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Question 1
Incorrect
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Which of the following statements is true regarding the umbilical cord?
Your Answer: Attaches the fetus to the allantois
Correct Answer: Is filled with jelly of Wharton
Explanation:The umbilical cord that connects the fetus to the placenta is about 50cm long. This tissue consists of the body stalk and vitelline duct. The former containing the allantoic diverticulum and the umbilical vessels. The latter contains the connection linking the digestive tube and the yolk sac. This cord is wrapped by stratum of ectoderm and gelatinous tissue or jelly of Wharton. The right umbilical vein plus the vitelline vessels and ducts disappear and this at birth the cord has three vessels which are the umbilical vein and two umbilical arteries.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 2
Correct
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A 43 year old man presents with a perianal abscess which is managed by incision and drainage. The wound measures 2.5cm x 2.5cm. What is the best step in management?
Your Answer: Allow the wound to heal by secondary intention
Explanation:Answer: Allow the wound to heal by secondary intention
A perianal abscess is a type of anorectal abscess that is confined to the perianal space. Other causes can include inflammatory bowel diseases such as Crohn’s disease, as well as trauma, or cancerous origins. Patients with recurrent or complex abscesses should be evaluated for Crohn’s disease. Perianal abscesses are the most common type of anorectal abscesses. These abscesses can cause significant discomfort for patients. They are located at the anal verge and if left untreated can extend into the ischioanal space or intersphincteric space since these areas are continuous with the perianal space. They can also cause systemic infection if left untreated. Patients will complain of anal pain which may be dull, sharp, aching, or throbbing. This may be accompanied by fever, chills, constipation, or diarrhoea. Patients with perianal abscess typically present with pain around the anus, which may or may not be associated with bowel movements, but is usually constant. Purulent discharge may be reported if the abscess is spontaneously draining, and blood per rectum may be reported in a spontaneously draining abscess.
A physical exam can typically rule out other causes of anal pain, such as haemorrhoids, and will yield an area of fluctuance or an area of erythema and induration in the skin around the perianal area. Cellulitis should be noted and marked if extending beyond the fluctuant area.
Perianal abscesses are an indication for timely incision and drainage. Antibiotic administration alone is inadequate and inappropriate. Once incision and drainage are performed, there is no need for antibiotic administration unless certain medical issues necessitate the use. Such conditions include valvular heart disease, immunocompromised patients, diabetic patients, or in the setting of sepsis. Antibiotics are also considered in these patients or cases with signs of systemic infection or significant surrounding cellulitis.
Incision and drainage are typically performed in an office setting, or immediately in the emergency department. Local anaesthesia with 1% lidocaine may be administered to the surrounding tissues. A cruciate incision is made as close to the anal verge as possible to shorten any potential fistula formation. Blunt palpation is used to ensure no other septation or abscess pocket is missed. It is useful before completion of procedure to excise a skin flap of the cruciate incision or the tips of the four skin flaps to ensure adequate drainage and prevent premature healing of the skin over the abscess pocket. Packing may be placed initially for haemostasis. Continual packing may be further utilized for healing by secondary intention. Patients are encouraged to keep the incision and drainage site clean. Sitz baths may assist in pain relief.
More extensive abscesses may require the operating room for the adequate exam under anaesthesia to ensure adequate drainage, as well as inspect for other diseases such as fistula in ano.
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This question is part of the following fields:
- Peri-operative Care
- Principles Of Surgery-in-General
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Question 3
Incorrect
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A 35-year-old woman in her 37th week of pregnancy complains of urinary incontinence. She is most likely to have:
Your Answer: Functional incontinence
Correct Answer: Stress incontinence
Explanation:Urinary incontinence is the involuntary excretion of urine from one’s body. It is often temporary and it almost always results from an underlying medical condition. Several types include:
– Stress incontinence is the voiding of urine following increased abdominal pressure e.g. laughing, coughing, pregnancy etc. It is the most common form of incontinence in women, most commonly due to pelvic floor muscle weakness, physical changes from pregnancy, childbirth and menopause. In men it is a common problem following a prostatectomy. Most lab results such as urine analysis, cystometry and postvoid residual volume are normal.
– Urge incontinence is involuntary loss of urine occurring for no apparent reason while suddenly feeling the need or urge to urinate. The most common cause of urge incontinence are involuntary and inappropriate detrusor muscle contractions.
– Functional incontinence – occurs when a person does not recognise the need to go to the toilet, recognise where the toilet is or get to the toilet in time. The urine loss may be large. Causes of functional incontinence include confusion, dementia, poor eyesight, poor mobility, poor dexterity or unwillingness. t
– Overflow incontinence – sometimes people find that they cannot stop their bladders from constantly dribbling or continuing to dribble for some time after they have passed urine. -
This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 4
Correct
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A 64 year old man who has undergone a total hip replacement is given an infusion of packed red cells. Which of the following adverse effects is most likely to occur as a result of this treatment?
Your Answer: Pyrexia
Explanation:Acute transfusion reactions present as adverse signs or symptoms during or within 24 hours of a blood transfusion. The most frequent reactions are fever, chills, pruritus, or urticaria, which typically resolve promptly without specific treatment or complications.
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This question is part of the following fields:
- Post-operative Management And Critical Care
- Principles Of Surgery-in-General
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Question 5
Correct
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A 30-year-old female undergoes a renal transplant for focal segmental glomerulosclerosis. Within hours of the operation, the patient becomes unwell with features consistent with severe systemic inflammatory response syndrome. The patient is immediately taken back to the theatre and the transplanted kidney is removed. What type of immunoglobulins is responsible for graft rejection?
Your Answer: IgG
Explanation:Rejection is related primarily to activation of T cells, which, in turn, stimulate specific antibodies against the graft. Various clinical syndromes of rejection can be correlated with the length of time after transplantation.
Hyperacute rejection
Hyperacute rejection of the renal allograft happens in the operating room within hours of the transplant, when the graft becomes mottled and cyanotic. This type of rejection is due to unrecognized compatibility of blood groups A, AB, B, and O (ABO) or to a positive T-cell crossmatch (class I human leukocyte antigen [HLA] incompatibility).
It is thought that IgG antibodies from the host bind to HLA-1 antigen of the donated organ.
No treatment exists, and nephrectomy is indicated.Acute rejection
Acute rejection appears within the first 6 months after transplantation and affects approximately 15% of transplanted kidneys. Rejection is secondary to prior sensitization to donor alloantigens (occult T-cell crossmatch) or a positive B-cell crossmatch.
Acute tubular interstitial cellular rejection is the most common type of rejection reaction, with an incidence of approximately 20-25%. Typically, it occurs between 1 and 3 months after transplantation. It is T-cell mediated, and injury is directed to the renal tubules. The standard for diagnosis is renal allograft biopsy. Mild rejections may be successfully reversed with corticosteroids alone, whereas moderate or severe rejections may require the use of anti–T-cell antibodies, either polyclonal or monoclonal.
Late acute rejection is strongly correlated with the scheduled withdrawal of immunosuppressive therapy 6 months after transplantation.Chronic rejection
Chronic rejection occurs more than 1 year after transplantation and is a major cause of allograft loss. It is a slow and progressive deterioration in renal function characterized by histologic changes involving the renal tubules, capillaries, and interstitium. Its precise mechanism is poorly defined and is an area of intense study. Diagnosis is by renal biopsy, and treatment depends on the identified cause if any. Application of conventional antirejection agents (e.g., corticosteroids or anti–T-cell antibodies) does not appear to alter the progressive course. -
This question is part of the following fields:
- Generic Surgical Topics
- Organ Transplantation
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Question 6
Correct
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A 51-year-old man is brought to the A&E department following a road traffic accident. He complains of lower abdominal pain. On examination, fracture of the pelvis along with distended, tender bladder is observed. What is the most likely diagnosis?
Your Answer: Urethral injury
Explanation:Pelvic fractures may cause laceration of the urethra. Urinary retention, blood at the urethral meatus, and a high-riding prostate on digital rectal examination are the typical features of urethral injury.
Up to 10% of male pelvic fractures are associated with urethral or bladder injuries. Urethral injury occurs mainly in males. It has two types.
1.Bulbar rupture:
a. most common
b. mostly associated with straddle-type injury, e.g. from bicycles
c. presentation with a triad of urinary retention, perineal haematoma, and blood at the meatus2. Membranous rupture:
a. can be extra- or intraperitoneal
b. occurs commonly due to pelvic fracture
c. symptomology may include penile or perineal oedema/haematoma
d. prostate displaced upwards (high-riding prostate)Ascending urethrogram is carried out in patients of suspected urethral injury. Suprapubic catheter is surgically placed and is indicated in:
1. External genitalia injuries (i.e. the penis and the scrotum)
2. Injury to the urethra caused by penetration, blunt trauma, continence- or sexual pleasure–enhancing devices, and mutilation. -
This question is part of the following fields:
- Generic Surgical Topics
- Urology
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Question 7
Correct
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what is the cause of a prolonged PT(prothrombin time)?
Your Answer: Liver disease
Explanation:PT measure the intrinsic pathway of coagulation. It determines the measure of the warfarin dose regime, liver disease and vit K deficiency status along with the clotting tendency of blood. PT measured factors are II,V,VII,X and fibrinogen. It is used along with aPTT which measure the intrinsic pathway.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 8
Correct
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An experiment is carried out to observe engulfment and phagocytosis of microbes. Strep pneumoniae are added to a solution of leukocytes with a substance added to enhance the process of phagocytosis. What is this substance?
Your Answer: Complement C3b
Explanation:C3b is cleaved from C3 complement with the help of the enzyme C3- convertase. It binds to the cell surface of the offending substance and opsonizes it. This makes it easy for the phagocytes to detect and eliminate them.
IgM does not act as an opsonin but igG does.
Selectins aid leukocytes to bind to the endothelial surfaces.
C5a is a chemo-attractant and histamine a vasodilator.
NADPH oxidises offending substance after phagocytosis within the macrophage. -
This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 9
Correct
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A 30-year-old male patient is undergoing an open appendicectomy. The surgeons extend the incision medially and suddenly encounter troublesome bleeding. What should be the best course of action?
Your Answer: Ligate the bleeding vessel
Explanation:Medial extension of an appendicectomy incision carries a risk of injury to the inferior epigastric artery which can bleed briskly. It is best managed by ligation.
Bleeding is a complication encountered in all branches of surgery. The decision as to how best to manage the bleed, depends upon its site, vessel, and circumstances.
1. Superficial dermal bleeding:
This will usually cease spontaneously. If not, then direct use of a monopolar or a bipolar cautery device will usually control the situation. Scalp wounds are a notable exception and bleeding from them may be brisk. In this situation, use of a mattress suture as a wound closure method will usually address the problem.2. Superficial arterial bleeding:
If the vessel can be safely identified in superficial arterial bleeding, then the easiest method is to apply a haemostatic clip and ligate the vessel.3. Major arterial bleeding:
If the vessel can be clearly identified and is accessible, then it may be possible to apply a clip and ligate the vessel. If the vessel is located in a pool of blood, then blind application of haemostatic clips is highly dangerous and may result in collateral injury. In this situation, evacuating the clot and packing the area is often safer. The pack can then be carefully removed when the required instruments are available. Some vessels may retract and bleeding may then be controlled by dissection of surrounding structures or underrunning the bleeding point.4. Major venous bleeding:
The safest initial course of action is to apply digital pressure to the bleeding point. To control the bleeding, thereafter, the surgeon will need a working suction device. Divided veins may require ligation.5. Bleeding from raw surfaces:
This may be mixed bleeding and can be troublesome. Spray diathermy and argon plasma coagulation are both useful agents. Certain topical haemostatic agents, such as surgicel, are useful in encouraging clot formation and may be used in conjunction with, or instead of, the above agents. -
This question is part of the following fields:
- Principles Of Surgery-in-General
- Surgical Technique And Technology
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Question 10
Correct
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Diuretics that act on the ascending limb of the loop of Henle produce:
Your Answer: Reduced active transport of sodium
Explanation:The loop of Henlé leads from the proximal convoluted tubule to the distal convoluted tubule. Its primary function uses a counter current multiplier mechanism in the medulla to reabsorb water and ions from the urine. It can be divided into four parts:
1. Descending limb of loop of Henlé – low permeability to ions and urea, while being highly permeable to water 2. Thin ascending limb of loop of Henlé – not permeable to water, but it is permeable to ions
3. Medullary thick ascending limb of loop of Henlé – sodium (Na+), potassium (K+) and chloride (Cl–) ions are reabsorbed by active transport. K+ is passively transported along its concentration gradient through a K+ channel in the basolateral aspect of the cells, back into the lumen of the ascending limb.
4. The cortical thick ascending limb – the site of action where loop diuretics such as furosemide block the K+/Na+/2Cl− co-transporters = reduced active transport. -
This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 11
Correct
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A 47 year old female undergoes a kidney transplant which comes from a cadaver. She has an uncomplicated surgery but on removal of the vascular clamps, the transplanted kidney immediately turns dusky and over the next few hours appears non viable. Which of the following best explains this event?
Your Answer: Hyper acute rejection
Explanation:Hyperacute rejection occurs almost immediately following organ implantation and necessitates immediate explant of the organ. Hyperacute rejection is uncommon with pre-transplantation cross-matches and screening. Hyperacute rejection (HAR) of the kidney was first recognized 20 years ago in cases of donor-recipient incompatibility for the major blood group and tissue antigen systems. Classic pathological changes described include early accumulation of PMNs in glomeruli and peritubular capillaries, progressive glomerular thrombosis, tubular necrosis, and eventual cortical necrosis. Reaction of host humoral antibodies with antigens on donor cells serves as one trigger of the clotting mechanism, which then proceeds in a nonspecific fashion.
Antigen systems other than the ABO groups that contribute to HAR reactions are leukocyte antigens, endothelial and monocyte antigens, and B cell antigens. It is also documented that glomerular thrombosis identical to HAR may occur secondary to endothelial damage after pulsatile perfusion. However, in such cases no specific deposition of immunoglobulins and complement is detected.
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This question is part of the following fields:
- Generic Surgical Topics
- Organ Transplantation
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Question 12
Incorrect
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A 6-year-old boy undergoes a closure of a loop colostomy. Which of the following should be used as a thromboprophylaxis?
Your Answer: Daily low dose low molecular weight heparin until discharged
Correct Answer: None
Explanation:Clinical characteristics associated with increased venous thromboembolism (VTE) risk in children (listed alphabetically, owing to the current lack of expert consensus or robust data regarding relative risk contributions)
-Anticipated hospitalization > 72 h
-Cancer (active, not in remission)
-Central venous catheter presence
-Oestrogen therapy started within the last 1 month
-Inflammatory disease (newly diagnosed, poorly controlled, or flaring)
-Intensive care unit admission
-Mechanical ventilation
-Mobility decreased from baseline (Braden Q‐score < 2)
-Obesity (BMI > 99th percentile for age)
-Post pubertal age
-Severe dehydration, requiring intervention
-Surgery > 90 min within last 14 days
-Systemic or severe local infection (positive sputum/blood culture or viral test result, or empirical antibiotics)
-Trauma as admitting diagnosisPharmacological prophylaxis may be instituted in the following risk groups:
Children in an ICU with a CVC and one other risk factor fit a high‐risk profile and may benefit from pharmacological thromboprophylaxis in the absence of strong contraindications.
For children with either a CVC or admission to an ICU (but not both), two risk factors are recommended before the initiation of pharmacological thromboprophylaxis.
For children with neither a CVC nor ICU admission, at least three risk factors should be present before the initiation of pharmacological thromboprophylaxis. -
This question is part of the following fields:
- Peri-operative Care
- Principles Of Surgery-in-General
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Question 13
Incorrect
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Which of the following chemotherapy regimens is most likely to be used in colorectal cancer?
Your Answer: CHOP
Correct Answer: FOLFOX
Explanation:Chemotherapy regimens are often identified by acronyms, identifying the agents used in the drug combination. However, the letters used are not consistent across regimens. FOLFOX is a chemotherapy regimen used for the treatment of colorectal cancer, made up of the following drugs: • FOL: fluorouracil (5-fluorouracil or 5-FU) • F: folinic acid (leucovorin) • OX: oxaliplatin (Eloxatin®).
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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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Hormones of the anterior pituitary include which of the following?
Your Answer: Prolactin
Explanation:The anterior pituitary gland (adenohypophysis or pars distalis) synthesizes and secretes:
1. FSH (follicle-stimulating hormone)
2. LH (luteinizing hormone)
3. Growth hormone
4. Prolactin
5. ACTH (adrenocorticotropic hormone)
6. TSH (thyroid-stimulating hormone).
The posterior pituitary gland (neurohypophysis) stores and secretes 2 hormones produced by the hypothalamus:
1. ADH (antidiuretic hormone or vasopressin)
2. Oxytocin -
This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 15
Correct
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Glucose is not secreted by the kidneys, and is filtered without a limit. What is the transport maximum for glucose?
Your Answer: 300 mg/dl
Explanation:Transport maximum (or Tm) refers to the point at which increases in concentration do not result in an increase in movement of a substance across a membrane. Glucose is not secreted, thus excretion = filtration – reabsorption. Both filtration and reabsorption are directly proportional to the concentration of glucose in the plasma. However, reabsorption has a transport maximum of about 300 mg/dl in healthy nephrons, while filtration has effectively no limit (within reasonable physiological ranges). So, if the concentration rises above 300 mg/dl, the body cannot retain all the glucose, leading to glucosuria. Glucosuria is nearly always caused by elevated blood glucose levels, most commonly due to untreated diabetes mellitus.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 16
Correct
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A 4-year-old child was brought to a paediatrician for consult due to a palpable mass in his abdomen. The child has poor appetite and regularly complains of abdominal pain. The child was worked up and diagnosed with a tumour. What is the most likely diagnosis ?
Your Answer: Nephroblastoma
Explanation:Nephroblastoma is also known as Wilms’ tumour. It is a cancer of the kidneys that typically occurs in children. The median age of diagnose is approximately 3.5 years. With the current treatment, approximately 80-90% of children with Wilms’ tumour survive.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 17
Incorrect
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Question 18
Correct
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Which one of the following is a derivative of the midgut?
Your Answer: Caecum
Explanation:The primary intestinal loop is formed from the midgut which gives rise to the distal half of the duodenum, the jejunum, ascending colon, proximal two thirds of the transverse colon and the ileum.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 19
Incorrect
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Anthrax is an infection caused by the bacterium Bacillus anthracis. Anthrax spores have been used as a biological warfare weapon. What is the drug of choice in treating anthrax infection?
Your Answer: Tetracycline
Correct Answer: Ciprofloxacin
Explanation:Early antibiotic treatment of anthrax is essential. A delay may significantly lessen the chances for survival of the patient. Treatment for anthrax infection include large doses of intravenous and oral antibiotics, such as fluoroquinolones (ciprofloxacin), doxycycline, erythromycin, vancomycin, or penicillin.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 20
Incorrect
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An electronic manufacturing engineer had abdominal distension and underwent a CT scan of the abdomen. Thereafter he was diagnosed with hepatic angiosarcoma. Exposure to what agent is responsible for the development of this neoplasm?
Your Answer: Aflatoxin
Correct Answer: Arsenic
Explanation:Hepatic angiosarcomas are associated with particular carcinogens which includes: arsenic , thorotrast, and polyvinyl chloride. With exposure to this three agents, there is a very long latent period of many years between exposure and the development of tumours.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 21
Correct
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A 42-year old woman presents to the doctor with jaundice. Her investigations show conjugated hyperbilirubinemia, raised urine bilirubin levels and low urine urobilinogen levels. What is the likely cause of her jaundice?
Your Answer: Blockage of the common bile duct
Explanation:The description of the patient here fits the diagnosis of obstructive jaundice or cholestasis, which results in conjugated hyperbilirubinemia. Cholestasis occurs due to impairment of bile flow, which can be anywhere from the liver cell canaliculus to the ampulla of Vater. Causes can be divided into intrahepatic and extrahepatic.
– Intrahepatic causes include hepatitis, drug toxicity, alcoholic liver disease, primary biliary cirrhosis, cholestasis of pregnancy and metastatic cancer.
– Extrahepatic causes include common duct stone, pancreatic cancer, benign stricture of the common duct, ductal carcinoma, pancreatitis and sclerosing cholangitis.
There is absence of bile constituents in the intestine, which causes spillage in the systemic circulation. Symptoms include pale stools, dark urine, pruritus, malabsorption leading to steatorrhea and deficiency of fat-soluble vitamins. Chronic cases can result in osteoporosis or osteomalacia due to vitamin D deficiency and Ca2+ malabsorption. Cholesterol and phospholipid retention produces hyperlipidaemia despite fat malabsorption (although increased liver synthesis and decreased plasma esterification of cholesterol also contribute); triglyceride levels are largely unaffected. The lipids circulate as a unique, low-density lipoprotein called lipoprotein X. -
This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 22
Correct
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A 53-year-old female with a history of rheumatoid presents with a suspected septic knee joint. A diagnostic aspiration is performed and sent to microbiology. Which of the organisms below is most likely to be responsible?
Your Answer: Staphylococcus aureus
Explanation:Septic arthritis, also known as infectious arthritis, may represent a direct invasion of the joint space by various microorganisms, most commonly caused by bacteria.
Neisseria gonorrhoeae remains the most common pathogen (75% of cases) among younger sexually active individuals.
Staphylococcus aureus infection causes the vast majority of acute bacterial arthritis cases in adults and in children older than 2 years. -
This question is part of the following fields:
- Clinical Microbiology
- Principles Of Surgery-in-General
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Question 23
Correct
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The surgical registrar is doing an exploratory laparotomy on a 35 year old lady of African descent with tuberculous of the abdomen and suspected perforation. The small bowel is matted due to adhesions and it is difficult to differentiate the ileum from the jejunum. Which of the following features is typical of the jejunum?
