Intussusception is a condition which is more common in boys. It mainly affects those between 3-24 months, although it can occur in older children with risk factors such as Henoch-Schönlein purpura (HSP), tumours etc.

Symptoms include abdominal pain which is sudden and colicky in nature. Vomiting is also a presenting complaint as well as circulatory collapse and shock. The passage of blood per rectum is a late and serious feature.

Physical examination may reveal a sausage shaped mass in the right upper quadrant. Clinical suspicion is usually confirmed by ultrasonography.

Reduction is usually achieved by hydrostatic enema, and if unsuccessful surgical intervention must be performed.

Morphine does not causes direct myocardial depression, although it may cause a bradycardia.

The hypotension associated with its use is due to the decrease in the systemic vascular resistance (SVR) which is due, in part, to histamine release. The histamine release may also cause bronchospasm. The production of antidiuretic hormone (ADH) is also increased by morphine.

Diamorphine has almost no affinity for the opioid receptor, and is a prodrug of morphine.

Phenylpiperidines include pethidine and fentanyl, whereas morphine is a phenanthrene.

Knowledge of the ECG with regard to the coronary anatomy provides a better understanding of the severity of ischaemia as well as a guide to appropriate treatment.

ST elevation in leads II, III and aVF suggests inferior myocardial infarction (MI) and is usually due to occlusion of the right coronary artery.

V1-4 elevation indicates an anterior MI and is usually a consequence of left anterior decending artery occlusion.

A posterior infarct (ST elevation in V6-8 with reciprocal changes anteriorly - ST depression in V1-3) is due to occlusion of the circumflex artery.

Infective causes plus inflammatory bowel disease should be considered in the differential diagnosis of a young man with bloody diarrhoea. Shigellosis is a possible cause. Most cases of Shigella infection are related to foreign travel. Unrelated to foreign travel, there has been an increase in sexually transmitted Shigella infection in men who have sex with men.

Amoebic trophozoites (the active form) may be seen in fresh stool in acute dysentery. However, amoebic cysts seen on microscopy for E. Histolytica have a sensitivity of <60% and a specificity of 10-50% in the diagnosis of possible amoebic dysentery. There are many non-pathological amoebae (e.g. E. dispar) and many asymptomatic patients have Entamoeba histolytica in their stool. Stool antigen (ELISA) for Entamoeba histolytica has sensitivity and specificity of >95%.

Watery diarrhoea would be expected with cholera and giardiasis.

Alteplase (tissue type plasminogen activator) is a thrombolytic and acts by activating plasminogen to form plasmin, which degrades fibrin and so breaks up thrombi. It is used in the treatment of myocardial infarction and life-threatening venous thrombosis.

Aprotinin is an enzyme inhibitor acting on plasmin and kallikrein and is classed as an anti-fibrinolytic, thus inhibiting fibrinolysis. It is indicated in patients at high risk of blood loss.

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Warfarin is an oral anticoagulant and it inhibits the synthesis of vitamin K dependant factors II, VII, IX and X. Hepatic enzyme inducing agents, for example, carbamazepine and phenobarbitone reduce its effect. Enzyme inhibitors, such as valproate, enhance the effect of warfarin. If the enzyme-inducing drug is withdrawn without reducing the dose of warfarin, haemorrhage may occur.

Factor VIIa (recombinant) is a purified coagulation factor used to treat patients with inhibitors to factors VIII and IX. It has been used successfully in patients with serious trauma in whom haemorrhage has been difficult to control surgically. Thus it can be classed as a procoagulant.

Heparin is an anticoagulant and its effects are monitored by measuring the activated partial thromboplastin time (APTT), although thrombin and clotting times are also prolonged. It accelerates the action of antithrombin III, which inhibits activated factors XII, XI, X, IX and thrombin.

Exercise therapy. This man needs to address his risk factors and stop smoking for improvement in his cardiovascular profile, but his walking is a quality of life problem since he covered 180 metres. Although one could perform an angioplasty or surgery it is not currently indicated; he should gain good symptomatic improvement from an exercise programme and in addition to improving his general health this has no iatrogenic risks associated with it. bypass

Popliteal-pedal bypass. This man has tissue loss with severe infragenicular disease. A "suck it and see" amputation of his hallux may work, but has the real risk of accelerating the tissue destruction in his foot and ultimately leading to limb loss. A popliteal-pedal bypass will take blood from an area of good flow to the point where it is required and although a technically difficult operation gives this man the best chance of limb salvage.

Intussusception occurs when a segment of bowel invaginates into its adjoining lower segment.

It is more common in boys. About 60% are under 1-year-old and 80%-90% under 2 years old. It is rare after the age of 6.

Intussusception is associated with:

Haemophilia Henoch-Schönlein purpura Haemangiomas, and GI lymphomas.

Clinical features include severe colicky abdominal pain and vomiting. Between attacks the infant may appear in good health.

The infant may pass 'redcurrant jelly' stools and a sausage shaped mass is palpable on abdominal examination.

Rectal examination may reveal blood in the majority of cases and occasionally the apex of the intussusception is palpable.

In addition to the ABO and rhesus systems, another eight blood group systems have been identified.

The Kell, Duffy and Kidd systems can cause both haemolytic transfusion reactions and the haemolytic disease of the newborn.

The P and MN systems can also cause both of these reactions, but they are rare events.

The Lutheran, Lewis, Scianna and Li systems are clinically of less importance because they do not cause the haemolytic disease of the newborn, and are unlikely to (or rarely) cause haemolytic transfusion reactions.

