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Question 1
Incorrect
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A 42-year-old woman comes in with a gradual onset of severe colicky abdominal pain and vomiting. She has not had a bowel movement today. Her only significant medical history is gallstones. During the examination, her abdomen appears distended, and a mass can be felt in the upper right quadrant. Bowel sounds can be heard as 'tinkling' on auscultation.
What is the SINGLE most probable diagnosis?Your Answer: Acute cholangitis
Correct Answer: Small bowel obstruction
Explanation:Gallstone ileus occurs when a gallstone becomes stuck in the small intestine, specifically at the caeco-ileal valve. This condition presents with similar symptoms to other causes of small bowel obstruction. Patients may experience colicky central abdominal pain, which can have a gradual onset. Vomiting is common and tends to occur earlier in the course of the illness compared to large bowel obstruction. Abdominal distension and the absence of flatus are also typical signs. Additionally, there may be a lack of normal bowel sounds or the presence of high-pitched tinkling sounds. A mass in the right upper quadrant of the abdomen may be palpable.
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This question is part of the following fields:
- Surgical Emergencies
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Question 2
Incorrect
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A patient with a previous history of painless rectal bleeding episodes is found to have a Meckel's diverticulum during a colonoscopy.
Which ONE statement about Meckel's diverticulum is accurate?Your Answer: They are twice as common in women than men
Correct Answer: They receive their blood supply from the mesentery of the ileum
Explanation:A Meckel’s diverticulum is a leftover part of the vitellointestinal duct, which is no longer needed in the body. It is the most common abnormality in the gastrointestinal tract, found in about 2% of people. Interestingly, it is twice as likely to occur in men compared to women.
When a Meckel’s diverticulum is present, it is usually located in the lower part of the small intestine, specifically within 60-100 cm (2 feet) of the ileocaecal valve. These diverticula are typically 3-6 cm (approximately 2 inches) long and may have a larger opening than the ileum.
Meckel’s diverticula are often discovered incidentally, especially during an appendectomy. Most of the time, they do not cause any symptoms. However, they can lead to complications such as bleeding (25-50% of cases), intestinal blockage (10-40% of cases), diverticulitis, or perforation.
These diverticula run in the opposite direction of the intestine’s natural folds but receive their blood supply from the ileum mesentery. They can be identified by a specific blood vessel called the vitelline artery. Typically, they are lined with the same type of tissue as the ileum, but they often contain abnormal tissue, with gastric tissue being the most common (50%) and pancreatic tissue being the second most common (5%). In rare cases, colonic or jejunal tissue may be present.
To remember some key facts about Meckel’s diverticulum, the rule of 2s can be helpful:
– It is found in 2% of the population.
– It is more common in men, with a ratio of 2:1 compared to women.
– It is located 2 feet away from the ileocaecal valve.
– It is approximately 2 inches long.
– It often contains two types of abnormal tissue: gastric and pancreatic.
– The most common age for clinical presentation is 2 years old. -
This question is part of the following fields:
- Surgical Emergencies
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Question 3
Incorrect
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A 35-year-old woman comes in with sharp pain during bowel movements. The pain usually continues for an additional 30-60 minutes afterward. She has also observed spots of bright red blood on the toilet paper when wiping. She has been experiencing constipation for the past few weeks.
What is the MOST suitable initial treatment option for this situation?Your Answer: Botulinum toxin injection
Correct Answer: Topical diltiazem
Explanation:An anal fissure is a tear in the wall of the anal mucosa that exposes the circular muscle layer. The majority of these tears occur in the posterior midline, and they are often caused by the passage of a large, hard stool after a period of constipation. If multiple fissures are present, it may indicate an underlying condition such as Crohn’s disease or tuberculosis.
Both men and women are equally affected by anal fissures, and they are most commonly seen in individuals in their thirties. The typical symptoms of an anal fissure include intense, sharp pain during bowel movements, which can last for up to an hour after passing stool. Additionally, there may be spots of bright red blood on the toilet paper when wiping, and a history of constipation.
