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  • Question 1 - A 68 year old man who is scheduled for an amputation suddenly presents...

    Correct

    • A 68 year old man who is scheduled for an amputation suddenly presents to the physician with episodes of vertigo and dysarthria. After a while he collapses and his GCS is recorded to be 3. Which of the following is the most likely diagnosis of this presentation?

      Your Answer: Basilar artery occlusion

      Explanation:

      The clinical presentation of basilar artery occlusion (BAO) ranges from mild transient symptoms to devastating strokes with high fatality and morbidity. Often, non-specific prodromal symptoms such as vertigo or headaches are indicative of BAO, and are followed by the hallmarks of BAO, including decreased consciousness, quadriparesis, pupillary and oculomotor abnormalities, dysarthria, and dysphagia. When clinical findings suggest an acute brainstem disorder, BAO has to be confirmed or ruled out as a matter of urgency. If BAO is recognised early and confirmed with multimodal CT or MRI, intravenous thrombolysis or endovascular treatment can be undertaken. The goal of thrombolysis is to restore blood flow in the occluded artery and salvage brain tissue; however, the best treatment approach to improve clinical outcome still needs to be ascertained.

    • This question is part of the following fields:

      • Emergency Medicine And Management Of Trauma
      • Principles Of Surgery-in-General
      13.7
      Seconds
  • Question 2 - A 65 year old man develops persistent pyrexia on his 2nd postoperative day....

    Incorrect

    • A 65 year old man develops persistent pyrexia on his 2nd postoperative day. He has undergone an open extended right hemicolectomy for carcinoma of the colonic-splenic flexure. What is the least likely cause?

      Your Answer: Anastomotic leak

      Correct Answer: Ileus

      Explanation:

      Pyrexia is a very common post operative finding and can most likely result from an infection. However, it is highly unlikely to occur as a result of ileus. Anastomotic leaks are uncommon after right sided colonic surgery. In this scenario atelectasis would be the most likely underlying cause, as open extended right hemicolectomies will necessitate a long midline incision.

    • This question is part of the following fields:

      • Peri-operative Care
      • Principles Of Surgery-in-General
      45.9
      Seconds
  • Question 3 - A 56 year old man is scheduled for flexible sigmoidoscopy to investigate bright...

    Correct

    • A 56 year old man is scheduled for flexible sigmoidoscopy to investigate bright red rectal bleeding. Which of the following would be the most appropriate preparation for this procedure?

      Your Answer: Single phosphate enema 30 minutes pre procedure

      Explanation:

      Bowel preparation is a significant aspect of the flexible sigmoidoscopy procedure. Clear visibility of the bowel mucosa is critical for a thorough examination. The combination of a light breakfast in the morning and the application of 1 or 2 phosphate enemas a few hours before the examination is a safe and commonly used method of preparing a patient for a flexible sigmoidoscopy procedure.

    • This question is part of the following fields:

      • Peri-operative Care
      • Principles Of Surgery-in-General
      31.4
      Seconds
  • Question 4 - A 68 year old woman has undergone surgical repair of her femoral hernia....

    Incorrect

    • 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: Risk of thermal injury to regional vessels as a result of tissue heating

      Correct 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
      75.7
      Seconds
  • Question 5 - A 62 year old woman who has undergone a right hip hemiarthroplasty for...

    Incorrect

    • A 62 year old woman who has undergone a right hip hemiarthroplasty for a fractured femoral neck, is found to have low serum sodium of 124mmol/L a few days postoperatively. Which of the following is the least likely cause of her deranged labs?

      Your Answer: Hypothyroidism

      Correct Answer: Vomiting

      Explanation:

      Vomiting usually results in hypokalaemia, and hyponatremia would least likely occur as a result of it. Hyponatremia is a common postoperative finding among patients and hence serum sodium must be carefully monitored. Addison disease, SIADH, diuretic therapy can all cause hyponatremia.

    • This question is part of the following fields:

      • Peri-operative Care
      • Principles Of Surgery-in-General
      36.6
      Seconds
  • Question 6 - A 40 year old woman has a full thickness burn on her foot...

    Correct

    • 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.

    • This question is part of the following fields:

      • Emergency Medicine And Management Of Trauma
      • Principles Of Surgery-in-General
      30
      Seconds
  • Question 7 - A woman with type II diabetes is undergoing a bilateral hernia repair as...

    Incorrect

    • A woman with type II diabetes is undergoing a bilateral hernia repair as a day-case procedure under general anaesthetic. Which of the following is most appropriate?

