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Question 1
Correct
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A young women following a road traffic accident suffered heavy blood loss and developed subsequent anaemia. Which of the following is a consequence of this?
Your Answer: A high reticulocyte count
Explanation:Anaemia refers to a decrease in the circulating levels of haemoglobin in the blood resulting in a reduced ability of the body to transport oxygen effectively. Anaemia from blood loss results in the body further compensating by releasing stored RBCs and immature RBCs from the bone marrow. Thus resulting in a high reticulocyte count.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 2
Correct
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A 30 year old female presented in the emergency with an irregular pulse. Her ECG showed absent P-waves with irregular RR interval. What is the most likely diagnosis?
Your Answer: Atrial fibrillation
Explanation:Atrial fibrillation is one of the most common cardiac arrhythmias. It is often asymptomatic but may present with symptoms of palpitations, fainting, chest pain and heart failure. Characteristic findings are: absence of P-waves, unorganised electrical activity in their place, irregularity of RR interval due to irregular conduction of impulses to the ventricles and if paroxysmal AF is suspected, episodes may be documented with the use of Holter monitoring
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 3
Incorrect
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Under normal conditions, what is the major source of energy of cardiac muscles?
Your Answer: Glucose
Correct Answer: Fatty acids
Explanation:Under basal conditions, most of the energy needed by cardiac muscle for metabolism is derived from fats (60%), 35% by carbohydrates, and 5% by ketones and amino acids. However, after intake of large amounts of glucose, lactate and pyruvate are mainly used. During prolonged starvation, fat acts as the primary source. 50% of the used lipids are sourced from circulating fatty acids.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 4
Correct
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Work of breathing (WOB) is the energy expended to inhale and exhale a breathing gas. Normally, maximal amount of work of breathing is required to overcome:
Your Answer: Elastic lung compliance
Explanation:The forces of elastance (compliance), frictional resistance and inertia have been identified as the forces that oppose lung inflation and deflation. The normal relaxed state of the lung and chest is partially empty. Further exhalation requires muscular work. Inhalation is an active process requiring work. About 60–66% of the total work performed by the respiratory muscles is used to overcome the elastic or compliance characteristics of the lung–chest cage, 30–35% is used to overcome frictional resistance and only 2–5% of the work is used for inertia.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 5
Correct
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Elevated mean corpuscular volume with hypersegmented neutrophils and low reticulocyte index is seen in on the blood count of a middle-aged lady about to undergo elective surgery. On enquiry, she mentions feeling tired for a few months. Which of the following investigations should be carried out in her to reach a diagnosis?
Your Answer: Serum vitamin B12 and folate
Explanation:Elevated levels of MCV indicates megaloblastic anaemia, which are associated with hypersegmented neutrophils. Likely causes include vitamin B12 or folate deficiency. Megaloblastic anaemia results from defective synthesis of DNA. As RNA production continues, the cells enlarge with a large nucleus. The cytoplasmic maturity becomes greater than nuclear maturity. Megaloblasts are produced initially in the marrow, before blood. Dyspoiesis makes erythropoiesis ineffective, causing direct hyperbilirubinemia and hyperuricemia. As all cell lines are affected, reticulocytopenia, thrombocytopenia and leukopenia develop. Large, oval blood cells (macro-ovalocytes) are released in the circulation, along with presence of hypersegmented neutrophils.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 6
Correct
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A 45-year-old female with a metallic heart valve has just undergone an elective paraumbilical hernia repair. In view of her metallic valve, she is given unfractionated heparin perioperatively. How should the therapeutic efficacy be monitored, assuming her renal function is normal?
Your Answer: Measurement of APTT
Explanation:Because of the substantial risk of thromboembolism early after valve replacement, perioperative initiation of anticoagulation is necessary, despite the increased risk for bleeding. Anticoagulation should be initiated within 24 h after the procedure with unfractionated heparin or low-molecular-weight heparin (LMWH).
Heparin is monitored by checking the activated partial thromboplastin time or anti-Xa activity.
Oral anticoagulants are monitored by INR. -
This question is part of the following fields:
- Peri-operative Care
- Principles Of Surgery-in-General
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Question 7
Correct
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Digital rectal examination of a 75-year old gentleman who presented to the surgical clinic with urinary retention revealed an enlarged, nodular prostate. PSA was found to be elevated, favouring the diagnosis of prostatic malignancy. Which of the given options is the most common malignant lesion affecting the prostate gland?
Your Answer: Adenocarcinoma
Explanation:Prostatic adenocarcinoma is the commonest solid malignancy and non-dermatological cancer in men above 50 years age. Increasing in incidence with age and the highest risk seen in the black population. About 75% of cases are seen in men over 65 years. Other tumours affecting the prostate include undifferentiated prostate cancer, squamous cell carcinoma, and ductal transitional carcinoma, but these occur less commonly. Sarcomas usually affect children. Hormones play a role in the aetiology of prostate adenocarcinoma unlike the other types. Intraepithelial neoplasia is considered a precursor of invasive malignancy.
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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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A 25 year old male patient who had sustained a stab wound in the middle of the posterior aspect of the left thigh, was discharged from hospital after dressing and antibiotic prophylaxis. Later on the patient developed bleeding through the wound and upon review, the source was discovered to be an artery that is the direct source of the medial and lateral circumflex arteries. Which is this artery that was injured?
Your Answer: Profunda femoris artery
Explanation:The medial and lateral circumflex arteries are direct branches of the Profunda femoris artery otherwise also known as the deep artery of the thigh. The Profunda femoris artery arises from the femoral artery just below the inguinal ligament (approximately 2-5cm below it).
The following are the branches of the deep artery of the thigh:
Lateral circumflex femoral artery
Medial circumflex femoral artery
Perforating arteries -
This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 9
Incorrect
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A 21-year-old woman presents with an episode of greenish discharge from the left nipple. Clinical examination of the breast is normal. Her breast USS report is U1 (normal). What should be the best course of action?
Your Answer: Undertake a microdochectomy
Correct Answer: Reassure and discharge
Explanation:This is likely to be a case of simple duct ectasia. Normal USS report coupled with normal examination would favour discharge from the clinic. Mammography is generally not helpful in this age group.
Possible causes of nipple discharge include:
1. Abscess
2. Birth control pills
3. Breast cancer
4. Ductal carcinoma in situ (DCIS)
5. Endocrine disorders
6. Excessive breast stimulation
7. Fibrocystic breasts (lumpy or rope-like breast tissue)
8. Galactorrhoea
9. Injury or trauma to the breast
10. Intraductal papilloma (benign, wart-like growth in a milk duct)
11. Mammary duct ectasia
12. Mastitis (an infection in breast tissue that most commonly affects women who are breast-feeding)
13. Medication use
14. Menstrual cycle hormone changes
15. Paget’s disease of the breast
16. Periductal mastitis
17. Pregnancy and breast-feeding
18. ProlactinomaAssessment and management of non-malignant nipple discharge includes:
1. Exclude endocrine disease
2. Nipple cytology is not carried out as it would be unhelpful
3. Smoking cessation advice given for duct ectasia
4. Total duct excision may be warranted for duct ectasia with severe symptoms -
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 patient is diagnosed with lung cancer. His physician told him that his lung cancer type is aggressive. It can grow rapidly and may undergo early metastasis, however it is very sensitive to chemotherapy and radiotherapy. Which lung cancer type is most likely present
Your Answer: Small-cell carcinoma
Explanation:Small-cell lung carcinoma (SCLC) is a type of highly malignant cancer that most commonly arises within the lung. SCLC usually metastasizes widely very early on in the natural history of the tumour, and in nearly all cases responds dramatically to chemotherapy and/or radiotherapy. Surgery has no role in the treatment of this disease.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 11
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 12
Correct
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What will the destruction of endoplasmic reticulum stop?
Your Answer: Synthesis of proteins
Explanation:The rough endoplasmic reticulum is the factory for the manufacturing of proteins. It contains ribosomes attached to it and transports proteins that are destined for membranes and secretions. The rough ER is connected to the nuclear envelope and to the cisternae of the Golgi apparatus by vesicles that shuttle between the two compartments.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 13
Correct
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A 14 year old girl suffers from haemophilia A and chronic knee pain with progressive swelling and deformity over the last 4 years. Test results reveal a significantly reduced factor VIII activity. Which of the following is seen in the knee joint space after an acute painful episode?
Your Answer: Cholesterol crystals
Explanation:Due to breakdown of the red blood cell membrane in haemophilic patients, cholesterol crystals are formed by the lipids. On the other hand lipofuscin deposition does not occur in haemolysis or haemorrhage. Neutrophil accumulation suggests acute inflammation. Anthracotic pigment is an exogenous carbon pigment that deposits in the lung from dust. Russell bodies are intracellular accumulations of immunoglobins in plasma cells. Curschmann’s spirals and Charcot Leyden crystals are pathognomonic of asthma.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 14
Incorrect
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A 26-year-old right-handed tennis player presents to the A&E department with a painful, swollen right arm. On examination, his upper limb pulses are present, but he has dusky fingers. A diagnosis of axillary vein thrombosis is made and confirmed. He is immediately started on low-molecular-weight heparin (LMWH).What should be the next best step of management to achieve venous patency?
Your Answer: Warfarin
Correct Answer: Catheter-directed tPA
Explanation:Catheter-directed thrombolysis (CDT) is recommended as the next step of management for patients with proximal upper-extremity deep vein thrombosis (UEDVT) of recent onset or severe symptoms.
Primary UEDVT is less common than secondary forms. The most common primary form is effort-related thrombosis, also called Paget-Schroetter syndrome. It usually occurs in otherwise healthy young men who report, before the onset of thrombosis, vigorous arm exercise such as lifting weights, playing badminton, pitching a baseball, or performing repetitive overhead activities, such as painting or car repair. Most patients with effort-related UEDVT have an underlying venous thoracic outlet syndrome (VTOS). Secondary causes of UEDVT include central line insertion, malignancy, or pacemakers.
Patients with UEDVT typically present with heaviness, discomfort, pain, paraesthesia, and swelling of the affected arm. Physical examination may reveal pitting oedema, redness, or cyanosis of the involved extremity; visible collateral veins at the shoulder or upper arm; and fever.
