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  • Question 1 - A 3 year old girl is taken to the clinic with a 3...

    Incorrect

    • A 3 year old girl is taken to the clinic with a 3 day history of feeling unwell and having a sore throat. When examined by the doctor, marked cervical lymphadenopathy is observed and the oropharynx is covered with a thick grey membrane which bleeds following attempted removal. Which of the following is the most likely diagnosis?

      Your Answer: Acute streptococcal pharyngitis

      Correct Answer: Diphtheria

      Explanation:

      Diphtheria is an infection caused by the bacterium Corynebacterium diphtheriae. Signs and symptoms may vary from mild to severe. They usually start two to five days after exposure. Symptoms often come on fairly gradually, beginning with a sore throat and fever. In severe cases, a grey or white patch develops in the throat. This can block the airway and create a barking cough as in croup. The neck may swell in part due to enlarged lymph nodes.

      The disease may remain manageable, but in more severe cases, lymph nodes in the neck may swell, and breathing and swallowing are more difficult. People in this stage should seek immediate medical attention, as obstruction in the throat may require intubation or a tracheotomy. Abnormal cardiac rhythms can occur early in the course of the illness or weeks later, and can lead to heart failure. Diphtheria can also cause paralysis in the eye, neck, throat, or respiratory muscles. Patients with severe cases are put in a hospital intensive care unit and given a diphtheria antitoxin (consisting of antibodies isolated from the serum of horses that have been challenged with diphtheria toxin). Since antitoxin does not neutralize toxin that is already bound to tissues, delaying its administration increases risk of death. Therefore, the decision to administer diphtheria antitoxin is based on clinical diagnosis, and should not await laboratory confirmation.
      Antibiotics are used in patients or carriers to eradicate C. diphtheriae and prevent its transmission to others. The Centres for Disease Control and Prevention recommends either:
      Metronidazole
      Erythromycin is given (orally or by injection) for 14 days (40 mg/kg per day with a maximum of 2 g/d), or
      Procaine penicillin G is given intramuscularly for 14 days (300,000 U/d for patients weighing <10 kg and 600,000 U/d for those weighing >10 kg); patients with allergies to penicillin G or erythromycin can use Rifampicin or clindamycin.

    • This question is part of the following fields:

      • Generic Surgical Topics
      • Head And Neck Surgery
      39.1
      Seconds
  • Question 2 - A 32 year old woman complains of a sudden, severe headache, the worst...

    Incorrect

    • A 32 year old woman complains of a sudden, severe headache, the worst one she has ever experienced and collapses. CT scan shows a subarachnoid haemorrhage. However, she currently has no signs of an elevated ICP. Which of the following drugs should be administered?

      Your Answer: Mannitol

      Correct Answer: Nimodipine

      Explanation:

      Nimodipine, a calcium-channel antagonist with a relatively selective vasodilatory effect on cerebral blood vessels, has been approved for improvement of neurologic deficits due to spasm following subarachnoid haemorrhage. Oral nimodipine is the most studied calcium channel blocker for prevention of vasospasm after Subarachnoid haemorrhage.
      An American Heart Association/American Stroke Association guideline recommends its use for this purpose (class I, level of evidence A). Calcium channel blockers have been shown to reduce the incidence of ischemic neurologic deficits, and nimodipine has been shown to improve overall outcome within 3 months of aneurysmal SAH. Calcium channel blockers and other antihypertensives should be used cautiously to avoid the deleterious effects of hypotension.

    • This question is part of the following fields:

      • Generic Surgical Topics
      • Surgical Disorders Of The Brain
      28
      Seconds
  • Question 3 - A 35 year old woman with cholecystitis is admitted for laparoscopic cholecystectomy. She...

    Incorrect

    • A 35 year old woman with cholecystitis is admitted for laparoscopic cholecystectomy. She has reported feeling unwell for the last 10 days. During the procedure, while attempting to dissect the distended gallbladder, only the fundus is visualized and dense adhesions make it difficult to access Calot's triangle. Which of the following would be the next best course of action?

      Your Answer: Dissect the adhesions off Calots triangle and continue with the cholecystectomy

      Correct Answer: Perform an operative cholecystostomy

      Explanation:

      Chronic cholecystitis can be a surgical challenge due to an inflammatory process that creates multiple adhesions, complicates dissection, and can hamper recognition of normal anatomical structures. In such cases cholecystostomy can be performed in order to alleviate the acute symptoms. Tube cholecystostomy allows for resolution of sepsis and delay of definitive surgery. Interval laparoscopic cholecystectomy can be safely performed once sepsis and acute infection has resolved.

    • This question is part of the following fields:

      • Generic Surgical Topics
      • Hepatobiliary And Pancreatic Surgery
      42.9
      Seconds
  • Question 4 - A 15 year old girl is diagnosed with familial adenomatous polyposis. Which of...

    Incorrect

    • A 15 year old girl is diagnosed with familial adenomatous polyposis. Which of the following is the most appropriate recommended step in management?

      Your Answer: Surveillance colonoscopy every 1–2 years from the age of 16 years onwards

      Correct Answer: Surveillance annual flexible sigmoidoscopy from age 13 years until age 30 years

      Explanation:

      Answer: Surveillance annual flexible sigmoidoscopy from age 13 years until age 30 years.

      Familial adenomatous polyposis (FAP) is the most common adenomatous polyposis syndrome. It is an autosomal dominant inherited disorder characterized by the early onset of hundreds to thousands of adenomatous polyps throughout the colon. If left untreated, all patients with this syndrome will develop colon cancer by age 35-40 years. In addition, an increased risk exists for the development of other malignancies.
      Most patients with FAP are asymptomatic until they develop cancer. As a result, diagnosing presymptomatic patients is essential.

      Of patients with FAP, 75%-80% have a family history of polyps and/or colorectal cancer at age 40 years or younger.

      Nonspecific symptoms, such as unexplained rectal bleeding (haematochezia), diarrhoea, or abdominal pain, in young patients may be suggestive of FAP.

      In a minority of FAP families a mutation cannot be identified and so annual flexible sigmoidoscopy should be offered to at risk family members from age 13–15 years until age 30, and at three to five year intervals thereafter until age 60 years.

    • This question is part of the following fields:

      • Colorectal Surgery
      • Generic Surgical Topics
      52.6
      Seconds
  • Question 5 - A 24-year-old female presents with a swelling located at the anterior border of...

    Incorrect

    • A 24-year-old female presents with a swelling located at the anterior border of the sternocleidomastoid muscle. The swelling is intermittent. On examination, it is soft and fluctuant. What is the most likely diagnosis?

      Your Answer: Thyroglossal cyst

      Correct Answer: Branchial cyst

      Explanation:

      Branchial cleft cysts are congenital anomalies that usually arise from second cleft/pouch, with remnants of the third and fourth pouch are rare. Children are typically born with these congenital lesions; however, they may not be evident for weeks, months, or possibly years. The lesions present as fistulae, cyst, sinus tracts, or cartilaginous remnants due to incomplete obliteration during embryogenesis.

