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Question 1
Correct
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An 80 year-old lady presents to the out patient clinic complaining of chest pain of 2 months' duration with a normal electrocardiogram and cardiac enzymes. A computed tomographic scan is done which reveals a mass lesion involving a structure in the middle mediastinum. Which among the following structures could be involved?
Your Answer: Ascending aorta
Explanation:The middle mediastinum is the broadest part of the mediastinal cavity containing the heart enclosed in the pericardium, ascending aorta, lower half of the superior vena cava with the azygos vein opening into it, the bifurcation of the trachea and the two bronchi, the pulmonary artery with its branches, pulmonary veins, phrenic nerves and bronchial lymph nodes. The most likely structure involved is the ascending aorta, perhaps with an aneurysm.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 2
Correct
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A 38-year old woman presents to the clinic with a 2 cm eczema-like lesion on the areolar region of her left breast, for 5 months. Biopsy of the lesion showed large cells at the dermal-epidermal junction with positive staining for mucin. What is the likely diagnosis?
Your Answer: Paget’s disease of the breast
Explanation:Paget’s disease of the breast or nipple resembles eczema in appearance with an underlying carcinoma typically. The disease is usually unilateral and presents with inflammation, oozing and crusting along with a non-healing ulcer. Treatment is often delayed due to the innocuous appearance but can be fatal. It results due to spread of neoplastic cells from the ducts of the mammary gland to the epithelium.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 3
Correct
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A 60 year old woman with Crohn's disease presents with a high output enterocutaneous fistula. She is started on total parenteral nutrition (TPN) to reduce the output of the fistula and improve her nutritional status. Which of the following statements regarding TPN is incorrect?
Your Answer: It may result in metabolic complications such a refeeding syndrome, resulting in hyperkalaemia, hypermagnesemia, and hyperphosphatemia
Explanation:Answer: It may result in metabolic complications such a refeeding syndrome, resulting in hyperkalaemia, hypermagnesemia, and hyperphosphatemia.
Refeeding syndrome can be defined as the potentially fatal shifts in fluids and electrolytes that may occur in malnourished patients receiving artificial refeeding (whether enterally or parenterally. These shifts result from hormonal and metabolic changes and may cause serious clinical complications. The hallmark biochemical feature of refeeding syndrome is hypophosphatemia. However, the syndrome is complex and may also feature abnormal sodium and fluid balance; changes in glucose, protein, and fat metabolism; thiamine deficiency; hypokalaemia; and hypomagnesaemia.
During refeeding, glycaemia leads to increased insulin and decreased secretion of glucagon. Insulin stimulates glycogen, fat, and protein synthesis. This process requires minerals such as phosphate and magnesium and cofactors such as thiamine. Insulin stimulates the absorption of potassium into the cells through the sodium-potassium ATPase symporter, which also transports glucose into the cells. Magnesium and phosphate are also taken up into the cells. Water follows by osmosis. These processes result in a decrease in the serum levels of phosphate, potassium, and magnesium, all of which are already depleted. The clinical features of the refeeding syndrome occur as a result of the functional deficits of these electrolytes and the rapid change in basal metabolic rate. -
This question is part of the following fields:
- Peri-operative Care
- Principles Of Surgery-in-General
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Question 4
Correct
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The Brunner glands secrete an alkaline product that helps maintain an optimal pH for pancreatic enzyme activity. Where are these glands located?
Your Answer: Submucosa of the duodeneum
Explanation:The Brunner glands are located in the submucosa of the duodenum. These glands are connected to the interstitial lumen by ducts that open into certain crypts. They secrete an alkaline product that protects the duodenal mucosa from the acidic chyme and helps achieve an optimal pH for the enzymes.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 5
Correct
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Severe abdominal pain radiating to the back, along with increased serum amylase levels, is seen in which of the following conditions?
Your Answer: Pancreatitis
Explanation:The primary test for diagnosis and monitoring of pancreatitis is amylase. Increased plasma levels of amylase can be found in: salivary trauma (including anaesthetic intubation), mumps, pancreatitis and renal failure. However, a rise in the total amylase levels over 10 times the upper limit of normal (ULN) is suggestive of pancreatitis; 5–10 times the ULN may indicate ileus or duodenal disease or renal failure. Lower levels are commonly found in salivary gland disease.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 6
Correct
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A 42 - year old male patient with an acute onset headache was brought in to the emergency department with suspicion of a subarachnoid haemorrhage (SAH). The SHO on call decided to have a diagnostic lumbar puncture after computed topography scan failed to support the suspicion. To perform a successful lumbar puncture without causing injury to the spine, which anatomical landmark should guide the SHO to locate the fourth vertebra for insertion of the spinal needle?