Diagnosis is made by:
1. FBC: platelet function
2. Coagulation profile
3. Liver function tests
4. Duplex scan: investigation of choice
5. D-dimer testing
6. CT scan: for VTOSTreatment options for primary UEDVT are as follows:
1. Anticoagulation therapy should be undertaken with a once-daily regimen of LMWH or fondaparinux for at least five days, followed by vitamin K antagonists for at least three months. Unfractionated heparin instead of LMWH is recommended for patients with renal failure or for those treated with CDT.2. Early thrombus removal and restoration of venous patency should be done immediately after starting the patient on heparin. Catheter-based therapy is recommended for patients with proximal UEDVT of recent onset and severe symptoms, low risk for bleeding complications, and good functional status.
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This question is part of the following fields:
- Generic Surgical Topics
- Vascular
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Question 15
Correct
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A patient sustained an injury to the facial nerve after it emerges from the stylomastoid foramen. What is the clinical impact of this injury?
Your Answer: Facial expression
Explanation:The facial nerve is the seventh of the twelve paired cranial nerves. It emerges from the brainstem between the pons and the medulla. It controls the muscles of facial expression and supplies taste fibres to the anterior two-thirds of the tongue. It also supplies preganglionic parasympathetic fibres to several head and neck ganglia. Its branches and distribution are as follows:
Inside the facial canal (proximal to the stylomastoid foramen):
– Greater petrosal nerve – provides parasympathetic innervation to the lacrimal gland, as well as special taste sensory fibres to the palate via the nerve of pterygoid canal
– Nerve to stapedius – provides motor innervation for the stapedius muscle in the middle ear
– Chord tympani – provides parasympathetic innervation to the submandibular and sublingual glands and special sensory taste fibres for the anterior two-thirds of the tongue
Outside the skull (distal to the stylomastoid foramen):
– Posterior auricular nerve – controls the movements of some of the scalp muscles around the ear
– Five major facial branches (in the parotid gland), from top to bottom: temporal branch, zygomatic branch, buccal branch, marginal mandibular branch and cervical branch. From the description given above it is obvious that injury to the facial nerve distal to the stylomastoid foramen will affect facial expression. -
This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 16
Incorrect
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Cyclophosphamide is used as a chemotherapy and immunosuppressant agent and is indicated in various diseases. One of the most severe complications of its use is cancer of the:
Your Answer:
Correct Answer: Urinary bladder
Explanation:Cyclophosphamide is used to treat various types of cancer and autoimmune disorders. The main use of cyclophosphamide is in combination with other chemotherapy agents in the treatment of lymphomas, some forms of leukaemia and some solid tumours. Side-effects include nausea and vomiting, bone marrow suppression, stomach ache, diarrhoea, darkening of the skin
ails, alopecia, lethargy, and haemorrhagic cystitis. Cyclophosphamide is itself carcinogenic, potentially causing transitional cell carcinoma of the bladder as a long-term complication. -
This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 17
Incorrect
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A 4 week old baby is taken to the clinic with bile stained vomiting. He had a congenital diaphragmatic hernia and an exomphalos. What is the most likely underlying condition?
Your Answer:
Correct Answer: Intestinal malrotation
Explanation:Answer: Intestinal malrotation
During normal abdominal development, the 3 divisions of the GI tract (i.e., foregut, midgut, hindgut) herniate out from the abdominal cavity, where they then undergo a 270º counter clockwise rotation around the superior mesenteric vessels. Following this rotation, the bowels return to the abdominal cavity, with fixation of the duodenojejunal loop to the left of the midline and the cecum in the right lower quadrant.
Intestinal malrotation refers to any variation in this rotation and fixation of the GI tract during development. Interruption of typical intestinal rotation and fixation during foetal development can occur at a wide range of locations; this leads to various acute and chronic presentations of disease. The most common type found in paediatric patients is incomplete rotation predisposing to midgut volvulus, requiring emergent operative intervention.
Acute midgut volvulus
Usually occurs during the first year of life
Sudden onset of bilious emesis
Diffuse abdominal pain out of proportion to physical examination
Acute duodenal obstruction
This anomaly is usually recognized in infants and is due to compression or kinking of the duodenum by peritoneal bands (Ladd bands).
Patients present with forceful vomiting, which may or may not be bile-stained, depending on the location of the obstruction with respect to the entrance of the common bile duct (ampulla of Vater).
Malrotation may occur as an isolated anomaly or in association with other congenital anomalies; 30-62% of children with malrotation have an associated congenital anomaly. All children with diaphragmatic hernia, gastroschisis, and omphalocele have intestinal malrotation by definition. Additionally, malrotation is seen in approximately 17% of patients with duodenal atresia and 33% of patients with jejunoileal atresia.
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This question is part of the following fields:
- Generic Surgical Topics
- Paediatric Surgery
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Question 18
Incorrect
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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:
Correct 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 19
Incorrect
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A 30-year-old male presents with a recurrent inguinal hernia on the left side of his abdomen and a newly diagnosed inguinal hernia on the right side. What is the best course of action?
Your Answer:
Correct Answer: Bilateral laparoscopic TEP repair
Explanation:Risk factors for Recurrent Inguinal Hernia with a moderate level of evidence include the presence of a sliding hernia, a diminished collagen type I/III ratio, increased systemic matrix metalloproteinase levels, obesity and open hernia repair under local anaesthesia by general surgeons.
The incorrect surgical technique is likely the most important reason for recurrence after primary IH repair.According to the guidelines:
– Laparo-endoscopic recurred inguinal hernia repair is strongly recommended after failed anterior tissue or Lichtenstein repair (evidence: moderate; recommendation: strong).
– Anterior repair is recommended after a failed posterior repair (evidence: moderate; recommendation: strong).
– An expert hernia surgeon should repair a recurrent Inguinal Hernia after failed anterior and posterior repair. Choice of technique depends on patient and surgeon specific factors (evidence: low; recommendation: strong upgraded).The EHS guidelines recommended for bilateral primary inguinal hernia repair, either a bilateral Lichtenstein or endoscopic approach.
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This question is part of the following fields:
- Generic Surgical Topics
- The Abdomen
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Question 20
Incorrect
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A 38-year old woman presents to the clinic with a 2 cm eczema-like lesion on the areolar region of her left breast, for 5 months. Biopsy of the lesion showed large cells at the dermal-epidermal junction with positive staining for mucin. What is the likely diagnosis?
Your Answer:
Correct Answer: Paget’s disease of the breast
Explanation:Paget’s disease of the breast or nipple resembles eczema in appearance with an underlying carcinoma typically. The disease is usually unilateral and presents with inflammation, oozing and crusting along with a non-healing ulcer. Treatment is often delayed due to the innocuous appearance but can be fatal. It results due to spread of neoplastic cells from the ducts of the mammary gland to the epithelium.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 21
Incorrect
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During a normal respiratory exhalation, what is the recoil alveolar pressure?
Your Answer:
Correct Answer: +10 cmH2O
Explanation:To determine compliance of the respiratory system, changes in transmural pressures (in and out) immediately across the lung or chest cage (or both) are measured simultaneously with changes in lung or thoracic cavity volume. Changes in lung or thoracic cage volume are determined using a spirometer with transmural pressures measured by pressure transducers. For the lung alone, transmural pressure is calculated as the difference between alveolar (pA; inside) and intrapleural (ppl; outside) pressure. To calculate chest cage compliance, transmural pressure is ppl (inside) minus atmospheric pressure (pB; outside). For the combined lung–chest cage, transmural pressure or transpulmonary pressure is computed as pA – pB. pA pressure is determined by having the subject deeply inhale a measured volume of air from a spirometer. Under physiological conditions the transpulmonary or recoil pressure is always positive; intrapleural pressure is always negative and relatively large, while alveolar pressure moves from slightly negative to slightly positive as a person breathes.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 22
Incorrect
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Which one of the following groups of lymph nodes is most likely to be inflamed due to paronychia involving the big toe?
Your Answer:
Correct Answer: Vertical group of superficial inguinal lymph nodes
Explanation:Paronychia affecting the big toe will result in inflammation of the superficial inguinal lymph nodes as it drains lymph from the big toe.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 23
Incorrect
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A 25 year old primi gravida lady was scheduled for a regular antenatal check up. During the vaginal exam of this lady, the registrar discovered a malignant growth on the anterior wall of her vagina. Which of the following structures, adjacent to the vagina, is likely to be involved as well?
Your Answer:
Correct Answer: Fundus of the bladder
Explanation:The fundus of the bladder is related anatomically to the anterior surface of the vagina and the urethra as well. If there was a malignant growth in the anterior surface of the vagina, then most likely the fundus of the bladder would be involved as well aspotentially the urethra.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 24
Incorrect
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A 14 year old boy is suspected of having CSF rhinorrhoea after sustaining a basal skull fracture. Which laboratory test would be able to accurately detect the presence of CSF?
Your Answer:
Correct Answer: Beta 2 transferrin assay
Explanation:Answer: Beta 2 transferrin assay
Beta-2-transferrin is a protein found only in CSF and perilymph. Since 1979, beta-2-transferrin has been used extensively by otolaryngologists in the diagnosis of CSF rhinorrhoea and skull-base cerebrospinal fluid fistulas. With sensitivity of 94% – 100%, and specificity of 98% – 100%, this assay has become the gold standard in detection of CSF leakage. CSF rhinorrhoea is characterized by clear or xanthochromic watery rhinorrhoea that may not become apparent until nasal packing is removed.
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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 25
Incorrect
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A 9 year old girl is admitted to the A&E department after having a fall. Her blood pressure is 101/56 mmHg, pulse is 91 and her abdomen is soft but tender on the left side. Imaging shows that there is a grade III splenic laceration. What is the best course of action?
Your Answer:
Correct Answer: Admit the child to the high dependency unit for close monitoring
Explanation:Answer: Admit the child to the high dependency unit for close monitoring.
Grade 3: This mid-stage rupture is a tear more than 3 cm deep. It can also involve the splenic artery or a hematoma that covers over half of the surface area. A grade 3 rupture can also mean that a hematoma is present in the organ tissue that is greater than 5 cm or expanding.
The trend in management of splenic injury continues to favour nonoperative or conservative management.
Most haemodynamically stable injuries can be managed non-operatively (especially Grades I to III). -
This question is part of the following fields:
- Emergency Medicine And Management Of Trauma
- Principles Of Surgery-in-General
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Question 26
Incorrect
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Which of the following abnormalities can be seen in patients with hypermagnesemia?
Your Answer:
Correct 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 27
Incorrect
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The neurotransmitters adrenaline, noradrenaline and dopamine are derived from which amino acid?
