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Question 1
Correct
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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 2
Correct
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The specialist registrar, while performing the repair of an infrarenal abdominal aortic aneurysm, decides not to re-implant the inferior mesenteric artery into the repaired abdominal aorta. She says that an anastomotic artery running along the border of the large intestine is good enough to supply blood to the territory of the inferior mesenteric artery. Which vessel is she referring to?
Your Answer: Marginal
Explanation:The marginal artery is a key anastomosis for the large intestine that runs around the border of the large intestine and is formed by the anastomosis of the branches of the ileocolic artery, right colic artery, middle colic artery, left colic artery and sigmoid artery. If a small artery is occluded, these branches allow blood to reach all segments of the colon.
The arcades are anastomotic loops between the arteries that provide alternative pathways for blood flow. They are more prominent in the small intestine than the large intestine.
Arteriae rectae are small branches that run from the marginal artery to reach the colon.
The ileocolic artery is the branch of the superior mesenteric artery that supplies the caecum, appendix and terminal part of the ileum.
The coronary arteries supply blood to the heart. -
This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 3
Incorrect
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A 30-year-old male presents to the clinic with a recurrent thyroid cyst. It has been drained on three different occasions. Each time the cyst is aspirated and cytology is reassuring. What is the most appropriate course of action?
Your Answer: Enucleation of the cyst
Correct Answer: Resection of the ipsilateral thyroid lobe
Explanation:Aspiration is the treatment of choice in thyroid cysts, but the recurrence rates are high (60%–90% of patients), particularly with repeated aspirations and large-volume cysts.
Percutaneous ethanol injection (PEI) has been studied in several large randomized controlled studies, with reported success in 82–85% of the cases after an average of 2 sessions, with a volume reduction of more than 85% from baseline size.
PEI may also be considered for hyperfunctioning nodules, particularly if a large fluid component is present. It has a success rate ranging from 64% to 95%, with a mean volume reduction of 66%, but recurrences are more common and the number of sessions required to achieve good response is higher (about 4 sessions per patient). PEI is a safe procedure, with the most common reported adverse effects being local pain, dysphonia, flushing, dizziness, and, rarely, recurrent laryngeal nerve damage.
Surgery, Lobectomy is also a reasonable therapy for cystic lesions, as an alternative to the previously mentioned procedures. -
This question is part of the following fields:
- Breast And Endocrine Surgery
- Generic Surgical Topics
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Question 4
Correct
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Which of the following is the cause of flattened (notched) T waves on electrocardiogram (ECG)?
Your Answer: Hypokalaemia
Explanation:The T-wave is formed due to ventricular repolarisation. Normally, it is seen as a positive wave. It can be normally inverted (negative) in V1 (occasionally in V2-3 in African-Americans/Afro-Caribbeans). Hyperacute T-waves are the earliest ECG change of acute myocardial infarction. ECG findings of hyperkalaemia include high, tent-shaped T-waves, a small P-wave and a wide QRS complex. Hypokalaemia results in flattened (notched) T-waves, U-waves, ST-segment depression and prolonged QT interval.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 5
Incorrect
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What is the nerve supply of the muscle that is inserted onto the crest of the lesser tubercle of the humerus?
Your Answer: Axillary
Correct Answer: Lower subscapular
Explanation:The muscle is the subscapularis muscle which is supplied by the lower subscapular nerve.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 6
Correct
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A 4-year-old boy inserts a crayon into his external auditory meatus. Attempts to remove it have not been successful. What is the best course of action?
Your Answer: Operate on the next emergency operating list
Explanation:The removal of foreign bodies from the ear is a common procedure in the emergency department.
Abandon attempts to retrieve a foreign body if complications arise. If the object migrates farther into the canal or if bleeding, oedema, or increasing pain develops, consult an ENT specialist. Repeated attempts to remove a foreign body from the ear may result in infection, perforation, or another morbidity.
The presence of a tympanic membrane (TM) perforation, contact of a foreign body with the tympanic membrane, or incomplete visualization of the auditory canal are indications for urgent-emergent ENT consultation for removal by operative microscope and speculum.
Local anaesthesia is invasive and is not generally used for uncomplicated ear foreign body removal because of the complex innervations of the external ear canal. -
This question is part of the following fields:
- Generic Surgical Topics
- Paediatric Surgery
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Question 7
Correct
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An amateur body-builder complains of increasing pain in his right shoulder after a few days of intense training. A surgeon aspirates clear fluid from his subdeltoid region. What's the most likely diagnosis?
Your Answer: Bursitis
Explanation:Bursae are potential cavities that contain synovial fluid, found in areas where friction occurs. Their function is to minimise friction and facilitate movement. Bursitis is the inflammation of one or more bursae, and they can occur in the shoulder, elbow, knee, ischium, amongst other joints. Acute bursitis can appear after strenuous exercise or activity, and chronic bursitis can develop following previous bursitis or trauma. Acute bursitis causes pain, tenderness, and swelling.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 8
Correct
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An 8 month old baby girl presents with a spiral fracture of her left humerus. Her father states that he grabbed her arm because she was falling off the park slide. He noticed that something was wrong and he rushed to the hospital with her. Which of the following is the most likely issue?
Your Answer: Accidental fracture
Explanation:In this case, there is no delay in treatment and the mechanism by which the fracture occurred fits accidental fracture.
A statement from the parent or guardian and any witnesses regarding how the child sustained the injury will help determine whether the injury is accidental or abusive. A statement from the parent or guardian explaining why he or she delayed in seeking medical treatment is important to the investigation because caretakers often postpone medical treatment or fail to provide treatment for an injured child to hide physical abuse. The abusing parent or caregiver may also put a child in oversized clothing or keep the child inside a residence for extended periods of time in an attempt to conceal the child’s injuries.
Parents who inflict fractures on their children tend to minimize the severity of the accident purported to cause the fracture, whereas many parents of children with accidental fractures will relate a history of high-energy events.
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This question is part of the following fields:
- Generic Surgical Topics
- Orthopaedics
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Question 9
Correct
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An 18 year old man is admitted to the intensive care unit with severe meningococcal sepsis. He is on maximal inotropic support and a CT scan of his chest and abdomen is performed. The adrenal glands show evidence of diffuse haemorrhage. Which of the following is the best explanation?
Your Answer: Waterhouse- Friderichsen syndrome
Explanation:Answer: Waterhouse- Friderichsen syndrome
Waterhouse-Friderichsen syndrome is a condition characterized by the abrupt onset of fever, petechiae, arthralgia, weakness, and myalgias, followed by acute haemorrhagic necrosis of the adrenal glands and severe cardiovascular dysfunction. The syndrome is most often associated with meningococcal septicaemia but may occur as a complication of sepsis caused by other organisms, including certain streptococcal species. This disorder may be associated with a history of splenectomy.
Fulminant infection from meningococcal bacteria in the bloodstream is a medical emergency and requires emergent treatment with vasopressors, fluid resuscitation, and appropriate antibiotics. Benzylpenicillin was once the drug of choice with chloramphenicol as a good alternative in allergic patients. Ceftriaxone is an antibiotic commonly employed today. Hydrocortisone can sometimes reverse the adrenal insufficiency. Amputations, reconstructive surgery, and tissue grafting are sometimes needed as a result of tissue necrosis (typically of the extremities) caused by the infection.
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This question is part of the following fields:
- Breast And Endocrine Surgery
- Generic Surgical Topics
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Question 10
Correct
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A lady presents to the out patient clinic with a painful boil on the skin of her mons pubis. Which nerve supplies the skin of the mons pubis?
Your Answer: Anterior labial
Explanation:Anterior labial branch is the terminal branch of the ilioinguinal nerve that innervates the skin of the mons pubis in women and the skin of the anterior scrotum in men.
The femoral branch of genitofemoral nerve innervates the upper medial thigh.
The iliohypogastric innervates muscles of the abdominal wall.
The subcostal nerve innervates muscles of the abdominal wall and the skin of the lower abdominal wall. -
This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 11
Correct
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Question 12
Correct
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A previously healthy 40-year-old housewife suddenly complains of a headache and loses consciousness. A CT scan reveals subarachnoid haemorrhage. Which of the following is the most probable cause?
Your Answer: Ruptured berry aneurysm
Explanation:Saccular aneurysms, also known as berry aneurysms, appear as a round outpouching and are the most common form of cerebral aneurysm. They are a congenital intracranial defect, and haemorrhage can occur at any age, but is most common between the ages of 40-65 years. A second rupture (rebleeding) sometimes occurs, most often within about 7 days of the first bleed.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 13
Incorrect
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A 32 year old presents with symptoms of an anal fistula. The clinician examines him in the lithotomy position and the external opening of the fistula is identified in the 7 o'clock position. At which of the following locations is the internal opening most likely to be found?
Your Answer: 7 o'clock
Correct Answer: 6 o'clock
Explanation:Goodsall’s rule can be used to clinically predict the course of an anorectal fistula tract. Imagine a line that bisects the anus in the coronal plane (transverse anal line). Any fistula that originates anterior to the line will course anteriorly in a direct route. Fistulae that originate posterior to the line will have a curved path. An exception to the rule are anterior fistulas lying more than 3 cm from the anus, which may open into the anterior midline of the anal canal.
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This question is part of the following fields:
- Colorectal Surgery
- Generic Surgical Topics
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Question 14
Correct
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Rapid Eye Movement (REM) sleep is typically associated with:
Your Answer: Penile erections
Explanation:Normal sleep comprises of alternate cycles between slow-wave sleep (non-REM sleep) and REM sleep. REM sleep is characterized by increased metabolic brain activity and EEG desynchronization. Somnambulism (sleepwalking), enuresis (bedwetting) and night terrors all occur during slow-wave sleep or during arousal from slow-wave sleep. In comparison, REM sleep is characterized by hypotonia of major muscle groups (excluding ocular muscles), dreams, nightmares and penile erection.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 15
Correct
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A 65 year old man develops persistent pyrexia on his 2nd postoperative day. He has undergone an open extended right hemicolectomy for carcinoma of the colonic-splenic flexure. What is the least likely cause?
Your Answer: Ileus
Explanation:Pyrexia is a very common post operative finding and can most likely result from an infection. However, it is highly unlikely to occur as a result of ileus. Anastomotic leaks are uncommon after right sided colonic surgery. In this scenario atelectasis would be the most likely underlying cause, as open extended right hemicolectomies will necessitate a long midline incision.
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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 16
Incorrect
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A young lady is taken to the A&E department after she falls from the 3rd floor balcony. A chest x-ray shows depression of the left main bronchus and deviation of the trachea to the right. What is the most likely injury that she sustained?
Your Answer: Tension pneumothorax
Correct Answer: Aortic rupture
Explanation:Answer: Aortic rupture
Aortic rupture is typically the result of a blunt aortic injury in the context of rapid deceleration. After traumatic brain injury, blunt aortic rupture is the second leading cause of death following blunt trauma. Thus, 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, exsanguination, and death. Traumatic aortic transection or rupture is associated with a sudden and rapid deceleration of the heart and the aorta within the thoracic cavity.
Features on plain chest radiography that suggest aortic injury and can help guide the further use of angiography include; an abnormal aortic arch contour, left apical cap, loss of the aorticopulmonary window, rightward deviation of the trachea, depression of the left main stem bronchus, and a wide left paravertebral pleural stripe. Also, widening of the mediastinum (greater than 8 cm) has a reported sensitivity of 81% to 100% and a specificity of 60%. -
This question is part of the following fields:
- Emergency Medicine And Management Of Trauma
- Principles Of Surgery-in-General
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Question 17
Correct
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In the emergency room, a nurse was introducing a catheter into the patients femoral vein for rapid fluid therapy. The femoral vein is situated inside the femoral sheath. Which of the following is true about that sheath?
