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Question 1
Incorrect
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A 45-year-old female with a metallic heart valve has just undergone an elective paraumbilical hernia repair. In view of her metallic valve, she is given unfractionated heparin perioperatively. How should the therapeutic efficacy be monitored, assuming her renal function is normal?
Your Answer: Measurement of Prothrombin time
Correct Answer: Measurement of APTT
Explanation:Because of the substantial risk of thromboembolism early after valve replacement, perioperative initiation of anticoagulation is necessary, despite the increased risk for bleeding. Anticoagulation should be initiated within 24 h after the procedure with unfractionated heparin or low-molecular-weight heparin (LMWH).
Heparin is monitored by checking the activated partial thromboplastin time or anti-Xa activity.
Oral anticoagulants are monitored by INR. -
This question is part of the following fields:
- Peri-operative Care
- Principles Of Surgery-in-General
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Question 2
Incorrect
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A 26-year-old female sought consultation due to excessive vaginal discharge. Vaginal smear showed numerous bacilli under the microscope. The organism was non-pathogenic. What is the most likely organism:
Your Answer: Gardnerella vaginalis
Correct Answer: Lactobacillus species
Explanation:Lactobacillus is a Gram-positive facultative bacteria. It is commonly present in the vagina and the gastrointestinal tract. Colonization of Lactobacillus is usually benign and it makes up a small portion of the gastrointestinal flora.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 3
Correct
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A 34 year old woman from the Indian origin presents to the clinic with a diffuse swelling of the left breast. She has a baby boy, four months old. On examination, she has jaundice and her left breast shows erythema. Which of the following options is the most likely?
Your Answer: Inflammatory carcinoma
Explanation:Inflammatory breast cancer is a rare form of advanced, invasive carcinoma, characterized by dermal lymphatic invasion of tumour cells. Most commonly a ductal carcinoma.
Clinical features include erythematous and oedematous (peau d’orange) skin plaques over a rapidly growing breast mass. Tenderness, burning sensation, blood-tinged nipple discharge. Axillary lymphadenopathy is usually present. 25% of patients have metastatic disease at the time of presentation.
Differential diagnosis includes mastitis, breast abscess, Paget disease of the breast
Treatment is usually done with chemotherapy + radiotherapy + radical mastectomy. This type of cancer is usually associated with a poor prognosis. 5-year survival with treatment: ∼ 50% (without treatment: < 5%) -
This question is part of the following fields:
- Breast And Endocrine Surgery
- Generic Surgical Topics
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Question 4
Correct
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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 5
Correct
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Which of these laboratory findings will indicate a fetal neural tube defect when done between 15 and 20 weeks of pregnancy?
Your Answer: Increased alpha-fetoprotein
Explanation:Maternal serum screening during the second trimester is a non-invasive way of identifying women at increased risk of having children with a neural tube defect and should be offered to all pregnant women. The results are most accurate when the sample is taken between 15 and 20 weeks of gestation. Elevated levels of alpha-fetoprotein suggest open spina bifida, anencephaly, risk of pregnancy complications, or multiple pregnancy.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 6
Correct
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A 55-year-old woman died 3 years after a cardiac transplant due to worsening congestive heart failure. Autopsy revealed diffuse hyperplasia of the vascular intima involving the entire length of the coronary arteries. The most probable cause of deterioration of the cardiac function is:
Your Answer: Coronary atherosclerosis
Explanation:Allograft coronary artery disease (CAD) can begin right after the transplant and is the major cause of later death in cardiac transplant recipients. This form of atherosclerosis progresses quickly resulting in allograft failure. Due to lack of premonitory symptoms CAD may lead to sudden death.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 7
Correct
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A patient is unable to move the mandible to the left. Which muscle is affected in this case?
Your Answer: Right lateral pterygoid muscle
Explanation:Patients with paralysis of the right pterygoid muscle are unable to move their mandible laterally to the left.
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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 17-year-old female was given an antibiotic for a urinary tract infection. After taking the medication the patient developed Steven-Johnson syndrome. Which particular antibiotic usually causes Steven-Johnson syndrome?