Your Answer:
Correct Answer: Tyrosine
Explanation:Tyrosine is the precursor to adrenaline, noradrenaline and dopamine. Tyrosine hydroxylase converts tyrosine to DOPA, which is in turn converted to dopamine, then to noradrenaline and finally adrenaline.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 28
Incorrect
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A 39 year old woman is admitted with acute cholecystitis which fails to settle. During a laparoscopic cholecystectomy, the gallbladder has evidence of an empyema and Calots triangle is inflamed. The surgeon suspects that a Mirizzi syndrome has occurred. What is the most appropriate course of action?
Your Answer:
Correct Answer: Undertake an operative cholecystostomy
Explanation:Mirizzi’s syndrome is a rare complication in which a gallstone becomes impacted in the cystic duct or neck of the gallbladder causing compression of the common hepatic duct, resulting in obstruction and jaundice. The obstructive jaundice can be caused by direct extrinsic compression by the stone or from fibrosis caused by chronic cholecystitis (inflammation).
Type I – No fistula present
Type IA – Presence of the cystic duct
Type IB – Obliteration of the cystic ductTypes II–IV – Fistula present
Type II – Defect smaller than 33% of the CHD diameter
Type III – Defect 33–66% of the CHD diameter
Type IV – Defect larger than 66% of the CHD diameterSimple cholecystectomy is suitable for type I patients. This patient has type I because no fistula is present.
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This question is part of the following fields:
- Generic Surgical Topics
- Hepatobiliary And Pancreatic Surgery
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Question 29
Incorrect
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Bile salt reuptake principally occurs where?
Your Answer:
Correct Answer: In the ileum
Explanation:90 – 95% of the bile salts are absorbed from the small intestine (mostly terminal ileum and then excreted again from the liver. This is known as the enterohepatic circulation. The entire pool recycles twice per meal and approximately 6 to 8 times per day.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 30
Incorrect
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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:
Correct 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 31
Incorrect
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A victim of assault in a domestic violence is stabbed in the left chest. The tip of the pen knife entered the pleural space just above the cardiac notch. Luckily the lung was spared as it would only occupy this space during deep inspiration. Which of these structures was pierced by the knife?
Your Answer:
Correct Answer: Costomediastinal recess
Explanation:The costomediastinal recess is located immediately next to the cardiac notch. The medial aspect of the superior lobe of the left lung, when fully inflated expands to this place. The lung wouldn’t enter the anterior or the posterior mediastinum which are found between the two pleural cavities.
The costodiaphragmatic recess is the lowest extent of the pleural cavity where the inferior lobes of the lungs would expand into in deep inhalation.
The cupola, is the part of the pleural cavity that extends above the first rib into the root of the neck. The superior most part of the superior lobe of the lung might extend into this part.
Pulmonary ligament: pleural fold that is located below the root of the lung where the visceral pleura and the mediastinal pleura are in continuity. -
This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 32
Incorrect
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Atractyloside is an inhibitor of electron transport chain. It is expected to have little or no effect on the functioning of which of the following cell types?
Your Answer:
Correct Answer: Red blood cells
Explanation:Electron transport chain is a series of electron carriers that are embedded in the mitochondrial membrane. It is the place where ATP is made. Inhibiting the electron transport chain will stop production of ATP. Red blood cells are the only cell in the given option which do not contain ATP.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 33
Incorrect
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A 40 year old man from Japan was diagnosed with cancer of the oesophagus. He is to undergo esophagectomy. While mobilizing the oesophagus in the neck, for resection and anastomosis with the stomach tube on the left side, the surgeon must be cautious not to injure a vital structure. Which of the following is it?
Your Answer:
Correct Answer: Thoracic duct
Explanation:The oesophagus is divided into 3 portions: cervical (part that is in the neck), thoracic portion and the abdominal portion. The cervical part is bordered by the trachea anteriorly and the prevertebral fascia covering the bodies of the 6,7 and 8th vertebra posteriorly. The thoracic duct lies on the left side at the level of the sixth cervical vertebra. The carotid sheath with its contents and lower poles of the lateral lobes of thyroid gland are lateral. The thoracic duct is the structure most likely to be injured.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 34
Incorrect
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Hyperplastic arteriosclerosis with fibrinoid necrosis, petechial haemorrhages, microinfarcts in the kidneys and elevated plasma renin are common findings in which of the following patients?
Your Answer:
Correct Answer: A 45-year-old woman with scleroderma
Explanation:Scleroderma, also known as systemic sclerosis, is a chronic disease of the connective tissue. Involvement of the kidneys occurs in patients with diffuse scleroderma, causing rapid onset of high blood pressure with hyperreninemia, thrombotic microangiopathy, and progressive renal failure.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 35
Incorrect
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A 6 week old preterm infant is scheduled for an inguinal hernia repair. Which of the following fluids should be ideally administered to him while he is on NPO?
Your Answer:
Correct Answer: 10% dextrose
Explanation:There is a substantial risk of hypoglycaemia in neonates following surgery, therefore 10% dextrose should be administered to them to avoid the complications associated with hypoglycaemia.
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This question is part of the following fields:
- Post-operative Management And Critical Care
- Principles Of Surgery-in-General
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Question 36
Incorrect
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A 56-year-old male is admitted for an elective hip replacement. Three days postoperatively you suspect he has had a pulmonary embolism. He has no past medical history of note. Blood pressure is 120/80 mmHg with a pulse of 90/min. The chest x-ray is normal. Following treatment with low-molecular-weight heparin, what is the most appropriate initial lung imaging investigation to perform?
Your Answer:
Correct Answer: Computed tomographic pulmonary angiography
Explanation:According to the ECS Guidelines 2019, Multidetector Computed tomographic pulmonary angiography (CTPA) is the method of choice for imaging the pulmonary vasculature in patients with suspected PE. It allows adequate visualization of the pulmonary arteries down to the subsegmental level.112–114 The Prospective Investigation On Pulmonary Embolism Diagnosis (PIOPED) II study observed a sensitivity of 83% and a specificity of 96% for (mainly four-detector) CTPA in PE diagnosis.
D-dimer levels are elevated in plasma in the presence of acute thrombosis because of simultaneous activation of coagulation and fibrinolysis. The negative predictive value of D-dimer testing is high, and a normal D-dimer level renders acute PE or DVT unlikely. On the other hand, the positive predictive value of elevated D-dimer levels is low and D-dimer testing is not useful for confirmation of PE.
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This question is part of the following fields:
- Post-operative Management And Critical Care
- Principles Of Surgery-in-General
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Question 37
Incorrect
-
The prostatic plexus of nerves contains nerve fibres that innervate penile tissue allowing for erection. From which of the following nerves do these fibres originate?
Your Answer:
Correct Answer: Pelvic splanchnics
Explanation:Pelvic splanchnic nerves are examples of the parasympathetic nerves that innervate the smooth muscle and glands of the pelvic viscera. They are also the nerves contributing fibres to the prostatic plexus which innervate penile erectile tissue.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 38
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:
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 39
Incorrect
-
A patient with this condition has extracellular fluid volume expansion:
Your Answer:
Correct Answer: Nephrotic syndrome
Explanation:Nephrotic syndrome is a syndrome comprising of signs of nephrosis, including proteinuria, hypoalbuminemia, and oedema. It is a component of glomerulonephritis, in which different degrees of proteinuria occur. Essentially, loss of protein through the kidneys leads to low protein levels in the blood , which causes water to be drawn into soft tissues (oedema). Severe hypoalbuminemia can also cause a variety of secondary problems, such as water in the abdominal cavity (ascites), around the heart or lung (pericardial effusion, pleural effusion), high cholesterol, loss of molecules regulating coagulation (hence increased risk of thrombosis). The most common sign is excess fluid in the body due to the serum hypoalbuminemia. Lower serum oncotic pressure causes fluid to accumulate in the interstitial tissues. Sodium and water retention aggravates the oedema.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 40
Incorrect
-
What is expected from complete transection of the inferior gluteal nerve when it emerges from the greater sciatic foramen?
Your Answer:
Correct Answer: Extension of the thigh would be the action most affected
Explanation:As the inferior gluteal nerve emerges from the greater sciatic foramen below the piriformis muscle, it divides into branches and enters the gluteus maximus muscle which extends the femur and bends the thigh in line with the body.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 41
Incorrect
-
Which of the following chemotherapy regimens is most likely to be used in colorectal cancer?
Your Answer:
Correct Answer: FOLFOX
Explanation:Chemotherapy regimens are often identified by acronyms, identifying the agents used in the drug combination. However, the letters used are not consistent across regimens. FOLFOX is a chemotherapy regimen used for the treatment of colorectal cancer, made up of the following drugs: • FOL: fluorouracil (5-fluorouracil or 5-FU) • F: folinic acid (leucovorin) • OX: oxaliplatin (Eloxatin®).
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 42
Incorrect
-
A 70-year-old male who has smoked since his teens complains of progressive shortness of breath and a persistent cough. Which of the following abnormalities is most likely to be present in his pulmonary function tests?
Your Answer:
Correct Answer: Increased residual volume
Explanation:Chronic obstructive pulmonary disease (COPD) is a type of obstructive lung disease characterized by long-term poor airflow. The main symptoms include shortness of breath and cough with sputum production. The best diagnostic test for evaluating patients with suspected chronic obstructive pulmonary disease (COPD) is lung function measured with spirometry. Key spirometrical measures may be obtained with a portable office spirometer and should include forced vital capacity (FVC) and the normal forced expiratory volume in the first second of expiration (FEV1). The ratio of FEV1 to forced vital capacity (FEV1/FVC) normally exceeds 0.75. Patients with COPD typically present with obstructive airflow. Complete pulmonary function testing may show increased total lung capacity, functional residual capacity and residual volume. A substantial loss of lung surface area available for effective oxygen exchange causes diminished carbon monoxide diffusion in the lung (DLco) in patients with emphysema. Tobacco smoking is the most common cause of COPD, with factors such as air pollution and genetics playing a smaller role.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 43
Incorrect
-
A 35 year old IV drug abuser arrives at the clinic with localized spinal pain. It is worse on movement and has been occurring for the last 2 months. The pain is refractory to analgesic treatment and is felt excruciatingly at rest too. He has no history of tuberculosis. Which of the following is the most likely diagnosis?
Your Answer:
Correct Answer: Osteomyelitis
Explanation:Complications of intravenous drug abuse, such as subcutaneous abscess, joint infections, osteomyelitis, overdose, hepatitis, and infective endocarditis, account for an increasing number of admissions in accident and emergency departments throughout the UK. The organisms that usually cause chronic osteomyelitis in intravenous drug users are Gram‐negative rods such as Pseudomonas aeruginosa and Gram‐positive cocci such as staphylococci. Early treatment is essential to prevent progressive bone destruction. TB tends to affect the thoracic spine and in other causes of osteomyelitis the lumbar spine is affected.