Your Answer: It has sparse aggregated lymph nodules
Explanation:The jejunum has a wider diameter, is thicker and more vascularized, hence of a deeper colour compared to the ileum. The valvulae conniventes (circular folds) of its mucous membranes are large and thick and its villi are larger than those in the ileum. The jejunum also has sparse aggregates of lymph nodules and most of its part occupies the umbilical and left iliac regions whilst the ileum is mostly in the umbilical, hypogastric, right iliac and pelvic regions.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 24
Correct
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A 27 year old lady presents with bright red rectal bleeding that occurs after defecation and is seen in the toilet bowl and on the tissue. She is constipated but her bowel habit is otherwise normal. A digital rectal examination is done which is also normal. What is the most likely diagnosis?
Your Answer: Haemorrhoidal disease
Explanation:Answer: Haemorrhoidal disease
Haemorrhoids are a normal part of the anatomy of the anorectum. They are vascular cushions that serve to protect the anal sphincter, aid closure of the anal canal during increased abdominal pressure, and provide sensory information that helps differentiate among stool, liquid and gas. Because of their high vascularity and sensitive location, they are also a frequent cause of pathology. Contributing factors include pregnancy, chronic constipation, diarrhoea or prolonged straining, weight lifting, and weakening of supporting tissue as a result of aging or genetics.
Haemorrhoids are classified according to their position relative to the dentate line. External haemorrhoids lie below the dentate line, are covered by squamous epithelium and innervated by cutaneous nerves. If symptomatic, the only definitive therapy is surgical excision.
Internal haemorrhoids arise above the dentate line, are covered by columnar cells and have a visceral nerve supply. They are further categorized — and treated — according to their degree of prolapse:
-Grade I haemorrhoids bleed but do not prolapse; on colonoscopy, they are seen as small bulges into the lumen.
-Grade II haemorrhoids prolapse outside the anal canal but reduce spontaneously.
-Grade III haemorrhoids protrude outside the anal canal and usually require manual reduction.
-Grade IV haemorrhoids are irreducible and constantly prolapsed. Acutely thrombosed haemorrhoids and those involving rectal mucosal prolapse are also grade IV.Most gastrointestinal and surgical societies advocate anoscopy and/or flexible sigmoidoscopy to evaluate any bright-red rectal bleeding. Colonoscopy should be considered in the evaluation of any rectal bleeding that is not typical of haemorrhoids such as in the presence of strong risk factors for colonic malignancy or in the setting of rectal bleeding with a negative anorectal examination.
Anal fissures are tears of the sensitive mucosal lining of the anus. Anal fissures often cause pain during and after a bowel movement, sometimes followed by throbbing pain for several hours. They are also often associated with itching and blood on toilet tissue, in the bowl, or on the surface of the stool. Anal fissures are caused by
trauma to the anal canal usually during bowel movements. Anal fissures are also sometimes caused by inflammatory bowel disease or infection. -
This question is part of the following fields:
- Colorectal Surgery
- Generic Surgical Topics
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Question 25
Incorrect
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Which of the following muscles attach to the hyoid bone?
Your Answer: Sternothyroid
Correct Answer: Middle pharyngeal constrictor
Explanation:The hyoid bone is a horseshoe-shaped bone situated in the anterior midline of the neck between the chin and the thyroid cartilage. A large number of muscles attach to the hyoid: Superiorly – the middle pharyngeal constrictor muscle, hyoglossus muscle, genioglossus, intrinsic muscles of the tongue and suprahyoid muscles. Inferiorly – the thyrohyoid muscle, omohyoid muscle and sternohyoid muscle.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 26
Correct
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A blood sample from a patient with polycythaemia vera will show which of the following abnormalities?
Your Answer: High platelet count
Explanation:Polycythaemia is a condition that results in an increase in the total number of red blood cells (RBCs) in the blood. It can be due to a myeloproliferative syndrome, chronically low oxygen levels or rarely malignancy. In primary polycythaemia/ polycythaemia vera the increase is due to an abnormality in the bone marrow, resulting in increased RBCs, white blood cells (WBCs) and platelets. In secondary polycythaemia the increase occurs due to high levels of erythropoietin either artificially or naturally. The increase is about 6-8 million/cm3 of blood. A type of secondary polycythaemia is physiological polycythaemia where people living in high altitudes who are exposed to hypoxic conditions produce more erythropoietin as a compensatory mechanism for thin oxygen and low oxygen partial pressure.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 27
Incorrect
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After having donated a unit of blood. The blood bank will prefer to use which of the following anticoagulants to store the blood?
Your Answer: Heparin
Correct Answer: Citrate
Explanation:Calcium is necessary for coagulation to occur. Citrate being a chelator and combining with calcium ions to form un-ionised compound will prevent coagulation. Following transfusion the citrate is removed by the liver with in a few minutes. Oxalate also works on the same principle but it is toxic to the body.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 28
Incorrect
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Intravenous diazepam was administered to a man who was brought to the emergency department with status epilepticus. He was administered 15 l/min oxygen via a reservoir bag mask. Blood investigations showed sodium = 140 mmol/l, potassium = 4 mmol/l and chloride = 98 mmol/l. His arterial blood gas analysis revealed pH 7.08, p(CO2)= 61.5 mmHg, p(O2) = 111 mmHg and standard bicarbonate = 17 mmol/l. This patient had:
Your Answer: Metabolic acidosis
Correct Answer: Mixed acidosis
Explanation:Acidosis with high p(CO2) and low standard bicarbonate indicates mixed acidosis. Lower p(O2) is due to breathing of 70% oxygen. The prolonged seizures lead to lactic acidosis and the intravenous diazepam is responsible for the respiratory acidosis. Treatment includes airway manoeuvres and oxygen, assisted ventilation if needed, and treatment with fluids.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 29
Correct
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During a clinical rotation in the ENT clinic, you observe a flexible bronchoscopy. As the scope is passed down the trachea, you see a cartilaginous structure that resembles a ship's keel and separates the right and the left main stem bronchi. This structure is the:
Your Answer: Carina
Explanation:The carina (a keel-like cartilage) is found at the bifurcation of the trachea separating the right from the left main stem bronchi. It is a little more to the left than to the right.
The cricoid cartilage is the inferior and posterior cartilage of the larynx.
The costal cartilage on the other hand elongates the ribs anteriorly and contribute to the elasticity of the thoracic cage.
The pulmonary ligament is a fold of pleura located below the root of the lung.
Tracheal rings are rings of cartilage that support the trachea.
Peritracheal fascia is a layer of connective tissue that invests the trachea from the outside and is not visible on bronchoscopy. -
This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 30
Correct
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A 34-year-old woman presents with an itching and bleeding pigmented lesion on her right thigh. What should be the most appropriate step of management?
Your Answer: Excision biopsy
Explanation:This may be a case of malignant melanoma. Excision biopsy is required to allow accurate histological assessment. If the diagnosis is confirmed, re-excision of margins may be required. Incisional or punch biopsy of lesions suspected to be melanoma is avoided.
Various options used for the treatment of skin lesions include:
1. Trucut biopsy
2. Punch biopsy
3. Excision biopsy
4. Wide excision biopsy
5. Incisional biopsy -
This question is part of the following fields:
- Generic Surgical Topics
- Skin Lesions
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Question 31
Correct
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Which of the following toxins most likely results in continuous cAMP production, which pumps H2O, sodium, potassium, chloride and bicarbonate into the lumen of the small intestine and results in rapid dehydration?
Your Answer: Cholera toxin
Explanation:The cholera toxin (CTX or CT) is an oligomeric complex made up of six protein subunits: a single copy of the A subunit (part A), and five copies of the B subunit (part B), connected by a disulphide bond. The five B subunits form a five-membered ring that binds to GM1 gangliosides on the surface of the intestinal epithelium cells. The A1 portion of the A subunit is an enzyme that ADP-ribosylates G proteins, while the A2 chain fits into the central pore of the B subunit ring. Upon binding, the complex is taken into the cell via receptor-mediated endocytosis. Once inside the cell, the disulphide bond is reduced, and the A1 subunit is freed to bind with a human partner protein called ADP-ribosylation factor 6 (Arf6). Binding exposes its active site, allowing it to permanently ribosylate the Gs alpha subunit of the heterotrimeric G protein. This results in constitutive cAMP production, which in turn leads to secretion of H2O, Na+, K+, Cl−, and HCO3− into the lumen of the small intestine and rapid dehydration. The gene encoding the cholera toxin was introduced into V. cholerae by horizontal gene transfer.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 32
Correct
-
The tympanic membrane is a thin semi-transparent membrane that separates the tympanic cavity from the bottom of the external acoustic meatus. The interior of the tympanic membrane is innervated by which of the following cranial nerves?
Your Answer: Glossopharyngeal
Explanation:The glossopharyngeal nerve, known as the ninth cranial nerve (CN IX), is a mixed nerve that carries afferent sensory and efferent motor information. The glossopharyngeal nerve has five distinct general functions:
– The branchial motor (special visceral efferent), supplies the stylopharyngeus muscle.
– The visceral motor (general visceral efferent), provides parasympathetic innervation of the parotid gland via the otic ganglion.
– The visceral sensory (general visceral afferent), carries visceral sensory information from the carotid sinus and carotid body.
– The general sensory (general somatic afferent), provides general sensory information from the inner surface of the tympanic membrane, upper pharynx (GVA), and the posterior one-third of the tongue.
– The visceral afferent (special visceral afferent), provides taste sensation from the posterior one-third of the tongue, including the circumvallate papillae. -
This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 33
Incorrect
-
The circle of Willis is an arterial anastomosis in the base of the brain and is one of the cerebrovascular safeguards in the brain. Where is the circle of Willis contained?
Your Answer: Cisterna pontis
Correct Answer: Cisterna basalis
Explanation:Cisterns refers to a system of intercommunicating pools formed by the subarachnoid space at the base of the brain and around the brainstem. Cisterna basalis/basal cistern (interpeduncular cistern) is found at the base of the brain between the two temporal lobes and it contains the arterial circle of Willis. The lumbar cistern is contained in the spinal canal while the foramen magna refers to the opening at the base of the skull though which the spinal cord enters into the skull.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 34
Correct
-
What best describes the muscles of the posterior compartment of the leg?
Your Answer: One of the posterior compartment leg muscles laterally rotates the femur
Explanation:The muscles of the back of the leg are subdivided into two groups: superficial and deep. Superficial muscles include gastrocnemius, soleus and plantaris and are the chief extensors of the foot at the ankle joint. Deep muscles include the tibialis posterior, flexor hallucis longus, flexor digitorum longus and popliteus
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 35
Correct
-
A 30-year-old male has had a sore throat for the past 5 days. Over the past 24 hours, he has noticed increasing and severe throbbing pain in the region of his right tonsil. He has pyrexia and on examination, he is noted to have swelling of this area. What is the most likely cause?
Your Answer: Quinsy
Explanation:Patients with a Quinsy or peritonsillar abscess (PTA) typically present with a history of acute pharyngitis accompanied by tonsillitis and worsening unilateral pharyngeal discomfort. Patients also may experience malaise, fatigue, and headaches. They often present with a fever and asymmetric throat fullness. Associated halitosis, odynophagia, dysphagia, and a hot potato–sounding voice occurs.
The presentation may range from acute tonsillitis with unilateral pharyngeal asymmetry to dehydration and sepsis. Most patients have severe pain. Examination of the oral cavity reveals marked erythema, asymmetry of the soft palate, tonsillar exudation, and contralateral displacement of the uvula.
Indications for considering the diagnosis of a PTA include the following:
Unilateral swelling of the peritonsillar area
Unilateral swelling of the soft palate, with anterior displacement of the ipsilateral tonsil
Nonresolution of acute tonsillitis, with persistent unilateral tonsillar enlargement
A PTA ordinarily is unilateral and located at the superior pole of the affected tonsil, in the supratonsillar fossa. At the level of the supratonsillar fold, the mucosa may appear pale and even show a small pimple. Palpation of the soft palate often reveals an area of fluctuance. Flexible nasopharyngoscopy and laryngoscopy are recommended in patients experiencing airway distress. The laryngoscopy is key to ruling out epiglottitis and supraglottitis, as well as vocal cord pathology. -
This question is part of the following fields:
- Generic Surgical Topics
- Head And Neck Surgery
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Question 36
Incorrect
-
When a patient that is less than 21 years of age develops a bone tumour. What is the most common benign bone tumour that would be considered in individuals below 21 years?
Your Answer: Giant-cell tumour
Correct Answer: Osteochondroma
Explanation:Osteochondroma is a benign new bone growth that protrudes from the outer contour of bones and is capped by growing cartilage. Nearly 80% of these lesions are noted before the age of 21 years.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 37
Correct
-
Which of the following structures is not easily palpable?
Your Answer: Styloid process of the temporal bone
Explanation:The styloid process is a thin, pointed process that projects antero-inferiorly from the base of the petrous temporal bone. It can vary in length from a short, stubby process to a slender, four to five centimetre rod. It forms from the cranial elements of the second pharyngeal arch. The tympanic plate of the temporal bone ensheathes the base of this process. The pointed, projecting portion of the process provides attachment to the stylohyoid and stylomandibular ligaments, and to three muscles – the styloglossus, stylohyoid, and stylopharyngeus. As the styloid process is covered by the various muscles, it is not easily palpable in live subjects.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 38
Incorrect
-
A 60 year old woman develops an enterocutaneous fistula which is high output following a recent stricturoplasty. Her medical history shows that she has been suffering from small bowel Crohn's disease for the past 17 years. A small bowel follow through shows it to be 14 cm from the DJ flexure and her overlying skin is becoming excoriated. What is the most appropriate course of action?
Your Answer: Undertake a further laparotomy and construct a proximal diverting stoma
Correct Answer: Commence TPN and octreotide
Explanation:Total parenteral nutrition (TPN) is usually indicated with suspected gastric, duodenal, or small-bowel fistula. When the fistula output is very high, discontinuance of oral intake is recommended because oral intake stimulates further losses of fluids, electrolytes, and protein via the fistula. A decrease in fistula output frequently occurs with the initiation of TPN.
Volume depletion from a proximal high-output fistula can be controlled with the use of the long-acting somatostatin analogue octreotide, which acts by inhibiting GI hormones. The administration of octreotide reportedly diminishes fistula output, but whether it shortens the time required for fistula closure remains to be determined.
Draus et al recommended a 3-day trial of octreotide, maintaining that if the fistula output is reduced during this time, then administration of the drug should be continued. Two meta-analyses showed that somatostatin and its analogues decreased the time for fistula closure and increased the closure rate. -
This question is part of the following fields:
- Generic Surgical Topics
- The Abdomen
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Question 39
Correct
-
A 39 year old man presents to the clinic with a headache. His blood pressure is found to be 175/110 on routine screening. Examination shows no abnormalities. However, further investigations show a left-sided adrenal mass on CT. Labs reveal an elevated plasma level of metanephrines. Which of the following would be the most likely cause of this presentation?
Your Answer: Pheochromocytoma
Explanation:Hypertension in a young patient without any obvious cause should be investigated.
A pheochromocytoma is a catecholamine-secreting tumour typically located in the adrenal medulla. Pheochromocytomas are usually benign (∼ 90% of cases) but may also be malignant. Classic clinical features are due to excess sympathetic nervous system stimulation and involve episodic blood pressure crises with paroxysmal headaches, diaphoresis, heart palpitations, and pallor. However, a pheochromocytoma may also present asymptomatically or with persistent hypertension. Elevated catecholamine metabolites in the plasma or urine confirm the diagnosis, while imaging studies in patients with positive biochemistry are used to determine the location of the tumour. Surgical resection is the treatment of choice, but is only carried out once alpha blockade with phenoxybenzamine has become effective.
Pheochromocytoma is said to follow a 10% rule:
,10% are extra-adrenal
,10% are bilateral
,10% are malignant
,10% are found in children
,10% are familial
,10% are not associated with hypertension
,10% contain calcification -
This question is part of the following fields:
- Breast And Endocrine Surgery
- Generic Surgical Topics
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Question 40
Correct
-
A victim of road traffic accident presented to the emergency department with a blood pressure of 120/90 mm Hg, with a drop in systolic pressure to 100 mm Hg on inhalation. This is known as:
Your Answer: Pulsus paradoxus
Explanation:Weakening of pulse with inhalation and strengthening with exhalation is known as pulsus paradoxus. This represents an exaggeration of the normal variation of the pulse in relation to respiration. It indicates conditions such as cardiac tamponade and lung disease. The paradox refers to the auscultation of extra cardiac beats on inspiration, as compared to the pulse. Due to a decrease in blood pressure, the radial pulse becomes impalpable along with an increase in jugular venous pressure height (Kussmaul sign). Normal systolic blood pressure variation (with respiration) is considered to be >10 mmHg. It is >100 mmHg in Pulsus paradoxus. It is also predictive of the severity of cardiac tamponade.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 41
Correct
-
Coagulation in the body (in vivo) is a process in which several proteins known as coagulation factors are activated in a cascade effect to stop bleeding. Which of the following initiates this cascade effect?
Your Answer: Tissue factor
Explanation:Tissue factor (TF), also known as ‘factor III’ or ‘thromboplastin’, is an anti-coagulation protein that initiates the extrinsic coagulation. TF acts as a transmembrane receptor for Factor VII/VIIa . It is expressed by endothelial cells but also certain tissues, such as the heart and brain.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 42
Correct
-
The uterine artery arises from the?
Your Answer: Internal iliac artery
Explanation:The uterine artery arises from the anterior division of the internal iliac artery and runs medially on the levator ani towards the uterine cervix.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 43
Correct
-
A 20-year-old woman presents with a posteriorly-sited anal fissure. Treatment with stool softeners and topical GTN have failed to improve the condition. Which of the following would be the most appropriate next step of management?
Your Answer: Injection of botulinum toxin
Explanation:The most appropriate management option to consider, after GTN or other topical nitrates have failed, is botulinum toxin injection. In males, a lateral internal sphincterotomy would be an acceptable alternative. In a female who has yet to conceive, this may predispose to an increased risk of sphincter dysfunction. Moreover, division of the external sphincter would result in faecal incontinence and is not a justified treatment for anal fissure.
Anal fissures are a common cause of painful, bright red rectal bleeding. Most fissures are idiopathic and present as a painful mucocutaneous defect in the posterior midline (90% cases). Fissures are more likely to be anteriorly located in females, particularly if they are multiparous. Diseases associated with fissure-in-ano include:
1. Crohn’s disease
2. Tuberculosis
3. Internal rectal prolapseDiagnostic options are as follows:
In most cases, the defect can be visualised as a posterior midline epithelial defect. Where symptoms are highly suggestive of the condition and examination findings are unclear, an examination under anaesthesia may be helpful. Atypical disease presentation should be investigated by colonoscopy and EUA, with biopsies of the area.For management of anal fissure:
1. Stool softeners are important as hard stools may tear the epithelium and result in recurrent symptoms. The most effective first-line agents are topically applied GTN (0.2%) or Diltiazem (2%) paste.
2. Resistant cases may benefit from injection of botulinum toxin or lateral internal sphincterotomy. Advancement flaps may be used to treat resistant cases. -
This question is part of the following fields:
- Colorectal Surgery
- Generic Surgical Topics
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Question 44
Correct
-
A 30 year-old male patient sustained a sharp blow to the right side of the head, over the temporal region during a vehicular accident. This resulted to the rupture of the principal artery that supplies the meninges. Which artery is affected?
Your Answer: Middle meningeal artery
Explanation:The middle meningeal artery is typically the third branch of the first part of the maxillary artery, one of the two terminal branches of the external carotid artery. After branching off the maxillary artery in the infratemporal fossa, it runs through the foramen spinosum to supply the dura mater and the calvaria. The middle meningeal artery is the largest of the three (paired) arteries that supply the meninges, the others being the anterior meningeal artery and the posterior meningeal artery. The anterior branch of the middle meningeal artery runs beneath the pterion. It is vulnerable to injury at this point, where the skull is thin. Rupture of the artery may give rise to an epidural hematoma .An injured middle meningeal artery is the most common cause of an epidural hematoma.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 45
Correct
-
A 22-year-old woman is involved in a road traffic accident. After a transient period of concussion, she is found to have a GCS of 15, by the paramedics. She is next observed on her arrival at the A&E department of the hospital and is found to have a GCS of 3 and a blown right pupil. Out of the following, which condition best accounts for this deterioration?
Your Answer: Transtentorial herniation
Explanation:The presence of blown right pupil is a sign of the third cranial nerve compression. The most likely cause is an extradural bleed. However, since this option is not listed, transtentorial herniation would be the most applicable answer. Intraventricular bleeds are typically more common in premature neonates and deterioration due to hydrocephalus is more chronic. Subdural haematoma has a slower onset of symptoms.
Transtentorial herniation is a type of cerebral herniaton. It is further divided into two types with the uncal herniation being the most common.
1. Descending transtentorial herniation: more frequently known as uncal herniation
2. Ascending transtentorial herniation: less common than uncal herniationUncal (transtentorial) herniation is herniation of the medial temporal lobe from the middle into the posterior fossa, across the tentorial opening. The cardinal signs are an acute loss of consciousness associated with ipsilateral oculomotor nerve palsy with a fixed and dilated pupil (blown pupil) and contralateral hemiparesis.
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This question is part of the following fields:
- Generic Surgical Topics
- Surgical Disorders Of The Brain
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Question 46
Correct
-
During a normal respiratory exhalation, what is the recoil alveolar pressure?