Your Answer: Iliac crest
Explanation:The safest spinal level for conducting a lumbar puncture, is at the level of the fourth lumbar vertebra. The anatomical landmark used to locate the fourth lumbar vertebra (L4), is the iliac crest. The needle can safely be inserted either above or below L4. The conus medullaris is at the level of the border of L1 and L2 so L4 is safely distant from it.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 7
Incorrect
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Purkinje fibres in the heart conduct action potentials at the rate of:
Your Answer: 5.0–8.5 m/s
Correct Answer: 1.5–4.0 m/s
Explanation:Purkinje fibres control the heart rate along with the sinoatrial node (SA node) and the atrioventricular node (AV node). The QRS complex is associated with the impulse passing through the Purkinje fibres. These fibres conduct action potential about six times faster than the velocity in normal cardiac muscle.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 8
Correct
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A lesion involving the lateral portion of the dorsal columns at the level of the nape of the neck will most likely affect:
Your Answer: Vibratory sensations from the ipsilateral arm
Explanation:At the level mentioned in the question, the lateral portion of dorsal columns comprises of the fasciculus cuneatus. Axons carrying the sensations of touch, vibration and proprioception from the ipsilateral arm enter the spinal cord and ascend in the fasciculus cuneatus, synapsing in the nucleus cuneatus of the caudal medulla. Secondary neurons from this nucleus give rise to internal arcuate fibres, which decussate and ascend to the thalamus as the medial lemniscus. Tertiary neurons from there project to the ipsilateral somatosensory cortex. Thus, any damage to the fasciculus cuneatus will result in a deficit in tactile, proprioceptive and vibratory sensations in the ipsilateral arm, and not the contralateral arm.
Fine motor control of the fingers is mainly carried by the ipsilateral lateral corticospinal tract in the lateral funiculus of the cord. Motor control of the contralateral foot is carried by the ipsilateral corticospinal tract in the lateral funiculus of the cord. Lack of sweating of the face could be produced by interruption of sympathetic innervation. Proprioception from the ipsilateral leg is carried by the fasciculus gracilis in the medial part of the dorsal columns. -
This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 9
Incorrect
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A 15-year-old girl was diagnosed with bacterial meningitis. Gram staining of the spinal fluid shows numerous polymorphonuclear neutrophils and Gram-positive cocci. Which is the empiric drug of choice to be given to the patient until the antibiotic sensitivity report is available?
Your Answer: Ceftriaxone
Correct Answer: Methicillin
Explanation:Bacterial meningitis (including meningococcal meningitis, Haemophilus influenzae meningitis, and staphylococcal meningitis) is a neurologic emergency that is associated with significant morbidity and mortality. Initiation of empiric antibacterial therapy is therefore essential for better outcomes. The patient appears to be suffering from meningitis caused by Staphylococcus aureus. Methicillin would be the drug of choice . It is bactericidal and unlike streptomycin and chloramphenicol it is not associated with toxicity
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 10
Correct
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A 70-year-old man who was previously healthy develops a rapidly progressing neurological deficit. A MRI reveals a large, poorly defined mass with central necrosis in his left temporal lobe. What is the most likely diagnosis?
Your Answer: Glioblastoma multiforme
Explanation:Glioblastoma multiforme, or grade 4 astrocytoma, is the most common and aggressive primary brain tumour. They are formed by small areas of necrotising tissue surrounded by highly anaplastic cells. Most of them arise from the deep white matter of the brain and quickly infiltrate it, becoming very large before they are symptomatic. The most common symptom is progressive memory, personality or neurological deficit due to temporal and frontal lobe involvement. It is most common in men, and risk factors include: neurofibromatosis, tuberous sclerosis, Von Hippel-Lindau disease, Li-Fraumeni syndrome, and Turcot syndrome.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 11
Correct
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what is the cause of a prolonged PT(prothrombin time)?
Your 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 12
Correct
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Which best describes the sartorius muscle?
Your Answer: Will flex the leg at the knee joint
Explanation:The sartorius muscle arises from tendinous fibres from the superior iliac spine. It passes obliquely across the thigh from lateral to medial and is inserted into the upper part of the medial side of the tibia. When the sartorius muscle contracts it will flex the leg at the knee joint.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 13
Correct
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A 56 year old mechanic undergoes a live related renal transplant. He had a good urine output and the graft appeared well perfused at the end of the operation. However, on the ward he suddenly becomes anuric. Which of the following is the most likely cause?