      Your Answer: They should be prescribed an insulin/dextrose sliding scale starting at 6 am on the day of surgery

      Correct Answer: They should be placed first on the operating list whenever possible

      Explanation:

      Answer: They should be placed first on the operating list whenever possible

      Patients with diet controlled diabetes are all
      suitable for day case surgery if the procedure itself
      is suitable for day surgery and all other criteria are
      fulfilled.
      People with diabetes controlled by oral or injected
      medication are suitable for day case surgery if:
      • They fulfil all day case criteria
      • They can be first / early on a morning or afternoon
      list.
      Prioritise patients with diabetes on the list. This reduces the starvation time and hence the likelihood of the patient requiring a VRIII.

      Insulin should never be stopped in people with Type 1 diabetes because this will lead to ketoacidosis. If the starvation period is expected to require omission of more than one meal, a variable rate intravenous insulin infusion (VRIII) with concomitant glucose and electrolyte infusion will be required. Insulin requirements are increased by:
      • Obesity
      • Prolonged or major surgery
      • Infection
      • Glucocorticoid treatment.
      When a VRIII is used, insulin and substrate should be infused continuously. If the infusion is stopped, there will be no insulin present in the circulation after 3-5 minutes leading to immediate catabolism.

    • This question is part of the following fields:

      • Peri-operative Care
      • Principles Of Surgery-in-General
      139.7
      Seconds
  • Question 8 - A 58 year old lady who has had a mastectomy undergoes a breast...

    Incorrect

    • A 58 year old lady who has had a mastectomy undergoes a breast reconstruction surgery. The breast implant is placed just anterior to her pectoralis major muscle. Which of the following methods of wound closure would be the most appropriate in this case?

      Your Answer: Use of a free myocutaneous flap

      Correct Answer: Use of a pedicled myocutaneous flap

      Explanation:

      The latissimus dorsi myocutaneous flap (LDMF) is one of the most reliable and versatile flaps used in reconstructive surgery. It is known for its use in chest wall and postmastectomy reconstruction and has also been used effectively for coverage of large soft tissue defects in the head and neck, either as a pedicled flap or as a microvascular free flap.

      The latissimus dorsi may be transferred as a myofascial flap, a myocutaneous flap, or as a composite osteomyocutaneous flap when harvested with underlying serratus anterior muscle and rib. For even greater reconstructive flexibility, the latissimus can be harvested for free tissue transfer in combination with any or all of the other flaps based on the subscapular vessels (the so-called subscapular compound flap or “mega-flap”), including serratus anterior, scapular, and parascapular flaps

    • This question is part of the following fields:

      • Emergency Medicine And Management Of Trauma
      • Principles Of Surgery-in-General
      54.6
      Seconds
  • Question 9 - A 46-year-old male is involved in a polytrauma and requires a massive transfusion...

    Incorrect

    • A 46-year-old male is involved in a polytrauma and requires a massive transfusion of packed red cells and fresh frozen plasma. Three hours later he develops marked hypoxia and his CVP is noted to be 10mm Hg. A chest x-ray shows bilateral diffuse pulmonary infiltrates. What is the most likely diagnosis?

      Your Answer: Pulmonary embolus

      Correct Answer: Transfusion associated lung injury

      Explanation:

      A massive blood transfusion is defined as the replacement of a patient’s total blood volume in <24 h
      The abnormalities which result include effects upon coagulation status, serum biochemistry, acid-base balance and temperature homeostasis.
      One of the complications is Transfusion-related acute lung injury
      (TRALI) which is the most common cause of major morbidity and death after transfusion. It presents as an acute respiratory distress syndrome (ARDS) either during or within 6 h of transfusion.

      Clinical features
      Hypoxaemia, dyspnoea, cyanosis, fever, tachycardia and hypotension result from non-cardiogenic pulmonary oedema. The radiographic appearance is of bilateral pulmonary infiltration, characteristic of pulmonary oedema. It is important to differentiate TRALI from other causes of ARDS such as circulatory overload or myocardial or valvular heart disease. Invasive monitoring in TRALI demonstrates normal intracardiac pressures

