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Question 1
Incorrect
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A 57 year old man, known case of schizophrenia, undergoes a cholecystectomy. He is administered metoclopramide for post operative nausea. Twenty minutes later, he presents with agitation, marked oculogyric crises and oromandibular dystonia. Which of the following drugs would most likely alleviate his symptoms?
Your Answer: Lorazepam
Correct Answer: Procyclidine
Explanation:An acute dystonic reaction is characterized by involuntary contractions of muscles of the extremities, face, neck, abdomen, pelvis, or larynx in either sustained or intermittent patterns that lead to abnormal movements or postures. The symptoms may be reversible or irreversible and can occur after taking any dopamine receptor-blocking agents.
The aetiology of acute dystonic reaction is thought to be due to a dopaminergic-cholinergic imbalance in the basal ganglia. Reactions usually occur shortly after initiation of an offending agent or an increased dose of a possible offending agent.
Anticholinergic agents and benzodiazepines, procyclidine are the most commonly used agents to reverse or reduce symptoms in acute dystonic reaction. Acute dystonic reactions are often transient but can cause significant distress to the patient. Although rare, laryngeal dystonia can cause life-threatening airway obstruction. -
This question is part of the following fields:
- Post-operative Management And Critical Care
- Principles Of Surgery-in-General
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Question 2
Incorrect
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A 30-year-old man who is a known case of von Willebrand disease has started bleeding following the excision of a sebaceous cyst.Administration of which of the following agents is most likely to be beneficial?
Your Answer: Factor X concentrate
Correct Answer: Desmopressin
Explanation:Desmopressin is useful in managing mild to moderate episodes of bleeding in von Willebrand disease (vWD).
vWD is the most common hereditary coagulopathy resulting from the deficiency or abnormal function of von Willebrand factor (vWF). vWF promotes platelet adhesion to damaged endothelium and other platelets and is also involved in the transport and stabilization of factor VIII.
There are seven subtypes of vWD. Type 1 vWD (autosomal dominant) is the most common and accounts for 80% of the cases. Type 2 vWD (autosomal dominant or recessive) accounts for 15% of the cases. There is a significant spectrum of severity ranging from spontaneous bleeding and epistaxis through to troublesome excessive bleeding following minor procedures.
Bleeding time is mostly used as a diagnostic test for vWD. Treatment options include administration of tranexamic acid for minor cases undergoing minor procedures. More significant bleeding or procedures respond well to desmopressin (DDAVP). It is most effective in type 1 vWD, less effective in type 2 and contraindicated in type 2B. Individuals who cannot have desmopressin or in whom it is contraindicated usually receive factor VIII concentrates containing vWF.
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This question is part of the following fields:
- Post-operative Management And Critical Care
- Principles Of Surgery-in-General
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Question 3
Correct
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A 39 year old woman returns from a holiday trip in Nepal and presents to her doctor with painless jaundice. On examination there is no organomegaly and she is not deeply jaundiced. What is most likely cause of her illness?
Your Answer: Hepatitis A infection
Explanation:Hepatitis A is a viral liver disease that can cause mild to severe illness. The hepatitis A virus (HAV) is transmitted through ingestion of contaminated food and water or through direct contact with an infectious person.
The risk of hepatitis A infection is associated with a lack of safe water, and poor sanitation and hygiene (such as dirty hands). Unlike hepatitis B and C, hepatitis A does not cause chronic liver disease and is rarely fatal, but it can cause debilitating symptoms and fulminant hepatitis (acute liver failure), which is often fatal.
Prodrome
In the prodrome, patients may have mild flulike symptoms of anorexia, nausea and vomiting, fatigue, malaise, low-grade fever (usually < 39.5°C), myalgia, and mild headache. Smokers often lose their taste for tobacco, like persons presenting with appendicitis. Icteric phase
In the icteric phase, dark urine appears first (bilirubinuria). Pale stool soon follows, although this is not universal. Jaundice occurs in most (70%-85%) adults with acute HAV infection; it is less likely in children and is uncommon in infants. The degree of icterus also increases with age. Abdominal pain occurs in approximately 40% of patients. Itching (pruritus), although less common than jaundice, is generally accompanied by jaundice.Arthralgias and skin rash, although also associated with acute HAV infection, are less frequent than the above symptoms. Rash more often occurs on the lower limbs and may have a vasculitic appearance.
Relapsing hepatitis A
Relapsing hepatitis A is an uncommon sequela of acute infection, is more common in elderly persons, and is characterized by a protracted course of symptoms of the disease and a relapse of symptoms and signs following apparent resolution. -
This question is part of the following fields:
- Clinical Microbiology
- Principles Of Surgery-in-General
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Question 4
Correct
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A 50-year-old female undergoes an ERCP for jaundice. 36 hours following the procedure she develops a fever and rigours. A blood culture is taken, which of the following organisms is most likely to be cultured?
Your Answer: Escherichia coli
Explanation:One of the most serious post-ERCP complications is cholangitis leading to subsequent septicaemia. Enteric bacteria enter the biliary tree by the hematogenous route or following endoscopic or radiologic manipulation. Improperly disinfected endoscopes and accessories may also introduce infection into the biliary tree. The most common organisms responsible for infection after ERCP are the Enterobacteriaceae (especially Escherichia coli and Klebsiella species), alpha-haemolytic streptococci, Pseudomonas aeruginosa, Enterococcus, and Staphylococcus epidermidis. In most patients with acute cholangitis, a single organism is isolated from blood cultures.
