Inflammation induces high systemic levels of acute-phase proteins. These proteins include C-reactive protein and vasopressin, which cause a range of systemic effects including;

Fever Increased blood pressure Decreased sweating, and Loss of appetite.

Thrombocythaemia occurs with chronic inflammation, for example, in rheumatoid arthritis.

Ferritin is an acute-phase reactant and serum levels rise in inflammation.

Caeruloplasmin is a copper carrying protein that is also an acute phase reactant.

Fibrinogen is a clotting factor and synthesis is increased by the liver in inflammation along with other acute phase proteins.

Complement proteins such as C3a and C5a have multiple roles in inflammation (chemotaxis, bacterial pore lysis) and serum levels rise accordingly.

This scenario describes a baby with whooping cough.

This illness tends to be more severe in younger infants, the organism responsible being Bordetella pertussis. This is more likely to be isolated from a nasopharyngeal swab than a throat swab.

Clinical manifestations include:

A paroxysmal cough (100%) Whoops (60%) Dyspnoea Apnoea Emesis, and Leucocytosis (with an absolute lymphocytosis of more than 10 ×109/L), being characteristic.

Complications include:

Pneumonia Bronchiectasis Emphysema, and Pneumothorax.

The forcefulness of the paroxysms often results in subconjunctival haemorrhages.

Dupuytren's contracture is a progressive thickening of the palmar fascia causing a flexion contracture of the hand, mainly affecting the ring and little fingers.

It is associated with diabetes mellitus.

Associations with alcohol consumption, liver disease, epilepsy and antiepileptic drugs, manual work and vibrating machinery have not been proven.

It is five to 10 times more common in men. The incidence increases with age and there may be a genetic component.

There may be associations with smoking and a low BMI. The relationship to Peyronie's disease is uncertain.

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The problem is that many associations seem to have been disproved but the original link is still believed.

The temporomandibular joint is situated between the condyle of the mandible below and the mandibular fossa above. It is a type of synovial joint but it is lined by fibrous cartilage, rather than the hyaline cartilage typical of synovial joints.

The joint cavity is divided into two by an articular disc. The capsule surrounding the joint is attached beyond the limits of the articular surfaces.

Superiorly, the capsule is attached to the anterior edge of the squamotympanic fissure. Laterally, the capsule is attached to the articular tubercle, which forms the lateral limit of the articular eminence and the prominent ridge of the bone forms the lateral lip of the glenoid cavity.

Medially, the capsule runs along the suture between the temporal and sphenoid bones and attaches anteriorly to the anterior end of the articular eminence. The capsule is strengthened medially and laterally by the collateral ligaments and the lateral ligaments are much stronger than the medial ligaments.

The medial collateral ligaments are attached to the medial part of the glenoid cavities and the medial poles of the condyle. Superiorly, they attach to the articular tubercles and the lateral margins of the glenoid cavities, and inferiorly run obliquely downwards and backwards to the lateral pole of the condyles. On the mandibular condyle, the capsule is attached below the anterior limit of the articular surface.

Nerves at risk during the peri-operative period include:

Optic nerve Ulnar nerve Radial nerve Saphenous nerve, and Common peroneal nerve.

The length of time spent in an abnormal position will increase the likelihood of problems.

The eyes and optic nerves are at risk from direct pressure from surgical instruments and elbows resting over the face.

The brachial plexus and its terminal branches are at risk from stretching or external pressure, particularly in the lateral position.

The lithotomy position can damage the saphenous and common peroneal nerves by pressure from the poles.

Neuronal injury is usually temporary and function returns with time, but occasionally damage is permanent.

Laryngeal papillomata, caused by papilloma virus, occur mainly in children but can also present in adults. They are commonly found over the vocal folds but sometimes may spread throughout the larynx and the tracheo-bronchial tree. These papillomas can be successfully treated by laser surgery.

Compartment syndrome is a devastating early complication usually seen after fractures, which must be recognised and treated early.

A rise in compartmental tissue pressure may be triggered by a number of factors, including soft tissue injury.

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If a sustained rise in tissue pressure above the arterial perfusion pressure occurs, muscles and nerves will be deprived of essential blood supply and ischaemic muscle further releases factors (such as free radicals) which increase capillary permeability, worsening the situation.

The main early feature is excessive pain which is made worse by passive stretch of the suspected group of muscles.

Compartment syndrome can occur in the presence of normal peripheral pulses, since it is the microvasculature which is initially affected.

Sensory loss may be detected early but motor weakness is a late sign.

Fasciotomy should be undertaken if the difference between the diastolic and the measured compartment pressure is less than 30 mmHg.

If not recognised and treated early, it could lead to Volkmann's ischaemic contracture.

Hypokalaemia is defined as a serum potassium of less than 3.5 mmol/L, and symptoms usually occur below 2.5 mmol/L.

A common cause of post-operative hypokalaemia is inadequate potassium intake, for example, intravenous fluid therapy without sufficient potassium supplementation. The daily maintenance potassium requirement is 0.5-1.0 mmol/kg per day.

ECG changes are common and includeL

T wave inversion S-T segment depression Q-T and P-R prolongation, and U waves.

Cardiac arrest may occur if attempts to raise the serum potassium are delayed and hypokalaemia is a cause of pulseless electrical activity (PEA).

Treatment of hypokalaemia in this patient should be with intravenous potassium, as he may still be on restricted oral intake or even be nil by mouth. Up to 40 mmol of potassium chloride can be added to each litre bag of fluid, but this method may not raise the serum potassium quickly enough. Therefore, it should be given by intravenous infusion at a rate not exceeding 40 mmol/hour.

In severe cases this upper limit may be exceeded with ECG monitoring, for example, in critical care areas, as there is a high risk of dysrhythmias, especially ventricular fibrillation.

One needs to calculate the incidence as follows:

In the group treated with warfarin there were 360 strokes (6% of 6000).

In the aspirin treated group there were 720 strokes (9% of 8000).

Thus, there are 1080 strokes amongst the treated population (n=14000) over a three year time period.

Therefore there are 360 strokes annually in the treated group (14000) giving an annual incidence of stroke of approximately 2.6%.

Note: remember to divide by three since the study lasted three years and the figures given are for the three years incidence rates.

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The internal intercostals are muscles of expiration.

Latissimus dorsi has no role in normal inspiration or expiration. It can (if the arms are fixed), act as an accessory muscle in forced expiration.

Normal expiration is mainly passive. Serratus posterior inferior has a minor role in pulling down the lower ribs. The rectus abdominus and all muscles of the abdominal wall, aid forced expiration by pushing the relaxing diaphragm upwards, and pulling the ribs down and inwards.

In deep forced inspiration, every muscle that can raise the ribs is brought into action, including the scalenus anterior and medius and the sternocleidomastoid muscle.

Penicillin given intravenously or intramuscularly would be the most suitable antibiotic to administer for the prevention of tetanus.

Metronidazole should be used if the patient is allergic to penicillin.

Tetanus toxoid should also be given as appropriate.

Penicillins are generally bactericidal, and exert their effect by combining with and inhibiting the transpeptidase enzyme which cross-links the peptidoglycans in the cell wall. This weakens the cell wall, and allows the cell to lyse under the influence of an osmotic gradient.

The widespread resistance to penicillins is due to beta-lactamase enzymes, which break the beta-lactam ring and inactivate the drug.

The beta-lactamase enzyme is often encoded in the bacterial plasmid. The plasmid is bacterial DNA (separate from the main chromosome) that can be translocated from bacterium to bacterium, and it is for this reason that resistance may be also transferred.

Although the penicillins have similar spectra of action, their specific spectra may be changed by altering the beta-lactam side chain.

They do not have significant toxic effects on humans, but allergy to them is common.

Tears of the gastrocnemius and soleus muscle fibres are due to sudden unaccustomed exercise. The pain may accompany underlying haemorrhage within the muscle belly.

Simmonds' test is positive if the Achilles tendon is ruptured (reduced plantar flexion of the ankle on squeezing the calf muscle). Rest, elevation and ice packs are usually sufficient to treat this condition. Physiotherapy may be required after the acute symptoms subside.

Hospitalisation and immobility increase the incidence of deep venous thrombosis. The other risk factors include:

Increasing age Pregnancy Oral contraceptive pill Surgery especially orthopaedic or pelvic Malignancy, and Past history of DVT and thrombophilia.

Clinical features include:

Redness Swelling

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Pain Calf tenderness Dilated superficial veins (sometimes), and Low grade pyrexia.

These signs and symptoms usually develop after 7-10 days post-operatively.

Tumours of the bone are important causes of progressive pain in the limbs in the absence of injury, particularly in children and young adults.

Acute swellings within the knee joint after trauma, without fractures, are usually due to damage to the cruciate ligaments or the menisci.

If the pain is severe and the joint movements are restricted, aspiration of the knee joint (either medial or lateral approach, depending on the effusion) under local anaesthetic will relieve the acute symptoms.

Diabetic patients, regardless of whether they are insulin dependent (type 1) or non-insulin dependent (type 2) should be scheduled for surgery early in the day. However, placing them first on the list is not always possible and this is widely accepted.

Diabetics as a rule are kept nil by mouth for the same duration (six hours for solids and two hours for clear fluids) as all patients scheduled for general anaesthesia.

The pre-operative management of diabetics is influenced by the method and efficiency of glucose control, rather than the type of diabetes they have. Patients with poor control of blood glucose should be admitted the day before and started on an insulin/glucose sliding scale until they reach the operating theatre. Thus optimal control of blood glucose can be achieved and monitored by frequent bedside assessment of the blood glucose (for example BM stix). However, this patient's glycaemic control appears good, as reflected by a HbA1c of 53 mmol/mol.

Well controlled diabetics can be treated as day cases, but they should omit the long acting oral hypoglycaemic drug or insulin the night before surgery. Blood glucose monitoring is still necessary, but they rarely require an insulin/glucose sliding scale.

In BLS in an infant the head position should be neutral. The infant's trachea is short and soft and may easily become compressed if the neck is extended. In an older child the head should be placed in a 'sniffing the air' (neck slightly extended) position to improve the airway.

