IMPORTANT NOTES BY:

dr.Mohamed Salah
facebook group: https://www.facebook.com/groups/
MasterTheMRCS

IMPORTANT 1 note
* corticospinal
Anterior for trunk.
Lateral for limbs.
* common carotid artery is lateral to parathyroid. And
bifurcation at C4.
* RPF measured by PAH.
* S& L( scaphoid & lunate) articulate with radius.
* tympanic membrane
》Outer surface by Auriculotemporal.
》Internal surface by CN9.
* CN3 lesion:
》eye deviation inferolateral.
》If caused by posterior communicating artery (painful palsy =
headache).
* if injury to facial nerve during parotid surgery: LMN
ipsilateral.
*sarcoid:asteroid bodies macrophages, B-lymphocytes
NOT T LYMPHOCTE.
*1 cm cystine stone.
Inherited stone
》radiodense as it contains sulfur.
》ttt alkaline diuresis.
▪︎ broca area supplied by middle cerebral artery
▪︎ urine acid stone:
》Acidic PH..
》in children with inborn errors of metabolism..
▪︎ ectopic testis 》 superficial inguinal POUCH ..
▪︎P. Value describes risk of type 1 statistical error.

IMPORTANT 2
* central tendon of diaphragm from septum transversarum.
*Biceps brachii attached to radial tuberosity. It's long head arises from
supraglenoid tubercle.
* L5 nerve roots compression: reduced ankle dorsiflexion. Loss
of sensation at lateral aspect of leg. Loss of EXTENSION of big
toe.
* S1 nerve root compression
absent ankle jerk.Loss of planterflexion.Loss of sensation at
lateral side of foot.
*central chemoreceptors respond to H hydrogen.Not O2.
* semitendenosis is hip extensor.
* in distal third of upper arms: musclocutanous nerve between
biceps and brachial.
* pneumococcal vaccine given after splenectomy by 2 weeks.
*Abducent CN 6 to LR.
▪︎trochlear CN 4 to S.O.
* capitate articulate with 3rd metacarbal, hamate articulate
with 4,5 metacarpal.
Capitate related to profundus.
* pectoralis major: insertion into lateral intertubercular groove
of humerus. Innervated lateral pectoral nerve.
* esophageal perforation :TPN
▪︎liver cell adenoma..
》relation to OCP.
》non encapsulated.
》Mixed echointy.heterogenous.

IMPORTANT 3

* all rotators of shoulder inserts greater tuberosity. Except

subscapularis in lesser.
*external jugular vein drains into subclavian.
* in Cxr Immediately inferior to aortic knuckle: pulmonary
trunk.
* when imaging and biopsy in breast are not concordant do
excisional biopsy.
*cryptospordium infection in immunocompromised patients.
*needle prick: most common infections:hepatitis B.
* Morton neuroma 3rd and 4th toes.
* neck swelling moves sideways chemodectoma.
* mythenia gravis vs eaton lambert: Eaton Lambert gets
better with excertion.
* syrinomyelia:
》Loss of pain and temperature on upper limbs.
*Vagina:
upper to internal iliac
Lower to inguinal.
* achondroplasia》AD
Defect in 》fibroblasts growth factor.
》Narrow spinal canal
* rapid growing keratin centre,, resolves with scarring
(karatoacanthoma )
* thorn injury easily bleeding: pyogenic granuloma. With hx of
minor trauma.
▪︎ Bowen disease.
Insitu SCC.. erythematosus scaling patch from sun exposed
skin.
▪︎extra intestinal manifestations of chrons:
sacroilitis..ankylosing spondylitis..aphthous ulcers..erythema
nodosum..pyoderma gangrenosum..
▪︎ factors increase risk of cancer in UC..
》 pancolitis ..unremitting disease
》 poor compliance to ttt.
▪︎hypospadius associated with cryptorchidim.
▪︎TB》 thoracic spine.
▪︎osteomyelitis 》cervical spine.
▪︎osteomyelitis 》 ttt by initially by antibiotics.
▪︎Rovsing sign NOT in retrocecal appendicitis..
》retrocecal 》poas stretch sign.

IMPORTANT 4

▪︎Maximum inhale + maximum exhale = VC.

* capitulum articulate radius C-R
* wasting on all muscle of hand 》T1
*content of 4th extensor compartment?
》Extensor digitorum
》Extensor indices.
* ulna articulate with trochlea.
U-T.
*Which muscles does not attach to radius?
A. Pronator quadratus
B. Biceps
C. Brachioradialis
D. Supinator
E. Brachialis.《《
》brachialis muscle inserts into ulna.other muscles 》radius.
* barrett with low grade dysplasia.
* axillary artery divided by pectoralis minor.
* larynx lymphatic
Supraglottic upper deep cervical.
Infraglottic lower deep cervical and pretracheal and
prelarngeal.
-Ariepiglottic and vestibular fold dense lymphatic nodal mets.
- glottic lymphatic watershed deficient.
* FPL》Flexion of interphalangeal of thumb.
Run in carpal tunnel.
Supplied by AIN.
▪︎ causes of carpal tunnel 》
Myxoedema..DM..acromegaly...
Rheumatic arthritis..
* obturator externus and gracils supplied by (obturator)nerve.
▪︎infraglenoid tubercle to long head of triceps.
▪︎ Amoebic abscess:
》Right lobe..
aspiration: sterile odourless fluid ( anchovy paste)
》Ttt metronidazole

IMPORTANT 5

* membranous urethra. Deep to urogenital diaphragm. Surrounded by

external urethral sphincter.
*suture are sterilization( ethylene oxide ). Hot air oven at 260 for 2
hour.
* genitofemoral nerve.
From L1,2....
* uterus fundus to paraortic LN
body to internal iliac LN.
* continuous dribbling of urine after prolonged delivery:
vescicovaginal fistula .
* adult hydrocele repaired through scrotal approach.
*fischer exact test used in small sample sizes.
*T.test for normal distribution data e.g weight.,
Used in large size data .
*glycin presents in all types of collagen.
* cardiac tamponade, 1st pericardiocentesis before CXR.
* Type 4 shock .1st do fluid resuscitation.
* 4 weeks postrenal transplantation ( acute rejection) T- cell
mediated.
*If co2 high and bicarb low then we could call it mixed acidosis
and vice versa.
* cryoprecipitate; contains only fibrinogen and factor 8.

IMPORTANT 6.

* temporal lobe herniation, with CN 3 compression dilatation of

pupil,and ptosis).
* child abuse ( non accidental)
Posterior rib #
Long bone #
*Angiomyolipoma..
》bilaterally renal mass.
》Hx epilepsy + learning disability.
* hypothermia》metabolic acidosis
*Dobutamine
》Mainly B1 intermediate dose
》ALPHA 1 in high dose
*amrinone PDE inhibitors
Used dobutamine in cardiogenic shock.
* tension pneumothorax
Pericardiocentesis before CXR
*GCS
-decerebrate posture (abnormal EXTENSION score 2.
- decorticate ( abnormal flexion, score 3)
-Mumbles incoherent score 2.
* pneumonia mostly in basal lung segment..
*FB mostly has medial right segment of lung.
* Antiphospholipid antibodies.
》lupus anticoagulant.
》Anti- cardiolipin.
》Anti- B2 glycoprotein .
* DIC consume factors 5&8.
▪︎BCC: pearly white raised edges.
• port wine stain:
》since birth..
》If associated with intracranial malformations cause
convulsions...
》struge Weber syndrome
▪︎Hyperlipidaemia and multiple myeloma are known to cause
pseudohyponatraemia, this is due to raised protein.
▪︎Multiple myeloma skull 》 osteolytic..
▪︎Choanal artesia.
Posterior nasal airway obstruction.
》Cyanosis increased with feeding.decreased by crying.
▪︎examples of type 3 hypersensitivity(immune complex):
》Serum sickness..SLE..
》Rheumatic arthritis..
》glomerunephritis.
IMPORTANT 7

*In NeuroFibromatosis 2 chromosome 22 bilateral Acoustic Neuromas

are characteristic with a family history of Neurofibroma.
▪︎Neurofibromatosis 1 chromosome 17 MEN 2b
*Astrocytoma :commonest childhood brain tumour.
*Neuroblastoma:
age under 4 years
calcified tumour.
diagnosis by MIBG.
Most common lytic bone metastasesz: neuroblastoma.
* fracture neck scapula
Dropping of the affected shoulder. Lengthening of the arm.
* shoulder anterior dislocations
Swelling is deltopectral groove.
Lowering of anterior axillary fold.
Prominent acromion.
* pancreatitis scenario
Epistaxis gastric pain
Patient take thiazide ( bendroflumethazide).
X-ray central loop
* galeazzi #distal radius
Dislocation of distal radioulnar joint. X-ray: disruption of
radioulnar joint.
▪︎lymphatic drainage of spongy urethra and glans penis: deep
inguinal .
▪︎prostatic and membranous urethra drains to internal iliac
nodes.
* Tissue factor.
Main reason in DIC.
*psoas major :Flexes the thigh at hip joint .
*Gastroschisis.:To right of normal umbilical.no sac.
* cervix of uterus to presacral LN.
*Motility disorder
Episodic retrosternal chest pain
Dysphagia to liquid .
Endoscopy no abnormalities.
*plantaris and soleus are in superficial posterior
compartment,.
popliteus in deep compartment.
*there's dural fold between optic chiasma and pituitary

IMPORTANT 8
* breast reconstructive
PEDICLE myocutaneous flap .
Also used in raw area after abdominoperineal.
* stroke  <3 hour:
》urgent refer to thrombolysis.
*tip of nose 》Ophthalmic.
Alaea nasi》 mandibular.
*entire female urethra
》 internal iliac nodes.
*Bucks fascia at base of penis .
▪︎ tamoxifen
》DVT&endometrial cancer.
* SIRS:
》Temperature >38 <36
》HR > 90
》WBCS > 12 < 4.
* chronic bronchitis COPD:
》shift of o2 curve in right.
retained co2
* predischarge after esophagectomy:
》feeding jejunostomy tube.
*Severe malnutrition 20% preoperative.
》NGT feeding.
* stroke more than 1 month》PEG
* Severe acute pancreatitis: (entral) feeding nasojejenal
tube .If required.
* head injury showing recovery:
Nasoentric feeding with fine bore( naso jejenal).
* marathon runner:
》 bradycardia with high SV.
▪︎CCK
》increase enzymes rich fluid from pancreas.(I - cells).
》Decrease emptying of stomach like secretin .
▪︎cause of increased gastric emptying:
Gastrin.. meticlopromide ( prokinetic)

▪︎Secretin:
》 increases hco3 rich fluid from pancreas .
▪︎most IMPORTANT factor for post operative prosthetic function
after BKA
》tibia cut 15 cm below knee .
▪︎Factors 5&8are sensitive to temperature
▪︎ posterior to perineal body is external anal sphincter.
▪︎portal vein》most posterior in porta hepatis.
▪︎brown tumour with hyperparathyroidism.
• CXR》white out both lungs
With hx and trauma lung contusion.
• paradoxically movements of chest》flail chest.
▪︎airways with suspected cervical injuries
》jaw thrust.
▪︎ posterior scalp》 C2,3.
• celiac autonomic plexus
》anterior to aorta.
▪︎inferior epigastric vessels lie on inner surface of transversus abdominis
and covered by peritoneum.

