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  • Question 1 - A 28-year-old electrician is brought to the A&E department after a high-voltage full-thickness...

    Correct

    • A 28-year-old electrician is brought to the A&E department after a high-voltage full-thickness burn to his left leg. His urinalysis shows haematuria 1+ and his blood reports show mild hyperkalaemia and serum CK level of 3000 U/L. What is the most likely explanation?

      Your Answer: Rhabdomyolysis

      Explanation:

      High-voltage electrical burns are associated with rhabdomyolysis. Acute tubular necrosis may also occur.

      Electrical burns occur following exposure to electrical current. Full-thickness burns are third-degree burns. With these types of burns, the epidermal and dermal layers of skin are destroyed, and the damage may even penetrate the layer of fat beneath the skin.

      Following the burn, there is a local response with progressive tissue loss and release of inflammatory cytokines. Systemically, there are cardiovascular effects resulting from fluid loss and sequestration of fluid into the third space. There is a marked catabolic response as well. Immunosuppression is common with large burns, and bacterial translocation from the gut lumen is a recognised event. Sepsis is a common cause of death following major burns.

      After the initial management and depth assessment of the burn, the patient is transferred to burn centre if:
      1. Needs burn shock resuscitation
      2. Face/hands/genitals affected
      3. Deep partial-thickness or full-thickness burns
      4. Significant electrical/chemical burns

      Management options include:
      1. The initial aim is to stop the burning process and resuscitate the patient. Adults with burns greater than 15% of total body surface area require burn fluid resuscitation. Fluids administration is calculated using the Parkland formula. Half of the fluid is administered in the first eight hours. A urinary catheter should be inserted and analgesics should be started.

      2. Conservative management is appropriate for superficial burns and mixed superficial burns that will heal in two weeks. More complex burns may require excision and skin grafting. Excision and primary closure is not generally practised as there is a high risk of infection.

      3. Circumferential full-thickness burns affecting a limb or severe torso burns impeding respiration may require escharotomy to divide the burnt tissue.

      4. There is no evidence to support the use of antimicrobial prophylaxis or topical antibiotics in burn patients.

    • This question is part of the following fields:

      • Emergency Medicine And Management Of Trauma
      • Principles Of Surgery-in-General
      20
      Seconds
  • Question 2 - 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
      47.7
      Seconds
  • Question 3 - A 39-year-old homosexual is admitted with diarrhoea of three-month duration. He is found...

    Incorrect

    • A 39-year-old homosexual is admitted with diarrhoea of three-month duration. He is found to be HIV positive with a CD4 cell count <50/μL. Which of the following organisms is most likely to be responsible?

      Your Answer: Vibrio cholera

      Correct Answer: Cryptosporidium

      Explanation:

      Based on the history and findings, the most likely causative organism is cryptosporidium. It can cause severe, chronic, and possibly fatal diarrhoea in immunocompromised patients.

      In patients with HIV/AIDS, clinical manifestations of cryptosporidiosis vary with the degree of immune compromise. Those with CD4 cell counts above 180–200/μL may be asymptomatic or develop self-limiting diarrhoeal illness. However, patients with advanced AIDS (CD4 cell counts <50/μL) can have severe diarrhoea that can persist for several months, resulting in severe dehydration, weight loss and malnutrition, extended hospitalizations, and mortality. In addition, patients with advanced AIDS are at greater risk of developing extraintestinal infection, particularly of the biliary, pancreatic, and respiratory tracts.

    • This question is part of the following fields:

      • Clinical Microbiology
      • Principles Of Surgery-in-General
      89.9
      Seconds
  • Question 4 - A 68 year old woman who underwent a mastectomy with axillary node clearance...

    Correct

    • A 68 year old woman who underwent a mastectomy with axillary node clearance for breast cancer is going to have a drain inserted to prevent seroma development. Which of the following devices should ideally be used?

      Your Answer: A closed suction drainage system made of polypropylene

      Explanation:

      A surgical drain is a tube used to remove pus, blood or other fluids from a wound. They are commonly placed by surgeons or interventional radiologists. Suction is applied through the drain to generate a vacuum and draw fluids into a bottle. Following breast surgery, it is standard practice to use a Redivac type system that is made of polypropylene.

    • This question is part of the following fields:

      • Principles Of Surgery-in-General
      • Surgical Technique And Technology
      32.4
      Seconds
  • Question 5 - A 12 year old girl is admitted with severe (35%) burns following a...

    Correct

    • A 12 year old girl is admitted with severe (35%) burns following a fire at home. She was transferred to the critical care unit after the wound was cleaned and dressed. She became tachycardic and hypotensive one day after skin grafts were done. She has vomited three times and blood was seen in it. What is the most likely diagnosis?

