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Question 1
Correct
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As a healthcare professional in the emergency department, you come across an elderly overweight man who appears to be in a drowsy state. Upon calling out his name, you hear a grunting sound. The patient has periorbital ecchymosis and clear fluid leaking from one nostril. Additionally, his oxygen saturation levels are at 82% on air.
Which airway adjunct should you avoid using in this patient?Your Answer: Nasopharyngeal airway
Explanation:If a patient is suspected or known to have a basal skull fracture, nasopharyngeal airways should not be used. This is because there is a rare risk of inserting the airway into the cranial cavity. Signs of a basal skull fracture include periorbital ecchymosis (raccoon eyes), CSF rhinorrhoea, haemotympanum, and mastoid process bruising (battle’s sign). While ET tubes, i-gels, and LMAs do not have contraindications, they should not be the first-line option and should only be inserted by a trained professional, typically an anaesthetist.
Nasopharyngeal Airway for Maintaining Airway Patency
Nasopharyngeal airways are medical devices used to maintain a patent airway in patients with decreased Glasgow coma score (GCS). These airways are inserted into the nostril after being lubricated, and they come in various sizes. They are particularly useful for patients who are having seizures, as an oropharyngeal airway (OPA) may not be suitable for insertion.
Nasopharyngeal airways are generally well-tolerated by patients with low GCS. However, they should be used with caution in patients with base of skull fractures, as they may cause further damage. It is important to note that these airways should only be inserted by trained medical professionals to avoid any complications. Overall, nasopharyngeal airways are an effective tool for maintaining airway patency in patients with decreased GCS.
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This question is part of the following fields:
- Surgery
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Question 2
Incorrect
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A 50-year-old woman comes to the clinic complaining of a painful and swollen hand. She reports having a fracture in her radius that was treated with a plaster cast for four weeks. Since then, she has noticed tenderness and shiny skin in the affected hand. What is the most probable diagnosis for her symptoms?
Your Answer: Myositis ossificans
Correct Answer: Complex regional pain syndrome
Explanation:Complex Regional Pain Syndromes (CRPS)
Complex Regional Pain Syndromes (CRPS) are a group of conditions that are characterized by localized or widespread pain, accompanied by swelling, changes in skin color and temperature, and disturbances in blood flow. People with CRPS may also experience allodynia (pain from stimuli that are not normally painful), hyperhidrosis (excessive sweating), and changes in nail or hair growth. In some cases, motor abnormalities such as tremors, muscle spasms, and involuntary movements may also occur. Contractures, or the shortening and tightening of muscles, may develop in later stages of the condition. CRPS can affect any part of the body, but it is most commonly seen in the limbs.
One of the defining features of CRPS is that it often develops after an injury, even one that may seem minor or insignificant. Symptoms may not appear until several months after the initial injury. CRPS was previously known as Reflex Sympathetic Dystrophy (RSD).
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This question is part of the following fields:
- Surgery
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Question 3
Incorrect
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A 49-year-old female patient complains of loin pain and haematuria. Upon urine dipstick examination, the results show:
Blood ++++
Nitrites POS
Leucocytes +++
Protein ++
Further urine culture reveals a Proteus infection, while an x-ray confirms the presence of a stag-horn calculus in the left renal pelvis. What is the probable composition of the renal stone?Your Answer: Calcium oxalate
Correct Answer: Struvite
Explanation:Stag-horn calculi consist of struvite and develop in urine with high alkalinity, which is often caused by the presence of ammonia-producing bacteria.