      They are often asymptomatic, but can often become tender, enlarged, or inflamed with possible abscess formation during episodes of upper respiratory tract infections.
      The patient can present with purulent drainage of the sinus to skin or pharynx from spontaneous rupture of branchial cleft cyst abscess. The most concerning symptoms include dysphagia, dyspnoea, and stridor due to cyst compression of the upper airway.

      The physical examination will differ depending on the location of the branchial cleft cyst:
      – A primary branchial cleft cyst is typically smooth, non-tender, fluctuant mass found between the external auditory canal and submandibular area. It is usually with the parotid gland and facial nerve. Two types of lesions exist. Type 1 is rare and characterized as duplication of the membranous external auditory canal. Type 2 lesions contain both ectoderm and mesoderm elements including cartilage. The patient usually presents with soft tissue mass or draining sinus located on the angle of the mandible or otorrhea, making an otologic exam critical in these cases.
      – A secondary branchial cleft cyst is located between the lower anterior border of the sternocleidomastoid and the tonsillar fossa of the pharynx. It can be in proximity to the glossopharyngeal and hypoglossal nerve as well as carotid vessels. Compared to the primary branchial cleft cysts, secondary cysts are tender if secondarily inflamed or infected. If it is associated with a sinus tract, a mucoid or purulent discharge may be present on the skin or into the pharynx.

      The treatment of a branchial cleft cyst is typically elective excision due to the risk of infection or present infection, further enlargement, or malignancy.

      – Carotid Body Tumour: Painless oropharyngeal or upper anterior triangle of the neck; pulsatile, compressible with a bruit or thrill, mobile from medial to lateral direction.
      – Bartonella henselae infection is Isolated, mobile, fluctuant, tender, warm, erythematous, > 2 cm near the site of inoculation.
      – Thyroglossal duct cyst: In the Midline, adjacent to the hyoid bone; rises with deglutition.

    • This question is part of the following fields:

      • Generic Surgical Topics
      • Head And Neck Surgery
      49.5
      Seconds
  • Question 6 - A 50-year-old man presents with bright red rectal bleeding that occurs post defecation...

    Incorrect

    • A 50-year-old man presents with bright red rectal bleeding that occurs post defecation and is noted on the toilet paper. It is also associated with severe pain. On external anal examination, a skin tag is identified at 6 o'clock position.Which of the following treatment options is most likely to be helpful?

      Your Answer: Rubber band ligation

      Correct Answer: Topical GTN

      Explanation:

      Since the most likely diagnosis is anal fissure, the correct treatment is topical nitrates.

      Anal fissures are a common cause of painful, bright red rectal bleeding. Most fissures are idiopathic and present as a painful mucocutaneous defect in the posterior midline (90% cases). Fissures are more likely to be anteriorly located in females, particularly if they are multiparous. Diseases associated with fissure-in-ano include:
      1. Crohn’s disease
      2. Tuberculosis
      3. Internal rectal prolapse

      Diagnostic options are as follows:
      In most cases, the defect can be visualised as a posterior midline epithelial defect. Where symptoms are highly suggestive of the condition and examination findings are unclear, an examination under anaesthesia may be helpful. Atypical disease presentation should be investigated by colonoscopy and EUA, with biopsies of the area.

      For management of anal fissure:
      1. Stool softeners are important as hard stools may tear the epithelium and result in recurrent symptoms. The most effective first-line agents are topically applied GTN (0.2%) or Diltiazem (2%) paste.
      2. Resistant cases may benefit from injection of botulinum toxin or lateral internal sphincterotomy. Advancement flaps may be used to treat resistant cases.

    • This question is part of the following fields:

      • Colorectal Surgery
      • Generic Surgical Topics
      81.6
      Seconds
  • Question 7 - A 14 year old boy is taken to the emergency room after complaining...

    Incorrect

    • A 14 year old boy is taken to the emergency room after complaining of sudden onset of pain in the left hemiscrotum despite not having any other urinary symptoms. The superior pole of the testis is tender on examination and the cremasteric reflex is particularly marked. What would be the underlying diagnosis?

      Your Answer: Torsion of the testis

      Correct Answer: Torsion of a testicular hydatid

      Explanation:

      Answer: Torsion of a testicular hydatid

      The appendix testis (or hydatid of Morgagni) is a vestigial remnant of the Müllerian duct, present on the upper pole of the testis and attached to the tunica vaginalis. It is present about 90% of the time. The appendix of testis can, occasionally, undergo torsion (i.e. become twisted), causing acute one-sided testicular pain and may require surgical excision to achieve relief. One third of patients present with a palpable blue dot discoloration on the scrotum. This is nearly diagnostic of this condition. If clinical suspicion is high for the serious differential diagnosis of testicular torsion, a surgical exploration of the scrotum is warranted. Torsion of the appendix of testis occurs at ages 0-15 years, with a mean at 10 years, which is similar to that of testicular torsion.

      Occasionally a torsion of the hydatid of Morgagni can produce symptoms mimicking those created by a testicular torsion; a torsion of the hydatid, however, does not lead to any impairment of testicular function.
      Absence of the cremasteric reflex is a sign of testicular torsion. This therefore confirms that the diagnosis is Torsion of a testicular hydatid.

    • This question is part of the following fields:

      • Generic Surgical Topics
      • Urology
      46
      Seconds
  • Question 8 - A 19 year old female presents with a firm mobile mass in the...

    Incorrect

    • A 19 year old female presents with a firm mobile mass in the upper outer quadrant of her left breast. Which of the following could be the underlying disease process?

      Your Answer: Breast cyst

      Correct Answer: Fibroadenoma

      Explanation:

      A fibroadenoma is a painless, unilateral, benign (non-cancerous) breast tumour that is a solid, not fluid-filled, lump. It occurs most commonly in women between the age of 14 to 35 years but can be found at any age. Fibroadenomas shrink after menopause, and therefore, are less common in post-menopausal women. Fibroadenomas are often referred to as a breast mouse due to their high mobility. Fibroadenomas are a marble-like mass comprising both epithelial and stromal tissues located under the skin of the breast. These firm, rubbery masses with regular borders are often variable in size.

      Duct ectasia, also known as mammary duct ectasia, is a benign (non-cancerous) breast condition that occurs when a milk duct in the breast widens and its walls thicken. This can cause the duct to become blocked and lead to fluid build-up. It’s more common in women who are getting close to menopause. But it can happen after menopause, too.

      Fat necrosis is a benign condition and does not increase the risk of developing breast cancer. It can occur anywhere in the breast and can affect women of any age. Men can also get fat necrosis, but this is very rare.

      Breast cysts are a benign condition. They’re one of the most common causes of a breast lump, and can develop in either one or both breasts. It’s thought they develop naturally as the breast changes with age due to normal changes in hormone levels. It’s common to have more than one cyst. Breast cysts can feel soft or hard and can be any size, ranging from a few millimetres to several centimetres. They’re usually oval or round in shape and can develop quickly.