      Pathogenesis
      Two different mechanisms for the pathogenesis of TRALI have been identified: immune (antibody-mediated) and non-immune. Immune TRALI results from the presence of leucocyte antibodies in the plasma of donor blood directed against human leucocyte antigens (HLA) and human neutrophil alloantigens (HNA) in the recipient. Antibodies present in the recipient only rarely cause TRALI. In up to 40% of patients, leucocyte antibodies cannot be detected in either donor or recipient. In these cases, it is possible that reactive lipid products released from the membranes of the donor blood cells act as the trigger. This is known as non-immune TRALI.
      The target cell in both forms of TRALI is the neutrophil granulocyte. On activation of their acute phase cycle, these cells migrate to the lungs where they become trapped within the pulmonary microvasculature. Oxygen-free radicals and other proteolytic enzymes are then released which destroy the endothelial cells of the lung capillaries. A pulmonary capillary leak syndrome develops with the exudation of fluid and protein into the alveoli resulting in pulmonary oedema. The majority of reactions are severe, and often life-threatening; 70% require mechanical ventilation and 6–9% are fatal. A definitive diagnosis requires antibody detection. The mortality in non-immune TRALI is lower, and the syndrome is encountered predominantly in critically ill patients.
      Other Complications of blood transfusion
      Early:
      – Haemolytic reactions
      Immediate
      Delayed
      – Non-haemolytic febrile reactions
      – Allergic reactions to proteins, IgA
      – Reactions secondary to bacterial contamination
      – Circulatory overload
      – Air embolism
      – Thrombophlebitis
      – Hyperkalaemia
      – Citrate toxicity
      – Hypothermia
      – Clotting abnormalities (after massive transfusion)
      Late:
      – Transmission of infection
      – Viral (hepatitis A, B, C, HIV, CMV)
      – Bacterial (Treponeum pallidum, Salmonella)
      – Parasites (malaria, toxoplasma)
      – Graft-vs-host disease
      – Iron overload (after chronic transfusions)
      – Immune sensitization (Rhesus D antigen)

    • This question is part of the following fields:

      • Post-operative Management And Critical Care
      • Principles Of Surgery-in-General
      110.7
      Seconds
  • Question 10 - A 55-year-old man is recovering following an elective right hemicolectomy for carcinoma of...

    Incorrect

    • A 55-year-old man is recovering following an elective right hemicolectomy for carcinoma of the caecum. His surgery is uncomplicated, when should oral intake resume?

      Your Answer: Only once the patient has passed flatus

      Correct Answer: Within 24 hours of surgery

      Explanation:

      It has been well established that any delay in the resumption of normal oral diet after major surgery is associated with increased rates of infectious complications and delayed recovery. Early oral diet is safe 4 h after surgery in patients with a new non-diverted colorectal anastomosis. Some report that low residue diet, rather than a clear liquid diet, after colorectal surgery is associated with less nausea, faster return of bowel function, and a shorter hospital stay without increasing postoperative morbidity when administered in association with prevention of postoperative ileus. Spontaneous food intake rarely exceeds 1200–1500 kcal/day. To reach energy and protein requirements, additional oral nutritional supplements are useful.

    • This question is part of the following fields:

      • Post-operative Management And Critical Care
      • Principles Of Surgery-in-General
      44.7
      Seconds
  • Question 11 - A 58 year old man presents to the clinic complaining of lower backache...

    Incorrect

    • A 58 year old man presents to the clinic complaining of lower backache refractory to medicine. He is a known case of metastatic prostate carcinoma, with spinal involvement. However, up until recently, he has had no problems with pain control. He takes 1g qds paracetamol daily. Neurological examination is unremarkable. Which of the following is the most appropriate next step in management?

      Your Answer: Switch to co-codamol 30/500

      Correct Answer: Add non steroidal anti inflammatory drug

      Explanation:

      Acetaminophen, NSAIDs, and opiates are recommended in the basic approach to cancer pain associated with bone metastases. They should provide patients with adequate analgesia when used appropriately. NSAIDs including COX2 inhibitors are especially useful for patients with bone pain. Acetaminophen is an effective analgesic but is a weak anti-inflammatory agent. Ketorolac tromethamine is a potent NSAID capable of relieving moderate to severe acute bone pain.

    • This question is part of the following fields:

      • Oncology
      • Principles Of Surgery-in-General
      117.7
      Seconds
  • Question 12 - A 53-year-old male undergoes an elective right hemicolectomy. A stapled ileocolic anastomosis is...

    Correct

    • A 53-year-old male undergoes an elective right hemicolectomy. A stapled ileocolic anastomosis is constructed. Eight hours later he becomes tachycardic and passes approximately 600ml of dark red blood per rectum. Which of the following processes is the most likely explanation for what happened?

