Intussusceptionisaconditionwhichismorecommoninboys.

Itmainlyaffectsthosebetween324
months,althoughitcanoccurinolderchildrenwithriskfactorssuchasHenochSchnleinpurpura
(HSP),tumoursetc.
Symptomsincludeabdominalpainwhichissuddenandcolickyinnature.Vomitingisalsoapresenting
complaintaswellascirculatorycollapseandshock.Thepassageofbloodperrectumisalateand
seriousfeature.
Physicalexaminationmayrevealasausageshapedmassintherightupperquadrant.Clinicalsuspicion
isusuallyconfirmedbyultrasonography.
Reductionisusuallyachievedbyhydrostaticenema,andifunsuccessfulsurgicalinterventionmustbe
performed.
Morphinedoesnotcausesdirectmyocardialdepression,althoughitmaycauseabradycardia.
Thehypotensionassociatedwithitsuseisduetothedecreaseinthesystemicvascularresistance
(SVR)whichisdue,inpart,tohistaminerelease.Thehistaminereleasemayalsocausebronchospasm.
Theproductionofantidiuretichormone(ADH)isalsoincreasedbymorphine.
Diamorphinehasalmostnoaffinityfortheopioidreceptor,andisaprodrugofmorphine.
Phenylpiperidinesincludepethidineandfentanyl,whereasmorphineisaphenanthrene.
KnowledgeoftheECGwithregardtothecoronaryanatomyprovidesabetterunderstandingofthe
severityofischaemiaaswellasaguidetoappropriatetreatment.
STelevationinleadsII,IIIandaVFsuggestsinferiormyocardialinfarction(MI)andisusuallydueto
occlusionoftherightcoronaryartery.
V14elevationindicatesananteriorMIandisusuallyaconsequenceofleftanteriordecendingartery
occlusion.
Aposteriorinfarct(STelevationinV 68withreciprocalchangesanteriorlySTdepressioninV 13)is
duetoocclusionofthecircumflexartery.
Infectivecausesplusinflammatoryboweldiseaseshouldbeconsideredinthedifferentialdiagnosisof
ayoungmanwithbloodydiarrhoea.Shigellosisisapossiblecause.MostcasesofShigellainfection
are related to foreign travel. Unrelated to foreign travel, there has been an increase in sexually
transmittedShigellainfectioninmenwhohavesexwithmen.
Amoebic trophozoites (the active form) may be seen in fresh stool in acute dysentery. However,
amoebiccystsseenonmicroscopyforE.Histolyticahaveasensitivityof<60%andaspecificityof10
50%inthediagnosisofpossibleamoebicdysentery.Therearemanynonpathologicalamoebae(e.g.
E.dispar)andmanyasymptomaticpatientshave Entamoebahistolytica intheirstool.Stoolantigen
(ELISA)forEntamoebahistolyticahassensitivityandspecificityof>95%.
Waterydiarrhoeawouldbeexpectedwithcholeraandgiardiasis.
Alteplase(tissuetypeplasminogenactivator)isathrombolyticandactsbyactivatingplasminogento
formplasmin,whichdegradesfibrinandsobreaksupthrombi.Itisusedinthetreatmentofmyocardial
infarctionandlifethreateningvenousthrombosis.
Aprotininisanenzymeinhibitoractingonplasminandkallikreinandisclassedasanantifibrinolytic,
thusinhibitingfibrinolysis.Itisindicatedinpatientsathighriskofbloodloss.

WarfarinisanoralanticoagulantanditinhibitsthesynthesisofvitaminKdependantfactorsII,VII,IX
andX.Hepaticenzymeinducingagents,forexample,carbamazepineandphenobarbitonereduceits
effect.Enzymeinhibitors,suchasvalproate,enhancetheeffectofwarfarin.Iftheenzymeinducing
drugiswithdrawnwithoutreducingthedoseofwarfarin,haemorrhagemayoccur.
Factor VIIa(recombinant) isapurified coagulation factor usedtotreat patientswithinhibitors to
factors VIII and IX. It has been used successfully in patients with serious trauma in whom
haemorrhagehasbeendifficulttocontrolsurgically.Thusitcanbeclassedasaprocoagulant.
Heparin is an anticoagulant and its effects are monitored by measuring the activated partial
thromboplastintime(APTT),althoughthrombinandclottingtimesarealsoprolonged.Itaccelerates
theactionofantithrombinIII,whichinhibitsactivatedfactorsXII,XI,X,IXandthrombin.
Exercisetherapy.Thismanneedstoaddresshisriskfactorsandstopsmokingforimprovementinhis
cardiovascular profile, but his walking is a quality of life problem since he covered 180 metres.
Althoughonecouldperformanangioplastyorsurgeryitisnotcurrentlyindicated;heshouldgaingood
symptomatic improvement from an exercise programme and in addition to improving his general
healththishasnoiatrogenicrisksassociatedwithit.bypass
Poplitealpedalbypass.Thismanhastissuelosswithsevereinfrageniculardisease.A"suckitandsee"
amputationofhishalluxmaywork,buthastherealriskofacceleratingthetissuedestructioninhis
footandultimatelyleadingtolimbloss.Apoplitealpedalbypasswilltakebloodfromanareaofgood
flowtothepointwhereitisrequiredandalthoughatechnicallydifficultoperationgivesthismanthe
bestchanceoflimbsalvage.
Intussusceptionoccurswhenasegmentofbowelinvaginatesintoitsadjoininglowersegment.
Itismorecommoninboys.About60%areunder1yearoldand80%90%under2yearsold.Itisrare
aftertheageof6.
Intussusceptionisassociatedwith:

Haemophilia

HenochSchnleinpurpura

Haemangiomas,and

GIlymphomas.

Clinicalfeaturesincludeseverecolickyabdominalpainandvomiting.Betweenattackstheinfantmay
appearingoodhealth.
Theinfant maypass'redcurrant jelly'stoolsandasausageshapedmassispalpableonabdominal
examination.
Rectal examination may reveal blood in the majority of cases and occasionally the apex of the
intussusceptionispalpable.
InadditiontotheABOandrhesussystems,anothereightbloodgroupsystemshavebeenidentified.
TheKell,DuffyandKiddsystemscancausebothhaemolytictransfusionreactionsandthehaemolytic
diseaseofthenewborn.

