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Question 1
Correct
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A Jewish man was diagnosed with haemophilia C. Which of the following factors is deficient in this form of haemophilia?
Your Answer: Factor XI
Explanation:Haemophilia C, also known as plasma thromboplastin antecedent (PTA) deficiency or Rosenthal syndrome, is a condition caused by the deficiency of the coagulation factor XI. The condition is rare and it is usually found in Ashkenazi Jews.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 2
Correct
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A 60-year old man with a left-sided indirect inguinal hernia underwent emergency surgery to relieve large bowel obstruction resulting from a segment of the bowel being strangulated in the hernial sac. The most likely intestinal segment involved is:
Your Answer: Sigmoid colon
Explanation:The sigmoid colon is the most likely segment involved as it is mobile due to the presence of the sigmoid mesocolon. The descending colon, although on the left side, is a bit superior and is also retroperitoneal. The ascending colon and caecum are on the right side of the abdomen. The rectum is too inferior to enter the deep inguinal ring and the transverse colon is too superior to be involved.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 3
Correct
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The pattern of drainage of the lymphatic and venous systems of the anterior abdominal wall is arranged around a horizontal plane above which drainage is in a cranial direction and below which drainage is in a caudal direction. Which horizontal plane is being referred to?
Your Answer: Level of the umbilicus
Explanation:The umbilicus is a key landmark for the lymphatic and venous drainage of the abdominal wall. Above it, lymphatics drain into the axillary lymph nodes and the venous blood drains into the superior epigastric vein, into the internal thoracic vein. Below it, lymphatics drain into the superficial inguinal lymph nodes while venous blood drains into the inferior epigastric vein and the external iliac vein.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 4
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 5
Correct
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Which of the cranial nerves is responsible for touch sensation on the skin over the maxilla region and the mandible?
Your Answer: Trigeminal
Explanation:The sensation of the face is provided by the trigeminal nerve which is cranial nerve V. It is also responsible for other motor functions such as biting and chewing. The trigeminal nerve has three branches; the ophthalmic nerve (V1), the maxillary nerve((V2) and the mandibular nerve (V3). These three branches exit the skull through separate foramina, namely; the superior orbital fissure, the foramen rotundum and the foramen ovale respectively. The mnemonic for this is ‘Standing room only’. The sensory fibres of the maxillary nerve are distributed to the lower eyelid and cheek, the nares and upper lip, the upper teeth and gums, the nasal mucosa, the palate and roof of the pharynx, the maxillary, ethmoid and sphenoid sinuses, and parts of the meninges. The sensory fibres of the mandibular nerve are distributed to the lower lip, the lower teeth and gums, the floor of the mouth, the anterior two-thirds of the tongue, the chin and jaw (except the angle of the jaw, which is supplied by C2–C3), parts of the external ear, and parts of the meninges. The mandibular nerve carries touch/ position and pain/temperature sensation from the mouth. The sensory fibres of the ophthalmic nerve are distributed to the scalp and forehead, the upper eyelid, the conjunctiva and cornea of the eye, the nose (including the tip of the nose), the nasal mucosa, the frontal sinuses and parts of the meninges (the dura and blood vessels). The sensory fibres of the maxillary nerve are distributed to the lower eyelid and cheek, the nares and upper lip, the upper teeth and gums, the nasal mucosa, the palate and roof of the pharynx, the maxillary, ethmoid and sphenoid sinuses, and parts of the meninges.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 6
Correct
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Muscles and tendons in the planter region of the foot mainly take blood supply from:
Your Answer: Posterior tibial artery
Explanation:The posterior tibial artery is the main source of blood supply to the posterior compartment of the leg.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 7
Incorrect
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Regarding the long head of the biceps femoris, which of the following is correct?
Your Answer: It arises from the same point as the gracilis muscle
Correct Answer: It crosses two joints
Explanation:The long head of the biceps femoris arises from the lower and inner impression on the back of the tuberosity of the ischium. It inserts with the short head in an aponeurosis which becomes a tendon and this tendon is inserted into the lateral side of the head of the fibula and the lateral condyle of the tibia, thus crossing two joints.
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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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The operating surgeon notices a structure lying alongside a herniated mass whilst repairing an indirect inguinal hernia in a female patient. Which structure could this be?
Your Answer: Round ligament of the uterus
Explanation:The main structure traversing the inguinal canal in women is the round ligament. In men, it is the spermatic cord.
The iliohypogastric nerve innervates the abdominal wall and runs between the transversus abdominis and internal oblique muscles before piercing the internal oblique at the anterior superior iliac spine to run between the internal and external obliques.
The inferior epigastric artery is between the peritoneum and the transversus abdominis creating the lateral umbilical fold.
The ovarian artery and the ovarian vein are branches from the descending aorta and inferior vena cava that supply the ovary in the pelvic cavity.
The pectineal ligament is a thick fascial layer over the pectineal line of the pubis. It doesn’t traverse the canal.
The broad ligament if found on the lateral sides of the uterus. -
This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 9
Correct
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A 25-year-old male is found to have a 5cm carcinoid tumour of the appendix. Imaging and diagnostic workup show no distant diseases. What is the best course of action?
Your Answer: Right hemicolectomy
Explanation:Carcinoid tumours are of neuroendocrine origin and derived from primitive stem cells in the gut wall, especially the appendix.
Signs and symptoms of carcinoid tumours vary greatly. Carcinoid tumours can be non-functioning presenting as a tumour mass or functioning. The sign and symptoms of a non-functioning tumour depend on the tumour location and size as well as on the presence of metastases. Therefore, findings range from no tumour-related symptoms (most carcinoid tumours) to full symptoms of carcinoid syndrome (primarily in adults).
– Periodic abdominal pain: Most common presentation for a small intestinal carcinoid; often associated with malignant carcinoid syndrome
– Cutaneous flushing: Early and frequent (94%) symptom
– Diarrhoea and malabsorption (84%)
– Cardiac manifestations (60%): Valvular heart lesions, fibrosis of the endocardium; may lead to heart failure with tachycardia and hypertension
– Wheezing or asthma-like syndrome (25%)
– Pellagra
– Carcinoid crisis can be the most serious symptom of carcinoid tumours and can be life-threatening. It can occur suddenly, after stress, or following chemotherapy and anaesthesia.Two surgical procedures can be applied to treat appendiceal Neuroendocrine Neoplasm (NEN): simple appendicectomy and oncological right-sided hemicolectomy.
– For T1 (ENETS) or T1a (UICC/AJCC) NEN (i.e. <1 cm), generally simple appendicectomy is curative and sufficient.
– For NEN >2 cm with a T3 stage (ENETS) or higher and T2 (UICC/AJCC) or higher respectively, a right-sided hemicolectomy is advised due to the increased risk of lymph node metastasis and long-term tumour recurrence and/or distant metastasis. The right-sided hemico- lectomy should be performed either as the initial surgical intervention should the problem be overt at that time, or during a second intervention. -
This question is part of the following fields:
- Colorectal Surgery
- Generic Surgical Topics
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Question 10
Correct
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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: 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 11
Correct
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The primary somatosensory cortex is located in the:
Your Answer: Postcentral gyrus
Explanation:The primary somatic sensory cortex is located in the postcentral gyrus and is the largest cortical receiving area for information from somatosensory receptors. Through corticocortical fibres, it then sends the information to other areas of the neocortex and further analysis takes place in the posterior parietal association cortex.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 12
Correct
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Which of the following muscles attaches to the pterygomandibular raphe?