Your Answer: The medial compartment is called the femoral canal
Explanation:The femoral sheath is situated ,4cm below the inguinal ligament. It is a prolongation of the abdominal fascia. The anterior wall is a prolongation of the transversalis fascia and the posterior wall, the iliac fascia. It is divided by two vertical septa into 3 compartments, lateral, intermediate, and medial. The medial compartment is known as the femoral canal and contains some lymphatic vessels. The lateral one contains the femoral artery and the intermediate one contains the femoral vein.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 18
Incorrect
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Which of the following structure contains the parasympathetic pre-ganglionic nucleus that innervates the iris sphincter muscle and the ciliary muscle?
Your Answer: Ciliary ganglion
Correct Answer: Edinger–Westphal nucleus
Explanation:The Edinger–Westphal nucleus (accessory oculomotor nucleus) is the parasympathetic pre-ganglionic nucleus that innervates the iris sphincter muscle and the ciliary muscle.
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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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If a catheter is placed in the main pulmonary artery of a healthy 30-year-old woman, which of the following will be its mean pulmonary arterial pressure?
Your Answer: 10 mmHg
Correct Answer: 15 mmHg
Explanation:The pulmonary artery pressure (PA pressure) is a measure of the blood pressure found in the main pulmonary artery. The hydrostatic pressure of the pulmonary circulation refers to the actual pressure inside pulmonary vessels relative to atmospheric pressure. Hydrostatic (blood pressure) in the pulmonary vascular bed is low compared with that of similar systemic vessels. The mean pulmonary arterial pressure is about 15 mmHg (ranging from about 13 to 19 mmHg) and is much lower than the average systemic arterial pressure of 90 mmHg.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 20
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 21
Correct
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Which of the following conditions can present with multiple abscesses that may discharge sulphur granules?
Your Answer: Actinomycosis
Explanation:Actinomycosis is primarily caused by any of the several members of the bacterial genus Actinomyces. These bacteria are generally anaerobes. And can cause multiple abscesses that may discharge sulphur granules.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 22
Incorrect
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A 36-year-old woman suddenly suffers from a generalized seizure. She was previously healthy. An emergency CT scan reveals a mass in the posterior fossa, with distortion of the lateral ventricles. After removing the tumour, the biopsy reveals it contains glial fibrillary acidic protein (GEAP). What's the most likely diagnosis?
Your Answer: Neuroblastoma
Correct Answer: Astrocytoma
Explanation:Astrocytomas are primary intracranial tumours derived from astrocyte cells of the brain. They can arise in the cerebral hemispheres, in the posterior fossa, in the optic nerve and, rarely, in the spinal cord. These tumours express glial fibrillary acidic protein (GFAP). In almost half of cases, the first symptom of an astrocytoma is the onset of a focal or generalised seizure. Between 60% and 75% of patients will have recurrent seizures during the course of their illness. Secondary clinical sequelae may be caused by elevated intracranial pressure (ICP) cause by the direct mass effect, increased blood volume, or increased cerebrospinal fluid (CSF) volume. CT will usually show distortion of the third and lateral ventricles, with displacement of the anterior and middle cerebral arteries. Histological diagnosis with tissue biopsy will normally reveal an infiltrative character suggestive of the slow growing nature of the tumour.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 23
Incorrect
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A 29-year-old man with gunshot to the abdomen is transferred to the operating theatre, following his arrival in the A&E department. He is unstable and his FAST scan is positive. During the operation, extensive laceration to the right lobe of the liver and involvement of the IVC are found, along with massive haemorrhage. What should be the most appropriate approach to blood component therapy?
Your Answer: Transfuse packed cells, FFP, and platelets in fixed ratio of 1:1:1
Correct Answer:
Explanation:There is strong evidence to support haemostatic resuscitation in the setting of massive haemorrhage due to trauma. This advocates the use of 1:1:1 ratio.
Uncontrolled haemorrhage accounts for up to 39% of all trauma-related deaths. In the UK, approximately 2% of all trauma patients need massive transfusion. Massive transfusion is defined as the replacement of a patient’s total blood volume in less than 24 hours or the acute administration of more than half the patient’s estimated blood volume per hour. During acute bleeding, the practice of haemostatic resuscitation has been shown to reduce mortality rates. It is based on the principle of transfusion of blood components in fixed ratios. For example, packed red cells, FFP, and platelets are administered in a ratio of 1:1:1.
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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 24
Correct
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Regarding innervation to the peroneus brevis muscle:
Your Answer: Could be damaged by a fracture of the neck of the fibula
Explanation:The peroneus brevis is supplied by the fourth and fifth lumbar and first sacral nerves through the superficial peroneal nerve which is one of the two terminal branches of the common peroneal nerve. The common peroneal nerve winds around the neck of the fibula and can be injured in cases of fractured neck of fibula.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 25
Correct
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During a splenectomy procedure of a 45-year old male patient with a bleeding ruptured spleen, the surgeon decided to clamp the splenic artery near the coeliac trunk to stop the bleeding. Which of the following organ/s parts will be least affected by the clamping?
Your Answer: Duodenum
Explanation:The duodenum is the only organ in the list that would not be affect by the clumping of the splenic artery as it is supplied by common hepatic artery (through the gastroduodenal artery) and the superior mesenteric artery (through the inferior pancreaticoduodenal artery). The splenic artery is the artery that supplies the spleen with oxygenated blood. The splenic artery before reaching the spleen also gives off branches that supply the stomach and the pancreas. The greater curvature and the fundus of the stomach is supplied the short gastric artery which branches off from the splenic artery. The left portion of the greater curvature of the stomach together with the greater omentum is supplied by the left gastro-omental artery of the splenic artery. The body and tail of the pancreas is supplied by branches of the splenic artery through the dorsal and superior pancreatic arteries and the caudal pancreatic arteries respectively.
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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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The muscle which has an antagonistic action to the serratus anterior muscle and is the primary protractor of the scapula is the?
Your Answer: Rhomboid major
Explanation:The rhomboid major arises from the second, third, fourth and fifth thoracic vertebrae. It is inserted into a narrow tendinous arch attached to the root of the spine of the scapula and the inferior angle. By its insertion in the inferior angle of the scapula, it acts on this angle and produces a slight rotation of the scapula on the side of the chest. It also retracts the scapula by working with the trapezius muscle.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 27
Correct
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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: 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 28
Correct
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A 32-year-old female is injured in a skiing accident. She suffers a blow to the occiput and is concussed for 5 minutes. On arrival in the ED, she is confused with a GCS 10/15. A CT scan shows no evidence of acute bleed or fracture but some evidence of oedema with the beginnings of mass effect. What is the best course of action?
Your Answer: Administration of intravenous mannitol
Explanation:Effective management of intracranial hypertension involves meticulous avoidance of factors that precipitate or aggravate increased intracranial pressure. When intracranial pressure becomes elevated, it is important to rule out new mass lesions that should be surgically evacuated. Medical management of increased intracranial pressure should include sedation, drainage of cerebrospinal fluid, and osmotherapy with either mannitol or hypertonic saline. For intracranial hypertension refractory to initial medical management, barbiturate coma, hypothermia, or decompressive craniectomy should be considered. Steroids are not indicated and may be harmful in the treatment of intracranial hypertension resulting from traumatic brain injury.
Mannitol is the most commonly used hyperosmolar agent for the treatment of intracranial hypertension.
Intravenous bolus administration of mannitol lowers the ICP in 1 to 5 minutes with a peak effect at 20 to 60 minutes. The effect of mannitol on ICP lasts 1.5 to 6 hours, depending on the clinical condition. Mannitol usually is given as a bolus of 0.25 g/kg to 1 g/kg body weight; when an urgent reduction of ICP is needed, an initial dose of 1 g/kg body weight should be given. Arterial hypotension (systolic blood pressure < 90 mm Hg ) should be avoided. -
This question is part of the following fields:
- Generic Surgical Topics
- Surgical Disorders Of The Brain
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Question 29
Correct
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Which of the following tumours is very radiosensitive?
Your Answer: Seminoma
Explanation:Seminoma is the most radiosensitive tumour and responds well to radiation therapy after unilateral orchidectomy. The ipsilateral inguinal areas are routinely not treated however, depending on the stage, the mediastinum and the left supraclavicular regions may also be irradiated.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 30
Correct
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A 40-year-old male pedestrian is brought to the A&E department after being hit by a car. On examination, he is found to be dyspnoeic and hypoxic despite administration of high flow oxygen therapy. Moreover, his pulse is 115bpm and blood pressure is 110/70 mmHg. The right side of his chest is hyper-resonant on percussion and has decreased breath sounds. His trachea is deviated to the left. What is the most likely underlying diagnosis?
Your Answer: Tension pneumothorax
Explanation:This patient has developed a tension pneumothorax following a blunt trauma.
Tension pneumothorax is a life-threatening condition that develops when air is trapped in the pleural cavity under positive pressure, displacing mediastinal structures and compromising cardiopulmonary function. Blunt or penetrating chest trauma that creates a flap-type defect on the surface of the lung can result in this life-threatening condition.
Signs and symptoms of tension pneumothorax include:
1. Chest pain that usually has a sudden onset, is sharp, and may lead to feeling of tightness in the chest
2. Dyspnoea and progressive hypoxia
3. Tachycardia
4. Hyperventilation
5. Cough
6. FatigueOn examination, hyper-resonant percussion note and tracheal deviation are typically found. Treatment is immediate without waiting for the CXR result and includes needle decompression and chest tube insertion.
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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 31
Correct
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A 78-year-old woman was brought to the emergency department with decreased consciousness, weakness and dehydration. Which serum electrolyte would most likely be low in this patient?
Your Answer: Na+
Explanation:Hyponatremia is a sodium level below 135 mEq/L. Signs and symptoms may include: nausea with vomiting, fatigue, headache or confusion, cramps or spasm, irritability and restlessness and severe cases may lead to seizures and comma.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 32
Incorrect
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A 1 week old baby boy is taken to the A&E department after a right sided groin swelling had been noticed. An examination is done and the testes are correctly located but there is a right sided inguinal hernia that is soft and easily reduced. Which of the following is the most appropriate management?
Your Answer: Surgery at 1 year of age
Correct Answer: Surgery over the next few days
Explanation:Answer: Surgery over the next few days
Inguinal hernia is a type of ventral hernia that occurs when an intra-abdominal structure, such as bowel or omentum, protrudes through a defect in the abdominal wall. Inguinal hernias do not spontaneously heal and must be surgically repaired because of the ever-present risk of incarceration. Generally, a surgical consultation should be made at the time of diagnosis, and repair (on an elective basis) should be performed very soon after the diagnosis is confirmed.
The infant or child with an inguinal hernia generally presents with an obvious bulge at the internal or external ring or within the scrotum. The parents typically provide the history of a visible swelling or bulge, commonly intermittent, in the inguinoscrotal region in boys and inguinolabial region in girls.
The swelling may or may not be associated with any pain or discomfort. -
This question is part of the following fields:
- Generic Surgical Topics
- Paediatric Surgery
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Question 33
Incorrect
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A patient sustained an iatrogenic injury to one of the structures passing through the deep inguinal ring. This was during an operation to repair an inguinal hernia. Which structure is most likely to be injured?
Your Answer: Ilioinguinal nerve
Correct Answer: Round ligament of the uterus
Explanation:The deep inguinal ring transmits the spermatic cord in the man and the round ligament of the uterus in the female. It is bound below and medially by the inferior epigastric vessels (so these don’t go through it).