Your Answer: +10 cmH2O
Explanation:To determine compliance of the respiratory system, changes in transmural pressures (in and out) immediately across the lung or chest cage (or both) are measured simultaneously with changes in lung or thoracic cavity volume. Changes in lung or thoracic cage volume are determined using a spirometer with transmural pressures measured by pressure transducers. For the lung alone, transmural pressure is calculated as the difference between alveolar (pA; inside) and intrapleural (ppl; outside) pressure. To calculate chest cage compliance, transmural pressure is ppl (inside) minus atmospheric pressure (pB; outside). For the combined lung–chest cage, transmural pressure or transpulmonary pressure is computed as pA – pB. pA pressure is determined by having the subject deeply inhale a measured volume of air from a spirometer. Under physiological conditions the transpulmonary or recoil pressure is always positive; intrapleural pressure is always negative and relatively large, while alveolar pressure moves from slightly negative to slightly positive as a person breathes.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 47
Correct
-
A patient in the recovery ward after cardiac surgery is noticed to have a small effusion in the lowest extent of the pleural cavity, into which no lung tissue extends. What is the name of this part of the pleural cavity?
Your Answer: Costodiaphragmatic recess
Explanation:The costodiaphragmatic recess is the part of the pleural cavity where the costal pleura is in continuity with the diaphragmatic pleura. It forms the lowest extent of the pleural cavity.
Costomediastinal recess: a tiny recess that is anteriorly located, where the costal pleura becomes continuous with the mediastinal pleura.
The cupola is the pleural cavity that extends above the first rib.
The inferior mediastinum refers to the posterior, middle and anterior mediastinal divisions together.
The pulmonary ligament on the other hand, is a pleural fold that is situated beneath the root of the lung on the medial aspect of the lung.
Oblique pericardial sinus is not part of the pleural cavity. -
This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 48
Incorrect
-
The superior ulnar collateral artery is a direct branch of this artery:
Your Answer: Ulnar
Correct Answer: Brachial
Explanation:The brachial artery gives rise to a small branch at the middle of the arm, which is the superior collateral artery. It descends accompanied by the ulnar nerve and anastomoses with the posterior ulnar recurrent and inferior ulnar collateral.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 49
Incorrect
-
Which of the following is a likely consequence of severe diarrhoea?
Your Answer: A metabolic alkalosis
Correct Answer: A decrease in the sodium content of the body
Explanation:Diarrhoea can occur due to any of the numerous aetiologies, which include infectious, drug-induced, food related, surgical, inflammatory, transit-related or malabsorption. Four mechanisms have been implicated in diarrhoea: increased osmotic load, increased secretion, inflammation and decreased absorption time. Diarrhoea can result in fluid loss with consequent dehydration, electrolyte loss (Na+, K+, Mg2+, Cl–) and even vascular collapse. Loss of bicarbonate ions can lead to a metabolic acidosis.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 50
Correct
-
Which one of the following groups of lymph nodes is most likely to be inflamed due to paronychia involving the big toe?
Your Answer: Vertical group of superficial inguinal lymph nodes
Explanation:Paronychia affecting the big toe will result in inflammation of the superficial inguinal lymph nodes as it drains lymph from the big toe.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 51
Correct
-
A 65-year old man, known with Type 2 diabetes and chronic renal failure, is likely to eventually present with which of the following conditions?
Your Answer: Secondary hyperparathyroidism
Explanation:When the parathyroid glands secrete excess parathyroid hormone (PTH) in response to hypocalcaemia, it is known as Secondary hyperparathyroidism and is often seen in patients with renal failure. In chronic renal failure, the kidneys fail to excrete adequate phosphorus and also fail to convert enough vitamin D to its active form. This leads to formation of insoluble calcium phosphate in the body which ultimately causes hypocalcaemia. The glands then undergo hyperplasia and hypertrophy leading to secondary hyperparathyroidism. Symptoms include bone and joint pains, along with limb deformities. The raised PTH also results in pleiotropic effects on blood, the immune system and nervous system.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 52
Correct
-
The glossopharyngeal nerve provides the parasympathetic innervation of the:
Your Answer: Parotid salivary gland
Explanation:The glossopharyngeal nerve provides parasympathetic innervation for the parotid salivary gland via the auriculotemporal nerve. The facial nerve supplies the parasympathetic innervation of the lacrimal, nasal, sublingual and submandibular glands.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 53
Correct
-
A 50-year old gentleman was recently diagnosed with hypertension, with no other abnormality on physical examination. Further investigations revealed the following : Na+ 144 mmol/l, K+ 3.0 mmol/l, Cl- 107 mmol/l, Bicarbonate 25 mmol/l. Blood glucose 5.8 mmol/l. What is the likely diagnosis?
Your Answer: Conn syndrome
Explanation:Overproduction of aldosterone (a mineralocorticoid) by the adrenal glands is known as Conn’s syndrome. It can be either due to an aldosterone-secreting adrenal adenoma (50-60% cases) or adrenal gland hyperplasia (40-50% cases). Excess aldosterone leads to sodium and water retention, along with potassium excretion. This leads to arterial (non-essential) hypertension. Conn’s syndrome is the commonest cause of primary hyperaldosteronism. Other symptoms include muscle cramps, headache (due to hypokalaemia) and metabolic alkalosis, which occurs due to increased secretion of H+ ions by the kidney. The raised pH of the blood traps calcium leading to symptoms of hypocalcaemia, which can be mimicked by liquorice ingestion and Liddle syndrome. To diagnose Conn’s syndrome, the ratio of renin and aldosterone is measured. Due to suppression of renin secretion, there is low renin to aldosterone ratio (<0.05). However, anti-hypertensives may affect the test results and should be withdrawn for 6 weeks. Computed tomography can also be done to detect the presence of adrenal adenoma.
Cushing’s syndrome does not cause hypokalaemia with normal serum glucose levels. Nelson’s syndrome refers to increased ACTH secretion due to pituitary adenoma. Pheochromocytoma will not lead to hypokalaemia even though hypertension can be seen. -
This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 54
Correct
-
A 28-year old lady comes to the surgical clinic with a recently detected lump in her right breast. On examination, the lump is found to be 1cm, rubbery, mobile with no palpable axillary nodes. Mammography reveals no microcalcifications and the opposite breast appears normal. What is the likely diagnosis?
Your Answer: Fibroadenoma
Explanation:A benign breast tumour, fibroadenoma is common below the age of 30 years and occurs due to oestrogenic excess. It is characterised by proliferation of both glandular and stromal elements. Fibroadenomas are usually solitary and are mobile, not fixed to surrounding structures. The tumour is elastic, nodular and encapsulated with a grey-white cut surface. The two main histological types include intracanalicular and pericanalicular types, with both types often present in the same tumour. In the intracanalicular type, the stromal proliferation component predominates causing compression of ducts making them appear slit-like. In pericanalicular type, the fibrous stroma dominates around the ductal spaces so that they remain oval on cross section.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 55
Correct
-
A 56 year old man presenting with acute appendicitis undergoes an appendicectomy through a lower midline laparotomy incision. Which of the following would be the best option for providing post operative analgesia?
Your Answer: Patient controlled analgesic infusion
Explanation:Patient-controlled analgesia (PCA) is a delivery system with which patients self-administer predetermined doses of analgesic medication to relieve their pain. The use of PCA in hospitals has been increasing because of its proven advantages over conventional intramuscular injections. These include improved pain relief, greater patient satisfaction, less sedation and fewer postoperative complications.
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This question is part of the following fields:
- Peri-operative Care
- Principles Of Surgery-in-General
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Question 56
Correct
-
An organ transplant patient may be at risk of developing which type of cancer?
Your Answer: Skin cancer
Explanation:The most common malignancies encountered in the post–solid organ transplant setting are non-melanoma skin cancers, post-transplant lymphoproliferative disorders and Kaposi’s sarcoma (KS). The pathogenesis of these tumours is likely related to the immunosuppressive drugs used post-transplantation and subsequent viral infection.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 57
Correct
-
An 11 year old girl undergoes a delayed open reduction and fixation of a significantly displaced supracondylar fracture. She complains of paraesthesia of the hand and significant forearm pain. The radial pulse is normal. What is the best course of action?
Your Answer: Fasciotomy
Explanation:Answer: Fasciotomy
Fasciotomy is a surgical procedure where the fascia is cut to relieve tension or pressure commonly to treat the resulting loss of circulation to an area of tissue or muscle. Fasciotomy is a limb-saving procedure when used to treat acute compartment syndrome. A delay in performing the procedure can lead to neurovascular complications or lead to the need for amputation of a limb. Complications can also involve the formation of scar tissue after the operation. A thickening of the surgical scars can result in the loss of mobility of the joint involved. This can be addressed through occupational or physical therapy.
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This question is part of the following fields:
- Generic Surgical Topics
- Orthopaedics
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Question 58
Correct
-
A 60 year old alcoholic man is seen in the A&E department. When asked his reason for being there, he says he is looking for a place to sleep for the night. He is examined by one of the doctors and has no evidence of trauma, a skull x-ray fails to show any evidence of fracture. He is placed on observation and ten hours later, he develops a sudden onset headache, falls into a coma and then dies. What is the most likely cause?
Your Answer: Sub arachnoid haemorrhage
Explanation:The classic symptom of subarachnoid haemorrhage is thunderclap headache (a headache described as like being kicked in the head, or the worst ever, developing over seconds to minutes). This headache often pulsates towards the occiput (the back of the head). About one-third of people have no symptoms apart from the characteristic headache, and about one in ten people who seek medical care with this symptom are later diagnosed with a subarachnoid haemorrhage. Vomiting may be present, and 1 in 14 have seizures. Confusion, decreased level of consciousness or coma may be present, as may neck stiffness and other signs of meningism.
In 85 percent of spontaneous cases the cause is a cerebral aneurysm—a weakness in the wall of one of the arteries in the brain that becomes enlarged. They tend to be located in the circle of Willis and its branches. While most cases are due to bleeding from small aneurysms, larger aneurysms (which are less common) are more likely to rupture. Aspirin also appears to increase the risk.
In 15–20 percent of cases of spontaneous SAH, no aneurysm is detected on the first angiogram. About half of these are attributed to non-aneurysmal perimesencephalic haemorrhage, in which the blood is limited to the subarachnoid spaces around the midbrain (i.e. mesencephalon). In these, the origin of the blood is uncertain. The remainder are due to other disorders affecting the blood vessels (such as cerebral arteriovenous malformations), disorders of the blood vessels in the spinal cord, and bleeding into various tumours.
Genetics may play a role in a person’s disposition to SAH; risk is increased three- to fivefold in first-degree relatives of people having had a subarachnoid haemorrhage. But lifestyle factors are more important in determining overall risk. These risk factors are smoking, hypertension (high blood pressure), and excessive alcohol consumption.
The absence of trauma and skull fracture rules out the other types of haemorrhages and haematomas. -
This question is part of the following fields:
- Generic Surgical Topics
- Surgical Disorders Of The Brain
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Question 59
Correct
-
Which of the following compensatory parameters is responsible for causing an increase in the blood pressure in a 30 year old patient with a BP of 40 mmHg?
Your Answer: Baroreceptor reflex
Explanation:The baroreflex or baroreceptor reflex is one of the body’s homeostatic mechanisms for regulating blood pressure. It provides a negative feedback response in which an elevated blood pressure will causes blood pressure to decrease; similarly, decreased blood pressure depresses the baroreflex, causing blood pressure to rise. The system relies on specialised neurones (baroreceptors) in the aortic arch, carotid sinuses and elsewhere to monitor changes in blood pressure and relay them to the brainstem. Subsequent changes in blood pressure are mediated by the autonomic nervous system. Baroreceptors include those in the auricles of the heart and vena cava, but the most sensitive baroreceptors are in the carotid sinuses and aortic arch. The carotid sinus baroreceptors are innervated by the glossopharyngeal nerve (CN IX); the aortic arch baroreceptors are innervated by the vagus nerve (CN X).
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 60
Correct
-
A 29-year-old man who plays social rugby presents with recurrent anterior dislocation of the right shoulder. Which of the following abnormalities is most likely to be present?
Your Answer: Bankart lesion
Explanation:This patient has a Bankart lesion which is the most common underlying abnormality in recurrent anterior dislocation of the shoulder.
Bankart lesion is an injury of the anterior (inferior) glenoid labrum of the shoulder due to anterior shoulder dislocation. When this happens, a pocket at the front of the glenoid forms that allows the humeral head to dislocate into it. It is usually visualised by CT and MRI scanning and is often repaired arthroscopically.
Shoulder fractures and dislocations usually result from low-energy falls in predominantly elderly females or from high-energy trauma in young males. They can be associated with nerve injury (commonly axillary), and fracture-dislocation of the humeral head. Anterior shoulder dislocation (glenohumeral dislocation) is the most common type of shoulder dislocation (>90%) and is usually traumatic in nature.
Early assessment of shoulder dislocation:
Careful history, examination, and documentation of neurovascular status of the upper limb, in particular the axillary nerve, is important. This should be re-assessed after manipulation. Early radiographs should also be done to confirm the direction of the dislocation.Initial management of anterior dislocation:
It consists of emergent closed reduction (to prevent lasting chondral damage) under Entonox and analgesia, but often requires conscious sedation. The affected arm should then be immobilised in a polysling. Initial management requires emergent reduction to prevent lasting chondral damage. -
This question is part of the following fields:
- Emergency Medicine And Management Of Trauma
- Principles Of Surgery-in-General
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Question 61
Correct
-
Injury of the ventral rami at this cervical spinal level will result in paralysis of the rectus capitis anterior muscle:
Your Answer: C1, C2
Explanation:The rectus capitis anterior is a short, flat muscle, situated immediately behind the upper part of the longus capitis. It is also known as the obliquus capitis superior. It aids in flexion of the head and the neck. Nerve supple is from C1 and C2.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 62
Incorrect
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A 3 month old infant is taken to the hospital after she is observed to have jaundice. Tests show an elevated conjugated bilirubin level. Diagnosis is confirmed by cholangiography during surgery. Which of the following is the best course of action?
Your Answer: Choledochoduodenostomy
Correct Answer: Roux-en-Y portojejunostomy
Explanation:In most cases of atresia, dissection into the porta hepatis and creation of a Roux-en-Y anastomosis with a 35 to 40-cm retro colic jejunal segment is the procedure of choice.
In the unusual circumstance of distal patency of the common duct with acceptable proximal luminal calibre, a modified portoenterostomy may be considered in place of the traditional Kasai procedure. However, the clinician must be aware that progression of disease pathophysiology may occur.Biliary atresia is characterized by obliteration or discontinuity of the extrahepatic biliary system, resulting in obstruction to bile flow. Regardless of aetiology, the clinical presentation of neonatal cholestasis is remarkably similar in most infants.
Typical symptoms include variable degrees of jaundice, dark urine, and light stools. In the case of biliary atresia, most infants are full-term, although a higher incidence of low birthweight may be observed. In most cases, acholic stools are not noted at birth but develop over the first few weeks of life. Appetite, growth, and weight gain may be normal.
Physical findings do not identify all cases of biliary atresia. No findings are pathognomonic for the disorder. Infants with biliary atresia are typically full term and may manifest normal growth and weight gain during the first few weeks of life.
Hepatomegaly may be present early, and the liver is often firm or hard to palpation. Splenomegaly is common, and an enlarging spleen suggests progressive cirrhosis with portal hypertension.
Direct hyperbilirubinemia is always an abnormal finding and it is typically present from birth in the foetal/embryonic form. Consider biliary atresia in all neonates with direct hyperbilirubinemia.
In the more common postnatal form, physiologic jaundice frequently merges into conjugated hyperbilirubinemia. The clinician must be aware that physiologic unconjugated hyperbilirubinemia rarely persists beyond 2 weeks. Infants with prolonged physiologic jaundice must be evaluated for other causes.
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This question is part of the following fields:
- Generic Surgical Topics
- Paediatric Surgery
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Question 63
Incorrect
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The dilator pupillae muscle is innervated by postganglionic sympathetic fibres. Where do the postganglionic sympathetic fibres originate?
Your Answer: Ciliary ganglion
Correct Answer: Superior cervical ganglion
Explanation:The postganglionic sympathetic axons are derived from the superior cervical ganglion and innervate the eye and lacrimal gland allowing for vasoconstriction of the iris and sclera, pupillary dilation, widening of the palpebral fissure, and a reduction in tear production.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 64
Correct
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During laparoscopic surgery to repair a direct inguinal hernia in a 68-year old man, the surgeon asked the registrar to look at the medial inguinal fossa to identify the direct inguinal hernia. To do so, she would have to look at the area that is between the:
Your Answer: Medial umbilical ligament and inferior epigastric artery
Explanation:The medial umbilical fold is made by the medial umbilical ligament-which is the obliterated portion of the umbilical artery, while the lateral umbilical fold is a fold of peritoneum over the inferior epigastric vessels. The median umbilical fold is a midline structure made by the median umbilical ligament i.e. the obliterated urachus. The medial inguinal fossa is the space on the inner abdominal wall between the medial umbilical fold and the lateral umbilical fold. It is place in the abdominal wall where there is an area of weak fascia i.e. the inguinal triangle through which direct inguinal hernias break through. The lateral inguinal fossa on the other hand is a space lateral to the lateral umbilical fold. Indirect inguinal hernias push through this space.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 65
Correct
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During pregnancy the uterus enlarges however after delivery it regresses to its original size. Which of the following organelles is responsible for this regression?
Your Answer: Lysosomes
Explanation:Lysosomes are formed by budding of the Golgi apparatus and contain enzymes which digest macromolecules. They are found in both plants and animals and are active in autophagic cell death, digestion after phagocytosis and for the cells own recycling process. They fuse with the molecules and release their content resulting in digestion.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 66
Correct
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The neurotransmitters adrenaline, noradrenaline and dopamine are derived from which amino acid?
Your Answer: Tyrosine
Explanation:Tyrosine is the precursor to adrenaline, noradrenaline and dopamine. Tyrosine hydroxylase converts tyrosine to DOPA, which is in turn converted to dopamine, then to noradrenaline and finally adrenaline.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 67
Incorrect
-
An 18 year old male is given a total of 6 litres of 0.9% sodium chloride solution, over 24 hours after having an elective right hemicolectomy. Which of the following complications may develop?
Your Answer: Hyperchloremic alkalosis
Correct Answer: Hyperchloremic acidosis
Explanation:Answer: Hyperchloremic acidosis
Hyperchloremic acidosis is a form of metabolic acidosis associated with a normal anion gap, a decrease in plasma bicarbonate concentration, and an increase in plasma chloride concentration. In general, the cause of a hyperchloremic metabolic acidosis is a loss of base, either a gastrointestinal loss or a renal loss.
1) Gastrointestinal loss of bicarbonate (HCO3-)
-Severe diarrhoea (vomiting will tend to cause hypochloraemic alkalosis)
-Pancreatic fistula with loss of bicarbonate rich pancreatic fluid
-Nasojejunal tube losses in the context of small bowel obstruction and loss of alkaline proximal small bowel secretions
-Chronic laxative abuse
2) Renal causes
-Proximal renal tubular acidosis with failure of (HCO3-) resorption
-Distal renal tubular acidosis with failure of H+
secretion
-Long-term use of a carbonic anhydrase inhibitor such as acetazolamide
3) Other causes
-Ingestion of ammonium chloride, hydrochloric acid, or other acidifying salts
-The treatment and recovery phases of diabetic ketoacidosis
-Volume resuscitation with 0.9% normal saline provides a chloride load, so that infusing more than 3-4L can cause acidosis
-Hyperalimentation (i.e., total parenteral nutrition).This patient received 6L of 0.9% normal saline which lead to hyperchloremic acidosis.
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This question is part of the following fields:
- Post-operative Management And Critical Care
- Principles Of Surgery-in-General
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Question 68
Incorrect
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Muscles and tendons in the planter region of the foot mainly take blood supply from:
Your Answer: Anterior tibial artery
Correct Answer: Posterior tibial artery
Explanation:The posterior tibial artery is the main source of blood supply to the posterior compartment of the leg.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 69
Incorrect
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A 68 year old man, known with colorectal carcinoma, is currently taking MST 30mg twice a day for pain relief. Which of the following doses of morphine would be the most adequate for breakthrough pain?
Your Answer: 15 mg
Correct Answer: 10 mg
Explanation:If pain occurs between regular doses of morphine (‘breakthrough pain’), an additional dose (‘rescue dose’) of immediate-release morphine should be given. Breakthrough dose = 1/6th of daily morphine dose
The total daily morphine dose is 30 * 2 = 60 mg, therefore the breakthrough dose should be one-sixth of this, 10 mg.
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This question is part of the following fields:
- Oncology
- Principles Of Surgery-in-General
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Question 70
Incorrect
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A pedestrian sustained a left fibula fractured following a hit-and-run. X-rays showed that there was a transverse fracture of the upper end of the fibula. It was manifested clinically by inability to flex his foot at the ankle joint plus weak extension of the phalanges. What nerve is suspected to be injured in such a case?
Your Answer: Tibial
Correct Answer: Deep peroneal
Explanation:The deep peroneal nerve supplies the muscles allowing for flexion of the foot at the ankle joint, namely the tibialis anterior and peroneus tertius muscles. The peroneus tertius, peroneus brevis, and peroneus longus evert the foot, whereas the tibialis anterior and tibialis posterior invert the foot. Fibres of the deep peroneal nerve originate from L4, L5, and S1.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 71
Incorrect
-
Below which level of the spinal cord will the inferior gluteal nerve be unaffected?
Your Answer: L5
Correct Answer: S3
Explanation:The inferior gluteal nerve arises from the dorsal divisions of the fifth lumbar and first and second sacral nerves. According to this fact any lesion at or below the S3 will not affect the inferior gluteal nerve.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 72
Incorrect
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Which of the following diseases causes abrupt vertigo, nausea, vomiting, tinnitus, and nystagmus?
