81 . In the diagnosis of infertility:
i) Axillary pigmentation would support a diagnosis of PCOS TRUE
ii) A day 21 progesterone level of >30 nmol/L suggests that ovulation has occurred TRUE
iii) Daily temperature charting, if followed correctly, is 90% sensitive for detecting if and when ovulation has occured FALSE
iv) Sheehans syndrome is a differential diagnosis in patients who experience infertility despite ovulation occurring FALSE
v) When compared to the general population there is an increased prevalence of coeliac disease in infertile patients. TRUE
Explanations
i) In the diagnosis of infertility: Axillary pigmentation would support a diagnosis of PCOS (TRUE)
Acanthosis nigricans is a sign of profound insulin resistance and is associated with PCOS and obesity. It presents as hyperpigmented thickening of skin folds in the neck or axillae.
ii) In the diagnosis of infertility: A day 21 progesterone level of >30 nmol/L suggests that ovulation has occurred (TRUE)
It is an indirect indicator of ovulation. Progesterone is released by the corpus luteum, thus increased levels suggest that ovulation has occurred.
iii) In the diagnosis of infertility: Daily temperature charting, if followed correctly, is 90% sensitive for detecting if and when ovulation has occured (FALSE)
Between 25% and 75% of ovulatory cycles will not show an adequate rise in basal body temperature. Therefore a 'flat' chart does not neccessarily indicate anovulation.
iv) In the diagnosis of infertility: Sheehans syndrome is a differential diagnosis in patients who experience infertility despite ovulation occurring (FALSE)
Sheehans syndrome is a rare syndrome of pituitary infarction following PPH (post partum haemorrhage). FSH and LH are not secreted and the patient becomes anovulatory and infertile as a result.
v) In the diagnosis of infertility: When compared to the general population there is an increased prevalence of coeliac disease in infertile patients. (TRUE)
Celiac disease is associated with increased infertility in men due to abnormality of the hypothalamo-pituitary axis, increased impotence and disordered spermatogenesis.
Celiac disease is also more common in infertile women with infertile women being 10 times more likely to suffer from celiac disease than the general population.
In people with Celiac disease following a gluten free diet can help increase their fertility.
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82 . Polycystic ovary syndrome
i) Is the commonest cause of anovulatory infertility TRUE
ii) Requires the presence of ovarian cysts FALSE
iii) Is associated with insulin resistance TRUE
iv) May be associated with increased cardiovascular morbidity TRUE
v) Serum concentrations of testosterone are increased TRUE
Explanations
i) Polycystic ovary syndrome Is the commonest cause of anovulatory infertility (TRUE)
Polycystic ovary syndrome accounts for approximately 75% of cases of anovulatory infertility
ii) Polycystic ovary syndrome Requires the presence of ovarian cysts (FALSE)
Early descriptions of the syndrome were based on ovarian morphology. This is not now considered an essential requirement for the diagnosis, but modern ultrasound techniques do show that the majority of women with polycystic ovaries do have ovarian cysts.
iii) Polycystic ovary syndrome Is associated with insulin resistance (TRUE)
Polycystic ovary syndrome is associated with a characteristic metabolic disoreder comprising hyperinsulinaemia, insulin resistance and dyslipidaemia.
iv) Polycystic ovary syndrome May be associated with increased cardiovascular morbidity (TRUE)
The risk of cardiovascular disease is increased by a factor of about sevenfold in patients with polycystic ovaries.
v) Polycystic ovary syndrome Serum concentrations of testosterone are increased (TRUE)
Serum concentrations of testosterone and other androgens are increased in polycystic ovary syndrome. Hypersecretion of luteinizing hormone also occurs. Particularly in anovulatory women, and is a specific but not very sensitive index of the syndrome.
Further notes:
A diagnosis of polycystic ovary syndrome is based on the association of hyperandrogenism with chronic anovulation in women without specific underlying disease of the adrenal or pituitary gland. The ovary is the principle source of the excess androgens. Management is aimed at the treatment of infertility, menstrual regulation, the treatment of hyperandrogenism and the prevention of long-term complications of the metabolic disturbances.