Resuscitation is commenced when there is an absent pulse for 10 seconds combined with other signs (no normal breathing, no spontaneous movement, no response to stimuli). An absent pulse alone is not enough as it can be difficult to feel. The infant's neck is short and fat and the carotid pulse may be difficult to identify, therefore the brachial or femoral pulse is palpated. Once the airway is checked, five initial slow rescue breaths are given; rapid breaths cause gastric distension. If there is no response, 15 chest compressions, 2 rescue breaths, and a further 15 chest compressions are given.

Thereafter the C:V ratio should be 3:1. The compression rate should be at least 100 and not more than 120/minute.

Two fingers are used to perform chest compressions for infants (or the hand encircling technique with both hands encircling the chest). The fingers should be placed one finger breadth above the xiphisternum. Compression should be 1/3 of the AP diameter of the chest.

Uric acid stones occur in 5-25% of all cases of nephrolithiasis. They are associated with hyperuricaemia and hyperuricosuria.

Predisposing factors for uric acid stone formation are:

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Dehydration High purine load (high protein diet) As a primary factor in idiopathic gout, and Associated with high cell turnover (for example, haematological malignancy).

Allopurinol is prescribed to treat gout and prevents uric acid formation - hence it reduces the frequency of uric acid stones.

Chronic renal failure is incorrect as there is hyperuricaemia without hyperuricosuria.

Hyperparathyroidism is associated with calcium stones, not uric acid stones.

The correct answer is thiazide diuretics. Thiazide diuretics cause hyperuricaemia and can predispose to hyperuricosuria and uric acid stone formation. Uric acid stones are also associated with underlying hypertension. Thiazide diuretics are used to treat calcium stones as they increase the reabsorption of calcium from the proximal tubules, preventing hypercalciuria.

Primary polycythaemia would predispose to uric acid stone formation, whereas secondary polycythaemia does not.

Hypercapnoea is defined as an end tidal CO2 over 6 kPa (45 mmHg) and occurs in a respiratory acidosis (not alkalosis). This may be a primary respiratory acidosis, for example:

head injury central nervous system depression spinal cord lesion, and fatigue of respiratory muscles.

A respiratory acidosis may also occur as a compensatory mechanism secondary to a metabolic alkalosis.

Increasing hypercapnia results in increased cardiac output and increased blood pressure.

Exhausted soda lime granules cause the inspired concentration of carbon dioxide to increase (rebreathing), and are a recognised cause of hypercapnoea.

Note that hypercapnoea is an increased ET CO2, and hypercarbia is an increased arterial PCO2.

Intravenous morphine is the gold standard opiate analgesic, against which the potency of other drugs is compared. The dose of intravenous morphine is 0.1-0.2 mg/kg.

It is an agonist at the various opioids' receptors and its actions are antagonised by naloxone (especially pain and respiratory depression). However, the half life of naloxone is shorter than the half life of the metabolites of morphine and this should be remembered when treating an opioids overdose.

Entonox is a gaseous mixture of oxygen and nitrous oxide in equal proportions (50:50). It provides moderate analgesia but the effects are short-lived and its use is contraindicated in patients with pulmonary disease.

Codeine is unlicensed for intravenous use and should only be given intramuscularly, orally or rectally.

Ketamine increases salivation and pretreatment with an anti-sialogogue such as glycopyrrolate is useful.

Arterial blood gas analysis requires knowledge of the inspired oxygen concentration (FiO2) before interpretation is possible.

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Arterial blood is aspirated from a superficial artery into a heparinised syringe. Local anaesthetic infiltration renders the procedure relatively painless.

Normal values taken on air are:

PaO2 of 13.3 kPa (100 mm Hg) PCO2 of 5.3 kPa (40 mm Hg).

A high plasma pH is an alkalaemia and a low pH is an acidaemia.

The variation in pH, PaCO2 and PaO2 between 35°C and 39°C is small. Corrections are required for hypothermia and hyperpyrexia. Newer machines will calculate the correction for temperature.

Obtaining a pre-operative blood gas on patients with pulmonary disease is not always indicated. Providing a result is available from within three months of the operation date and the patient's symptoms remain unchanged, then a repeat test is unnecessary.

Covering the sample syringe with ice reduces the inaccuracy which may result due to ongoing blood cell metabolism. However, this is only necessary when a delay between obtaining the sample and analysis is anticipated

Toxigenesis, or the ability to produce toxins, is an underlying mechanism by which many bacterial pathogens produce disease.

At a chemical level, there are two types of bacterial toxins

Lipopolysaccharides, which are associated with the cell walls of Gram negative bacteria, and Proteins, which are released from bacterial cells and may act at tissue sites removed from the

site of bacterial growth.

The lipopolysaccharide toxins are referred to as endotoxins and the extracellular diffusible toxins are referred to as exotoxins.

Exotoxins are soluble proteins produced by the living bacteria and are generally specific for the pathogenic bacteria involved (can be produced by both Gram positive and Gram negative bacteria, for example, enterotoxigenic Escherichia coli).

Bacterial protein toxins are the most powerful human poisons known and retain high activity at very high dilutions.

Their effect may be neutralised by the antitoxin and this is used as a treatment (toxoid).

Spondylolisthesis is the slipping forward of one vertebra in relation to another.

Isthmic spondylolisthesis is one type (of five) and appears to be a form of repetitive stress fracture; the incidence is much higher in teenage gymnasts and other sports persons. It commonly occurs between the ages of 7 and 10.

The signs and symptoms include:

Low back ache Hamstring spasm Fifth lumbar nerve root pain Disturbance in the sagittal profile of the spine with an acute kyphosis, and Neurological symptoms in the legs.

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On examination, there may be a step in the line of the spinous processes; straight leg raising test may be reduced due to hamstring spasm.

The history of pale stool and malabsorption of fat-soluble vitamins (low vitamin D and hence low calcium) together with elevated alkaline phosphatase suggests biliary obstruction and hence pancreatic carcinoma.

Folate and B12 absorption are unaffected and so mean corpuscular volume (MCV) is normal though a normochromic normocytic anaemia is often a feature.

The grossly elevated alkaline phosphatase would be excessive for purely a vitamin D deficiency and is far more in keeping with biliary obstruction.

Change in bowel habit in an elderly patient with a microcytic anaemia and elevated alkaline phosphatase yet normal calcium suggests colonic carcinoma with hepatic metastases as the likely diagnosis.

The young male with change in bowel habit, elevated MCV associated with folate/B12 malabsorption and hypocalcaemia with mildly elevated alkaline phosphatase (more in keeping with a vitamin D deficiency/osteomalacia) suggests a diagnosis of coeliac disease. All patients with iron deficiency anaemia should be screened for coeliac disease.

The first series of results with normal calcium and phosphate but elevated alkaline phosphatase and normal PTH suggests a diagnosis of Paget's disease. Hypercalcaemia usually occurs with immobility. A dramatic rise in alkaline phosphatase may suggest malignant transformation.

The second series of results with lowish normal calcium, low phosphate, elevated alkaline phosphatase and PTH suggests a diagnosis of osteomalacia/vitamin D deficiency. This is a common entity in the elderly and associated with ethnicity. Bone aches and pains together with proximal muscle weakness may feature.

The third series has elevated calcium, lowish phosphate (arguing against vitamin D excess), elevated alkaline phosphatase and a suppressed PTH concentration. This picture suggests ectopic PTH secretion by a tumour such as a squamous cell carcinoma of the lung. The condition is as a consequence of the secretion of PTH related peptide (PTHrp) which has sequence homology to PTH but does not cross react in assays.

In the case of the 20-year-old, survival of a patient with confined Hodgkin's lymphoma, would be expected to be higher than 50%, with figures for survival approaching 80%.

In the case of the 22-year-old man, the prognosis is excellent at nearly 100% if node negative, and 90% if node positive.

The prognosis is excellent for the 37-year-old man, approaching 99% at five years.

The 52-year-old lady will undergo a mastectomy/wide local excision and axillary lymph node clearance and chemotherapy with a five year survival of approximately 70-80%.

In the case of the 60-year-old man with what appears to be curative liver resection, the survival at five years has improved to over 50%.

Post-partum breast abscess occurs in breastfeeding mothers. They usually result from Staphylococcus aureus introduced through cracks in the nipple-areolar complex and are usually situate peripherally. Infection may also result at weaning due to engorgement of the breast or from the child developing teeth.

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Early breast infections (that is, before pus forms) may be treated successfully with antibiotics. When pus forms the treatment is ultrasound guided needle aspiration (mammography requires compression of the painful breast between radiographic plates and is therefore contraindicated).

Surgical incision and drainage may result in a mammory-cutaneous fistula and is only indicated if the abscess is very loculated, fails to respond to repeated guided aspirations or if the overlying skin is necrotic.

Pain increases sympathetic output leading to increased myocardial oxygen demand and therefore the risk of myocardial ischaemia, especially in patients with pre-existing heart disease.

Poorly managed post-operative pain results in delayed mobilisation and in turn increased risk of DVT.

Poor management of post operative pain impairs the patient's ability to cough and deep breathe leading to retention of secretions, atelectasis and pneumonia.

Effective analgesia improves respiratory function.

PRN regimes rely on the patient requesting analgesia when in pain and there may be considerable time delay between request and administration.

In addition peak plasma levels obtained by IM opiod injections and the time taken to reach these levels varies between patients. The standard regime is therefore optimal for only a small number of patients.

The plasma concentrations of opiods required to provide effective analgesia may vary up to fourfold between patients.

An indirect inguinal hernia travels down the inguinal canal on anterio-lateral side of the spermatic cord. Indirect inguinal hernias occur in 2% of full term infants and 10% of preterm infants. The male to female ratio is 10:1 with the right side being affected twice as often as the left.

They usually present as a bulge in the groin when the baby cries. These hernias frequently present with irreducibility. The infant appears to be distressed with the distress worsening when the lump is examined. Most paediatric surgeons practise taxis (reduction under sedation) followed by herniotomy soon after.

