially all appears well and then the clinical staff
become concerned because the baby develops recurrent episodes of cyanosis. These are worse during feeding and
improve dramatically when the baby cries. The most likely underlying diagnosis is:
A. Choanal atresia
B. Oesophageal reflux
C. Tetralogy of Fallot
D. Oesophageal atresia
E. Congenital diaphragmatic hernia
Answer:
A
In Choanal atresia the episodes of cyanosis are usually worst during feeding. Improvement may be seen when the baby cries as the
oropharyngeal airway is used.

Choanal atresia: Congenital disorder with an incidence of 1 in 7000 births. Posterior nasal airway occluded by soft tissue or
bone. Associated with other congenital malformations e.g. coloboma. Babies with unilateral disease may go unnoticed. Babies
with bilateral disease will present early in life as they are obligate nasal breathers. Treatment is with fenestration procedures
designed to restore patency.

39. A 28 year old lady presents with a pigmented lesion on her calf. Excisional biopsy confirms a diagnosis of melanoma
measuring 1cm in diameter with a Breslow thickness of 0.5mm. The lesion is close <1 mm to all resection margins.
Which of the following surgical resection margins is acceptable for this lesion?
A. 5 cm
B. 1 cm
C. 0.5 cm
D. 2 cm
E. 3 cm

Answer: B
The main diagnostic features (major criteria): Change in size. Change in shape. Change in colour
Secondary features (minor criteria): Diameter >6mm. Inflammation. Oozing or bleeding. Altered sensation
Treatment: Suspicious lesions should undergo excision biopsy. The lesion should be removed in completely as incision biopsy
can make subsequent histopathological assessment difficult. Once the diagnosis is confirmed the pathology report should be
reviewed to determine whether further re-exicision of margins is required (see below):
Margins of excision-Related to Breslow thickness: Lesions 0-1mm thick:1cm. Lesions 1-2mm thick:1- 2cm (Depending upon
site and pathological features). Lesions 2-4mm thick:2-3 cm (Depending upon site and pathological features). Lesions >4 mm
thick:3cm
Further treatments such as sentinel lymph node mapping, isolated limb perfusion and block dissection of regional lymph node
groups should be selectively applied.

40. A 20 year old man is involved in a road traffic accident. Following the incident he is unable to extend his wrist. However,
this improves over the following weeks. Which type of injury is he most likely to have sustained?
A. Radial nerve neurotmesis

194
B. Radial nerve neuropraxia
C. Axillary nerve axonotmesis
D. Ulnar nerve neuropraxia
E. Ulnar nerve axonotmesis

Answer: B
Transient loss of function makes neuropraxia the most likely injury. The wrist extensors are innervated by the radial nerve
making this the most likely site of injury.
Neuropraxia: Nerve intact but electrical conduction is affected. Myelin sheath integrity is preserved. Full recovery. Autonomic
function preserved. Wallerian degeneration does not occur

41. A 53 year old lady has undergone a bilateral breast augmentation procedure many years previously. The implants are
tense and uncomfortable and are removed. During their removal the surgeon encounters a dense membrane
surrounding the implants, it has a coarse granular appearance. The tissue is sent for histology and it demonstrates
fibrosis with the presence of calcification. The underlying process responsible for these changes is:
A. Hyperplasia
B. Dysplasia
C. Metastatic calcification
D. Dystrophic calcification
E. Necrosis

Answer: D
Breast implants often become surrounded by a pseudocapsule and this may secondarily then be subjected to a process of
dystrophic calcification.

Pathological calcification: Dystrophic calcification:Deposition of calcium deposits in tissues that have undergone, degeneration,
damage or disease in the presence of normal serum calcium levels. Metastatic calcification:Deposition of calcium deposits in
tissues that are otherwise normal in the presence of increased serum calcium levels

42. A 4 year old girl presents with symptoms of right sided loin pain, lethargy and haematuria. On examination she is
pyrexial and has a large mass in the right upper quadrant. The most likely underlying diagnosis is:
A. Perinephric abscess
B. Nephroblastoma
C. Renal cortical adenoma
D. Grawitz tumour
E. Squamous cell carcinoma of the kidney

Answer: B
In a child of this age, with the symptoms described a nephroblastoma is the most likely diagnosis. A perinephric abscess is most
unlikely. If an abscess were to occur it would be confined to Gertotas fascia in the first instance, and hence anterior extension
would be unlikely.

Nephroblastoma (Wilms tumours): Usually present in first 4 years of life. May often present as a mass associated with
haematuria (pyrexia may occur in 50%). Often metastasise early (usually to lung). Treated by nephrectomy. Younger children
have better prognosis (<1 year of age =80% overall 5 year survival)

Theme: Thyroid neoplasms

A. Follicular carcinoma
B. Anaplastic carcinoma
C. Medullary carcinoma
D. Papillary carcinoma
E. Lymphoma
F. Hashimotos thyroiditis
G.Graves disease
For the following histological descriptions please select the most likely underlying thyroid neoplasm. Each option may be used
once, more than once or not at all.

44. A 22 year old female undergoes a thyroidectomy. The resected specimen shows a non encapsulated tumour with
papillary projections and pale empty nuclei.

195
 Answer: Papillary carcinoma
The presence of papillary structures together with the cytoplasmic features described is strongly suggestive of papillary
carcinoma. They are seldom encapsulated.