IMPORTANT 9

▪︎All skull foramina in sphenoid except stylomastoid and jugular at

temporal.
▪︎posterior cerebral artery connect to circles of Willis through posterior
communicating artery
▪︎1st branch of ICA Ophthalmic.
▪︎Autoclave destroys TB.
•SSI percentage:
》Clean <5%
》Clean contaminated 5-10%.
(Laparoscopic cholecystectomy)
》Dirty 25-40%.
▪︎quadriceps femoris in anterior compartment.
▪︎Biceps femoris in posterior compartment.
•Nephroblastoma.Wilms
》ttt:resection +chemotherapy.
▪︎gastroduedenal artery
》 anterior to pancreas head.
▪︎Coarctation of aorta.
》Rib notching (collateral circulation).
》Systolic murmur at posterior aspect of 4th intercostal space.
▪︎spleen developed
》Septum transversum :central tendon.
》Cervical somites 5 to 7 : muscular component.
》pleuroperitoneal membranes: membrane surrounds viscera.
▪︎tracheastomy site
Longitudinal incision from thyroid cartilage to suprasternal
notch.
》Or transverse incision 2 fingers above suprasternal notch.
•radial nerve
》between brachialis and brachioradialis.
▪︎hischschprung:
》Contrast enema show cone shaped.
•ureter derived 》
mesonephric duct.
▪︎ neurogenic shock.
》hypotension.bradycardia
▪︎hypothalamus responsible for para sympathetic through brain
stem and responsible for sympathetic through spinal cord.
•Kartagener
》Sinusitis.Brochiectasis.
》Infertility..dexstrocardia.
• painful arch syndrome: Impingment..
Pain in abduction 60 to 120 .
Extreme of movement are painless.
▪︎deep circumflex iliac artery arises from femoral artery above
inguinal ligament, not liable to injury in access to femoral vein.

IMPORTANT 10 posted
▪︎2nd arch nerve》Facial.
▪︎Ant to pancreatic neck
》pyloro-duodunal jt
》(post :SMV join splenic v)
▪︎Vessel run anterior to ureter》 Gonadal
▪︎PR in male exam what is felt at post-lateral》puborectalis .
▪︎PV exam
》anterior = base/posterior wall of bladder.
▪︎Uretero-vesical junctions:
》at Ischial spine.
•Hyperacute graft rejection
》 due to pre-existent antibodies to HLA antigens and is
therefore IgG mediated
▪︎Gut rotation axis》SMA
▪︎Labral tear》 MRI.
▪︎Cant pass colonoscope beyong hepatic flexure
》 Do CT colonography.
▪︎Meniscal injury
》Knee injury + locking
》tender joint line.
▪︎Blue toe + inguinal LN
》melanoma.
▪︎Nephroblastoma (wilms)
》well circumscribed,not calcified,
》not cross midline.
》Hypertension. Fever.
▪︎neuroblastoma:
》irregular, fixed not mobile..
》can cross midline.. calcified.
▪︎ hepatitis C is more infectious than hepatitis B following
needle stick injury.
▪︎Peritrochanteric lesions have greatest risks of fracture (due to
loading).
▪︎lesions from breast cancer are usually lytic and therefore at
higher risk rather than sclerotic lesions from prostate cancer.
¤ structures separates posterior cruciate ligament from
popliteal artery.
》Oblique popliteal ligament.
▪︎ascariasis
》Indian with cough
》Both eggs and worm in stool.
▪︎Paget disease of bone.
》Uncontrolled bone turnovers.
》Culprit osteoclast.
》Increased ALP.
》Normal calcium and normal phosphate..
》Scenario》skull thickening + sensorineural hearing loss +
old age.
■ in osteomalacia 》decreased calcium and phosphate
▪︎Triad of Wernicke
》encephalopathy
》Acute confusion.Ataxia..
》Ophthalmoplegia.
▪︎Collagen defect :
》Osteogenesis imperfecta》 collagen 1.
》Ehlar Danlos = collagen 1 & 3.
▪︎causes pseudohaematuria
》Rifampicin.phenytoin.
》levodopa.methyldopa,and quinine.
▪︎Painful red raised on hand
》Osler nodes .
》Deposits of immune complex.
》With SLE.IE.hemolytic anaemia
▪︎GB relation
》posterior》transverse colon &1st part duodenum.
》Medially:quadrate lobe.
》Lateral: right lobe .
▪︎Desmoid tumor
》myofibroplast
》occure in 15 % of FAP.
▪︎ most common extracolonic site of of FAP》 duodenal polyps.
▪︎Malignant obstructed jaundice:
》If respectable: Insertion of plastic stent.
》If irresectable:Metallic stent
▪︎ hydatid cystic liver
》CI aspiration..
》mebendazole followed by resection.
IMPORTANT 11 posted

▪︎Fracture radial head

》Pain supination and pronation .
▪︎Fracture neck femur
》Garden 1,2 fixation with screw.
》Garden 3,4 interrupt blood supply》 arthroplasty.
▪︎Gelofusine used in septic shock, volume expansion remain in
intra vascular space for prolonged period.
▪︎Pentastarch should not be used in patients with an allergy to
corn.
¤Actinomycosis:
》in appendicitis.Sulfur granules
》Common in head and neck.
》TTT penicillin .
▪︎Giant cell tumour
》Multinucleated giant cell (osteoclast like).
》At epiphysis.
》Local aggression,so recurrence after excision .
▪︎Felty:
》Rheumatic.splenomegaly
neutropenia .
▪︎Parotid (Nerve supply ):-
》Parasympathetic》 CN9 through Auriculotemporal.
》Sympathetic: Superior cervical ganglion.
》Sensory: geater auricular nerve.
▪︎Ttt UC》》☆emergency( megacolon)》subtotal, end ileostomy
and mucous fistula.
☆Elective》panproctocolectomy & ileoanal pouch.
▪︎Facial nerve
Branches in facial canal
》Greater petrosal.
》Nerve to stapedius.
》Chorda tympani.
▪︎Age of operation
》Undescended testis 1 year (6 to 18 month)
》Umbilical hernia 3 years.
》Inguinal hernia next list.
》Congenital hydrocele at age 2 years by ligation of processes.
▪︎ isopretenol: in bradycardia of heart transplantation patients.
▪︎Solitary rectal ulcer syndrome.
》obstructed defecation.
》indurated areas in anterior rectum 3 cm from anal verge .
》Biopsy shows fibromuscular obliteration.
▪︎ Positive rinne test
》sound heard by air conduction batter than that of bone.
▪︎Negative rinne》conductive deafness( middle ear effusion)
▪︎Human herpes virus 8》kaposi
》HPV 16/18 for high grade dysplasia(anal)
》HPV type 6》low grade dysplasia.
》cervical .anal.Vulval
▪︎EPV
》nasopharngal.
》hodgkin...burkitt.
▪︎ ARDS.
》DECREASED Surfactant.
》Poor diffusion》 main cause of hypoxemia.
》CVP <18.
》Pao2》less than 9kPa.
》Ttt》low tidal volume in ventilator.
▪︎Lateral medullary syndrome (posterior inferior cerebellar
artery) Wallenberg's syndrome:
》Ipsilateral: ataxia.nystagmus, dysphagia,facial numbness.
》Contralateral: limb sensory loss.
▪︎Mesothelioma.
》asbestos.
》ttt extrapleural pneumonectomy.
》resistant to radiotherapy .
▪︎Cyanosis heart disease
》In neonates》TGA.
》after delivery by 1 to 2 month: TOF
▪︎Most common of acyanotic:
》VSD
▪︎DPA is lateral to EHL.
▪︎ trochlear nerve palsy
》vertical diplopia during downward steps.
▪︎ abducent nerve palsy:
》Convergence due to loss of LR.
▪︎ CN3 Palsy:
》eye downward and lateral . Dilated fixed pupil .
▪︎Malrotation with volvulus.
UPPER GIT contrast studies show medial displacement of DJ
flexure.
US:abnormal orientation of SMA.
‫ العالج‬ladds procedure .
▪︎Thoracoacromial trunk injury in level 3LN axillary clearance .
IMPORTANT 13 posted

▪︎ lymphatic from central tongue and posterior 1/3 》bilaterally deep

cervical LN.
▪︎ cancer tongue 》 HPV.
▪︎LMNL
》flaccid paralysis.
》Atrophy of muscle.
》Loss of reflex.
》Muscular fasculation.
▪︎lumber artery
》posterior sited.
》cause of back bleeding in repair of aorta aneurysm.
▪︎95% of foreskins retractile
》at16 years .
▪︎musclocutanous nerve
》Pierce coracobrachialis.
》Above elbow》Pierce deep facia lateral to biceps.
▪︎ temporal lobe》lateral to cavernous sinus.
▪︎blade》Gamma irradiation.
▪︎Plastics》ethylene oxide.
▪︎ suture kit 》hot air oven at 160 for 2 hour.
▪︎EWING sarcoma:
》diaphysis.
》Small round tumour.
》Blood Mets.
》ttt》chemotherapy + surgery
▪︎Lesser petrosal nerve》 glosspharyngeal》otic》parotid.
▪︎Greater petrosal nerve》facial nerve 》
pterygopalatine》lacrimal.
▪︎Struvate stones.
》composition》Mg.ammonium.
phosphate.
》love alkaline ph.
▪︎DALM associated with UC》
》ttt panproctocolectomy.
▪︎Dextran 70
》Used in sepsis
》S.E:Anaphylaxis .ARF.
▪︎CN12》 run above lingual artery.
▪︎Muscle of thenar
》APB..FPB..OP..
▪︎ inversion and eversion 》at level of subtalar joint.
▪︎armpit(axillary skin) intercostobrachial.
▪︎middiastolic murmur,increased on left lateral》Mitral stenosis.
In pregnant Indian..
▪︎Retinal and cerebellar haemangiomas 》Von Hippel-Lindau.
》Retinal haemangiomas are bilateral in 25% of patients and
may lead to vitreous haemorrhage.
▪︎blown right pupil is sign of third cranial nerve compression.
》most likely cause is extradural bleed.
▪︎SCC of skin:
》follow transplantation with immune suppression .
》Keratin pearl formation.
》Ttt wide location excision.
▪︎ structures suspends spinal cord in dural sheath?
》 Denticulate ligaments.
▪︎lobule of ear
》superficial cervical LN.
▪︎ Polyglactin》violet vicryle.
▪︎PDS:polydioxanone
》Absorbable monofilament.
》1\0 》 mass closure.
▪︎coeliac disease (malnourished patient).
》Dermatitis herptiformis.
》Itchy blisters in young adults.
》Villous atrophy.
▪︎Melanoma:
》Most common》superficial spreading.
-nodular:
》Worst prognosis》Early lymphatic spread..
》Raised demarcated..
》in leg..trunk.
▪︎Nasopharngeal carcinoma
》otalgia.epistaxis.
》CN3 palsy..
》EPV.lymphadenopathy.
》radiotherapy.
▪︎ EPV》spontaneous splenic rapture.
▪︎used to control spasticity by reducing presynaptic
acetylcholine release?
》Botulinum toxin A..
▪︎ painless red velvety lesions at mucous membranes:
》Erythroplakia .
▪︎Drug induced gynaecomastia
DISCO.
Digitalis.Isoniazid.Spironolactone.Cimitidine ..Oestrogen
▪︎In ttt with radioactive iodine
》hypothyroidism in 80 % of cases
▪︎ end diastolic volume = preload.
▪︎ ĹP done at Subarachnoid space..