      Atypical hyperplasia is a precancerous condition that affects cells in the breast. Atypical hyperplasia describes an accumulation of abnormal cells in the breast.

    • This question is part of the following fields:

      • Breast And Endocrine Surgery
      • Generic Surgical Topics
      32.5
      Seconds
  • Question 9 - A 10 year old child presents with enlarged tonsils that meet in the...

    Correct

    • A 10 year old child presents with enlarged tonsils that meet in the midline. Oropharyngeal examination confirms this finding and you also notice petechial haemorrhages affecting the oropharynx. On systemic examination he is noted to have splenomegaly. What is the most likely cause?

      Your Answer: Acute Epstein Barr virus infection

      Explanation:

      Answer: Acute Epstein Barr virus infection

      The Epstein–Barr virus is one of eight known human herpesvirus types in the herpes family, and is one of the most common viruses in humans. Infection with Epstein-Barr virus (EBV) is common and usually occurs in childhood or early adulthood.
      EBV is the cause of infectious mononucleosis, an illness associated with symptoms and signs like:
      fever,
      fatigue,
      swollen tonsils,
      headache, and
      sweats,
      sore throat,
      swollen lymph nodes in the neck, and
      sometimes an enlarged spleen.
      Although EBV can cause mononucleosis, not everyone infected with the virus will get mononucleosis. White blood cells called B cells are the primary targets of EBV infection.

    • This question is part of the following fields:

      • Generic Surgical Topics
      • Head And Neck Surgery
      118.5
      Seconds
  • Question 10 - A 51 year old female presents with a sensation of grittiness in her...

    Correct

    • A 51 year old female presents with a sensation of grittiness in her eyes which has been present for the past few months. She also complains of symptoms of a dry mouth. On examination, she is seen with a swelling of her parotid gland. However, she has no evidence of facial nerve palsy. Which of the following is the most likely underlying diagnosis?

      Your Answer: Sjogren's syndrome

      Explanation:

      Sjogren syndrome (SS) is a long-term autoimmune disease that affects the body’s moisture-producing glands. Primary symptoms are a dry mouth and dry eyes. Other symptoms can include dry skin, vaginal dryness, a chronic cough, numbness in the arms and legs, feeling tired, muscle and joint pains, and thyroid problems. Those affected are at an increased risk (5%) of lymphoma. It primarily affects women in their peri and post-menopausal years of life.

    • This question is part of the following fields:

      • Generic Surgical Topics
      • Head And Neck Surgery
      184
      Seconds
  • Question 11 - An 18-year-old male is admitted with a three-month history of intermittent pain in...

    Correct

    • An 18-year-old male is admitted with a three-month history of intermittent pain in the right iliac fossa. He suffers from episodic diarrhoea and has lost two kilograms of weight. On examination, he is febrile and has right iliac fossa tenderness.What is the most likely diagnosis?

      Your Answer: Inflammatory bowel disease

      Explanation:

      A history of weight loss and intermittent diarrhoea makes inflammatory bowel disease (IBD) the most likely diagnosis. Conditions such as appendicitis and infections have a much shorter history. Although Meckel’s diverticulum can bleed and cause inflammation, it seldom causes marked weight loss. Irritable bowel syndrome (IBS) presents with alternating episodes of constipation and diarrhoea along with abdominal pain, bloating, and gas.

    • This question is part of the following fields:

      • Generic Surgical Topics
      • The Abdomen
      84
      Seconds
  • Question 12 - A 25-year-old male is found to have a 5cm carcinoid tumour of the...

    Correct

    • 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
      10.6
      Seconds
  • Question 13 - A 56-year-old woman trips over a step, injuring her right ankle. Examination reveals...

    Correct

    • A 56-year-old woman trips over a step, injuring her right ankle. Examination reveals tenderness over the lateral malleolus and X-ray demonstrates an undisplaced fracture distal to the syndesmosis. What should be the best course of action?

      Your Answer: Application of ankle boot

      Explanation:

      The patient has a Weber type A fracture, based on the Danis-Weber classification system for lateral malleolar fractures. It is a stable ankle injury and can, therefore, be managed conservatively. Whilst this patient could also be treated in a below-knee plaster, most clinicians, nowadays, treat this injury in an ankle boot. Patients are also advised to mobilise with the ankle boot as pain allows and can wean themselves off as the symptoms improve.

      The Danis-Weber classification system is based on the level of the fibula fracture in relation to the syndesmosis (the connection between the distal ends of the tibia and fibula). The more proximal, the greater the risk of syndesmotic injury and, therefore, fracture instability.

      1. Weber type A: fracture below the level of the syndesmosis
      2. Weber type B: fracture at the level of the syndesmosis/level of the tibial plafond
      3. Weber type C: fracture above the level of the syndesmosis. This includes Maisonneuve fracture (proximal fibula fracture) which can be associated with ankle instability.

      Ankle fractures are common. They affect men and women in equal numbers, but men have a higher rate as young adults (sports and contact injuries), and women have a higher rate post-menopausal (fragility-type fractures). Patients present, following a traumatic event, with a painful, swollen ankle, and reluctance/inability to bear weight.

      Radiographs of clearly deformed or dislocated joints are not necessary, and removing the pressure on the surrounding soft tissues from the underlying bony deformity is the priority. If the fracture pattern is not clinically obvious, then plain radiographs are appropriate. Antero-posterior, lateral, and mortise views are essential to evaluate fracture displacement and syndesmotic injury. Decreased tibiofibular overlap, medial joint clear space, and lateral talar shift all indicate a syndesmotic injury.

      When deciding upon treatment for an ankle fracture, one must consider both the fracture and the patient. Diabetic patients and smokers are at greater risk of post-operative complication, especially wound problems and infection. Likewise, the long term outcome of post-traumatic arthritis from a malunited ankle fracture is extremely important for a young patient, but not as relevant in the elderly. Unimalleolar Weber type A fractures, by definition, are stable and therefore, can be mobilised fully in an ankle boot.

    • This question is part of the following fields:

      • Generic Surgical Topics
      • Orthopaedics
      92.5
      Seconds
  • Question 14 - A 28-year-old male injured his ankle playing football. On examination, he has tenderness...

    Correct

    • A 28-year-old male injured his ankle playing football. On examination, he has tenderness over both medial and lateral malleoli. X-ray demonstrates a bimalleolar fracture with a displaced distal fibula fracture, at the level of the syndesmosis and fracture of the medial malleolus with talar shift. The ankle has been provisionally reduced and splinted in the emergency department. What is the most appropriate management?