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83 . Endometrial carcinoma:
i) Has a higher incidence in developed countries TRUE
ii) Is associated with diabetes TRUE
iii) May be excluded in post menopausal women with <5mm>
iv) Disease is confined to the uterus at presentation in the majority (>70%) TRUE
v) 5 year survival at Stage I is >80% TRUE
Explanations
i) Endometrial carcinoma: Has a higher incidence in developed countries (TRUE)
This may be due to the increased frequency of related risk factors ie. factors related to unopposed oestrogens:
Obesity, Low parity, HRT, PCOS, Tamoxifen.
ii) Endometrial carcinoma: Is associated with diabetes (TRUE)
Insulin resistance confers a greater risk for endometrial carcinoma
iii) Endometrial carcinoma: May be excluded in post menopausal women with <5mm>
This is true for post menopausal women. However this measurement cannot not be relied upon in a pre-menopausal woman.
iv) Endometrial carcinoma: Disease is confined to the uterus at presentation in the majority (>70%) (TRUE)
The majority of endometrial carcinomas present at Stage I with confinement to the uterus.This may be in part due to presenting sypmtoms, which are often quickly acted upon. It presents as post menopausal or abnormal vaginal bleeding in 75-80% women.
v) Endometrial carcinoma: 5 year survival at Stage I is >80% (TRUE)
Using the FIGO surgical staging classification, Stage I disease has a 5yr survival of 87% (though some subsets of stage I have 90% survival).
Thus there is a very good chance of cure with treatment which commonly consists of surgical treatment - total hysterectomy with bilateral salpingo-oopherectomy +/- radiotherapy.
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84 . An increased risk of ectopic preganancy is seen with:
i) Previous Chlamydia infection TRUE
ii) Previous Candida infection FALSE
iii) Conception whilst on COCP (combined oral contraceptive pill) FALSE
iv) Conception whilst on POP (progesterone only pill) TRUE
v) Artificial insemination FALSE
Explanations
i) An increased risk of ectopic preganancy is seen with: Previous Chlamydia infection (TRUE)
A first chlamydial infection causes damage to fallopian tubes in 10% of cases. Scarring or obstruction of the tubes increases the risk of ectopic pregnancy.
ii) An increased risk of ectopic preganancy is seen with: Previous Candida infection (FALSE)
There is no increased risk.
iii) An increased risk of ectopic preganancy is seen with: Conception whilst on COCP (combined oral contraceptive pill) (FALSE)
COCP's have been shown to protect against ectopic pregnancy.
iv) An increased risk of ectopic preganancy is seen with: Conception whilst on POP (progesterone only pill) (TRUE)
There is evidence to suggest that women who concieve while taking a POP will be 3x more likely to have an ectopic pregnancy than the general population.
NB: the overal risk of ectopic pregnancy in women on the POP is less than the general population, however if women on the POP do become preganant (as the question implies) they are more likely to have an ectopic pregnancy.
v) An increased risk of ectopic preganancy is seen with: Artificial insemination (FALSE)
There is no increased risk
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85 . Dupuytren's Contracture:
i) Is more common in men. TRUE
ii) Is characterised by thickening and contracture of the palmar aponeurosis. TRUE
iii) Characteristically causes flexion of the metacarpophalangeal, proximal interphalangeal and distal interphalangeal joints. FALSE
iv) Is associated with epilepsy. TRUE
v) Surgical management is usually by fasciotomy or fasciectomy. TRUE
Explanations
i) Dupuytren's Contracture: Is more common in men. (TRUE)
Dupuytren's contracture is more common in men, usually elderly.
ii) Dupuytren's Contracture: Is characterised by thickening and contracture of the palmar aponeurosis. (TRUE)
There is fibrosis of the palmar aponeurosis which produces a flexion derformity. It is often bilateral and may occasionally affect the plantar fascia too. Involvement of the plantar fascia is given the name plantar fascitis as the name Duputren's Contracture traditionally only describes contracture of the palmar fascia.
iii) Dupuytren's Contracture: Characteristically causes flexion of the metacarpophalangeal, proximal interphalangeal and distal interphalangeal joints. (FALSE)
Causes flexion at the metacarpophalangeal and proximal interphalangeal joints. The distal interphalangeal (DIP) joints are not characteristically involved but compensatory flexion or hyperextension of the DIP joints may be seen
iv) Dupuytren's Contracture: Is associated with epilepsy. (TRUE)
In most cases it is idiopathic, but can be familial or associated with liver disease, epilepsy and phenytoin use.
v) Dupuytren's Contracture: Surgical management is usually by fasciotomy or fasciectomy. (TRUE)
Fasciectomy or fasciotomy is performed to straighten the flexed fingers.
