MRCS NOTES (1) Brachial plexus: (1) Roots --> b/w Scalenous Anterior and Medius (2) Trunks --> Posterior triangle of neck (3) Divisions --> behind clavicle (4) Cords --> In Axilla ( related to 2nd part of axillary artery)

(2) Phrenic nerve descends on anterior aspect of scalenous anterior and is in the posterior triangle of neck throughout its course in the neck.

(3) Deep branch of ulnar nerve supplies interossei and adductor pollicis (froments sign when this is damaged) (1) Superficial branch supplies plamaris brevis. (2) Middle finger has no palmar interossei.

(4) Recurrent branch of median nerve is purely motor and supplies the thenar eminence.

(5) Ulnar nerve is medial to ulnar artery and they both pass through the canal of Guyon canal at the wrist.

(6) Ganzer muscle is an abberation of flexor pollicis longus and may affect the anterior interoseeus nerve.

(7) Extensor Indicis is medial to extensor to extensor digitorum

(8) Right coronary artery originates from the anterior sinus, left coronary artery originates from the left posterior sinus.

(9) Coronary sinus tributaries are great cardiac vein(running in anterior interventricular groove), middle cardiac vein(running in posterior IV groove), and small cardiac vein(along the marginal artery). (1) Venea corda minimie/smallest cardiac veins/thebasian veins drain directly into the heart. (2) A left SVC drains into the coronary sinus.

(10)Right coronary artery supplies SA node in 60% of cases and AV node in 80% of cases. RCA arises from anterior aortic sinus and LCA from left posterior aortic sinus.

(11)Heart valves are made up of extracellular matrix rich is dense collagen, elastin and prostaglandins, along with valve interstitial cells.

(12)Porcine heart valves have the benefit of avoiding anticoagulation but have to be replaced after 10 years because they get stenosed due to calcifications.

(13)Oblique cardiac recess is between pulmonary veins( LA and pericardium) (1) Transverse is between pulmonary trunk and aorta anteriorly, and SVC and left atrium posteriorly.

(14)Great cerebral vein is formed by the union of 2 internal cerebral veins, and joins the inferior saggital sinus to form the straight sinus.

(15)Pia mater forms the choroid plexus with astrocytes.

1 of 19 (16) Dorsal rami of C1, L4 and L5 have no cutaneous branches.

(17) Diplopia walking downward and unable to abduct is trochlear nerve injury.

(18)Danger area of face is drained by (1) anterior facial and ophthalmic veins (2) Pterygoid venous plexus

(19)Opening of ampulla of Vater in on posteromedial aspect of 2nd part of (major duodenal paiila), use monopolar cutting for sphincterotomy. (1) Use monopolar blend for polypectomy

(20)Ischial spine: (1) Anatomical landmark for puedendal nerve block, used for episiotomy. (2) At the level of vesico-ureteric junction(for Xray detection of stones) (3) marks the pelvic outlet. (4) Level of levator ani

(21) lympahtics drain to superficial inguinal nodes below the denate line and internal illiac nodes above the dentate line.

(22) Distal articulation of cuboid and hamate are 4th and 5th metatarsal/metacarpal. Capitate is the largest carpal bone and articulates with 2nd,3rd and 4th metacarpals. (1) Scaphoid and lunate artiulate with radius. (2) Capitate is related to profundus tendon

(23)Axillary nerve supplies deltoid and teres MINOR. (1) teres major is supplied by lower subscapular nerve and thoracodorsal nerve aka middle subscapular nerve.

(24)Nerve injury at hip surgery (1) Posterior approach ---> Sciatic nerve (2) Postolateral approach ---> Superior gluteal nerve

(25)Meralgia parasthetica is burning pain on anterolateral part of proximal thigh due to damage of lateral cutaneous nerve of thigh under the lateral aspect of inguinal ligament. (1) LCN of thigh and psoas major are both L2, L3. (2) Femoral nerve supplies illiacus and lies on it.

(26) In carotid endarterectomy: (1) Hypoglossal nerve can be damaged (2) Facial vein is divided

(27)Cervical vertebrae: (1) bifid spinous process, small body (2) C7 is known as vertebrae prominens because it has a long spine (3) foramen transversum is present in upper 6 vertebrae for transmission of vertebral artery

2 of 19 (28)Thyroid horomones decrease oxidative phosphorylation by increasing uncoupling proteins so that increase heat production takes place, so thyroid horomones increase in responce to cold and decrease in responce to heat. (1) If used alone for preop, iodine can intensify thyrotoxicosis. (2) PTU increases vascularity of thyroid gland.

(29)Pregnancy and other growth states are risk factor for folic acid deficiency.

(30)Hassal corpuscles are found in the thymus, which is derived from 3rd parangeal pouch, along with inferior thyroid.

(31)Most common cause of ARDS is sepsis.

(32)Hepatomegaly in Kwashiorkor patients is due to fatty infiltrates.

(33)Morton neuroma: (1) aka intermetatarsal neuroma, betweeen metatarsals causes constant pain in foot. the interdigital nerve transverses inferior to the intermetatarsal ligament. It may be compressed or stretched by repetitive toe flexion and extension. This causes reactive overgrowth of connective tissue and arterial sclerosis. This leads to nerve ischemia and atrophy. Pain is due to nerves getting caught up in the scar tissue. (2) Feels like walking on a marble (3) Treatment involves getting a soft sole, NSAIDS, Sclerosing/Steroid Injections. (4) Stress/March fracture is fracture of 2nd metatarsal(longest and thinest) head due to repeated trauma. (5) Freiberg disease is anterior metatarsalagia of 2nd metatarsal in pubertal growth.