45. A thyroidectomy specimen from a 43 year old lady shows a mass with prominent oxyphil cells and scanty thyroid
colloid.
Answer Follicular carcinoma
Hurthle cell tumours are a variant of follicular neoplasms in which oxyphil cells predominate. They have a poorer prognosis than
conventional follicular neoplasms

46. A 32 year old lady undergoes a thyroidectomy for a mild goitre. The resected specimen shows an intense lymphocytic
infiltrate with acinar destruction and fibrosis.
Answer: Hashimotos thyroiditis
Lymphocytic infiltrates and fibrosis are typically seen in Hashimotos thyroiditis. In Lymphoma only dense lymphatic type tissue
is usually present.

Thyroid neoplasms
Lesion:Common features
Follicular adenoma: Usually present as a solitary thyroid nodule. Malignancy can only be excluded on formal histological
assessment
Papillary carcinoma: Usually contain a mixture of papillary and colloidal filled follicles. Histologically tumour has papillary
projections and pale empty nuclei. Seldom encapsulated. Lymph node metastasis predominate. Haematogenous metastasis rare.
Account for 60% of thyroid cancers
Follicular carcinoma:May appear macroscopically encapsulated, microscopically capsular invasion is seen. Without this
finding the lesion is a follicular adenoma.Vascular invasion predominates. Multifocal disease rare. Account for 20% of all
thyroid cancers
Anaplastic carcinoma: Most common in elderly females. Local invasion is a common feature. Account for 10% of thyroid
cancers. Treatment is by resection where possible, palliation may be achieved through isthmusectomy and radiotherapy.
Chemotherapy is ineffective.
Medullary carcinoma:Tumours of the parafollicular cells (C Cells). C cells derived from neural crest and not thyroid tissue.
Serum calcitonin levels often raised. Familial genetic disease accounts for up to 20% cases. Both lymphatic and haematogenous
metastasis are recognised, nodal disease is associated with a very poor prognosis.

47. A 43 year old lady with hypertension is suspected of having a phaeochromocytoma. Which of the following investigations
is most likely to be beneficial in this situation?
A. Dexamethasone suppression test
B. Urinary 5-Hydroxyindoleacetic Acid (5-HIAA)
C. Histamine provocation test
D. Tyramine provocation test
E. Urinary vanillymandelic acid measurements
Answer:
E
Urinary VMA measurements are not completely specific but constitute first line assessment. Stimulation tests of any sort are not
justified in first line assessments.

Phaeochromocytoma: Neuroendocrine tumour of the chromaffin cells of the adrenal medulla. Hypertension and hyperglycaemia
are often found: 10% of cases are bilateral. 10% occur in children. 11% are malignant (higher when tumour is located outside the
adrenal). 10% will not be hypertensive. Familial cases are usually linked to the Multiple endocrine neoplasia syndromes
(considered under its own heading). Most tumours are unilateral (often right sided) and smaller than 10cm. Diagnosis: Urine
analysis of vanillymandelic acid (VMA) is often used (false positives may occur e.g. in patients eating vanilla ice cream!). Blood
testing for plasma metanephrine levels. CT and MRI scanning are both used to localise the lesion.

Treatment: Patients require medical therapy first. An irreversible alpha adrenoreceptor blocker should be given, although
minority may prefer reversible bockade(1). Labetolol may be co-administered for cardiac chronotropic control. Isolated beta
blockade should not be considered as it will lead to unopposed alpha activity. These patients are often volume depleted and will
often require moderate volumes of intra venous normal saline perioperatively. Once medically optimised the phaeochromocytoma
should be removed. Most adrenalectomies can now be performed using a laparoscopic approach(2). The adrenals are highly
vascular structures and removal can be complicated by catastrophic haemorrhage in the hands of the inexperienced. This is
particularly true of right sided resections where the IVC is perilously close. Should the IVC be damaged a laparotomy will be
necessary and the defect enclosed within a Satinsky style vascular clamp and the defect closed with prolene sutures. Attempting to
interfere with the IVC using any instruments other than vascular clamps will result in vessel trauma and make a bad situation
much worse.
196
 Incidental adrenal lesions
Adrenal lesions may be identified on CT scanning performed for other reasons(3). Factors suggesting benign disease on CT
include(4): Size less than 3cm. Homogeneous texture. Lipid rich tissue. Thin wall to lesion

All patients with incidental lesions should be managed jointly with an endocrinologist and full work up as described above.
Patients with functioning lesions or those with adverse radiological features (Particularly size >3cm) should proceed to surgery.

48. A 46 year old lady presents with symptoms of diarrhoea, weight loss of 10 Kg and a skin rash of erythematous blisters
involving the abdomen and buttocks. The blisters have an irregular border and both intact and ruptured vesicles. What
is the most likely diagnosis?
A. Colonic adenocarcinoma
B. Pancreatic adenocarcinoma
C. Tropical sprue
D. Glucagonoma
E. Insulinoma

Answer: D
Glucagonoma Is strongly associated with necrolytic migratory erythema.

Glucagonoma: Rare pancreatic tumours arising from the alpha cells of the pancreas.Glucagon levels markedly elevated. Symptoms
include diarrhoea, weight loss and necrolytic migratory erythema. A serum level of glucagon >1000pg/ml usually suggests the
diagnosis, imaging with CT scanning is also required. Treatment is with surgical resection.

49. A 56 year old man presents with symptoms of neuropathic facial pain and some weakness of the muscles of facial
expression on the right side. On examination he has a hard mass approximately 6cm anterior to the right external
auditory meatus. What is the most likely diagnosis?
A. Pleomorphic adenoma
B. Adenocarcinoma
C. Mucoepidermoid carcinoma
D. Adenoid cystic carcinoma
E. Lymphoma

Answer: D The patient is most likely to have a malignant lesion within the parotid. Of the malignancies listed; adenoid cystic
carcinoma has the greatest tendency to perineural invasion.

