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Question 1
Incorrect
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A 5-year-old child presents with fever and otalgia. Greenish pustular discharge was seen in his left ear during physical examination. The patient is diagnosed with otitis externa. Which of the following organisms most likely caused the infection?
Your Answer: Staphylococcus aureus
Correct Answer: Pseudomonas aeruginosa
Explanation:P. aeruginosa is a multidrug resistant pathogen recognised for its ubiquity, its advanced antibiotic resistance mechanisms and its association with serious illnesses – especially hospital-acquired infections such as ventilator-associated pneumonia and various septic syndromes. The species name aeruginosa is a Latin word meaning verdigris (copper rust), referring to the blue-green colour of laboratory cultures of the species. This blue-green pigment is a combination of two metabolites of P. aeruginosa, pyocyanin (blue) and pyoverdine (green), which impart the blue-green characteristic colour of cultures.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 2
Incorrect
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A 25 year old woman is trapped for several hours after falling down a slope while hiking in the winter. She is airlifted to the nearest hospital where she was found to be hypothermic with a core temperature of 29oC. What is the most effective method of raising core temperature?
Your Answer: Re-warming with electric blankets
Correct Answer: Instillation of warmed intra peritoneal fluid
Explanation:Answer: Instillation of warmed intra peritoneal fluid
Hypothermia describes a state in which the body’s mechanism for temperature regulation is overwhelmed in the face of a cold stressor. Hypothermia is classified as accidental or intentional, primary or secondary, and by the degree of hypothermia.
Active central rewarming is the fastest and most invasive method of rewarming. It involves use of warm IV fluids, gastric lavage and peritoneal dialysis by warm fluids. Peritoneal dialysis can be safely done with crystalloid dialysate at 40 to 42°C and it raises the body temperature by 4 to 6°C/hour. -
This question is part of the following fields:
- Emergency Medicine And Management Of Trauma
- Principles Of Surgery-in-General
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Question 3
Correct
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A 54-year-old woman is re-admitted to the hospital with shortness of breath and sharp chest pain 2 weeks after surgical cholecystectomy. The most probable cause of these clinical findings is:
Your Answer: Pulmonary embolus
Explanation:Pulmonary embolism is caused by the sudden blockage of a major lung blood vessel, usually by a blood clot. Symptoms include sudden sharp chest pain, cough, dyspnoea, palpitations, tachycardia or loss of consciousness. Risk factors for developing pulmonary embolism include long periods of inactivity, surgery, trauma, pregnancy, oral contraceptives, oestrogen replacement, malignancies and venous stasis.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 4
Correct
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Which tumour site is more commonly involved in adults than in children?
Your Answer: Lung
Explanation:In adults, the most common primary site of tumour is in the lungs, compared to children wherein the most common primary site is the blood.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 5
Incorrect
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In the glomerulus of the kidney, the mesangium is a structure associated with the capillaries. It has extraglomerular mesangial cells that:
Your Answer: Are major contributors to the extracellular matrix
Correct Answer: Form the juxtaglomerular apparatus in combination with the macula densa and juxtaglomerular cells
Explanation:The mesangium is an inner layer of the glomerulus, within the basement membrane surrounding the glomerular capillaries. The mesangial cells are phagocytic and secrete the amorphous basement membrane-like material known as the mesangial matrix. They are typically separated from the lumen of the capillaries by endothelial cells. The other type of cells in the mesangium are the extraglomerular mesangial cells which form the juxtaglomerular apparatus in combination with two other types of cells: the macula densa of the distal convoluted tubule and juxtaglomerular cells of the afferent arteriole. This apparatus controls blood pressure through the renin–angiotensin–aldosterone system.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 6
Correct
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Which Statement is true of the brachial plexus?
Your Answer: The posterior cord continues as the axillary nerve
Explanation:The lateral cord continues as the musculocutaeous nerve.
The medial cord continues as the ulnar nerve.
The posterior cord continues as the radial nerve and the axillary nerve.
The nerve to subclavius muscle is a branch of the C6 root.
The suprascapular nerve is a branch from the upper trunk. -
This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 7
Correct
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An old man fell and fractured a carpal bone articulating with the pisiform bone. Which bone was most likely fractured?
Your Answer: Triquetral
Explanation:The pisiform bone has an oval facet for articulation with the triquetral bone. The pisiform bone is a sesamoid bone, and is anterior to the other carpal bones.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 8
Correct
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A 29-year-old pregnant woman develops severe hypoxaemia with petechial rash and confusion following a fracture to her left femur. Which is the most probable cause of these symptoms in this patient?
Your Answer: Fat embolism
Explanation:Fat embolism is a life-threatening form of embolism in which the embolus consists of fatty material or bone marrow particles that are introduced into the systemic venous system. It may be caused by long-bone fractures, orthopaedic procedures, sickle cell crisis, parenteral lipid infusion, burns and acute pancreatitis. Patients with fat embolism usually present with symptoms that include skin, brain, and lung dysfunction.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 9
Correct
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A 40 year old man is currently recovering after a live donor related liver transplant. He has been given a daily dose of corticosteroids to decrease the risk of graft rejection. Which of the following will not occur as a result of their administration?