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There are a number of criteria used in the Ranson's scoring system which reflect prognosis associated with acute pancreatitis.

Ranson's criteria on admission that signify a worse prognosis include:

Criteria present at 0 hours:

Age >55 years old - 1 point WBC >16 ×109 - 1 point Glucose >11.1 mmol/L - 1 point LDH >350 U/L - 1 point AST >250 U/L - 1 point

Criteria present at 48 hours:

Hematocrit fall of 10% or greater - 1 point Urea rise of 1.8 mmol/L or more despite fluids - 1 point Serum Calcium <2 mmol/L - 1 point pO2 <60 mmHg - 1 point Base deficit >4 meq/L - 1 point Fluid sequestration >6000 mL - 1 point

The internal jugular vein originates at the jugular foramen.

It initially lies posterior to the carotid artery, as it descends in the carotid sheath it lies lateral first to the internal then the common carotid artery within the carotid sheath.

It passes anterior to the subclavian artery to join the subclavian vein and then form the brachiocephalic vein; the left and right brachiocephalic veins unite to form the superior vena cava.

The internal jugular vein receives a lymphatic trunk at its union with the subclavian vein.

The external jugular vein drains into the subclavian vein.

Tension pneumothorax is a life-threatening surgical emergency, since failure to relieve the tension may result in a cardio-respiratory arrest. It usually occurs following penetrating or blunt injuries to the chest, and frequently following major traumas.

In tension pneumothorax, the air is drawn into the pleural space with each inspiration, but has no route to escape; thus acting as a one-way valve.

Patients present with:

Respiratory distress Tachycardia Hypotension Distended neck veins Decreased air-entry in the affected lung, and Deviation of trachea and mediastinum to the opposite side.

However, not all these signs and symptoms are always present.

The classical history of Boerhaave's syndrome is of severe vomiting and retching followed by extremely severe retrosternal and upper abdominal pain. Shock develops rapidly.

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There is a history of alcoholism or heavy drinking in 40% of patients. The site of rupture is usually in the left posterolateral distal oesophagus and is several centimetres long. Subcutaneous emphysema (crepitus) is only present in 27% of patients and is a relatively late sign.

An initial chest x ray will show mediastinal or free peritoneal gas. After hours or days, pleural effusion(s), often with a pneumothorax, and a widened mediastinum develops. The diagnosis is confirmed with a CT scan followed by a gastrografin swallow to assess the extent of the oesophageal leak.

The main treatment is surgery, which should be within 24 hours. Mortality is 20-50% and is increased with delay in treatment. The oesophagus is repaired or resected and the mediastinum drained. Occasionally contained leaks may be managed conservatively. Endoscopic covered stents have been used. Surgery is the only effective option when there is extensive mediastinal contamination or delay in diagnosis.

Mallory-Weiss syndrome is the cause of bleeding in 5% of patients with upper gastrointestinal haemorrhage. Longitudinal mucosal lacerations in the distal oesophagus and proximal stomach cause bleeding from submucosal arteries. Most tears are single. The condition was originally described in 1929, related to vomiting in alcoholic patients.

Other associations include:

Coughing Epileptic convulsions Closed chest massage Blunt abdominal injury, and Hiccups under anaesthesia.

Hiatus hernia appears to be a predisposing factor (40-100%). Some patients have epigastric or back pain. The blood loss is usually small and self-limiting.

Transfusions may be needed and endoscopic haemostatic treatment may be required. Rarely, with protracted vomiting, perforation may occur.

In this procedure all the diseased tissue is removed but the patient avoids a permanent stoma. The patient has to be well motivated to deal with the possible complications (anastomotic leak, adhesional obstruction, poor function, pouchitis).

A loop ileostomy is constructed near the pouch in the right iliac fossa to allow the anastomosis to heal. The loop ileostomy is closed at eight to 10 weeks.

Carcinoma is the commonest of large bowel obstructions. The operation of choice for an obstructing sigmoid tumour is a Hartmann's procedure. The tumour is removed (sigmoid colectomy) and a colostomy formed. (Sometimes there may be enough distal sigmoid to bring out as a mucous fistula rather than do a Hartmann's procedure. This would be easier to close subsequently.)

Primary anastomosis should usually be avoided, as there is a higher risk of anastomotic leak in patients presenting with obstruction.

If the proximal colon is grossly dilated and ischaemic then a subtotal colectomy and ileostomy should be performed.

The operation of choice is a right hemicolectomy, thus removing the tumour. If there is no evidence of perforation then a primary anastomosis would be performed. However, there is a much higher risk of anastomotic breakdown in a contaminated field. Therefore an end ileostomy is formed. A mucus fistula is also required, to allow mucus to drain from the remaining colon.

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Dysphagia is defined as difficulty in swallowing, in contrast to odynophagia which refers to painful deglutition.

Dysphagia could be due to intra-luminal, mural (including muscular disorders), extrinsic or functional causes. The symptom may be described by some as sticking sensation.

The site is usually well localised, especially in the upper two thirds of the oesophagus, due to its innervation pattern (somatic as opposed to visceral).

Retrosternal burning is most characteristic of GORD. It may be aggravated by food and drinks. The fact that this is associated with stickiness of food in this elderly woman, probably suggests that she has a stricture probably benign as she is otherwise well.

The 70-year-old man clearly has a malignant stricture or carcinoma of the oesophagus. Difficulty in initiation of swallowing is usually a pharyngeal problem; in view of his age and of the choices provided, he is most likely to suffer from carcinoma of the pharynx.