Your Answer: Guillain–Barré syndrome
Correct Answer: Vestibular neuronitis
Explanation:Vestibular neuronitis or labyrinthitis causes a self-limited episode of vertigo, presumably due to inflammation of the vestibular division of cranial nerve VIII. Its causes are unknown, It may be due to a virus, but it can be related to a bacterial infection, head injury, stress, allergy, or as a reaction to medication. Symptoms can last up to 7-10 days.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 73
Incorrect
-
Which of the following is NOT true regarding malignant hyperpyrexia
Your Answer: It can be caused by suxamethonium
Correct Answer: It can be caused by nitrous oxide
Explanation:Malignant hyerpyrexia occurs in 1 in 150,000. All inhalational anaesthetic agents and suxamethonium, except nitrous oxide can cause malignant hyperpyrexia.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 74
Incorrect
-
A 26-year-old female presents to her GP complaining of a two day history of right upper quadrant pain, fever and a white vaginal discharge. She has seen the GP twice in 12 weeks complaining of pelvic pain and dyspareunia. What is the most likely cause?
Your Answer: Ruptured ectopic pregnancy
Correct Answer: Pelvic inflammatory disease
Explanation:Pelvic inflammatory disease (PID) is an infectious and inflammatory disorder of the upper female genital tract, including the uterus, fallopian tubes, and adjacent pelvic structures. Infection and inflammation may spread to the abdomen, including perihepatic structures (Fitz-Hugh−Curtis syndrome). The classic high-risk patient is a menstruating woman younger than 25 years who has multiple sex partners, does not use contraception, and lives in an area with a high prevalence of sexually transmitted disease (STD).
PID is initiated by an infection that ascends from the vagina and cervix into the upper genital tract. Chlamydia trachomatis is the predominant sexually transmitted organism associated with PID. Of all acute PID cases, less than 50% test positive for the sexually transmitted organisms such as Chlamydia trachomatis and Neisseria gonorrhoea.
Other organisms implicated in the pathogenesis of PID include Gardnerella vaginalis (which causes bacterial vaginosis (BV), Haemophilus influenzae, and anaerobes such as Peptococcus and Bacteroides species. Laparoscopic studies have shown that in 30-40% of cases, PID is polymicrobial.
The most common presenting complaint is lower abdominal pain. Abnormal vaginal discharge is present in approximately 75% of cases. Unanticipated vaginal bleeding, often postcoital, is reported in about 40% of cases. Temperature is higher than 38°C (found in 30% of cases), nausea, and vomiting manifest late in the clinical course of the disease. Abnormal uterine bleeding is present in more than one-third of patients.
Right upper quadrant tenderness, especially if associated with jaundice, may indicate associated Fitz-Hugh−Curtis syndrome. -
This question is part of the following fields:
- Generic Surgical Topics
- The Abdomen
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Question 75
Incorrect
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A 60 year-old patient being treated for hypertension presents to the ED with swelling of the left upper limb due to poor venous return. On examination, it is found that an aneurysm of the ascending aorta is impinging on a large vein lying immediately anterosuperior to it. Which vein is it likely to be?
Your Answer: Left superior intercostal
Correct Answer: Left brachiocephalic
Explanation:Among the veins listed, only the left brachiocephalic vein is anterosuperior to the ascending aorta. The right brachiocephalic vein being on the right side would not be affected by the aortic aneurysm.
The azygos vein lies deep in the chest on the right side.
The internal thoracic vein lies interior to the anterior wall of the chest.
The left superior intercostal vein is close to the aortic arch, crossing it laterally. This vein drains the 2nd to 4th interspaces on the left side.
The Right internal jugular vein joins the right brachiocephalic vein which would not be affected by the aneurysm. -
This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 76
Correct
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A computer tomography guided needle biopsy is done on a patient with a cystic swelling in the left chest. The radiologist inserted the biopsy needle into the 9th intercostal space along the mid axillary line to aspirate the swelling and obtain tissue for histological diagnosis. In which space is the swelling most likely to be?
Your Answer: Costodiaphragmatic recess
Explanation:The costodiaphragmatic recess is the lowest point of the pleural sac where the costal pleura becomes the diaphragmatic pleura. At the midclavicular line, this is found between ribs 6 and 8; at the paravertebral lines, between ribs 10 and 12 and between ribs 8 and 10 at the midaxillary line.
The cardiac notch: is an indentation of the heart on the left lung, located on the anterior surface of the lung.
Cupola: part of the parietal pleura that extends above the first rib.
Oblique pericardial sinus: part of the pericardial sac located posterior to the heart behind the left atrium.
Costomediastinal recess: a reflection of the pleura from the costal surface to the mediastinal surface, is on the anterior surface of the chest.
The inferior mediastinum: is the space in the chest occupied by the heart. -
This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 77
Incorrect
-
A 66 year old male, was involved in a MVA. He sustained third degree burns to his abdomen and open bleeding wound to his left leg. The patient complains of dizziness. He is a known hypertensive but during examination was found to be hypotensive. His heart rate is 120/min, with regular rhythm. What is the possible cause of his hypotension?
Your Answer: Occluded Foley catheter
Correct Answer: Hypovolaemia
Explanation:Hypovolemia can be recognized by tachycardia, diminished blood pressure, and the absence of perfusion as assessed by skin signs (skin turning pale) and/or capillary refill time. The patient may feel dizzy, faint, nauseated, or very thirsty. Common causes of hypovolemia are loss of blood, loss of plasma which occurs in severe burns and lesions discharging fluid, loss of body sodium and consequent intravascular water which may occur in cases of diarrhoea and vomiting. In this case the cause of patients hypotension is due to hypovolemia from both loss of plasma and blood.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 78
Incorrect
-
The superior pancreaticoduodenal artery, the artery that supplies blood to the pancreas and the duodenum, is a branch of the:
Your Answer: Coeliac artery
Correct Answer: Gastroduodenal artery
Explanation:The superior pancreaticoduodenal artery together with the right gastroepiploic artery form the two branches of the gastroduodenal artery which divides at the lower border of the duodenum.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 79
Incorrect
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A 29-year-old woman is brought to the A&E department with chest pain after being involved in a road traffic accident. Clinical examination is essentially unremarkable and she is discharged. However, she is subsequently found dead at home. What could have been the most likely underlying injury?
Your Answer: Diaphragmatic rupture
Correct Answer: Traumatic aortic disruption
Explanation:Aortic injuries not resulting in immediate death may be due to a contained haematoma. Clinical signs are subtle, and diagnosis may not be apparent on clinical examination. Without prompt treatment, the haematoma usually bursts and the patient dies.
Traumatic aortic disruption, or aortic transection, is typically the result of a blunt aortic injury in the context of rapid deceleration. This condition is commonly fatal as blood in the aorta is under great pressure and can quickly escape the vessel through a tear, resulting in rapid haemorrhagic shock and death. A temporary haematoma may prevent the immediate death. Injury to the aorta during a sudden deceleration commonly originates near the terminal section of the aortic arch, also known as the isthmus. This portion lies just distal to the take-off of the left subclavian artery at the intersection of the mobile and fixed portions of the aorta. As many as 80% of the patients with aortic transection die at the scene before reaching a trauma centre for treatment.
A widened mediastinum may be seen on the X-ray of a person with aortic rupture. Other findings on CXR may include:
1. Deviation of trachea/oesophagus to the right
2. Depression of left main stem bronchus
3. Widened paratracheal stripe/paraspinal interfaces
4. Obliteration of space between aorta and pulmonary artery
5. Rib fracture/left haemothoraxDiagnosis can be made by angiography, usually CT aortogram.
Treatment options include repair or replacement. The patient should, ideally, undergo endovascular repair.
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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 80
Incorrect
-
A elderly patient with bulbar palsy is bed ridden. While swallowing he aspirates one of his tablets into his lungs. In which bronchopulmonary segments is it most likely to end up?
Your Answer: Medial segmental bronchus of the right middle lobe
Correct Answer: Superior segmental bronchus of the right inferior lobe
Explanation:Inhaled objects are more likely to enter the right lung for several reasons. First the right bronchus is shorter, wider and more vertical than the left bronchus. Also, the carina (a ridge-like structure at the point of tracheal bifurcation) is set a little towards the left. The superior segmental bronchus branches posteriorly off the intermediate bronchus or the inferior lobe bronchus and is thus more likely to receive the foreign body that enters the right main bronchus. The lingula is only found on the left lung. The terminal bronchiole is a very small space almost impossible for the tablet to lodge here.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 81
Correct
-
A 22-year old man presented with a mass in his left scrotum which was more prominent when standing and felt like a 'bag of worms'. Examination revealed a non-tender mass along the spermatic cord. Also, the right testis was larger than the left testis. What is the likely diagnosis?
Your Answer: Varicocele
Explanation:Varicocele refers to dilatation and increased tortuosity of the pampiniform plexus – which is a network of veins found in spermatic cord that drain the testicle. Defective valves or extrinsic compression can result in outflow obstruction and cause dilatation near the testis. Normal diameter of the small vessels ranges from 0.5 – 1.5mm. A varicocele is a dilatation more than 2mm.
The plexus travels from the posterior aspect of testis into the inguinal canal with other structures forming the spermatic cord. They then form the testicular veins out of which the right testicular vein drains into the inferior vena cava and the left into the left renal vein.
It affects 15-20% men, and 40% of infertile males. Usually diagnosed in 15-25 years of age, they are rarely seen after 40 years of age. Because of the vertical path taken by the left testicular vein to drain into left renal vein, 98% idiopathic varicoceles occur on the left side. It is bilateral in 70% cases. Right-sided varicoceles are rare.
Symptoms include pain or heaviness in the testis, infertility, testicular atrophy, a palpable mass, which is non-tender and along the spermatic cord (resembling a ‘bag of worms’). The testis on the affected side might be smaller.
Diagnosis can be made by ultrasound. Provocative measures such as Valsalva manoeuvre or making the patient stand up to increase the dilatation by increasing the intra-abdominal venous pressure. -
This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 82
Incorrect
-
Which of the following arteries, if ligated, will most likely affect blood supply to the pancreas?
Your Answer: Ileocolic
Correct Answer: Superior mesenteric
Explanation:The pancreas is a glandular organ in the body that produces important hormones such as insulin and glucagon. Its blood supply is from branches of the coeliac artery, superior mesenteric artery and the splenic artery. These are the arteries that if ligated, would affect blood supply to the pancreas.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 83
Incorrect
-
A 34 year old athlete presents to the clinic after receiving a hard blow to his palm that has resulted into a painful swelling over the volar aspect of his hand. On examination, pain is felt on wrist movement and longitudinal compression of the thumb. Which of the following is the most likely injury?
Your Answer: Ganglion
Correct Answer: Scaphoid fracture
Explanation:The scaphoid bone is the most commonly fractured carpal bone. Fractures are most often localized in the middle third of the scaphoid bone.
Generally, scaphoid bone fractures result from indirect trauma when an individual falls onto the outstretched hand with a hyperextended and radially deviated wrist. Pain when applying pressure to the anatomical snuffbox is highly suggestive of a scaphoid bone fracture.
X-ray is the initial test of choice for diagnosis. Computer tomography and magnetic resonance imaging may be indicated, if x-ray findings are negative but clinical suspicion is high.
Treatment can be conservative (e.g., wrist immobilization) or in certain cases surgical (e.g., proximal pole fracture). Complications include non-union and avascular necrosis. -
This question is part of the following fields:
- Generic Surgical Topics
- Orthopaedics
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Question 84
Correct
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The gluteus medius muscle:
Your Answer: Is supplied by the superior gluteal nerve
Explanation:The gluteus medius is situated on the outer surface of the pelvis. It arises from the outer surface of the ilium between the iliac crest and posterior gluteal line above and the anterior gluteal line below. The gluteus medius is supplied by the fourth and fifth lumbar and first sacral nerves through the superior gluteal nerve
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 85
Correct
-
A 30-year-old man is undergoing surgery for a left inguinal hernia. During the operation, the sac is opened to reveal a large Meckel's diverticulum. What type of hernia is this?
Your Answer: Littre's hernia
Explanation:Hernia containing Meckel’s diverticulum is termed as Littre’s hernia.
Hernias occur when a viscus or part of it protrudes from within its normal anatomical cavity. A Littre’s hernia is an abdominal wall hernia that involves the Meckel’s diverticulum which is a congenital outpouching or bulge in the lower part of the small intestine and is a leftover of the umbilical cord.
Management of Littre’s hernia includes resection of the diverticulum followed by herniorrhaphy.
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This question is part of the following fields:
- Generic Surgical Topics
- The Abdomen
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Question 86
Correct
-
What is the percentage of bone calcium that is freely exchangeable with the extracellular fluid that is available for buffering changes in the calcium ion balance?
Your Answer: 1%
Explanation:Around 1% of calcium in the body is available for buffering changes in calcium ion balance. These are mainly derived from the bone that are freely exchangeable with extracellular fluid.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 87
Correct
-
Where do the seminal vesicles lie?
Your Answer: Base of the bladder and rectum
Explanation:The seminal vesicles are two lobulated membranous pouches situated between the fundus of the bladder and rectum and act as a reservoir for the semen and secrete a fluid that is added to the seminal fluid. Each sac is pyramidal in shape but they all vary in size not only in different individuals but also in the same individuals. The anterior surface is in contact with the fundus of the bladder, extending from near the termination of the ureter to the base of the prostate. Each vesicle consist of single tube, which gives off several irregular caecal diverticula. These separate coils and the diverticula are connected by fibrous tissue.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 88
Incorrect
-
A 34 year old woman from the Indian origin presents to the clinic with a diffuse swelling of the left breast. She has a baby boy, four months old. On examination, she has jaundice and her left breast shows erythema. Which of the following options is the most likely?
Your Answer: Invasive ductal carcinoma
Correct Answer: Inflammatory carcinoma
Explanation:Inflammatory breast cancer is a rare form of advanced, invasive carcinoma, characterized by dermal lymphatic invasion of tumour cells. Most commonly a ductal carcinoma.
Clinical features include erythematous and oedematous (peau d’orange) skin plaques over a rapidly growing breast mass. Tenderness, burning sensation, blood-tinged nipple discharge. Axillary lymphadenopathy is usually present. 25% of patients have metastatic disease at the time of presentation.
Differential diagnosis includes mastitis, breast abscess, Paget disease of the breast
Treatment is usually done with chemotherapy + radiotherapy + radical mastectomy. This type of cancer is usually associated with a poor prognosis. 5-year survival with treatment: ∼ 50% (without treatment: < 5%) -
This question is part of the following fields:
- Breast And Endocrine Surgery
- Generic Surgical Topics
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Question 89
Incorrect
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A 60 year old patient with a history of carcinoma of the head of the pancreas, and obstructive jaundice presents with a spontaneous nose bleed and easy bruising. What is the most likely reason for this?
Your Answer: Vitamin B12 deficiency
Correct Answer: Vitamin-K-dependent clotting factors deficiency
Explanation:Vitamin K is a fat soluble vitamin requiring fat metabolism to function properly to allow for its absorption. People with obstructive jaundice develop vitamin k deficiency as fat digestion is impaired. Vit K causes carboxylation of glutamate residue and hence regulates blood coagulation including: prothrombin (factor II), factors VII, IX, X, protein C, protein S and protein Z.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 90
Incorrect
-
Medulloblastoma usually occurs in children between 5 to 9 years old. Where does medulloblastoma commonly originate from?
Your Answer: Pons
Correct Answer: Cerebellar vermis
Explanation:Medulloblastoma is the most common malignant brain tumour in children, accounting for 10-20% of primary CNS neoplasms. Most of the tumours originate in the cerebellar vermis.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 91
Incorrect
-
A 5 year old boy presents with an abnormal gait. On examination, his WCC was found to be 12 and ESR was 31. Past medical history shows a recent viral illness. Which of the following is the cause of these symptoms?
Your Answer: Osteomyelitis
Correct Answer: Transient synovitis
Explanation:Transient synovitis (TS) is the most common cause of acute hip pain in children aged 3-10 years. The disease causes arthralgia and arthritis secondary to a transient inflammation of the synovium of the hip. Biopsy reveals only nonspecific inflammation and hypertrophy of the synovial membrane. Ultrasonography demonstrates an effusion that causes bulging of the anterior joint capsule. Synovial fluid has increased proteoglycans.
Unilateral hip or groin pain is the most common symptom reported; however, some patients with transient synovitis (TS) may report medial thigh or knee pain. Transient synovitis has the highest incidence rate among causes of nontraumatic hip pain in children. Guidelines for chronic hip pain have been established.Causes
No definitive cause of transient synovitis is known, although the following have been suggested:
– Patients with transient synovitis often have histories of trauma, which may be a cause or predisposing factor.
– One study found an increase in viral antibody titres in 67 of 80 patients with transient synovitis.
– Postvaccine or drug-mediated reactions and an allergic disposition have been cited as possible causes.The following studies may be indicated in transient synovitis (TS):
– CBC count: The white blood cell (WBC) count may be slightly elevated.
– Erythrocyte sedimentation rate (ESR) may be slightly elevated. One study found that the combination of an ESR greater than 20 mm/h and/or a temperature greater than 37.5°C identified 97% of individuals with septic hip. -
This question is part of the following fields:
- Generic Surgical Topics
- Orthopaedics
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Question 92
Incorrect
-
For calculation of cardiac output by Fick's principle, which of the following vessels is the best source of venous blood to determine the arterial-to-venous oxygen tension difference?
Your Answer: Pulmonary vein
Correct Answer: Pulmonary artery
Explanation:Fick’s principle states that the total uptake (or release) of a substance by peripheral tissues is equal to the product of the blood flow to the peripheral tissues and the arterial– venous concentration difference (gradient) of the substance. It is used to measure the cardiac output, and the formula is Cardiac output = oxygen consumption divided by arteriovenous oxygen difference. Assuming there are no shunts across the pulmonary system, the pulmonary blood flow equals the systemic blood flow. The arterial and venous blood oxygen content is measured by sampling from the pulmonary artery (low oxygen content) and pulmonary vein (high oxygen content). Peripheral arterial blood is used as a surrogate for the pulmonary vein.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 93
Correct
-
A 26-year-old man is playing football when he slips during a tackle. His left knee becomes painful immediately after. Several hours later, he notices that the knee has become swollen. Following a course of NSAIDs and rest, the situation improves. However, he presents to the clinic with recurrent pain. On examination, it is impossible to fully extend the knee, although the patient is able to do so when asked. What is the most likely injury?
Your Answer: Torn meniscus
Explanation:Twisting or rotational injuries to the knee in sports, followed by delayed onset of knee swelling and locking are strongly suggestive of a meniscal tear. Arthroscopic meniscectomy is the usual treatment.
Meniscal tear is one of the most common knee injuries, characterized by:
1. A popping sensation
2. Delayed swelling or stiffness of the affected knee
3. Pain, especially when twisting or rotating the knee
4. Difficulty straightening the knee fully
5. Locking of knee in place (patient may be able to unlock the knee)In older adults, degenerative changes of the knee can also contribute to a torn meniscus with little or no trauma.
A torn meniscus may lead to knee instability, inability to move the knee normally, or persistent/recurrent knee pain. There is a strong likelihood of developing osteoarthritis in the injured knee.
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This question is part of the following fields:
- Oncology
- Principles Of Surgery-in-General
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Question 94
Correct
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From which source does the lingual artery originate?
Your Answer: External carotid
Explanation:The lingual artery arises from the external carotid between the superior thyroid artery and facial artery. It can be located easily on the lower surface of the tongue. The terminal branch of the lingual artery is the deep lingual artery. On its course the lingual artery gives off side branches: dorsal lingual branches that supply the dorsum of the tongue till the epiglottis; sublingual artery that supplies the sublingual gland.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 95
Incorrect
-
Whipple's procedure involves mobilizing the head of the pancreas. As the surgeon does this, he must be careful to avoid injury to a key structure that is found lying behind the head of the pancreas. Which vital structure is this?
Your Answer: Splenic vein
Correct Answer: Common bile duct
Explanation:The posterior relations of the head of the pancreas include: the inferior vena cava, the common bile duct, the renal veins, the right crus of the diaphragm and the aorta.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 96
Incorrect
-
A 12 month old baby boy is taken to the office with a history of failure to thrive. He is observed to have a large head and to be small for his age. A cupped appearance of the epiphysis of the wrist is seen on the x-ray. Which condition is this linked to?
Your Answer: Marfans
Correct Answer: Rickets
Explanation:Answer: Rickets
Rickets is a disease of growing bone that is unique to children and adolescents. It is caused by a failure of osteoid to calcify in a growing person.
The signs and symptoms of rickets can include:pain – the bones affected by rickets can be sore and painful, so the child may be reluctant to walk or may tire easily; the child’s walk may look different (waddling)
skeletal deformities – thickening of the ankles, wrists and knees, bowed legs, soft skull bones and, rarely, bending of the spine
dental problems – including weak tooth enamel, delay in teeth coming through and increased risk of cavities
poor growth and development – if the skeleton doesn’t grow and develop properly, the child will be shorter than average
fragile bones – in severe cases, the bones become weaker and more prone to fractures.Marfan syndrome (MFS) is a genetic disorder of the connective tissue. The degree to which people are affected varies. People with Marfan tend to be tall and thin, with long arms, legs, fingers and toes. They also typically have flexible joints and scoliosis. The most serious complications involve the heart and aorta, with an increased risk of mitral valve prolapse and aortic aneurysm. Other commonly affected areas include the lungs, eyes, bones and the covering of the spinal cord.