Your Answer: Necrosis of activated lymphocytes
Explanation:Corticosteroids are responsible for an array of side effects. However, necrosis has a different pathophysiology and is not usually linked with corticosteroid usage.
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This question is part of the following fields:
- Generic Surgical Topics
- Organ Transplantation
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Question 10
Correct
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A young man was thrown from a vehicle in a collision. He landed on his head and shoulder tip, stretching the left side of his neck. A neurological examination revealed that the fifth and sixth cervical nerves had been torn from the spinal cord. What is the most obvious clinical manifestation of this?
Your Answer: Abduction
Explanation:In the case of injuries to the upper roots of the brachial plexus there is complete loss of abduction. The muscle performing this movement is the supraspinatus. This initiates the movement, followed by the deltoid muscle, which allows for complete abduction. Both these muscles are innervated by nerves originating from C5 and C6. The injury to these roots results in a condition named Erb-Duchenne’s palsy.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 11
Correct
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A 21 year old female presents to the clinic with axillary lymphadenopathy and symptoms suggestive of Hodgkin's lymphoma. Which of the following tests should be done?
Your Answer: Excision biopsy of a lymph node
Explanation:Answer: Excision biopsy of a lymph node
Hodgkin lymphoma is an uncommon cancer that develops in the lymphatic system, which is a network of vessels and glands spread throughout your body. In Hodgkin lymphoma, B-lymphocytes (a particular type of lymphocyte) start to multiply in an abnormal way and begin to collect in certain parts of the lymphatic system, such as the lymph nodes (glands). The affected lymphocytes lose their infection-fighting properties, making you more vulnerable to infection. The most common symptom of Hodgkin lymphoma is a painless swelling in a lymph node, usually in the neck, armpit or groin.
A histologic diagnosis of Hodgkin lymphoma is always required. An excisional lymph node biopsy is recommended because the lymph node architecture is important for histologic classification.Features of Hodgkin lymphoma include the following:
Asymptomatic lymphadenopathy may be present (above the diaphragm in 80% of patients)
Constitutional symptoms (unexplained weight loss [>10% of total body weight] within the past 6 months, unexplained fever >38º C, or drenching night sweats) are present in 40% of patients; collectively, these are known as B symptoms
Intermittent fever is observed in approximately 35% of cases; infrequently, the classic Pel-Ebstein fever is observed (high fever for 1-2 week, followed by an afebrile period of 1-2 week)
Chest pain, cough, shortness of breath, or a combination of those may be present due to a large mediastinal mass or lung involvement; rarely, haemoptysis occurs
Pruritus may be present
Pain at sites of nodal disease, precipitated by drinking alcohol, occurs in fewer than 10% of patients but is specific for Hodgkin lymphoma
Back or bone pain may rarely occur
A family history is also helpful; in particular, nodular sclerosis Hodgkin lymphoma (NSHL) has a strong genetic component and has often previously been diagnosed in the family.
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This question is part of the following fields:
- Principles Of Surgery-in-General
- Surgical Technique And Technology
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Question 12
Correct
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Which of the following malignancies is likely to have the best prognosis?
Your Answer: Papillary carcinoma of the thyroid
Explanation:Papillary carcinoma accounts for 70-80% of all thyroid cancers and is seen commonly in people aged 30-60 years. It is more aggressive in elderly patients. 10-20% cases may have recurrence or persistent disease. More common in females with a female to male ratio of 3:1. Papillary carcinomas can also contain follicular carcinomas. The common route of spread is through lymphatics to regional nodes in one-third cases and pulmonary metastasis can also occur. Papillary carcinomas of the thyroid have the best prognosis, especially in patients less than 45 years of age with small tumours confined to the thyroid gland.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 13
Correct
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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: 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 14
Correct
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A 45-year old male patient with a long history of alcoholism developed liver cirrhosis that has led to portal hypertension. Which of the following plexuses of veins is most likely dilated in this patient?
Your Answer: Haemorrhoidal plexus
Explanation:The haemorrhoidal plexus or also known as the rectal plexus is a venous plexus that surrounds the rectum. This venous plexus in males communicates anteriorly with the vesical plexus and uterovaginal plexus in females. This venous plexus forms a site of free communication between the portal and systemic venous systems. In the case of portal hypertension this plexus would most likely dilate due to the increased pressure.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 15
Correct
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A 55-year-old male chronic smoker is diagnosed with non-small-cell cancer. His right lung underwent complete atelectasis and he has a 7cm tumour involving the chest wall. What is the stage of the lung cancer of this patient?
Your Answer: T3
Explanation:Non-small-cell lung cancer is staged through TNM classification. The stage of this patient is T3 because based on the TNM classification the tumour is staged T3 if > 7 cm or one that directly invades any of the following: Chest wall (including superior sulcus tumours), diaphragm, phrenic nerve, mediastinal pleura, or parietal pericardium; or the tumour is in the main bronchus < 2 cm distal to the carina but without involvement of the carina, Or it is associated with atelectasis/obstructive pneumonitis of the entire lung or separate tumour nodule(s) in the same lobe.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 16
Incorrect
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A young male was diagnosed with hepatitis A, which clinically resolved in 2 weeks. What will his liver biopsy done after 6 months show?