Globus hystericus (syndrome) mainly affects people between 30 to 60. The predominant symptom is a feeling of lump and is not a true dysphagia. It is most pronounced for dry swallow (swallowing own saliva) than when eating or drinking.

Elderly patients with per rectal bleeding, change in bowel habits, and weight loss should be considered to have colonic cancer unless proven otherwise. Increase in age is a risk factor for developing colonic cancer.

The other risk factors include:

a family history of colon cancer familial adenomatous polyposis diet rich in red meat, and longstanding ulcerative colitis or Crohn's disease.

The clinical presentation of patients with colonic malignancy depends on the site of the tumour.

Right-sided colonic carcinoma commonly presents with:

anaemia tiredness malaise pallor, and loss of weight.

The left sided colonic carcinoma presents with:

change in the bowel habits bleeding per rectum, and intestinal obstruction.

Rectal carcinoma, in addition to the features seen in left-sided colonic carcinoma, is associated with a sense of incomplete evacuation of the bowel (tenesmus). Tumours of the caecum affecting the ileocaecal valve can also present with symptoms of lower small bowel obstruction.

Investigations for suspected colonic malignancy include:

full blood cell count renal function and electrolytes liver function tests (to rule out hepatic involvement)

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plain x ray of the abdomen, and ultrasound and CT scans.

Carcinoembryonic antigen (CEA) is the commonly used tumour marker to diagnose colonic malignancy and subsequently to assess the progress, including recurrence.

Surgery remains the mainstay of management of colonic tumours though a colonic stent maybe placed in left sided obstruction as a bridge to surgery. Radiotherapy and chemotherapy have their roles in selected patients. A temporary or a permanent colostomy is frequently required following the surgical treatment of left-sided colonic tumours.

The changes in hyperkalaemia begin with peaked T waves, particularly in the precordial leads. Then a widened QRS complex (>120 msec) when the potassium is >6.5. There may also be decreased p wave amplitude and an increased PR interval. With a potassium >7.0 there may be a bradycardia and AV block. Eventually p waves are lost and a sine wave may develop. This is often a fatal arrhythmia.

WPW is associated with an accessory bundle, which causes a delta wave (notch) preceding the QRS complex, giving the impression of a shorter PR interval. However, the delta wave is characteristic.

Other causes of prolonged QT include:

Congenital prolonged QT (Lown-Ganong-Levine syndrome) Hypocalcaemia Drug therapy (Amiodarone, Sotalol)

Pericarditis is associated with concave upward ST segment elevation on the ECG, versus convex upward ST segment elevation in MI.

Regarding cannulation for cardiopulmonary bypass, please choose the most appropriate answer from the list.

In which structure is the venous cannula placed when a patient is undergoing a tricuspid valve replacement?

Incorrect - The correct answer is Vena cava

When the right side of the heart has to be opened, separate cannulae are inserted into the superior and inferior venae cava. Purse-string sutures are snared around the incisions to produce a blood- and airtight seal.

In which structure is the arterial cannula from the cardiopulmonary bypass circuit placed?

Incorrect - The correct answer is Ascending aorta

The blood drained from the heart is passed through the oxygenator in which it is separated from a gas mixture by a system of membranes. The blood is then returned to the patient under pressure through a roller pump via an arterial filter and air bubble detector. The arterial cannula is usually positioned in the ascending aorta.

In which structure is the venous cannula placed when a patient is undergoing a mitral valve replacement?

Incorrect - The correct answer is Right atrium

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Cardiopulmonary bypass allows whole body perfusion in which the pumping action of the heart and oxygenation of blood by the lungs are replaced by an extracorporeal circuit. The returning venous blood is diverted from the heart using a large bore cannula inserted in the right atrial appendage.

Malignant melanoma may be subungual, buccal, anal, and present on any mucosal surface, not merely in the dermis/epidermis.

The incidence of malignant melanoma of the skin has been rising rapidly in the white populations around the world for several decades. Incidence rates in Great Britain increased from around 2 per 100,000 population for males and 3 per 100,000 population for females in 1971 to 7 and 9 per 100,000 population for men and women respectively in 1996, a threefold increase.

Amelanotic malignant melanoma most commonly occurs in the setting of melanoma metastasis to the skin, presumably because of the inability of these poorly differentiated cancer cells to synthesise melanin pigment.

More than 50% of cases are believed to arise de novo without a pre-existing pigmented lesion.

Tumour size is only one of the criteria used in the AJCC 2009 Revised Melanoma Staging. Tumour thickness and mitotic rate (mitoses/mm2) are the most important prognostic factors in the primary tumour.

The ventral branches of the aorta include the coeliac artery and superior and inferior mesenteric arteries.

These ventral branches give rise to:

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

Anterior and posterior superior pancreaticoduodenal arteries (coeliac trunk) with the inferior pancreaticoduodenal (superior mesenteric branch) around the head of the pancreas and second part of the duodenum.

The marginal artery anastomosis between the middle colic and the left colic. The superior rectal artery (inferior mesenteric) with the middle rectal (internal iliac) and/or the

inferior rectal (internal pudendal from internal iliac).

The right gastric artery most frequently originates from the proper hepatic artery (~53%). It can also originate:

from the region where common hepatic artery divides into its branches (~20%) from the left hepatic branch (~15%) as a branch of the gastroduodenal artery (~8%), or as branch of the common hepatic artery (~4%).

The incidence of cleft lip and palate is one in 600 live births, and 1:1000 live births for isolated cleft palate.

