1.Regarding genitourinary prolapse:
i) Enterocele describes small bowel herniation into the vagina. TRUE
ii) Enterocele will inevitably accompany Procidentia TRUE
iii) Surgical repair is contraindicated in eldery patients FALSE
iv) Ring pessaries may be left in place indefinitely FALSE
v) Postnatal pelvic floor exercises have a proven benefit in avoiding later prolapse FALSE
Explanations
i) Regarding genitourinary prolapse: Enterocele describes small bowel herniation into the vagina. (TRUE)
This may happen independently of uterine prolapse
ii) Regarding genitourinary prolapse: Enterocele will inevitably accompany Procidentia (TRUE)
Procidentia describes complete uterine prolapse where the uterus lies outside the vulva. This inevitably is accompanied by some degree of enterocele as there is loss of integrity to the endopelvic fascia and small bowel will fill the space created by the descended uterus.
iii) Regarding genitourinary prolapse: Surgical repair is contraindicated in eldery patients (FALSE)
Repair surgery is often very well tolerated in eldery patients with very significant symptom benefits. Therefore elderly patients may well be suitable candidates for repair procedures.
iv) Regarding genitourinary prolapse: Ring pessaries may be left in place indefinitely (FALSE)
They should be removed periodically for cleaning as an increased risk of infection will occur.
v) Regarding genitourinary prolapse: Postnatal pelvic floor exercises have a proven benefit in avoiding later prolapse (FALSE)
Though anecdotally this may be true, there is no proven reduction in prolapse occurance with pelvic floor exercises initiated postnatally.
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2.tuning fork tests for hearing are
i) Are not as good as whisper or voice tests for checking hearing in the consultation room. FALSE
ii) A patient with normal hearing will hear air conduction of sound from the tuning fork louder than bone conduction of sound. TRUE
iii) On examination with the Weber test, a patient hears the sound loudest in their right ear; this result is consistent with a diagnosis of right sided glue ear. TRUE
iv) On examination with the Weber test, a patient hears the sound loudest in their right ear; this result is consistent with a diagnosis of right sided acoustic neuroma. FALSE
v) On examination a pateint is Rinne positive in their left ear and Rinne negative in their right ear. The Weber test is heard loudest in their left ear. This is consistent with a diagnosis of comlete right sided sensorineural deafness. TRUE
i) Tuning fork tests for hearing: Are not as good as whisper or voice tests for checking hearing in the consultation room. (FALSE)
Tuning fork tests are much more sensitive than whisper and voice tests. In fact, whisper and voice tests are relatively useless unless performed in a quiet room with sound pressure level meters.
ii) Tuning fork tests for hearing: A patient with normal hearing will hear air conduction of sound from the tuning fork louder than bone conduction of sound. (TRUE)
The Rinnie test is used to compare air conduction of sound and bone conduction of sound. A normal patient will hear the tuning fork better by air conduction rather than bone conduction. This result is known as Rinne positive.
iii) Tuning fork tests for hearing: On examination with the Weber test, a patient hears the sound loudest in their right ear; this result is consistent with a diagnosis of right sided glue ear. (TRUE)
A patient with right sided glue ear will have a conductive hearing loss in their right ear. Thus the patient will have heightened bone conduction hearing on their right side and the Weber test will be heard loudest on that side.
iv) Tuning fork tests for hearing: On examination with the Weber test, a patient hears the sound loudest in their right ear; this result is consistent with a diagnosis of right sided acoustic neuroma. (FALSE)
An acoustic neuroma damages the vestibulo cochlear nerve resulting in a unilateral sensorineural hearing loss. With a unilateral sensorineural hearing loss the Weber test will sound loudest in the unaffected ear; in the case the left ear. The answer is therefore false.
v) Tuning fork tests for hearing: On examination a pateint is Rinne positive in their left ear and Rinne negative in their right ear. The Weber test is heard loudest in their left ear. This is consistent with a diagnosis of complete right sided sensorineural deafness. (TRUE)
the fact that the patient is Rinne negative in their right ear may appear consistent with a conductive hearing loss rather than a sensorineural hearing loss, however this is not the case:
A severe, unilateral sensorineural hearing loss will result in the contralateral ear picking up sound better than the affected ear during the Rinne test. Sound transmition to the contralateral ear will be greatest through bone as the sound will be transmitted through the skull, sound transmission through the air to the contralateral side will be minimal; thus pateints with severe or complete sensorineural hearing loss will be Rinne negative in the affected ear. In an examination such patients should be re-tested with appropriate sound masking in the contralateral ear (using a noise emitter), this masking should correct the Rinne test and nothing is likely to be heard in the affected ear at all.