Your Answer: Periportal fibrosis
Correct Answer: Normal architecture
Explanation:Hepatitis A is the most common acute viral hepatitis, more common in children and young adults. It is caused by Hepatitis A virus, which is a single-stranded RNA picornavirus. The primary route of spread of Hepatitis A is the faecal-oral route. Consumption of contaminated raw shellfish is also a likely causative factor. The shedding of the virus in faecal matter occurs before the onset of symptoms and continues a few days after. Hepatitis A does not lead to chronic hepatitis or cirrhosis, and there is no known chronic carrier state. Hence, a biopsy performed after recovery will show normal hepatocellular architecture.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 17
Correct
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The normal location of the major duodenal papilla:
Your Answer: Descending part of the duodenum
Explanation:The major duodenal papilla is on the descending portion of the duodenum on the medial side, about 7-10cm from the pylorus. The pancreatic ducts and the common bile ducts unite and open by a common orifice on the summit of the duodenal papilla.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 18
Correct
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The Henderson–Hasselbalch equation describes the derivation of pH as a measure of acidity. According to this equation, the buffering capacity of the system is at maximum when the number of free anions compared with undissociated acid is:
Your Answer: Equal
Explanation:In 1908, Lawrence Joseph Henderson wrote an equation describing the use of carbonic acid as a buffer solution. Later, Karl Albert Hasselbalch re-expressed that formula in logarithmic terms, resulting in the Henderson–Hasselbalch equation. The equation is also useful for estimating the pH of a buffer solution and finding the equilibrium pH in acid–base reactions. Two equivalent forms of the equation are: pH = pKa + log10 [A–]/[HA] or pH = pKa + log10 [base]/[acid]. Here, pKa is − log10(Ka) where Ka is the acid dissociation constant, that is: pKa = –log10(Ka) = –log10 ([H3 O+][A–]/[HA]) for the reaction: HA + H2 O ≈ A– + H3 O+ In these equations, A– denotes the ionic form of the relevant acid. Bracketed quantities such as [base] and [acid] denote the molar concentration of the quantity enclosed. Maximum buffering capacity is found when pH = pKa or when the number of free anions to undissociated acid is equal and buffer range is considered to be at a pH = pKa ± 1.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 19
Correct
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Which of the following is a true statement regarding secretion of gastric acid?
Your Answer: Acetylcholine increases gastric acid secretion
Explanation:Gastric acid secretion is increased by acetylcholine, histamine and gastrin, with the help of cAMP as a secondary messenger. They increase H+ and Cl- secretion by increasing the number of H+/K+ ATPase molecules and Cl- channels. In contrast, gastric acid secretion is decreased by somatostatin, epidermal growth factor and prostaglandins.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 20
Correct
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A 24-year-old woman presents with an infected sebaceous cyst. On examination, it is swollen, erythematous, and discharging pus. What should be the most appropriate treatment?
Your Answer: Incision and drainage with excision of the cyst wall and packing of the defect
Explanation:The correct treatment for an infected sebaceous cyst is incision and drainage with removal of the cyst wall. Conservation of the cyst wall invariably leads to recurrence. Furthermore, the infected wound must not be primarily closed. The administration of antibiotics without drainage of sepsis is futile.
A sebaceous cyst is a rounded swollen area of the skin formed by an abnormal sac of retained excretion (sebum) from the sebaceous follicles. It can occur anywhere but is most commonly formed on scalp, ears, back, face, and upper arm (not on palms of the hands and soles of the feet). The correct treatment for an infected sebaceous cyst is incision and drainage with removal of the cyst wall. Excision of the cyst wall needs to be complete to prevent recurrence.
Cock’s peculiar tumour is a suppurating and ulcerated sebaceous cyst, which may resemble a squamous cell carcinoma.
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This question is part of the following fields:
- Generic Surgical Topics
- Skin Lesions
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Question 21
Correct
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A 20 year old is brought to the A&E after he fell from a moving cart. The boy has sustained blunt abdominal injury, and the there is a possibility of internal bleeding as the boy is in shock. An urgent exploratory laparotomy is done in the A&E theatre. On opening the peritoneal cavity, the operating surgeon notices a torn gastrosplenic ligament with a large clot around the spleen. Which artery is most likely to have been injured in this case?
Your Answer: Short gastric
Explanation:The short gastric arteries branch from the splenic artery near the splenic hilum to travel back in the gastrosplenic ligament to supply the fundus of the stomach. Therefore, these may be injured in this case.
The splenic artery courses deep to the stomach to reach the hilum of the spleen. It doesn’t travel in the gastrosplenic ligament although it does give off branches that do.
The middle colic artery is a branch of the superior mesenteric artery that supplies the transverse colon.
Gastroepiploic artery is the largest branch of the splenic artery that courses between the layers of the greater omentum to anastomose with the right gastroepiploic.
Left gastric artery, a branch of the coeliac trunk. It supplies the left half of the lesser curvature. -
This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 22
Correct
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A 4-month-old boy is brought to the clinic by his mother who has noticed a swelling in the right hemiscrotum. On examination, there is a firm mass affecting the right spermatic cord distally, the testis is felt separately from it. What is the most likely diagnosis?
