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  • Question 1 - A 50 year old man presents to the hospital with an episode...

    Correct

    • A 50 year old man presents to the hospital with an episode of alcoholic pancreatitis. He makes progress slowly but steadily. He is reviewed clinically at 7 weeks following admission. On examination, he is seen with a diffuse fullness of his upper abdomen and on imaging, a collection of fluid is found to be located behind the stomach. Tests show that his serum amylase is mildly elevated. Which of the following is the most likely explanation?

      Your Answer: Pseudocyst

      Explanation:

      A pancreatic pseudocyst is a circumscribed collection of fluid rich in pancreatic enzymes, blood, and necrotic tissue, typically located in the lesser sac of the abdomen. Pancreatic pseudocysts are usually complications of pancreatitis, although in children they frequently occur following abdominal trauma. Pancreatic pseudocysts account for approximately 75% of all pancreatic masses.
      Signs and symptoms of pancreatic pseudocyst include abdominal discomfort and indigestion.

      Diagnosis of Pancreatic pseudocyst can be based on cyst fluid analysis:
      Carcinoembryonic antigen (CEA) and CEA-125 (low in pseudocysts and elevated in tumours);
      Fluid viscosity (low in pseudocysts and elevated in tumours);
      Amylase (usually high in pseudocysts and low in tumours)

      The most useful imaging tools are:

      -Ultrasonography – the role of ultrasonography in imaging the pancreas is limited by patient habitus, operator experience and the fact that the pancreas lies behind the stomach (and so a gas-filled stomach will obscure the pancreas).
      -Computerized tomography – this is the gold standard for initial assessment and follow-up.
      -Magnetic resonance cholangiopancreatography (MRCP) – to establish the relationship of the pseudocyst to the pancreatic ducts, though not routinely used.

    • This question is part of the following fields:

      • Generic Surgical Topics
      • Hepatobiliary And Pancreatic Surgery
      2
      Seconds
  • Question 2 - A 33 year old firefighter is recovering from an appendicectomy where the operation...

    Incorrect

    • A 33 year old firefighter is recovering from an appendicectomy where the operation was complicated by the presence of perforation. On observation, he is seen to be vomiting and his urine output is decreasing. Which intravenous fluid should be initially administered, pending analysis of his urea and electrolyte levels?

      Your Answer:

      Correct Answer: Hartmann's solution

      Explanation:

      Compound Sodium Lactate (Hartmann’s) is used:
      • for intravenous fluid and electrolyte replacement
      • as a source of bicarbonate in the treatment of mild to moderate metabolic acidosis associated with dehydration or associated with potassium deficiency
      • as a vehicle for intravenous drug delivery, if the drugs are compatible with the solutions

      The total amount of electrolytes per litre are: sodium 131 mmol, potassium 5mmol, chloride 112 mmol, calcium 2mmol, bicarbonate (as lactate) 28 mmol.
      The osmolality is approximately 255 mOsm/kg water. The solutions are isotonic, sterile, non-pyrogenic and do not contain antimicrobial agent or added buffers. The pH range is 5.0 to 7.0. Compound Sodium Lactate

      Ringer’s lactate solution (RL), also known as sodium lactate solution and Hartmann’s solution, is a mixture of sodium chloride, sodium lactate, potassium chloride, and calcium chloride in water. It is used for replacing fluids and electrolytes in those who have low blood volume or low blood pressure.

      Hartmann’s solution is often preferred over normal saline as it contains both fluids and electrolytes. The solution is also associated with fewer adverse effects and it can be administered to both adults and children.

    • This question is part of the following fields:

      • Post-operative Management And Critical Care
      • Principles Of Surgery-in-General
      9
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  • Question 3 - A 26 year old policewoman is admitted with bloody diarrhoea. She has been...

    Incorrect

    • A 26 year old policewoman is admitted with bloody diarrhoea. She has been passing 10 stools per day, Hb-8.1, albumin-21. Her stool culture is negative and there is evidence of colitis on endoscopy. She has been on intravenous steroids for 5 days and has now developed megacolon. Her haemoglobin is falling and inflammatory markers are static. Which of the following is the best course of action?

      Your Answer:

      Correct Answer: Undertake a sub total colectomy and end ileostomy

      Explanation:

      The operation aims to remove most of your large bowel including the blood supply and associated lymph glands and leave the rectum behind. It is most commonly recommended for inflammatory bowel disease like ulcerative colitis and Crohn’s disease.

      It is also recommended for other bowel conditions like familial adenomatous polyposis, and when there is more than one bowel cancer.

      In inflammatory bowel disease such as ulcerative colitis the small bowel is brought out to the skin of the tummy as an ileostomy and the remaining bowel (rectum) is closed off and left inside. In other conditions where possible, the two ends of the remaining healthy bowel (small bowel to rectum) are re-joined (an anastomosis). Most
      people therefore do not require a stoma. However some people benefit from having a stoma made depending on circumstances regarding:
      1) Their general state of health (heart disease, lung disease, diabetes, vascular disease, smoking, steroid medications, being undernourished);
      2) Factors which cannot be seen until the surgeon can see inside your tummy (more extensive disease than originally thought, extensive pelvic scarring from previous surgery or other treatment, excessive bleeding).
      Temporary stomas are made to divert faeces away from the join (de-functioning) to give the best chance to heal if there is concern it may be slow to heal.

      Emergency indications for surgical intervention in severe UC include free perforation, haemorrhage or systemic instability. An urgent indication for colectomy is a severe attack that is unresponsive to medical therapy.