Parotid gland malignancy: Most parotid neoplasms (80%) are benign lesions. Most commonly present with painless mass in
cheek region. Up to 30% may present with pain, when this is associated with a discrete mass lesion in the parotid it usually
indicates perineural invasion. Perineural invasion is very unlikely to occur in association with benign lesions. 80% of patients with
facial nerve weakness caused by parotid malignancies will have nodal metastasis and a 5 year survival of 25%
Types of malignancy
Mucoepidermoid carcinoma: 30% of all parotid malignancies. Usually low potential for local invasiveness and metastasis
(depends mainly on grade)
Adenoid cystic carcinoma:Unpredictable growth patter. Tendency for perineural spread. Nerve growth may display skip lesions
resulting in incomplete excision. Distant metastasis more common (visceral rather than nodal spread). 5 year survival 35%
Mixed tumours: Often a malignancy occurring in a previously benign parotid lesion
Acinic cell carcinoma:Intermediate grade malignancy. May show perineural invasion. Low potential for distant metastasis. 5 year
survival 80%
Adenocarcinoma:Develops from secretory portion of gland. Risk of regional nodal and distant metastasis. 5 year survival
depends upon stage at presentation, may be up to 75% with small lesions with no nodal involvement
Lymphoma:Large rubbery lesion, may occur in association with Warthins tumours. Diagnosis should be based on regional nodal
biopsy rather than parotid resection Treatment is with chemotherapy (and radiotherapy)

50. A 20 year old African lady undergoes an open appendicectomy. She is reviewed for an unrelated problem 8 months
later. On abdominal inspection the wound site is covered by shiny dark protuberant scar tissue that projects beyond the
limits of the skin incision. Which of the following is the most likely underlying process?
A. Hypertrophic scar
B. Keloid scar
C. Marjolins ulcer
D. Repeated episodes of wound sepsis

197
E. Mycosis fungoides

Answer: B
Keloid scars extend beyond the limits of the incision. Mycosis fungoides is a cutaneous T cell lymphoma.

Wound healing: Surgical wounds are either incisional or excisional and either clean, clean contaminated or dirty. Although the
stages of wound healing are broadly similar their contributions will vary according to the wound type.
The main stages of wound healing include:
Haemostasis: Vasospasm in adjacent vessels, platelet plug formation and generation of fibrin rich clot.
Inflammation: Neutrophils migrate into wound (function impaired in diabetes). Growth factors released, including basic
fibroblast growth factor and vascular endothelial growth factor. Fibroblasts replicate within the adjacent matrix and migrate into
wound. Macrophages and fibroblasts couple matrix regeneration and clot substitution.
Regeneration: Platelet derived growth factor and transformation growth factors stimulate fibroblasts and epithelial cells.
Fibroblasts produce a collagen network. Angiogenesis occurs and wound resembles granulation tissue.
Remodeling: Longest phase of the healing process and may last up to one year (or longer). During this phase fibroblasts become
differentiated (myofibroblasts) and these facilitate wound contraction.. Collagen fibres are remodeled. Microvessels regress
leaving a pale scar.
The above description represents an idealised scenario. A number of diseases may distort this process. It is obvious that one of the
key events is the establishing well vascularised tissue. At a local level angiogenesis occurs, but if arterial inflow and venous return
are compromised then healing may be impaired, or simply nor occur at all. The results of vascular compromise are all too
evidence in those with peripheral vascular disease or those poorly constructed bowel anastomoses.
Conditions such as jaundice will impair fibroblast synthetic function and overall immunity with a detrimental effect in most parts
of healing.
Problems with scars: Hypertrophic scars: Excessive amounts of collagen within a scar. Nodules may be present histologically
containing randomly arranged fibrils within and parallel fibres on the surface. The tissue itself is confined to the extent of the
wound itself and is usually the result of a full thickness dermal injury. They may go on to develop contractures. Keloid scars:
Excessive amounts of collagen within a scar. Typically a keloid scar will pass beyond the boundaries of the original injury. They
do not contain nodules and may occur following even trivial injury. They do not regress over time and may recur following
removal.
Drugs which impair wound healing: Non steroidal anti inflammatory drugs. Steroids. Immunosupressive agents. Anti neoplastic
drugs
Closure: Delayed primary closure is the anatomically precise closure that is delayed for a few days but before granulation tissue
becomes macroscopically evident. Secondary closure refers to either spontaneous closure or to surgical closure after granulation
tissue has formed.

51. The pathogenicity of the tubercle bacillus is due to which of the following?
A. Necrosis caused by expanding granulomas
B. Ability to multiply within fibroblasts
C. Delayed hypersensitivity reaction against bacteria
D. Effect of antibody response
E. Direct toxic effect on host cells

Answer: C
Mycobacteria stimulate a specific T cell response of cell mediated immunity. This is effective in reducing the infection, the
delayed hypersensitivity also damages tissues. Necrosis occurs in TB but is usually within the granuloma.

Tuberculosis pathology: Is a form of primary chronic inflammation, caused by the inability of macrophages to kill the
Mycobacterium tuberculosis. The macrophages often migrate to regional lymph nodes, the lung lesion plus affected lymph
nodes is referred to as a Ghon complex.This leads to the formation of a granuloma which is a collection of epithelioid
histiocytes. There is the presence of caseous necrosis in the centre. The inflammatory response is mediated by a type 4
hypersensitivity reaction. In healthy individuals the disease may be contained, in the immunocompromised disseminated
(miliary TB) may occur.

Diagnosis: Waxy membrane of mycobacteria prevents binding with normal stains. Ziehl - Neelsen staining is typically used.
Culture based methods take far longer.