Your Answer: Rhabdomyosarcoma
Explanation:Rhabdomyosarcoma (RMS) is the most common soft tissue sarcoma in children.
Rhabdomyosarcoma usually manifests as an expanding mass. Tumours in superficial locations may be palpable and detected relatively early, but those in deep locations (e.g., retroperitoneum) may grow large before causing symptoms.
Symptoms depend on the location of the tumour, and pain may be present. Typical presentations of nonmetastatic disease, by location, are as follows:
Orbit: Proptosis or dysconjugate gaze
Paratesticular: Painless scrotal mass, testes are felt separately
Prostate: Bladder or bowel difficulties
Uterus, cervix, bladder: Menorrhagia or metrorrhagia
Vagina: Protruding polypoid mass (botryoid, meaning a grapelike cluster)
Extremity: Painless mass
Parameningeal (ear, mastoid, nasal cavity, paranasal sinuses, infratemporal fossa, pterygopalatine fossa): Upper respiratory symptoms or painIn the international classification of rhabdomyosarcoma, there are 5 recognized variants: embryonal, alveolar, botryoid embryonal, spindle cell embryonal and anaplastic. The most common variant is embryonal, most associated with tumours of the genitourinary tract and the head and neck. Histologically, the embryonal subtype resembles that of a 6- to an 8-week old embryo.
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This question is part of the following fields:
- Generic Surgical Topics
- Urology
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Question 23
Correct
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An episiotomy is indicated for a woman during a difficult vaginal delivery. Whilst the registrar was performing this procedure she made a median cut too far through the perineal body cutting the structure immediately posterior. Which structure is this?
Your Answer: External anal sphincter
Explanation:An episiotomy is an incision that is made whenever there is a risk of a tear during vaginal deliver. A posterolateral incision, as opposed to a median incision is preferred. Of the options given, the external anal sphincter lies right posterior to the perineal body. The sacrospinous and the sacrotuberous ligaments are deep in the perineum that they should not be involved in this.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 24
Correct
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Leukotrienes normally function during an asthma attack and work to sustain inflammation. Which of the following enzymes would inhibit their synthesis?
Your Answer: 5-lipoxygenase
Explanation:Leukotrienes are produced from arachidonic acid with the help of the enzyme 5-lipoxygenase. This takes place in the eosinophils, mast cells, neutrophils, monocytes and basophils. They are eicosanoid lipid mediators and take part in allergic and asthmatic attacks. They are both autocrine as well as paracrine signalling molecules to regulate the body’s response and include: LTA4, LTB4, LTC4, LTD4, LTE4 and LTF4.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 25
Correct
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What is formed when the ductus deferens unites with the duct of the seminal vesicle?
Your Answer: Ejaculatory duct
Explanation:The deferens is a cylindrical structure with dense walls and an extremely small lumen It is joined at an acute angle by the duct of the seminal vesicles to form the ejaculatory duct, which traverses the prostate behind it’s middle lobe and opens into the prostatic portion of the urethra, close to the orifice of the prostatic utricle.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 26
Correct
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A 34-year old gentleman presented with acute pancreatitis to the emergency department. On enquiry, there was found to be a history of recurrent pancreatitis, eruptive xanthomas and raised plasma triglyceride levels associated with chylomicrons. Which of the following will be found deficient in this patient?
Your Answer: Lipoprotein lipase
Explanation:The clinical features mentioned here suggest the diagnosis of hypertriglyceridemia due to lipoprotein lipase (LPL) deficiency. LPL aids in hydrolysing the lipids in lipoproteins into free fatty acids and glycerol. Apo-CII acts as a co-factor. Deficiency of this enzyme leads to hypertriglyceridemia.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 27
Correct
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A 68-year-old woman complains of headaches, dizziness, and memory loss. About a month ago, she fell from a staircase but only suffered mild head trauma. What is the most likely diagnosis in this case?
Your Answer: Chronic subdural haematoma
Explanation:A quarter to a half of patients with chronic subdural haematoma have no identifiable history of head trauma. If a patient does have a history of head trauma, it usually is mild. The average time between head trauma and chronic subdural haematoma diagnosis is 4–5 weeks. Symptoms include decreased level of consciousness, balance problems, cognitive dysfunction and memory loss, motor deficit (e.g. hemiparesis), headache or aphasia. Some patients present acutely. They usually result from tears in bridging veins which cross the subdural space, and may cause an increase in intracranial pressure (ICP).
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 28
Correct
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Whilst snorkelling, a 30-year old gentleman has the respiratory rate of 10/min, tidal volume of 550 ml and an effective anatomical dead space of 250 ml. What is his alveolar ventilation?