      In the setting of severe UC, the procedure of choice is subtotal colectomy and ileostomy. The residual rectal disease is controllable in most patients. In general, there are advantages to the subtotal colectomy approach, including a lower morbidity if pelvic dissection is not performed, preservation of the rectum so that reconstructive procedures can be performed later, and allowing the definitive procedure to be deferred to an optimal situation when the patient is off immunosuppressive medications and has improved nutritional status. Usually, the staged reconstruction with IPAA or definitive total proctocolectomy is performed several months later.

    • This question is part of the following fields:

      • Colorectal Surgery
      • Generic Surgical Topics
      0
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  • Question 4 - A 30-year-old man presents to the A&E department after being shot in the...

    Incorrect

    • A 30-year-old man presents to the A&E department after being shot in the back, in the lumbar region. On examination, he has increased tone and hyperreflexia of his right leg and hemianaesthesia of his left leg.

      What is the most likely diagnosis?

      Your Answer:

      Correct Answer: Brown-Sequard syndrome

      Explanation:

      This is a case of Brown-Sequard syndrome.

      Brown-Sequard syndrome is caused by hemisection of the spinal cord following stab injuries or lateral vertebral fractures. It results in ipsilateral paralysis (pyramidal tract), and also loss of proprioception and fine discrimination(dorsal columns). Pain and temperature sensations are lost on the contralateral side. This is because the fibres of the spinothalamic tract have decussated below the level of the cord transection.

    • This question is part of the following fields:

      • Generic Surgical Topics
      • Orthopaedics
      0
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  • Question 5 - An 18 year old male is given a total of 6 litres of...

    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:

      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.

    • This question is part of the following fields:

      • Post-operative Management And Critical Care
      • Principles Of Surgery-in-General
      0
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  • Question 6 - A 15 year old girl is diagnosed with familial adenomatous polyposis. Which of...

    Incorrect

    • A 15 year old girl is diagnosed with familial adenomatous polyposis. Which of the following is the most appropriate recommended step in management?

      Your Answer:

      Correct Answer: Surveillance annual flexible sigmoidoscopy from age 13 years until age 30 years

      Explanation:

      Answer: Surveillance annual flexible sigmoidoscopy from age 13 years until age 30 years.

      Familial adenomatous polyposis (FAP) is the most common adenomatous polyposis syndrome. It is an autosomal dominant inherited disorder characterized by the early onset of hundreds to thousands of adenomatous polyps throughout the colon. If left untreated, all patients with this syndrome will develop colon cancer by age 35-40 years. In addition, an increased risk exists for the development of other malignancies.
      Most patients with FAP are asymptomatic until they develop cancer. As a result, diagnosing presymptomatic patients is essential.

      Of patients with FAP, 75%-80% have a family history of polyps and/or colorectal cancer at age 40 years or younger.

      Nonspecific symptoms, such as unexplained rectal bleeding (haematochezia), diarrhoea, or abdominal pain, in young patients may be suggestive of FAP.

      In a minority of FAP families a mutation cannot be identified and so annual flexible sigmoidoscopy should be offered to at risk family members from age 13–15 years until age 30, and at three to five year intervals thereafter until age 60 years.

    • This question is part of the following fields:

      • Colorectal Surgery
      • Generic Surgical Topics
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  • Question 7 - A 20 year old male presents to the clinic with progressive pain in...

    Incorrect

    • A 20 year old male presents to the clinic with progressive pain in his neck and back which has gotten worse over the past 7 months. Past medical history shows that he was an inpatient with a disease flare of ulcerative colitis. He is seen on examination with a stiff back and limited spinal extension on bending forward. What is the diagnosis?

      Your Answer:

      Correct Answer: Ankylosing spondylitis

      Explanation:

      Answer: Ankylosing spondylitis

      Ankylosing spondylitis (AS), a spondyloarthropathy, is a chronic, multisystem inflammatory disorder involving primarily the sacroiliac (SI) joints and the axial skeleton. Key components of the patient history that suggest AS include the following:
      Insidious onset of low back pain – The most common symptom
      Onset of symptoms before age 40 years
      Presence of symptoms for more than 3 months
      Symptoms worse in the morning or with inactivity
      Improvement of symptoms with exercise

      General symptoms of AS include the following:

      Those related to inflammatory back pain – Stiffness of the spine and kyphosis resulting in a stooped posture are characteristic of advanced-stage AS.
      Peripheral enthesitis and arthritis
      Constitutional and organ-specific extra-articular manifestations
      Fatigue is another common complaint, occurring in approximately 65% of patients with AS. Increased levels of fatigue are associated with increased pain and stiffness and decreased functional capacity.
      Pharmacologic therapy

      Agents used in the treatment of AS include the following:

      Nonsteroidal anti-inflammatory drugs (NSAIDs)
      Sulfasalazine
      Tumour necrosis factor-α (TNF-α) antagonists
      Corticosteroids

      AS is the prototype of the spondyloarthropathies, a family of related disorders that also includes reactive arthritis (ReA), psoriatic arthritis (PsA), spondyloarthropathy associated with inflammatory bowel disease (IBD), undifferentiated spondyloarthropathy (USpA), and, possibly, Whipple disease and Behçet disease (see the image below). The spondyloarthropathies are linked by common genetics (the human leukocyte antigen [HLA] class-I gene HLA-B27) and a common pathology (enthesitis). The aetiology of AS is not understood completely; however, a strong genetic predisposition exists. A direct relationship between AS and the HLA-B27 gene has been determined. The precise role of HLA-B27 in precipitating AS remains unknown; however, it is believed that HLA-B27 may resemble or act as a receptor for an inciting antigen (e.g., a bacterial antigen).

    • This question is part of the following fields:

      • Generic Surgical Topics
      • Orthopaedics
      0
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  • Question 8 - A 35-year-old male presents to the urology department for investigation of pyelonephritis. He...

