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Question 1
Correct
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A 42 year old female has a redo thyroidectomy for a multinodular goitre. She develops oculogyric crises and diffuse muscle spasm a day after completing surgery. Which of the following is the best course of action?
Your Answer: Administration of intravenous calcium
Explanation:Tetany: A condition that is due usually to low blood calcium (hypocalcaemia) and is characterized by spasms of the hands and feet, cramps, spasm of the voice box (larynx), and overactive neurological reflexes. Tetany is generally considered to result from very low calcium levels in the blood. However, tetany can also result from reduction in the ionized fraction of plasma calcium without marked hypocalcaemia, as is the case in severe alkalosis (when the blood is highly alkaline).
Hypocalcaemic tetany (HT) is the consequence of severely lowered calcium levels (<2.0 mmol/l), usually in patients with chronic hypocalcaemia. The causal disease for hypocalcaemic tetany is frequently a lack of parathyroid hormone (PTH), (e. g. as a complication of thyroid surgery) or, rarely, resistance to PTH. HT due to severe and painful clinical symptoms requires rapid i. v. calcium replacement by central venous catheter on an intensive care unit.
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This question is part of the following fields:
- Breast And Endocrine Surgery
- Generic Surgical Topics
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Question 2
Correct
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Question 3
Incorrect
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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: Pulmonary embolus
Correct 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.
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This question is part of the following fields:
- Emergency Medicine And Management Of Trauma
- Principles Of Surgery-in-General
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Question 4
Correct
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Which ectopic tissue is usually contained in the Meckel's diverticulum?
Your Answer: Gastric
Explanation:The Meckel’s diverticulum is a vestigial remnant of the omphalomesenteric duct. This structure is also referred to as the vitelline and contains two types of ectopic tissue, namely; gastric and pancreatic.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 5
Incorrect
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A patient is unable to move the mandible to the left. Which muscle is affected in this case?
Your Answer: Left lateral pterygoid muscle
Correct Answer: Right lateral pterygoid muscle
Explanation:Patients with paralysis of the right pterygoid muscle are unable to move their mandible laterally to the left.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 6
Correct
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The pterion is clinically significant as it marks an area of weakness on the skull. What structure lies beneath it?
Your Answer: Anterior branches of the middle meningeal artery
Explanation:The pterion is the area where four bones, the parietal, frontal, greater wing of sphenoid and the squamous part of the temporal bone meet. It overlies the anterior branch of the middle meningeal artery on the internal aspect of the skull. The pterion is the weakest part of the skull. Slight trauma to this region can cause extradural hematoma.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 7
Correct
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A 30-year-old man with Crohn's disease has undergone a number of resections. His BMI is currently 18 kg/m2 and his albumin levels are 2.5 g/dL. He generally feels well but does have a small localised perforation of his small bowel. The gastroenterologists are giving him azathioprine. What should be the most appropriate advice regarding feeding?
Your Answer: Parenteral feeding
Explanation:This patient is malnourished. Although surgery is imminent, it is best for him to be nutritionally optimised first. As he may have reduced surface area for absorption and has a localised perforation, total parenteral nutrition (TPN) is likely the best feeding modality.
The National Institute for Health and Care Excellence (NICE) has laid down guidelines for identifying patients as malnourished or at risk of malnourishment, in order to start oral, enteral, or parenteral nutrition support, alone or in combination.