      Your Answer: Surgical fixation

      Explanation:

      The patient has Denis B fracture, unstable fracture requiring open reduction and internal fixation (ORIF)
      open reduction internal fixation indications:
      – any talar displacement
      – displaced isolated medial malleolar fracture
      – displaced isolated lateral malleolar fracture
      – bimalleolar fracture and bimalleolar-equivalent fracture
      – posterior malleolar fracture with > 25% or > 2mm step-off
      – Bosworth fracture-dislocations
      – open fractures
      – malleolar non-union

      Danis-Weber classification:
      type A
      below the level of the talar dome
      usually transverse
      tibiofibular syndesmosis intact
      deltoid ligament intact
      medial malleolus occasionally fractured
      usually stable if medial malleolus intact
      type B
      the distal extent at the level of the talar dome; may extend some distance proximally
      usually spiral
      tibiofibular syndesmosis usually intact, but a widening of the distal tibiofibular joint (especially on stressed views) indicates syndesmotic injury
      medial malleolus may be fractured
      the deltoid ligament may be torn, indicated by a widening of the space between the medial malleolus and talar dome
      variable stability, dependent on the status of medial structures (malleolus/deltoid ligament) and syndesmosis; may require ORIF
      Weber B fractures could be further subclassified as 9
      B1: isolated
      B2: associated with a medial lesion (malleolus or ligament)
      B3: associated with a medial lesion and fracture of the posterolateral tibia
      type C
      above the level of the ankle joint
      tibiofibular syndesmosis disruption with a widening of the distal tibiofibular articulation
      medial malleolus fracture or deltoid ligament injury often present
      a fracture may arise as proximally as the level of the fibular neck and not visualized on ankle films, requiring knee or full-length tibia-fibula radiographs (Maisonneuve fracture)
      unstable: usually requires ORIF
      Weber C fractures can be further subclassified as 6
      C1: diaphyseal fracture of the fibula, simple
      C2: diaphyseal fracture of the fibula, complex
      C3: proximal fracture of the fibula
      a fracture above the syndesmosis results from external rotation or abduction forces that also disrupt the joint
      usually associated with an injury to the medial side

    • This question is part of the following fields:

      • Generic Surgical Topics
      • Orthopaedics
      60.2
      Seconds
  • Question 15 - A 32-year-old man is brought to the emergency department following a crush injury...

    Correct

    • A 32-year-old man is brought to the emergency department following a crush injury to his right forearm. On examination, the arm is tender, red, and swollen. There is clinical evidence of an ulnar fracture, and the patient cannot move his fingers. What should be the most appropriate course of action?

      Your Answer: Fasciotomy

      Explanation:

      The combination of a crush injury, limb swelling, and inability to move digits raises suspicion of compartment syndrome that would require a fasciotomy.

      Compartment syndrome is a particular complication that may occur following fractures, especially supracondylar fractures and tibial shaft injuries. It is characterised by raised pressure within a closed anatomical space which may, eventually, compromise tissue perfusion, resulting in necrosis.

      The clinical features of compartment syndrome include:
      1. Pain, especially on movement
      2. Paraesthesia
      3. Pallor
      4. Paralysis of the muscle group may also occur

      Diagnosis is made by measurement of intracompartmental pressure. Pressures >20mmHg are abnormal and >40mmHg are diagnostic.

      Compartment syndrome requires prompt and extensive fasciotomy. Myoglobinuria may occur following fasciotomy, resulting in renal failure. Therefore, aggressive IV fluids are required. If muscle groups are frankly necrotic at fasciotomy, they should be debrided, and amputation may have to be considered.

    • This question is part of the following fields:

      • Generic Surgical Topics
      • Orthopaedics
      60.1
      Seconds
  • Question 16 - A 39 year old woman is admitted with acute cholecystitis which fails to...

    Correct

    • A 39 year old woman is admitted with acute cholecystitis which fails to settle. During a laparoscopic cholecystectomy, the gallbladder has evidence of an empyema and Calots triangle is inflamed. The surgeon suspects that a Mirizzi syndrome has occurred. What is the most appropriate course of action?

      Your Answer: Undertake an operative cholecystostomy

      Explanation:

      Mirizzi’s syndrome is a rare complication in which a gallstone becomes impacted in the cystic duct or neck of the gallbladder causing compression of the common hepatic duct, resulting in obstruction and jaundice. The obstructive jaundice can be caused by direct extrinsic compression by the stone or from fibrosis caused by chronic cholecystitis (inflammation).

      Type I – No fistula present

      Type IA – Presence of the cystic duct
      Type IB – Obliteration of the cystic duct

      Types II–IV – Fistula present

      Type II – Defect smaller than 33% of the CHD diameter
      Type III – Defect 33–66% of the CHD diameter
      Type IV – Defect larger than 66% of the CHD diameter

      Simple cholecystectomy is suitable for type I patients. This patient has type I because no fistula is present.

    • This question is part of the following fields:

      • Generic Surgical Topics
      • Hepatobiliary And Pancreatic Surgery
      134.5
      Seconds
  • Question 17 - A 20 year old female is rushed to the hospital after developing severe...

    Incorrect

    • A 20 year old female is rushed to the hospital after developing severe back pain and weakness in both legs after completing the long jump. She is seen with a prominent sacrum on examination and her lower back pain is severe. Which of the following is the underlying cause?

      Your Answer: Spondylolysis

      Correct Answer: Spondylolisthesis

      Explanation:

      Answer: Spondylolisthesis

      Spondylolisthesis is a condition in which a bone (vertebra) in the spine moves forward out of the proper position onto the bone below it.

      Causes
      In children, spondylolisthesis usually occurs between the fifth bone in the lower back (lumbar vertebra) and the first bone in the sacrum (pelvis) area. It is often due to a birth defect in that area of the spine or sudden injury (acute trauma).

      In adults, the most common cause is abnormal wear on the cartilage and bones, such as arthritis. The condition mostly affects people over 50 years old. It is more common in women than in men.

      Bone disease and fractures can also cause spondylolisthesis. Certain sports activities, such as gymnastics, weightlifting, and football, greatly stress the bones in the lower back. They also require that the athlete constantly overstretch (hyperextend) the spine. This can lead to a stress fracture on one or both sides of the vertebra. A stress fracture can cause a spinal bone to become weak and shift out of place.

      Symptoms
      Symptoms of spondylolisthesis may vary from mild to severe. A person with spondylolisthesis may have no symptoms. Children may not show symptoms until they’re 18 years old.

      The condition can lead to increased lordosis (also called swayback). In later stages, it may result in kyphosis (round back) as the upper spine falls off the lower spine.

      Symptoms may include any of the following:

      Lower back pain
      Muscle tightness (tight hamstring muscle)
      Pain, numbness, or tingling in the thighs and buttocks
      Stiffness
      Tenderness in the area of the vertebra that is out of place
      Weakness in the legs

      Ankylosing spondylitis (AS) is a type of arthritis in which there is a long-term inflammation of the joints of the spine.[2] Typically the joints where the spine joins the pelvis are also affected. Occasionally other joints such as the shoulders or hips are involved. Eye and bowel problems may also occur. Back pain is a characteristic symptom of AS, and it often comes and goes. Stiffness of the affected joints generally worsens over time.

