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Stem2: A patient known to have hypothyroidism with a hard swelling in the inguinal region, the GP sent her for a biopsy. If the inguinal LNS was lymphoma what are the distinct types of lymphoma? SpoilerHodgkin Non-Hodgkin How malignant cells survive in LNSs SpoilerMalignant tumours release growth factors such as VEGF-C (vascular endothelial growth factor C) to induce lymphatic vessel expansion (lymph angiogenesis) in primary tumours and in draining sentinel LNs, thereby promoting LN metastasis Why is melanoma pigmented? SpoilerBecause of melanin Mention 4 types of melanoma? SpoilerLentigo maligna Superficial spreading Desmoplastic melanoma Acral melanoma Nodular melanomas A lesion under the toenail was found and the decision to amputate the toe and excise the LNs. What is the reason behind this decision? SpoilerTo prevent metastasis Safety margin Pain control What is epithelioid melanoma? SpoilerType of melanoma with cells resembling epithelium because of Abundant eosinophilic cytoplasm Enlarged round to oval shaped nuclei. Gene mutation in familial malignant melanoma? SpoilerBRAF gene Postoperatively the wound is red and swollen. Culture revealed diplococci give examples? SpoilerGram-negative diplococci Neisseria sp. Haemophilus Brucella Moraxella catarrhalis Acinetobacter Gram-positive diplococci SpoilerStreptococcus pneumoniae Enterococcus. Next the patient became toxic with rapid spread of infection what do you think the cause? SpoilerNecrotizing fasciitis

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Stem: Polytrauma, young girl on her bicycle and involved in an RTA. Possible neck injury and fracture How will you assess the patient? SpoilerAccording to ATLS protocol. What is the general principle of ATLS? SpoilerX control bleeding Airway with cervical spine stabilization Breathing Circulation Disability Exposure Elaborate the breathing assessment of this patient Look (evidence of respiratory distress) Listen (signs of partial airway obstruction or compromise) Feel (air or fluid) Respiratory rate What will be the breathing problem in this patient and what is its effect on the lung? SpoilerThis patient may have shallow breathing because of the possibility of affection of the phrenic nerve. Its effect on the lung is SpoilerDecrease in alveolar ventilation Alveolar collapse Lung atelectasis Respiratory acidosis Why does this patient have respiratory depression? Affection of phrenic nerve Intercostal muscles paralysis CO₂ retention Brain stem injury What investigation will you next order? CT MRI Given the following MRI, what is the pathology? MRI sagittal view showing C5 fracture with retropulsion of the spinal cord Here's the extracted text, continuing from the previous section: What is significance of this fracture? C5 nerve root injury → phrenic nerve affection → weakness of diaphragm → reduced breathing effort → accumulation of CO₂ and alveolar collapse → respiratory acidosis How will you assess the respiratory function of this patient? ABG Given the following ABG, interpret? ↓ PH, ↑ PCO2, normal bicarbonate and hypoxia. Uncompensated respiratory acidosis What type of respiratory failure? Type 2 How to manage respiratory failure? With BiPAP (bi-level positive airways pressure) aka non-invasive ventilation (NIV) You may be given ABG showing partially compensated respiratory alkalosis with hypercapnia. What will you do in the ER to improve that? Good ventilation and high-flow oxygen The decision is made to do fixation by neurosurgery, what is one thing you will do before surgery? Triple immobilization Consent for the surgery Why this patient has lower limb weakness? Because the patient has spinal cord injury What are incomplete spinal cord injuries? / What spinal cord syndromes do you know? Central cord syndrome Anterior cord syndrome Brown-Séquard syndrome Posterior cord syndrome Spinal cord compression and central cord oedema with selective destruction of lateral corticospinal tract Injury to anterior spinal cord caused by: • Direct osseous compression of the anterior spinal cord • Anterior spinal artery injury Caused by complete cord hemitransection Very rare Loss • Motor deficit worse in UE than LE (some preserved motor function) Preserved • Sacral sparing Loss • LCT   o motor function • LST   o pain   o temperature Preserved • DC • proprioception • vibratory sense Ipsilateral deficit • LCT   o motor function • DC   o proprioception   o vibratory sense Contralateral deficit • LST   o pain   o temperature   o spinothalamic tracts cross at spinal cord level (classically 2 levels below) Loss • proprioception Preserved • motor, pain, and light touch What is the first line of management of this patient? Dexamethasone (in any fracture spine we're afraid from oedema) What will be the consequences of affected breathing in this patient? Shallow breathing leads to alveolar hypoventilation and alveolar collapse and lung atelectasis. How to manage the respiratory condition in this patient, given that he is already on 100% oxygen? Call for help (anaesthesia and ITU and my consultant) Transfer patient to ITU Intubation by anaesthesia What will you do for this patient after discharge? Rehabilitation Physiotherapy Spirometry TEDS Neck brace

You are the SHO in the orthopaedic department. A 35-year-old man, Mr. James Carter, sustained a knee injury following a sports accident three months ago and was diagnosed with a post-traumatic meniscal tear. He was listed for an arthroscopic meniscectomy, but his operation has been cancelled twice before due to emergency cases. Unfortunately, his surgery has been postponed again today for the same reason. Your task is to update Mr Carter and address his concerns.

