41.Oesophageal malignancy
i) Men are affected over 10 times more commonly than women FALSE
ii) Patients with coeliac disease are at increased risk TRUE
iii) The majority of patients with tylosis develop adenocarcinoma of the oesophagus during their life time FALSE
iv) The incidence of oesophageal adenocarcinoma in the Western World is rising faster than that of any other solid tumour TRUE
v) Adenocarcinomas typically affect the upper and middle thirds of the oesophagus FALSE
Explanations
i) Oesophageal malignancy Men are affected over 10 times more commonly than women (FALSE)
Male to female ratio varies between different sources from anything between 2:1 and 7:1 (male:female)
ii) Oesophageal malignancy Patients with coeliac disease are at increased risk (TRUE)
Principle modifiable risk factors are alcohol and tobacco.
Other risk factors include:
- Consumption of nitrosamines (pickled food, smoked meats)
- Coeliac disease
- Tylosis (rare autosomal dominant condition characterised by hyperkeratosis of palma and plantar surfaces - almost all these patients develop squamous cell cancinoma of the oesophagus)
- Achalasia
- Stricutres
- Plummer-Vinson syndrome
- Associated with other head and neck tumours (probably because of similar aetiological factors)
- HPV infection (esp 16 and 18) a/w squamous ca.
Also anecdotal suggestions that the following are risk factors:
- Chronic consumption of hot liquids
- Betel nut ingestion
- Asbestos exposure
- Air pollution
- Spicy diet
iii) Oesophageal malignancy The majority of patients with tylosis develop adenocarcinoma of the oesophagus during their life time (FALSE)
Tylosis is a rare autosomal dominant condition characterised by hyperkeratosis of the palma and plantar surfaces. Almost all patients with this condition go on to develop SQUAMOUS carcinoma of the oesophagus
iv) Oesophageal malignancy The incidence of oesophageal adenocarcinoma in the Western World is rising faster than that of any other solid tumour (TRUE)
The incidence of adenocarcinoma is rising at a rate of about 5% per year!
v) Oesophageal malignancy Adenocarcinomas typically affect the upper and middle thirds of the oesophagus (FALSE)
Squamous tumors typically affect the upper third, adenocarcinomas are more common in the lower third of the oesophagus.
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42.Oesophageal cancer:
i) Typically presents late in the disease process TRUE
ii) Commonly presents with right recurrent laryngeal nerve palsy FALSE
iii) Patients with Barrett's oesophagus require regular endoscopy to exclude malignant transformation TRUE
iv) Barrett's oesophagus is characterised by metaplasia with replacement of the usual columnar epithelium with a stratified squamous epithelium FALSE
v) Patients with known Barrett's oesophagus have a dismal prognosis if they go on to develop oesophageal malignancy FALSE
Explanations
i) Oesophageal cancer: Typically presents late in the disease process (TRUE)
Usually presents late in the disease process
ii) Oesophageal cancer: Commonly presents with right recurrent laryngeal nerve palsy (FALSE)
This is an uncommon presentation. It usually presents with progressive dysphagia to solids and later liquids, weight loss is common.
Unusual presentations:
- Cervical lymph node
- Left Recurrent laryngeal nerve palsy
- Overflow respiratory complications
iii) Oesophageal cancer: Patients with Barrett's oesophagus require regular endoscopy to exclude malignant transformation (TRUE)
10% of patients with GORD develop Barrett's oesophagus.
1% of patients with Barrett's go on to develop oesophageal malignancy every year. Therefore regular endoscopy is indicated
iv) Oesophageal cancer: Barrett's oesophagus is characterised by metaplasia with replacement of the usual columnar epithelium with a stratified squamous epithelium (FALSE)
The usual epithelium of the oesophagus is stratified squamous. In Barrett's this epithelium undergoes metaplasia to become a columnar structure that resembles gastric mucosa
v) Oesophageal cancer: Patients with known Barrett's oesophagus have a dismal prognosis if they go on to develop oesophageal malignancy (FALSE)
Tumours detected by screening of patient's with known Barrett's have a much better prognosis with a 95% 5 year survival post tumour resection.