Inguinal lymph nodes are frequently confused with an irreducible inguinal or femoral hernia. They are usually multiple and associated with constitutional symptoms of fever and malaise and may be an early manifestation of lymphoma.

The surgeon can be confident that the lump is a lymph node if lateral to the femoral pulse as inguinal and femoral hernias are medial.

The commonest causes of 'acute scrotum' in childhood are testicular torsion, torsion of an appendix testis and idiopathic scrotal oedema.

Testicular torsion can occur at any age, with a peak incidence between 14 and 20 years. It usually presents with severe testicular pain, but this may be absent, and the testis should be examined in all boys with abdominal symptoms.

If torsion is clinically suspected, then radiological investigations have little to offer. None are diagnostic, and may delay surgery. Testicular viability is reduced with increasing time from the onset of symptoms.

Following reduction of a torsion, 3-point fixation with an non-absorbable suture should be performed. The contralateral testis should also be fixed.

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Local anaesthetic agents block the smaller (<1 micrometer in diameter) unmyelinated C fibres first, then the B fibres (1-3 micrometers) and finally the larger A fibres (1-20 micrometers).

Temperature and pain sensation are carried by the small C fibres, whereas proprioception is carried by A-alpha fibres, hence temperature is blocked before proprioception.

Preganglionic class B fibres are myelinated, whereas the postganglionic class C fibres are unmyelinated, hence unmyelinated fibres are theoretically blocked first.

Motor function is provided by the largest diameter nerves (A-alpha) which are blocked after the C fibres that carry temperature sensation.

The radial nerve gives off the posterior interosseous nerve in the forearm.

The posterior interosseous nerve emerges from below the brachioradialis at the level of the elbow joint. Then it passes between the humeral and ulnar heads of supinator to curve laterally around the radial neck to enter the extensor compartment of the forearm.

The posterior interosseous nerve supplies all extensors except extensor carpi radialis longus which is supplied by the radial nerve.

The nerve travels along the interosseous membrane giving articular branches to the elbow, wrist and intercarpal joints

This patient has systemic inflammatory response syndrome, possibly caused by acute pancreatitis given the finding of an isolated dilated loop of small bowel on abdominal radiograph. However, the initial treatment is the same independent of the underlying cause.

All of the above answers are reasonable, however resuscitation of the sick patient still follows the ABC algorithm:

Airway Breathing Circulation.

Airway control and oxygen to maintain normal saturations is the first part of that algorithm. Subsequent fluid resuscitation and treatment of the underlying cause can then be initiated. The need for invasive monitoring and intensive care is then assessed, depending on the response to initial treatment.

The peak systolic velocity in the cavernosal arteries is normally less than 0.4 m/s. A higher flow in the presence of priapism is indicative of high-flow (arterial) priapism.

Priapism is primary or idiopathic in 60% of cases.

Twenty per cent of secondary priapism cases are haematologic in origin, for example:

Sickle cell disease Leukaemia, and Heparin therapy.

Other causes are:

Neurogenic Traumatic, and Infectious.

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On the basis of aetiology, priapism can be broadly divided into low flow (veno-occlusive) and high flow (arterial) varieties.

The former involves a physiologic or mechanical obstruction to venous drainage of the penis which causes a build-up of viscous, poorly oxygenated blood within the corpora cavernosa. The origin of priapism in these cases may be secondary to multiple areas of sludging and thrombosis.

The major causes of veno-occlusive priapism are:

Complication of sickle cell disease Haematopoietic malignancy, and A hypercoagulable state.

Arterial (high-flow) priapism is a physiologically distinct entity which is markedly less common than the veno-occlusive form. Arterial priapism results from unregulated inflow of arterial blood into the lacunar spaces of the corpora cavernosa from a lacerated cavernous artery, bypassing regulatory function of helicine arterioles.

Aetiology of increased arterial inflow may be:

Secondary to arteriovenous fistula Frank arterial laceration with extravasation, and A pseudoaneurysm.

Although most cases of high flow priapism are secondary to blunt or penetrating trauma to the perineum or penis, a large majority of cases - especially in adults - may be idiopathic, without history of pertinent trauma or findings of anatomic abnormalities.

Arterial priapism may be treated with arterial ligation or percutaneous embolisation. Other therapeutic modalities, such as sustained perineal compression and ice packs, or intracavernous administration of alpha-adrenergic agonists have proven to be less effective.

Not that much given away by this history just the issue of a prolonged bleed after prior dental extraction. The most likely diagnosis when considering this patient is von Willebrand's disease which is an autosomal dominant condition and is one of the commonest bleeding disorders.

Most cases are mild, with bleeding after only mild injury, particularly mucosal membrane injuries. The condition is due to a reduction or structural abnormality of von Willebrand's factor, which has the dual role of promoting normal platelet function and stabilising coagulation factor VIII.

Von Willebrand's disease can give normal results on screening tests, and diagnosis may require specialist investigation. Most patients with mild disease respond to desmopressin (DDAVP), but clotting factor concentrates are needed for a minority (the more severe type 2 and type 3 [which is autosomal recessive]).

This pregnant female has features suggesting eclampsia, and the prolonged bleeding from venepuncture sites suggests disseminated intravascular coagulation (DIC).

In this complication, there is prolonged prothrombin time and activated partial thromboplastin time (APTT) together with thrombocytopenia and increased fibrinogen consumption (as manifested by increased fibrin degradation products). A blood film would show microangiopathic changes with fragmented red cells and helmet cells.

There are several other obstetric causes of DIC including retroplacental haemorrhage, retained dead fetus, and amniotic fluid embolus.

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A cohort study takes a group of individuals and follows them for a period of time, the aim being to study whether the exposure to a particular aetiological factor has any effect on the incidence of disease.

As such they are relatively time consuming and expensive to perform. Advantages include being able to study exposure factors that are rare and being less susceptible to recall bias than case-control studies.

They are also able to measure the incidence/risk of a disease.

Results are usually expressed as the relative risk of developing the disease given exposure to the aetiological factor.

DDAVP (desmopressin) is the choice treatment for mild von Willebrand's disease, which would include type I, and the majority of type II, although there is some controversy in type II B as it is thought that DDAVP can exacerbate thrombocytopenia that can accompany this type of von Willebrand's.

It is of no use in type III - severe von Willebrand's disease. The history tells us that she has mild disease.

You would not use cryoprecipitate or fresh frozen plasma in these patients in this era due to potential viral transmission risk from blood products.

For severe disease you would use a von Willebrand factor concentrate, not factor VIII concentrate.

The anterior tibial artery is formed by the bifurcation of the popliteal artery in the calf, which passes forwards above the upper border of the interosseous membrane to reach the extensor compartment.

The artery with both of its veins run inferiorly on the interosseous membrane and passes between the two malleoli anteriorly to become the dorsalis pedis.

Tibialis anterior lies medial to the artery throughout.

Extensor digitorum longus and peroneus tertius lie laterally.

The deep peroneal nerve runs laterally initially and then passes in front in the middle third.

He is still actively bleeding and haemodilution will not have been achieved so his Hb will be lower than the result given. It will take at least 30-60 minutes before he is back in theatre and anaesthetized (CEPOD lists/emergency sections/crash calls/no porter etc). With IHD he is at at high risk of a perioperative MI. He should have the blood first as crossmatched blood is available.

His observations could be caused by pain. However in the face of a falling haemoglobin, a rising pulse rate and an increasing loss into his drains this patient needs to return to theatre.

His blood pressure is not critically low and although many would give crystalloid or colloid it is reasonable in an elderly man with ischaemic heart disease to give blood if it is easily available. Overload with non-oxygen carrying fluid should be avoided (although the red cells are not functional for a while).

The British Thoracic Society guidelines on community acquired pneumonia in adults recommend use of the CURB-65.

This is a 5-point score, one point for each of:

Confusion Urea more than 7 mmol/L

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Respiratory rate 30/min or more Systolic Blood pressure below 90 mmHg (or diastolic below 60 mmHg) Age 65 years or older.

If the CURB score is 1-2 then risk of death is increased and hospital admission should be considered.

A CURB score of 3 or more puts the patient at high risk of death and hospital admission is warranted.

NICE guidelines recommend that patients who have had a suspected TIA who are at high risk of a stroke (ABCD score of 4 or above) should have aspirin (300 mg OD) started immediately. They also need specialist assessment and investigation within 24 hours of onset of symptoms. Secondary prevention measures should be introduced as soon as the diagnosis is confirmed, with consideration of individual risk factors.

The ABCD scoring system uses:

Age ≥60 1 pointBP ≥140/90 mmHg at initial evaluation 1 point

Clinical featuresUnilateral weakness 2 pointsIsolated speech disturbance 1 pointOther 0 points

Duration of symptoms≥60 minutes 2 points10-59 minutes 1 point< 10 minutes 0 points

Diabetes mellitus Present 1 point

Although you cannot calculate the ABCD score with the information given in this question, aspirin remains the most appropriate answer.

Carotid endarterectomy has been established as an effective treatment for both symptomatic patients and asymptomatic patients who are shown to have carotid artery stenosis. It reduces the risk of disabling stroke or death by 48% in a person with severe symptomatic carotid stenosis (>70%) who has had a TIA. The peri-operative risk of disabling stroke or death is approximately 3%. Current UK guidelines recommend endarterectomy for symptomatic patients with greater than 70% stenosis, based on the North American Symptomatic Carotid Endarterectomy Trial which showed clear benefit. The endarterectomy should be performed as soon as the patient is fit for surgery, preferably within two weeks of a TIA.

The benefit is marginal for symptomatic patients with 50-69% stenosis, but may be greater in male patients. NICE recommends these patients are also considered for endarterectomy. There is significantly less benefit for asymptomatic patients, even those with greater than 60% stenosis. Patients with less than 50% stenosis should not be considered for carotid surgery.

Recurrent stenosis can occur in 1-20% of patients following endarterectomy, and re-operation is needed in 1-3% of cases. Ipsilateral strokes occur in 9% of patients following endarterectomy, and 26% of those treated with medical management alone (within 2 years).

