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  • Question 1 - A 21 year old lady notices a non-tender, mobile breast lump while doing...

    Incorrect

    • A 21 year old lady notices a non-tender, mobile breast lump while doing her breast self-examination. The lump is smooth and not tethered to her skin. What is the diagnosis?

      Your Answer: Lipoma

      Correct Answer: Fibroadenoma

      Explanation:

      Answer: Fibroadenoma

      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.

      Fibroadenoma tends to occur in early age. It is most commonly found in adolescents and less commonly found in postmenopausal women. The incidence of fibroadenoma decreases with increasing age and generally found before 30 years of age in females in the general population. It is estimated that 10% of the world’s female population suffers from fibroadenoma once in a lifetime.

    • This question is part of the following fields:

      • Breast And Endocrine Surgery
      • Generic Surgical Topics
      43.3
      Seconds
  • Question 2 - A 35 year old man presents to his family doctor with swelling of...

    Correct

    • 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.

    • This question is part of the following fields:

      • Generic Surgical Topics
      • Head And Neck Surgery
      24.3
      Seconds
  • Question 3 - A 56 year old woman with end stage renal failure undergoes a renal...

    Correct

    • A 56 year old woman with end stage renal failure undergoes a renal transplant with a donation after circulatory death (DCD) kidney. The transplanted organ has a cold ischaemic time of 26 hours and a warm ischaemic time of 55 minutes. Post operatively, she receives immunosuppressive therapy. 10 days later her weight has increased, she becomes oliguric and feels systemically unwell. She also complains of swelling over the transplant site that is painful. What is the most likely cause?

      Your Answer: Acute rejection

      Explanation:

      Prolonged cold ischemia time (CIT) may contribute to the perception of the graft as being suboptimal since donation after circulatory death (DCD) kidneys may be considered less tolerant of CIT. In fact, previous reports recommend restriction of CIT to 12 to 18 hours when transplanting DCD kidneys and a recent UK registry analysis identified increased risks of DCD graft failure with CIT longer than 12 hours.
      The donated kidney in this case had a CIT of 26 hours and the patient presented with symptoms 10 days later which would lead to acute rejection.

    • This question is part of the following fields:

      • Generic Surgical Topics
      • Organ Transplantation
      77
      Seconds
  • Question 4 - A 29-year-old lady who is a known case of Graves' disease presents with...

    Correct

    • A 29-year-old lady who is a known case of Graves' disease presents with a relapse on stopping the antithyroid drugs. Radioiodine is offered as the next treatment by the endocrinologists. Which of the following statements regarding such treatment is false?

      Your Answer: It increases the risk of parathyroid carcinoma

      Explanation:

      All of the listed options are true regarding radioiodine therapy, except for the first option. Treatment with radioiodine does not increase the risk of parathyroid carcinoma.

      Recurrence of Graves’ disease is treated similar to normal Graves’ disease. However, some patients may need definitive treatment with radioiodine or thyroidectomy. These patients are usually hypothyroid post treatment and are treated with L-thyroxine until their TSH values are within normal parameters.

    • This question is part of the following fields:

      • Breast And Endocrine Surgery
      • Generic Surgical Topics
      172.4
      Seconds
  • Question 5 - A 21-year-old woman is admitted with loin pain and fever. She has given...

    Incorrect

    • A 21-year-old woman is admitted with loin pain and fever. She has given a history of haematuria for the past one week with associated dysuria, for which she was started on trimethoprim as an empirical outpatient treatment.What is the most likely diagnosis?

      Your Answer: Stone disease

      Correct Answer: Pyelonephritis

      Explanation:

      This is most likely a case of pyelonephritis.

      Acute pyelonephritis is a common bacterial infection of the renal pelvis and kidneys most often seen in young adult women. History and physical examination are the most important tools for diagnosis. Most patients have fever, although it may be absent early in the illness. E. coli is the most common pathogen in acute pyelonephritis.

      For diagnosing the disease:
      1. A positive urinalysis confirms the diagnosis in patients with a compatible history and physical examination.
      2. Urine culture should be obtained in all patients to guide antibiotic therapy if the patient does not respond to initial empirical antibiotic regimens.
      3. Imaging, usually with contrast-enhanced CT scan, is not necessary unless there is no improvement in the patient’s symptoms or if there is recurrence of symptoms after initial improvement.

      Outpatient treatment is appropriate for most patients. Inpatient therapy is recommended for patients who have severe illness or in whom a complication is suspected. Oral beta-lactam antibiotics and trimethoprim/sulfamethoxazole are generally inappropriate for outpatient therapy because of high resistance rates. Several antibiotic regimens can be used for inpatient treatment, including fluoroquinolones, aminoglycosides, and cephalosporins.

