Supinators of the forearm are:

Biceps brachii (Involved in rapid supination with elbow flexed and supination against resistance.)
Supinator (Mainly concerned with slow supination with elbow extended.)
Ref: B.D. Chaurasia’s Human Anatomy, 4th Edition, Vol 1, p151.

Anterior choroidal artery arises from the internal carotid artery.
Anterior cerebral artery is a branch of internal carotid artery.
Posterior cerebral artery is a branch of vertebral artery.
Anterior communicating artery is a branch of anterior cerebral artery.

Mandibular nerve can be divided into 3 parts – main trunk, anterior division and posterior division.
Muscles supplied by main trunk:
Tensor veli palatini
Tensor tympani
Medial pterygoid
Muscles supplied by anterior division:
Lateral pterygoid
Temporalis
Masseter
Muscles supplied by posterior division:
Anterior belly of digastric
Mylohyoid

Couinaud’s segmental nomenclature is based on position of hepatic veins and portal vein. It is the French system.

Anterior ethmoidal artery arises from ophthalmic branch of internal carotid artery.

• When light energy is absorbed by rhodopsin, photoactivation of electrons in the retinal portion of rhodopsin leads to the change of cis form of retinal into the all trans form.
• The first stage in the reformation of rhodopsin is to reconvert the all trans retinal into 11 cis retinal.
• This process is catalysed by the enzyme – retinal isomerase.

Ref: Textbook of Medical Physiology, Guyton and Hall, 11th edition, page 629.

• Inhibin is secreted by the sertoli cells in males and by the granulosa cells in females.
• It inhibits the secretion of Gonadotrophin Releasing Hormone.
• It is a glycoprotein with molecular weight between 10,000 and 30,000.
• It has potent inhibitory feedback effect on the anterior pituitary gland which in turn provides negative feedback mechanism for the control of spermatogenesis.

Ref: Textbook of Medical Physiology, Guyton and Hall, 11th edition, page 1007.

• Hensen’s cells are supporting cells of organ of Corti which lie outside the outer hair cells.
• Reticular lamina is a tough membrane which is supported by rods of Corti.
• Tectorial membrane is a thin, gelatinous, elastic structure made of glycoprotein.
• Efferent cholinergic fibers arise from ipsilateral and contralateral superior olivary nucleus.

Ref: Textbook of Physiology, A K Jain, 3rd edition, Volume 2, page 1103.

• Juxtamedullary nephrons comprise 14-15% nephrons in the kidney.
• They have large sized glomeruli which are situated at the junction of the cortex and medulla of the kidney.
• The rate of filtration is high.
• They have long loops of Henle which penetrate into the medulla.
• Their Henle loops manifest vascular supply in the form of vasa recta.
• Both descending and ascending limbs of loop of Henle contain thin segments. (In cortical nephrons, descending limb contains a thin segment whereas the ascending limb contains a thick segment.)

• Somatomedin increases glucose oxidation in fat.
• Activity of somatomedin is reduced by protein deficiency and glucocorticoids.
• It has insulin like effect on tissues and causes lipolysis and increased glucose and amino acid transport by muscle.

Ref: Textbook of Physiology, A K Jain, 3rd edition, Volume 2, page 670.

• Primary hyperaldosteronism is characterised by absence of peripheral oedema, metabolic alkalosis and marked fall in plasma potassium levels.
• There is rise in plasma sodium, but decrease in sodium content of sweat, saliva and GI secretions.

DIFFERENCE BETWEEN ESTROUS CYCLE AND MENSTRUAL CYCLE

• Estrous cycle in seen in non primate mammals, whereas menstrual cycle is seen in higher primates like humans.
• If conception does not occur, endometrium is reabsorbed in estrous cycle, whereas endometrium is shed in menstrual cycle.
• Females are sexually receptive only near the time of ovulation in estrous cycle. In menstrual cycle, it does not depend on the time of ovulation.Menstrual cycle in human females

COMPONENTS OF MENSTRUAL CYCLE

• It has 3 components – Ovarian cycle, Uterine cycle (endometrial cycle) and Hormonal cycle.
• The ovarian cycle consists of 3 phases – Follicular phase, Ovulation and Luteal phase.
• The uterine cycle consists of 3 phases – Menstrual phase, Proliferative phase and Secretory phase.