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43. PSA (Prostate Specific Antigen)
i) PSA is a chymotrypsin-like serine protease of the kallikrein family exclusively produced by the prostatic epithelium. TRUE
ii) It is normally present in the semen TRUE
iii) May be elevated by up to 20 ng/dL following digital rectal examination therefore necessitating that blood is taken before clinical examination in clinic FALSE
iv) Is unreliable if taken accutely in a patient presenting with urinary retention TRUE
v) PSA is expected to rise slightly with advancing age TRUE
Explanations
i) PSA (Prostate Specific Antigen) PSA is a chymotrypsin-like serine protease of the kallikrein family exclusively produced by the prostatic epithelium. (TRUE)
PSA is a chymotrypsin-like serine protease of the kallikrein family exclusively
produced by the prostatic epithelium
ii) PSA (Prostate Specific Antigen) It is normally present in the semen (TRUE)
PSA is normally present in abundance in the semen
iii) PSA (Prostate Specific Antigen) May be elevated by up to 20 ng/dL following digital rectal examination therefore necessitating that blood is taken before clinical examination in clinic (FALSE)
DRE may be associated with a small, and largely insignificant rise in serum PSA: certainly DRE should not account for a PSA level of 20, however it would be recommended to take bloods prior to examination
iv) PSA (Prostate Specific Antigen) Is unreliable if taken accutely in a patient presenting with urinary retention (TRUE)
PSA may be elevated in any of the following conditions:
- Urinary retention
- BPH
- Prostatic instrumentation
- Prostatitis
- Prostatic infarction
v) PSA (Prostate Specific Antigen) PSA is expected to rise slightly with advancing age (TRUE)
The PSA rises slightly with age. Therefore the 'normal range' for PSA is dependent upon the patient's age
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44. Non-Hodgkin Lymphoma (NHL)
i) Is usually of B-Cell origin TRUE
ii) A nodular growth patter is an indicator of poor prognosis FALSE
iii) Typically affects young males FALSE
iv) 5 year survival is approximately 80-90% from presentation. FALSE
v) Burkitt's lymphoma is an aggressive subtype of NHL that commonly presents with thoracic mass FALSE
Explanations
i) Non-Hodgkin Lymphoma (NHL) Is usually of B-Cell origin (TRUE)
85% B-cell origin
15% T-cell or natural killer cell origin
ii) Non-Hodgkin Lymphoma (NHL) A nodular growth patter is an indicator of poor prognosis (FALSE)
Nodular growth pattern (growth resembles normal B-cell growth) is an indicator of better prognosis.
Diffuse growth pattern suggests a poorer prognosis
iii) Non-Hodgkin Lymphoma (NHL) Typically affects young males (FALSE)
It is a disease of older age.
Hodgkin's lymphoma predominatly affects young males
iv) Non-Hodgkin Lymphoma (NHL) 5 year survival is approximately 80-90% from presentation. (FALSE)
5 year survival of Hodgkin lymphoma is 80-90% from presentation.
5 year survival for NHL is only about 50%
v) Non-Hodgkin Lymphoma (NHL) Burkitt's lymphoma is an aggressive subtype of NHL that commonly presents with thoracic mass (FALSE)
Burkitt's lymphoma is an aggressive subtype, strongly associated with EBV infection, it often presents with a large abdominal mass that can cause GI obstruction
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45. Tumour pathophysiology
i) E-cadherin is a major epithelial cell adhesion molecule; its expression is down-regulated in several carcinomas TRUE
ii) Up-regulation of integrin expression is associated with a greater metastatic potential FALSE
iii) Tumour angiogenesis is required when the tumour exceeds 0.1mm in size FALSE
iv) Protease secretion is associated with greater metastatic potenital TRUE
v) Tumours with high growth fractions are usually more susceptible to chemotherapy TRUE
Explanations
i) Tumour pathophysiology E-cadherin is a major epithelial cell adhesion molecule; its expression is down-regulated in several carcinomas (TRUE)
E-cadherin is a major epithelial cell adhesion molecule; its expression is down-regulated in several carcinomas
ii) Tumour pathophysiology Up-regulation of integrin expression is associated with a greater metastatic potential (FALSE)
Integrins are molecules that bind epithelial cells to the basement membrane. Reduced expression of expression of integrins is associated with increased metastatic potential
iii) Tumour pathophysiology Tumour angiogenesis is required when the tumour exceeds 0.1mm in size (FALSE)
Angiogenesis is required once the tumout exceeds 1-2mm in size
iv) Tumour pathophysiology Protease secretion is associated with greater metastatic potenital (TRUE)
Proteases are required to degrade the extracellular matrix, metallo-proteinase secretion is required for angiogenesis. Production of proteases is associated with a greater malignant potential.
v) Tumour pathophysiology Tumours with high growth fractions are usually more susceptible to chemotherapy (TRUE)
The growth fraction refers to the number of cells that can be seen to be multiplying. Growth factors of 0.2 (20%) are considered to be very high.
