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Question 1
Correct
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A 30-year-old professional footballer is admitted to the emergency department. During a tackle, his leg is twisted with his knee flexed. He hears a loud crack and his knee rapidly becomes swollen. Which of the following is the main site of injury?
Your Answer: Anterior cruciate ligament
Explanation:Anterior cruciate ligament (ACL) injuries are most often a result of low-velocity, noncontact, deceleration injuries and contact injuries with a rotational component. Contact sports also may produce injury to the ACL secondary to twisting, valgus stress, or hyperextension all directly related to contact or collision.
Symptoms of an acute ACL injury may include the following:
– Feeling or hearing a “pop” sound in the knee
– Pain and inability to continue the activity
– Swelling and instability of the knee
– Development of a large hemarthrosisDifferential Diagnoses
A- Medial Collateral Knee Ligament Injury
Contact, noncontact, and overuse mechanisms are involved in causing MCL injuries.
Contact injuries involve a direct valgus load to the knee. This is the usual mechanism in a complete tear.
Noncontact, or indirect, injuries are observed with deceleration, cutting, and pivoting motions. These mechanisms tend to cause partial tears.
Overuse injuries of the MCL have been described in swimmers. The whip-kick technique of the breaststroke has been implicated. This technique involves repetitive valgus loads across the knee.B- Posterior Cruciate Ligament Injury
Knowledge of the mechanism of injury is helpful. The following 4 mechanisms of PCL injury are recognized:
– A posteriorly directed force on a flexed knee, e.g., the anterior aspect of the flexed knee striking a dashboard, may cause PCL injury.
– A fall onto a flexed knee with the foot in plantar flexion and the tibial tubercle striking the ground first, directing a posterior force to the proximal tibia, may result in injury to the PCL.
– Hyperextension alone may lead to an avulsion injury of the PCL from the origin. This kind of injury may be amenable to repair.
– An anterior force to the anterior tibia in a hyperextended knee with the foot planted results in combined injury to the knee ligaments along with knee dislocation.In chronic PCL tears, discomfort may be experienced with the following positions or activities:
– A semi flexed position, as with ascending or descending stairs or an incline
– Starting a run
– Lifting a load
– Walking longer distances
– Retro patellar pain symptoms may be reported as a result of posterior tibial sagging.
– Swelling and stiffness may be reported in cases of chondral damage.
– Individuals may describe a sensation of instability when walking on uneven ground
– Medial joint line pain may be reported. -
This question is part of the following fields:
- Generic Surgical Topics
- Orthopaedics
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Question 2
Correct
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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.
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This question is part of the following fields:
- Generic Surgical Topics
- The Abdomen
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Question 3
Correct
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A 35 year old man presents to his family doctor with swelling of his face. On examination, the swelling was noted to be to the below and to the left of his nose. When the area is palpated, it feels like the underlying bone is cracking. What is the most likely diagnosis?
Your Answer: Ameloblastoma
Explanation:Ameloblastoma is a rare, benign or cancerous tumour of odontogenic epithelium (ameloblasts, or outside portion, of the teeth during development) much more commonly appearing in the lower jaw than the upper jaw.
Ameloblastomas can be found both in the maxilla and mandible. Although, 80% are situated in the mandible with the posterior ramus area being the most frequent site. The neoplasms are often associated with the presence of unerupted teeth, displacement of adjacent teeth and resorption of roots.Symptoms include a slow-growing, painless swelling leading to facial deformity. As the swelling gets progressively larger it can impinge on other structures resulting in loose teeth and malocclusion. Bone can also be perforated leading to soft tissue involvement.
The lesion has a tendency to expand the bony cortices because of the slow growth rate of the lesion allows time for the periosteum to develop a thin shell of bone ahead of the expanding lesion. This shell of bone cracks when palpated. This phenomenon is referred to as Egg Shell Cracking or crepitus, an important diagnostic feature.
Maxillary ameloblastomas can be dangerous and even lethal. Due to thin bone and weak barriers, the neoplasm can extend into the sinonasal passages, pterygomaxillary fossa and eventually into the cranium and brain. Rare orbital invasion of the neoplasm has also been reported.
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This question is part of the following fields:
- Generic Surgical Topics
- Head And Neck Surgery
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Question 4
Incorrect
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A 20-year-old female presents with a nodule on the posterior aspect of her right calf. It has been present for the past six months and was initially formed at the site of an insect bite. On examination, the overlying skin is faintly pigmented, and the nodule appears small in size. However, on palpation, it appears to be nearly twice the size. What is the most likely diagnosis?
Your Answer: Pilar cyst
Correct Answer: Dermatofibroma
Explanation:Dermatofibromas may be pigmented and are often larger than they appear. They frequently occur at the sites of previous trauma.
Dermatofibromas are small, noncancerous (benign) skin growths that can develop anywhere on the body but most often appear on the lower legs, upper arms, or upper back. These nodules are common in adults but are rare in children. They can be pink, grey, red, or brown in colour and may change colour over the years. They are firm and often feel like a stone under the skin. When pinched from the sides, the top of the growth may dimple inward. These lesions feel larger than they appear visually.
Dermatofibromas are usually painless, but some people experience tenderness or itching. Most often, a single nodule develops, but some can develop numerous dermatofibromas.
