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Question 1
Correct
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A 55-year-old alcoholic male presents with acute pancreatitis. He is clinically dehydrated. His blood results show normal renal function and electrolytes. Which of the intravenous fluids below should be prescribed?
Your Answer: Hartmann's solution
Explanation:Management of Acute Pancreatitis revolves around supportive care, adequate nutrition, and intravenous hydration. The rationale for hydration is based on the need to resolve the hypovolemia that occurs secondary to vomiting, reduced oral intake, third space extravasation, respiratory losses and diaphoresis. Besides, early hydration provides macrocirculatory and microcirculatory support to prevent the cascade of events leading to pancreatic necrosis.
There is a lack of high level evidence to guide the choice of fluid in AP. Crystalloids are recommended by the American Gastroenterological Association, and colloids (packed red blood cells) are considered in cases of low haematocrit (< 25%) and low serum albumin (< 2 g/dL). Among the crystalloids, Ringer's lactate solution is preferred over Normal saline. However, there is an urgent need of studies on this issue. -
This question is part of the following fields:
- Peri-operative Care
- Principles Of Surgery-in-General
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Question 2
Correct
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The middle meningeal artery is the largest among the arteries that supplies that dura mater of the brain. What is the terminal branch of the middle meningeal artery?
Your Answer: Maxillary artery
Explanation:The middle meningeal artery is the largest of the three (paired) arteries that supply the meninges. The middle meningeal artery is typically the third branch of the first part of the maxillary artery, one of the two terminal branches of the external carotid artery.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 3
Correct
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A 26 year old policewoman is admitted with bloody diarrhoea. She has been passing 10 stools per day, Hb-8.1, albumin-21. Her stool culture is negative and there is evidence of colitis on endoscopy. She has been on intravenous steroids for 5 days and has now developed megacolon. Her haemoglobin is falling and inflammatory markers are static. Which of the following is the best course of action?
Your Answer: Undertake a sub total colectomy and end ileostomy
Explanation:The operation aims to remove most of your large bowel including the blood supply and associated lymph glands and leave the rectum behind. It is most commonly recommended for inflammatory bowel disease like ulcerative colitis and Crohn’s disease.
It is also recommended for other bowel conditions like familial adenomatous polyposis, and when there is more than one bowel cancer.
In inflammatory bowel disease such as ulcerative colitis the small bowel is brought out to the skin of the tummy as an ileostomy and the remaining bowel (rectum) is closed off and left inside. In other conditions where possible, the two ends of the remaining healthy bowel (small bowel to rectum) are re-joined (an anastomosis). Most
people therefore do not require a stoma. However some people benefit from having a stoma made depending on circumstances regarding:
1) Their general state of health (heart disease, lung disease, diabetes, vascular disease, smoking, steroid medications, being undernourished);
2) Factors which cannot be seen until the surgeon can see inside your tummy (more extensive disease than originally thought, extensive pelvic scarring from previous surgery or other treatment, excessive bleeding).
Temporary stomas are made to divert faeces away from the join (de-functioning) to give the best chance to heal if there is concern it may be slow to heal.Emergency indications for surgical intervention in severe UC include free perforation, haemorrhage or systemic instability. An urgent indication for colectomy is a severe attack that is unresponsive to medical therapy.
In the setting of severe UC, the procedure of choice is subtotal colectomy and ileostomy. The residual rectal disease is controllable in most patients. In general, there are advantages to the subtotal colectomy approach, including a lower morbidity if pelvic dissection is not performed, preservation of the rectum so that reconstructive procedures can be performed later, and allowing the definitive procedure to be deferred to an optimal situation when the patient is off immunosuppressive medications and has improved nutritional status. Usually, the staged reconstruction with IPAA or definitive total proctocolectomy is performed several months later.
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This question is part of the following fields:
- Colorectal Surgery
- Generic Surgical Topics
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Question 4
Correct
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The primary motor cortex is located in the:
Your Answer: Precentral gyrus
Explanation:The primary motor cortex is located in the dorsal part of the precentral gyrus and the anterior bank of the central sulcus. The precentral gyrus lies anterior to the postcentral gyrus and is separated from it by a central sulcus. Its anterior border is the precentral sulcus, while inferiorly it borders to the lateral fissure (Sylvian fissure).
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 5
Correct
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What is the chief ligament preventing posterior sliding of the tibia on the femur ?