    • This question is part of the following fields:

      • Generic Surgical Topics
      • Urology
      142.7
      Seconds
  • Question 6 - A 30-year-old male presents with a discharging sinus in his nasal cleft. He...

    Incorrect

    • A 30-year-old male presents with a discharging sinus in his nasal cleft. He is found to have a pilonidal sinus. Which statement is false?

      Your Answer: A rare complication is squamous cell carcinoma

      Correct Answer: In a patient with an acute abscess the Bascoms procedure is the treatment of choice.

      Explanation:

      Typical pilonidal sinus disease (PSD) occurs in the natal cleft i.e. sacrococcygeal region.
      However, some occupation related pilonidal sinuses occurs in webs of fingers e.g. hairdresser, sheep shearer, dog groomer, slaughterman or milker.
      Other locations where pilonidal sinuses may occur include penis shaft, axilla, intermammary area, groin, nose, neck, clitoris, suprapubic area, occiput, prepuce, chin, periungual region, breast, face and umbilicus.

      Although the pilonidal disease may manifest as an abscess, a pilonidal sinus, a recurrent or chronic pilonidal sinus, or a perianal pilonidal sinus, the most common manifestation of pilonidal disease is a painful, fluctuant mass in the sacrococcygeal region.
      Initially, 50% of patients first present with a pilonidal abscess that is cephalad to the hair follicle and sinus infection. Pain and purulent discharge from the sinus tract is present 70-80% of the time and are the two most frequently described symptoms. In the early stages preceding the development of an abscess, only cellulitis or folliculitis is present. The abscess is formed when a folliculitis expands into the subcutaneous tissue or when a pre-existing foreign body granuloma becomes infected.
      The diagnosis of a pilonidal sinus can be made by identifying the epithelialized follicle opening, which can be palpated as an area of deep induration beneath the skin in the sacral region. These tracts most commonly run in the cephalad direction. When the tract runs in the caudal direction, perianal sepsis may be present.

      The ideal treatment for a pilonidal sinus varies according to the clinical presentation of the disease. First, it is important to divide the pilonidal disease into the following three categories, which represent different stages of the clinical course:
      – Acute pilonidal abscess
      – Chronic pilonidal disease
      – Complex or recurrent pilonidal disease

      Acute pilonidal abscess:
      A pilonidal abscess is managed by incision, drainage, and curettage of the abscess cavity to remove hair nests and skin debris. This can be accomplished in the surgical office or the emergency department, using local anaesthesia.
      If possible, the drainage incision should be made laterally, away from the midline. Wounds heal poorly in the deep, intergluteal natal cleft, for two reasons. The first is the frictional motion of the deep cleft, which creates continuous irritation to the healing wound; the second is the midline nature of the wound, which is a product of constant lateral traction during sitting.

      Chronic pilonidal disease is the term applied when patients have undergone at least one pilonidal abscess drainage procedure and continue to have a pilonidal sinus tract. The term also refers to a pilonidal sinus that is associated with a chronic discharge without an acute abscess. Surgical options for management of a noncomplicated chronic pilonidal sinus include the following:
      Excision and laying open of the sinus tract
      Excision with primary closure
      Wide and deep excision to the sacrum
      Incision and marsupialization
      Bascom procedure
      Asymmetrical incisions
      Skin flaps have also been described to cover a sacral defect after wide excision. Similarly, this keeps the scar off the midline and flattens the natal cleft.

    • This question is part of the following fields:

      • Colorectal Surgery
      • Generic Surgical Topics
      64.1
      Seconds
  • Question 7 - A 27 year old lady presents with bright red rectal bleeding that occurs...

    Correct

    • A 27 year old lady presents with bright red rectal bleeding that occurs after defecation and is seen in the toilet bowl and on the tissue. She is constipated but her bowel habit is otherwise normal. A digital rectal examination is done which is also normal. What is the most likely diagnosis?