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This question is part of the following fields:
- Generic Surgical Topics
- Skin Lesions
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Question 5
Correct
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A 36 year old female presents to the clinic with a 6 week history of discomfort just below her ribcage which is relieved by eating. She develops haematemesis and undergoes an upper GI endoscopy. An actively bleeding ulcer is noted in the first part of the duodenum. What is the best course of action?
Your Answer: Injection with adrenaline
Explanation:Upper gastrointestinal (GI) bleeding is usually defined by a bleeding source proximal to the ligament of Treitz although some may also include a bleeding source in the proximal jejunum. Upper GI bleeding emergencies are characterized by hematemesis, melena, haematochezia (if the bleeding is massive and brisk) and evidence of hemodynamic compromise such as dizziness, syncope episodes and shock. The most commonly used endoscopic haemostatic interventions include epinephrine (adrenaline) injection, thermal coagulation and endoscopic clipping at the ulcer site to constrict, compress and/or destroy the bleeding vessel. Injection of 30 mL diluted epinephrine (1:10 000) can effectively prevent recurrent bleeding with a low rate of complications. The optimal injection volume of epinephrine for endoscopic treatment of an actively bleeding ulcer (spurting or oozing) is 30 mL.
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This question is part of the following fields:
- Generic Surgical Topics
- Upper Gastrointestinal Surgery
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Question 6
Correct
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A 41 year old paediatrician presents with right upper quadrant pain and a sensation of abdominal fullness. A 6.7 cm hyperechoic lesion in the right lobe of the liver is detected when an ultrasound scan is done. Tests show that the serum AFP is normal. What is the most likely underlying lesion?
Your Answer: Haemangioma
Explanation:A cavernous liver haemangioma or hepatic haemangioma is a benign tumour of the liver composed of hepatic endothelial cells. It is the most common liver tumour, and is usually asymptomatic and diagnosed incidentally on radiological imaging. Liver haemangiomas are thought to be congenital in origin. Several subtypes exist, including the giant hepatic haemangioma, which can cause significant complications. This large, atypical haemangioma of the liver may present with abdominal pain or fullness due to haemorrhage, thrombosis or mass effect. It may also lead to left ventricular volume overload and heart failure due to the increase in cardiac output which it causes. Further complications are Kasabach-Merritt syndrome, a form of consumptive coagulopathy due to thrombocytopaenia, and rupture.
As one of the benign neoplasms, the AFP level of hepatic cavernous haemangioma patients is not usually outside the normal range.
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This question is part of the following fields:
- Generic Surgical Topics
- Hepatobiliary And Pancreatic Surgery
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Question 7
Incorrect
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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: Combined skeletal and soft tissue reconstruction on a scheduled operating list
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.
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This question is part of the following fields:
- Generic Surgical Topics
- Orthopaedics
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Question 8
Correct
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A 3 month old baby boy is taken to the hospital for recurrent colicky abdominal pain and intermittent intestinal obstruction. The transverse colon is herniated into the thoracic cavity, through a mid line defect and this is shown when imaging is done. What is the cause of this defect?
Your Answer: Morgagni hernia
Explanation:Morgagni hernias are one of the congenital diaphragmatic hernias (CDH), and are characterized by herniation through the foramen of Morgagni. When compared to Bochdalek hernias, Morgagni hernias are:
-anterior
-more often right-sided (,90%)
-small
-rare (,2% of CDH)
-at low risk of prolapseOnly ,30% of patients are symptomatic. Newborns may present with respiratory distress at birth similar to a Bochdalek hernia. Additionally, recurrent chest infections and gastrointestinal symptoms have been reported in those with previously undiagnosed Morgagni hernia.
The image of the transverse colon is herniated into the thoracic cavity, through a mid line defect and this indicates that it is a Morgagni hernia since the foramen of a Morgagni hernia occurs in the anterior midline through the sternocostal hiatus of the diaphragm, with 90% of cases occurring on the right side.Clinical manifestations of congenital diaphragmatic hernia (CDH) include the following:
Early diagnosis – Right-side heart; decreased breath sounds on the affected side; scaphoid abdomen; bowel sounds in the thorax, respiratory distress, and/or cyanosis on auscultation; CDH can often be diagnosed in utero with ultrasonography (US), magnetic resonance imaging (MRI), or bothLate diagnosis – Chest mass on chest radiography, gastric volvulus, splenic volvulus, or large-bowel obstruction
Congenital hernias (neonatal onset) – Respiratory distress and/or cyanosis occurs within the first 24 hours of life; CDH may not be diagnosed for several years if the defect is small enough that it does not cause significant pulmonary dysfunction
Congenital hernias (childhood or adult onset) – Obstructive symptoms from protrusion of the colon, chest pain, tightness or fullness the in chest, sepsis following strangulation or perforation, and many respiratory symptoms occur.
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This question is part of the following fields:
- Generic Surgical Topics
- The Abdomen
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Question 9
Incorrect
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A 26-year-old female presents with a long history of obstructed defecation and chronic constipation. She often strains to open her bowels for long periods and occasionally notices that she has passed a small amount of blood. On examination, she has an indurated area located anteriorly approximately 3cm proximal to the anal verge. What is the most likely diagnosis?