ThePandMNsystemscanalsocausebothofthesereactions,buttheyarerareevents.
TheLutheran,Lewis,SciannaandLisystemsareclinicallyoflessimportancebecausetheydonot
cause the haemolytic disease of the newborn, and are unlikely to (or rarely) cause haemolytic
transfusionreactions.
ThereareanumberofcriteriausedintheRanson'sscoringsystemwhichreflectprognosisassociated
withacutepancreatitis.
Ranson'scriteriaonadmissionthatsignifyaworseprognosisinclude:
Criteriapresentat0hours:

Age>55yearsold1point

WBC>161091point

Glucose>11.1mmol/L1point

LDH>350U/L1point

AST>250U/L1point

Criteriapresentat48hours:

Hematocritfallof10%orgreater1point

Ureariseof1.8mmol/Lormoredespitefluids1point

SerumCalcium<2mmol/L1point

pO2<60mmHg1point

Basedeficit>4meq/L1point

Fluidsequestration>6000mL1point

Theinternaljugularveinoriginatesatthejugularforamen.
Itinitiallyliesposteriortothecarotidartery,asitdescendsinthecarotidsheathitlieslateralfirsttothe
internalthenthecommoncarotidarterywithinthecarotidsheath.
Itpassesanteriortothesubclavianarterytojointhesubclavianveinandthenformthebrachiocephalic
vein;theleftandrightbrachiocephalicveinsunitetoformthesuperiorvenacava.
Theinternaljugularveinreceivesalymphatictrunkatitsunionwiththesubclavianvein.
Theexternaljugularveindrainsintothesubclavianvein.

Tensionpneumothoraxisalifethreateningsurgicalemergency,sincefailuretorelievethetensionmay
resultinacardiorespiratoryarrest.Itusuallyoccursfollowingpenetratingorbluntinjuriestothe
chest,andfrequentlyfollowingmajortraumas.
Intensionpneumothorax,theairisdrawnintothepleuralspacewitheachinspiration,buthasnoroute
toescape;thusactingasaonewayvalve.
Patientspresentwith:

Respiratorydistress

Tachycardia

Hypotension

Distendedneckveins

Decreasedairentryintheaffectedlung,and

Deviationoftracheaandmediastinumtotheoppositeside.

However,notallthesesignsandsymptomsarealwayspresent.
The classical history of Boerhaave's syndrome is of severe vomiting and retching followed by
extremelysevereretrosternalandupperabdominalpain.Shockdevelopsrapidly.
Thereisahistoryofalcoholismorheavydrinkingin40%ofpatients.Thesiteofruptureisusuallyin
theleftposterolateral distaloesophagusandisseveral centimetreslong.Subcutaneousemphysema
(crepitus)isonlypresentin27%ofpatientsandisarelativelylatesign.
An initial chest x ray will show mediastinal or free peritoneal gas. After hours or days, pleural
effusion(s), often with a pneumothorax, and a widened mediastinum develops. The diagnosis is
confirmedwithaCTscanfollowedbyagastrografinswallowtoassesstheextentoftheoesophageal
leak.
Themaintreatmentissurgery,whichshouldbewithin24hours.Mortalityis2050%andisincreased
with delay in treatment. The oesophagus is repaired or resected and the mediastinum drained.
Occasionallycontainedleaksmaybemanagedconservatively.Endoscopiccoveredstentshavebeen
used.Surgeryistheonlyeffectiveoptionwhenthereisextensivemediastinalcontaminationordelayin
diagnosis.
MalloryWeiss syndrome is the cause of bleeding in 5% of patients with upper gastrointestinal
haemorrhage.Longitudinalmucosallacerationsinthedistaloesophagusandproximalstomachcause
bleedingfromsubmucosalarteries.Mosttearsaresingle.Theconditionwasoriginallydescribedin
1929,relatedtovomitinginalcoholicpatients.
Otherassociationsinclude:

Coughing

Epilepticconvulsions

Closedchestmassage

Bluntabdominalinjury,and

Hiccupsunderanaesthesia.

Hiatusherniaappearstobeapredisposingfactor(40100%).Somepatientshaveepigastricorback
pain.Thebloodlossisusuallysmallandselflimiting.
Transfusionsmaybe needed andendoscopichaemostatictreatment maybe required.Rarely,with
protractedvomiting,perforationmayoccur.
Inthisprocedureallthediseasedtissueisremovedbutthepatientavoidsapermanentstoma.The
patienthastobewellmotivatedtodealwiththepossiblecomplications(anastomoticleak,adhesional
obstruction,poorfunction,pouchitis).
Aloopileostomyisconstructednearthepouchintherightiliacfossatoallowtheanastomosistoheal.
Theloopileostomyisclosedateightto10weeks.
Carcinomaisthecommonestoflargebowelobstructions.Theoperationofchoiceforanobstructing
sigmoid tumour is a Hartmann's procedure. The tumour is removed (sigmoid colectomy) and a
colostomyformed.(Sometimestheremaybeenoughdistalsigmoidtobringoutasamucousfistula
ratherthandoaHartmann'sprocedure.Thiswouldbeeasiertoclosesubsequently.)
Primaryanastomosisshouldusuallybeavoided,asthereisahigherriskofanastomoticleakinpatients
presentingwithobstruction.
Iftheproximalcolonisgrosslydilatedandischaemicthenasubtotalcolectomyandileostomyshould
beperformed.
Theoperationofchoiceisarighthemicolectomy,thusremovingthetumour.Ifthereisnoevidenceof
perforationthenaprimaryanastomosiswouldbeperformed.However,thereisamuchhigherriskof
anastomoticbreakdowninacontaminatedfield.Thereforeanendileostomyisformed.Amucusfistula
isalsorequired,toallowmucustodrainfromtheremainingcolon.
Dysphagiaisdefinedasdifficultyinswallowing,incontrasttoodynophagiawhichreferstopainful
deglutition.
Dysphagiacouldbeduetointraluminal,mural(includingmusculardisorders),extrinsicorfunctional
causes.Thesymptommaybedescribedbysomeasstickingsensation.
Thesiteisusuallywelllocalised,especiallyintheuppertwothirdsoftheoesophagus,duetoits
innervationpattern(somaticasopposedtovisceral).
RetrosternalburningismostcharacteristicofGORD.Itmaybeaggravatedbyfoodanddrinks.The
factthatthisisassociatedwithstickinessoffoodinthiselderlywoman,probablysuggeststhatshehas
astrictureprobablybenignassheisotherwisewell.
The70yearoldmanclearlyhasamalignantstrictureorcarcinomaoftheoesophagus.Difficultyin
initiation of swallowing is usually a pharyngeal problem; in view of his age and of the choices
provided,heismostlikelytosufferfromcarcinomaofthepharynx.
Globushystericus(syndrome)mainlyaffectspeoplebetween30to60.Thepredominantsymptomisa
feelingoflumpandisnotatruedysphagia.Itismostpronouncedfordryswallow(swallowingown
saliva)thanwheneatingordrinking.