      Your Answer: Haemorrhoidal disease

      Explanation:

      Answer: Haemorrhoidal disease

      Haemorrhoids are a normal part of the anatomy of the anorectum. They are vascular cushions that serve to protect the anal sphincter, aid closure of the anal canal during increased abdominal pressure, and provide sensory information that helps differentiate among stool, liquid and gas. Because of their high vascularity and sensitive location, they are also a frequent cause of pathology. Contributing factors include pregnancy, chronic constipation, diarrhoea or prolonged straining, weight lifting, and weakening of supporting tissue as a result of aging or genetics.
      Haemorrhoids are classified according to their position relative to the dentate line. External haemorrhoids lie below the dentate line, are covered by squamous epithelium and innervated by cutaneous nerves. If symptomatic, the only definitive therapy is surgical excision.
      Internal haemorrhoids arise above the dentate line, are covered by columnar cells and have a visceral nerve supply. They are further categorized — and treated — according to their degree of prolapse:
      -Grade I haemorrhoids bleed but do not prolapse; on colonoscopy, they are seen as small bulges into the lumen.
      -Grade II haemorrhoids prolapse outside the anal canal but reduce spontaneously.
      -Grade III haemorrhoids protrude outside the anal canal and usually require manual reduction.
      -Grade IV haemorrhoids are irreducible and constantly prolapsed. Acutely thrombosed haemorrhoids and those involving rectal mucosal prolapse are also grade IV.

      Most gastrointestinal and surgical societies advocate anoscopy and/or flexible sigmoidoscopy to evaluate any bright-red rectal bleeding. Colonoscopy should be considered in the evaluation of any rectal bleeding that is not typical of haemorrhoids such as in the presence of strong risk factors for colonic malignancy or in the setting of rectal bleeding with a negative anorectal examination.

      Anal fissures are tears of the sensitive mucosal lining of the anus. Anal fissures often cause pain during and after a bowel movement, sometimes followed by throbbing pain for several hours. They are also often associated with itching and blood on toilet tissue, in the bowl, or on the surface of the stool. Anal fissures are caused by
      trauma to the anal canal usually during bowel movements. Anal fissures are also sometimes caused by inflammatory bowel disease or infection.

    • This question is part of the following fields:

      • Colorectal Surgery
      • Generic Surgical Topics
      72.9
      Seconds
  • Question 8 - A 60 year old man receives a cadaveric renal transplant for treatment of...

    Incorrect

    • A 60 year old man receives a cadaveric renal transplant for treatment of end stage renal failure. The organ is ABO group matched only. On completion of the vascular anastomoses the surgeons remove the clamps. Over the course of the next fifteen minutes, the donated kidney becomes dusky and swollen and appears non viable. Which of the following is the most likely process that has caused this event?

      Your Answer: IgG anti HLA Class I antibodies from the donor

      Correct Answer: IgG anti HLA Class I antibodies in the recipient

      Explanation:

      Antibody-mediated rejection (AMR) is defined as allograft rejection caused by antibodies of the recipient directed against donor-specific HLA molecules and blood group antigens. Although the mechanism by which HLA I antibodies promote inflammation and proliferation has been revealed by experimental models, the pathogenesis of HLA II antibodies is less defined. Antibodies to HLA II frequently accompany chronic rejection in renal transplants. AMR has been recognized as the leading cause of graft loss after kidney transplant if there is a donor-host antigenic disparity. Antibodies can be produced against epitopes of the antigen that differ from self by as little as one amino acid. Pre-existing antibodies or the development of de novo antibodies after transplantation has become a biomarker for AMR graft loss. HLA antibodies are risk factors for hyperacute, acute, and chronic allograft rejections.

      The specificity of HLA antibodies can be determined using single-antigen luminex beads that consist of fluorescent microbeads conjugated to single recombinant HLA class I and class II molecules. Complement-fixing ability would be assessed by the binding of C1q to HLA antibodies present in the serum. In several studies, C1q-positive DSA had associated with antibody-mediated rejection in renal transplantation compared with antibodies identified only by IgG. Complement-fixing ability is relevant to hyperacute and acute rejections. Hyperacute rejection is predominantly complement-mediated severe allograft injury occurring within hours of transplantation. It is caused by high titre of pre-existing HLA or non-HLA antibodies in presensitized patients. But the incidence of hyperacute rejection is reduced due to improved DSA detection methods and desensitization protocols.

    • This question is part of the following fields:

      • Generic Surgical Topics
      • Organ Transplantation
      78.3
      Seconds
  • Question 9 - A 46 year old policeman was admitted with peritonitis secondary to a perforated...

    Incorrect

    • A 46 year old policeman was admitted with peritonitis secondary to a perforated appendix. A laparoscopic appendicectomy was done but he had a stormy post operative course. He has now started to develop increasing abdominal pain and has been vomiting. A laparotomy is performed and at operation a large amount of small bowel shows evidence of patchy areas of infarction. Which of the following is the most likely cause?