Image credits : Wikipedia

Vitamin K dependant clotting factors are II, VII, IX and X. Vitamin K is required for the gamma carboxylation of glutamic acid residues.

Thrombin inhibitors in plasma are:

• Antithrombin III (75% of total activity)
• Alpha 2 macroglobulin
• Heparin cofactor II (minor)
• Alpha 1 antitrypsin (minor)

So both A and D are correct, but the best answer is D (Alpha 2 macroglobulin).

Siggard Andersen normogram helps to predict the acid base status of blood. PCO2 is plotted in the Y axis and pH in the X axis.

Action potential is an ‘all or none’ phenomenon. Increasing the amplitude beyond the threshold level does not influence the outcome.

GABA is the main inhibitory neurotransmitter.

Excitatory neurotransmitters – Glutamate, Aspartate
Inhibitory neurotransmitters – Glycine, GABA (Gamma Amino Butyric Acid)

Valvular events in cardiac cycle:

• Atrio-ventricular valves close at the end of diastole
• Semilunar valves open at the end of isovolumetric contraction phase
• Semilunar valves close at the end of systole
• Atrio-ventricular valves open at the end of isovolumetric relaxation phase

• Ripstein’s operation is the abdominal approach for rectal prolapse.
• The abdominal approach is recommended in patients with complete rectal prolapse who are otherwise in good health.
• In Ripstein’s operation, the rectosigmoid junction is hitched up to the front of the sacrum using a teflon sling.

Ref: Bailey and Love’s Short Practice of Surgery, 25th edition, p 1225.

• Teratoma arises from totipotent cells in the rete testis.
• Histologically it is classified into 4 types:
  • Teratoma differentiated
  • Malignant teratoma intermediate
  • Malignant teratoma anaplastic
  • Malignant teratoma trophoblastic
• The most common type is malignant teratoma intermediate.
• It contains malignant and incompletely differentiated components.

Ref: Bailey and Love’s Short Practice of Surgery, 25th edition, p 1385.

• Hereditary pancreatitis is an autosomal dominant disorder.
• It has 80% penetrance.
• It is associated with mutations in the cationic trypsinogen gene located on chromosome 7.
• IgG4 concentrations are elevated in autoimmune pancreatitis.

Ref: Bailey and Love’s Short Practice of Surgery, 25th edition, p 1146.

• Stemmer’s sign is seen in lymphoedema.
• Skin on the dorsum of the toes cannot be pinched due to subcutaneous fibrosis.
• This is called Stemmer’s sign.

Ref: Bailey and Love’s Short Practice of Surgery, 25th edition, p 947.

• Caroli’s disease is congenital dilatation of the intrahepatic biliary tree.
• This disease is complicated by presence of intrahepatic stone formation.
• Patients can present with abdominal pain or sepsis.
• Biliary stasis with stone formation can lead to biliary sepsis.
• Malignant change in the ductal system can lead to cholangiocarcinoma.

Ref: Bailey and Love’s Short Practice of Surgery, 25th edition, p 1093.

• Neuroendocrine tumours of the stomach are rare tumours which comprise about 5% of all neuroendocrine tumours of the gastrointestinal tract.
• The most frequent neuroendocrine tumour of the stomach is type I tumour.
• Type III tumours are low grade malignant differentiated tumours.
• Serum gastrin is normal.
• The common symptom is upper gastrointestinal bleeding.
• Gastrectomy, lymph node resection and resection of liver metastases is the treatment of choice.

Ref: Bailey and Love’s Short Practice of Surgery, 25th edition, p 821.

Most common cause of delayed obstruction of urinary tract after Transurethral Resection of Prostate (TURP) is bladder neck stenosis.

Late complications of TURP include:

• Urethral stricture (3.8%)
• Bladder neck stenosis (4%)
• Stress incontinence (2.2%)
• Sexual dysfunction: retrograde ejaculation (65-70%) and erectile dysfunction (6%).