Your Answer: Rectal cancer
Correct Answer: Solitary rectal ulcer syndrome
Explanation:Solitary rectal ulcer syndrome is a rare disorder that involves straining during defecation, a sense of incomplete evacuation, and sometimes passage of blood and mucus by rectum.
The syndrome is poorly named because associated lesions may be solitary or multiple and ulcerated or nonulcerated; they range from mucosal erythema to ulcers to small mass lesions.
Lesions are typically located in the anterior rectal wall within 10 cm of the anal verge.
It is probably caused by localized ischemic injury or prolapse of the distal rectal mucosa. Diagnosis is clinical with confirmation by flexible sigmoidoscopy and biopsy. Treatment is a bowel regimen for mild cases, but surgery is sometimes needed if rectal prolapse is the cause.The cardinal symptom of Fissure in ano is pain.
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This question is part of the following fields:
- Colorectal Surgery
- Generic Surgical Topics
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Question 10
Incorrect
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A 4-year-old boy is brought to the clinic with symptoms of urinary hesitancy and poor stream. Which of the following is the most likely underlying diagnosis?
Your Answer:
Correct Answer: Posterior urethral valves
Explanation:In children, more common causes of Urinary tract obstruction include the following:
UPJ or UVJ obstruction
Ectopic ureter
Ureterocoele
Megaureter
Posterior urethral valvesPosterior urethral valves:
During the early stages of embryogenesis, the most caudal end of the wolffian duct is absorbed into the primitive cloaca at the site of the future verumontanum in the posterior urethra. In healthy males, the remnants of this process are the posterior urethral folds, called plicae colliculi. Histologic studies suggest that PUVs are formed at approximately 4 weeks’ gestation, as the wolffian duct fuses with the developing cloaca.
Congenital obstructing posterior urethral membrane (COPUM) was first proposed by Dewan and Goh and was later supported by histologic studies by Baskin. This concept proposes that instead of a true valve, a persistent oblique membrane is ruptured by initial catheter placement and, secondary to rupture, forms a valve like configuration.
Indicators of possible PUVs later in childhood include the following:
Urinary tract infection (UTI)
Diurnal enuresis in boys older than 5 years
Secondary diurnal enuresis
Voiding pain or dysfunction
Abnormal urinary stream -
This question is part of the following fields:
- Generic Surgical Topics
- Paediatric Surgery
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Question 11
Incorrect
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A 36 year old woman arrives at the emergency department with signs of hypovolemic shock. Abdominal CT reveals a haemorrhagic lesion in the right kidney. Surgical resection of this lesion is carried out followed by a biopsy which reveals an angiomyolipomata. which of the following would be the most likely diagnosis?
Your Answer:
Correct Answer: Tuberous sclerosis
Explanation:Tuberous sclerosis is a genetic disorder characterized by the growth of numerous noncancerous (benign) tumours in many parts of the body. These tumours can occur in the skin, brain, kidneys, and other organs, in some cases leading to significant health problems. Tuberous sclerosis also causes developmental problems, and the signs and symptoms of the condition vary from person to person.
Virtually all affected people have skin abnormalities, including patches of unusually light-coloured skin, areas of raised and thickened skin, and growths under the nails. Tumours on the face called facial angiofibromas are also common beginning in childhood.
Tuberous sclerosis often affects the brain, causing seizures, behavioural problems such as hyperactivity and aggression, and intellectual disability or learning problems. Some affected children have the characteristic features of autism, a developmental disorder that affects communication and social interaction. Benign brain tumours can also develop and these tumours can cause serious or life-threatening complications.
Kidney tumours are common in people with tuberous sclerosis; these growths can cause severe problems with kidney function and may be life-threatening in some cases. Additionally, tumours can develop in the heart, lungs, and the retina.
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This question is part of the following fields:
- Generic Surgical Topics
- Urology
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Question 12
Incorrect
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A 26-year-old woman presents with right iliac fossa pain and history of some bloodstained vaginal discharge. On examination, she has diffuse lower abdominal tenderness and is afebrile with a heart rate of 97 bpm and blood pressure of 120/70 mmHg. Considering these signs and symptoms, what should be the most appropriate course of action?
Your Answer:
Correct Answer: Abdominal and pelvic USS
Explanation:The history of bloodstained vaginal discharge and lower abdominal tenderness makes ectopic pregnancy a strong possibility. Therefore, a pregnancy test (for beta hCG) and abdominal and pelvic USS should be performed. If the beta HCG is high, that is an indication for intrauterine pregnancy. If it is not, then an ectopic pregnancy is likely, and surgery should be considered.
Generally, the differential diagnosis of right iliac fossa (RIF) pain includes:
1. Appendicitis
2. Crohn’s disease
3. Mesenteric adenitis
4. Diverticulitis
5. Meckel’s diverticulitis
6. Perforated peptic ulcer
7. Incarcerated right inguinal or femoral hernia
8. Bowel perforation secondary to caecal or colon carcinoma
9. Gynaecological causes—pelvic inflammatory disease/salpingitis/pelvic abscess/ectopic pregnancy/ovarian torsion/threatened or complete abortion
10. Urological causes—ureteric colic/urinary tract infection/Testicular torsion
11. Other causes—tuberculosis/typhoid/ infection with herpes zoster -
This question is part of the following fields:
- Generic Surgical Topics
- The Abdomen
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Question 13
Incorrect
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A 46 year old politician with chronic hepatitis for several years visits the clinic for a review. Recently, his AFP is noted to be increased and an abdominal ultrasound demonstrates a 2.2cm lesion in segment V of the liver. What is the most appropriate course of action?