The ilioinguinal nerve, although it courses through the inguinal canal, does not pass through it.
The iliohypogastric nerves run between the internal oblique and transversus abdominis in the abdominal wall, piercing the internal oblique at the anterior superior iliac spine to travel just deep to the external oblique.
The inferior epigastric artery runs between the transversus abdominis and the peritoneum forming the lateral umbilical fold.
The medial umbilical ligament is the obliterated umbilical artery that it lies within the medial umbilical fold of peritoneum. -
This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 34
Correct
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A 1 year old baby boy is taken to the doctor by his mother who is concerned that she cannot feel his testis. On examination by the doctor, his testis are not palpable either in the scrotum or the inguinal region and cannot be seen on ultrasound either. Which of the following is the most appropriate next stage in management?
Your Answer: Laparoscopy
Explanation:Answer: Laparoscopy
The diagnostic accuracy of laparoscopy for impalpable testis is well recognized. Approximately 20% of undescended testes are truly impalpable, and laparoscopy is actually regarded as the gold standard for their localization; none of the currently available imaging techniques (ultrasound, computerized tomography, or magnetic resonance imaging) has proven to be 100% reliable in predicting the presence or absence of a testis.
In this respect, not only can laparoscopy be considered the most reliable tool to provide information on the location of the testis but also to confirm its absence.Undescended testes in boys is a very common congenital abnormality in which one or both testes does not reach the bottom of the scrotum prior to birth. The incidence of the condition is 3–5% among all boys at birth, and decreases to 0.8–1% after 6 months of age.
Males with undescended testes have a lower sperm count, poorer quality sperm, and lower fertility rate, compared to males whose testicles descend normally; the rate of subfertility increases with bilateral involvement and increasing age at the time of orchidopexy. -
This question is part of the following fields:
- Generic Surgical Topics
- Urology
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Question 35
Correct
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Which is the correct order of tendons passing from medial to lateral-posterior to the medial malleolus?
Your 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 36
Incorrect
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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 37
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: Unfractionated heparin and compression stockings
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 38
Correct
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The gastrosplenic ligament also known as the gastrolienal ligament is the structure that connects the greater curvature of the stomach to the hilum of the spleen. Which of the following arteries would most likely be injured if a surgeon accidentally tore this ligament?
Your Answer: Short gastric
Explanation:The short gastric arteries arise from the end of the splenic arteries and form five to seven branches. The short gastric arteries inside the gastrosplenic ligament from the left to the right, supply the greater curvature of the stomach. The hepatic artery proper runs inside the hepatoduodenal ligament. The right gastric artery and the left gastric artery are contained in the hepatogastric ligament. The caudal pancreatic artery branches off from the splenic artery and supplies the tail of the pancreas. The middle colic artery supplies the transverse colon. The splenic artery does not travel in the gastrosplenic ligament and so it would not be damaged by a tear to this ligament.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 39
Correct
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A 56 year old female is placed on Tamoxifen for the treatment of ER-positive breast cancer. Which malignancy is associated with Tamoxifen use?
Your Answer: Endometrial cancer
Explanation:A meta-analysis found that there was a twofold increase in the risk of endometrial cancer following extended versus standard adjuvant tamoxifen therapy in patients with breast cancer.
The systematic review of four randomized controlled trials showed that the absolute risk of endometrial cancer in patients receiving adjuvant tamoxifen for 10 years was 3.2% compared with 1.5% in patients receiving 5-year standard therapy (cumulative risk ratio [RR] 2.29, 1.60 to 3.28, P<0.001).
The breast cancer treatment tamoxifen (sometimes called by its brand name, Nolvadex) increases the risk of developing endometrial cancer, but not nearly enough to outweigh its benefits against breast cancer in most women. This risk occurs because of the way tamoxifen works: Even as it acts against the growth-promoting effects of the female hormone oestrogen in breast tissue, it acts like an oestrogen in other tissues, such as the bones and the uterus. This can be good news for the bones because oestrogen helps preserve bone density, but it may slightly increase the risk of cancer in the uterus. According to the American Cancer Society, the risk of developing endometrial cancer from tamoxifen is about 1 in 500 — a small risk, but higher than that for women in the general population. Tamoxifen also slightly increases the risk of uterine sarcoma, a cancer that begins in the muscle of the uterine wall.Tamoxifen belongs to a class of medications known as selective oestrogen response modifiers (SERMs). Another SERM called Fareston (chemical name: toremifene) has been found to increase the risk of endometrial hyperplasia, or the overgrowth of cells lining the uterus. Hyperplasia itself is not cancer but can sometimes develop into cancer. Evista (chemical name: raloxifene), another SERM used to lower the risk of breast cancer in high-risk women, does not have oestrogen-like effects on the uterus and does not increase endometrial cancer risk.
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This question is part of the following fields:
- Breast And Endocrine Surgery
- Generic Surgical Topics
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Question 40
Correct
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The blood-brain barrier is a membrane that separates the circulating blood from the brain extracellular fluid in the central nervous system (CNS). Which of the following statements regarding the blood– brain barrier is CORRECT?
Your Answer: It breaks down in areas of brain that are infected
Explanation:The blood–brain barrier is a membrane that controls the passage of substances from the blood into the central nervous system. It is a physical barrier between the local blood vessels and most parts of the central nervous system and stops many substances from travelling across it. During meningitis, the blood–brain barrier may be disrupted. This disruption may increase the penetration of various substances (including either toxins or antibiotics) into the brain. A few regions in the brain, including the circumventricular organs, do not have a blood–brain barrier.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 41
Correct
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Decreased velocity of impulse conduction through the atrioventricular node (AV node) in the heart will lead to:
Your Answer: Increased PR interval
Explanation:AV node damage may lead to an increase in the PR interval to as high as 0.25 – 0.40 s (normal = 0.12 – 0.20 s). In the case of severe impairment, there might be a complete failure of passage of impulses leading to complete block. In this case, the atria and ventricles will beat independently of each other.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 42
Incorrect
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A teenager presents to her family doctor with recurrent throat and chest infections, fatigue and gradual loss of vision. X-rays are done which show brittle bones with no differentiation between the cortex and the medulla. What is her diagnosis?
Your Answer: Osteogenesis imperfecta
Correct Answer: Osteopetrosis
Explanation:Answer: Osteopetrosis
Osteopetrosis is a clinical syndrome characterized by the failure of osteoclasts to resorb bone. As a consequence, bone modelling and remodelling are impaired. The defect in bone turnover characteristically results in skeletal fragility despite increased bone mass, and it may also cause hematopoietic insufficiency, disturbed tooth eruption, nerve entrapment syndromes, and growth impairment.
Many patients have bone pains. Bony defects are common and include neuropathies due to cranial nerve entrapment (e.g., with deafness, with facial palsy), carpal tunnel syndrome, and osteoarthritis. Bones are fragile and may fracture easily. Approximately 40% of patients have recurrent fractures. Osteomyelitis of the mandible occurs in 10% of patients.Other manifestations include visual impairment due to retinal degeneration and psychomotor retardation. Bone marrow function is not compromised.
Osteogenesis imperfecta (OI), also known as brittle bone disease, is a group of genetic disorders that mainly affect the bones. It results in bones that break easily. The severity may be mild to severe. Other symptoms may include a blue tinge to the whites of the eye, short height, loose joints, hearing loss, breathing problems and problems with the teeth. Complications may include cervical artery dissection and aortic dissection.
The underlying mechanism is usually a problem with connective tissue due to a lack of type I collagen. This occurs in more than 90% of cases due to mutations in the COL1A1 or COL1A2 genes. These genetic problems are often inherited from a person’s parents in an autosomal dominant manner or occur via a new mutation. There are at least eight main types, with type I being the least severe and type II the most severe.
Osteomalacia it is the disease in which softening of the bones caused by impaired bone metabolism primarily due to inadequate levels of available phosphate, calcium, and vitamin D, or because of resorption of calcium. The impairment of bone metabolism causes inadequate bone mineralization. Osteomalacia in children is known as rickets, and because of this, use of the term Osteomalacia is often restricted to the milder, adult form of the disease. Signs and symptoms can include diffuse body pains, muscle weakness, and fragility of the bones. In addition to low systemic levels of circulating mineral ions necessary for bone and tooth mineralization, accumulation of mineralization-inhibiting proteins and peptides (such as osteopontin and ASARM peptides) occurs in the extracellular matrix of bones and teeth, likely contributing locally to cause matrix hypomineralization (Osteomalacia).
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This question is part of the following fields:
- Generic Surgical Topics
- Orthopaedics
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Question 43
Correct
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A 78-year-old man who has been bedridden for a month is prescribed griseofulvin. What class of drugs does griseofulvin belong to?
Your Answer: Antifungal
Explanation:Griseofulvin is an antifungal drug. It is administered orally, and it is used to treat ringworm infections of the skin and nails. It binds to keratin in keratin precursor cells and makes them resistant to fungal infections. Griseofulvin works by interfering with fungal mitosis.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 44
Correct
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A 33 year old woman presents to the ER after being involved in a road traffic accident. Her knee has hit the dashboard. Examination reveals a posteriorly displaced tibia. Injury to which of the following structures has resulted in this presentation?
Your Answer: Posterior cruciate ligament
Explanation:The posterior drawer test is a physical exam technique that is done to assess the integrity of the posterior cruciate ligament (PCL). The PCL is attached to the posterior intercondylar area of the tibia and passes anteriorly, medially, and upward to attach to the lateral side of the medial femoral condyle.
This ligament prevents backward displacement of the tibia or forward sliding of the femur. Injury to the ligament allows displacement of the tibia -
This question is part of the following fields:
- Generic Surgical Topics
- Orthopaedics
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Question 45
Incorrect
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What causes a reduction in pulmonary functional residual capacity?
Your Answer: Asthma
Correct Answer: Pulmonary fibrosis
Explanation:Pulmonary functional residual capacity (FRC) is = volume of air present in the lungs at the end of passive expiration.
Obstructive diseases (e.g. emphysema, chronic bronchitis, asthma) = an increase in FRC due to an increase in lung compliance and air trapping.
Restrictive diseases (e.g. pulmonary fibrosis) result in stiffer, less compliant lungs and a reduction in FRC. -
This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 46
Incorrect
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A 64 year old diabetic man presents with a deep laceration of his lateral thigh which measures 3cm in depth by 7cm in length, that penetrates to the bone. There are no signs of fracture. His diabetes is diet controlled and is on low dose prednisolone therapy for polymyalgia rheumatica. Which of the following options should be employed most safely for the wound management of this patient?
Your Answer: Primary closure using deep tension sutures
Correct Answer: Delayed primary closure
Explanation:Delayed primary closure is often intentionally applied to lacerations that are not considered clean enough for immediate primary closure. The wound is left open for 5-10 days; then, it is sutured closed to decrease the risk of wound infection. Improved blood flow at the wound edges, which develops increasingly over the first few days, is another benefit of this style of wound healing and can be associated with progressive increases in resistance to infections. The combination of diabetes and steroids makes wound complications more likely. Despite his high risk, a primary skin graft or flap is unlikely to be a safer option.
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This question is part of the following fields:
- Emergency Medicine And Management Of Trauma
- Principles Of Surgery-in-General
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Question 47
Incorrect
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A 35-year old lady presents to her GP with vague abdominal symptoms. Examination reveals a normal size spleen. Which of the following is the likely diagnosis?