      Your Answer: Anastomotic staple line bleeding

      Explanation:

      Complications related to stapled anastomoses include bleeding, device failure, and anastomotic failure, which include stricture or leak.
      Stricture: Patient discomfort, need for additional procedures
      Bleeding: Hemodynamic implications, difficult intraoperative visualization
      Anastomotic leak: Increase in local recurrence, decreased overall survival, sepsis, need for diverting ostomy, increased hospital cost, increased use of hospital resources, decreased quality of life.
      Anastomotic bleeding is a common complication of stapled anastomoses, and it can lead to hemodynamic instability and anaemia, sometimes requiring transfusion or additional procedures. To this end, there are efforts aimed at reducing staple line haemorrhage by using buttressing techniques.

    • This question is part of the following fields:

      • Principles Of Surgery-in-General
      • Surgical Technique And Technology
      53.2
      Seconds
  • Question 13 - A 45-year-old male has symptoms of carcinoid syndrome. Which of the following is...

    Correct

    • A 45-year-old male has symptoms of carcinoid syndrome. Which of the following is the most effective therapeutic agent in controlling the symptoms?

      Your Answer: Octreotide

      Explanation:

      Carcinoid syndrome occurs in ∼20% of cases of well-differentiated endocrine tumours of the jejunum or ileum (midgut neuroendocrine tumours (NET) and consists of (usually) dry flushing (without sweating; 70% of cases) with or without palpitations, diarrhoea (50% of cases) and intermittent abdominal pain (40% of cases); in some patients, there is also lacrimation and rhinorrhoea.
      Carcinoid syndrome occurs less often with NETs of other origins and is very rare in association with rectal NETs. It is usually due to metastasis to the liver, with the release of vasoactive compounds, including biogenic amines (e.g., serotonin and tachykinins), into the systemic circulation. However, it may also occur in the absence of liver metastases if there is direct retroperitoneal involvement, with venous drainage bypassing the liver. Pain due to hepatic enlargement may also be a presenting feature, as may upper right abdominal pain (similar to that of pulmonary infarction) secondary to either haemorrhage into, or necrosis of, a hepatic secondary tumour. Wheezing and pellagra are less common presenting features. CHD is present in ∼20% of patients at presentation and usually indicates that the syndrome has been present for several years.

      The aim of treatment should be curative where possible but it is palliative in the majority of cases.
      Surgery is the only curative treatment.
      Administration of specific medications to treat symptoms should, therefore, start as soon as clinical and biochemical signs indicate the presence of hypersecretory NETs, even before the precise localisation of primary and metastatic lesions is confirmed.

      The only proven hormonal management of NETs is by the administration of somatostatin analogues.
      Somatostatin analogues bind principally to SSTR subtypes 2 (with high affinity) and 5 (with lower affinity), thus inhibiting the release of various peptide hormones in the gut, pancreas and pituitary; they also antagonise growth factor effects on tumour cells, and, at very high dosage, may induce apoptosis. The effects of somatostatin analogues are demonstrable as biochemical response rates (inhibition of hormone production) in 30–70% of patients and as symptomatic control in the majority of patients.
      There are two commercially available somatostatin analogues: octreotide and lanreotide.

    • This question is part of the following fields:

      • Principles Of Surgery-in-General
      • Surgical Technique And Technology
      42.3
      Seconds
  • Question 14 - A 11 year girl presents to the A&E department with a full thickness...

    Correct

    • A 11 year girl presents to the A&E department with a full thickness burn to her right arm, which she got when a firework that she was playing with exploded. Which statement is not characteristic of the situation?

      Your Answer: The burn area is extremely painful until skin grafted

      Explanation:

      Answer: The burn area is extremely painful until skin grafted

      Third-degree burns destroy the epidermis and dermis. Third-degree burns may also damage the underlying bones, muscles, and tendons. The burn site appears white or charred. There is no sensation in the area since the nerve endings are destroyed. These are not normally painful until after skin grafting is done since the nerve endings have been destroyed.

    • This question is part of the following fields:

      • Emergency Medicine And Management Of Trauma
      • Principles Of Surgery-in-General
      113.9
      Seconds
  • Question 15 - A 27-year-old man presents to the A&E department with a headache and odd...

    Correct

    • A 27-year-old man presents to the A&E department with a headache and odd behaviour after being hit on the side of his head by a bat. Whilst waiting for a CT scan, he becomes drowsy and unresponsive. What is the most likely underlying injury?