Following patients are identified as malnourished:
1. BMI <18.5 kg/m2
2. Unintentional weight loss of >10% within the last 3–6 months
3. BMI <20 kg/m2 and unintentional weight loss of >5% within the last 3–6 monthsFollowing patients are at risk of malnutrition:
1. Eaten nothing or little for >5 days and/or likely to eat little or nothing for the next 5 days or longer
2. Poor absorptive capacity and/or
3. High nutrient loss and/or
4. High metabolic rateConsidering the method of parenteral nutrition:
1. For feeding <14 days, consider feeding via a peripheral venous catheter
2. For feeding >30 days, use a tunnelled subclavian line,
continuous administration in severely unwell patients
3. If feed needed for >2 weeks, consider changing from continuous to cyclical feeding
4. Do not give >50% of daily regime to unwell patients in the first 24–48 hours
5. In surgical patients, if malnourished with unsafe swallow or a non-functional GI tract or perforation, consider perioperative parenteral feeding. -
This question is part of the following fields:
- Post-operative Management And Critical Care
- Principles Of Surgery-in-General
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Question 8
Incorrect
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Linezolid is an antibiotic used for the treatment of infections caused by bacteria that are resistant to other antibiotics. Which of the following organisms is most likely to be effectively treated by linezolid?
Your Answer: Pseudomonas aeruginosa
Correct Answer: Methicillin-resistant Staphylococcus aureus
Explanation:Linezolid is a synthetic antibiotic used for the treatment of infections caused by multiresistant bacteria, including streptococci and methicillin-resistant Staphylococcus aureus (MRSA). Linezolid is effective against Gram-positive pathogens, notably Enterococcus faecium, S. aureus, Streptococcus agalactiae, Streptococcus pneumoniae and Streptococcus pyogenes. It has almost no effect on Gram-negative bacteria and is only bacteriostatic against most enterococci.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 9
Correct
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A 49-year-old male patient is recovering from a right hemicolectomy for Crohn's disease. He is oliguric and dehydrated owing to a high output ileostomy. His electrolytes are normal. Out of the following, which intravenous fluid should be administered?
Your Answer: Hartmann's solution
Explanation:Hartmann’s solution is the preferred fluid among the listed options.
In UK, Guidelines on Intravenous Fluid Therapy for Adult Surgical Patients (GIFTASUP) and The National Institute for Health and Care Excellence (NICE) guidelines were devised to try and develop a consensus on how to administer intravenous fluids (IV) postoperatively. A decade ago, it was a commonly held belief that little harm would occur as a result of excessive administration of normal saline, and many oliguric postoperative patients received enormous quantities of IV fluids. As a result, they developed hyperchloraemic acidosis. With greater understanding of this potential complication, the use of electrolyte-balanced solutions (Hartmann’s or Ringer Lactate solution) is now favoured over normal saline.
The guidelines further include:
1. Fluids given should be documented clearly.
2. Assess the patient’s fluid status when they leave the theatre.
3. If the patient is haemodynamically stable and euvolaemic, aim to restart oral fluid intake as soon as possible.
4. If the patient is oedematous, hypovolaemia if present should be treated first. This should then be followed by a negative balance of sodium and water, monitored closely.
5. Solutions such as Dextran 70 should be cautiously used in patients with sepsis as there is a risk of developing acute renal injury. -
This question is part of the following fields:
- Post-operative Management And Critical Care
- Principles Of Surgery-in-General
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Question 10
Incorrect
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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: Atenolol
Correct 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
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Question 11
Incorrect
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A 36-year-old woman suddenly suffers from a generalized seizure. She was previously healthy. An emergency CT scan reveals a mass in the posterior fossa, with distortion of the lateral ventricles. After removing the tumour, the biopsy reveals it contains glial fibrillary acidic protein (GEAP). What's the most likely diagnosis?
Your Answer: Ependymoma
Correct Answer: Astrocytoma
Explanation:Astrocytomas are primary intracranial tumours derived from astrocyte cells of the brain. They can arise in the cerebral hemispheres, in the posterior fossa, in the optic nerve and, rarely, in the spinal cord. These tumours express glial fibrillary acidic protein (GFAP). In almost half of cases, the first symptom of an astrocytoma is the onset of a focal or generalised seizure. Between 60% and 75% of patients will have recurrent seizures during the course of their illness. Secondary clinical sequelae may be caused by elevated intracranial pressure (ICP) cause by the direct mass effect, increased blood volume, or increased cerebrospinal fluid (CSF) volume. CT will usually show distortion of the third and lateral ventricles, with displacement of the anterior and middle cerebral arteries. Histological diagnosis with tissue biopsy will normally reveal an infiltrative character suggestive of the slow growing nature of the tumour.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 12
Correct
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Which of these substances is secreted by pericytes in the juxtaglomerular cells?