      Your Answer: Curling's ulcers

      Explanation:

      Answer: Curling’s ulcers

      Curling’s ulcer is an acute gastric erosion resulting as a complication from severe burns when reduced plasma volume leads to ischemia and cell necrosis (sloughing) of the gastric mucosa. The most common mode of presentation of stress ulcer is the onset of acute upper GI bleed like hematemesis or melena in a patient with the acute critical illness.

      A similar condition involving elevated intracranial pressure is known as Cushing’s ulcer. Cushing’s ulcer is a gastro-duodenal ulcer produced by elevated intracranial pressure caused by an intracranial tumour, head injury or other space-occupying lesions. The ulcer, usually single and deep, may involve the oesophagus, stomach, and duodenum. Increased intracranial pressure may affect different areas of the hypothalamic nuclei or brainstem leading to overstimulation of the vagus nerve or paralysis of the sympathetic system. Both of these circumstances increase secretion of gastric acid and the likelihood of ulceration of gastro-duodenal mucosa.

      Mallory-Weiss syndrome is characterized by upper gastrointestinal bleeding secondary to longitudinal mucosal lacerations (known as Mallory-Weiss tears) at the gastroesophageal junction or gastric cardia. However, Mallory-Weiss syndrome may occur after any event that provokes a sudden rise in the intragastric pressure or gastric prolapse into the oesophagus, including antecedent transoesophageal echocardiography. Precipitating factors include retching, vomiting, straining, hiccupping, coughing, primal scream therapy, blunt abdominal trauma, and cardiopulmonary resuscitation. In a few cases, no apparent precipitating factor can be identified. One study reported that 25% of patients had no identifiable risk factors.

    • This question is part of the following fields:

      • Emergency Medicine And Management Of Trauma
      • Principles Of Surgery-in-General
      96.1
      Seconds
  • Question 6 - A 65 year old man with a longstanding history of severe osteoarthritis of...

    Incorrect

    • A 65 year old man with a longstanding history of severe osteoarthritis of the hip is scheduled to undergo a total hip replacement. The skin has been prepared and antibiotics administered. Which of the following would be the most important precaution in reducing the risk of infection?

      Your Answer: Extended antibiotic chemoprophylaxis as routine

      Correct Answer: Laminar flow theatre

      Explanation:

      Laminar flow theatres aim to reduce the number of infective organisms in the theatre air by generating a continuous flow of bacteria free air. In laminar flow theatres air may be ‘changed’ in theatre more than 300 times per hour compared to standard positive pressure theatre rates of 15-25 air changes per hour.
      Shaving skin on the ward increases infection rates and extended chemoprophylaxis increases the risk of antibiotic associated diarrhoea

    • This question is part of the following fields:

      • Principles Of Surgery-in-General
      • Surgical Technique And Technology
      61.1
      Seconds
  • Question 7 - A 64 year old man has been in ICU with ARDS for a...

    Incorrect

    • A 64 year old man has been in ICU with ARDS for a week following acute pancreatitis. He is being mechanically ventilated. Which of the following is the best option for maintenance of the patency of his airway?

      Your Answer: Endotracheal tube

      Correct Answer: Tracheostomy

      Explanation:

      Tracheostomy is an operative procedure that creates a surgical airway in the cervical trachea. It is most often performed in patients who have had difficulty weaning off a ventilator, followed by those who have suffered trauma or a catastrophic neurologic insult. High-flow oxygen via tracheostomy may reduce the inspiratory effort and enhance tidal volume by delivering high-flow oxygen and facilitate weaning from prolonged mechanical ventilation in patients with restrictive pulmonary dysfunction.

    • This question is part of the following fields:

      • Post-operative Management And Critical Care
      • Principles Of Surgery-in-General
      89.1
      Seconds
  • Question 8 - A 50-year-old male is due to undergo laparotomy for small bowel obstruction. What...

    Correct

    • A 50-year-old male is due to undergo laparotomy for small bowel obstruction. What is the best option for maintaining his airway?

      Your Answer: Insertion of cuffed endotracheal tube

      Explanation:

      Patients with bowel obstruction who have either been vomiting or at high risk of regurgitation of gastric contents on the induction of anaesthesia. Aspiration of stomach contents from the pharynx is prevented by sealing off the airway. This is achieved by passing a cuffed endotracheal tube and the patient is in considerable danger from the moment consciousness is lost until this has been done. All methods of inducing general anaesthesia in intestinal obstruction rely on the speedy insertion of such a tube, and the anaesthetist must ensure pre-operatively that the patient can be intubated.
      Cricoid pressure. As soon as the patient loses consciousness, an assistant exerts firm backwards pressure on the cricoid cartilage, obliterating the oesophageal lumen. This prevents regurgitated fluids from entering the pharynx from below, it prevents anaesthetic gases from entering (and distending) the stomach from above, and it facilitates intubation by pushing the larynx posteriorly.