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86 . The Hand:
i) Carpal tunnel syndrome is associated with hypothyroidism. TRUE
ii) An ulnar nerve palsy produces a 'claw hand' and sensory loss over the thumb and lateral two and a half digits. FALSE
iii) A fracture to the shaft of the humerus is associated with wrist drop. TRUE
iv) A median nerve lesion produces wasting of the medial two lumbricals. FALSE
v) Erb's palsy produces a characteristic 'waiter's tip' sign. TRUE
Explanations
i) The Hand: Carpal tunnel syndrome is associated with hypothyroidism. (TRUE)
Causes of carpel tunnel syndrome:
1. Endocrine: acromegaly, hypothyroidism
2. Connective Tissue diseases: rheumatoid arthritis.
3. Fluid retention: congestive cardiac failure, pregnancy.
4. Trauma.
ii) The Hand: An ulnar nerve palsy produces a 'claw hand' and sensory loss over the thumb and lateral two and a half digits. (FALSE)
It does produce a claw hand position but causes sensory loss over the little and ring fingers. A median nerve lesion produces sensory loss over the lateral three and a half digits.
iii) The Hand: A fracture to the shaft of the humerus is associated with wrist drop. (TRUE)
Wrist drop occurs from radial nerve damage. The radial nerve lies in the spiral groove and can therefore be damaged by fractures of the shaft of the humerus.
iv) The Hand: A median nerve lesion produces wasting of the medial two lumbricals. (FALSE)
A median lesion produces motor loss and wasting of the 'L.O.A.F.' muscles of the hand:
Lumbricals (lateral two)
Opponens pollicis
Abductor pollicis brevis (easiest to test)
Flexor pollicis brevis.
v) The Hand: Erb's palsy produces a characteristic 'waiter's tip' sign. (TRUE)
Erb's palsy (C5, C6 roots) is most commonly caused by birth trauma and injury. The arm is internally rotated with the forearm pronated and the palm facing backwards (waiter's tip sign).
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87 . Lesions of the ulnar nerve are associated with:
i) Wasting of the thenaR eminence FALSE
ii) Parasthesia of the medial aspect of the palm and the little finger and the medial side of the ring finger TRUE
iii) Impaired abduction of the fingers TRUE
iv) Impaired extension of the metacarpal-phalangeal (MCP) joints FALSE
v) A positive Froment's sign TRUE
Explanations
i) Lesions of the ulnar nerve are associated with: Wasting of the thena eminence (FALSE)
The thena eminence is the bulk of muscles at the base of the thumb, these may become wasted in median nerve lesions - not ulnaer nerve lesions.
The hypothena eminence is the bulk of mucles on the medial aspect of the hand proximal to the little finger. The hypothena eminence may become wasted in ulnar nerve lesions
ii) Lesions of the ulnar nerve are associated with: Parasthesia of the medial aspect of the palm and the little finger and the medial side of the ring finger (TRUE)
This is true, the ulnar nerve also provides sensory innervation to the medial aspect of the dorsum of the hand.
iii) Lesions of the ulnar nerve are associated with: Impaired abduction of the fingers (TRUE)
The ulnar nerve supplies the dorsal interossei which abduct the fingers
iv) Lesions of the ulnar nerve are associated with: Impaired extension of the metacarpal-phalangeal (MCP) joints (FALSE)
The extensors of the MCP joints are innervated by the radial nerve.
v) Lesions of the ulnar nerve are associated with: A positive Froment's sign (TRUE)
Froment's test may demonstrate an ulnar nerve lesion; it specifically tests the function of adductor pollicis
Froment's sign relates to abnormal grip of a piece of paper. The patient is asked to make a fist, thumb uppermost. They are then asked to grip a piece of paper on to their fist using their thumb. Normally the thumb pad will be flat. However if there is an ulnar nerve lesion affecting adductor pollicis the grip will be abnormal and the thumb will be flexed and partially on its side.