Your Answer: Renal artery thrombosis
Explanation:Acute renal artery thrombosis is a devastating complication of renal transplantation that can result in graft loss if not detected early. Surgical and technical errors are the major cause of renal artery thrombosis. Renal artery thrombosis usually presents with sudden onset oliguria or anuria accompanied by pain and tenderness over the graft site. Patients may develop thrombocytopenia due to platelet aggregation at the thrombosis site. The imaging modality of choice for diagnosis of renal artery thrombosis is colour Doppler sonography. Conventional, computed tomography (CT) and magnetic resonance (MR) angiography may also be used to confirm the presence of renal artery thrombosis. Although there are reports of successful resolution of post-transplant acute renal artery thrombosis with endovascular and surgical modalities such as percutaneous thrombus aspiration, intra-arterial injection of fibrinolytic agents and surgical thrombectomy, renal artery thrombosis usually results in ischemic necrosis and graft loss.
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This question is part of the following fields:
- Generic Surgical Topics
- Organ Transplantation
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Question 14
Correct
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Which tumour marker is associated with medullary carcinoma of thyroid?
Your Answer: Calcitonin
Explanation:Medullary carcinoma of thyroid accounts for 3% of thyroid cancers. It arises from the parafollicular cells (C cells) of the thyroid gland that produce calcitonin. It is often familial and caused by mutation of ret proto-oncogene, but can occasionally be sporadic. The familial cases can also occur as part of MEN syndromes IIA and IIB. The high calcitonin leads to down-regulation of the receptors, which does not affect the calcium levels significantly. Medullary carcinoma of thyroid shows characteristic amyloid deposits that stain positively with Congo red. The initial presentation consists of an asymptomatic thyroid nodule. Many cases are diagnosed due to routine screening of relatives of patients with MEN IIA and IIB. Medullary carcinoma can also cause ectopic production of other hormones/peptides such as adrenocorticotrophic hormone, vasoactive intestinal polypeptide, kallikreins and serotonin.
Metastasis from medullary carcinoma spread via the lymphatics to cervical and mediastinal nodes, and can also affect the liver, lungs and bone. Diagnosis is by raised serum calcitonin levels. A provocative test with calcium (15 mg/kg intravenously over 4 hours) also aids in diagnosis by leading to excessive secretion of calcitonin. X-ray might also show dense, conglomerate calcification.
CA-125 is frequently elevated in ovarian carcinomas. CA 15-3 is often associated with breast carcinomas. Alpha-fetoprotein is seen raised in hepatomas and gonadal tumours. Elevated HCG is associated with normal pregnancies, gonadal tumours, and choriocarcinomas. Thyroglobulin is used for surveillance in papillary carcinoma of thyroid. CA 19-9 is used in the management of pancreatic cancer. -
This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 15
Correct
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A woman that presented with dyspnoea, chest pain and cough was found to have a serous pleural effusion. This finding is most likely to be associated with which of the following conditions?
Your Answer: Congestive heart failure
Explanation:A pleural effusion is defined as an abnormal collection of fluid in the pleural space. Pleural effusion can result from excess fluid production or decreased absorption or both. Thoracentesis and laboratory testing help determine the origin of the accumulated fluid. Serous fluid accumulation in the pleural space indicates the presence of a hydrothorax and is most likely to develop secondary to congestive heart failure.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 16
Incorrect
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Which of these substances is secreted by pericytes in the juxtaglomerular cells?
Your Answer: Erythropoietin
Correct 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 17
Correct
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Choose the most correct answer regarding the obturator internus muscle.
Your Answer: It emerges from the pelvis through the lesser sciatic foramen
Explanation:The obturator internus arises from the inner surface of the anterolateral wall of the pelvis and the pelvic surface of the obturator membrane. The fibres converge rapidly towards the lesser sciatic foramen and end in four or five tendinous bands and leave the pelvis through the lesser sciatic foramen.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 18
Correct
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A 55-year-old woman complains of pain in the proximal and distal interphalangeal joins, and back pain which has increased over the last 4 years and worsens after activity. X-rays reveal Heberden’s and Bouchard’s nodes in her interphalangeal joints and the presence of osteophytes in her spine. What is the most likely diagnosis?