• Penoscrotal stricture, Bulbar stricture, Membranous urethral stricture and Submeatal strictures are subtypes of urethral strictures.
• Urethral stricture can be treated by end to end urethroplasty.
• Bladder neck stenosis can be corrected by endoscopic incision.

References: 

• Manual Endourology: Training for Residents By Rudolf Hohenfellner, Jens-Uwe Stolzenburg
• Post-TURP obliterative urethral stricture: Unusual treatment and favourable result. African Journal of Urology; A. Bhageria, , B. Nayak, P.K. Rai, P.N. Dogra

MANAGEMENT OF A CASE OF ABDOMINAL TRAUMA

• Maintenance of airway, breathing and circulation is the first priority
• The patient should be intubated in case of airway block
• If the breathing is compromised, the patient should be ventilated with a high fraction of inspired oxygen
• Large bore IV cannulas should be inserted and IV fluids should be administered
• In case of external bleeding, direct pressure should be applied to control it
• Spinal immobilisation should be done in cases with suspected spinal cord injury

Indications for laparotomy in blunt trauma abdomen

• Hemodynamically unstable patients with shock
• Signs of peritonitis
• Progressive deterioration of the patient’s status
• Identification of hemoperitoneum after Focused Assessment with Sonography in Trauma (FAST) or Diagnostic Peritoneal Lavage (DPL)

Non surgical management

• If the patent is hemodynamically stable, further investigations like CT scan can be done to visualise the site of injury

Surgical orchidopexy should be done if spontaneous descent has not occurred by 1 year of age.

90% of all abdominal aortic aneurysms greater than 4 cm are caused by atherosclerotic disease.

• Lord’s plication is a surgical procedure used for the treatment of hydrocele
• The hydrocele fluid is drained and the redundant sac is plicated
• It is used for treatment of small and medium sized hydroceles

The sympathetic system controls the blood flow to skin (not muscle). Sympathetic tone has a vasoconstrictor effect. Hence lumbar sympathectomy will cause vasodilation and increased blood flow to skin of toes.

Causes of blood stained nipple discharge

• Intraductal papilloma
• Carcinoma
• Duct ectasia
• Fibrocystic disease

• Lyre sign is an angiographic finding seen in carotid body tumour of the neck.
• There is splaying apart of internal and external carotid arteries on angiogram.

Ref: Diseases of Ear, Nose and Throat by P.L. Dhingra, 5th edition, p460.

• Hitzelberger’s sign is seen in acoustic neuroma.
• It occurs due to involvement of the 7th cranial nerve.
• There is early involvement of the sensory fibers which causes hypoesthesia of the posterior meatal wall.
• Paraesthesia of face and reduced corneal sensitivity occurs due to involvement of 5th cranial nerve.

Ref: Diseases of Ear, Nose and Throat by P.L. Dhingra, 5th edition, p124, 125.

• Orbital apex syndrome is a complication of paranasal sinus infection.
• Superior orbital fissure syndrome along with involvement of maxillary division of trigeminal nerve and optic nerve is known as orbital apex syndrome.
• In superior orbital fissure syndrome, there is progressive paralysis of abducent, oculomotor and trochlear nerves.

Ref: Diseases of Ear, Nose and Throat by P.L. Dhingra, 5th edition, p213.
Image credits: https://en.wikipedia.org/wiki/File:Gray777.png

• Eagle’s syndrome is characterised by pain in tonsillar fossa and upper neck.
• Pain radiates of ipsilateral ear.
• There is aggravation of pain on swallowing.
• It is caused by calcification of stylohyoid ligament / elongation of styloid process.

Ref: Diseases of Ear, Nose and Throat by P.L. Dhingra, 5th edition, p287.

• Gradenigo’s syndrome is seen in petrositis.
• It is characterised by lateral rectus palsy, persistent ear discharge and deep seated ear or retro-orbital pain.
• Mastoid tenderness, hearing loss and sagging of posterosuperior meatal wall are seen acute mastoiditis.

Ref: Diseases of Ear, Nose and Throat by P.L. Dhingra, 5th edition, p86, 89.

Elevated scapula can be seen as a part of Klippel Feil syndrome. But it does not constitute the characteristic triad.

Brown tumour occurs due to the increased osteoclastic activity in hyperparathyroidism. It is a benign mass of reactive tissue.