Types of Renal Stones and their Appearance on X-ray
Renal stones, also known as kidney stones, are solid masses that form in the kidneys due to the accumulation of certain substances. There are different types of renal stones, each with a unique appearance on x-ray. Calcium oxalate stones are the most common, accounting for 40% of cases, and appear opaque on x-ray. Mixed calcium oxalate/phosphate stones and calcium phosphate stones also appear opaque and make up 25% and 10% of cases, respectively. Triple phosphate stones, which develop in alkaline urine and are composed of struvite, account for 10% of cases and appear opaque as well. Urate stones, which are radiolucent, make up 5-10% of cases. Cystine stones, which have a semi-opaque, ‘ground-glass’ appearance, are rare and only account for 1% of cases. Xanthine stones are the least common, accounting for less than 1% of cases, and are also radiolucent. Staghorn calculi, which involve the renal pelvis and extend into at least 2 calyces, are composed of triple phosphate and are more likely to develop in alkaline urine. Infections with Ureaplasma urealyticum and Proteus can increase the risk of their formation.
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This question is part of the following fields:
- Surgery
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Question 4
Correct
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A 26-year-old woman weighing 70kg is brought to the emergency department with burns covering 25% of her body surface area.
Using the Parkland formula, calculate the volume of Hartmann's solution that is recommended to be given in the first 8 hours after the burn.Your Answer: 3.5L
Explanation:To calculate the amount of Hartmann’s solution to be administered in the first 24 hours after a burn, multiply the body surface area by the weight in kilograms. For example, if the body surface area is 4 and the weight is 70 kg, the calculation would be 4 x 25 x 70 = 7000 ml. Half of this amount should be given within the first 8 hours after the burn, which equals 3.5 liters.
Fluid Resuscitation for Burns
Fluid resuscitation is necessary for patients with burns that cover more than 15% of their total body area (10% for children). The primary goal of resuscitation is to prevent the burn from deepening. Most fluid is lost within the first 24 hours after injury, and during the first 8-12 hours, fluid shifts from the intravascular to the interstitial fluid compartments, which can compromise circulatory volume. However, fluid resuscitation causes more fluid to enter the interstitial compartment, especially colloid, which should be avoided in the first 8-24 hours. Protein loss also occurs.
The Parkland formula is used to calculate the total fluid requirement in 24 hours, which is given as 4 ml x (total burn surface area (%)) x (body weight (kg)). Fifty percent of the total fluid requirement is given in the first 8 hours, and the remaining 50% is given in the next 16 hours. The resuscitation endpoint is a urine output of 0.5-1.0 ml/kg/hour in adults, and the rate of fluid is increased to achieve this.
It is important to note that the starting point of resuscitation is the time of injury, and fluids already given should be deducted. After 24 hours, colloid infusion is begun at a rate of 0.5 ml x (total burn surface area (%)) x (body weight (kg)), and maintenance crystalloid (usually dextrose-saline) is continued at a rate of 1.5 ml x (burn area) x (body weight). Colloids used include albumin and FFP, and antioxidants such as vitamin C can be used to minimize oxidant-mediated contributions to the inflammatory cascade in burns. High tension electrical injuries and inhalation injuries require more fluid, and monitoring of packed cell volume, plasma sodium, base excess, and lactate is essential.
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This question is part of the following fields:
- Surgery
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Question 5
Incorrect
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A 20-year-old student falls from a 2nd-floor window. She is persistently hypotensive. A chest x-ray shows a widened mediastinum with depression of the left main bronchus and deviation of the trachea to the right. What is the most probable injury?
Your Answer: Tension pneumothorax
Correct Answer: Aortic rupture
Explanation:The patient has suffered a deceleration injury and is experiencing ongoing low blood pressure due to a contained hematoma. This suggests that there may be a rupture in the aorta, although a widened mediastinum may not always be visible on a chest X-ray. To obtain a more accurate assessment of the injury, a CT angiogram is recommended. The fact that the patient has been experiencing persistent hypotension from an early stage is more indicative of a hematoma than a tension pneumothorax, which typically only causes low blood pressure as a final symptom before cardiac arrest.