      Your Answer: Extradural haematoma

      Explanation:

      Extradural haematoma is the most likely cause of this patient’s symptomology. The middle meningeal artery is prone to damage when the temporal side of the head is hit.

      Patients who suffer head injuries should be managed according to ATLS principles and extracranial injuries should be managed alongside cranial trauma. Inadequate cardiac output compromises the CNS perfusion, irrespective of the nature of cranial injury.

      An extradural haematoma is a collection of blood in the space between the skull and the dura mater. It often results from acceleration-deceleration trauma or a blow to the side of the head. The majority of extradural haematomas occur in the temporal region where skull fractures cause a rupture of the middle meningeal artery. There is often loss of consciousness following a head injury, a brief regaining of consciousness, and then loss of consciousness again—lucid interval. Other symptoms may include headache, confusion, vomiting, and an inability to move parts of the body. Diagnosis is typically by a CT scan or MRI, and treatment is generally by urgent surgery in the form of a craniotomy or burr hole.

    • This question is part of the following fields:

      • Emergency Medicine And Management Of Trauma
      • Principles Of Surgery-in-General
      12.8
      Seconds
  • Question 16 - A 55-year-old female is admitted one week following a cholecystectomy with profuse diarrhoea....

    Incorrect

    • 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: Campylobacter 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
      45.4
      Seconds
  • Question 17 - A middle aged man who is reported to have a penicillin allergy is...

    Incorrect

    • 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: Adrenaline 1:10000 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

    • This question is part of the following fields:

      • Emergency Medicine And Management Of Trauma
      • Principles Of Surgery-in-General
      119.7
      Seconds
  • Question 18 - A 64 year old woman arrives at the emergency department with acute bowel...

    Incorrect

    • A 64 year old woman arrives at the emergency department with acute bowel obstruction. She complains of vomiting up to 15 times per day and is currently taking erythromycin. She is now complaining of dizziness that is sudden in onset. ECG shows torsades de pointes. Which of the following is the most appropriate step in her management?

      Your Answer: IV Adrenaline

      Correct Answer: IV Magnesium sulphate

      Explanation:

      Torsade de pointes is an uncommon and distinctive form of polymorphic ventricular tachycardia (VT) characterized by a gradual change in the amplitude and twisting of the QRS complexes around the isoelectric line. Torsade de pointes, often referred to as torsade, is associated with a prolonged QT interval, which may be congenital or acquired. Torsade usually terminates spontaneously but frequently recurs and may degenerate into ventricular fibrillation. This woman is likely to have hypokalaemia and hypomagnesaemia as a result of vomiting. In addition to this, the erythromycin will predispose her to torsades de pointes. The patient should be given Magnesium 2g over 10 minutes. Knowledge of the management of this peri arrest diagnosis is hence important in surgical practice.

    • This question is part of the following fields:

      • Emergency Medicine And Management Of Trauma
      • Principles Of Surgery-in-General
      50.7
      Seconds
  • Question 19 - A 40-year-old motorcyclist is involved in a road traffic accident. A FAST scan...

    Incorrect

    • 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: Fully mobilise the spleen to inspect it

      Correct 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.

    • This question is part of the following fields:

      • Emergency Medicine And Management Of Trauma
      • Principles Of Surgery-in-General
      55.8
      Seconds
  • Question 20 - A 43-year-old male with no significant medical history is currently being kept nil-by-mouth...

    Incorrect

    • A 43-year-old male with no significant medical history is currently being kept nil-by-mouth for an elective bilateral inguinal hernia repair. Which of the following describes the best fluid regimen for this patient over the following 24 hours?

      Your Answer: 2 L Hartmann’s solution and 1 L 5% dextrose with 20 mmol potassium

      Correct Answer: 1 L normal saline with 20 mmol potassium and 2 L 5% dextrose with 20 mmol potassium in each bag

      Explanation:

      If patients need IV fluids for routine maintenance alone, restrict the initial prescription to:
      25–30 ml/kg/day of water and
      approximately 1 mmol/kg/day of potassium, sodium and chloride and
      approximately 50–100 g/day of glucose to limit starvation ketosis.
      Weight-based potassium prescriptions should be rounded to the nearest common fluids available (for example, a 67 kg person should have fluids containing 20 mmol and 40 mmol of potassium in 24 hours). Potassium should not be added to intravenous fluid bags as this is dangerous.