Your Answer: Sickle cell anaemia
Correct Answer: Idiopathic thrombocytopenic purpura
Explanation:Idiopathic thrombocytopenic purpura (ITP) is a disease caused due to development of an antibody against a platelet antigen (autoantibody). In childhood disease, the autoantibody gets triggered by binding of viral antigen to the megakaryocytes. Presentation includes unexplained thrombocytopenia, petechiae and bleeding from mucosal surfaces. The spleen usually does not enlarge in size. However, splenomegaly can occur due to coexisting viral infection. Marrow examination reveals normal or increased number of megakaryocytes. Diagnosis is by exclusion of other thrombocytopenic disorders.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 48
Correct
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Which of these HLA alleles is most likely to be present in ankylosing spondylitis?
Your Answer: HLA-B27
Explanation:Ankylosing spondylitis usually appears between the ages of 20-40 years old and is more frequent in men. It is strongly associated with HLA-B27, along with other spondyloarthropathies, which can be remembered through the mnemonic PAIR (Psoriasis, Ankylosing spondylitis, Inflammatory bowel disease, and Reactive arthritis).
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 49
Correct
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The rotator cuff surrounds the shoulder joint and consists of the supraspinatus, infraspinatus, subscapularis and which one other muscle?
Your Answer: Teres minor
Explanation:The correct answer is the teres minor muscle. These group of muscles play an important role in protecting the shoulder joint and keeping the head of the humerus in the glenoid fossa of the scapula. This fossa is somehow shallow and needs support to allow for the full mobility that the shoulder joint has.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 50
Correct
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Which condition presents with a positive urine dipstick test for blood, but no blood cells on urine microscopy?
Your Answer: Myoglobinuria
Explanation:Myoglobinuria, or presence of myoglobulin in the urine is seen due to rhabdomyolysis (muscle destruction). Common causes of rhabdomyolysis include trauma, electrical injuries, burns, venom and drugs. Damaged muscle leads to release of myoglobin in the blood. Ideally, the released myoglobin gets filtered and excreted by the kidneys. However, excess myoglobin can occlude the renal filtration system leading to acute tubular necrosis and acute renal dysfunction.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 51
Correct
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A 20-year old gentleman was brought to the emergency department with headache and nausea for 2 days. He also complained of intolerance to bright light and loud sounds. Lumbar puncture showed glucose < 45 mg/dl, protein > 5 mg/dl and neutrophil leucocytosis. The likely diagnosis is:
Your Answer: Meningitis
Explanation:Diagnosis of meningitis can be carried out with examination of cerebrospinal fluid (CSF) with a lumbar puncture (LP). In a case of bacterial meningitis, the CSF analysis will show:
– Opening pressure: > 180 mmH2O
– White blood cell count: 10–10 000/μl with neutrophil predominance
– Glucose: < 40 mg/dl
– CSF glucose to serum glucose ratio: < 0.4
– Protein: > 4.5 mg/dl
– Gram stain: positive in > 60%
– Culture: positive in > 80%
– Latex agglutination: may be positive in meningitis due to Streptococcus pneumoniae, Neisseria meningitidis, Haemophilus influenzae, Escherichia coli and group B streptococci
– Limulus, lysates: positive in Gram-negative meningitis -
This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 52
Incorrect
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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: Perform a small bowel bypass procedure
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 53
Correct
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A 45-year-old pregnant woman develops high blood pressure at 20 weeks. She complains of headaches and swollen feet, and a test reveals proteinuria (350 mg/day). Which of the following is the most likely diagnosis?
Your Answer: Pre-eclampsia
Explanation:Pre-eclampsia (PE) is a disorder of pregnancy characterized by the onset of high blood pressure (two separate readings taken at least 6 h apart of 140/90 or more) and often a significant amount of protein in the urine (>300 mg of protein in a 24-h urine sample). While blood pressure elevation is the most visible sign of the disease, it involves generalised damage to the maternal endothelium of the kidneys and liver, with the release of vasopressive factors only secondary to the original damage. Pre-eclampsia may develop at varying times within pregnancy and its progress differs among patients; most cases present pre-term. It has no known cure apart from ending the pregnancy (induction of labour or abortion). It may also present up to 6 weeks post partum. Risk factors for pre-eclampsia include obesity, prior hypertension, older age, and diabetes mellitus.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 54
Correct
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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 55
Correct
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A 36 year old female who is admitted in the intensive care unit after being involved in a motor vehicle accident is being considered as an organ donor following discussion with her family. What is not a precondition for the diagnosis of brainstem death?
Your Answer: A PaCO2 of > 7 kPa has been documented
Explanation:In adults 50% of the cases of brain death follow severe head injury, 30% are due to subarachnoid haemorrhage and 20% are due to a severe hypoxic-ischaemic event. Thus supra-tentorial catastrophes lead to pressure effect which cause the irretrievable death of the brain-stem.
The Criteria for Diagnosis of Brain-Stem Death
All the pre-conditions must be satisfied and
there should be demonstrably no pharmacological or
metabolic reason for the coma before formally testing the
integrity of the brain-stem reflexes.Pre Conditions
1. The patient is comatose and mechanically ventilated
for apnoea.
2. The diagnosis of structural brain damage has been
established or the immediate cause of coma is known.
3. A period of observation is essential.Exclusions
1. Drugs are not the cause of coma e.g. barbiturates.
Neuromuscular blockade has been demonstrably reversed.
2. Hypothermia does not exist.
3. There is no endocrine or metabolic disturbance.Testing for Brain-Stem Death
Reflexes involving brain-stem function.
1. No pupillary response to light.
2. No corneal reflex.
3. No vestibulo ocular reflex (Caloric test).
4. Doll’s eye reflex
5. No motor response to pain – in the Vth nerve distribution.
6. No gag reflex in response to suction through endotracheal tube or tracheostomy.
7. Apnoea persists despite a rise in PaCO2 to greater than 50 mmHg (6.6kPa) against a background of a normal PaO2.Diagnosis is to be made by two doctors who have been registered for more than five years and are competent in the procedure. At least one should be a consultant. Testing should be undertaken by the doctors together and must always be performed completely and successfully on two occasions in total.
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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 56
Correct
-
A 58-year-old woman diagnosed with deep vein thrombosis had been using warfarin for 10 days. When she presented to the doctor she had haemorrhagic bullae and necrotic lesions in her lower limbs and buttocks. Deficiency of which of the following proteins may have caused the necrotic skin lesions?
Your Answer: Protein C
Explanation:Warfarin-induced skin necrosis is a rare complication of anticoagulant therapy that requires immediate drug cessation. The most common cutaneous findings include petechiae that progress to ecchymoses and haemorrhagic bullae. Warfarin inactivates vitamin K-dependent clotting factors II, VII, IX, and X and vitamin K-dependent proteins C and S. The concentration of protein C falls more rapidly than other vitamin K-dependent factors because they have a shorter half-lives. Skin necrosis is seen mainly in patients with prior protein C deficiency.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 57
Correct
-
During cardiac catheterisation, if the blood sample from the catheter shows an oxygen saturation of 70%, and the pressure ranging from 12 to 24 mm Hg, it implies that the catheter tip is located in the:
Your Answer: Pulmonary artery
Explanation:Normal values for various parameters are as follows:
Systolic arterial blood pressure (SBP): 90–140 mmHg.
Diastolic arterial blood pressure: 60–90 mmHg.
Mean arterial blood pressure (MAP): SBP + (2 × DBP)/3 (normal range: 70-105 mmHg).
Right atrial pressure (RAP): 2–6 mmHg.
Systolic right ventricular pressure (RVSP): 15–25 mmHg.
Diastolic right ventricular pressure (RVDP): 0–8 mmHg.
Pulmonary artery pressure (PAP): Systolic (PASP) is 15-25 mmHg and Diastolic (PADP) is 8–15 mmHg.
Pulmonary artery wedge pressure (PAWP): 6–12 mmHg.
Left atrial pressure (LAP): 6–12 mmHg.
Thus, the given value indicates that the position of catheter tip is likely to be in the pulmonary artery. -
This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 58
Incorrect
-
Into which vein does the left and right thyroid vein drain?
Your Answer: Internal jugular vein
Correct Answer: Brachiocephalic vein
Explanation:The brachiocephalic vein is formed by the confluence of the subclavian and internal jugular veins. In addition it receives drainage from: the left and right internal thoracic veins (also called internal mammary veins), left and right inferior thyroid veins
and the left superior intercostal vein -
This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 59
Incorrect
-
The circle of Willis is one of the cerebrovascular safeguards comprised of the left and the right posterior communicating artery. Which of the following arteries in the brain is connected to the posterior cerebral artery by these posterior communicating arteries?
Your Answer: Vertebral artery
Correct Answer: Internal carotid artery
Explanation:The Circle of Willis is an anastomosis of cerebral arteries that are located at the base of the brain. The Circle of Willis is one of the important safeguards that ensure back up of blood supply to parts of the brain in case of any cerebrovascular accident. The Circle of Willis is made up of an anterior portion of arteries including; the anterior cerebral arteries. The anterior cerebral arteries are connected to the posterior portion of the circle of Willis by the anterior communicating artery. The posterior portion is made up of the posterior cerebral artery which branch off from the basilar artery. The posterior cerebral artery are connected to the anterior portion of the circle of Willis by the posterior communicating artery. The posterior communicating artery connects the posterior cerebral artery to the internal carotid artery. The circle of Willis receives blood supply from the left and right internal carotid arteries that continues as the middle cerebral artery and posteriorly from the two vertebral arteries that join to form the basilar artery.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 60
Correct
-
In a neurological exam on a robbery with violence victim, it was discovered that the victim had lost sense of touch to the skin over her cheek and chin (maxilla and mandible region). Where are the cell bodies of the nerve that is responsible for touch sensations of this region located?
Your Answer: Cranial nerve V ganglion
Explanation:The skin over the cheek and the maxilla are innervated by the trigeminal nerve (CN V). The trigeminal nerve has three major branches and it is the largest cranial nerve. The three branches of the trigeminal nerve are; the ophthalmic nerve, the maxillary nerve and the mandibular nerve. The trigeminal nerves ganglion is a sensory nerve ganglion know as the trigeminal ganglion (also referred to as the Gasser’s ganglion or the semilunar ganglion). It is contained in the dura matter in a cavity known as the Meckel’s cave, which covers the trigeminal impression near the apex of the petrous part of the temporal bone.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 61
Correct
-
A 49-year-old man, smoker, complains of a persisting and worsening cough over the past few months. He also has noted blood in his sputum. The patient has no other major health conditions. Which of the following investigative procedures should be done first?
Your Answer: Sputum cytology
Explanation:Sputum cytology is a diagnostic test used for the examination of sputum under a microscope to determine if abnormal cells are present. It may be used as the first diagnostic procedure to help detect a suspected lung cancer or certain non-cancerous lung conditions.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 62
Correct
-
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: 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 63
Incorrect
-
A 55-year-old woman died 3 years after a cardiac transplant due to worsening congestive heart failure. Autopsy revealed diffuse hyperplasia of the vascular intima involving the entire length of the coronary arteries. The most probable cause of deterioration of the cardiac function is:
Your Answer: Amyloidosis
Correct Answer: Coronary atherosclerosis
Explanation:Allograft coronary artery disease (CAD) can begin right after the transplant and is the major cause of later death in cardiac transplant recipients. This form of atherosclerosis progresses quickly resulting in allograft failure. Due to lack of premonitory symptoms CAD may lead to sudden death.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 64
Incorrect
-
A 50 year-old man, who sustained a head injury experienced sudden onset of horizontal double vision. He is diagnosed with lateral rectus palsy. Which of the following nerves is affected in this condition?
Your Answer: Trochlear
Correct Answer: Abducent
Explanation:The lateral rectus muscle is one of the 6 extra-ocular muscles that control eye movements. It is responsible for abduction and is the only muscle that is innervated by the abducens nerve (CN VI).
