ANAT

1. General anat (HEAD AND NECK)

Arch of aorta
Sagittal section: vagus
Thyroid: nerve, blood supply, venous drainage
How many parathyroid glands, where they are. Point out one parathyroid gland. What does
it secrete? What does PTH do?
Briefly describe embroyology of thyroid (satisfied with saying descends from 1 st-2nd
pharyngeal pouch)
How do thyroglossal cysts form?
Brachial plexus: Examiner described a Erb’s palsy. Which nerve roots are involved in this?
Point out the superior trunk of the brachial plexus.
Demonstrate the position seen in Erb’s palsy. What is this position called? A: Waiter’s tip.
What are the roots involved in an inferior brachial plexus lesion?
What does this result in? Paralysis of intrinsic muscles of the hand and loss of sensation over
little finger and medial aspect of arm.

2. General anat (LOWER LIMBS)

RTA. Injuries to lower limb.
What are the structures medial to femoral vein? femoral canal.
What are the other structures inside femoral triangle?
What is this muscle? Rectus femoris. What does it do at hip and knee. Flex hip and extend
knee
Point out the tensor fascia lata. What inserts into it? Gluteus maximus. ?Vastus lateralis
(both visible at specimen)
What does it do in the knee? It stabilizes the knee in full extension.

Another specimen: What muscle is this? Gluteus medius, minimus.

What is the action at the hip. Abductor of hip joint to prevent pelvic tilt during walking

3. Bladder: (male). Annoying examiner who always looks irritated

What is this? bladder. What bladder? (urinary bladder? Dunno what examiner wants)
What are the peritoneal relations: Superior surface, upper part of the posterior surface.
Blood supply of bladder: Superior and inferior vesical. Arises from the internal iliac artery
Base supplied by artery of ductus deferens in male.
Vaginal artery in female.

Point out the internal iliac.

What is the muscle in the wall: detrusor. What is the histo of this muscle? Smooth muscle.
Epithelial lining: Transitional cell
Nerve supply of the muscle: Vesical and prostatic plexuses (give me more details? I didnt’
know)
Sympathetic fibres from T10 –L2
Parasymp from pelvic splanchnic N (s2-s4)
 What are the 2 most common type of tumour:
1) TCC. 2) SCC in developed countries.
In developing countries, 75% are SCC because of parasites

What are the symptoms of bladder CA?

Painless haematuria
Urinary tract infection
Systemic symptoms (he looked disdainful)
Irritative symptoms. (freq, urgency, nocturia)

4. Surgical patho. Lady with gastric CA post op. PMH of alcohol intake and COPD, fatty liver
found intra op
What are 2 (or 3) Risk factors for gastric ca:
Tobacco smoke
Nitrosamines
Male
Blood group A
Hpylori.

Reasons for acute confusion postop:

I spammed all the stuff below but turns out he wanted Alcohol withdrawal

Other reasons:
UTI (less likely as it is v early)
Hypoxia
Pain
Electrolyte imbalance
Medications

Look at Patho report, and pick out main points to tell family:
Signet cell, nodes positive, margins not clear.
Prognosis poor.
Require chemo
May require another surgery

6 months later, patient presents with ascites, mild jaundice, hard liver edge
Causes:
Secondary metz vs HCC
What are 2 pathological investigations you can use to confirm this: ???????? totally no idea. I
gave him CTAP, US HBS, AFP all of which was not what he wanted.
Do an peritoneal tap with cytology.

5. Clinical exam: (bilateral thyroid enlargement)

2 distinct enlargements found in an already large size pt, so i wrongly said only 1 enlarged.
 What findings?
Differential?
Investigation?
Management?

Note: Listen to enlarged thyroid, this chap really had bruit!

6. Clinical exam: (vascular arterial exam)

Calf pain, legs are cold.
Unusual scar pattern on left side: Scar over groin crease (left side)
Proximal scar over mid thigh
Large erythematous swelling over prox thigh, at the scar.
Distal thigh has another separate scar.

Pulses: left side pulses not palpable from femoral downwards.

BP cuff available.
Did beurger’s test. (nothing found)
Doptone avail – but failed to notice and hence didn’t use it
(did not do ABPI)

What could be the cause? Minimal discussion as I ran out of time – this station sure fail.

7. Abdo exam by actor: Cholecystitis

Murphy’s positive, tender over RHC with voluntary guarding
Some tenderness over mc burneys

What are the differentials:

Cholescysitis
Appendicitis
Pancreatitis

What invx would you do?