----------------------------------------------------------------------
3.Facial palsy:
i) Is most commonly identified as a Bell's palsy TRUE
ii) Lower motor neurone lesions may be distinguished because they are characterised by sparing of the frontalis muscle on the affected side FALSE
iii) If a result of Ramsay Hunt Syndrome the prognosis is poor with less than 70% of patients making a full recovery TRUE
iv) May occur in Guillian Barre syndrome TRUE
v) May follow acute sinusitis FALSE
Explanations
i) Facial palsy: Is most commonly identified as a Bell's palsy (TRUE)
The most common cause of facial palsy is Bell's palsy which is a lower motor neurone lesion.
ii) Facial palsy: Lower motor neurone lesions may be distinguished because they are characterised by sparing of the frontalis muscle on the affected side (FALSE)
This is false: upper motor neurone lesions are characterised by sparing of the frontalis muscle. Lower mototr neurone lesions result in complete paralysis of the affected side.
iii) Facial palsy: If a result of Ramsay Hunt Syndrome the prognosis is poor with less than 70% of patients making a full recovery (TRUE)
This is true; Ramsay Hunt Syndrome (herpes zoster oticus) is associated with a poor prognosis; 10% of patients become deaf and less than 60% of patients recover well.
iv) Facial palsy: May occur in Guillian Barre syndrome (TRUE)
Guillian Barre syndrome is a syndrome characterised by weakness and numbness of the peripheral nerves. It can occasionally spread to involve the facial nerve causing a bilateral facial nerve palsy. The prognosis is excellent with the vast majority of patients making a full recovery.
v) Facial palsy: May follow acute sinusitis (FALSE)
Acute sinusitis does not cause facial palsy.
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4. The following features are associated with acromegaly
i) Heart failure TRUE
ii) Visual field defects TRUE
iii) Increased risk of carcinoma of the colon TRUE
iv) Suppression of GH levels after oral glucose FALSE
v) Medical treatment is the recommended long term treatment for most patients with acromegaly FALSE
Explanations
i) The following features are associated with acromegaly Heart failure (TRUE)
This a consequence of generalised visceromegaly
ii) The following features are associated with acromegaly Visual field defects (TRUE)
Acromegaly results from a pituiitay adenoma which will expand in the pituitary fossa, compressing the optic chiasm causing initially a bitemporal upper quadrantanopia and progressing to a bitemporal hemianopia
iii) The following features are associated with acromegaly Increased risk of carcinoma of the colon (TRUE)
Patients with acromegaly are at increased risk of joint, cardiovascular, respiratory and malignant diseases. Colonoscopic surveillance has been advocated.
iv) The following features are associated with acromegaly Suppression of GH levels after oral glucose (FALSE)
This describes the response in a normal subject. GH levels fail to suppress after the administration of glucose in acromegaly
v) The following features are associated with acromegaly Medical treatment is the recommended long term treatment for most patients with acromegaly (FALSE)
Trans-sphenoidal surgery can cure about 80% of microadenomas (tumours under 1cm), though it is less effective for macroadenomas. Octreotide is effective, but is expensive, must be given by injection, and has many side effects including gallstone formation due to bile stasis. Radiotherapy is also effective but is slow to act.
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5.Peri-operative pain is associated with the following complications:
i) Hypertension TRUE
ii) Pneumonia TRUE
iii) Reduced gastric emptying TRUE
iv) Urinary retention TRUE
v) Increased risk of DVT (deep vein thrombosis) TRUE
Complications of pain:
Cardiovascular:
- Hypertension
- Tacchycardia
- Increased myocardial oxygen demand
Respiratory:
- Reduced respiratory effort and impaired coughing causing:
--- Atealectasis
--- Sputum retention
--- Pneumonia
Urinary
- Urinary retention
GI
- Delayed gastric emptying
- Reduced bowel movement
Other
- Reduced mobility - can lead to DVT etc.
- Lack of sleep
- Anxiety and other psychological problems.