Acute cholangitis is a clinical syndrome characterized by fever, jaundice, and abdominal pain that develops as a result of stasis and infection in the biliary tract. It is also referred to as Charcot’s Triad. Cholangitis was first described by Charcot as a serious and life-threatening illness; however, it is now recognized that the severity can range from mild to life-threatening.
Risk factors for post-ERCP infection include the use of combined percutaneous and endoscopic procedures, stent placement in malignant strictures, the presence of jaundice, low case volume, and incomplete or failed biliary drainage. Patients who are immunocompromised are more likely to experience an infectious complication.
Prevention and/or reduction of the risk of post-ERCP infectious complications can be achieved by judicious use of preprocedural antibiotics and intraprocedural steps, such as minimizing or avoiding contrast injection in patients with known biliary obstruction or cholangitis, endoscopic decompression, including the placement of a biliary stent when complete drainage cannot be achieved, and prompt percutaneous drainage if endoscopic drainage is not possible or incomplete. Prophylactic preprocedural antibiotics should be given to patients with jaundice and suspected mechanical obstruction. In addition, patients with sclerosing cholangitis, pancreatic pseudocysts, and those who are immunocompromised should also receive preprocedural antibiotics
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This question is part of the following fields:
- Clinical Microbiology
- Principles Of Surgery-in-General
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Question 5
Correct
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A 56-year-old male is admitted for an elective hip replacement. Three days postoperatively you suspect he has had a pulmonary embolism. He has no past medical history of note. Blood pressure is 120/80 mmHg with a pulse of 90/min. The chest x-ray is normal. Following treatment with low-molecular-weight heparin, what is the most appropriate initial lung imaging investigation to perform?
Your Answer: Computed tomographic pulmonary angiography
Explanation:According to the ECS Guidelines 2019, Multidetector Computed tomographic pulmonary angiography (CTPA) is the method of choice for imaging the pulmonary vasculature in patients with suspected PE. It allows adequate visualization of the pulmonary arteries down to the subsegmental level.112–114 The Prospective Investigation On Pulmonary Embolism Diagnosis (PIOPED) II study observed a sensitivity of 83% and a specificity of 96% for (mainly four-detector) CTPA in PE diagnosis.
D-dimer levels are elevated in plasma in the presence of acute thrombosis because of simultaneous activation of coagulation and fibrinolysis. The negative predictive value of D-dimer testing is high, and a normal D-dimer level renders acute PE or DVT unlikely. On the other hand, the positive predictive value of elevated D-dimer levels is low and D-dimer testing is not useful for confirmation of PE.
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This question is part of the following fields:
- Post-operative Management And Critical Care
- Principles Of Surgery-in-General
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Question 6
Correct
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A 30 year old man presents with a surgical wound that is erythematous, tender and discharging pus. He states that he had undergone an inguinal hernia repair eight days earlier. What is the cause of this?
Your Answer: Infection with Staphylococcus aureus
Explanation:Answer: Infection with Staphylococcus aureus
Surgical site infections (SSIs) are among the most common healthcare-associated infections, and contribute significantly to patient morbidity and healthcare costs. Staphylococcus aureus is the most common microbial cause. The epidemiology of S. aureus is changing with the dissemination of newer clones and the emergence of mupirocin resistance. Pre-operative screening, using culture- or molecular-based methods, and subsequent decolonization of patients who are positive for methicillin-susceptible S. aureus and methicillin-resistant S. aureus (MRSA) reduces SSIs and hospital stay. This applies especially to major clean surgery, such as cardiothoracic and orthopaedic, involving the insertion of implanted devices. However, it requires a multi-disciplinary approach coupled with patient education. Universal decolonization pre-operatively without screening for S. aureus may compromise the capacity to monitor for the emergence of new clones of S. aureus, contribute to mupirocin resistance, and prevent the adjustment of surgical prophylaxis for MRSA (i.e. replacement of a beta-lactam agent with a glycopeptide or alternative).
A surgical site infection is an infection that occurs after surgery in the part of the body where the surgery took place. Surgical site infections can sometimes be superficial infections involving the skin only. Other surgical site infections are more serious and can involve tissues under the skin, organs, or implanted material.
Symptoms include:
Redness and pain around the area where you had surgery
Drainage of cloudy fluid from your surgical wound
Fever -
This question is part of the following fields:
- Clinical Microbiology
- Principles Of Surgery-in-General
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Question 7
Incorrect
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A 71 year old woman is being observed at the hospital for severe epigastric pain. Her abdomen is soft and non tender. However, the medical intern states that you should look at the ECG which looks abnormal. Which of the following features is an indication for urgent coronary thrombolysis or percutaneous intervention?
Your Answer: ST elevation of 1mm in leads V1 to V6
Correct Answer: ST elevation of greater than 1mm in leads II, III and aVF
Explanation:Percutaneous coronary intervention (PCI), also known as coronary angioplasty, is a nonsurgical technique for treating obstructive coronary artery disease, including unstable angina, acute myocardial infarction (MI), and multivessel coronary artery disease (CAD).
Inferior STEMI is usually caused by occlusion of the right coronary artery, or less commonly the left circumflex artery, causing infarction of the inferior wall of the heart.
The ECG findings of an acute inferior myocardial infarction include the following:
ST segment elevation in the inferior leads (II, III and aVF)
Reciprocal ST segment depression in the lateral and/or high lateral leads (I, aVL, V5 and V6) -
This question is part of the following fields:
- Emergency Medicine And Management Of Trauma
- Principles Of Surgery-in-General
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Question 8
Correct
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A 54-year-old male presents with central chest pain and vomiting. He has drunk a bottle of vodka. On examination, there is some mild crepitus in the epigastric region. What is the likely diagnosis?