    Incorrect

    • A 35-year-old male presents to the urology department for investigation of pyelonephritis. He reports malaise, pyrexia, lymphadenopathy, and a maculopapular rash. The monospot test is negative. Due to a given history of recent high-risk sexual behaviour, you are asked to exclude HIV seroconversion illness in this patient.

      Which of the following should be the most appropriate investigation?

      Your Answer:

      Correct Answer: p24 antigen test

      Explanation:

      P24 antigen test is used as one of the main investigations in diagnosing HIV seroconversion illness.

      Some people experience a short illness soon after they contract HIV. This is known as seroconversion illness, or primary or acute HIV infection. It is the period when someone with HIV is at their most infectious.

      HIV seroconversion is symptomatic in 60%–80% of the patients and typically presents as a glandular fever-type illness. Increased symptomatic severity is associated with poorer long-term prognosis. It typically occurs 2–3 weeks after contracting the virus.

      Signs and symptoms include:
      1. Sore throat
      2. Malaise, myalgia, and arthralgia
      3. Diarrhoea
      4. Maculopapular rash
      5. Oral ulcers
      6. Lymphadenopathy
      7. Meningoencephalitis (rarely)

      HIV PCR and p24 antigen test can confirm the diagnosis. The former is the most common and accurate test and consists of both a screening ELISA and a confirmatory western blot assay. P24 antigen test is also used as the mainstay of diagnosis and is usually positive from about 1 week to 3–4 weeks after an infection with HIV.

    • This question is part of the following fields:

      • Clinical Microbiology
      • Principles Of Surgery-in-General
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  • Question 9 - A middle-aged man undergoes an upper gastrointestinal endoscope for a benign oesophageal stricture....

    Incorrect

    • A middle-aged man undergoes an upper gastrointestinal endoscope for a benign oesophageal stricture. During the procedure, he suffers an iatrogenic perforation at the site. Imaging shows a contained leak and a small amount of surgical emphysema. Which of the following is the most appropriate nutritional option?

      Your Answer:

      Correct Answer: Total parenteral nutrition

      Explanation:

      Iatrogenic perforation of the gastrointestinal tract
      related to diagnostic or therapeutic endoscopy is
      a rare but severe adverse event, associated with
      significant morbidity and mortality

      Conservative treatment may be suitable for patients with limited oesophageal injury and contained leakage. Such patients include those suffering endoscopic iatrogenic perforation, as the patient is likely to be fasted and the diagnosis made promptly. They must remain nil by mouth, with appropriate antibiotic cover, and proton pump inhibitor therapy, total parenteral nutrition, and continued observation. Similarly, medical treatment might be suitable for cases of inoperable malignant stricture, that is, palliation.

    • This question is part of the following fields:

      • Generic Surgical Topics
      • Upper Gastrointestinal Surgery
      0
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  • Question 10 - A 58 year old man presents with complaints of recurrent episodes of diarrhoea...

    Incorrect

    • A 58 year old man presents with complaints of recurrent episodes of diarrhoea over the past week that has resulted in marked exhaustion and fatigue. He underwent a successful cadaveric renal transplant last year and was able to return to his job as a swimming instructor. Stool microscopy is carried out and it shows evidence of cysts. Which of the following is the most likely source of infection?

      Your Answer:

      Correct Answer: Cryptosporidium

      Explanation:

      Cryptosporidium infection occurs through the faecal-oral route of transmission. It usually lasts for 5–7 days. In immunocompetent patients it is self-limiting (nitazoxanide may be used to shorten the duration). In immunocompromised patients: Antiretroviral therapy to elevate the CD4 cell count/restore the immune system is essential prior to eradication with antiparasitic drugs. Diarrhoea is the main disease. The cysts are typically identified on stool microscopy.

    • This question is part of the following fields:

      • Clinical Microbiology
      • Principles Of Surgery-in-General
      0
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  • Question 11 - A 32-year-old woman presents with a long history of severe perianal Crohn's disease...

    Incorrect

    • A 32-year-old woman presents with a long history of severe perianal Crohn's disease involving multiple fistulae. Her disease is progressive with multiple episodes of rectal bleeding. However, she wants to avoid a stoma.

      Colonoscopy and small bowel study reveals that the disease does not extend beyond the rectum.

      What should be the best operative strategy?

      Your Answer:

      Correct Answer: Proctectomy and end stoma

      Explanation:

      Proctectomy with end stoma is the best operative strategy in severe perianal and/or rectal Crohn’s disease.

      Surgical resection of Crohn’s disease does not provide a complete cure but it may produce substantial symptomatic improvement. Indications for surgery include complications such as fistulae, abscess formation, and strictures.

      Colonoscopy and a small bowel study (e.g. MR enteroclysis imaging) are used to stage Crohn’s disease to facilitate decision-making regarding surgery.
      Complex perianal fistulae are best managed with long-term draining seton sutures. Severe perianal and/or rectal Crohn’s disease usually require proctectomy with formation of end stoma. Ileoanal pouch reconstruction carries a high risk of fistula formation and pouch failure and is, therefore, not recommended. Terminal ileal Crohn’s remains one of the most common form of the disease, and it may be treated with limited ileocaecal resections.

    • This question is part of the following fields:

      • Colorectal Surgery
      • Generic Surgical Topics
      0
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  • Question 12 - A 40 year old man is currently recovering after a live donor related...

    Incorrect

    • A 40 year old man is currently recovering after a live donor related liver transplant. He has been given a daily dose of corticosteroids to decrease the risk of graft rejection. Which of the following will not occur as a result of their administration?