Your Answer: Sulphonamides
Explanation:Stevens–Johnson syndrome (SJS) is a type of severe skin reaction. The most common cause is certain medications such as lamotrigine, carbamazepine, allopurinol, sulphonamide antibiotics, and nevirapine.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 9
Incorrect
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A 30-year-old male undergoes an ileocaecal resection and end ileostomy for Crohn's disease. One year later he presents with a deep painful ulcer at his stoma site. What is the most likely diagnosis?
Your Answer: Poorly fitting appliance
Correct Answer: Pyoderma gangrenosum
Explanation:One of the less common but more challenging issues is ulceration of the skin or pyoderma gangrenosum (PG). Although PG was initially thought to be associated with Crohn’s or inflammatory bowel disease, it is now also known to be associated with malignancies, blood dyscrasias, diabetes, and hepatitis. Pyoderma has been described in several forms, but the ulcerative presentation usually occurs on the abdomen, perineum, and lower extremities. The lesions begin as discrete pustules that erupt and coalesce into a classic painful ulcer with a violaceous border and undermined edge. Multiple lesions are common.
PG is a significant complication associated with prolonged pain and increased morbidity.
As its aetiology and pathophysiology are poorly understood, multiple treatments have been employed. These include multiple topical therapies and corticosteroids given topically, intralesionally, or orally. Cyclosporin has also been tried, but Fauld and associates noted weak evidence for its use in pyoderma gangrenosum.
Peristomal pyoderma presents challenges to successful pouching. The size of the ulceration and its proximity to the stoma affects the seal of the appliance to the skin. The goal for management is to promote healing while maintaining adequate wear time of the pouch. The painful nature of PG ulcerations influences the options for topical care. Small ulcerations can usually be treated with stoma powder or antimicrobial powder covered by a piece of hydrocolloid. A foam dressing over the ulceration is helpful if the ulcer is particularly moist. Silver dressings in sheet form or calcium alginates have also been effective. The goal of topical therapy is to use a modality that can absorb the moisture and allow for appliance adhesion. -
This question is part of the following fields:
- Generic Surgical Topics
- Skin Lesions
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Question 10
Correct
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What is the nerve supply of the muscle that is inserted onto the crest of the lesser tubercle of the humerus?
Your Answer: Lower subscapular
Explanation:The muscle is the subscapularis muscle which is supplied by the lower subscapular nerve.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 11
Correct
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Which of the following structures lying posterior to the ovary are at risk of injury in excision of a malignant tumour in the right ovary?
Your Answer: Ureter
Explanation:The ovaries are two nodular structures situated one on either side of the uterus in relation to the lateral wall of the pelvis and attached to the back of the broad ligament of the uterus, lying posteroinferiorly to the fallopian tubes. Each ovary has a lateral and medial surface. The ureter is at greater risk of iatrogenic injury at this location.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 12
Correct
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A 30-year-old man who is a known case of von Willebrand disease has started bleeding following the excision of a sebaceous cyst.Administration of which of the following agents is most likely to be beneficial?
Your Answer: Desmopressin
Explanation:Desmopressin is useful in managing mild to moderate episodes of bleeding in von Willebrand disease (vWD).
vWD is the most common hereditary coagulopathy resulting from the deficiency or abnormal function of von Willebrand factor (vWF). vWF promotes platelet adhesion to damaged endothelium and other platelets and is also involved in the transport and stabilization of factor VIII.
There are seven subtypes of vWD. Type 1 vWD (autosomal dominant) is the most common and accounts for 80% of the cases. Type 2 vWD (autosomal dominant or recessive) accounts for 15% of the cases. There is a significant spectrum of severity ranging from spontaneous bleeding and epistaxis through to troublesome excessive bleeding following minor procedures.
Bleeding time is mostly used as a diagnostic test for vWD. Treatment options include administration of tranexamic acid for minor cases undergoing minor procedures. More significant bleeding or procedures respond well to desmopressin (DDAVP). It is most effective in type 1 vWD, less effective in type 2 and contraindicated in type 2B. Individuals who cannot have desmopressin or in whom it is contraindicated usually receive factor VIII concentrates containing vWF.
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This question is part of the following fields:
- Post-operative Management And Critical Care
- Principles Of Surgery-in-General
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Question 13
Correct
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A 31 year old woman arrives at the clinic due to a tender breast lump. On examination, there is a fluctuant and tender mass. She has a 2 month old child. Which of the following most likely caused her breast lump?