(34)Pilon fracture is a fracture of tibia and fibula at the lower aspect, its fixation is done by a external fixator known as delta frame. (1) Delta frame has a transcalcaneal pin and a tibial pin (2) Once soft tissue injury is resolved 2-3 weeks and ORIF is done with plates and screws.

(35) of RA: (1) Hallmark is perivascular mononuclear infiltrates in the synvoium (2) A pannus contains inflammatory cells, granulomatous tisse and fibroblasts. (3) A rheumatoid nodule contain necrobiotic granulomatous inflammation.

(36)Claudication: (1) Thigh claudication : Illiac vessels, if buttocks are involved then common illiac(leiriche syndrome) (2) Calf claudication : due to atheroma in superficial femoral artery at the level of the adductor hiatus. (3) Ankle claudication : Popliteal artery

(37)Doppler: (1) Frequency observed after reflection of ultrasound waves varies on the approach of the fluid. Higher frequency of approaching fluid and lesser frequency of leaving fluid. (2) A normal artery has a triphasic waveform (3) Mild stenosis : Increase in velocity and a biphasic waveform (4) Tight stenosis : Even more increase in velocity and a monophasic waveform (5) Distal to stenosis : decreased velocity and a monophasic signal.

(38)Enhanced Recovery Protocol aka ERAS:

3 of 19 (1) Perioperative counselling (2) Optimization of nutrition ( Carbohydrate loading 2h before surgery) (3) Standarised analgesia and anasthetic regimens (4) Early mobilisation

(39) Recommendations: (1) No bowel preparation for GI surgery except surgery of (2) Fleet anema may also be used for left sided anastomosis (3) Avoid elective drains except APR surgery (4) Smoking cessation for 4 weeks and decrease comorbids including obesity (5) Avoid anxiolytics in hip replacement surgery (6) Give antiemetics atleast 2, if risk factors are present (7) Avoid prophylactic NG tubes

(40)Pain of stone in renal pelvis is reffered to T11, T12, L1

(41)Symptoms of testicular torsion plus black spot above testes is likly to be torsion of hyatid of morgagni. It is called the blue dot sign and is seen because the torsion is of hemorrhagic type.

(42)Fat embolism syndrome has neurological symptoms and a rash, onset is usually 12h after insult.

(43)Use isoproterenol or epinephrine for bradycardia in most transplant patients but give low dose as there is increase sensitivity to these sympathetomimetics. (1) Use bipolar diathermy if pacemaker is present

(44)Tail of pancreas is present in lienorenal ligament and may be damaged while ligation of splenic hilum takes place in spleenectomy. This will result in hyperamylasemia. (1) ligation of short gastric vessels in gastrosplenic ligamant may cause direct damage to funus of and a gastrocutaneous fistula.

(45) Thrombocytosis usually occours immediately following spleenectomy as the splenic reserve is mobilised, if more than 1M, aspirin is considered. (1) Other immediate changes include reticuloctosis. (2) Late changes include increase in monocytes and lymphocytes. (3) Blood picture includes Howell jolly bodies, heinz bodies, pappenheimer bodies, poikilocytosis, target cells. (4) Most sensitive scan for hypospleenism is radionucleotide labelled red scan

(46)Descent of testes is anatomically aided by gubernaculum while the horomoes testosterone and CGRP aid in the inguinoscrotal phase. (1) Cryptochidism is used for undescended testes after 3 months of age, a laproscopy is advised to locate testes not found on palpation. (2) Surgical correction is recommended after 6 months.

(47) Parametric data is tested by: Student T test(paired and unpaired) if two variables are being compared. If more than 2 are being compared then ANOVA test is used. (1) Non parametric data is tested by kruskal wallis test if more than 2 variables, otherwise Wilcoxon test for paired data and Mann Whitney test for unpaired data. (2) Post research multiple correctional analysis is done by bonferroni method. (3) Pretest probabilities(PPV and NPV) are dependent on prevalence. (4) Corelation coefficient in parametric data is Pearson, in non parametric spearman. (5) Case control studies are done for rare conditions.

4 of 19 (48) A menisceal cyst usually presents as a slowly growing painful lateral swelling in knee. It can be treated by partial arthoscopic menisectomy.

(49)Femur fracture: (1) If externally rotated : Neck, trochanteric fracture( neck fracture causes pain in groin, trochanteric causes pain in trochancteric area) (2) Adducted hip : Dashboard injury, posterior dislocation of femur, associated with sciatic nerve injury. Should be immediately reduced by closed reduction(within 6 hours) to avoid osteonecrosis. If unsuccessful, or unstable ORIF.

(50)Simmonds thompson test is used to access rupture of Achilles tendon.

(51)Sinus Tarsi is a tunnel between talus and calcaneum laden with CT and receptors for propioception. ST syndrome can cause localised tenderness anterior to lateral malleolus and difficulty walking on uneven surfaces.