Your Answer: Oesophageal perforation
Explanation:Boerhaave syndrome classically presents as the Mackler triad of chest pain, vomiting, and subcutaneous emphysema due to oesophageal rupture, although these symptoms are not always present.
The classic clinical presentation of Boerhaave syndrome usually consists of repeated episodes of retching and vomiting, typically in a middle-aged man with recent excessive dietary and alcohol intake.
These repeated episodes of retching and vomiting are followed by a sudden onset of severe chest pain in the lower thorax and the upper abdomen. The pain may radiate to the back or to the left shoulder. Swallowing often aggravates the pain.
Typically, hematemesis is not seen after oesophageal rupture, which helps to distinguish it from the more common Mallory-Weiss tear.
Swallowing may precipitate coughing because of the communication between the oesophagus and the pleural cavity. -
This question is part of the following fields:
- Emergency Medicine And Management Of Trauma
- Principles Of Surgery-in-General
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Question 9
Incorrect
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A 30 year old waiter is stabbed in the right upper quadrant during a fight at the restaurant and is haemodynamically unstable. He is rushed to the hospital where a laparotomy is performed and the liver has some extensive superficial lacerations and is bleeding profusely. He becomes progressively more haemodynamically unstable. What is the best management option?
Your Answer: Occlude the hepatic inflow with a pringles manoeuvre and suture the defects
Correct Answer: Pack the liver and close the abdomen
Explanation:Perihepatic packing is a surgical procedure used in connection with surgery to the liver. In this procedure the liver is packed to stop non arterial bleeding, most often caused by liver injury.
During this surgery laparotomy pads are placed around the site of the bleeding. The main purpose of hepatic packing is to prevent the person from succumbing to the trauma triad of death. Under- or over-packing of the liver can cause adverse outcomes, and if the bleeding cannot be controlled through this surgical method, the Pringle manoeuvre is an alternate technique that can be utilized.
Rebleeding, constant decline of haemoglobin and increased transfusion requirement, as well as the failure of angioembolization of actively bleeding vessels are a few factors which indicate the need for laparotomy.
The operative approach has also evolved over the last two decades. Direct suture ligation of the parenchymal bleeding vessel, perihepatic packing, repair of venous injury under total vascular isolation and damage control surgery with utilization of preoperative and/or postoperative angioembolization are the preferred methods, compared to anatomical resection of the liver and use of the atriocaval shunt.
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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 10
Incorrect
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A 22-year-old man undergoes incision and drainage of an axillary abscess. How should the wound be managed?
Your Answer: Packing with gauze
Correct Answer: Packing with alginate dressing
Explanation:The wound of this patient should be packed with alginate dressing. Abscess wounds should not undergo primary closure. Moreover, use of gauze is inappropriate and would be difficult to redress.
Alginate dressings are absorbent wound care products that contain sodium and calcium fibres derived from seaweed. An individual dressing is able to absorb up to 20 times its own weight. These dressings, which are easy to use, mold themselves to the shape of the wound, which helps ensure that they absorb wound drainage properly. In abscesses requiring incision and drainage, alginate dressings are well-tolerated and their removal causes minimal pain.
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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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A 40 year old woman has a full thickness burn on her foot after being trapped in a burning building. The limb has no fractures but the burn is well circumscribed. She starts complaining of tingling of her foot which has a dusky look after 3 hours. Which of the following is the best management step?
Your Answer: Escharotomy
Explanation:Answer: Escharotomy
Escharotomy is the surgical division of the nonviable eschar, which allows the cutaneous envelope to become more compliant. Hence, the underlying tissues have an increased available volume to expand into, preventing further tissue injury or functional compromise.
Full-thickness circumferential and near-circumferential skin burns result in the formation of a tough, inelastic mass of burnt tissue (eschar). The eschar, by virtue of this inelasticity, results in the burn-induced compartment syndrome. This is caused by the accumulation of extracellular and extravascular fluid within confined anatomic spaces of the extremities or digits. The excessive fluid causes the intracompartmental pressures to increase, resulting in collapse of the contained vascular and lymphatic structures and, hence, loss of tissue viability. The capillary closure pressure of 30 mm Hg, also measured as the compartment pressure, is accepted as that which requires intervention to prevent tissue death.
The circumferential eschar over the torso can lead to significant compromise of chest wall excursions and can hinder ventilation. Abdominal compartment syndrome with visceral hypoperfusion is associated with severe burns of the abdomen and torso. (A literature review by Strang et al found the prevalence of abdominal compartment syndrome in severely burned patients to be 4.1-16.6%, with the mean mortality rate for this condition in these patients to be 74.8%). Similarly, airway patency and venous return may be compromised by circumferential burns involving the neck.
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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 12
Correct
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A 30-year-old man with Crohn's disease has undergone a number of resections. His BMI is currently 18 kg/m2 and his albumin levels are 2.5 g/dL. He generally feels well but does have a small localised perforation of his small bowel. The gastroenterologists are giving him azathioprine. What should be the most appropriate advice regarding feeding?
Your Answer: Parenteral feeding
Explanation:This patient is malnourished. Although surgery is imminent, it is best for him to be nutritionally optimised first. As he may have reduced surface area for absorption and has a localised perforation, total parenteral nutrition (TPN) is likely the best feeding modality.
The National Institute for Health and Care Excellence (NICE) has laid down guidelines for identifying patients as malnourished or at risk of malnourishment, in order to start oral, enteral, or parenteral nutrition support, alone or in combination.