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46. Tumour markers:
i) CA 15-3 is primarily used to monitor hepatic malignancy FALSE
ii) CA 19-9 is used as a marker of pancreatic malignancy TRUE
iii) Calcitonin levels are often elevated in papillary carcinoma of the thyroid FALSE
iv) CA 125 is primarily used to monitor bowel malignancy FALSE
v) ACTH is elevated in some small cell lung carcinomas TRUE
Explanations
i) Tumour markers: CA 15-3 is primarily used to monitor hepatic malignancy (FALSE)
CA 15-3 is occassionally elevated in breast cancer and is used to monitor progression of breast Ca.
It may also be elevated in pancreatic cancer but is not espescially useful in this condition
ii) Tumour markers: CA 19-9 is used as a marker of pancreatic malignancy (TRUE)
Ca 19-9 is of some benefit in identifying patients with pancreatic malignancy given a suggestive clinical picture. It is also used to monitor progression of the disease
iii) Tumour markers: Calcitonin levels are often elevated in papillary carcinoma of the thyroid (FALSE)
Calcitonin levels are elevated in some medullary thyroid carcinomas (medullary carcinomas arise from the parafollicular C-cells that secrete calcitonin)
iv) Tumour markers: CA 125 is primarily used to monitor bowel malignancy (FALSE)
CA 125 is primarily used to monitor ovarian malignancy, however it is very non-specific and may be raised in bowel cancer
v) Tumour markers: ACTH is elevated in some small cell lung carcinomas (TRUE)
Ectopic ACTH may be secreted by a number of malignancies of which small cell (oat cell) lung cancer is the most common. Others include:
- Carcinoid tumours
- Thymomas
- Pancreatic islet cell tumors
- Medullary carcinomas of the thyroid
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47. Breast cancer:
part item correct
answer your
answer mark average
i) Ductal carcinoma in situ (DCIS) confers an 80-90% risk of developing breast cancer in the subsequent 10 years FALSE B 0 -0.26
ii) DCIS is often identified by areas of microcalcification seen on mammography TRUE B 0 0.71
iii) 80-90% of malignancies are ductal carcinomas TRUE B 0 0.34
iv) A tumour with metastases to ipsilateral internal mammary lymph nodes would be given the stage N3 TRUE B 0 -0.08
v) Paget's disease of the nipple is classified as a T4 tumour FALSE B 0 0.06
TOTALS: 0 0.76
Explanations
i) Breast cancer: Ductal carcinoma in situ (DCIS) confers an 80-90% risk of developing breast cancer in the subsequent 10 years (FALSE)
DCIS confers a 25-50% risk of breast cancer at 10-15 years.
ii) Breast cancer: DCIS is often identified by areas of microcalcification seen on mammography (TRUE)
As DCIS grows it outstrips its blood supply causing central necrosis. The dead tissue may then calcify to form microcalcification within the ductal system.
Please note that although microcalcification seen on radiological investigations is a good way of identifying areas affected by DCIS it is not in itself diagnostic: DCIS is a pathological diagnosis requiring biopsy.
iii) Breast cancer: 80-90% of malignancies are ductal carcinomas (TRUE)
Ductal: 80-90%
Lobular: 1-10%
Mucinous: 5%
Medullary: 1-5%
Pagets: 2%
Apocrine: 1%
iv) Breast cancer: A tumour with metastases to ipsilateral internal mammary lymph nodes would be given the stage N3 (TRUE)
N1 - Axillary lymph nodes, no fixation
N2 - Axillary nodes with fixation
N3 - Internal mammary nodes
v) Breast cancer: Paget's disease of the nipple is classified as a T4 tumour (FALSE)
Paget's disease of the nipple is a ductal carcinoma involving the epidermis. It is graded according to the size of the tumour
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48 . Pancreatic malignancy:
i) Is more common in women FALSE
ii) Usually arises from the islet cells of the pancreas FALSE
iii) Over a third of cases arise in the pancreatic tail FALSE
iv) The majority of tumours are associated with mutation of k-ras TRUE
v) Over 60% of patients have metastases at the time of presentation TRUE
Explanations
i) Pancreatic malignancy: Is more common in women (FALSE)
It is twice as common in men
ii) Pancreatic malignancy: Usually arises from the islet cells of the pancreas (FALSE)
95% of malignancies develop from the exocrine portion of the pancreas including the ductal epithelium, acinar cells, connective tissue, and lymphatic tissue. ISlet cell tumours are much less common.