• Clavicular fracture heals with good functional results even if there is moderate displacement of the fracture ends
• Perfect reduction is not essential
• Treatment consists of a ‘Figure of Eight’ bandage which is periodically tightened
• A  sling can be used initially to support the upper limb
• In case of elderly patients with risk of axillary neurovascular compression, only a sling is used instead of the ‘figure of eight’ bandage
• Open reduction is done in case of non union, neurovascular damage, floating shoulder and wide separation of the fracture ends with interposition of soft tissue.

Gallow’s traction is used in infants and children with femoral fractures.

Indications Gallows Traction

• Child must weigh less than 12 kg
• Femoral fractures
• Skin must be intact

• Gaisbock’s syndrome is polycythemia due to reduction in plasma volume.
• It is usually seen in smokers, obese individuals and in patients with hypertension.
• Anaesthetic implications include cardiovascular problems and risk of deep vein thrombosis.
• May require venesection.

• Guttmann’s sign is stuffiness of the nostril which is a sign of successful stellate ganglion block.
• The other signs of successful stellate ganglion block include Horner’s syndrome, engorged veins of the arm, flushing of the conjunctiva and sclera, increase in skin temperature and anhydrosis of the face and neck.

Ref: Lee’s Synopsis of Anaesthesia. 13th edition. p444.

• Thiopental is contraindicated in porphyria, status asthmaticus, pericardial tamponade, and severe shock.
• It causes centrally mediated respiratory depression.
• It can cause laryngeal spasm and bronchoconstriction in asthmatics.
• Thiopental causes depression of myocardial contractility.
• Peripheral vascular resistance falls and it can lead to hypotension, which can be exaggerated if there is hypovolemia.

Ref: Lee’s Synopsis of Anaesthesia. 13th edition. p154, 156.

• Enflurane and Sevoflurane can induce epilepsy.
• The effect is much more pronounced with Enflurane.
• Tip to remember: Enflurane = Epilepsy (both start with E).
• Enflurane can also increase the intracranial pressure.
• Isoflurane can cause coronary steal syndrome.
• Methoxyflurane is nephrotoxic and can cause high output renal failure.

ANAESTHETIC AGENT CONTRAINDICATED IN HYPERTENSIVES

• Ketamine increases heart rate, cardiac output and blood pressure
• These effects are due to stimulation of the sympathetic nervous system and decrease in reuptake of noradrenaline
• Hence it is contraindicated in:
  • Hypertensives
  • Ischemic  heart disease
  • Congestive cardiac failure
  • Arterial aneurysms
• It is also contraindicated in patients with increased intracranial tension
• It produces dissociative anaesthesia

• Atracurium is the preferred muscle relaxant in a patient with liver dysfunction / renal failure
• It undergoes non specific ester hydrolysis and non enzymatic degradation ( Hoffman degradation )
• It does not depend on the liver / kidney for its deactivation
• Other muscle relaxants that can be given in liver / renal disease are Cisatracurium and Mivacurium

Sevoflurane is the fastest acting among the options given. Desflurane is THE fastest acting inhalational agent.

Anesthetic agents implicated in malignant hyperthermia:

• Succinyl choline
• Halothane
• Isoflurane

Attic cholesteatoma is an indication for modified radical mastoidectomy. (Canal wall down mastoidectomy)

Features of Ménière’s disease are:

• Aural fullness
• Fluctuating sensorineural deafness
• Fluctuating tinnitus
• Episodic vertigo

After 24 hours of myocardial infarction, there is coagulative necrosis of myofibers with neutrophil infiltration.

Pro apoptotic genes – bax, bad, bcl-xS
Anti apoptotic genes – bcl-2, bcl-xL

Inositol triphosphate (IP3) and diacylglycerol (DAG) are second messengers for G protein coupled receptors. IP3 stimulates release of calcium from endoplasmic reticulum. DAG activates protein kinase C.

Valine can be replaced by glutamic acid, aspartic acid or alanine at position 67 of hemoglobin to produce Hb Milwaukee, Hb Bristol and Hb Sydney respectively. All of these are functionally normal hemoglobin types.