      Your Answer: Superior mesenteric artery embolus

      Correct Answer: Mesenteric venous thrombosis

      Explanation:

      Mesenteric venous thrombosis (MVT) is a blood clot in one or more of the major veins that drain blood from the intestine. The superior mesenteric vein is most commonly involved. The exact cause of MVT is unknown. However, there are many diseases that can lead to MVT. Many of the diseases cause swelling (inflammation) of the tissues surrounding the veins, and include:
      Appendicitis
      Cancer of the abdomen
      Diverticulitis
      Liver disease with cirrhosis
      High blood pressure in the blood vessels of the liver
      Abdominal surgery or trauma
      Pancreatitis
      Inflammatory bowel disorders
      Heart failure
      Protein C or S deficiencies
      Polycythaemia vera
      Essential thrombocythemia
      People who have disorders that make the blood more likely to stick together (clot) have a higher risk for MVT. Birth control pills and oestrogen medicines also increase risk.

      MVT is more common in men than women. It mainly affects middle aged or older adults. Symptoms may include any of the following:
      Abdominal pain, which may get worse after eating and over time; Bloating; Constipation; Bloody diarrhoea; Fever; Septic shock; Lower gastrointestinal bleeding; Vomiting and nausea.
      Blood thinners (most commonly heparin or related medicines) are used to treat MVT when there is no associated bleeding. In some cases, medicine can be delivered directly into the clot to dissolve it. This procedure is called thrombolysis. Less often, the clot is removed by thrombectomy.

    • This question is part of the following fields:

      • Generic Surgical Topics
      • Vascular
      79
      Seconds
  • Question 10 - A 7 year old boy is taken to the doctor by his mother...

    Incorrect

    • A 7 year old boy is taken to the doctor by his mother after she observed a swelling in his right hemiscrotum. On examination, it transilluminates. What is the next best step in his management?

      Your Answer: Undertake a Lords procedure via an inguinal approach

      Correct Answer: Division of the patent processus vaginalis via an inguinal approach

      Explanation:

      The inguinal approach, with ligation of the processus vaginalis high within the internal inguinal ring, is the procedure of choice for paediatric hydroceles (typically, communicating). If a testicular tumour is identified on testicular ultrasonography, an inguinal approach with high control/ligation of the cord structures is mandated.

      Approximately 10% of patients with testicular teratomas may present with a cystic mass that may transilluminate during the physical examination. Similarly, adults with testicular tumours may present with new-onset scrotal swelling. If this diagnosis is considered, measuring serum alpha-fetoprotein and human chorionic gonadotropin (hCG) levels is indicated to exclude malignant teratomas or other germ cell tumours.

    • This question is part of the following fields:

      • Generic Surgical Topics
      • Paediatric Surgery
      39
      Seconds
  • Question 11 - 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
      29.6
      Seconds
  • Question 12 - A 39 year old man presents with dysphagia, which he has had for...

    Incorrect

    • A 39 year old man presents with dysphagia, which he has had for several years. Medical history shows that he has achalasia and has had numerous dilatations. Over the past month, his dysphagia has worsened. At endoscopy, a friable mass is noted in the oesophagus. What is the most likely diagnosis?

      Your Answer: Adenocarcinoma

      Correct Answer: Squamous cell carcinoma

      Explanation:

      Achalasia is a rare neurological deficit of the oesophagus that produces an impaired relaxation of the lower oesophageal sphincter and decreased motility of the oesophageal body. Achalasia is generally accepted to be a pre-malignant disorder, since, particularly in the mega-oesophagus, chronic irritation by foods and bacterial overgrowth may contribute to the development of dysplasia and carcinoma.
      When oesophageal cancer develops in patients with underlying achalasia, diagnosis tends to be in the more advanced stages of cancer, compared to cases with no achalasia, because both physicians and patients often regard symptoms such as dysphagia and chest discomfort as attributable to the achalasia, rather than to other causes. Therefore, additional approaches that would lead to earlier diagnosis might be pursued less aggressively.
      Achalasia is a predisposing factor for oesophageal squamous cell carcinoma.

    • This question is part of the following fields:

      • Generic Surgical Topics
      • Upper Gastrointestinal Surgery
      100.7
      Seconds
  • Question 13 - 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
      51.9
      Seconds
  • Question 14 - 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
      57.9
      Seconds
  • Question 15 - A 32-year-old female presents with painful bright red bleeding that occurs post defecation....

    Correct

    • A 32-year-old female presents with painful bright red bleeding that occurs post defecation. Digital rectal examination is too uncomfortable for the patient, perineal inspection shows a prominent posterior skin tag. What is the best course of action?