All patients with suspected non-disabling stroke or TIA who are considered as candidates for carotid endarterectomy should have carotid imaging within 1 week. If the patient has had a disabling stroke there is no real benefit in them undergoing the procedure.

Modified-release dipyridamole is indicated in combination with aspirin only once a TIA has been confirmed by a specialist. Alone, it is recommended only if aspirin is contraindicated or not tolerated.

Clopidogrel is recommended in patients who have had an ischaemic stroke, rather than a TIA.

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Warfarin is only indicated with cerebral venous sinus thrombosis, or if the patient has atrial fibrillation.

Please note that for this explanation we have used the North American Symptomatic Carotid Endarterecomy Trial (NASCET) criteria, as opposed to the European Carotid Surgery Trialists' Collaborative Group (ECST) criteria when discussing carotid endarterectomy. Patients should be considered for endarterctomy if they have symptomatic carotid stenosis of 70-99% as assessed according to the ECST criteria. Carotid imaging reports will state which criteria are being used.

The intercostal nerves pass between the internal intercostal (deep to, not superficial) and transversus muscles.

The collateral branch supplies muscles, parietal pleura and the periosteum of the ribs. The lateral cutaneous branch supplies the skin over the intercostal space.

The lower five intercostal nerves supply the skin over the abdomen (the umbilicus is T10)

The intercostal nerves represent the ventral rami of the first eleven thoracic spinal nerves. The twelfth (being below the twelfth rib) is subcostal, hence is called the subcostal nerve.

Each intercostal nerve is connected to a ganglion of the sympathetic trunk by rami communicantes, to and from which they carry preganglionic and postganglionic fibres which innervate blood vessels, sweat glands, and muscles.

Pectoralis major is supplied by the medial and lateral pectoral nerves (C6,7,8)

The uterine artery is a branch of the anterior trunk of the internal iliac artery and provides the main blood supply to the uterus. It first runs downwards on the lateral wall of the pelvis in the same direction as the ureter; then turns inwards and forwards, lying in the base of the broad ligament.

By this change of direction it crosses above the ureter, at a distance of about 2 cm from the uterus, at the level of the internal os. On reaching the wall of the uterus it turns upwards to run tortuously to the upper part of the uterus where it anastomoses with the ovarian artery.

In this part of its course it sends many branches into the substance of the uterus. The artery supplies a branch to the ureter as it crosses it and shortly afterwards another branch is given off to supply the cervix and upper vagina.

The thoracic aorta is at risk in any patient sustaining a significant decelerating force (e.g. fall from a height or high speed road traffic accident, not from penetrating injuries).

Widening of the mediastinum may have been overlooked on the original AP radiograph. This is a sensitive sign of aortic rupture, though not very specific: 90% of widened mediastina are due to venous bleeding.

Other features frequently associated with aortic rupture are:

Fractures of the upper three ribs Deviation of the trachea to the right Depression of the left mainstem bronchus Deviation of the nasogastric tube to the right Loss of the aortic knob, and Pleural capping.

This is a typical history of Ménière's disease. The attacks are paroxysmal, last for hours and consist of:

Vertigo Vomiting

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Pressure within the ear, and Deafness.

After many attacks the patient may develop irreversible sensorineural deafness (of low frequency).

Prochlorperazine or cinnarizine usually helps vomiting, and restriction of salt and fluid may hasten resolution. Occasionally diuretics may be used but there is little evidence for efficacy.

Vertigo is uncommonly associated with unilateral hearing loss caused by acoustic neuroma.

In benign positional vertigo the episodes of vertigo last seconds and are precipitated by movement.

Labyrinthitis is characterised by acute disabling vertigo, usually preceded by an upper respiratory tract infection and is very rarely episodic.

Vertebrobasilar ischaemic attacks last minutes and typically the vertigo is a mild swaying or swimming sensation.

Vitamins K is a fat soluble vitamin together with vitamins A, D and E. Obstructive jaundice (as described) inhibits fat digestion and hence absorption of fat soluble vitamins. Vitamin K is necessary for the y-carboxylation of glutamic acid residues on factors II, VII, IX and X and on proteins C and S.

The prothrombin time (PT) and activated partial thromboplastin time (APTT) are prolonged and there may be bruising, haematuria and gastrointestinal or cerebral bleeding.

Antibiotic action can be categorised as follows:

Inhibition of cell membrane synthesis:

Lincomycins.

Inhibition of protein synthesis:

Tetracyclines Macrolides Aminoglycosides Chloramphenicol.

Inhibtion of DNA formation:

Sulphonamides/trimethoprim Quinolones Metronidazole.

Inhibition of cell wall synthesis:

Penicillins Vancomycin Cephalosporins Macrolides.

Head injury is the commonest cause of trauma death in children aged 1-15 years. In infancy (up to 12 months of age) the commonest cause of fatal head injury is child abuse.

Primary brain damage is caused by:

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Cerebral lacerations Cerebral contusions Dural sac tears, and Diffuse axonal injury.

Secondary damage occurs because of the consequences of the brain injury, or from associated injuries and stress.

Causes of this include ischaemia from poor cerebral perfusion due to raised intracranial pressure, and ischaemia due to blood loss and hypotension.

Hypoxia and hypoglycaemia are other causes.

An Addisonian crisis may be precipitated by any stressful event. Frequently this is an infection.

Pregnancy is a recognised cause. This may be due to increasing metabolic demands or vomiting.

There may be:

severe back, leg or abdominal pain severe vomiting and diarrhoea confusion/psychosis lethargy fever convulsions tachycadia, and tachypnoea.

The features of an Addisonian crisis include:

Hypotension Hypoglycaemia Hyponatraemia Hyperkalaemia Hypercalcaemia Hyperuricaemia, and Low serum bicarbonate.

Free radicals are molecules that contain one or more unpaired electrons. They are formed from aerobic metabolism and include:

Superoxide Hydroxyl ions, and Nitric oxide.

They are implicated in disease processes such as atherosclerosis as well as many inflammatory conditions and disorders such as adult respiratory distress syndrome (ARDS).

The pathophysiology of aneurysm disease is most likely to be due to up-regulation of elastases in the vessel wall.

The subclavian vein is a continuation of the axillary vein, beginning at the lateral border of the first rib.

It passes anterior to scalenus anterior.

The subclavian and internal jugular vein unite to form the brachiocephalic vein, subsequently the left and right brachiocephalic veins unite to form the superior vena cava.

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The thoracic duct enters the left subclavian.

The brachiocephalic trunk is a branch of the aortic arch, which divides to form the right subclavian and right common carotid arteries.

The problem with popliteal aneurysms is that they thrombose and in doing so take out the run-off which often leads to limb loss, although occasionally they do rupture and bleed. In view of this, vascular surgeons intervene electively by bypass, tie off the vessel above and below the aneurysm with a double tie of a non-absorbable suture such as nylon.

The left popliteal is still quite small at the moment and so one would follow this up and if it grew to a diameter greater than 2.5 cm consider intervention.

This man's aneurysm has thrombosed and in doing so has left him with an ischaemic limb surviving on a single vessel. The options now are a distal bypass, thrombolysis or wait and see.

Thrombolysis is not without risk in a gentleman of this age and can worsen the situation by causing an ischaemia/reperfusion event resulting in compartment syndrome; also it can dislodge a clot which then takes out the remaining single vessel.

Aggressive reconstructive femoral-distal bypass is usually reserved for critical ischaemia (rest pain, inability to sleep, tissue loss) and involves extensive dissection.

In the acute phase patients often improve as collaterals form and so the initial plan for this gentleman should be to encourage mobilisation and reassess his function - since he is only a few days from thrombosis and has a viable limb; he will probably improve with time which would thus result in avoiding surgery.

Obviously if the limb deteriorates then bypass is indicated.

The extent of dysfunction depends on the level of injury of the facial nerve.

If injury is proximal to geniculate ganglion, for examplein the internal auditory meatus, taste is lost in the anterior two thirds of the tongue. Also secretion from submandibular, sublingual and lacrimal glands is impaired.

Hyperacusis is due to paralysis of stapedius. The orbicularis oculi is affected, causing inability to blink or close eyelids.

Sensation over the face is supplied by the trigeminal nerve, and sweat glands are controlled by the sympathetic nervous system (e.g. anhydrosis in Horner's syndrome).

The ECG changes of hypomagnesaemia are almost the same as those of hypokalaemia:

Flattening of T waves ST segment depression Prominent U waves Prolonged PR interval, and Prolonged QT interval

There is a risk of atrial and ventricular ectopics and ventricular arrhythmias. There is an increased risk of digoxin toxicity.

In chronic hypomagnesaemia, there is impaired synthesis and release of parathyroid hormone (PTH), and target organ response to PTH is impaired. This produces secondary hypocalcaemia.

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Hypomagnesaemia may result (like hypokalaemia) from the use of potassium 'wasting' diuretics (loop diuretics and thiazides, for example, furosemide).

The following are all characteristic of biliary atresia:

chalk-coloured stools  dark urine weight loss jaundice, and abdominal distension.

Breast milk jaundice is a benign self limiting condition causing unconjugated hyperbilirubinaemia; biliary atresia causes prolonged obstructive jaundice.

If the isotope passes from the liver into the duodenum the bile ducts would be patent, unlike in biliary atresia.

Osteoporosis and osteomalacia are potential consequences of vitamin D malabsorbtion.

Monoclonal antibodies are used to detect serum antigens associated with specific malignancies. These tumour markers are most useful for monitoring response to therapy and detecting early relapse. With the exception of prostate-specific antigen (PSA), tumour markers do not have sufficient sensitivity or specificity for use in screening.

Cancer antigen (CA) 27.29 most frequently is used to follow response to therapy in patients with metastatic breast cancer.

Carcinoembryonic antigen is used to detect relapse of colorectal cancer, and CA 19-9 may be helpful in establishing the nature of pancreatic masses.

CA 125 is useful for evaluating pelvic masses in postmenopausal women, monitoring response to therapy in women with ovarian cancer, and detecting recurrence of this malignancy.