IMPORTANT 14 posted
▪︎DDH
》Leg length inequality.
》U/S in 1st 3 month.
》In early childhood diagnosis by Barlow ortolani test.
》plain film》shenton line form smooth arch.
▪︎scenario》weight loss + deep jaundice + dark velvety and of tongue
《acanthosis nigricans》
▪︎nerve injury if arm left in supine position》 ulnar.
▪︎ patient with MI in last week. 30 to 40 % he will have another MI in
perioperative.
▪︎flumazenil》 benzodiazepine (midazolam)
▪︎ naloxone》 morphine (N-M).
▪︎ homonymous hemianopia if
》Incongruous defects》optic tract.
》Congruous》optic radiation.
》Macular sparing》occipital lobe.
▪︎Bitemporal hemianopia:
Chiasma compression.
》If more in upper quadrant: 》 compression from below by pituitary..
》If more in lower quadrant:
Compression from above
》craniopharngioma.
▪︎preparation of colonoscopy with fe deficiency anaemia taking ferrous
sulfate
》stop ferrous sulfate 7day before procedure and administer oral
purgative one day before procedure.
▪︎Subarachnoid scanario:
》No hx of trauma.
》No evidence of fracture.
》Sudden onset headache and collapse.
▪︎Extensive burn:
》keratinocyte migration for heal.
》cardiac output decreased by 50%in 1st 30 minute.
》there is hemolysis 》NOT polycythemia.
▪︎ Merkel cell tumour.
1-hyperchromatic epithelial cells.
2-periorbital area(common ). 3-lymphovascular invasion.
4-viscral mets.
5- more than 10 mm need sentinel biopsy.
》preexisting merkel cell polyomavirus..
》excision is 1st line..
▪︎Pheochromocytoma:
》10% normotensive.
》10 bilateral..
-when extra adrenal》 malignant.
▪︎ acute subdural:
》Sign of laterization.Highly lethal.
》Rapid deterioration.
▪︎Mucoepidermoid carcinoma
》Facial nerve palsy..
》Cystic mass..
》Lymphadenopathy
》FNA》Mucous cells .
▪︎abducent nerve palsy scenario
》Sign of increased ICP(epileptic fits.
》headache.papilloedema.. diplopia).
▪︎GCS:
M5》 localize pain
M4》 withdrawn from pain
M3 》decorticate(flexion to pain)
M2》 decerebrate ( EXTENSION to pain
V4》confusion.
V3》 words(inappropriate).
V2》 sounds (groaning grunts)incomprehensive.
▪︎Le Fort 3》periborbital swelling & flattened face..
▪︎Weber's syndrome
1-Ipsilateral CN3 palsy
2-Contralateral weakness .
▪︎Heberden》 distal IPJ
Bouchard》 proximal IPJ.
▪︎Blood transfusion (GVHD )
》Due to transfusion of irradiated blood ( leukaemia)
》4 to 30 day after transfusion
》Lymphatic proliferation
》Fever...Erythroderma.
》Desquamation.
▪︎secondary brain damage:
》Meningitis..herniation..
》hypoxia..oedema.
▪︎ gastrin hormone:
》Trophic effects on gastric mucosa.
》Increased gastric motility.
▪︎caudal block
》 Milgan Morgan.
▪︎appendectomy through midline.》PCA.
▪︎Chemotherapy in breast
Given when grade 3 tumour with nodepositive in young female.
》Screening in UK done by 2 view mammography read by 2 consultant
radiology.
▪︎Pelvic sepsis after hysterectomy
》E.coli &bacteroid.
▪︎Fistula after appendectomy:
》bacteroid .
▪︎Osteomyelitis after implants:
》staph.
▪︎Ludwig:
》streptococcus pyogenes.
▪︎Hemicranitomy indications, :
》Age <50
》clinical deficit in middle cerebral artery.
》decreased consciousness..
》>50% territory infarction .
▪︎Streptococcus:
☆ALPHA(pneumonia &viridans).
☆BETA:
Group A》 pyogenes)》》
》Necrotizing fasciitis.
》Cellulitis with ●lymphangitis(red lines in infected wounds)
》glomerunephritis..
IMPORTANT 15 posted

▪︎first compartment under extensor retinaculum of wrist

》EPB and APL
( anterior boundary of snuff )
▪︎ posterior boundary of snuff box 》EPL
▪︎Koebner phenomenon
》NOT Occur》 lupus Vulgaris.
》Lupus Vulgaris: jelly like nodules.
▪︎Koebner phenomenon describes skin lesions at site of injury.
seen in》Psoriasis..Vitiligo..Warts
Lichen planus..Lichen sclerosus
Molluscum contagiosum
▪︎C4 corresponds to lower neck just above clavicle.
▪︎T7 is level of xiphoid process.
▪︎Desmopressin useful in managing bleeding from vWD.
▪︎Vasopressin (ADH):
》From posterior pituitary.
》Increases H2O permeability in DCT and CD.
》vasoconstrictor approach which is likely to be of brief
duration.
▪︎great cerebral vein (great vein of Galen),
》formed by union of two internal cerebral veins.
》short trunk ends》 straight sinus.
▪︎PE》Respiratory alkalosis due to hyperventillation.
▪︎Fournier gangrene.
》E.coli.bacteroid
▪︎Pediatric #
》Toddler: oblique tibial # .
Buckle
》incomplete cortical disruption resulting in periosteal
haematoma only
》Green stick
unilateral cortical breach only plus periosteal haematoma.
▪︎MAG3
》best for assess obstructed kidney.
》 in failing transplants.
▪︎Micturating cystoutrethrogram
》assess vescoureteric reflux
▪︎Familial hypocalciuric hypercalcemia.
》Increased serum calcium and serum PTH
》Decreased urinary calcium.
》Diagnosis by calcium to creatinine ratio < (.01).
▪︎TEF》Commonest: distal.
▪︎angiotensin 2》 VC.
▪︎Brachial artery
》start t.major.
》End neck of radius .
▪︎Weak ankle plantarfiexion; altered sensation on sole of foot;
loss of ankle jerk reflex.
》S1 root compression .
▪︎Trotter's triad (diagnosis of nasopharyngeal carcinoma)
》Unilateral conductive hearing loss.
》Ipsilateral facial & ear pain.
》Ipsilateral paralysis of soft palate..
▪︎left fifth intercostal space at edge of sternum.structure
penetrated?
》Right ventricle.
▪︎ painful arch syndrome. Shoulder Impingment..
》supraspinatus tendinitis.
▪︎Clostridium perfringes.
》ttt: penicillin v. clindamycin.
▪︎clostridium perfringens
》 cause food poisoning 》 take several hours to appear with
abdominal pain.
▪︎man with severe head injury is being ventilated using
intermittent positive pressure.consequence ?
》Decreased cardiac preload.
▪︎Hardinge style
(lateral approach) you divide transverse branch of lateral
circumflex iliac .
▪︎Digastric
Anterior belly》 mylohoid
Posterior belly》 facial.
▪︎Pisiform》Sesamoid bone in tendon of FCU .
▪︎Prostatic and membranous urethra 》 internal iliac LN.
▪︎VC》 maximum exhale after maximum inhale.
= IRV (3L) + ERV (1L)= 4L.
▪︎reduction of VC》 increase risk of perioperative hypoxia.
▪︎Stimulation of insulin by
》AA.FA.
》vagal.gastrin
》secretin.CCK.
▪︎C fibres》mechanothermal
▪︎A- alpha
motor &proprioception
▪︎A β fibre
touch and pressure.
▪︎B fibres》autonomic fibres.
▪︎Rectal varices
》Ttt: I.v terilpressin .

IMPORTANT 16
▪︎ pudendal nerve S2,3,4
▪︎Littres hernia ,: Mekel
Richter: small bowel
▪︎Osteoprosis.
decreased bone density.
few trabeculea.
Thinning of cortex.
vertebral body#.
diagnosis DEXA
ttt: biphosphonate....
▪︎Adductor canal syndrome
Pulse is present at full EXTENSION
▪︎Septic arthritis.:Staph aureus.
In young sexual active: neisseria
-Ttt: penicillin if sensitive flucloxacillin.
▪︎ Cleft palate👈 occurs as a result of non fusion of the two
palatine shelves.
▪︎Unilateral isolated cleft lip👈 represents failure of nasolabial
ring fusion.
▪︎Postmenopausal smokers with retroareolar abscess.
anaerobic ..ttt metronidazole
▪︎Extravasation :
Chemotherapy:cold compresses
TPN: hyaluronidase
Vinca alkaloid:warm.
▪︎E.coli ..Subtype 0157 hemolytic ureamic syndrome
▪︎Staph aureus:
Exotoxin: TSS toxic shock syndrome
Endotoxin: GE severe diarrhoea, necrosis and ulcer in colon .
▪︎Malignant fibrous histiocytoma:
From bone and soft tissue
.ttt excision with radiotherapy.
▪︎DMSA:
ascertain split function of kidneys.in case of staghorn stone.
Used for looking for renal scarring in VUR .
▪︎VUR diagnosis by micturating cystourethrogram .
▪︎Very well located tender at upper pole of testicles with bluish
hea:
torsion hydatid of morgagni.
▪︎Tumour suppression gene.. p53..BRCA1,2..RB gene.
BRACA 1 (chromosome 17)
BRACA 2 ( chromosome 13).
▪︎Anterior wall of femoral sheath is continuation of Fascia
transversalis.
▪︎Posterior wall of femoral sheath is continuous from Psoas
fascia and iliacus fasica.
▪︎most superficial of popliteal fossa? Tibial nerve.
▪︎ UOP in hypovolaemia shock
1.. >30
2...20~30
3....5~15
4...<5
▪︎Gastrinoma
In duodenum mainly.
MEN1
somatostatin scintigraphy.
Can be in ovary.
Positive secretin stimulation test.
▪︎In dehydration:
Increased urea to creatinine ratio.
Metabolic acidosis.
Rising Hematocrit.
Urinary Na <20
▪︎Normal Gap Acidosis: HARDUP
H - Hyperalimentation
A - Acetazolamide
R - Renal tubular acidosis
D - Diarrhoea
U - Ureteral diversion
P - Pancreatic fistula/parenteral saline.

▪︎Obstructive lung disease

FEV/ FVC reduced <70.
Asthma ..COPD ..Brochiectasis
▪︎Restrictive :
FEV1/ FVC increased >70
Pulmonary fibrosis
Asbestos ..Sarcoidosis
ARDS ..Kyphoscoliosis .

▪︎Transfer to burn centre if:

• Adult > 20% TBSA total burns (second or third degree)
or > 5% full thickness (third degree).
• Injuries to specific body areas, eyes, ears, face, hands,
genitalia, associated inhalation injury
• Significant electrical/chemical.
• child (< 10 years) with partial or full-thickness burns > 10%
TBSA.
▪︎What are 3 major vessels supplying blood to the hip joint?
Answer:
1.Medial circumflex femoral a.
2.Lateral circumflex femoral a.
3.Ligamentum teres
▪︎structure is at risk during lateral approach to hip joint?
Superior gluteal nerve