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88 . Median nerve lesions are associated with:
i) Wasting of the thena eminence TRUE
ii) Wasting of the hypothena eminence FALSE
iii) Opposition of the thumb may be impaired TRUE
iv) Froment's sign may be seen FALSE
v) Sensation over the medial aspect of the hand (little finger side) may be impaired FALSE
Explanations
i) Median nerve leasions are associated with: Wasting of the thena eminence (TRUE)
The thena eminence is the bulk of muscles at the base of the thumb, these may become wasted in median nerve lesions.
ii) Median nerve leasions are associated with: Wasting of the hypothena eminence (FALSE)
This is a feature of ulnar nerve injury. The hypothena eminence is the bulk of mucles on the medial aspect of the hand proximal to the little finger.
iii) Median nerve leasions are associated with: Opposition of the thumb may be impaired (TRUE)
Opposition of the thumb to the little finger may be imapired - the action of opponens policis is the principal motor test for median nerve lesions
iv) Median nerve leasions are associated with: Froment's sign may be seen (FALSE)
This is a sign of an ulnar nerve lesion; it specifically tests the function of adductor pollicis
Froment's sign relates to abnormal grip of a piece of paper. The patient is asked to make a fist, thumb uppermost. They are then asked to grip a piece of paper on to their fist using their thumb. Normally the thumb pad will be flat. However if there is an ulnar nerve lesion affecting adductor pollicis the grip will be abnormal and the thumb will be flexed and partially on its side.
v) Median nerve leasions are associated with: Sensation over the medial aspect of the hand (little finger side) may be impaired (FALSE)
This is the territory of the ulnar nerve. The median nerve provides sensation to the lateral digits of the hand - thumb, index and middle fingers. However due to differences in individuals and because of the shared innervation between nerves the sensory function of the median nerve is best tested at the tip of the index finger
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89 . Fractures:
i) Colles fracture may be complicated by Sudeck's atropy TRUE
ii) 2-3 units of blood can be lost from a closed femoral shaft fracture in an adult male TRUE
iii) Spiral fractures heal more quickly than transverse fractures TRUE
iv) The radial nerve is at risk from fractures of the medial humeral epicondyl FALSE
v) The femoral head is at risk of avascular necrosis following inter-trachanteric fracture of the femur FALSE
Explanations
i) Fractures: Colles fracture may be complicated by Sudeck's atropy (TRUE)
Fractures may be complicated by Sudeck's atrophy (reflex sympathetic distrophy). Colles fracture is more commonly associated with this condition than most.
ii) Fractures: 2-3 units of blood can be lost from a closed femoral shaft fracture in an adult male (TRUE)
2-3 units of blood can be lost following a closed femoral fracture. - A person could loose the majority of their circulating blood volume with bilateral femoral fractures!
iii) Fractures: Spiral fractures heal more quickly than transverse fractures (TRUE)
Spiral fractures heal more quickly than transverse fractures
iv) Fractures: The radial nerve is at risk from fractures of the medial humeral epicondyl (FALSE)
The radial nerve runs in the radial groove around the back of the mid humeral shaft to run anterior to the lateral humeral epicondyl at the elbow joint. It is therefore not at significant risk from fractures of the medial epicondyl
v) Fractures: The femoral head is at risk of avascular necrosis following inter-trachanteric fracture of the femur (FALSE)
The medial circumflex artery supplies the majority of the femoral head through arteries that run over the capsule to penetrate the bone at the dital neck of the femur. Intra-trochanteric fractures occur below this point.
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90 . Osteoporosis
i) Can be defined as a bone mineral density 2.5 standard deviations below the mean for a young person TRUE
ii) Is associated with an increased risk of fractures in vertebral bodies, distal forearm and proximal femur TRUE
iii) Is less prevalent in patients with diabetes mellitus FALSE
iv) Can be confirmed by the use of dual-energy x-ray absorptionometry TRUE
v) Can be prevented by bed rest and immobilisation FALSE
Explanations
i) Osteoporosis Can be defined as a bone mineral density 2.5 standard deviations below the mean for a young person (TRUE)
Osteoporosis is a systemic disease characterised by a reduction in bone mass and micro-architectural deteriration
ii) Osteoporosis Is associated with an increased risk of fractures in vertebral bodies, distal forearm and proximal femur (TRUE)
The bones at high risk of fracture are those that contain a high proportion of trabecular bone and include the vertebral bodies and proximal femur.