----------------------------------------------------------------------------------------------------
6.Facial nerve injury occuring as a result of parotidectomy may cause:
i) Loss of taste sensation to anterior tongue FALSE
ii) Loss of the corneal reflex TRUE
iii) Reduced submandibular and sublingual salivary secretions FALSE
iv) Ipsilateral weakness of frontalis TRUE
v) Loss of facial sensation FALSE
Explanations
i) Facial nerve injury occuring as a result of parotidectomy may cause: Loss of taste sensation to anterior tongue (FALSE)
The chorda tympani branches off the facial nerve before it emerges from the stylomastoid foramen
ii) Facial nerve injury occuring as a result of parotidectomy may cause: Loss of the corneal reflex (TRUE)
Sensory afferents from CN V (Trigeminal)
Motor efferents of CN VII (Facial)
iii) Facial nerve injury occuring as a result of parotidectomy may cause: Reduced submandibular and sublingual salivary secretions (FALSE)
Facial nerve efferents to the submandibular and sublingual salivary glands branch off the Chorda Tympani which branches of the main facial nerve before it exists the stylomastoid foramen
iv) Facial nerve injury occuring as a result of parotidectomy may cause: Ipsilateral weakness of frontalis (TRUE)
Nerve damage during a parotidectomy will cause a lower motor neurone lesion and thus ipsilateral weakness of frontalis.
However if there is an upper motor neurone lesion there is sparing of frontalis function bilaterally as there are efferents from both cerebral hemispheres to both sides of frontalis. However this cross innervation occurs within the cranium and the facial nerve itself does not cross over to supply both sides of the frontalis muscle
v) Facial nerve injury occuring as a result of parotidectomy may cause: Loss of facial sensation (FALSE)
Sensory supply to the face is provided by the trigeminal nerve (CN V). The facial nerve innervates the muscles of facial expression.
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7. A 32 year old woman presents to her GP with a 2 week history of a hoarse voice.
i) If her hoarsness does not resolve within the following 5 weeks she should then be referred to a specialist FALSE
ii) The most common cause of hoarsness is acute laryngitis TRUE
iii) If acute laryngitis is diagnosed she should be treated with broad spectrum antibiotics FALSE
iv) The patient also has signs of hypothyroidism: if this diagnosis is confirmed it could explain the hoarseness. TRUE
v) A Vagus nerve palsy would not cause hoarseness. FALSE
Explanations
i) A 32 year old woman presents to her GP with a 2 week history of a hoarse voice. If her hoarsness does not resolve within the following 5 weeks she should then be referred to a specialist (FALSE)
This is false; if a patient remains hoarse for over a month they should then be referred urgently to a specialist: 7 weeks (NB: symptoms present for 2 weeks before presentation) is far too long to wait before referring because dysphonia is an important sign of neoplasia.
ii) A 32 year old woman presents to her GP with a 2 week history of a hoarse voice. The most common cause of hoarsness is acute laryngitis (TRUE)
Acute laryngitis is very common and often causes dysphonia. The aetiology of acute laryngitis may be:
- Infective (associated with upper respiratory tract infections)
- Traumatic (Eg: following shouting)
- Chemical (Eg: smoking, inhalation of chemicals)
iii) A 32 year old woman presents to her GP with a 2 week history of a hoarse voice. If acute laryngitis is diagnosed she should be treated with broad spectrum antibiotics (FALSE)
Acute layngitis usually has a viral aetiology and resolves spontaneously. Antibiotics are unlikely to have much effect on clinical outcome, even if the infection is bacterial as by the time the antibiotic is becoming effective, the body will usually have mounted a good immune response.
iv) A 32 year old woman presents to her GP with a 2 week history of a hoarse voice. The patient also has signs of hypothyroidism: if this diagnosis is confirmed it could explain the hoarseness. (TRUE)
Hypothyroidism can cause oedema of the vocal cords and a resulting hoarse voice. A deepening and hoarsness of the voice is a well recognised symptom of hypothyroidism.
v) A 32 year old woman presents to her GP with a 2 week history of a hoarse voice. A Vagus nerve palsy would not cause hoarseness. (FALSE)
The vocal cords are innervated by both the vagus and recurrent laryngeal nerves; damage to either of these nerves can cause hoarsness,
-----------------------------------------------------------------------------------------------------------------------------
8.Oligohydramnios is associated with
i) Potters syndrome TRUE
ii) Anencephaly FALSE
iii) Rhesus alloimmunization FALSE
iv) Post maturity TRUE
v) Amniotic bands TRUE
Explanations
i) Oligohydramnios is associated with: Potters syndrome (TRUE)
This syndrome comprises of renal agenesis, pulmonary hypoplasia and characteristic facies including micrognanthia and low set ears. As the kidney is non-functional ther is no urine output resulting in decreased amniotic fluid.