Your Answer: 3000 ml/min
Explanation:Alveolar ventilation is the amount of air reaching the alveoli per minute. Alveolar ventilation = respiratory rate × (tidal volume – anatomical dead space volume). Thus, alveolar ventilation = 10 × (550 − 250) = 3000 ml/min.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 29
Incorrect
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The muscle that depresses the glenoid fossa directly is the:
Your Answer: Latissimus dorsi
Correct Answer: Pectoralis minor
Explanation:Situated at the upper part of the thorax beneath the pectoralis major, is a thin pectoralis minor, triangular muscle. It originates from the third, fourth and fifth ribs, near the cartilage and from the aponeurosis which covers the intercostals. These fibres move upwards and laterally to join and form a flat tendon. This is inserted into the medial border and upper surface of the coracoid process of the scapula. Through this medial anterior thoracic nerve, fibres from the pectoralis minor are received from the eighth cervical and first thoracic nerves. This pectoralis minor pushes down on the point of the shoulder (glenoid fossa), drawing the scapula downward and medially towards the thorax which throws the inferior angle backwards.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 30
Correct
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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: 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 31
Correct
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A 41 year old lawyer presents with diarrhoea and bleeding from the rectum which has been occurring for the past 16 days. She has also noticed that she has had incontinence at night. What is her most likely diagnosis?
Your Answer: Inflammatory bowel disease
Explanation:Answer: Inflammatory bowel disease
Inflammatory bowel disease (IBD) is an idiopathic disease caused by a dysregulated immune response to host intestinal microflora. The two major types of inflammatory bowel disease are ulcerative colitis (UC), which is limited to the colonic mucosa, and Crohn disease (CD), which can affect any segment of the gastrointestinal tract from the mouth to the anus, involves skip lesions, and is transmural. There is a genetic predisposition for IBD, and patients with this condition are more prone to the development of malignancy.
Generally, the manifestations of IBD depend on the area of the intestinal tract involved. The symptoms, however, are not specific for this disease. They are as follows:
Abdominal cramping
Irregular bowel habits, passage of mucus without blood or pus
Weight loss
Fever, sweats
Malaise, fatigue
Arthralgias
Growth retardation and delayed or failed sexual maturation in children
Extraintestinal manifestations (10-20%): Arthritis, uveitis, or liver disease
Grossly bloody stools, occasionally with tenesmus: Typical of UC, less common in CD
Perianal disease (e.g., fistulas, abscesses): Fifty percent of patients with CD
The World Gastroenterology Organization (WGO) indicates the following symptoms may be associated with inflammatory damage in the digestive tract [1] :
Diarrhoea: mucus or blood may be present in the stool; can occur at night; incontinence may occur
Constipation: this may be the primary symptom in ulcerative colitis, when the disease is limited to the rectum; obstipation may occur and may proceed to bowel obstruction
Bowel movement abnormalities: pain or rectal bleeding may be present, as well as severe urgency and tenesmus
Abdominal cramping and pain: commonly present in the right lower quadrant in Crohn disease; occur peri umbilically or in the left lower quadrant in moderate to severe ulcerative colitis
Nausea and vomiting: occurs more often in Crohn disease than in ulcerative colitis
The nocturnal diarrhoea and incontinence are important symptoms in diagnosis IBD.
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This question is part of the following fields:
- Colorectal Surgery
- Generic Surgical Topics
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Question 32
Incorrect
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A 36 year old female presents to the clinic with a 6 week history of discomfort just below her ribcage which is relieved by eating. She develops haematemesis and undergoes an upper GI endoscopy. An actively bleeding ulcer is noted in the first part of the duodenum. What is the best course of action?
Your Answer: Whipple's procedure
Correct Answer: Injection with adrenaline
Explanation:Upper gastrointestinal (GI) bleeding is usually defined by a bleeding source proximal to the ligament of Treitz although some may also include a bleeding source in the proximal jejunum. Upper GI bleeding emergencies are characterized by hematemesis, melena, haematochezia (if the bleeding is massive and brisk) and evidence of hemodynamic compromise such as dizziness, syncope episodes and shock. The most commonly used endoscopic haemostatic interventions include epinephrine (adrenaline) injection, thermal coagulation and endoscopic clipping at the ulcer site to constrict, compress and/or destroy the bleeding vessel. Injection of 30 mL diluted epinephrine (1:10 000) can effectively prevent recurrent bleeding with a low rate of complications. The optimal injection volume of epinephrine for endoscopic treatment of an actively bleeding ulcer (spurting or oozing) is 30 mL.
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This question is part of the following fields:
- Generic Surgical Topics
- Upper Gastrointestinal Surgery
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Question 33
Incorrect
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A 12 year old boy presents with a sharp pain on the left side of his lower back. His parents both have a similar history of the condition. His urine tests positive for blood. A radio dense stone is seen in the region of the mid ureter when a KUB style x-ray is done. Which of the following is most likely the composition of the stone?
Your Answer: Calcium phosphate stone
Correct Answer: Cystine stone
Explanation:Answer: Cystine stone
Cystinuria is a genetic cause of kidney stones with an average prevalence of 1 in 7000 births. Cystine stones are found in 1 to 2 percent of stone formers, although they represent a higher percentage of stones in children (approximately 5 percent). Cystinuria is an inherited disorder. Inherited means it is passed down from parents to children through a defect in a specific gene. In order to have cystinuria, a person must inherit the gene from both parents.