Ehlers-Danlos syndrome is a group of inherited disorders that affect your connective tissues — primarily your skin, joints and blood vessel walls. People who have Ehlers-Danlos syndrome usually have overly flexible joints and stretchy, fragile skin. This can become a problem if you have a wound that requires stitches, because the skin often isn’t strong enough to hold them.
A more severe form of the disorder, called Ehlers-Danlos syndrome, vascular type, can cause the walls of your blood vessels, intestines or uterus to rupture.Osteoporosis is a disease in which bone weakening increases the risk of a broken bone. It is the most common reason for a broken bone among the elderly. Bones that commonly break include the vertebrae in the spine, the bones of the forearm, and the hip. Until a broken bone occurs there are typically no symptoms. Bones may weaken to such a degree that a break may occur with minor stress or spontaneously. Chronic pain and a decreased ability to carry out normal activities may occur following a broken bone.
Osteoporosis may be due to lower-than-normal maximum bone mass and greater-than-normal bone loss. Bone loss increases after menopause due to lower levels of oestrogen. Osteoporosis may also occur due to a number of diseases or treatments, including alcoholism, anorexia, hyperthyroidism, kidney disease, and surgical removal of the ovaries.
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This question is part of the following fields:
- Generic Surgical Topics
- Orthopaedics
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Question 97
Incorrect
-
A 53-year-old woman is diagnosed with cellulitis surrounding her leg ulcer. A swab is taken and oral flucloxacillin is started. The following result is obtained:
Your Answer: No change
Correct Answer: Add penicillin
Explanation:Streptococci may be divided into alpha and beta haemolytic types
Alpha haemolytic streptococci
The most important alpha haemolytic streptococcus is Streptococcus pneumoniae (pneumococcus). Pneumococcus is a common cause of pneumonia, meningitis and otitis media. Another clinical example is Streptococcus viridans
Beta haemolytic streptococci
These can be subdivided into group A and B
Group A
most important organism is Streptococcus pyogenes
responsible for erysipelas, impetigo, cellulitis, type 2 necrotizing fasciitis and pharyngitis/tonsillitis
immunological reactions can cause rheumatic fever or post-streptococcal glomerulonephritis
erythrogenic toxins cause scarlet feverGroup B
Streptococcus agalactiae may lead to neonatal meningitis and septicaemia
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This question is part of the following fields:
- Clinical Microbiology
- Principles Of Surgery-in-General
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Question 98
Incorrect
-
A 26 year old lady slips in her house and lands on her right arm. She has anatomical snuffbox tenderness but no x-rays either at the time or subsequently have shown evidence of a scaphoid fracture. She has been immobilised in a futura splint for two weeks and is now asymptomatic. What is the best course of action?
Your Answer: Application of futura splint and fracture clinic review
Correct Answer: Discharge with reassurance
Explanation:The College of Emergency Medicine states that the patient should be discharged with no follow-up required if the patient presents with anatomical snuffbox tenderness and plain radiographs show no fracture when done initially and after when wrist splint has been used.
A scaphoid fracture is a break of the scaphoid bone in the wrist. Symptoms generally includes pain at the base of the thumb which is worse with use of the hand. The anatomic snuffbox is generally tender and swelling may occur. Complications may include non-union of the fracture, avascular necrosis, and arthritis.
Scaphoid fractures are most commonly caused by a fall on an outstretched hand. Diagnosis is generally based on examination and medical imaging. Some fractures may not be visible on plain X-rays. In such cases a person may be casted with repeat X-rays in two weeks or an MRI or bone scan may be done.
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This question is part of the following fields:
- Generic Surgical Topics
- Orthopaedics
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Question 99
Incorrect
-
In a splenectomy procedure, special care is emphasized on the preservation of the tail of the pancreas that is closely associated with the spleen to avoid post operative pancreatic fistula. As a general surgeon conducting a splenectomy where are you most likely to find the tail of the pancreas in the abdominal cavity?
Your Answer: Transverse mesocolon
Correct Answer: Splenorenal ligament
Explanation:The tail of the pancreas is the only intraperitoneal part of the pancreas and is found contained in the splenorenal ligament of the peritoneal cavity. The splenorenal ligament is derived from the peritoneum where the wall of the general peritoneal cavity connects to the omental bursa between the spleen and the left kidney. This ligament contains the splenic vessels and the tail of the pancreas.
The gastrocolic ligament stretches from the greater curvature of the stomach to the transverse colon, connecting the two.
The gastrosplenic ligament is derived from the greater omentum and is the structure that connects the stomach to the hilum of the spleen. The gastrosplenic ligament continues from the splenic flexure of the colon to the diaphragm and acts as a support to the spleen.
The transverse colon is connected to the abdominal wall by the mesocolon ligament.
The falciform ligament on the other hand, attaches the liver to the ventral wall of the abdomen.
The hepatoduodenal ligament connects the porta hepatis of the liver to the superior part of the duodenum. -
This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 100
Incorrect
-
A young girl who presented with a clinical picture of type I hypersensitivity reaction with eosinophilia is most likely to have?
Your Answer: Dust inhalation
Correct Answer: Liver flukes
Explanation:Usually a parasitic infection will be associated with a type I hypersensitivity reaction.
Amyloid deposition will not cause an immune reaction.
Organic dust will lead to a type III hypersensitivity reaction.
Cell mediated as well as humoral immune mechanism play a part in syphilis, but they are do not specifically cause a type I reaction.
Malaria is cause by plasmodium and is not cause of a hypersensitivity reaction.
Atopic dermatitis will not be accompanied by eosinophilia. -
This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 101
Correct
-
A 32-year-old female presents with painful bright red bleeding that occurs post defecation. Digital rectal examination is too uncomfortable for the patient, perineal inspection shows a prominent posterior skin tag. What is the best course of action?
Your Answer: Prescribe topical diltiazem
Explanation:An Anal fissure is a cut or a tear in the anal canal typically caused by passing a hard stool. Patients often complain of severe anal pain and bleeding with bowel movements. On physical examination, you may see the fissure or just the sentinel tag. If the examination appears normal, you can elicit point tenderness. We recommend against continuing the digital rectal examination or anoscopy if the patient is having pain during the examination.
The primary goals of therapy are to properly bulk the stool with adequate fibre and relax the anal muscle. Specific steps include the following:
Properly bulk the stool with adequate fibre to minimize constipation and diarrhoea; both frequent bowel movements and hard bowel movements can lead to an anal fissure.
Temporary use of laxatives such as daily Miralax or senna. The dose of Miralax can be titrated up or down to achieve desired results. As the patient’s fibre supplementation increases, the need for Miralax will diminish.
Chronic use of laxatives should be avoided because it can lead to worsening colonic function and constipation.
Diltiazem 2% ointment is to be placed on the anal muscle 3 times daily—continue for a minimum of 8 weeks, even if symptoms improve earlier.
If a patient cannot tolerate diltiazem or is breastfeeding or pregnant, 0.2% nitroglycerin-compounded ointment can be prescribed. However, the proper dose of nitroglycerin is important as too high of a dose can cause severe headaches.
Do NOT prescribe haemorrhoid ointments or suppositories, especially steroid-based ones. Steroid ointments do not help. They do cause perianal skin thinning and dermatitis. At best, they act as a placebo, but they often are used chronically and cause unpleasant perianal skin changes.
Use mental anal muscle relaxation: Actively thinking about relaxing sphincter tone.
Consider sitz baths: Soaking the anal area in warm water induces relaxation. Warmer water induces more relaxation. No additives are needed.
Surgical intervention (such as Botox injections or sphincterotomy) is considered for patients whose symptoms do not improve with the above management strategies. It is imperative that the patient increases fibre and water intake so bowel movements are very soft before the surgical intervention to maximize chances of postoperative healing. -
This question is part of the following fields:
- Colorectal Surgery
- Generic Surgical Topics
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Question 102
Correct
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A 13 month old baby was taken to the hospital after his father saw that he had periorbital oedema for two days. He is seen by the doctor and noted to have facial oedema and a tender distended abdomen. His temperature is 39.1 and his blood pressure is 91/46 mmHg. There is also clinical evidence of poor peripheral perfusion. What is the diagnosis?
Your Answer: Spontaneous bacterial peritonitis
Explanation:Answer: Spontaneous bacterial peritonitis
The presence of periorbital and facial oedema with normal blood pressure in this toddler indicates that he has nephrotic syndrome. Nephrotic syndrome can be associated with a series of complications that can affect an individual’s health and quality of life:
Spontaneous bacterial peritonitis can develop where there is ascites present. This is a frequent development in children but very rarely found in adults.Spontaneous bacterial peritonitis (SBP) is the development of a bacterial infection in the peritoneum, despite the absence of an obvious source for the infection. It is specifically an infection of the ascitic fluid – an increased volume of peritoneal fluid. Ascites is most commonly a complication of cirrhosis of the liver. It can also occur in patients with nephrotic syndrome. SBP has a high mortality rate.
The diagnosis of SBP requires paracentesis, a sampling of the peritoneal fluid taken from the peritoneal cavity. If the fluid contains large numbers of white blood cells known as neutrophils (>250 cells/µL), infection is confirmed and antibiotics will be given, without waiting for culture results. In addition to antibiotics, infusions of albumin are usually administered.
Signs and symptoms of spontaneous bacterial peritonitis (SBP) include fevers, chills, nausea, vomiting, abdominal pain and tenderness, general malaise, altered mental status, and worsening ascites. Thirteen percent of patients have no signs or symptoms. In cases of acute or chronic liver failure SBP is one of the main triggers for hepatic encephalopathy, and where there is no other clear causal indication for this, SBP may be suspected.
These symptoms can also be the same for a spontaneous fungal peritonitis (SFP) and therefore make a differentiation difficult. Delay of diagnosis can delay antifungal treatment and lead to a higher mortality rate.
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This question is part of the following fields:
- Generic Surgical Topics
- The Abdomen
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Question 103
Incorrect
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A 20 year old is brought to the A&E after he fell from a moving cart. The boy has sustained blunt abdominal injury, and the there is a possibility of internal bleeding as the boy is in shock. An urgent exploratory laparotomy is done in the A&E theatre. On opening the peritoneal cavity, the operating surgeon notices a torn gastrosplenic ligament with a large clot around the spleen. Which artery is most likely to have been injured in this case?
Your Answer: Splenic
Correct Answer: Short gastric
Explanation:The short gastric arteries branch from the splenic artery near the splenic hilum to travel back in the gastrosplenic ligament to supply the fundus of the stomach. Therefore, these may be injured in this case.
The splenic artery courses deep to the stomach to reach the hilum of the spleen. It doesn’t travel in the gastrosplenic ligament although it does give off branches that do.
The middle colic artery is a branch of the superior mesenteric artery that supplies the transverse colon.
Gastroepiploic artery is the largest branch of the splenic artery that courses between the layers of the greater omentum to anastomose with the right gastroepiploic.
Left gastric artery, a branch of the coeliac trunk. It supplies the left half of the lesser curvature. -
This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 104
Correct
-
Both the arytenoid muscles and the lateral cricoarytenoid muscles perform this action on the glottis:
Your Answer: Close the glottis
Explanation:Both the arytenoid and the cricoartenoid muscles close the glottis. The lateral cricoarytenoid muscles extend from the lateral cricoid cartilage to the muscular process of the arytenoid cartilage. By rotating the arytenoid cartilages medially, these muscles adduct the vocal cords and thereby close the rima glottidis. The arytenoid muscle adducts or approximates the arytenoid cartilages, and thus closes the aperture of the glottis.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 105
Correct
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Post-total gastrectomy, there will be a decreased production of which of the following enzymes?
Your Answer: Pepsin
Explanation:Pepsin is a protease that is released from the gastric chief cells and acts to degrade proteins into peptides. Released as pepsinogen, it is activated by hydrochloric acid and into pepsin itself. Gastrin and the vagus nerve trigger the release of pepsinogen and HCl when a meal is ingested. Pepsin functions optimally in an acidic environment, especially at a pH of 2.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 106
Correct
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A 30 year old female presented in the emergency with an irregular pulse. Her ECG showed absent P-waves with irregular RR interval. What is the most likely diagnosis?
Your Answer: Atrial fibrillation
Explanation:Atrial fibrillation is one of the most common cardiac arrhythmias. It is often asymptomatic but may present with symptoms of palpitations, fainting, chest pain and heart failure. Characteristic findings are: absence of P-waves, unorganised electrical activity in their place, irregularity of RR interval due to irregular conduction of impulses to the ventricles and if paroxysmal AF is suspected, episodes may be documented with the use of Holter monitoring
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 107
Correct
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A 45-year-old woman was brought to the emergency department due to fever and chills. She has a history of recurrent UTI and complains of dysuria and urinary frequency. Urinary white blood cell count is >200 cell/high power field. If urine culture is performed, what is the most likely organism that will grow?
Your Answer: Escherichia coli
Explanation:The pathogen that most likely causes recurrent urinary tract infection in young women are E. coli, Enterococcus and Staphylococcus saprophyticus.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 108
Correct
-
What is the role of factor VII in coagulation?
Your Answer: Initiates the process of coagulation in conjunction with tissue factor
Explanation:The main role of factor VII is to initiate the process of coagulation along with tissue factor (TF). TF is found in the blood vessels and is not normally exposed to the bloodstream. When a vessel is injured tissue factor is exposed to blood and circulating factor VII. Factor VII is converted to VIIa by TF.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 109
Correct
-
A 44-year old gentleman presented to the hospital in congestive cardiac failure. On further investigation, he was found to have a right-sided retroperitoneal mass. On enquiry, he gave a history of intermittent hypertensive attacks. 24-hour urine specimen revealed raised metanephrine and vanillylmandelic acid levels. What is the likely diagnosis?
Your Answer: Pheochromocytoma
Explanation:A neuroendocrine tumour of the chromaffin cells in adrenal medulla, pheochromocytoma secretes excessive catecholamines – adrenaline (epinephrine) and noradrenaline (norepinephrine). Pheochromocytomas are also known as the ‘10% tumour’. This is because 10% of them are bilateral, 10% are malignant, and 10% are extra-adrenal. Extra-adrenal paragangliomas (also known as extra-adrenal pheochromocytomas) are less common than pheochromocytomas and arise in the ganglia of sympathetic nervous system. Around 25% of pheochromocytomas are familial. Symptoms are described as feeling of ‘impending doom’, and include tachycardia, hypertension, palpitations, anxiety, headaches and pallor. Orthostatic hypertension is typically seen where there is a more than 100 mmHg fall in systolic pressure when the patient stands up. Pheochromocytomas can also lead to malignant hypertension. Diagnosis is by measurement of catecholamines and metanephrines in blood or in 24-hour urine, after exclusion of other possible causes such as stress, hypoglycaemia and drugs (methyldopa, dopamine agonists, ganglion-blocking antihypertensive). Imaging is also needed to localize the tumour. Localization of the tumour can also be done by Iodine-131 meta-iodobenzylguanidine (I131-MIBG) imaging.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 110
Correct
-
Where is the foramen ovale located?
Your Answer: Sphenoid
Explanation:The foramen ovale is an oval shaped opening in the middle cranial fossa located at the posterior base of the greater wing of the sphenoid bone, lateral to the lingula. It transmits the mandibular division of the trigeminal nerve (CN Vc), accessory meningeal artery, emissary veins between the cavernous sinuses and pterygoid plexus, otic ganglion, and occasionally the nervus spinosus and lesser petrosal nerve.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 111
Incorrect
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A 69 year old woman presents with chest pain. She has undergone esophagogastrectomy for carcinoma of the distal oesophagus. The next day, a brisk bubbling is noticed in the chest drain when the suction is applied. Which of the following would be the most likely cause of this finding?
Your Answer: Anastomotic leak
Correct Answer: Air leak from lung
Explanation:The possible causes of post-operative pneumothorax after thoracotomy and esophagectomy include lung parenchymal leak/injury, bronchopleural fistula, ruptured bullae and malpositioned chest drains. When suction is applied to the chest drainage system, active and persistent bubbling may be seen. Although an anastomotic leak may produce a small pneumothorax, a large volume air leak is more indicative of lung injury.
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This question is part of the following fields:
- Peri-operative Care
- Principles Of Surgery-in-General
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Question 112
Correct
-
A 65-year-old man complains of headaches, weakness, cramps, and confusion; blood tests reveal he has severe hyponatremia. The most likely cause is:
Your Answer: Severe diarrhoea or vomiting
Explanation:Hyponatraemia occurs when the sodium level in the plasma falls below 135 mmol/l. Hyponatraemia is an abnormality that can occur in isolation or, more commonly as a complication of other medical illnesses. Severe hyponatraemia may cause osmotic shift of water from the plasma into the brain cells. Typical symptoms include nausea, vomiting, headache and malaise. As the hyponatraemia worsens, confusion, diminished reflexes, convulsions, stupor or coma may occur. The cause of hyponatremia is typically classified by a person’s fluid status into low volume, normal volume, and high volume. Low volume hyponatremia can occur from diarrhoea, vomiting, diuretics, and sweating.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 113
Correct
-
A 65 year old man with a longstanding history of severe osteoarthritis of the hip is scheduled to undergo a total hip replacement. The skin has been prepared and antibiotics administered. Which of the following would be the most important precaution in reducing the risk of infection?
Your Answer: Laminar flow theatre
Explanation:Laminar flow theatres aim to reduce the number of infective organisms in the theatre air by generating a continuous flow of bacteria free air. In laminar flow theatres air may be ‘changed’ in theatre more than 300 times per hour compared to standard positive pressure theatre rates of 15-25 air changes per hour.
Shaving skin on the ward increases infection rates and extended chemoprophylaxis increases the risk of antibiotic associated diarrhoea -
This question is part of the following fields:
- Principles Of Surgery-in-General
- Surgical Technique And Technology
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Question 114
Correct
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A CT-scan of the lung shows a tumour crossing the minor (horizontal) fissure. This fissure separates:
Your Answer: The middle lobe from the upper lobe
Explanation:The horizontal fissure separates the upper lobe from the middle lobe. The oblique fissure on the other hand separates the lower lobe from both the middle and upper lobes. The lingula is found only on the left lung.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 115
Incorrect
-
A 5 year old boy is taken to the family doctor following a history of difficult, painful defecation with bright red rectal bleeding. Which of the following would be the diagnosis?
Your Answer: Juvenile polyp
Correct Answer: Anal fissure
Explanation:An anal fissure is a painful linear tear or crack in the distal anal canal, which, in the short term, usually involves only the epithelium and, in the long term, involves the full thickness of the anal mucosa. Anal fissures develop with equal frequency in both sexes; they tend to occur in younger and middle-aged persons.
Treatment should include stool softeners and lifestyle advice. Failure of medical therapy is an indication for surgical therapy. Controversy mostly involves continued efforts to find a medical therapy for anal fissure that is as successful as the surgical therapy for the condition.
Typically, the patient reports severe pain during a bowel movement, with the pain lasting several minutes to hours afterward. The pain recurs with every bowel movement, and the patient commonly becomes afraid or unwilling to have a bowel movement, leading to a cycle of worsening constipation, harder stools, and more anal pain. Approximately 70% of patients note bright-red blood on the toilet paper or stool. Occasionally, a few drops may fall in the toilet bowl, but significant bleeding does not usually occur with an anal fissure.Children with intussceception usually present at a relatively young age with colicky abdominal pain, together with a mass on clinical examination. The often cited red current jelly type stool is a rare but classical feature.
Juvenile polyps may occur as part of the familial polyposis coli syndromes. The lesions, which are hamartomas, are often cherry red if they protrude externally.
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This question is part of the following fields:
- Generic Surgical Topics
- Paediatric Surgery
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Question 116
Incorrect
-
A 30-year-old woman is diagnosed with Hodgkin's lymphoma. Which of the following chemotherapy regimens would be used in this case?
Your Answer: BEP
Correct Answer: ABVD
Explanation:ABVD is a chemotherapy regimen used in the first-line treatment of Hodgkin’s lymphoma. It consists of concurrent treatment with the chemotherapy drugs, adriamycin, bleomycin, vinblastine and dacarbazine. It supplanted the older MOPP protocol.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 117
Incorrect
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A patient with this type of tumour is advised to follow up regularly for monitoring of tumour size as there is a strong correlation with malignant potential and tumour size. Which of the following is the most likely tumour in this patient?
Your Answer: Prostate adenocarcinoma
Correct Answer: Renal adenocarcinoma
Explanation:The distinction between a benign renal adenoma and renal adenocarcinoma is commonly made on the basis of size. Tumours less than 2 cm in size rarely become malignant as opposed to those greater than 3 cm.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 118
Correct
-
A 32-year-old man presented with a metabolic acidosis and increased anion gap. What is the most likely cause of the changes of the anion gap in this patient?
Your Answer: Lactic acidosis
Explanation:High anion gap in metabolic acidosis is caused generally by the elevation of the levels of acids like ketones, lactate, sulphates in the body, which consume the bicarbonate ions. Other causes of a high anion gap include overdosing on salicylates, uraemia, rhabdomyolysis, hypocalcaemia, hypomagnesaemia, or ingestion of toxins such as ethylene glycol, methanol, propyl alcohol, cyanide and iron.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 119
Incorrect
-
The otic ganglion receives its preganglionic sympathetic fibres from which of the following nerves?
Your Answer: Trigeminal nerve
Correct Answer: Glossopharyngeal nerve
Explanation:The otic ganglion is a small (2–3 mm), oval shaped, flattened parasympathetic ganglion of a reddish-grey colour, located immediately below the foramen ovale in the infratemporal fossa and on the medial surface of the mandibular nerve. The preganglionic parasympathetic fibres originate in the inferior salivatory nucleus of the glossopharyngeal nerve. They leave the glossopharyngeal nerve by its tympanic branch and then pass via the tympanic plexus and the lesser petrosal nerve to the otic ganglion. Here, the fibres synapse, and the postganglionic fibres pass by communicating branches to the auriculotemporal nerve, which conveys them to the parotid gland. They produce vasodilator and secretomotor effects.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 120
Correct
-
A 64 year old woman received midazolam before a colonoscopy. During the procedure her respiratory rate slows down and she becomes hypoxic. The anaesthetist decides to reverse her sedation. Which of the following drugs should be administered?