(52)Abdominal aneursym are followed by USG surveillance: (1) if 3-3.9cm : every 2-3 years (2) if 4-5.4cm : every 6-12 months (3) Mortality of ruptured aneurysm is 75% overall and 50% in hosptial.

(53)Aspirin and clopidogrel should be stopped 2 weeks before elective surgery, COCPs one month before surgery.

(54)Failure of caudal part of metanephron to develop will result in renal agensis.

(55)Ottawa rules are used to screen patients presenting with ankle injuries for an Xray. (1) Point of tenderness at posterior edge of medial or lateral malleolus (2) inability to bear weight( walk 4 steps) (3) If one is positive, go for Xray

(56)Scores relevant to pre-op: (1) POSSUM(V-POSSUM,O-POSSUM,CR-POSSUM) (2) ACPGBI (3) APACHE (4) St Mark lymph node scoring system (5) Adjuvant online (6) ASA (7) Charles comorbidity index( 1 year mortality)

(57)A major possible complication og Hickmans line is air embolism.

(58)Anxiety increases levels of circulating catecholamines and causes bronchodilation.

(59)On X ray lateral view, cricoid cartilage is the most prominent structure.

(60)Nutritional Support is given to: (1) BMI <18.5 (2) >10% weight loss in 6 months (3) BMI <20 and >5% weight loss

If <14 days, use peripheral line If >30 days, use central line

5 of 19 Continous feeding is recommended in ITU patients. Complications of TPN include decrease phosphate, hypokalemia, increased LFTs, hyperchloremic acidosis. NOT hypocalcemia.

(61) Uncuffed ETT tubes are used in children to reduce the risk of tracheal injury.

(62)Laproscopic approach recommended by RCS is Hassons, Varess approach risk intestinal injury. Insufflation pressure is around 10mm Hg.

(63)Streptococcus bovis cause post colonoscopy sepsis and also associated with colorectal cancer.

(64)Rifampicin is DNA dependent RNA polymerase inhibitor used with vancomycin or dalfopristine/teicoplanin for MRSA non healing ulcers. Mupirocin is used for MRSA nasal colonisers TDS x 5 days. Chlorhexidine is used to skin. OD x 5 Days

(65)Alcoks Canal aka Pudendal canal: (1) Internal puedenal artery ( gives inferior rectal artery, perineal artery, urethral artery and dorsal artery of penis) (2) Internal puedendal vein (3) Pudendal nerve, divides inside the canal( gives inferior rectal nerve, perineal nerve and dorsal nerve of penis)

(66) Post renal transplant, the renal function is suboptimal, which results is hyperkalmeia, metabolic acidosis, hypomagnesemia and tertiary hyperparathyroidism(hypercalcemia and hypophosphatemia). (1) Commenest technical complication of renal transplant is ureteric anastomosis due to poor blood supply.

(67)Most common anatomical variation of portal vein is an absent right portal vein.

(68)After liver transplant from an O group patient, a graft vs host reaction should be anticipated as the liver clears hosts RBCs and causes immune hemolysis, administer O positive blood to this patient and intensify immunosupression.

(69)Weakest part of the orbit is the inferior maxilla, followed by lamina paprycea medially.

(70)Pleomorphic microcalicifcations, branching pattern is likely to be comedo type of DCIS requiring wide local excision with radiotherpay.

(71)Botulinum toxin inhibits presynaptic nerve terminal to decrease the release of Acetylcholine.

(72)Post phlebetic syndrome/Post thrombotic syndrome is pain heaviness, itching swelling and varicose veins after 1 month of DVT. Managed by pentoxylphyline and compression stocking.

(73)Level of illiac crest is L4. LP below or above this level is safe in adults. (1) Termination of spinal cord : L1 (2) Termination of subarachnoid space : S2 (3) Termination of pia matter : Coccyx (4) Denticulate ligaments are extension of pia matter that adhere the spinal cord to the canal.

6 of 19 (74)Functional residual capacity is measured by Helium dilution method and increases with old age, COPD, Upright position. Decreases by use of muscle relaxants as they relax diaphragm.

(75)Outcome audit : It is a type of audit that checks if any event has occoured due to a specific nursing intervention. Assume outcome accurately and demonstrate the quality of care that was provided. (1) Stock issues, mesh expired, out of date, these issues are assessed by systems based audit.

(76)Amyloidosis is extracellular accumulation of amyloid proteins, these are usually AA protein chronic infections but AL in multiple myeloma.

(77)Suprapubic area is supplied by illiohypogastric nerve, T12, L1

(78)Child with infection and rose pink rash around an area of cellulitis is erysipela caused by streptococcus pyogenes.

(79)FFPs are stored in -18 degrees and donot need Rh or ABO compatibility. (1) FFP and platelets(also donot need ABO compatibility) contains citrate anticoagulant and may chelate calcium to cause hypocalcemia (2) Most common complication of FFP is urticaria (3) Use <24h if thawed. (4) Plasma of red cells stored >1 month have 2-10 mmol potassium and cause hyperkalemia. (5) Platelts can cause gram positive infection while PRBCs can cause gram negative infections. (6) Cryoprecipitate is given in massive hemorrhage contains factor 8 and 13, vWF and fibrinogen.