Your Answer: Osteoarthritis
Explanation:Osteoarthritis is most common in older adults, predominating in women between the ages of 40 and 70; after this age, men and women are affected equally. It affects an entire joint, with disruption and potential loss of joint cartilage, along with other joint changes, including bone hypertrophy (osteophyte formation). The pain is usually gradual and is worse after activity, with occasional joint swelling. X-ray findings include marginal osteophytes, narrowing of the joint space, increased density of the subchondral bone, subchondral cyst formation, bony remodelling and joint effusions.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 19
Correct
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Which nerve lies immediately medial to the psoas major muscle?
Your Answer: Obturator
Explanation:The obturator nerve is formed from the ventral divisions of the 2nd, 3rd and 4th lumbar nerves. It courses through the fibres of the psoas major and emerges from the medial border near the pelvic brim.
The iliohypogastric nerve comes from the first lumbar nerve and emerges from the upper part of the lateral border of psoas major.
The ilioinguinal nerve arises with the iliohypogastric nerve from the first lumbar nerve and also emerges from the lateral border of the psoas major muscle.
The lateral femoral cutaneous nerve comes from the posterior division of the 2nd and 3rd lumbar nerves to emerge from the lateral border of the psoas major muscle near its middle.
The femoral nerve also arises from the dorsal divisions, but of the 2nd, 3rd and 4th lumbar nerves and courses through the muscle fibres to emerge at the lower part of the lateral border.
The coccygeal nerve doesn’t arise from the lumbar plexus but from the sacral plexus. -
This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 20
Correct
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A 50-year-old male is recovering on the high dependency unit following a long and complex laparotomy. His preoperative medication includes an ACE inhibitor for blood pressure control. For the past two hours, he has been oliguric with a urine output of 10ml/hr-1. What the most appropriate immediate course of action?
Your Answer: Administer a fluid challenge
Explanation:Using fluids to correct hypovolaemia is a dynamic process that requires ongoing evaluation of clinical and haemodynamic indices. Thus, the use of the fluid challenge provides a successful method of adjusting the fluid volume to the patient’s need.
The fluid challenge is a method of safely restoring circulating volume according to physiological need rather than using fixed haemodynamic end-points. The fluid is given in small aliquots to produce a known increment in circulating volume with an assessment of the dynamic haemodynamic response to each aliquot. No fixed haemodynamic end-point is assumed and the technique provides a diagnostic test of hypovolaemia (via an appropriate positive response of the circulation to fluid) and a method of titrating the optimal dose of fluid to the individual’s requirement.
The response of SV and/or CVP (or PAWP) should be monitored during a fluid challenge. The basis of the fluid challenge is to achieve a known increase in intravascular volume by rapid infusion of a bolus of colloid fluid (200 ml).
In the inadequately filled left ventricle, a fluid challenge will increase SV. Failure to increase SV with a fluid challenge may indicate a circulation that is unresponsive to fluid or an inadequate challenge. -
This question is part of the following fields:
- Post-operative Management And Critical Care
- Principles Of Surgery-in-General
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Question 21
Incorrect
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In the glomerulus of the kidney, the mesangium is a structure associated with the capillaries. It has extraglomerular mesangial cells that:
Your Answer: Provide structural support for and regulate blood flow of the glomerular capillaries by their contractile activity
Correct Answer: Form the juxtaglomerular apparatus in combination with the macula densa and juxtaglomerular cells
Explanation:The mesangium is an inner layer of the glomerulus, within the basement membrane surrounding the glomerular capillaries. The mesangial cells are phagocytic and secrete the amorphous basement membrane-like material known as the mesangial matrix. They are typically separated from the lumen of the capillaries by endothelial cells. The other type of cells in the mesangium are the extraglomerular mesangial cells which form the juxtaglomerular apparatus in combination with two other types of cells: the macula densa of the distal convoluted tubule and juxtaglomerular cells of the afferent arteriole. This apparatus controls blood pressure through the renin–angiotensin–aldosterone system.
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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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Myoglobin is released as a result of rhabdomyolysis from damaged skeletal muscles. What function do they perform in the muscle?
Your Answer: Acts like haemoglobin and binds with O2
Explanation:Myoglobin is a pigmented globular protein made up of 153 amino acids with a prosthetic group containing haem around which the apoprotein folds. It is the primary oxygen carrying protein of the muscles. The binding of oxygen to myoglobin is unaffected by the oxygen pressure as it has an instant tendency to bind given its hyperbolic oxygen curve. It releases oxygen at very low pO2 levels.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 23
Correct
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A histological examination of a lump showed an abnormal amount and arrangement of normal tissue in an otherwise normal area. This condition is known as?