ii) Oligohydramnios is associated with: Anencephaly (FALSE)
Anencephaly is a neural tube defect that results in a malformed brain, spinal cord and often foetal head. Anencephaly may cause polyhydramnios in between 40 and 50% of cases (seen at 26 weeks) and polyhydramnios is thought to be due to the foetal inability to swallow - this mechanism occurs in oesophageal/duodenal atresia also.
iii) Oligohydramnios is associated with: Rhesus alloimmunization (FALSE)
In a severe case this may cause Hydrops fetalis (generalised oedema as liver diverts action to rbc formation therefore producing little albumin). This condition will result in increased amniotic fluid.
iv) Oligohydramnios is associated with: Post maturity (TRUE)
There is a slight volume reduction post term, this is not in itself significant.
v) Oligohydramnios is associated with: Amniotic bands (TRUE)
These may occur between the amnion and the head, body or limbs of the fetus. They complicate oligohydramnios.
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9.Malaria
i) There are only three organisms that cause clinically detectable maleria: Plasmodium falciparum, Plasmodium maleriae and Plasmodium vivax. FALSE
ii) Malaria caused by Plasmodium Vivax is characteristically short lived lasting only a matter of days FALSE
iii) The organisms that cause malaria are protozoa. TRUE
iv) The cardinal symptoms of malarial infection are vomiting and diarrhoea. FALSE
v) P. falciparum accounts for 80% of malaria cases and appoximately 90% malaria deaths. TRUE
Explanations
i) Malaria There are only three organisms that cause clinically detectable maleria: Plasmodium falciparum, Plasmodium maleriae and Plasmodium vivax. (FALSE)
There is a foUrth organism that causes maleria: Plasmodium ovale.
ii) Malaria Malaria caused by Plasmodium Vivax is characteristically short lived lasting only a matter of days (FALSE)
Malaria caused by P. vivax and P. ovale in an untreated individual characteristically causes flares of symptoms over 2-3 months with diminishing frequency of attacks. Both organisms may stay latent in the liver causing recurrent malaria up to 5 years after the initial episode.
iii) Malaria The organisms that cause malaria are protozoa. (TRUE)
Protozoa are single cell eukaryotes.
iv) Malaria The cardinal symptoms of malarial infection are vomiting and diarrhoea. (FALSE)
The three main symptoms are fever, chills and sweating, but there may be many other symptoms including diarrhoea and vomiting.
v) Malaria P. falciparum accounts for 80% of malaria cases and appoximately 90% malaria deaths. (TRUE)
P. falciparum is relatively more dangerous because it enters red blood cells much more efficiently than the other Plasmoium spp.
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10 . Cardiac massage
i) should be discontinued if there is a rib fracture, because of the risk of pneumothorax.
ii) is of no benefit if the pupils have been dilated for more than 5 minutes.
iii) should be done in the left lateral position if the patient has a full stomach.
iv) by a single person should be done with one hand feeling the carotid pulse, to monitor the effectiveness.
v) can be discontinued when the ECG complexes return.
ALL ARE FALSE .
Explanations
i) Cardiac massage should be discontinued if there is a rib fracture, because of the risk of pneumothorax. (FALSE)
Cardiopulmonary resuscitation should be of primary importance. The risk of pneumothorax from a rib fracture should not limit an attempt at resuscitation
ii) Cardiac massage is of no benefit if the pupils have been dilated for more than 5 minutes. (FALSE)
Brainstem death is accompanied by fixed dilated pupils, but the reverse is not necessarily true. Localised brainstem injuries can cause dilated pupils, as can drugs: atropine, ganglion blockers, adrenaline. Five minutes is sometimes not long enough to collect enough information to be sure that resuscitation can justifiably be discontinued.
Fixed dilated pupils are not diagnostic of brain stem death in the acute setting - only after 48 hours do they become suggestive of significant cerebral /brain stem injury.
iii) Cardiac massage should be done in the left lateral position if the patient has a full stomach. (FALSE)
Potential problems from a full stomach are less than from an ineffective cardiac massage.
iv) Cardiac massage by a single person should be done with one hand feeling the carotid pulse, to monitor the effectiveness. (FALSE)
Effective cardiopulmonary resuscation requires the use of both hands
v) Cardiac massage can be discontinued when the ECG complexes return. (FALSE)
ECG complexes only tell that there is electrical activity. Electromechanical dissociation occurs when there is cardiac electrical activity but no effective cardiac output.