Alpha-fetoprotein (AFP), a marker for hepatocellular carcinoma, sometimes is used to screen highly selected populations and to assess hepatic masses in patients at particular risk for developing hepatic malignancy.

Testing for the beta subunit of human chorionic gonadotropin (b-hCG) is an integral part of the diagnosis and management of gestational trophoblastic disease.

Combined AFP and b-hCG testing is an essential adjunct in the evaluation and treatment of nonseminomatous germ cell tumours, and in monitoring the response to therapy.

AFP and b-hCG also may be useful in evaluating potential origins of poorly differentiated metastatic cancer.

PSA is used to screen for prostate cancer, detect recurrence of the malignancy, and evaluate specific syndromes of adenocarcinoma of unknown primary.

The central venous pressure (CVP) waveform consists of named waves and descents:

'a wave' is due to atrial contraction 'c wave' is thought to be due to transmitted pulsation from the carotid arteries, or to the

bulging of the tricuspid valve into the right atrium 'v wave' is due to the rise in atrial pressure before tricuspid opening 'x descent' is due to atrial relaxation 'y descent' is due to atrial emptying as blood enters the ventricle.

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In atrial fibrillation no 'a wave' is seen; in tricuspid stenosis the 'a wave' is enlarged, and in tricuspid regurgitation the 'v wave' is enlarged.

Notification of certain infectious diseases is obligatory under the 2010 Health Protection (Notification) Regulations. See the Public Health England website for further details.

Notifiable diseases include:

Food poisoning Haemolytic uraemic syndrome Meningitis Meningococcal septicaemia Rubella Malaria Mumps Measles, and TB.

Chicken pox, gas gangrene, HIV and MRSA are not notifiable diseases. However, the surveillance of Meticillin-resistant Staphylococcus aureus (MRSA) bacteraemia has been mandatory for all NHS acute trusts in England since 2004.

Diabetics often have some element of neuropathy. This means that significant progression of ulceration/infection may not be noticed by the patient. Frequent checks of the ulcers are essential.

Diuretics are only used to treat oedema of general cause (e.g. in congestive cardiac failure). They do not accelerate healing.

Leg ulcers are not necessarily always painful, and there is no evidence to indicate that treatment with antibiotics accelerates healing.

Arterial ulcers should not be treated with compression bandages.

The deltoid muscle is supplied by the axillary nerve, which has a nerve root of C5, C6.

The gastrocnemius is supplied by the tibial nerve, which has a nerve root of S1, S2.

Rectus femoris and the three vastus muscles (intermedius, medialis and lateralis) are all supplied by the femoral nerve, which has a nerve root of L2, L3, L4.

Triceps brachii is supplied by the radial nerve, which has a nerve root of C7

The pituitary gland lies in the pituitary fossa which is located in the sphenoid bone and lies close to the floor of the third ventricle. It can be functionally divided into anterior and posterior lobes.

The anterior lobe secretes the following:

Growth hormone Prolactin Adrenocorticotrophic hormone (ACTH) Thyrotropin Lutenising hormone (LH), and Follicle stimulating hormone (FSH).

The secretion of these hormones is controlled by releasing and inhibitory factors released by the hypothalamus.

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Oxytocin and vasopressin are secreted from the posterior lobe (not anterior) of the pituitary.

Vasopressin (antidiuretic hormone) is a neuropeptide which is synthesised in the cell bodies of the supraoptic and paraventricular nuclei (not in the pituitary). It is then transported down their axons to the posterior lobe of the pituitary gland from which it is secreted.

The hindbrain comprises:

The myelencephalon (medulla oblongata and lower part of the fourth ventricle) The metencephalon (pons, cerebellum and intermediate part of fourth ventricle), and Isthmus rhombencephalon.

The medulla oblongata opens into the fourth ventricle.

The nucleus ambiguous gives rise to fibres of the accessory, vagus and glossopharyngeal nerves.

The locus caeruleus receives sensory fibres from the trigeminal nerve.

The three parts of the cerebellum include the vermis and the two hemispheres which are confluent.

The pyramids (spinothalamic tracts) are medial to the olives.

The median portion of the cerebellum is the vermis and the cerebellar hemispheres lie lateral to it.

Class A-alpha fibres provide motor function and proprioception sensation.

Class A-beta fibres carry touch and pressure sensation.

Class A-gamma fibres provide motor function to muscle spindles.

Class A-delta fibres carry pain, cold and touch sensation.

Myelinated class B nerves are autonomic preganglionic fibres.

Unmyelinated class C nerves are autonomic postganglionic fibres which also carry pain and temperature sensation.

A midline sternotomy gives optimal access to the heart, ascending aorta, aortic arch, arch vessels and both hemidiaphragms. However, median sternotomy affords a limited exposure of both pleural spaces and the anterior hilar structures. Median sternotomy results in the least compromise of pulmonary function in the early post-operative period of any thoracic incision. It also produces less postoperative pain than a thoracotomy.

The clam shell approach is used to gain quick access to the superior mediastinum. The manubrium is divided with bone cutters to the level of the manubrial-sternal joint. The intercostal muscles in the second intercostal space are divided to the mid-axillary line where the rib is divided on each side. This forms the so called 'clam shell' opening. The posterolateral thoracotomy is the most common incision for pulmonary resection. This incision also provides optimal exposure of mediastinal and hilar structures plus the hemidiaphragm on each side. On the right side it provides the best exposure of the tracheal carina.

The female urethra is a narrow membranous canal, about 4 cm long, extending from the internal to the external urethral orifice.

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It is placed behind the symphysis pubis, embedded in the anterior wall of the vagina, and its direction is obliquely downward and forward; it is slightly curved with the concavity directed forward.

Its lining is composed of stratified squamous epithelium, which becomes transitional near the bladder.

The urethra consists of three coats:

Muscular Erectile, and Mucous.

The muscular layer is a continuation of that of the bladder.

Between the superior and inferior fascia of the urogenital diaphragm, the female urethra is surrounded by the sphincter urethrae.

Somatic innervation of the external urethral sphincter is supplied by the pudendal nerve.

The uro-genital sinus may be divided into three component parts. The first of these is the cranial portion which is continuous with the allantois and forms the bladder proper. The pelvic part of the sinus forms the prostatic urethra and epithelium as well as the membranous urethra and bulbo urethral glands in the male and the membranous urethra and part of the vagina in females

Tracheal tubes can either be made of disposable plastic or red rubber which are reusable.

The tube size refers to the internal diameter in mm not the external diameter. The internal diameter (ID) is marked on the outside of the tube (some manufacturers also have the external diameter marked on the outside).

Plastic tubes have a radio-opaque line running along their entire length (rather than the entire tube being radio-opaque), which allows their position to be identified on x rays.

The internal diameter of the tube is marked in millimetres on the outside (not the external diameter).

The bevel located at the end of the tube is usually oval in shape and is left-facing (not right), which improves the view of the vocal cords during intubation.

Oxford tubes are L-shaped and have a bevel that faces posteriorly. They have thick walls which increase the external diameter, making them wider for a given internal diameter (not narrower).

RAE (Ring, Adair and Elwyn) tubes are preformed and can be either north or south facing, cuffed or uncuffed. The cuffed RAE tubes have one Murphy eye, whereas the uncuffed version has two eyes.

Uncuffed tubes are mainly used in paediatric anaesthesia and two Murphy eyes ensure adequate ventilation should the tube be too long.

The British National Formulary states that peripheral neuropathy is the only common side-effect of isoniazid. It is more likely to occur in the presence of pre-existing risk factors such as:

diabetes alcohol dependence chronic renal failure pregnancy malnutrition, and HIV infection.

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Supplementation with pyridoxine, vitamin B6, reduces the risk.

The left gastric artery supplies the distal oesophagus, cardia and body of the stomach (passing along the lesser curvature and anastomosing with the right gastric artery).

The middle colic artery supplies the transverse colon.

The left colic artery supplies the left colon from the splenic flexure to the sigmoid.

The right gastroepiploic artery supplies the greater curve of the stomach from the antrum to the body and anastomoses with the left gastroepiploic artery (a branch of the splenic artery).

Mutations of the p53 gene on chromosome 17p12 are implicated in some inherited and also sporadic forms of breast cancer.

BRCA1 confers a risk of 83% for breast cancer and 63% for ovarian cancer. There is a modest increase in risk for colon and prostate. The BRCA1 gene is on chromosome 17q21.

BCRA2 confers the same risk as BRCA1 for breast cancer in women and is less involved in ovarian cancer. The BRCA2 gene is on chromosome 13q12.

The ataxia telangiectasia (AT) gene on chromosome 11q22 is thought to play an important role in breast cancer, accounting for up to 13% cases in some reports.

In the United Kingdom up to 10% of new cases have an inherited basis which is equivalent to over 1,000 women per year

Patients with deep venous thrombosis (DVT) usually present with physical signs that are unreliable or non-specific, and frequently require investigation to confirm the diagnosis.

Some calf vein thromboses can be asymptomatic.

Risk factors associated with thromboembolic disease (DVT and pulmonary embolism) include hypercoagulable states, such as deficiencies of:

Protein C Protein S Antithrombin III, and Plasminogen.

Other risk factors include:

Malignancy Prolonged immobility The oral contraceptive pill Pregnancy Obesity Previous DVT Varicose veins Polycythaemia Myocardial infarction Cardiac failure, and Connective tissue diseases.

Lumbar (not thoracic) epidurals and spinals have been associated with a reduced incidence of DVT. This has been attributed to the increased blood flow to the lower limbs, reduced venous stasis and reduced blood viscosity (from intravenous fluid loading)

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Laryngoscopes are used to perform direct laryngoscopy and can be classed as curved or straight, according to the shape of the blade.

Straight blade laryngoscopes include the following types:

Miller Soper Wisconsin, and Seward.

They are designed to be advanced over the epiglottis which is then lifted in order to view the larynx.

Straight blades are commonly used for intubating neonates and infants but can just as easily be used in adults.

Curved bladed laryngoscopes (not straight) are designed so that the tip is placed into the vallecula; examples include the:

Macintosh Polio, and McCoy.