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 65
Correct
-
A 67 year old man brought to the emergency department with acute pancreatitis is immediately intubated and put on a ventilator. His intra-abdominal pressure is measured using a bladder catheter connected to manometry. Which of the following would most likely represent the pressure effect seen in abdominal compartment syndrome?
Your Answer: Bladder pressure of 16–25 mmHg does not require decompression
Explanation:Bladder pressures below 5mm Hg are expected in healthy patients. Pressures between 10 to 15 mmHg can be expected following abdominal surgery and in obese patients. Bladder pressures over 25 mmHg are highly suspicious of abdominal compartment syndrome and should be correlated clinically. It is recommended that pressure measurements be trended to show and recognize the worsening of intra-abdominal hypertension. Recommended management at this stage includes fluid resuscitation and if the pressure rises beyond the critical threshold of 25 mmHg, abdominal decompression is required.
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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 66
Correct
-
A 19 year old male patient exhibiting signs of shock was brought to the casualty after he had fallen from the 3rd floor of a building. An examination carried out revealed tenderness on the left mid-posterior axillary line and low blood pressure. Further palpation revealed a large swelling that protruded downward and medially below the left costal margin. X-rays showed that the 9th and the 10th ribs were fractured near their angles. Considering these results, which abdominal organ was likely injured by the fractured ribs.
Your Answer: Spleen
Explanation:The spleen, left kidney, stomach, the splenic flexure of the colon and the suprarenal glands are all in the same quadrant- the left upper quadrant. However, the spleen is the most readily injured organ when there is fracture to the 10th, 11th and the 12th ribs because of its close association with these ribs. This patient exhibits a great indication of a ruptured spleen (tenderness on the left mid and posterior axillary line). The spleen is a thin capsulated organ with a spongy parenchyma, allowing it to bleed profusely in the event of injury. The liver, head of the pancreas and the duodenum are all in the right upper quadrant.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 67
Incorrect
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A 46-year-old male complains of sharp chest pain. He is due to have elective surgery to replace his left hip. He has been bed-bound for 3 months. He suddenly collapses; his blood pressure is 70/40mmHg, heart rate 120 bpm and his saturations are 74% on air. He is deteriorating in front of you. What is the next best management plan?
Your Answer: Unfractionated heparin
Correct Answer: Thrombolysis with Alteplase
Explanation:The patient has Pulmonary embolism (PE).
PE is when a thrombus becomes lodged in an artery in the lung and blocks blood flow to the lung. Pulmonary embolism usually arises from a thrombus that originates in the deep venous system of the lower extremities; however, it rarely also originates in the pelvis, renal, upper extremity veins, or the right heart chambers. After travelling to the lung, large thrombi can lodge at the bifurcation of the main pulmonary artery or the lobar branches and cause hemodynamic compromise.
The classic presentation of PE is the abrupt onset of pleuritic chest pain, shortness of breath, and hypoxia. However, most patients with pulmonary embolism have no obvious symptoms at presentation. Rather, symptoms may vary from sudden catastrophic hemodynamic collapse to gradually progressive dyspnoea.
Physical signs of pulmonary embolism include the following:
Tachypnoea (respiratory rate >16/min): 96%
Rales: 58%
Accentuated second heart sound: 53%
Tachycardia (heart rate >100/min): 44%
Fever (temperature >37.8°C [100.04°F]): 43%
Diaphoresis: 36%
S3 or S4 gallop: 34%
Clinical signs and symptoms suggesting thrombophlebitis: 32%
Lower extremity oedema: 24%
Cardiac murmur: 23%
Cyanosis: 19%
Management
Anticoagulation and thrombolysis
Immediate full anticoagulation is mandatory for all patients suspected of having DVT or PE. Diagnostic investigations should not delay empirical anticoagulant therapy.
Thrombolytic therapy should be used in patients with acute pulmonary embolism who have hypotension (systolic blood pressure< 90 mm Hg) who do not have a high bleeding risk and in selected patients with acute pulmonary embolism not associated with hypotension who have a low bleeding risk and whose initial clinical presentation or clinical course suggests a high risk of developing hypotension.
Long-term anticoagulation is critical to the prevention of recurrence of DVT or pulmonary embolism because even in patients who are fully anticoagulated, DVT and pulmonary embolism can and often do recur.
Thrombolytic agents used in managing pulmonary embolism include the following:
– Alteplase
– ReteplaseHeparin should be given to patients with intermediate or high clinical probability before imaging.
Unfractionated heparin (UFH) should be considered (a) as a first dose bolus, (b) in massive PE, or (c) where rapid reversal of effect may be needed.
Otherwise, low molecular weight heparin (LMWH) should be considered as preferable to UFH, having equal efficacy and safety and being easier to use.
Oral anticoagulation should only be commenced once venous thromboembolism (VTE) has been reliably confirmed.
The target INR should be 2.0–3.0; when this is achieved, heparin can be discontinued.
The standard duration of oral anticoagulation is: 4–6 weeks for temporary risk factors, 3 months for first idiopathic, and at least 6 months for other; the risk of bleeding should be balanced with that of further VTE. -
This question is part of the following fields:
- Emergency Medicine And Management Of Trauma
- Principles Of Surgery-in-General
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Question 68
Correct
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A 50 year old man was admitted to the surgical ICU following a hemicolectomy for carcinoma of the caecum. A full blood count revealed: haematocrit = 30%, erythrocytes = 4 × 106/μ, haemoglobin level = 8 g/dl. To determine the likely cause of his anaemia, red blood cell indices were calculated. Which RBC indices are correct?
Your Answer: MCHC = haemoglobin concentration/haematocrit
Explanation:Mean corpuscular haemoglobin concentration (MCHC) is calculated simply by dividing the haemoglobin concentration (8 g/dl) by the haematocrit (0.3). The normal range is 31–36 g/dl. This patient has a hypochromic anaemia (MCHC = 8/0.3 = 26.7 g/dl). Dividing the haemoglobin concentration × 10 by erythrocyte number yields mean corpuscular haemoglobin (MCH). Normal range is 25.4–34.6 pg/cell and this patient has a significantly reduced cellular haemoglobin content (MCH = 8 × 10/4 = 20 pg/cell). Mean corpuscular volume (MCV) is calculated by dividing haematocrit × 1000 by erythrocyte number (4 × 106/μl). Normal range is 80–100 fl and this patient has a microcytic anaemia (MCV = 0.3 × 1000/4 = 75 fl). Microcytic, hypochromic anaemia is characteristic for iron-deficiency.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 69
Correct
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A patient with a long standing lower motor neuron lesion will have:
Your Answer: Muscle wasting
Explanation:Lower motor neurons (LMNs) connect the brainstem and spinal cord to muscle fibres. Damage to lower motor neurons is indicated by abnormal electromyographic potentials, fasciculations, paralysis, weakening and wasting of skeletal muscles.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 70
Incorrect
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A 25 year-old male patient was brought to the hospital due to a vehicular accident. A skull x-ray was done which revealed a fracture along the base of the middle cranial fossa. The patient has no sense of touch over the skin over his cheek and chin. Injury to the maxillary and the mandibular nerves is suspected. In which foramina do these two affected sensory branches leave the cranial cavity.
Your Answer: Foramen ovale and foramen spinosum
Correct Answer: Foramen rotundum and foramen ovale
Explanation:The patient’s clinical manifestations suggests an injury to the maxillary and mandibular nerves. The maxillary branch (V2) of the trigeminal nerve (CN V) passes through and exits the skull via the pterygopalatine fossa and the foramen rotundum. At the base of the skull the foramen ovale (Latin: oval window) is one of the larger of the several holes (the foramina) that transmit nerves through the skull. The foramen ovale is situated in the posterior part of the sphenoid bone, posterolateral to the foramen rotundum. The following structures pass through foramen ovale: mandibular nerve, motor root of the trigeminal nerve, accessory meningeal artery (small meningeal or paradural branch, sometimes derived from the middle meningeal artery), lesser petrosal nerve, a branch of the glossopharyngeal nerve and
an emissary vein connecting the cavernous sinus with the pterygoid plexus of veins. Occasionally it will also carry the anterior trunk of the middle meningeal vein. -
This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 71
Correct
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A 47 -year-old male was admitted due to a bleeding peptic ulcer. On his 3rd hospital day, he developed a cardiac arrhythmia. His serum potassium was markedly elevated. What is the most likely cause of hyperkalaemia in this patient?
Your Answer: Multiple blood transfusions
Explanation:Patients with gastrointestinal bleeding often require blood transfusion. Among the various side effects of blood transfusions, is the increase of potassium levels. The use of stored blood for transfusions is followed by an increase of serum potassium levels. Potassium level increases are more pronounced in patients who receive blood stored for more than 12 d. Furthermore, the lysis and destruction of red blood cells, especially in the transfusion of older PRBCs, can further increase potassium levels. Excessive use of a PPi has been associated with hyperkaelemia however would be less likely in this acute setting.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 72
Correct
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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/dLWCC: 20 x 10^9/LRetic count: 30% What is the most likely underlying cause?
Your 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.
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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 73
Correct
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A 42-year-old woman is admitted with sepsis and right flank pain. Twenty-four hours ago, she was started on trimethoprim, by the GP, for a urinary tract infection (UTI).Which of the following organisms is the most likely causative agent?
Your Answer: E. coli
Explanation:Ascending infection of the urinary tract is most commonly caused by Escherichia coli (E.coli). Other organisms may be accountable. However, these are less common.
E. coli are gram-negative rods. They have a wide range of subtypes and some are normal gut commensals. Most varieties of E. coli are harmless or cause relatively brief diarrhoea. But a few nasty strains, such as E. coli O157:H7, can cause severe abdominal cramps, bloody diarrhoea, and vomiting. Some strains of E. coli are also resistant to a large number of antibiotics used to treat gram-negative infections.
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This question is part of the following fields:
- Clinical Microbiology
- Principles Of Surgery-in-General
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Question 74
Correct
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A 9 year old boy is admitted with right iliac fossa pain and an appendicectomy is to be performed.Which of the following incision is the best for this procedure?
Your Answer: Lanz
Explanation:Answer: Lanz
The Lanz and Gridiron incisions are two incisions that can be used to access the appendix, predominantly for appendectomy.
Both incisions are made at McBurney’s point (two-thirds from the umbilicus to the anterior superior iliac spine). They involve passing through all of the abdominal muscles, transversalis fascia, and then the peritoneum, before entering the abdominal cavity.
The Lanz incision is a transverse incision, whilst the Gridiron incision is oblique (superolateral to inferomedial). Due to its continuation with Langer’s lines, the Lanz incision produces much more aesthetically pleasing results with reduced scarring.
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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 30 year old welder presents to his family doctor with symptoms of chronic ear discharge and a left-sided facial nerve palsy. On examination, he has foul smelling fluid draining from his left ear and a complete left-sided facial nerve palsy. What is the most likely cause?
Your Answer: Adenoid cystic carcinoma
Correct Answer: Cholesteatoma
Explanation:A cholesteatoma consists of squamous epithelium that is trapped within the skull base and that can erode and destroy important structures within the temporal bone. They often become infected and can result in chronically draining ears. Treatment almost always consists of surgical removal. The majority (98%) of people with cholesteatoma have ear discharge or conductive hearing loss or both in the affected ear.
Other more common conditions (e.g. otitis externa) may also present with these symptoms, but cholesteatoma is much more serious and should not be overlooked. If a patient presents to a doctor with ear discharge and hearing loss, the doctor should consider cholesteatoma until the disease is definitely excluded.