The initial management approach for an anal fissure involves non-operative measures such as using stool softeners and bulking agents. To alleviate the intense anal pain, analgesics and topical local anesthetics may be prescribed. According to a recent meta-analysis, first-line therapy should involve the use of topical GTN or diltiazem, with botulinum toxin being used as a rescue treatment if necessary (Modern perspectives in the treatment of chronic anal fissures. Ann R Coll Surg Engl. 2007 Jul;89(5):472-8.)
Sphincterotomy, a surgical procedure, should be reserved for cases where the fissure does not heal with conservative measures. It has a success rate of 90%.
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This question is part of the following fields:
- Surgical Emergencies
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Question 4
Correct
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You evaluate a 35-year-old male patient who has been diagnosed with an anal fissure. He has been undergoing treatment for the last two months, which includes lactulose, senna, topical creams with local anesthetics, and topical GTN ointment. However, his symptoms continue to persist, and he describes the pain during bowel movements as intolerable.
What would be the most suitable next step in managing this patient's condition?Your Answer: Botulinum toxin injection
Explanation:An anal fissure is a tear in the wall of the anal mucosa that exposes the circular muscle layer. The majority of these tears occur in the posterior midline. The most common cause is the passage of a large, hard stool after a period of constipation. If multiple fissures are present, it may indicate an underlying condition such as Crohn’s disease or tuberculosis.
Both men and women are equally affected by anal fissures, and they are most commonly seen in individuals in their thirties. The typical symptoms of an anal fissure include intense, sharp pain during bowel movements, which can last up to an hour after passing stool. Additionally, there may be spots of bright red blood on the toilet paper when wiping, and a history of constipation.
The initial management of an anal fissure involves non-operative measures such as using stool softeners and bulking agents. To alleviate the intense anal pain, analgesics and topical local anesthetics may be prescribed. According to a recent meta-analysis, first-line therapy should involve the use of topical GTN or diltiazem, with botulinum toxin being used as a rescue treatment if necessary (Modern perspectives in the treatment of chronic anal fissures. Ann R Coll Surg Engl. 2007 Jul;89(5):472-8.)
Sphincterotomy, a surgical procedure, should be reserved for fissures that do not heal and has a success rate of 90%. Anal dilatation, also known as Lord’s procedure, is rarely used nowadays due to the high risk of subsequent fecal incontinence.
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This question is part of the following fields:
- Surgical Emergencies
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Question 5
Incorrect
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You review a patient with chronic severe back pain with a medical student that has examined the patient. He feels the most likely diagnosis is lumbar disc herniation. He explains that all five features of Reynold’s pentad are present.
Which of the following does NOT form part of Reynold’s pentad?Your Answer: Jaundice
Correct Answer: Raised white cell count
Explanation:Ascending cholangitis occurs when there is an infection in the common bile duct, usually caused by a stone that has led to a blockage of bile flow. This condition is known as choledocholithiasis. The typical symptoms of ascending cholangitis are jaundice, fever (often accompanied by chills), and pain in the upper right quadrant of the abdomen. It is important to note that ascending cholangitis is a serious medical emergency that can be life-threatening, as patients often develop sepsis. Approximately 10-20% of patients may also experience altered mental status and low blood pressure due to septic shock. When these additional symptoms are present along with the classic triad of symptoms (Charcot’s triad), it is referred to as Reynold’s pentad. Urgent biliary drainage is the recommended treatment for ascending cholangitis. While a high white blood cell count is commonly seen in this condition, it is not considered part of Reynold’s pentad.
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This question is part of the following fields:
- Surgical Emergencies
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Question 6
Incorrect
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A 65-year-old man presents with unintentional weight loss and a noticeable lump in his abdomen. A CT scan reveals a sizable tumor in the sigmoid colon.
Where is the mass most likely to be felt when palpating the surface marking?Your Answer: Left hypochondrium
Correct Answer: Left iliac fossa
Explanation:The sigmoid colon is the last segment of the colon and is primarily situated in the left iliac fossa.