Cystine is a homodimer of the amino acid cysteine. Patients with cystinuria have impairment of renal cystine transport, with decreased proximal tubular reabsorption of filtered cystine resulting in increased urinary cystine excretion and cystine nephrolithiasis. The cystine transporter also promotes the reabsorption of dibasic amino acids, including ornithine, arginine, and lysine, but these compounds are soluble so that an increase in their urinary excretion does not lead to stones. Intestinal cystine transport is also diminished, but the result is of uncertain clinical significance.Cystinuria only causes symptoms if you have a stone. Kidney stones can be as small as a grain of sand. Others can become as large as a pebble or even a golf ball. Symptoms may include:
Pain while urinating
Blood in the urine
Sharp pain in the side or the back (almost always on one side)
Pain near the groin, pelvis, or abdomen
Nausea and vomitingStruvite stones are a type of hard mineral deposit that can form in your kidneys. Stones form when minerals like calcium and phosphate crystallize inside your kidneys and stick together. Struvite is a mineral that’s produced by bacteria in your urinary tract. Bacteria in your urinary tract produce struvite when they break down the waste product urea into ammonia. For struvite to be produced, your urine needs to be alkaline. Having a urinary tract infection can make your urine alkaline. Struvite stones often form in women who have a urinary tract infection.
Calcium oxalate stones are the most common type of kidney stone. Kidney stones are solid masses that form in the kidney when there are high levels of calcium, oxalate, cystine, or phosphate and too little liquid. There are different types of kidney stones. Your healthcare provider can test your stones to find what type you have. Calcium oxalate stones are caused by too much oxalate in the urine.
What is oxalate and how does it form stones?
Oxalate is a natural substance found in many foods. Your body uses food for energy. After your body uses what it needs, waste products travel through the bloodstream to the kidneys and are removed through urine. Urine has various wastes in it. If there is too much waste in too little liquid, crystals can begin to form. These crystals may stick together and form a solid mass (a kidney stone). Oxalate is one type of substance that can form crystals in the urine. This can happen if there is too much oxalate, too little liquid, and the oxalate “sticks” to calcium while urine is being made by the kidneys.Uric acid stones are the most common cause of radiolucent kidney stones in children. Several products of purine metabolism are relatively insoluble and can precipitate when urinary pH is low. These include 2- or 8-dihydroxyadenine, adenine, xanthine, and uric acid. The crystals of uric acid may initiate calcium oxalate precipitation in metastable urine concentrates.
Uric acid stones form when the levels of uric acid in the urine is too high, and/or the urine is too acidic (pH level below 5.5) on a regular basis. High acidity in urine is linked to the following causes:
Uric acid can result from a diet high in purines, which are found especially in animal proteins such as beef, poultry, pork, eggs, and fish. The highest levels of purines are found in organ meats, such as liver and fish. Eating large amounts of animal proteins can cause uric acid to build up in the urine. The uric acid can settle and form a stone by itself or in combination with calcium. It is important to note that a person’s diet alone is not the cause of uric acid stones. Other people might eat the same diet and not have any problems because they are not prone to developing uric acid stones.
There is an increased risk of uric acid stones in those who are obese or diabetic.
Patients on chemotherapy are prone to developing uric acid stones.Only cystine stone is inherited.
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This question is part of the following fields:
- Generic Surgical Topics
- Urology
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Question 34
Incorrect
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A 15 year old girl is taken to the A&E after complaining of right iliac fossa pain which started suddenly. She is well other than having some right iliac fossa tenderness but no guarding. She has no fever and the urinary dipstick result is normal. Her last menstrual cycle was 14 days ago which was also normal and the pregnancy test done is negative. What is the most likely underlying condition?
Your Answer: Crohn's disease
Correct Answer: Mittelschmerz
Explanation:Answer: Mittelschmerz
Mittelschmerz is midcycle abdominal pain due to leakage of prostaglandin-containing follicular fluid at the time of ovulation. It is self-limited, and a theoretical concern is treatment of pain with prostaglandin synthetase inhibitors, which could prevent ovulation. The pain of mittelschmerz usually occurs in the lower abdomen and pelvis, either in the middle or to one side. The pain can range from a mild twinge to severe discomfort and usually lasts from minutes to hours. In some cases, a small amount of vaginal bleeding or discharge might occur. Some women have nausea, especially if the pain is very strong.
Diagnosis of pelvic pain in women can be challenging because many symptoms and signs are insensitive and nonspecific. As the first priority, urgent life-threatening conditions (e.g., ectopic pregnancy, appendicitis, ruptured ovarian cyst) and fertility-threatening conditions (e.g., pelvic inflammatory disease, ovarian torsion) must be considered.
Many women never have pain at ovulation. Some women, however, have mid-cycle pain every month, and can tell by the pain that they are ovulating.
As an egg develops in the ovary, it is surrounded by follicular fluid. During ovulation, the egg and the fluid, as well as some blood, are released from the ovary. While the exact cause of mittelschmerz is not known, it is believed to be caused by the normal enlargement of the egg in the ovary just before ovulation. Also, the pain could be caused by the normal bleeding that comes with ovulation.