Your Answer: Renin
Explanation:The juxtaglomerular cells synthesise, store and secrete the enzyme renin in the kidney. They are specialised smooth muscle cells in the wall of the afferent arteriole that delivers blood to the glomerulus and thus play a critical role in the renin– angiotensin system and so in renal autoregulation.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 13
Incorrect
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A 38 year old man is to undergo excision of the base of the prostate for malignant growth, which of the following structures is directly related to the base of the prostate?
Your Answer: Rectum
Correct Answer: Urinary bladder
Explanation:The prostate is situated in the pelvic cavity and is also located immediately below the internal urethral orifice at the commencement of the urethra. It is held in position by the puboprostatic ligaments, the superior fascia of the urogenital diaphragm and the anterior portions of the levatores ani. The base of the prostate is directed upward and is attached to the inferior surface of the urinary bladder while the apex is directed downward and is in contact with the superior fascia of the urogenital diaphragm.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 14
Correct
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Prostatectomy carries a risk of loss of penile erection due to injury to the prostatic plexus responsible for an erection. From which nerves do these fibres originate?
Your Answer: Pelvic splanchnics
Explanation:Erection is a function of the parasympathetic nerves. Of the nerves listed, only the pelvic splanchnic nerves have parasympathetic fibres that innervate the smooth muscles and glands of the pelvic viscera.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 15
Correct
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A young man is involved in a motorcycle accident in which he is thrown several metres in the air before dropping to the ground. He is found with two fractures in the 2nd and 3rd rib and his chest movements are irregular. Which of the following is the most likely underlying condition?
Your Answer: Flail chest injury
Explanation:Answer: Flail chest injury
Flail chest is a life-threatening medical condition that occurs when a segment of the rib cage breaks due to trauma and becomes detached from the rest of the chest wall. Two of the symptoms of flail chest are chest pain and shortness of breath.
It occurs when multiple adjacent ribs are broken in multiple places, separating a segment, so a part of the chest wall moves independently. The number of ribs that must be broken varies by differing definitions: some sources say at least two adjacent ribs are broken in at least two places, some require three or more ribs in two or more places. The flail segment moves in the opposite direction to the rest of the chest wall: because of the ambient pressure in comparison to the pressure inside the lungs, it goes in while the rest of the chest is moving out, and vice versa. This so-called paradoxical breathing is painful and increases the work involved in breathing.
Flail chest is usually accompanied by a pulmonary contusion, a bruise of the lung tissue that can interfere with blood oxygenation. Often, it is the contusion, not the flail segment, that is the main cause of respiratory problems in people with both injuries.
Surgery to fix the fractures appears to result in better outcomes.
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This question is part of the following fields:
- Emergency Medicine And Management Of Trauma
- Principles Of Surgery-in-General
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Question 16
Incorrect
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Into which vein does the left and right thyroid vein drain?
Your Answer: External jugular vein
Correct Answer: Brachiocephalic vein
Explanation:The brachiocephalic vein is formed by the confluence of the subclavian and internal jugular veins. In addition it receives drainage from: the left and right internal thoracic veins (also called internal mammary veins), left and right inferior thyroid veins
and the left superior intercostal vein -
This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 17
Correct
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A 66-year-old man complains of constant headaches. On physical examination, the only relevant sign is a dark brown mole located on left his arm which has grown in size over the years and is itchy and painful. A MRI of the brain revealed a solitary lesion at the grey-white junction in the right frontal lobe, without ring enhancement. This lesion is most likely to be:
Your Answer: Metastatic carcinoma
Explanation:The location of the mass at the grey–white junction is typical of a metastasis. The most frequent types of metastatic brain tumours originate in the lung, skin, kidney, breast and colon. These tumour cells reach the brain via the bloodstream. This patient is likely to have skin cancer, which caused the metastatic brain tumour.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 18
Incorrect
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what is the cause of a prolonged PT(prothrombin time)?