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This question is part of the following fields:
- Generic Surgical Topics
- Orthopaedics
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Question 44
Incorrect
-
A 55 year old man undergoes a live donor related renal transplant. He has noticed that over the past few years following the transplant, his renal function has progressively deteriorated. What is the most likely underlying explanation?
Your Answer:
Correct Answer: Type IV hypersensitivity reaction
Explanation:Transplantation is a process by which cells, tissues, or organs (a graft) from the donor are transplanted into a host (or recipient). The immune system’s ability to recognize and respond to foreign antigens bring challenges to transplantation.
Type IV hypersensitivity is characterized by cell-mediated response rather than antibodies as in other types of hypersensitivity reactions. Specifically, the T lymphocytes are involved in the development of the sensitivity, hence called cell-mediated hypersensitivity.
After exposure to antigens, through a series of biochemical events, the T-cells will be activated. By releasing some chemicals, the T-cells activate other white blood cells to mount an immune response.
Rejection of transplant occurs months to years later. In chronic rejection, there is intimal fibrosis with vascular thickening, leading to ischemic changes. Mononuclear infiltrates with prominent plasma cells are present. -
This question is part of the following fields:
- Generic Surgical Topics
- Organ Transplantation
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Question 45
Incorrect
-
A 20-year-old woman is admitted with right upper quadrant pain. On examination, there is tenderness in the right upper quadrant region. Imaging shows signs of acute cholecystitis due to gallstones. The common bile duct appears normal and liver function tests are normal as well. What should be the most appropriate course of action?
Your Answer:
Correct Answer: Laparoscopic cholecystectomy during the next 24–48 hours
Explanation:In most cases, the treatment of choice for acute cholecystitis is cholecystectomy performed early in the illness. The procedure can be carried out laparoscopically even when acute inflammation is present. Delayed surgery particularly around five to seven days after presentation is much more technically challenging and is often best deferred.
Up to 24% of women and 12% of men may have gallstones. Of these, up to 30% may develop local infection and cholecystitis. The classical symptom of cholecystitis is colicky right upper quadrant pain that occurs postprandially. Others include swinging pyrexia, and general feeling of being unwell. They are usually worst following a fatty meal when cholecystokinin levels are highest and gallbladder contraction is maximal.
Murphy’s sign is positive on examination. The standard diagnostic work-up consists of abdominal ultrasound and liver function tests. For management, cholecystectomy should ideally be done within 48 hours of presentation. In patients unfit for surgery, percutaneous drainage may be considered.
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This question is part of the following fields:
- Generic Surgical Topics
- Hepatobiliary And Pancreatic Surgery
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Question 46
Incorrect
-
Which is the site of action of the drug omeprazole?
Your Answer:
Correct Answer: H+/K+ ATPase
Explanation:H+/K+-ATPase or ‘proton pump’ located in the canalicular membrane plays a major role in acid secretion. The ATPase here is magnesium-dependent. Omeprazole is a proton pump inhibitor and blocks H+/K+- ATPase.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 47
Incorrect
-
A 26-year-old male falls and hits his head against a wall. There is a brief loss of consciousness. When assessed in accident and emergency he is alert and orientated with a GCS of 15. Imaging shows no fracture of the skull. What is his risk of having an intracranial haematoma that requires removal?
Your Answer:
Correct Answer: 1 in 6000
Explanation:Risk of haematoma (requiring removal) in adults attending accident and emergency units following head injury.
Risk Factor Risk of haematoma
Oriented, no skull fracture 1 in 5983
Not oriented, no skull fracture 1 in 121
Skull fracture, Orientated 1 in 32
Skull fracture, Not orientated 1 in 4 -
This question is part of the following fields:
- Generic Surgical Topics
- Surgical Disorders Of The Brain
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Question 48
Incorrect
-
A 41 year old paediatrician presents with right upper quadrant pain and a sensation of abdominal fullness. A 6.7 cm hyperechoic lesion in the right lobe of the liver is detected when an ultrasound scan is done. Tests show that the serum AFP is normal. What is the most likely underlying lesion?
Your Answer:
Correct Answer: Haemangioma
Explanation:A cavernous liver haemangioma or hepatic haemangioma is a benign tumour of the liver composed of hepatic endothelial cells. It is the most common liver tumour, and is usually asymptomatic and diagnosed incidentally on radiological imaging. Liver haemangiomas are thought to be congenital in origin. Several subtypes exist, including the giant hepatic haemangioma, which can cause significant complications. This large, atypical haemangioma of the liver may present with abdominal pain or fullness due to haemorrhage, thrombosis or mass effect. It may also lead to left ventricular volume overload and heart failure due to the increase in cardiac output which it causes. Further complications are Kasabach-Merritt syndrome, a form of consumptive coagulopathy due to thrombocytopaenia, and rupture.
As one of the benign neoplasms, the AFP level of hepatic cavernous haemangioma patients is not usually outside the normal range.
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This question is part of the following fields:
- Generic Surgical Topics
- Hepatobiliary And Pancreatic Surgery
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Question 49
Incorrect
-
The chest X-ray of a 72 year old patient reveals the presence of a round lesion containing an air-fluid level in the left lung. These findings are most probably suggestive of:
Your Answer:
Correct Answer: Lung abscess
Explanation:Lung abscesses are collections of pus within the lung that arise most commonly as a complication of aspiration pneumonia caused by oral anaerobes. Older patients are more at risk due to poor oral hygiene, gingivitis an inability to handle their oral secretions due to other diseases. Chest X-ray most commonly reveals the appearance of an irregularly shaped cavity with an air-fluid level.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 50
Incorrect
-
A 33 year old woman presents with a complaint of dysphagia. She has a ten year history of treatment refractory anaemia secondary to menorrhagia. Which of the following is the most likely underlying cause?
Your Answer:
Correct Answer: Plummer Vinson syndrome
Explanation:Iron deficiency anaemia (IDA) is the most common form of anaemia worldwide and can be due to inadequate intake, decreased absorption (e.g., atrophic gastritis, inflammatory bowel disease), increased demand (e.g., during pregnancy), or increased loss (e.g., gastrointestinal bleeding, menorrhagia) of iron. Prolonged deficiency depletes the iron stores in the body, resulting in decreased erythropoiesis and anaemia.
Symptoms are nonspecific and include fatigue, pallor, lethargy, hair loss, brittle nails, and pica. Diagnostic lab values include low haemoglobin, microcytic, hypochromic red blood cells on peripheral smear, and low ferritin and iron levels. Once diagnosed, the underlying cause should be determined. Patients at risk for underlying gastrointestinal malignancy should also undergo a colonoscopy.
Iron deficiency anaemia is treated with oral (most common) or parenteral iron supplementation. Severe anaemia or those with concomitant cardiac conditions may also require blood transfusions. The underlying cause of IDA should also be corrected. IDA may manifest as Plummer-Vinson syndrome (PVS): triad of postcricoid dysphagia, upper oesophageal webs, and iron deficiency anaemia -
This question is part of the following fields:
- Generic Surgical Topics
- Upper Gastrointestinal Surgery
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Question 51
Incorrect
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A 65 year old man is brought to the emergency department after he collapsed at the bus station. Clinical examination is significant for a ruptured abdominal aortic aneurysm. On arrival he is hypotensive and moribund. Which of the following is most likely to be his ASA?
Your Answer:
Correct Answer: 5
Explanation:ASA-V: A moribund patient who is not expected to survive without the operation. Examples include (but not limited to): ruptured abdominal/thoracic aneurysm, massive trauma, intracranial bleed with mass effect, ischemic bowel in the face of significant cardiac pathology or multiple organ/system dysfunction
ASA Grading
1 – No organic physiological, biochemical or psychiatric disturbance. The surgical pathology is localised and has not invoked systemic disturbance
2 – Mild or moderate systemic disruption caused either by the surgical disease process or though underlying pre-existing disease
3 – Severe systemic disruption caused either by the surgical pathology or pre-existing disease
4 – Patient has severe systemic disease that is a constant threat to life
5 – A patient who is moribund and will not survive without surgery -
This question is part of the following fields:
- Peri-operative Care
- Principles Of Surgery-in-General
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Question 52
Incorrect
-
A 43 year old female with thyrotoxicosis is referred to the endocrinology clinic because she was poorly controlled on carbimazole and has received orbital radiotherapy for severe proptosis. She had improved clinically but she relapsed on stopping her carbimazole. What is the best course of action?
Your Answer:
Correct Answer: Total thyroidectomy
Explanation:Due to this patient having a relapse after using carbimazole following orbital radiotherapy for severe proptosis., total thyroidectomy is the treatment of choice.
Thyroidectomy is the definitive surgical management for Graves thyrotoxicosis and usually requires a short course of pre-treatment with thionamides or inorganic iodine to achieve euthyroid state; this reduces operative complications and thyroid vascularity. Although subtotal thyroidectomy was once practiced, most surgeons now recommend complete thyroidectomy to minimize chances of relapse.Radioactive iodine (I-131) is widely used to treat the thyrotoxicosis of Graves’ disease, but, despite its demonstrable efficacy and safety, there have long been concerns about its possible adverse effect on thyroid eye disease. A study showed that after radioiodine treatment 15% of patients developed new or worsened ophthalmopathy, whereas this occurred in only 3% of patients treated with methimazole and in none treated with radioiodine plus prednisone. In the radioiodine group 24% of those with pre-existing ophthalmopathy suffered an exacerbation, whereas only 8% of patients without eye disease at baseline developed it.
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This question is part of the following fields:
- Breast And Endocrine Surgery
- Generic Surgical Topics
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Question 53
Incorrect
-
If the blood flow is constant, oxygen extraction by tissues will show the greatest decrease due to which of the following interventions?
Your Answer:
Correct Answer: Tissue cooling
Explanation:With a constant blood flow to a given tissue bed, there will be an increase in oxygen extraction by the tissue with the following; an increase in tissue metabolism and oxygen requirements: warming (or fever), exercise, catecholamines and thyroxine. With cooling, the demand for oxygen decreases, leading to decreased oxygen extraction.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 54
Incorrect
-
A 42-year-old female has undergone a total thyroidectomy for multinodular goitre. You are called to see her because of respiratory distress. On examination, she has marked stridor, her wound seems healthy but there is a swelling within the operative site. What is the most likely explanation for this problem?
Your Answer:
Correct Answer: Contained haematoma
Explanation:Airway obstruction: In the first 24 hours it is most likely from a compressive hematoma. After 24 hours consider laryngeal dysfunction secondary to hypocalcaemia.