Pelvic inflammatory disease can be ruled out if the patient is not sexually active. -
This question is part of the following fields:
- Generic Surgical Topics
- The Abdomen
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Question 35
Correct
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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: 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 36
Incorrect
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A football player sustained an injury to his ankle. The wound went through the skin, subcutaneous tissue and flexor retinaculum. Which other structure passing under the retinaculum may be injured?
Your Answer: Plantar arterial arch
Correct Answer: Tibial nerve
Explanation:The flexor retinaculum is immediately posterior to the medial malleolus. The structures that pass under the flexor retinaculum from anterior to posterior are: tendon of the tibialis posterior, flexor digitorum longus, posterior tibial artery (and vein), tibial nerve and tendon of flexor hallucis longus. The tibial nerve is the only one which lies behind the flexor retinaculum.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 37
Incorrect
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An infant, 5 weeks and 6 days old born with a large sub-aortic ventricular septal defect, is prepared for pulmonary artery banding through a left thoracotomy (the child is not fit for a surgical closure). The surgeon initially passes his index finger immediately behind two great arteries in the pericardial sac to mobilise the great arteries in order to pass the tape around the pulmonary artery. Into which space is the surgeon's finger inserted?
Your Answer: Cardiac notch
Correct Answer: Transverse pericardial sinus
Explanation:Cardiac notch: is an indentation on the left lung of the heart.
Coronary sinus: a venous sinus on the surface of the heart (the posterior aspect) that receives blood from the smaller veins that drain the heart.
Coronary sulcus: a groove on the heart between the atria and ventricles.
Transverse pericardial sinus: located behind the aorta and pulmonary trunk and anterior to the superior vena cava.
Oblique pericardial sinus: located behind the left atrium. Accessed from the inferior side (or the apex) of the heart upwards.
Horizontal pericardial sinus: this is a made-up term. -
This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 38
Incorrect
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Which lymph nodes are likely to be enlarged in a patient who has malignant growth involving the anus?
Your Answer: Periaortic
Correct Answer: Superficial inguinal
Explanation:The lymphatics from the anus, skin of the perineum and the scrotum end in the superficial inguinal nodes. In case of a malignant growth of the anus, the superficial inguinal lymph nodes would most likely be enlarge.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 39
Incorrect
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An experiment was conducted in which the skeletal muscle protein (not smooth muscle) involved in contraction was selectively inhibited. Which protein was inhibited?
Your Answer: Tropomyosin
Correct Answer: Troponin
Explanation:The mechanism of contraction of smooth muscles is different from that of skeletal muscles in which the contractile protein is troponin whilst in smooth muscle contraction is a protein called calmodulin. Calmodulin reacts with calcium ions and stimulates the formation of myosin crossbridges.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 40
Correct
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Which of the following structures, is the area in which the superior cerebral veins drain into?
Your Answer: Superior sagittal sinus
Explanation:The superior cerebral veins are predominantly located on the superior aspect of the brain. They are 8 to 12 in number and they drain the lateral, medial and superior aspects of the cerebral hemispheres.
These veins drain into the superior sagittal sinus, also known as the superior longitudinal sinus – which is located along the attached margin of the falx cerebri. -
This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 41
Incorrect
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A 9 year old boy is admitted with right iliac fossa pain and an appendicectomy is to be performed.Which of the following incision is the best for this procedure?
Your Answer: Kockers
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 42
Incorrect
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A 40-year old man sustained a deep laceration to the sole of his left foot. It was found that the belly of extensor digitorum muscle was lacerated and the lateral tarsal artery was severed. The lateral tarsal artery is a branch of the:
Your Answer: Popliteal artery
Correct Answer: Dorsalis pedis artery
Explanation:The lateral tarsal artery arises from the dorsalis pedis, as the vessel crosses the navicular bone
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 43
Incorrect
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A 41 year old woman presents with severe anal pain on defecation and fresh blood which is only seen on the tissue. She states that she is too sore to tolerate a rectal examination at clinic. What would be the most appropriate initial management?
Your Answer: Lateral internal sphincterotomy
Correct Answer: Glyceryl trinitrate (0.2–0.4%) applied topically
Explanation:An anal fissure is a painful linear tear or crack in the distal anal canal, which, in the short term, usually involves only the epithelium and, in the long term, involves the full thickness of the anal mucosa. Typically, the patient reports severe pain during a bowel movement, with the pain lasting several minutes to hours afterward. The pain recurs with every bowel movement, and the patient commonly becomes afraid or unwilling to have a bowel movement, leading to a cycle of worsening constipation, harder stools, and more anal pain. Approximately 70% of patients note bright-red blood on the toilet paper or stool. Occasionally, a few drops may fall in the toilet bowl, but significant bleeding does not usually occur with an anal fissure.
Second-line medical therapy consists of intra-anal application of 0.4% nitro-glycerine (NTG; also called glycerol trinitrate) ointment directly to the internal sphincter. Nitro-glycerine rectal ointment is approved by the US Food and Drug Administration (FDA) for moderate-to-severe pain associated with anal fissures and may be considered when conservative therapies have failed. -
This question is part of the following fields:
- Colorectal Surgery
- Generic Surgical Topics
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Question 44
Incorrect
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Which of the following statements is true of Colles’ fracture?