52. A 45 year old women with a thyroid carcinoma undergoes a total thyroidectomy. The post operative histology report
shows a final diagnosis of medullary type thyroid cancer. Which of the tests below is most likely to be of clinical use in
screening for disease recurrence?
A. Serum CA 19-9 Levels
B. Serum thyroglobulin levels
C. Serum PTH levels
D. Serum calcitonin levels
E. Serum TSH levels
198
 Answer: D

Medullary thyroid cancers often secrete calcitonin and monitoring the serum levels of this hormone is useful in detecting sub
clinical recurrence.

53. A 15 year old boy undergoes an emergency splenectomy for trauma. He makes a full recovery and is discharged home.
Eight weeks post operatively the general practitioner performs a full blood count with a blood film. Which of the
following is most likely to be present?
A. Myofibroblasts
B. Howell-Jolly bodies
C. Multinucleate giant cells
D. Reed Sternberg Cells
E. None of the above

Answer: B
Post splenectomy blood film features: Howell- Jolly bodies. Pappenheimer bodies. Target cells. Irregular contracted
erythrocytes
As the filtration function is the spleen is no longer present Howell-Jolly bodies are found.

Post splenectomy blood film changes: The loss of splenic tissue results in the inability to readily remove immature or
abnormal red blood cells from the circulation. The red cell count does not alter significantly. However, cytoplasmic inclusions
may be seen e.g. Howell-Jolly bodies. In the first few days after splenectomy target cells, siderocytes and reticulocytes will
appear in the circulation. Immediately following splenectomy a granulocytosis (mainly composed of neutrophils) is seen, this is
replaced by a lymphocytosis and monocytosis over the following weeks.
The platelet count is usually increased and this may be persistent, oral antiplatelet agents may be needed in some patients.

54. A 43 year old women is identified as being a carrier of a BRCA 1 mutation. Apart from breast cancer, which of the
following malignancies is she at greatest risk of developing?
A. Colonic cancer
B. Ovarian cancer
C. Follicular carcinoma of the thyroid
D. Pituitary adenoma
E. Phaeochromocytoma

Answer: B
BRCA 1 mutation patients are 55% more likely to get ovarian cancer. Those with BRCA 2 are 25% more likely. The risk of
developing other malignancies is slightly increased but not to the same extent, and not enough to justify screening.

Genetics and surgical disease: Some of the more commonly occurring genetic conditions occurring in surgical patients are
presented here.
Li-Fraumeni Syndrome: Autosomal dominant. Consists of germline mutations to p53 tumour suppressor gene. High incidence
of malignancies particularly sarcomas and leukaemias. Diagnosed when: *Individual develops sarcoma under 45 years. *First
degree relative diagnosed with any cancer below age 45 years and another family member develops malignancy under 45 years or
sarcoma at any age
BRCA 1 and 2: Carried on chromosome 17. Linked to developing breast cancer (60%) risk. Associated risk of developing
ovarian cancer (55% with BRCA 1 and 25% with BRCA2).
Lynch Syndrome: Autosomal dominant . Develop colonic cancer and endometrial cancer at young age. 80% of affected
individuals with get colonic and or endometrial cancer. High risk individuals may be identified using the Amsterdam criteria
Amsterdam criteria: Three or more family members with a confirmed diagnosis of colorectal cancer, one of whom is a first
degree (parent, child, sibling) relative of the other two. Two successive affected generations. One or more colon cancers
diagnosed under age 50 years. Familial adenomatous polyposis (FAP) has been excluded.
Gardners syndrome: Autosomal dominant familial colorectal polyposis. Multiple colonic polyps. Extra colonic diseases include:
skull osteoma, thyroid cancer and epidermoid cysts. Desmoid tumours are seen in 15%. Mutation of APC gene located on
chromosome 5. Due to colonic polyps most patients will undergo colectomy to reduce risk of colorectal cancer. Now considered a
variant of familial adenomatous polyposis coli

55. A 53 year old man is due to undergo a splenectomy as a treatment for refractory haemolytic anaemia. The underlying
pathological basis for haemolytic anaemia is thought to be a Type 2 hypersensitivity response. Which of the following
mechanisms best describes this process
A. Deposition of immune complexes
B. Cell mediated immune response
C. IgE mediated response
199
D. Formation of autoantibodies against cell surface antigens
E. None of the above

Answer: D
Mnemonic for the reactions and the mediators involved
ACID EGG-T : Type 1 Anaphylactic. Type 2 Cytotoxic. Type 3 Immune complex. Type 4 Delayed type. EGG T (mediators): IgE.
IgG. IgG. T cells. Type 2 hypersensitivity reactions (which includes haemolytic anaemia) are associated with formation of
antibody against cell surface antigens.

56. A 25 year old man is injured in a road traffic accident. His right tibia is fractured and is managed by fasciotomies and
application of an external fixator. Over the next 48 hours his serum creatinine rises and urine is sent for microscopy,
muddy brown casts are identified. What is the most likely underlying diagnosis?
A. Acute interstitial nephritis
B. Acute tubular necrosis
C. Glomerulonephritis
D. IgA Nephropathy
E. Thin basement membrane disease

Answer: B
This patient is likely to have had compartment syndrome (tibial fracture + fasciotomies) which may produce myoglobinuria. The
presence of worsening renal function, together with muddy brown casts is strongly suggestive of acute tubular necrosis. Acute
interstitial nephritis usually arises from drug toxicity and does not usually produce urinary muddy brown casts. Thin basement
membrane disease is an autosomal dominant condition that causes persistent microscopic haematuria, but not worsening renal
function.