Your Answer: Superior pharyngeal constrictor muscle
Explanation:The pterygomandibular raphé (pterygomandibular ligament) provides attachment on its posterior border to the superior pharyngeal constrictor and on its anterior border to the buccinator muscle.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 13
Correct
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A 64 year old man with a history of recurrent anal cancer undergoes a salvage abdominoperineal excision of the anus and rectum. He was treated with radical chemotherapy prior to the procedure. At the conclusion of the surgery, there is a 10cm by 10cm perineal skin defect. Which of the following closure options would be most appropriate in this case?
Your Answer: Pedicled myocutaneous flap
Explanation:As a reconstructive option after extensive surgery, pedicled musculocutaneous flaps offer several advantages in the setting of previous radiotherapy. Rotational skin flaps will comprise of irradiated tissue and thus won’t heal well.
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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 14
Correct
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The surgical registrar is doing an exploratory laparotomy on a 35 year old lady of African descent with tuberculous of the abdomen and suspected perforation. The small bowel is matted due to adhesions and it is difficult to differentiate the ileum from the jejunum. Which of the following features is typical of the jejunum?
Your Answer: It has sparse aggregated lymph nodules
Explanation:The jejunum has a wider diameter, is thicker and more vascularized, hence of a deeper colour compared to the ileum. The valvulae conniventes (circular folds) of its mucous membranes are large and thick and its villi are larger than those in the ileum. The jejunum also has sparse aggregates of lymph nodules and most of its part occupies the umbilical and left iliac regions whilst the ileum is mostly in the umbilical, hypogastric, right iliac and pelvic regions.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 15
Incorrect
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A 30-year-old woman presents with a history of severe epigastric pain that worsens post prandially. On examination, the abdomen is soft and non tender with no palpable mass felt. However, a bruit is heard in the epigastrium, on auscultation. Imaging with USS shows no gallstones and OGD is normal as well. What is the most likely diagnosis?
Your Answer: Sphincter of Oddi dysfunction
Correct Answer: Median arcuate ligament syndrome
Explanation:The most likely diagnosis is median arcuate ligament syndrome (MALS).
MALS, also known as coeliac artery compression syndrome, is a condition characterized by abdominal pain attributed to compression of the coeliac artery and the coeliac ganglia by the median arcuate ligament. The pain may be related to meals, may be accompanied by weight loss, and may be associated with an abdominal bruit.
The diagnosis of MALS is one of exclusion, as many healthy patients demonstrate some degree of coeliac artery compression in the absence of symptoms. Consequently, a diagnosis of MALS is typically only entertained after more common conditions have been ruled out. Once suspected, screening for MALS can be done with USS and confirmed with CT or MRI scan.
Treatment is generally surgical, the mainstay being open or laparoscopic division or separation of the median arcuate ligament combined with removal of the celiac ganglia. The majority of patients benefit from surgical intervention. Poorer responses to treatment tend to occur in patients of older age, those with a psychiatric condition or who use alcohol, have abdominal pain unrelated to meals, or who have not experienced weight loss.
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This question is part of the following fields:
- Generic Surgical Topics
- Vascular
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Question 16
Correct
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A 47 year old accountant presents with symptoms of biliary colic and tests confirmed the diagnosis of gallstones. Which of the procedures listed below would most likely increase the risk of gallstone formation?
Your Answer: Ileal resection
Explanation:Ileal resection may lead to bile acid malabsorption and an altered biliary lipid composition. A “bile acid deficiency” in the enterohepatic circulation with a relative excess of cholesterol and cholesterol supersaturated bile might ensue, causing cholesterol gallstone formation.
In patients with Crohn’s disease involving the small
intestine, the prevalence of gall-bladder stones is higher
than that in the general population. One hypothesis
for this increased risk is that bile acid malabsorption,
secondary to impaired active bile acid transport as a
consequence of ileal disease/resection, leads to a
reduction in the total bile acid pool size and an increase
in biliary cholesterol saturation. In patients with
ulcerative or Crohn’s colitis, or who have undergone
colectomy, the bile acid malabsorption is less than that
in those with ileal dysfunction or resection, but the risk
of gallstone formation is still increased, allegedly by the
same mechanism. -
This question is part of the following fields:
- Generic Surgical Topics
- Hepatobiliary And Pancreatic Surgery
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Question 17
Correct
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When a patient that is less than 21 years of age develops a bone tumour. What is the most common benign bone tumour that would be considered in individuals below 21 years?
Your Answer: Osteochondroma
Explanation:Osteochondroma is a benign new bone growth that protrudes from the outer contour of bones and is capped by growing cartilage. Nearly 80% of these lesions are noted before the age of 21 years.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 18
Incorrect
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A 13 year old boy is admitted to the surgical ward with appendicitis. Medical history shows that he has been taking Metoclopramide. He is normally fit and well. However, he is reported to be acting strange and on examination, he is agitated with a clenched jaw and eyes are deviated upwards. What is his diagnosis?
Your Answer: Serotonin syndrome
Correct Answer: Oculogyric crisis
Explanation:Answer: Oculogyric crisis
Oculogyric crisis is an acute dystonic reaction of the ocular muscles characterized by bilateral dystonic elevation of visual gaze lasting from seconds to hours. This reaction is most commonly explained as an adverse reaction to drugs such as antiemetics, antipsychotics, antidepressants, antiepileptics, and antimalarials. Metoclopramide is a benzamide selective dopamine D2 receptor antagonist that is used as an antiemetic, with side effects that are seen frequently in children.1 The most common and most important side effects of metoclopramide are acute extrapyramidal symptoms, which require immediate treatment. Acute dystonic reactions occur as contractions of the muscles, opisthotonos, torticollis, dysarthria, trismus, and oculogyric crisis.
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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 19
Correct
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Decreased velocity of impulse conduction through the atrioventricular node (AV node) in the heart will lead to:
Your Answer: Increased PR interval
Explanation:AV node damage may lead to an increase in the PR interval to as high as 0.25 – 0.40 s (normal = 0.12 – 0.20 s). In the case of severe impairment, there might be a complete failure of passage of impulses leading to complete block. In this case, the atria and ventricles will beat independently of each other.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 20
Incorrect
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A 44 year old actor presents with an attack of mild acute pancreatitis. Imaging identifies gallstones but a normal calibre bile duct, and a peripancreatic fluid collection. Which management option would be the most appropriate?
Your Answer: Insertion of a radiological drain
Correct Answer: Cholecystectomy once the attack has settled
Explanation:Pancreatitis is inflammation of the pancreas with variable involvement of regional tissues or remote organ systems. Acute pancreatitis (AP) is characterized by severe pain in the upper abdomen and elevation of pancreatic enzymes in the blood. In the majority of patients,
Biliary pancreatitis should always be treated eventually with a cholecystectomy after the process has subsided.
Feeding should be introduced enterally as the patient’s anorexia and pain resolves.
The use of nasogastric aspiration offers no clear advantage in patients with mild AP, but is beneficial in patients with profound pain, severe disease, paralytic ileus, and intractable vomiting.