Your Answer: Involves the ulnar styloid process
Correct Answer: Is a cause of carpal tunnel syndrome
Explanation:Colles’ fracture is a distal fracture of the radius that is a known cause of carpal tunnel syndrome (compression of the median nerve in the carpal tunnel). It rarely results in ulnar nerve compression. A Colles’ fracture is extra-articular and does not extend into the wrist joint, otherwise this would make it an intra-articular fracture (Barton’s fracture). The distal fragment in a Colles’ fracture is displaced dorsally, unlike in a Smith’s fracture where the distal fragment is displaced volarly (ventrally). Associated fracture of the ulnar styloid process may occur and is a common associated injury.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 45
Incorrect
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A young man is hit in the head with a bar stool and is rushed to the A&E department. On arrival, he opens his eyes in response to pain, his only verbal responses are in the form of groans and grunts. He flexes his forearms away from the painful stimuli when it is applied. Calculate his Glasgow coma score.
Your Answer: 5
Correct Answer: 8
Explanation:Answer: 8
Eye Opening Response
Spontaneous–open with blinking at baseline – 4 points
Opens to verbal command, speech, or shout – 3 points
Opens to pain, not applied to face – 2 point
None – 1 pointVerbal Response
Oriented – 5 points
Confused conversation, but able to answer questions – 4 points
Inappropriate responses, words discernible – 3 points
Incomprehensible speech – 2 points
None – 1 pointMotor Response
Obeys commands for movement – 6 points
Purposeful movement to painful stimulus – 5 points
Withdraws from pain – 4 points
Abnormal (spastic) flexion, decorticate posture – 3 points
Extensor (rigid) response, decerebrate posture – 2 points
None – 1 pointHe opens his eyes to pain and groans or grunts. He flexes his forearms away from the painful stimuli This gives him a Glasgow score of 8: eye opening response of 2, verbal response 2 and motor response 4.
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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 46
Incorrect
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A 30 year old female suffered from mismatched transfusion induced haemolysis. Which substance will be raised in the plasma of this patient?
Your Answer: Melanin
Correct Answer: Bilirubin
Explanation:Bilirubin is a yellow pigment that is formed due to the break down of RBCs. Haemolysis results in haemoglobin that is broken down into a haem portion and globin which is converted into amino acids and used again. Haem is converted into unconjugated bilirubin in the macrophages and shunted to the liver. In the liver it is conjugated with glucuronic acid making it water soluble and thus excreted in the urine. Its normal levels are from 0.2-1 mg/dl. Increased bilirubin causes jaundice and yellowish discoloration of the skin.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 47
Incorrect
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Evaluation of a 60-year old gentleman, who has been a coal miner all his life and is suspected to have pulmonary fibrosis reveals the following: normal FEV1, arterial oxygen saturation 92%, alveolar ventilation 6000 ml/min at a tidal volume of 600 ml and a breathing rate of 12 breaths/min. There are also pathological changes in lung compliance and residual volume. Which of the following is most accurate about his residual volume?
Your Answer: Is part of vital capacity
Correct Answer: Cannot be measured directly with a spirometer
Explanation:Residual volume is the air left in the lungs after maximal expiration is done. Thus, this is not a part of vital capacity and cannot be measured with a spirometer directly. It can be measured by the methods such as body plethysmography or inert gas dilution. Expiratory reserve volume is vital capacity minus inspiratory capacity. Resting volume of lungs is he sum of residual volume and expiratory reserve volume. Lungs recoil inward until the recoil pressure becomes zero, which corresponds to a volume significantly lower than residual volume.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 48
Incorrect
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Cancer of the testis most likely metastases to which set of lymph nodes?
Your Answer: Common iliac
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 49
Incorrect
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A 39 year old man with a long standing inguinal hernia inquires about the risk of strangulation over the next year if he decides not to have surgery done. He is seen with a small, direct inguinal hernia. Which percentage matches with the likely risk of strangulation over the year?
Your Answer: 40%
Correct Answer:
Explanation:Indirect inguinal hernias have a higher risk of strangulation. The risk of strangulation and obstruction is lowest for direct inguinal hernias as they have a wide neck, which can often be monitored and managed conservatively. A study conducted showed that the cumulative probability of strangulation for inguinal hernias was 2.8 per cent, rising to 4.5 per cent after 2 years.
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This question is part of the following fields:
- Generic Surgical Topics
- The Abdomen
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Question 50
Incorrect
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Regarding the venous drainage of the heart which of these is correct?
Your Answer:
Correct Answer: The great cardiac vein is the largest tributary of the coronary sinus and this vein starts at the apex of the heart and ascends with the anterior ventricular branch of the left coronary artery
Explanation:Most of the veins of the heart open into the coronary sinus. This is a wide venous channel, about 2.25 cm in length, situated in the posterior part of the coronary sulcus and covered by muscular fibres from the left atrium. Its tributaries are the great, small and middle cardiac veins, the posterior vein of the left ventricle and the oblique vein of the left atrium. The great cardiac vein is the largest tributary of the coronary sinus.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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SESSION STATS - PERFORMANCE PER SPECIALTY