iii) Pancreatic malignancy: Over a third of cases arise in the pancreatic tail (FALSE)
Most commonly arise in the head of the pancreas:
- Head 75%
- Body 15 - 20%
- Tail 5 - 10%
iv) Pancreatic malignancy: The majority of tumours are associated with mutation of k-ras (TRUE)
- 80-95% have mutations in the KRAS2 gene
- 85-98% have mutations, deletions, or hypermethylation in the CDKN2 gene
- 50% have mutations in TP53
- 55% have homozygous deletions or mutations of Smad4
Also note that high risk pre-cursor conditions are often associated with genetic changes, for example patients with chronic pancreatitis:
- 30% have mutations in TP16
- 10% have K-ras mutations
(adapted from www.emedicine.com)
v) Pancreatic malignancy: Over 60% of patients have metastases at the time of presentation (TRUE)
Approximately 75% of patients have metastases at the time of presentation. Only 15% of tumours are resectable
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49 . Fibroadenomas
i) Are benign neoplasms FALSE
ii) Are rarely multiple FALSE
iii) May regress spontaneously TRUE
iv) Progress to malignancy in about 10% of cases FALSE
v) Clinical diagnosis of fibradenoma is over 90% accurate without investigation FALSE
Explanations
i) Fibroadenomas Are benign neoplasms (FALSE)
Fibroadenomas areaberrations of development rather than neoplasms. They develop from a single lobule
ii) Fibroadenomas Are rarely multiple (FALSE)
Fibroadenomas are frequently multiple and often bilateral
iii) Fibroadenomas May regress spontaneously (TRUE)
Fibroadenomas occassionally increase in size but usually do not. They may regress spontaneously
iv) Fibroadenomas Progress to malignancy in about 10% of cases (FALSE)
Fibroadenomas do not have any malignant potential
v) Fibroadenomas Clinical diagnosis of fibradenoma is over 90% accurate without investigation (FALSE)
Clinical diagnosis is often inaccurate and thus FNA /core biospy /USS is always indicated.
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50 . Hereditary non-polyposis colorectal carcinoma (HNPCC) syndrome:
i) Is associated with increased risk of endometrial cancer TRUE
ii) Accounts for 3-5% of cases of colorectal carcinoma TRUE
iii) HNPCC occurs as a result of k-ras mutation FALSE
iv) Patients with HNPCC syndrome require sigmoidoscopy every 1 to 2 years after the age of 20 FALSE
v) HNPCC is characterised by rapid malignant change of adenomas TRUE
Explanations
i) Hereditary non-polyposis colorectal carcinoma (HNPCC) syndrome: Is associated with increased risk of endometrial cancer (TRUE)
HNPCC increases the relative risk of the following malignancies (life time risk in brackets):
- Colonic cancer (90%)
- Endometrium (40%)
- Excretory urinary tract, stomach, biliary tract (about 10%)
- Small intestine (10%)
- Ovary (3%)
ii) Hereditary non-polyposis colorectal carcinoma (HNPCC) syndrome: Accounts for 3-5% of cases of colorectal carcinoma (TRUE)
HNPCC accounts for 3-5% of cases of colorectal carcinoma
iii) Hereditary non-polyposis colorectal carcinoma (HNPCC) syndrome: HNPCC occurs as a result of k-ras mutation (FALSE)
HNPCC occurs due to mutation of various DNA mismatch repair genes.
iv) Hereditary non-polyposis colorectal carcinoma (HNPCC) syndrome: Patients with HNPCC syndrome require sigmoidoscopy every 1 to 2 years after the age of 20 (FALSE)
HNPCC related carcinomas are principally found in the ascending colon and will thus be missed by sigmoidoscopy: colonoscopy is indicated every 1-2 years after the age of 20 and yearly after the age of 40 for patients with HNPCC.
v) Hereditary non-polyposis colorectal carcinoma (HNPCC) syndrome: HNPCC is characterised by rapid malignant change of adenomas (TRUE)
Adenomas usually undergo malignant change over a protracted course of about 10 years. HNPCC is associated with minimal adenoma formation, but any adenomas that are present are likely to undergo rapid malignant change.