AP is a mild, self-limiting disease that resolves spontaneously without complications. Patients can be initiated on a low-fat diet initially and need not invariably start their dietary advancement using a clear liquid diet. Systematic reviews and meta-analyses have shown that administration of enteral nutrition may reduce mortality and infectious complications compared with parenteral nutrition. Although the ideal timing to initiate enteral feeding remains undetermined, administration within 48 hours appears to be safe and tolerated. -
This question is part of the following fields:
- Generic Surgical Topics
- Hepatobiliary And Pancreatic Surgery
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Question 21
Correct
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Which of the following arteries, if ligated, will most likely affect blood supply to the pancreas?
Your Answer: Superior mesenteric
Explanation:The pancreas is a glandular organ in the body that produces important hormones such as insulin and glucagon. Its blood supply is from branches of the coeliac artery, superior mesenteric artery and the splenic artery. These are the arteries that if ligated, would affect blood supply to the pancreas.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 22
Incorrect
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A teenager presents with pain and swelling in a limb which increases after activity. X-rays reveal an expansible, eccentric, lytic lesion in the metaphysis distally in the affected bone surrounded by new bone. What is the most likely diagnosis?
Your Answer: Osteosarcoma
Correct Answer: Aneurysmal bone cyst
Explanation:Aneurysmal bone cysts tend to develop in patients younger than 20 years old. They usually occur in the metaphyseal region of long bones, and are cystic lesions composed of numerous blood filled channels that grow slowly. In X-rays, they show up as circumscribed lesions, sometimes surrounded by new bone.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 23
Correct
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A 45 year old female had a stroke and was diagnosed with a homonymous hemianopsia. Which of the following structures was likely affected?
Your Answer: Optic radiation
Explanation:Hemianopia or hemianopsia, is the loss of vision of half of the eye or loss of half the visual field. Homonymous hemianopia is the loss of vision or blindness on half of the same side of both eyes (visual field) – either both lefts of the eyes or both rights of the eyes. This condition is mainly caused by cerebrovascular accidents like a stroke that affects the optic radiation.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 24
Correct
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A 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: 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 25
Correct
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A 23 year old woman is Rh -ve and she delivered a baby with a Rh+ blood group. What measure can be performed to prevent Rh incompatibility in the next pregnancy?
Your Answer: Immunoglobulin D
Explanation:Rh disease is also known as erythroblastosis fetalis and is a disease of the new-born. In mild states it can cause anaemia with reticulocytosis and in severe forms causes severe anaemia, morbus hemolytcus new-born and hydrops fetalis. RBCs of the Rh+ baby can cross the placenta and enter into the maternal blood. As she is Rh- her body will form antibodies against the D antigen which will pass through the placenta in subsequent pregnancies.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 26
Correct
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A 32 year old woman presents to the ER with recurrent episodes of non specific abdominal pain. The labs including blood tests appear to be normal. Ct scan is done for further evaluation. The CT reveals a 1.5 cm nodule in the right adrenal gland that is associated with a lipid rich core. Urinary VMA is found to be within the normal range. Which of the following is the most likely diagnosis?
Your Answer: Benign non functional adenoma
Explanation:Adrenal adenomas are benign tumours of the adrenal glands, which can be either functioning or non-functioning. Though the majority are clinically silent, functional adenomas from the cortex of medulla can lead to overproduction of any of their associated hormones. Benign adenomas often have a lipid rich core that is readily identifiable on CT scanning. In addition the nodules are often well circumscribed.
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This question is part of the following fields:
- Breast And Endocrine Surgery
- Generic Surgical Topics
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Question 27
Correct
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A 35-year-old female notices bloody discharge from her left nipple. She is, otherwise, asymptomatic. On examination, there are no discrete lesions to feel, and mammography shows dense breast tissue but no mass lesion.What is the most likely cause?
Your Answer: Intraductal papilloma
Explanation:Intraductal papilloma is the most common cause of blood-stained nipple discharge in young females.
An intraductal papilloma is a benign breast condition that develops in one or more of the milk ducts in the
breast. It is usually close to the nipple, but can
sometimes be found elsewhere in the breast. It most commonly occurs in women between ages 35–55 and generally does not increase the risk of developing breast cancer. There are no known risk factors for intraductal papilloma.Signs and symptoms include:
1. Small lump or a discharge of
clear or blood-stained fluid from the nipple
2. Discomfort or pain around the area (usually not painful)Diagnosis can be made by:
1. Breast examination
2. Mammogram
3. Ultrasound scan
4. Core biopsy
5. Fine needle aspirationWomen under the age of 40 are more likely to have an
ultrasound scan than a mammogram. The breast tissue in such patients can be dense which can
make the X-ray image in a mammogram less clear.
However, some women under 40 may still have
a mammogram.Intraductal papillomas are often removed using
surgery. The surgical options include:
1. Excision biopsy
2. Vacuum assisted excision biopsyIf nipple discharge continues, then further surgical options are explored:
1. Microdochectomy (removal of the affected duct or ducts)
2. Total duct excision (removal of all the major ducts) -
This question is part of the following fields:
- Breast And Endocrine Surgery
- Generic Surgical Topics
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Question 28
Correct
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Lung compliance is increased by:
Your Answer: Emphysema
Explanation:Lung compliance is increased by emphysema, acute asthma and increasing age and decreased by alveolar oedema, pulmonary hypertension, atelectasis and pulmonary fibrosis.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 29
Correct
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A 30 year old man suffered severe blood loss, approx. 20-30% of his blood volume. What changes are most likely seen in the pulmonary vascular resistance (PVR) and pulmonary artery pressure (PAP) respectively following this decrease in cardiac output?
Your Answer: Increase Decrease
Explanation:Hypovolemia will result in the activation of the sympathetic adrenal discharge resulting is a decrease pulmonary artery pressure and an elevated pulmonary vascular resistance.
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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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All the following statements are FALSE regarding the ophthalmic division of the trigeminal nerve, except:
Your Answer: It provides sensory innervation for most of the globe and motor innervation to smooth muscle in the globe
Correct Answer: The ophthalmic nerve is the smallest branch of the trigeminal nerve
Explanation:The ophthalmic nerve is the smallest of the three trigeminal divisions. The cutaneous branches of the ophthalmic nerve supply the conjunctiva, the skin over the forehead, the upper eyelid, and much of the external surface of the nose.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 31
Incorrect
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A 45-year-old female is receiving chemotherapy for the treatment of metastatic breast cancer. You are called because it has become apparent that her doxorubicin infusion has extravasated. What is the most appropriate course of action?
Your Answer: Stop the infusion and apply a warm compress to the site
Correct Answer: Stop the infusion and apply a cold compress to the site
Explanation:Extravasation is the process by which any liquid (fluid or drug) accidentally leaks into the surrounding tissue. In terms of cancer therapy, extravasation refers to the inadvertent infiltration of chemotherapy into the subcutaneous or subdermal tissues surrounding the intravenous or intra-arterial administration site.
Extravasated drugs are classified according to their potential for causing damage as ‘vesicant’, ‘irritant’ and ‘non-vesicant’.
Doxorubicin is one of the vesicant drugs.
Regardless of the chemotherapy drug, early initiation of treatment is considered mandatory. In this context, patient education is crucial for prompt identification of the extravasation.
Step 1: Stop the infusion and leave the needle in place
Step 2: Identify the extravasated agent
Step 3: Leave the cannula in place, gently aspirate the agent and avoid manual compression, then remove the cannula
Step 4: Use a pen to outline the extravasated area
Step 5: Start Specific measures
Step 5A: For Anthracyclines (Doxorubicin), Apply cold compressions for 20 minutes, 4 times daily for 1-2 days.