The standard Macintosh blade used in adults is the right-sided version. The left-sided blade may be used in patients with facial deformities that make the use of the standard blade difficult.

The Macintosh Polio blade is at an angle of 120 degrees to the handle, and was designed to intubate patients in the iron lung.

The McCoy laryngoscope (1993) is based on the standard Macintosh blade (not Robertshaw's), with a lever operated hinged tip, which can improve the view at laryngoscopy.

Achalasia cardia is a neuromuscular failure of relaxation at the lower end of the oesophagus due to loss of ganglion cells from the myenteric (Auerbach's) plexus. The myenteric plexus contains paraasympathertic and sympathetic fibres. It is the main motor supply (motility) to the gastrointestinal tract. Absence of ganglion cells in the neural plexus of the intestinal wall leads to Hirschsprung's disease. Meissner's plexus contains only sympathetic fibres and is secretomotor to the mucosa.

It is more common in females (3:2) and is frequently seen during the third decade of life.

There is progressive dysphagia to solids and liquids, chest pain and regurgitation of old food from the dilated oesophageal sac.

x Ray reveals a dilated oesophagus with a tapering lower oesophageal segment, likened to a bird's beak, which fails to relax.

There is absence of gastric air bubbles because the dilated oesophagus never completely empties and therefore swallowed air cannot pass into the stomach.

Chest x ray shows air or fluid level behind the heart and the expanded oesophagus gives the appearance of a 'double right heart border'.

The superior laryngeal nerve is a branch of the vagus nerve.

It has two branches:

the smaller external branch, which supplies the cricothyroid muscle (not internal branch)

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the larger internal branch, which provides sensation to the larynx above the level of the vocal cords.

The superior laryngeal nerve can be blocked below and anterior to the greater cornu of the hyoid bone (not lesser cornu), which is where the nerve divides into its two branches.

Cephalosporins (cefuroxime) inhibit bacterial cell wall synthesis. They inhibit the attachment of new peptoglycan to the cell wall. They also inhibit polymerisation.

Penicillins block the terminal cross-linking reaction between alanine and glycine of bacterial cell wall mucopeptide formation.

Acylovir inhibits nucleotide metabolism.

Quinolones (ciprofloxacin) inhibit DNA replication.

Rifampicin inhibits DNA dependent RNA polymerase.

Streptomycin inhibits ribosome function.

Additionally, Erythromycin also inhibits protein synthesis by interrupting ribosomal function.

Vancomycin is a complex glycopeptide active against Gram positive bacteria and inhibits cell wall synthesis.

Sulphonamides block thymidine and purine synthesis by inhibiting microbial folic acid synthesis.

Complications of breast carcinoma can be related to the disease itself but also a consequence of the treatment employed.

Lymphoedema is not uncommon and may represent impaired lymph drainage related to the surgery itself or carcinomatous impairment of lymph drainage.

Hypercalcaemia may arise as a consequence of bony infiltration or from the release of ectopic PTHrp. Symptoms include:

thirst bone pains polyuria abdominal pains constipation, and depression.

Advanced carcinomatous deposits may occur in the vertbrae or spinal cord and present with an advancing paraparesis. Signs would include:

extensor planatar responses weakness increased tone, and exaggerated reflexes.

A sensory level may also be found.

Leukaemias are the commonest cancers in childhood, followed by brain tumours and lymphomas. Neuroblastoma and Wilms' tumour are equal fourth commonest.

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Wilms' tumour accounts for most childhood renal neoplasms, and it is associated with congenital abnormalities such as:

Genitourinary abnormalities (4%) Hemihypertrophy (3%) Sporadic aniridia (1%).

Deletions on chromosome 11 account for 33% of cases (bilateral cases occur in 10%).

There are three associated syndromes with Wilms' tumour:

WAGR syndrome (Wilms' tumour, aniridia, genitourinary malformations, mental retardation) Denys-Drash syndrome (Wilms' tumour, nephropathy, genital abnormalities) Beckwith-Wiedemann syndrome.

Prognosis is usually excellent, with stage 1 disease having a 97% survival, stage 2 disease a 92% survival and stage 3 disease an 87% survival. Stage 4 disease has a 73% survival rate

The patient has achalasia, which is a functional obstruction at the lower oesophageal sphincter caused by a failure of relaxation combined with a failure of oesophageal body peristalsis leading to oesophageal dilatation (megaoesophagus).

Barium swallow demonstrates a characteristic dilated oesophagus and "rats tail" or "bird beak" appearance distally. Monometric findings are diagnostic.

Current American College of Gastroenterology Guidelines (2013) recommend balloon dilatation or surgical myotomy as initial therapy in fit patients. Bouginage is not effective in achalasia. Botulinum therapy is recommended as second line or in patients unfit for endoscopic dilatation or surgery. Pharmacological therapy is reserved those unfit or unwilling for more definitive therapy or failed botulinum therapy. Per oral endoscopic myotomy is currently an experimental technique gaining in popularity.

Decalcification of cartilage is a feature of pseudogout/calcium pyrophosphate arthropathy

Pancreatic calcification is a feature of chronic pancreatitis.

Radio-opaque calcific stones, as opposed to Radio-lucent renal calculi, are a feature of hyperparathyroidism.

A short fourth metacarpal is a feature of pseudohypoparathyroidism.

There is an increased incidence in males compared to females (13:10).

Rectal cancers often present with rectal bleeding, caecal cancers present with obstructive symptoms or a mass, classically on the acute take with small bowel obstruction and anaemia.

Patients with familial adenopolyposis coli carry a genetic mutation (chromosome 5q21) which is inherited in autosomal dominant fashion and will develop adenocarcinoma of the colon.

It is associated with ulcerative colitis and Crohn's.

Lung is the most common cause of cancer related death in men, with prostate cancer the second most common cause and bowel cancer the third most common cause in men. However, bowel cancer is the second most common cause of deaths from cancer for combined males/female.

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Intravenous contrast agents increase the diagnostic yield of plain radiography and can be used to delineate the kidneys, ureters and bladder and also blood vessels in angiography.

Modern non-ionic contrast agents have a reduced incidence of side effects.

Side effects have an overall incidence of 5% and include:

Nausea Vomiting Hives Rash Flushing Renal impairment Cardiopulmonary, and Anaphylactic reactions.

The last two can occur with little or no warning and can be fatal.

The use of intravenous contrast agents carries a mortality risk of 1 per 100000 injections.

Patients with asthma are given prophylactic corticosteroids prior to the use of these agents.

The use of contrast agents in patients taking metformin carries a risk of lactic acidosis and should be stopped prior to the use of these agents and should not be restarted until the renal function has returned to normal.

Thoracic outlet syndrome - the mass in the neck represents a cervical rib. The subclavian artery can be compressed between the clavicle and either a cervical rib or band or scalenus anterior. Symptoms range from asymptomatic through to incapacitating ischaemia. A chest radiograph should be performed to identify any cervical ribs and a duplex scan should be performed at rest and in the Roos position/test. (aka elevated stress test - slow repetitive finger clenching in the 'surrender' position, that is, replicates the symptoms in less than three minutes)

Embolic. The most likely diagnosis is embolic as he is likely to have developed a mural thrombus following his recent MI. The diagnosis is confirmed by an arterial duplex of the arm and an echocardiogram. If he has signs of acute ischaemia, he will require an embolectomy or thrombolysis.

Nearly all cases of mitral stenosis are the result of rheumatic fever. The infection follows a throat infection with beta-haemolytic Streptococci whose antigen cross reacts with various tissues of the body. The mitral valve is the most common and most severely affected. Clinically atrial fibrillation is common, the diastolic murmur is the result of turbulence as the left ventricle fills through the stenosed valve. The natural history is of steady deterioration.

In aortic stenosis effort syncope is thought to arise from cardiac reflexes stimulated when the heart becomes overloaded. The murmur is best heard over the aortic area and radiates well to the carotid arteries. The majority of stenoses are degenerative, occurring on previously bicuspid valves with presentation in the later years of life. Some are congenital and may present at any age. Those secondary to rheumatic fever often also have mitral valve involvement and present in middle age.

Tricuspid regurgitation is relatively common and is usually secondary to heart failure, it occurs when the right ventricle enlarges sufficiently to stretch the valve ring. The murmur is usually indistinguishable from mitral regurgitation. The condition may resolve with treatment of the heart failure but usually requires an annuloplasty.

Nodular melanoma is the most malignant type. These may occur over any part of the body. These are palpable, deeply pigmented, and usually convex in shape; they may bleed or ulcerate. It is sharply delineated from the surrounding skin. It has a poor prognosis with early lymphatic involvement.

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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.

Amelanotic melanoma is non-pigmented and acral-lentiginous melanoma is common in the extremities, palm and sole. Acral lentiginous melanoma is mostly seen in Japanese and in dark skinned races. As in nodular melanomas, their prognosis is poor

Keratoacanthoma is the 'self-healing' squamous cell carcinoma. It is seen mostly on sun-exposed sites. It is usually solitary but may be multiple. It presents as a fleshy, elevated and nodular lesion with a central hyperkeratotic core.

The most significant histologic feature is its rapid growth. The short history and rapid increase in size suggest keratoacanthoma rather than squamous cell carcinoma.

A parietal lobe tumour is associated with disturbed sensation, including localisation of touch and disturbed two point discrimination. The typical associated visual field defect is a lower homonymous quadrantanopia, and it affects the upper fibres of the optic radiation. This is the classical lesion, and tumours of the temporal lobe tend to produce superior homomomous quadrantanopia. However, very large tumours can produce homonymous hemianopia.

Bilateral occipital infarction results in cortical blindness, where the brain is unable to process the light signals it receives from the retina and optic nerves.

A central retinal artery occlusion would typically result in sudden uniocular blindness. Causes of central retinal artery occlusion include emboli (e.g. in carotid stenosis, AF) and giant cell arteritis

At the upper border of the atlas, the spinal cord is directly continuous with the medulla oblongata. Inferiorly, the cord usually extends as far as the first lumbar intervertebral disc where it terminates as the conus medullaris.