    • This question is part of the following fields:

      • Post-operative Management And Critical Care
      • Principles Of Surgery-in-General
      17.9
      Seconds
  • Question 9 - A 26-year-old man is playing football when he slips during a tackle. His...

    Correct

    • A 26-year-old man is playing football when he slips during a tackle. His left knee becomes painful immediately after. Several hours later, he notices that the knee has become swollen. Following a course of NSAIDs and rest, the situation improves. However, he presents to the clinic with recurrent pain. On examination, it is impossible to fully extend the knee, although the patient is able to do so when asked. What is the most likely injury?

      Your Answer: Torn meniscus

      Explanation:

      Twisting or rotational injuries to the knee in sports, followed by delayed onset of knee swelling and locking are strongly suggestive of a meniscal tear. Arthroscopic meniscectomy is the usual treatment.

      Meniscal tear is one of the most common knee injuries, characterized by:
      1. A popping sensation
      2. Delayed swelling or stiffness of the affected knee
      3. Pain, especially when twisting or rotating the knee
      4. Difficulty straightening the knee fully
      5. Locking of knee in place (patient may be able to unlock the knee)

      In older adults, degenerative changes of the knee can also contribute to a torn meniscus with little or no trauma.

      A torn meniscus may lead to knee instability, inability to move the knee normally, or persistent/recurrent knee pain. There is a strong likelihood of developing osteoarthritis in the injured knee.

    • This question is part of the following fields:

      • Oncology
      • Principles Of Surgery-in-General
      74
      Seconds
  • Question 10 - A 31-year-old woman who is 30 weeks pregnant presents with sudden onset of...

    Incorrect

    • A 31-year-old woman who is 30 weeks pregnant presents with sudden onset of chest pain associated with loss of consciousness. On examination, she is afebrile and her heart rate is 120 bpm, blood pressure is 170/90 mmHg, and saturation is 93% on 15L oxygen. Furthermore, an early diastolic murmur and occasional bibasilar crepitations are auscultated and mild pedal oedema is observed. Her ECG shows ST-segment elevation in leads II, III, and aVF.What is the most likely diagnosis?

      Your Answer: Mitral valve stenosis

      Correct Answer: Aortic dissection

      Explanation:

      The most likely diagnosis is aortic dissection.

      Aortic dissection occurs following a tear in the aortic intima with subsequent separation of the tissue within the weakened media by the propagation of blood. There are four different classifications of aortic dissection and the commonest one used is the Stanford classification dividing them into type A and type B. A type A dissection involves the ascending aorta and/or the arch whilst type B dissection involves only the descending aorta and occurs distal to the origin of the left subclavian artery.

      Aortic dissection in pregnancy occurs most commonly in the third trimester due to the hyperdynamic state and hormonal effect on vasculature. Other common predisposing factors for aortic dissection include Marfans syndrome, Ehlers-Danlos syndrome, and bicuspid aortic valve. Aortic dissection often presents with sudden severe, tearing chest pain, vomiting, and syncope, most often from acute pericardial tamponade. The patient may be hypertensive, clinically. The right coronary artery may become involved in the dissection, causing myocardial infarct in up to 2% of the cases (hence ST-segment elevation in the inferior leads). An aortic regurgitant murmur may be auscultated.

      The management options during pregnancy include:
      1. <28 weeks of gestation: aortic repair with the foetus kept in utero
      2. 28–32 weeks of gestation: dependent on foetal condition
      3. >32 weeks of gestation: caesarean section followed by aortic repair in the same operation

    • This question is part of the following fields:

      • Emergency Medicine And Management Of Trauma
      • Principles Of Surgery-in-General
      66.8
      Seconds
  • Question 11 - A 35-year-old aid worker becomes unwell whilst helping at the scene of a...

    Incorrect

    • 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: Campylobacter jejuni

      Correct 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
      75.8
      Seconds
  • Question 12 - A 43-year-old female with liver cirrhosis is recovering following an emergency paraumbilical hernia...

    Incorrect

    • 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: 1.8% saline

      Correct 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.

    • This question is part of the following fields:

      • Post-operative Management And Critical Care
      • Principles Of Surgery-in-General
      93.5
      Seconds
  • Question 13 - A young lady is rushed to the A&E department after being stabbed on...

    Correct

    • A young lady is rushed to the A&E department after being stabbed on her way home. She coughs up blood and a drain is placed into the left chest which removes 750ml of frank blood. She fails to improve and has been given 4 units of blood. Her CVP is now 13. What is the best course of action?