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51 . Cutaneous naevi
i) Junctional naevi contain melanocytic naevi cells clustered together in the epidermis just above the dermal - epidermal junction FALSE
ii) Compund naevi consist of clustered intradermal and junctional melanocytic naevus cells TRUE
iii) The appearence of hypo pigmented haloes around existing naevi is highly suggestive of malignancy FALSE
iv) Junctional naevi are characteristically flat, macular, pigmented lesions TRUE
v) Compund naevi have a high malignant potential FALSE
Explanations
i) Cutaneous naevi Junctional naevi contain melanocytic naevi cells clustered together in the epidermis just above the dermal - epidermal junction (FALSE)
Lentigo is characterised by increased numbers of melanocytic naevus cells within the basal layer of the epidermis. It is strongly associated with exposure to UV light but is itself benign.
The melanocytic naevus cells of junctional naevi exist just deep to the junction - they all remain within the dermis
ii) Cutaneous naevi Compund naevi consist of clustered intradermal and junctional melanocytic naevus cells (TRUE)
Compund naevi consist of clustered intradermal and junctional melanocytic naevus cells
iii) Cutaneous naevi The appearence of hypo pigmented haloes around existing naevi is highly suggestive of malignancy (FALSE)
HaLo naevi (often appear on the trunks of children and adolescents, often multiple) represent immune destruction of naevus cells and this is followed by involution of the naevus. Halo naevi are associated with an increased risk of developing vitiligo.
iv) Cutaneous naevi Junctional naevi are characteristically flat, macular, pigmented lesions (TRUE)
Junctional naevi are characteristically flat, macular, pigmented lesions
v) Cutaneous naevi Compund naevi have a high malignant potential (FALSE)
About 30% of malignant melenomas have histological evidence that they arose from a pre-existing naevus, but to state that normal naevi had a high malignant potential would be incorrect.
People with dysplastic naevus syndrome are. however, at a markedly increased risk.
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52 . Lung cancer
i) Disease up to and including T3 N2 M0 may be considered for surgical resection with curative intent TRUE
ii) Fine needle aspiration cytology is recommended for investigating lesions in the peripheral lung that may represent primary lung cancer FALSE
iii) Pancoast's tumour is characterised by invasion of the ipsilateral, ascending sympathetic chain TRUE
iv) Nodal involvement is graded as N3 if contralateral hilar nodes are involved TRUE
v) Segmentectomy can be considered for peripheral lesions less than 2cm in size TRUE
Explanations
i) Lung cancer Disease up to and including T3 N2 M0 may be considered for surgical resection with curative intent (TRUE)
Disease up to and including T3 N2 M0 (Stage IIIa) may be considered for surgical resection with curative intent
ii) Lung cancer Fine needle aspiration cytology is recommended for investigating lesions in the peripheral lung that may represent primary lung cancer (FALSE)
FNA can result in seeding of the tumour and is therefore not recommended for lesions thought to be primary lung malignancies
iii) Lung cancer Pancoast's tumour is characterised by invasion of the ipsilateral, ascending sympathetic chain (TRUE)
Pancoast's tumour is found in the apex of the lung and invades the ascending sympathetic chain, ultimately resulting in Horner's syndrome: unilateral meiosis, ptosis and anhydrosis
iv) Lung cancer Nodal involvement is graded as N3 if contralateral hilar nodes are involved (TRUE)
Nodal involvement is graded as N3 if contralateral hilar nodes are involved
v) Lung cancer Segmentectomy can be considered for peripheral lesions less than 2cm in size (TRUE)
Segmentectomy can be considered for peripheral lesions less than 2cm in size
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53 . Lung cancer
i) Small cell carcinomas account for approximately 20-25% of all lung malignancies TRUE
ii) Squamous cell carcinoma is usually located peripherally within the lungs FALSE
iii) Adenocarcinomas are more likely to present with metastatic disease than squamous cell carcinoma TRUE
iv) Small cell cancers usually present with disseminated disease TRUE
v) Paraneoplastic syndromes are most frequently associated with large cell carcinoma FALSE
Explanations
i) Lung cancer Small cell carcinomas account for approximately 20-25% of all lung malignancies (TRUE)
Small cell (Oat cell) account for 20-25% of all lung malignancies
ii) Lung cancer Squamous cell carcinoma is usually located peripherally within the lungs (FALSE)
Squamous carcinomas are usually found in the large bronchi, they account for 30-50% of all lung malignancies
iii) Lung cancer Adenocarcinomas are more likely to present with metastatic disease than squamous cell carcinoma (TRUE)
Incidence of adenocarcinoma appears to be rising. About 50% of cases occur in the periphery of the lung. Adenocarcinomas are more prone to metastatic spread than squamous cell carcinomas