Following patients are identified as malnourished:
1. BMI <18.5 kg/m2
2. Unintentional weight loss of >10% within the last 3–6 months
3. BMI <20 kg/m2 and unintentional weight loss of >5% within the last 3–6 monthsFollowing patients are at risk of malnutrition:
1. Eaten nothing or little for >5 days and/or likely to eat little or nothing for the next 5 days or longer
2. Poor absorptive capacity and/or
3. High nutrient loss and/or
4. High metabolic rateConsidering the method of parenteral nutrition:
1. For feeding <14 days, consider feeding via a peripheral venous catheter
2. For feeding >30 days, use a tunnelled subclavian line,
continuous administration in severely unwell patients
3. If feed needed for >2 weeks, consider changing from continuous to cyclical feeding
4. Do not give >50% of daily regime to unwell patients in the first 24–48 hours
5. In surgical patients, if malnourished with unsafe swallow or a non-functional GI tract or perforation, consider perioperative parenteral feeding. -
This question is part of the following fields:
- Post-operative Management And Critical Care
- Principles Of Surgery-in-General
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Question 13
Incorrect
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A young lady is stabbed in the chest when she was leaving a party and she develops a cardiac arrest in the A&E department. What is the best course of action?
Your Answer: Immediate CT scanning with ongoing CPR
Correct Answer: Thoracotomy
Explanation:Answer: Thoracotomy
Cardiac arrest after penetrating chest trauma may be an indication for emergency thoracotomy. A successful outcome is possible if the patient has a cardiac tamponade and the definitive intervention is performed within 10 minutes of loss of cardiac output.
EMERGENCY “CLAM SHELL” THORACOTOMYIndication:
Penetrating chest/epigastric trauma associated with cardiac arrest (any rhythm).
Contraindications:
Definite loss of cardiac output for greater than 10 minutes.Any patient who has a cardiac output, including hypotensive patients.
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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 14
Correct
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A 26-year-old woman who is 18 weeks pregnant presents with sudden chest pain. On examination, her heart rate is 130 bpm, blood pressure is 150/70 mmHg, and saturation is 92% on 15L oxygen. Signs of thrombophlebitis are seen in the left leg. Moreover, auscultation of the heart reveals no murmurs and her chest is clear.What is the most likely diagnosis?
Your Answer: Pulmonary embolism
Explanation:Chest pain, hypoxia, and clear chest on auscultation in pregnancy should lead to a high suspicion of pulmonary embolism (PE).
PE is one of the leading causes of mortality in pregnancy. Evaluation with low-dose perfusion scintigraphy may be preferable to computed tomographic pulmonary angiography (CTPA).
PE is treated with LMWH throughout pregnancy and for 4–6 weeks after childbirth. Warfarin is contraindicated in pregnancy (though may be continued in women with mechanical heart valves due to a significant risk of thromboembolism). -
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 53-year-old woman is diagnosed with cellulitis surrounding her leg ulcer. A swab is taken and oral flucloxacillin is started. The following result is obtained:
Your Answer: Add clindamycin
Correct Answer: Add penicillin
Explanation:Streptococci may be divided into alpha and beta haemolytic types
Alpha haemolytic streptococci
The most important alpha haemolytic streptococcus is Streptococcus pneumoniae (pneumococcus). Pneumococcus is a common cause of pneumonia, meningitis and otitis media. Another clinical example is Streptococcus viridans
Beta haemolytic streptococci
These can be subdivided into group A and B
Group A
most important organism is Streptococcus pyogenes
responsible for erysipelas, impetigo, cellulitis, type 2 necrotizing fasciitis and pharyngitis/tonsillitis
immunological reactions can cause rheumatic fever or post-streptococcal glomerulonephritis
erythrogenic toxins cause scarlet feverGroup B
Streptococcus agalactiae may lead to neonatal meningitis and septicaemia
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This question is part of the following fields:
- Clinical Microbiology
- Principles Of Surgery-in-General
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Question 16
Incorrect
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A 35-year-old male presents to the urology department for investigation of pyelonephritis. He reports malaise, pyrexia, lymphadenopathy, and a maculopapular rash. The monospot test is negative. Due to a given history of recent high-risk sexual behaviour, you are asked to exclude HIV seroconversion illness in this patient. Which of the following should be the most appropriate investigation?
Your Answer: Antibodies to HIV-2
Correct Answer: p24 antigen test
Explanation:P24 antigen test is used as one of the main investigations in diagnosing HIV seroconversion illness.
Some people experience a short illness soon after they contract HIV. This is known as seroconversion illness, or primary or acute HIV infection. It is the period when someone with HIV is at their most infectious.
HIV seroconversion is symptomatic in 60%–80% of the patients and typically presents as a glandular fever-type illness. Increased symptomatic severity is associated with poorer long-term prognosis. It typically occurs 2–3 weeks after contracting the virus.
Signs and symptoms include:
1. Sore throat
2. Malaise, myalgia, and arthralgia
3. Diarrhoea
4. Maculopapular rash
5. Oral ulcers
6. Lymphadenopathy
7. Meningoencephalitis (rarely)HIV PCR and p24 antigen test can confirm the diagnosis. The former is the most common and accurate test and consists of both a screening ELISA and a confirmatory western blot assay. P24 antigen test is also used as the mainstay of diagnosis and is usually positive from about 1 week to 3–4 weeks after an infection with HIV.
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This question is part of the following fields:
- Clinical Microbiology
- Principles Of Surgery-in-General
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Question 17
Correct
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A 30 year old female chef is taken to the hospital after complaining of abdominal pain in the right iliac fossa with fever and diarrhoea. She is taken to the theatre for an appendicectomy but her appendix appears normal. However, her terminal ileum appears thickened and engorged. Which of the following has most likely caused her infection?