(80)Flail Chest: (1) Always associated with lung contusion, always give analgesia with bupivacine. (2) Chest intubation if hemo or pneumthorax (3) Tidal Volume decrease due to fail segment paradoxical movement (4) ETT if cyanosis or respiratory failure, use IPPV. (5) Local infiltration with bupivacaine decreases FRC and compliance, increases airway resistance and ventilatory dead space, causes basal atelectasis.

(81) Subclavian Steel syndrome can be diagnosed by duplex scanning or angiography. Treatment is insertion of stent

(82)All lesions of the spinal cord below L1 are lower motor neuron lesion with flaccid paralysis, extensor plantar responce, reduced relfexes etc.

(83)Best test for parathyroid adenoma is technicium-sestamibi scan although intraoperative methylene blue is also used. The radioactive sestamibi scan is useless in multinodular goitres and it is taken up by throid. both CT and MRI have poor senstivity 60-70%. (1) Most important pre op scan before sistrunk procedure is isotope uptake scan to see if there is viable thyroid issue apart from the thyroglossal cyst which is to be excised. (2) Hurthle cell tumor is a variant of follicular CA, have prominent oxiphil cells and poor prognosis.

7 of 19 (84) Facet arthropathy: (1) Pain in lower back worsened on twisting or bending forward. (2) Causes include weight lifting jobs and increasing age (3) Diagnosis by intra facet injection causing pain relief (4) Treatment is rest, analgesia, steroids.

(85) Ladd procedure is done for correction of malroation of intestines in which ladds bands, joining the liver and the colon are taken down.

(86)Whiting maneuvre is used in ramstedt pyloromyotomy

(87) Prostate CA with mets should be treated initally by horomal therapy. LHRH may cause acute flare of disease so always give antiandrogens with it. (1) Prostate CA reaches spine via valveless veins of betron. (2) PSA upper limit is (age-20)/10 (3) BRCA 2 mutation is associated with male breast cancer and prostate cancer. (4) Li Frameni cancers are Adrenal, Breast, Brain, Sarcoma, and Leukemia. Also prostate.

(88) Always consider meckels diverticulum in patient with stomach ache and normal gastroscopy and colonoscopy. Especially if he has iron deficiency.

(89)External jugular vein: (1) formed by post branch of retromandicular vein and posterior auricular vein, drains into subclavain vein. (2) Surface landmark : angle of mandible to mid clavicle. (3) If divided near clavicle, will result in air embolism and investing fascia keeps it open.

(90)Bankart lesion predisposes to recurrent anterior dislocation(abduted and laterally rotated) of the shouder joint, it leads to Hill Sachs fracture(posterolateral fracture of head of humerus due to impaction with glenoid labrum). (1) Anterior dislocation : Suclus sign on xray (2) Posterior dislocation : Light bulb sign on xray

(91)Parsonage turner syndrome is a post viral muscle wasting syndrome seen commonly after EBV infection.

(92)Osgood Schlatters disease is caused by microfractures of tibial tuberosity and inflammation of quadriceps tendon in athletic growing adolescents.

(93)Appendicitis: (1) No guarding or tenderness ---> operate on next day list (2) Tenderness but no guarding ---> operate within 6 hours (3) Tenderness plus guarding. ---> operate within 2 hours

(94)If breast CA is grade 3 on histology, or lymph nodes are positive, give chemotherapy and Herceptin.

(95)Prilocaine causes methhaemoglobinemia and its anitdote is methylene blue.

(96)Pyogenic granulomas(redish) and dermatofibromas(bigger than they appear due to dermal extension) commonly appear at site of trauma.

8 of 19 (97)Elderly person with multiple ITCHY irregular pigmented superficial torso lesion is likely to be seborrheic wart. Treatment by shave biopsy and cautery

(98)Exomphalos and diaphragmatic hernia are commonly assoicated with intestinal malrotation. (1) Cryptochidism is associated with hypospadius. (2) Turner syndrome is associated with coarctation of aorta (3) Exomphalos minor<5cm is assoicated with Wilms tumor, Exomphalos Major is associated with TOF. (4) Coarctation of aorta is associated with bicuspid valve (5) small left colon syndrome is associated with Maternal DM.

(99)Microdochectomy is used for solitary intraductal papilloma, Hadfield operation is used for duct ectasia/

(100)Priapsim can be low flow(veno occlusive) or high flow(unregulated arterial flow), low flow more dangerous and can lead to impotence. Treat by cold compress and repeated aspiration.

(101) Serotonin causes vasoconstriction is unhealthy vessels and vasodilation in healthy vessels.

(102) 4 Collateral venous systems exist: (1) azygous (2) long thoracic left (3) long thoracic right (4) internal mammary

(103)Beta blockers and NSAID decrease renin production.

(104)Empyema of GB: (1) Septic patient, high WBC, RUQ tenderness but no jaundice (2) Treatment in elderly is percutaneous GB drainage (3) in young fit patients, do emergency open cholecystectomy. (105)Transtuzumab causes reversible dilated cardiomyopathy, doxorubicin causes irreversible dilated cardiomyopathy.

(106)McMurray test is used to access menisceal tears. Lachman test is anterior drawer test for ACL.

(107)Oblique fissure of lung : medial border of scapula fully abducted Transverse fissure : 4th rib to join the oblique fissure

(108)Rectal prolapse in adults leads to increased chances of CA, but not in children.