iv) Lung cancer Small cell cancers usually present with disseminated disease (TRUE)
Small cell cancers spread rapidly and usually present with disseminated metastases. Treatment is primarily with chemotherapy
v) Lung cancer Paraneoplastic syndromes are most frequently associated with large cell carcinoma (FALSE)
Paraneoplastic syndromes are most commonly seen with small cell carcinoma
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54 . Thyroid malignancy
i) Papillary carcinoma requires total thyroidectomy and TSH supression using high levels of thyroxine replacement TRUE
ii) Block dissection of cervical lymph nodes improves survival FALSE
iii) Follicular carcinomas are more common in patients with MEN IIa FALSE
iv) Anaplastic carcinomas respond well to chemotherapy FALSE
v) Follicular carcinoma spreads haematologenously TRUE
Explanations
i) Thyroid malignancy Papillary carcinoma requires total thyroidectomy and TSH supression using high levels of thyroxine replacement (TRUE)
Both Papillary and follicular carcinomas require total thyroidectomy and TSH supresion using high dose thyroxine
ii) Thyroid malignancy Block dissection of cervical lymph nodes improves survival (FALSE)
Node picking is indicated rather than en-block dissection of the cervical nodes
iii) Thyroid malignancy Follicular carcinomas are more common in patients with MEN IIa (FALSE)
MEN IIa and MEN IIb are associated with medullary thyroid carcinomas
iv) Thyroid malignancy Anaplastic carcinomas respond well to chemotherapy (FALSE)
Anaplastic carcinomas grow rapidly with 20% 1 year survival. Surgical debulking and radiotherapy may be indicated. LArgerly unresponsive to chemotherapy
v) Thyroid malignancy Follicular carcinoma spreads haematologenously (TRUE)
Spread of thyroid malignancy:
Papillary: lymphatic
Follicular: haematogenous
Anaplastic: both
Medullary: both
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55 . In the assessment and management of major trauma
part item correct
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i) deaths follow a trimodal distribution TRUE
ii) The standard series of x-rays taken after the primary survey consists of an AP cervical spine, chest and pelvis, other x-rays are only ordered if indicated FALSE
iii) cardiac tamponade is chacterised by raised BP, low JVP and muffled heart sounds FALSE
iv) assessment of uncomplicated limb factures should occur during the primary survey FALSE
v) deterioration of the casualty during the primary survey should lead to the secondary survey FALSE
Explanations
i) In the assessment and management of major trauma deaths follow a trimodal distribution (TRUE)
Early deaths invariably occur at the scene of the accident and usually form severe thoraco abdominal or head trauma. The second peal occur in the 'golden hour' and are the focus of the ATLS system. The third peak occurs after days or weeks and is the result of sepsis or multiorgan failure
ii) In the assessment and management of major trauma The standard series of x-rays taken after the primary survey consists of an AP cervical spine, chest and pelvis, other x-rays are only ordered if indicated (FALSE)
The series of x-rays take on completion of the primary survey should include a LATERAL cervical spine, chest and pelvis
iii) In the assessment and management of major trauma cardiac tamponade is chacterised by raised BP, low JVP and muffled heart sounds (FALSE)
Cardiac tamponade results from blood within the pericardial sac. It results in hypotension, a raised JVP and muffled heart sounds
iv) In the assessment and management of major trauma assessment of uncomplicated limb factures should occur during the primary survey (FALSE)
Potentially life threating injuries are assessed during the primary survey. Uncomplicated limb fractures should be assessed and managed during the secondary survey
v) In the assessment and management of major trauma deterioration of the casualty during the primary survey should lead to the secondary survey (FALSE)
If unexplained deterioration of the casualty occurs during the any phase of the trauma assessment then the ABC of the primary survey should be revisted.
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56 . Duodenal ulcers:
i) Occur more commonly in smokers than in non-smokers TRUE
ii) Are a recognised complication of hyperparathyroidism TRUE
iii) Are associated with Helicobacter Pylori infection in 40% to 50% of patients FALSE
iv) Are symptomatic in approximately 40% to 60% of cases TRUE
v) May be managed conservatively with corticosteroids FALSE
Explanations
i) Duodenal ulcers: Occur more commonly in smokers than in non-smokers (TRUE)
Predisposing factors for the development of duodenal ulcers include smoking, alcohol, blood group O, non-steroidal anti-inflammatory drugs, stress and Zollinger-Ellison syndrome.
ii) Duodenal ulcers: Are a recognised complication of hyperparathyroidism (TRUE)
Peptic ulceration is associated with hyperparathyroidism. Increased levels of parathyroid hormone cause serum calcium to rise and this stimulates gastric acid secretion and increases the risk of peptic ulceration.