Elderlypatientswithperrectalbleeding,changeinbowelhabits,andweightlossshouldbeconsidered
tohavecoloniccancerunlessprovenotherwise.Increaseinageisariskfactorfordevelopingcolonic
cancer.
Theotherriskfactorsinclude:

afamilyhistoryofcoloncancer

familialadenomatouspolyposis

dietrichinredmeat,and

longstandingulcerativecolitisorCrohn'sdisease.

Theclinicalpresentationofpatientswithcolonicmalignancydependsonthesiteofthetumour.
Rightsidedcoloniccarcinomacommonlypresentswith:

anaemia

tiredness

malaise

pallor,and

lossofweight.

Theleftsidedcoloniccarcinomapresentswith:

changeinthebowelhabits

bleedingperrectum,and

intestinalobstruction.

Rectalcarcinoma,inadditiontothefeaturesseeninleftsidedcoloniccarcinoma,isassociatedwitha
sense of incomplete evacuation of the bowel (tenesmus). Tumours of the caecum affecting the
ileocaecalvalvecanalsopresentwithsymptomsoflowersmallbowelobstruction.
Investigationsforsuspectedcolonicmalignancyinclude:

fullbloodcellcount

renalfunctionandelectrolytes

liverfunctiontests(toruleouthepaticinvolvement)

plainxrayoftheabdomen,and

ultrasoundandCTscans.

Carcinoembryonic antigen (CEA) is the commonly used tumour marker to diagnose colonic
malignancyandsubsequentlytoassesstheprogress,includingrecurrence.
Surgeryremainsthemainstayofmanagementofcolonictumoursthoughacolonicstentmaybeplaced
inleftsidedobstructionasabridgetosurgery.Radiotherapyandchemotherapyhavetheirrolesin
selectedpatients.Atemporaryorapermanentcolostomyisfrequentlyrequiredfollowingthesurgical
treatmentofleftsidedcolonictumours.
ThechangesinhyperkalaemiabeginwithpeakedTwaves,particularlyintheprecordialleads.Thena
widenedQRScomplex(>120msec)whenthepotassiumis>6.5.Theremayalsobedecreasedpwave
amplitudeandanincreasedPRinterval.Withapotassium>7.0theremaybeabradycardiaandAV
block.Eventuallypwavesarelostandasinewavemaydevelop.Thisisoftenafatalarrhythmia.
WPWisassociatedwithanaccessorybundle,whichcausesadeltawave(notch)precedingtheQRS
complex,givingtheimpressionofashorterPRinterval.However,thedeltawaveischaracteristic.
OthercausesofprolongedQTinclude:

CongenitalprolongedQT(LownGanongLevinesyndrome)

Hypocalcaemia

Drugtherapy(Amiodarone,Sotalol)

Pericarditis is associated with concave upward ST segment elevation on the ECG, versus convex
upwardSTsegmentelevationinMI.
Regardingcannulationforcardiopulmonarybypass,pleasechoosethemostappropriateanswerfrom
thelist.
In which structure is the venous cannula placed when a patient is undergoing a tricuspid valve
replacement?
IncorrectThecorrectanswerisVenacava
Whentherightsideofthehearthastobeopened,separatecannulaeareinsertedintothesuperiorand
inferior venae cava. Pursestring sutures are snared around the incisions to produce a blood and
airtightseal.
Inwhichstructureisthearterialcannulafromthecardiopulmonarybypasscircuitplaced?
IncorrectThecorrectanswerisAscendingaorta
Theblooddrainedfromtheheartispassedthroughtheoxygenatorinwhichitisseparatedfromagas
mixturebyasystemofmembranes.Thebloodisthenreturnedtothepatientunderpressurethrougha
rollerpumpviaanarterialfilterandairbubbledetector.Thearterialcannulaisusuallypositionedin
theascendingaorta.
In which structure is the venous cannula placed when a patient is undergoing a mitral valve
replacement?
IncorrectThecorrectanswerisRightatrium

Cardiopulmonarybypassallowswholebodyperfusioninwhichthepumpingactionoftheheartand
oxygenationofbloodbythelungsarereplacedbyanextracorporealcircuit.Thereturningvenous
bloodisdivertedfromtheheartusingalargeborecannulainsertedintherightatrialappendage.
Malignantmelanomamaybesubungual,buccal,anal,andpresentonanymucosalsurface,notmerely
inthedermis/epidermis.
Theincidenceofmalignantmelanomaoftheskinhasbeenrisingrapidlyinthewhitepopulations
aroundtheworldforseveraldecades. Incidencerates inGreatBritainincreasedfromaround2per
100,000populationformalesand3per100,000populationforfemalesin1971to7and9per100,000
populationformenandwomenrespectivelyin1996,athreefoldincrease.
Amelanoticmalignantmelanomamostcommonlyoccursinthesettingofmelanomametastasistothe
skin, presumably because of the inability of these poorly differentiated cancer cells to synthesise
melaninpigment.
Morethan50%ofcasesarebelievedtoarisedenovowithoutapreexistingpigmentedlesion.
TumoursizeisonlyoneofthecriteriausedintheAJCC2009RevisedMelanomaStaging.Tumour
thicknessandmitoticrate(mitoses/mm2)arethemost important prognosticfactorsintheprimary
tumour.
The ventral branches of the aorta include the coeliac artery and superior and inferior mesenteric
arteries.
Theseventralbranchesgiveriseto:

Left gastric artery branches with the aortic oesophageal branches around the lower
oesophagus.

Anteriorandposteriorsuperiorpancreaticoduodenalarteries(coeliactrunk)withtheinferior
pancreaticoduodenal(superiormesentericbranch)aroundtheheadofthepancreasandsecond
partoftheduodenum.

Themarginalarteryanastomosisbetweenthemiddlecolicandtheleftcolic.

Thesuperiorrectalartery(inferiormesenteric)withthemiddlerectal(internaliliac)and/orthe
inferiorrectal(internalpudendalfrominternaliliac).

Therightgastricarterymostfrequentlyoriginatesfromtheproperhepaticartery(~53%).Itcanalso
originate:

fromtheregionwherecommonhepaticarterydividesintoitsbranches(~20%)

fromthelefthepaticbranch(~15%)

asabranchofthegastroduodenalartery(~8%),or

asbranchofthecommonhepaticartery(~4%).

Theincidenceofcleftlipandpalateisonein600livebirths,and1:1000livebirthsforisolatedcleft
palate.

TheincidenceincreasesintheOrientalgroups(1:500)anddecreasesintheblackpopulation(1:2000).
The highest incidence reported for cleft lip and palate occurs in the Native American tribes of
Montana,USA(1:276).
Thetypicaldistributionofclefttypesis:

Cleftlipalone15%

Cleftlipandpalate45%

Isolatedcleftpalate40%.