Your Answer:
Correct Answer: Liver MRI
Explanation:In patients with liver tumours, it is crucial to detect and stage the tumours at an early stage (to select patients who will benefit from curative liver resection, and avoid unnecessary surgery). Therefore, an optimal preoperative evaluation of the liver is necessary, and a contrast-enhanced MRI is widely considered the state-of-the-art method. Liver MRI without contrast administration is appropriate for cholelithiasis but not sufficient for most liver tumour diagnoses.
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This question is part of the following fields:
- Generic Surgical Topics
- Hepatobiliary And Pancreatic Surgery
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Question 14
Incorrect
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A 31 year old banker with known multiple gastric ulcers visits the surgical clinic for a review. She has not improved despite taking proton pump inhibitors for two months. Tests show that she now has a gastrinoma. Which statement is false in relation to her diagnosis?
Your Answer:
Correct Answer: Most commonly found in the pancreas
Explanation:A gastrinoma is a gastrin-secreting tumour that can occur in the pancreas, although it is most commonly found in the duodenum. Duodenal wall gastrinomas have been identified in 40-50% of patients. These duodenal wall tumours are frequently small and multiple. Sporadic tumours occurring in the pancreas tend to be solitary and have a greater malignant potential as compared to duodenal gastrinomas.
Primary tumours also occur in a variety of ectopic sites, including the body of the stomach, jejunum, peripancreatic lymph nodes, splenic hilum, omentum, liver, gallbladder, common bile duct, and the ovary. Over 50% of gastrinomas are malignant and can metastasize to the regional lymph nodes and the liver. One fourth of gastrinomas are related to multiple endocrine neoplasia (MEN) type I and are associated with hyperparathyroidism and pituitary adenomas.
The symptoms in 90-95% of patients with gastrinomas are similar to the symptoms of common peptic ulcer disease. Usually, persistent abdominal pain exists that is less responsive to medical treatment.
Sometimes, symptoms may relate to a complication of peptic ulcer disease, such as bleeding (e.g., melena, hematemesis), gastric outlet obstruction (e.g., vomiting), and perforation (e.g., peritoneal irritation).
Other symptoms include gastroesophageal reflux, diarrhoea, steatorrhea, and weight loss, all of which are secondary to acid hypersecretion. Vitamin B-12 malabsorption, which is not correctable by oral intrinsic factor, may also be observed.Somatostatin receptor scintigraphy (SRS) is very useful to identify the primary lesions preoperatively. SRS is the most sensitive non-invasive method for localizing the primary tumours and metastases. It also is helpful for detecting the presence of liver or bone metastasis.
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This question is part of the following fields:
- Generic Surgical Topics
- Upper Gastrointestinal Surgery
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Question 15
Incorrect
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A 2-day-old baby presents with recurrent episodes of choking and cyanotic episodes. There is a history of polyhydramnios. What is the most likely diagnosis?
Your Answer:
Correct Answer: Oesophageal atresia
Explanation:Oesophageal atresia encompasses a group of congenital anomalies comprising an interruption of the continuity of the oesophagus combined with or without a persistent communication with the trachea.
The diagnosis of oesophageal atresia may be suspected prenatally by the finding of a small or absent fetal stomach bubble on an ultrasound scan performed after the 18th week of gestation. Overall the sensitivity of ultrasonography is 42% but in combination with polyhydramnios, the positive predictive value is 56%. Polyhydramnios alone is a poor indicator of oesophageal atresia (1% incidence).
The newborn infant of a mother with polyhydramnios should always have a nasogastric tube passed soon after delivery to exclude oesophageal atresia. Infants with oesophageal atresia are unable to swallow saliva and are noted to have excessive salivation requiring repeated suctioning. At this stage, and certainly, before the first feed, a stiff wide-bore (10–12 French gauge) catheter should be passed through the mouth into the oesophagus. In oesophageal atresia, the catheter will not pass beyond 9–10 cm from the lower alveolar ridge. A plain X-ray of the chest and abdomen will show the tip of the catheter arrested in the superior mediastinum (T 2–4) while gas in the stomach and intestine signifies the presence of a distal tracheoesophageal fistula. The absence of gastrointestinal gas is indicative of isolated atresia. A fine bore catheter may curl up in the upper pouch giving the false impression of an intact oesophagus or rarely it may pass through the trachea and proceed distally into the oesophagus through the fistula. The X-ray may reveal additional anomalies such as a double bubble appearance of duodenal atresia, vertebral or rib abnormalities.
Delaying the diagnosis until the infant presents with coughing and choking during the first feed is no longer acceptable in modern paediatric practice.Duodenal atresia is typically characterized by the onset of vomiting within hours of birth. While vomitus is most often bilious, it may be nonbilious because 15% of defects occur proximal to the ampulla of Vater.
Pyloric stenosis, also known as infantile hypertrophic pyloric stenosis (IHPS), is the most common cause of intestinal obstruction in infancy. IHPS occurs secondary to hypertrophy and hyperplasia of the muscular layers of the pylorus, causing a functional gastric outlet obstruction.