IMPORTANT 17 posted
▪︎Cavernous sinus syndrome
caused by cavernous sinus tumours.
》nasopharyngeal malignancy locally invaded cavernous sinus.
Diagnosis:opthalmoplegia, proptosis, Horner's.
▪︎hyperuricaemia causes
-Increased synthesis:
》psoriasis..lesch nyhan..
-Decreased production
》Aspirin..alcohol.
》》Others DKA..thiazide..lead.
》NOT hyperthyroidism.●
▪︎structures passing through greater as well as lesser sciatic foramina?
P – Pudendal nerve
I – Internal pudendal vessels
N – Nerve to obturator internus
▪︎onuf necleus》anterior horn of S2.
▪︎urge incontinence
》detrosur muscle overactive..
▪︎alveolar ventilation= minute ventilation(500) - dead space (150) = 350
ml.
▪︎H.pylori:gram-ve.
》Live only in gastric mucosa.
》Can live in ectopic gastric metaplasia...
》Product urease.
》No typical feature in endoscopy .
¤PAN
》with hepatitis B.renal disease..
》.fibrinoid necrosis.
▪︎ Renal papillary necrosis :
》UTI...NSAID in DM.
》X ray 》ring calcification .
▪︎causes of increased glucagon:
》AA.sympathetic.
》catecholamines.acetylcholine
▪︎VSD
》Right side HF..
》AR..IE.
》eisenmenger syndrome.
▪︎Waterhouse–Friderichsen syndrome (WFS)
adrenal gland failure due to bleeding into adrenal glands,
》caused by severe bacterial infection.Neisseria meningitidis.
▪︎falsely elevate 5-HIAA to avoid diagnosing carcinoid syndrome
incorrectly.
》spinach, cheese, wine, caffeine, tomatoes.《Naproxen》
》Monoamine oxidase inhibitors
》Recent surgery.
▪︎Carcinoid:
》secretory diarrhoea despite fasting .
》liver mets is must to cause carcinoid syndrome..
》Image by somatostatin scintigraphy.
》 ttt by octreotide.
▪︎ ttt of pancreatic fistula 》 octreotide.
▪︎ECG features》 hypokalemia
》U waves
》Small or absent T waves (occasionally inversion).
》Prolonged PR interval
》ST depression.
》Long QT interval.
▪︎ commonest cause of hypokalemia 》 diuretics.
▪︎Hyperkalemia 》ECG
》tented T.wave.
》wide QRS( as hypercalcemia)
》 loss of P.
》 ventricle fibrillation
▪︎Hypercalcemia narrow QRS.
▪︎Hypocalcemia
》Prolonged QT 》 IMPORTANT
》wide QRS.
▪︎hypocalcemia
》 ttt》 calcium gluconate
》if severe 》 calcium chloride.
▪︎ PE》T wave inversion V1-V3.
▪︎Shin of tibia (poor blood supply)
》If large wound》split thickness skin grafts
▪︎CYSTIC FIBROSIS》 ABSENT VAS DEFFERANCE
▪︎Alpha blocker
》used in ttt of BPH.
》cause hypotension.
》so CI in pilot.
》Alternative 5 alfa reductase inhibitors》 take months to act.
▪︎Immediate CT head (within 1 hour)
》GCS < 13 on admission
》GCS<15 2 hours after admission.
》Focal neurology
》Vomiting > 1 episode
》Post traumatic seizure.
》Coagulopathy.
▪︎Trastuzumab(HER receptors)
》Given in young ladies with [ER negative] with extensive nodal
metastases●
▪︎Infliximab (tumour necrosis alpha inhibitors).
》Given in perianal chrons after sepsis removed.
▪︎Imitinib (tyrosine kinase inhibitors).》》GIST.
▪︎Pleomorphic adenoma:
biphasic appearance (mixed stromal + epithelial element)
▪︎Gleason
》Till 4 well differentiate
》4- 7 moderate
》>7 poor .
▪︎5 year survival
》<5% pancreas cancer.
》5- 10% esophageal.
》25% metastases prostatic.
》70% Duke B
》90 % Duke A
▪︎Superficial inguinal pouch
》site of ectopic testis.
》Other sites of ectopic testes:
base of penis,femoral triangle and perineum.
▪︎Diathermy
Polypectomy》monopolar with blend mode.
Monopolar :
Cutting
》 Nonmodulated. High energy evaporate fluids
Coagulation
》 low energy
》 Make coagulum.
》 modulated
▪︎Blend mode
》Alternative cutting and coagulation.
▪︎CUSA and harmonic
》High frequency oscillation.
》 brain . Liver
▪︎Clostridium perfringens & streptococcus pneumonia
》ttt is penicillin.
▪︎Bacteroid》Metronidazole.
▪︎Klebsiella:
》Live in soil ( e.g Bush thorn )
》gentamycin
▪︎Inhibitor of cell wall.
》Penicillin
》Cephalosprins
▪︎Inhibitors of protein synthesis:
》Aminoglycosides.
》■Macrolid.
▪︎Inhibitors of DNA synthesis
》Quinolones
》Metronidazole

IMPORTANT 18
▪︎Ondansterone
》Serotonin anatagonist
》5HT3 blocker
》Block chemoreceptors trigger zone.
》in vomiting in terminal patient( post chemotherapy vomiting).
Postoperative vomiting.
▪︎Vomiting in gastroparesis:
Meticlopromide (dopamine receptors blocker)
▪︎ vomiting in autonomic gastropathy》erythromycin》 for vomiting in
vagotomized stomach
• dopamine anatagonist: 》prochlorperazin.
▪︎ dopamine 》 B1》 increased myocardial contractlity and increased
coronary blood flow
》 also adrenaline increases coronary blood flow.
▪︎Pain of bone》NSAIDS.
▪︎subcostal flank approach to kidney, which incised to increase upward
mobility of 12th rib?
》costovertebral ligament .
▪︎pudendal canal
》located on lateral wall of ischioanal fossa.
》In this location, it lies on inferior border of Obturator internus.
▪︎man is admitted with severe haematemesis.Upper GI endoscopy
identifies posterior gastric ulcer. Bleeding from
》Splenic artery
▪︎rectum is supplied by 3 vessels
》Superior rectal artery《 inferior mesenteric.
》Middle and inferior rectal. artery 《internal pudendal
▪︎acute phase response protein.
INCREASED
》ferritin
》Fibrinogen
》Caeruloplasmin
DECREASED:
Albumin
Transferrin
Cortical binding proteins
▪︎Cardiogenic Shock:
》(Increased PAOP)
》increased SVR (vasoconstriction in response to low BP)
》decreased cardiac output
▪︎Septic shock:
》similar response may occur in anaphylactic & neurogenic shock.
》reduced SVR《VD
》normal/increased COP.
▪︎renin reduced by
》Beta blockers & NSAIDS.
▪︎ beta blockers Cause
》hyperkalemia.
▪︎Prolactin:
》increased by TRH thyrotropin releasing hormone.
》decreased by dopamine.
▪︎ endocrine response to trauma
》Decreased
Insulin.testosterone.estrogen
》No change TSH..LH..FSH
▪︎lung compliance
》increased by Age.emphysema.
》 decreased by atelectasis
▪︎Follicular thyroid carcinoma:
》oxyphil cell .scanty colliod.
》Encapsulated.
▪︎prerenal AKI
》Decreased urinary Na
》Increased urine osmolarity
●ATN: Opposition of AKI
▪︎ TLCO raised:
》asthma.
》Pulmonary haemorrhage,
》left-to-right cardiac shunts
》polycythaemia.
▪︎Nausea 》inhibitor to gastric acid secretion..
▪︎Canon a wave》T.S
▪︎abscent A wave 》AF.
▪︎Oxaliplatin:
》Downstaging of liver mets due to CRC.
》Inhibitor to DNA synthesis.
》SE》 neuropathic
》 used in Duke C.( +ve LN)
●Cyclophosphamide:
》Alkylating.
》Used in nodepositive breast cancer.
●Goserelin:
LHRH agonist
Prostatic cancer
●Flutamide》
》Androgen anatagonist .
▪︎5- fluorouracil
》Antimetabolite
》In Duke C CRC.
▪︎Bleomycin plus cisplatin
》 used to testicular seminoma》Which is lymphatic spread.
▪︎Sickle cell anemia 》no anal fissure.
Leukaemia》NO anal pruritus.
▪︎Pethidine :
》Structural differences from morphine.
》toxic metabolite norpethidine clearance by kidney .
》10 % potency of morphine .
▪︎Pes Anserinus Bursitis:
sportsmen due to overuse.
》pain in medial proximal tibia.
●McMurray test is negative: medial meniscal injury is excluded.
▪︎Perthes:
》presenting with a limp.
》Early disease can be missed on x-ray( flattened femoral head)
》MRI often demonstrate areas of hypoperfusion and subtle changes
that allow for earlier diagnosis.
》Hyperactivity and short stature are associated with Perthes.
▪︎treatment of colorectal liver metastasis》chemotherapy followed by
surgical resection.
》Palliation would generally only be considered if patient were frail or
widespread disease.

IMPORTANT 19 posted.
▪︎situations where data is normally distributed and paired samples are
taken from same individuals (such as following an intervention)
》paired T Test may be used.
》Multiple testing and post hoc analysis = bonferoni
▪︎Normal DistribuTTion=TTest.
▪︎Data which not normally distributed cannot be analysed in this way
and non parametric test must be used.
》Chi Squared
》Mann Whitney U tests.
If sample size is small》Fishers exact used.
▪︎only muscle supplied by superficial branch of ulnar nerve is
PALMARIS BREVIS.
●only two flexor muscles not supplied by median nerve are
medial part of FDP and FCU.
▪︎Compartment syndrome
Earliest sign》pain out of proportion to injury to clinical situation.
》Most sensitive》 pain on passive stretching of involved compartment
▪︎Osteomalacia.
》low:calcium, phosphate
》raised:ALP
x-ray: children - cupped, ragged metaphyseal surfaces.
》X-ray:adults - translucent bands (Looser's zones or pseudofractures)
》Treatment:calcium & vitamin D
▪︎ keratoacanthoma
》Rapid increase of size over weeks then regression.
▪︎THR done to patient with preexisting joint disease.
》Done to patient with high life expectancy .
》Done to patient with good level and activity.
》Hemiarthroplasty done in older. Less mobile patient
▪︎Osteopetrosis:
》boy has tiredness, recurrent throat and chest infections, gradual loss
of vision.
》x-ray》brittle bones with no differentiation between cortex and
medulla:
》AR
》young adults.
》present with anaemia or thrombocytopaenia due to decreased
marrow space.
》 failure of bone resorption by osteoclast.
》 hard dense bone.
▪︎ Rheumatic arthritis NOT cause thrombocytopenia.
▪︎20y old woman trips over a step, injuring her ankle.
Examination:tenderness over lateral malleolus.
x-ray:undisplaced fracture distal to syndesmosis. action?
》ankle boot.
▪︎Which statements relating to quadratus lumborum is false?
A.Causes flexion of thoracic spine (correct).
》 Flexion by rectus abdminius.
B.Causes rib cage to be pulled down
C.Innervated by anterior primary rami of T12 and L1-3
D.Attached to iliac crest
E.Inserts into 12th rib.
▪︎Necrotizing enterocolitis
》Bloody stool
》Bile stained vomiting.
------------------‐————
▪︎Duodenal atresia.
》 scenario hx 》 trisomy
》 start hours after delivery
》X-ray:double bubbles sign.
》duedenoduodenostomy
----------‐------------‐------------
▪︎Malrotation with volvulus》
》associated with exomphalos and diaphragmatic hernia.
》 scaphoid abdomen
》 bilious vomiting.
》 after delivery by 7 day's
》UPPER GIT contrast》 medial displacement of DJ flexure.
》US abnormal orientation of SMA.
》Treatment 》ladds procedure .
▪︎active electrode is placed in DIRECT CONTACT with tissue and is
characterised by low current and high voltage over broad area.
(Desiccation)
D》D
▪︎electrosurgical mode whereby electrode is HELD AWAY from tissue.
current utilises low amplitude and high voltage.
(Fulguration)
▪︎sinusoidal, NON modulated waveform is produced and vaporises
tissues.
》Cutting current.
▪︎Delormes
Excision of mucosa.
Plication of rectum for external prolapse.
Altmeir.
Resection is colon via perineal approach. so》 leak
▪︎Rectopexy 》Via abdominal approach.
▪︎ Site of action:
》Frusemide :
Thick ascending loop of henle. Na/ k/cl transport.
▪︎Amiloride / thiazide
DCT.
▪︎Aldosterone》DCT. (Na/k) exchange ●●
▪︎ADH/ spironolactone》CD.
▪︎spironolactone:
》Non competitive anatagonist to aldosterone.
▪︎catecholamine from
》tyrosine.
▪︎95% of filtered calcium is reabsorbed in renal tubules.
▪︎dumping syndrome 《《 release of insulin.