Your Answer: Flumazenil
Explanation:Reversal of the central effects of midazolam by intravenous flumazenil after general anaesthesia. Since many benzodiazepines have longer half lives than flumazenil patients still require close monitoring after receiving the drug. Other drugs provided in the options would not characteristically be used for the reversal of midazolam.
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This question is part of the following fields:
- Peri-operative Care
- Principles Of Surgery-in-General
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Question 121
Incorrect
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Multiple, non-tender lymphadenopathy with biopsy showing several crowded follicles of small, monomorphic lymphocytes and the absence of Reed-Sternberg cells is seen in which of the following?
Your Answer: Hodgkin’s disease, lymphocyte predominance type
Correct Answer: Poorly differentiated lymphocytic lymphoma
Explanation:Malignant lymphoma usually causes non-tender lymphadenopathy, unlike the tender lymphadenopathy caused by infections (including infectious mononucleosis caused by Epstein-Barr virus). Also, the lymphoid hyperplasia seen in infectious mononucleosis is benign and polyclonal.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 122
Correct
-
A 40 year old man sustained a fracture to the surgical neck of his left humerus. Which of the following arteries is suspected to be injured in this case?
Your Answer: Posterior humeral circumflex
Explanation:The posterior humeral circumflex artery arises from the axillary artery and runs with the axillary nerve through the quadrangular space which is bounded laterally by the surgical neck of the humerus. After winding around the surgical neck of the humerus, it is distributed to the deltoid muscle and the shoulder joint. Thus fractures in the surgical neck of the humerus could result in an injury to this artery.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 123
Incorrect
-
Which of the following muscles is innervated by the inferior branch of the right recurrent laryngeal nerve?
Your Answer: Cricothyroid
Correct Answer: Posterior cricoarytenoid
Explanation:The posterior cricoarytenoid muscle, which is the sole abductor of the vocal folds, receives its innervation from the inferior laryngeal nerve which is a continuation of the recurrent laryngeal nerve.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 124
Correct
-
Which of the following is responsible for the activation of pepsinogen released in the stomach?
Your Answer: Acid pH and pepsin
Explanation:Pepsinogen is the inactive precursor of pepsin. Once secreted, it comes in contact with hydrochloric acid and pepsin, previously formed, and undergoes cleavage to form active pepsin.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 125
Correct
-
Skeletal muscle fibres are divided into two basic types, type I (slow-twitch fibres) and type II (fast-twitch fibres). Fast muscle fibres do which of the following:
Your Answer: Use anaerobic metabolism
Explanation:Skeletal muscles are divided into two types:
1) type I also known as the slow twitch fibres. They use oxygen for their metabolism and as a result they have a high endurance potential. To support this they have abundant mitochondria and myoglobin, so they appear red/dark.
2) type II fibres also called fast twitch fibres, are low endurance fibres used during anaerobic metabolism. They are required for short bursts of strength and cannot sustain contractions for long periods of time. -
This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 126
Incorrect
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An operation to resect a tumour of the right lung was stopped as the chest surgeon said that the tumour was crossing the oblique fissure. Which structures are separated by the oblique fissure of the right lung?
Your Answer: Lower lobe from middle lobe only
Correct Answer: Lower lobe from both upper and middle lobes
Explanation:The oblique fissure on the right lung separates the lower lobe from both the middle and upper lobe. The lingual is only found on the left lung and is part of the upper lobe.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 127
Incorrect
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A specialist registrar was performing the bi-lateral surgical removal of the adrenal glands. He first removed the left adrenal gland before moving on to the right one. However, the registrar noticed that the removal of the right adrenal gland would be a challenge because of an overlying structure. What was this structure that overlies the right suprarenal glad?
Your Answer: Right crus of the diaphragm
Correct Answer: Inferior vena cava
Explanation:The adrenal glands or the suprarenal glands are small glands that are found on top of each of the kidneys. They are retroperitoneal glands. The right adrenal gland is found on top of the right kidney and is closely associated with the inferior vena cava as it directly drains into this large vein. In the case where the right adrenal gland is to be surgically removed, the inferior vena cava might prove a problem to manoeuvre as it overlies the right suprarenal gland. The other blood vessels such as the aorta, right renal, superior mesenteric, splenic artery and the hepatic vein as well as the right crus are not closely associated with either of the suprarenal glands.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 128
Correct
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Following an accident, a man was unable to extend the wrist and metacarpophalangeal joints, despite sensation being intact. Which nerve was likely damaged?
Your Answer: Posterior interosseous nerve
Explanation:The posterior interosseous nerve which causes, what is known as the posterior interosseous nerve syndrome. The nerve is compressed before it bifurcates to form the medial and lateral branches. The compression is beyond the origin of the branches to the radial wrist extensors and the radial sensory nerve. The result of such a case is paralysis of the digital extensors and the extensor carpi ulnaris, resulting in dorsoradial deviation of the wrist.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 129
Correct
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Which of the following veins empties into the left renal vein?
Your Answer: Left suprarenal
Explanation:The left suprarenal vein empties into the left renal vein which crosses the vertebral column to reach the inferior vena cava. The left renal vein also receives the left gonadal vein.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 130
Correct
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A 6 year-old boy is brought to you coughing. He is suspected to have aspirated a Lego piece which he was seen playing with. Where would you expect the piece to be?
Your Answer: Right main bronchus
Explanation:Inhaled objects are more likely to enter the right lung for several reasons. First the right bronchus is shorter, wider and more vertical than the left bronchus. Also, the carina (a ridge-like structure at the point of tracheal bifurcation) is set a little towards the left. The terminal bronchiole is a very small space and impossible for the seed to lodge here.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 131
Correct
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A 39 year old woman was taken to the surgical clinic for symptoms related to varicose veins. She has noticed that these first developed when she was pregnant. A truncal varicosity of the medial leg was seen on examination but there are no ulcers or skin changes. A hand held Doppler examination demonstrates sapheno-popliteal junction reflux. Which of the following is the best course of action?
Your Answer: Arrange a duplex scan
Explanation:Saphenopopliteal (SPJ) reflux may be present in 20–25% of patients with primary varicose veins. Pre-operative colour duplex marking increases the accuracy of localisation of the SPJ at operation and is considered to be the gold standard for this purpose. A prospective study of 50 consecutive primary SSV ligations was undertaken and it showed that duplex was highly accurate in correctly locating the SPJ to within an accuracy of 20 mm in 98% of cases. The comparative figure for short saphenous vein (SSV) palpation was 48%. Palpation alone therefore cannot be recommended as a means of determining the site of SPJ and duplex continues to remain the gold standard for the preoperative localisation of the SPJ.
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This question is part of the following fields:
- Generic Surgical Topics
- Vascular
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Question 132
Incorrect
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A neonate is diagnosed with cryptorchidism of the right side (undescended testis). Which is the LEAST likely place to find the testis?
Your Answer: Pelvic brim
Correct Answer: Perineum
Explanation:Embryologically the testes are retroperitoneal structures in the posterior abdominal wall, attached to the anterolateral abdominal wall by the gubernaculum. The gubernaculum ‘pulls’ the testes through the deep inguinal ring, inguinal canal and superficial inguinal ring and over the pelvic brim. The gubernaculum is preceded by the processus vaginalis that is derived from the peritoneum anterior to the testes. The processus vaginalis pushes the muscle and fascial layers. These eventually make up the canal and the spermatic cord, into the scrotum. The gubernaculum persists as the scrotal ligament while part of the processus vaginalis remains as a bursa-like sac i.e. the tunica vaginalis testes. The testes therefore could be caught in any one of these places along its path of descending. The testes are never in the perineum.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 133
Correct
-
An operation to remove a segment of the oesophagus through a right thoracotomy is complicated when a tear develops in a large venous structure in the posterior mediastinum that empties into the superior vena cava. Which of the following structures is likely to be injured?
Your Answer: Azygos vein
Explanation:The azygos vein is formed by the union of the right subcostal veins and the ascending lumbar veins at the level of the 12th thoracic vertebra. It enters the thorax through the aortic hiatus to ascend in the posterior mediastinum and arching over the right main bronchus posteriorly at the root of the right lung to join the superior vena cava before it pierces the pericardium.
The basilic vein is a vein on the medial aspect of the arm that ascends to become the axillary vein.
The cephalic vein is also a vein of the arm.
The external jugular and brachiocephalic vein are not in the posterior mediastinum.
The median cubital vein is found in the cubital fossa of the arm. -
This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 134
Correct
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During an anatomy revision session, medical students are told that the posterior wall of the rectus sheath ends in a thin curved margin whose concavity is directed downwards. What is the name of this inferior border of the rectus sheath?
Your Answer: Arcuate line
Explanation:The rectus sheath is a tendinous sheath that encloses the rectus abdominis muscle. It covers the entire anterior surface however on the posterior surface of the muscle the sheath is incomplete ending inferiorly at the arcuate line. Below the arcuate line, the rectus abdominis is covered by the transversalis fascia. The linea alba is a band of aponeurosis on the midline of the anterior abdominal wall, which extends from the xiphoid process to the pubic symphysis. It is formed by the combined abdominal muscle aponeuroses. This is a useful site for midline incision during abdominal surgery because it does not carry many blood vessels. All of the other answer choices are related to the inguinal canal.
The falx inguinalis (sometimes called the inguinal falx or conjoint tendon), is the inferomedial attachment of the transversus abdominis with some fibres of the internal abdominal oblique – it contributes to the posterior wall of the inguinal canal.
The inguinal ligament is the ligament that connects the anterior superior iliac spine with the pubic tubercle – it makes the floor of the inguinal canal.
The internal (deep) inguinal ring is the entrance to the inguinal canal, where the transversalis fascia pouches out and creates an opening through which structures can leave the abdominal cavity. -
This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 135
Correct
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A 45-year-old female will undergo a diagnostic laparoscopy. Which of the agents listed below should be used for inducing pneumoperitoneum?
Your Answer: Carbon dioxide
Explanation:Laparoscopic surgery involves insufflation of a gas (usually carbon dioxide) into the peritoneal cavity producing a pneumoperitoneum. This causes an increase in intra-abdominal pressure (IAP). Carbon dioxide is insufflated into the peritoneal cavity at a rate of 4–6 litre min−1 to a pressure of 10–20 mm Hg. The pneumoperitoneum is maintained by a constant gas flow of 200–400 ml min−1.
Carbon dioxide is the most frequently used gas for insufflation of the abdomen as it is colourless, non-toxic, non-flammable and has the greatest margin of safety in the event of a venous embolus (highly soluble). It is absorbed readily from the peritoneum, causing an increase in PaCO2. This has direct, as well as indirect (by raising catecholamine levels), effects on the cardiovascular system. Thus, tachycardia, increased cardiac contractility and reduction in the diastolic filling can result in decreased myocardial oxygen supply to demand ratio and greater risk of myocardial ischaemia.
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This question is part of the following fields:
- Principles Of Surgery-in-General
- Surgical Technique And Technology
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Question 136
Incorrect
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An 8 year old boy presents with a history of repeated bacterial/pyogenic infections. He had a normal recovery from chickenpox and measles and shows normal antibody response. A decrease in which of the cell types can best explain this history of repeated pyogenic infections?
Your Answer: T lymphocytes
Correct Answer: Neutrophils
Explanation:A decrease in the number of granulocytes, particularly neutrophils is known as agranulocytosis and it increases the susceptibility of an individual towards recurrent infections. Neutropenia can be either due to decreased production or increased elimination of neutrophils.
Ineffective agranulopoiesis is seen in: 1. myeloid stem cell suppression, 2. disease conditions associated with granulopoiesis such as megaloblastic anaemia and myelodysplastic syndromes, 3. rare genetic diseases, 4. splenic sequestration and 5. increased peripheral utilization. -
This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 137
Incorrect
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A young girl injured her arm following a fall down the steps On examination, it was found that her left proximal radioulnar joint had dislocated and the annular ligament was stretched. This will make which movement extremely painful?
Your Answer: Elbow extension
Correct Answer: Supination
Explanation:Supination is the rotation of the forearm so that the palm of the hand faces anteriorly. This is performed by the biceps brachii and supinator of the extensor muscles of the thumb. The opposite action of moving the palm from an anterior-facing position to a posterior-facing position is called pronation. Pronation is performed by the pronator teres and pronator quadratus.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 138
Incorrect
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Which of the following is NOT a Gram-negative rod?
Your Answer: Legionella
Correct Answer: Clostridium tetani
Explanation:Gram-positive rods include Clostridia, Listeria and diphtheroids.
Gram-negative rods include Escherichia coli, Klebsiella, Yersinia, Haemohilus, Pseudomonas, Shigella, Legionella, proteus and Salmonella -
This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 139
Incorrect
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A 35 year-old female developed food poisoning 24H after eating canned food. She complained of abdominal cramps, with nausea and vomiting. Shortly after she suddenly developed weakness, blurring of vision, difficulty in swallowing and breathing. Which of the following organisms is most likely associated with fatal food poisoning?
Your Answer: Escherichia coli
Correct Answer: Clostridium botulinum
Explanation:C. botulinum is a Gram-positive, rod-shaped, spore-forming bacterium. It is an obligate anaerobe, meaning that oxygen is poisonous to the cells. Only botulinum toxin types A, B, E, and F cause disease in humans. Types A, B, and E are associated with foodborne illness. Botulism poisoning can occur due to preserved or home-canned, low-acid food that was not processed using correct preservation times and/or pressure. Signs and symptoms of foodborne botulism typically begin between 18 and 36 hours after the toxin gets into the body, but can range from a few hours to several days, depending on the amount of toxin ingested. Botulinum that is produced by Clostridium botulinum can cause respiratory and muscular paralysis.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 140
Incorrect
-
The Carpal tunnel does NOT contain:
Your Answer: Flexor digitorum profundus
Correct Answer: Flexor carpi ulnaris
Explanation:The contents of the carpal tunnel include:
– Median nerve
– Flexor digitorum supervicialis
– Flexor digitorum profundus
– Flexor policis longus
– Flexor carpi radialis -
This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 141
Incorrect
-
The fundus of the stomach receives blood supply from the same artery as the greater curvature of the stomach. Which of the following arteries when ligated will disrupt blood supply to the fundus of the stomach through this artery?
Your Answer: Left gastroepiploic
Correct Answer: Splenic
Explanation:The fundus of the stomach along with the greater curvature of the stomach receive blood supply from the short gastric artery. The short gastric artery arises from the end of the splenic artery. The ligation of the splenic artery therefore would cause a disruption of blood supply to the fundus of the stomach.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 142
Incorrect
-
During a street fight a boy sustained a laceration below the elbow. It was a deep cut that led to profuse bleeding from an artery situated on the supinator muscle immediately below the elbow. The vessel most likely to have been injured is?
Your Answer: Common interosseous artery
Correct Answer: Radial recurrent artery
Explanation:The radial recurrent artery is situated on the supinator muscle then passing between the brachialis and the brachioradialis muscles. It originates from the radial artery and ends by anastomosing with the terminal part of the Profunda brachii.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 143
Incorrect
-
A 3 year old boy is taken to the doctor by his mother who has noticed that he has been having rectal bleeding for a few months and a cherry red lesion appeared at the anal verge after defecation. Which of the following is most likely the diagnosis?
Your Answer: Villous adenoma
Correct Answer: Juvenile polyp
Explanation:Juvenile polyps are benign hamartomas with neoplastic potential that are the most frequent gastrointestinal polyp of childhood, with the peak incidence between 3 and 5 years of age.. The presence of multiple juvenile polyps may indicate a premalignant condition commonly named juvenile polyposis coli or juvenile polyposis syndrome (JPS). In contrast, single or solitary juvenile polyps generally are considered benign sporadic lesions that confer little to no future risk of malignancy. Most frequent presentation is painless rectal bleeding. Other features include a prolapsing rectal mass and abdominal pain.
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This question is part of the following fields:
- Generic Surgical Topics
- Paediatric Surgery
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Question 144
Incorrect
-
A 14 year-old girl is found to have haemophilia B. What pathological problem does she have?
Your Answer: Deficiency of platelets
Correct Answer: Deficiency of factor IX
Explanation:Haemophilia B (also known as Christmas disease) is due to a deficiency in factor IX. Haemophilia A is due to a deficiency in factor VIII.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 145
Incorrect
-
A 39 year old hiker slips down a slope and injures her hand on an oak tree. On examination, she is tender in the anatomical snuffbox and on bimanual palpation. X-rays with scaphoid views show no evidence of fracture. What is the most appropriate course of action?
Your Answer: Application of tubigrip bandage and fracture clinic review
Correct Answer: Application of futura splint and fracture clinic review
Explanation:A scaphoid fracture is a break of the scaphoid bone in the wrist. Symptoms generally include pain at the base of the thumb which is worse with use of the hand. The anatomic snuffbox is generally tender and swelling may occur. Complications may include non-union of the fracture, avascular necrosis, and arthritis.
Scaphoid fractures are most commonly caused by a fall on an outstretched hand. Diagnosis is generally based on examination and medical imaging. Some fractures may not be visible on plain X-rays. In such cases a person may be casted with repeat X-rays in two weeks or an MRI or bone scan may be done.
Scaphoid fractures are often diagnosed by PA and lateral X-rays. However, not all fractures are apparent initially. Therefore, people with tenderness over the scaphoid (those who exhibit pain to pressure in the anatomic snuff box) are often splinted in a thumb spica for 7–10 days at which point a second set of X-rays is taken. If there was a hairline fracture, healing may now be apparent. Even then a fracture may not be apparent. A CT Scan can then be used to evaluate the scaphoid with greater resolution. The use of MRI, if available, is preferred over CT and can give one an immediate diagnosis. Bone scintigraphy is also an effective method for diagnosing a fracture which does not appear on x-ray. -
This question is part of the following fields:
- Generic Surgical Topics
- Orthopaedics
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Question 146
Incorrect
-
Which foramen contains the vertebral artery?
Your Answer: Jugular foramen
Correct Answer: Foramen magnum
Explanation:The foramen magnum is found in the most inferior part of the posterior cranial fossa. It is traversed by vital structures including the medulla oblongata. Its contents include the following: medulla oblongata, meninges, spinal root of the accessory nerve, vertebral arteries, anterior and posterior spinal arteries, tectorial membrane and alar ligaments.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 147
Incorrect
-
A 70-year old man who is suspected to have a perforated colonic diverticulum is explored in theatre through a midline incision. This incision will be through the:
Your Answer: Arcuate line
Correct Answer: Linea alba
Explanation:The linea alba is the point where this incision was made. It is a tendinous raphe in the midline of the abdomen extending between the xiphoid process and the symphysis pubis. It is placed between the medial borders of the recti and is formed by the blending of the aponeuroses of the external and internal obliques and transversi.
The linea aspera is a vertical ridge on the posterior surface of the femur.
The arcuate line is the inferior border of the posterior rectus sheath behind the rectus abdominis muscle.
The semilunar line is the lateral margin of the rectus abdominis.
The iliopectineal line is a line on the pelvic bones formed by the arcuate line of the ilium and the pectineal line of the pubis. -
This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 148
Incorrect
-
A 41 year old librarian undergoes a gastric bypass surgery and she returns to the clinic complaining that she develops vertigo and crampy abdominal pain after eating. Which of the following is the underlying cause?
Your Answer: Insulin resistance
Correct Answer: Dumping syndrome
Explanation:Dumping syndrome is the effect of altered gastric reservoir function, abnormal postoperative gastric motor function, and/or pyloric emptying mechanism. Clinically significant dumping syndrome occurs in approximately 10% of patients after any type of gastric surgery and in up to 50% of patients after laparoscopic Roux-en-Y gastric bypass. Dumping syndrome has characteristic alimentary and systemic manifestations. It is a frequent complication observed after a variety of gastric surgical procedures, such as vagotomy, pyloroplasty, gastrojejunostomy, and laparoscopic Nissan fundoplication. Dumping syndrome can be separated into early and late forms, depending on the occurrence of symptoms in relation to the time elapsed after a meal.
Postprandially, the function of the body of the stomach is to store food and to allow the initial chemical digestion by acid and proteases before transferring food to the gastric antrum. In the antrum, high-amplitude contractions triturate the solids, reducing the particle size to 1-2 mm. Once solids have been reduced to this desired size, they are able to pass through the pylorus. An intact pylorus prevents the passage of larger particles into the duodenum. Gastric emptying is controlled by the fundic tone, antropyloric mechanisms, and duodenal feedback. Gastric surgery alters each of these mechanisms in several ways.The late dumping syndrome is suspected in the person who has symptoms of hypoglycaemia in the setting of previous gastric surgery, and this late dumping can be proven with an oral glucose tolerance test (hyperinsulinemic hypoglycaemia), as well as gastric emptying scintigraphy, which shows the abnormal pattern of initially delayed and then accelerated gastric emptying.
The clinical presentation of dumping syndrome can be divided into GI symptoms and vasomotor symptoms. GI symptoms include early satiety, crampy abdominal pain, nausea, vomiting, and explosive diarrhoea. Vasomotor symptoms include diaphoresis, flushing, dizziness, palpitations, and an intense desire to lie down.
The expression of these symptoms varies in different individuals. Most patients with early dumping have both GI and vasomotor symptoms, while patients with late dumping have mostly vasomotor symptoms. Patients with severe dumping often limit their food intake to avoid symptoms. This leads to weight loss and, over time, malnutrition.