(109)Aortopulmonary nodes cannot be biopsied in mediastinoscopy.

(110)Endothoracic fascia is a fascia between inner aspect of chest wall and parietal pleura, it is used as a plane in pleuropneumonectomy.

9 of 19 (111)In Acute pancreatitis: (1) Alcohol induced : use ransom scoe (2) Gallstone induced : use glassgow score (3) Acute pancreatitis can cause sterile pus collection in abdomen (4) frank hemorrhage will cause grey turner sign (5) Psedocyst will be electively excised via gastrocystectomy

PaO2 <60 mmHg Age > 55 Neutophila > 15 Calcium <2 Renal function Urea >16 Enzyme(AST) >200 Albumin <32 Serum glucose <10

Mild=1 Moderate=2 Severe >2

(112)Lundh meal and serum lipase are used to asses exocrine pancreas.

(113)IHodgkin lymphoma: (1) Hallmark is presence of reed sternberg cells, owl eyed nuclei (2) Best prognosis is in lymphcyte rich (3) worse prognosis is lymphcyte depleted (4) Nodular sclerosis has lacunar cells (5) Lymphocyte predominant has popcorn cells

(114)Dehydration is a risk factor for renal stones. (1) All stones are radioopaque except uric acid and xanthine stones. (2) Calcium phosphate are the most radioopaque. (3) Cysteinurea is autosomal recessive condition associated with cysteine stones (4) ureteric stones can be seen at tip of transverse processes L2-L5 (5) Ischial spine represents pelviureteric juntion (6) gonadal artery passes anterior to ureter

(115)Type IV hypertriglyceridemia is Autosomal dominant and causes Acute pancreatitis. TAGs are increased due to increased vLDL production by liver. (1) Type 1 hyperchylomicronemia can also cause acute pancreatitis with xanthomas, occours due to LPL or apo C2 deficiency. (2) Type 2 hypercholesterolemia is due to decreased LDL receptors.

(116) Cryptogenic Fibrosing Alveolitis causes typical restrictive changes, such as normal FEV/ FVC, decreased DLCO, decreased TLC.

(117)Neer Classification is used to classify fracture of upper humerus, these fractures often involve axillary nerve.

(118)Thrombolysis administered through peripheral vein is as effective as through a pulomary artery catheter. (1) It is indication in acute on chronic thrombos formation in acute limb ischemia (2) Acute axillary vein thrombosis(after trauma) (3) Acute pulomary embolism which is causing heart failure

10 of 19 (119)PT and aPTT are both elevated in Vitamin K deficiency. Oral Vit K reversal takes 24 hours, IV takes 6 hours. (1) Incase of major bleeding on warfarin, reverse with PCC and Vit K(Factor 6 has short half life), give FFP incase PCC is not available (2) Incase of minor bleeding stop warfarin and give Vit K. (3) Factor 5 and 8 are and are sensitive to temperature hence FFP stored at -18. They are also most rapidly consumed in DIC. (4) Factor 8 is not synthesized in the liver but in endothelium and is present in wiebel palade bodies with WvF, which stabilises it.

(120)Nifedipine can cause migraines, swelling and facial flushing. (1) Amytriptyline can cause acute urinary retension and orthostatic hypotension (2) Finasteride reduced chances of acute urinary retension

(121)Important dermatomes: (1) thumb, lateral forearm : C6 (2) middle finger : C7 (3) little finger : C8 (4) Axilla, medial arm : T2 (5) Nipple : T5 (6) Xiphoid Process : T7 (7) Umbilicus. : T10 (8) Inguinal ligament : T12 (9) Knee joint : L3,4 (10)Big toe : L5 (11)Lateral calcaneum : S1 (12)popliteal fossa : S2 (13)Anus : S4 and S5

(122) Presence of periosteum is necessary over the bone to allow grafting.

(123)Ligament of Berry is investing fascia which fuses posteriorly, attaches to cricoid cartilage.

(124)Fibroadenoma and phyllodes tumors are both fibroepithelial tumors. (1) Fibroadenoma >3 cm is to be excision biopsied to rule out phyllodes tumor (2) phyllodes tumor is leaf like in appearance with spindle cell stroma. (3) It is rapidly growing

(125)Marfan syndrome: (1) Pectus excavatum/carinatum (2) Pes cavus(flat foot) (3) Scoliosis (4) Arachnodactly (5) Bilateral inguinal hernia (6) Ectopia lentis( Upwards and outwards)

(126)Salivary glands release 1.5 L of everyday (1) Alkaline in nature (2) Isotonic at secretion, becomes hypotonic as it reaches the mouth (3) Increased parasympathetic supply increases volume of saliva, decreases sodium and increased Na content. (opposite to aldosterone) (4) sympathetic stimulation cause scanty, enzyme rich saliva.

11 of 19 (127)DeBakey Classification: (1) 1 is ascending and descending both (2) 2 is ascending only (3) 3A is descending up to level of diaphragm (4) 3B is descending below diaphragm

(128)Renal trauma can be categorised by CT scan with contrast (1) Contained hematoma (2) <1 cm laceration (3) Laceration >1 cm (4) Laceration through cortex medulla and collecting system (5) Hilar avulsion/Shattered Kidney

4 and 5 are generally indications for nephrectomy.