      Your Answer: Prescribe topical diltiazem

      Explanation:

      An Anal fissure is a cut or a tear in the anal canal typically caused by passing a hard stool. Patients often complain of severe anal pain and bleeding with bowel movements. On physical examination, you may see the fissure or just the sentinel tag. If the examination appears normal, you can elicit point tenderness. We recommend against continuing the digital rectal examination or anoscopy if the patient is having pain during the examination.
      The primary goals of therapy are to properly bulk the stool with adequate fibre and relax the anal muscle. Specific steps include the following:
      Properly bulk the stool with adequate fibre to minimize constipation and diarrhoea; both frequent bowel movements and hard bowel movements can lead to an anal fissure.
      Temporary use of laxatives such as daily Miralax or senna. The dose of Miralax can be titrated up or down to achieve desired results. As the patient’s fibre supplementation increases, the need for Miralax will diminish.
      Chronic use of laxatives should be avoided because it can lead to worsening colonic function and constipation.
      Diltiazem 2% ointment is to be placed on the anal muscle 3 times daily—continue for a minimum of 8 weeks, even if symptoms improve earlier.
      If a patient cannot tolerate diltiazem or is breastfeeding or pregnant, 0.2% nitroglycerin-compounded ointment can be prescribed. However, the proper dose of nitroglycerin is important as too high of a dose can cause severe headaches.
      Do NOT prescribe haemorrhoid ointments or suppositories, especially steroid-based ones. Steroid ointments do not help. They do cause perianal skin thinning and dermatitis. At best, they act as a placebo, but they often are used chronically and cause unpleasant perianal skin changes.
      Use mental anal muscle relaxation: Actively thinking about relaxing sphincter tone.
      Consider sitz baths: Soaking the anal area in warm water induces relaxation. Warmer water induces more relaxation. No additives are needed.
      Surgical intervention (such as Botox injections or sphincterotomy) is considered for patients whose symptoms do not improve with the above management strategies. It is imperative that the patient increases fibre and water intake so bowel movements are very soft before the surgical intervention to maximize chances of postoperative healing.

    • This question is part of the following fields:

      • Colorectal Surgery
      • Generic Surgical Topics
      52.5
      Seconds
  • Question 16 - A 30-year-old professional footballer is admitted to the emergency department. During a tackle,...

    Correct

    • 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 hemarthrosis

      Differential 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
      24.5
      Seconds
  • Question 17 - A 30-year-old man is admitted to the hospital with an embolus in the...

    Incorrect

    • A 30-year-old man is admitted to the hospital with an embolus in the brachial artery. A cervical rib is suspected as being the underlying cause. From which of the following vertebral levels does the cervical rib arise?

      Your Answer: C2

      Correct Answer: C7

      Explanation:

      A cervical rib in humans is an extra rib which arises from the C7 vertebra. Its presence is a congenital abnormality located above the normal first rib, and it consists of an anomalous fibrous band that often originates from C7 and may arc towards but rarely reaches the sternum. It is estimated to occur in 0.2% to 0.5% of the population. People may have a cervical rib on the right, left, or both sides.

      Most cases of cervical ribs are not clinically relevant and do not have symptoms; cervical ribs are generally discovered incidentally. However, they vary widely in size and shape, and in rare cases, they may cause problems such as contributing to thoracic outlet syndrome due to compression of the lower trunk of the brachial plexus or subclavian artery.

      Compression of the brachial plexus may be identified by weakness of the muscles near the base of the thumb. Compression of the subclavian artery is often diagnosed by finding a positive Adson’s sign on examination, where the radial pulse in the arm is lost during abduction and external rotation of the shoulder.

      Treatment is most commonly undertaken when there is evidence of neurovascular compromise. A transaxillary approach is the traditional operative method for excision of the cervical rib.

    • This question is part of the following fields:

      • Generic Surgical Topics
      • Vascular
      27.5
      Seconds
  • Question 18 - A 51-year-old man is brought to the A&E department following a road traffic...

    Incorrect

    • A 51-year-old man is brought to the A&E department following a road traffic accident. He complains of lower abdominal pain. On examination, fracture of the pelvis along with distended, tender bladder is observed. What is the most likely diagnosis?

      Your Answer: Clot retention

      Correct Answer: Urethral injury

      Explanation:

      Pelvic fractures may cause laceration of the urethra. Urinary retention, blood at the urethral meatus, and a high-riding prostate on digital rectal examination are the typical features of urethral injury.

      Up to 10% of male pelvic fractures are associated with urethral or bladder injuries. Urethral injury occurs mainly in males. It has two types.
      1.Bulbar rupture:
      a. most common
      b. mostly associated with straddle-type injury, e.g. from bicycles
      c. presentation with a triad of urinary retention, perineal haematoma, and blood at the meatus

      2. Membranous rupture:
      a. can be extra- or intraperitoneal
      b. occurs commonly due to pelvic fracture
      c. symptomology may include penile or perineal oedema/haematoma
      d. prostate displaced upwards (high-riding prostate)

      Ascending urethrogram is carried out in patients of suspected urethral injury. Suprapubic catheter is surgically placed and is indicated in:
      1. External genitalia injuries (i.e. the penis and the scrotum)
      2. Injury to the urethra caused by penetration, blunt trauma, continence- or sexual pleasure–enhancing devices, and mutilation.