Thoracic Trauma: Common Conditions and Treatment
Thoracic trauma can result in various conditions that require prompt medical attention. Tension pneumothorax, for instance, occurs when pressure builds up in the thorax due to a laceration to the lung parenchyma with a flap. This condition is often caused by mechanical ventilation in patients with pleural injury. Symptoms of tension pneumothorax overlap with cardiac tamponade, but hyper-resonant percussion note is more likely. Flail chest, on the other hand, occurs when the chest wall disconnects from the thoracic cage due to multiple rib fractures. This condition is associated with pulmonary contusion and abnormal chest motion.
Pneumothorax is another common condition resulting from lung laceration with air leakage. Traumatic pneumothoraces should have a chest drain, and patients should never be mechanically ventilated until a chest drain is inserted. Haemothorax, which is most commonly due to laceration of the lung, intercostal vessel, or internal mammary artery, is treated with a large bore chest drain if it is large enough to appear on CXR. Surgical exploration is warranted if more than 1500 ml blood is drained immediately.
Cardiac tamponade is characterized by elevated venous pressure, reduced arterial pressure, and reduced heart sounds. Pulsus paradoxus may also occur with as little as 100 ml blood. Pulmonary contusion is the most common potentially lethal chest injury, and arterial blood gases and pulse oximetry are important. Early intubation within an hour is necessary if significant hypoxia is present. Blunt cardiac injury usually occurs secondary to chest wall injury, and ECG may show features of myocardial infarction. Aorta disruption, diaphragm disruption, and mediastinal traversing wounds are other conditions that require prompt medical attention.
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This question is part of the following fields:
- Surgery
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Question 6
Correct
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A 42-year-old male presents to the emergency department with intermittent abdominal pain in the right upper quadrant (RUQ). The pain started 3 hours ago, and is described as a sharp pain that comes and goes. The pain does not radiate anywhere, but it has progressively worsened throughout the day.
Upon examination, the patient appears to be in pain at rest, but does not appear clammy or pale. He is very tender in the right upper quadrant, but no guarding or rebound tenderness is felt.
His vital signs are as follows:
Heart rate = 105 beats per minute.
Respiratory rate = 20 breaths per minute.
Blood pressure = 130/85 mmHg.
Temperature = 38.5ºC.
What is the most appropriate next investigation to perform?Your Answer: Ultrasound scan
Explanation:When acute cholecystitis is suspected, ultrasound is the preferred diagnostic method. The main differential diagnoses are biliary colic, acute cholecystitis, and ascending cholangitis. Acute cholecystitis is the most probable cause, given the duration of abdominal pain (which typically lasts less than 2 hours in biliary colic) and the mild systemic symptoms (as opposed to the severe illness seen in ascending cholangitis). Ultrasound is preferred due to its accuracy in detecting gallstones and assessing gallbladder abnormalities, as well as its non-invasive and cost-effective nature. CT and X-rays are less desirable due to their radiation risks. While MRCP is a non-invasive imaging technique that can visualize the hepatopancreatobiliary tract, it is recommended to start with ultrasound before considering more detailed investigations such as MRCP. ERCP is a diagnostic and therapeutic procedure, but it is usually preceded by other imaging tests due to the potential for complications such as perforation.
Acute cholecystitis is a condition where the gallbladder becomes inflamed. This is usually caused by gallstones, which are present in 90% of cases. The remaining 10% of cases are known as acalculous cholecystitis and are typically seen in severely ill patients who are hospitalized. The pathophysiology of acute cholecystitis is multifactorial and can be caused by gallbladder stasis, hypoperfusion, and infection. In immunosuppressed patients, it may develop due to Cryptosporidium or cytomegalovirus. This condition is associated with high morbidity and mortality rates.
The main symptom of acute cholecystitis is right upper quadrant pain, which may radiate to the right shoulder. Patients may also experience fever and signs of systemic upset. Murphy’s sign, which is inspiratory arrest upon palpation of the right upper quadrant, may be present. Liver function tests are typically normal, but deranged LFTs may indicate Mirizzi syndrome, which is caused by a gallstone impacted in the distal cystic duct, causing extrinsic compression of the common bile duct.
