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Stem 2 A 69-year-old male presented with 1 month history of bilateral groin lumps. O/E firm non-tender lumps with grey scales. Doppler ultrasound findings include diffuse testicular infiltration, enlargement with hypervascularity, or multifocal areas of hypoechoic, solid and hypervascular nodules within testes. Orchidectomy was done & testicles were found to be white tan pink & fleshy. Pathology report: Malignant cells are pleomorphic and non-cohesive, with large irregular nuclei and prominent nucleoli. There is vascular invasion and sclerosis of seminiferous tubules. No intratubular germ cell neoplasia. The neoplastic cells typically express CD20 In light of the pathology report given, what's the diagnosis? SpoilerLymphoma Talk about classification of testicular tumours & give an example for each? Germ Cell Tumour SpoilerSeminoma: classic, spermatocytic, anaplastic. Teratoma Choriocarcinoma Yolk sac Non-germ cell tumour SpoilerSex cord stromal:Non-seminoma: Leydig cell tumour Sertoli cell Others: metastasis and lymphoma Describe the microscopic morphology of testicular teratoma vs seminoma? Seminoma SpoilerSheet-like cord of cells separated by fibrous septa that contain lymphocytes. Large, prominent nucleoli Teratoma !Composed of various types of cells or organs component He presents with PE a year later & is found to have large mass at the region of para-aortic LNs compressing renal vessels. Debulking surgery done, but tumour can't be totally resected. Frozen section showed thyroid tissue. Why? SpoilerTeratoma has the 3 germ cell lines (mesoderm, endoderm, ectoderm) which can differentiate to any of its derivatives Whats name for a monodermal thyroid-predominant teratoma specifically in the ovary SpoilerIt is called struma ovarii Explain findings in adenocarcinoma SpoilerFailure of differentiation and subsequent malignant transformation of epithelial differentiation line. What's the composition of PE? SpoilerPlatelets Polymerized fibrin Admixed circulatory cells Which clotting factor allowing polymerization of fibrin? SpoilerActivated factor 8 Explain coagulation cascade Intrinsic Pathway SpoilerTrigger: Internal damage to the blood vessel wall (e.g. plaque rupture). Initiation: Exposure of negatively charged surfaces, such as collagen, activates factor XII (Hageman factor).Initiation: Cascade: A series of reactions involving factors XII, XI, IX, VIII, and X. Extrinsic Pathway SpoilerTrigger: External trauma causing tissue injury Initiation: Tissue factor (TF) is released from damaged cells, which activates factor VII Cascade: Cascade: Activated factor VII (VIIa) activates factor X. Activated factor X (Xa) joins the common pathway Common Pathway Convergence: Both the intrinsic and extrinsic pathways converge at the activation of factor X. Thrombin Formation: Factor Xa, along with factor V, calcium, and phospholipids, activates prothrombin to form thrombin. Fibrin Formation: Thrombin converts fibrinogen into fibrin, which forms a mesh-like structure that traps platelets and blood cells, forming a blood clot What is the cause of PE in this patient? Explain SpoilerVenous stasis (compression) Hypercoagulable state (tumour) Where could a β-hCG found in a normal male? SpoilerSeminal plasma

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Parasagittal meningioma Tumour: Parasagittal meningioma Typical presentation Gradually progressive contralateral lower limb weakness Focal seizures in the leg UMN signs Why Compression of the Paracentral lobule (leg area of the Primary motor cortex). Exam clue Progressive leg weakness + seizures → parasagittal meningioma. Acoustic neuroma (vestibular schwannoma) Tumour: Vestibular schwannoma Typical presentation Unilateral hearing loss Tinnitus Balance problems Later: Facial numbness Facial weakness Why Compression of: Vestibulocochlear nerve (CN VIII) Facial nerve (CN VII) Exam clue Progressive unilateral deafness. Pituitary adenoma Tumour: Pituitary adenoma Typical presentation Bitemporal hemianopia Why Compression of the Optic chiasm. Other clues: Hormonal symptoms (galactorrhoea, acromegaly, Cushing's). Exam clue Loss of temporal visual fields. Cerebellopontine angle tumour Often a Vestibular schwannoma. Symptoms Hearing loss Facial numbness Ataxia Structures involved: Trigeminal nerve Facial nerve Vestibulocochlear nerve Exam clue Multiple cranial nerve deficits in the cerebellopontine angle. Frontal lobe tumour Commonly a Glioma. Typical presentation Personality change Disinhibition Poor judgement Sometimes urinary incontinence Structure affected: Frontal lobe Exam clue Behavioural change before neurological deficit. ✅ Very high-yield MRCS pattern Symptom Likely tumour Leg weakness Parasagittal meningioma Unilateral deafness Vestibular schwannoma Bitemporal hemianopia Pituitary adenoma Behaviour change Frontal lobe tumour Multiple cranial nerve palsies CPA tumour

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