Acute Renal Failure: Final pathway is tubular cell death. Renal medulla is a relatively hypoxic environment making it susceptible
to renal tubular hypoxia. Renovascular autoregulation maintains renal blood flow across a range of arterial pressures. Estimates of
GFR are best indices of level of renal function. Useful clinical estimates can be obtained by considering serum creatinine, age, race,
gender and body size. eGFR calculations such as the Cockcroft and Gault equation are less reliable in populations with high GFR's.
Nephrotoxic stimuli such as aminoglycosides and radiological contrast media induce apoptosis. Myoglobinuria and haemolysis
result in necrosis. Overlap exists and proinflammatory cytokines play and important role in potentiating ongoing damage. Post-
operative renal failure is more likely to occur in patients who are elderly, have peripheral vascular disease, high BMI, have COPD,
receive vasopressors, are on nephrotoxic medication or undergo emergency surgery. Avoiding hypotension will reduce risk of renal
tubular damage. There is no evidence that administration of ACE inhibitors or dopamine reduces the incidence of post-operative
renal failure.

57. A 56 year old man has undergone a radical nephrectomy. The pathologist bisects the kidney and identifies a pink fleshy
tumour in the renal pelvis. What is the most likely disease?
A. Renal cell carcinoma
B. Transitional cell carcinoma
C. Angiomyolipoma
D. Phaeochromocytoma
E. Renal adenoma
Ansewr:
B
Most renal tumours are yellow or brown in colour. TCC's are one of the few tumours to appear pink.
The finding of a TCC in the renal pelvis mandates a nephroureterectomy.

Renal cell carcinoma: Most present with haematuria (50%). Common renal tumour (85% cases). Paraneoplastic features include
hypertension and polycythaemia. Most commonly has haematogenous mestastasis. Treatment:Usually radical or partial
ephrectomy

Nephroblastoma:Rare childhood tumour. It accounts for 80% of all genitourinary malignancies in those under the age of 15
years. Up to 90% will have a mass. 50% will be hypertensive Diagnostic work up includes ultrasound and CT scanning.
Treatment:Surgical resection combined with chemotherapy (usually vincristine, actinomycin D and doxorubicin

Neuroblastoma: Most common extracranial tumour of childhood. 80% occur in those under 4 years of age. Tumour of neural
crest origin (up to 50% occur in the adrenal gland). The tumour is usually calcified and may be diagnosed using MIBG scanning.
Staging is with CT:Surgical resection, radiotherapy and chemotherapy

200
 Transitional cell carcinoma: Accounts for 90% of upper urinary tract tumour, but only 10% of renal tumours. Males affected
3x more than females. Occupational exposure to industrial dyes and rubber chemicals may increase risk. Up to 80% present with
painless haematuria. Diagnosis and staging is with CT IVU. Treatment: Radical nephroureterectomy

Angiomyolipoma:80% of these hamartoma type lesions occur sporadically, the remainder are seen in those with tuberous
sclerosis. Tumour is composed of blood vessels, smooth muscle and fat. Massive bleeding may occur in 10% of cases.
Treatment: 50% of patients with lesions >4cm will have symptoms and will require surgical resection

58. A 65 year old lady presents with a lesion affecting her right breast. On examination she has a weeping, crusting lesion
overling the right nipple, the areolar region is not involved. There is no palpable mass lesion in the breast, there is a
palpable axillary lymph node. The patients general practitioner has tried treating the lesion with 1% hydrocortisone
cream, with no success. What is the most likely diagnosis?
A. Infection with Staphylococcus aureus
B. Pagets disease of the nipple
C. Phyllodes tumour
D. Nipple eczema
E. Basal cell carcinoma

Answer: B
A weeping, crusty lesion such as this is most likely to represent Pagets disease of the nipple (especially since the areolar region is
spared). Although no mass lesion is palpable, a proportion of patients will still have an underlying invasive malignancy (hence the
lymphadenopathy).

Pagets disease of the nipple: Pagets disease is an eczematoid change of the nipple associated with an underlying breast
malignancy and it is present in 1-2% of patients with breast cancer. In half of these patients, it is associated with an underlying
mass lesion and 90% of such patients will have an invasive carcinoma. 30% of patients without a mass lesion will still be found
to have an underlying carcinoma. The remainder will have carcinoma in situ.
Pagets disease differs from eczema of the nipple in that it involves the nipple primarily and only latterly spreads to the areolar
(the opposite occurs in eczema). Diagnosis is made by punch biopsy, mammography and ultrasound of the breast.
Treatment will depend on the underlying lesion.

59. A 73 year old man presents with haemoptysis and is suspected of suffering from lung cancer. On examination he has an
enlarged supraclavicular lymph node. Which of the following features is most likely to be present on histological
examination?
A. Increased mitoses
B. Apoptosis
C. Barr Bodies
D. Multinucleate giant cells
E. Granuloma

Answer: A
Increased mitoses are commonly seen in association with malignant transformation of cells. Apoptosis is not a common feature
of metastatic cancer. Barr Bodies are formed during X chromosome inactivation in female somatic cells.
Histopathology of malignancy: Abnormal tissue architecture. Coarse chromatin. Invasion of basement membrane*. Abnormal
mitoses. Angiogenesis. De-differentiation. Areas of necrosis. Nuclear pleomorphism

*= Those features that distinguish invasive malignancy from in situ disease

60. Which of the following pathological explanations best describes the initial pathological processes occurring in an
abdominal aortic aneurysm in an otherwise well 65 year old, hypertensive male?
A. Loss of elastic fibres from the adventitia
B. Loss of collagen from the adventitia
C. Loss of collagen from the media
D. Loss of elastic fibres from the media
E. Decreased matrix metalloproteinases in the adventitia
Answer:
D
In established aneurysmal disease there is dilation of all layers of the arterial wall and loss of both elastin and collagen. The
primary event is loss of elastic fibres with subsequent degradation of collagen fibres.