      Sodium chloride 0.9%, with or without additional potassium, is one of the most commonly used IV fluids in UK practice.

      Glucose 5% solution provides a useful means of giving free water for, once the glucose is metabolised, the fluid is distributed throughout total body water. It is, therefore, a potentially useful means of correcting or preventing simple dehydration and the glucose content will also help to prevent starvation ketosis, although it is important to recognize that it will not make much of a contribution to covering patients overall nutritional needs. The use of 5% glucose, will increase risks of significant hyponatraemia, particularly in children, the elderly, patients on diuretics and those with excess ADH due to osmotic and non-osmotic stimuli (a problem is seen quite frequently in hospitalized patients). Nevertheless, hyponatremia is likely to be avoided by not exceeding recommended volumes of maintenance IV fluids and by careful monitoring of patients’ clinical volume status and electrolyte measurements.

    • This question is part of the following fields:

      • Peri-operative Care
      • Principles Of Surgery-in-General
      56.6
      Seconds
  • Question 21 - A 38-year-old man presents to the A&E department after sustaining a single gunshot...

    Correct

    • 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: 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.

    • This question is part of the following fields:

      • Emergency Medicine And Management Of Trauma
      • Principles Of Surgery-in-General
      64.6
      Seconds
  • Question 22 - A 35-year-old aid worker becomes unwell whilst helping at the scene of a...

    Correct

    • A 35-year-old aid worker becomes unwell whilst helping at the scene of a recent earthquake. He develops vomiting and soon afterwards, profuse watery diarrhoea. What is the most likely infective organism?

      Your Answer: Vibrio cholera

      Explanation:

      The passage of extremely loose and watery stools is characteristic of Vibrio cholera infection. Most of the other gastroenteric infections do not produce such watery motions.

      Vibrio cholerae is a Gram-negative, comma-shaped bacterium. It’s natural habitat is brackish or saltwater. Some strains of V. cholerae cause the disease cholera.

      Transmission occurs through the ingestion of contaminated water or food. Sudden large outbreaks are usually caused by a contaminated water supply. Outbreaks and endemic and sporadic cases are often attributed to raw or undercooked seafood.

      Symptoms of the disease include sudden onset of effortless vomiting and profuse watery diarrhoea. Correction of fluid and electrolyte losses are the mainstay of treatment. Most cases resolve shortly afterwards, and therefore, antibiotics are not generally indicated.

    • This question is part of the following fields:

      • Clinical Microbiology
      • Principles Of Surgery-in-General
      69
      Seconds
  • Question 23 - A 68 year old man, known with colorectal carcinoma, is currently taking MST...

    Incorrect

    • 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: 30 mg

      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.

    • This question is part of the following fields:

      • Oncology
      • Principles Of Surgery-in-General
      32
      Seconds
  • Question 24 - A 25-year-old woman hits her head on the steering wheel during a collision...

    Incorrect

    • A 25-year-old woman hits her head on the steering wheel during a collision with another car. She is brought to the A&E department with periorbital swelling and a flattened appearance of the face. What is the most likely injury?

      Your Answer: Le Fort I fracture affecting maxilla

      Correct Answer: Le Fort III fracture affecting the maxilla

      Explanation:

      The flattened appearance of the face is a classical description of the dish-face deformity associated with Le Fort III fracture of the midface.

      The term Le Fort fractures is applied to transverse fractures of the midface involving the maxillary bone and surrounding structures in either a horizontal, pyramidal, or transverse direction. There are three grades of Le Fort fractures:

      1. Le Fort I
      It is the horizontal fracture of the maxilla. Violent force over a more extensive area above the level of the
      teeth will result in this type of fracture. Horizontal fracture line is seen above the apices of the maxillary teeth, detaching the tooth-bearing portion of the maxilla from the rest of the facial skeleton. Floating maxilla and Guerin’s sign is seen in such patients.

      2. Le Fort II
      It is a pyramidal or subzygomatic fracture. Violent force in the central region extending from glabella to the alveolus results in this type of fracture, resulting in ballooning or moon-face facial deformity.

      3. Le Fort III
      It is a high-level transverse or suprazygomatic fracture associated with craniofacial disjunction. The entire facial skeleton moves as a single block as a result of the trauma. The patient develops a characteristic panda facies and dish-face deformity.

    • This question is part of the following fields:

      • Emergency Medicine And Management Of Trauma
      • Principles Of Surgery-in-General
      79.9
      Seconds
  • Question 25 - A 20-year-old African man is admitted to the hospital with acute severe abdominal...