Classically, the infant with pyloric stenosis has nonbilious vomiting or regurgitation, which may become projectile (in as many as 70% of cases), after which the infant is still hungry.
Emesis may be intermittent initially or occur after each feeding.
Emesis should not be bilious as the obstruction is proximal to the common bile duct. The emesis may become brown or coffee colour due to blood secondary to gastritis or a Mallory-Weiss tear at the gastroesophageal junction.
As the obstruction becomes more severe, the infant begins to show signs of dehydration and malnutrition, such as poor weight gain, weight loss, marasmus, decreased urinary output, lethargy, and shock.
The infant may develop jaundice, which is corrected upon correction of the disease. -
This question is part of the following fields:
- Generic Surgical Topics
- Paediatric Surgery
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Question 16
Incorrect
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A 30-year-old woman presents with a history of severe epigastric pain that worsens post prandially. On examination, the abdomen is soft and non tender with no palpable mass felt. However, a bruit is heard in the epigastrium, on auscultation. Imaging with USS shows no gallstones and OGD is normal as well. What is the most likely diagnosis?
Your Answer:
Correct Answer: Median arcuate ligament syndrome
Explanation:The most likely diagnosis is median arcuate ligament syndrome (MALS).
MALS, also known as coeliac artery compression syndrome, is a condition characterized by abdominal pain attributed to compression of the coeliac artery and the coeliac ganglia by the median arcuate ligament. The pain may be related to meals, may be accompanied by weight loss, and may be associated with an abdominal bruit.
The diagnosis of MALS is one of exclusion, as many healthy patients demonstrate some degree of coeliac artery compression in the absence of symptoms. Consequently, a diagnosis of MALS is typically only entertained after more common conditions have been ruled out. Once suspected, screening for MALS can be done with USS and confirmed with CT or MRI scan.
Treatment is generally surgical, the mainstay being open or laparoscopic division or separation of the median arcuate ligament combined with removal of the celiac ganglia. The majority of patients benefit from surgical intervention. Poorer responses to treatment tend to occur in patients of older age, those with a psychiatric condition or who use alcohol, have abdominal pain unrelated to meals, or who have not experienced weight loss.
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This question is part of the following fields:
- Generic Surgical Topics
- Vascular
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Question 17
Incorrect
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A 39 year old hiker slips down a slope and injures her hand on an oak tree. On examination, she is tender in the anatomical snuffbox and on bimanual palpation. X-rays with scaphoid views show no evidence of fracture. What is the most appropriate course of action?
Your Answer:
Correct Answer: Application of futura splint and fracture clinic review
Explanation:A scaphoid fracture is a break of the scaphoid bone in the wrist. Symptoms generally include pain at the base of the thumb which is worse with use of the hand. The anatomic snuffbox is generally tender and swelling may occur. Complications may include non-union of the fracture, avascular necrosis, and arthritis.
Scaphoid fractures are most commonly caused by a fall on an outstretched hand. Diagnosis is generally based on examination and medical imaging. Some fractures may not be visible on plain X-rays. In such cases a person may be casted with repeat X-rays in two weeks or an MRI or bone scan may be done.
Scaphoid fractures are often diagnosed by PA and lateral X-rays. However, not all fractures are apparent initially. Therefore, people with tenderness over the scaphoid (those who exhibit pain to pressure in the anatomic snuff box) are often splinted in a thumb spica for 7–10 days at which point a second set of X-rays is taken. If there was a hairline fracture, healing may now be apparent. Even then a fracture may not be apparent. A CT Scan can then be used to evaluate the scaphoid with greater resolution. The use of MRI, if available, is preferred over CT and can give one an immediate diagnosis. Bone scintigraphy is also an effective method for diagnosing a fracture which does not appear on x-ray. -
This question is part of the following fields:
- Generic Surgical Topics
- Orthopaedics
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Question 18
Incorrect
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A 26-year-old female presents to her GP complaining of a two day history of right upper quadrant pain, fever and a white vaginal discharge. She has seen the GP twice in 12 weeks complaining of pelvic pain and dyspareunia. What is the most likely cause?
Your Answer:
Correct Answer: Pelvic inflammatory disease
Explanation:Pelvic inflammatory disease (PID) is an infectious and inflammatory disorder of the upper female genital tract, including the uterus, fallopian tubes, and adjacent pelvic structures. Infection and inflammation may spread to the abdomen, including perihepatic structures (Fitz-Hugh−Curtis syndrome). The classic high-risk patient is a menstruating woman younger than 25 years who has multiple sex partners, does not use contraception, and lives in an area with a high prevalence of sexually transmitted disease (STD).
PID is initiated by an infection that ascends from the vagina and cervix into the upper genital tract. Chlamydia trachomatis is the predominant sexually transmitted organism associated with PID. Of all acute PID cases, less than 50% test positive for the sexually transmitted organisms such as Chlamydia trachomatis and Neisseria gonorrhoea.
Other organisms implicated in the pathogenesis of PID include Gardnerella vaginalis (which causes bacterial vaginosis (BV), Haemophilus influenzae, and anaerobes such as Peptococcus and Bacteroides species. Laparoscopic studies have shown that in 30-40% of cases, PID is polymicrobial.