The incidence increases in the Oriental groups (1:500) and decreases in the black population (1:2000). The highest incidence reported for cleft lip and palate occurs in the Native American tribes of Montana, USA (1:276).

The typical distribution of cleft types is:

Cleft lip alone - 15% Cleft lip and palate - 45% Isolated cleft palate - 40%.

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Genetic influence is more significant in combined cleft lip and palate than cleft palate alone where environmental factors such as maternal epilepsy and drugs (for example, steroids, diazepam, phenytoin) exert a greater influence.

Although most clefts of the lip and palate occur as an isolated deformity, the Pierre Robin sequence remains the most common syndrome. This syndrome comprises isolated cleft palate, retrognathia and a posteriorly displaced tongue (glossoptosis), which is associated with respiratory and feeding difficulties.

Facial nerve palsies may be caused by lesions affecting any part of its course. It arises in the medulla and emerges between pons and medulla, passes through the posterior fossa in close proximity to the middle ear before emerging from the stylomastoid foramen to pass underneath the parotid gland.

Causes can be divided into:

Intracranial - brainstem tumours, stroke, multiple sclerosis, acoustic neuroma Intratemporal - otitis media, Ramsay Hunt syndrome, cholesteatoma Infratemporal - parotid tumours, trauma Others - sarcoid, Guillain-Barré syndrome, diabetes, Bell's palsy.

This patient present with symptoms suggesting amaurosis fugax.

In this case NICE guidelines suggest that the most appropriate therapy would be Clopidogrel 75 mg od or aspirin 75 mg od plus dipyridamole modified release 200 mg bd (not a choice in this list as you can only have one correct answer). There is little evidence that one or other of these regimens is superior. Clopidogrel has the advantage of being one tablet a day so compliance is likely to be better.

In this case, he has atrial fibrillation (AF), and the most appropriate treatment would be warfarin. AF with amaurosis fugax would suggest a very high future risk of completed stroke, and this risk is minimised most with warfarin.

NICE guidelines on Vascular disease - clopidogrel and dipyridamole (TA210) lists the best treatment as clopidogrel for occlusive events, aspirin and dipyridamole for TIAs, moving down the list if intolerant to the first-line treatment.

With any acute swollen scrotum the fear is of torsion of testis. This is uncommon in the neonate, and is much commoner around puberty. Presentation is with a hard, tender testis, and spermatic cord -/+ a red scrotum.

Torsion of the appendage of testis has a peak incidence of between 4 and 8 years of age, as does acute idiopathic scrotal oedema. In the former, there is a tender upper pole of testis with a blue spot on transillumination. In the latter the erythema extends beyond the scrotum and the testis is minimally tender.

Epididymitis is rare before puberty, and presents with a tender epididymus (urological investigations are needed, as it is associated with reflux of infected urine via the vas deferens).

Inguinal herniae which are irreducible, have a peak incidence below 2 years of age. A firm immobile tender swelling is found in the scrotum, which becomes inflamed as the strangulation occurs. Occasionally, acute hydroceles can also present with a mobile blue transilluminating swelling at 1-3 years of age.

Differential diagnoses of solitary painful ulcer in the rectum at 60 years of age are:

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cancer solitary rectal ulcer syndrome (otherwise known as ulcerative proctocolitis), and rarely infections, such as amoebiasis or bilharziosis.

The best response amongst those given here is ulcerative proctocolitis.

The posterior triangle of the neck contains:

Nerves:

Spinal accessory nerve (Xi) Cervical Plexus (lesser occipital, greater auricular, transverse cervical and supraclavicular)

Arteries:

3rd part of the Subclavian Artery Transverse Cervical and Suprascapular Arteries (both branches of the Thyrocervical Trunk) Occipital Artery

Veins:

External Jugular Vein

Lymph Nodes:

The inferior belly of omohyoid

The brachial plexus lies deep to the prevertebral fascia.

There are numerous indications for the formation of a tracheostomy.

These include:

The upper airway obstruction To facilitate airway suction, and To decrease the work of breathing and to allow weaning from mechanical ventilation.

Once the decision has been made to go ahead, a tracheostomy may be performed percutaneously or openly.

When using the open method, a midline incision is made and the thyroid isthmus divided and ligated, and a vertical incision made between the second, third and fourth tracheal rings (as the formation of windows and flaps increases the risk of stenosis), and the cuff is inflated.

However, in children, cuffed tubes should be avoided due to the risk of tracheal stenosis and mucosal ulceration.

Bleeding from the tracheotomy wound is also a recognised complication, and best treated by not deflating the cuff or removing the tube (as they help to tamponade the bleeding) but by giving oxygen, ventilating the patient, and gaining IV access, whilst calling for help.

Criterion for the removal of tracheostomy tubes: the patient is able to maintain their own airway and ventilate adequately.

Indicators of this are: a low inspired oxygen concentration, adequate carbon dioxide elimination, minimal sputum production and that the patient is not heavily sedated and able to co-operate!

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Non-functioning pituitary tumour (NFPT) causing endocrine disturbance.

Incorrect - The correct answer is Free T4 8.2 nmol/L, TSH 2.1 mU/L

A NFPT may be associated with hypopituitarism and secondary hypothyroidism, with a low thyroxine (T4), plus normal or low thyroid-stimulating hormone (TSH) levels. If the T4 is low yet the TSH is normal, then this would suggest that the TSH is abnormally low for the T4, suggesting that the pituitary hypothalamic axis is dysfunctional. It is also possible for a non-functioning pituitary tumour to not cause hypothyroidism and the patient to be euthyroid.