      Your Answer: Thoracotomy in theatre

      Explanation:

      Answer: Thoracotomy in theatre

      A high CVP of 13 indicates cardiac tamponade. Cardiac tamponade is a clinical syndrome caused by the accumulation of fluid in the pericardial space, resulting in reduced ventricular filling and subsequent hemodynamic compromise. The condition is a medical emergency, the complications of which include pulmonary oedema, shock, and death.
      A pericardiotomy via a thoracotomy is mandatory for lifesaving cardiac decompression in acute traumatic cardiac tamponade in cases of ineffective drainage due to clot formation within the pericardial space. Wherever possible a patient needing surgery for penetrating chest trauma should be moved to an operating theatre where optimal surgical expertise and facilities are available.

    • This question is part of the following fields:

      • Emergency Medicine And Management Of Trauma
      • Principles Of Surgery-in-General
      66.2
      Seconds
  • Question 14 - A 25 year old man is taken to the A&E department after being...

    Incorrect

    • A 25 year old man is taken to the A&E department after being hit in the head with a batton. He opens his eyes to pain and groans or grunts. He extends his hands at the elbow on application of painful stimulus. What is his Glasgow coma score?

      Your Answer: 7

      Correct Answer: 6

      Explanation:

      Answer: 6

      Eye Opening Response
      Spontaneous–open with blinking at baseline – 4 points
      Opens to verbal command, speech, or shout – 3 points
      Opens to pain, not applied to face – 2 point
      None – 1 point

      Verbal Response
      Oriented – 5 points
      Confused conversation, but able to answer questions – 4 points
      Inappropriate responses, words discernible – 3 points
      Incomprehensible speech – 2 points
      None – 1 point

      Motor Response
      Obeys commands for movement – 6 points
      Purposeful movement to painful stimulus – 5 points
      Withdraws from pain – 4 points
      Abnormal (spastic) flexion, decorticate posture – 3 points
      Extensor (rigid) response, decerebrate posture – 2 points
      None – 1 point

      He opens his eyes to pain and groans or grunts. He extends his hands at the elbow on application of painful stimulus. This gives him a Glasgow score of 6: eye opening response of 2, verbal response 2 and motor response 2.

    • This question is part of the following fields:

      • Emergency Medicine And Management Of Trauma
      • Principles Of Surgery-in-General
      12.2
      Seconds
  • Question 15 - A 63 year old lawyer presents with marked agitation after undergoing a transurethral...

    Correct

    • A 63 year old lawyer presents with marked agitation after undergoing a transurethral resection of the prostate which took one hour to perform. He has a heart rate of 105 beats per minute and his blood pressure is 170/100mmHg. He is suspected to be in a fluid overloaded state. Lab results reveal a sodium level of 120mmol/L. Which of the following is the most likely cause of this presentation?

      Your Answer: TURP syndrome

      Explanation:

      Complications of Transurethral Resection: TURP
      T URP syndrome
      U rethral stricture/UTI
      R etrograde ejaculation
      P erforation of the prostate

      TURP syndrome can cause a wide variety of symptoms that include asymptomatic hyponatremia, ECG changes, fatigue, vomiting, confusion, visual loss, coma and death. In a conscious and alert patient, changes in the mental state of may be the first sign of TURP syndrome and bladder perforation.

    • This question is part of the following fields:

      • Peri-operative Care
      • Principles Of Surgery-in-General
      84.6
      Seconds
  • Question 16 - A 30 year old woman presents to the A&E department after being trapped...

    Correct

    • A 30 year old woman presents to the A&E department after being trapped in a house fire. Her limb burns are partial thickness but the torso burns are full thickness. She has been receiving intravenous fluid and she was intubated by paramedics. Her ventilation pressure requirements are rising. What is the best course of action?

      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
      62.1
      Seconds
  • Question 17 - A 56-year-old male is admitted for an elective hip replacement. Three days postoperatively...

    Correct

    • 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.

    • This question is part of the following fields:

      • Post-operative Management And Critical Care
      • Principles Of Surgery-in-General
      92.7
      Seconds
  • Question 18 - A 55-year-old alcoholic male presents with acute pancreatitis. He is clinically dehydrated. His...

    Correct

    • A 55-year-old alcoholic male presents with acute pancreatitis. He is clinically dehydrated. His blood results show normal renal function and electrolytes. Which of the intravenous fluids below should be prescribed?

      Your Answer: Hartmann's solution

      Explanation:

      Management of Acute Pancreatitis revolves around supportive care, adequate nutrition, and intravenous hydration. The rationale for hydration is based on the need to resolve the hypovolemia that occurs secondary to vomiting, reduced oral intake, third space extravasation, respiratory losses and diaphoresis. Besides, early hydration provides macrocirculatory and microcirculatory support to prevent the cascade of events leading to pancreatic necrosis.
      There is a lack of high level evidence to guide the choice of fluid in AP. Crystalloids are recommended by the American Gastroenterological Association, and colloids (packed red blood cells) are considered in cases of low haematocrit (< 25%) and low serum albumin (< 2 g/dL). Among the crystalloids, Ringer's lactate solution is preferred over Normal saline. However, there is an urgent need of studies on this issue.