Your Answer: Posterior cruciate
Explanation:The posterior cruciate ligament is attached to the posterior intercondyloid fossa of the tibia and the lateral and front part of the medial condyle of the femur. It resists sliding of the tibia posteriorly.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 6
Correct
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A 42 year old women presents with end stage renal failure and is prepared to receive a kidney from her husband. HLA testing showed that they are not a 100% match and she is given immunosuppressant therapy for this. Three months later when her renal function tests were performed she showed signs of deteriorating renal function, with decreased renal output, proteinuria of +++ and RBCs in the urine. She was given antilymphocyte globulins and her condition reversed. What type of graft did this patient receive?
Your Answer: Allograft
Explanation:Allograft describes a graft between two of the same species. As the donor and the recipients are history-incompatible, rejection of the graft is common and is controlled by immunosuppressive drug therapy. Isograft and syngraft are synonymous and referred to a graft transferred between genetically identical individuals e.g. identical twins. In this case rejection is rare as they are history-compatible.
Autograft refers to transfer of one part of the body to another location.
Xenograft is transfer of tissue from another species e.g. pig to human in valve replacement surgeries and rejection is very high. -
This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 7
Correct
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A 34 year old man is suffering from septic shock and receives an infusion of Dextran 70. Which of the following complications may potentially ensue?
Your Answer: Anaphylaxis
Explanation:Dextran 40 and 70 have a higher rate of causing anaphylaxis than either gelatins or starches.
Dextrans are branched polysaccharide molecules, with dextran 40 and 70 available. The high-molecular-weight dextran 70 may persist for up to eight hours. They inhibit platelet aggregation and leucocyte plugging in the microcirculation, thereby, improving flow through the microcirculation. They are primarily used in sepsis.
Unlike many other intravenous fluids, dextrans are a recognised cause of anaphylaxis. -
This question is part of the following fields:
- Peri-operative Care
- Principles Of Surgery-in-General
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Question 8
Correct
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The circle of Willis is an arterial anastomosis in the base of the brain and is one of the cerebrovascular safeguards in the brain. Where is the circle of Willis contained?
Your Answer: Cisterna basalis
Explanation:Cisterns refers to a system of intercommunicating pools formed by the subarachnoid space at the base of the brain and around the brainstem. Cisterna basalis/basal cistern (interpeduncular cistern) is found at the base of the brain between the two temporal lobes and it contains the arterial circle of Willis. The lumbar cistern is contained in the spinal canal while the foramen magna refers to the opening at the base of the skull though which the spinal cord enters into the skull.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 9
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 10
Correct
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A 56 year old man, on his 8th day following a left hemicolectomy, complains of swinging pyrexia over the past 48 hours. Clinical examination is significant for an ileus. Which of the following investigations would be the most appropriate?
Your Answer: Abdominal CT scan with IV contrast
Explanation:Abdominal CT with IV contrast would be carried out in this case and this presentation has most likely resulted due to an anastomotic leak with abscess formation which is a common complication following surgery. This can occur in any of the branches and anticipating the likely complication and appropriate avoidance will minimize their occurrence. Detailed imaging is required to allow accurate diagnosis and further planning.
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This question is part of the following fields:
- Principles Of Surgery-in-General
- Surgical Technique And Technology
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Question 11
Correct
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The ability of the bacteria to cause disease or its virulence is related to :
Your Answer: Toxin and enzyme production
Explanation:The pathogenicity of an organism or its ability to cause disease is determined by its virulence factors. Many bacteria produce virulence factors that inhibit the host’s immune system. The virulence factors of bacteria are typically proteins or other molecules that are synthesized by enzymes. These proteins are coded for by genes in chromosomal DNA, bacteriophage DNA or plasmids. The proteins made by the bacteria can poison the host cells and cause tissue damage.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 12
Correct
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A 68 year old woman has undergone surgical repair of her femoral hernia. The surgeon used bipolar diathermy for haemostasis. Which of the following options would be regarded as the greatest risk with the usage of bipolar diathermy?
Your Answer: Fires when used near alcoholic skin preparations that have pooled
Explanation:An operating room fire is rare but a well-known hazard that can result in significant patient morbidity. When it comes to the disposal of surgical spirits, the SPC for chlorhexidine states: ‘The solution is flammable. The risk of surgical fires due to spirit-based skin preparation fluid should be actively reduced. Data from the US show that up to 650 surgical fires occur each year, with up to 5% causing death or serious harm.
Diathermy use electric currents to produce local heat and thereby facilitate haemostasis or surgical dissection. There are two major types of diathermy:
1. Monopolar – current flows through a handheld device, from the tip of the device into the patient. The earth electrode is located some distance away.