FBC, UECr, LFT, Amylase
Imaging: US HBS, CTAP (for appendix), MRCP(if dilated CBD found on US, or suspect
pancreatitis)
If there is gallstones found? Do ERCP.

Vitals chart shown. Fever, mild tachycardia.

UFEME: Normal
Treatment:
NBM IV drip,
Analgesia abx (Roc, flagyl)

8. PACEMAKER
 Patient for elective lap chole.
CVS exam.
No chest scars.
No signs of cardiac failure.

Implication of pacemakers on surgery.

Cardiac defibrillator turned off.

What investigations would you do.

ECG.
2Decho.

Read ECG. Pacing spikes seen.

9. HISTORY TAKING (PR bleed)

6 months history of PR bleed. Bowel habits change.
Heavy smoker and drinker.
Brother had colon ca at age 55.

Differentials:
Colon CA, IBD, Haemorrhoids.

Investigations:
FBC, UECr, LFT, Colonoscopy.

Next: Stage disease: Tumour markers, CT thorax, abdo pelvis, bone scan.

10. HISTORY TAKING (KNEE PAIN)

Refered by GP for knee pain.
Pain stiffness, feeling of giving way. Doesnt exercise still have pain. Night pain.

Differentials:
OA, RA, Gout

Treatment options:
Medical:
Analgesia
Physio
Injections
Ops.

11. Confused patient history taking.

Planned for op. In the ward he was found to be confused.
Assess patient’s mental state.
 Do you know what you are here for.
Aware of operation?
Assess AMT

What is your assessment.

What you going to do.
Inform consultant
Inform family
Delirium workup: Hypoglycemia, chest infection (fbc, uecr, blood culture), electrolyte
inbalances, UTI (UFEME), Alcohol.
Speak to family to find out if this is acute.
Speak to anaesthetist

12. CRITICAL CARE (ADRENAL GLAND)

80 years on long term steroids going for esophagectomy.

What are the layers.

Hormones secreted
What is the control. Hypothalamic pituitary axis.

Effect of glucocorticoid on the body:

Cortisol.

What happens on long term steroids going for surgery.

Stop. Bridge with IV hydrocort.

Hypotension
Nausea
Vomiting

CRH – ACTH – CORTISOL

13. CRITICAL CARE (ABG)

Patient given alot of morphine after op.
In respiratory distress.
ABG shows respiratory acidosis. No compensation.
How is CO2 carried in the body
Ionized form.
Dissolved in water
Carboxyhaemoglobin

Draw equation.

How does morphine cause respiratory depression.

Works on the MIu receptors in the brain.
 How do you treat this patient.
Naxolon.
How do you give naloxon. IV 0.1-0.3mg. every 1 to 2 mins IV infusion.
Whats the dose?
Where should he be managed.
Needs to be intubated. ICU.
What is the side effect of naloxon.
Withdrawal. Pain, nausea vomiting, seizures.

BZD.works on gaba receptors in the brain. Fluminazil. 0.1 – 0.2mg.

14. CRITICAL CARE (CXR pneumothorax, CT Brain, SDH)

What are the features you look at to confirm it is adequate.
What type of pneumothorax: Simple. No evidence of midline shift.
Management: Chest tube
How to do.

SDH:
GCS.
Cause of drop in GCS. SDH
Management.
ATLS principles.
Intubate. Protect airway and allow hyperventilation. Decrease CO2.
Signs of raised intracranial pressure: Cushing’s reflex. Papilledema, dilated pupil

15. Procedure: Excision of naevus.

Introduce yourself. Check that its correct patient. Ensure patient knows what you are going
to do.
Ask to see the consent form. Check correct site and lump.
False skin pasted on.
Suture: Use nonabsorbable interrupted sutures.
What to do if there are gaps in wound? Put steri - strips.

Will it be painful after LA wears off? Must say I would give oral analgesia
Inform the patient that she has to STO
Will have to review the histo results in clinic
Can i shower? Keep water proof dressing. Wound dry for 3 days.

16. OT listing.
Sigmoid colectomy allergy to penicillin and iodine.
MRSA for left BKA.
COPD pacemaker on warfarin for inguinal hernia op.
 Switch the last two.

Where to place diathermy pad – choose

17. COPD patient with perf in the ward. Talk to ITU reg to book bed – he will tell you there’s a
young asthmatic who may require the bed. Discussion on indications for ITU management
(invasive ventilation and failure of more than 1 organ system)

18. Patient came in with ascites. Ascitic tap found malignant cells. CT scan down, offered US
instead. Talk to patient’s wife (angry but she wasn’t very angry) and explain findings and
subsequent management. Let her lead the discussion, she was very helpful.