      Your Answer:

      Correct Answer: Necrosis of activated lymphocytes

      Explanation:

      Corticosteroids are responsible for an array of side effects. However, necrosis has a different pathophysiology and is not usually linked with corticosteroid usage.

    • This question is part of the following fields:

      • Generic Surgical Topics
      • Organ Transplantation
      0
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  • Question 13 - A 46 year old politician with chronic hepatitis for several years visits the...

    Incorrect

    • A 46 year old politician with chronic hepatitis for several years visits the clinic for a review. Recently, his AFP is noted to be increased and an abdominal ultrasound demonstrates a 2.2cm lesion in segment V of the liver. What is the most appropriate course of action?

      Your Answer:

      Correct Answer: Liver MRI

      Explanation:

      In patients with liver tumours, it is crucial to detect and stage the tumours at an early stage (to select patients who will benefit from curative liver resection, and avoid unnecessary surgery). Therefore, an optimal preoperative evaluation of the liver is necessary, and a contrast-enhanced MRI is widely considered the state-of-the-art method. Liver MRI without contrast administration is appropriate for cholelithiasis but not sufficient for most liver tumour diagnoses.

    • This question is part of the following fields:

      • Generic Surgical Topics
      • Hepatobiliary And Pancreatic Surgery
      0
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  • Question 14 - A 32 year old woman who works as a teacher presents with a...

    Incorrect

    • A 32 year old woman who works as a teacher presents with a swollen, oedematous leg. She hails from Africa, from an area that is poorly sanitized and prevalent with mosquitoes. She travelled to England two weeks back. Which of the following is the most likely diagnosis?

      Your Answer:

      Correct Answer: Filariasis

      Explanation:

      Lymphatic filariasis, commonly known as elephantiasis, is a painful and profoundly disfiguring disease. In communities where filariasis is transmitted, all ages are affected. While the infection may be acquired during childhood its visible manifestations may occur later in life, causing temporary or permanent disability. The disease is caused by three species of thread-like nematode worms, known as filariae – Wuchereria bancrofti, Brugia malayi and Brugia timori. Male worms are about 3–4 centimetres in length, and female worms 8–10 centimetres. The male and female worms together form “nests” in the human lymphatic system.

      Filarial infection can cause a variety of clinical manifestations, including lymphoedema of the limbs, genital disease (hydrocele, chylocele, and swelling of the scrotum and penis) and recurrent acute attacks, which are extremely painful and are accompanied by fever. The vast majority of infected people are asymptomatic, but virtually all of them have subclinical lymphatic damage and as many as 40% have kidney damage, with proteinuria and haematuria.

    • This question is part of the following fields:

      • Generic Surgical Topics
      • Vascular
      0
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  • Question 15 - A 30 year old man presents with a surgical wound that is erythematous,...

    Incorrect

    • A 30 year old man presents with a surgical wound that is erythematous, tender and discharging pus. He states that he had undergone an inguinal hernia repair eight days earlier. What is the cause of this?

      Your Answer:

      Correct Answer: Infection with Staphylococcus aureus

      Explanation:

      Answer: Infection with Staphylococcus aureus

      Surgical site infections (SSIs) are among the most common healthcare-associated infections, and contribute significantly to patient morbidity and healthcare costs. Staphylococcus aureus is the most common microbial cause. The epidemiology of S. aureus is changing with the dissemination of newer clones and the emergence of mupirocin resistance. Pre-operative screening, using culture- or molecular-based methods, and subsequent decolonization of patients who are positive for methicillin-susceptible S. aureus and methicillin-resistant S. aureus (MRSA) reduces SSIs and hospital stay. This applies especially to major clean surgery, such as cardiothoracic and orthopaedic, involving the insertion of implanted devices. However, it requires a multi-disciplinary approach coupled with patient education. Universal decolonization pre-operatively without screening for S. aureus may compromise the capacity to monitor for the emergence of new clones of S. aureus, contribute to mupirocin resistance, and prevent the adjustment of surgical prophylaxis for MRSA (i.e. replacement of a beta-lactam agent with a glycopeptide or alternative).

      A surgical site infection is an infection that occurs after surgery in the part of the body where the surgery took place. Surgical site infections can sometimes be superficial infections involving the skin only. Other surgical site infections are more serious and can involve tissues under the skin, organs, or implanted material.

      Symptoms include:
      Redness and pain around the area where you had surgery
      Drainage of cloudy fluid from your surgical wound
      Fever

    • This question is part of the following fields:

      • Clinical Microbiology
      • Principles Of Surgery-in-General
      0
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  • Question 16 - A 47-year-old male is referred to a clinic for consideration of resection of...

    Incorrect

    • A 47-year-old male is referred to a clinic for consideration of resection of lung malignancy. He reports shortness of breath and haemoptysis. Investigations reveal corrected calcium of 2.84 mmol/l, FEV 1 of 1.9L and histology of squamous cell carcinoma. The patient is noted to have hoarseness of voice. Which one of the following is a contraindication to surgical resection in lung cancer?

      Your Answer:

      Correct Answer: Vocal cord paralysis

      Explanation:

      The hoarseness of voice implies vocal cord paralysis denoting the spread of malignancy which is a contraindication to surgery.

      Summary of Guidelines on the selection of patients with lung cancer for surgery (Related to this case)

      PART I: FITNESS FOR SURGERY
      Age:
      1. Perioperative morbidity increases with advancing age. Elderly patients undergoing lung resection are more likely to require intensive perioperative support. Preoperatively, a careful assessment of co-morbidity needs to be made.
      2. Surgery for clinically stage I and II disease can be as effective in patients over 70 years as in younger patients. Such patients should be considered for surgical treatment regardless of age.
      3. Age over 80 alone is not a contraindication to lobectomy or wedge resection for clinical stage I disease.
      4. Pneumonectomy is associated with higher mortality risk in the elderly. Age should be a factor in deciding suitability for pneumonectomy.

