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Question 1
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A 7-month-old abandoned baby with congenital non-communicating hydrocephalus is hosted by a clinic at its new-born hostel. A CT scan of the baby's brain reveals what might be a blockage of the ventricular system between the third and the fourth ventricles. Which of the following is the most likely blocked structure?
Your Answer: Cerebral aqueduct
Explanation:The drainage of cerebral spinal fluid from the third ventricle to the fourth ventricle is carried out by the cerebral aqueduct. The cerebral aqueduct is the narrowest passageway in the entire ventricular system and thus forms the most common site of blockage of flow of cerebrospinal fluid. The interventricular foramen allows passage of CSF to the third ventricle. The foramen of Luschka and Magendie are located on the fourth ventricle and allow passage of CSF to the subarachnoid space from the ventricular system. The pontine cistern is a space located on the ventral aspect of the pons. The cisterna magna is an opening on the subarachnoid space between the pia matter and the arachnoid.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 2
Incorrect
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A 64 year old diabetic man presents with a deep laceration of his lateral thigh which measures 3cm in depth by 7cm in length, that penetrates to the bone. There are no signs of fracture. His diabetes is diet controlled and is on low dose prednisolone therapy for polymyalgia rheumatica. Which of the following options should be employed most safely for the wound management of this patient?
Your Answer: Primary closure in layers
Correct Answer: Delayed primary closure
Explanation:Delayed primary closure is often intentionally applied to lacerations that are not considered clean enough for immediate primary closure. The wound is left open for 5-10 days; then, it is sutured closed to decrease the risk of wound infection. Improved blood flow at the wound edges, which develops increasingly over the first few days, is another benefit of this style of wound healing and can be associated with progressive increases in resistance to infections. The combination of diabetes and steroids makes wound complications more likely. Despite his high risk, a primary skin graft or flap is unlikely to be a safer option.
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This question is part of the following fields:
- Emergency Medicine And Management Of Trauma
- Principles Of Surgery-in-General
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Question 3
Correct
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A 76-year-old woman is diagnosed with diabetes mellitus after a urine test revealed she has glucosuria. Glucosuria may occur due to inadequate glucose reabsorption at:
Your Answer: Proximal convoluted tubule
Explanation:Glucose is reabsorbed almost 100% via sodium–glucose transport proteins (apical) and GLUT (basolateral) in the proximal convoluted tubule. Glycosuria or glucosuria is a condition of osmotic diuresis typical in those suffering from diabetes mellitus. Due to a lack of insulin, plasma glucose levels are above normal. This leads to saturation of receptors in the kidneys and glycosuria usually at plasma glucose levels above 11 mmol/l. Rarely, glycosuria is due to an intrinsic problem with glucose reabsorption within the kidneys (such as Fanconi syndrome), producing a condition termed renal glycosuria.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 4
Correct
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The basilar artery arises from the confluence of which two arteries?
Your Answer: Vertebral
Explanation:The basilar artery is part of the vertebrobasilar system. It is formed by the confluence of the two vertebral arteries which arise from the subclavian arteries. These two vertebral arteries merge at the level of cranial nerve VI at the junction between the pons and the medulla oblangata to form what is know as the basilar artery. This vertebrobasilar system supplies the upper spinal cord, brainstem, cerebellum, and posterior part of brain.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 5
Incorrect
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A 33 year old morbidly obese women is considered for bariatric surgery. Which of the options provided below would most likely be associated with the highest long term failure rates?
Your Answer: Gastric band
Correct Answer: Intra gastric balloon
Explanation:The intragastric balloon aids weight loss by slowing the rate at which food enters the stomach and by stimulating gastric stretch receptors. But lifestyle changes, including behaviour modification, exercise and a healthy diet, are crucial for maintaining weight loss once the device is removed. Intragastric balloon is really only suitable as a bridge to a more definitive surgical solution and is associated with a high failure rates and complications.
Gastric banding: band applied to upper stomach which can be inflated or deflated with normal saline. This affects satiety. Over a 5 year period complications requiring further surgery occur in up to 15% cases.
Roux-en-Y gastric bypass: a gastric pouch is formed and connected to the jejunum. Patients achieve greater and more long-term weight loss than gastric banding.
Sleeve gastrectomy: body and fundus resected to leave a small section of stomach
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This question is part of the following fields:
- Generic Surgical Topics
- Upper Gastrointestinal Surgery
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Question 6
Incorrect
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Following a fracture in the fibula, an artery contained in a fibrous canal between tibialis posterior and flexor hallucis longus was lacerated. Which of the following arteries was injured?