Geneticinfluenceismoresignificantincombinedcleftlipandpalatethancleftpalatealonewhere
environmental factors such as maternal epilepsy and drugs (for example, steroids, diazepam,
phenytoin)exertagreaterinfluence.
Althoughmostcleftsofthelipandpalateoccurasanisolateddeformity,thePierreRobinsequence
remainsthemostcommonsyndrome.Thissyndromecomprisesisolatedcleftpalate,retrognathiaanda
posteriorly displaced tongue (glossoptosis), which is associated with respiratory and feeding
difficulties.
Facialnervepalsiesmaybecausedbylesionsaffectinganypartofitscourse.Itarisesinthemedulla
andemergesbetweenponsandmedulla,passesthroughtheposteriorfossaincloseproximitytothe
middleearbeforeemergingfromthestylomastoidforamentopassunderneaththeparotidgland.
Causescanbedividedinto:

Intracranialbrainstemtumours,stroke,multiplesclerosis,acousticneuroma

Intratemporalotitismedia,RamsayHuntsyndrome,cholesteatoma

Infratemporalparotidtumours,trauma

Otherssarcoid,GuillainBarrsyndrome,diabetes,Bell'spalsy.

Thispatientpresentwithsymptomssuggestingamaurosisfugax.
InthiscaseNICEguidelinessuggestthatthemostappropriatetherapywouldbeClopidogrel75mgod
oraspirin75mgodplusdipyridamolemodifiedrelease200mgbd(notachoiceinthislistasyoucan
onlyhaveonecorrectanswer).Thereislittleevidencethatoneorotheroftheseregimensissuperior.
Clopidogrelhastheadvantageofbeingonetabletadaysocomplianceislikelytobebetter.
Inthiscase,hehasatrialfibrillation(AF),andthemostappropriatetreatmentwouldbewarfarin.AF
withamaurosisfugax wouldsuggest avery highfuture riskofcompleted stroke,and thisriskis
minimisedmostwithwarfarin.
NICEguidelinesonVasculardiseaseclopidogrelanddipyridamole(TA210)liststhebesttreatment
as clopidogrel for occlusive events, aspirin and dipyridamole for TIAs, moving down the list if
intoleranttothefirstlinetreatment.

Withanyacuteswollenscrotumthefearisoftorsionoftestis.Thisisuncommonintheneonate,andis
muchcommoneraroundpuberty.Presentationiswithahard,tendertestis,andspermaticcord/+ared
scrotum.
Torsionoftheappendageoftestishasapeakincidenceofbetween4and8yearsofage,asdoesacute
idiopathicscrotaloedema.Intheformer,thereisatenderupperpoleoftestiswithabluespoton
transillumination.Inthelattertheerythemaextendsbeyondthescrotumandthetestisisminimally
tender.
Epididymitisisrarebeforepuberty,andpresentswithatenderepididymus(urologicalinvestigations
areneeded,asitisassociatedwithrefluxofinfectedurineviathevasdeferens).
Inguinalherniaewhichareirreducible,haveapeakincidencebelow2yearsofage.Afirmimmobile
tender swelling is found in the scrotum, which becomes inflamed as the strangulation occurs.
Occasionally,acutehydrocelescanalsopresentwithamobilebluetransilluminatingswellingat13
yearsofage.

Differentialdiagnosesofsolitarypainfululcerintherectumat60yearsofageare:

cancer

solitaryrectalulcersyndrome(otherwiseknownasulcerativeproctocolitis),and

rarelyinfections,suchasamoebiasisorbilharziosis.

Thebestresponseamongstthosegivenhereisulcerativeproctocolitis.
Theposteriortriangleoftheneckcontains:
Nerves:

Spinalaccessorynerve(Xi)

CervicalPlexus(lesseroccipital,greaterauricular,transversecervicalandsupraclavicular)

Arteries:

3rdpartoftheSubclavianArtery

TransverseCervicalandSuprascapularArteries(bothbranchesoftheThyrocervicalTrunk)

OccipitalArtery

Veins:

ExternalJugularVein

LymphNodes:
Theinferiorbellyofomohyoid

10

Thebrachialplexusliesdeeptotheprevertebralfascia.
Therearenumerousindicationsfortheformationofatracheostomy.
Theseinclude:

Theupperairwayobstruction

Tofacilitateairwaysuction,and

Todecreasetheworkofbreathingandtoallowweaningfrommechanicalventilation.

Oncethedecisionhasbeenmadetogoahead,atracheostomymaybeperformedpercutaneouslyor
openly.
Whenusingtheopenmethod,amidlineincisionismadeandthethyroidisthmusdividedandligated,
andaverticalincisionmadebetweenthesecond,thirdandfourthtrachealrings(astheformationof
windowsandflapsincreasestheriskofstenosis),andthecuffisinflated.
However,inchildren,cuffedtubesshouldbeavoidedduetotheriskoftrachealstenosisandmucosal
ulceration.
Bleeding from the tracheotomy wound is also a recognised complication, and best treated by not
deflatingthecufforremovingthetube(astheyhelptotamponadethebleeding)butbygivingoxygen,
ventilatingthepatient,andgainingIVaccess,whilstcallingforhelp.
Criterionfortheremovaloftracheostomytubes:thepatientisabletomaintaintheirownairwayand
ventilateadequately.
Indicators of this are: a low inspired oxygen concentration, adequate carbon dioxide elimination,
minimalsputumproductionandthatthepatientisnotheavilysedatedandabletocooperate!
Nonfunctioningpituitarytumour(NFPT)causingendocrinedisturbance.
IncorrectThecorrectanswerisFreeT48.2nmol/L,TSH2.1mU/L
ANFPTmaybeassociatedwithhypopituitarismandsecondaryhypothyroidism,withalowthyroxine
(T4),plusnormalorlowthyroidstimulatinghormone(TSH)levels.IftheT4islowyettheTSHis
normal,thenthiswouldsuggestthattheTSHisabnormallylowfortheT4,suggestingthatthepituitary
hypothalamicaxisisdysfunctional.Itisalsopossibleforanonfunctioningpituitarytumourtonot
causehypothyroidismandthepatienttobeeuthyroid.
Subclinicalhypothyroidism.
FreeT412.1nmol/L,TSH7.9mU/L
Correct
SubclinicalhypothyroidismisassociatedwithanormalT4,butanelevatedTSHlevel.Thissuggestsa
developing thyroid failure. The raised TSH signals a reacting pituitary, with the elevated TSH
endeavouringtoincreaseT4secretionfromthethyroid.
Subclinicalhyperthyroidism.
FreeT418.6nmol/L,TSH0.07