Other less common symptoms (all less than 15%) of cholesteatoma may include pain, balance disruption, tinnitus, earache, headaches and bleeding from the ear. There can also be facial nerve weakness. Balance symptoms in the presence of a cholesteatoma raise the possibility that the cholesteatoma is eroding the balance organs in the inner ear.
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This question is part of the following fields:
- Generic Surgical Topics
- Head And Neck Surgery
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Question 76
Correct
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Which of the following organs is most likely to have dendritic cells?
Your Answer: Skin
Explanation:Dendritic cells are part of the immune system and they function mainly as antigen presenting cells. They are present in small quantities in tissues which are in contact in the external environment. Mainly in the skin and to a lesser extent in the lining of the nose, lungs, stomach and intestines. In the skin they are known as Langerhans cells.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 77
Incorrect
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A 4-year-old boy is referred to the clinic with a scrotal swelling. On examination, the mass does not transilluminate and it is impossible to palpate normal cord above it. What is the most likely diagnosis?
Your Answer: Lymphatic malformation
Correct Answer: Indirect inguinal hernia
Explanation:An inguinal hernia is a common condition requiring surgical repair in the paediatric age group.
The infant or child with an inguinal hernia generally presents with an obvious bulge at the internal or external ring or within the scrotum. The parents typically provide the history of a visible swelling or bulge, commonly intermittent, in the inguinoscrotal region in boys and inguinolabial region in girls.
The swelling may or may not be associated with any pain or discomfort. More commonly, no pain is associated with a simple inguinal hernia in an infant. The parents may perceive the bulge as being painful when, in truth, it causes no discomfort to the patient.
The bulge commonly occurs after crying or straining and often resolves during the night while the baby is sleeping.
Indirect hernias are more common on the right side because of delayed descent of the right testicle. Hernias are present on the right side in 60% of patients, on the left is 30%, and bilaterally in 10% of patients.
Physical examination of a child with an inguinal hernia typically reveals a palpable smooth mass originating from the external ring lateral to the pubic tubercle. The mass may only be noticeable after coughing or performing a Valsalva manoeuvre, and it should be reduced easily. Occasionally, the examining physician may feel the loops of intestine within the hernia sac. In girls, feeling the ovary in the hernia sac is not unusual; it is not infrequently confused with a lymph node in the groin region. In boys, palpation of both testicles is important to rule out an undescended or retractile testicle.
In boys, differentiating between a hernia and a hydrocele is not always easy. Transillumination has been advocated as a means of distinguishing between the presence of a sac filled with fluid in the scrotum (hydrocele) and the presence of bowel in the scrotal sac. However, in cases of inguinal hernia incarceration, transillumination may not be beneficial because any viscera that is distended and fluid-filled in the scrotum of a young infant may also transilluminate. A rectal examination may be helpful if intestine can be felt descending through the internal ring.
A femoral hernia can be very difficult to differentiate from an indirect inguinal hernia. Its location is below the inguinal canal, through the femoral canal. The differentiation is often made only at the time of operative repair, once the anatomy and relationship to the inguinal ligament are clearly visualized. The signs and symptoms for femoral hernias are essentially the same as those described for indirect inguinal hernias. -
This question is part of the following fields:
- Generic Surgical Topics
- Paediatric Surgery
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Question 78
Correct
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A 10 year old child presents with enlarged tonsils that meet in the midline. Oropharyngeal examination confirms this finding and you also notice petechial haemorrhages affecting the oropharynx. On systemic examination he is noted to have splenomegaly. What is the most likely cause?
Your Answer: Acute Epstein Barr virus infection
Explanation:Answer: Acute Epstein Barr virus infection
The Epstein–Barr virus is one of eight known human herpesvirus types in the herpes family, and is one of the most common viruses in humans. Infection with Epstein-Barr virus (EBV) is common and usually occurs in childhood or early adulthood.
EBV is the cause of infectious mononucleosis, an illness associated with symptoms and signs like:
fever,
fatigue,
swollen tonsils,
headache, and
sweats,
sore throat,
swollen lymph nodes in the neck, and
sometimes an enlarged spleen.
Although EBV can cause mononucleosis, not everyone infected with the virus will get mononucleosis. White blood cells called B cells are the primary targets of EBV infection. -
This question is part of the following fields:
- Generic Surgical Topics
- Head And Neck Surgery
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Question 79
Correct
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Arterial blood gas analysis of a man admitted with acute exacerbation of chronic obstructive pulmonary disease (COPD) showed the following: pH = 7.28, p(CO2) = 65.5 mmHg, p(O2)= 60 mmHg and standard bicarbonate = 30.5 mmol/l. This patient had:
Your Answer: Respiratory acidosis
Explanation:Acidosis with high p(CO2) and normal standard bicarbonate indicates respiratory acidosis, commonly seen in acute worsening of COPD patients. Respiratory acidosis occurs due to alveolar hypoventilation which leads to increased arterial carbon dioxide concentration (p(CO2)). This in turn decreases the HCO3 –/p(CO2) and decreases pH. In acute respiratory acidosis, the p(CO2) is raised above the upper limit of normal (over 45 mm Hg) with a low pH. However, in chronic cases, the raised p(CO2) is accompanied with a normal or near-normal pH due to renal compensation and an increased serum bicarbonate (HCO3 – > 30 mmHg).
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 80
Incorrect
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Which muscle is responsible for directing the gaze downward when the eye is abducted?
Your Answer: Inferior oblique muscle
Correct Answer: Inferior rectus muscle
Explanation:The inferior rectus muscle is a muscle in the orbit. As with most of the muscles of the orbit, it is innervated by the inferior division of oculomotor nerve (Cranial Nerve III). It depresses, adducts, and helps laterally rotate the eye.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 81
Incorrect
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Which of the following statements regarding the arteries in the neck are TRUE?
Your Answer: The carotid sinus is located below the origin of the external carotid artery
Correct Answer: The thyrocervical trunk typically gives rise to the inferior thyroid artery, transverse cervical artery and suprascapular artery
Explanation:The thyrocervical trunk is one of the three branches of the first part of the subclavian artery and gives numerous branches which supply viscera of the neck, the brachial plexus, neck muscles and scapular anastomoses. The vertebral arteries are major arteries of the neck. They arise as branches from the subclavian arteries and merge to form the single midline basilar artery. The carotid sinus is a dilated area at the base of the internal carotid artery just superior to the bifurcation of the internal carotid and external carotid at the level of the superior border of thyroid cartilage.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 82
Correct
-
A 30-year-old male is playing tennis when he suddenly collapses and has a GCS of 4 when examined. What is the most likely cause?
Your Answer: Subarachnoid haemorrhage
Explanation:The term subarachnoid haemorrhage (SAH) refers to extravasation of blood into the subarachnoid space between the pial and arachnoid membranes. SAH constitutes half of all spontaneous atraumatic intracranial haemorrhages; the other half consists of bleeding that occurs within the brain parenchyma.
Intracranial saccular aneurysms (“berry aneurysms”) represent the most common aetiology of nontraumatic SAH; about 80% of cases of SAH result from ruptured aneurysms. -
This question is part of the following fields:
- Generic Surgical Topics
- Surgical Disorders Of The Brain
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Question 83
Correct
-
Which of the following organelles have the capacity to regenerate and spontaneously replicate?
Your Answer: Mitochondrion
Explanation:A mitochondria is a membrane bound organelle found in eukaryotic cells. They are called the powerhouse of the cell and are the place where ATP is formed from energy generated through metabolism. They are capable of replication as well as repair and regeneration.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 84
Incorrect
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A 30 year old gym coach presented to the surgical out patient clinic with a lump in the inguinal region. He was booked for surgery, during which, the surgeon opened the inguinal region and found a hernial sac with a small segment of intestine projecting through the abdominal wall. It was located just above the inguinal ligament and lateral to the inferior epigastric vessels. What type of hernia was this?
Your Answer: An incisional hernia
Correct Answer: An indirect inguinal hernia
Explanation:An indirect inguinal hernia exits the abdominal cavity lateral to the inferior epigastric vessels and enters the inguinal canal through the deep inguinal ring. These are the most common types of hernias often caused by heavy weigh lifting. Direct inguinal hernias exit the abdominal cavity medial to the inferior epigastric vessels through weak fascia.
Congenital inguinal hernias are indirect hernias that occur due to persistence of the processus vaginalis.
Femoral hernias occur when abdominal viscera push through the femoral ring in the femoral canal.
Incisional hernia occurs after surgery when the omentum or organ protrudes through a previous site of incision.
Obturator hernia are a very rare type of hernia where the pelvic or abdominal contents protrude through the obturator foramen. -
This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 85
Correct
-
A 68 year old woman who underwent a mastectomy with axillary node clearance for breast cancer is going to have a drain inserted to prevent seroma development. Which of the following devices should ideally be used?
Your Answer: A closed suction drainage system made of polypropylene
Explanation:A surgical drain is a tube used to remove pus, blood or other fluids from a wound. They are commonly placed by surgeons or interventional radiologists. Suction is applied through the drain to generate a vacuum and draw fluids into a bottle. Following breast surgery, it is standard practice to use a Redivac type system that is made of polypropylene.
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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 86
Correct
-
A 5 year old boy is rushed to the A&E department after accidentally inhaling a Brazil nut. He is seen to be extremely distressed and cyanotic and imaging shows that it is lodged in the left main bronchus. Which of the following is the best course of action?
Your Answer: Arrange immediate transfer to theatre for bronchoscopy
Explanation:A small number of foreign body aspirations are incidentally found after chest radiography or bronchoscopic inspection. Patients may be asymptomatic or may be undergoing testing for other diagnoses. If present, physical findings may include stridor, fixed wheeze, localized wheeze, or diminished breath sounds. If obstruction is severe, cyanosis may occur. Signs of consolidation can accompany post obstructive pneumonia.
Bronchoscopy can be used diagnostically and therapeutically. Most aspirated foreign bodies are radiolucent. Radiologic procedures do not have extreme diagnostic accuracy, and aspiration events are not always detected. Rigid bronchoscopy usually requires heavy intravenous sedation or general anaesthesia. The rigid bronchoscope has important advantages over the flexible bronchoscope. The larger diameter of the rigid bronchoscope facilitates the passage of various grasping devices, including a flexible bronchoscope. A better chance of quick, successful extraction and better capabilities of suctioning clotted blood and thick secretions are offered by the rigid bronchoscope. The paediatric flexible bronchoscope lacks a hollow working channel through which instruments may be inserted or blood and secretions may be aspirated.
Unlike the flexible bronchoscope, the patient can be ventilated through the rigid scope; therefore, ventilation of the patient can be maintained. Rigid bronchoscopy is the procedure of choice for removing foreign bodies in children and in most adults. Success rates for extracting foreign bodies are reportedly more than 98%. Large solid and semisolid objects are best managed emergently in the operating room with a rigid bronchoscope and appropriate grasping instruments. -
This question is part of the following fields:
- Generic Surgical Topics
- Paediatric Surgery
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Question 87
Correct
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A 54 year old man fell off his bicycle. He felt a severe pain in his hand and wasn't able to move it. It was found that a carpal bone in the distal row was fractured. Which is the most likely bone?
Your Answer: Trapezium
Explanation:There are eight carpal bones which are arranged in two rows, proximal and distal; scaphoid, lunate, triquetral and pisiform are of proximal row. Trapezium, trapezoid, capitate and hamate are of the distal row.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 88
Correct
-
A 25-year-old man is involved in vigorous intercourse and suddenly feels a snap. His penis becomes swollen and painful immediately after. The admitting surgeon suspects a penile fracture. Which of the following is the most appropriate initial management?