In this patient, the most likely cause is a haematoma.
Definitive therapy is opening the surgical incision to evacuate the hematoma. Re-intubation may be lifesaving for persistent airway obstruction. Consider awake fibreoptic intubation. -
This question is part of the following fields:
- Peri-operative Care
- Principles Of Surgery-in-General
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Question 55
Incorrect
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A 66 year old woman undergoes an emergency hip hemiarthroplasty. The procedure is complicated by a fracture of the femoral shaft following the insertion of the prosthesis. She is seen postoperatively to be unsteady on her feet and she is depressed. She remains bedbound for 2 weeks and is slow to progress despite adequate physiotherapy. Which of the following physiological changes is not seen after prolonged immobilization?
Your Answer:
Correct Answer: Bradycardia
Explanation:Answer: Bradycardia
Prolonged bed rest and immobilization inevitably lead to complications. Such complications are much easier to prevent than to treat. Musculoskeletal complications include loss of muscle strength and endurance, contractures and soft tissue changes, disuse osteoporosis, and degenerative joint disease. Cardiovascular complications include an increased heart rate (tachycardia), decreased cardiac reserve, orthostatic hypotension, and venous thromboembolism.
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This question is part of the following fields:
- Peri-operative Care
- Principles Of Surgery-in-General
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Question 56
Incorrect
-
What principal artery that supplies the meninges is susceptible to rupture following trauma to the side of the head over the temporal region:
Your Answer:
Correct Answer: Middle meningeal artery
Explanation:The middle meningeal artery normally arises from the first or mandibular segment of the maxillary artery. The artery runs in a groove on the inside of the cranium, this can clearly be seen on a lateral skull X-ray. An injured middle meningeal artery is the most common cause of an epidural hematoma.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 57
Incorrect
-
A 20-year old involved in a brawl was stabbed in the anterior chest in a structure that is in close proximity to where the first rib articulates with the sternum. What is the structure that was most likely injured?
Your Answer:
Correct Answer: Sternoclavicular joint
Explanation:The first rib articulates with the sternum right below the sternoclavicular joint.
The sternal angle articulates with the costal cartilage of the second rib.
The nipple is found between the fourth and the fifth ribs, in the fourth intercostal space.
The xiphoid process is located right below the point of articulation of the costal cartilage of rib 7 with the sternum.
The root of the lung is the part of the lung where neurovascular structures enter and leave the lung.
Acromioclavicular joint is the point of articulation between the acromion process and the clavicle, near the shoulder. -
This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 58
Incorrect
-
A 45-year-old male who has a long term history of alcohol misuse is admitted with a history of an attack of vomiting after an episode of binge drinking. After vomiting, he developed sudden onset left-sided chest pain, which is pleuritic in nature. On examination, he is profoundly septic and drowsy with severe epigastric tenderness and left sided chest pain. What is the most likely cause?
Your Answer:
Correct Answer: Boerhaaves syndrome
Explanation:Boerhaave’s syndrome is also known as spontaneous oesophageal rupture or effort rupture of the oesophagus. Although vomiting is thought to be the most common cause, other causes include weightlifting, defecation, epileptic seizures, abdominal trauma, compressed air injury, and childbirth, all of which can increase the pressure in the oesophagus and cause a barogenic oesophageal rupture.
It usually follows excessive alcohol intake or overeating, or both, because either of these can induce vomiting.
The rupture is transmural.
A provider should suspect Boerhaave’s syndrome when a patient presents with retrosternal chest pain with or without subcutaneous emphysema when associated with heavy alcohol intake and severe or repeated vomiting. Up to one-third of patients do not present with these symptoms. The actual clinical presentation of Boerhaave syndrome will depend on the level of the perforation, the degree of leakage, and the time since the onset of the injury. Typically, the patient will present with pain at the site of perforation, usually in the neck, chest, epigastric region, or upper abdomen. Cervical perforations can present with neck pain, dysphagia, or dysphonia; intra-thoracic perforations with chest pain; and intra-abdominal perforations with epigastric pain radiating to the shoulder or back. History of increased intra-oesophageal pressure for any reason followed by chest pain should prompt consideration of this condition. Physical exam findings may include abnormal vitals (tachycardia, tachypnoea, fever), decreased breath sounds on the perforated side, mediastinal emphysema, and Hamman’s sign (mediastinal “crackling” accompanying every heartbeat) in left lateral decubitus position. -
This question is part of the following fields:
- Emergency Medicine And Management Of Trauma
- Principles Of Surgery-in-General
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Question 59
Incorrect
-
upon stroking the plantar surface of a patient's foot, extension of toes was noted. This is likely to be accompanied with:
Your Answer:
Correct Answer: Spasticity
Explanation:An upper motor neuron lesion affects the neural pathway above the anterior horn cell or motor nuclei of the cranial nerves, whereas a lower motor neurone lesion affects nerve fibres travelling from the anterior horn of the spinal cord to the relevant muscles. An upper motor neurone lesions results in the following:
– Spasticity in the extensor muscles (lower limbs) or flexor muscles (upper limbs).
– ‘clasp-knife’ response where initial resistance to movement is followed by relaxation
– Weakness in the flexors (lower limbs) or extensors (upper limbs) with no muscle wasting
– Brisk tendon jerk reflexes
– Positive Babinski sign (on stimulation of the sole of the foot, the big toe is raised rather than curled downwards) -
This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 60
Incorrect
-
A middle aged man who is reported to have a penicillin allergy is given a dose of intravenous co-amoxiclav before undergoing an inguinal hernia repair. His vital signs a few minutes after are: pulse 131bpm and blood pressure 61/42mmHg. Which of the following is the first line treatment?
Your Answer:
Correct Answer: Adrenaline 1:1000 IM
Explanation:Answer: Adrenaline 1:1000 IM
Early treatment with intramuscular adrenaline is the treatment of choice for patients having an anaphylactic reaction. IM Injection:
Adults: The usual dose is 500 micrograms (0.5ml of adrenaline 1/1000). If necessary, this dose may be repeated several times at 5-minute intervals according to blood pressure, pulse and respiratory function.
Additional measures
Beta2-agonists for bronchospasm: administer salbutamol or terbutaline by aerosol or nebuliser.
Antihistamines: administer both H1and H2receptor blockers slowly intravenously:
promethazine 0.5-1 mg/kg
and
ranitidine 1 mg/kg or famotidine 0.4 mg/kg or cimetidine 4 mg/kg
Corticosteroids: administer intravenously: hydrocortisone 2-6 mg/kg or dexamethasone 0.1-0.4 mg/kg
Nebulised adrenaline (5 mL of 1:1000) may be tried in laryngeal oedema and often will ease upper airways obstruction. However, do not delay intubation if upper airways obstruction is progressive.Anaphylaxis is an acute, potentially fatal, multiorgan system reaction caused by the release of chemical mediators from mast cells and basophils. The classic form involves prior sensitization to an allergen with later reexposure, producing symptoms via an immunologic mechanism.
Anaphylaxis most commonly affects the cutaneous, respiratory, cardiovascular, and gastrointestinal systems. The skin or mucous membranes are involved in 80-90% of cases. A majority of adult patients have some combination of urticaria, erythema, pruritus, or angioedema. However, for poorly understood reasons, children may present more commonly with respiratory symptoms followed by cutaneous symptoms. It is also important to note that some of the most severe cases of anaphylaxis present in the absence of skin findings.
Initially, patients often experience pruritus and flushing. Other symptoms can evolve rapidly, such as the following:
Dermatologic/ocular: Flushing, urticaria, angioedema, cutaneous and/or conjunctival injection or pruritus, warmth, and swelling
Respiratory: Nasal congestion, coryza, rhinorrhoea, sneezing, throat tightness, wheezing, shortness of breath, cough, hoarseness, dyspnoea
Cardiovascular: Dizziness, weakness, syncope, chest pain, palpitations
Gastrointestinal: Dysphagia, nausea, vomiting, diarrhoea, bloating, cramps
Neurologic: Headache, dizziness, blurred vision, and seizure (very rare and often associated with hypotension)
Other: Metallic taste, feeling of impending doom
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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 61
Incorrect
-
A 43 year old detective undergoes a vasectomy at the local hospital. He is reviewed at the request of his general practitioner. On examination, he has a small rounded nodule adjacent to the vas. Which of the following is the most likely underlying diagnosis?
Your Answer:
Correct Answer: Sperm granuloma
Explanation:A sperm granuloma is a lump of extravasated sperm that appears along the vasa deferentia or epididymides in vasectomized men.
Sperm granulomas are rounded or irregular in shape, one millimetre to one centimetre or more, with a central mass of degenerating sperm surrounded by tissue containing blood vessels and immune system cells. Sperm granulomas can be either asymptomatic or symptomatic (i.e., either not painful or painful, respectively). If it is painful, it can be treated using over-the-counter anti-inflammatory /pain medication. If it causes unbearable discomfort, it may need to be surgically removed. However, they generally heal by themselves. Statistics suggest that between 15-40% of men may develop a granuloma post-vasectomy. -
This question is part of the following fields:
- Generic Surgical Topics
- Urology
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Question 62
Incorrect
-
A 25-year-old woman complains of generalised swelling and particularly puffiness around the eyes which is worst in the morning. Laboratory studies showed: Blood urea nitrogen (BUN) = 30 mg/dl, Creatinine = 2. 8 mg/dl, Albumin = 2. 0 mg/dl, Alanine transaminase (ALT) = 25 U/l, Bilirubin = 1 mg/dl. Urine analysis shows 3+ albumin and no cells.Which of the following is the most likely diagnosis?
Your Answer:
Correct Answer: Nephrotic syndrome
Explanation:Nephrotic syndrome is a disorder in which the glomeruli have been damaged, characterized by:
– Proteinuria (>3.5 g per 1.73 m2 body surface area per day, or > 40 mg per square meter body surface area per hour in children)
– Hypoalbuminemia (< 2,5 g/dl)
– Hyperlipidaemia, and oedema (generalized anasarca). -
This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 63
Incorrect
-
Question 64
Incorrect
-
A 26-year-old female patient had the following blood report: RBC count = 4. 0 × 106/μl, haematocrit = 27% and haemoglobin = 11 g/dl, mean corpuscular volume (MCV) = 80–100 fl, mean corpuscular haemoglobin concentration (MCHC) = 31–37 g/dl. Which of the following is correct regarding this patient’s erythrocytes:
Your Answer:
Correct Answer: Normal MCV
Explanation:MCV is the mean corpuscular volume and it is calculated from the haematocrit and the RBC count. It is normally 90 fl. Mean corpuscular haemoglobin concentration (MCHC) [g/dl] = haemoglobin [g/dl]/haematocrit = 11/0.27 = 41 g/dl and is higher than normal range (32 to 36 g/dL).