      Although the cause of ankylosing spondylitis is unknown, it is believed to involve a combination of genetic and environmental factors. More than 90% of those affected in the UK have a specific human leukocyte antigen known as the HLA-B27 antigen. The underlying mechanism is believed to be autoimmune or autoinflammatory. Diagnosis is typically based on the symptoms with support from medical imaging and blood tests. AS is a type of seronegative spondyloarthropathy, meaning that tests show no presence of rheumatoid factor (RF) antibodies. It is also within a broader category known as axial spondylarthritis.

      The signs and symptoms of ankylosing spondylitis often appear gradually, with peak onset being between 20 and 30 years of age. Initial symptoms are usually a chronic dull pain in the lower back or gluteal region combined with stiffness of the lower back. Individuals often experience pain and stiffness that awakens them in the early morning hours.

      As the disease progresses, loss of spinal mobility and chest expansion, with a limitation of anterior flexion, lateral flexion, and extension of the lumbar spine, are seen. Systemic features are common, with weight loss, fever, or fatigue often present. Pain is often severe at rest but may improve with physical activity, but inflammation and pain to varying degrees may recur regardless of rest and movement.

    • This question is part of the following fields:

      • Generic Surgical Topics
      • Orthopaedics
      169.8
      Seconds
  • Question 18 - A 7 year old girl is taken to her family doctor because her...

    Incorrect

    • A 7 year old girl is taken to her family doctor because her mother is concerned that she has a small epithelial defect anterior to the left ear and it has been noted to discharge foul smelling material for the past 3 days. What is the most likely explanation?

      Your Answer: Otitis media

      Correct Answer: Pre auricular sinus

      Explanation:

      The preauricular sinus is a benign congenital malformation of the preauricular soft tissues. Mostly it is noted during routine ear, nose and throat examination, though can present as an infected and discharging sinus. Preauricular sinus is more often unilateral, only occasionally are bilateral forms inherited. The right side is more often involved and females more than males. Most sinuses are clinically silent, eventual, however not rare, appearance of symptoms is related to an infectious process. Erythema, swelling, pain and discharge are familiar signs and symptoms of infection. The most common pathogens causing infection are Staphylococcal species and, less frequently Proteus, Streptococcus and Peptococcus species.

      Courses of treatment typically include the following:
      – Draining the pus occasionally as it can build up a strong odour
      – Antibiotics when infection occurs.
      – Surgical excision is indicated with recurrent fistula infections, preferably after significant healing of the infection.
      In case of a persistent infection, infection drainage is performed during the excision operation. The operation is generally performed by an appropriately trained specialist surgeon e.g. a otolaryngologist or a specialist General Surgeon.
      The fistula can be excised as a cosmetic operation even though no infection appeared. The procedure is considered an elective operation in the absence of any associated complications.

    • This question is part of the following fields:

      • Generic Surgical Topics
      • Head And Neck Surgery
      92.7
      Seconds
  • Question 19 - A 12 year old boy presents with a sharp pain on the left...

    Incorrect

    • A 12 year old boy presents with a sharp pain on the left side of his lower back. His parents both have a similar history of the condition. His urine tests positive for blood. A radio dense stone is seen in the region of the mid ureter when a KUB style x-ray is done. Which of the following is most likely the composition of the stone?

      Your Answer: Calcium oxalate stone

      Correct Answer: Cystine stone

      Explanation:

      Answer: Cystine stone

      Cystinuria is a genetic cause of kidney stones with an average prevalence of 1 in 7000 births. Cystine stones are found in 1 to 2 percent of stone formers, although they represent a higher percentage of stones in children (approximately 5 percent). Cystinuria is an inherited disorder. Inherited means it is passed down from parents to children through a defect in a specific gene. In order to have cystinuria, a person must inherit the gene from both parents.
      Cystine is a homodimer of the amino acid cysteine. Patients with cystinuria have impairment of renal cystine transport, with decreased proximal tubular reabsorption of filtered cystine resulting in increased urinary cystine excretion and cystine nephrolithiasis. The cystine transporter also promotes the reabsorption of dibasic amino acids, including ornithine, arginine, and lysine, but these compounds are soluble so that an increase in their urinary excretion does not lead to stones. Intestinal cystine transport is also diminished, but the result is of uncertain clinical significance.

      Cystinuria only causes symptoms if you have a stone. Kidney stones can be as small as a grain of sand. Others can become as large as a pebble or even a golf ball. Symptoms may include:

      Pain while urinating
      Blood in the urine
      Sharp pain in the side or the back (almost always on one side)
      Pain near the groin, pelvis, or abdomen
      Nausea and vomiting

      Struvite stones are a type of hard mineral deposit that can form in your kidneys. Stones form when minerals like calcium and phosphate crystallize inside your kidneys and stick together. Struvite is a mineral that’s produced by bacteria in your urinary tract. Bacteria in your urinary tract produce struvite when they break down the waste product urea into ammonia. For struvite to be produced, your urine needs to be alkaline. Having a urinary tract infection can make your urine alkaline. Struvite stones often form in women who have a urinary tract infection.

      Calcium oxalate stones are the most common type of kidney stone. Kidney stones are solid masses that form in the kidney when there are high levels of calcium, oxalate, cystine, or phosphate and too little liquid. There are different types of kidney stones. Your healthcare provider can test your stones to find what type you have. Calcium oxalate stones are caused by too much oxalate in the urine.

      What is oxalate and how does it form stones?
      Oxalate is a natural substance found in many foods. Your body uses food for energy. After your body uses what it needs, waste products travel through the bloodstream to the kidneys and are removed through urine. Urine has various wastes in it. If there is too much waste in too little liquid, crystals can begin to form. These crystals may stick together and form a solid mass (a kidney stone). Oxalate is one type of substance that can form crystals in the urine. This can happen if there is too much oxalate, too little liquid, and the oxalate “sticks” to calcium while urine is being made by the kidneys.

      Uric acid stones are the most common cause of radiolucent kidney stones in children. Several products of purine metabolism are relatively insoluble and can precipitate when urinary pH is low. These include 2- or 8-dihydroxyadenine, adenine, xanthine, and uric acid. The crystals of uric acid may initiate calcium oxalate precipitation in metastable urine concentrates.
      Uric acid stones form when the levels of uric acid in the urine is too high, and/or the urine is too acidic (pH level below 5.5) on a regular basis. High acidity in urine is linked to the following causes:
      Uric acid can result from a diet high in purines, which are found especially in animal proteins such as beef, poultry, pork, eggs, and fish. The highest levels of purines are found in organ meats, such as liver and fish. Eating large amounts of animal proteins can cause uric acid to build up in the urine. The uric acid can settle and form a stone by itself or in combination with calcium. It is important to note that a person’s diet alone is not the cause of uric acid stones. Other people might eat the same diet and not have any problems because they are not prone to developing uric acid stones.
      There is an increased risk of uric acid stones in those who are obese or diabetic.
      Patients on chemotherapy are prone to developing uric acid stones.