Your Answer: Hamartoma
Explanation:A hamartoma is a condition best described as tissue normally present in an area arranged haphazardly in an disorganized, abnormal fashion. They are never malignant and do not metastasis.
All the neoplastic, cancerous lesions comprise of a mixture of different cells that are not normal to that area.
Metaplasia is a change in the type of the epithelium. -
This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 24
Correct
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A 32 year old woman with a history of Crohn's disease, presents with a recurrent discharging anal fistula. Examination reveals a low anal fistula with involvement of a small area of the external anal sphincter muscle. Which of the following is the most appropriate management plan?
Your Answer: Insertion of a loose seton
Explanation:Fistulotomy could achieve good results in terms of wound healing and incontinence in strictly selected patients with Crohn’s disease suffering from low-lying trans-sphincteric fistulae. For more high-lying or complicated fistulae, seton placement is more appropriate. For high transsphincteric fistulae, the only option is placement of loose seton.
Fistulae are classified into four main groups according to anatomical location and the degree of sphincter involvement. Simple uncomplicated fistulae are low and do not involve more than 30% of the external sphincter. Complex fistulae involve the sphincter, have multiple branches or are non cryptoglandular in origin -
This question is part of the following fields:
- Colorectal Surgery
- Generic Surgical Topics
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Question 25
Correct
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A 24-year old, lactating mother presents to the clinic with a tender, 1.5cm mass just below the right nipple, which shows multiple fissures. What finding is likely associated with her condition?
Your Answer: Staphylococcus aureus infection
Explanation:Breast abscess occur commonly in lactating mothers in the postpartum period due to cracking of the nipple. It is commonly caused due to Staphylococcus aureus infection. Fat necrosis usually results from trauma wherein an ill-defined mass is formed. Ductal carcinomas are malignant masses which are not tender usually, and rare in the young age group. Plasma cell mastitis affect women in an older age group. Sclerosing adenosis is a type of fibrocystic disease which can lead to a tender, cystic mass but no fissuring or cracks are seen in the nipple. Fibroadenoma and lipomas are non-tender, well-defined masses.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 26
Correct
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Which of the following foramen provides passage of the facial nerve?
Your Answer: Internal acoustic meatus
Explanation:The internal auditory meatus provides a passage through which the vestibulocochlear nerve, the facial nerve, and the labyrinthine artery (an internal auditory branch of the basilar artery) can pass from inside the skull to structures of the inner ear and face.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 27
Incorrect
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A 40-year-old chef presents to the hospital with profuse bloody diarrhoea. He also complains of frequent urge to defecate and pain before and during defecation. A sigmoidoscopy is arranged which reveals necrosis and ulceration of the descending colon mucosa. What is the most likely underlying cause?
Your Answer: Ischaemic colitis
Correct Answer: Infection with enteroinvasive E. coli
Explanation:Necrosis and ulcers of the colon are a feature of infection with enteroinvasive E. coli (EIEC). It presents with a dysentery-type illness similar to shigellosis.
E. coli have different strains that cause a wide range of conditions. The four main types are:
1. Enteropathogenic E. coli—cause watery diarrhoea, vomiting, and low-grade fever
2. Enteroinvasive E. coli—cause dysentery, large bowel necrosis, and ulcers
3. Enterotoxigenic E. coli—cause traveller’s diarrhoea
4. Enterohaemorrhagic E. coli 0157:H7—cause haemorrhagic colitis, haemolytic uremic syndrome, and thrombotic thrombocytopenic purpura
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This question is part of the following fields:
- Clinical Microbiology
- Principles Of Surgery-in-General
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Question 28
Correct
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Investigations in a 40-year old gentleman with splenomegaly reveal the following: haemoglobin 21.5 g/dl, haematocrit 66%, mean corpuscular volume (MCV) 86 fl, mean cell haemoglobin concentration 34 g/dl, mean corpuscular haemoglobin 34.5 pg, platelet count 450 × 109/l, and white blood cell count 12 × 109/l, with 81% polymorphonuclear leukocytes, 4% bands, 3% monocytes, and 7% lymphocytes. What is the likely diagnosis?
Your Answer: Polycythaemia vera
Explanation:The markedly increased haematocrit, along with thrombocytosis and the leucocytosis suggest a myeloproliferative disorder.
Polycythaemia vera is the commonest myeloproliferative disorders occurring more often in males (about 1.4 to 1). The mean age at diagnosis is 60 years (range 15–90 years) with 5% of patients below 40 years at onset. It involves increased production of all cell lines, including red blood cells (independent of erythropoietin), white blood cells and platelets. If confined only to red blood cells, it is known as ‘primary erythrocytosis’. There is an increase in blood volume and hyperviscosity occurs, predisposing to thrombosis. Increased bleeding occurs due to abnormal functioning of platelets. Patients become hypermetabolic, and increased cell turnover leads to hyperuricaemia.