The most common presenting complaint is lower abdominal pain. Abnormal vaginal discharge is present in approximately 75% of cases. Unanticipated vaginal bleeding, often postcoital, is reported in about 40% of cases. Temperature is higher than 38°C (found in 30% of cases), nausea, and vomiting manifest late in the clinical course of the disease. Abnormal uterine bleeding is present in more than one-third of patients.
Right upper quadrant tenderness, especially if associated with jaundice, may indicate associated Fitz-Hugh−Curtis syndrome. -
This question is part of the following fields:
- Generic Surgical Topics
- The Abdomen
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Question 19
Incorrect
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A 30-year-old female presents with a painless lump in the upper outer quadrant of her left breast. Ultrasound is indeterminate (U3). Two core biopsies show normal breast tissue (B1). What is the most appropriate course of action?
Your Answer:
Correct Answer: Undertake an excision biopsy of the lump
Explanation:Discrete masses graded P3 or R3/M3 or U3 and above should be triple assessed using core biopsy rather than FNAC unless core biopsy is not feasible.
When cytology or biopsy has been reported as C1 or B1 it will require a further biopsy to delineate the pathology in most instances.
The exceptions are when the lesion is suspected to be a lipoma or hamartoma following imaging and discussion. Following triple assessment, if there is non-concordance by more than one grade then further biopsy and or investigations should be undertaken.
In this case, Excisional biopsy is the next required biopsy to delineate the pathology. -
This question is part of the following fields:
- Breast And Endocrine Surgery
- Generic Surgical Topics
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Question 20
Incorrect
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A 32-year-old female is injured in a skiing accident. She suffers a blow to the occiput and is concussed for 5 minutes. On arrival in the ED, she is confused with a GCS 10/15. A CT scan shows no evidence of acute bleed or fracture but some evidence of oedema with the beginnings of mass effect. What is the best course of action?
Your Answer:
Correct Answer: Administration of intravenous mannitol
Explanation:Effective management of intracranial hypertension involves meticulous avoidance of factors that precipitate or aggravate increased intracranial pressure. When intracranial pressure becomes elevated, it is important to rule out new mass lesions that should be surgically evacuated. Medical management of increased intracranial pressure should include sedation, drainage of cerebrospinal fluid, and osmotherapy with either mannitol or hypertonic saline. For intracranial hypertension refractory to initial medical management, barbiturate coma, hypothermia, or decompressive craniectomy should be considered. Steroids are not indicated and may be harmful in the treatment of intracranial hypertension resulting from traumatic brain injury.
Mannitol is the most commonly used hyperosmolar agent for the treatment of intracranial hypertension.
Intravenous bolus administration of mannitol lowers the ICP in 1 to 5 minutes with a peak effect at 20 to 60 minutes. The effect of mannitol on ICP lasts 1.5 to 6 hours, depending on the clinical condition. Mannitol usually is given as a bolus of 0.25 g/kg to 1 g/kg body weight; when an urgent reduction of ICP is needed, an initial dose of 1 g/kg body weight should be given. Arterial hypotension (systolic blood pressure < 90 mm Hg ) should be avoided. -
This question is part of the following fields:
- Generic Surgical Topics
- Surgical Disorders Of The Brain
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Question 21
Incorrect
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A 25-year-old man is involved in vigorous intercourse and suddenly feels a snap. His penis becomes swollen and painful immediately after. The admitting surgeon suspects a penile fracture. Which of the following is the most appropriate initial management?
Your Answer:
Correct Answer: Immediate surgical exploration
Explanation:Suspected penile fractures should be surgically explored and the injury repaired.
Penile fractures are a rare type of urological trauma. The injury is usually in the proximal part of the penile shaft and may involve the urethra. A classical history of a snapping sensation followed by immediate pain is usually given by the patient (usually during vigorous intercourse). On examination, a tense haematoma is most commonly noted, and if the urethra is injured, blood may be seen at the meatus.
The correct management involves surgical exploration and repair of the injury. A circumferential incision is made immediately inferior to the glans and the penile shaft is inspected. Injuries are usually sutured and the urethra is repaired over a catheter.
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This question is part of the following fields:
- Generic Surgical Topics
- Urology
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Question 22
Incorrect
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A 34 year old woman of Singaporean descent arrives at clinic for a pre operative assessment of varicose veins. On auscultation, a mid diastolic murmur is heard at the apex. The murmur is accentuated when the patient lies in the left lateral position. Which of the following is the most likely underlying lesion?
Your Answer:
Correct Answer: Mitral valve stenosis
Explanation:A mid diastolic murmur at the apex is a classical description of a mitral stenosis (MS) murmur.
MS a valvular anomaly of the mitral valve that leads to obstruction of blood flow into the left ventricle. The most common cause of MS is rheumatic fever. The clinical manifestations depend on the extent of stenosis: reduced mitral opening leads to progressive congestion behind the stenotic valve. Acute decompensation can cause pulmonary oedema. Echocardiography is the main diagnostic tool for evaluating the mitral valve apparatus, left atrial size, and pulmonary pressure. In the event of high grade and/or symptomatic stenosis, percutaneous valvuloplasty or surgical valve replacement is often required.Types and causes of murmurs:
Ejection systolic: Aortic stenosis, pulmonary stenosis, HOCM, ASD, Fallot’s
Pan-systolic: Mitral regurgitation, tricuspid regurgitation, VSD
Late systolic: Mitral valve prolapse, coarctation of aorta
Early diastolic: Aortic regurgitation, Graham-Steel murmur (pulmonary regurgitation)
Mid diastolic: Mitral stenosis, Austin-Flint murmur (severe aortic regurgitation) -
This question is part of the following fields:
- Generic Surgical Topics
- Vascular
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Question 23
Incorrect
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A 55 year old man undergoes a live donor related renal transplant for end stage renal failure. He had good urine output following surgery but it was noticed while he was on the ward that his urinary catheter is not draining despite the urostomy continuing to drain urine. Which intervention would be appropriate in this case?