Your Answer: von Willebrand factor deficiency
Correct Answer: Liver disease
Explanation:PT measure the intrinsic pathway of coagulation. It determines the measure of the warfarin dose regime, liver disease and vit K deficiency status along with the clotting tendency of blood. PT measured factors are II,V,VII,X and fibrinogen. It is used along with aPTT which measure the intrinsic pathway.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 19
Incorrect
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A surgeon performing a Whipple's procedure, that involves mobilizing the head of the pancreases, accidentally injured a structure immediately posterior to the neck of the pancreases which bled out. Which structure is most likely to have been injured?
Your Answer: Portal vein
Correct Answer: Superior mesenteric artery
Explanation:The splenic vein runs behind the pancreas, receives the inferior mesenteric vein and joins the superior mesenteric vein to form the portal vein behind the pancreatic neck.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 20
Correct
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A 45-year-old male is involved in a road traffic accident. He suffers significant injuries to his thorax, he has bilateral haemopneumothoraces and a suspected haemopericardium. He is to undergo surgery, what is the best method of accessing these injuries?
Your Answer: Clam shell thoracotomy
Explanation:Thoracic trauma accounts for > 25% of all traumatic injuries and is a leading cause of death in all age groups. The majority of thoracic trauma patients require only conservative management (e.g. analgesia, simple chest drainage). However, a subset of these patients will show signs of deterioration in the emergency department, especially with penetrating injuries. Such patients may require an emergency thoracotomy for rapid access to the thoracic cavity so that pericardial tamponade can be released and haemorrhage controlled. Furthermore, in severe thoracic trauma cases, specific injuries are difficult to confidently rule out or identify, even if they can be anticipated. Therefore, it is recommended to use an approach that provides the most rapid access to all vital chest organs for assessment and control.
Clamshell thoracotomy (also known as bilateral anterolateral thoracotomy) or hemi-clamshell (longitudinal sternotomy and anterolateral thoracotomy) are techniques used to provide complete exposure of the thoracic cavity (heart, mediastinum and lungs). Studies have demonstrated that it is easier to control the cardiac wound using this approach compared to the standard left anterolateral thoracotomy, as it gives wider exposure for all injuries, which are then easier to control surgically through the larger incision.
Contraindications:
Absolute:
– Traumatic cardiac arrest where the underlying pathology is so severe as to render the procedure futile (e.g. severe traumatic brain injury)
Relative:
Blunt cardiac injury with no signs of life or organised cardiac rhythm -
This question is part of the following fields:
- Emergency Medicine And Management Of Trauma
- Principles Of Surgery-in-General
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Question 21
Incorrect
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What is a major source of fuel being oxidised by the skeletal muscles of a man who has undergone starvation for 7 days?
Your Answer: Muscle triglycerides
Correct Answer: Serum fatty acids
Explanation:Starvation is the most extreme form of malnutrition. Prolonged starvation can lead to permanent organ damage and can be fatal. Starved individuals eventually lose significant fat and muscle mass as the body uses these for energy.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 22
Correct
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Pain in the right upper quadrant of the abdomen on ingestion of a fatty meal is seen in a condition which involves which of the following substances?
Your Answer: Cholecystokinin
Explanation:The clinical scenario described here favours the presence of gallstones. During food ingestion, vagal discharges stimulate gallbladder contraction. Moreover, presence of fat and amino acids in the intestinal lumen stimulates the release of cholecystokinin (CCK) in the duodenum. This causes sustained gallbladder contraction and relaxation of the sphincter of Oddi. If gallstones are present, there will be inflammation in the gallbladder and CCK will aggravate it due to contractions.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 23
Incorrect
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A 55 year old man develops increasing lower abdominal pain, fever and atrial fibrillation on the 5th day following a high anterior resection for cancer of the rectosigmoid junction. These symptoms developed over the last 12 hours. Which of the following investigations would be the most useful in this case?