iii) Osteoporosis Is less prevalent in patients with diabetes mellitus (FALSE)
The risk of osteoporosis is increased in several metabolic disorders including diabetes, thyrotoxicosis and Cushing's syndrome
iv) Osteoporosis Can be confirmed by the use of dual-energy x-ray absorptionometry (TRUE)
Dual-energy x-ray absorptionometry is a precise and accurate means of diagnosis osteoporosis. It involves exposure to only low doses of x-rays and allows measuremement of bone density in bones of clinical interest.
v) Osteoporosis Can be prevented by bed rest and immobilisation (FALSE)
Bed rest and immobilisation increases the risk of osteoporosis. The risk can be reduced by exercise, an adequate dietary intake of calcium, avoiding excessive alcohol intake and stopping smoking.
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91 . Peripheral nerve lesions:
i) Transection of the axillary nerve results in winging of the scapula FALSE
ii) Transection of the musculocutaneous nerve results in loss of triceps function FALSE
iii) Transection of the median nerve will result in denervation of opponens pollicis TRUE
iv) Transection of the superficial radial nerve results in an inability to extend the wrist FALSE
v) Transection of the ulnar nerve results in loss of sensation to the anatomical snuff box FALSE
Explanations
i) Peripheral nerve lesions: Transection of the axillary nerve results in winging of the scapula (FALSE)
The axillary nerve supplies the deltoid (abduction of the arm) and badge area of skin.
Winging of the scapula results from damage to the long thoracic nerve (C5, 6 and 7)
ii) Peripheral nerve lesions: Transection of the musculocutaneous nerve results in loss of triceps function (FALSE)
The musculocutaneous nerve innervates biceps and brachialis (elbow flexion) and provides sensation to the lateral aspect of the forarm (via the lateral cutaneous nerve of the forearm)
Triceps is innervated by the radial nerve
iii) Peripheral nerve lesions: Transection of the median nerve will result in denervation of opponens pollicis (TRUE)
Screening tests for the median nerve injury include checking sensation over the tip on the index finger and asking the patient to oppose their thumb to their little finger (opponens pollicis) and abduction of the thumb whilst palpating the body of abductor pollicis brevis (but note that abductor pollicis longus is innervated byt eh radial nerve)
iv) Peripheral nerve lesions: Transection of the superficial radial nerve results in an inability to extend the wrist (FALSE)
The superficial radial nerve provides only cutaneous, sensory innervation.
The posterior interossius nerve (a terminal branch of the radial nerve) supplies the extensor compartment of the forearm. It provides no cutaneous innervation
v) Peripheral nerve lesions: Transection of the ulnar nerve results in loss of sensation to the anatomical snuff box (FALSE)
The anatomical snuff box is primarily innervated by the superficial branch of the radial artery.
Ulnar nerve function is tested by:
Sensation: Lateral aspect of little finger
Motor: Abduction of index finger
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92 . Regarding septic arthritis
i) 50% cases occur in children less than 3 years old TRUE
ii) Haemophilus influenzae is the commonest organism identified in children aged 8 to 13 FALSE
iii) Neisseria meningitidis causes septic arthritis in adults FALSE
iv) In children, 10% of patients have multiple joints involved TRUE
v) Untreated can lead to destruction of articular cartilage TRUE
Explanations
i) Regarding septic arthritis 50% cases occur in children less than 3 years old (TRUE)
More than 50% cases occur in children less than 3 years old.
ii) Regarding septic arthritis Haemophilus influenzae is the commonest organism identified in children aged 8 to 13 (FALSE)
Haemophilus influenzae is the commonest organism indentified in non-immune infants. However, Staph aureus is more common in older children and adults
iii) Regarding septic arthritis Neisseria meningitidis causes septic arthritis in adults (FALSE)
Neisseria gonorrhoea (not meningitidis) causes septic arthtritis in adults
iv) Regarding septic arthritis In children, 10% of patients have multiple joints involved (TRUE)
In adults, usually only one joint is involved. In children, multiple joints may be involved.
v) Regarding septic arthritis Untreated can lead to destruction of articular cartilage (TRUE)
Untreated septic arthritis is associated with significant morbidity. Complications include avascular necrosis, growth disturbance and secondary osteoarthritis.