    • This question is part of the following fields:

      • Peri-operative Care
      • Principles Of Surgery-in-General
      18.5
      Seconds
  • Question 19 - A 29-year-old man with gunshot to the abdomen is transferred to the operating...

    Incorrect

    • A 29-year-old man with gunshot to the abdomen is transferred to the operating theatre, following his arrival in the A&E department. He is unstable and his FAST scan is positive. During the operation, extensive laceration to the right lobe of the liver and involvement of the IVC are found, along with massive haemorrhage. What should be the most appropriate approach to blood component therapy?

      Your Answer: Transfuse packed cells and FFP in a fixed ratio of 4:1

      Correct Answer:

      Explanation:

      There is strong evidence to support haemostatic resuscitation in the setting of massive haemorrhage due to trauma. This advocates the use of 1:1:1 ratio.

      Uncontrolled haemorrhage accounts for up to 39% of all trauma-related deaths. In the UK, approximately 2% of all trauma patients need massive transfusion. Massive transfusion is defined as the replacement of a patient’s total blood volume in less than 24 hours or the acute administration of more than half the patient’s estimated blood volume per hour. During acute bleeding, the practice of haemostatic resuscitation has been shown to reduce mortality rates. It is based on the principle of transfusion of blood components in fixed ratios. For example, packed red cells, FFP, and platelets are administered in a ratio of 1:1:1.

    • This question is part of the following fields:

      • Emergency Medicine And Management Of Trauma
      • Principles Of Surgery-in-General
      68.2
      Seconds
  • Question 20 - A 56 year old man, on his 8th day following a left hemicolectomy,...

    Incorrect

    • A 56 year old man, on his 8th day following a left hemicolectomy, complains of swinging pyrexia over the past 48 hours. Clinical examination is significant for an ileus. Which of the following investigations would be the most appropriate?

      Your Answer: Erect chest x-ray

      Correct Answer: Abdominal CT scan with IV contrast

      Explanation:

      Abdominal CT with IV contrast would be carried out in this case and this presentation has most likely resulted due to an anastomotic leak with abscess formation which is a common complication following surgery. This can occur in any of the branches and anticipating the likely complication and appropriate avoidance will minimize their occurrence. Detailed imaging is required to allow accurate diagnosis and further planning.

    • This question is part of the following fields:

      • Principles Of Surgery-in-General
      • Surgical Technique And Technology
      25.1
      Seconds
  • Question 21 - A 4-year-old boy suffers 20% burns to the torso. On examination, there is...

    Correct

    • A 4-year-old boy suffers 20% burns to the torso. On examination, there is fixed pigmentation and the affected area has a white and dry appearance. Which of the following options represents the best management plan?

      Your Answer: Split thickness skin graft

      Explanation:

      Burn depth is classified as first, second, third, or fourth degree, as follows:
      First-degree burns are usually red, dry, and painful. Burns initially termed first-degree are often actually superficial second-degree burns, with sloughing occurring the next day.
      Second-degree burns are often red, wet, and very painful. Their depth, ability to heal, and propensity to form hypertrophic scars vary enormously.
      Third-degree burns are generally leathery in consistency, dry, insensate, and waxy. These wounds will not heal, except by contraction and limited epithelial migration, with resulting hypertrophic and unstable cover. Burn blisters can overlie both second- and third-degree burns. The management of burn blisters remains controversial, yet intact blisters help greatly with pain control. Debride blisters if infection occurs.
      Fourth-degree burns involve underlying subcutaneous tissue, tendon, or bone. Usually, even an experienced examiner has difficulty accurately determining burn depth during an early examination. As a general rule, burn depth is underestimated upon initial examination.

      The management plan for patients with large burns that require inpatient care is usually determined by the physiology of the burn injury.
      Hospitalization is divided into 4 general phases, including (1) initial evaluation and resuscitation, (2) initial wound excision and biologic closure, (3) definitive wound closure, and (4) rehabilitation and reconstruction.