11

Correct
Theconverseappliesforsubclinicalhyperthyroidism,wherepituitarysecretionisbeinginhibitedby
theexcessivefortheindividual(althoughstillinnormalrange)T4.
Thyroid function tests are some of the most frequently requested blood tests, and their accurate
interpretationisessential.
Congenitaldiaphragmaticherniasoccurinapproximately1in4,000livebirths.
NinetypercentoccurintheposteriorportionofthediaphragmthroughtheforamenofBochdalekof
which90%areontheleft(theliverisontherightsidesomaybethereasonthemajoritypassthrough
theleftsideofthediaphragm).
Thecommonestclinicalpresentationiswithrespiratorydistressintheneonatalperiodanddueto
pulmonaryhypoplasiaandcompression.Theabdomenoftenhasascaphoidappearance.
About40%ofpatientshaveassociatedcongenitalanomalies.
Thediagnosiscanbeconfirmedradiologicallywithbowelloopsseeninthechest.
Neonatesusuallyrequiresedation,ventilationandintestinaldecompressionpriortosurgerybetween36
and72hoursafterbirth.

12

Theme:HearingLoss

A
B
C
D
E
F

Conductive hearing loss

High frequency hearing loss
Noise-induced hearing loss
Ototoxic hearing loss
Sensori-neural hearing loss
Speech discrimination loss

Foreachscenariodescribedbelow,choosethesinglemostlikelycorrespondingtypeofhearingloss
fromthegivenlistofoptions.
Eachoptionmaybeusedonce,morethanonceornotatall.
Amotherbringsher7yearoldgirltoseeyou.Shehashadamoderatehearinglossandhascopedwell
withhearingaidsforthelastthreeyears,butshehasbeenrecentlynotedbyherteachertobemore
withdrawntowardsherpeersinclass.Inspiteofherbeingteasedforbeinga"teacher'spet"andnow
sittingatthefrontoftheclassroomconstantly,heracademicperformancehasdeteriorated.

Correct
Hearinglossshouldbeconsideredinchildrenifthereisanysuspicionfromparentsorteachersbased
onbehaviouralchanges.Accurateelectrophysiologicaltestingcanbeeasilyandnoninvasivelycarried
outinchildrenofanyage.
Eveninthosepatientsknowntohaveahearingloss,vigilanceisimportantasprogressivechanges
oftenoccur.Aschoolagechildmayfindincreasingdifficultyhearingtheteacherandneedtositatthe
frontoftheroomtohearbetterandlipread.Thisindicatesalossofspeechdiscriminationability.
Thislosscanalsooccurinadultswithaprogressiveloss,includingthosealreadyusinghearingaids.
Somegoontoreceiveacochlearimplantwhichcangivethemtheabilitytohearspeechclearlyagain.
A22yearoldmancomestoseeyou.Hewasrecentlyonholidayandlearnedtowaterski.Ontheday
beforereturninghome,hefellwhilewaterskiingatspeedandsustainedablowtotherightsideofhis
head.Onotoscopyyouseeasmallholeinthetympanicmembrane.Youreferhimforaudiological
assessment.Hehasamildhearinglossontherightwithnormalboneconduction.

Correct
Hearinglossisbroadlycategorisedintotwoaetiologicaltypes:conductiveandsensorineural.
Conductivelossesaffectouterand/ormiddleearfunction(forexample,tympanicmembranerupture)
andwillleadtoimpairedairconductionwithnormalboneconduction.
Sensorineurallossesresultfromhaircelllossesinthecochlea(innerear)andbothairandbone
conductionareaffected.
An18montholdbabyisbroughttoyoubyhismother.HewasbornintheUKinahospitalwith
universalhearingscreeningandwasfoundtohavenormalhearingatbirth.Whenthechildwas5
monthsoldthefamilymovedtoChinaforasixmonthperiodafterwhichtheyreturnedtotheUK.
WhileinChinathebabycontractedpneumoniaandwashospitalisedinthelocalregionalhospitalfor
IVantibiotictherapy.

Correct
Anypatientofanyagewithabilateralseveretoprofoundhearinglossshouldbeconsideredapotential
cochlearimplantcandidate.

13

Thecausesofsensorineuralhearinglossesincludeotoxicity(duetoagentssuchasgentamicin,
cisplatinandotherchemotherapeuticagents),bacterialmeningitis,skullfracture,noiseexposure,
presbycusis,geneticsyndromesandhereditarydeafnessandmanyofthe"unknown"causesofhearing
loss.
Gentamicinisstillusedinsomecountrieswithouttherecommendedstrictmonitoringofcirculating
levels,andhaircelltoxicityresults.
A65yearoldmancomestoseeyoucomplainingthathehasbeenmisunderstandingsomewordsin
conversationeveninquietenvironmentssuchasathomewithhiswife.Hehasnopriorhistoryof
hearingloss.Yousendhimforanaudiogramwhichshowsadipinthe68kHzrange.
IncorrectThecorrectanswerisHighfrequencyhearingloss
Highfrequencyhearinglossisknownasthe"invisibledisability"asitspresenceisoftennotobvious
fromhistoryandbasicclinicalexamination.Earlystagesofsomehearinglossescanbeassubtleasan
adulthavingtroubleunderstandingafewwordsofconversationinagerelatedhearinglossesthehigh
frequencysoundsofsomeconsonants(forexample,"sss"or"fff")arelostfirst.
Achildborninahospitalwithauniversalneonatalscreeningprogrammedoesnotpassthefirstand
secondscreeningproceduresandgoesonforfulldiagnosticassessment.Thechildhasaprofound
bilateralhearingloss.Theoutcomeofthethoroughinvestigationsisthatthechildreceivesacochlear
implant.

Correct
Hearinglossisbroadlycategorisedintotwoaetiologicaltypes:conductiveandsensorineural.
Conductivelossesaffectouterand/ormiddleearfunction(forexample,tympanicmembranerupture)
andwillleadtoimpairedairconductionwithnormalboneconduction.
Sensorineurallossesresultfromhaircelllossesinthecochlea(innerear)andbothairandbone
conductionareaffected.
Hearinglossisalsoclassifiedaccordingtodegreeofloss.Itisexpressedasthenumberofdecibelsof
hearinglossthatispresentcomparedtosomeonewithnormalhearing.

Mild
Moderate
Severe
Profound

25-40 dB loss
40-70 dB loss
70-90 dB loss
>90 dB loss

14

Thelongsaphenousveincanbedividedintosixanatomicalregions:
1.

Femoraltriangle

2.

Anteriorfemoralregion

3.

Patellarregion

4.

Posteromediallowerleg

5.

Anteromediallowerleg,and

6.

Foot.