Usually asymptomatic, occasionally symptoms include weakness, pruritus, headache, light-headedness, visual disturbances, fatigue and dyspnoea. Face appears red with engorged retinal veins. Lower extremities appear red and painful, along with digital ischaemia (erythromelalgia). Hepatomegaly is common and massive splenomegaly is seen in 75% patients. Thrombosis can lead to stroke, deep venous thrombosis, myocardial infarction, retinal artery or vein occlusion, splenic infarction (often with a friction rub) or Budd–Chiari syndrome. Gastrointestinal bleeding is seen in 10-20% patients. Hypermetabolism can lead to low-grade fevers and weight loss. Late features include complications of hyperuricaemia (e.g. gout, renal calculi). 1.5% to 10% cases transform to acute leukaemia. -
This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 29
Correct
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A 30-year-old woman undergoes a laparotomy for a perforated duodenal ulcer and broad-spectrum antibiotics are administered. However, she develops hearing impairment postoperatively.Which of the following agents is responsible for this adverse effect?
Your Answer: Gentamicin
Explanation:Ototoxicity is a recognised adverse reaction with the aminoglycoside antibiotics.
Gentamicin belongs to a class of drugs known as aminoglycoside antibiotics. It is a broad-spectrum antibiotic that is most affective against aerobic gram-negative rods. Gentamicin acts by inhibiting bacterial protein synthesis. This creates a pool of inactive bacterial ribosomes that can no longer re-initiate and translate new proteins.
The hearing loss produced by gentamicin is known as gentamycin-induced ototoxicity. The antibiotic itself is not dangerous. It becomes toxic when it binds to iron in the blood and produces destructive chemical agents known as free radicals.
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This question is part of the following fields:
- Peri-operative Care
- Principles Of Surgery-in-General
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Question 30
Correct
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A patient is diagnosed with lung cancer. His physician told him that his lung cancer type is aggressive. It can grow rapidly and may undergo early metastasis, however it is very sensitive to chemotherapy and radiotherapy. Which lung cancer type is most likely present
Your Answer: Small-cell carcinoma
Explanation:Small-cell lung carcinoma (SCLC) is a type of highly malignant cancer that most commonly arises within the lung. SCLC usually metastasizes widely very early on in the natural history of the tumour, and in nearly all cases responds dramatically to chemotherapy and/or radiotherapy. Surgery has no role in the treatment of this disease.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 31
Correct
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An 11 year old girl undergoes a delayed open reduction and fixation of a significantly displaced supracondylar fracture. She complains of paraesthesia of the hand and significant forearm pain. The radial pulse is normal. What is the best course of action?
Your Answer: Fasciotomy
Explanation:Answer: Fasciotomy
Fasciotomy is a surgical procedure where the fascia is cut to relieve tension or pressure commonly to treat the resulting loss of circulation to an area of tissue or muscle. Fasciotomy is a limb-saving procedure when used to treat acute compartment syndrome. A delay in performing the procedure can lead to neurovascular complications or lead to the need for amputation of a limb. Complications can also involve the formation of scar tissue after the operation. A thickening of the surgical scars can result in the loss of mobility of the joint involved. This can be addressed through occupational or physical therapy.
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This question is part of the following fields:
- Generic Surgical Topics
- Orthopaedics
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Question 32
Correct
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A 30-year-old male presents to the clinic with a recurrent thyroid cyst. It has been drained on three different occasions. Each time the cyst is aspirated and cytology is reassuring. What is the most appropriate course of action?
Your Answer: Resection of the ipsilateral thyroid lobe
Explanation:Aspiration is the treatment of choice in thyroid cysts, but the recurrence rates are high (60%–90% of patients), particularly with repeated aspirations and large-volume cysts.
Percutaneous ethanol injection (PEI) has been studied in several large randomized controlled studies, with reported success in 82–85% of the cases after an average of 2 sessions, with a volume reduction of more than 85% from baseline size.
PEI may also be considered for hyperfunctioning nodules, particularly if a large fluid component is present. It has a success rate ranging from 64% to 95%, with a mean volume reduction of 66%, but recurrences are more common and the number of sessions required to achieve good response is higher (about 4 sessions per patient). PEI is a safe procedure, with the most common reported adverse effects being local pain, dysphonia, flushing, dizziness, and, rarely, recurrent laryngeal nerve damage.
