Tiêu đề 2011.pdf ✅

Her specialty choices were 1. H&N, 2. Thorax & Abdo, 3.Limbs and spine Physio/Critical Care 1. Case of a ruptured AAA, pt has hypothermia, massive blood loss and coagulopathy, (a) discuss causes of hypothermia, (b) discussion on different types of blood products Whole blood – rarely used nowadays as separated into its components Packed red cells – whole blood from which plasma has been removed to haematocrit about 70 percent. RBCs suspended in SAG-M (sodium chloride, adenine, glucose and mannitol) volume about 180-350ml, largely increases Hb by 1 g/dl, stored at 4 degrees Celsius. Has no coagulation factors, WBC die after ???? Platelets – should be given within 60 minutes used for low numbers or non- functioning platelets Fresh frozen plasma – 200ml from 1 donor unit, stored at -30 degrees Celsius, contains all coagulation factors but takes 30min to thaw out. Cryoprecipitate – 20ml of FFP supernatant containing factor VII:C, VII:vWF and fibrinogen Clotting factor concentrates – VIII, IX Albumin Immunoglobulins (c) complication of massive blood transfusion Massive blood transfusion is the replacement of the entire circulating blood volume within 24 hours (or 1⁄2 the blood volume witin 6 hours) Hypothermia – use blood warmer before transfusing Citrate toxicity – uncommon, causes hypocalcemia from citrate binding Hyperkalemia Dilutional coagulopathy – transfuse fresh frozen plasma (30min to thaw) and platelets if count is low enough 2. Acute pancreatitis, (a) clinical features, (b) severity scoring systems, show blood results and point out which ones are part of the severity scoring system. (c) general management of acute pancreatitis
3. Read CXR = pneumothorax, (a) how to insert chest tube, and (b) how to treat tension pneumothorax, Read CT brain= SDH, (a) Glasgow coma scale (b) How to manage pt with acute drop in GCS Practical skill station 1. Excision biopsy of a skin lesion, and T&S. There is a fake skin plastered onto the patient's thigh, then all the surgical equipment is lay out on the surgical table, you're supposed to pick the correct equipment to use for the excision and then T&S, including type of blade, forceps, needle holder, type of suture material to use. The examiner does not talk to you, he's like a fly on the wall, watches your excision/suture technique 2. Insert IV cannula for a patient post-RTA with pelvic fracture, and write in the paper IMR what fluid regime you would give the patient. Anatomy/pathology (hardest amongst all category, apparently Edinburgh is BIG on anatomy so better study hard for anatomy if you're going to Edinburgh for exams) 1. Brachial plexus injury (a) test C5 and C6 dermatome (b) Nerves from brachial plexus that are supplied from C5 and C6, (c) muscle attachment of the trapezium and the suprasupinator including their various movements, (d) test patient's abduction of shoulder and flexion of elbow, name the muscles that supinate and pronate the forearm 2. Cadaver with face, neck and thorax. The examiner points to the various anatomy on the cadavar, then you must label it. Anatomy tested includes, (a) common carotid, (b) internal and external carotid, (c) facial artery, (d) hypoglossal nerve, (e) phrenic nerve, (f) vagus nerve, (g) thoracic inlet. (h) some discussion on subclavian steal syndrome, pathophysiology and clinical presentation 3. Internal view of base of skull, (a) anatomy of the middle cranial fossa, including the boundaries, and contents of each foramen. Cranial fossae Anterior Middle Posterior