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 65
Incorrect
-
A 55 year-old construction worker is diagnosed with malignant melanoma. He was exposed to what substance which increased his risk in developing mesothelioma?
Your Answer:
Correct Answer: Asbestos
Explanation:Mesothelioma is a rare, aggressive form of cancer that develops in the lining of the lungs, abdomen or heart. It is linked to inhalation of asbestos commonly used in ship building and the insulation industry. It has no known cure and has a very poor prognosis.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 66
Incorrect
-
An abdominal aortogram shows occlusion of the inferior mesenteric artery. Which of the following segments of bowel is most likely to have preserved arterial supply?
Your Answer:
Correct Answer: Caecum
Explanation:The inferior mesenteric artery supplies blood to the end of the transverse colon and all distal structures in the gastrointestinal tract i.e. splenic flexure, descending colon, sigmoid colon and rectum would all be deprived of blood if it were occluded. The caecum receives blood from the superior mesenteric artery so it would not be affected.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 67
Incorrect
-
A 55-year-old male presents with an ulcerated mass at the anal verge. A biopsy is taken and the histology demonstrates as squamous cell carcinoma. Which of the following viral infection is most likely to have contributed to the development of the condition?
Your Answer:
Correct Answer: Human papillomavirus 16
Explanation:Anal squamous cell cancer is believed to be directly linked to the presence of a complex inflammatory process most commonly caused by HPV infection (particularly with serotypes 16 and 18) in the histologically unique area of the anal squamocolumnar epithelium. In one Scandinavian study, serotype 16 HPV DNA was detected in 73% of anal cancer specimens, and serotype 16, 18, or both were detected in 84% of specimens. In contrast, no rectal cancer specimens contained HPV DNA.
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This question is part of the following fields:
- Clinical Microbiology
- Principles Of Surgery-in-General
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Question 68
Incorrect
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A 4-year-old boy develops a persistent fever following an open appendicectomy for gangrenous appendicitis. On examination, he has erythema of the wound and some abdominal distension. What is the most appropriate course of action?
Your Answer:
Correct Answer: Arrange an abdominal ultrasound scan
Explanation:Post-operative fever is very common.
It is known to occur after all types of surgical procedures, irrespective of the type of anaesthesia.
Postoperative fever can occur after minor surgical procedures but is rare and depends on the type of procedure. Overall, both abdominal and chest procedures result in the highest incidence of postoperative fever.In this case:
Acute Fever
Fever occurs in the first week (1 to 7 POD)
POD 7 (5 to 10): Wound infection: Risk increases if the patient is immunocompromised (e.g., diabetic), abdominal wound, duration of surgery greater than 2 hours or contamination during surgery. Signs include erythema, warmth, tenderness, discharge.
Rule out abscess or collections by physical exam plus ultrasound if needed. If an abscess is present, drainage and antibiotics are needed. Prevention is by careful surgical technique and prophylactic antibiotics (e.g., intravenous cefazolin at the time of induction of anaesthesia as well as postoperatively if needed)Other causes of Postoperative fever:
An Immediate Fever
Fever occurs immediately after surgery or within hours on postoperative days (POD) 0 or 1.
– Malignant hyperthermia: high-grade fever (greater than 40 C), occurs shortly after inhalational anaesthetics or muscle relaxant (e.g., halothane or succinylcholine), may have a family history of death after anaesthesia. Laboratory studies will reveal with metabolic acidosis and hypercalcemia. If not readily recognized, it can cause cardiac arrest. The treatment is intravenous dantrolene, 100% oxygen, correction of acidosis, cooling blankets, and watching for myoglobinuria.
– Bacteraemia: High-grade fever (greater than 40 C) occurring 30 to 40 minutes after the beginning of the procedure (e.g., Urinary tract instrumentation in the presence of infected urine). Management includes blood cultures three times and starting empiric antibiotics.
– Gas gangrene of the wound: High-grade fever (greater than 40 C) occurring after gastrointestinal (GI) surgery due to contamination with Clostridium perfringens; severe wound pain; treat with surgical debridement and antibiotics.
– Febrile non-haemolytic transfusion reaction: Fevers, chills, and malaise 1 to 6 hours after surgery (without haemolysis). Management: Stop transfusion (rule out haemolytic transfusion reaction) and give antipyretics (avoid aspirin in the thrombocytopenic patient).B. Acute Fever
– Fever occurs in the first week (1 to 7 POD).
POD 1 to 3: atelectasis: After prolonged intubation, the presence of upper abdominal incision, inadequate postoperative pain control, lying supine. Should be prevented by incentive spirometry, semi-recumbent position, adequate pain control, early ambulation. Clinically may be asymptomatic or with increased work of breathing, respiratory alkalosis, chest x-ray with volume loss. Treatment includes spirometry, chest physiotherapy, semi-recumbent position (improves expansion of alveoli by preventing pressure from intra-abdominal organs on the diaphragm and hence improving functional residual capacity)
– POD 3: Unresolved atelectasis resulting in pneumonia (respiratory symptoms, Chest x-ray with infiltrate or consolidation, sputum culture, empiric antibiotics and modify according to culture result and sensitivity), or development of urinary tract infection (urine analysis and culture, treat with empiric antibiotics and modify according to culture result and sensitivity)
– POD 5: Thrombophlebitis (may be asymptomatic or symptomatic, diagnose with Doppler ultrasound of deep leg and pelvic veins and treat with heparin)
– POD 7: Pulmonary embolism (tachycardia, tachypnoea, pleuritic chest pain, ECG with right heart strain pattern (a low central venous pressure goes against diagnosis), arterial blood gas with hypoxemia and hypocapnia, confirm diagnosis with CT angiogram, and treat with heparin, if recurrent pulmonary embolism while anticoagulated with therapeutic INR, Inferior vena cava filter placement is the next stepC. Subacute Fever
Fever occurs between postoperative weeks 1 and 4.
– POD 10: Deep infection (pelvic or abdominal abscess and if abdominal abscess could be sub-hepatic or sub-phrenic). A digital rectal exam to rule out the pelvic abscess and CT scan to localize intra-abdominal abscess. Treatment includes re-exploration vs. radiological guided percutaneous drainage
Drugs: Diagnosis of exclusion includes rash and peripheral eosinophiliaD. Delayed Fever
Fever after more than 4 weeks.
Skin and soft tissue infections (SSTI)
Viral infections -
This question is part of the following fields:
- Principles Of Surgery-in-General
- Surgical Technique And Technology
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Question 69
Incorrect
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Which of the following conditions is likely to result in splenomegaly, hypochromic anaemia and hemochromatosis in a young male?
Your Answer:
Correct Answer: β-Thalassaemia
Explanation:Beta-thalassaemia is due to decreased production of β-polypeptide chains, with an autosomal inheritance pattern. Carrier patients (heterozygotes) are asymptomatic and have mild to moderate microcytic anaemia. This is known as thalassaemia minor. Homozygotes (β-thalassaemia major, or Cooley’s anaemia) develop severe anaemia and marrow hyperactivity. The disease presents at 1-2 years of age with severe anaemia and transfusional and absorptive iron overload. Patients also present with jaundice, leg ulcers, massive splenomegaly and cholelithiasis. The disease can also lead to splenic sequestration leading to faster destruction of transfused red blood cells. Increased marrow activity causes thickening of cranial bones. Involvement of long bones is also seen, which can cause pathological fractures and growth impairment. There is iron deposition in various organs, which can lead to heart failure or hepatic failure (leading to cirrhosis). Thalassaemias are suspected in presence of family history, or signs suggesting microcytic haemolytic anaemia. Further test and quantitative haemoglobin studies are useful. In beta-thalassaemia, there is an increase in serum bilirubin, iron and ferritin levels. There is severe anaemia, often with haemoglobin < 6 g/dl. There is an elevated red blood cell count, which are microcytic. Peripheral blood smear is diagnostic with nucleated erythroblasts, target cells, small pale red blood cells, and punctate basophilia.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 70
Incorrect
-
A 30-year-old female presents with a breast lump. She has previously undergone a breast augmentation with an implant. What is the imaging technique of choice?
Your Answer:
Correct Answer: Ultrasound
Explanation:Patients with breast implants present the radiologist with specific challenges, such as the identification and distinction of implant and breast tissue, diagnosis of implant defects and implant-related complications as well as diagnosis and follow-up of unrelated breast diseases such as mastitis or breast cancer.
Whereas mammography is the first-line method before surgery, ultrasound is the mainstay of post-procedural imaging, unless there is concern about rupture.
Although mammography and ultrasonography are the standard first steps in the diagnostic workup, magnetic resonance imaging (MRI) is the most useful imaging modality for the characterisation of breast implants because of its high spatial resolution and contrast between implants and soft tissues and absence of ionising radiation. -
This question is part of the following fields:
- Breast And Endocrine Surgery
- Generic Surgical Topics
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Question 71
Incorrect
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A correct statement about the RECTUM:
Your Answer:
Correct Answer: It is an important anastomotic site for the portal and caval (systemic) venous systems
Explanation:The rectum is part of the gastrointestinal tract that is continuous above with the sigmoid colon and below with the anal canal. It contains both longitudinal and circular smooth muscles. These are supplied by the enteric nervous system. It is about 12 cm long. It has no sacculations comparable with those of the colon. It has three permanent transverse folds called the valves of Houston. The peritoneum is related to the upper two thirds of the rectum only whereas the lower part is not covered by peritoneum. It is supplied by the superior rectal (hemorrhoidal) branch of the inferior mesenteric artery and the median sacral artery that is a direct branch from the abdominal aorta. It is drained by veins that begin as a plexus that surround the anus. These veins form anastomoses with the portal system (portocaval anastomoses).
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 72
Incorrect
-
The transmembrane proteins responsible for resting membrane potential of vascular smooth muscle cells was blocked by a drug. Which of the following transmembrane proteins were blocked by this drug?
Your Answer:
Correct Answer: K+ channels
Explanation:The resting membrane potential is due to selective permeability of the membrane to potassium ions. The Na/K pump is responsible for the generation of a gradient across the membrane and it is due to the inherent ability of the K channels to allow diffusion back into the nerve at rest which charges the cells. In reality, the resting membrane potential is more positive because of small contributions by Na+ channels, Cl− channels and non-selective cation channels.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 73
Incorrect
-
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:
Correct 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 74
Incorrect
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A 34-year-old woman has been suffering from headaches, fever, vomiting, and confusion for the last 5 days. A CT scan reveals an oedematous mass with ring enhancement in the left temporal region. It is biopsied, revealing glial cells, necrosis, neutrophils and lymphocytes. What is the most likely diagnosis?