2. Bipolar – current flows from one electrode to another however, both electrodes are usually contained within the same device e.g. a pair of forceps. The result is that heating is localised to the area between the two electrodes and surrounding tissue damage is minimised. However this may create a spark and ignite flammable solutions. -
This question is part of the following fields:
- Principles Of Surgery-in-General
- Surgical Technique And Technology
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Question 13
Correct
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Which one of the following groups of lymph nodes is most likely to be inflamed due to paronychia involving the big toe?
Your Answer: Vertical group of superficial inguinal lymph nodes
Explanation:Paronychia affecting the big toe will result in inflammation of the superficial inguinal lymph nodes as it drains lymph from the big toe.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 14
Correct
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A 40-year-old motorcyclist is involved in a road traffic accident. A FAST scan in the emergency department shows free intrabdominal fluid. A laparotomy is performed during which there is evidence of small liver laceration that has stopped bleeding and a tear to the inferior pole of the spleen. What is the best course of action?
Your Answer: Attempt measures to conserve the spleen
Explanation:Spleen injuries are among the most frequent trauma-related injuries. At present, they are classified according to the anatomy of the injury. The optimal treatment strategy, however, should take into consideration the hemodynamic status, the anatomic derangement, and the associated injuries. The management of splenic trauma patients aims to restore the homeostasis and the normal physiopathology especially considering the modern tools for bleeding management.
The trend in the management of splenic injury continues to favour nonoperative or conservative management. This varies from institution to institution but usually includes patients with stable hemodynamic signs, stable haemoglobin levels over 12-48 hours, minimal transfusion requirements (2 U or less), CT scan injury scale grade of 1 or 2 without a blush, and patients younger than 55 years.
Surgical therapy is usually reserved for patients with signs of ongoing bleeding or hemodynamic instability. In some institutions, CT scan–assessed grade V splenic injuries with stable vitals may be observed closely without operative intervention, but most patients with these injuries will undergo exploratory laparotomy for more precise staging, repair, or removal.A retrospective analysis by Scarborough et al compared the effectiveness of nonoperative management with immediate splenectomy for adult patients with grade IV or V blunt splenic injury. The study found that both approaches had similar rates of in-hospital mortality (11.5% in the splenectomy group vs 10.0%), however, there was a higher incidence of infectious complications in the immediate splenectomy group. The rate of failure in the nonoperative management was 20.1% and symptoms of a bleeding disorder, the need for an early blood transfusion, and grade V injury were all early predictors of nonoperative management failure.
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This question is part of the following fields:
- Emergency Medicine And Management Of Trauma
- Principles Of Surgery-in-General
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Question 15
Incorrect
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A 20 year old man is involved in a car accident where he is thrown out of the car. He is seen with distended neck veins and a weak pulse on admission. The trachea is central. Which of the following is the most likely cause?
Your Answer: Tension pneumothorax
Correct Answer: Hemopericardium
Explanation:Answer: Hemopericardium
Hemopericardium refers to the presence of blood within the pericardial cavity, i.e. a sanguineous pericardial effusion. If enough blood enters the pericardial cavity, then a potentially fatal cardiac tamponade can occur. There is a very long list of causes but some of the more common are:
-ruptured myocardial infarction
-ruptured left ventricular aneurysm
-aortic dissection
-pericarditis
-trauma
-blunt/penetrating/deceleration
-iatrogenic, e.g. pacemaker wire insertion
-cardiac malignancies
-ruptured coronary artery aneurysm
-post-thrombolysisCardiac tamponade is a clinical syndrome caused by the accumulation of fluid in the pericardial space, resulting in reduced ventricular filling and subsequent hemodynamic compromise. The condition is a medical emergency, the complications of which include pulmonary oedema, shock, and death.
Symptoms vary with the acuteness and underlying cause of the tamponade. Patients with acute tamponade may present with dyspnoea, tachycardia, and tachypnoea. Cold and clammy extremities from hypoperfusion are also observed in some patients. Other symptoms and signs may include the following:
Elevated jugular venous pressurePulsus paradoxus
Chest pressure
Decreased urine output
Confusion
Dysphoria
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This question is part of the following fields:
- Emergency Medicine And Management Of Trauma
- Principles Of Surgery-in-General
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Question 16
Correct
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Risk factors for hepatocellular carcinoma do NOT include:
Your Answer: Heptitis E
Explanation:Risk factors for hepatocellular carcinoma include hepatitis B and C, aflatoxin, anabolic steroids, alcohol cirrhosis and primary liver disease.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 17
Correct
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A young male was diagnosed with hepatitis A, which clinically resolved in 2 weeks. What will his liver biopsy done after 6 months show?