Your Answer: Yersinia enterocolitica
Explanation:Answer: Yersinia enterocolitica
Yersinia enterocolitica (see the image below) is a bacterial species in the family Enterobacteriaceae that most often causes enterocolitis, acute diarrhoea, terminal ileitis, mesenteric lymphadenitis, and pseudo appendicitis but, if it spreads systemically, can also result in fatal sepsis. Symptoms of Y enterocolitica infection typically include the following:
Diarrhoea – The most common clinical manifestation of this infection; diarrhoea may be bloody in severe cases
Low-grade fever
Abdominal pain – May localize to the right lower quadrant
Vomiting – Present in approximately 15-40% of cases
Mesenteric adenitis, mesenteric ileitis, and acute pseudo appendicitis
These manifestations are characterized by the following symptoms (although nausea, vomiting, diarrhoea, and aphthous ulcers of the mouth can also occur):Fever
Abdominal pain
Tenderness of the right lower quadrant
Leucocytosis
Pseudo appendicitis syndrome is more common in older children and young adults. Patients with Y enterocolitica infection often undergo appendectomy; several Scandinavian studies suggested a prevalence rate of 3.8-5.6% for infection with Y enterocolitica in patients with suspected appendicitis.
Analysis of several common-source outbreaks in the United States found that 10% of 444 patients with symptomatic, undiagnosed Y enterocolitica infection underwent laparotomy for suspected appendicitis.
Human clinical Y enterocolitica infections ensue after ingestion of the microorganisms in contaminated food or water or by direct inoculation through blood transfusion.
Y enterocolitica is potentially transmitted by contaminated unpasteurized milk and milk products, raw pork, tofu, meats, oysters, and fish. Outbreaks have been associated with raw vegetables; the surface of vegetables can become contaminated with pathogenic microorganisms through contact with soil, irrigation water, fertilizers, equipment, humans, and animals.
Pasteurized milk and dairy products can also cause outbreaks because Yersinia can proliferate at refrigerated temperatures.
Animal reservoirs of Y enterocolitica include swine (principle reservoir), dogs, cats, cows, sheep, goats, rodents, foxes, porcupines, and birds.
Reports of person-to-person spread are conflicting and are generally not observed in large outbreaks. Transmission via blood products has occurred, however, and infection can be transmitted from mother to new-born infant. Faecal-oral transmission among humans has not been proven.
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This question is part of the following fields:
- Clinical Microbiology
- Principles Of Surgery-in-General
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Question 18
Incorrect
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A 64 year old man who sustained an iatrogenic injury to both the ureters after undergoing a subtotal colectomy, develops renal failure. Labs show an elevated serum potassium level of 6.9 mmol/L. The ECG is most likely to show which of the following abnormalities?
Your Answer: Increased PR interval
Correct Answer: Peaked T waves
Explanation:Early ECG changes of hyperkalaemia, typically seen at a serum potassium levels of 5.5-6.5 mEq/L, include the following:
– Tall, peaked T waves with a narrow base (best seen in precordial leads)
– Shortened QT interval
– ST-segment depression -
This question is part of the following fields:
- Post-operative Management And Critical Care
- Principles Of Surgery-in-General
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Question 19
Correct
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A 64 year old man registered at the hernia clinic, suddenly presents with speech problems and left sided weakness which has lasted longer than 5 minutes. The head CT shows no signs of intracerebral bleed. Which of the following would be the next most appropriate step of management?
Your Answer: Urgent referral for thrombolysis
Explanation:Patients treated with moderate-dose intravenous thrombolysis within 3 hours after the onset of stroke symptoms benefit substantially from therapy, despite a modest increase in the rate of symptomatic haemorrhage. This patient is within 3h of symptom onset of a stroke, therefore he should be urgently referred to the medical team for thrombolysis, before Aspirin is given. According to the current guidelines, in order to limit the
risk of an intracranial haemorrhagic complication, no antiplatelet treatment should be administered in the 24 hours that follow treatment of an ischemic stroke by intravenous thrombolysis. -
This question is part of the following fields:
- Emergency Medicine And Management Of Trauma
- Principles Of Surgery-in-General
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Question 20
Incorrect
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A group of surgeons in the colorectal unit wish to identify if there is a significant difference in their individual leak rates for anterior resection of the rectum. Which investigation would be appropriate?
Your Answer: Chi squared test
Correct Answer: Kruskall Wallis test
Explanation:Answer: Kruskall Wallis test
Kruskall Wallis test is a non-parametric method for testing whether samples originate from the same distribution. It is used for comparing two or more independent samples of equal or different sample sizes. It extends the Mann–Whitney U test, which is used for comparing only two groups. The parametric equivalent of the Kruskal–Wallis test is the one-way analysis of variance (ANOVA).
T-tests are useful for comparing the means of two samples. There are two types: paired and unpaired.Paired means that both samples consist of the same test subjects. A paired t-test is equivalent to a one-sample t-test.
Unpaired means that both samples consist of distinct test subjects. An unpaired t-test is equivalent to a two-sample t-test.
A chi-squared test, also written as χ2 test, is any statistical hypothesis test where the sampling distribution of the test statistic is a chi-squared distribution when the null hypothesis is true. The chi-squared test is used to determine whether there is a significant difference between the expected frequencies and the observed frequencies in one or more categories.Fisher’s exact test is a statistical test used to determine if there are non-random associations between two categorical variables.