You are a core surgical trainee in the outpatient clinic. A 52-year-old man is referred by his GP with recurrent upper abdominal pain and weight loss. He has a background of heavy alcohol use. Site of pain (epigastric, radiating to back) Onset and duration (acute vs chronic, recurrent episodes) Character of pain (deep, boring, constant) Radiation (especially straight through to the back) Severity and impact on daily activities Timing and relation to meals (worse after eating) Relieving/exacerbating factors (leaning forward, alcohol, food) Associated nausea and vomiting Weight loss and anorexia Steatorrhoea (pale, greasy, foul-smelling stools) Symptoms of diabetes mellitus (polyuria, polydipsia) History of alcohol intake (quantity, duration) Previous episodes of acute pancreatitis Gallstone history or biliary symptoms (jaundice, colic) Drug history (e.g. steroids, azathioprine) Family history of pancreatic disease or malignancy

MRCS B Prostate Gland Stem: A 68-year-old man presents to his GP with a 6-month history of increasing urinary frequency, nocturia, and a weak urinary stream with hesitancy. He denies any haematuria or weight loss. On examination, his abdomen is soft and non-tender, with no palpable bladder. What are the superior and inferior relations of the prostate gland? SpoilerSuperior – neck of the bladder Inferior – external urethral sphincter Describe the zonal anatomy of the prostate. Which zone is most commonly affected by carcinoma, and which by benign hyperplasia? SpoilerPeripheral zone – largest zone, most common site of prostate carcinoma, palpable on DRE Transition zone – surrounds the urethra, most common site of benign prostatic hyperplasia Central zone – surrounds the ejaculatory ducts What is the arterial supply to the prostate? SpoilerInferior vesical artery, from the anterior division of the internal iliac artery. What is the venous drainage of the prostate and how is it implicated in prostatic malignancy? SpoilerProstatic venous plexus Has a connection with the valveless vertebral veins, which may be a passage of spread of malignancy. Prostate symptoms can be classified as storage or voiding symptoms, give two examples of each. Storage SpoilerFrequency Nocturia Urgency Incontinence Voiding SpoilerTerminal dribbling Slow stream Slow to start voiding What is an important part of the examination of a male patient with storage or voiding symptoms? How may we distinguish between benign or malignant pathology? SpoilerDigital rectal examination. May feel a smooth enlargement suggestive of benign disease, or a craggy, hard mass, which would suggest malignant disease. What tumour marker is used to help diagnose and monitor prostate cancer, and what are its limitations? SpoilerProstate-specific antigen (PSA) Not specific to malignancy – can also be raised in BPH, prostatitis, and after instrumentation (e.g. catheterisation, DRE) Lacks sensitivity and specificity, so used alongside DRE and biopsy rather than as a standalone diagnostic test Give two options for the pharmacological management of benign prostatic hyperplasia. Spoiler5-alpha reductase inhibitors – e.g. Finasteride. Anticholinergic agents – e.g. Tolterodine Alpha blockers can also be used. Give two risk factors for prostate cancer. SpoilerEthnicity – more common in people of black ethnicity. Age – people aged over 50 are much more likely to have prostate malignancy.

@florianecaffart @Photosaurus hi hi merci !

Vagus nerve course in thorax & abdomen? Thorax: Left vagus nerve SpoilerCrosses in front of the left subclavian artery. Enters the thorax between the left common carotid and subclavian arteries. Descends on the left side of the aortic arch. Travels behind the phrenic nerve. Courses behind the root of the left lung. Deviates medially and downwards to reach the esophagus and form the esophageal plexus with the right vagus nerve. Right vagus nerve SpoilerCrosses in front of the first part of the subclavian artery. Travels behind the innominate vessels. Reaches the thorax on the right side of the trachea. Inclines behind the hilum of the right lung. Courses medially towards the esophagus to form the esophageal plexus with the left vagus nerve. Abdomen: SpoilerThe oesophageal plexus, formed by the union of the right and left vagus nerves, The vagus nerve enters the abdomen through the oesophageal hiatus at the level of the tenth thoracic vertebra (T10). It divides into the anterior and posterior vagal trunks, which innervate the stomach, small intestine, liver, gallbladder, pancreas, and spleen. Nerves in oesophageal hiatus? SpoilerAnt & post vagal trunks. What do they supply? SpoilerStomach, duodenum, jejunum, ileum, cecum, ascending colon, medial 2/3 of transverse colon, spleen, pancreas, gall bladder Muscle dissected to see thyroid? SpoilerSternohyoid muscle