Step 5B: Using Specific Antidotes as Topical Dimethyl sulfoxide (DMSO) or Dexrazoxane -
This question is part of the following fields:
- Oncology
- Principles Of Surgery-in-General
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Question 32
Correct
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An old man presented with atrophy of the thenar eminence despite the sensation over it still being intact. What is the injured nerve in this case?
Your Answer: Median nerve
Explanation:Atrophy of the thenar muscles means injury to the motor supply of these muscles. The nerve that sends innervation to it is the median nerve. But the median nerve does not provide sensory innervation to the overlying skin so sensation is spared.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 33
Correct
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The ability of the bacteria to cause disease or its virulence is related to :
Your Answer: Toxin and enzyme production
Explanation:The pathogenicity of an organism or its ability to cause disease is determined by its virulence factors. Many bacteria produce virulence factors that inhibit the host’s immune system. The virulence factors of bacteria are typically proteins or other molecules that are synthesized by enzymes. These proteins are coded for by genes in chromosomal DNA, bacteriophage DNA or plasmids. The proteins made by the bacteria can poison the host cells and cause tissue damage.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 34
Correct
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A 30-year old lady was admitted to the general surgical ward after a diagnosis of perforation of the first part of the duodenum that resulted from a long standing ulcer. If this perforation led to the expulsion of the gastric content that resulted to the erosion of an artery found in this part of the duodenum (the posterior of the first part of the duodenum). Which of the following arteries is this most likely to be?
Your Answer: Gastroduodenal
Explanation:The proximal part of the duodenum is supplied by the gastroduodenal artery. This artery is found descending behind the first part of the duodenum after branching from the hepatic artery. If gastric content was to be expelled in the posterior portion of the first part of the duodenum, then this artery would be most likely to be damaged. The common hepatic artery and the left gastric artery are branches of the coeliac trunk that are found superior to the duodenum. The proper hepatic artery is a branch of the common hepatic artery also found superior to the duodenum. The superior mesenteric artery is found behind the pancreas as a branch of the aorta that is at the bottom of the L1 level. The right gastric artery arises above the pylorus from the proper hepatic artery and supplies the lesser curvature of the stomach. The intestinal arteries supply the ileum and the jejunum.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 35
Correct
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A urologist makes a transverse suprapubic incision to retrieve a stone from the urinary bladder. Which of the following abdominal wall layers will the surgeon NOT traverse?
Your Answer: Posterior rectus sheath
Explanation:Pfannenstiel incision (a transverse suprapubic incision) is made below the arcuate line. Thus, there is no posterior layer of the rectus sheath here, only the transversalis fascia lines the inner layer of the rectus abdominis. The layers traversed include: skin, superficial fascia (fatty and membranous), deep fascia, anterior rectus sheath, rectus abdominis muscle, transversalis fascia, extraperitoneal connective tissue and peritoneum.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 36
Correct
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The vascular structure found on the right side of the fifth lumbar vertebra is?
Your Answer: Inferior vena cava
Explanation:The most likely vascular structure is the inferior vena cava. The inferior vena cava is formed by the joining of the two common iliac arteries, the right and the left iliac artery, at the level of the fifth lumbar vertebra( L5). The inferior vena cava passes along the right side of the vertebral column. It enters the thoracic cavity into the underside of the heart through the caval opening of the diaphragm at the level of the eight thoracic vertebra (T8).
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 37
Correct
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Which of the following statements regarding the arteries in the neck are TRUE?
Your Answer: The thyrocervical trunk typically gives rise to the inferior thyroid artery, transverse cervical artery and suprascapular artery
Explanation:The thyrocervical trunk is one of the three branches of the first part of the subclavian artery and gives numerous branches which supply viscera of the neck, the brachial plexus, neck muscles and scapular anastomoses. The vertebral arteries are major arteries of the neck. They arise as branches from the subclavian arteries and merge to form the single midline basilar artery. The carotid sinus is a dilated area at the base of the internal carotid artery just superior to the bifurcation of the internal carotid and external carotid at the level of the superior border of thyroid cartilage.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 38
Correct
-
Which one of the following muscles is innervated by the facial nerve?
Your Answer: Buccinator
Explanation:Buccinator is a muscle of facial expression and is therefore innervated by the facial nerve. The lateral pterygoid, masseter, anterior belly of digastric and temporalis are all muscles of mastication and therefore innervated by the mandibular division of the trigeminal nerve.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 39
Correct
-
During cardiac catheterisation in a 20-year old man, the following data is obtained: Pressure (mmHg), O2 saturation (%) Right atrium 7 (N = 5) 90 (N = 75), Right ventricle 35/7 (N = 25/5) 90 (N = 75), Pulmonary artery 35/8 (N = 25/15), 90 (N = 75), Left atrium 7 (N = 9) 95 (N = 95), Left ventricle 110/7 (N = 110/9) 95 (N = 95), Aorta 110/75 (N = 110/75) 95 (N = 95) where N = Normal value. What is the likely diagnosis?
Your Answer: Atrial septal defect
Explanation:A congenital heart disease, ASD or atrial septal defect leads to a communication between the right and left atria due to a defect in the interatrial septum. This leads to mixing of arterial and venous blood from the right and left side of the heart. The hemodynamic significance of this defect depends on the presence of shunting of blood. Normally, the left side of the heart has higher pressure than the right as the left side has to pump blood throughout the body. A large ASD (> 9 mm) will result in a clinically significant left-to-right shunt, causing volume overload of the right atrium and ventricle, eventually leading to heart failure. Cardiac catheterization would reveal very high oxygen saturation in the right atrium, right ventricle and pulmonary artery. Eventually, the left-to-right shunt will lead to pulmonary hypertension and increased afterload in the right ventricle, along with the increased preload due to the shunted blood. This will either cause right ventricular failure, or raise the pressure in the right side of the heart to equal or more than that in the left. Elevation of right atrial pressure to that of left atrial pressure would thus lead to diminishing or complete cessation of the shunt. If left uncorrected, there will be reversal of the shunt, known as Eisenmenger syndrome, resulting in clinical signs of cyanosis as the oxygen-poor blood form right side of the heart will mix with the blood in left side and reach the peripheral vascular system.
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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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A 33 year old woman, with invasive ductal carcinoma, presents with a lesion suspicious for metastatic disease in the left lobe of her liver. Past history includes wide local excision and axillary node clearance (5 nodes present) of the tumour. It is oestrogen receptor negative and HER 2 positive with vascular invasion. Which of the following agents will be the most beneficial in this setting?
Your Answer: Trastuzumab
Explanation:The treatment approach primarily depends on the histopathologic classification and the disease stage and involves a combination of surgical management, radiation therapy, and systemic therapy. Surgical management is either breast-conserving therapy (BCT) or mastectomy. Systemic therapy has significantly improved in recent years with the development of hormone therapy (tamoxifen) and targeted therapy (trastuzumab). The most important prognostic factors are lymph node status, tumour size, patient’s age, and tumour receptor status (hormone receptors and HER2).
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This question is part of the following fields:
- Breast And Endocrine Surgery
- Generic Surgical Topics
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Question 41
Incorrect
-
Calculate the cardiac output of a patient with the following measurements: oxygen uptake 200 ml/min, oxygen concentration in the peripheral vein 7 vol%, oxygen concentration in the pulmonary artery 10 vol% and oxygen concentration in the aorta 15 vol%.