IMPORTANT 20 posted
▪︎Metastatic bone disease:
》radiotherapy.
▪︎primary sclerosing cholangitis:
》Scarring of intrahepartic and extrahepatic bile duct ..
》With UC or HIV
》Positive ANCA 80%
》positive ANA 20- 50%...
》Main risk for cholangiocarcinoma.
▪︎acral lentiginous melanoma
》sole of foot.
▪︎ulnar nerve》 medial to brachial artery in arm.
▪︎ascending loop of henle
》impermeable to water.
▪︎middle cardiac vein
》accompanies》 posterior interventricular artery.
▪︎old female has undergone renal transplant 12 months
previously. Over past weeks there concerns about
deteriorating renal function. investigation?
(MAG 3 renogram)
》Because it excreted by renal tubular cells .
》MAG 3 renogram provides excellent imaging of renal
function.
》used in failing transplants.
▪︎innervation of lateral aspect of flexor digitorum profundus?
》AIN
▪︎ posterior longitudinal ligament 》separate intervertebral disc
from spinal cord.
▪︎hyperacute rejection
》IgG anti HLA class 1 Antibody in recipient.
▪︎Obstructed left colon cancer
》left hemicolectomy plus on- table lavage.
▪︎Obstructed right colon cancer.》right hemicolectomy.
●Obstructed splenic flexure cancer.
》extended right hemicolectomy
▪︎Elective right hemicolectomy.
》need preparation.
▪︎Cecal diameter 12 cm
》Impending perforation.
▪︎Obstructed sigmoid cancer.
》high anterior resection . Hartmann??
▪︎Laxatives》
Bulk forming 》
Bran..mathylcelllose
-Osmotic
Magnesium sulfate
Magnesium citrate
》Stimulant:
》Bisacodyl..Senna
Docusate .
▪︎old man presents with significant lower urinary tract
symptoms and diagnosed as BPH.drug produce slowest
response?
Finasteride 》 less retrograde ejaculatio.
》5 alpha reductase inhibitors prevent acute urinary retention.
▪︎2 year child with high out ileostomy
》 .9 NACL plus K.

IMPORTANT 21
▪︎cardiac tamponade:
》Large-bore needle insertion between xiphoid process and left 7th
costal cartilage, aiming towards left shoulder.
▪︎cardiac tamponade
》Always muffled heart sounds.
▪︎Paget disease
》 affects nipple primarily then to areola .
》punch biopsy ..90% have underlying invasive ductal
carcinoma .
▪︎substances released from sympathetic nervous system to
stimulate adrenal medulla?
》Acetyl choline.
▪︎ CN 9 & CN10 《from medulla.
▪︎old man presented with backpain for 1 month and irregular
urine stream,
PR: hard prostate mass, his PSA more than 300. first
treatment?
》hormonal.
▪︎ carcinoma of caecum.
what proportion of patients presenting with this diagnosis will
have synchronous lesions? 》5%.
▪︎structure limits straight-vertical-downward movement of
spleen
》Left colic flexure.
▪︎ transpyloric plane:
》through neck of pancreas
▪︎Which not stimulate insulin release:
》Gastrin.
》Protein.Secretin.
》Vagal cholinergic action.
》Atenolol 》beta blockers 》(inhibitor insulin release)
▪︎man with type 2 DM, bipolar disorder and COPD has bloods
taken during perioperative assessment .chest x-ray 》normal.
Na 125.cause for hyponatraemia?
》Carbamazepine
●SIADH
》carbamazepine,
》sulfonylureas, SSRIs, tricyclics.
▪︎Lithium
》 diabetes insipidus + high sodium.
▪︎Meconium ileus
》Associated with CF.
》Abdomen distended.
》x-ray》no fluid level.
•Hirschbrungs:
》Boy with delayed passage meconium.
》Full thickness biopsy.
》Aganglionic narrow segment.
▪︎adenoma recolonscopy 》》》
》Within 1 year》 if : 5 adenoma, 3 of them greater than 1m.
》Within 3 years 》 if 3 or 4 adenoma, 1 of them more than
1cm.
▪︎SIADH 》 hyponatremia..urine osmolarity >900.

IMPORTANT 22
▪︎66 year male is admitted to vascular ward for amputation.
He reports episodes of vertigo and dysarthria. suddenly collapses with
glasgow coma score of 3. diagnosis?
Basilar artery occlusion.
▪︎HCC.
NOT chemoradiosenstative..if used.. in palliative situation
▪︎carbamazepine in ttt trigeminal neuralgia..
▪︎rare to have fractures through anatomical neck.
Anatomical neck fractures which are displaced by >1cm carry a risk of
avascular necrosis to humeral head.
So ttt hemiarthroplasty.
▪︎In children commonest injury pattern is a greenstick fracture through
surgical neck.
▪︎Impacted fractures of surgical neck are usually managed with a collar
and cuff for 3 weeks followed by physiotherapy.
▪︎machinest at PVC factory with large irregular mass in right lobe of
liver.. angiosarcoma ( vinyl chloride )..
▪︎seminoma: sheet like lobular pattern of cells with fibrous
septa..lymphatic inclusions..
▪︎40 year old male presents with non painful, bilateral scrotal swellings
over 3 years.
swellings are smooth and adherent to testicular surface.diagnosis?
(Epididymal cyst)
testis is palpated therefore this differentiates it from hydrocele.
▪︎epididymorchitis:
May caused by amiodarone..
In age below 35 cause chlamdia..
▪︎neuropraxia:
Impaired conduction..wallerian degeneration NOT occur..
Full recovery..
Transient loss of function
▪︎facial nerve injury below geniculate ganglion: preservation of
lacrimation..
▪︎heart borders
Right: right atrium
Inferior: right ventricle..
▪︎CI to ESWL:
Cardiac pacemaker and AAA.
▪︎UB tumour from T2 to T4a is radical cystectomy +/- radiotherapy ..
▪︎ painless profuse rectal bleeding with hx of TIA taking statins..
》diverticular bleeding
▪︎Classification of oncogenes
1-Sis
2-Myc
3-RET.》 In MEN
4-Src.
5-Ras:on chromosome 12.
Most frequently observed in colorectal adenoma and carcinoma.
▪︎Ki 67 》nuclear proliferation marker. used in immunohistochemistry.
Although, Ki67 positivity is marker of malignancy, it is not itself, an
oncogene.
▪︎old lady with pain in both hands and difficulty with dropping objects.
examination: middle finger PIP joint is fixed in flexion of approximately
300 and the DIP joint is fixed in hyperextension. finding? .. Boutonniere
.
▪︎4 year old is admitted with right iliac fossa pain and is due to undergo
appendicectomy. nursing staff would like to give child an infusion of
intravenous fluid whilst waiting for theatre. Assuming electrolytes are
normal, which appropriate fluid ?
0.9% Saline solution..
▪︎Suxamethonium
Depolarizing ms relaxant.
Fastest and shortest duration.
Hyperkalemia.
Malignant hyperthermia.
▪︎Atracurium
Non depolarizing
Histamine release.
Not excreted by liver or kidney
Reversed by neostigmine.
Vecuronium & pancuronium are ms relaxant
▪︎After nurse cuts umbilical cord, which structure will not contain
oxygenated blood ??
Umbilical vein ( ductus venosus).
▪︎Which of variables listed below is not considered in sequential organ
failure assessment (SOFA) tool?
Bilirubin
Urea 》 correct
Mean arterial pressure
Platelet count
Creatinine
▪︎pupilary reflex:
afferent limb has nerve fibers running within optic nerve (CN II). Each
efferent limb has nerve fibers running along oculomotor nerve (CN III).
▪︎positive pressure ventilation decreases cardiac preload.
Decrease SV..
▪︎ACTH stimulation test 》 if suspect addison..
▪︎Insulin tolerance test 》 gold standard assay for adrenal insufficiency.

IMPORTANT 23
▪︎ LEFT temporal lobe extra dural haematoma causes LEFT CN3
PALSY
▪︎ superficial peroneal nerve anterior to lateral malleolus.
▪︎liposarcomas?
-Core biopsies in low grade liposarcomas may be normal.
- pseudocapsule.
-It is unlikely in lesion measuring less than 5cm.
-Pulmonary metastasis are common.
-Retroperitoneum.
-Resistant to radiotherapy.
▪︎Malignant fibrous histiocytoma is commonest variant of sarcoma.
-presence of pseudocapsule 》 local recurrence after resection.
- resection with radiotherapy
▪︎ parathyroid neoplasms:
5% due to carcinoma..
80% due to adenoma..
Adenoma is encapsulated .
85% of primary -hyperparathyroidism due to adenoma ..
▪︎serum calcium to creatinine ratio:
> .01 primary hyperparathyroidism..
< .01 hypocalciuric hypercalcemia..
▪︎structures separates ulnar artery from median nerve?Pronator teres .
▪︎osteosarcoma:
-Mesenchymal cells with osteoblastic differentiation.
-New bone formation..periosteal elevation
-Metaphysis..
Ttt surgery plus chemotherapy..
▪︎Glioblastoma multiformes
Transverse midline
Central necrosis.
Worst prognosis..
▪︎lung adenocarcinoma
Never smoking..at periphery
▪︎Small cell lung cancer》
Early Mets...main bronchial tree.
Smoker..Chemosensetive
▪︎ stripple cell in lead poisoning..
▪︎old lady investigated for episodes of painless haematuria. With long
term smoking ..cause? TCC bladder
▪︎UB cancer with schistosomiasis 》 SCC.
▪︎pharyngeal pouch 》
Between thyropharyngeus and cricopharyngeus..
▪︎Leukoplakia》thick, white or grayish patches form usually inside your
mouth. Smoking is most common cause.
associated with HIV.
Can not be rubbed off.
▪︎lymphoma..can be with long standing sjogren ..
▪︎Cohort
Observational and prospective
▪︎Case control :
Observational and retrospective
▪︎feature of oesphageal atresia in neonates?
A. High incidence of polyhydramnios .
C. Distal tracheoesphageal. fistula is commonest variant.
D. High incidence of associated imperforate anus.
E. Absence of gastric bubble on antenatal ultrasound.
▪︎less of lumbar lordosis.
restriction of spinal movements.
positive Shober test
reduced chest expansion.
diagnosis?
Ankylosing spondylitis
Sacroiliac pain increases with rest.Relief by movement
x-ray bamboo spine
HLA B27 gene..
▪︎Isolated pulmonary metastases from CRC.
Treatment by resection.
Residual anal SCC after local radiotherapy ,ttt by abdominoperineal
resection.
Metastatic prostate cancer not involve the bone, ttt by hormone
If bone invaded ttt by radiotherapy .
Diffuse intracranial metastases, ttt by radiotherapy plus steroid.
▪︎What is most significant event to contribute to wound healing
immediately following injury?
Platelet degranulation.
▪︎8 year old boy presents with abdominal pain,twelve hour history of
vomiting,fever of 38.3 and four day history of diarrhoea. His abdominal
pain has been present for past week.
Appendix abscess
▪︎least risk of developing osteoporosis?
Obesity》 correct
Long term unfractionated heparin therapy
Gastrectomy
Osteogenesis imperfecta.
Diabetes.
▪︎auriculotemporal branch of mandibular nerve. with the nerve to
external acoustic meatus supplies the anterior and superior wall of the
canal with sensory innervation.
auricular branch of the vagus nerve supplies the posterior and inferior
walls of the canal, and facial nerve may also supply it due to its
connection with the vagus nerve.
▪︎SIADH.
* Hyponatremia
* Increases urine osmolarity
* Decreased serum osmolarity
Causes ABCCD
A analgesia opioid NSAIDS
B barbiturates
C cyclophosphamide. (Carbamazepine ).
D diuretics thiazide

IMPORTANT 24 posted
▪︎32 y man is diagnosed as carcinoma of caecum.
his mother developed uterine cancer at age 39. maternal uncle died
from colonic cancer aged 38.His brother developed colonic cancer with
micro satellite instability aged 37.
operative ?
》Panproctocolectomy and end ileostomy.
diagnosis》 one of familial cancer.
▪︎SCC. Skin
》spread lymphatic.
》from keratinocye...with HIV.
》high risk (xeroderma pigmentosum. Albinism).
》poor prognosis (>2cm in diameter. >4mm depths)
》Rough scaly surface & Flat reddish plaque.
》Safty margins 》 》
If <2cm diameter 》 need 4 cm margin
> 2cm》6mm margin.
▪︎ SCC at cheek
》can use radiotherapy
》Over nose 》 CI radiotherapy.
▪︎Le Fort II fractures?
1-Excessive mobility of palate.
3-Malocclusion of teeth
4-Enopthalmos.
5-Parasthesia in region supplied by infraorbital nerve.
》》Affects maxilla. Nasal bone..medial aspect of orbit.
▪︎ le Fort 3》
》Often bilateral
》 frontoethamoid
》Superior orbit.
》Ethamoid to sphenoid.
▪︎Osteoclastoma》
》x-ray with multiple lytic and lucent areas (Soap bubble)
appearances.
》Clear defined borders..
》Pathological fractures occur.
》usually indolent.
▪︎ligamentum flavum
》anterior to spinous processes●
▪︎dural sac end》 S2.
》Spinal cord L1
》LP L4,5.
▪︎has greatest impact on PPV on test?
》Prevalence.
▪︎penile # 》 exploration
▪︎Stone 1cm in upper third ureter + partial obstruction.
Failure conservative 》 ESWL..
▪︎subchondral cyst
》 osteoarthritis.
▪︎ osteoarthritis
》 lateral deviation of fingers tips
》Heberden nodules .
》Bouchered nodules
▪︎baroreceptors
》 1st heamostatic response in fall in arterial blood pressure..
▪︎At endoscopy, mucosa in patients with Crohns disease
》cobblestones.
》 mucosal islands (pseudopolyps)》 ulcerative colitis.
▪︎Iliopsoas abscess.
》Recurrence 15%.
》crohn's 2ndary causes.
》CT guided drainage.
》Iliopsoas muscle arises in lateral borders of T12 to L5.