Subclinical hypothyroidism.

Free T4 12.1 nmol/L, TSH 7.9 mU/L

Correct

Subclinical hypothyroidism is associated with a normal T4, but an elevated TSH level. This suggests a developing thyroid failure. The raised TSH signals a reacting pituitary, with the elevated TSH endeavouring to increase T4 secretion from the thyroid.

Subclinical hyperthyroidism.

Free T4 18.6 nmol/L, TSH 0.07

Correct

The converse applies for subclinical hyperthyroidism, where pituitary secretion is being inhibited by the excessive for the individual (although still in normal range) T4.

Thyroid function tests are some of the most frequently requested blood tests, and their accurate interpretation is essential.

Congenital diaphragmatic hernias occur in approximately 1 in 4,000 live births.

Ninety percent occur in the posterior portion of the diaphragm through the foramen of Bochdalek of which 90% are on the left (the liver is on the right side so may be the reason the majority pass through the left side of the diaphragm).

The commonest clinical presentation is with respiratory distress in the neonatal period and due to pulmonary hypoplasia and compression. The abdomen often has a scaphoid appearance.

About 40% of patients have associated congenital anomalies.

The diagnosis can be confirmed radiologically with bowel loops seen in the chest.

Neonates usually require sedation, ventilation and intestinal decompression prior to surgery between 36 and 72 hours after birth.

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Theme:Hearing Loss

A Conductive hearing lossB High frequency hearing lossC Noise-induced hearing lossD Ototoxic hearing lossE Sensori-neural hearing lossF Speech discrimination loss

For each scenario described below, choose the single most likely corresponding type of hearing loss from the given list of options.

Each option may be used once, more than once or not at all.

A mother brings her 7-year-old girl to see you. She has had a moderate hearing loss and has coped well with hearing aids for the last three years, but she has been recently noted by her teacher to be more withdrawn towards her peers in class. In spite of her being teased for being a "teacher's pet" and now sitting at the front of the classroom constantly, her academic performance has deteriorated.

Correct

Hearing loss should be considered in children if there is any suspicion from parents or teachers based on behavioural changes. Accurate electrophysiological testing can be easily and non-invasively carried out in children of any age.

Even in those patients known to have a hearing loss, vigilance is important as progressive changes often occur. A school age child may find increasing difficulty hearing the teacher and need to sit at the front of the room to hear better and lip-read. This indicates a loss of speech discrimination ability.

This loss can also occur in adults with a progressive loss, including those already using hearing aids. Some go on to receive a cochlear implant which can give them the ability to hear speech clearly again.

A 22-year-old man comes to see you. He was recently on holiday and learned to waterski. On the day before returning home, he fell while waterskiing at speed and sustained a blow to the right side of his head. On otoscopy you see a small hole in the tympanic membrane. You refer him for audiological assessment. He has a mild hearing loss on the right with normal bone conduction.

Correct

Hearing loss is broadly categorised into two aetiological types: conductive and sensorineural.

Conductive losses affect outer and/or middle ear function (for example, tympanic membrane rupture) and will lead to impaired air conduction with normal bone conduction.

Sensorineural losses result from hair-cell losses in the cochlea (inner ear) and both air and bone conduction are affected.

An 18-month-old baby is brought to you by his mother. He was born in the UK in a hospital with universal hearing screening and was found to have normal hearing at birth. When the child was 5-months-old the family moved to China for a six month period after which they returned to the UK. While in China the baby contracted pneumonia and was hospitalised in the local regional hospital for IV antibiotic therapy.

Correct

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Any patient of any age with a bilateral severe to profound hearing loss should be considered a potential cochlear implant candidate.

The causes of sensorineural hearing losses include otoxicity (due to agents such as gentamicin, cisplatin and other chemotherapeutic agents), bacterial meningitis, skull fracture, noise exposure, presbycusis, genetic syndromes and hereditary deafness and many of the "unknown" causes of hearing loss.

Gentamicin is still used in some countries without the recommended strict monitoring of circulating levels, and hair cell toxicity results.

A 65-year-old man comes to see you complaining that he has been misunderstanding some words in conversation - even in quiet environments such as at home with his wife. He has no prior history of hearing loss. You send him for an audiogram which shows a dip in the 6-8 kHz range.

Incorrect - The correct answer is High frequency hearing loss

High frequency hearing loss is known as the "invisible disability" as its presence is often not obvious from history and basic clinical examination. Early stages of some hearing losses can be as subtle as an adult having trouble understanding a few words of conversation - in age related hearing losses the high frequency sounds of some consonants (for example, "sss" or "fff") are lost first.

A child born in a hospital with a universal neonatal screening programme does not pass the first and second screening procedures and goes on for full diagnostic assessment. The child has a profound bilateral hearing loss. The outcome of the thorough investigations is that the child receives a cochlear implant.

Correct

Hearing loss is broadly categorised into two aetiological types: conductive and sensorineural.

Conductive losses affect outer and/or middle ear function (for example, tympanic membrane rupture) and will lead to impaired air conduction with normal bone conduction.

Sensorineural losses result from hair-cell losses in the cochlea (inner ear) and both air and bone conduction are affected.

Hearing loss is also classified according to degree of loss. It is expressed as the number of decibels of hearing loss that is present compared to someone with normal hearing.

Mild 25-40 dB lossModerate 40-70 dB loss

Severe 70-90 dB lossProfound >90 dB loss

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The long saphenous vein can be divided into six anatomical regions:

1. Femoral triangle2. Anterior femoral region3. Patellar region4. Posteromedial lower leg5. Anteromedial lower leg, and6. Foot.