iii) Duodenal ulcers: Are associated with Helicobacter Pylori infection in 40% to 50% of patients (FALSE)
Duodenal ulcers are Helicobacter pylori positive in 90% of cases. Gastric ulcers are positive in 80% of cases.
iv) Duodenal ulcers: Are symptomatic in approximately 40% to 60% of cases (TRUE)
Duodenal ulcers are symptomatic in about 50% of patients and usually cause epigastric pain that is worse at night and relieved by eating. Gastric ulcers typically cause pain that is worsened by eating.
v) Duodenal ulcers: May be managed conservatively with corticosteroids (FALSE)
Neither duodenal nor gastric ulcers should be treated with corticosteroids. In fact, steroids are associated with the development of peptic ulcers and may exacerbate existing ulcers. Treatment options for peptic ulcers include the use of H2 antagonists such as ranitidine, proton pump inhibitors such as omeprazole and antibiotic therapy to eradicate Helicobacter pylori. Surgery is occasionally required for persistent ulcers or for complications such as perforation or haemorrhage.
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57 . The following statements are true of colonic diverticulosis:
i) In the Western world between 25 - 40% of people aged over 60 have diverticula TRUE
ii) A low-fibre diet predisposes to the development of diverticula TRUE
iii) A barium follow through is the radiological investigation of choice for imaging diverticulae FALSE
iv) Rectal bleeding is a recognised complication TRUE
v) Over 90% of complications occur in the descending colon FALSE
Explanations
i) The following statements are true of colonic diverticulosis: In the Western world between 25 - 40% of people aged over 60 have diverticula (TRUE)
Diverticulosis is common and about 33% of people aged over 60 years in the Western world have diverticula.
ii) The following statements are true of colonic diverticulosis: A low-fibre diet predisposes to the development of diverticula (TRUE)
Lack of dietary fibre is thought to lead to a high intraluminal pressure which forces the mucosa to herniate through the layers of bowel muscle, thus forming diverticula.
iii) The following statements are true of colonic diverticulosis: A barium follow through is the radiological investigation of choice for imaging diverticulae (FALSE)
A barium enema is the radiological investigation of choice for imaging colonic diverticulae
iv) The following statements are true of colonic diverticulosis: Rectal bleeding is a recognised complication (TRUE)
Bleeding can occur due to erosion of a vessel at the mouth of a diverticulum and this is a common cause of rectal bleeding. The haemorrhage is usually painless and sudden, but can result in a significant amount of blood loss. Other causes of rectal bleeding include colorectal carcinoma, polyps, haemorrhoids, anal fissure, trauma, radiation proctitis and angiodysplasia.
v) The following statements are true of colonic diverticulosis: Over 90% of complications occur in the descending colon (FALSE)
95% of complications occur in the sigmoid colon as this is the site where diverticula predominantly occur. Complications include acute diverticulitis, perforation, fistula or abscess formation, bowel obstruction and haemorrhage.
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58 . The following usually transilluminate on examination of the scrotum:
part item correct
answer your
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i) Testiuclar tumour. FALSE F +1 0.96
ii) Gumma FALSE F +1 0.74
iii) Hydrocele. TRUE T +1 0.98
iv) Epididymal cyst. TRUE F -1 0.72
v) Indirect Inguinal Henia. FALSE F +1 0.87
TOTALS: 3 4.27
Explanations
i) The following usually transilluminate on examination of the scrotum: Testiuclar tumour. (FALSE)
Testicular tumours are not transilluminable.
ii) The following usually transilluminate on examination of the scrotum: Gumma (FALSE)
A gumma is a small soft tumour, charateristic of tertiary syphilis, that occurs in testes, connective tissue, the liver, brain, heart or bone.
iii) The following usually transilluminate on examination of the scrotum: Hydrocele. (TRUE)
Hydrocele: the result of excessive fluid collecting in the tunica vaginalis. Fluctuant and transilluminable. There are 4 types with a Vaginal hydrocele being the most common.
iv) The following usually transilluminate on examination of the scrotum: Epididymal cyst. (TRUE)
These usually transilluminate very well, however old, chronic cysts may not transluminate so well.
v) The following usually transilluminate on examination of the scrotum: Indirect Inguinal Henia. (FALSE)
An indirect inguinal hernia is a protrusion of bowel which has extended into the scrotum and is not transilluminable.