Overlies Orbit, nasal cavities Nasopharynx, carotid sheath Contains Frontal lobe Temporal lobes, pituitary Brainstem, cerebellum Floor Anteriorly: Orbital plate of the frontal bone Midline: ethmoid bone (with cribriform plate, crista galli) Posteriorly: lesser wing of sphenoid Middle: Body of sphenoid Laterally: Greater wings of sphenoid + Squamous part of temporal bone Posterior boundary: petrous part of temporal bone Anterior wall: petrous temporal bone laterally, sphenoid and basilar part of occipital bone medially Floor/lateral wall: occipital bone Structures Nerves: -Olfactory (20-30) -Anterior ethmoidal n. Vessels -Anterior ethmoidal a. -Emissary veins Optic canal: -Optic n -Ophthalmic a. Superior orbital fissure: -CN III, IV, VI, Va -Ophthalmic veins Foramen rotundum -maxillary nerve Foramen ovale -mandibular nerve Foramen spinosum: -middle meningeal artery Foramen lacerum: -Upper opening of carotid canal contains the internal carotid artery Internal acoustic meatus: -CN VII, VIII -Labyrinthine arteries Jugular foramen -internal jugular v. -CN IX, X, XI Hypoglossal foramen -CNXII Foramen magnum -Spinal cord (continuation of medulla oblongata) -Vertebral arteries -Spinal accessory nerves enter the skull (b) Discussed anatomy of the eye, layers of eyeball, and ophthalmic artery supplies which layer, danger zone, otitis externa, malignant otitis externa (this is was my 1st choice specialty, I totally died, did not study anatomy of eye at all) Anatomy of the eye: The eye is under 25mm in all diameters. There are 2 segments, the prominent and transparent anterior segment (1/6th of the eyeball) and a larger opaque posterior segment (5/6th eyeball). There are 3 layers: the fibrous coat, the vascular coat and the retinal coat. Fibrous coat – 1. transparent anterior cornea and 2. opaque posterior sclera (responsible for maintenance of the shape of the eyeball and receives insertion of the extraocular muscles) it is pierced posteriorly by the optic neve. They are connected by the sclerocorneal junction. Vascular coat - 1. Choroid is a thin and highly vascular membrane lining the inner surface of the sclera. It is pierced posteriorly by the optic nerve. It is connected anteriorly to the iris by the ciliary body. 2. Ciliary body : (a) Ciliary ring – fibrous ring continuous with the choroid (b) Ciliary processes – 60-80 folds radially between ciliary ring and the iris, connected posteriorly to the suspensory ligament of the lens
(c) Ciliary muscles – outer radial and inner circular layer of smooth muscle responsible for changes in the convexity of the lens in accommodation and supplied by parasympathetic fibres transmitted in the oculomotor III. 3. Iris – contractile disc surrounding the pupil (a) anterior mesothelial lining (b) connective tissue stroma containing pigment cells (c) radially arranged smooth muscle fibres – dilator of the sphincter (supplied by sympathetic system) circular group – papillary sphincter (supplied by parasympathetic fibres in the oculomotor nerve) Neural coat - 1. Retina – formed by outer pigmented and inner nervous layer, interposed between the choroid and hyaloid membrane of the vitreous. Anteriorly it presents an irregular edge, the ora serrata, while posteriorly the nerve fibres on its surface collect to form the optic nerve. Posterior pole has a macula lutea, the site of central vision, just medial to this is the pale optic disc formed by the passage of nerve fibres through the retina. Ophthalmic artery originates from the internal carotid immediately after its emergence from the cavernous sinus, enters the orbit through the optic foramen below and lateral to the optic nerve and supplies the orbital contents and the skin above the eyebrow. Most importantly, it gives off the central artery of the retina which emerges from the disc and divides into upper and lower branches, each of which divides into a nasal and temporal branch. 4. Colonoscopy biopsy histo report, patient has UC and histo shows adenocarcinoma. (a) Discuss management of UC, complication of steroid therapy, (b) Addisonian crisis, staging and treatment of colon CA Acute adrenocortical insufficiency presenting with hypotension, shock, hypoglycaemia, hyponatremia, dehydration. Shock – cortisol is necessary for vasopressors to increase vascular tone Blood tests include Na, ACTH, cortisol and synacthen test. Treatment is resuscitation and supportive treatment: Fluids, Inotropes if necessary, IV hydrocortisone 100mg Q6H. Physical examination 1. Pre-op assessment of respiratory system for patient who is a chronic smoker, discuss pre-op investigation 2. Examination of the parotid gland, discussion investigation and management of a parotid gland mass, type of parotid neoplasia (my 1st choice specialty)