The pia mater is a highly vascular layer which closely invests the spinal cord and nerves, and surrounds the termination of the spinal cord (conus medullaris) and continues as the filum terminale as far as the posterior surface of the coccyx.

The arachnoid membrane is continuous with the cranial arachnoid through the foramen magnum and below, it ends at the level of the second sacral vertebra.

The spinal nerves are attached to the spinal cord by anterior and posterior nerve roots. The region of the spinal cord to which one pair of anterior and posterior nerve root attaches is called a spinal segment.

The spinal cord receives its arterial supply from the anterior and posterior spinal arteries which arise from the vertebral arteries and are reinforced by branches of deep cervical, intercostal and lumbar arteries.

Sensitivity relates to the probability that the person with a disease will be correctly identified with the disease. Therefore, in this study, 50 subjects have the disease, of whom 40 are correctly identified with the disease giving a sensitivity of 80%.

The specificity is the probability that a person without the disease will be correctly identified by the test. In this case, there are 900 subjects without the disease of whom 840 were identified by the test - giving a specificity of 93%.

This is perhaps best illustrated by annotating the table used in the question:

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Test positive Test negativeBiopsy positive 40 (True Positives) 10 (False Negatives)Biopsy negative 60 (False Positives) 840 (True Negatives)

Sensitivity = True Positives / (True Positives + False Negatives) = 40/(40+10) = 80%

Specificity = True Negatives / (True Negatives + False Positives) = 840/(840+60) = 93%

Venous ulcers usually lie proximal to the medial or lateral malleolus, though they may extend to the ankle or dorsum of the foot. They are frequently secondary to venous incompetence as a result of varicose veins or deep venous thrombosis. Lipodermatosclerosis sometimes accompanies venous ulcers.

Neuropathic ulcers can result from peripheral sensory neuropathy secondary to alcohol abuse. These ulcers are due to altered sensory neuropathy (diabetic neuritis, spina bifida, tabes dorsalis, leprosy).

Neuropathic ulcers usually develop at the sites of trauma (pressure) such as toes and heels. ABPIs in diabetic patients may be falsely high due to the rigid vessel walls. Therefore, in diabetic patients it is important to assess peripheral sensory neuropathy which may be a cause for the ulceration.

Sickle cell disease is hereditary haemolytic anaemia occurring mainly among those of African (Afro-Caribbean) origin. The haemoglobin S molecule crystallises during reduced blood oxygen tension causing vascular occlusion. Depending on the affected vessel, patients may have bone or joint pain, priapism, neurological abnormalities, skin ulcers.

The presentation of sudden onset of severe headache associated with nausea and/or vomiting is typical of a subarachnoid haemorrhage.

Computed tomography (CT) scan of the head should be performed in all suspected patients and has a sensitivity of 90-95%. There are no advantages to performing an MR scan brain if the CT scan is negative.

A lumbar puncture is performed in negative CT scan patients with specific identification of xanthochromia. If xanthochromia is detected, as in this patient, a CT cerebral angiogram (CTA) should be arranged urgently. A CT angiogram is easier to arrange, requires less expertise to perform (important out of hours) and is safer than catheter-based digital subtraction angiography (DSA) cerebral angiography. It is also more practical for unstable patients. Catheter-based DSA remains the gold standard but helical CTA is approaching this level of accuracy.

Magnetic resonance (MR) angiography is less sensitive.

There is no evidence of infection in this patient and, therefore commencement of antibiotics is not required.

With a GCS of 12, the patient should be able to maintain their own airway. Intubation may be necessary once the GCS falls below 8.

The presentation of sudden onset of severe headache associated with nausea and/or vomiting is typical of a subarachnoid haemorrhage.

Computed tomography (CT) scan of the head should be performed in all suspected patients and has a sensitivity of 90-95%. There are no advantages to performing an MR scan brain if the CT scan is negative.

A lumbar puncture is performed in negative CT scan patients with specific identification of xanthochromia. If xanthochromia is detected, as in this patient, a CT cerebral angiogram (CTA) should

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be arranged urgently. A CT angiogram is easier to arrange, requires less expertise to perform (important out of hours) and is safer than catheter-based digital subtraction angiography (DSA) cerebral angiography. It is also more practical for unstable patients. Catheter-based DSA remains the gold standard but helical CTA is approaching this level of accuracy.

Magnetic resonance (MR) angiography is less sensitive.

There is no evidence of infection in this patient and, therefore commencement of antibiotics is not required.

With a GCS of 12, the patient should be able to maintain their own airway. Intubation may be necessary once the GCS falls below 8.

Classically gout is associated with erythema, inflammation and marked pain of the big toe, but it can affect any joint and it is usually mono/oligoarticular. The disorder is due to urate crystal deposition, and the differential here would rest between septic arthritis. Aspiration of the joint may be expected to reveal negatively birefringent urate crystals. Serum urate concentrations may be unhelpful, as these may fall in an acute attack. Rheumatoid arthritis would not be expected to present like this, as the condition is usually a symmetrical deforming arthropathy of smaller joints.

In CN III palsy the affected eye will deviate down and out with a dilated pupil often unreactive to light and accommodation. Complete or partial ptosis may also be present.

Lesions in the cerebellopontine angle are often caused by an acoustic neuroma. The frontalis is spared in all upper motor neurone lesions involving cranial nerve VII, not in this case.

A positive Rinne's test is when air conduction is better than bone conduction, a normal result. A negative Rinne's test indicates the presence of conductive deafness.

Parietal lesions cause lower quadratic hemianopia whilst temporal lesions cause upper quadrantic hemianopia.

The facial nerve supplies the anterior 2/3rds of the tongue.

H-type fistulae are an uncommon variant of the tracheo-oesophageal fistulae and have an associated mortality of 10-20%.

Disruption to division of the embryonic trachea and oesophagus occurs in the fourth week of fetal life.

Vertebral, renal, tracheal, anal and limb abnormalities are associated. The condition has a high mortality rate.

Persistent abnormalities in the distal oesophagus at the site of repair occurs (for example, strictures).

Dilatation may be required.

Irregular hepatomegaly may be found in:

Late alcoholic hepatitis with underlying cirrhosis Malignancy Carcinoid Tertiary syphilis, and Actinomycosis.

Amoebic abscess would also cause irregular liver edge.

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Smooth hepatomegaly is usually found in congestive cardiac failure, sarcoid affecting the liver.

Hepatomegaly is usually present in Budd-Chiari syndrome (portal vein thrombosis) but is smooth and tender. Ascites is also present.

Appropriate prophylactic antibacterials for a relatively clean procedure such as arterial surgery includes second or third generation cephalosporins or co-amoxiclav as the drugs of choice.

Bacteriostatic agents such as erythromycin are inappropriate.

Flucloxacillin would not have a broad enough spectrum of activity to be considered appropriate.

Metronidazole would be effective in cases where anaerobic agents would be considered problematic and would be used adjunctively in diabetic wounds, etc.

Vancomycin would be an appropriate agent in those at suspected high risk of methicillin-resistant Staphylococcus aureus (MRSA) or in units where MRSA is a problem.

There is no standard regimen but co-amoxiclav appears to be the most common antibiotic used. Some local formularies add metronidazole because of the risk of faecal/anaerobic contamination in the groin.

For those with penicillin allergy a single dose each of gentamicin and teicoplanin may be recommended +/- metronidazole. The important part is ensuring the antibiotic chosen has been given before the skin is incised.

Penicillin resistance due to the production of penicillinase is a common problem particularly in Escherichia coli, Staphylococcus aureus and Enterobacter which are mostly insensitive.

N. meningitidis is generally sensitive and less than 20% resistance is found in Pseudomonas and H. influenzae species.

However, the incidence continues to rise.

Thoracic aortic dissections are classified according to either the DeBakey or the Stanford classifications. DeBakey has three types:

1. Type 1 involves the ascending and descending aorta;2. Type 2 is limited to the ascending aorta;3. Type 3 is limited to the descending aorta with a tear distal to the origin of the left subclavian

artery.

Stanford type A incorporates the DeBakey types 1 and 2, and Stanford type B is similar to the DeBakey type 3.

Ascending aortic dissections require immediate surgical repair.

Descending aortic dissections should initially be managed by induced hypotension and beta adrenoreceptor blockade. Systemic arterial pressure measurement should be via a cannula inserted into the right radial artery, as the left subclavian artery may be involved in the dissection or clamped at surgery.

A severe metabolic acidosis (not alkalosis), may develop during aortic cross clamping, which may require bicarbonate administration.

Known precipitants of gout include:

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Low dose aspirin Thiazides Allopurinol B blockers, and ACE inhibitors.

Therefore these should not be given during acute attacks.

Corticosteroids are like high dose aspirin or non-steroidal anti-inflammatory drugs (NSAIDs) and are treatments for acute gout

Staphylococcus epidermidis is part of the normal skin flora. On microscopy there are Gram-positive cocci, arranged in grape-like clusters and white, raised, cohesive colonies are formed. It is distinguished from S. aureus, also found on skin, which has large, round, golden-yellow colonies.

S. epidermidis is usually insensitive to antibiotics, including penicillin, amoxicillin, and methicillin.

Although it is often a contaminant in blood cultures it is associated with line infections. Central venous catheters are an especially likely site of infection even in the absence of overt exit site sepsis.

They should not be ignored but interpreted in the clinical context, and usually the blood cultures should be repeated.

In patients with central lines, blood cultures should be taken both peripherally and from the central line as semi-quantitative microbiological techniques are available that may point to the central line as the principal site of infection.

The P wave represents depolarisation of the atria, the QRS complexes depolarisation of the ventricles and the T wave repolarisation.

The Q wave is typically down going in V6.

In AVR the p wave, QRS complex and T waves are predominantly negative.

An initial upstroke may suggest left bundle branch block.

Elevation of the ST segment may be pathogenic due to ischaemia/infarction or ventricular disease.

This patient has impotence associated with a probable neuropathy, and the most appropriate and satisfying initial treatment would be sildenafil.

If this were to fail, then a vacuum device could be offered, but this is not often acceptable for the patient. Therefore intracavernosal injections could be tried, and they can be successful in approximately 80% of patients.