Pathology of abdominal aortic aneurysm: Abdominal aortic aneurysms occur primarily as a result of the failure of elastic
proteins within the extracellular matrix. Anuerysms typically represent dilation of all layers of the arterial wall. Most aneurysms
are caused by degenerative disease. After the age of 50 years the normal diameter of the infrarenal aorta is 1.5cm in females and
201
 1.7cm in males. Diameters of 3cm and greater, are considered aneurysmal. The pathophysiology involved in the development of
aneurysms is complex and the primary event is loss of the intima with loss of elastic fibres from the media. This process is
associated with, and potentiated by, increased proteolytic activity and lymphocytic infiltration.

Major risk factors for the development of aneurysms include smoking and hypertension. Rare but important causes include
syphilis and connective tissues diseases such as Ehlers Danlos type 1 and Marfans syndrome.

61. A 28 year old lady has a malignant melanoma removed from her calf. Which of the following pathological criteria
carries the greatest prognostic weighting?
A. Vascular invasion
B. Abnormal mitoses
C. Breslow thickness
D. Perineural invasion
E. Lymphocytic infiltrates

Answer: C
The Breslow thickness has considerable prognostic importance. Lymphocytic infiltrates may be associated with an improved
prognosis, but do not carry nearly the same weight as increased thickness.

62. A 34 year old lady undergoes an elective cholecystectomy for attacks of recurrent cholecystitis due to gallstones.
Microscopic assessment of the gallbladder is most likely to show which of the following?
A. Dysplasia of the fundus
B. Widespread necrosis
C. Ashoff-Rokitansky sinuses
D. Metaplasia of the fundus
E. None of the above

Answer: C
Aschoff-Rokitansky sinuses are the result of hyperplasia and herniation of epithelial cells through the fibromuscular layer of the
gallbladder wall. They may be macroscopic or microscopic. Ashoff-Rokitansky sinuses may be identified in cases of chronic
cholecystitis and gallstones. Although gallstones may predispose to the development of gallbladder cancer the actual incidence
of dysplasia and metaplastic change is rare. In the elective setting described above necrosis would be rare.

Gallbladder: Fibromuscular sac with capacity of 50ml. Columnar epithelium. Relations of the gallbladder: Anterior: Liver.
Posterior: Covered by peritoneum. Transverse colon. 1st part of the duodenum. Laterally: Right lobe of liver. Medially:
Quadrate lobe of liver. Arterial supply: Cystic artery (branch of Right hepatic artery). Venous drainage: Cystic vein. Nerve
supply: Sympathetic- mid thoracic spinal cord, Parasympathetic- anterior vagal trunk
Common bile duct: Origin: Confluence of cystic and common hepatic ducts. Relations at origin: Medially - Hepatic artery.
Posteriorly- Portal vein. Relations distally:Duodenum – anteriorly. Pancreas - medially and laterally Right renal vein –
posteriorly. Arterial supply: Branches of hepatic artery and retroduodenal branches of gastroduodenal artery.

Calot's triangle: Medially: Common hepatic duct. Inferiorly:Cystic duct. Superiorly:Inferior edge of liver. Contents:Cystic
artery

63. Which of the following are not true of Li-Fraumeni syndrome?

A. It consists of mutations to the p53 tumour suppressor gene
B. Is likely to be present in a teenager presenting with a liposarcoma
C. It has an autosomal dominant inheritance pattern
D. Affected individuals are unlikely to develop acute myeloid leukaemia
E. Adrenal malignancies are more common than in normal population

Answer: D

They are at high risk of developing leukaemia.

64. A 35 year old type 1 diabetic presents with difficulty mobilising and back pain radiating to the thigh. He has a
temperature of 39 oC and has pain on extension of the hip. He is diagnosed with an iliopsoas abscess. Which of the
following statements is false in relation to his diagnosis?
A. Staphylococcus aureus is the most likely primary cause
B. Recurrence occurs in 60% cases
C. More common in males
D. Crohn's is the most likely secondary cause

202
E. CT guided drainage is preferable first line management
Answer:
B
Classical features include: a limp, back pain and fever. Recurrence rates are about 15-20%. Staphylococcus is the commonest
primary cause, others include Streptococcus and E.coli. Management is ideally by CT guided drainage.

Iliopsoas abscess: Collection of pus in iliopsoas compartment (iliopsoas and iliacus): Causes: Primary: Haematogenous spread
of bacteria. Staphylococcus aureus: most common. Secondary: Crohn's (commonest cause in this category). Diverticulitis,
Colorectal cancer. UTI, GU cancers. Vertebral osteomyelitis. Femoral catheter, lithotripsy. Endocarditis. Note the mortality rate
can be up to 19-20% in secondary iliopsoas abscesses compared with 2.4% in primary abscesses. Clinical features: Fever.
Back/flank pain. Limp. Weight loss

Clinical examination: Patient in the supine position with the knee flexed and the hip mildly externally rotated. Specific tests to
diagnose iliopsoas inflammation: Place hand proximal to the patient's ipsilateral knee and ask patient to lift thigh against your
hand. This will cause pain due to contraction of the psoas muscle. Lie the patient on the normal side and hyperextend the
affected hip. In inflammation this should elicit pain as the psoas muscle is stretched.