      Only cystine stone is inherited.

    • This question is part of the following fields:

      • Generic Surgical Topics
      • Urology
      78.9
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  • Question 20 - An 18 year old military recruit complains of sudden onset of severe pain...

    Incorrect

    • An 18 year old military recruit complains of sudden onset of severe pain in the forefoot after several weeks of training exercises. Examination shows tenderness along the second metatarsal and an x-ray done indicates the presence of callus surrounding the shaft of the second metatarsal. What is his diagnosis?

      Your Answer: Mortons neuroma

      Correct Answer: Stress fracture

      Explanation:

      Answer: Stress fracture

      A stress fracture is caused by repetitive and submaximal loading of the bone, which eventually becomes fatigued and leads to a true fracture. The typical presentation is a complaint of increasing pain in the lower extremity during exercise or activity. The patient’s history usually reveals a recent increase in either training volume or intensity. Stress fractures result from recurrent and repetitive loading of bone. The stress fracture differs from other types of fractures in that in most cases, no acute traumatic event precedes the symptoms.

      Normal bone remodelling occurs secondary to increased compressive or tensile loads or increased load frequency. In the normal physiologic response, minor microdamage of the bone occurs. This is repaired through remodelling. Stress fractures develop when extensive microdamage occurs before the bone can be adequately remodelled.
      Common findings on physical examination may include tenderness or pain on palpation or percussion of the bone. Erythema or oedema may be present at the site of the stress fracture. Loading or stress of the affected bone may also produce symptoms.

      A stress fracture can be difficult to see on an X-ray, because the bone often appears normal in the X-ray, and the small cracks can’t be seen. X-rays may not help diagnose a stress fracture unless it has started to heal. When the bone starts to heal, it creates a callus, or lump, that can be seen on X-rays. The doctors may recommend a bone scan or magnetic resonance imaging (MRI), which is more sensitive than an X-ray and can spot stress fractures early.

      Freiberg disease is a degenerative process involving the epiphyses resulting in osteonecrosis of subchondral cancellous bone. If the process is altered in such a way as to restore normal physiology, this may be followed by regeneration or recalcification. If not, the process continues to subchondral collapse and eventual fragmentation of the joint surface.
      Patients who have Freiberg disease typically present with complaints of activity-related forefoot pain. Walking alone is often sufficient to cause pain. Some patients describe an extended (months to years) history of chronic forefoot pain with episodic exacerbation, whereas others present with pain of recent onset that is related to a specific injury or event. A history of trauma may not be noted. Patients may present with stiffness and a limp. The pain is often vague and poorly localized to the forefoot. Some patients describe the sensation of a small, hard object under the foot.

      Physical examination typically reveals a limited range of motion (ROM), swelling, and tenderness with direct palpation of the metatarsophalangeal (MTP) joint. In early stages of the disease, MTP tenderness may be the only finding. In later stages, crepitus or deformity may be present. A skin callus may be seen on the plantar surface of the affected metatarsal head.

      Radiography
      Depending on the stage of the disease, radiographs may show only sclerosis and widening of the joint space (early), with complete collapse of the metatarsal head and fragmentation later. Osteochondral loose bodies may be seen late in the disease as well. Oblique views may be especially useful for achieving a full appreciation of subtle changes early in the disease. One study advocated the use of radiographs to assess musculoskeletal foot conditions in women related to poorly fitting shoes.
      Occasionally, patients are completely asymptomatic, with changes noted on radiographs taken for other reasons. Whether these patients later develop symptomatic Freiberg disease is not known.

    • This question is part of the following fields:

      • Generic Surgical Topics
      • Orthopaedics
      65
      Seconds
  • Question 21 - A 49 year old carpenter is rushed to the hospital after falling from...

    Incorrect

    • A 49 year old carpenter is rushed to the hospital after falling from the roof of a house. He has an open fracture of his tibia with a 14 cm wound and he is neurovascularly intact. What is the most appropriate course of action?

      Your Answer: Thorough wound debridement in the emergency department

      Correct Answer: Intravenous antibiotics, photography and application of saline soaked gauze with impermeable dressing

      Explanation:

      The administration of antibiotics is best considered therapeutic, rather than prophylactic, because of the high risk of infection in the absence of antibiotics.

      Although debate still surrounds some aspects of antibiotic administration for open fractures, the following generalizations can be made:

      – All patients with open fractures should receive cefazolin or equivalent gram-positive coverage; this may be sufficient
      – Type II or type III injuries likely benefit from the addition of adequate gram-negative coverage, typically with an aminoglycoside
      – Injuries at risk for anaerobic infections (e.g., farm injuries, severe tissue necrosis) probably benefit from the addition of penicillin or clindamycin.

      Digital photos are helpful for documenting the initial appearance of the extremity and can be a valuable addition to the medical record. Digital imaging allows other members of the treatment team to see the wound preoperatively without repeated manipulations of the wound.
      Gauze swabs soaked in normal saline are frequently used as dressing on open wounds.

      The Oxford Handbook for Medical school recommends that open fractures should be sealed with saline-soaked gauze and impermeable dressing after removal of gross contaminants.

    • This question is part of the following fields:

      • Generic Surgical Topics
      • Orthopaedics
      42.3
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  • Question 22 - A 34 year old woman arrives at the clinic with a goitre and...

    Incorrect

    • A 34 year old woman arrives at the clinic with a goitre and is diagnosed with autoimmune thyroiditis. She is most likely to develop which of the following types of cancers?

      Your Answer: None of the above

      Correct Answer: Lymphoma

      Explanation:

      Pre-existing chronic autoimmune (Hashimoto’s) thyroiditis is the only known risk factor for primary thyroid lymphoma and is present in approximately one-half of patients. Among patients with Hashimoto’s thyroiditis, the risk of thyroid lymphoma is at least 60 times higher than in patients without thyroiditis.

    • This question is part of the following fields:

      • Generic Surgical Topics
      • Head And Neck Surgery
      71.8
      Seconds
  • Question 23 - A 39 year old woman was taken to the surgical clinic for symptoms...

    Correct

    • A 39 year old woman was taken to the surgical clinic for symptoms related to varicose veins. She has noticed that these first developed when she was pregnant. A truncal varicosity of the medial leg was seen on examination but there are no ulcers or skin changes. A hand held Doppler examination demonstrates sapheno-popliteal junction reflux. Which of the following is the best course of action?

      Your Answer: Arrange a duplex scan

      Explanation:

      Saphenopopliteal (SPJ) reflux may be present in 20–25% of patients with primary varicose veins. Pre-operative colour duplex marking increases the accuracy of localisation of the SPJ at operation and is considered to be the gold standard for this purpose. A prospective study of 50 consecutive primary SSV ligations was undertaken and it showed that duplex was highly accurate in correctly locating the SPJ to within an accuracy of 20 mm in 98% of cases. The comparative figure for short saphenous vein (SSV) palpation was 48%. Palpation alone therefore cannot be recommended as a means of determining the site of SPJ and duplex continues to remain the gold standard for the preoperative localisation of the SPJ.