(129) On PR examination: (1) if an abscess is felt above dentate line it is ischiorectal abscess (2) If felt further above, pelvirectal abscess

(130)Sticking of food to gullet is usually as sign of benign esophageal stricture (1) Every person with GERD need 2 yearly endoscopic surveillance with quadrantic biopsy (2) low grade dysplasia needs 6 monthly endoscopy and biopsy (3) high grade dysplasia mostly have cancer associated with it so treatment is endoscopic resection. (4) T1 unifocal lesion can also be excised by endoscopic resection. (5) Multifocal disease need esophagectomy (6) Upper 1/3 can be treated by chemoradiotherapy (7) Very distal tumor(Type 2 i.e within 1cm GEJ) can be amendable to transhiatal appraoch. (8) H.pylori gastritis has almost no endoscopic features, diagnosis made by antral biopsy and CLO test. (9) Radiotherapy is first line in treating Nasopharyngeal CA, associated with EBV.

(131)Truss support can be used for people with ingional hernia, who are unfit for surgery. Chances of strangulation are <5% per year. (1) Incase of partially reducible inguinal hernia, use expedited repair as these tend to obstruct.

(132) Indications for thoracotomy include (1) loss of more than 1.5L blood initially or (2) ongoing losses of >200ml per hour for >2 hours (3) Penetrating trauma causing cardiac tamponade In emergency always use anterolateral 5th ICS incision. 5th intercostal space Posterolateral is used to access lung, hilum and mid esphagus(elective) 7th posterolateral is used to access lower , diaphragm, heart and pericardium(elective)

(133)Incase of RTA with tenderness and CT scan not able to exclude diaphragmatic injury, proceed to laprotomy.

12 of 19 (134)Beta 2 microglobulin is assoicated with multiple myeloma (1) MM is most common tumor of bone (2) MM and hypertriglyceridemia can cause pseduohyponatremia (3) MM is associated with AL protein.

(135) Recurrent metastatic endometrial carcinoma should be treated by medroxyprogesterone(depo provera) (1) Uterus is frequently retroverted in older women.

(136)Modified Kessler technique is used to repair tendons. Ideal suture for this is Ethibond. (1) Whitting maneuvre is used to prevent perforation after ramstedt pyloromyotomy (2) Lembert suture technique is used to approximate serosa by inverting suture pattern, risk of stenosis. (3) Correct approximation of skin is done with appostion and slight eversion. (4) vascular anastomsis is done from inside to outside with round bodies non absorbable suture to avoid raising intimal flap. Also EVERT edges to prevent intimal disruption. (5) In GI surgery, INVERT the edges to discourage leakage and appose mucosa (6) In duct surgery, INVERT the edges to discourage leakage and appose mucosa. (7) While applying surgical scrub the field should be cleaned from center out and dirty areas(groin, perineum) should be cleaned last. (8) Ideal temperature for theatre is 20-22, but 26 in children as they cannot regulate temperature well. (9) Use PDS 3/0 for subcuticular skin closure.

(137)Bowel prep: (1) Phosphate enema 30 mins before procedure in sigmoidoscopy (2) Purgatives last day in colonoscopy, stop iron a week before (3) NPO 6 hours before endoscopy (4) ERCP, check INR, if peritonism develops post ERCP, do a CT scan to delineate injury.

(138)Pneumoperitoneum increases PEEP, PaCO2, MAP and SVR and decreases urine output.

(139)Patellar trauma (1) if indirect injury : transverse fracture, straight cylinder cast if undisplaced, ORIF if displaced. (2) Direct trauma : communited fracture, manage conservatively. Recurrent displacement of patella can occour if lateral condyle is not properly developed.

(140)Illiohypogastric and illioinguinal nerves run between internal oblique and transversus abdominus.

(141)Fistula in ano are probed by lockhart mummary probes (1) donot probe an acute inflamed fistula or one associated with an abscess (2) All crohns fistula are treated by a loose seton(non cuting)

(142)Tibetian or high altitude or COPD populations are susceptible to carotid body tumors, paraganglionomas.

(143)A cervical rib is an elongation of transverse process of 7th cervical vertebrae.

13 of 19 (144)Colonoscopic surveillance: (1) After Polypectomy R0 Large >1 cm --> 3 years (2) high risk finding at baseline( 5 premaligant polyps or >2 premalignant polyps with 1 colorectal polyp) --> 3 years (3) After Colorectal surgery ---> 1 year (4) R1 large polp ---> view site at 6 months and scope at 1 year (5) non high risk ---> regular surveillance Synchronous colonic tumors are seen in 5% of cases.

(145)All colonic polyps are dysplastic (1) people with lymph node positive tumors need chemotherapy. (2) Involvement of mesorectum means long course chemoradiotherapy followed by resection

(146) Inferior thyroid artery enters the thyroid gland at C6 (1) hyoid at C3. (2) Common carotid divided at C3

(147), , CCK, glucose, aminoacid, fatty acid, B adrenergic drugs, vagus all increase insulin release. (1) half life of insulin is less than 30 mins. (2) It is decreased due to surgical stress, along with estrogen and testosterone (3) TSH, FH, LH have no change (4) Increase plasma amino acid increase glucagon release

(148)Glucagonoma is assoicated with diarrhea, weightloss and necrolytic migratory rash.