Your Answer: Immediate surgical exploration
Explanation:Suspected penile fractures should be surgically explored and the injury repaired.
Penile fractures are a rare type of urological trauma. The injury is usually in the proximal part of the penile shaft and may involve the urethra. A classical history of a snapping sensation followed by immediate pain is usually given by the patient (usually during vigorous intercourse). On examination, a tense haematoma is most commonly noted, and if the urethra is injured, blood may be seen at the meatus.
The correct management involves surgical exploration and repair of the injury. A circumferential incision is made immediately inferior to the glans and the penile shaft is inspected. Injuries are usually sutured and the urethra is repaired over a catheter.
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This question is part of the following fields:
- Generic Surgical Topics
- Urology
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Question 89
Correct
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A 50-year-old male is recovering on the high dependency unit following a long and complex laparotomy. His preoperative medication includes an ACE inhibitor for blood pressure control. For the past two hours, he has been oliguric with a urine output of 10ml/hr-1. What the most appropriate immediate course of action?
Your Answer: Administer a fluid challenge
Explanation:Using fluids to correct hypovolaemia is a dynamic process that requires ongoing evaluation of clinical and haemodynamic indices. Thus, the use of the fluid challenge provides a successful method of adjusting the fluid volume to the patient’s need.
The fluid challenge is a method of safely restoring circulating volume according to physiological need rather than using fixed haemodynamic end-points. The fluid is given in small aliquots to produce a known increment in circulating volume with an assessment of the dynamic haemodynamic response to each aliquot. No fixed haemodynamic end-point is assumed and the technique provides a diagnostic test of hypovolaemia (via an appropriate positive response of the circulation to fluid) and a method of titrating the optimal dose of fluid to the individual’s requirement.
The response of SV and/or CVP (or PAWP) should be monitored during a fluid challenge. The basis of the fluid challenge is to achieve a known increase in intravascular volume by rapid infusion of a bolus of colloid fluid (200 ml).
In the inadequately filled left ventricle, a fluid challenge will increase SV. Failure to increase SV with a fluid challenge may indicate a circulation that is unresponsive to fluid or an inadequate challenge. -
This question is part of the following fields:
- Post-operative Management And Critical Care
- Principles Of Surgery-in-General
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Question 90
Incorrect
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A week after a renal transplant the patient received antilymphocyte globulins. Shortly after she developed fever and hypotension. Which of the following mechanisms is involved in this response?
Your Answer: Type I hypersensitivity
Correct Answer: Type III hypersensitivity
Explanation:Type III hypersensitivity is characterized by soluble immune complexes which are aggregations of IgG and IgM antibodies with antigens that deposit in different tissues e.g. the skin, joints, kidneys. They can then trigger an immune response by activating the complement cascade. This reaction can take hours to develop and examples include: immuno-complex glomerulonephritis, rheumatoid arthritis, SLE, subacute bacterial endocarditis, arthus reaction and serum sickness.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 91
Correct
-
A 60 year old man receives a cadaveric renal transplant for treatment of end stage renal failure. The organ is ABO group matched only. On completion of the vascular anastomoses the surgeons remove the clamps. Over the course of the next fifteen minutes, the donated kidney becomes dusky and swollen and appears non viable. Which of the following is the most likely process that has caused this event?
Your Answer: IgG anti HLA Class I antibodies in the recipient
Explanation:Antibody-mediated rejection (AMR) is defined as allograft rejection caused by antibodies of the recipient directed against donor-specific HLA molecules and blood group antigens. Although the mechanism by which HLA I antibodies promote inflammation and proliferation has been revealed by experimental models, the pathogenesis of HLA II antibodies is less defined. Antibodies to HLA II frequently accompany chronic rejection in renal transplants. AMR has been recognized as the leading cause of graft loss after kidney transplant if there is a donor-host antigenic disparity. Antibodies can be produced against epitopes of the antigen that differ from self by as little as one amino acid. Pre-existing antibodies or the development of de novo antibodies after transplantation has become a biomarker for AMR graft loss. HLA antibodies are risk factors for hyperacute, acute, and chronic allograft rejections.
The specificity of HLA antibodies can be determined using single-antigen luminex beads that consist of fluorescent microbeads conjugated to single recombinant HLA class I and class II molecules. Complement-fixing ability would be assessed by the binding of C1q to HLA antibodies present in the serum. In several studies, C1q-positive DSA had associated with antibody-mediated rejection in renal transplantation compared with antibodies identified only by IgG. Complement-fixing ability is relevant to hyperacute and acute rejections. Hyperacute rejection is predominantly complement-mediated severe allograft injury occurring within hours of transplantation. It is caused by high titre of pre-existing HLA or non-HLA antibodies in presensitized patients. But the incidence of hyperacute rejection is reduced due to improved DSA detection methods and desensitization protocols.
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This question is part of the following fields:
- Generic Surgical Topics
- Organ Transplantation
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Question 92
Correct
-
A 39 year old male is identified as having gallstones after presenting with colicky right upper quadrant pain. An abdominal ultrasound scan was done. Which of the following is the best course of action?
Your Answer: Liver function tests
Explanation:In patients with suspected gallstone complications, blood tests should include a complete blood cell (CBC) count with differential, liver function panel, and amylase and lipase. Up to 24% of women and 12% of men may have gallstones. Of these up to 30% may develop local infection and cholecystitis.
Acute cholecystitis is associated with polymorphonuclear leucocytosis. However, up to one third of the patients with cholecystitis may not manifest leucocytosis. In severe cases, mild elevations of liver enzymes may be caused by inflammatory injury of the adjacent liver.
Patients with cholangitis and pancreatitis have abnormal laboratory test values. Importantly, a single abnormal laboratory value does not confirm the diagnosis of choledocholithiasis, cholangitis, or pancreatitis; rather, a coherent set of laboratory studies leads to the correct diagnosis.
Choledocholithiasis with acute common bile duct (CBD) obstruction initially produces an acute increase in the level of liver transaminases (alanine and aspartate aminotransferases), followed within hours by a rising serum bilirubin level. The higher the bilirubin level, the greater the predictive value for CBD obstruction. CBD stones are present in approximately 60% of patients with serum bilirubin levels greater than 3 mg/dL.
If obstruction persists, a progressive decline in the level of transaminases with rising alkaline phosphatase and bilirubin levels may be noted over several days. Prothrombin time may be elevated in patients with prolonged CBD obstruction, secondary to depletion of vitamin K (the absorption of which is bile-dependent). Concurrent obstruction of the pancreatic duct by a stone in the ampulla of Vater may be accompanied by increases in serum lipase and amylase levels.
Repeated testing over hours to days may be useful in evaluating patients with gallstone complications. Improvement of the levels of bilirubin and liver enzymes may indicate spontaneous passage of an obstructing stone. Conversely, rising levels of bilirubin and transaminases with progression of leucocytosis in the face of antibiotic therapy may indicate ascending cholangitis with the need for urgent intervention. Blood culture results are positive in 30%-60% of patients with cholangitis.
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This question is part of the following fields:
- Generic Surgical Topics
- Hepatobiliary And Pancreatic Surgery
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Question 93
Correct
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Which of the following abnormalities can be seen in patients with hypermagnesemia?
Your Answer: Respiratory depression
Explanation:Hypermagnesemia is an electrolyte disturbance in which there is a high level of magnesium in the blood. It is defined as a level greater than 1.1 mmol/L. Symptoms include weakness, confusion, decreased breathing rate, and cardiac arrest.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 94
Correct
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Staphylococcus aureus can be identified in the laboratory based on the clotting of plasma. Which microbial product is responsible for this activity?
Your Answer: Coagulase
Explanation:Staphylococcus aureus is the most pathogenic species and is implicated in a variety of infections. S. aureus can be identified due to its production of coagulase. The staphylococcal enzyme coagulase will cause inoculated citrated rabbit plasma to gel or coagulate. The coagulase converts soluble fibrinogen in the plasma into insoluble fibrin.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 95
Correct
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A 33 year old woman, with invasive ductal carcinoma, presents with a lesion suspicious for metastatic disease in the left lobe of her liver. Past history includes wide local excision and axillary node clearance (5 nodes present) of the tumour. It is oestrogen receptor negative and HER 2 positive with vascular invasion. Which of the following agents will be the most beneficial in this setting?
Your Answer: Trastuzumab
Explanation:The treatment approach primarily depends on the histopathologic classification and the disease stage and involves a combination of surgical management, radiation therapy, and systemic therapy. Surgical management is either breast-conserving therapy (BCT) or mastectomy. Systemic therapy has significantly improved in recent years with the development of hormone therapy (tamoxifen) and targeted therapy (trastuzumab). The most important prognostic factors are lymph node status, tumour size, patient’s age, and tumour receptor status (hormone receptors and HER2).
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This question is part of the following fields:
- Breast And Endocrine Surgery
- Generic Surgical Topics
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Question 96
Incorrect
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A 32 year old man has a perianal abscess at 6 o'clock position. Which of the following is the most appropriate step in the management of this patient?
Your Answer: MRI of the pelvis
Correct Answer: Examination under anaesthetic and drainage of sepsis
Explanation:Optimal physical assessment of an anorectal abscess may require anaesthesia to alleviate patient discomfort that would otherwise limit the extent of the examination.
Drainage should be carried out promptly to prevent the sepsis worsening. Perianal incisions to allow drainage of pus should be circumanal, thus reducing the likelihood of damage to the sphincters and thereby preventing faecal incontinence. -
This question is part of the following fields:
- Colorectal Surgery
- Generic Surgical Topics
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Question 97
Correct
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Low molecular weight heparin (LMWH) has less side effects than heparin and is used in the prophylaxis and treatment of venous and arterial thrombotic disorders. Which of the following is LMWHs mechanism of action?
Your Answer: Inhibition of factor Xa
Explanation:Low molecular weight heparin (LMWH) is a anticoagulant that differs from normal heparin in that it has only short chains of polysaccharide. LMWH inhibits thrombin formation by converting antithrombin from a slow to a rapid inactivator of coagulation factor Xa.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 98
Correct
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A 34-year-old woman with pelvic inflammatory disease is administered ceftriaxone. The subclass of antibiotics that ceftriaxone belongs to is:
Your Answer: Third-generation cephalosporins
Explanation:Ceftriaxone is a third-generation cephalosporin antibiotic. It has a broad spectrum of activity against Gram-positive and Gram-negative bacteria. Its indications include middle ear infections, endocarditis, meningitis, pneumonia, bone and joint infections, intra-abdominal infections, skin infections, urinary tract infections, gonorrhoea, and pelvic inflammatory disease.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 99
Correct
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A histological examination of a lump showed an abnormal amount and arrangement of normal tissue in an otherwise normal area. This condition is known as?
Your Answer: Hamartoma
Explanation:A hamartoma is a condition best described as tissue normally present in an area arranged haphazardly in an disorganized, abnormal fashion. They are never malignant and do not metastasis.
All the neoplastic, cancerous lesions comprise of a mixture of different cells that are not normal to that area.
Metaplasia is a change in the type of the epithelium. -
This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 100
Correct
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Which of the following is NOT a Gram-negative rod?
Your 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 101
Correct
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Which of the following is a true statement regarding secretion of gastric acid?
Your Answer: Acetylcholine increases gastric acid secretion
Explanation:Gastric acid secretion is increased by acetylcholine, histamine and gastrin, with the help of cAMP as a secondary messenger. They increase H+ and Cl- secretion by increasing the number of H+/K+ ATPase molecules and Cl- channels. In contrast, gastric acid secretion is decreased by somatostatin, epidermal growth factor and prostaglandins.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 102
Correct
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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: 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 103
Correct
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A 27-year-old ski instructor who falls off a ski lift and sustains a spiral fracture of the midshaft of the tibia. Attempts to achieve a satisfactory position in plaster have failed. Overlying tissues are healthy. What is the most appropriate course of action?