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This question is part of the following fields:
- Management And Legal Issues In Surgery
- Principles Of Surgery-in-General
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Question 21
Incorrect
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A 63 year old woman reports colicky abdominal pain and foul smelling diarrhoea on the 4th day following a cholecystectomy for acute cholecystitis. Her surgery was complicated as the gallbladder spilled stones intraoperatively. She has been on ciprofloxacin therapy ever since her surgery. Which of the following organisms is most likely responsible for her symptoms?
Your Answer: E-Coli
Correct Answer: Clostridium difficile
Explanation:Clostridioides difficile (C. difficile; formerly known as Clostridium difficile) is a gram-positive rod-shaped bacillus that is commonly involved in antibiotic-associated diarrhoea. As the bacterial spores are difficult to eradicate and easily transmitted (via faecal-oral transmission), the C. difficile infection rate is particularly high among hospitalized patients and residents in long-term care facilities.
Colonization with C. difficile occurs following antibiotic treatment of other diseases, as the bacteria is particularly resistant to antibiotics. The resulting damage to the intestinal flora promotes infection, which may be accompanied by high fever, abdominal pain, and characteristically foul-smelling diarrhoea. The most severe form of C. difficile infection is pseudomembranous colitis, which may lead to ileus, sepsis, and toxic megacolon. In most cases, however, colonization results in asymptomatic carriage rather than symptomatic infection.
Diagnosis is usually made via detection of the C. difficile toxin and/or corresponding genes in stool samples. C. difficile infections are treated with oral vancomycin or oral fidaxomicin. Following diagnosis, strict adherence to hygiene measures and patient isolation is essential, especially in hospitals and other healthcare settings. -
This question is part of the following fields:
- Clinical Microbiology
- Principles Of Surgery-in-General
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Question 22
Correct
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A 43-year-old female with liver cirrhosis is recovering following an emergency paraumbilical hernia repair. She has been slow to resume oral intake and has been receiving regular boluses of normal saline for oliguria. Which of the following intravenous fluids should be considered?
Your Answer: Human albumin solution 4.5%
Explanation:In a surgical patient, hepatic dysfunction translates into an increased risk of infection, haemorrhage, thrombosis, and a prolonged half-life of numerous drugs (e.g., opioids and benzodiazepines). The associated imbalance of neuroendocrine mediators (e.g., vasopressin, renin-angiotensin-aldosterone system, and nitric oxide) also potentiates sodium and fluid retention, resulting in a background hyperdynamic circulation with splanchnic venous congestion and systemic vasodilation.
In emergency surgery, stress response to the underlying condition, anaesthesia, and surgical trauma increase the risk of hepatic decompensation and associated multi-system failure. Changes in hepatic perfusion with shock and fluid shifts further compromise hepatocellular synthetic and excretory functions. In addition, endotoxemia from gram-negative sepsis potentiates platelet aggregation and creates a state of low-grade disseminated intravascular coagulation.
Activation of the renin-angiotensin-aldosterone system with hypersecretion of vasopressin acts as compensatory mechanisms to preserve arterial pressure and replenish effective circulating volume when blood is pooled in the splanchnic territory. With the progression of cirrhosis, avidity for water and sodium increases, and dilutional hyponatremia results from water retention. In advanced cases, exacerbation of these abnormalities leads to hepatorenal syndrome (HRS). HRS is characterized by a rapid decline in renal function with low urinary excretion of sodium due to severe renal vasoconstriction and diminished or absent cortical perfusion. This syndrome is potentially reversible but carries an extremely poor prognosis.Owing to raised intra-abdominal pressure due to ascites and muscle weakness from decreased muscle mass and malnutrition, umbilical and inguinal hernia incidence is higher in patients with cirrhosis.
If the patient with cirrhosis has umbilical hernia with obstructive symptoms such as intermittent incarceration or trophic skin changes, surgical repair should be considered.Euvolemia and electrolyte homeostasis should be maintained under strict clinical and laboratory monitoring. Acute kidney injury in the absence of hemodynamic instability, use of nephrotoxic drugs, or parenchymal renal disease suggests the diagnosis of hepatorenal syndrome. Additional diagnostic criteria include no improvement in renal function after volume expansion with albumin and diuretic withdrawal. Treatment of hepatorenal syndrome requires the use of splanchnic vasoconstrictors (terlipressin, noradrenalin, or midodrine) and albumin infusion. Improved renal function has been demonstrated with medical treatment, but a mortality benefit is only ultimately achieved with liver transplantation. TIPS placement and renal and hepatic replacement therapies can be indicated as bridging strategies.
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This question is part of the following fields:
- Post-operative Management And Critical Care
- Principles Of Surgery-in-General
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Question 23
Incorrect
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A 58 year old woman is scheduled for the exploration of the common bile duct and insertion of a T tube. Which of the following devices would be most appropriately used in this patient?
Your Answer: Latex T tube on suction drainage
Correct Answer: Latex T tube on passive drainage
Explanation:The special part of the equipment is the T tube itself. As the name refers, it is a special tube in the shape of T with a shorter transverse part (20 cm) that stays inside the CBD (after trimming) and a long longitudinal part (60 cm) that extends from the middle of the transverse part to an end that connects with a drainage bag. This portion extends from the CBD to outside the abdominal cavity when applied. It comes with different circumference sizes (10, 12, 14, 16, 18 Fr). T tube can be made of different materials like latex, silicone, red rubber and polyvinyl chloride (PVC). PVC is very inert causing the least tissue reaction with lack of tissue tract formation making it the least favourable material for T tube placement purposes. Silicon has many favourable physical properties, but it can disintegrate with poor handling making it not a practical option for long-term placement. Latex has the desired properties to be the most commonly used. Red rubber is an alternative if latex can not be used or is not available.