Ithasalinearcourseintheleg.Itascendsvertically,posteriortothemedialborderofthetibia.
Itisaccompaniedbythelegbranchofthesaphenousnerve.Thisanatomicalrelationobviouslycarries
ariskofsensorydisordersfollowingstripping.
Atthekneethelongsaphenousveintravelsposteriorlytothemedialfemoralcondyle(secondconstant
anatomicallandmark).
Itthentravelssuperficiallyoverthemedialregionofthethigh,remainingparalleltothemedialedgeof
thesartoriusmuscle.
Inthefemoraltriangle,thelongsaphenousveinformsanarchasitpenetratesintothedepthofthe
thigh.ItperforatesthecribriformfasciaimmediatelyaboveAllanBurn'sligament,whichactually
correspondstoareinforcementorfoldofthecribriformfascia.
Thearchofthelongsaphenousveinthenopensontotheanteriorsurfaceofthefemoralvein4
centimetresbelowtheinguinalligament.Itentersthefemoralveinatthisjunctionwhichthenpasses
throughthefemoralcanal.
Theexternalpudendalveinsdraintotheiliacveins.Thelongsaphenousmaydrainintotheposterior
tibialveins.
Thevalvesoftheperforatingveinsshouldpreventbackflowofbloodfromthedeeptothesuperficial
system.
In75%ofoccasionsthelongsaphenousreceivesbloodfromthesuperficialexternalpudendalveins.

Score
6
5
4
3
2
1

EyeOpening

Eyesopenspontaneously
Eyesopentoverbalcommand
Eyesopentopain
None

VerbalResponse

Orientated
Confused
Inappropriatewords
Incomprehensiblesounds
None

MotorResponse
Obeyscommands
Localisingpain
Withdrawingfrompain
Flexiontopain
Extensiontopain
None

15

Myastheniagravisisanautoimmunediseasecharacterisedbyskeletalmuscleweaknessandincreased
fatigability.
Ninetypercentofpatientshaveantibodiesagainstthepostsynapticacetylcholinereceptorsatthe
neuromuscularjunction.Sixtyfivepercentofpatientswithmyastheniagravishavehyperplasiaofthe
thymusand12%haveathymoma.
Treatmentiswithacetylcholinesteraseinhibitors,forexample,pyridostigmine,whichmaycausea
cholinergiccrisisinoverdosage.Sideeffectsoftreatmentinclude:

Diarrhoea

Urinaryfrequency

Meiosis

Excessivesalivation,and

Lacrimation.

Amyastheniccrisis(suddenworseningandspreadingweakness)maybeprovokedbydrugomission,
infectionandstress.
Preoperativeassessmentofrespiratoryfunctionisimportant.Pyridostigmineisusuallywithheldon
themorningofsurgeryandthenrestartedinreduceddosagepostoperatively.
Atracheostomydoesimproveweaningfromventilatorysupport,butitisnotperformedroutinelyafter
athymectomy.Thesepatientsareoftenextubatablewithin24hoursontheICUifnotimmediately
afterthesurgery.
Thesehistologicalfeaturesaretypicalofcoeliacdiseasewith:

Villousatrophy

Crypthyperplasia/hypertrophy

Inflammatoryinfiltrateofthelaminapropria,and

Intraepitheliallymphocytes.

UsefulserologyincludesantiTTGantibodieswhichwouldbeexpectedinover90%ofcases.
Treatmentofthiscasewouldthereforeentailglutenfreediet.

16

A4yearoldboyborninNorthAfricahaspresentedwithrecurrentchestinfectionandwheezesince
birth.Onauscultationhehasanejectionsystolicmurmurandarumblingmiddiastolicmurmur.Heis
alsonotedtohaveafixedandwidelysplitsecondheartsound.
IncorrectThecorrectanswerisAtrialseptaldefect
Therearetwomaintypesofatrialseptaldefect:

Ostiumsecundumdeficencyoftheforamenovaleandatrialseptum,and

Ostiumprimiumdefectoftheatrioventricularseptum.

Bothpresentwithsimilarsymptoms.
Allsymptomaticchildrenshouldbeofferedsurgery,whichconsistsofclosingthedefectprimarilywith
suturesorwithapatch.
A6weekoldboyisnotedtohavealoudsystolicmurmurathissixweekcheck.Themotherreports
thathefeedswellandisheisonthe50thcentileforweightandheight.
IncorrectThecorrectanswerisVentricularseptaldefect
Ventricularseptaldefects(VSDs)arecommonandareoftwomaintypes:

Perimembranousclosetothetricuspidvalve,and

Muscularcompletelysurroundedbymuscle.

MostchildrenareasymptomaticwithmostVSDsclosingspontaneouslywithinthefirstfewyearsof
life.
Symptomsincludefailuretothrive,recurrentchestinfectionsandheartfailure.Surgeryisindicatedif
thereareseveresymptomswithfailuretothriveorpulmonaryhypertension.Untreatedpulmonary
hypertensionwillprogresstoirreversibledamageofthepulmonarycapillaryvascularbed.
A6weekoldboyisnotedtohaveacontinuousmurmur.Themotherreportsthathefeedswellandis
heisonthe50thcentileforweightandheight.
IncorrectThecorrectanswerisPatentductusarteriosus
Theductusarteriosusconnectsthepulmonaryarterytothedescendingaorta.Failuretocloseshortly
afterbirthfrequentlyoccursinpretermorsickinfants.Inotherchildrenitisduetoadefectinthe
muscleoftheduct.Childrenareusuallyasymptomaticbutmaydevelopsignsofheartfailure.Ifthe
PDAfailstoclosethensurgical/transvenousclosureisadvisedtoabolishthelifelongriskofbacterial
endocarditis.

17

Peripheralarteriovenousaccessisrequiredifapatientrequireslongtermhaemodialysis.Mostare
formedunderlocalanaestheticinadaycasesetting.Mostfistulaeareformedasdistallyonthearmas
possible,byanendtosidetechniqueontothearterytoreducetheriskofvenoushypertensionandsteal
syndrome.Priortocreatingafistulaitisnecessarytobeabletopalpateadistalpulse.
TheNationalKidneyFoundationKidneyDiseaseOutcomesQualityInitiative(NKFKDOQI)advocate
routineduplexingofthearteryandveintoidentifyanatomicalabnormalitiesordisease.
Fistulafailureisassociatedwith:

Smallvesselsize

Lowfistulaflowratefollowingconstruction

Anastomosismethod(clipsarebetterthansuturing)

Accessposition(moredistalisbetter)

Gender(betterpatencyratesinmen)

Age(pooreroutcomesintheelderly)

Obesity,and

Smoking.