Your Answer: Normal architecture
Explanation:Hepatitis A is the most common acute viral hepatitis, more common in children and young adults. It is caused by Hepatitis A virus, which is a single-stranded RNA picornavirus. The primary route of spread of Hepatitis A is the faecal-oral route. Consumption of contaminated raw shellfish is also a likely causative factor. The shedding of the virus in faecal matter occurs before the onset of symptoms and continues a few days after. Hepatitis A does not lead to chronic hepatitis or cirrhosis, and there is no known chronic carrier state. Hence, a biopsy performed after recovery will show normal hepatocellular architecture.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 18
Correct
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An 8 year old boy presents with bleeding from the nose. From which area did the bleeding most likely originate?
Your Answer: Kiesselbach's plexus
Explanation:Answer: Kiesselbach’s plexus
Epistaxis is defined as acute haemorrhage from the nostril, nasal cavity, or nasopharynx. The source of 90% of anterior nosebleeds within the Kiesselbach’s plexus (also known as Little’s area) on the anterior nasal septum.
Kiesselbach’s plexus (Kiesselbach’s area or Little’s area) is a vascular region of the anteroinferior nasal septum that comprises four arterial anastomoses:
1)anterior ethmoidal artery – a branch of the ophthalmic artery
2)sphenopalatine artery -
This question is part of the following fields:
- Generic Surgical Topics
- Head And Neck Surgery
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Question 19
Correct
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What is the action of the muscle of the orbit that originates on the lesser wing of the sphenoid bone, just above the optic foramen?
Your Answer: Elevation of the upper eyelid
Explanation:The levator palpebrae superioris is the muscle in the orbit that elevates the superior (upper) eyelid. The levator palpebrae superioris originates on the lesser wing of the sphenoid bone, just above the optic foramen and receives somatic motor input from the ipsilateral superior division of the oculomotor nerve.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 20
Correct
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A 21-year-old woman presents with intermittent diarrhoea for the past eight months and loss in weight of about two kilograms. Colonoscopy is carried out in which appearances of melanosis coli are identified. This is confirmed on biopsy. What could be the most likely cause of melanosis coli in this patient?
Your Answer: Laxative abuse
Explanation:Melanosis coli may have occurred as a result of laxative abuse in this patient.
Melanosis coli, also pseudomelanosis coli, is a disorder of pigmentation of the wall of the colon, often identified at the time of colonoscopy. It is benign, and may have no significant correlation with the disease. The brown pigment seen is lipofuscin in macrophages, not melanin.
According to the World Health Organisation (WHO), chronic diarrhoea is defined as lasting for more than 14 days. It is very common in irritable bowel syndrome (IBS). Patients may be divided into those with diarrhoea-predominant IBS and those with constipation-predominant IBS. Along with diarrhoea/constipation, clinical features such as abdominal pain, bloating, weight loss, change in bowel habit, lethargy, nausea, backache, and bladder symptoms are also seen. Bloody diarrhoea is more common in ulcerative colitis than in Crohn’s disease.
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This question is part of the following fields:
- Colorectal Surgery
- Generic Surgical Topics
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Question 21
Correct
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Which is the correct superficial to deep order of structures that would be affected following a knife wound to the lateral aspect of the knee?
Your Answer: skin, fibular collateral ligament, popliteus muscle tendon, lateral meniscus
Explanation:Skin, fibular collateral ligament, popliteus muscle tendon and lateral meniscus is the correct order of structures covering the lateral aspect of the knee joint from a superficial to deep.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 22
Incorrect
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Which of the following is NOT a Gram-negative rod?
Your Answer: Escherichia coli
Correct Answer: Clostridium tetani
Explanation:Gram-positive rods include Clostridia, Listeria and diphtheroids.
Gram-negative rods include Escherichia coli, Klebsiella, Yersinia, Haemohilus, Pseudomonas, Shigella, Legionella, proteus and Salmonella -
This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 23
Correct
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A 40-year old man sustained a deep laceration to the sole of his left foot. It was found that the belly of extensor digitorum muscle was lacerated and the lateral tarsal artery was severed. The lateral tarsal artery is a branch of the:
Your Answer: Dorsalis pedis artery
Explanation:The lateral tarsal artery arises from the dorsalis pedis, as the vessel crosses the navicular bone
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 24
Correct
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Which of the following structures is not easily palpable?