Your Answer: Echocardiogram
Correct Answer: Abdominal CT scan
Explanation:Atrial fibrillation occurring after a colonic resection most likely represents an anastomotic leak. The best modality to visualize this would be an abdominal CT scan. Any bowel anastomosis can leak, sometimes as a result of technical failings and at other times, its patient factors such as background disease that contribute. As a general rule, rectal resections carry the highest risk of anastomotic leak. Indeed, low anterior resections are routinely defunctioned with loop ileostomy to mitigate the clinically effects of a leak. Left sided colonic resections carry a higher risk of anastomotic leak than right sided resections. The reason for this is that an ileocolic anastomosis (or indeed any small bowel anastomosis) has a very low risk of leak (provided the small bowel is otherwise healthy). Where a leak is suspected (new AF and raised inflammatory markers 5 days post resection), the correct course of action is to arrange cross sectional imaging with a CT scan. If a leak is confirmed and the patient is septic, then they should go back to theatre, the anastomosis taken down and the bowel ends exteriorized.
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This question is part of the following fields:
- Post-operative Management And Critical Care
- Principles Of Surgery-in-General
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Question 24
Correct
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A 35-year-old woman in her 37th week of pregnancy complains of urinary incontinence. She is most likely to have:
Your Answer: Stress incontinence
Explanation:Urinary incontinence is the involuntary excretion of urine from one’s body. It is often temporary and it almost always results from an underlying medical condition. Several types include:
– Stress incontinence is the voiding of urine following increased abdominal pressure e.g. laughing, coughing, pregnancy etc. It is the most common form of incontinence in women, most commonly due to pelvic floor muscle weakness, physical changes from pregnancy, childbirth and menopause. In men it is a common problem following a prostatectomy. Most lab results such as urine analysis, cystometry and postvoid residual volume are normal.
– Urge incontinence is involuntary loss of urine occurring for no apparent reason while suddenly feeling the need or urge to urinate. The most common cause of urge incontinence are involuntary and inappropriate detrusor muscle contractions.
– Functional incontinence – occurs when a person does not recognise the need to go to the toilet, recognise where the toilet is or get to the toilet in time. The urine loss may be large. Causes of functional incontinence include confusion, dementia, poor eyesight, poor mobility, poor dexterity or unwillingness. t
– Overflow incontinence – sometimes people find that they cannot stop their bladders from constantly dribbling or continuing to dribble for some time after they have passed urine. -
This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 25
Correct
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A 40-year-old man presents to the acute surgical unit with acute pancreatitis. Over the next few days, he becomes dyspnoeic and his saturations are 89% on air and CVP is 16 mmHg. CXR shows bilateral pulmonary infiltrates.What is the most likely diagnosis?
Your Answer: Acute respiratory distress syndrome
Explanation:Acute pancreatitis is known to precipitate acute respiratory distress syndrome (ARDS) which is characterised by bilateral pulmonary infiltrates and severe hypoxaemia in the absence of evidence for cardiogenic pulmonary oedema. Pulmonary oedema is excluded by the CVP reading of <18 mmHg in this scenario. ARDS is subdivided into two stages. Early stage consists of an exudative phase of injury with associated oedema. The later stage is one of repair and consists of fibroproliferative changes. Subsequent scarring may result in poor lung function. ARDS can also lead to multiple organ failure. Various causes of ARDS include:
1. Sepsis
2. Direct lung injury
3. Trauma
4. Acute pancreatitis
5. Long bone fracture or multiple fractures (through fat embolism)
6. Head injury (sympathetic nervous stimulation which leads to acute pulmonary hypertension)Management options are:
1. Treat the underlying cause
2. Antibiotics (if signs of sepsis)
3. Negative fluid balance, i.e. diuretics
4. Recruitment manoeuvres such as prone ventilation and use of positive end-expiratory pressure (PEEP)
5. Mechanical ventilation strategy using low tidal volumes, as conventional tidal volumes may cause lung injury (only treatment found to improve survival rates) -
This question is part of the following fields:
- Post-operative Management And Critical Care
- Principles Of Surgery-in-General
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Question 26
Correct
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A young man undergoes a total thyroidectomy and develops respiratory stridor and a small haematoma in the neck, 5 hours after surgery. Which of the following is the most appropriate course of action?