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93 . Dupuytren's contracture
i) involves the plantar fascia FALSE
ii) is more common in men TRUE
iii) more commonly affects the index and middle finger FALSE
iv) is often bilateral TRUE
v) has a high recurrence rate following surgery TRUE
Explanations
i) Dupuytren's contracture involves the plantar fascia (FALSE)
Dupuytren's contracture involve's the palmar fascia of the hand. The plantar fascia is on the sole of the foot. Dupuytren's contracture is occasionally associated with plantar fascitis - a similar condition, but one that involves the plantar fascia of the feet.
ii) Dupuytren's contracture is more common in men (TRUE)
Dupuytren's contracture affects about 5% of men over 50 years. The male to female ratio is approximately 4 to one.
iii) Dupuytren's contracture more commonly affects the index and middle finger (FALSE)
Dupuytren's contracture usually affects the ring and little finger. The contracture occurs at the metacarpophalangeal and proximal interphalangeal joint.
iv) Dupuytren's contracture is often bilateral (TRUE)
In about 65% cases Dupuytren's contracture is a bilateral disease
v) Dupuytren's contracture has a high recurrence rate following surgery (TRUE)
Approxmately 50% of patients undergoing Dupuytren's contracture surgery develop recurrence
Further notes:
Dupuytren's contracture is fibroproliferative disease of the palmar fascia. It was first described in 1614 but Dupuytren presented a detailed anatomical study of the disease in 1831. Its aetiology is unclear but it may be inherited as autosomal dominant condition with limited penetrance. Its is associated with diabetes, alcohol excess and epilespy. Treatment id by fasciotomy or fasciectomy.
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94 . Radial nerve lesions are associated with:
i) Wasting of the palma interossei characterised by guttering between the metacarpals. FALSE
ii) Parasthesia affecting over two thirds of the dorsum of the hand FALSE
iii) Impaired extension of the metacarpo-phalangeal (MCP) joints TRUE
iv) Wrist drop TRUE
v) Fractures of the shaft of the humerus TRUE
Explanations
i) Radial nerve lesions are associated with: Wasting of the palma interossei characterised by guttering between the metacarpals. (FALSE)
Both the palma and dorsal interossei are supplied by the ulnar nerve.
ii) Radial nerve lesions are associated with: Parasthesia affecting over two thirds of the dorsum of the hand (FALSE)
The radial nerve provides sensory innervation to about half of the dorsum of the hand, however the ulnar nerve provides innervation to the other half and there may be considerable cross innervation, thus parasthesia is very unlikely to cover over a half, let alone over 2/3rds of the dorsum of the hand in a lesion purely of the radial nerve.
Because of cross innervation the sensory supply of the radial nerve is best tested in the first dorsal webspace.
iii) Radial nerve lesions are associated with: Impaired extension of the metacarpo-phalangeal (MCP) joints (TRUE)
The radial nerve supplies the extensors of the MCP joint.
iv) Radial nerve lesions are associated with: Wrist drop (TRUE)
Wrist drop may also occur if the lesion is high enough.
v) Radial nerve lesions are associated with: Fractures of the shaft of the humerus (TRUE)
The radial nerve runs in the radial groove of the humerus and thus is easily damaged by humeral shaft fractures.
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95 . Achilles tendon rupture
i) Is more common in elderly women FALSE
ii) is often associated with Achiles tendonitis FALSE
iii) usually occurs about 2-3 cm proximal to the calcaneal insertion of the tendon TRUE
iv) can be managed either surgically or non-operatively TRUE
v) treated surgically has a re-rupture rate of less than 5% TRUE
Explanations
i) Achilles tendon rupture Is more common in elderly women (FALSE)
Achilles tendon rupture is most commonly seen in fit young or middles aged men
ii) Achilles tendon rupture is often associated with Achiles tendonitis (FALSE)
Patients usually do not give a history of previous pain or discomfort
iii) Achilles tendon rupture usually occurs about 2-3 cm proximal to the calcaneal insertion of the tendon (TRUE)
Rupture usually occurs at this site. It has been postulated that this is a region of relative ischaemia and thus tendon weakness
iv) Achilles tendon rupture can be managed either surgically or non-operatively (TRUE)
Surgical repair can be performed using a non-absorbable suture inserted either with an open or percutaneous technique. Non-operative management involves the use of an equinus short-leg cast.
v) Achilles tendon rupture treated surgically has a re-rupture rate of less than 5% (TRUE)
The re-rupture rate is reduced in those managed surgically. Non-operative management is associated with re-rupture rate of up to 40%.