It has a linear course in the leg. It ascends vertically, posterior to the medial border of the tibia.

It is accompanied by the leg branch of the saphenous nerve. This anatomical relation obviously carries a risk of sensory disorders following stripping.

At the knee the long saphenous vein travels posteriorly to the medial femoral condyle (second constant anatomical landmark).

It then travels superficially over the medial region of the thigh, remaining parallel to the medial edge of the sartorius muscle.

In the femoral triangle, the long saphenous vein forms an arch as it penetrates into the depth of the thigh. It perforates the cribriform fascia immediately above Allan Burn's ligament, which actually corresponds to a reinforcement or fold of the cribriform fascia.

The arch of the long saphenous vein then opens onto the anterior surface of the femoral vein 4 centimetres below the inguinal ligament. It enters the femoral vein at this junction which then passes through the femoral canal.

The external pudendal veins drain to the iliac veins. The long saphenous may drain into the posterior tibial veins.

The valves of the perforating veins should prevent backflow of blood from the deep to the superficial system.

In 75% of occasions the long saphenous receives blood from the superficial external pudendal veins.

Score Eye Opening Verbal Response Motor Response6 - - Obeys commands5 - Orientated Localising pain4 Eyes open spontaneously Confused Withdrawing frompain3 Eyes open to verbal command Inappropriate words Flexion to pain2 Eyes open to pain Incomprehensible sounds Extension to pain1 None None None

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Myasthenia gravis is an autoimmune disease characterised by skeletal muscle weakness and increased fatigability.

Ninety per cent of patients have antibodies against the post-synaptic acetylcholine receptors at the neuromuscular junction. Sixty five per cent of patients with myasthenia gravis have hyperplasia of the thymus and 12% have a thymoma.

Treatment is with acetylcholinesterase inhibitors, for example, pyridostigmine, which may cause a cholinergic crisis in over-dosage. Side effects of treatment include:

Diarrhoea Urinary frequency Meiosis Excessive salivation, and Lacrimation.

A myasthenic crisis (sudden worsening and spreading weakness) may be provoked by drug omission, infection and stress.

Pre-operative assessment of respiratory function is important. Pyridostigmine is usually withheld on the morning of surgery and then restarted in reduced dosage post-operatively.

A tracheostomy does improve weaning from ventilatory support, but it is not performed routinely after a thymectomy. These patients are often extubatable within 24 hours on the ICU if not immediately after the surgery.

These histological features are typical of coeliac disease with:

Villous atrophy Crypt hyperplasia/hypertrophy Inflammatory infiltrate of the lamina propria, and Intra-epithelial lymphocytes.

Useful serology includes anti-TTG antibodies which would be expected in over 90% of cases.

Treatment of this case would therefore entail gluten-free diet.

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A 4-year-old boy born in North Africa has presented with recurrent chest infection and wheeze since birth. On auscultation he has an ejection systolic murmur and a rumbling mid-diastolic murmur. He is also noted to have a fixed and widely split second heart sound.

Incorrect - The correct answer is Atrial septal defect

There are two main types of atrial septal defect:

Ostium secundum deficency of the foramen ovale and atrial septum, and Ostium primium defect of the atrioventricular septum.

Both present with similar symptoms.

All symptomatic children should be offered surgery, which consists of closing the defect primarily with sutures or with a patch.

A 6-week-old boy is noted to have a loud systolic murmur at his six week check. The mother reports that he feeds well and is he is on the 50th centile for weight and height.

Incorrect - The correct answer is Ventricular septal defect

Ventricular septal defects (VSDs) are common and are of two main types:

Perimembranous - close to the tricuspid valve, and Muscular - completely surrounded by muscle.

Most children are asymptomatic with most VSDs closing spontaneously within the first few years of life.

Symptoms include failure to thrive, recurrent chest infections and heart failure. Surgery is indicated if there are severe symptoms with failure to thrive or pulmonary hypertension. Untreated pulmonary hypertension will progress to irreversible damage of the pulmonary capillary vascular bed.

A 6-week-old boy is noted to have a continuous murmur. The mother reports that he feeds well and is he is on the 50th centile for weight and height.

Incorrect - The correct answer is Patent ductus arteriosus

The ductus arteriosus connects the pulmonary artery to the descending aorta. Failure to close shortly after birth frequently occurs in preterm or sick infants. In other children it is due to a defect in the muscle of the duct. Children are usually asymptomatic but may develop signs of heart failure. If the PDA fails to close then surgical/transvenous closure is advised to abolish the lifelong risk of bacterial endocarditis.

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Peripheral arteriovenous access is required if a patient requires long-term haemodialysis. Most are formed under local anaesthetic in a day case setting. Most fistulae are formed as distally on the arm as possible, by an end-to-side technique onto the artery to reduce the risk of venous hypertension and steal syndrome. Prior to creating a fistula it is necessary to be able to palpate a distal pulse.

The National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NKF KDOQI) advocate routine duplexing of the artery and vein to identify anatomical abnormalities or disease.

Fistula failure is associated with:

Small vessel size Low fistula flow rate following construction Anastomosis method (clips are better than suturing) Access position (more distal is better) Gender (better patency rates in men) Age (poorer outcomes in the elderly) Obesity, and Smoking.

Complications of A-V fistula are infection, haemorrhage and steal syndrome.

A patient with recurrent right upper quadrant pain with normal ultrasound, gastroscopy and MRCP.