Investigation: CT is gold standard

Management: Antibiotics. Percutaneous drainage. Surgery is indicated if: 1. Failure of percutaneous drainage. 2. Presence of an
another intra-abdominal pathology which requires surgery

Surgical approach: The authors technique for draining these collections is given here. Review the CT scans and plan surgical
approach. An extraperitoneal approach is important. The collection usually extends inferiorly and can be accessed from an
incision at a level of L4 on the affected side. GA. Transverse laterally placed incision. Incise external oblique. Split the
subsequent muscle layers.
As you approach the peritoneum use blunt dissection to pass laterally around it. Remember the ureter and gonadal veins lie
posterior at this level. Eventually you will enter the abscess cavity, a large amount of pus is usually released at this point. Drain
the area with suction and washout with saline. Place a corrugated drain well into the abscess cavity. If you have made a small
skin incision it is reasonable to bring the drain up through the skin wound. Otherwise place a lateral exit site and close the skin
and external oblique. If you do this ensure that you use interrupted sutures. Anchor the drain with strong securely tied silk
sutures (it is extremely tiresome if it falls out!)

65. Which of the following statements relating to parathyroid neoplasms is incorrect?

A. 15% of cases are due to parathyroid carcinoma
B. 80% of cases are due to parathyroid adenomas
C. Parathyroid adenomas are often encapsulated
D. 10% of parathyroid adenomas develop in ectopically located glands
E. 85% of cases of primary hyperparathyroidism are due to solitary adenomas
Answer:
A
Parathyroid carcinomas account for up to 5% of tumours. Adenomas are often encapsulated .Lesions that are fibrotic and
densely adherent to the gland may be a carcinoma. 85% cases of primary hyperparathyroidism are due to a single adenoma and
this is the reason some surgeons favour a focussed parathyroidectomy.

Parathyroid glands and disorders of calcium metabolism

Primary hyperparathyroidism: PTH (Elevated). Ca2+ (Elevated). Phosphate (Low). Serum Calcium: Creatinine clearance
ratio > 0.01. Clinical features: May be asymptomatic if mild. Recurrent abdominal pain (pancreatitis, renal colic). Changes to
emotional or cognitive state. Causes: Most cases due to solitary adenoma (80%), multifocal disease occurs in 10-15% and
parathyroid carcinoma in 1% or less. Management: Indications for surgery: Elevated serum Calcium > 1mg/dL above normal.
Hypercalciuria > 400mg/day. Creatinine clearance < 30% compared with normal. Episode of life threatening hypercalcaemia.
Nephrolithiasis. Age < 50 years. Neuromuscular symptoms. Reduction in bone mineral density of the femoral neck, lumbar
spine, or distal radius of more than 2.5 standard deviations below peak bone mass (T score lower than -2.5)

Secondary hyperparathyroidism: PTH (Elevated). Ca2+ (Low or normal). Phosphate (Elevated). Vitamin D levels (Low).
Clinical features: May have few symptoms. Eventually may develop bone disease, osteitis fibrosa cystica and soft tissue
calcifications. Causes: Parathyroid gland hyperplasia occurs as a result of low calcium, almost always in a setting of chronic
renal failure. Management: Usually managed with medical therapy. Indications for surgery in secondary (renal)
hyperparathyroidism: Bone pain. Persistent pruritus. Soft tissue calcifications

203
 Tertiary hyperparathyroidism: Ca2+ (Normal or high). PTH (Elevated). Phosphate levels (Decreased or Normal). Vitamin D
(Normal or decreased). Alkaline phosphatase (Elevated). Clinical features: Metastatic calcification. Bone pain and / or fracture.
Nephrolithiasis. Pancreatitis. Causes: Occurs as a result of ongoing hyperplasia of the parathyroid glands after correction of
underlying renal disorder, hyperplasia of all 4 glands is usually the cause. Management: Usually treatment is surgical. The
presence of an autonomously functioning parathyroid gland may require surgery. If the culprit gland can be identified then it
should be excised. Otherwise total parathyroidectomy and re-implantation of part of the gland may be required.

Differential diagnoses
It is important to consider the rare but relatively benign condition of benign familial hypocalciuric hypercalcaemia, caused by an
autosomal dominant genetic disorder. Diagnosis is usually made by genetic testing and concordant biochemistry (Serum
Calcium: Creatinine clearance ratio <0.01-distinguished from primary hyperparathyroidism).

66. A 20 year old girl presents with a thyroid cancer, she is otherwise well with no significant family history. On
examination she has a nodule in the left lobe of the thyroid with a small discrete mass separate from the gland itself.
Which of the following is the most likely cause?
A. Follicular carcinoma
B. Anaplastic carcinoma
C. Medullary carcinoma
D. Papillary carcinoma
E. B Cell Lymphoma

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

67. A 28 year old lady is breast feeding her first child. She presents with discomfort of the right breast. Clinical examination
demonstrates erythema and an area that is fluctuant. Aspiration and culture of the fluid is most likely to demonstrate
infection with which of the following organisms?
A. Clostridium perfringens
B. Staphylococcus aureus
C. Streptococcus pyogenes
D. Staphylococcus epidermidis
E. Actinomycosis

Answer: B
Staphylococcus aureus is the commonest cause. The infants mouth is usually the source as it damages the nipple areolar
complex allowing entry of bacteria.

Breast abscess: In lactational women Staphylococcus aureus is the most common cause. Typical presentation is with a tender
mass in a lactating women. There is often tenderness and pain and a fluctuant mass. Diagnosis and treatment is performed using
USS and associated drainage of the abscess cavity. Antibiotics should also be administered. Where there is necrotic skin
overlying the abscess, the patient should undergo surgery

68. An 18 year old rock climber falls onto his left arm and sustains a large haematoma of the left upper arm. Unfortunately
the wound associated with the injury is neglected and it becomes infected. Which of the following changes is least likely
to occur?
A. Axillary lymphadenopathy
B. Leucopenia
C. Tenderness
D. Mild pyrexia
E. Local formation of yellow pus

Answer: B
Leucopenia would be unusual and should prompt a search for another cause.