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This question is part of the following fields:
- Surgical Emergencies
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Question 7
Correct
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A 7-year-old boy is brought to the Emergency Department with lower abdominal pain and a high temperature. During the examination, he experiences tenderness in the right iliac fossa, leading to a working diagnosis of acute appendicitis. However, he adamantly refuses to flex his thigh at the hip. When his thigh is passively extended, his abdominal pain intensifies significantly.
What is the probable location of the appendix in this particular patient?Your Answer: Retrocaecal
Explanation:This patient is exhibiting the psoas sign, which is a medical indication of irritation in the iliopsoas group of hip flexors located in the abdomen. In this particular case, it is highly likely that the patient has acute appendicitis.
The psoas sign can be observed by extending the patient’s thigh while they are lying on their side with their knees extended, or by asking the patient to actively flex their thigh at the hip. If these movements result in abdominal pain or if the patient resists due to pain, then the psoas sign is considered positive.
The pain occurs because the psoas muscle is adjacent to the peritoneal cavity. When the muscles are stretched or contracted, they rub against the inflamed tissues nearby, causing discomfort. This strongly suggests that the appendix is positioned retrocaecal.
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This question is part of the following fields:
- Surgical Emergencies
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Question 8
Incorrect
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A concerned parent brings his 10-month-old son to the Emergency Department. He was previously healthy, but suddenly began vomiting this morning, and the father mentions that the last vomit was a vivid shade of green. The baby has been crying uncontrollably for periods of 15-20 minutes and then calming down in between. Upon examination, the child appears slightly pale, and there is no detectable bowel in the lower right quadrant.
What is the SINGLE most probable diagnosis?Your Answer: Pyloric stenosis
Correct Answer: Intussusception
Explanation:Intussusception occurs when a section of the bowel folds into another section, causing a blockage. This can be due to a specific underlying issue, like a Meckel’s diverticulum, or it can happen without any specific cause. The condition is most commonly seen in boys between the ages of 5 and 10 months. Symptoms include sudden vomiting and episodes of abdominal pain that come and go. The vomit quickly becomes greenish-yellow in color. Dance’s sign, which is the absence of bowel in the lower right part of the abdomen, may be observed. Redcurrant jelly-like stools are a late indication of the condition. It is believed that more than 90% of cases are caused by a non-specific underlying issue, often viral infections like rotavirus, adenovirus, and human herpesvirus 6.
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This question is part of the following fields:
- Surgical Emergencies
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Question 9
Incorrect
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A 42-year-old man presents with occasional right upper quadrant pain. The pain typically lasts for 20 to 45 minutes and then goes away on its own. Nausea frequently accompanies the pain. The pain tends to occur following the consumption of a high-fat meal.
What is the SINGLE most probable diagnosis?Your Answer:
Correct Answer: Gallstones
Explanation:This patient is displaying symptoms and signs that are consistent with a diagnosis of biliary colic. Biliary colic occurs when a gallstone temporarily blocks either the cystic duct or Hartmann’s pouch, leading to contractions in the gallbladder. The blockage is relieved when the stone either falls back into the gallbladder or passes through the duct.
Patients with biliary colic typically experience colicky pain in the upper right quadrant of their abdomen. This pain can last anywhere from 15 minutes to 24 hours and is often accompanied by feelings of nausea and vomiting. It is not uncommon for the pain to radiate into the right scapula area.
Eating fatty foods can exacerbate the pain as they stimulate the release of cholecystokinin, which in turn causes the gallbladder to contract.
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This question is part of the following fields:
- Surgical Emergencies
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Question 10
Incorrect
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A 65-year-old woman comes in with lower abdominal discomfort and rectal bleeding. An abdominal CT scan is conducted and reveals a diagnosis of diverticulitis.
Which part of her large intestine is most likely to be impacted?Your Answer:
Correct Answer: Sigmoid colon
Explanation:Diverticulitis primarily affects the sigmoid colon in about 90% of cases. As a result, it is more commonly associated with pain in the left iliac fossa.
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This question is part of the following fields:
- Surgical Emergencies
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