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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 24
Incorrect
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A 51-year-old male sustained a severe blunt injury just below the bridge of the nose with industrial machinery. Imaging demonstrates a fracture involving the superior orbital fissure. On examination, an ipsilateral pupillary defect is present and loss of the corneal reflexes. In addition to these examination findings, all of the following are present except?
Your Answer: Complete ophthalmoplegia
Correct Answer: Nystagmus
Explanation:The clinical symptoms of Superior Orbital Fissure Syndrome can be explained by the nerve involvement on an anatomic basis.
External ophthalmoplegia is secondary to impairment of the oculomotor, trochlear, and abducens nerves.
Ptosis develops because of lost tension and function of the levator palpebrae superior muscle involving the superior branch of the oculomotor nerve, and loss of tone in Muller’s muscle involving the sympathetic fibre arising from the cavernous sinus.
Proptosis is caused by a decreased tension of the extraocular muscles, which normally are globe retractors, thereby allowing forward movement of the globe.
The fixed dilated pupil with loss of accommodation arises from disruption of the parasympathetic fibres coursing with the oculomotor nerve.
Compromise of the lacrimal and frontal nerves of the ophthalmic branches of the trigeminal nerve results in anaesthesia of the forehead and upper eyelid, lacrimal hyposecretion, and possibly in retro-orbital pain and neuralgia along the path of the nerve.
Because of the disruption of the sensory nasociliary nerve, there may be anaesthesia of the cornea and the bridge of the nose with loss of the corneal reflex. When the disruption is partial, the corneal reflex remains intact.
If the optic nerve is also involved including the above-mentioned symptoms, it is known as the orbital apex syndrome. -
This question is part of the following fields:
- Emergency Medicine And Management Of Trauma
- Principles Of Surgery-in-General
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Question 25
Correct
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A 33 year old firefighter is recovering from an appendicectomy where the operation was complicated by the presence of perforation. On observation, he is seen to be vomiting and his urine output is decreasing. Which intravenous fluid should be initially administered, pending analysis of his urea and electrolyte levels?
Your Answer: Hartmann's solution
Explanation:Compound Sodium Lactate (Hartmann’s) is used:
• for intravenous fluid and electrolyte replacement
• as a source of bicarbonate in the treatment of mild to moderate metabolic acidosis associated with dehydration or associated with potassium deficiency
• as a vehicle for intravenous drug delivery, if the drugs are compatible with the solutionsThe total amount of electrolytes per litre are: sodium 131 mmol, potassium 5mmol, chloride 112 mmol, calcium 2mmol, bicarbonate (as lactate) 28 mmol.
The osmolality is approximately 255 mOsm/kg water. The solutions are isotonic, sterile, non-pyrogenic and do not contain antimicrobial agent or added buffers. The pH range is 5.0 to 7.0. Compound Sodium LactateRinger’s lactate solution (RL), also known as sodium lactate solution and Hartmann’s solution, is a mixture of sodium chloride, sodium lactate, potassium chloride, and calcium chloride in water. It is used for replacing fluids and electrolytes in those who have low blood volume or low blood pressure.
Hartmann’s solution is often preferred over normal saline as it contains both fluids and electrolytes. The solution is also associated with fewer adverse effects and it can be administered to both adults and children.
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This question is part of the following fields:
- Post-operative Management And Critical Care
- Principles Of Surgery-in-General
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Question 26
Incorrect
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A 52-year-old female presents with pain in her proximal femur. Imaging demonstrates a bone metastasis from an unknown primary site. CT scanning with arterial phase contrast shows that the lesion is hypervascular. From which of the following primary sites is the lesion most likely to have originated?
Your Answer: Breast
Correct Answer: Renal
Explanation:In females, the breasts and lungs are the most common primary disease sites; approximately 80% of cancers that spread to bone arise in these locations. In males, cancers of the prostate and lungs make up 80% of the carcinomas that metastasize to bone. The remaining 20% of primary disease sites in patients of both sexes are the kidney, gut, and thyroid, as well as sites of unknown origin.
On contrast-enhanced CT scans, RCC is usually solid, and decreased attenuation suggestive of necrosis is often present. Sometimes, RCC is a predominantly cystic mass, with thick septa and wall nodularity.
RCC may also appear as a completely solid and highly enhancing mass -
This question is part of the following fields:
- Oncology
- Principles Of Surgery-in-General
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Question 27
Incorrect
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A middle aged man who is reported to have a penicillin allergy is given a dose of intravenous co-amoxiclav before undergoing an inguinal hernia repair. His vital signs a few minutes after are: pulse 131bpm and blood pressure 61/42mmHg. Which of the following is the first line treatment?
Your Answer: Hydrocortisone 100mg IV
Correct Answer: Adrenaline 1:1000 IM
Explanation:Answer: Adrenaline 1:1000 IM
Early treatment with intramuscular adrenaline is the treatment of choice for patients having an anaphylactic reaction. IM Injection:
Adults: The usual dose is 500 micrograms (0.5ml of adrenaline 1/1000). If necessary, this dose may be repeated several times at 5-minute intervals according to blood pressure, pulse and respiratory function.
Additional measures
Beta2-agonists for bronchospasm: administer salbutamol or terbutaline by aerosol or nebuliser.