ComplicationsofAVfistulaareinfection,haemorrhageandstealsyndrome.
Apatientwithrecurrentrightupperquadrantpainwithnormalultrasound,gastroscopyandMRCP.
Correct
AHIDA(HepatobiliaryIminodiaceticAcid)scanisanuclearimagingprocedureusedtoevaluatethe
functionofthegallbladder.Aradioactivetracer,usuallya99Tciminodiaceticacidchelatecomplex,is
injectedperipherallythenallowedtocirculatetotheliverwhereitisexcretedintothebiliarysystem
andstoredbythegallbladderandbiliarysystem.Ahealthyfunctioninggallbladdershouldoutlinefully
withinonehour.
Axillarysentinellymphnodebiopsy.
Correct
Toassessaxillarylymphnodearadiocolloidissuperficiallyinjectedoverlyingthetumouror
superficiallyattheperiareolarmargin.Thisisbecauselymphdrainsfromthedeepbreastparenchyma
superficiallytothesubdermallymphatics.Subdermallymphaticsdraintotheaxillaviathesubareolar
plexusthroughoneormorefinalcommonlymphaticchannels.
Radiocolloidinjectionallowspreoperativesentinelnodeimagingusingagammacamera.Thecolloids
areefficientlytrappedinthesentinelnode(whereasbluedyestypicallypassintosecondechelon
nodes).TheuniversalradioactivetracerusedisTechnetium99m.Technetiumhasseveraladvantages,
asitisapuregammaradiationemitter,henceoffersexcellenttissuepenetration.

18

19

Theme:Antibioticregimesinabdominal/pelvicinfections
A Ciprofloxcinfor1week
B Doxycyclinefor1week
C Doxycyclinefor2weeks
D Meropenam
E Metronidrazoleanddoxcyclinefor2weeks
F Piperacillin
G Vancomycin
Foreachofthescenariosbelow,choosethesinglebesttreatmentfromthoselisted.
Eachoptionmaybeusedonce,morethanonceornotatall
Ayoungwomanwithanonspecificgenitalinfection.
IncorrectThecorrectanswerisDoxycyclinefor1week
Nonspecificgenitalinfectionisaninfectionoftheurethraorcervix,whereacausecannotbe
demonstratedonroutineinvestigations.FurtherinvestigationsdemonstrateChlamydiatrachomatisin
3050%andUreaplasmaurealyticumin1040%ofcases.TreatmentiswithDoxycyclineor
Azithromycinfor7days.
A22yearoldwomanpresentswithpyrexiaandlowerabdominalpain.Pelvicultrasoundconfirms
salpingitis.
Correct
Pelvicinflammatorydiseaseisusuallytheresultofinfectionascendingfromtheendocervixcausing:

endometritis

salpingitis

parametritis

oophoritis

tuboovarianabscess,and/or

pelvicperitonitis.

NeisseriagonorrhoeaeandChlamydiatrachomatisaccountforaquarterofcases.Gardnerella
vaginalis,anaerobesandotherorganismscommonlyfoundinthevaginamayalsobeimplicated.
A51yearoldleukaemiapatientwithtyphlitisonCT.
IncorrectThecorrectanswerisMeropenam
Typhlitis(neutropenicenterocolitis)isalifethreatening,necrotizingenterocolitisoccurringprimarily
inneutropenicpatients.Typhlitisoccursmostcommonlyinindividualswithhaematologic
malignancieswhoareneutropenicandhavebreakdownofgutmucosalintegrityasaresultofcytotoxic

20

chemotherapy.Treatmentinvolvesbowelrest,NGTandintravenousfluids.Closemonitoringwith
serialabdominalexaminationsinanintensivecaresettingisrequired.
Intravenousantibioticsshouldincludecoverforgramnegativeandanaerobicorganisms,including
Clostridiumspecies.Metronidazolemayalsobeconsideredifpseudomembranouscolitiscannot
immediatelybeexcluded.Laparotomyisindicatedifperitonitisdevelops.

A75yearoldretiredbuilderhasapigmentedlesiononhisforeheadwithadarkerpatchinonearea.
Correct
Lentigomaligna(Hutchinson'smelanoticfreckle)istheleastmalignantvariety(carcinomainsitu).Itis
morecommonlyseenintheelderly.Itpresentsasanirregularbrownpatchcommonlyoverthecheek.
Malignantchangesarerecognisedbythickening,darkeningandthedevelopmentofdiscretetumour
nodule(s).Thisindicatesdermalinvasionbymalignantmelanocytesandthelesionisthenalentigo
malignamelanoma.
A46yearoldmanpresentswithapainlessfirmlumponhisarm.Thislumphasbeenpresentformany
years.
IncorrectThecorrectanswerisSebaceouscyst
Sebaceouscystsareintradermallesionscontainingkeratinanditsbreakdownproducts.Itissurrounded
byawallofstratifiedsquamouskeratinisingepithelium.Theycommonlyoccurovertheface,chest
andshoulders.Theyhaveacharacteristicpunctum,usuallyinthecentreofthelesion,whichblocksthe
sebaceousoutflow.
A40yearoldNigerianmanpresentswithapigmentedlesiondeeptothelefthalluxnailplate.
IncorrectThecorrectanswerisAcralmalignantmelanoma
Acrallentiginousmelanomasariseonthepalms/solesoraroundthetoenailsandaremorecommonin
darkskinnedpeoples.
A32weekpregnantwomanwithrightsidedabdominalpain.
IncorrectThecorrectanswerisAppendicitis
Acuteappendicitisisthemostcommonsurgicalemergencyinpregnancy.Appendicitisinpregnancyshould
besuspectedwhenapregnantwomancomplainsofnewonsetofcentralorrightsidedabdominalpain.One
studyfoundconsiderablefoetallossafterappendicetomyduringpregnancyinthefirstandsecond
trimester.
Reference:
AndersenB,NielsenTF.Appendicitisinpregnancy:diagnosis,managementandcomplications.ActaObstet
GynecolScand.1999;78:75862.
A7yearoldgirlpresentswithhaematuriaandsuprapubicpain.
IncorrectThecorrectanswerisUrinarytractinfection

21

Ina7yearoldgirlthemostlikelycauseofhaematuriaandsuprapubicpainisurinarytractinfection.
Haematuriamaybeattributabletourinarystonesorunderlyinganatomicalconditionssuchas
vesicoureteralreflux,renalvascularabnormalities,PUJobstruction,VUJobstructionandtumours.
Awomanwhois18weekspregnantpresentswithsuprapubicpainandhistoryofrecentcough.
IncorrectThecorrectanswerisIgAnephropathy
IgAnephropathy(Berger'sdisease)isthemostcommonglomerulonephritisworldwide,and
characteristicallyaffectsyoungmales,presentingwithfrankhaematuriaafteranepisodeofpharyngitis.
Howeveritmayalsopresentwithproteinuria,microscopichaematuria,renalfailureorhypertension.Itis
probablypartofaspectrumofdiseasewithHenochSchoenleinPurpura,whichpresentswitharthritis,
rash,abdominalpainandnephritis.InboththerearemesangialIgAdepositsinthekidney