    • This question is part of the following fields:

      • Generic Surgical Topics
      • Urology
      70.8
      Seconds
  • Question 19 - An 11 month old baby boy is taken to the clinic with a...

    Correct

    • An 11 month old baby boy is taken to the clinic with a history of a right groin swelling. A photograph on the father's mobile phone, shows what looks like an inguinal hernia. What is the most appropriate course of action?

      Your Answer: Undertake an open inguinal herniotomy

      Explanation:

      Answer: Undertake an open inguinal herniotomy

      Inguinal hernia is a type of ventral hernia that occurs when an intra-abdominal structure, such as bowel or omentum, protrudes through a defect in the abdominal wall. Inguinal hernias do not spontaneously heal and must be surgically repaired because of the ever-present risk of incarceration. Generally, a surgical consultation should be made at the time of diagnosis, and repair (on an elective basis) should be performed very soon after the diagnosis is confirmed.

      The infant or child with an inguinal hernia generally presents with an obvious bulge at the internal or external ring or within the scrotum. The parents typically provide the history of a visible swelling or bulge, commonly intermittent, in the inguinoscrotal region in boys and inguinolabial region in girls. The swelling may or may not be associated with any pain or discomfort.

      Open herniotomy is its standard treatment against which all alternative modalities of treatment are evaluated. It is credited with being easy to perform, having a high success rate, and low rate of complications.
      The use of prosthetic mesh in these patients is rare, however not uncalled for. Laparoscopic inguinal herniotomy is significantly associated with longer operative time for unilateral cases and a reduction in metachronous hernia development when compared to open inguinal herniotomy. There was a trend towards higher recurrence rate for laparoscopic repairs and shorter operative time for bilateral cases. A well conducted randomized controlled trial is warranted to compare both approaches.

    • This question is part of the following fields:

      • Generic Surgical Topics
      • The Abdomen
      17.1
      Seconds
  • Question 20 - A 30-year-old male falls onto an outstretched hand. On examination, there is tenderness...

    Correct

    • A 30-year-old male falls onto an outstretched hand. On examination, there is tenderness of the anatomical snuffbox. However, forearm and hand x-rays are normal. What is the most appropriate course of action?

      Your Answer: Place in futura splint and review in fracture clinic

      Explanation:

      The hallmark of anatomical snuffbox tenderness is highly sensitive for scaphoid fractures but lacks specificity. Due to the lack of specificity, those with snuffbox tenderness should undergo radiographic studies of the wrist. Those with initial negative imaging can be managed with either a thumb spica short-armed splint or advanced imaging by MRI or CT to determine if a fracture exists. Given the unique blood flow to the scaphoid, fracture location is important in determining treatment options to prevent avascular necrosis of the bone.

    • This question is part of the following fields:

      • Generic Surgical Topics
      • Orthopaedics
      112.5
      Seconds
  • Question 21 - A 30-year-old woman presents with a history of severe epigastric pain that worsens...

    Incorrect

    • 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: GORD

      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.

    • This question is part of the following fields:

      • Generic Surgical Topics
      • Vascular
      37.5
      Seconds
  • Question 22 - A 2-day-old baby presents with recurrent episodes of choking and cyanotic episodes. There...

    Correct

    • 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: 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
      38.6
      Seconds
  • Question 23 - A 35 year old woman with cholecystitis is admitted for laparoscopic cholecystectomy. She...

    Correct

    • 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: 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
      108
      Seconds
  • Question 24 - A 30 year old woman complains of left sided abdominal pain that radiates...

    Incorrect

    • A 30 year old woman complains of left sided abdominal pain that radiates to her groin. Detailed workup reveals microscopic haematuria on dipstick. Which of the following would be the most likely cause?

      Your Answer: Staghorn calculus

      Correct Answer: Ureteric calculus

      Explanation:

      The classic presentation of a ureteric colic is acute, colicky flank pain radiating to the groin. The pain is often described as the worst pain the patient has ever had experienced. Ureteric colic occurs as a result of obstruction of the urinary tract by calculi at the narrowest anatomical areas of the ureter: the pelviureteric junction (PUJ), near the pelvic brim at the crossing of the iliac vessels and the narrowest area, the vesicoureteric junction (VUJ). Location of pain may be related but is not an accurate prediction of the position of the stone within the urinary tract. As the stone approaches the vesicoureteric junction, symptoms of bladder irritability may occur.