Your Answer: Styloid process of the temporal bone
Explanation:The styloid process is a thin, pointed process that projects antero-inferiorly from the base of the petrous temporal bone. It can vary in length from a short, stubby process to a slender, four to five centimetre rod. It forms from the cranial elements of the second pharyngeal arch. The tympanic plate of the temporal bone ensheathes the base of this process. The pointed, projecting portion of the process provides attachment to the stylohyoid and stylomandibular ligaments, and to three muscles – the styloglossus, stylohyoid, and stylopharyngeus. As the styloid process is covered by the various muscles, it is not easily palpable in live subjects.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 25
Correct
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A construction worker is brought to the A&E after a fall on site. The patient is conscious but complains of inability to feel his legs. A neurological examination reveals that he has no cutaneous sensation from his umbilicus to his toes. What is the likely level of the spinal cord that is injured?
Your Answer: T10
Explanation:The umbilicus has a relatively consistent position in humans and thus serves as an important land mark. The skin around the waist at the level of the umbilicus is supplied by the tenth thoracic spinal nerve (T10 dermatome).
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 26
Correct
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Which of these structures is most likely to be damaged if a patient loses consciousness days or weeks after an otherwise insignificant head trauma, especially in elderly patients?
Your Answer: Dural bridging vein
Explanation:A subdural haematoma is a type of hematoma, usually associated with traumatic brain injury, in which blood collects between the dura mater and the pia-arachnoid mater. Symptoms of subdural haemorrhage have a slower onset than those of epidural haemorrhages because the lower pressure veins bleed more slowly than arteries. These injuries are more common in elderly patients, especially those taking antiplatelet or anticoagulant drugs. Oedema and increased intracranial pressure are unusual.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 27
Incorrect
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A surgeon ligates the left superior suprarenal artery whilst preforming a left adrenalectomy. Where does the left superior suprarenal artery originate?
Your Answer: Left gastric artery
Correct Answer: Left inferior phrenic artery
Explanation:The superior suprarenal arteries arises from the inferior phrenic artery on either side.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 28
Incorrect
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Which best describes the suprascapular nerve?
Your Answer: It innervates the teres minor muscle
Correct Answer: It contains nerve fibres from C5 and C6 spinal cord segments
Explanation:The suprascapular nerve arises from the cervical spinal nerves 5 and 6 after coming together to form common trunk. This nerve supplies the supraspinatus and infraspinatus muscles giving off branches to the shoulder joint.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 29
Incorrect
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A 68 year old man, known with colorectal carcinoma, is currently taking MST 30mg twice a day for pain relief. Which of the following doses of morphine would be the most adequate for breakthrough pain?
Your Answer:
Correct Answer: 10 mg
Explanation:If pain occurs between regular doses of morphine (‘breakthrough pain’), an additional dose (‘rescue dose’) of immediate-release morphine should be given. Breakthrough dose = 1/6th of daily morphine dose
The total daily morphine dose is 30 * 2 = 60 mg, therefore the breakthrough dose should be one-sixth of this, 10 mg.
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This question is part of the following fields:
- Oncology
- Principles Of Surgery-in-General
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Question 30
Incorrect
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The most likely cause of a low p(O2) in arterial blood is:
Your Answer:
Correct Answer: Hypoxic hypoxia
Explanation:Hypoxia is when the whole body or a region is deprived of adequate oxygen supply. Different types of hypoxia include the following:
– Hypoxic hypoxia, which occurs due to poor oxygen supply, as a result of low partial pressure of oxygen in arterial blood. This could be due to low partial pressure of atmospheric oxygen (e.g., at high altitude), sleep apnoea, poor ventilation because of chronic obstructive pulmonary disease or respiratory arrest, or shunts. The other types of hypoxia have a normal partial pressure of oxygen.
– Anaemic hypoxia occurs due to low total oxygen content of the blood, with a normal arterial oxygen pressure.
– Hyperaemic hypoxia occurs due to poor delivery of oxygen to target tissues, such as in carbon monoxide poisoning or methemoglobinemia.
– Histotoxic hypoxia results due to inability of the cells to use the delivered oxygen due to disabled oxidative phosphorylation enzymes.
– Ischaemic (or stagnant) hypoxia occurs due to local flow restriction of well-oxygenated blood, seen in cases like cerebral ischaemia, ischaemic heart disease and intrauterine hypoxia. -
This question is part of the following fields:
- Basic Sciences
- Physiology
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