Your Answer: Breast abscess
Explanation:A breast abscess is a localised collection of pus in the breast tissue. It is usually caused by a bacterial infection. Breast infections, including mastitis and breast abscesses, are most often seen in women aged 15 to 45 years. Mastitis can occur as a result of breastfeeding and if left untreated it can progress to an abscess. The bacteria most commonly associated with this is staphylococcus aureus.
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This question is part of the following fields:
- Breast And Endocrine Surgery
- Generic Surgical Topics
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Question 14
Correct
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A 55-years-old man presented to the emergency department complaining of a squeezing sensation in his chest that has spread to his neck with associated worsening shortness of breath. Which of these laboratory tests would you ask for in this patient:
Your Answer: Creatine kinase-MB
Explanation:Creatine kinase-MB is a test that usually is ordered when the patient has chest pain as a cardiac marker. When a heart attack is suspected and a troponin test (which is more specific for heart damage), is not available CK-MB is ordered. There are 3 forms of CK: CK-MM, CK-BB and CK-MB. CK-MB is commonly found in heart tissue, therefore injured heart muscle cells release CK-MB into the blood. Elevated CK-MB levels indicate that it is probable that a person has recently had a heart attack.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 15
Correct
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A teenager is taken to his doctor because his mother noticed a patch of hair overlying his lower lumbar spine and a birth mark at the same location. Neurological examination of the lower limbs is normal. What is the likely diagnosis?
Your Answer: Spina bifida occulta
Explanation:Answer: Spina bifida occulta
Spina Bifida Occulta is the mildest type of spina bifida. It is sometimes called “hidden” spina bifida. With it, there is a small gap in the spine, but no opening or sac on the back. The spinal cord and the nerves usually are normal. Many times, Spina Bifida Occulta is not discovered until late childhood or adulthood. This type of spina bifida usually does not cause any disabilities.
Eighty percent of those with a spinal cord problem will have skin over the defect with:
a hairy patch
a fatty lump
a haemangioma—a red or purple spot made up of blood vessels
a dark spot or a birthmark—these are red and don’t include blue-black marks, called “Mongolian spots”
a skin tract (tunnel) or sinus—this can look like a deep dimple, especially if it’s too high (higher than the top of the buttocks crease), or if its bottom can’t be seen
a hypopigmented spot—an area with less skin colour.Myelocele is herniation of spinal cord tissue through a defect in a region of the vertebral column. The protrusion of the tissue is flush with the level of the skin surface. In myelocele, the spinal cord is exposed so that nerve tissue lies exposed on the surface of the back without even a covering of skin or of the meninges, the membranous tissue surrounding the brain and spinal cord.
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This question is part of the following fields:
- Generic Surgical Topics
- Orthopaedics
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Question 16
Correct
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A patient presents with loss of fine touch and sense of proprioception in the lower part of the body (below T6). He is likely to have a lesion involving:
Your Answer: Gracile nucleus
Explanation:The gracile nucleus is located in the medulla oblongata and is one of the dorsal column nuclei involved in the sensation of fine touch and proprioception. It contains second-order neurons of the dorsal column–medial lemniscus system, that receive inputs from sensory neurones of the dorsal root ganglia and send axons that synapse in the thalamus.
The gracile nucleus and fasciculus carry epicritic, kinaesthetic and conscious proprioceptive information from the lower part of the body (below the level of T6 in the spinal cord). Similar information from the upper part of body (above T6, except for face and ear) is carried by the cuneate nucleus and fasciculus. The information from face and ear is carried by the primary sensory trigeminal nucleus. -
This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 17
Correct
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A 54 year old man undergoes Milligan Morgan haemorrhoidectomy. He had no associated co-morbidities. Which of the following would be the best option for immediate post operative analgesia?
Your Answer: Caudal block
Explanation:Open haemorrhoidectomy is traditionally viewed as a painful procedure. Most operations are performed under general or regional anaesthesia. Following excisional haemorrhoidectomy, severe pain is not unusual, a well placed caudal anaesthetic will counter this. A pudendal nerve block is an alternative but is less effective than a caudal.