(149)Maisonneuvre fracture : unstable ankle injury with proximal fibula fracture. (1) Weber 1 : Ankle booot (2) Weber 2 : If congruent ankle, use below knee case (3) Weber C: Always ORIF with plates

(150)Minimally displaced spiral fracture of tibia in a child should be treated by groin to foot cast.

(151)For venous ulcer always so for Class 2/3 compression stocking if no DVT is present, then proceed for surgery.

(152)Incase of femoral hernia (1) If elective use lotheissen approach(transinguinal), it may however weaken inguinal canal and lead to inguinal hernia (2) if elective and very thin female, use in lockwood approach(infra inguinal) (3) In all cases of emergency repair use McEvedy(High extraperitoneal) appraoch.

(153)TEA inhibits plasminogens conversion to plasmin. Benefit in bleeding trauma if given within 3 hours. Also can be given in minor bleeds in vWD.

(154)Lumbar canal stenosis is diagnosed by MRI and treatment is laminectomy.

(155)Reflux gastritis causes foveolar cell hyperplasia in the stomach.

14 of 19 (156)Caudal block is preferred form of postop analgesia in morgan milligan hemorrhoidectomy (1) metronidazole also decreases post op pain (2) phenol 20% is no longer used (3) Used rubber band ligation for grade 1 and 2.

(157)Bowen disease in SCC in situ, glans is a common site.

(158) In Pulp space infection arterial thrombosis and necrosis of dital phalanx occurs EXCEPT the base which has a proximal branch (1) MCC is staph aureus

(159)Stability of sacroilliac joints is due to: (1) Illiolumbar ligament (2) posterior sacroilliac ligament (3) Sacrotuberous and sacrospinous ligaments

(160) Popliteal lymph nodes drain lateral side of foot and heel. (1) A few lymphatics draining the thumb reach deltopectoral groove but ultimately drain into apical nodes. (2) Popliteus is attached to lateral condyle. (3) ACL attaches to lateral condyle.

(161) Kochers incision may damage 9th ICN resulting in atrophy and weakness of upper rectus and incisional hernia.

(162)breast abscess and subphrenic abscess should be drained subcutaneously by USG guided or CT guided approach.

(163)Junction of and duodenum is marked by prepyloric vein of Mayo.

(164)Ureter lies first lateral and then above the lateral fornix of vagina. (1) Barr bodies are inactivated female X chromosomes

(165)blood supply of scaphoid is from dorsal surface at the waist, majority from radial artery. (1) 80% supply from carpal branch of radial artery( via retrograde flow) (2) 20% from volar radial artery which supplies distal

(166)Adductor canal syndrome : Occlusion on knee flexion (1) Popliteal entrapment syndrome: occlusion on full extension (2) Popliteal entrapment is due to medial gastrocnemius head

(167)Lingual nerve winds around submandicular(whartons duct) (1) most commonly damaged on 3rd molar extraction(nueropraxia)

(168) Modified Neck dissection (1) Type 1: Accessory nerve preserved (2) Type 2: Accessory nerve and IJV preserved (3) Type 3 : Accessory nerve, IJV and sternoclediomastoid preserved

15 of 19 (169)Paralysis of Recurrent laryngeal nerve leaves vocal cords in paramedian position(between adduction and abduction) (1) Triangle of Beahr is bounded by common carotid laterally medially by traches and superiorly by inferior thrroid artery, it is the location of RCN. (2) Familial Medullary CA thyroid is usually multifocal.

(170)Lower half of pinna, both sides is innervated by great auricular nerve and drains into superficial cervical nodes (1) upper half of medial pinna, lesser occipital nerve and mastoid/deep cervical nodes (2) upper part of lateral pinna, auriculotemporal nerve and superficial parotid nodes. (3) EAM is innervated by auriculotemporal, vagus nerve and nervus intermedius(branch of facial nerve).

(171)Tibial nerve innervates ALL muscles of the foot except extensor digitorum brevis which is innervated by common peroneal nerve.

(172)Posterior interosseous nerve maybe trapped in arcade of Frohse(supinator arch).

(173)All clotting factors are serine proteases except 3(cytokine receptor protein), 5 and 8(glycoproteins) and 13(transglutaminase). (1) Dabigatran is a thrombin inhibitor and is inactivated by Idarucizumab, used it patients with HIT.

(174)If cannot be found during appendectomy, divide the lateral peritoneal attachments of the ceacum.

(175)Internal mammary artery supplies 60% of blood to the breasts. (1) 70% of lymph drains into axillary nodes. (2) Pectoralis minor divides axillary region, it is supplied by medial pectoral nerve.

(176)Opiods and normothermia supress hypothalmic and pituitary responces in surgery. (1) IL-6 is the main surgery cytokine (2) Radiation is the main cause of intraoperative heat loss. (3) Tissue factor(3) is a critical mediator for DIC, most rapidly consumed factors are V and VIII

(177)In hypercalcemia, give medical therapy with fluids if Ca>3 (1) Alendronate is first line, rapid onset (2) Zolendronate can be used in CA. (3) Use prednisolone if myeloma, sarcoidosis or Vit D intoxication is suspected. (4) If Calcitonin is used, it has a very short duration of action, use another agent with it.

(178)In order to attain a palpable femoral pulse 65 mm MAP is needed.