Your Answer: 3500 ml/min
Correct Answer: 4000 ml/min
Explanation:The Fick’s principle states that the uptake of a substance by an organ equals the arteriovenous difference of the substance multiplied by the blood flowing through the organ. We can thus calculate the pulmonary blood flow with pulmonary arterial (i.e., mixed venous) oxygen content, aortic oxygen content and oxygen uptake. The pulmonary blood flow, systemic blood flow and cardiac output can be considered the same assuming there are no intracardiac shunts. Thus, we can calculate the cardiac output. Cardiac output = oxygen uptake/(aortic − mixed venous oxygen content) = 200 ml/min/(15 ml O2/100 ml − 10 ml O2/100 ml) = 200 ml/min/(5 ml O2/100 ml) = 200 ml/min/0.05 = 4000 ml/min.
It is crucial to remember to use pulmonary arterial oxygen content and not peripheral vein oxygen content, when calculating the cardiac output by Fick’s method. -
This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 42
Correct
-
A young man is brought to the doctor and a lesion is seen on the dorsal surface of his right hand. It is examined and it is found to be a soft fluctuant swelling which is more pronounced when he is making a fist. What is the possible nature of the lesion?
Your Answer: Ganglion
Explanation:Answer: Ganglion
A ganglion cyst is a fluid-filled swelling that usually develops near a joint or tendon. The cyst can range from the size of a pea to the size of a golf ball. Ganglion cysts look and feel like a smooth lump under the skin.
They’re made up of a thick, jelly-like fluid called synovial fluid, which surrounds joints and tendons to lubricate and cushion them during movement.
Ganglions can occur alongside any joint in the body, but are most common on the wrists (particularly the back of the wrist), hands and fingers.
Ganglions are harmless, but can sometimes be painful. If they do not cause any pain or discomfort, they can be left alone and may disappear without treatment, although this can take a number of years.
It’s not clear why ganglions form. They seem to happen when the synovial fluid that surrounds a joint or tendon leaks out and collects in a sac.
They are most common in younger people between the ages of 15 and 40 years, and women are more likely to be affected than men. These cysts are also common among gymnasts, who repeatedly apply stress to the wrist. -
This question is part of the following fields:
- Generic Surgical Topics
- Orthopaedics
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Question 43
Incorrect
-
A 45-year-old male has symptoms of carcinoid syndrome. Which of the following is the most effective therapeutic agent in controlling the symptoms?
Your Answer: Glucagon
Correct Answer: Octreotide
Explanation:Carcinoid syndrome occurs in ∼20% of cases of well-differentiated endocrine tumours of the jejunum or ileum (midgut neuroendocrine tumours (NET) and consists of (usually) dry flushing (without sweating; 70% of cases) with or without palpitations, diarrhoea (50% of cases) and intermittent abdominal pain (40% of cases); in some patients, there is also lacrimation and rhinorrhoea.
Carcinoid syndrome occurs less often with NETs of other origins and is very rare in association with rectal NETs. It is usually due to metastasis to the liver, with the release of vasoactive compounds, including biogenic amines (e.g., serotonin and tachykinins), into the systemic circulation. However, it may also occur in the absence of liver metastases if there is direct retroperitoneal involvement, with venous drainage bypassing the liver. Pain due to hepatic enlargement may also be a presenting feature, as may upper right abdominal pain (similar to that of pulmonary infarction) secondary to either haemorrhage into, or necrosis of, a hepatic secondary tumour. Wheezing and pellagra are less common presenting features. CHD is present in ∼20% of patients at presentation and usually indicates that the syndrome has been present for several years.The aim of treatment should be curative where possible but it is palliative in the majority of cases.
Surgery is the only curative treatment.
Administration of specific medications to treat symptoms should, therefore, start as soon as clinical and biochemical signs indicate the presence of hypersecretory NETs, even before the precise localisation of primary and metastatic lesions is confirmed.The only proven hormonal management of NETs is by the administration of somatostatin analogues.
Somatostatin analogues bind principally to SSTR subtypes 2 (with high affinity) and 5 (with lower affinity), thus inhibiting the release of various peptide hormones in the gut, pancreas and pituitary; they also antagonise growth factor effects on tumour cells, and, at very high dosage, may induce apoptosis. The effects of somatostatin analogues are demonstrable as biochemical response rates (inhibition of hormone production) in 30–70% of patients and as symptomatic control in the majority of patients.
There are two commercially available somatostatin analogues: octreotide and lanreotide. -
This question is part of the following fields:
- Principles Of Surgery-in-General
- Surgical Technique And Technology
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Question 44
Incorrect
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A 77-year-old woman's renal function is tested. The following results were obtained during a 24-h period: Urine flow rate: 2. 0 ml/min, Urine inulin: 0.5 mg/ml, Plasma inulin: 0.02 mg/ml, Urine urea: 220 mmol/l, Plasma urea: 5 mmol/l. What is the urea clearance?
Your Answer: 320 ml/min
Correct Answer: 88 ml/min
Explanation:Urea is reabsorbed in the inner medullary collecting ducts of the nephrons. The clearance (C) of any substance can be calculated as follows: C = (U × V)/P, where U and P are the urine and plasma concentrations of the substance, respectively and V is the urine flow rate. So, glomerular filtration rate = (0.220 × 2. 0)/0.005 = 88 ml/min.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 45
Correct
-
A 22-year-old male presents with a 10-day history of right-sided abdominal pain. Prior to this, he was well. On examination, he has a low-grade fever and a palpable mass in the right iliac fossa. The rest of his abdomen is soft. An abdominal USS demonstrates matted bowel loops surrounding a thickened appendix. What is the best course of action?
Your Answer: Manage conservatively with antibiotics
Explanation:The patient mostly has an appendicular mass.
At present, the treatment of choice for uncomplicated acute appendicitis in adults continues to be surgical. The inflammation in acute appendicitis may sometimes be enclosed by the patient’s own defence mechanisms, by the formation of an inflammatory phlegmon or a circumscribed abscess. The management of these patients is controversial. An immediate appendectomy may be technically demanding. The exploration often ends up in an ileocecal resection or a right-sided hemicolectomy. Recently, the conditions for conservative management of these patients have changed due to the development of computed tomography and ultrasound, which has improved the diagnosis of enclosed inflammation and made drainage of intra-abdominal abscesses easier. New efficient antibiotics have also given new opportunities for nonsurgical treatment of complicated appendicitis. The traditional management of these patients is nonsurgical treatment followed by interval appendectomy to prevent a recurrence. The need for interval appendectomy after successful nonsurgical treatment has recently been questioned because the risk of recurrence is relatively small.
In patients with suspicion of contained appendiceal inflammation, based on a palpable mass or long duration of symptoms, the diagnosis should be confirmed by imaging techniques, especially CT scan. The patient should receive primary nonsurgical treatment with antibiotics and abscess drainage as needed. After successful nonsurgical treatment, no interval appendectomy is indicated in some cases, but the patient should be informed about the risk of recurrence especially in the presence of appendicolith. The risk of missing another underlying condition (cancer or CD) is low, but motivates a follow-up with a colon examination and/or a CT scan or US, especially in patients above the age of 40 years. -
This question is part of the following fields:
- Generic Surgical Topics
- The Abdomen
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Question 46
Incorrect
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A 29 year old female bus driver presents to her family doctor with severe retrosternal chest pain and recurrent episodes of dysphagia. She states that these occur at irregular intervals and often resolve spontaneously. There are no physical abnormalities on examination and she seems well. What is her diagnosis?