Your Answer: Intramedullary nail
Explanation:Initially, all tibial shaft fractures should be stabilized with a long posterior splint with the knee in 10-15° of flexion and the ankle flexed at 90°
Closed fractures with minimal displacement or stable reduction may be treated nonoperatively with a long leg cast, but cast application should be delayed for 3-5 days to allow early swelling to diminish. The cast should extend from the midthigh to the metatarsal heads, with the ankle at 90° of flexion and the knee extended. The cast increases tibial stability and can decrease pain and swelling.
Despite proper casting techniques and adequate follow-up, not all nonoperatively treated tibial shaft fractures heal successfully.
Operative fixation is required when fractures are unstable. Surgical options include plating, external fixation, intramedullary nailing, and, in some cases, amputation.
Intramedullary nailing with locking screws (see the image below) has become the treatment of choice for most tibial shaft fractures. The prevalence of non-union and malunion is greatly decreased in comparison with the other methods of fixation. Patients are also able to return to low-impact activities much sooner than they can with the other treatments. -
This question is part of the following fields:
- Generic Surgical Topics
- Orthopaedics
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Question 104
Correct
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Which of the following variables are needed to calculate inspiratory reserve volume of a patient?
Your Answer: Tidal volume, vital capacity and expiratory reserve volume
Explanation:Vital capacity = inspiratory reserve volume + tidal volume + expiratory reserve volume. Thus, inspiratory reserve volume can be calculated if tidal volume, vital capacity and expiratory reserve volume are known.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 105
Correct
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A 25-year-old male is found to have a 5cm carcinoid tumour of the appendix. Imaging and diagnostic workup show no distant diseases. What is the best course of action?
Your Answer: Right hemicolectomy
Explanation:Carcinoid tumours are of neuroendocrine origin and derived from primitive stem cells in the gut wall, especially the appendix.
Signs and symptoms of carcinoid tumours vary greatly. Carcinoid tumours can be non-functioning presenting as a tumour mass or functioning. The sign and symptoms of a non-functioning tumour depend on the tumour location and size as well as on the presence of metastases. Therefore, findings range from no tumour-related symptoms (most carcinoid tumours) to full symptoms of carcinoid syndrome (primarily in adults).
– Periodic abdominal pain: Most common presentation for a small intestinal carcinoid; often associated with malignant carcinoid syndrome
– Cutaneous flushing: Early and frequent (94%) symptom
– Diarrhoea and malabsorption (84%)
– Cardiac manifestations (60%): Valvular heart lesions, fibrosis of the endocardium; may lead to heart failure with tachycardia and hypertension
– Wheezing or asthma-like syndrome (25%)
– Pellagra
– Carcinoid crisis can be the most serious symptom of carcinoid tumours and can be life-threatening. It can occur suddenly, after stress, or following chemotherapy and anaesthesia.Two surgical procedures can be applied to treat appendiceal Neuroendocrine Neoplasm (NEN): simple appendicectomy and oncological right-sided hemicolectomy.
– For T1 (ENETS) or T1a (UICC/AJCC) NEN (i.e. <1 cm), generally simple appendicectomy is curative and sufficient.
– For NEN >2 cm with a T3 stage (ENETS) or higher and T2 (UICC/AJCC) or higher respectively, a right-sided hemicolectomy is advised due to the increased risk of lymph node metastasis and long-term tumour recurrence and/or distant metastasis. The right-sided hemico- lectomy should be performed either as the initial surgical intervention should the problem be overt at that time, or during a second intervention. -
This question is part of the following fields:
- Colorectal Surgery
- Generic Surgical Topics
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Question 106
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 107
Correct
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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 108
Correct
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A 54-year-old woman is re-admitted to the hospital with shortness of breath and sharp chest pain 2 weeks after surgical cholecystectomy. The most probable cause of these clinical findings is:
Your Answer: Pulmonary embolus
Explanation:Pulmonary embolism is caused by the sudden blockage of a major lung blood vessel, usually by a blood clot. Symptoms include sudden sharp chest pain, cough, dyspnoea, palpitations, tachycardia or loss of consciousness. Risk factors for developing pulmonary embolism include long periods of inactivity, surgery, trauma, pregnancy, oral contraceptives, oestrogen replacement, malignancies and venous stasis.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 109
Correct
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A 42 - year old male patient with an acute onset headache was brought in to the emergency department with suspicion of a subarachnoid haemorrhage (SAH). The SHO on call decided to have a diagnostic lumbar puncture after computed topography scan failed to support the suspicion. To perform a successful lumbar puncture without causing injury to the spine, which anatomical landmark should guide the SHO to locate the fourth vertebra for insertion of the spinal needle?
Your Answer: Iliac crest
Explanation:The safest spinal level for conducting a lumbar puncture, is at the level of the fourth lumbar vertebra. The anatomical landmark used to locate the fourth lumbar vertebra (L4), is the iliac crest. The needle can safely be inserted either above or below L4. The conus medullaris is at the level of the border of L1 and L2 so L4 is safely distant from it.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 110
Correct
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Question 111
Correct
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Which of the following muscles aid in inspiration?
Your Answer: Diaphragm and external intercostals
Explanation:The diaphragm and external intercostals are muscles of inspiration as they increase the volume of thoracic cavity and reduce the intrathoracic pressure. Muscles of expiration include abdominal muscles and internal intercostals.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 112
Incorrect
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Which of the following conditions may cause hypovolaemic hyponatraemia?
Your Answer: Diuretic therapy
Correct Answer: Cirrhosis
Explanation:The most common cause of hypovolaemic hyponatraemia include: liver cirrhosis, congestive heart failure and nephrotic syndrome. In hypovolaemic hyponatraemia, both sodium and water content increase: Increase in sodium content leads to hypervolemia and water content to hyponatraemia.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 113
Correct
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Some substances, such as Chromium-51 and Technetium-99, are freely filtered but not secreted or absorbed by the kidney. In these cases, their clearance rate is equal to:
Your Answer: Glomerular filtration rate
Explanation:If a substance passes through the glomerular membrane with perfect ease, the glomerular filtrate contains virtually the same concentration of the substance as does the plasma and if the substance is neither secreted nor reabsorbed by the tubules, all of the filtered substance continues on into the urine. Glomerular filtration rate (GFR) describes the flow rate of filtered fluid through the kidney.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 114
Correct
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Which statement is true regarding the diaphragmatic openings:
Your Answer: The thoracic duct passes through the opening at T12
Explanation:The diaphragmatic openings are:
T8 – opening for the inferior vena cavaand the right phrenic nerve
T10 – opening for the oesophagusand the left gastric artery and vein
T12 – opening for the aorta, the thoracic duct and azygos vein. -
This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 115
Correct
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Regarding the posterior compartment of the leg, which is correct?
Your Answer: The muscles plantarflex the foot and are innervated by the tibial nerve
Explanation:The muscles of the back of the leg are subdivided into two groups: superficial and deep. Superficial muscles include gastrocnemius, soleus and plantaris. Deep muscles include tibialis posterior, flexor hallucis longus, flexor digitorum longus and popliteus. The superficial ( calf muscles) which are responsible for plantarflexion of the foot are supplied by the tibial nerve as follows: the gastrocnemius and soleus muscles are supplied by the first and second sacral nerves and the plantaris by the fourth and fifth lumbar and first sacral nerve (the tibial nerve).
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 116
Correct
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A 28 year old teacher is readmitted following a difficult appendicectomy. On examination, her wound is erythematous and, on incision, foul smelling pus is drained. Which of the following organisms is responsible?
Your Answer: Bacteroides fragilis
Explanation:Bacteroides species are anaerobic bacteria that are predominant components of the bacterial florae of mucous membranes and are therefore a common cause of endogenous infections. Bacteroides infections can develop in all body sites, including the CNS, the head, the neck, the chest, the abdomen, the pelvis, the skin, and the soft tissues. Inadequate therapy against these anaerobic bacteria may lead to clinical failure.
These bacteria are resistant to penicillins, mostly through the production of beta-lactamase. Anaerobic bacteria can infect deep wounds, deep tissues, and internal organs where there is little oxygen. These infections are characterized by abscess formation, foul-smelling pus, and tissue destruction. Anaerobes outnumber aerobes by 1000:1 in the large intestine; thus, they play an important role in almost all intra-abdominal infections.
Secondary peritonitis and abdominal abscesses generally occur after entry of enteric organisms into the peritoneal cavity through perforation of the intestine or other viscus as a result of obstruction, infarction, or trauma.
Most visceral abscesses (e.g., hepatic), chronic cholecystitis, perforated and gangrenous appendicitis, postoperative wound infections and abscesses, diverticulitis, and any infection associated with faecal contamination of the abdominal cavity involve both aerobes and anaerobes.
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This question is part of the following fields:
- Clinical Microbiology
- Principles Of Surgery-in-General
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Question 117
Correct
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A 30-year-old woman known with Von Willebrand disease (vWD) has to undergo surgery. Which of these complications is most unlikely in this patient?
Your Answer: Hemarthrosis
Explanation:Von Willebrand disease (vWD) is an inherited haemorrhagic disorder characterised by the impairment of primary haemostasis. It is caused by the deficiency or dysfunction of a protein named von Willebrand factor. The most common manifestation due to the condition is abnormal bleeding. Complications include easy bruising, hematomas, epistaxis, menorrhagia, prolonged bleeding and severe haemorrhage. Hemarthrosis is a complication that is more commonly found in haemophilia.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 118
Incorrect
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A 57-year-old male smoker noted a lump on his inner lip. Upon physical examination the lump measured more than 2 cm but less than 4 cm in its greatest dimension. He is diagnosed with squamous cell carcinoma of the lip. What is the stage of the patient's cancer according to the TNM staging for head and neck cancers?
Your Answer: T3
Correct Answer: T2
Explanation:Head and neck cancer is a group of cancers that starts within the mouth, nose, throat, larynx, sinuses, or salivary glands. The TNM staging system used for head and neck cancers is a clinical staging system that allows physicians to compare results across patients, assess prognosis, and design appropriate treatment regimens. The staging is as follows; Primary tumour (T): Tis: pre-invasive cancer (carcinoma in situ), T0: no evidence of primary tumour, T1: tumour 2 cm or less in its greatest dimension, T2: tumour more than 2 cm but not more than 4 cm, T3: tumour larger than 4 cm, T4: tumour with extension to bone, muscle, skin, antrum, neck, etc and TX: minimum requirements to assess primary tumour cannot be met. Regional lymph node involvement (N): N0: no evidence of regional lymph node involvement, N1: evidence of involvement of movable homolateral regional lymph nodes, N2: evidence of involvement of movable contralateral or bilateral regional lymph nodes, N3: evidence of involvement of fixed regional lymph nodes and NX: Minimum requirements to assess the regional nodes cannot be met. Distant metastases (M): M0: no evidence of distant metastases, M1: evidence of distant metastases and MX: minimum requirements to assess the presence of distant metastases cannot be met. Staging: Stage I: T1 N0 M0, Stage II: T2 N0 M0, Stage III: T2NOMO and T3N1MO, Stage IV: T4N1M0, any TN2M0, any TN3M0, any T and any NM1. The depth of infiltration is predictive of the prognosis. With increasing depth of invasion of the primary tumour, the risk of nodal metastasis increases and survival decreases. The patient in this scenario therefore has a T2 tumour.
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