    Incorrect

    • A 20-year-old African man is admitted to the hospital with acute severe abdominal pain. He has just flown to UK after a long-haul flight, and the pain developed mid-flight. On examination, there is tenderness in the left upper abdominal quadrant. His blood tests, done on his arrival, show:Hb: 5 g/dLWCC: 20 x 10^9/LRetic count: 30% What is the most likely underlying cause?

      Your Answer: Beta thalassaemia minor

      Correct Answer: Sickle cell anaemia

      Explanation:

      The combination of a high reticulocyte count and severe anaemia indicates aplastic crisis in patients with sickle cell anaemia. Another differential can be that of a transient aplastic crisis due to parvovirus. This is less likely as it causes reticulocytopenia rather than reticulocytosis.

      Parvovirus B19 infects erythroid progenitor cells in the bone marrow and causes temporary cessation of red blood cell production. People who have underlying haematologic abnormalities such as sickle cell anaemia are at risk of cessation of red blood cell production if they become infected. This can result in a transient aplastic crisis. It is more common in people of African, Indian, and Middle Eastern backgrounds. Typically, these patients have a viral prodrome followed by anaemia, often with haemoglobin concentrations falling below 5.0 g/dL and reticulocytosis.

    • This question is part of the following fields:

      • Emergency Medicine And Management Of Trauma
      • Principles Of Surgery-in-General
      80.8
      Seconds
  • Question 26 - A 42-year-old woman is admitted with sepsis and right flank pain. Twenty-four hours...

    Incorrect

    • A 42-year-old woman is admitted with sepsis and right flank pain. Twenty-four hours ago, she was started on trimethoprim, by the GP, for a urinary tract infection (UTI).Which of the following organisms is the most likely causative agent?

      Your Answer: Mycobacterium tuberculosis

      Correct Answer: E. coli

      Explanation:

      Ascending infection of the urinary tract is most commonly caused by Escherichia coli (E.coli). Other organisms may be accountable. However, these are less common.

      E. coli are gram-negative rods. They have a wide range of subtypes and some are normal gut commensals. Most varieties of E. coli are harmless or cause relatively brief diarrhoea. But a few nasty strains, such as E. coli O157:H7, can cause severe abdominal cramps, bloody diarrhoea, and vomiting. Some strains of E. coli are also resistant to a large number of antibiotics used to treat gram-negative infections.

    • This question is part of the following fields:

      • Clinical Microbiology
      • Principles Of Surgery-in-General
      23.8
      Seconds
  • Question 27 - A 33 year old firefighter is recovering from an appendicectomy where the operation...

    Incorrect

    • 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: Gelofusin

      Correct 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 solutions

      The 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 Lactate

      Ringer’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.

    • This question is part of the following fields:

      • Post-operative Management And Critical Care
      • Principles Of Surgery-in-General
      49.5
      Seconds
  • Question 28 - A 28 year old teacher is readmitted following a difficult appendicectomy. On examination,...

    Incorrect

    • A 28 year old teacher is readmitted following a difficult appendicectomy. On examination, her wound is erythematous and, on incision, foul smelling pus is drained. Which of the following organisms is responsible?

      Your Answer: Staphylococcus aureus

      Correct Answer: Bacteroides fragilis

      Explanation:

      Bacteroides species are anaerobic bacteria that are predominant components of the bacterial florae of mucous membranes and are therefore a common cause of endogenous infections. Bacteroides infections can develop in all body sites, including the CNS, the head, the neck, the chest, the abdomen, the pelvis, the skin, and the soft tissues. Inadequate therapy against these anaerobic bacteria may lead to clinical failure.

      These bacteria are resistant to penicillins, mostly through the production of beta-lactamase. Anaerobic bacteria can infect deep wounds, deep tissues, and internal organs where there is little oxygen. These infections are characterized by abscess formation, foul-smelling pus, and tissue destruction. Anaerobes outnumber aerobes by 1000:1 in the large intestine; thus, they play an important role in almost all intra-abdominal infections.

      Secondary peritonitis and abdominal abscesses generally occur after entry of enteric organisms into the peritoneal cavity through perforation of the intestine or other viscus as a result of obstruction, infarction, or trauma.

      Most visceral abscesses (e.g., hepatic), chronic cholecystitis, perforated and gangrenous appendicitis, postoperative wound infections and abscesses, diverticulitis, and any infection associated with faecal contamination of the abdominal cavity involve both aerobes and anaerobes.