Your Answer: Gastro-oesophageal reflux
Correct Answer: Achalasia
Explanation:Answer: Achalasia
Achalasia is a primary oesophageal motility disorder characterized by the absence of oesophageal peristalsis and impaired relaxation of the lower oesophageal sphincter (LES) in response to swallowing. The LES is hypertensive in about 50% of patients. These abnormalities cause a functional obstruction at the gastroesophageal junction (GEJ).
Symptoms of achalasia include the following:Dysphagia (most common)
Regurgitation
Chest pain (behind the sternum)
Heartburn
Weight loss
Physical examination is non-contributory.
Treatment recommendations are as follows:
Initial therapy should be either graded pneumatic dilation (PD) or laparoscopic surgical myotomy with a partial fundoplication in patients fit to undergo surgery
Procedures should be performed in high-volume centres of excellence
Initial therapy choice should be based on patient age, sex, preference, and local institutional expertise
Botulinum toxin therapy is recommended for patients not suited to PD or surgery
Pharmacologic therapy can be used for patients not undergoing PD or myotomy and who have failed botulinum toxin therapy (nitrates and calcium channel blockers most common).
The invasion of the oesophageal neural plexus by the tumour can cause nonrelaxation of the LES, thus mimicking achalasia. This condition is known as malignant pseudo achalasia. Since contrast radiography and endoscopy frequently fail to differentiate these 2 entities, patients with a presumed diagnosis of achalasia but who have a shorter duration of symptoms, greater weight loss, and a more advanced age and who are referred for minimally invasive surgery should undergo additional imaging studies, including endoscopic ultrasound and computed tomography with fine cuts of the gastroesophageal junction, to rule out cancer.
Effort rupture of the oesophagus, or Boerhaave syndrome, is a spontaneous perforation of the oesophagus that results from a sudden increase in intraoesophageally pressure combined with negative intrathoracic pressure (e.g., severe straining or vomiting). The classic clinical presentation of Boerhaave syndrome usually consists of repeated episodes of retching and vomiting, typically in a middle-aged man with recent excessive dietary and alcohol intake.
These repeated episodes of retching and vomiting are followed by a sudden onset of severe chest pain in the lower thorax and the upper abdomen. The pain may radiate to the back or to the left shoulder. Swallowing often aggravates the pain.
Typically, hematemesis is not seen after oesophageal rupture, which helps to distinguish it from the more common Mallory-Weiss tear.
Swallowing may precipitate coughing because of the communication between the oesophagus and the pleural cavity. Shortness of breath is a common complaint and is due to pleuritic pain or pleural effusion.
A pulmonary embolism is a blood clot that occurs in the lungs.
It can damage part of the lung due to restricted blood flow, decrease oxygen levels in the blood, and affect other organs as well. Large or multiple blood clots can be fatal.
The most common symptom of a pulmonary embolism is shortness of breath. This may be gradual or sudden.Other symptoms of a pulmonary embolism include:
anxiety
clammy or bluish skin
chest pain that may extend into your arm, jaw, neck, and shoulder
fainting
irregular heartbeat
light-headedness
rapid breathing
rapid heartbeat
restlessness
spitting up blood
weak pulse -
This question is part of the following fields:
- Emergency Medicine And Management Of Trauma
- Principles Of Surgery-in-General
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Question 47
Incorrect
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As per the Poiseuille-Hagen formula, doubling the diameter of a vessel will change the resistance of the vessel from 16 peripheral resistance units (PRU) to:
Your Answer: 32 PRU
Correct Answer: 1 PRU
Explanation:Poiseuille-Hagen formula for flow in along narrow tube states that F = (PA– PB) × (Π/8) × (1/η) × (r4/l) where F = flow, PA– PB = pressure difference between the two ends of the tube, η = viscosity, r = radius of tube and L = length of tube. Also, flow is given by pressure difference divided by resistance. Hence, R = 8ηL ÷ Πr4. Hence, the resistance of the vessel changes in inverse proportion to the fourth power of the diameter. So, if the diameter of the vessel is increased to twice the original, it will lead to decrease in resistance to one-sixteenth its initial value.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 48
Correct
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A 58 year old lady who has had a mastectomy undergoes a breast reconstruction surgery. The breast implant is placed just anterior to her pectoralis major muscle. Which of the following methods of wound closure would be the most appropriate in this case?
Your Answer: Use of a pedicled myocutaneous flap
Explanation:The latissimus dorsi myocutaneous flap (LDMF) is one of the most reliable and versatile flaps used in reconstructive surgery. It is known for its use in chest wall and postmastectomy reconstruction and has also been used effectively for coverage of large soft tissue defects in the head and neck, either as a pedicled flap or as a microvascular free flap.
The latissimus dorsi may be transferred as a myofascial flap, a myocutaneous flap, or as a composite osteomyocutaneous flap when harvested with underlying serratus anterior muscle and rib. For even greater reconstructive flexibility, the latissimus can be harvested for free tissue transfer in combination with any or all of the other flaps based on the subscapular vessels (the so-called subscapular compound flap or “mega-flap”), including serratus anterior, scapular, and parascapular flaps
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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 49
Correct
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A 52 year old man complains of significant abdominal pain and presents to his family doctor. Past medical history shows that he is recovering following a live donor related renal transplant. Which analgesic drug would be avoided in this patient?
Your Answer: Diclofenac
Explanation:As a class, NSAIDs are known to have direct nephrotoxic effects including afferent vasoconstriction leading to reduced glomerular filtration; allergic reactions leading to tubulointerstitial nephritis; nephrotic syndromes, which commonly include minimal change disease and membranous glomerulonephropathy; fluid and sodium retention; worsening of pre-existing hypertension; papillary necrosis and various electrolyte disturbances, including hyponatremia, hyperkalaemia and type 4 renal tubular acidosis.
The use of NSAIDs should be minimized among patients with Stage 3 CKD and avoided in those with Stage 4 or Stage 5 CKD with residual kidney function or recipients of kidney transplant regardless of CKD stage. It is conceivable that compromised intraglomerular hemodynamic may be potentiated with concurrent use of NSAIDs and calcineurin inhibitors in the transplant setting.
Diclofenac which is an NSAID should therefore be avoided in this patient. -
This question is part of the following fields:
- Generic Surgical Topics
- Organ Transplantation
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Question 50
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 51
Correct
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Which condition presents with a positive urine dipstick test for blood, but no blood cells on urine microscopy?
Your Answer: Myoglobinuria
Explanation:Myoglobinuria, or presence of myoglobulin in the urine is seen due to rhabdomyolysis (muscle destruction). Common causes of rhabdomyolysis include trauma, electrical injuries, burns, venom and drugs. Damaged muscle leads to release of myoglobin in the blood. Ideally, the released myoglobin gets filtered and excreted by the kidneys. However, excess myoglobin can occlude the renal filtration system leading to acute tubular necrosis and acute renal dysfunction.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 52
Incorrect
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The bronchial circulation is a part of the circulatory system that supplies nutrients and oxygen to the pulmonary parenchyma. What percentage of cardiac output is received by bronchial circulation?