      Early excision and closure of full-thickness wounds change the natural history of burn injury, avoiding the otherwise common occurrence of wound sepsis. Wound size is the most important factor in determining the need for early operation

      Medications
      See the list below:
      – Silver sulfadiazine – Broad antibacterial spectrum; painless application
      – Aqueous 0.5% silver nitrate – Broad-spectrum coverage, including fungi; leeches electrolytes
      – Mafenide acetate – Broad antibacterial spectrum; penetrates eschar best
      – Petrolatum – Bland and nontoxic
      – Various debriding enzymes – Useful in selected partial-thickness wounds
      – Various antibiotic ointments – Useful in many superficial partial-thickness wounds
      Membranes
      See the list below:
      – Porcine xenograft – Adheres to wound coagulum and provides excellent pain control
      – Split-thickness allograft – Vascularizes and provides durable temporary closure of wounds
      – Various hydrocolloid dressings – Provide vapour and bacteria barrier while absorbing wound exudate
      – Various impregnated gauzes – Provide vapour and bacteria barrier while allowing drainage
      – Various semipermeable membranes – Provide vapour and bacteria barrier
      – Acticoat (Westhaim Biomedical, Saskatchewan, Canada) – Nonadherent wound dressing that delivers a low concentration of silver for antisepsis
      – Biobrane (Dow-Hickman, Sugarland, Tex) – Synthetic bilaminate that facilitates fibrovascular tissue growth into the inner layer and provides temporary vapour and bacteria barrier
      – Transcyte (Smith and Nephew, Largo, Fla) – Synthetic bilaminate that facilitates fibrovascular tissue growth into the inner layer populated with allogenic fibroblasts and overlying layer that provides temporary vapour and bacteria barrier
      – AlloDerm R – Consists of cell-free allogenic human dermis; requires an immediate thin overlying autograft
      – Integra R – Provides scaffold for neodermis; requires delayed thin autograft

    • This question is part of the following fields:

      • Principles Of Surgery-in-General
      • Surgical Technique And Technology
      123.6
      Seconds
  • Question 22 - A 56-year-old female undergoes a low anterior resection for rectal cancer. The procedure...

    Incorrect

    • A 56-year-old female undergoes a low anterior resection for rectal cancer. The procedure is performed as open surgery, what is the most appropriate method for closure of the abdominal wall?

      Your Answer: Mass closure of the abdomen obeying Jenkins rule using 2/0 PDS

      Correct Answer: Mass closure of the abdomen obeying Jenkins rule using 1 PDS

      Explanation:

      A midline incision is the most commonly used route of access to the abdominal cavity.
      Peritoneal closure
      A number of randomized, controlled trials have shown no benefit to peritoneal closure; thus, refraining from closing the peritoneum is a commonly accepted practice. Some surgeons believe that closure of the peritoneum reduces adhesions between the abdominal contents and the suture line; however, at this time, there is only limited scientific evidence for this belief.
      Fascial closure
      The technique of fascial closure is highly variable among surgeons; however, the various approaches may be grouped into two primary methods as follows:
      Layered closure
      Mass closure
      Layered closure is the sequential closure of each fascial layer individually. The primary advantage of this method is that multiple suture strands exist so that if a suture breaks, the incision is held intact by the remaining sutures.
      Mass closure is continuous fascial closure with a single suture. This method allows even distribution of tension across the entire length of the suture, resulting in minimization of tissue strangulation. The goal is an approximation of tissue edges to allow scar formation. Excessive tension leads to tissue necrosis and eventual failure of the closure.
      The theoretical disadvantage of mass closure is that a single suture is responsible for maintaining the integrity of the closure. The benefits of mass closure include decreased cost and decreased operating time. There is no evidence that mass closure is associated with an increased incidence of hernia formation or wound dehiscence.
      When rectus muscle is incorporated, using absorbable suture and a loose closure in order to decrease postoperative pain and tissue necrosis is important. The assistant following the continuous closure should apply sufficient tension to approximate the tissue without strangulating it. The suture is run in 1-cm intervals (maximally), with at least a 1-cm bite of fascia in each throw.
      The two primary methods of skin closure are with suture or staples. Suture closure is generally performed with 3-0 or 4-0 absorbable suture in a running subcuticular fashion or with nylon running or interrupted transdermal suture. Staple closure is a viable alternative to suturing the skin. In a study comparing scar cosmesis at 6 months, no difference in appearance existed in patients with suture versus staple skin closure
      What is Jenkins Rule?
      It is a rule for closure of the abdominal wound. It states that for a continuous suture, the length of suture used should be at least four times the length of the wound with sutures 1cm apart and with 1cm bites of the wound edge

    • This question is part of the following fields:

      • Principles Of Surgery-in-General
      • Surgical Technique And Technology
      126.2
      Seconds
  • Question 23 - A 62 year old man presents with sudden onset of palpitations. ECG shows...

    Incorrect

    • A 62 year old man presents with sudden onset of palpitations. ECG shows broad complex tachycardia at a rate of 150 beats per minute. The blood pressure is 120/82 mmHg and there is no evidence of heart failure. The doctor wants to prescribe a rate controlling medication. Which of the following should be avoided in this case?

      Your Answer: Amiodarone

      Correct Answer: Verapamil

      Explanation:

      The use of intravenous diltiazem or verapamil is contraindicated in patients with ventricular tachycardia. The IV administration of a calcium channel blocker can precipitate cardiac arrest in such patients.
      Marked hemodynamic deterioration and ventricular fibrillation have occurred in patients with wide-complex ventricular tachycardia (QRS >= 0.12 seconds) treated with IV verapamil.