      Pulmonary function:
      There should be a formal liaison in borderline cases between the referring chest physician and the thoracic surgical team.
      2.No further respiratory function tests are required for a lobectomy if the post-bronchodilator FEV1 is >1.5 litres and for a pneumonectomy, if the post-bronchodilator FEV1 is >2.0 litres, provided that there is no evidence of interstitial lung disease or unexpected disability due to shortness of breath.
      STEP 1
      3.All patients not clearly operable on the basis of spirometry should have: (a) full pulmonary function tests including estimation of transfer factor (TLCO); (b) measurement of oxygen saturation on air at rest; and (c) a quantitative isotope perfusion scan if a pneumonectomy is being considered.
      4.These data should be used to calculate estimated postoperative FEV1 expressed as % predicted and the estimated postoperative TLCO expressed as % predicted, using either the lung scan for pneumonectomy or an anatomical equation for lobectomy, taking account of whether the segments to be removed are ventilated or obstructed.
      STEP 2
      5.(a) Estimated postoperative FEV1 >40% predicted and estimated postoperative TLCO >40% predicted and oxygen saturation (SaO 2) >90% on air: average risk.
      (b)Estimated postoperative FEV1 <40% predicted and estimated postoperative TLCO <40% predicted: high risk.
      (c)All other combinations: consider exercise testing.
      6.Patients for whom the risk of resection is still unclear after step 2 tests should be referred for exercise testing.
      STEP 3
      7.(a) The best distance on two shuttle walk tests of <25 shuttles (250 m) or desaturation during the test of more than 4% SaO 2 indicates a patient is a high risk for surgery.
      (b)Other patients should be referred for a formal cardiopulmonary exercise test. For cardiopulmonary exercise testing peak oxygen consumption (V˙O 2peak) of more than 15 ml/kg/min indicates that a patient is an average risk for surgery.
      (c)A V˙O 2peak of <15 ml/kg/min indicates that a patient is a high risk for surgery. PART II: OPERABILITY
      Diagnosis and staging
      1.All patients being considered for surgery should have a plain chest radiograph and a computed tomographic (CT) scan of the thorax including the liver and adrenal glands.
      2.Confirmatory diagnostic percutaneous needle biopsy in patients presenting with peripheral lesions is not mandatory in patients who are otherwise fit, particularly if there are previous chest radiographs showing no evidence of a lesion.
      3.Patients with mediastinal nodes greater than 1 cm in short-axis diameter on the CT scan should undergo biopsy by staging mediastinoscopy, anterior mediastinotomy, or needle biopsy as appropriate.
      Operability and adjuvant therapy
      1.The proportion of patients found to be inoperable at operation should be 5–10%.
      2.Patients with stage I (cT1N0 and cT2N0) and stage II (cT1N1, cT2N1 and cT3N0) tumours should be considered operable.
      3.Patients with stage I tumours have a high chance and those with stage II tumours a reasonable chance of being cured by surgery alone.
      4.Patients who are known preoperatively to have stage IIIA (cT3N1 and cT1–3N2) tumours have a low chance of being cured by surgery alone but might be considered operable in the context of a trial of surgery and adjuvant chemotherapy.
      5.Participation in prospective trials of multimodality treatment for locally advanced disease is strongly recommended.
      6.Some small individual studies indicate a place for surgery in T4N0 and T4N1 tumours within stage IIIB, few long term data are available. Generally, stage IIIB tumours with node involvement and stage IV tumours should be considered inoperable.
      7.There is no place for postoperative radiotherapy following complete primary tumour resection.

    • This question is part of the following fields:

      • Oncology
      • Principles Of Surgery-in-General
      0
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  • Question 17 - A 42-year-old female has undergone a total thyroidectomy for multinodular goitre. You are...

    Incorrect

    • A 42-year-old female has undergone a total thyroidectomy for multinodular goitre. You are called to see her because of respiratory distress. On examination, she has marked stridor, her wound seems healthy but there is a swelling within the operative site. What is the most likely explanation for this problem?

      Your Answer:

      Correct Answer: Contained haematoma

      Explanation:

      Airway obstruction: In the first 24 hours it is most likely from a compressive hematoma. After 24 hours consider laryngeal dysfunction secondary to hypocalcaemia.
      In this patient, the most likely cause is a haematoma.
      Definitive therapy is opening the surgical incision to evacuate the hematoma. Re-intubation may be lifesaving for persistent airway obstruction. Consider awake fibreoptic intubation.

    • This question is part of the following fields:

      • Peri-operative Care
      • Principles Of Surgery-in-General
      0
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  • Question 18 - A 58 year old woman is scheduled for the exploration of the common...

    Incorrect

    • A 58 year old woman is scheduled for the exploration of the common bile duct and insertion of a T tube. Which of the following devices would be most appropriately used in this patient?

      Your Answer:

      Correct Answer: Latex T tube on passive drainage

      Explanation:

      The special part of the equipment is the T tube itself. As the name refers, it is a special tube in the shape of T with a shorter transverse part (20 cm) that stays inside the CBD (after trimming) and a long longitudinal part (60 cm) that extends from the middle of the transverse part to an end that connects with a drainage bag. This portion extends from the CBD to outside the abdominal cavity when applied. It comes with different circumference sizes (10, 12, 14, 16, 18 Fr). T tube can be made of different materials like latex, silicone, red rubber and polyvinyl chloride (PVC). PVC is very inert causing the least tissue reaction with lack of tissue tract formation making it the least favourable material for T tube placement purposes. Silicon has many favourable physical properties, but it can disintegrate with poor handling making it not a practical option for long-term placement. Latex has the desired properties to be the most commonly used. Red rubber is an alternative if latex can not be used or is not available.