Ultrasound is the first-line investigation for acute cholecystitis. If the diagnosis remains unclear, cholescintigraphy (HIDA scan) may be used. In this test, technetium-labelled HIDA is injected IV and taken up selectively by hepatocytes and excreted into bile. In acute cholecystitis, there is cystic duct obstruction, and the gallbladder will not be visualized.
The treatment for acute cholecystitis involves intravenous antibiotics and cholecystectomy. NICE now recommends early laparoscopic cholecystectomy, within 1 week of diagnosis. Previously, surgery was delayed for several weeks until the inflammation had subsided. Pregnant women should also proceed to early laparoscopic cholecystectomy to reduce the chances of maternal-fetal complications.
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This question is part of the following fields:
- Surgery
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Question 7
Incorrect
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A 65-year-old man with benign prostatic hyperplasia complains of lower abdominal pain and difficulty urinating. Upon catheter insertion, over 2L of clear urine is drained, providing immediate pain relief. Three hours later, the patient reports pale pink urine color but is otherwise feeling well with stable vital signs. What is the best course of action for management?
Your Answer: Start bladder irrigation
Correct Answer: Monitor - no immediate action required
Explanation:If the patient is stable, decompression haematuria does not require further management. It is a common occurrence after catheterisation for chronic urinary retention and typically resolves on its own within a few days. Monitoring the patient is important to ensure the bleeding does not worsen. Bladder washouts and irrigation are not necessary in this case. Tranexamic acid is not recommended for haematuria as it can cause bladder outflow obstruction. Red blood cell transfusion is only necessary if the patient becomes haemodynamically unstable or if there is a significant drop in haemoglobin levels.
Understanding Chronic Urinary Retention
Chronic urinary retention is a condition that develops gradually and is usually painless. It can be classified into two types: high pressure retention and low pressure retention. High pressure retention is often caused by bladder outflow obstruction and can lead to impaired renal function and bilateral hydronephrosis. On the other hand, low pressure retention does not affect renal function and does not cause hydronephrosis.
When chronic urinary retention is diagnosed, catheterisation may be necessary to relieve the pressure in the bladder. However, this can lead to decompression haematuria, which is a common side effect. This occurs due to the rapid decrease in pressure in the bladder and usually does not require further treatment.
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This question is part of the following fields:
- Surgery
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Question 8
Incorrect
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A 52-year-old man is shot in the abdomen and suffers a significant intra-abdominal injury. He undergoes a laparotomy, bowel resection, and end colostomy, and requires a 6-unit blood transfusion due to an associated vascular injury. After a prolonged recovery, he is paralyzed and ventilated for 2 weeks in the intensive care unit. He is given total parenteral nutrition and eventually weaned off the ventilator and transferred to the ward. During a routine blood test, the following results are observed:
Full blood count
Hb 11.3 g/dl
Platelets 267 x 109/l
WBC 10.1 x109/l
Urea and electrolytes
Na+ 131 mmol/l
K+ 4.6 mmol/l
Urea 2.3 mmol/l
Creatinine 78 µmol/l
Liver function tests
Bilirubin 25 µmol/l
ALP 445 u/l
ALT 89 u/l
γGT 103 u/l
What is the most probable underlying cause for the noted abnormalities?Your Answer: Delayed type blood transfusion reaction
Correct Answer: Total parenteral nutrition
Explanation:Liver function tests are often affected by TPN, which can cause cholestasis but it is unlikely to lead to the formation of gallstones as seen in the image. While blood transfusion reactions may cause hepatitis, they usually present earlier and with changes in haemoglobin, which is rare in modern times.