i) Enterocele describes small bowel herniation into the vagina. TRUE
ii) Enterocele will inevitably accompany Procidentia TRUE
iii) Surgical repair is contraindicated in eldery patients FALSE
iv) Ring pessaries may be left in place indefinitely FALSE
v) Postnatal pelvic floor exercises have a proven benefit in avoiding later prolapse FALSE
Explanations
i) Regarding genitourinary prolapse: Enterocele describes small bowel herniation into the vagina. (TRUE)
This may happen independently of uterine prolapse
ii) Regarding genitourinary prolapse: Enterocele will inevitably accompany Procidentia (TRUE)
Procidentia describes complete uterine prolapse where the uterus lies outside the vulva. This inevitably is accompanied by some degree of enterocele as there is loss of integrity to the endopelvic fascia and small bowel will fill the space created by the descended uterus.
iii) Regarding genitourinary prolapse: Surgical repair is contraindicated in eldery patients (FALSE)
Repair surgery is often very well tolerated in eldery patients with very significant symptom benefits. Therefore elderly patients may well be suitable candidates for repair procedures.
iv) Regarding genitourinary prolapse: Ring pessaries may be left in place indefinitely (FALSE)
They should be removed periodically for cleaning as an increased risk of infection will occur.
v) Regarding genitourinary prolapse: Postnatal pelvic floor exercises have a proven benefit in avoiding later prolapse (FALSE)
Though anecdotally this may be true, there is no proven reduction in prolapse occurance with pelvic floor exercises initiated postnatally.
---------------------------------------------------------------------------------------------------------------------------------------------
2.tuning fork tests for hearing are
i) Are not as good as whisper or voice tests for checking hearing in the consultation room. FALSE
ii) A patient with normal hearing will hear air conduction of sound from the tuning fork louder than bone conduction of sound. TRUE
iii) On examination with the Weber test, a patient hears the sound loudest in their right ear; this result is consistent with a diagnosis of right sided glue ear. TRUE
iv) On examination with the Weber test, a patient hears the sound loudest in their right ear; this result is consistent with a diagnosis of right sided acoustic neuroma. FALSE
v) On examination a pateint is Rinne positive in their left ear and Rinne negative in their right ear. The Weber test is heard loudest in their left ear. This is consistent with a diagnosis of comlete right sided sensorineural deafness. TRUE
i) Tuning fork tests for hearing: Are not as good as whisper or voice tests for checking hearing in the consultation room. (FALSE)
Tuning fork tests are much more sensitive than whisper and voice tests. In fact, whisper and voice tests are relatively useless unless performed in a quiet room with sound pressure level meters.
ii) Tuning fork tests for hearing: A patient with normal hearing will hear air conduction of sound from the tuning fork louder than bone conduction of sound. (TRUE)
The Rinnie test is used to compare air conduction of sound and bone conduction of sound. A normal patient will hear the tuning fork better by air conduction rather than bone conduction. This result is known as Rinne positive.
iii) Tuning fork tests for hearing: On examination with the Weber test, a patient hears the sound loudest in their right ear; this result is consistent with a diagnosis of right sided glue ear. (TRUE)
A patient with right sided glue ear will have a conductive hearing loss in their right ear. Thus the patient will have heightened bone conduction hearing on their right side and the Weber test will be heard loudest on that side.
iv) Tuning fork tests for hearing: On examination with the Weber test, a patient hears the sound loudest in their right ear; this result is consistent with a diagnosis of right sided acoustic neuroma. (FALSE)
An acoustic neuroma damages the vestibulo cochlear nerve resulting in a unilateral sensorineural hearing loss. With a unilateral sensorineural hearing loss the Weber test will sound loudest in the unaffected ear; in the case the left ear. The answer is therefore false.
v) Tuning fork tests for hearing: On examination a pateint is Rinne positive in their left ear and Rinne negative in their right ear. The Weber test is heard loudest in their left ear. This is consistent with a diagnosis of complete right sided sensorineural deafness. (TRUE)
the fact that the patient is Rinne negative in their right ear may appear consistent with a conductive hearing loss rather than a sensorineural hearing loss, however this is not the case:
A severe, unilateral sensorineural hearing loss will result in the contralateral ear picking up sound better than the affected ear during the Rinne test. Sound transmition to the contralateral ear will be greatest through bone as the sound will be transmitted through the skull, sound transmission through the air to the contralateral side will be minimal; thus pateints with severe or complete sensorineural hearing loss will be Rinne negative in the affected ear. In an examination such patients should be re-tested with appropriate sound masking in the contralateral ear (using a noise emitter), this masking should correct the Rinne test and nothing is likely to be heard in the affected ear at all.