Antihistamines: administer both H1and H2receptor blockers slowly intravenously:
promethazine 0.5-1 mg/kg
and
ranitidine 1 mg/kg or famotidine 0.4 mg/kg or cimetidine 4 mg/kg
Corticosteroids: administer intravenously: hydrocortisone 2-6 mg/kg or dexamethasone 0.1-0.4 mg/kg
Nebulised adrenaline (5 mL of 1:1000) may be tried in laryngeal oedema and often will ease upper airways obstruction. However, do not delay intubation if upper airways obstruction is progressive.Anaphylaxis is an acute, potentially fatal, multiorgan system reaction caused by the release of chemical mediators from mast cells and basophils. The classic form involves prior sensitization to an allergen with later reexposure, producing symptoms via an immunologic mechanism.
Anaphylaxis most commonly affects the cutaneous, respiratory, cardiovascular, and gastrointestinal systems. The skin or mucous membranes are involved in 80-90% of cases. A majority of adult patients have some combination of urticaria, erythema, pruritus, or angioedema. However, for poorly understood reasons, children may present more commonly with respiratory symptoms followed by cutaneous symptoms. It is also important to note that some of the most severe cases of anaphylaxis present in the absence of skin findings.
Initially, patients often experience pruritus and flushing. Other symptoms can evolve rapidly, such as the following:
Dermatologic/ocular: Flushing, urticaria, angioedema, cutaneous and/or conjunctival injection or pruritus, warmth, and swelling
Respiratory: Nasal congestion, coryza, rhinorrhoea, sneezing, throat tightness, wheezing, shortness of breath, cough, hoarseness, dyspnoea
Cardiovascular: Dizziness, weakness, syncope, chest pain, palpitations
Gastrointestinal: Dysphagia, nausea, vomiting, diarrhoea, bloating, cramps
Neurologic: Headache, dizziness, blurred vision, and seizure (very rare and often associated with hypotension)
Other: Metallic taste, feeling of impending doom
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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 28
Incorrect
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A 38-year-old man presents to the A&E department after sustaining a single gunshot wound to his left thigh. He complains of paraesthesia in his left foot. On examination, he is noted to have a large haematoma on the medial aspect of his left thigh. There are weak palpable pulses distal to the injury, and the patient is unable to move his foot. What should be the most appropriate initial management of this patient?
Your Answer: Fasciotomy of the anterior compartment
Correct Answer: Immediate exploration and repair
Explanation:The classic presentation of arterial injury include the five Ps: pallor, pain, paraesthesia, paralysis, and pulselessness. In the extremities, the tissues most sensitive to anoxia are the peripheral nerves and striated muscles. Early development of paraesthesia and paralysis indicates that there is significant ischaemia present, and therefore, immediate exploration and repair are warranted. Presence of a palpable pulse does not exclude an arterial injury because this may represent a transmitted pulsation through a blood clot.
When severe ischaemia is present, the repair must be completed within six to eight hours to prevent irreversible muscle ischaemia and loss of limb function. Delay to obtain a conventional angiogram or to observe for change needlessly prolongs the ischaemic time. Fasciotomy may be required but should be done in conjunction with and after re-establishment of arterial flow. Local wound exploration is not recommended because brisk haemorrhage may be encountered without prior securing of vascular control.
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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 29
Incorrect
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A 29-year-old man who plays social rugby presents with recurrent anterior dislocation of the right shoulder. Which of the following abnormalities is most likely to be present?
Your Answer: Rotator cuff tear
Correct Answer: Bankart lesion
Explanation:This patient has a Bankart lesion which is the most common underlying abnormality in recurrent anterior dislocation of the shoulder.
Bankart lesion is an injury of the anterior (inferior) glenoid labrum of the shoulder due to anterior shoulder dislocation. When this happens, a pocket at the front of the glenoid forms that allows the humeral head to dislocate into it. It is usually visualised by CT and MRI scanning and is often repaired arthroscopically.
Shoulder fractures and dislocations usually result from low-energy falls in predominantly elderly females or from high-energy trauma in young males. They can be associated with nerve injury (commonly axillary), and fracture-dislocation of the humeral head. Anterior shoulder dislocation (glenohumeral dislocation) is the most common type of shoulder dislocation (>90%) and is usually traumatic in nature.
Early assessment of shoulder dislocation:
Careful history, examination, and documentation of neurovascular status of the upper limb, in particular the axillary nerve, is important. This should be re-assessed after manipulation. Early radiographs should also be done to confirm the direction of the dislocation.Initial management of anterior dislocation:
It consists of emergent closed reduction (to prevent lasting chondral damage) under Entonox and analgesia, but often requires conscious sedation. The affected arm should then be immobilised in a polysling. Initial management requires emergent reduction to prevent lasting chondral damage. -
This question is part of the following fields:
- Emergency Medicine And Management Of Trauma
- Principles Of Surgery-in-General
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Question 30
Incorrect
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A 55-year-old female is admitted one week following a cholecystectomy with profuse diarrhoea. Apart from a minor intra-operative bile spillage incurred during removal of the gallbladder, the procedure was uncomplicated. What is the most likely diagnosis?
Your Answer: Salmonella infection
Correct Answer: Clostridium difficile infection
Explanation:Clostridium difficile is an anaerobic, gram-positive, spore-forming bacillus that is responsible for the majority of cases of antibiotic-associated diarrhoea in surgical patients. While the spectrum of disease may range from asymptomatic carrier state to life-threatening toxic megacolon, the typical presentation in surgical patients is diarrhoea developing in the first few days after initiation of antibiotic therapy, including single-dose prophylactic perioperative antibiotics.
In routine cases with bile spillage, surgeons generally do use antibiotic prophylaxis; 80% give one dose only while 88% give one or more prophylactic doses of an antibiotic. Co-amoxiclav is the most commonly used antibiotic in all settings. -
This question is part of the following fields:
- Clinical Microbiology
- Principles Of Surgery-in-General
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