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59 . Features that are suggestive of a diagnosis of acute appendicitis include
i) Left iliac fossa pain. FALSE
ii) A positive Murphy's sign FALSE
iii) A positive Rovsing's sign TRUE
iv) A normal white cell count FALSE
v) A raised CRP (C Reactive Protein) level TRUE
Explanations
i) Features that are suggestive of a diagnosis of acute appendicitis include Left iliac fossa pain. (FALSE)
Acute appendicitis characteristically presents with peri-umbilical pain that then localises to the right iliac fossa. Left iliac fossa pain is not usually consistent with a diagnosis of appendicitis.
ii) Features that are suggestive of a diagnosis of acute appendicitis include A positive Murphy's sign (FALSE)
This is false. A positive Murphy¡¦s sign is indicative of significant inflammation of the right upper quadrant and is most often seen due to gall bladder and liver disease.
To elicit Murphy¡¦s sign the patient should be flat on their back. The examiner should then place their hand just under the patients lower ribs on the right hand side (the area just over the gall bladder). The patient should then be asked to take a deep breath. If the patient suddenly stops inhaling because of intense pain they can be said to be Murphy¡¦s positive.
The pain occurs because as the patient inhales, the diaphragm descends pushing the liver and gall bladder towards the examiner¡¦s hand. The pressure of the hand will cause pain if the liver or gall bladder are inflamed.
Source: Dr Arai (www.iVillageHealth.com)
iii) Features that are suggestive of a diagnosis of acute appendicitis include A positive Rovsing's sign (TRUE)
Patients with acute appendicitis will often be Rovsing positive.
Elliciting the sign:
If a patient experiences pain focused at McBurney's Point (the area of skin over the appendix) when the left side of the abdomen is palpated they are Rovsing positive.
iv) Features that are suggestive of a diagnosis of acute appendicitis include A normal white cell count (FALSE)
The white cell count may be normal, however it is much more likely to be raised.
v) Features that are suggestive of a diagnosis of acute appendicitis include A raised CRP (C Reactive Protein) level (TRUE)
CRP is usually markedly raised in appendicitis.
C-reactive protein (CRP) is an acute-phase reactant synthesized by the liver in response to bacterial infection. Serum levels begin to rise within 6-12 hours of acute tissue inflammation. A rapid assay is widely available.
Further notes:
Diagnosis of acute appendicitis depends on clinical signs and symptoms more than tests like CRP. The combination of clincal signs (local tenderness, rebound tenderness..etc) and history and raised WBCs are the main diagnostic criteria. In females we have to rule out ectopic pregnancy (pregnancy test) and other female genital tract causes of abdominal pain.
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60 . A patient is admitted profoundly shocked wtih a ruptured aortic aneurysm. Before he can be anaesthetised, the following are mandatory:
i) an erect chest x-ray, PA and lateral. FALSE
ii) an Hb measurement. FALSE
iii) a 12-lead ECG. FALSE
iv) a ready availability of blood, uncross-matched if necessary. TRUE
v) at least 1 wide-bore intravenous cannula in place. TRUE
Explanations
i) A patient is admitted profoundly shocked wtih a ruptured aortic aneurysm. Before he can be anaesthetised, the following are mandatory: an erect chest x-ray, PA and lateral. (FALSE)
Delays the life saving operation unnecessarily.
ii) A patient is admitted profoundly shocked wtih a ruptured aortic aneurysm. Before he can be anaesthetised, the following are mandatory: an Hb measurement. (FALSE)
Delays the life saving operation unnecessarily.
iii) A patient is admitted profoundly shocked wtih a ruptured aortic aneurysm. Before he can be anaesthetised, the following are mandatory: a 12-lead ECG. (FALSE)
Delays the life saving operation unnecessarily.
iv) A patient is admitted profoundly shocked wtih a ruptured aortic aneurysm. Before he can be anaesthetised, the following are mandatory: a ready availability of blood, uncross-matched if necessary. (TRUE)
The patient is likely to need a lot of blood, quickly!
v) A patient is admitted profoundly shocked wtih a ruptured aortic aneurysm. Before he can be anaesthetised, the following are mandatory: at least 1 wide-bore intravenous cannula in place. (TRUE)
You need a wide bore cannula in place to quickly deliver the blood and fluids that the patient is likely to require.
Further notes:
A pre-op assessment question. A critical situation needs concentration on the essentials and rejection of the items that are only going to delay life-saving treatment without advancing the diagnosis or assessment of fitness. The patient is in extremis, and only a surgical operation will save him, but the surgical operation needs lots of blood and something to give it through.
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