      Calcium stones (calcium oxalate, calcium phosphate and mixed calcium oxalate and phosphate) are the most common type of stone, while up to 20% of cases present with uric acid, cystine and struvite stones.

      Physical examination typically shows a patient who is often writhing in distress and pacing about trying to find a comfortable position; this is, in contrast to a patient with peritoneal irritation who remains motionless to minimise discomfort. Tenderness of the costovertebral angle or lower quadrant may be present. Gross or microscopic haematuria occurs in approximately 90% of patients; however, the absence of haematuria does not preclude the presence of stones.

    • This question is part of the following fields:

      • Generic Surgical Topics
      • Urology
      38.2
      Seconds
  • Question 25 - A 35 year old IV drug abuser arrives at the clinic with localized...

    Incorrect

    • A 35 year old IV drug abuser arrives at the clinic with localized spinal pain. It is worse on movement and has been occurring for the last 2 months. The pain is refractory to analgesic treatment and is felt excruciatingly at rest too. He has no history of tuberculosis. Which of the following is the most likely diagnosis?

      Your Answer: Potts disease of the spine

      Correct Answer: Osteomyelitis

      Explanation:

      Complications of intravenous drug abuse, such as subcutaneous abscess, joint infections, osteomyelitis, overdose, hepatitis, and infective endocarditis, account for an increasing number of admissions in accident and emergency departments throughout the UK. The organisms that usually cause chronic osteomyelitis in intravenous drug users are Gram‐negative rods such as Pseudomonas aeruginosa and Gram‐positive cocci such as staphylococci. Early treatment is essential to prevent progressive bone destruction. TB tends to affect the thoracic spine and in other causes of osteomyelitis the lumbar spine is affected.

    • This question is part of the following fields:

      • Generic Surgical Topics
      • Orthopaedics
      175.6
      Seconds
  • Question 26 - A 39-year-old man is admitted with a tender mass in the right groin,...

    Correct

    • A 39-year-old man is admitted with a tender mass in the right groin, fever, and sweating. He is on multi-drug therapy for HIV infection. On examination, a tender swelling is noted in his right groin. The pain is exacerbated by hip extension. What is the most likely diagnosis?

      Your Answer: Psoas abscess

      Explanation:

      The patient has a primary psoas abscess.

      Psoas (or iliopsoas) abscess is a collection of pus in the iliopsoas muscle compartment. It may arise via contiguous spread from adjacent structures or by the haematogenous route from a distant site. Psoas abscesses may be either primary or secondary. Primary cases often develop in the immunosuppressed and may occur as a result of haematogenous spread. Secondary cases may occur as a complication of intra-abdominal diseases such as Crohn’s disease.

      Patients usually present with lower back pain and if the abscess is extensive, a mass that may be localised to the inguinal region or femoral triangle. In most cases, the diagnosis can be made clinically. Where it is not clear, an ultrasound scan is often the most convenient investigation.

      Smaller collections may be percutaneously drained. If the collection is larger, or the percutaneous route fails, then surgery (via a retroperitoneal approach) should be performed.

    • This question is part of the following fields:

      • Generic Surgical Topics
      • The Abdomen
      52
      Seconds
  • Question 27 - A 35-year-old female notices bloody discharge from her left nipple. She is, otherwise,...

    Correct

    • A 35-year-old female notices bloody discharge from her left nipple. She is, otherwise, asymptomatic. On examination, there are no discrete lesions to feel, and mammography shows dense breast tissue but no mass lesion.What is the most likely cause?

      Your Answer: Intraductal papilloma

      Explanation:

      Intraductal papilloma is the most common cause of blood-stained nipple discharge in young females.

      An intraductal papilloma is a benign breast condition that develops in one or more of the milk ducts in the
      breast. It is usually close to the nipple, but can
      sometimes be found elsewhere in the breast. It most commonly occurs in women between ages 35–55 and generally does not increase the risk of developing breast cancer. There are no known risk factors for intraductal papilloma.

      Signs and symptoms include:
      1. Small lump or a discharge of
      clear or blood-stained fluid from the nipple
      2. Discomfort or pain around the area (usually not painful)

      Diagnosis can be made by:
      1. Breast examination
      2. Mammogram
      3. Ultrasound scan
      4. Core biopsy
      5. Fine needle aspiration

      Women under the age of 40 are more likely to have an
      ultrasound scan than a mammogram. The breast tissue in such patients can be dense which can
      make the X-ray image in a mammogram less clear.
      However, some women under 40 may still have
      a mammogram.