Understanding Total Parenteral Nutrition
Total parenteral nutrition is a commonly used method of providing nutrition to surgical patients who are nutritionally compromised. The bags used in this method contain a combination of glucose, lipids, and essential electrolytes, with the exact composition being determined by the patient’s nutritional requirements. While it is possible to infuse this nutrition peripherally, doing so may result in thrombophlebitis. As such, longer-term infusions should be administered into a central vein, preferably via a PICC line.
Complications associated with total parenteral nutrition are related to sepsis, refeeding syndromes, and hepatic dysfunction. It is important to monitor patients closely for any signs of these complications and adjust the nutrition accordingly. By understanding the basics of total parenteral nutrition, healthcare professionals can provide optimal care to their patients and ensure their nutritional needs are being met.
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This question is part of the following fields:
- Surgery
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Question 9
Incorrect
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A 32-year-old woman with long-standing varicose veins presents to the hospital with a burning pain over one of the veins, accompanied by tenderness and redness in the surrounding skin. On examination, a worm-like mass is felt, and the tissue appears erythematosus and hard. There is no evidence of deep vein thrombosis, and observations are normal. An ankle-brachial pressure index of 1.0 is recorded, and a Doppler reveals a lack of compressibility and an intraluminal thrombus in the superficial vein. What is the recommended treatment for this condition?
Your Answer: Rivaroxaban
Correct Answer: Compression stockings
Explanation:Compression stockings are the recommended treatment for superficial thrombophlebitis. This is because they are effective in managing symptoms and aiding in the resolution of the condition. The patient’s history of varicose veins, along with examination and investigation results, strongly support the diagnosis of superficial thrombophlebitis. The ankle-brachial pressure index was checked to ensure that the arterial supply is sufficient, as compression stockings may compromise this. In addition to compression stockings, a low-molecular-weight heparin or fondaparinux may also be used. Intravenous antibiotics are not necessary in this case, as there is no evidence of severe infection. Rivaroxaban and warfarin are not typically used in the management of superficial thrombophlebitis, as there is no evidence of deep vein thrombosis. While some vascular surgeons may prescribe topical heparinoid, there is little evidence supporting its use in treating this condition, and it is not part of the main guidelines for management.
Superficial thrombophlebitis is inflammation associated with thrombosis of a superficial vein, usually the long saphenous vein of the leg. Around 20% of cases have an underlying deep vein thrombosis (DVT) and 3-4% may progress to a DVT if untreated. Treatment options include NSAIDs, topical heparinoids, compression stockings, and low-molecular weight heparin. Patients with clinical signs of superficial thrombophlebitis affecting the proximal long saphenous vein should have an ultrasound scan to exclude concurrent DVT. Patients with superficial thrombophlebitis at, or extending towards, the saphenofemoral junction can be considered for therapeutic anticoagulation for 6-12 weeks.
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This question is part of the following fields:
- Surgery
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Question 10
Incorrect
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Your senior consultant has asked the scrub nurse to hand him the same suture. You recall from your surgical term that polyglactin sutures are absorbable and have various uses. Which surgical procedure is your senior consultant performing that necessitates the use of these sutures?
Your Answer: Abdominal wall closure
Correct Answer: Circumcision
Explanation:Surgical Sutures: Types and Uses in Different Procedures
Surgical sutures are essential tools in various medical procedures. Surgeons need to consider three properties of sutures, including absorbable or non-absorbable, natural or synthetic, and monofilament or multifilament.
For circumcisions, Vicryl Rapide is an ideal rapidly dissolving absorbable suture that breaks down within two weeks, eliminating the need for removal. On the other hand, bowel anastomosis requires longer-acting absorbable sutures like PDS or Vicryl.
Non-absorbable Prolene (polypropylene) is necessary for arterial anastomosis and suturing hernia mesh in place. The abdominal wall closure requires strong and long-acting sutures like PDS.
In summary, the type of suture used in a surgical procedure depends on the specific needs of the patient and the surgeon’s preference. Understanding the different types of sutures and their uses is crucial in ensuring successful surgical outcomes.
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This question is part of the following fields:
- Surgery
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