Correct

A HIDA (Hepatobiliary Iminodiacetic Acid) scan is a nuclear imaging procedure used to evaluate the function of the gallbladder. A radioactive tracer, usually a 99Tc-iminodiacetic acid chelate complex, is injected peripherally then allowed to circulate to the liver where it is excreted into the biliary system and stored by the gallbladder and biliary system. A healthy functioning gallbladder should outline fully within one hour.

Axillary sentinel lymph node biopsy.

Correct

To assess axillary lymph node a radiocolloid is superficially injected overlying the tumour or superficially at the periareolar margin. This is because lymph drains from the deep breast parenchyma superficially to the subdermal lymphatics. Subdermal lymphatics drain to the axilla via the subareolar plexus through one or more final common lymphatic channels.

Radiocolloid injection allows pre-operative sentinel node imaging using a gamma camera. The colloids are efficiently trapped in the sentinel node (whereas blue dyes typically pass into second echelon nodes). The universal radioactive tracer used is Technetium-99 m. Technetium has several advantages, as it is a pure gamma radiation emitter, hence offers excellent tissue penetration.

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Theme:Antibiotic regimes in abdominal/pelvic infectionsA Ciprofloxcin for 1 weekB Doxycycline for 1 weekC Doxycycline for 2 weeksD MeropenamE Metronidrazole and doxcycline for 2 weeksF PiperacillinG Vancomycin

For each of the scenarios below, choose the single best treatment from those listed.

Each option may be used once, more than once or not at all

A young woman with a non-specific genital infection.

Incorrect - The correct answer is Doxycycline for 1 week

Non-specific genital infection is an infection of the urethra or cervix, where a cause cannot be demonstrated on routine investigations. Further investigations demonstrate Chlamydia trachomatis in 30-50% and Ureaplasma urealyticum in 10-40% of cases. Treatment is with Doxycycline or Azithromycin for 7 days.

A 22-year-old woman presents with pyrexia and lower abdominal pain. Pelvic ultrasound confirms salpingitis.

Correct

Pelvic inflammatory disease is usually the result of infection ascending from the endocervix causing:

endometritis salpingitis parametritis oophoritis tuboovarian abscess, and/or pelvic peritonitis.

Neisseria gonorrhoeae and Chlamydia trachomatis account for a quarter of cases. Gardnerella vaginalis, anaerobes and other organisms commonly found in the vagina may also be implicated.

A 51-year-old leukaemia patient with typhlitis on CT.

Incorrect - The correct answer is Meropenam

Typhlitis (neutropenic enterocolitis) is a life-threatening, necrotizing enterocolitis occurring primarily in neutropenic patients. Typhlitis occurs most commonly in individuals with haematologic malignancies who are neutropenic and have breakdown of gut mucosal integrity as a result of cytotoxic chemotherapy. Treatment involves bowel rest, NGT and intravenous fluids. Close monitoring with serial abdominal examinations in an intensive care setting is required.

Intravenous antibiotics should include cover for gram-negative and anaerobic organisms, including Clostridium species. Metronidazole may also be considered if pseudomembranous colitis cannot immediately be excluded. Laparotomy is indicated if peritonitis develops.

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A 75-year-old retired builder has a pigmented lesion on his forehead with a darker patch in one area.

Correct

Lentigo maligna (Hutchinson's melanotic freckle) is the least malignant variety (carcinoma in situ). It is more commonly seen in the elderly. It presents as an irregular brown patch commonly over the cheek. Malignant changes are recognised by thickening, darkening and the development of discrete tumour nodule(s). This indicates dermal invasion by malignant melanocytes and the lesion is then a lentigo maligna melanoma.

A 46-year-old man presents with a painless firm lump on his arm. This lump has been present for many years.

Incorrect - The correct answer is Sebaceous cyst

Sebaceous cysts are intradermal lesions containing keratin and its breakdown products. It is surrounded by a wall of stratified squamous keratinising epithelium. They commonly occur over the face, chest and shoulders. They have a characteristic punctum, usually in the centre of the lesion, which blocks the sebaceous outflow.

A 40-year-old Nigerian man presents with a pigmented lesion deep to the left hallux nail plate.

Incorrect - The correct answer is Acral malignant melanoma

Acral lentiginous melanomas arise on the palms/soles or around the toenails and are more common in dark skinned peoples.

A 32-week-pregnant woman with right-sided abdominal pain.

Incorrect - The correct answer is Appendicitis

Acute appendicitis is the most common surgical emergency in pregnancy. Appendicitis in pregnancy should be suspected when a pregnant woman complains of new onset of central or right sided abdominal pain. One study found considerable foetal loss after appendicetomy during pregnancy in the first and second trimester.

Reference:

Andersen B, Nielsen TF. Appendicitis in pregnancy: diagnosis, management and complications. Acta Obstet Gynecol Scand. 1999;78:758-62.

A 7-year-old girl presents with haematuria and suprapubic pain.

Incorrect - The correct answer is Urinary tract infection

In a 7-year-old girl the most likely cause of haematuria and suprapubic pain is urinary tract infection. Haematuria may be attributable to urinary stones or underlying anatomical conditions such as vesicoureteral reflux, renal vascular abnormalities, PUJ obstruction, VUJ obstruction and tumours.

A woman who is 18 weeks pregnant presents with suprapubic pain and history of recent cough.