    • This question is part of the following fields:

      • Principles Of Surgery-in-General
      • Surgical Technique And Technology
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  • Question 19 - An 18 year old military recruit complains of sudden onset of severe pain...

    Incorrect

    • An 18 year old military recruit complains of sudden onset of severe pain in the forefoot after several weeks of training exercises. Examination shows tenderness along the second metatarsal and an x-ray done indicates the presence of callus surrounding the shaft of the second metatarsal. What is his diagnosis?

      Your Answer:

      Correct Answer: Stress fracture

      Explanation:

      Answer: Stress fracture

      A stress fracture is caused by repetitive and submaximal loading of the bone, which eventually becomes fatigued and leads to a true fracture. The typical presentation is a complaint of increasing pain in the lower extremity during exercise or activity. The patient’s history usually reveals a recent increase in either training volume or intensity. Stress fractures result from recurrent and repetitive loading of bone. The stress fracture differs from other types of fractures in that in most cases, no acute traumatic event precedes the symptoms.

      Normal bone remodelling occurs secondary to increased compressive or tensile loads or increased load frequency. In the normal physiologic response, minor microdamage of the bone occurs. This is repaired through remodelling. Stress fractures develop when extensive microdamage occurs before the bone can be adequately remodelled.
      Common findings on physical examination may include tenderness or pain on palpation or percussion of the bone. Erythema or oedema may be present at the site of the stress fracture. Loading or stress of the affected bone may also produce symptoms.

      A stress fracture can be difficult to see on an X-ray, because the bone often appears normal in the X-ray, and the small cracks can’t be seen. X-rays may not help diagnose a stress fracture unless it has started to heal. When the bone starts to heal, it creates a callus, or lump, that can be seen on X-rays. The doctors may recommend a bone scan or magnetic resonance imaging (MRI), which is more sensitive than an X-ray and can spot stress fractures early.

      Freiberg disease is a degenerative process involving the epiphyses resulting in osteonecrosis of subchondral cancellous bone. If the process is altered in such a way as to restore normal physiology, this may be followed by regeneration or recalcification. If not, the process continues to subchondral collapse and eventual fragmentation of the joint surface.
      Patients who have Freiberg disease typically present with complaints of activity-related forefoot pain. Walking alone is often sufficient to cause pain. Some patients describe an extended (months to years) history of chronic forefoot pain with episodic exacerbation, whereas others present with pain of recent onset that is related to a specific injury or event. A history of trauma may not be noted. Patients may present with stiffness and a limp. The pain is often vague and poorly localized to the forefoot. Some patients describe the sensation of a small, hard object under the foot.

      Physical examination typically reveals a limited range of motion (ROM), swelling, and tenderness with direct palpation of the metatarsophalangeal (MTP) joint. In early stages of the disease, MTP tenderness may be the only finding. In later stages, crepitus or deformity may be present. A skin callus may be seen on the plantar surface of the affected metatarsal head.

      Radiography
      Depending on the stage of the disease, radiographs may show only sclerosis and widening of the joint space (early), with complete collapse of the metatarsal head and fragmentation later. Osteochondral loose bodies may be seen late in the disease as well. Oblique views may be especially useful for achieving a full appreciation of subtle changes early in the disease. One study advocated the use of radiographs to assess musculoskeletal foot conditions in women related to poorly fitting shoes.
      Occasionally, patients are completely asymptomatic, with changes noted on radiographs taken for other reasons. Whether these patients later develop symptomatic Freiberg disease is not known.

    • This question is part of the following fields:

      • Generic Surgical Topics
      • Orthopaedics
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  • Question 20 - A 30-year-old professional footballer is admitted to the emergency department. During a tackle,...

    Incorrect

    • A 30-year-old professional footballer is admitted to the emergency department. During a tackle, his leg is twisted with his knee flexed. He hears a loud crack and his knee rapidly becomes swollen. Which of the following is the main site of injury?

      Your Answer:

      Correct Answer: Anterior cruciate ligament

      Explanation:

      Anterior cruciate ligament (ACL) injuries are most often a result of low-velocity, noncontact, deceleration injuries and contact injuries with a rotational component. Contact sports also may produce injury to the ACL secondary to twisting, valgus stress, or hyperextension all directly related to contact or collision.

      Symptoms of an acute ACL injury may include the following:
      – Feeling or hearing a “pop” sound in the knee
      – Pain and inability to continue the activity
      – Swelling and instability of the knee
      – Development of a large hemarthrosis

      Differential Diagnoses
      A- Medial Collateral Knee Ligament Injury
      Contact, noncontact, and overuse mechanisms are involved in causing MCL injuries.
      Contact injuries involve a direct valgus load to the knee. This is the usual mechanism in a complete tear.
      Noncontact, or indirect, injuries are observed with deceleration, cutting, and pivoting motions. These mechanisms tend to cause partial tears.
      Overuse injuries of the MCL have been described in swimmers. The whip-kick technique of the breaststroke has been implicated. This technique involves repetitive valgus loads across the knee.

      B- Posterior Cruciate Ligament Injury
      Knowledge of the mechanism of injury is helpful. The following 4 mechanisms of PCL injury are recognized:
      – A posteriorly directed force on a flexed knee, e.g., the anterior aspect of the flexed knee striking a dashboard, may cause PCL injury.
      – A fall onto a flexed knee with the foot in plantar flexion and the tibial tubercle striking the ground first, directing a posterior force to the proximal tibia, may result in injury to the PCL.
      – Hyperextension alone may lead to an avulsion injury of the PCL from the origin. This kind of injury may be amenable to repair.
      – An anterior force to the anterior tibia in a hyperextended knee with the foot planted results in combined injury to the knee ligaments along with knee dislocation.