Your Answer:
Correct Answer: Bladder wash out
Explanation:In this patient, a blocked catheter is the case because the urine is flowing into the urostomy bag but it is not able to pass through the catheter.
It is recommended that in cases without hypotension, a bladder washout should be done if there is clot retention. The catheter may also be changed. -
This question is part of the following fields:
- Generic Surgical Topics
- Organ Transplantation
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Question 24
Incorrect
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A 32 year old woman who works as a teacher presents with a swollen, oedematous leg. She hails from Africa, from an area that is poorly sanitized and prevalent with mosquitoes. She travelled to England two weeks back. Which of the following is the most likely diagnosis?
Your Answer:
Correct Answer: Filariasis
Explanation:Lymphatic filariasis, commonly known as elephantiasis, is a painful and profoundly disfiguring disease. In communities where filariasis is transmitted, all ages are affected. While the infection may be acquired during childhood its visible manifestations may occur later in life, causing temporary or permanent disability. The disease is caused by three species of thread-like nematode worms, known as filariae – Wuchereria bancrofti, Brugia malayi and Brugia timori. Male worms are about 3–4 centimetres in length, and female worms 8–10 centimetres. The male and female worms together form “nests” in the human lymphatic system.
Filarial infection can cause a variety of clinical manifestations, including lymphoedema of the limbs, genital disease (hydrocele, chylocele, and swelling of the scrotum and penis) and recurrent acute attacks, which are extremely painful and are accompanied by fever. The vast majority of infected people are asymptomatic, but virtually all of them have subclinical lymphatic damage and as many as 40% have kidney damage, with proteinuria and haematuria.
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This question is part of the following fields:
- Generic Surgical Topics
- Vascular
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Question 25
Incorrect
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A 59 year old woman presents to the hospital with a 2.1cm mobile breast mass. A mammogram is indeterminate (M3), an ultrasound scan shows benign changes (U2), and clinical examination is also indeterminate (P3). What is the next best course of action?
Your Answer:
Correct Answer: Image guided core biopsy
Explanation:Image guided core biopsy (US-directed biopsy) is performed for lesions that are palpable, but also for non-palpable, mammogram-detected lesions with a corresponding abnormality visualized on US. US-guided core biopsy is technically easier than stereotactic-guided biopsy as real-time imaging allows the surgeon to visualize the biopsy as it occurs. Using sterile technique and local anaesthesia, a small puncture is made with an 11-knife blade and the needle is placed near the edge of the lesion and fired, which inserts it into the lesion for a sample to be retrieved. When placed parallel to the needle the position of the needle can be visualized on US.
If the core biopsy result is benign and is concordant with imaging findings, continued surveillance is acceptable. If the result is indeterminate or image-discordant, surgical excision is indicated to rule out malignancy. In order to determine the appropriate management and surveillance of a lesion, the histologic, imaging, and clinical findings must be taken into account for an assessment of concordance to be performed. In addition, surgical excision is indicated for a core biopsy that demonstrates atypical hyperplasia (lobular or ductal) or lobular carcinoma in situ or neoplasia as the incidence of coexisting ductal carcinoma in situ or invasive carcinoma may be as high as 30% due to potential sampling error.
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This question is part of the following fields:
- Breast And Endocrine Surgery
- Generic Surgical Topics
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Question 26
Incorrect
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A 32-year-old woman presents with a long history of severe perianal Crohn's disease involving multiple fistulae. Her disease is progressive with multiple episodes of rectal bleeding. However, she wants to avoid a stoma.Colonoscopy and small bowel study reveals that the disease does not extend beyond the rectum.What should be the best operative strategy?
Your Answer:
Correct Answer: Proctectomy and end stoma
Explanation:Proctectomy with end stoma is the best operative strategy in severe perianal and/or rectal Crohn’s disease.
Surgical resection of Crohn’s disease does not provide a complete cure but it may produce substantial symptomatic improvement. Indications for surgery include complications such as fistulae, abscess formation, and strictures.
Colonoscopy and a small bowel study (e.g. MR enteroclysis imaging) are used to stage Crohn’s disease to facilitate decision-making regarding surgery.
Complex perianal fistulae are best managed with long-term draining seton sutures. Severe perianal and/or rectal Crohn’s disease usually require proctectomy with formation of end stoma. Ileoanal pouch reconstruction carries a high risk of fistula formation and pouch failure and is, therefore, not recommended. Terminal ileal Crohn’s remains one of the most common form of the disease, and it may be treated with limited ileocaecal resections. -
This question is part of the following fields:
- Colorectal Surgery
- Generic Surgical Topics
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Question 27
Incorrect
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A 30-year-old male is playing tennis when he suddenly collapses and has a GCS of 4 when examined. What is the most likely cause?