      Intraductal papillomas are often removed using
      surgery. The surgical options include:
      1. Excision biopsy
      2. Vacuum assisted excision biopsy

      If nipple discharge continues, then further surgical options are explored:
      1. Microdochectomy (removal of the affected duct or ducts)
      2. Total duct excision (removal of all the major ducts)

    • This question is part of the following fields:

      • Breast And Endocrine Surgery
      • Generic Surgical Topics
      40.8
      Seconds
  • Question 28 - A 30 year old carpenter falls off the roof of a house and...

    Correct

    • A 30 year old carpenter falls off the roof of a house and lands on his right arm. X-ray and clinical examination show that he has fractured the proximal ulna and associated radial dislocation. Which of the following names would be used to describe this injury?

      Your Answer: Monteggia's

      Explanation:

      The Monteggia fracture refers to a dislocation of the proximal radio-ulnar joint (PRUJ) in association with a forearm fracture, most commonly a fracture of the ulna. Depending on the type of fracture and severity, they may experience elbow swelling, deformity, crepitus, and paraesthesia or numbness. Some patients may not have severe pain at rest, but elbow flexion and forearm rotation are limited and painful.
      The dislocated radial head may be palpable in the anterior, posterior, or anterolateral position. In Bado type I and IV lesions, the radial head can be palpated in the antecubital fossa. The radial head can be palpated posteriorly in type II lesions and laterally in type III lesions.

      Colles’ fractures have the following 3 features:
      – Transverse fracture of the radius
      – 1 inch proximal to the radio-carpal joint
      – Dorsal displacement and angulation

      Smith’s fracture (reverse Colles’ fracture)
      – Volar angulation of distal radius fragment (Garden spade deformity)
      – Caused by falling backwards onto the palm of an outstretched hand or falling with wrists flexed

      Bennett’s fracture
      – Intra-articular fracture of the first carpometacarpal joint
      – Impact on flexed metacarpal, caused by fist fights
      – X-ray: triangular fragment at ulnar base of metacarpal

      Galeazzi fracture
      – Radial shaft fracture with associated dislocation of the distal radioulnar joint

      Pott’s fracture
      – Bimalleolar ankle fracture
      – Forced foot eversion

      Barton’s fracture
      – Distal radius fracture (Colles’/Smith’s) with associated radiocarpal dislocation
      – Fall onto extended and pronated wrist
      – Involvement of the joint is a defining feature

    • This question is part of the following fields:

      • Generic Surgical Topics
      • Orthopaedics
      43.5
      Seconds
  • Question 29 - 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
      139.3
      Seconds
  • Question 30 - A 40-year-old man is brought to the A&E department in an unconscious state,...

    Correct

    • A 40-year-old man is brought to the A&E department in an unconscious state, following a car collision. He was driving at a high speed of 140 km/hr, wearing a seat belt, when his car collided with a brick wall. CT scan of the brain appears to be normal. However, he remains in a persistent vegetative state. What is the most likely underlying cause?

      Your Answer: Diffuse axonal injury

      Explanation:

      This is a case of diffuse axonal injury (DAI) which occurs when the head is rapidly accelerated or decelerated.

      DAI is a form of traumatic brain injury which occurs when the brain rapidly shifts inside the skull as an injury is occurring. The long connecting fibres in the brain called axons are sheared as the brain rapidly accelerates and decelerates inside the hard bone of the skull. There are two components of DAI:
      1. Multiple haemorrhages
      2. Diffuse axonal damage in the white matter

      Up to two-thirds of the changes occurs at the junction of the grey and white matter due to the different densities of the tissue. These are mainly histological and axonal damage is secondary to biochemical cascades. Often, there are no signs of a fracture or contusion. DAI typically causes widespread injury to the brain leading to loss of consciousness. The changes in the brain are often very tiny and can be difficult to detect using CT or MRI scans.

    • This question is part of the following fields:

      • Generic Surgical Topics
      • Surgical Disorders Of The Brain
      65.9
      Seconds

SESSION STATS - PERFORMANCE PER SPECIALTY

Breast And Endocrine Surgery (2/3) 67%
Generic Surgical Topics (17/30) 57%
Head And Neck Surgery (3/3) 100%
Organ Transplantation (1/2) 50%
Urology (0/4) 0%
Colorectal Surgery (2/3) 67%
Vascular (0/3) 0%
Paediatric Surgery (1/2) 50%
Upper Gastrointestinal Surgery (0/1) 0%
The Abdomen (3/3) 100%
Orthopaedics (3/4) 75%
Hepatobiliary And Pancreatic Surgery (1/1) 100%
Surgical Disorders Of The Brain (1/1) 100%
Passmed