Fortwoyearsa38yearoldwomanhashadintermittentshootingpainalongtherightfifthfinger.
IncorrectThecorrectanswerisThoracicoutletsyndrome
Thoracicoutletsyndrome(TOS)iscausedbycompressionofthebrachialplexus,subclavianarteryor
subclavianveininthethoracicoutlet.Almostallpatients(95%)presentwithneurologicalsymptoms.
handpainisoftenmostsevereinthefourthandfifthfingers.
Therearemanynonanatomicalcauses,including:

repetitivepressure

sports(e.g.weightlifting,archery,swimming,andtennis)

occupationsinvolvingrepeatedoverheadwork(e.g.plastering,painting,shelfstacking)

obesity,and

poorposture.

Trauma,suchasfracturedclavicle,maycauseTOS.
Thecommonestanatomicalcauseofarterialsymptomsisacervicalrib,whichoccursin0.4%ofthe
population.Although70%ofcervicalribsarebilateral,symptomstendtobeunilateral.
Neurologicalsymptomsandsignsinclude:

pain

paraesthesia

weakness,and

musclewasting.

Vascularsymptomsandsignsinclude:

distendedarmveinswhichdonotcollapseevenonlimbelevation

22

venousthrombosis

cyanosis

oedema

arterialthrombosis(acuteischaemiaorclaudication)andembolisation(digitalischaemia),and

poststenoticdilatationandaneurysmformation

A68yearoldwomanhasdevelopedintermittentpaininthethenareminence.Thesymptomsare
exacerbatedwhenliftingheavyobjects.
IncorrectThecorrectanswerisOsteoarthritisinjoint
Osteoarthritisofthefirstcarpometacarpaljointisextremelycommonandina65yearoldladyisthe
mostlikelydiagnosis.Swellingisusuallybonyhardandduetoosteophyteformationwhichcanleadto
theappearanceofsquaringofthehand.
A28yearoldfemalesecretarycomplainsofpaininherdominantindexfinger.Thesymptomsworsen
throughtheday.
IncorrectThecorrectanswerisCarpaltunnelsyndrome
Themediannerveentersthehandthroughthecarpaltunnel,deeptotheflexorretinaculum,alongwith
theninetendonsoftheflexorsdigitorumsuperficialisandprofundusandtheflexorpollicislongus.
Thecarpaltunnelisthechanneldeeptotheflexorretinaculumbetweenthetuberclesofthescaphoid
andtrapezoidbonesonthelateralsideandthepisiformandhookofhamateonthemedialside.
Distaltothecarpaltunnel,themediannervesuppliesthethreethenarmusclesandthefirstandsecond
lumbricals.Italsosendssensoryfibrestotheskinoftheentirepalmarsurface,thesidesofthefirst
threedigits,thelateralhalfofthefourthdigitandthedorsumofthedistalhalvesofthesedigits.
Howeverthepalmarbranch,whichsuppliesthecentralpalm,arisesproximaltothecarpaltunneland
doesnottraversethetunnel,itrunssuperficialtotheflexorreticulumthereforethereisnolossof
sensationintheskinincarpaltunnelsyndrome.
Carpaltunnelsyndromeisduetoinflammationofsynovialsheathsthatsignificantlyreducesthesizeof
thecarpaltunnel.Fluidretention,infection,andexcessiveexerciseofthefingersmaycauseswellingof
thetendonsortheirsynovialsheaths.
Themediannerveisthemostsensitivestructureinthecarpaltunnelandthereforeismostaffected.
Progressivelossofcoordinationandstrengthinthethumbisduetoweaknessoftheabductorpollicis.
Astheconditionprogresses,sensorychangesradiateintotheforearmandaxilla.

23

A59yearoldmanisundergoingafemorodistalbypassgraftforcriticalischaemia.Avenousconduit
isused.Thevascularsurgeonwantstoavoidasizemismatchbetweentheendsoftheconduittobe
anastomosed.Avalvulotomecuttingknifeispulledbackthroughthegrafttodisruptthevalvesinthe
veinlumem.
IncorrectThecorrectanswerisInsitu
Insitugraftingisthemethodofchoiceforvesselsaroundthekneeornearthefoot.Theveintributaries
areligatedandtheupperendisthenfreedandmobilisedfromthefemoralveinwhichisoversewen.
Theveinisthenanastomosedtotheartery.Theclampsarethendividedandtheveinisallowedto
distendproximaltothefirstcompetentvalve.Thevalvulotomeisthenpasseduptheveintothe
distendedsegmentandisthengentlywithdrawndisruptingthevalvesonebyone.Thedistalendis
thenanastomosedtotheartery.
A67yearoldmanpresentstothevascularoutpatientsclinicwithrightfootrestpainandbilateralshort
distanceclaudication.Heunderwentacoronaryarterybypassgraftingtwoyearsbeforeinwhichthe
longsaphenousveinwasharvestedfromtherightleg.Heunfortunatelydevelopedanextensive
iliofemoralDVTintheleftleginthepostoperativeperiodfollowingtheCABG.Avascularprocedure
isplannedonhisrightleg.
Correct
Thismanhasnolegveinsavailabletoactasaconduit.MostcommonlyaPTFEgraftisused.
However,thereisalowerpatencyrateatoneyearwithsyntheticgraftscomparedtovenousgrafts.
Somevascularsurgeonsrecommendharvestofarmveinswhenlegveinsarenotavailable.
A63yearoldmanpresentstothephysiciansfollowingatransientischaemicattack,onexaminationhe
hasafever.InitialbloodculturesgrewStreptococcus.AnabdominalCTscanshoweda5.7cminfra
renalabdominalaorticaneurysm,therearesignstheaneurysmmaybemycotic.
IncorrectThecorrectanswerisImpregnated
Thediagnosisofamycoticorganismcanonlybedefinitelymadewhenorganismsareculturedfrom
theaneurysmwall.Astheaneurysmisgreaterthan5.5cm,itrequiresrepair.Ifasyntheticgraftisto
beuseditshouldbeimpregnatedwithantibiotics.Thepatientwillrequireaprolongedcourseofiv
antibioticsbasedonculturespreoperativelyandforatleasttwoweekspostoperatively.Some
surgeonsstilladvocateatwostageapproachwithanaxillobifemoralgraftbeingformedfirstandthen
ligationoftheabdominalaortaanumberofweekslater.

24