      In chronic PCL tears, discomfort may be experienced with the following positions or activities:
      – A semi flexed position, as with ascending or descending stairs or an incline
      – Starting a run
      – Lifting a load
      – Walking longer distances
      – Retro patellar pain symptoms may be reported as a result of posterior tibial sagging.
      – Swelling and stiffness may be reported in cases of chondral damage.
      – Individuals may describe a sensation of instability when walking on uneven ground
      – Medial joint line pain may be reported.

    • This question is part of the following fields:

      • Generic Surgical Topics
      • Orthopaedics
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  • Question 21 - A 20-year-old African man is admitted to the hospital with acute severe abdominal...

    Incorrect

    • A 20-year-old African man is admitted to the hospital with acute severe abdominal pain. He has just flown to UK after a long-haul flight, and the pain developed mid-flight. On examination, there is tenderness in the left upper abdominal quadrant.

      His blood tests, done on his arrival, show:
      Hb: 5 g/dL
      WCC: 20 x 10^9/L
      Retic count: 30%

      What is the most likely underlying cause?

      Your Answer:

      Correct Answer: Sickle cell anaemia

      Explanation:

      The combination of a high reticulocyte count and severe anaemia indicates aplastic crisis in patients with sickle cell anaemia. Another differential can be that of a transient aplastic crisis due to parvovirus. This is less likely as it causes reticulocytopenia rather than reticulocytosis.

      Parvovirus B19 infects erythroid progenitor cells in the bone marrow and causes temporary cessation of red blood cell production. People who have underlying haematologic abnormalities such as sickle cell anaemia are at risk of cessation of red blood cell production if they become infected. This can result in a transient aplastic crisis. It is more common in people of African, Indian, and Middle Eastern backgrounds. Typically, these patients have a viral prodrome followed by anaemia, often with haemoglobin concentrations falling below 5.0 g/dL and reticulocytosis.

    • This question is part of the following fields:

      • Emergency Medicine And Management Of Trauma
      • Principles Of Surgery-in-General
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  • Question 22 - A 26-year-old female presents to her GP complaining of a two day history...

    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:

      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 23 - A 35 year old woman with uncontrolled hypertension presents with a thyroid nodule....

    Incorrect

    • A 35 year old woman with uncontrolled hypertension presents with a thyroid nodule. Family history is significant for total thyroidectomies of both sisters. Which of the following would be the most likely underlying pathology of her thyroid lesion?

      Your Answer:

      Correct Answer: Medullary thyroid cancer

      Explanation:

      Multiple endocrine neoplasia type 2 (MEN2) is a hereditary condition associated with 3 primary types of tumours: medullary thyroid cancer, parathyroid tumours, and pheochromocytoma. MEN2 is classified into subtypes based on clinical features. Virtually all patients with classical MEN2A develop medullary thyroid carcinoma (MTC), which is often the first manifestation of the disease and usually occurs early in life. Pheochromocytomas (PHEOs) tend to be diagnosed several years later or simultaneously with the MTC.

    • This question is part of the following fields:

      • Breast And Endocrine Surgery
      • Generic Surgical Topics
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  • Question 24 - A 25 year old lady visits her regular doctor to have a skin...

    Incorrect

    • A 25 year old lady visits her regular doctor to have a skin lesion excised from her thigh. At her 3 month follow-up appointment, the doctor notes that the scar is contracting. Which of the following allows this process to happen?

      Your Answer:

      Correct Answer: Myofibroblasts

      Explanation:

      Answer: Myofibroblasts

      Fibroblasts are a type of cell which have mesenchymal origin and can exhibit either non-contractile or highly contractile phenotype. Under normal conditions, fibroblasts function to maintain tissue homeostasis by regulating the turnover of extracellular matrix (ECM). When tissues are injured, however, fibroblasts around the injured region differentiate into myofibroblasts, a type of highly contractile cells that produce abundant ECM proteins. While the mechanisms of wound healing are not completely understood, it has become clear that both fibroblasts and myofibroblasts play a critical role in the wound healing process. Specifically, the traction forces of fibroblasts and coordinated contraction of myofibroblasts are believed to be responsible for wound contraction and closure. However, excessive myofibroblast activity, accompanied by elevated levels of mechanical stress in the healing region, often causes scar tissue formation, and in the worst case, contracture of tissues (e.g. Dupuytren’s contracture), leading to local immobilization and loss of function.

    • This question is part of the following fields:

      • Peri-operative Care
      • Principles Of Surgery-in-General
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  • Question 25 - A 3-year-old boy is brought to the A&E department following a trauma. He...

    Incorrect

    • A 3-year-old boy is brought to the A&E department following a trauma. He is haemodynamically unstable. Initial attempts at intravenous access are proving unsuccessful.

      What should be the best course of action?

      Your Answer:

      Correct Answer: Insert an intraosseous infusion system

      Explanation:

      Gaining venous access in small children is challenging most of the times especially in cases of trauma. Therefore, intraosseous infusions should be preferred in this setting. Broviac lines are long-term IV access systems with narrow lumens and, hence, would be unsuitable.

      Intraosseous access is typically undertaken at the anteromedial aspect of the proximal tibia and provides access to the marrow cavity and circulatory system. Although traditionally preferred in paediatric practice, it may be used in adults as well, and a wide range of fluids can be infused using this approach.