----------------------------------------------------------------------
3.Facial palsy:
i) Is most commonly identified as a Bell's palsy TRUE
ii) Lower motor neurone lesions may be distinguished because they are characterised by sparing of the frontalis muscle on the affected side FALSE
iii) If a result of Ramsay Hunt Syndrome the prognosis is poor with less than 70% of patients making a full recovery TRUE
iv) May occur in Guillian Barre syndrome TRUE
v) May follow acute sinusitis FALSE
Explanations
i) Facial palsy: Is most commonly identified as a Bell's palsy (TRUE)
The most common cause of facial palsy is Bell's palsy which is a lower motor neurone lesion.
ii) Facial palsy: Lower motor neurone lesions may be distinguished because they are characterised by sparing of the frontalis muscle on the affected side (FALSE)
This is false: upper motor neurone lesions are characterised by sparing of the frontalis muscle. Lower mototr neurone lesions result in complete paralysis of the affected side.
iii) Facial palsy: If a result of Ramsay Hunt Syndrome the prognosis is poor with less than 70% of patients making a full recovery (TRUE)
This is true; Ramsay Hunt Syndrome (herpes zoster oticus) is associated with a poor prognosis; 10% of patients become deaf and less than 60% of patients recover well.
iv) Facial palsy: May occur in Guillian Barre syndrome (TRUE)
Guillian Barre syndrome is a syndrome characterised by weakness and numbness of the peripheral nerves. It can occasionally spread to involve the facial nerve causing a bilateral facial nerve palsy. The prognosis is excellent with the vast majority of patients making a full recovery.
v) Facial palsy: May follow acute sinusitis (FALSE)
Acute sinusitis does not cause facial palsy.
--------------------------------------------------------------------------------------------------------
4. The following features are associated with acromegaly
i) Heart failure TRUE
ii) Visual field defects TRUE
iii) Increased risk of carcinoma of the colon TRUE
iv) Suppression of GH levels after oral glucose FALSE
v) Medical treatment is the recommended long term treatment for most patients with acromegaly FALSE
Explanations
i) The following features are associated with acromegaly Heart failure (TRUE)
This a consequence of generalised visceromegaly
ii) The following features are associated with acromegaly Visual field defects (TRUE)
Acromegaly results from a pituiitay adenoma which will expand in the pituitary fossa, compressing the optic chiasm causing initially a bitemporal upper quadrantanopia and progressing to a bitemporal hemianopia
iii) The following features are associated with acromegaly Increased risk of carcinoma of the colon (TRUE)
Patients with acromegaly are at increased risk of joint, cardiovascular, respiratory and malignant diseases. Colonoscopic surveillance has been advocated.
iv) The following features are associated with acromegaly Suppression of GH levels after oral glucose (FALSE)
This describes the response in a normal subject. GH levels fail to suppress after the administration of glucose in acromegaly
v) The following features are associated with acromegaly Medical treatment is the recommended long term treatment for most patients with acromegaly (FALSE)
Trans-sphenoidal surgery can cure about 80% of microadenomas (tumours under 1cm), though it is less effective for macroadenomas. Octreotide is effective, but is expensive, must be given by injection, and has many side effects including gallstone formation due to bile stasis. Radiotherapy is also effective but is slow to act.
---------------------------------------------------------------------------------------------------------------------------------------------------
5.Peri-operative pain is associated with the following complications:
i) Hypertension TRUE
ii) Pneumonia TRUE
iii) Reduced gastric emptying TRUE
iv) Urinary retention TRUE
v) Increased risk of DVT (deep vein thrombosis) TRUE
Complications of pain:
Cardiovascular:
- Hypertension
- Tacchycardia
- Increased myocardial oxygen demand
Respiratory:
- Reduced respiratory effort and impaired coughing causing:
--- Atealectasis
--- Sputum retention
--- Pneumonia
Urinary
- Urinary retention
GI
- Delayed gastric emptying
- Reduced bowel movement
Other
- Reduced mobility - can lead to DVT etc.
- Lack of sleep
- Anxiety and other psychological problems.