Your Answer: Posterior tibial
Correct Answer: Peroneal
Explanation:The peroneal artery is deeply seated at the back of the fibular side of the leg, contained in a fibrous canal between the tibialis posterior and the flexor hallucis longus.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 7
Correct
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An 80 year-old quadriplegic man has been lying supine for 7 weeks in a critical care ward. He develops a right lung abscess that is draining by gravity to a particular region of the lung. Which is the most likely site of pus collection?
Your Answer: Superior segment of the lower lobe
Explanation:The superior segmental bronchus of the lower lobe of the right lung branches posteriorly off the intermediate bronchus or the inferior lobe bronchus. It is therefore more likely to receive fluid or foreign bodies that enter the right main bronchus especially when the patient is supine.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 8
Correct
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A 21-year-old woman presents with intermittent diarrhoea for the past eight months and loss in weight of about two kilograms. Colonoscopy is carried out in which appearances of melanosis coli are identified. This is confirmed on biopsy. What could be the most likely cause of melanosis coli in this patient?
Your Answer: Laxative abuse
Explanation:Melanosis coli may have occurred as a result of laxative abuse in this patient.
Melanosis coli, also pseudomelanosis coli, is a disorder of pigmentation of the wall of the colon, often identified at the time of colonoscopy. It is benign, and may have no significant correlation with the disease. The brown pigment seen is lipofuscin in macrophages, not melanin.
According to the World Health Organisation (WHO), chronic diarrhoea is defined as lasting for more than 14 days. It is very common in irritable bowel syndrome (IBS). Patients may be divided into those with diarrhoea-predominant IBS and those with constipation-predominant IBS. Along with diarrhoea/constipation, clinical features such as abdominal pain, bloating, weight loss, change in bowel habit, lethargy, nausea, backache, and bladder symptoms are also seen. Bloody diarrhoea is more common in ulcerative colitis than in Crohn’s disease.
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This question is part of the following fields:
- Colorectal Surgery
- Generic Surgical Topics
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Question 9
Correct
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A 25 year old man is taken to the A&E department after being hit in the head with a batton. He opens his eyes to pain and groans or grunts. He extends his hands at the elbow on application of painful stimulus. What is his Glasgow coma score?
Your Answer: 6
Explanation:Answer: 6
Eye Opening Response
Spontaneous–open with blinking at baseline – 4 points
Opens to verbal command, speech, or shout – 3 points
Opens to pain, not applied to face – 2 point
None – 1 pointVerbal Response
Oriented – 5 points
Confused conversation, but able to answer questions – 4 points
Inappropriate responses, words discernible – 3 points
Incomprehensible speech – 2 points
None – 1 pointMotor Response
Obeys commands for movement – 6 points
Purposeful movement to painful stimulus – 5 points
Withdraws from pain – 4 points
Abnormal (spastic) flexion, decorticate posture – 3 points
Extensor (rigid) response, decerebrate posture – 2 points
None – 1 pointHe opens his eyes to pain and groans or grunts. He extends his hands at the elbow on application of painful stimulus. This gives him a Glasgow score of 6: eye opening response of 2, verbal response 2 and motor response 2.
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This question is part of the following fields:
- Emergency Medicine And Management Of Trauma
- Principles Of Surgery-in-General
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Question 10
Correct
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A 6 year old girl falls during dance class and fractures the growth plate of her left wrist. Which system can be used to classify the injury?
Your Answer: Salter - Harris system
Explanation:A Salter–Harris fracture is a fracture that involves the epiphyseal plate or growth plate of a bone, specifically the zone of provisional calcification. It is a common injury found in children, occurring in 15% of childhood long bone fractures.
There are nine types of Salter–Harris fractures; types I to V as described by Robert B Salter and W Robert Harris in 1963, and the rarer types VI to IX which have been added subsequently:
Type I – transverse fracture through the growth plate (also referred to as the physis): 6% incidence
Type II – A fracture through the growth plate and the metaphysis, sparing the epiphysis: 75% incidence, takes approximately 12-90 weeks or more in the spine to heal.
Type III – A fracture through growth plate and epiphysis, sparing the metaphysis: 8% incidence
Type IV – A fracture through all three elements of the bone, the growth plate, metaphysis, and epiphysis: 10% incidence
Type V – A compression fracture of the growth plate (resulting in a decrease in the perceived space between the epiphysis and metaphysis on x-ray): 1% incidence
Type VI – Injury to the peripheral portion of the physis and a resultant bony bridge formation which may produce an angular deformity (added in 1969 by Mercer Rang)
Type VII – Isolated injury of the epiphyseal plate (VII–IX added in 1982 by JA Ogden)
Type VIII – Isolated injury of the metaphysis with possible impairment of endochondral ossification
Type IX – Injury of the periosteum which may impair intramembranous ossificationThe mnemonic SALTER can be used to help remember the first five types.