Surgery, Lobectomy is also a reasonable therapy for cystic lesions, as an alternative to the previously mentioned procedures. -
This question is part of the following fields:
- Breast And Endocrine Surgery
- Generic Surgical Topics
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Question 33
Correct
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The renal tubule is the portion of the nephron that contains the fluid that has been filtered by the glomerulus. Which of the following substances is actively secreted into the renal tubules?
Your Answer: Potassium
Explanation:The renal corpuscle filters out solutes from the blood, delivering water and small solutes to the renal tubule for modification. In normal circumstances more than 90% of the filtered load of K is reabsorbed by the proximal tubules and loops of Henlé and almost all K appearing in the urine has been secreted by the late distal tubules and collecting tubules. So the rate of excretion is usually independent of the rate of filtration, but is closely tied to the rate of secretion and control of K excretion, largely accomplished by control of the secretion rate. Around 65–70% of the filtered potassium is reabsorbed along with water in the proximal tubule and the concentration of potassium in the tubular fluid varies little from that of the plasma.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 34
Correct
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A 64 year old man who has undergone a total hip replacement is given an infusion of packed red cells. Which of the following adverse effects is most likely to occur as a result of this treatment?
Your Answer: Pyrexia
Explanation:Acute transfusion reactions present as adverse signs or symptoms during or within 24 hours of a blood transfusion. The most frequent reactions are fever, chills, pruritus, or urticaria, which typically resolve promptly without specific treatment or complications.
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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 35
Correct
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When a penile tumour invades the subepithelial connective tissue of the penis, what is its stage?
Your Answer: T1
Explanation:The TNM staging used for penile cancer is as follows:
TX: primary tumour cannot be assessed
T0: primary tumour is not evident
Tis: carcinoma in situ is present
Ta: non-invasive verrucous carcinoma is present
T1: tumour is invading subepithelial connective tissue
T2: tumour is invading the corpora spongiosum or cavernosum
T3: tumour invading the urethra or prostate
T4: tumour invading other adjacent structures.
In this case, the patient has a T1 tumour. -
This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 36
Correct
-
Carbachol is a cholinergic agonist. In which of these cases should carbachol be administered?
Your Answer: Cataract surgery
Explanation:Carbachol (carbamylcholine) is a cholinergic agent, a choline ester and a positively charged quaternary ammonium compound. It is primarily used for various ophthalmic purposes, such as for treating glaucoma, or for use during ophthalmic surgery. It is usually administered topically to the eye or through intraocular injection. It is not well absorbed in the gastro-intestinal tract and does not cross the blood–brain barrier.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 37
Correct
-
The majority of gallstones are mainly composed of:
Your Answer: Cholesterol
Explanation:Bile salts are formed out of cholesterol in the liver cells. Occasionally, precipitation of cholesterol occurs resulting into cholesterol stones developing in the gall bladder.
These cholesterol gallstones are the most common type and account for 80% of all gallstones. Another type, accounting for 20% gallstones is pigment stones which are composed of bilirubin and calcium salts. Occasionally, stones of mixed origin are also seen. -
This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 38
Correct
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A 34 year old woman of Singaporean descent arrives at clinic for a pre operative assessment of varicose veins. On auscultation, a mid diastolic murmur is heard at the apex. The murmur is accentuated when the patient lies in the left lateral position. Which of the following is the most likely underlying lesion?
Your Answer: Mitral valve stenosis
Explanation:A mid diastolic murmur at the apex is a classical description of a mitral stenosis (MS) murmur.
MS a valvular anomaly of the mitral valve that leads to obstruction of blood flow into the left ventricle. The most common cause of MS is rheumatic fever. The clinical manifestations depend on the extent of stenosis: reduced mitral opening leads to progressive congestion behind the stenotic valve. Acute decompensation can cause pulmonary oedema. Echocardiography is the main diagnostic tool for evaluating the mitral valve apparatus, left atrial size, and pulmonary pressure. In the event of high grade and/or symptomatic stenosis, percutaneous valvuloplasty or surgical valve replacement is often required.Types and causes of murmurs:
Ejection systolic: Aortic stenosis, pulmonary stenosis, HOCM, ASD, Fallot’s
Pan-systolic: Mitral regurgitation, tricuspid regurgitation, VSD
Late systolic: Mitral valve prolapse, coarctation of aorta
Early diastolic: Aortic regurgitation, Graham-Steel murmur (pulmonary regurgitation)
Mid diastolic: Mitral stenosis, Austin-Flint murmur (severe aortic regurgitation) -
This question is part of the following fields:
- Generic Surgical Topics
- Vascular
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Question 39
Correct
-
A 55-year-old cleaner is admitted after a fall. She is haemodynamically unstable and a CT has shown a massive retroperitoneal haematoma. She is on warfarin. What is the most appropriate course of action?