Your Answer:
Correct Answer: Subarachnoid haemorrhage
Explanation:The term subarachnoid haemorrhage (SAH) refers to extravasation of blood into the subarachnoid space between the pial and arachnoid membranes. SAH constitutes half of all spontaneous atraumatic intracranial haemorrhages; the other half consists of bleeding that occurs within the brain parenchyma.
Intracranial saccular aneurysms (“berry aneurysms”) represent the most common aetiology of nontraumatic SAH; about 80% of cases of SAH result from ruptured aneurysms. -
This question is part of the following fields:
- Generic Surgical Topics
- Surgical Disorders Of The Brain
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Question 28
Incorrect
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A 30-year-old man is undergoing surgery for a left inguinal hernia. During the operation, the sac is opened to reveal a large Meckel's diverticulum. What type of hernia is this?
Your Answer:
Correct Answer: Littre's hernia
Explanation:Hernia containing Meckel’s diverticulum is termed as Littre’s hernia.
Hernias occur when a viscus or part of it protrudes from within its normal anatomical cavity. A Littre’s hernia is an abdominal wall hernia that involves the Meckel’s diverticulum which is a congenital outpouching or bulge in the lower part of the small intestine and is a leftover of the umbilical cord.
Management of Littre’s hernia includes resection of the diverticulum followed by herniorrhaphy.
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This question is part of the following fields:
- Generic Surgical Topics
- The Abdomen
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Question 29
Incorrect
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A 12 hour old baby is seen to be cyanotic whilst feeding and crying. A diagnosis of congenital heart disease is suspected by the team of doctors. Which of the following is the most likely cause?
Your Answer:
Correct Answer: Transposition of the great arteries
Explanation:Answer: Transposition of the great arteries
Transposition of the great arteries (TGA) is the most common cyanotic congenital heart lesion that presents in neonates. The hallmark of transposition of the great arteries is ventriculoarterial discordance, in which the aorta arises from the morphologic right ventricle and the pulmonary artery arises from the morphologic left ventricle.
Infants with transposition of the great arteries (TGA) are usually born at term, with cyanosis apparent within hours of birth.
The clinical course and manifestations depend on the extent of intercirculatory mixing and the presence of associated anatomic lesions. Note the following:
Transposition of the great arteries with intact ventricular septum: Prominent and progressive cyanosis within the first 24 hours of life is the usual finding in infants if no significant mixing at the atrial level is evident.
Transposition of the great arteries with large ventricular septal defect: Infants may not initially manifest symptoms of heart disease, although mild cyanosis (particularly when crying) is often noted. Signs of congestive heart failure (tachypnoea, tachycardia, diaphoresis, and failure to gain weight) may become evident over the first 3-6 weeks as pulmonary blood flow increases.
Transposition of the great arteries with ventricular septal defect and left ventricular outflow tract obstruction: Infants often present with extreme cyanosis at birth, proportional to the degree of left ventricular (pulmonary) outflow tract obstruction. The clinical history may be similar to that of an infant with tetralogy of Fallot.
Transposition of the great arteries with ventricular septal defect and pulmonary vascular obstructive disease: Progressively advancing pulmonary vascular obstructive disease can prevent this rare subgroup of patients from developing symptoms of congestive heart failure, despite a large ventricular septal defect. Most often, patients present with progressive cyanosis, despite an early successful palliative procedure.
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This question is part of the following fields:
- Generic Surgical Topics
- Paediatric Surgery
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Question 30
Incorrect
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A 37 year old firefighter notices a swelling in his left hemiscrotum and visits his family doctor. A left sided varicocele was noticed when he was examined. The ipsilateral testis is normal on palpation. Which of the following would be the best course of action?
Your Answer:
Correct Answer: Abdominal ultrasound
Explanation:Abdominal Ultrasound is the imaging method of choice for varicocele.
A varicocele is abnormal dilation and enlargement of the scrotal venous pampiniform plexus which drains blood from each testicle. While usually painless, varicoceles are clinically significant because they are the most commonly identified cause of abnormal semen analysis, low sperm count, decreased sperm motility, and abnormal sperm morphology. Varicoceles are far more common (80% to 90%) in the left testicle. If a left varicocele is identified, there is a 30% to 40% probability it is a bilateral condition.There are three theories as to the anatomical cause:
– The Nutcracker effect which occurs when the left internal spermatic vein gets caught between the superior mesenteric artery and the aorta. This entrapment causes venous compression and spermatic vein obstruction.
– Failure of the anti-reflux valve where the internal spermatic vein joins the left renal vein. This failure causes reflux and retrograde flow in the testicular vein.
– Angulation at the juncture of the left internal spermatic vein and the left renal vein.Varicoceles are usually asymptomatic. The patient may describe a bag of worms if the varicocele is large enough. Varicoceles present as soft lumps above the testicle, usually on the left side of the scrotum. Patients may sometimes complain of pain or heaviness in the scrotum.
A sudden onset of varicocele in a man over the age of 30 years requires the exclusion of renal tumours, particularly in elderly patients. In such cases it is necessary to extend diagnostic ultrasonography with abdominal examination. The diagnosis of varicocele is based on medical history and physical examination, which involves palpation and observation of the scrotum at rest and during the Valsalva manoeuvre. -
This question is part of the following fields:
- Generic Surgical Topics
- Urology
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