(179)Cardiac index = CO/TBSA (N = 2.5/4)

(180)Beta blocker, heparin and RTA cause hyperkalemia (1) Amiodarone is a recognized cause of epididymoorchitis (2) 5 FU is a recognized cause of palmar planter erythrodysthesia (3) Doxorubicin intercalates with DNA, generates free radicals and interferes with topoisomerase 2, dexrazonxane is used to prevent cardiotoxicity with doxorubicin. Use cold compress incase of extravasation.

16 of 19 (4) Ciclosporin and tacrolimus are calcineurin inhibitors and cause nephrotoxicity and DM respectively. Azathioprine causes myelosupression and alopecia.

(181)The TLCo increases in (1) Asthma (2) Pulmonary hemorrhage (3) Left to Right Shunt (4) Polycythemia Physiological shunting in lungs is always greater than anatomical shunting.

(182)Relative polycythemia occours in burns due to fluid loss from the vessels.

(183)2,3 DPG is a by product of glycolysis and it becomes deficient it periods of prolonged starvation shifting the hemoglobin dissociation curve to the left.

(184)Before endoscopy do a glasgow-blatchford bleeding score (1) After endoscopy Rockall score is calculated (1) Age (2) Blood Pressure (3) Comorbidities (4) Diagnosis(source of bleed) (5) Evidence of bleeding

(185)Latency period for occupational cancers is 15 years for men and 20 years for women (1) Angiosarcoma of liver associated with PVC (2) Mesothelioma with asbestos exposure (3) Breast CA with women working night shifts (4) Wood craftsmanship(dust) associated with ethmoidal CA

(186)Wucherera bancrofti causes Filariasis, endemic in Asia, treatment by diethycarbamazine (1) S.hematobium is treated by single dose of praziquantel (2) Fasciola hepatica is treated by triclabendazole, some patients need ERCP

(187)Most common cause of osteolytic bone mets in children is Neuroblastoma (1) differentiate neuroblastoma from nephroblastoma by presence of calcifications is the former. Nephroblastoma also is likely to cause hypertension. (2) Aggressive fibromatosis is associated with APC mutations in FAP, gardner syndrome. (3) Bilateral acoustic neuromas is a feature of NF-2. (4) Bilateral retinal hemorrhages with brain tumors is a feature of Von Hippel Lindau.

(188)Selective IgA deficiency: (1) People who donot have IgA are immunosensitised against it, if given a blood transfusion with IgA, they develop anaphylactic reation.

(189)HIV can be detected earliest after exposure 3-4 weeks by p24 antigen (1) HIV-1 HIV-2 antibodies are developed later and are most sensitive (2) Western blot is the confirmatory test

17 of 19 (190)Relative opioid potency (1) Codeine 100 (2) Tramadol 50 (3) Morphine(PO) 10 (4) Oxycodone(PO) 5 (5) Diamorphine(SC) 3

Breakthrough dose is 1/6th of total dose Always give antiemetics increase dose 30-50%

(191)V5 lead is most sensitive to detech myocardial ischemia intraoperatively in a high risk patient, it is known as the poor mans lead.

(192)Ureterosigmoidostomy causes metabolic acidosis. (1) normal urine osmolality is 500-800mOsm

(193)In type I DM always use insulin sliding scale intraoperatively, 0.45% NaCL, 5%, 0.3 KCl%

(194)Redivac drain is a closed suction system made of proline, used in breast and thyroid surgery. (1) Wallace robinson is a non suction drain system used in colorectal surgery (2) Penrose drain are latex drains

(195)Donot use NO in anasthesia for COPD patients, will rupture bullae causing pneumothorax.

(196)Capral tunnel syndrome is diagnosed by tinnel and phalen tests but gold standard is electrophysiological studies.

(197)Neonates have blood 85ml/kg and greater than 30ml blood loss is an indication for transfusion.

(198)Black gallstones are due to unconjugated bilirubin (1) Brown stones are a mix of cholesterol and bilirubin stones (2) Yellow stones are cholesterol stones (3) 10% of patients presenting with biliary colic have stones in CBD as well.

(199)Dorsal primary ramus supplies skin of back and true back muscles (1) Ventral primary ramus supplies skin of limb, trunk and other muscles.

(200)Tears >2 cm in rotator cuff should be repaired surgically. (1) Meniscial tears and unlikely to heal conservatively. (2) Impacted fracture of surgical neck of humerus should be treated by collar and cuff.

(201)Hyperactivity and short stature are associated with perthes disease (1) Treat those over 6 with disease involving >50% of head of femur.

(202)Intragastric balloon is a bridge to a more definitive surgery and on itself has a high risk of long term failure. (1) Consider bariatric surgery in BMI >40 or >35 and a comorbidity. (2) Ensure 6 month of conservative treatment

(203) Urethral catheterisation for > 6 weeks can lead to stricture formation.

18 of 19 (204)In tourniquet surgery: (1) First Exsanguinate arm using esmarch bandage/elevation, 5 min at 90 degree for arm, 5 min at 45 degree for leg (2) Safe limit for application of tourniquet is 1-3 hours. (3) if >2 hour surgery, tourniquet should be deflated for 5 mins every 30 mins. (4) Pressure for upper arm : 200-250mm Hg, for thigh = 250-300 mm Hg.

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