Your Answer: 12%
Correct Answer: 2%
Explanation:The bronchial circulation is part of the systemic circulation and receives about 2% of the cardiac output from the left heart. Bronchial arteries arise from branches of the aorta, intercostal, subclavian or internal mammary arteries. The bronchial arteries supply the tracheobronchial tree with both nutrients and O2. It is complementary to the pulmonary circulation that brings deoxygenated blood to the lungs and carries oxygenated blood away from them in order to oxygenate the rest of the body.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 53
Correct
-
A 46-year old lady presents with chief complaints of a large mass in the left breast. Histopathology of the mass revealed a stromal component with an epithelial component. What is the likely lesion?
Your Answer: Phyllodes tumour
Explanation:Phyllodes tumours are large, quickly growing tumours which arise from the periductal stroma of the breast. These are fibroepithelial tumours and account for less than 1% of breast cancers. These tumours can be benign, borderline or malignant based on the histology. The tumour usually affects adult women, mostly between the age of 40 to 50 years. It can be confused with fibroadenoma, which however affects much younger patients.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 54
Correct
-
A patient gives a history of dull discomfort in her abdomen associated with pain that she points to be on her right shoulder and right scapula. The following organs are most likely to be source of her pain:
Your Answer: Liver, duodenum and gallbladder
Explanation:Referred pain is felt at a point away from the source of the pain or the unpleasant sensation. It arises when a nerve is damaged or compressed at a point but the pain is felt at another site that is the territory of that nerve. Common abdominal causes of referred pain to the shoulder and the shoulder blade are the liver, duodenum and gall bladder.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 55
Incorrect
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A 31-year-old woman who is 30 weeks pregnant presents with sudden onset of chest pain associated with loss of consciousness. On examination, she is afebrile and her heart rate is 120 bpm, blood pressure is 170/90 mmHg, and saturation is 93% on 15L oxygen. Furthermore, an early diastolic murmur and occasional bibasilar crepitations are auscultated and mild pedal oedema is observed. Her ECG shows ST-segment elevation in leads II, III, and aVF.What is the most likely diagnosis?
Your Answer: Pulmonary embolism
Correct Answer: Aortic dissection
Explanation:The most likely diagnosis is aortic dissection.
Aortic dissection occurs following a tear in the aortic intima with subsequent separation of the tissue within the weakened media by the propagation of blood. There are four different classifications of aortic dissection and the commonest one used is the Stanford classification dividing them into type A and type B. A type A dissection involves the ascending aorta and/or the arch whilst type B dissection involves only the descending aorta and occurs distal to the origin of the left subclavian artery.
Aortic dissection in pregnancy occurs most commonly in the third trimester due to the hyperdynamic state and hormonal effect on vasculature. Other common predisposing factors for aortic dissection include Marfans syndrome, Ehlers-Danlos syndrome, and bicuspid aortic valve. Aortic dissection often presents with sudden severe, tearing chest pain, vomiting, and syncope, most often from acute pericardial tamponade. The patient may be hypertensive, clinically. The right coronary artery may become involved in the dissection, causing myocardial infarct in up to 2% of the cases (hence ST-segment elevation in the inferior leads). An aortic regurgitant murmur may be auscultated.
The management options during pregnancy include:
1. <28 weeks of gestation: aortic repair with the foetus kept in utero
2. 28–32 weeks of gestation: dependent on foetal condition
3. >32 weeks of gestation: caesarean section followed by aortic repair in the same operation -
This question is part of the following fields:
- Emergency Medicine And Management Of Trauma
- Principles Of Surgery-in-General
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Question 56
Correct
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A 37-year-old woman with a history of rheumatic heart disease presents with 10 days recurrent low fever. Patient underwent laboratory work up and was diagnosed with infective endocarditis. What is the most likely organism that caused the infective endocarditis in this patient?
Your Answer: Streptococcus viridans
Explanation:Subacute bacterial endocarditis is often due to streptococci of low virulence, mainly streptococcus viridans. It is a mild to moderate illness which progresses slowly over weeks and months (>2weeks) and has low propensity to hematogenously seed to extracardiac sites.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 57
Correct
-
The oesophagus is an important part of the alimentary canal. It receives blood from various arteries in the body. Which one of the following is an artery that will lead to some level of ischaemia to the oesophagus when ligated?
Your Answer: Left inferior phrenic
Explanation:The oesophagus receives its blood supply from the following arteries: the inferior thyroid branch of the thyrocervical trunk, the descending thoracic aorta, the left gastric branch of the coeliac artery and the from the left inferior phrenic artery of the abdominal aorta. Hence ligation of the left inferior phrenic will lead to ischemia to some portions of the oesophagus.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 58
Correct
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Which of the following organs of the abdominal cavity is completely covered by the peritoneum?
Your Answer: Spleen
Explanation:Of the organs listed, the spleen is the only organ that is completely intraperitoneal, that is entirely in the peritoneum. Other completely intraperitoneal organs include the stomach, liver, appendix and the small intestines. The kidney, Inferior vena cava, aorta and the suprarenal glands are all retroperitoneal organs. The pancreas and the duodenum are partially retroperitoneal, with the tail of the pancreas in the peritoneum found in the splenorenal ligament while only the first part of the duodenum is intraperitoneal. For the intraperitoneal organs remember SALTD SPRSS
S = Stomach
A = Appendix
L = Liver
T = Transverse colon
D = Duodenum (only the 1st part)S = Small intestines
P = Pancreas (only the tail)
R = Rectum (only the upper 3rd)
S = Sigmoid colon
S = SpleenFor retroperitoneal, just remember SADPUCKER:
S = suprarenal glands
A = Aorta and IVC
D = Duodenum (all but the 1st part)
P = Pancreas (all but the tail)
U = Ureter and bladder
C = Colon (ascending and descending)
K = Kidneys
E = Oesophagus
R = Rectum (Lower two-thirds)For secondarily retroperitoneal remember ‘Pussy Cat Dolls“:
P = Pancreas
C = Colon (only ascending and descending)
D = Duodenum (only parts 2-4) -
This question is part of the following fields:
- Anatomy
- Basic Sciences
-
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Question 59
Correct
-
What is the pH of freshly formed saliva at ultimate stimulation?
Your Answer: 8
Explanation:Saliva has four major components: mucus (lubricant), α-amylase (enzyme that initiates digestion of starch), lingual lipase (enzyme that begins fat digestion), and a slightly alkaline electrolyte solution for moistening food. As the secretion rate of saliva increases, its osmolality increases. Moreover, the pH changes from slightly acidic (at rest) to basic (pH 8) at ultimate stimulation. This occurs due to increase of HCO3-. Amylase and mucus also increase in concentration after stimulation.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 60
Correct
-
Glucose is the most important source of energy for cellular respiration. The transport of glucose in the renal tubular cells occurs via:
Your Answer: Secondary active transport with sodium
Explanation:In 1960, Robert K. Crane presented for the first time his discovery of the sodium-glucose cotransport as the mechanism for glucose absorption. Glucose transport through biological membranes requires specific transport proteins. Transport of glucose through the apical membrane of renal tubular as well as intestinal epithelial cells depends on the presence of secondary active Na+–glucose symporters, SGLT-1 and SGLT-2, which concentrate glucose inside the cells, using the energy provided by co-transport of Na+ ions down their electrochemical gradient.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 61
Correct
-
A 27-year-old male is admitted with left-sided loin pain that radiates to his groin. His investigations demonstrate a 9mm left-sided calculus within the proximal ureter. What is the most appropriate course of action?