Incorrect - The correct answer is IgA nephropathy

IgA nephropathy (Berger's disease) is the most common glomerulonephritis worldwide, and characteristically affects young males, presenting with frank haematuria after an episode of pharyngitis. However it may also present with proteinuria, microscopic haematuria, renal failure or hypertension. It is probably part of a spectrum of disease with Henoch Schoenlein Purpura, which presents with arthritis, rash, abdominal pain and nephritis. In both there are mesangial IgA deposits in the kidney

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For two years a 38-year-old woman has had intermittent shooting pain along the right fifth finger.

Incorrect - The correct answer is Thoracic outlet syndrome

Thoracic outlet syndrome (TOS) is caused by compression of the brachial plexus, subclavian artery or subclavian vein in the thoracic outlet. Almost all patients (95%) present with neurological symptoms. hand pain is often most severe in the fourth and fifth fingers.

There are many non-anatomical causes, including:

repetitive pressure sports (e.g. weight lifting, archery, swimming, and tennis) occupations involving repeated overhead work (e.g. plastering, painting, shelf stacking) obesity, and poor posture.

Trauma, such as fractured clavicle, may cause TOS.

The commonest anatomical cause of arterial symptoms is a cervical rib, which occurs in 0.4% of the population. Although 70% of cervical ribs are bilateral, symptoms tend to be unilateral.

Neurological symptoms and signs include:

pain paraesthesia weakness, and muscle wasting.

Vascular symptoms and signs include:

distended arm veins which do not collapse even on limb elevation venous thrombosis cyanosis oedema arterial thrombosis (acute ischaemia or claudication) and embolisation (digital ischaemia), and post-stenotic dilatation and aneurysm formation

A 68-year-old woman has developed intermittent pain in the thenar eminence. The symptoms are exacerbated when lifting heavy objects.

Incorrect - The correct answer is Osteoarthritis in joint

Osteoarthritis of the first carpometacarpal joint is extremely common and in a 65-year-old lady is the most likely diagnosis. Swelling is usually bony hard and due to osteophyte formation which can lead to the appearance of squaring of the hand.

A 28-year-old female secretary complains of pain in her dominant index finger. The symptoms worsen through the day.

Incorrect - The correct answer is Carpal tunnel syndrome

The median nerve enters the hand through the carpal tunnel, deep to the flexor retinaculum, along with the nine tendons of the flexors digitorum superficialis and profundus and the flexor pollicis longus.

The carpal tunnel is the channel deep to the flexor retinaculum between the tubercles of the scaphoid and trapezoid bones on the lateral side and the pisiform and hook of hamate on the medial side.

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Distal to the carpal tunnel, the median nerve supplies the three thenar muscles and the first and second lumbricals. It also sends sensory fibres to the skin of the entire palmar surface, the sides of the first three digits, the lateral half of the fourth digit and the dorsum of the distal halves of these digits.

However the palmar branch, which supplies the central palm, arises proximal to the carpal tunnel and does not traverse the tunnel, it runs superficial to the flexor reticulum - therefore there is no loss of sensation in the skin in carpal tunnel syndrome.

Carpal tunnel syndrome is due to inflammation of synovial sheaths that significantly reduces the size of the carpal tunnel. Fluid retention, infection, and excessive exercise of the fingers may cause swelling of the tendons or their synovial sheaths.

The median nerve is the most sensitive structure in the carpal tunnel and therefore is most affected. Progressive loss of coordination and strength in the thumb is due to weakness of the abductor pollicis. As the condition progresses, sensory changes radiate into the forearm and axilla.

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A 59-year-old man is undergoing a femoro-distal bypass graft for critical ischaemia. A venous conduit is used. The vascular surgeon wants to avoid a size mismatch between the ends of the conduit to be anastomosed. A valvulotome cutting knife is pulled back through the graft to disrupt the valves in the vein lumem.

Incorrect - The correct answer is In-situ

In situ grafting is the method of choice for vessels around the knee or near the foot. The vein tributaries are ligated and the upper end is then freed and mobilised from the femoral vein which is oversewen. The vein is then anastomosed to the artery. The clamps are then divided and the vein is allowed to distend proximal to the first competent valve. The valvulotome is then passed up the vein to the distended segment and is then gently withdrawn disrupting the valves one by one. The distal end is then anastomosed to the artery.

A 67-year-old man presents to the vascular outpatients clinic with right foot rest pain and bilateral short distance claudication. He underwent a coronary artery bypass grafting two years before in which the long saphenous vein was harvested from the right leg. He unfortunately developed an extensive iliofemoral DVT in the left leg in the postoperative period following the CABG. A vascular procedure is planned on his right leg.

Correct

This man has no leg veins available to act as a conduit. Most commonly a PTFE graft is used. However, there is a lower patency rate at one year with synthetic grafts compared to venous grafts. Some vascular surgeons recommend harvest of arm veins when leg veins are not available.

A 63-year-old man presents to the physicians following a transient ischaemic attack, on examination he has a fever. Initial blood cultures grew Streptococcus. An abdominal CT scan showed a 5.7 cm infra-renal abdominal aortic aneurysm, there are signs the aneurysm may be mycotic.

Incorrect - The correct answer is Impregnated

The diagnosis of a mycotic organism can only be definitely made when organisms are cultured from the aneurysm wall. As the aneurysm is greater than 5.5 cm, it requires repair. If a synthetic graft is to be used it should be impregnated with antibiotics. The patient will require a prolonged course of iv antibiotics based on cultures pre-operatively and for at least two weeks post-operatively. Some surgeons still advocate a two stage approach with an axillo-bifemoral graft being formed first and then ligation of the abdominal aorta a number of weeks later.

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