N.B.: This mnemonic requires the reader to imagine the bones as long bones, with the epiphyses at the base.I – S = Slip (separated or straight across). Fracture of the cartilage of the physis (growth plate)
II – A = Above. The fracture lies above the physis, or Away from the joint.
III – L = Lower. The fracture is below the physis in the epiphysis.
IV – TE = Through Everything. The fracture is through the metaphysis, physis, and epiphysis.
V – R = Rammed (crushed). The physis has been crushed.
Alternatively, SALTER can be used for the first 6 types, as above but adding Type V — ‘E’ for ‘Everything’ or ‘Epiphysis’ and Type VI — ‘R’ for ‘Ring’. -
This question is part of the following fields:
- Generic Surgical Topics
- Orthopaedics
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Question 11
Correct
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A patient gives a history of dull discomfort in her abdomen associated with pain that she points to be on her right shoulder and right scapula. The following organs are most likely to be source of her pain:
Your Answer: Liver, duodenum and gallbladder
Explanation:Referred pain is felt at a point away from the source of the pain or the unpleasant sensation. It arises when a nerve is damaged or compressed at a point but the pain is felt at another site that is the territory of that nerve. Common abdominal causes of referred pain to the shoulder and the shoulder blade are the liver, duodenum and gall bladder.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 12
Incorrect
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A 1 week old baby boy is taken to the A&E department after a right sided groin swelling had been noticed. An examination is done and the testes are correctly located but there is a right sided inguinal hernia that is soft and easily reduced. Which of the following is the most appropriate management?
Your Answer: Surgery once the child is 6 months old
Correct Answer: Surgery over the next few days
Explanation:Answer: Surgery over the next few days
Inguinal hernia is a type of ventral hernia that occurs when an intra-abdominal structure, such as bowel or omentum, protrudes through a defect in the abdominal wall. Inguinal hernias do not spontaneously heal and must be surgically repaired because of the ever-present risk of incarceration. Generally, a surgical consultation should be made at the time of diagnosis, and repair (on an elective basis) should be performed very soon after the diagnosis is confirmed.
The infant or child with an inguinal hernia generally presents with an obvious bulge at the internal or external ring or within the scrotum. The parents typically provide the history of a visible swelling or bulge, commonly intermittent, in the inguinoscrotal region in boys and inguinolabial region in girls.
The swelling may or may not be associated with any pain or discomfort. -
This question is part of the following fields:
- Generic Surgical Topics
- Paediatric Surgery
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Question 13
Incorrect
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Endometrial hyperplasia is most likely to be associated with which of the following conditions?
Your Answer: Mature cystic teratoma
Correct Answer: Fibrothecoma
Explanation:A benign tumour arising from the ovarian stroma, fibrothecoma are bilateral in 10% cases. The thecoma component of the tumour can produce oestrogen leading to endometrial hyperplasia. The thecoma is rich in lipid content and is responsible for the yellowish appearance of the tumour. Meig’s syndrome is the presence of fibrothecoma with a right-sided hydrothorax.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 14
Correct
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A 5 year-old-child with fever complains of sore throat . She was brought to her paediatrician for consult because she has also developed a rash and has swollen lymph nodes. Upon physical examination she cried when her liver was palpated and the tip of her spleen is slightly palpable. Full blood count shows haemoglobin 13 g/dL, Haematocrit 40%, white blood cell count 13x109/L with a WBC differential count of 45 neutrophils, 4 bands, 26 lymphocytes, 15 atypical lymphocytesm, 10 monocytes and 1 eosinophil. Whick is the most likely infectious agent that is responsible for the patient's condition?
Your Answer: Epstein–Barr virus
Explanation:Epstein-Barr virus (EBV), also known as human herpes virus 4,is a member of the herpes virus family. EBV spreads most commonly through bodily fluids, primarily saliva. EBV can cause infectious mononucleosis. Symptoms of EBV can include fatigue, fever, inflamed throat, swollen lymph nodes in the neck, enlarged spleen, swollen liver and rash.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 15
Correct
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Question 16
Correct
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A surgeon performing a Whipple's procedure, that involves mobilizing the head of the pancreases, accidentally injured a structure immediately posterior to the neck of the pancreases which bled out. Which structure is most likely to have been injured?
Your Answer: Superior mesenteric artery
Explanation:The splenic vein runs behind the pancreas, receives the inferior mesenteric vein and joins the superior mesenteric vein to form the portal vein behind the pancreatic neck.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 17
Correct
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Injury to this nerve will result to the loss of general sensory innervation of the lacrimal gland:
Your Answer: Ophthalmic nerve
Explanation:The lacrimal glands are paired, almond-shaped exocrine glands, that secrete the aqueous layer of the tear film. The lacrimal nerve, derived from the ophthalmic nerve, supplies the sensory component of the lacrimal gland. The greater petrosal nerve, derived from the facial nerve, supplies the parasympathetic autonomic component of the lacrimal gland.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 18
Correct
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A 39 year old woman returns from a holiday trip in Nepal and presents to her doctor with painless jaundice. On examination there is no organomegaly and she is not deeply jaundiced. What is most likely cause of her illness?