Impotence is a common disorder, with approximately 50% of males over the age of 50 suffering impotence at any time. Causes range from psychological to neurological and hormonal. In the majority of cases, impotence is psychological, and it can be improved by addressing the fundamental issues that may be problematic in relations or relating to the sex itself.

In those that are not psychological, drug therapy is often contributory and removing/altering the medication may assist.

The first line medical treatment for impotence, is an oral prostaglandin inhibitor, such as sildenafTil (Viagra).

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The lymphatic drainage of the thumb and index finger (indeed the lateral part of the hand) follow the cephalic vein and drain into the infraclavicular group of nodes.

The tendon of flexor digitorum profundus (FDP) inserts into the base of the distal phalanx (the tendon of flexor digitorum superficialis (FDS) splits around FDP, and inserts into the base of the middle phalanx), contraction of which, causes flexion of the distal interphalangeal (DIP) joint.

Tenderness in the anatomical snuffbox is classically a sign of a fractured scaphoid.

The capitate is the first carpal bone to ossify in the first year of life (strictly speaking the carpus is cartilaginous at birth). The remainder of the carpal bones ossify at various intervals up until the age of 12 years, when all bones are ossified.

A median nerve lesion would result in wasting of the thenar eminence, but not of the hypothenar eminence .

The hypoglossal nerve crosses the external carotid artery just above its bifurcation. Damage to this nerve results in loss of normal motor functions of the tongue (on protrusion, the tongue is pulled towards the affected side). During a carotid endarterectomy, the hypoglossal is the most commonly injured cranial nerve.

The external laryngeal nerve runs close to the superior thyroid artery and supplies the cricothyroid muscle. Damage to this nerve causes loss of phonation over prolonged periods of time.

The ansa cervicalis lies within the carotid sheath and supplies the infrahyoid strap muscles, can be divided with impunity, and frequently is routinely.

The pharyngeal branch of the vagus nerve is at risk of injury at a higher level and paralysis of this nerve causes difficulty in swallowing.

The marginal mandibular branch of the facial nerve can be damaged by retraction during the procedure but usually recovers in six months.

The left phrenic nerve passes inferiorly down the neck to the lateral border of scalenus anterior.

It passes medially across the border of scalenus anterior, parallel to the internal jugular vein which lies inferomedially. At this point it is deep to the prevertebral fascia, the transverse cervical artery and the suprascapular artery.

It descends between the left subclavian and the left common carotid arteries, and crosses the left surface of the arch of the aorta. It then courses along the pericardium, superficial to the left auricle and left ventricle, piercing the diaphragm just to the left of the pericardium.

It carries sensory fibres from the pleura, pericardium and a small part of the peritoneum.

EPO is released in response to hypoxia (not hypercapnia) and anaemia. It is mostly synthesised in the kidney, hence EPO requirement in renal failure, although the liver may contribute up to 20% of EPO production.

It specifically stimulates red blood cell (RBC) production, and it is less effective in iron deficient states.

Side effects of EPO treatment include increased blood pressure.

In 0.5-1% of individuals, the costal elements of the seventh cervical vertebra form projections called cervical ribs.

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Commonly they have a head, neck, and tubercle, with varying amounts of body. They extend into the posterior triangle of the neck where they may be free anteriorly, or be attached to the first rib and/or sternum.

Usually these ribs cause no symptoms, and are diagnosed after incidental finding on CXR. In some cases, the subclavian artery and the lower trunk of the brachial plexus are kinked where they pass over the cervical rib. Compression of these structures between this extra rib and the anterior scalene muscle may produce symptoms of nerve and arterial compression, producing the "neurovascular compression syndrome".

Often the tingling, numbness, and impaired circulation to the upper limb do not appear until the age of puberty when the neck elongates and the shoulders tend to droop slightly

Coeliac disease Dermatitis herpetiformis Zollinger-Ellison syndrome Giardiasis Tropical sprue Hypogammaglobulinaemia, and Partially treated Crohn's disease.

Delcò et al.1 write: "In 1962, Shiner and Drury reported partial and subtotal villous atrophy in 6 out of 11 patients with Crohn's disease. By contrast, Milewski et al could not find any villous atrophy in a group of 41 patients with regional enteritis. Subsequently, multiple case reports described the coexistence of celiac sprue with inflammatory bowel diseases, but none of these studies was able to provide statistical evidence for this association."

In the past diarrhoea was common following intentional vagotomy for peptic ulcer disease. With the introduction of proton-pump inhibitors this surgery is now rarely performed. Most post-vagotomy diarrhoea results from iatrogenic injury to the vagus during surgery on the stomach or the oesophagus.

The diarrhoea typically fades away over the first few post-operative months and is generally non-capacitating.

Spurious (overflow) diarrhoea is a trickling down of liquid faeces through channels in an impacted solid collection in the rectum. The condition is more common in the elderly and in bedridden patients. Unless the condition responds to conservative measures, manual evacuation under anaesthetic is usually required.

The anticoagulant effects of warfarin may be exacerbated through the inhibition of its metabolism by cytochrome P450.

Omeprazole, metronidazole, cimetidine and amiodarone may all do this and so INR should be carefully monitored.

However, rifampicin induces P450 and so would reduce the anticoagulant effects of warfarin (as may other inducers of P450 such as some anticonvulsants).

Oestrogen may reduce the anticoagulant effect independently of P450.

Coeliac disease leads to an increased risk of both adenocarcinoma and lymphoma of the small bowel, which return to baseline with diet.

Longstanding disease may lead to other complications such as ulcerative jejunitis and stricturing. The changes in the bowel make it less able to absorb nutrients, minerals and the fat-soluble vitamins A, D, E, and K.

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Coeliac disease has been linked to:

Dermatitis herpetiformis Epilepsy Ataxia Myelopathy Peripheral neuropathy Malnutrition Hyposplenism Diabetes mellitus type 1 Autoimmune thyroiditis, and Primary biliary cirrhosis.

This is clinically a T1 N0 (Stage I) tumour. Two randomised controlled trial have shown no difference in survival between wide local excision with local adjuvant radiotherapy and mastectomy after 20 years of follow up.

Wide local excision with sentinel node biopsy is the most appropriate initial management. Subsequent treatment will depend on the result of the sentinel node examination (intraoperative touch prep cytology) and the histology of the primary tumour.

Modified radical mastectomy with axillary dissection or radiotherapy is not appropriate for a tumour that may well remain T1 N0 (stage I) after surgery.

Wide local excision alone is inadequate. It is essential to stage the axilla as only 70% of involved nodes are detectable on clinical examination.

Further therapy to the axilla is not indicated if the sentinal node is negative but axillary clearance or radiotherapy will be required if there is nodal disease

Osteomyelitis is usually due to Staphylococcus aureus infection.

Streptococcus pyogenes, Haemophilis influenzae and Gram negative organisms can also infect bone, causing osteomyelitis.

In children, the infection is usually acquired by haematogenous spread to the metaphysis of long bones.

The dead bone within the medullary canal is the sequestrum.

New subperiosteal bone formation is the involucrum.

Somatisation in children consists of the persistent experience and complaints of somatic distress that cannot be fully explained by a medical diagnosis. Somatisation often occurs in response to psychosocial stress and generally persists even after the acute stressor has resolved, resulting in the child and family believing that the correct medical diagnosis has not yet been found. In this case, the death of the mother may be the precipitating factor.

All the following criteria are required for a diagnosis:

four different pain sites (for example, head, abdomen, back, joints, extremities, chest, rectum) or functions (for example, menstruation, sexual intercourse, urination)

two gastrointestinal symptoms other than pain (for example, nausea, bloating, vomiting not caused by diarrhoea, or intolerance of several different foods)

one sexual or reproductive symptom other than pain, and

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one pseudoneurological symptom (for example, impaired balance, paralysis, aphonia, urinary retention).

Abdominal migraine is also known as cyclical vomiting syndrome, and is most frequent in adolescents. Patients have violent and sometimes prolonged episodes of vomiting. Attacks may be precipitated by stress, intercurrent infections, or menses. Almost 78% have prodromal symptoms including nausea, headache, fever, emotional withdrawal, lethargy, sleep pattern changes, and crying.

Lung abscess may follow suppurative pneumonia if accompanied by bronchial obstruction. Bronchoscopy is essential to exclude bronchial obstruction by benign or malignant conditions, bacteriology may also be obtained. Percutaneous catheter drainage is required if the patient is toxic. Pulmonary resection is required if conservative therapy fails.

Bronchiectasis results from destruction of the normal bronchial architecture. The damage is usually initiated in childhood when severe infections are exacerbated by bronchial obstructions. With chronic infection there is progressive bronchial dilatation and thickening (seen as tramlines on chest radiograph) and mucus gland hyperplasia. Pulmonary resection is only indicated if bronchiectasis is localised and unilateral.

The "Bundle of His" consists of three fascicles:

1. The right bundle branch2. The anterior fascicle of the left bundle branch, and3. The posterior fascicle of the left bundle branch.

Bifascicular block describes the combination of right bundle branch and either left anterior or left posterior hemiblock. Left anterior hemiblock causes left axis deviation, and left posterior hemiblock causes right axis deviation.

A-V conduction is maintained by the remaining functional fascicle. Impaired conduction in the latter may be manifest by a prolonged P-R interval.

Bifascicular block may progress to trifascicular block, and may be an indication for the insertion of a permanent cardiac pacemaker.

Right bundle branch block (RBBB) in isolation, is a normal ECG variant. The delayed right ventricular depolarisation results in a second positive wave in the right ventricular leads, and a second negative wave in the left ventricular leads.

Diagnostic features include:

Widened QRS complex, ad Second positive wave in V1.

Other features include:

Deep slurred S waves in leads I, aVL, V4-6

S-T segment, and T wave changes in leads V1-3.

Left bundle branch block (LBBB) is always pathological. In the presence of LBBB, the diagnosis of ventricular hypertrophy, myocardial ischaemia/ infarction, and abnormalities of the P wave, QRS complex or S-T segment cannot be made using conventional ECG criteria.

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