Your Answer:
Correct Answer: Cerebral abscess
Explanation:A cerebral abscess can result from direct extension of cranial infections, penetrating head trauma, haematogenous spread, or for unknown causes. An abscess forms when an area of cerebral inflammation becomes necrotic and encapsulated by glial cells and fibroblasts. Oedema around the abscess can increase the intracranial pressure. Symptoms result from increased intracranial pressure and mass effects. It is most frequent in the third decade of life, and when it occurs in children, it is usually associated with congenital heart disease.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 75
Incorrect
-
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:
Correct 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 76
Incorrect
-
Below which level of the spinal cord will the inferior gluteal nerve be unaffected?
Your Answer:
Correct Answer: S3
Explanation:The inferior gluteal nerve arises from the dorsal divisions of the fifth lumbar and first and second sacral nerves. According to this fact any lesion at or below the S3 will not affect the inferior gluteal nerve.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 77
Incorrect
-
Laboratory findings in a patient with dark urine and yellowish skin revealed a prolonged prothrombin time. Which of the following is the most likely cause of this finding?
Your Answer:
Correct Answer: Liver damage
Explanation:Various conditions may prolong the prothrombin time (PT), including: warfarin use, vitamin K deficiency, liver disease, disseminated intravascular coagulopathy, hypofibrinogenemia, heparin infusion, massive blood transfusion and hypothermia. Liver disease causes prolonging of PT due to diminished synthesis of clotting factors. Dark urine colour and jaundice are indicators of the presence of a liver disease in this patient.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 78
Incorrect
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A 69 year old woman presents with chest pain. She has undergone esophagogastrectomy for carcinoma of the distal oesophagus. The next day, a brisk bubbling is noticed in the chest drain when the suction is applied. Which of the following would be the most likely cause of this finding?
Your Answer:
Correct Answer: Air leak from lung
Explanation:The possible causes of post-operative pneumothorax after thoracotomy and esophagectomy include lung parenchymal leak/injury, bronchopleural fistula, ruptured bullae and malpositioned chest drains. When suction is applied to the chest drainage system, active and persistent bubbling may be seen. Although an anastomotic leak may produce a small pneumothorax, a large volume air leak is more indicative of lung injury.
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This question is part of the following fields:
- Peri-operative Care
- Principles Of Surgery-in-General
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Question 79
Incorrect
-
After a severe asthma attack, a 26-year-old woman is left in a markedly hypoxic state. In which of the following organs are the arterial beds most likely to be vasoconstricted due to the hypoxia?
Your Answer:
Correct Answer: Lungs
Explanation:Hypoxic pulmonary vasoconstriction is a local response to hypoxia resulting primarily from constriction of small muscular pulmonary arteries in response to reduced alveolar oxygen tension. This unique response of pulmonary arterioles results in a local adjustment of perfusion to ventilation. This means that if a bronchiole is obstructed, the lack of oxygen causes contraction of the pulmonary vascular smooth muscle in the corresponding area, shunting blood away from the hypoxic region to better-ventilated regions. The purpose of hypoxic pulmonary vasoconstriction is to distribute blood flow regionally to increase the overall efficiency of gas exchange between air and blood.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 80
Incorrect
-
A young lady is stabbed in the chest when she was leaving a party and she develops a cardiac arrest in the A&E department. What is the best course of action?
Your Answer:
Correct Answer: Thoracotomy
Explanation:Answer: Thoracotomy
Cardiac arrest after penetrating chest trauma may be an indication for emergency thoracotomy. A successful outcome is possible if the patient has a cardiac tamponade and the definitive intervention is performed within 10 minutes of loss of cardiac output.
EMERGENCY “CLAM SHELL” THORACOTOMYIndication:
Penetrating chest/epigastric trauma associated with cardiac arrest (any rhythm).
Contraindications:
Definite loss of cardiac output for greater than 10 minutes.Any patient who has a cardiac output, including hypotensive patients.
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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 81
Incorrect
-
Infection to all of the following will lead to enlargement of the superficial inguinal lymph nodes, except for:
Your Answer:
Correct Answer: Ampulla of the rectum
Explanation:The superficial inguinal lymph nodes form a chain immediately below the inguinal ligament. They receive lymphatic supply from the skin of the penis, scrotum, perineum, buttock and abdominal wall below the level of the umbilicus.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 82
Incorrect
-
A generally healthy young man undergoes surgery for an acute abdomen and he is given suxamethonium. After the surgery, he is taken to the recovery room where he develops a tachycardia of 122 bpm and a temperature of 40.1ºC. He also has generalised muscular rigidity. What is his diagnosis?
Your Answer:
Correct Answer: Malignant hyperthermia
Explanation:Answer: Malignant hyperthermia
Malignant hyperthermia (MH) is a life-threatening clinical syndrome of hypermetabolism involving the skeletal muscle. It is triggered in susceptible individuals primarily by the volatile inhalational anaesthetic agents and the muscle relaxant succinylcholine, though other drugs have also been implicated as potential triggers. MH is not an allergy but an inherited disorder that is found both in humans and in swine.
In persons susceptible to MH, the ryanodine receptor in skeletal muscle is abnormal, and this abnormality interferes with regulation of calcium in the muscle. An abnormal ryanodine receptor that controls calcium release causes a build-up of calcium in skeletal muscle, resulting in a massive metabolic reaction.
This hypermetabolism causes increased carbon dioxide production, metabolic and respiratory acidosis, accelerated oxygen consumption, heat production, activation of the sympathetic nervous system, hyperkalaemia, disseminated intravascular coagulation (DIC), and multiple organ dysfunction and failure. Early clinical signs of MH include an increase in end-tidal carbon dioxide (even with increasing minute ventilation), tachycardia, muscle rigidity, tachypnoea, and hyperkalaemia. Later signs include fever, myoglobinuria, and multiple organ failure.
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This question is part of the following fields:
- Post-operative Management And Critical Care
- Principles Of Surgery-in-General
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Question 83
Incorrect
-
A 5 year old boy accidentally spills boiling water over his legs and is diagnosed with superficial partial thickness burns. Which of the following is least likely to occur?
Your Answer:
Correct Answer: Damage to sweat glands
Explanation:Superficial burns are confined in the depth of the epidermis, and all dermal appendages and nerve endings are intact. Superficial burns generally heal in 3 to 5 days with minimal intervention and do not leave significant scarring as they typically heal by re epithelialization. Therefore the sweat glands will be intact.
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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 84
Incorrect
-
A surgeon performing a laparoscopic repair of an inguinal hernia visualizes a loop of bowel protruding through the abdominal wall to form a direct inguinal hernia. When this is viewed from the side of the abdomen with a laparoscope, in which region would the hernial sac be?
Your Answer:
Correct Answer: Medial inguinal fossa
Explanation:In a direct inguinal hernia, visceral contents exit the abdomen through a weak point in the fascia in the medial inguinal fossa i.e. the area between the medial and lateral umbilical folds. Such a hernia doesn’t pass through the deep inguinal ring or the lateral inguinal fossa. Note that direct hernias can go through the superficial inguinal ring, although rarely. The supravesical fossa, between the median and medial umbilical folds, is formed by a peritoneal reflection from the anterior abdominal wall onto the bladder and the retrovesical fossa is the region behind the urinary bladder.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 85
Incorrect
-
After surgery, a patient developed a stitch granuloma . Which leukocyte in the peripheral blood will become an activated macrophage in this granuloma?
Your Answer:
Correct Answer: Monocyte
Explanation:Monocytes are leukocytes that protect the body against infections and move to the site of infection within 8-12 hours to deal with it. They are produced in the bone marrow and shortly after being produced are released into the blood stream where they circulate until an infection is detected. When called upon they leave the circulation and transform into macrophages within the tissue fluid and thus gain the capability to phagocytose the offending substance. Monocyte count is part of a complete blood picture. Monocytosis is the state of excess monocytes in the peripheral blood and may be indicative of various disease states. Examples of processes that can increase a monocyte count include: • chronic inflammation • stress response • hyperadrenocorticism • immune-mediated disease • pyogranulomatous disease • necrosis • red cell regeneration.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 86
Incorrect
-
A 34-year-old man with poorly controlled Crohn's disease is nutritionally compromised. A decision is made to start TPN.Which of the following routes should be the most appropriate for its administration?
Your Answer:
Correct Answer: Internal jugular vein via a central venous catheter
Explanation:Since TPN solutions irritate the veins, they are best administered via a central line. The femoral route has a higher incidence of line-associated sepsis and is, thus, best avoided in this setting.
The National Institute for Health and Care Excellence (NICE) has laid down guidelines for identifying patients as malnourished or at risk of malnourishment, in order to start oral, enteral, or parenteral nutrition support, alone or in combination.
Following patients are identified as malnourished:
1. BMI <18.5 kg/m2
2. Unintentional weight loss of >10% within the last 3–6 months
3. BMI <20 kg/m2 and unintentional weight loss of >5% within the last 3–6 monthsFollowing patients are at risk of malnutrition:
1. Eaten nothing or little for >5 days and/or likely to eat little or nothing for the next 5 days or longer
2. Poor absorptive capacity and/or
3. High nutrient loss and/or
4. High metabolic rateConsidering the method of parenteral nutrition:
1. For feeding <14 days, consider feeding via a peripheral venous catheter
2. For feeding >30 days, use a tunnelled subclavian line,
continuous administration in severely unwell patients
3. If feed needed for >2 weeks, consider changing from continuous to cyclical feeding
4. Do not give >50% of daily regime to unwell patients in the first 24–48 hours
5. In surgical patients, if malnourished with unsafe swallow or a non-functional GI tract or perforation, consider perioperative parenteral feeding. -
This question is part of the following fields:
- Post-operative Management And Critical Care
- Principles Of Surgery-in-General
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Question 87
Incorrect
-
A 30 year old woman complains of left sided abdominal pain that radiates to her groin. Detailed workup reveals microscopic haematuria on dipstick. Which of the following would be the most likely cause?