    • This question is part of the following fields:

      • Emergency Medicine And Management Of Trauma
      • Principles Of Surgery-in-General
      100.4
      Seconds
  • Question 24 - A 29-year-old woman is brought to the A&E department with chest pain after...

    Correct

    • A 29-year-old woman is brought to the A&E department with chest pain after being involved in a road traffic accident. Clinical examination is essentially unremarkable and she is discharged. However, she is subsequently found dead at home. What could have been the most likely underlying injury?

      Your Answer: Traumatic aortic disruption

      Explanation:

      Aortic injuries not resulting in immediate death may be due to a contained haematoma. Clinical signs are subtle, and diagnosis may not be apparent on clinical examination. Without prompt treatment, the haematoma usually bursts and the patient dies.

      Traumatic aortic disruption, or aortic transection, is typically the result of a blunt aortic injury in the context of rapid deceleration. This condition is commonly fatal as blood in the aorta is under great pressure and can quickly escape the vessel through a tear, resulting in rapid haemorrhagic shock and death. A temporary haematoma may prevent the immediate death. Injury to the aorta during a sudden deceleration commonly originates near the terminal section of the aortic arch, also known as the isthmus. This portion lies just distal to the take-off of the left subclavian artery at the intersection of the mobile and fixed portions of the aorta. As many as 80% of the patients with aortic transection die at the scene before reaching a trauma centre for treatment.

      A widened mediastinum may be seen on the X-ray of a person with aortic rupture. Other findings on CXR may include:
      1. Deviation of trachea/oesophagus to the right
      2. Depression of left main stem bronchus
      3. Widened paratracheal stripe/paraspinal interfaces
      4. Obliteration of space between aorta and pulmonary artery
      5. Rib fracture/left haemothorax

      Diagnosis can be made by angiography, usually CT aortogram.

      Treatment options include repair or replacement. The patient should, ideally, undergo endovascular repair.

    • This question is part of the following fields:

      • Emergency Medicine And Management Of Trauma
      • Principles Of Surgery-in-General
      65.7
      Seconds
  • Question 25 - A 9 year old girl is admitted to the A&E department after having...

    Correct

    • A 9 year old girl is admitted to the A&E department after having a fall. Her blood pressure is 101/56 mmHg, pulse is 91 and her abdomen is soft but tender on the left side. Imaging shows that there is a grade III splenic laceration. What is the best course of action?

      Your Answer: Admit the child to the high dependency unit for close monitoring

      Explanation:

      Answer: Admit the child to the high dependency unit for close monitoring.

      Grade 3: This mid-stage rupture is a tear more than 3 cm deep. It can also involve the splenic artery or a hematoma that covers over half of the surface area. A grade 3 rupture can also mean that a hematoma is present in the organ tissue that is greater than 5 cm or expanding.
      The trend in management of splenic injury continues to favour nonoperative or conservative management.
      Most haemodynamically stable injuries can be managed non-operatively (especially Grades I to III).

    • This question is part of the following fields:

      • Emergency Medicine And Management Of Trauma
      • Principles Of Surgery-in-General
      122.8
      Seconds
  • Question 26 - A 24 year old man hits his head during a fall whilst he...

    Incorrect

    • A 24 year old man hits his head during a fall whilst he is intoxicated. He is taken to the doctor and is disorientated despite opening his eyes in response to speech and being able to talk. He is also able to obey motor commands. What would be his Glasgow coma score?

      Your Answer: 8

      Correct Answer: 13

      Explanation:

      Answer: 13

      Eye Opening Response
      Spontaneous–open with blinking at baseline – 4 points
      Opens to verbal command, speech, or shout – 3 points
      Opens to pain, not applied to face – 2 point
      None – 1 point

      Verbal Response
      Oriented – 5 points
      Confused conversation, but able to answer questions – 4 points
      Inappropriate responses, words discernible – 3 points
      Incomprehensible speech – 2 points
      None – 1 point

      Motor Response
      Obeys commands for movement – 6 points
      Purposeful movement to painful stimulus – 5 points
      Withdraws from pain – 4 points
      Abnormal (spastic) flexion, decorticate posture – 3 points
      Extensor (rigid) response, decerebrate posture – 2 points
      None – 1 point

      He is seen to be disorientated despite opening his eyes in response to speech and being able to talk. He is also able to obey motor commands. His score is therefore 13: 3 for eye opening response, 4 for verbal response and 6 for motor response.

    • This question is part of the following fields:

      • Emergency Medicine And Management Of Trauma
      • Principles Of Surgery-in-General
      17.7
      Seconds
  • Question 27 - A 34 year old man is undergoing an inguinal hernia repair as a...