IMPORTANT 25
▪︎ bupivacaine
》Dose 3mg/kg
Concentration .25% mean each ml has 2.5 mg.
70 kg》 56 ml.
▪︎conus medullaris L1,2.
▪︎Campylobacter jejuni
》Infection similar manner to acute appendicitis.
》Pyrexia.
》gram negative.
》Infection accounts for 26% case of Guillain-Barre syndrome
》commonest cause of infective diarrhoea.
》 BIRDS is reservoir
▪︎7 year old boy falls off wall distance is 7 feet.
He lands on his left side and there is left flank bruising. no
haematuria .otherwise stable and haemoglobin is within
normal limits. action?
abdominal USS.
▪︎lymphatic from rectum
》 paraortic..
▪︎psammoma bodies
》 cluster of calcification.
▪︎Takayasu arteritis:
》large vessels.
》young assian female
》absent peripheral pulse
》Upper limb claudication
》..ttt steroid.
▪︎Giant cell arteritis
》Temporal arterities
▪︎compartment syndrome
》pain worsened by passive stretching of affected
compartment.
▪︎neutrophils
》produce H2O2.
▪︎Which does not cause red urine?
A. Rifampicin
B.Phosphaturia .(answer)cloudy urine
C. Beetroot
D. Rhubarb
E. Blackberries.
▪︎All of following can cause Hypokalaemia with acidosis
Except :
Diarrhoea
Vomiting. (correct answer )
Renal tubular acidosis
Acetazolamide
Partially treated DKA
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.
▪︎73 y old lady investigated for anaemia. 》colonoscopy:flat
broad based lesion in caecum.
biopsied and histology:adenoma with high grade dysplasia.
D. Snare polypectomy
E. Segmental colonic resection answer .
correct answer is Segmental colonic resection
This is most likely a malignancy and should be resected.
Polypectomy of flat broad lesions in right colon is difficult and
where concern arises right hemicolectomy is probably safest
option.
▪︎marfan
》High arched palate.
》Arachnodactyly
》Scoliosis
》Pectus excavatum
▪︎linear branching microcalcification
》 comedo DCI.
▪︎Li fraumini 》sarcoma + leukaemia+ adrenal ..
▪︎dry mouth that has been present for past few months.
sensation of grittiness in eyes.
examination :diffuse swelling of her parotid gland. no evidence
of facial nerve palsy.
》Sjogrens
▪︎dysphagia (esophageal web)
plus anaemia resistant to ttt
》 plummer vinson syndrome
▪︎ Negatively birefringent crystals
》 gout.
▪︎positive birefringent crystals 》 pseudogout.
P》P.
▪︎pseudogout
》 x-ray 》chondrocalcinosis
》 joint aspiration 》calcium pyrophosphate.
》 blood 》 transferrin saturation

IMPORTANT 26. Posted

▪︎ clear cell
》 subtype from RCC metastases to lung.
▪︎long reflex 》 barrett 》adenocarcinoma..
▪︎Obstructed rectal cancer
》Loop colostomy.
■Cancer staging:
●Rectum cancer:
T3N2.
T3 till pericolic fat, not invaded to peritoneam.
N2 mean at least 4 more are positive.
T4》 tethering to prostate 》 ttt long coarse
chemoradiotherapy
▪︎Dukes
A. Into submucosa
B1. into muscularis propria.
B2 through muscularis propria.
C1: node positive. Plus B1
C2 node positive Plus B2
▪︎Submandibular
》secrete 800- 1000ml saliva per day.
》typically produce mixed
seromucinous secretions.
parasympathetic 》serous.
》parasympathetic fibres are derived from chorda tympani
nerves and submandibular ganglion》they travel via lingual
nerves.
▪︎ saliva》 highest content of K.
▪︎Radial nerve injury level:
》Low injury (elbow)》PIN affected so unable to extend fingers
and weakness of thumb abduction.
》Very high lesion (axilla)》triceps loss.
▪︎ radial nerve 》 brachioradialis.
BEST.
● radial nerve injury in axilla》 NOT affect EXTENSION at
interphalangeal joint 》》 lumbricals still function
▪︎Fracture neck femur
》Extracapular e.g intertrochantric ttt by DHS.
》Cannulated hip screw are used for intracapsular #.
▪︎ bipolar diathermy
》Low current.high frequency.
》high voltage.
▪︎Gleason
Till 4》well differentiate
4- 7 moderate
>7 》poor.
▪︎PSC (sclerosing cholangitis )
》(IBD) ulcerative colitis.
Cholangitis 》 colitis.
▪︎ Cholangitis due to ERCP》E.COLI 》 AB 》 amoxicillin,
cephalosprins, carbapenems. aminoglycosides.
▪︎Antimitochondrial antibodies are characteristic serological
marker for PBC( primary biliary cirrhosis)..
Cirrhosis 》 autoimmune.
▪︎ cyclosporin S.E
》Nephrotoxic..hisutism.
gingival hyperplasia..
▪︎heterotopic graft
》 transplantation of donor organs to different anatomical
site..
E.g kidney.
▪︎accelerated graft rejection up to one week post transplant.
▪︎ acute rejection
》from 1 week to 100 day.
▪︎Le fort 3
》Frontoethamoid region
》Superior and lateral orbit.
Zygomatic arch
》Ethamoid to sphenoid
》It is craniofacial dysfunction
CSF rhinorrhea.
▪︎proximal ulnar nerve damage (elbow).
》 ring and little fingers paralysis in full EXTENSION.
●little finger dermatome 》C8.
▪︎preserved elbow EXTENSION
》 radial nerve injury in spiral groove.
▪︎stone kidney
<2cm ESWL
>2 CM PCNL.
▪︎Stone lower calyx >1cm 》》PCNL

IMPORTANT 27
▪︎ spinal shock 》 flaccidity..loss of reflexes ( bulbocavernosal). Seen
after spinal cord injury.
▪︎urethral catheter for 6 week 》urethral strictures.
▪︎kidney injury
Grade 2》 laceration <1cm without extravasation.
Grade 3 》>1cm with extravasation.
Grade 4》 reach corticonedullary junction.
▪︎testicular tumour staging 》
1》 confident to testis
2》 abdominal nodes
3》 supradiaphragmatic
4 》 extranodal ( lung)
▪︎hydrocele 》
》NOT Palpable TESTIS
》 can get above swelling.
▪︎ inability to get above swelling 》 inguinoscrotal hernia.
▪︎old male presents with a swollen, painful right scrotum after being
kicked in groin area.
There is painful swelling of right scrotum and underlying testis cannot
be easily palpated. action?
Scrotal exploration
Testicular USS
answer
Scrotal exploration
Acute haematocele: tense, tender and non transilluminating mass.
testis will need surgical exploration to evacuate blood and repair any
damage.
▪︎torsion testicular appendage 》
Boy 11 year with thickening of the cord.
▪︎ polycystic kidney:
Always bilaterally renal mass with protinuria.
▪︎irregular testis 》 tumour.
▪︎Pseudomonas ttt》
Penicillin or cephalosprins.
▪︎MRSA carries 》 mupirocin intranasal.
▪︎Potts 》 TB osteomyelitis.
Asian patient..low back pain for few months.
▪︎Chemotherapy 》uric acid stone.
▪︎pain and temperature 》 spinothalamic
▪︎Trabeculea carnea 》right & left ventricle.
▪︎ infundibulum (also known as conus arteriosus) is conical pouch
formed from upper and left angle of right ventricle.
▪︎FAP associated with duodenal polyps which is most common extra
colonic site.
FAP associated with gastric fundal polyps.
▪︎athletic 15 year old boy presents with knee pain of 3 weeks.worst
during activity and settles with rest.
examination:tenderness tibial tuberosity and swelling at this site.
diagnosis?
Osgood Schlatters disease.
▪︎Salter Harris 》
2 》 metaphysis
3》 growth plate +epiphysis +metaphysis(SPARED).
4》 through all.
▪︎12 year-old boy who is small for his age presents to clinic with poor
muscular development and hyper-mobile fingers.
x-rays》multiple fractures of long bones and irregular patches of
ossification.diagnosis?
Osteogenesis imperfecta
(Defects in Collagen type 1)
》Osteogenesis imperfecta is caused by defective osteoid formation
due to congenital inability to produce adequate intercellular substances
like osteoid, collagen and dentine.
Radiology》 translucent bones, multiple fractures, particularly of long
bones, wormian bones (irregular patches of ossification) and a trefoil
pelvis.
▪︎C2- Occipt and Top neck
C3- Clavicle and low neck
C4- Below clavicle
C5 to T1 UPPER LIMB
C5- elbow and biceps flexion
C6- wrist extension
C7- Elbow and triceps extension + cervical rib
C8- long finger flexion
T1- small finger abduction
T4 - Nipple
T6- trachea bifurcation and Xiphoid process.
T12- Above hip girdle
S1- Heel and middle back of leg
S2- back of thigh
S3- Medial side of buttocks
S4- perineal Region
S5- skin adjacent to anus
S3,4.5 Anal spincter
L1 to L5 Hip Girdle
L1 - Groin
L2- ant. Surface of thigh and hip flexor
L3- Knee extension and quadriceps
L4-5 Ankle dorsiflexion and tibialis anterior
L5 -toe extensor and hallicous longus
S1- ankle planter flexion and gastrocnemius.
▪︎jamaican + splenomegaly + ulcer at shin 》》 sickle anaemia
▪︎arterial ulcer 》 punched out edges.
▪︎venous ulcer 》 sloping edge at gaiter area.
▪︎thyroid lymphoma 》 B cell.
▪︎carotid image 》
CT scan add better evaluation than duplex in case of dense
hemiplagia.
▪︎graft survival 》
5 year patency rate
Aorobifem 》 90%
Fem- fem 》 80 %
Fem- pop (vein)》 70%.
IMPORTANT 28 posted
▪︎ ulcer
》 undermined edge and bluish tinge 》 TB.
▪︎outbreak of E.COLI diarrhoea necessitates 》 ward closure .
● E.coli 》 diverticular abscess.
▪︎single used suture
》 ethylene oxide.
▪︎pain at rest + hypercalcemia + high ALP
》 metastases from breast to bone.
▪︎hx of steroid + normal calcium plus normal ALP. vertebral
body#
》 osteoporosis.
●chondromalacia patellae
》teenage girl with knee pain on walking down stairs.
》quadriceps wasting.
▪︎talipes equinovarus:
》Adducted and inverted calcaneus.
》Medial displacement of navicular bone.
》nearly always bilaterally.
》 Wedge shaped head of talus.
》Severe Tibio-talar plantar flexion.
》conservative ttt 1st.
▪︎accidental vs Non accidental
Newborn # ..
In accidental 》 child taken very soon to hospital.
▪︎# below syndesmosis
Intial 》 below knee cast Up to midfoot, then after radiology
union appear 》 aircast boot
▪︎old patient with # at level of syndesmosis》 below knee cast
Up to midfoot.
》 Bad bone Quality.
▪︎technetium bone scan superior to MRI in Perthes.
● 2Cm lesion with suspect HCC 》 do MRI》》multifocal.
▪︎Barton's #》 radiocarpal dislocation.
▪︎comminuted #》 open reduction and internal fixation.
▪︎adult .spiral # with healthy covering 》 IMN .
▪︎pancreas from ventral and dorsal endodermal outgrowth of
duodenum.
▪︎spondylolisthesis
》Athletic with Sudden severe back pain plus prominent
sacrum.
》Scotty dog in plain film
▪︎achalasia:
》retrosternal chest pain.
》dysphagia to liquid and solid.
》 1st line ttt 》 ENDOSCOPY DILATATION●
▪︎high grade barrett and multifocal
》 esophagectomy.
▪︎any esophageal cancer metastases is contraindicated for
resection of esophageal cancer.
▪︎burn DRESSING
》 hydrogel better than silver.
▪︎BMI 50 》 referred early to bariatric surgery.
▪︎old lady undergone colonoscopy》1.5cm lesion in
caecum.histology》sessile serrated polyp with traditional
features. management ?
》colonoscopic polypectomy.
▪︎6 day baby was born at 33 weeks.suffering from respiratory
distress and has been receiving ventilatory support on NICU.
developed abdominal distension and septic.
Ultrasound》free fluid and evidence of small bowel
dilatation.blood pressure remained labile despite inotropic
support.
》Laparotomy (NEC).