Your Answer:
Correct Answer: Ureteric calculus
Explanation:The classic presentation of a ureteric colic is acute, colicky flank pain radiating to the groin. The pain is often described as the worst pain the patient has ever had experienced. Ureteric colic occurs as a result of obstruction of the urinary tract by calculi at the narrowest anatomical areas of the ureter: the pelviureteric junction (PUJ), near the pelvic brim at the crossing of the iliac vessels and the narrowest area, the vesicoureteric junction (VUJ). Location of pain may be related but is not an accurate prediction of the position of the stone within the urinary tract. As the stone approaches the vesicoureteric junction, symptoms of bladder irritability may occur.
Calcium stones (calcium oxalate, calcium phosphate and mixed calcium oxalate and phosphate) are the most common type of stone, while up to 20% of cases present with uric acid, cystine and struvite stones.
Physical examination typically shows a patient who is often writhing in distress and pacing about trying to find a comfortable position; this is, in contrast to a patient with peritoneal irritation who remains motionless to minimise discomfort. Tenderness of the costovertebral angle or lower quadrant may be present. Gross or microscopic haematuria occurs in approximately 90% of patients; however, the absence of haematuria does not preclude the presence of stones.
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This question is part of the following fields:
- Generic Surgical Topics
- Urology
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Question 88
Incorrect
-
A 55 year old man develops increasing lower abdominal pain, fever and atrial fibrillation on the 5th day following a high anterior resection for cancer of the rectosigmoid junction. These symptoms developed over the last 12 hours. Which of the following investigations would be the most useful in this case?
Your Answer:
Correct Answer: Abdominal CT scan
Explanation:Atrial fibrillation occurring after a colonic resection most likely represents an anastomotic leak. The best modality to visualize this would be an abdominal CT scan. Any bowel anastomosis can leak, sometimes as a result of technical failings and at other times, its patient factors such as background disease that contribute. As a general rule, rectal resections carry the highest risk of anastomotic leak. Indeed, low anterior resections are routinely defunctioned with loop ileostomy to mitigate the clinically effects of a leak. Left sided colonic resections carry a higher risk of anastomotic leak than right sided resections. The reason for this is that an ileocolic anastomosis (or indeed any small bowel anastomosis) has a very low risk of leak (provided the small bowel is otherwise healthy). Where a leak is suspected (new AF and raised inflammatory markers 5 days post resection), the correct course of action is to arrange cross sectional imaging with a CT scan. If a leak is confirmed and the patient is septic, then they should go back to theatre, the anastomosis taken down and the bowel ends exteriorized.
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This question is part of the following fields:
- Post-operative Management And Critical Care
- Principles Of Surgery-in-General
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Question 89
Incorrect
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Which of these structures does NOT pass posterior to the medial malleolus?
Your Answer:
Correct Answer: Saphenous vein
Explanation:The saphenous vein passes anterior to the medial malleolus. The structures passing posterior, from nearest to furthest include: tibial, posterior tendon, flexor digitorum longus tendon, posterior tibial artery, posterior tibial vein, posterior tibial nerve and the flexor hallucis longus tendon.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 90
Incorrect
-
Selective destruction of which of the following cells will affect antibody synthesis?
Your Answer:
Correct Answer: Plasma cells
Explanation:Plasma cell are memory cells. After the antigen Is engulfed by the B cells it is presented to the CD4+ helper cells via the MCH II receptor and this leads to their activation which in turn stimulates the B cells to form antibodies against that specific antigen. Some B cells differentiate into plasma cells also called memory cells that get activated after subsequent infection.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 91
Incorrect
-
A child defecates a few minutes after being fed by the mother. This is most likely due to:
Your Answer:
Correct Answer: Gastrocolic reflex
Explanation:The gastrocolic reflex is a physiological reflex that involves increase in colonic motility in response to stretch in the stomach and by-products of digestion in the small intestine. It is shown to be uneven in its distribution throughout the colon, with the sigmoid colon affected more than the right side of the colon in terms of a phasic response. Various neuropeptides have been proposed as mediators of this reflex, such as serotonin, neurotensin, cholecystokinin and gastrin.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 92
Incorrect
-
Injury to this nerve will result to the loss of general sensory innervation of the lacrimal gland:
Your Answer:
Correct Answer: Ophthalmic nerve
Explanation:The lacrimal glands are paired, almond-shaped exocrine glands, that secrete the aqueous layer of the tear film. The lacrimal nerve, derived from the ophthalmic nerve, supplies the sensory component of the lacrimal gland. The greater petrosal nerve, derived from the facial nerve, supplies the parasympathetic autonomic component of the lacrimal gland.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 93
Incorrect
-
A 48-year-old female with haematemesis is admitted to accident and emergency in hypovolaemic shock. She undergoes resuscitation including administration of packed red cells. The blood transfusion centre will not release certain blood products unless a ‘massive bleeding’ protocol is initiated. Which of the following is not a definition of massive bleeding?
Your Answer:
Correct Answer: Ongoing blood loss of 100 mL/min
Explanation:Various definitions of massive blood transfusion (MBT) have been published in the medical literature such as:
– Replacement of one entire blood volume within 24 h
– Transfusion of >10 units of packed red blood cells (PRBCs) in 24 h
– Transfusion of >20 units of PRBCs in 24 h
– Transfusion of >4 units of PRBCs in 1 h when on-going need is foreseeable
– Replacement of 50% of total blood volume (TBV) within 3 h.
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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 94
Incorrect
-
A 48-year-old man smoker presented to the doctor complaining of a persistent cough and shortness of breath. A chest X-ray indicated the presence of a right upper lung mass. Biopsy of the mass revealed the presence of pink cells with large, irregular nuclei. What is the most probable diagnosis?
Your Answer:
Correct Answer: Squamous cell carcinoma
Explanation:Squamous cell carcinoma, is a type of non-small cell lung cancer that accounts for approximately 30% of all lung cancers. The presence of squamous cell carcinoma is often related with a long history of smoking and the presence of persistent respiratory symptoms. Chest radiography usually shows the presence of a proximal airway lesion. Histological findings include keratinisation that takes the form of keratin pearls with pink cytoplasm and cells with large, irregular nuclei.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 95
Incorrect
-
The line which divides the perineum into two triangles is connected to the?
Your Answer:
Correct Answer: Ischial tuberosities
Explanation:The perineum has it’s deep boundaries in front of the pubic arch and the arcuate ligament of the pubis, behind the tip of the coccyx and on either side of the inferior rami of the pubis and ischium and the sacrotuberous ligament. It also corresponds to the outlet of the pelvis. A line drawn transversely across, in front of the ischial tuberosities divides the space into two portions, the posterior contains the termination of the anal canal and the anterior, contains the external urogenital organs.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 96
Incorrect
-
A 40 year old male presents with jaundice and is diagnosed as having a carcinoma of the head of the pancreas. Despite being deeply jaundiced, his staging investigations are negative for metastatic disease. What is the best method of biliary decompression in this case?
Your Answer:
Correct Answer: ERCP and placement of stent
Explanation:ERCP is a highly sensitive means of detecting pancreatic and/or biliary ductal abnormalities in pancreatic carcinoma. Among patients with pancreatic adenocarcinoma, 90-95% have abnormalities on ERCP findings.
ERCP is more invasive than the other diagnostic imaging modalities available for pancreatic carcinoma. ERCP also carries a 5-10% risk of significant complications. Because of this morbidity, it is usually reserved as a therapeutic procedure for biliary obstruction or for the diagnosis of unusual pancreatic neoplasms, such as intraductal pancreatic mucinous neoplasms (IPMN).
ERCP findings provide only limited staging information, but ERCP does have the advantage of allowing for therapeutic palliation of obstructive jaundice with either a plastic or metal biliary stent. -
This question is part of the following fields:
- Generic Surgical Topics
- Hepatobiliary And Pancreatic Surgery
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Question 97
Incorrect
-
What is the nerve supply of the muscle that is inserted onto the crest of the lesser tubercle of the humerus?
Your Answer:
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 98
Incorrect
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A 35 year old man presents with venous varicosities which are suspected to have resulted due to Klippel-Trenaunay syndrome. Which of the following would not be associated with this condition?
Your Answer:
Correct Answer: Long saphenous vein involvement
Explanation:Klippel-Trenaunay syndrome is a condition that affects the development of blood vessels, soft tissues (such as skin and muscles), and bones. The disorder has three characteristic features: a red birthmark called a port-wine stain, abnormal overgrowth of soft tissues and bones, and vein malformations.
Most people with Klippel-Trenaunay syndrome are born with a port-wine stain. This type of birthmark is caused by swelling of small blood vessels near the surface of the skin. Port-wine stains are typically flat and can vary from pale pink to deep maroon in colour.
Klippel-Trenaunay syndrome is also associated with overgrowth of bones and soft tissues beginning in infancy. Usually this abnormal growth is limited to one limb, most often one leg. However, overgrowth can also affect the arms or, rarely, the torso.
Malformations of veins are the third major feature of Klippel-Trenaunay syndrome. These abnormalities include varicose veins and deep veins in the limbs. Malformations of deep veins increase the risk of a deep vein thrombosis (DVT).
Other complications of Klippel-Trenaunay syndrome can include cellulitis, lymphedema, and internal bleeding from abnormal blood vessels. Less commonly, this condition is also associated with fusion of certain fingers or toes (syndactyly) or the presence of extra digits (polydactyly).
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This question is part of the following fields:
- Generic Surgical Topics
- Vascular
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Question 99
Incorrect
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Cancer of the testis most likely metastases to which set of lymph nodes?
Your Answer:
Correct Answer: Aortic
Explanation:The lymphatic drainage of an organ is related to its blood supply. The lymphatic drainage of the testis drains along the testicular artery to reach the lymph nodes along the aorta.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 100
Incorrect
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A 45-year-old man complains of shortness of breath, cough and chest pain. Chest X ray revealed a perihilar mass with bronchiectasis in the left mid-lung. Which of the following is most probably associated with these findings?
Your Answer:
Correct Answer: Bronchial carcinoid
Explanation:Bronchial carcinoids are neuroendocrine tumours that arise from Kulchitsky’s cells of the bronchial epithelium. Kulchitsky’s cells belong to the diffuse endocrine system. Patients affected by this tumour may be asymptomatic or may present with symptoms of airway obstruction, like dyspnoea, wheezing, and cough. Other common findings are recurrent pneumonia, haemoptysis, chest pain and paraneoplastic syndromes. Chest radiographs are abnormal in the majority of cases. Peripheral carcinoids usually present as a solitary pulmonary nodule. For central lesions common findings include hilar or perihilar masses with or without atelectasis, bronchiectasis, or consolidation. Bronchial carcinoids most commonly arise in the large bronchi causing obstruction.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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