    • This question is part of the following fields:

      • Generic Surgical Topics
      • Vascular
      59.3
      Seconds
  • Question 24 - A 34-year-old female teacher is admitted with severe epigastric pain. Her blood reports...

    Incorrect

    • A 34-year-old female teacher is admitted with severe epigastric pain. Her blood reports show normal levels of serum amylase. In order to exclude a perforated viscus and determine whether pancreatitis is present, what should be the best course of action?

      Your Answer: Order an erect CXR and plain abdominal film

      Correct Answer: Request a CT scan of the abdomen and pelvis with intravenous contrast

      Explanation:

      A CT scan with IV contrast is needed because a scan without contrast will exclude a perforated viscus but will not be able to determine the presence of pancreatitis.

      Acute pancreatitis may be mild or life-threatening but it usually subsides. Gallstones and alcohol abuse are the main causes of acute pancreatitis. Severe abdominal pain is the predominant symptom.

      For diagnosis of acute pancreatitis, serum lipase is both more sensitive and specific than serum amylase.
      Serum amylase levels do not correlate with disease severity and may give both false positive and negative results. Three scoring systems are used to assess the severity of the disease, which are Glasgow pancreatitis score, Ranson criteria, and APACHE II scoring system.

      Management options are as follows:
      1. There is very little evidence to support the administration of antibiotics to patients with acute pancreatitis. These may contribute to antibiotic resistance and increase the risks of antibiotic-associated diarrhoea.
      2. Patients with acute pancreatitis due to gallstones should undergo early cholecystectomy.
      3. Patients with obstructed biliary system due to stones should undergo early ERCP.
      4. Patients with infected necrosis should undergo either radiological drainage or surgical necrosectomy.

    • This question is part of the following fields:

      • Generic Surgical Topics
      • Hepatobiliary And Pancreatic Surgery
      71.3
      Seconds
  • Question 25 - A 30-year-old male has had a sore throat for the past 5 days....

    Correct

    • A 30-year-old male has had a sore throat for the past 5 days. Over the past 24 hours, he has noticed increasing and severe throbbing pain in the region of his right tonsil. He has pyrexia and on examination, he is noted to have swelling of this area. What is the most likely cause?

      Your Answer: Quinsy

      Explanation:

      Patients with a Quinsy or peritonsillar abscess (PTA) typically present with a history of acute pharyngitis accompanied by tonsillitis and worsening unilateral pharyngeal discomfort. Patients also may experience malaise, fatigue, and headaches. They often present with a fever and asymmetric throat fullness. Associated halitosis, odynophagia, dysphagia, and a hot potato–sounding voice occurs.
      The presentation may range from acute tonsillitis with unilateral pharyngeal asymmetry to dehydration and sepsis. Most patients have severe pain. Examination of the oral cavity reveals marked erythema, asymmetry of the soft palate, tonsillar exudation, and contralateral displacement of the uvula.
      Indications for considering the diagnosis of a PTA include the following:
      Unilateral swelling of the peritonsillar area
      Unilateral swelling of the soft palate, with anterior displacement of the ipsilateral tonsil
      Nonresolution of acute tonsillitis, with persistent unilateral tonsillar enlargement
      A PTA ordinarily is unilateral and located at the superior pole of the affected tonsil, in the supratonsillar fossa. At the level of the supratonsillar fold, the mucosa may appear pale and even show a small pimple. Palpation of the soft palate often reveals an area of fluctuance. Flexible nasopharyngoscopy and laryngoscopy are recommended in patients experiencing airway distress. The laryngoscopy is key to ruling out epiglottitis and supraglottitis, as well as vocal cord pathology.

    • This question is part of the following fields:

      • Generic Surgical Topics
      • Head And Neck Surgery
      79.5
      Seconds
  • Question 26 - A 15 year old girl is taken to the A&E after complaining of...

    Incorrect

    • A 15 year old girl is taken to the A&E after complaining of right iliac fossa pain which started suddenly. She is well other than having some right iliac fossa tenderness but no guarding. She has no fever and the urinary dipstick result is normal. Her last menstrual cycle was 14 days ago which was also normal and the pregnancy test done is negative. What is the most likely underlying condition?

      Your Answer: Appendicitis

      Correct Answer: Mittelschmerz

      Explanation:

      Answer: Mittelschmerz

      Mittelschmerz is midcycle abdominal pain due to leakage of prostaglandin-containing follicular fluid at the time of ovulation. It is self-limited, and a theoretical concern is treatment of pain with prostaglandin synthetase inhibitors, which could prevent ovulation. The pain of mittelschmerz usually occurs in the lower abdomen and pelvis, either in the middle or to one side. The pain can range from a mild twinge to severe discomfort and usually lasts from minutes to hours. In some cases, a small amount of vaginal bleeding or discharge might occur. Some women have nausea, especially if the pain is very strong.
      Diagnosis of pelvic pain in women can be challenging because many symptoms and signs are insensitive and nonspecific. As the first priority, urgent life-threatening conditions (e.g., ectopic pregnancy, appendicitis, ruptured ovarian cyst) and fertility-threatening conditions (e.g., pelvic inflammatory disease, ovarian torsion) must be considered.
      Many women never have pain at ovulation. Some women, however, have mid-cycle pain every month, and can tell by the pain that they are ovulating.
      As an egg develops in the ovary, it is surrounded by follicular fluid. During ovulation, the egg and the fluid, as well as some blood, are released from the ovary. While the exact cause of mittelschmerz is not known, it is believed to be caused by the normal enlargement of the egg in the ovary just before ovulation. Also, the pain could be caused by the normal bleeding that comes with ovulation.
      Pelvic inflammatory disease can be ruled out if the patient is not sexually active.

    • This question is part of the following fields:

      • Generic Surgical Topics
      • The Abdomen
      42.5
      Seconds
  • Question 27 - A 6 year old girl falls during dance class and fractures the growth...

    Correct

    • A 6 year old girl falls during dance class and fractures the growth plate of her left wrist. Which system can be used to classify the injury?

      Your Answer: Salter - Harris system

      Explanation:

      A Salter–Harris fracture is a fracture that involves the epiphyseal plate or growth plate of a bone, specifically the zone of provisional calcification. It is a common injury found in children, occurring in 15% of childhood long bone fractures.
      There are nine types of Salter–Harris fractures; types I to V as described by Robert B Salter and W Robert Harris in 1963, and the rarer types VI to IX which have been added subsequently:
      Type I – transverse fracture through the growth plate (also referred to as the physis): 6% incidence
      Type II – A fracture through the growth plate and the metaphysis, sparing the epiphysis: 75% incidence, takes approximately 12-90 weeks or more in the spine to heal.
      Type III – A fracture through growth plate and epiphysis, sparing the metaphysis: 8% incidence
      Type IV – A fracture through all three elements of the bone, the growth plate, metaphysis, and epiphysis: 10% incidence
      Type V – A compression fracture of the growth plate (resulting in a decrease in the perceived space between the epiphysis and metaphysis on x-ray): 1% incidence
      Type VI – Injury to the peripheral portion of the physis and a resultant bony bridge formation which may produce an angular deformity (added in 1969 by Mercer Rang)
      Type VII – Isolated injury of the epiphyseal plate (VII–IX added in 1982 by JA Ogden)
      Type VIII – Isolated injury of the metaphysis with possible impairment of endochondral ossification
      Type IX – Injury of the periosteum which may impair intramembranous ossification

      The mnemonic SALTER can be used to help remember the first five types.
      N.B.: This mnemonic requires the reader to imagine the bones as long bones, with the epiphyses at the base.