Your Answer: Arrange a percutaneous extra corporeal shock wave lithotripsy
Explanation:EAU Guidelines on Urolithiasis recommend that
Proximal Ureteral Stone:
< 10 mm: shock wave lithotripsy (SWL) or ureterorenoscopy (URS)
> 10 mm: 1. URS (ante- or retrograde) 2. SWLContraindications of extracorporeal shock wave lithotripsy:
– Pregnancy, due to the potential effects on the foetus.
– Bleeding diatheses, which should be compensated for at least 24 hours before and 48 hours after
treatment.
– Uncontrolled UTIs
– Severe skeletal malformations and severe obesity, which prevent targeting of the stone.
– Arterial aneurysm in the vicinity of the stone.
– Anatomical obstruction distal to the stone.Lowering shock wave frequency from 120 to 60-90 shock waves/min improves SFRs.
The number of shock waves that can be delivered at each session depends on the type of lithotripter and shock wave power. There is no consensus on the maximum number of shock waves.
Starting SWL on a lower energy setting with stepwise power (and SWL sequence) ramping can achieve vasoconstriction during treatment, which prevents renal injury. -
This question is part of the following fields:
- Generic Surgical Topics
- Urology
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Question 62
Correct
-
Which of the following has the highest content of triglycerides?
Your Answer: Chylomicron
Explanation:Created by the small intestinal cells, chylomicrons are large lipoprotein molecules which transport lipids to the liver, adipose, cardiac and skeletal tissue. Chylomicrons are mainly composed of triglycerides (,85%) along with some cholesterol and cholesteryl esters. Apo B-48 is the main apolipoprotein content.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 63
Correct
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A 45 -year-old female is recently diagnosed with breast cancer. She has a 8-cm-diameter mass in her left breast, with enlarged left axillary node. What is the most likely stage of her disease?
Your Answer: IIIA
Explanation:Stage IIIA breast cancer is T0–2 N2 M0 or T3 N1-2 M0 disease. It describes invasive breast cancer in which either: the tumour is smaller than 5 cm in diameter and has spread to 4 to 9 axillary lymph nodes; or it is found through imaging studies or clinical exam to have spread to internal mammary nodes (near the breastbone found during imaging tests or a physical exam); or the tumour is larger than 5 cm and has spread to 1 to 9 axillary nodes, or to internal mammary nodes. In this stage, the cancer has not metastasized (spread to distant sites).
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 64
Correct
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Which of the following is the most abundant WBC seen in a smear from a healthy person.
Your Answer: Neutrophils
Explanation:neutrophils are the most abundant cell type of the WBC. These phagocytes are found normally in the blood and increase in number are seen during an acute inflammation. These the percentages of WBC in blood Neutrophils: 40 to 60%
Lymphocytes: 20 to 40%
Monocytes: 2 to 8%
Eosinophils: 1 to 4%
Basophils: 0.5 to 1%
Band (young neutrophil): 0 to 3%. eosinophils, basophils, neutrophils are known as granulocytes and monocytes and lymphocytes as agranulocytes. -
This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 65
Correct
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Chest X-ray of a 45-year old gentleman with a week history of pleurisy showed a small pneumothorax with moderate-sized pleural effusion. Arterial blood gas analysis showed p(CO2) = 23 mmHg, p(O2) = 234.5 mmHg, standard bicarbonate = 16 mmol/l. What are we most likely dealing with?
Your Answer: Compensated respiratory alkalosis
Explanation:Normal pH with low p(CO2) and low standard bicarbonate could indicate either compensated respiratory alkalosis or a compensated metabolic acidosis. However, the history of hyperventilation for 5 days (pleurisy) favours compensated respiratory alkalosis. Compensated metabolic acidosis would have been likely in a diabetic patient with fever, vomiting and high glucose (diabetic ketoacidosis).
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 66
Correct
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Which of the following clinical signs will be demonstrated in a case of Brown-Séquard syndrome due to hemisection of the spinal cord at mid-thoracic level?
Your Answer: Ipsilateral spastic paralysis, ipsilateral loss of vibration and proprioception (position sense) and contralateral loss of pain and temperature sensation beginning one or two segments below the lesion
Explanation:Brown–Séquard syndrome results due to lateral hemisection of the spinal cord and results in a loss of motricity (paralysis and ataxia) and sensation. The hemisection of the cord results in a lesion of each of the three main neural systems: the principal upper motor neurone pathway of the corticospinal tract, one or both dorsal columns and the spinothalamic tract. As a result of the injury to these three main brain pathways the patient will present with three lesions. The corticospinal lesion produces spastic paralysis on the same side of the body (the loss of moderation by the upper motor neurons). The lesion to fasciculus gracilis or fasciculus cuneatus results in ipsilateral loss of vibration and proprioception (position sense). The loss of the spinothalamic tract leads to pain and temperature sensation being lost from the contralateral side beginning one or two segments below the lesion. At the lesion site, all sensory modalities are lost on the same side, and an ipsilateral flaccid paralysis.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 67
Correct
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A 60 year old woman develops an enterocutaneous fistula which is high output following a recent stricturoplasty. Her medical history shows that she has been suffering from small bowel Crohn's disease for the past 17 years. A small bowel follow through shows it to be 14 cm from the DJ flexure and her overlying skin is becoming excoriated. What is the most appropriate course of action?
Your Answer: Commence TPN and octreotide
Explanation:Total parenteral nutrition (TPN) is usually indicated with suspected gastric, duodenal, or small-bowel fistula. When the fistula output is very high, discontinuance of oral intake is recommended because oral intake stimulates further losses of fluids, electrolytes, and protein via the fistula. A decrease in fistula output frequently occurs with the initiation of TPN.
Volume depletion from a proximal high-output fistula can be controlled with the use of the long-acting somatostatin analogue octreotide, which acts by inhibiting GI hormones. The administration of octreotide reportedly diminishes fistula output, but whether it shortens the time required for fistula closure remains to be determined.
Draus et al recommended a 3-day trial of octreotide, maintaining that if the fistula output is reduced during this time, then administration of the drug should be continued. Two meta-analyses showed that somatostatin and its analogues decreased the time for fistula closure and increased the closure rate. -
This question is part of the following fields:
- Generic Surgical Topics
- The Abdomen
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Question 68
Correct
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What percentage of the cardiac output is delivered to the brain?
Your Answer: 15%
Explanation:Among all body organs, the brain is most susceptible to ischaemia. Comprising of only 2.5% of total body weight, the brain receives 15% of the cardiac output. Oxygen extraction is also higher with venous oxygen levels approximating 13 vol%, and arteriovenous oxygen difference of 7 vol%.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 69
Correct
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The following branch of the aorta is unpaired:
Your Answer: Coeliac artery
Explanation:Branches that stem from the abdominal aorta can be divided into three: the visceral branches, parietal branches and terminal branches. Of the visceral branches, the suprarenal, renal, testicular and ovarian arteries are paired while the coeliac artery and superior and inferior mesenteric arteries are unpaired. Of the parietal branches the inferior phrenic and lumbar arteries are paired while the middle sacral artery is unpaired. The terminal branches i.e. the common iliac arteries are paired.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 70
Correct
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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: 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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SESSION STATS - PERFORMANCE PER SPECIALTY