IMPORTANT 29 posted
▪︎motorcyclist involved in RTA.humerus fractured. radial nerve injured.
Which muscles least affected at this site?
A. Extensor carpi radialis brevis
B. Brachioradialis
C. Abductor pollicis longus ( correct ) supplied by PIN
D. Extensor pollicis brevis.
▪︎metastatic lower esophageal tumour 》metal stent
▪︎ metastatic upper esophagus tumour 》chemotherapy.
▪︎zinc absorbed
》duodenum and jejenum.
▪︎Rockall of upper GIT bleeding
》age.
》shock (Bp).
》co-morbid (liver or cardiac).
NOT aspirin.
● aspirin inhibitor thrombaxane A2.
▪︎Nottingham prognostic index
(Tumour is ×.2)+ LN score + grade score.
<2.5 excellent
>5.4 poor
▪︎malignant breast mass with clinical and imaging not
suspicious for axillary disease
》Do sentinel biopsy.
▪︎low grade multifocal DCI
》simple mastectomy.
▪︎poor vision plus bilateral gynaecomastia
》 prolactin.
▪︎ cori cycle 》 erythrocyte.
▪︎ Gastric HCL Factors
》+ By
♤Parasympathetic
♤Vagal..ACH
♤Histamine.
♤Gastrin 》》 bind to cholecystokinin B receptors
》- By
Sympathetic.
Catecholamines
Atropine ..
Vasopressin
■ ATROPINE 》 TC
▪︎sick euthyoid
》ICU patient
》Low TSH. low T4.
▪︎secondary hypothyroidism
》 low TSH..low T4.
▪︎young lady with grade 3 breast cancer with nodal metastases
》 chemotherapy.
▪︎gastric lymphoma 》B
▪︎Trendlenberg test
》Affected side up
》Healthy side down 》 try to compensate.
▪︎obstructed carcinoma splenic flexure 》 extended right
hemicolectomy.
▪︎Rectal cancer 10 cm from anal verge 》 high anterior
resection and covering ileostomy.
▪︎colovesical fistula investigation 》 CT.
▪︎high output small bowel fistula 》TPN plus octertide
▪︎young patient with rectal bleeding and diarrhoea and
incontinence 》 proctatitis.
▪︎inferior thyroid artery enter thyroid at 》C6.
▪︎BCC
》prognosis depends upon histological type.
》pearly white.
》Raised edges ●
▪︎COHN syndrome
HTN plus hypokalemia
IMPORTANT 30 posted
▪︎ bascom of PNS on elective basis.》not in acute condition
▪︎platelet
》 transfusion no need for crossmatching
▪︎anaesthesia
》 late sign indicates poor prognosis of compartment.
▪︎insulin should NOT be stopped in type 1DM.
▪︎most common tendon rupture in cut wrist 》 FCU.
▪︎flexible sigmoidoscopy preparation
》 phosphate enema at morning
▪︎caudate
》superior to porta hepatis.
▪︎reticulo-endothelial cells of spleen》 white pulp.
▪︎large defects in face
》 full thickness graft
▪︎acute adrenal insufficiency ttt
》hydrocortisone 100 mg I.V
▪︎time of surgery
Straight forward acute cholecystitis 》 within 24 hour.
Straight forward acute appendicitis 》 within 6 hour
▪︎Nylon sutures
》monofilament
》smooth, soft and excellent knot security.
》 non-absorbable
》tensile strength. ...
》infection resistant.
》used for general closure, skin and plastic surgery.
■isolated hemisensory loss.
》 LACUNAR infarction.
▪︎anterior cerebral vs middle one
》 middle 》 aphasia.
▪︎diarrhoea. Stood floating in toilet water.Egyptian
》 giardia.
▪︎EMPYEMA
》operative cholecystostomy.
▪︎PTC
》 used in failed ERCP.
▪︎post ERCP severe abdominal pain 》 pancreatitis or duedenal
perforation 》 CT.
▪︎ duedenal ulcer
》 marked pain several hours after eating.
》when present with melena 》 posterior sited.
》 when present with peritonitis 》 anterior sited.
● NO duedenal ulcer with atrophic gastritis.
▪︎Etomidate ●●●
》Cause ♤adrenal suppression.
》Safety cardiac profile ●●
▪︎Epirubicin
》 intercalation is DNA.
Used in regimen FEC for breast cancer.
C 》 Cyclophosphamide
F》 fluorouracil
▪︎vertebrae
》 lumber vertebrae has NO tranverse process foramen.
》 spinous process formed by 2 laminae posteriorly.
▪︎blood in circle of Willis NOT mix.
▪︎dorsalis pedis pulse
》 lateral to EHL.
▪︎venous ulcer
》 punch biopsy
》 use skin grafts
NO excision.
▪︎anaplastic thyroid carcinoma
》》SPINDLE cells
●Wuchereria 》》 filariasis
■Thyroid peroxidase antibodies 》hashimoto 》 lymphocytic
infiltrates and acinar destruction
●After splenectomy:
》Howell jolly bodies
》pappenheimer bodies
》target cells +
》contracted RBCs
》 thrombocytosis
● mycotic aneurysm
》Salmonella then steph
● chronic granulocytic leakemia
》 massive splenomegaly
●Tibial plateau #
▪︎Shatzker 2: vertical split of lateral condyle, affects lateral
meniscus.
▪︎Shatzker 4: # of medial condyle, with medial meniscus
injury, possible arterial damage
▪︎Shatzker 3# depression of articular surface with intact
condyle
▪︎Type 4 # of both condyles
● meniscus injury
▪︎ knee locking
》 can not fully EXTENSION
IMPORTANT 31 posted
▪︎ nerve injury with tournique
》 radial nerve.
▪︎pulmonary oedema after blood transfusion NOT responding to
frusemide
》 transfusion associated lung injury.(Neutrophilic mediated)
TALI.
▪︎amyloid type
AA》 Rheumatic
AL 》 MM
Beta》 RF.
▪︎ACL
》 Attached to posteromedial aspect of lateral condyle of
femur.
▪︎redo-fundoplication
》vagal injury 》delayed gastric emptying.
▪︎tracheastomy
》long term weaning from ventilator.
》 decreased work of breathing.
▪︎Propofol
》Antiemetic properties so used in day case surgery
》 maintenance of sedation in Icu.
■Thiopenton
》Appendectomy
》Used in rapid sequence of abduction.
》Extreme rapid onset.
》Market myocardial depression.
■Ketamine. ♤♤
》Strong analgesia
》Little myocardial depression,
》used in hemodynamic unstable. ♤♤♤ RTA
》Dissociative anaesthetic.
》Etomidate
》Safety cardiac profile
▪︎Amitriptyline
》1st in Neuropathic pain
》If patient has orthostatic hypotension》 pregabalin.
▪︎Duloxetine
》Neuropathic pain of DM.
▪︎NEC
》mortality of 30%
》Most frequently presents in premature neonates less than
32 weeks gestation.
》managed early by conservative ttt.
》May be minimised by use of breast milk over formula feeds.
▪︎in splenectomy
》 platelet given after splenic artery ligation.
》 preoperative vaccination》2 week.
▪︎procaine 》NOT Amino amide
IMPORTANT 32

Important changes at birth :