Early dumping syndrome generally occurs within 15 minutes of ingesting a meal and is attributable to the rapid transit of food into the small intestine, whereas late dumping syndrome occurs later and may be attributed to hypoglycaemia with tremors, cold sweats, difficulty in concentrating, and loss of consciousness.
Early dumping systemic symptoms are as follows:
Desire to lie down
Palpitations
Fatigue
Faintness
Syncope
Diaphoresis
Headache
FlushingEarly dumping abdominal symptoms are as follows:
Epigastric fullness
Diarrhoea
Nausea
Abdominal cramps
BorborygmiLate dumping symptoms are as follows:
Perspiration
Shakiness
Difficulty to concentrate
Decreased consciousness
Hunger -
This question is part of the following fields:
- Generic Surgical Topics
- Upper Gastrointestinal Surgery
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Question 149
Incorrect
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A 35 year old opera singer undergoes a thyroidectomy and post-operatively, he develops stridor and is unable to speak. What is the best explanation for this symptom?
Your Answer: Bilateral superior laryngeal nerve injury
Correct Answer: Bilateral recurrent laryngeal nerve injury
Explanation:This patient has aphonia due to bilateral damage to the recurrent laryngeal nerve. Bilateral recurrent laryngeal nerve (RLN) injury is rare for benign thyroid lesions (0.2%). After extubation-stridor, respiratory distress, aphonia occurs due to the closure of the glottic aperture necessitating immediate intervention and emergency intubation or tracheostomy. Intra-operative identification and preservation of the RLN minimizes the risk of injury.
The recurrent laryngeal nerves control all intrinsic muscles of the larynx except for the cricothyroid muscle. These muscles act to open, close, and adjust the tension of the vocal cords, and include the posterior cricoarytenoid muscles, the only muscle to open the vocal cords. The nerves supply muscles on the same side of the body, with the exception of the interarytenoid muscle, which is innervated from both sides.The nerves also carry sensory information from the mucous membranes of the larynx below the lower surface of the vocal fold, as well as sensory, secretory and motor fibres to the cervical segments of the oesophagus and the trachea.
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This question is part of the following fields:
- Generic Surgical Topics
- Head And Neck Surgery
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Question 150
Incorrect
-
Which of the following will show decreased hearing when tested by air conduction but normal hearing when tested by bone conduction?
Your Answer: Poor hair cell function in cochlea
Correct Answer: Fibrosis causing fixation of the ossicles
Explanation:As the cochlea is embedded into bone, the vibrations from the bone are transmitted directly to the fluid in the cochlea. Hence, any damage to the ossicles or tympanic membrane will not show an abnormal result on bone conduction test.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 151
Incorrect
-
A 41-year-old man presents with a newly pigmented lesion on his right shin, which has been increasing in size. On examination, the lesion has regular borders and normal-appearing skin appendages.What should be the best course of action?
Your Answer: Excision with 0.5 cm margin
Correct Answer: Excision biopsy
Explanation:Lesions bearing normal dermal appendages and regular borders are likely to be benign pigmented naevi. Therefore diagnostic and not radical excision is indicated. Incision biopsy should not be done.
Melanocytic naevi are pigmented moles. Some moles are present at birth or appear within the first two years of life. These are known as congenital melanocytic naevi. Most develop during childhood and early adult life and are, consequently, called acquired melanocytic naevi. The number of moles increase up to the age of 30–40. Thereafter, the number of naevi tend to decrease. New moles appearing in adulthood need to be monitored and checked if growing or changing. Moles can be found anywhere on the skin, including on the hands and feet, genitals, eyes, and scalp.
There are three main types of acquired melanocytic naevi:
1. Junctional melanocytic naevi: flat and usually circular.
2. Compound melanocytic naevi: raised brown bumps most of which are hairy, some have a slightly warty surface.
3. Intradermal melanocytic naevi: raised and often hairy bumps, similar to compound naevi but more pale coloured (often skin-coloured). -
This question is part of the following fields:
- Generic Surgical Topics
- Skin Lesions
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Question 152
Incorrect
-
A 5-year-old child diagnosed with nephrotic syndrome developed generalised oedema. What is the mechanism for the development of oedema in patients with nephrotic syndrome?
Your Answer: Lymphatic obstruction
Correct Answer: Decreased colloid osmotic pressure
Explanation:The development of oedema in nephrotic syndrome has traditionally been viewed as an underfill mechanism. According to this view, urinary loss of protein results in hypoalbuminemia and decreased plasma oncotic pressure. As a result, plasma water translocates out of the intravascular space and results in a decrease in intravascular volume. In response to the underfilled circulation, effector mechanisms are then activated that signal the kidney to secondarily retain salt and water. While an underfill mechanism may be responsible for oedema formation in a minority of patients, recent clinical and experimental findings would suggest that oedema formation in most nephrotic patients is the result of primary salt retention. Direct measurements of blood and plasma volume or measurement of neurohumoral markers that indirectly reflect effective circulatory volume are mostly consistent with either euvolemia or a volume expanded state. The ability to maintain plasma volume in the setting of a decreased plasma oncotic pressure is achieved by alterations in transcapillary exchange mechanisms known to occur in the setting of hypoalbuminemia that limit excessive capillary fluid filtration.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 153
Correct
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A 60-year-old female has sudden onset of high-grade fever associated with cough with productive rusty-coloured sputum. Chest x-ray showed left-sided consolidation. What is the most accurate test for the diagnosis of this patient?
Your Answer: Sputum culture
Explanation:Sputum culture is used to detect and identify the organism that are infecting the lungs or breathing passages.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 154
Correct
-
On exploration of an axillary wound, a branch from the third part of the axillary artery was found to be transected. Which of the following arteries would have been likely injured?
Your Answer: Anterior humeral circumflex
Explanation:The axillary artery gives off many branches from the first, second, or third parts along its course. The third part of the axillary artery gives off two branches: the anterior humeral circumflex artery and the posterior humeral circumflex artery.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 155
Incorrect
-
A 59-year-old woman with hyperaldosteronism is prescribed a diuretic. Which of the following diuretics promotes diuresis by opposing the action of aldosterone?
Your Answer: Mannitol
Correct Answer: Potassium-sparing diuretic
Explanation:The term potassium-sparing refers to an effect rather than a mechanism or location. Potassium-sparing diuretics act by either antagonising the action of aldosterone (spironolactone) or inhibiting Na+ reabsorption in the distal tubules (amiloride). This group of drugs is often used as adjunctive therapy, in combination with other drugs, for the management of chronic heart failure. Spironolactone, the first member of the class, is also used in the management of hyperaldosteronism (including Conn’s syndrome) and female hirsutism (due to additional antiandrogen actions).
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 156
Incorrect
-
What is the most likely condition a new born infant is likely to suffer from, if he/she was born with incomplete fusion of the embryonic endocardial cushions?
Your Answer: Tetralogy of Fallot
Correct Answer: An atrioventricular septal defect
Explanation:The endocardial cushions in the heart are the mesenchymal tissue that make up the part of the atrioventricular valves, atrial septum and ventricular septum. An incomplete fusion of these mesenchymal cells can cause an atrioventricular septal defect. The terms endocardial cushion defect, atrioventricular septal defect and common atrioventricular canal defect can be used interchangeably with one another.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 157
Incorrect
-
Which of the following diseases can cause paraesthesia along the distribution of the median nerve of the hand, especially after activities which require flexion and extension of the wrist?
Your Answer: Hypertrophic osteoarthropathy
Correct Answer: Carpal tunnel syndrome
Explanation:Carpal tunnel syndrome tends to occur in women between the ages of 30-50. There are many risk factors, including diabetes, hypothyroidism, obesity, pregnancy, and repetitive wrist work. Symptoms include pain in the hand and wrist, tingling, and numbness distributed along the median nerve (the palmar side of the thumb, the index and middle fingers, and the radial half of the ring finger), which worsens at night.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 158
Incorrect
-
Which of the following coagulation factors cross-links fibrin?
Your Answer: Factor II
Correct Answer: Factor XIII
Explanation:Factor XIII, also known as fibrin stabilizing factor, is an enzyme of the coagulation cascade that crosslinks fibrin. Deficiency of FXIII may cause bleeding tendency but paradoxically, it may also predispose to thrombosis.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 159
Incorrect
-
A young man came to the emergency room after an accident. The anterior surface of his wrist was lacerated with loss of sensation over the thumb side of his palm. Which nerves have been damaged?
Your Answer: Lateral antebrachial cutaneous
Correct Answer: Median
Explanation:The median nerve provides cutaneous innervation to the skin of the palmar radial three and a half fingers. Also the site of injury indicates that the medial nerve may have been injured as it passes into the hand by crossing over the anterior wrist.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 160
Incorrect
-
Which is a feature of the action of insulin?
Your Answer: Promotes phosphate release from bone
Correct Answer: Promotes protein synthesis
Explanation:Insulin is produced by the beta-cells of the islets of Langerhans in the pancreas. Its actions include:
– promoting uptake of glucose into cells
– glycogen synthesis (glycogenesis)
– protein synthesis
– stimulation of lipogenesis (fat formation).
– driving potassium into cells – used to treat hyperkaelamia.
Parathyroid hormone and activated vitamin D are the principal hormones involved in calcium/phosphate metabolism, rather than insulin. -
This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 161
Correct
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A 16 year-old boy was stabbed in the right supraclavicular fossa. The sharp object punctured the portion of the parietal pleura that extends above the first rib. What is the name of this portion of the parietal pleura?
Your Answer: Cupola
Explanation:Endothoracic fascia: the connective tissue (fascia) that is between the costal parietal pleura and the inner wall of the chest wall.
Costomediastinal recess: the point where the costal pleura becomes mediastinal pleura.
Costodiaphragmatic recess: is the lowest point of the pleural sac where the costal pleura becomes diaphragmatic pleura.
Cupola: the part of the parietal pleura that extends above the first rib level into the root of the neck.
Costocervical recess: this is a made-up term.
Peritracheal fascia: a layer of connective tissue that invests the trachea. -
This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 162
Incorrect
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A 36-year old gentleman with a history of cough for 4 weeks came to the hospital. Examination revealed multiple lymphadenopathy with splenomegaly. Investigations revealed haemoglobin 11 g/dl, haematocrit 32.4%, mean corpuscular volume (MCV) 93 fl, white blood cell count 63 × 109/l, and platelet count 39 × 109/l; along with characteristic Auer rods on peripheral blood smear. What is the likely diagnosis?
Your Answer: Chronic lymphocytic leukaemia (CLL)
Correct Answer: Acute myelogenous leukaemia (AML)
Explanation:AML, or acute myeloid leukaemia is the commonest acute leukaemia affecting adults. increasing in incidence with age. It is a malignancy of the myeloid line of white blood cells. It results in rapid proliferation of abnormal cells, which accumulate in the marrow. Interference with normal cell production leads to a drop in red blood cells, white blood cells and platelets. This causes symptoms such as tiredness, shortness of breath, tendency to bleed or bruise easily and recurrent infections. AML is known to progress quickly and can lead to death in weeks and months if not treated. Leukemic blasts of AML show presence of Auer rods. These are clumps of azurophilic granular material that form needles in the cytoplasm. Composed of fused lysosomes, these contain peroxidase, lysosomal enzymes and crystalline inclusions. Auer rods are classically present in myeloid blasts of M1, M2, M3 and M4 acute leukaemia. They also help to distinguish the preleukemia myelodysplastic syndromes.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 163
Incorrect
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An excision of a mass in the right parietal area of the head will be performed. In which layer of the scalp are the nerves and blood vessels located?
Your Answer: Loose areolar connective tissue
Correct Answer: Connective tissue
Explanation:The scalp is the anatomical area bordered by the face at the front, and by the neck at the sides and back. The scalp is usually described as having five layers:
1. The skin which contains numerous sebaceous glands and hair follicles.
2. The connective tissue, a dense subcutaneous layer of fat and fibrous tissue that lies beneath the skin, containing the nerves and vessels of the scalp.
3. The aponeurosis or galea aponeurotica, a tough layer of dense fibrous tissue which runs from the frontalis muscle anteriorly to the occipitalis posteriorly.
4. The loose areolar connective tissue layer provides an easy plane of separation between the upper three layers and the pericranium.
5. The pericranium is the periosteum of the skull bones and provides nutrition to the bone and the capacity for repair. -
This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 164
Incorrect
-
What is the normal glomerular filtration rate?
Your Answer: 50 mL/min
Correct Answer: 125 mL/min
Explanation:The normal glomerular filtration rate (GFR) in humans is 125 mL/min. After the age of 40, GFR decreases progressively by about 0.4–1.2 mL/min per year.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 165
Incorrect
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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: 550 mmol/day
Correct 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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Question 166
Incorrect
-
During an exploratory laparotomy a herniation of bowel is identified between the lateral edge of the rectus abdominis, the inguinal ligament and the inferior epigastric vessels. These boundaries define the hernia as being a:
Your Answer: Femoral hernia
Correct Answer: Direct inguinal hernia
Explanation:The boundaries given define the inguinal triangle which is the site for direct inguinal hernias. Indirect inguinal hernias occur lateral to the inferior epigastric vessels.
Femoral hernias protrude through the femoral ring, into the femoral canal.
Umbilical hernias protrude through a defect in the umbilical area.
Obturator hernias, occur through the obturator foramen. These are very rare. -
This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 167
Correct
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A 45-year old with sarcoidosis has enlarged tracheobronchial lymph nodes. Which nerve is most likely to be irritated in this patient?
Your Answer: Left recurrent laryngeal
Explanation:Tracheobronchial lymph nodes are located at the bifurcation of the trachea and are in three groups i.e. the right superior, left superior and inferior. The aorta arches over the left bronchus near the point of tracheal bifurcation. Thus, the nerves that are closely associated with the aorta might be irritated if these nodes become inflamed. The left recurrent laryngeal nerve is such a nerve. The phrenic nerves, both the left and the right, are lateral and thus would not be affected. The right recurrent nerve loops around the right subclavian artery and is distant from this area. The right vagus artery is not associated with the aorta and the sympathetic chain is located in the posterior chest parallel to the vertebra, also not associated with the tracheobronchial tree.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 168
Incorrect
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Which is the correct order of tendons passing from medial to lateral-posterior to the medial malleolus?
Your Answer: Flexor hallucis longus, flexor digitorum longus, posterior tibial
Correct Answer: Posterior tibial, flexor digitorum longus, flexor hallucis longus
Explanation:The correct order of structures is the tendon of tibialis posterior, tendon of flexor digitorum longus, posterior tibial artery (and vein), tibial nerve and tendon of flexor hallucis longus.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 169
Incorrect
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A 40 year old patient with an history of obesity has been diagnosed with meralgia parasthetica. The condition was discovered to be caused by the pinching of the lateral femoral cutaneous nerve. Injuries at what spinal levels usually affect this nerve?
Your Answer: L1, L2
Correct Answer: L2, L3
Explanation:The lateral femoral cutaneous nerve of the thigh arises from the dorsal division of the lumbar plexus of the second and the third lumbar nerves (L2 – L3). Spinal injuries at this level are likely to affect the lateral femoral cutaneous nerve. The lateral femoral cutaneous nerve innervates the skin on the lateral aspect of the thigh.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 170
Incorrect
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A 38 year-old man falls on an outstretched hand. X-rays indicate an anterior dislocation of one of the carpal bones. Which carpal bone is most commonly dislocated?
Your Answer: Scaphoid
Correct Answer: Lunate
Explanation:The scaphoid bone is the most commonly fractured carpal bone and has an increased risk of avascular necrosis.
The lunate is the most commonly dislocated carpal bone. The displaced bone may compress the median nerve in the carpal tunnel. -
This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 171
Correct
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Purkinje fibres in the heart conduct action potentials at the rate of:
Your Answer: 1.5–4.0 m/s
Explanation:Purkinje fibres control the heart rate along with the sinoatrial node (SA node) and the atrioventricular node (AV node). The QRS complex is associated with the impulse passing through the Purkinje fibres. These fibres conduct action potential about six times faster than the velocity in normal cardiac muscle.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 172
Correct
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A 29-year-old woman is due to undergo a laparoscopic cholecystectomy. Which of the following intra-abdominal pressures should typically be set on the gas insufflation system?
Your Answer: 10 mmHg
Explanation:A pressure of 10 mmHg should be set on the gas insufflation system.
Laparoscopic surgery may be performed in a number of body cavities. In some areas, irrigation solutions are preferred. In the abdomen, however, insufflation with carbon dioxide gas is commonly used. The amount of gas delivered is adjusted to maintain a constant intra-abdominal pressure of 12–15 mmHg. Excessive intra-abdominal pressure may reduce venous return and lead to hypotension. Too little insufflation will risk obscuring the surgical view.
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This question is part of the following fields:
- Principles Of Surgery-in-General
- Surgical Technique And Technology
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Question 173
Incorrect
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A 30-year-old man who is a known case of von Willebrand disease has started bleeding following the excision of a sebaceous cyst.Administration of which of the following agents is most likely to be beneficial?
Your Answer: Factor VII concentrate
Correct Answer: Desmopressin
Explanation:Desmopressin is useful in managing mild to moderate episodes of bleeding in von Willebrand disease (vWD).
vWD is the most common hereditary coagulopathy resulting from the deficiency or abnormal function of von Willebrand factor (vWF). vWF promotes platelet adhesion to damaged endothelium and other platelets and is also involved in the transport and stabilization of factor VIII.
There are seven subtypes of vWD. Type 1 vWD (autosomal dominant) is the most common and accounts for 80% of the cases. Type 2 vWD (autosomal dominant or recessive) accounts for 15% of the cases. There is a significant spectrum of severity ranging from spontaneous bleeding and epistaxis through to troublesome excessive bleeding following minor procedures.
Bleeding time is mostly used as a diagnostic test for vWD. Treatment options include administration of tranexamic acid for minor cases undergoing minor procedures. More significant bleeding or procedures respond well to desmopressin (DDAVP). It is most effective in type 1 vWD, less effective in type 2 and contraindicated in type 2B. Individuals who cannot have desmopressin or in whom it is contraindicated usually receive factor VIII concentrates containing vWF.
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This question is part of the following fields:
- Post-operative Management And Critical Care
- Principles Of Surgery-in-General
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Question 174
Incorrect
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The accumulation of eosinophils within tissues is mostly regulated by which of the following cytokines?
Your Answer: Interleukin-1
Correct Answer: Interleukin-5
Explanation:IL-5 is produced by TH2 helper cells and by mast cells. They stimulate increased secretion of immunoglobulins and stimulate B cell growth. They are the major regulators in eosinophil activation and control. They are also released from eosinophils and mast cells in asthmatic patients and are associate with a many other allergic conditions.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 175
Correct
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Which of the following conditions is likely to result in splenomegaly, hypochromic anaemia and hemochromatosis in a young male?
Your Answer: β-Thalassaemia
Explanation:Beta-thalassaemia is due to decreased production of β-polypeptide chains, with an autosomal inheritance pattern. Carrier patients (heterozygotes) are asymptomatic and have mild to moderate microcytic anaemia. This is known as thalassaemia minor. Homozygotes (β-thalassaemia major, or Cooley’s anaemia) develop severe anaemia and marrow hyperactivity. The disease presents at 1-2 years of age with severe anaemia and transfusional and absorptive iron overload. Patients also present with jaundice, leg ulcers, massive splenomegaly and cholelithiasis. The disease can also lead to splenic sequestration leading to faster destruction of transfused red blood cells. Increased marrow activity causes thickening of cranial bones. Involvement of long bones is also seen, which can cause pathological fractures and growth impairment. There is iron deposition in various organs, which can lead to heart failure or hepatic failure (leading to cirrhosis). Thalassaemias are suspected in presence of family history, or signs suggesting microcytic haemolytic anaemia. Further test and quantitative haemoglobin studies are useful. In beta-thalassaemia, there is an increase in serum bilirubin, iron and ferritin levels. There is severe anaemia, often with haemoglobin < 6 g/dl. There is an elevated red blood cell count, which are microcytic. Peripheral blood smear is diagnostic with nucleated erythroblasts, target cells, small pale red blood cells, and punctate basophilia.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 176
Incorrect
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A 33 year old woman presents to the clinic with abdominal pain and a progressively worsening condition. She is admitted with cholangitis. Lab results reveal:Serum bilirubin: 180, Alkaline phosphatase: 348, Serum amylase: 1080. Standard treatment is carried out and her Glasgow score is 3. Which of the following is the most appropriate step in her management?
Your Answer: Pancreatic necrosectomy
Correct Answer: ERCP
Explanation:ERCP serves as a primary therapeutic modality for management of biliary pancreatitis in specific situations: pancreatitis due to microlithiasis, specific types of sphincter of Oddi dysfunction, pancreas divisum, ascariasis and malignancy. It is important that her coagulation status is normalized prior to performing this procedure.
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This question is part of the following fields:
- Generic Surgical Topics
- Hepatobiliary And Pancreatic Surgery
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Question 177
Incorrect
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A 25-year old man presented to the clinic with swelling of the penis. His uncircumcised penis was erythematous and oedematous. The foreskin could not be retracted over the glans. Which of the following agents is the likely cause of his condition?
Your Answer: Human papillomavirus
Correct Answer: Staphylococcus aureus
Explanation:Inflammation of the glans penis is known as balanitis. Associated involvement of the foreskin is then known as balanoposthitis. More likely to occur in men who have a tight foreskin that is difficult to pull back, or poor hygiene.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 178
Incorrect
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A 29-year-old female presents with a history of increasingly severe ano-rectal pain for the past 24 hours. On examination, she has a low-grade fever, and the skin surrounding the anus appears normal. She has not, however, tolerated an attempted digital rectal examination (DRE). What is the most likely diagnosis?