    Incorrect

    • A 34 year old man is undergoing an inguinal hernia repair as a day case procedure and is being given sevoflurane. Which of the following is the best option for maintaining his airway during the procedure?

      Your Answer: Use of Guedel airway

      Correct Answer: Insertion of laryngeal mask

      Explanation:

      The laryngeal airway mask (LAM) is a device for anaesthetic air way management. The primary advantage of the laryngeal airway mask (LAM) over the face mask during general anaesthesia includes the ability to obtain, secure, and maintain a patent airway. The laryngeal mask airway is passed beyond the tongue, forming a seal with the laryngeal inlet and eliminating the most common cause of upper airway obstruction in the non-intubated patient.

      Maintenance of a patent airway with fewer episodes of oxygen desaturation has been demonstrated for the LAM as compared with the face mask. Environmental inhalational gas exposure values associated with the use of a LAM have been shown to be less than those achieved with a face mask and comparable to those with the use of an endotracheal tube. Ocular and facial nerve injuries associated with prolonged face mask use are also avoided. The advantages of the laryngeal mask airway include anaesthetic management, induction, maintenance, and emergence.

      The placement of the LMA can be accomplished without muscle relaxants and laryngoscopy. The avoidance of succinylcholine may decrease the incidence of post-operative myalgias. Significant and potentially detrimental hemodynamic changes associated with both laryngoscopy and tracheal intubation are also attenuated and are of shorter duration with the use of the laryngeal mask airway. Compared with an endotracheal tube, the anaesthetic requirement for tolerance of the LAM has also been reported to be less. Differences in the response to the LAM are also seen during emergence from anaesthesia. The LAM is well tolerated, with a lower reported incidence of hyperactive respiratory occurrences (e.g., coughing, laryngospasm, breath holding) than with an endotracheal tube. The anatomic placement of the LAM, with its lack of impingement on the trachea and vocal cords, minimizes complications that are potentially associated with intubation. According to Swann et al. incidence of postoperative sore throat as well as hoarseness is less with the LAM compared with the endotracheal tube.

    • This question is part of the following fields:

      • Post-operative Management And Critical Care
      • Principles Of Surgery-in-General
      73.1
      Seconds
  • Question 28 - 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
      49.6
      Seconds
  • Question 29 - An 18 year old male is given a total of 6 litres of...

    Incorrect

    • An 18 year old male is given a total of 6 litres of 0.9% sodium chloride solution, over 24 hours after having an elective right hemicolectomy. Which of the following complications may develop?

      Your Answer: Hyperchloremic alkalosis

      Correct Answer: Hyperchloremic acidosis

      Explanation:

      Answer: Hyperchloremic acidosis

      Hyperchloremic acidosis is a form of metabolic acidosis associated with a normal anion gap, a decrease in plasma bicarbonate concentration, and an increase in plasma chloride concentration. In general, the cause of a hyperchloremic metabolic acidosis is a loss of base, either a gastrointestinal loss or a renal loss.

      1) Gastrointestinal loss of bicarbonate (HCO3-)
      -Severe diarrhoea (vomiting will tend to cause hypochloraemic alkalosis)
      -Pancreatic fistula with loss of bicarbonate rich pancreatic fluid
      -Nasojejunal tube losses in the context of small bowel obstruction and loss of alkaline proximal small bowel secretions
      -Chronic laxative abuse
      2) Renal causes
      -Proximal renal tubular acidosis with failure of (HCO3-) resorption
      -Distal renal tubular acidosis with failure of H+
      secretion
      -Long-term use of a carbonic anhydrase inhibitor such as acetazolamide
      3) Other causes
      -Ingestion of ammonium chloride, hydrochloric acid, or other acidifying salts
      -The treatment and recovery phases of diabetic ketoacidosis
      -Volume resuscitation with 0.9% normal saline provides a chloride load, so that infusing more than 3-4L can cause acidosis
      -Hyperalimentation (i.e., total parenteral nutrition).

      This patient received 6L of 0.9% normal saline which lead to hyperchloremic acidosis.

    • This question is part of the following fields:

      • Post-operative Management And Critical Care
      • Principles Of Surgery-in-General
      161.6
      Seconds
  • Question 30 - A 64 year old man registered at the hernia clinic, suddenly presents with...

    Correct

    • 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
      56.8
      Seconds

SESSION STATS - PERFORMANCE PER SPECIALTY

Emergency Medicine And Management Of Trauma (8/13) 62%
Principles Of Surgery-in-General (16/30) 53%
Clinical Microbiology (0/2) 0%
Surgical Technique And Technology (3/6) 50%
Post-operative Management And Critical Care (2/6) 33%
Oncology (1/1) 100%
Peri-operative Care (2/2) 100%
Passmed