    • This question is part of the following fields:

      • Peri-operative Care
      • Principles Of Surgery-in-General
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  • Question 26 - A 11 year girl presents to the A&E department with a full thickness...

    Incorrect

    • A 11 year girl presents to the A&E department with a full thickness burn to her right arm, which she got when a firework that she was playing with exploded. Which statement is not characteristic of the situation?

      Your Answer:

      Correct Answer: The burn area is extremely painful until skin grafted

      Explanation:

      Answer: The burn area is extremely painful until skin grafted

      Third-degree burns destroy the epidermis and dermis. Third-degree burns may also damage the underlying bones, muscles, and tendons. The burn site appears white or charred. There is no sensation in the area since the nerve endings are destroyed. These are not normally painful until after skin grafting is done since the nerve endings have been destroyed.

    • This question is part of the following fields:

      • Emergency Medicine And Management Of Trauma
      • Principles Of Surgery-in-General
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  • Question 27 - A 40-year-old man has been diagnosed with anal fissure, which has failed to...

    Incorrect

    • A 40-year-old man has been diagnosed with anal fissure, which has failed to respond to first-line treatment.

      What should be the next most appropriate treatment?

      Your Answer:

      Correct Answer: 15–30 units of botulinum toxin injected into the internal anal sphincter

      Explanation:

      The next appropriate step would be to perform an examination under anaesthesia and inject 15–30 units of botulinum toxin into the internal anal sphincter.

      Anal fissures are commonly seen in the colorectal clinic and 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 prolapse

      Diagnostic 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 (however, up to 25% of the patients fail to respond). 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 28 - A 26 year old man is admitted for severe anorexia nervosa and he...

    Incorrect

    • A 26 year old man is admitted for severe anorexia nervosa and he is given nasogastric feeding which is initially tolerated well. Four days later, he becomes acutely agitated and confused. On examination, his heart rate is 121/min with regular rhythm and a blood pressure of 97/86 mmHg. despite all this, he appears adequately hydrated and has no fever. Which investigation would be the best one for this patient?

      Your Answer:

      Correct Answer: Serum phosphate

      Explanation:

      Answer: Serum phosphate

      Refeeding syndrome can be defined as the potentially fatal shifts in fluids and electrolytes that may occur in malnourished patients receiving artificial refeeding (whether enterally or parenterally. These shifts result from hormonal and metabolic changes and may cause serious clinical complications. The hallmark biochemical feature of refeeding syndrome is hypophosphatemia. However, the syndrome is complex and may also feature abnormal sodium and fluid balance; changes in glucose, protein, and fat metabolism; thiamine deficiency; hypokalaemia; and hypomagnesaemia.
      During refeeding, glycaemia leads to increased insulin and decreased secretion of glucagon. Insulin stimulates glycogen, fat, and protein synthesis. This process requires minerals such as phosphate and magnesium and cofactors such as thiamine. Insulin stimulates the absorption of potassium into the cells through the sodium-potassium ATPase symporter, which also transports glucose into the cells. Magnesium and phosphate are also taken up into the cells. Water follows by osmosis. These processes result in a decrease in the serum levels of phosphate, potassium, and magnesium, all of which are already depleted. The clinical features of the refeeding syndrome occur as a result of the functional deficits of these electrolytes and the rapid change in basal metabolic rate.

      Symptoms of hypophosphatemia include:

      confusion or hesitation
      seizures
      muscle breakdown
      neuromuscular problems
      acute heart failure

      Deficiency in thiamine can lead to Korsakoff’s syndrome (retrograde and anterograde amnesia, confabulation) and Wernicke’s encephalopathy (ocular abnormalities, ataxia, confusional state, hypothermia, coma). These symptoms are not present in the patient so Thiamine deficiency can be ruled out and there is no need to do tests for Serum vitamin B.

    • This question is part of the following fields:

      • Peri-operative Care
      • Principles Of Surgery-in-General
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  • Question 29 - A 29-year-old woman is brought to the A&E department with chest pain after...

    Incorrect

    • 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:

      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 haemothorax

      Diagnosis can be made by angiography, usually CT aortogram.

      Treatment options include repair or replacement. The patient should, ideally, undergo endovascular repair.

    • This question is part of the following fields:

      • Emergency Medicine And Management Of Trauma
      • Principles Of Surgery-in-General
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  • Question 30 - A 57 year old man, known case of schizophrenia, undergoes a cholecystectomy. He...

    Incorrect

    • A 57 year old man, known case of schizophrenia, undergoes a cholecystectomy. He is administered metoclopramide for post operative nausea. Twenty minutes later, he presents with agitation, marked oculogyric crises and oromandibular dystonia. Which of the following drugs would most likely alleviate his symptoms?

      Your Answer:

      Correct Answer: Procyclidine

      Explanation:

      An acute dystonic reaction is characterized by involuntary contractions of muscles of the extremities, face, neck, abdomen, pelvis, or larynx in either sustained or intermittent patterns that lead to abnormal movements or postures. The symptoms may be reversible or irreversible and can occur after taking any dopamine receptor-blocking agents.
      The aetiology of acute dystonic reaction is thought to be due to a dopaminergic-cholinergic imbalance in the basal ganglia. Reactions usually occur shortly after initiation of an offending agent or an increased dose of a possible offending agent.
      Anticholinergic agents and benzodiazepines, procyclidine are the most commonly used agents to reverse or reduce symptoms in acute dystonic reaction. Acute dystonic reactions are often transient but can cause significant distress to the patient. Although rare, laryngeal dystonia can cause life-threatening airway obstruction.

    • This question is part of the following fields:

      • Post-operative Management And Critical Care
      • Principles Of Surgery-in-General
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SESSION STATS - PERFORMANCE PER SPECIALTY

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