----------------------------------------------------------------------------------------------------
6.Facial nerve injury occuring as a result of parotidectomy may cause:
i) Loss of taste sensation to anterior tongue FALSE
ii) Loss of the corneal reflex TRUE
iii) Reduced submandibular and sublingual salivary secretions FALSE
iv) Ipsilateral weakness of frontalis TRUE
v) Loss of facial sensation FALSE
Explanations
i) Facial nerve injury occuring as a result of parotidectomy may cause: Loss of taste sensation to anterior tongue (FALSE)
The chorda tympani branches off the facial nerve before it emerges from the stylomastoid foramen
ii) Facial nerve injury occuring as a result of parotidectomy may cause: Loss of the corneal reflex (TRUE)
Sensory afferents from CN V (Trigeminal)
Motor efferents of CN VII (Facial)
iii) Facial nerve injury occuring as a result of parotidectomy may cause: Reduced submandibular and sublingual salivary secretions (FALSE)
Facial nerve efferents to the submandibular and sublingual salivary glands branch off the Chorda Tympani which branches of the main facial nerve before it exists the stylomastoid foramen
iv) Facial nerve injury occuring as a result of parotidectomy may cause: Ipsilateral weakness of frontalis (TRUE)
Nerve damage during a parotidectomy will cause a lower motor neurone lesion and thus ipsilateral weakness of frontalis.
However if there is an upper motor neurone lesion there is sparing of frontalis function bilaterally as there are efferents from both cerebral hemispheres to both sides of frontalis. However this cross innervation occurs within the cranium and the facial nerve itself does not cross over to supply both sides of the frontalis muscle
v) Facial nerve injury occuring as a result of parotidectomy may cause: Loss of facial sensation (FALSE)
Sensory supply to the face is provided by the trigeminal nerve (CN V). The facial nerve innervates the muscles of facial expression.
------------------------------------------------------------------------------------------------------------------------------------
7. A 32 year old woman presents to her GP with a 2 week history of a hoarse voice.
i) If her hoarsness does not resolve within the following 5 weeks she should then be referred to a specialist FALSE
ii) The most common cause of hoarsness is acute laryngitis TRUE
iii) If acute laryngitis is diagnosed she should be treated with broad spectrum antibiotics FALSE
iv) The patient also has signs of hypothyroidism: if this diagnosis is confirmed it could explain the hoarseness. TRUE
v) A Vagus nerve palsy would not cause hoarseness. FALSE
Explanations
i) A 32 year old woman presents to her GP with a 2 week history of a hoarse voice. If her hoarsness does not resolve within the following 5 weeks she should then be referred to a specialist (FALSE)
This is false; if a patient remains hoarse for over a month they should then be referred urgently to a specialist: 7 weeks (NB: symptoms present for 2 weeks before presentation) is far too long to wait before referring because dysphonia is an important sign of neoplasia.
ii) A 32 year old woman presents to her GP with a 2 week history of a hoarse voice. The most common cause of hoarsness is acute laryngitis (TRUE)
Acute laryngitis is very common and often causes dysphonia. The aetiology of acute laryngitis may be:
- Infective (associated with upper respiratory tract infections)
- Traumatic (Eg: following shouting)
- Chemical (Eg: smoking, inhalation of chemicals)
iii) A 32 year old woman presents to her GP with a 2 week history of a hoarse voice. If acute laryngitis is diagnosed she should be treated with broad spectrum antibiotics (FALSE)
Acute layngitis usually has a viral aetiology and resolves spontaneously. Antibiotics are unlikely to have much effect on clinical outcome, even if the infection is bacterial as by the time the antibiotic is becoming effective, the body will usually have mounted a good immune response.
iv) A 32 year old woman presents to her GP with a 2 week history of a hoarse voice. The patient also has signs of hypothyroidism: if this diagnosis is confirmed it could explain the hoarseness. (TRUE)
Hypothyroidism can cause oedema of the vocal cords and a resulting hoarse voice. A deepening and hoarsness of the voice is a well recognised symptom of hypothyroidism.
v) A 32 year old woman presents to her GP with a 2 week history of a hoarse voice. A Vagus nerve palsy would not cause hoarseness. (FALSE)
The vocal cords are innervated by both the vagus and recurrent laryngeal nerves; damage to either of these nerves can cause hoarsness,
-----------------------------------------------------------------------------------------------------------------------------
8.Oligohydramnios is associated with
i) Potters syndrome TRUE
ii) Anencephaly FALSE
iii) Rhesus alloimmunization FALSE
iv) Post maturity TRUE
v) Amniotic bands TRUE
Explanations
i) Oligohydramnios is associated with: Potters syndrome (TRUE)
This syndrome comprises of renal agenesis, pulmonary hypoplasia and characteristic facies including micrognanthia and low set ears. As the kidney is non-functional ther is no urine output resulting in decreased amniotic fluid.