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This question is part of the following fields:
- Peri-operative Care
- Principles Of Surgery-in-General
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Question 18
Correct
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Which of the following arteries, that runs on the superior aspect of the first part of the duodenum, forms the lower boundary of the epiploic foramen (also known as the foramen of Winslow)?
Your Answer: Hepatic
Explanation:The epiploic foramen is an important anatomical opening that allows for the communication between the greater peritoneal sac and the lesser peritoneal sac. Its boundaries are formed; superiorly by the caudate lobe of the liver, anteriorly by the hepatoduodenal ligament (containing the components of the portal triad), inferiorly by the first part of the duodenum and posteriorly by the peritoneum covering the inferior vena cava. The superior aspect of the first part of the duodenum, which forms the inferior boundary of the foramen of Winslow, forms the course of the hepatic artery before it ascends to the porta hepatis where it divides into its right and left branches.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 19
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 20
Correct
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Which of the following muscles is innervated by the inferior branch of the right recurrent laryngeal nerve?
Your Answer: Posterior cricoarytenoid
Explanation:The posterior cricoarytenoid muscle, which is the sole abductor of the vocal folds, receives its innervation from the inferior laryngeal nerve which is a continuation of the recurrent laryngeal nerve.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 21
Incorrect
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A 55-year-old male presents with an ulcerated mass at the anal verge. A biopsy is taken and the histology demonstrates as squamous cell carcinoma. Which of the following viral infection is most likely to have contributed to the development of the condition?
Your Answer: Human immunodeficiency virus 1
Correct Answer: Human papillomavirus 16
Explanation:Anal squamous cell cancer is believed to be directly linked to the presence of a complex inflammatory process most commonly caused by HPV infection (particularly with serotypes 16 and 18) in the histologically unique area of the anal squamocolumnar epithelium. In one Scandinavian study, serotype 16 HPV DNA was detected in 73% of anal cancer specimens, and serotype 16, 18, or both were detected in 84% of specimens. In contrast, no rectal cancer specimens contained HPV DNA.
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This question is part of the following fields:
- Clinical Microbiology
- Principles Of Surgery-in-General
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Question 22
Correct
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In the adult heart, the sinus venosus gives rise to the:
Your Answer: Coronary sinus
Explanation:The sinus venosus is a large quadrangular cavity which precedes the atrium on the venous side of the chordate heart. It exists distinctly only in the embryonic heart (where it is found between the two venae cavae); however, the sinus venosus persists in the adult. In the adult, it is incorporated into the wall of the right atrium to form a smooth part called the sinus venarum, which is separated from the rest of the atrium by a ridge of fibres called the crista terminalis. The sinus venosus also forms the SA node and the coronary sinus.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 23
Correct
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A patient sustained an injury to the facial nerve after it emerges from the stylomastoid foramen. What is the clinical impact of this injury?
Your Answer: Facial expression
Explanation:The facial nerve is the seventh of the twelve paired cranial nerves. It emerges from the brainstem between the pons and the medulla. It controls the muscles of facial expression and supplies taste fibres to the anterior two-thirds of the tongue. It also supplies preganglionic parasympathetic fibres to several head and neck ganglia. Its branches and distribution are as follows:
Inside the facial canal (proximal to the stylomastoid foramen):
– Greater petrosal nerve – provides parasympathetic innervation to the lacrimal gland, as well as special taste sensory fibres to the palate via the nerve of pterygoid canal
– Nerve to stapedius – provides motor innervation for the stapedius muscle in the middle ear
– Chord tympani – provides parasympathetic innervation to the submandibular and sublingual glands and special sensory taste fibres for the anterior two-thirds of the tongue
Outside the skull (distal to the stylomastoid foramen):
– Posterior auricular nerve – controls the movements of some of the scalp muscles around the ear
– Five major facial branches (in the parotid gland), from top to bottom: temporal branch, zygomatic branch, buccal branch, marginal mandibular branch and cervical branch. From the description given above it is obvious that injury to the facial nerve distal to the stylomastoid foramen will affect facial expression. -
This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 24
Incorrect
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A patient sustained an iatrogenic injury to one of the structures passing through the deep inguinal ring. This was during an operation to repair an inguinal hernia. Which structure is most likely to be injured?