Your Answer: Solitary rectal ulcer
Correct Answer: Intersphincteric abscess
Explanation:Presence of fever and severe pain point towards the diagnosis of an abscess rather than a fissure. Although fissures may be painful, they do not, in themselves, cause fever. Moreover, a case of fissure-in-ano typically presents with bright red PR bleed.
The management option for intersphincteric abscess includes examination of the ano-rectum under general anaesthesia and drainage of the sepsis.
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This question is part of the following fields:
- Colorectal Surgery
- Generic Surgical Topics
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Question 179
Incorrect
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A 3 year old boy is awaiting surgery for a ruptured appendix and the nurse wants to give him an infusion of intravenous fluid whilst waiting for theatre. Given that his electrolytes are normal, which of the following infusion fluid would be appropriate?
Your Answer: None of the above
Correct Answer: 0.9% Saline solution
Explanation:Indications for IV fluids include:
– Resuscitation and circulatory support
– Replacing on-going fluid losses
– Maintenance fluids for children for whom oral fluids are not appropriate
– Correction of electrolyte disturbancesAccording to the NICE guidelines, if children and young people need IV fluid resuscitation, use glucose‑free crystalloids that contain sodium in the range 131–154 mmol/litre, with a bolus of 20 ml/kg over less than 10 minutes. Take into account pre‑existing conditions (for example, cardiac disease or kidney disease), as smaller fluid volumes may be needed.
All the others are contraindicated according to the guidelines as they are either made of glucose or are colloids.
Gelofusine is a 4% w/v solution of succinylated gelatine (also known as modified fluid gelatine) used as an intravenous colloid, and behaves much like blood filled with albumins.
Dextrose solution is a mixture of dextrose (glucose) and water. It is used to treat low blood sugar or water loss without electrolyte loss. Intravenous sugar solutions are in the crystalloid family of medications. They come in a number of strengths including 5%, 10%, and 50% dextrose.
0.45% saline/ 5% glucose solution also contains glucose hence it is contraindicated. -
This question is part of the following fields:
- Generic Surgical Topics
- Paediatric Surgery
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Question 180
Incorrect
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A 34-year-old woman has been suffering from headaches, fever, vomiting, and confusion for the last 5 days. A CT scan reveals an oedematous mass with ring enhancement in the left temporal region. It is biopsied, revealing glial cells, necrosis, neutrophils and lymphocytes. What is the most likely diagnosis?
Your Answer: Glioblastoma multiforme
Correct Answer: Cerebral abscess
Explanation:A cerebral abscess can result from direct extension of cranial infections, penetrating head trauma, haematogenous spread, or for unknown causes. An abscess forms when an area of cerebral inflammation becomes necrotic and encapsulated by glial cells and fibroblasts. Oedema around the abscess can increase the intracranial pressure. Symptoms result from increased intracranial pressure and mass effects. It is most frequent in the third decade of life, and when it occurs in children, it is usually associated with congenital heart disease.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 181
Incorrect
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The specimen sent to the pathologist for examination was found to be benign. Which one of the following is most likely a benign tumour?
Your Answer: Haematoma
Correct Answer: Warthin’s tumour
Explanation:Warthin’s tumour is also known as papillary cystadenoma lymphomatosum. It is a benign cystic tumour of the salivary glands containing abundant lymphocytes and germinal centres. It has a slightly higher incidence in males and most likely occur in older adults aged between 60 to 70 years. This tumour is also associated with smoking. Smokers have an eight-fold greater risk in developing the tumour compared to non-smokers.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 182
Correct
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Which of the following causes the maximum increase in the secretion of antidiuretic hormone (ADH)?
Your Answer: Increased plasma osmolarity
Explanation:The most potent stimulus for ADH release is increased plasma osmolarity. Decreased plasma volume is a less potent stimulus in comparison. However, decrease blood volume and arterial pressure due to severe haemorrhage does lead to ADH secretion. Hypothalamic releasing factors do not control the release of posterior pituitary hormones ADH and oxytocin.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 183
Incorrect
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A 27 year old women works in a dry-cleaning shop. She was exposed to massive amounts of carbon tetrachloride on her skin as well as inhaled. Which of the following organs is most susceptible to damage?
Your Answer: Stomach
Correct Answer: Liver
Explanation:Carbon tetrachloride (CCl4) is a common agent used in the dry cleaning industry and is thought to cause the formation of free radicals. It causes rapid breakdown of the endoplasmic reticulum due to decomposition of lipids and severe liver cell injury. Within less than 30 mins, hepatic protein synthesis declines, lipid export is reduced due to lack of apoprotein and there is an influx of calcium and cell death.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 184
Incorrect
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At which cervical level does the common carotid artery bifurcate into the internal and external carotid arteries?
Your Answer: C6
Correct Answer: C4
Explanation:The common carotid arteries are present on the left and right sides of the body. These arteries originate from different sources, but follow symmetrical courses. The right common carotid originates in the neck from the brachiocephalic trunk; the left from the aortic arch in the thorax. These split into the external and internal carotid arteries at the upper border of the thyroid cartilage, at around the level of the fourth cervical vertebra.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 185
Incorrect
-
Leakage from a silicone breast implant can lead to:
Your Answer: Fibrocystic disease
Correct Answer: Pain and contracture
Explanation:Breast implants are mainly: saline-filled and silicone gel-filled. Complications include haematoma, fluid collections, infection at the surgical site, pain, wrinkling, asymmetric appearance, wound dehiscence and thinning of the breast tissue.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 186
Incorrect
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A 70-year-old man suffers an ischaemic stroke and develops a left homonymous hemianopia. Where is the likely infarct?
Your Answer: Left occipital lobe
Correct Answer: Right occipital lobe
Explanation:The man has a left homonymous hemianopia which means he is unable to view objects in the left visual field. This information is processed by the right primary visual cortex which lies in the right occipital lobe.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 187
Incorrect
-
Which of the following has the least malignant potential?
Your Answer: Tubulovillous adenoma
Correct Answer: Hyperplastic polyp
Explanation:Non-neoplastic (non-adenomatous) colonic polyps include hyperplastic polyps, hamartomas, juvenile polyps, pseudopolyps, lipomas, leiomyomas and others.
An autosomal dominant condition, Peutz–Jeghers syndrome is a disease that is characterized by multiple hamartomatous polyps in the stomach, small bowel and colon. Symptoms of this syndrome include hyperpigmentation of the skin and mucous membranes, especially of the lips and gums.
Juvenile polyps develop in children, and once they outgrow their blood supply, they autoamputate around puberty. In cases of uncontrolled bleeding or intussusception, treatment is needed.
Inflammatory polyps and pseudopolyps occur in chronic ulcerative colitis and Crohn’s disease. There is an increased risk of cancer with multiple juvenile polyps (not with sporadic polyps). -
This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 188
Incorrect
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A 35 year old male patient sustained a traumatic head injury. The patient had loss of consciousness, woke up momentarily when he was in the emergency room but became drowsy and comatose a few hours after. CT scan of the brain showed accumulation of blood between the dura and the cranial bone on the left side of his head. What type of haemorrhage did the patient have?
Your Answer: Subarachnoid
Correct Answer: Epidural
Explanation:Epidural hematoma, also known as epidural bleeding, is a type of traumatic brain injury (TBI) in which a build-up of blood occurs between the dura mater (the tough outer membrane of the central nervous system) and the skull. The spinal cord is also covered by a layer of dura mater, so epidural bleeds may also occur in the spinal column. Often due to trauma, the condition is potentially deadly because the build-up of blood may increase pressure in the intracranial space, compressing delicate brain tissue, and causing brain shift. The condition is present in one to three percent of head injuries. Around 15–20% of epidural hematomas are fatal.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 189
Incorrect
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Out of the following options, which malignancy has the highest potential for multicentricity?
Your Answer: Squamous cell carcinoma of penis
Correct Answer: Transitional cell carcinoma
Explanation:Transitional cell carcinomas can arise anywhere in the urothelium lining the urinary tract; and hence are known to be multicentric and recur commonly. Prostatic adenocarcinoma most commonly involves the posterior lobe of the prostate gland. Although renal cell carcinomas occasionally show multicentricity, it is not common. Penile carcinomas are usually locally infiltrative lesions. Wilm’s tumours are usually solitary, but can be bilateral or multicentric in 10% cases. Small cell carcinoma of lung and teratomas are usually solitary.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 190
Incorrect
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A 1 day old baby girl is born with severe respiratory compromise. She is seen to have a scaphoid abdomen and an absent apex beat. Which anomaly does this baby have?
Your Answer: Necrotising enterocolitis
Correct Answer: Bochdalek hernia
Explanation:Answer: Bochdalek hernia
A Bochdalek hernia is one of two forms of a congenital diaphragmatic hernia, the other form being Morgagni hernia. A Bochdalek hernia is a congenital abnormality in which an opening exists in the infant’s diaphragm, allowing normally intra-abdominal organs (particularly the stomach and intestines) to protrude into the thoracic cavity. In the majority of patients, the affected lung will be deformed, and the resulting lung compression can be life-threatening. Bochdalek hernias occur more commonly on the posterior left side (85%, versus right side 15%).
In normal Bochdalek hernia cases, the symptoms are often observable simultaneously with the baby’s birth. A few of the symptoms of a Bochdalek Hernia include difficulty breathing, fast respiration and increased heart rate. Also, if the baby appears to have cyanosis (blue-tinted skin) this can also be a sign. Another way to differentiate a healthy baby from a baby with Bochdalek Hernia, is to look at the chest immediately after birth. If the baby has a Bochdalek Hernia it may appear that one side of the chest cavity is larger than the other and or the abdomen seems to be scaphoid (caved in).
Situs inversus (also called situs transversus or oppositus) is a congenital condition in which the major visceral organs are reversed or mirrored from their normal positions. The normal arrangement of internal organs is known as situs solitus while situs inversus is generally the mirror image of situs solitus. Although cardiac problems are more common than in the general population, most people with situs inversus have no medical symptoms or complications resulting from the condition, and until the advent of modern medicine it was usually undiagnosed. In the absence of congenital heart defects, individuals with situs inversus are homeostatically normal, and can live standard healthy lives, without any complications related to their medical condition. There is a 5–10% prevalence of congenital heart disease in individuals with situs inversus totalis, most commonly transposition of the great vessels. The incidence of congenital heart disease is 95% in situs inversus with levocardia.
Cystic fibrosis is a progressive, genetic disease that causes persistent lung infections and limits the ability to breathe over time. In people with CF, mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) gene cause the CFTR protein to become dysfunctional. When the protein is not working correctly, it’s unable to help move chloride — a component of salt — to the cell surface. Without the chloride to attract water to the cell surface, the mucus in various organs becomes thick and sticky. In the lungs, the mucus clogs the airways and traps germs, like bacteria, leading to infections, inflammation, respiratory failure, and other complications.
Necrotizing enterocolitis (NEC) is a medical condition where a portion of the bowel dies. It typically occurs in new-borns that are either premature or otherwise unwell. Symptoms may include poor feeding, bloating, decreased activity, blood in the stool, or vomiting of bile.
The exact cause is unclear. Risk factors include congenital heart disease, birth asphyxia, exchange transfusion, and premature rupture of membranes. The underlying mechanism is believed to involve a combination of poor blood flow and infection of the intestines. Diagnosis is based on symptoms and confirmed with medical imaging.Morgagni hernias are one of the congenital diaphragmatic hernias (CDH), and is characterized by herniation through the foramen of Morgagni. When compared to Bochdalek hernias, Morgagni hernias are:
-anterior
-more often right-sided (,90%)
-small
-rare (,2% of CDH)
-at low risk of prolapseOnly ,30% of patients are symptomatic. New-borns may present with respiratory distress at birth similar to a Bochdalek hernia. Additionally, recurrent chest infections and gastrointestinal symptoms have been reported in those with previously undiagnosed Morgagni hernia.
The image of the transverse colon is herniated into the thoracic cavity, through a mid line defect and this indicates that it is a Morgagni hernia since the foramen of a Morgagni hernia occurs in the anterior midline through the sternocostal hiatus of the diaphragm, with 90% of cases occurring on the right side.Clinical manifestations of congenital diaphragmatic hernia (CDH) include the following:
Early diagnosis – Right-side heart; decreased breath sounds on the affected side; scaphoid abdomen; bowel sounds in the thorax, respiratory distress, and/or cyanosis on auscultation; CDH can often be diagnosed in utero with ultrasonography (US), magnetic resonance imaging (MRI), or both
Late diagnosis – Chest mass on chest radiography, gastric volvulus, splenic volvulus, or large-bowel obstruction
Congenital hernias (neonatal onset) – Respiratory distress and/or cyanosis occurs within the first 24 hours of life; CDH may not be diagnosed for several years if the defect is small enough that it does not cause significant pulmonary dysfunction
Congenital hernias (childhood or adult onset) – Obstructive symptoms from protrusion of the colon, chest pain, tightness or fullness the in chest, sepsis following strangulation or perforation, and many respiratory symptoms occur. -
This question is part of the following fields:
- Generic Surgical Topics
- The Abdomen
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Question 191
Incorrect
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A 14-year old girl presented with a 2cm, mobile, cystic mass in the midline of her neck. Fine needle aspiration of the mass revealed clear fluid. This is most likely a case of:
Your Answer: Lymph node metastasis of follicular carcinoma
Correct Answer: Thyroglossal duct cyst
Explanation:Thyroglossal cyst is the most common congenital thyroid anomaly which is clinically significant and affects women more than men. It is a vestigial remnant of developing thyroid. Although the thyroglossal cyst can develop anywhere along the thyroglossal duct, the most common site is in the midline between the isthmus of thyroid and hyoid bone, or just above the hyoid. Thyroglossal cysts are also associated with ectopic thyroid tissue. Clinically, the cyst moves upward with protrusion of the tongue. Rarely, the persistent duct can become malignant (thyroglossal duct carcinoma) where the cancerous cells arise in the ectopic thyroid tissue that are deposited along the duct. Exposure to radiation is a predisposing factor.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 192
Incorrect
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Which of these is secreted by both macrophages and muscle cells?
Your Answer: Interleukin 1
Correct Answer: Interleukin-6
Explanation:IL-6 is secreted by the T cells and macrophages and is a pro inflammatory cytokine. It is secreted in response to trauma e.g. burns and tissue damage that leads to inflammation. Apart from this its is also a myokine and is elevated due to muscle contraction. Other functions include: stimulate osteoclast formation when secreted by osteoblasts, mediate fever in acute phase response and are responsible for energy metabolism in muscle and fatty tissues. Inhibitors of IL-6 e.g. oestrogen are used as a treatment for postmenopausal osteoporosis.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 193
Incorrect
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A 32-year-old man presents with aching pain and discomfort in his right testicle. He has generally been feeling unwell for the past 48 hours as well. On examination, tenderness of the right testicle and an exaggerated cremasteric reflex has been found. What should be the appropriate course of action?
Your Answer: Reassure and discharge
Correct Answer: Administration of antibiotics
Explanation:This is likely a case of epididymo-orchitis which usually occurs due to infection with gonorrhoea or chlamydia in this age group (<35 years). Epididymo-orchitis is an acute inflammation of the epididymis and often involves the testis. It is usually caused by bacterial infection which spreads from the urethra or bladder. Amiodarone is a recognised non-infective cause of epididymitis, which resolves on stopping the drug. On examination, tenderness is usually confined to the epididymis, which may facilitate differentiating it from torsion where pain usually affects the entire testis.
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This question is part of the following fields:
- Generic Surgical Topics
- Urology
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Question 194
Incorrect
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A 55 year old lady underwent an uneventful appendicectomy. Two hours later, her arterial blood gas analysis on room revealed pH: 7.30, p(CO2): 53 mmHg and p(O2): 79 mmHg. What is the most likely cause of these findings?
Your Answer: Primary cardiac failure
Correct Answer: Alveolar hypoventilation
Explanation:In the given problem, there is respiratory acidosis due to hypercapnia from a low respiratory rate and/or volume (hypoventilation). Causes of hypoventilation include conditions impairing the central nervous system (CNS) respiratory drive, impaired neuromuscular transmission and other causes of muscular weakness (drugs and sedatives), along with obstructive, restrictive and parenchymal pulmonary disorders. Hypoventilation leads to hypoxia and hypercapnia reduces the arterial pH. Severe acidosis leads to pulmonary arteriolar vasoconstriction, systemic vascular dilatation, reduced myocardial contractility, hyperkalaemia, hypotension and cardiac irritability resulting in arrhythmias. Raised carbon dioxide concentration also causes cerebral vasodilatation and raised intracranial pressure. Over time, buffering and renal compensation occurs. However, this might not be seen in acute scenarios where the rise in p(CO2) occurs rapidly.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 195
Incorrect
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A 15 year old girl presented to the emergency with a history of chronic cough, fever and weight loss. Her chest X-ray showed multiple nodules 1-4 cm in size and some of them with cavitation especially in the upper lobe. A sputum sample was positive for acid fast bacilli. Which of the following cells played a part in the development of the lung lesions?
Your Answer: Fibroblast
Correct Answer: Macrophage
Explanation:The characteristic cells in granulomatous inflammation are giant cells, formed from merging macrophages and epithelioid cells elongated with granular eosinophilic cytoplasm. Granulomatous reactions are seen in patients with tuberculosis. A tuberculous/caseating granuloma is characterised by a zone of central necrosis lined with giant multinucleated giant cells (Langhans cells) and surrounded by epithelioid cells, lymphocytes and fibroblasts. The caseous zone is present due to the damaged and dead giant cells and epithelioid cells.
Mast cells are only few in number and fibroblasts lay down collagen.
Basophils are not present.
The giant cell made up of macrophages are the most abundant cells in this inflammatory process. -
This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 196
Incorrect
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A young women following a road traffic accident suffered heavy blood loss and developed subsequent anaemia. Which of the following is a consequence of this?
Your Answer: A decreased respiratory rate
Correct Answer: A high reticulocyte count
Explanation:Anaemia refers to a decrease in the circulating levels of haemoglobin in the blood resulting in a reduced ability of the body to transport oxygen effectively. Anaemia from blood loss results in the body further compensating by releasing stored RBCs and immature RBCs from the bone marrow. Thus resulting in a high reticulocyte count.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 197
Correct
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Which is the CORRECT statement regarding the small intestine:
Your Answer: The superior mesenteric artery courses between the body and uncinate process of the pancreas before the artery supplies the jejunum and ileum
Explanation:The small intestine extends from the pylorus to the ileocecal valve where It ends in the large intestine. It is surrounded on the sides and above by the large intestine. It is related anteriorly with the greater omentum and abdominal wall. Is connected to the vertebral column by a fold of peritoneum or otherwise known as the mesentery. Is divided into three portions: the duodenum, jejunum and ileum. The jejunum and ileum are supplied by the superior mesenteric artery that courses between the body and uncinate process of the pancreas before it gives off intestinal branches.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 198
Incorrect
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A 33 year old mechanic presents to the A&E department with epigastric pain. An endoscopy is done which shows that he has a punched out ulcer on the anterior wall of the stomach which is shallow and measures 0.8cm in diameter. What is the most likely diagnosis?
Your Answer: Dieulafoy lesion
Correct Answer: Acute peptic ulcer
Explanation:Peptic ulcer disease can involve the stomach or duodenum. Gastric and duodenal ulcers usually cannot be differentiated based on history alone, although some findings may be suggestive. Epigastric pain is the most common symptom of both gastric and duodenal ulcers, characterized by a gnawing or burning sensation and that occurs after meals—classically, shortly after meals with gastric ulcers and 2-3 hours afterward with duodenal ulcers.
Upper gastrointestinal (GI) endoscopy is the preferred diagnostic test in the evaluation of patients with suspected peptic ulcer disease. At endoscopy, gastric ulcers appear as discrete mucosal lesions with a punched-out smooth ulcer base, which often is filled with whitish fibrinoid exudate. Ulcers tend to be solitary and well circumscribed and usually are 0.5-2.5 cm in diameter.
Treatment of peptic ulcers varies depending on the aetiology and clinical presentation. The initial management of a stable patient with dyspepsia differs from the management of an unstable patient with upper gastrointestinal (GI) haemorrhage. In the latter scenario, failure of medical management not uncommonly leads to surgical intervention.Treatment options include empiric antisecretory therapy, empiric triple therapy for H pylori infection, endoscopy followed by appropriate therapy based on findings, and H pylori serology followed by triple therapy for patients who are infected. Breath testing for active H pylori infection may be used.
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This question is part of the following fields:
- Generic Surgical Topics
- Upper Gastrointestinal Surgery
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Question 199
Incorrect
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A 7-year-old boys undergoes a testicular biopsy after a tumour is found in his right testis. Elements similar to hair and teeth are found in it. What kind of tumour is this?
Your Answer: Choriocarcinoma
Correct Answer: Teratoma
Explanation:A teratoma is a tumour containing tissue elements that are similar to normal derivatives of more than one germ layer. They usually contain skin, hair, teeth and bone tissue and are more common in children, behaving as a benign tumour. After puberty, they are regarded as malignant and can metastasise.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 200
Incorrect
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What is the mostly likely cause of prolonged activated partial thromboplastin time (aPPT) ?
Your Answer:
Correct Answer: Heparin therapy
Explanation:The partial thromboplastin time (PTT) or activated partial thromboplastin time (aPTT) is an indicator for measuring the efficacy of both the intrinsic and common coagulation pathway. Prolonged aPTT may indicate: use of heparin, antiphospholipid antibody and coagulation factor deficiency (e.g., haemophilia). Deficiencies of factors VIII, IX, XI and XII and rarely von Willebrand factor (if causing a low factor VIII level) may lead to a prolonged aPTT correcting on mixing studies.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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SESSION STATS - PERFORMANCE PER SPECIALTY