Further notes:
The achilles tendon is formed from the combined tendons of soleus and gastrocnemius. It is enclosed in paratenon rather than a synovial sheath. Rupture occurs within the tendon itself and not at the musculotendenous junction. Rupture usually occurs due to sudden force being applied to a dorsiflexed foot
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96 . Neuropraxia
i) Typically occurs following crush injuries TRUE
ii) Is characterised by segmental demyelination TRUE
iii) The axon distal to the lesion undergoes Wallerian degeneration FALSE
iv) Tinel’s sign will be negative in patients with neuropraxia TRUE
v) Complete recovery of nervous function is unlikely FALSE
Explanations
i) Neuropraxia Typically occurs following crush injuries (TRUE)
Neuropraxia usually results from crush injuries or tourniquet use
ii) Neuropraxia Is characterised by segmental demyelination (TRUE)
Neuropraxia is characterised by segmental demyelination, while the axon itself remain intact. Conduction occurs normally above and below the lesion.
iii) Neuropraxia The axon distal to the lesion undergoes Wallerian degeneration (FALSE)
Wallerian degeneration occurs when the distal axon becomes separated from the rest of the cell.
iv) Neuropraxia Tinel’s sign will be negative in patients with neuropraxia (TRUE)
Tinel’s sign is the presence of painful paraesthesia on percussion over the area of regenerating nerves and may be positive in patients with axonotmesis and neurotmesis
v) Neuropraxia Complete recovery of nervous function is unlikely (FALSE)
Spontaneous recovery usually occurs over days to weeks
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97 . Axonotmesis
i) Is typically caused by penetrating trauma FALSE
ii) Is characterised by damage causing division of the axon at the site of injury TRUE
iii) The axon proximal to the site of injury undergoes Wallerian change FALSE
iv) The axon re-grows at a rate of about 1mm per day TRUE
v) Tinel’s sign will be negative FALSE
Explanations
i) Axonotmesis Is typically caused by penetrating trauma (FALSE)
Typically occurs following closed stretch injuries
ii) Axonotmesis Is characterised by damage causing division of the axon at the site of injury (TRUE)
The injury causes the axon to separate. The distal portion undergoes Wallerian degeneration whilst the proximal axon attempts to re-grow along the intact endoneurial tube.
iii) Axonotmesis The axon proximal to the site of injury undergoes Wallerian change (FALSE)
The distal axon undergoes Wallerian degeneration
iv) Axonotmesis The axon re-grows at a rate of about 1mm per day (TRUE)
The axon re-grows, along the endonurial tube, at a rate of about 1mm per day
v) Axonotmesis Tinel’s sign will be negative (FALSE)
Tinel’s sign is likely to be positive
Tinel’s sign is the presence of painful paraesthesia on percussion over the area of regenerating nerves and may be positive in patients with axonotmesis and neurotmesis
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98 . Peripheral nerve lesions
part item correct
answer your
answer mark average
i) Transection of the femoral nerve results in inability to adduct the hip FALSE T -1 0.47
ii) Transection of the obturator nerve results in inability to abduct the hip FALSE T -1 0.24
iii) Transection of the superficial peroneal nerve results in foot drop FALSE
iv) Stripping of the great saphenous vein can result in loss of sensation to the medial aspect of the foot TRUE
v) Blunt trauma to the popliteal fossa can damage the sciatic nerve FALSE
Explanations
i) Peripheral nerve lesions Transection of the femoral nerve results in inability to adduct the hip (FALSE)
The adductors are supplied by the obturator nerve
Femoral nerve:
Sensation to anterior surface of thigh
Motor to knee extensors
ii) Peripheral nerve lesions Transection of the obturator nerve results in inability to abduct the hip (FALSE)
The abductors (Gluteus medius and minimus and tensor fasciae latae) are supplied by the superior gluteal nerve.