Theme: Tumour markers

A. Invasive ductal carcinoma of the breast

B. Prostate cancer
C. Gastric cancer
D. Ovarian cancer
E. Colorectal cancer
204
 F. Pancreatic adenocarcinoma
G.Seminoma testicular cancer
H.Non-seminomatous testicular cancer
I. Hepatocellular carcinoma

For each tumour marker please select the most likely underlying malignancy. Each option may be used once, more than once or
not at all.

69. Raised beta-human chorionic gonadotropin with a raised alpha-feto protein level
Answer: Non-seminomatous testicular cancer
A raised alpha-feto protein level excludes a seminoma

70. Elevated CA 19-9

Answer: Pancreatic adenocarcinoma

71. Raised alpha-feto protein level in a 54-year-old woman

Answer: Hepatocellular carcinoma

Tumour markers may be divided into: monoclonal antibodies against carbohydrate or glycoprotein tumour antigens. Tumour
antigens. enzymes (alkaline phosphatase, neurone specific enolase). Hormones (e.g. calcitonin, ADH)
It should be noted that tumour markers usually have a low specificity
Monoclonal antibodies: CA 125: Ovarian cancer. CA 19-9: Pancreatic cancer. CA 15-3: Breast cancer. NB: The breast cancer
tumour marker is not specific or sensitive enough to be used routinely.
Tumour antigens: Prostate specific antigen (PSA): Prostatic carcinoma. Alpha-feto protein (AFP): Hepatocellular carcinoma,
teratoma. Carcinoembryonic antigen (CEA):Colorectal cancer

Theme: Benign breast lesions

A. Fibroadenoma
B. Breast abscess
C. Cyst of Montgomery's gland
D. Galactocele
E. Lipoma
F. Duct ectasia
G.Intraductal papilloma
H.Fat necrosis

What is the most likely diagnosis for the scenario given? Each option may be used once, more than once or not at all.

72. A 64 year old obese female presents with a breast lump. She was hit on the breast by a cricket ball when playing with her
grandson.
Answer: Fat necrosis
An obese, post menopausal woman, with a history of trauma points towards fat necrosis. Trauma causes inflammation of fat
cells, leading to formation of a lump. Mammography will be needed to differentiate it from breast disease.

73. A 21 year old female notices a bloody discharge from the nipple. She is otherwise well. On examination there are no
discrete lesions to feel and mammography shows dense breast tissue but no mass lesion.
Answer: Intraductal papilloma
Intraductal papillomata are the commonest cause of blood stained nipple discharge in younger women. There is seldom any
palpable mass. An ultrasound is required and possibly a galactogram.

74. A 18 year old female notices a non tender mobile breast lump. Clinically there is a smooth lump which is not tethered to
the skin.
Answer: Fibroadenoma
Also called a breast 'mouse' due to its mobility. It is a benign condition arising from the breast lobule. May enlarge in
pregnancy.

Benign Breast lesions

Fibroadenoma: Develop from a whole lobule. Mobile, firm breast lumps. 12% of all breast masses. Over a 2 year period up to
30% will get smaller. No increase in risk of malignancy. Treatment: If >3cm surgical excision is usual, Phyllodes tumours
should be widely excised (mastectomy if the lesion is large)

205
 Breast cyst: 7% of all Western females will present with a breast cyst. Usually presents as a smooth discrete lump (may be
fluctuant). Small increased risk of breast cancer (especially if younger). Treatment: Cysts should be aspirated, those which are
blood stained or persistantly refill should be biopsied or excised
Sclerosing adenosis, (radial scars and complex sclerosing lesions):Usually presents as a breast lump or breast pain. Causes
mammographic changes which may mimic carcinoma. Cause distortion of the distal lobular unit, without hyperplasia (complex
lesions will show hyperplasia). Considered a disorder of involution, no increase in malignancy risk. Treatment: Lesions should
be biopsied, excision is not mandatory
Epithelial hyperplasia:Variable clinical presentation ranging from generalised lumpiness through to discrete lump. Disorder
consists of increased cellularity of terminal lobular unit, atypical features may be present. Atypical features and family history
of breast cancer confers greatly increased risk of malignancy. Treatment :If no atypical features then conservative, those with
atypical features require either close monitoring or surgical resection
Fat necrosis: Up to 40% cases usually have a traumatic aetiology. Physical features usually mimic carcinoma. Mass may
increase in size initially. Treatment: Imaging and core biopsy
Duct papilloma: Usually present with nipple discharge. Large papillomas may present with a mass. The discharge usually
originates from a single duct. Treatment: No increase risk of malignancy: Microdochectomy

75. A 17 year old man is identified as having a Meckels diverticulum. From which of the following embryological structures
is it derived?
A. Foregut
B. Hindgut
C. Uranchus
D. Cloaca
E. Vitello-intestinal duct

Answer: E
Rule of 2's: 2% of population. 2 inches (5cm) long. 2 feet (60 cm) from the ileocaecal valve. 2 x's more common in men. 2
tissue types involved

The Meckels diverticulum is a persistence of the vitello-intestinal duct. Meckel's diverticulum: Congenital abnormality
resulting in incomplete obliteration of the vitello-intestinal duct. Normally, in the foetus, there is an attachment between the
vitello-intestinal duct and the yolk sac.This disappears at 6 weeks gestation. The tip is free in majority of cases. Associated with
enterocystomas, umbilical sinuses, and omphaloileal fistulas. Arterial supply: omphalomesenteric artery. 2% of population, 2
inches long, 2 feet from the ileocaecal valve. Typically lined by ileal mucosa but ectopic gastric mucosa can occur, with the risk
of peptic