ii) Oligohydramnios is associated with: Anencephaly (FALSE)
Anencephaly is a neural tube defect that results in a malformed brain, spinal cord and often foetal head. Anencephaly may cause polyhydramnios in between 40 and 50% of cases (seen at 26 weeks) and polyhydramnios is thought to be due to the foetal inability to swallow - this mechanism occurs in oesophageal/duodenal atresia also.
iii) Oligohydramnios is associated with: Rhesus alloimmunization (FALSE)
In a severe case this may cause Hydrops fetalis (generalised oedema as liver diverts action to rbc formation therefore producing little albumin). This condition will result in increased amniotic fluid.
iv) Oligohydramnios is associated with: Post maturity (TRUE)
There is a slight volume reduction post term, this is not in itself significant.
v) Oligohydramnios is associated with: Amniotic bands (TRUE)
These may occur between the amnion and the head, body or limbs of the fetus. They complicate oligohydramnios.
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9.Malaria
i) There are only three organisms that cause clinically detectable maleria: Plasmodium falciparum, Plasmodium maleriae and Plasmodium vivax. FALSE
ii) Malaria caused by Plasmodium Vivax is characteristically short lived lasting only a matter of days FALSE
iii) The organisms that cause malaria are protozoa. TRUE
iv) The cardinal symptoms of malarial infection are vomiting and diarrhoea. FALSE
v) P. falciparum accounts for 80% of malaria cases and appoximately 90% malaria deaths. TRUE
Explanations
i) Malaria There are only three organisms that cause clinically detectable maleria: Plasmodium falciparum, Plasmodium maleriae and Plasmodium vivax. (FALSE)
There is a foUrth organism that causes maleria: Plasmodium ovale.
ii) Malaria Malaria caused by Plasmodium Vivax is characteristically short lived lasting only a matter of days (FALSE)
Malaria caused by P. vivax and P. ovale in an untreated individual characteristically causes flares of symptoms over 2-3 months with diminishing frequency of attacks. Both organisms may stay latent in the liver causing recurrent malaria up to 5 years after the initial episode.
iii) Malaria The organisms that cause malaria are protozoa. (TRUE)
Protozoa are single cell eukaryotes.
iv) Malaria The cardinal symptoms of malarial infection are vomiting and diarrhoea. (FALSE)
The three main symptoms are fever, chills and sweating, but there may be many other symptoms including diarrhoea and vomiting.
v) Malaria P. falciparum accounts for 80% of malaria cases and appoximately 90% malaria deaths. (TRUE)
P. falciparum is relatively more dangerous because it enters red blood cells much more efficiently than the other Plasmoium spp.
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10 . Cardiac massage
i) should be discontinued if there is a rib fracture, because of the risk of pneumothorax.
ii) is of no benefit if the pupils have been dilated for more than 5 minutes.
iii) should be done in the left lateral position if the patient has a full stomach.
iv) by a single person should be done with one hand feeling the carotid pulse, to monitor the effectiveness.
v) can be discontinued when the ECG complexes return.
ALL ARE FALSE .
Explanations
i) Cardiac massage should be discontinued if there is a rib fracture, because of the risk of pneumothorax. (FALSE)
Cardiopulmonary resuscitation should be of primary importance. The risk of pneumothorax from a rib fracture should not limit an attempt at resuscitation
ii) Cardiac massage is of no benefit if the pupils have been dilated for more than 5 minutes. (FALSE)
Brainstem death is accompanied by fixed dilated pupils, but the reverse is not necessarily true. Localised brainstem injuries can cause dilated pupils, as can drugs: atropine, ganglion blockers, adrenaline. Five minutes is sometimes not long enough to collect enough information to be sure that resuscitation can justifiably be discontinued.
Fixed dilated pupils are not diagnostic of brain stem death in the acute setting - only after 48 hours do they become suggestive of significant cerebral /brain stem injury.
iii) Cardiac massage should be done in the left lateral position if the patient has a full stomach. (FALSE)
Potential problems from a full stomach are less than from an ineffective cardiac massage.
iv) Cardiac massage by a single person should be done with one hand feeling the carotid pulse, to monitor the effectiveness. (FALSE)
Effective cardiopulmonary resuscation requires the use of both hands
v) Cardiac massage can be discontinued when the ECG complexes return. (FALSE)
ECG complexes only tell that there is electrical activity. Electromechanical dissociation occurs when there is cardiac electrical activity but no effective cardiac output.
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