    • This question is part of the following fields:

      • Clinical Microbiology
      • Principles Of Surgery-in-General
      86
      Seconds
  • Question 29 - A 26-year-old Indian woman who is 18 weeks pregnant presented with increasing shortness...

    Correct

    • A 26-year-old Indian woman who is 18 weeks pregnant presented with increasing shortness of breath, chest pain, and was coughing clear sputum. On examination, she was afebrile with a blood pressure of 140/80 mmHg, heart rate of 130 bpm and saturation of 94% on 15L oxygen. Furthermore, there was a mid-diastolic murmur, bibasilar crepitations, and mild pedal oedema. Her urgent CXR was requested. Suddenly, she deteriorated and had a respiratory arrest. Her CXR showed bilateral complete whiteout of her lungs. What could be the most likely explanation?

      Your Answer: Mitral valve stenosis

      Explanation:

      Mitral valve stenosis is the most common cause of cardiac abnormality occurring in pregnant women. It is becoming less common in the UK population; however, it should be considered in women from countries where there is a higher incidence of rheumatic heart disease. Physiological changes in pregnancy may cause an otherwise asymptomatic patient to suddenly deteriorate.

      Mitral stenosis causes a mid-diastolic murmur which may be difficult to auscultate unless the patient is placed in the left lateral position. These patients are at risk of atrial fibrillation (up to 40%) which can also contribute to rapid decompensation such as pulmonary oedema (hence, whiteout of lungs seen on CXR). Balloon valvuloplasty is the treatment of choice in patients with mitral valve stenosis.

    • This question is part of the following fields:

      • Emergency Medicine And Management Of Trauma
      • Principles Of Surgery-in-General
      25.1
      Seconds
  • Question 30 - A 30-year-old male patient is undergoing an open appendicectomy. The surgeons extend the...

    Incorrect

    • A 30-year-old male patient is undergoing an open appendicectomy. The surgeons extend the incision medially and suddenly encounter troublesome bleeding. What should be the best course of action?

      Your Answer:

      Correct Answer: Ligate the bleeding vessel

      Explanation:

      Medial extension of an appendicectomy incision carries a risk of injury to the inferior epigastric artery which can bleed briskly. It is best managed by ligation.

      Bleeding is a complication encountered in all branches of surgery. The decision as to how best to manage the bleed, depends upon its site, vessel, and circumstances.

      1. Superficial dermal bleeding:
      This will usually cease spontaneously. If not, then direct use of a monopolar or a bipolar cautery device will usually control the situation. Scalp wounds are a notable exception and bleeding from them may be brisk. In this situation, use of a mattress suture as a wound closure method will usually address the problem.

      2. Superficial arterial bleeding:
      If the vessel can be safely identified in superficial arterial bleeding, then the easiest method is to apply a haemostatic clip and ligate the vessel.

      3. Major arterial bleeding:
      If the vessel can be clearly identified and is accessible, then it may be possible to apply a clip and ligate the vessel. If the vessel is located in a pool of blood, then blind application of haemostatic clips is highly dangerous and may result in collateral injury. In this situation, evacuating the clot and packing the area is often safer. The pack can then be carefully removed when the required instruments are available. Some vessels may retract and bleeding may then be controlled by dissection of surrounding structures or underrunning the bleeding point.

      4. Major venous bleeding:
      The safest initial course of action is to apply digital pressure to the bleeding point. To control the bleeding, thereafter, the surgeon will need a working suction device. Divided veins may require ligation.

      5. Bleeding from raw surfaces:
      This may be mixed bleeding and can be troublesome. Spray diathermy and argon plasma coagulation are both useful agents. Certain topical haemostatic agents, such as surgicel, are useful in encouraging clot formation and may be used in conjunction with, or instead of, the above agents.

    • This question is part of the following fields:

      • Principles Of Surgery-in-General
      • Surgical Technique And Technology
      0
      Seconds

SESSION STATS - PERFORMANCE PER SPECIALTY

Emergency Medicine And Management Of Trauma (9/12) 75%
Principles Of Surgery-in-General (15/29) 52%
Peri-operative Care (1/5) 20%
Surgical Technique And Technology (3/4) 75%
Post-operative Management And Critical Care (1/3) 33%
Oncology (0/2) 0%
Clinical Microbiology (1/3) 33%
Passmed