Your Answer: Re-open the neck wound
Explanation:Answer: Re-open the neck wound
Thyroidectomy: complications
Airway obstruction (compressing hematoma, tracheomalacia)Incidence of hematoma is 1-2%, tracheomalacia incidence is <1%. Acute airway obstruction from hematoma may occur immediately postoperatively and is the most frequent cause of airway obstruction in the first 24 hours. Definitive therapy is opening the surgical incision to evacuate the hematoma. Re-intubation may be lifesaving for persistent airway obstruction. Consider awake fibreoptic intubation.
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This question is part of the following fields:
- Post-operative Management And Critical Care
- Principles Of Surgery-in-General
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Question 27
Incorrect
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A 40-year-old man has been diagnosed with anal fissure, which has failed to respond to first-line treatment. What should be the next most appropriate treatment?
Your Answer: 15–30 units of botulinum toxin injected into the external anal sphincter
Correct Answer: 15–30 units of botulinum toxin injected into the internal anal sphincter
Explanation:The next appropriate step would be to perform an examination under anaesthesia and inject 15–30 units of botulinum toxin into the internal anal sphincter.
Anal fissures are commonly seen in the colorectal clinic and are a common cause of painful, bright red rectal bleeding. Most fissures are idiopathic and present as a painful mucocutaneous defect in the posterior midline (90% cases). Fissures are more likely to be anteriorly located in females, particularly if they are multiparous. Diseases associated with fissure-in-ano include:
1. Crohn’s disease
2. Tuberculosis
3. Internal rectal prolapseDiagnostic options are as follows:
In most cases, the defect can be visualised as a posterior midline epithelial defect. Where symptoms are highly suggestive of the condition and examination findings are unclear, an examination under anaesthesia may be helpful. Atypical disease presentation should be investigated by colonoscopy and EUA, with biopsies of the area.For management of anal fissure:
1. Stool softeners are important as hard stools may tear the epithelium and result in recurrent symptoms (however, up to 25% of the patients fail to respond). The most effective first-line agents are topically applied GTN (0.2%) or Diltiazem (2%) paste.
2. Resistant cases may benefit from injection of botulinum toxin or lateral internal sphincterotomy. Advancement flaps may be used to treat resistant cases. -
This question is part of the following fields:
- Colorectal Surgery
- Generic Surgical Topics
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Question 28
Incorrect
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A 27-year-old woman has chronic low serum calcium levels. Which of the following conditions may be responsible for the hypocalcaemia in this patient?
Your Answer: Primary hyperparathyroidism
Correct Answer: Hypoparathyroidism
Explanation:Chronic hypocalcaemia is mostly seen in patients with hypoparathyroidism as a result of accidental removal or damage to parathyroid glands during thyroidectomy.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 29
Incorrect
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Whipple's procedure involves mobilizing the head of the pancreas. As the surgeon does this, he must be careful to avoid injury to a key structure that is found lying behind the head of the pancreas. Which vital structure is this?
Your Answer: Portal vein
Correct Answer: Common bile duct
Explanation:The posterior relations of the head of the pancreas include: the inferior vena cava, the common bile duct, the renal veins, the right crus of the diaphragm and the aorta.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 30
Incorrect
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Medulloblastoma usually occurs in children between 5 to 9 years old. Where does medulloblastoma commonly originate from?
Your Answer: Pons
Correct Answer: Cerebellar vermis
Explanation:Medulloblastoma is the most common malignant brain tumour in children, accounting for 10-20% of primary CNS neoplasms. Most of the tumours originate in the cerebellar vermis.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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SESSION STATS - PERFORMANCE PER SPECIALTY