      I – S = Slip (separated or straight across). Fracture of the cartilage of the physis (growth plate)
      II – A = Above. The fracture lies above the physis, or Away from the joint.
      III – L = Lower. The fracture is below the physis in the epiphysis.
      IV – TE = Through Everything. The fracture is through the metaphysis, physis, and epiphysis.
      V – R = Rammed (crushed). The physis has been crushed.
      Alternatively, SALTER can be used for the first 6 types, as above but adding Type V — ‘E’ for ‘Everything’ or ‘Epiphysis’ and Type VI — ‘R’ for ‘Ring’.

    • This question is part of the following fields:

      • Generic Surgical Topics
      • Orthopaedics
      107.6
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  • Question 28 - A 48 year old woman with episodes of recurrent urinary tract sepsis presents...

    Incorrect

    • A 48 year old woman with episodes of recurrent urinary tract sepsis presents with a staghorn calculus of the right kidney. Her urinary pH is 7.8. An abdominal x-ray shows a faint outline of the calculus. What would be the most likely composition of the stone?

      Your Answer: Calcium oxalate

      Correct Answer: Struvite

      Explanation:

      Staghorn calculi refer to branched stones that fill all or part of the renal pelvis and branch into several or all of the calyces. They are most often composed of struvite (magnesium ammonium phosphate) and/or calcium carbonate apatite. These stones are often referred to as ‘infection stones’ since they are strongly associated with urinary tract infections with urea splitting organisms. Small struvite and/or calcium carbonate apatite stones can grow rapidly over a period of weeks to months into large staghorn calculi involving the calyces and entire renal pelvis. If left untreated, this can lead to deterioration of kidney function and end-stage renal disease. In addition, since the stones often remain infected, there is a risk of developing sepsis. Thus, most patients require definitive surgical treatment.

      Struvite stones account for 15% of renal calculi. They are associated with chronic urinary tract infection (UTI) with gram-negative, urease-positive organisms that split urea into ammonia, which then combines with phosphate and magnesium to crystalize into a calculus. Usual organisms include Proteus, Pseudomonas, and Klebsiella species. Escherichia coli is not capable of splitting urea and, therefore, is not associated with struvite stones. Because ammonia, a base, is produced during the catalytic process, the urine pH is typically greater than 7.
      Underlying anatomical abnormalities that predispose patients to recurrent kidney infections should be sought and corrected. UTI does not resolve until the stone is removed entirely.
      This patient has a urine pH of 7.8 which is very alkaline.

    • This question is part of the following fields:

      • Generic Surgical Topics
      • Urology
      68.7
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  • Question 29 - A 47 year old female undergoes a kidney transplant which comes from a...

    Correct

    • A 47 year old female undergoes a kidney transplant which comes from a cadaver. She has an uncomplicated surgery but on removal of the vascular clamps, the transplanted kidney immediately turns dusky and over the next few hours appears non viable. Which of the following best explains this event?

      Your Answer: Hyper acute rejection

      Explanation:

      Hyperacute rejection occurs almost immediately following organ implantation and necessitates immediate explant of the organ. Hyperacute rejection is uncommon with pre-transplantation cross-matches and screening. Hyperacute rejection (HAR) of the kidney was first recognized 20 years ago in cases of donor-recipient incompatibility for the major blood group and tissue antigen systems. Classic pathological changes described include early accumulation of PMNs in glomeruli and peritubular capillaries, progressive glomerular thrombosis, tubular necrosis, and eventual cortical necrosis. Reaction of host humoral antibodies with antigens on donor cells serves as one trigger of the clotting mechanism, which then proceeds in a nonspecific fashion.

      Antigen systems other than the ABO groups that contribute to HAR reactions are leukocyte antigens, endothelial and monocyte antigens, and B cell antigens. It is also documented that glomerular thrombosis identical to HAR may occur secondary to endothelial damage after pulsatile perfusion. However, in such cases no specific deposition of immunoglobulins and complement is detected.

    • This question is part of the following fields:

      • Generic Surgical Topics
      • Organ Transplantation
      43
      Seconds
  • Question 30 - A 45-year-old man has a long history of ulcerative colitis. His symptoms are...

    Incorrect

    • A 45-year-old man has a long history of ulcerative colitis. His symptoms are well-controlled with steroids. However, attempts at steroid weaning and use of steroid-sparing drugs have repeatedly failed. He wishes to avoid a permanent stoma. Which of the following should be the best operative strategy?

      Your Answer: Subtotal colectomy and construction of an ileoanal pouch

      Correct Answer:

      Explanation:

      In patients with ulcerative colitis (UC) where medical management is not successful, surgical resection (pan-proctocolectomy) may offer a chance of cure. Those patients wishing to avoid a permanent stoma may be considered for an ileoanal pouch. However, this procedure is only offered in the elective setting.

      Patients with inflammatory bowel disease (UC and Crohn’s disease) frequently present in surgical practice. Elective indications for surgery in UC include disease that requires maximal therapy or prolonged courses of steroids.

      Long-standing UC is associated with a risk of malignant transformation. Dysplastic transformation of the colonic epithelium with associated mass lesions is an absolute indication for a proctocolectomy. Restorative options in UC include an ileoanal pouch. Complications of such a pouch include anastomotic dehiscence, pouchitis, and poor physiological function with seepage and soiling.
      .
      Emergency presentation of poorly-controlled colitis that fails to respond to medical therapy should usually be managed with a subtotal colectomy. Excision of the rectum is a procedure with a higher morbidity and is not generally performed in the emergency setting.

    • This question is part of the following fields:

      • Colorectal Surgery
      • Generic Surgical Topics
      41.9
      Seconds

SESSION STATS - PERFORMANCE PER SPECIALTY

Generic Surgical Topics (12/30) 40%
Head And Neck Surgery (3/7) 43%
Surgical Disorders Of The Brain (0/1) 0%
Hepatobiliary And Pancreatic Surgery (1/3) 33%
Colorectal Surgery (1/4) 25%
Urology (0/3) 0%
Breast And Endocrine Surgery (0/1) 0%
The Abdomen (1/2) 50%
Orthopaedics (4/7) 57%
Vascular (1/1) 100%
Organ Transplantation (1/1) 100%
Passmed