Obturator nerve:
Sensation to the medial thigh
Motor to the adductor compartment of the thigh
iii) Peripheral nerve lesions Transection of the superficial peroneal nerve results in foot drop (FALSE)
The deep peroneal nerve supplies tibialis anterior (ankle dorsiflexion)
Superficial peroneal nerve:
Sensation to dorsum of foot
Motor to peroneus longus and peroneus brevis – test motor function by asking the patient to evert their foot
iv) Peripheral nerve lesions Stripping of the great saphenous vein can result in loss of sensation to the medial aspect of the foot (TRUE)
Saphenous vein stripping can cause damage to the saphenous nerve which runs with the vein. The saphenous nerve supplies sensation to the medial aspects of the knee, calf and foot.
v) Peripheral nerve lesions Blunt trauma to the popliteal fossa can damage the sciatic nerve (FALSE)
The sciatic nerve divides into the Tibial and Common Peroneal nerves about two thirds of the way down the thigh.
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99 . ECG monitoring and rhythms
Branch 1: The leads are sited in the following manner: Red to the right shoulder; green to the left shoulder; yellow to the left upper quadrant of the abdomen
Answer 1: FALSE
Explanation 1: Red to Right shoulder
YeLLow to Left shoulder
Green to spleen
The contacts should be placed over bony prominences rather than muscles
Branch 2: The waveform displayed on the monitors is usually selected to be from lead II
Answer 2: TRUE
Explanation 2: Lead II shows the greatest deflection for p-waves and is usually used to monitor the ECG
Branch 3: Asystole shows as a completely flat line on the monitor
Answer 3: FALSE
Explanation 3: Asystole is usually represented by a wandering baseline. A truly flat line suggests lead disconnection.
Branch 4: A patient's ECG shows a broad QRS complex tacchycardia. If capture beats are seen this suggests that the true rhythm is a supraventricular tacchycardia with abberant conduction
Answer 4: FALSE
Explanation 4: A broad complex tacchycardia usually represents VT. However patients with an existing ventricular conduction abnormality could show a broad complex tacchycardia due to an underlying SVT. Such patient will NOT have fusion or capture beats on their ECG.
Fusion and capture beats occur in patients with true VT (depolarising focus in the ventrical) where normally conducted beats may be superimposed on the background of VT.
Capture beat = normally conducted QRS
Fusion beat = partially normally conducted QRS and partially abberantly conducted impulse
Branch 5: Fusion beats may be seen in patients with ventricular tacchycardia
Answer 5: TRUE
Explanation 5: Fusion beats occur when 2 seperate areas of the heart depolarise at the same time eg: the SA node depolarises at the same /similar time as an ectopic ventricular focus - both beats are fused together. Part of the beat will look like a normal QRS, part will look like a VE. Plus - See answer to branch 4 above.
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100 . Choking
Branch 1: A 60 year old man begins choking in a restaurant - he is coughing violently but still breathing. No immediate intervention is required
Answer 1: T
Explanation 1: If the patient is choking but still breathing they should be encouraged to cough but no other intervention is required unless they obstruct their airway or begin to tire.
Branch 2: A 30 year old woman is choking in a restaurant. She is not managing to breath and is becoming cyanosed, there is no visible foreign body in her upper airway - You should stand her upright and provide 5 back slaps
Answer 2: F
Explanation 2: She should be bent well forward before attempting the back slaps.
Branch 3: Foreign bodies more commonly obstruct the right main bronchus than the left
Answer 3: T
Explanation 3: Due to the structure of the carina and the fact that the right main bronchus is more verticle foreign bodies are more likely to fall into and obstruct the right main bronchus.
Branch 4: In a choking patient with an obstructed airway abdominal thrusts are inidcated before attempting back slaps
Answer 4: F
Explanation 4: See notes at the bottom of the page
Branch 5: Adrenaline (epinephrine) is contraindicated in cardio-respiratory arrest secondary to choking
Answer 5: F
Explanation 5: If the patient is unconscious follow the standard BLS /ALS algorithm
Notes: Protocol for choking:
In a concious patient who is breathing:
- Encourage to cough - do nothing else
In a concious patient who is either not breathing or becoming exhausted
- Inspect the mouth and remove any foreign body
- Lean well forward, provide up to 5 back slaps
- Whilst leant forward provide up to 5 abdominal thrusts
- Reassess mouth for FB then repeat the process
In an unconscious patient commence BLS /ALS
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