1 - Urachus (Allantois) >>>>>>>>> Single, median umblical ligament.
2 - Umbilical arteries >>>>> Right and left medial umblical ligaments.
3 - Ductus venosus >>>>>>>>> Ligamentum venosum
4 - Ductus arteriosus >>>>>>>>> Ligamentum arteriosum (6th arch )
5 - Left umblical vien >>>>>>> Ligamentum teres ( round ligament) in
free edge of falciform ligament.
7 - Foramin ovale >>>>>>>>> Obilterate at birth >> fossa ovalis but
may remain patent into adulthood in about 20 % of cases.
Urinary system :
from intermediate cell mass ( pronephros , mesonephros ,
metanephros )
1 - Pronephros ( Forekidney) >>>>>>
7 pronephric tubules and single duct
2 - Mesonephros ( Midkidney )>>>>
* cranial 44 tubules will degenerate
* caudal 26 will develop of male genital duct system
* mesonephric duct >>>> ureteric bud >>>> collecting like ureter.
3 - Metanephros (Hindkidney or permanant ) >>>>
caudal 1/4 nephrogenic cord >>> secretory part of kidney.
Genital system
▪︎Mesonephric duct (Wolffian) >>>>
Upper part >>>>> epididymis
Middle part >>>> vas deferns
Lower part >>>> seminal vesicle
Caudal part >>>> ejaculatory duct
NB
Remainant of this duct >>>> appendix epididmios , paradidymis
Paramesonephric duct (Mullerian) >>>>
Upper part >>>> uterine tube except intramural part
Middle part >>>> intramural part ... horn of uterus
Lower part >>>> uterus and upper 3/5 of vagina
lower 2/5 of vagina >>>>> uterovaginal canal from lower part +
sinovaginal bulb
NB
Remainant of this duct >>>> appendix testis
IMOPRTANT ABNORMALITIES
1 - Congenital recto-vesical and vesico-vaginal fistula >>>>>
incomplete development of CLOACA septum
2 - Hypospadius >>>> External uretheral opening under surface of
penis
3 - Epispadius >>>>> Opening in dorsum of penis
4 - Testis descent >>>> Contraction of GUBERNACULUM
5 - Persistent processes vaginalis >>>>>
* Congenital hydrocele if communication is small
* Congenital inguinal hernia if communication is wide
Spina bifida :
1 - Spina bifida occulta
Defect in vertebral arches
2 - Spina bifida with meningocele
Meninges project through vertebral defect forming sac filled with CSF
3 - Spina bifida with meningomyelocele
Meninges and spinal cord project through vertebral defect forming a
sac
Clefts :
1 - Cleft palate >>>>>>
Failure of fusion between two palatine processes posteriorly and
primary palate
( median) anteriorly
2 - Perforated palate >>>>
Failure of fusion between two palatine processes at certain point at
midline
3 - Cleft lip >>>>
palatine sheeveled.
Congenital heart diseases :
Cynotic ( 3 T 1 P )
1 - TGA most common at birth
2 - Tetra logy of fallot most common overall
3 - Tricuspid Artesia
4 - Pulmonary stenosis.
Acynotic
1 - VSD most common 30 %
2 - ASD more common in adults
3 - PDA
4 - Coarctaction of aorta.
Pharyngeal arches and pouches :
Pouches
1st pouch >>>>> eustichian tube
2nd pouch >>>>> palatine tonsil
3rd pouch >>>>> sup part ...... inferior parathyroid
inf part ......... thymus
4th pouch >>>>> sup parathyroid
6th pouch >>>>> parafollicular C cells
NB
Thyroid gland from >>>>>>>>>>>>> Foramin caecum.
Arches
1st arch ( massive list of Ms)
Artery Maxillary
Nerve Mandibular
Muscles ( MAT * 2 ) Mylohyoid , Mastication
Ant 2/3 of tongue , Ant belly of diagastric
Tensor tympani , Tensor palatine
Bones Meckles , Mandible , SpenoMandibular lig
Middle ear bones ( malleus and incus )
2nd arch ( massive list of Ss)
Artery Stapedial
Nerve Seventh ( Facial)
Muscles Smiling muscles ( expression) , Stapedius
Stylohyoid , poSt belly of diagaStric
Bones Stapes , Styloid , Stylohyoid lig , leSSer horn of hyoid
3rd arch ( massive list of Gs)
Artery ICA
Nerve Glossopharyngeal
Muscles StylopharenGeous
Bones Greater horn of hyoid
4th arch ( Right subclavian and Arch of aortaS are Talent PLayers of
Cricket)
Artery Right subclavian , Arch of Aota
Nerve Superior laryngeal
Bones Thyroid cartilage
Muscles Pharyngeal constrictors , Levator veli , Cricothyroid
6th arch ( Please Dont Remember * Laryngael* )
Artery Pulmonary artery , Ductus areteriousm
Nerve Reccurent laryngeal
Bones All laryngal except of 4th arch
Muscles All intrinisic laryngeal except of 4th arch
▪︎oxyphil cells 》 parathyroid.
▪︎
IMPORTANT 34 posted
▪︎ sinus tarsi
Between talus and calceneum
▪︎anastrazole
》adjuvant for node positive premenopausal breast cancer.
▪︎saphenous n.
》L3.4.
▪︎lateral border of the foot by
》S1.
▪︎myathenia gravis
》 Antibodies against postsynaptic Ach receptors
▪︎metanephrone 》 kidney
▪︎physiological dead space increased by 》》 PE.
▪︎anatomical dead space measured by 》》Fowler's method .
▪︎Lumber puncture 》 bleeding from vertebral venous plexus.
▪︎epidural space contains numerous nerve roots and venous
plexus
▪︎post heart transplantation 》 what increase COP
》》 increased atrial filling.
▪︎MIXED acidosis 》》
Decreased Hco3 & increased Co2.
▪︎morning headache 》 frontal glioma.
▪︎tumour of 4th ventricle of brain 》 Ependymoma.
▪︎ scenario》 hx of angina 》 operation 》 hypotension
》 caused by reduced SV.
▪︎Myeloma 》 NOT cause a vascular necrosis.
▪︎Nimodipine.
》calcium channel blocker.
》reduces cerebral vasospasm.
》administered in subarachnoid haemorrhage.
▪︎stress incontinence
》 initial management 》 pelvic floor excersize
▪︎left 9th inntercostal space
》 left kidney .
●medial collateral ligament damage
》 positive valgus stress test
》 minimal joint effusion.
▪︎Hartman 》》 ringer lactate.
▪︎adhesive capsultitis ( frozen shoulder) 》 can follow axillary
nodes clearance of breast cancer 》 all active movement are
reduced.
▪︎lunate dislocation
》 median nerve injury.
●gritti stokes amputation
》 patella retained

IMPORTANT 35 posted
* all rotators of shoulder inserts greater tuberosity. Except
subscapularis in 》lesser.
*external jugular vein drains into 》subclavian.
* in Cxr Immediately inferior to aortic knuckle: 》pulmonary trunk.
* when imaging and biopsy in breast are not concordant do
》excisional biopsy.
*cryptospordium infection in immunocompromised patients.
*needle prick: most common infections:hepatitis B.
* Morton neuroma
》3rd and 4th toes.
* neck swelling moves sideways 》chemodectoma.
* mythenia gravis vs eaton lambert: Eaton Lambert gets better with
excertion.
* syrinomyelia:
》Loss of pain and temperature on upper limbs.
*Vagina●
●upper to internal iliac
●Lower to inguinal●
* achondroplasia》AD
Defect in 》fibroblasts growth factor.
》Narrow spinal canal
* rapid growing keratin centre,, resolves with scarring
(karatoacanthoma )
* thorn injury easily bleeding: pyogenic granuloma.
》hx of minor trauma.
● thorn prick pulp infection
》 streptococcus pyogenes
▪︎ Bowen disease.
》Insitu SCC.
》erythematosus scaling patch from sun exposed skin.
▪︎extra intestinal manifestations chrons:
》sacroilitis..
》ankylosing spondylitis..
》aphthous ulcers..
》erythema nodosum.
》pyoderma gangrenosum..
▪︎ factors increase risk of cancer in UC..
》 pancolitis ..unremitting disease
》 poor compliance to ttt.
▪︎hypospadius associated with cryptorchidim.
● Hypospadius
》 urogenital fold.
▪︎TB》 thoracic spine.
▪︎osteomyelitis
》cervical spine.
》ttt 》initially by antibiotics.
▪︎ scenario 》IVDU /temp 39\back pain》 osteomyelitis.
▪︎Rovsing sign NOT in retrocecal appendicitis..
》retrocecal 》poas stretch sign.
● sickle cell with sudden Hb drop with reduced reticulocyte count 》》
parovirus.
●retromandibular vein formed by union of superficial temporal and
maxillary veins.
●Breast cancer wide local excision 》》
》 Negative sentinel 》 NO NEED FOR AXILLARY CLEARANCE AT
ALL.
》 positive margins after resection 》RADIOTHERAPY NOT ENOUGH
》》 better 》 COMPLETION MASTECTOMY.
■5 year survival
<5% pancreas cancer.
5- 10% esophageal.
25% metastases prostatic.
70% Duke B
90 % Duke A
*Morton’s neuroma cause or pathophysiology?
》perineural fibrosis
*Type of amyloid in
rhematoid arthritis-》AA
ESRD》BETA2
》Multiple myeloma》 AL
*patella fracture management
》wire binding
●post esophagectomy stricture Tx
》balloon dilatation
▪︎not injured during tracheostomy
》》ascending pharyngeal a.
●intrinsic pathway consists of factors I, II, IX, X, XI, and XII.
Respectively, each one is named, fibrinogen, prothrombin, Christmas
factor, Stuart-Prower factor, plasma thromboplastin, and Hageman
factor.
●non parametric data = does not follow normal distribution =
man whitey if comparing 2
kruksul if comparing multiple Group comparisons
●parametric data = follow normal distrbution = TTest
●if you read (( correlation )) = pearson parametric / sperarman non
parametric
●multiple Analysis not multiple groups * = Bonferoni.
●hypovolaemia
》 increased specific gravity.
●lateral ptregoid
》 open mouth.
▪︎Tranexamic acid
》inhibit plasmin thus prevents fibrin degradation.
IMPORTANT 36 posted
● cardiac shadow
Left-》 left ventricle
Right 》 right atrium
●hypercapnea 》 cerebral VD.
■ middle cerebral artery 》 Ophthalmic artery
● central chemoreceptors are stimulated by arterial
hypercapnia
●charlson scored》 predict 10 year mortality
》 co.morbidity score
▪︎ post splenectomy
》 triple vaccine plus penicillin
▪︎venous ulcer ECZEMA around ankle.
▪︎no INTRAMEDULLARY NAIL in children fracture.
▪︎ileo-ileal intussceception 》 laparotomy
▪︎FB at left main bronchus
》 Immediately transfer to theatre. Under GA.
▪︎ pulmonary artery below right main bronchus.
▪︎Hyperkalemia
》Start with Ca gluconate first ( stabilize myocardium)
》Then insulin and glucose.
▪︎6 month boy brought to clinic with difficulty breathing and
weight loss. examination:firm para testicular mass.diagnosis?
》Rhabdomyosarcoma
▪︎arterial ulcer
》 well demarcated edge
》Grey white base
》 painful
》NO ankle swelling.
▪︎malignant otitis externa
》 DM
》 NOT responding to AB.
》Pseudomonas
▪︎rash of anthrax
》pink, itchy bumps that occur at site where B. anthracis
comes into contact with scratched or otherwise open skin.
● TCC
》 pink fleshy tumour
▪︎Weber B # with undisplaced # with congruent ankle mortis
》》 below knee cast
▪︎anterior gastrojejostomy 》》 strongly associated with
delayed gastric emptying.
▪︎in ileostomy of UC 》 skin ulcer 》 pyoderma gangrenosum.
▪︎Duct ectesia 》 Not risk for malignancy .
▪︎BBB impermeable to H ion
▪︎old blood 》less DPG》 shift O2 curve to left .》 Decrease O2
delivery to tissue.
●Bainbridge reflex
》 increased HR due to rapid infusion of blood
》 Not involved in blood loss
●hip dislocation
》 posterior 》 limb adducted and medially rotated
》 anterior 》 limb 》 external rotated
●Arnold chiarri malformation
》 spinothalamic tract
●CPP= MAP-ICP=70 》 normal
MAP= D + .3(S-D)
●starvation
Decreased DPG.. shift O2 curve to left.
●prerenal cause 》 decrease hydrostatic pressure in
nephron》 anuria
● medullary thyroid cancer
》 amyloid deposition
●cholesteatoma
》 chronic discharge
》facial nerve palsy
》foul smell
》 Pseudomonas
● leydig cell tumour
》 gynaecomastia

IMPORTANT
Sympathetic chains:
Clinical importance
· Interruption of the head and neck supply of the sympathetic nerves
will result in an ipsilateral Horners
syndrome.
· For treatment of hyperhidrosis the sympathetic denervation can be
achieved by removing the second and
third thoracic ganglia with their rami.
Removal of T1 will cause a Horners syndrome and is therefore not
performed.
· In patients with vascular disease of the lower limbs a lumbar
sympathetomy may be performed, either
radiologically or (more rarely now) surgically. The ganglia of L2 and
below are disrupted. If L1 is removed then ejaculation may be
compromised

TOP IMPORTANT
Isolated pulmonary metastases from CRC. Treatment by resection.
Residual anal SCC after local radiotherapy ,ttt by abdominoperineal
resection.
Metastatic prostate cancer not involve the bone, ttt by
hormone
If bone invaded ttt by radiotherapy .
Diffuse intracranial metastases, ttt by radiotherapy plus
steroid.

Oxaliplatin:
Downstaging of liver mets due to CRC.
Inhibitor to DNA synthesis.
Cyclophosphamide:
Alkylating.
Used in nodepositive breast cancer.
Goserelin:
LHRH agonist
Prostatic cancer
Flutamide
Androgen anatagonist .
5- fluorouracil
Antimetabolite
In Duke C CRC.
Bleomycin plus cisplatin. Are used to testicular seminoma
Important ·
The brachial plexus and subclavian artery pass between the anterior
and middle scalenes relations through a space called the scalene
hiatus/fissure.
The subclavian vein and phrenic nerve pass anteriorly to the anterior
scalene as it crosses over the first rib.

IMPORTANT NOTES BY:

dr.Mohamed Salah
facebook group: https://www.facebook.com/groups/
MasterTheMRCS