Your Answer: Hepatitis A infection
Explanation:Hepatitis A is a viral liver disease that can cause mild to severe illness. The hepatitis A virus (HAV) is transmitted through ingestion of contaminated food and water or through direct contact with an infectious person.
The risk of hepatitis A infection is associated with a lack of safe water, and poor sanitation and hygiene (such as dirty hands). Unlike hepatitis B and C, hepatitis A does not cause chronic liver disease and is rarely fatal, but it can cause debilitating symptoms and fulminant hepatitis (acute liver failure), which is often fatal.
Prodrome
In the prodrome, patients may have mild flulike symptoms of anorexia, nausea and vomiting, fatigue, malaise, low-grade fever (usually < 39.5°C), myalgia, and mild headache. Smokers often lose their taste for tobacco, like persons presenting with appendicitis. Icteric phase
In the icteric phase, dark urine appears first (bilirubinuria). Pale stool soon follows, although this is not universal. Jaundice occurs in most (70%-85%) adults with acute HAV infection; it is less likely in children and is uncommon in infants. The degree of icterus also increases with age. Abdominal pain occurs in approximately 40% of patients. Itching (pruritus), although less common than jaundice, is generally accompanied by jaundice.Arthralgias and skin rash, although also associated with acute HAV infection, are less frequent than the above symptoms. Rash more often occurs on the lower limbs and may have a vasculitic appearance.
Relapsing hepatitis A
Relapsing hepatitis A is an uncommon sequela of acute infection, is more common in elderly persons, and is characterized by a protracted course of symptoms of the disease and a relapse of symptoms and signs following apparent resolution. -
This question is part of the following fields:
- Clinical Microbiology
- Principles Of Surgery-in-General
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Question 19
Correct
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A 57 year old male who had previously undergone a sigmoid colectomy for carcinoma returns to the clinic for a follow up. Imaging shows that he has a 3.1cm foci of metastatic disease in segment IV of the liver. What is the most appropriate course of action?
Your Answer: Chemotherapy followed by surgical resection
Explanation:Colorectal cancer is one of the most common types of cancer in Western populations. The liver is the first location of metastatic disease; as the main mechanism of dissemination is through the portal system. In addition, the liver may be the sole site of metastasis in 30 to 40% of patients with advanced disease.
Unfortunately, 20% of these patients will develop metastasis in the lungs and >50% in liver. In 20 to 25% of patients at the time of diagnosis, hepatic metastatic disease can be identified clinically, and 40 to 50% will develop during the first 3 years after the primary tumour is diagnosed.
When metastatic lesions are localized in the liver, which corresponds to 30% of patients, there are several options for localized treatment, such as hepatic partial resection, localized ablative therapy, administration of chemotherapy by infusion of the hepatic artery, systemic chemotherapy, and isolated hepatic fusion for patients with high doses of chemotherapy. Surgical resection is the most effective treatment for hepatic metastasis in colorectal cancer, but only a few patients are candidates for initial surgery. Patients with hepatic metastasis that cannot be surgically resected are managed initially with chemotherapy and later are subject to surgery, and these patients present a similar survival rate to those undergoing surgery initially.
Prior to hepatic resection, patients with hepatic metastatic disease frequently receive neoadjuvant chemotherapy, which can aid in disappearing or hidden radiological lesions.
The 5-year survival rate after hepatic resection is 25-40%. -
This question is part of the following fields:
- Colorectal Surgery
- Generic Surgical Topics
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Question 20
Correct
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A 49-year-old woman with acute renal failure has a total plasma [Ca2+] = 2. 5 mmol/l and a glomerular filtration rate of 160 l/day. What is the estimated daily filtered load of calcium?
Your Answer: 240 mmol/day
Explanation:Calcium is the most abundant mineral in the human body. The average adult body contains in total approximately 1 kg of calcium of which 99% is in the skeleton in the form of calcium phosphate salts. The extracellular fluid (ECF) contains approximately 22 mmol, of which about 9 mmol is in the plasma. About 40% of total plasma Ca2+ is bound to proteins and not filtered at the glomerular basement membrane. Therefore, the estimated daily filtered load is 1.5 mmol/l × 160 l/day = 240 mmol/day. The exact amount of free versus total Ca2+ depends on the blood pH: free Ca2+ increases during acidosis and decreases during alkalosis.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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SESSION STATS - PERFORMANCE PER SPECIALTY