Your Answer: Ilioinguinal nerve
Correct Answer: Round ligament of the uterus
Explanation:The deep inguinal ring transmits the spermatic cord in the man and the round ligament of the uterus in the female. It is bound below and medially by the inferior epigastric vessels (so these don’t go through it).
The ilioinguinal nerve, although it courses through the inguinal canal, does not pass through it.
The iliohypogastric nerves run between the internal oblique and transversus abdominis in the abdominal wall, piercing the internal oblique at the anterior superior iliac spine to travel just deep to the external oblique.
The inferior epigastric artery runs between the transversus abdominis and the peritoneum forming the lateral umbilical fold.
The medial umbilical ligament is the obliterated umbilical artery that it lies within the medial umbilical fold of peritoneum. -
This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 25
Incorrect
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A 53-year-old woman is diagnosed with cellulitis surrounding her leg ulcer. A swab is taken and oral flucloxacillin is started. The following result is obtained:
Your Answer: Add clindamycin
Correct Answer: Add penicillin
Explanation:Streptococci may be divided into alpha and beta haemolytic types
Alpha haemolytic streptococci
The most important alpha haemolytic streptococcus is Streptococcus pneumoniae (pneumococcus). Pneumococcus is a common cause of pneumonia, meningitis and otitis media. Another clinical example is Streptococcus viridans
Beta haemolytic streptococci
These can be subdivided into group A and B
Group A
most important organism is Streptococcus pyogenes
responsible for erysipelas, impetigo, cellulitis, type 2 necrotizing fasciitis and pharyngitis/tonsillitis
immunological reactions can cause rheumatic fever or post-streptococcal glomerulonephritis
erythrogenic toxins cause scarlet feverGroup B
Streptococcus agalactiae may lead to neonatal meningitis and septicaemia
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This question is part of the following fields:
- Clinical Microbiology
- Principles Of Surgery-in-General
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Question 26
Correct
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All the following arteries contribute to the blood supply of the hip joint except:
Your Answer: Pudendal
Explanation:The blood supply to the hip joint is from two main arteries, the medial circumflex femoral and lateral circumflex femoral arteries. These are branches of the deep artery of the thigh, which itself is a branch of the femoral artery. There is contribution of blood supply from the inferior gluteals, foveal and obturator arteries.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 27
Incorrect
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Whipple's procedure involves mobilizing the head of the pancreas. As the surgeon does this, he must be careful to avoid injury to a key structure that is found lying behind the head of the pancreas. Which vital structure is this?
Your Answer: Portal vein
Correct Answer: Common bile duct
Explanation:The posterior relations of the head of the pancreas include: the inferior vena cava, the common bile duct, the renal veins, the right crus of the diaphragm and the aorta.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 28
Incorrect
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Choose the most correct answer regarding the common peroneal nerve.
Your Answer: While part of the sciatic nerve, it innervates nothing in the posterior thigh
Correct Answer: It gives rise to the nerve that supplies the anterior compartment leg muscles
Explanation:The common peroneal nerve divides beneath the peroneus longus muscle and gives off articular and lateral sural cutaneous nerves which supply muscular branches to the muscles of the anterior compartment of the leg which are the tibialis anterior, extensor digitorum, peroneus tertius and extensor hallucis longus.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 29
Correct
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The chest X-ray of a 72 year old patient reveals the presence of a round lesion containing an air-fluid level in the left lung. These findings are most probably suggestive of:
Your Answer: Lung abscess
Explanation:Lung abscesses are collections of pus within the lung that arise most commonly as a complication of aspiration pneumonia caused by oral anaerobes. Older patients are more at risk due to poor oral hygiene, gingivitis an inability to handle their oral secretions due to other diseases. Chest X-ray most commonly reveals the appearance of an irregularly shaped cavity with an air-fluid level.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 30
Correct
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A patient at the time of her second delivery opted for a bilateral pudendal nerve block. In order to inject the anaesthetic agent near the pudendal nerve a anaesthetic consultant had to insert a finger into the vagina and press laterally to palpate which landmark?
Your Answer: Ischial spine
Explanation:The ischial spine is always palpated through the walls of the vagina when performing a transvaginal pudendal nerve block and can easily be palpated on the lateral wall of the vagina.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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SESSION STATS - PERFORMANCE PER SPECIALTY