Your Answer: Infusion of human prothrombin complex and vitamin K
Explanation:Active, serious haemorrhage due to Warfarin should be treated with four-factor prothrombin complex concentrate (PCC), if available.
While costly, an essential advantage FFP confers to emergency care is that, in contrast to FFP, it results in a more rapid reversal of coagulopathy and does not require thawing or blood group typing. Additionally, it has a reduced risk of volume overload, transfusion-related acute lung injury, transfusion reactions, and infectious disease transmission. Despite these advantages, no mortality benefit has been proven for PCC compared with FFP.
Alternatively, recombinant factor VIIa (rFVIIa) has been reported to be effective in rapidly lowering INR due to warfarin toxicity and may be considered if PCC is not available. FFP is effective at lowering the INR and was historically first-line therapy for warfarin toxicity with serious or life-threatening bleeding, although it has now been superseded by PCC, which lowers the INR more rapidly. If PCC or rFVIIa is not available, 4 units of FFP may be administered instead.
Administer vitamin K1, 10 mg, by slow IV infusion, -
This question is part of the following fields:
- Principles Of Surgery-in-General
- Surgical Technique And Technology
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Question 40
Correct
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A 25 year-old female medical student presents with fever, lack of appetite, rashes, sore throat and lymphadenopathy. Peripheral smear shows atypical lymphocytes. Which is the most likely organism responsible for this patient's condition?
Your Answer: Epstein–Barr virus
Explanation:Epstein-Barr virus is in the herpes family of viruses and most people will become infected with EBV sometime during their lives. EBV commonly causes infectious mononucleosis, or mono, a contagious viral illness that initially attacks the lymph nodes in the neck and throat. When these tissues become less effective in fighting infection, sore throats, swelling of the nodes and fever may result.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 41
Correct
-
A 33 year old morbidly obese women is considered for bariatric surgery. Which of the options provided below would most likely be associated with the highest long term failure rates?
Your Answer: Intra gastric balloon
Explanation:The intragastric balloon aids weight loss by slowing the rate at which food enters the stomach and by stimulating gastric stretch receptors. But lifestyle changes, including behaviour modification, exercise and a healthy diet, are crucial for maintaining weight loss once the device is removed. Intragastric balloon is really only suitable as a bridge to a more definitive surgical solution and is associated with a high failure rates and complications.
Gastric banding: band applied to upper stomach which can be inflated or deflated with normal saline. This affects satiety. Over a 5 year period complications requiring further surgery occur in up to 15% cases.
Roux-en-Y gastric bypass: a gastric pouch is formed and connected to the jejunum. Patients achieve greater and more long-term weight loss than gastric banding.
Sleeve gastrectomy: body and fundus resected to leave a small section of stomach
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This question is part of the following fields:
- Generic Surgical Topics
- Upper Gastrointestinal Surgery
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Question 42
Correct
-
A 26-year-old woman who is 18 weeks pregnant presents with sudden chest pain. On examination, her heart rate is 130 bpm, blood pressure is 150/70 mmHg, and saturation is 92% on 15L oxygen. Signs of thrombophlebitis are seen in the left leg. Moreover, auscultation of the heart reveals no murmurs and her chest is clear.What is the most likely diagnosis?
Your Answer: Pulmonary embolism
Explanation:Chest pain, hypoxia, and clear chest on auscultation in pregnancy should lead to a high suspicion of pulmonary embolism (PE).
PE is one of the leading causes of mortality in pregnancy. Evaluation with low-dose perfusion scintigraphy may be preferable to computed tomographic pulmonary angiography (CTPA).
PE is treated with LMWH throughout pregnancy and for 4–6 weeks after childbirth. Warfarin is contraindicated in pregnancy (though may be continued in women with mechanical heart valves due to a significant risk of thromboembolism). -
This question is part of the following fields:
- Emergency Medicine And Management Of Trauma
- Principles Of Surgery-in-General
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Question 43
Correct
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An 18-year-old male is admitted with a three-month history of intermittent pain in the right iliac fossa. He suffers from episodic diarrhoea and has lost two kilograms of weight. On examination, he is febrile and has right iliac fossa tenderness.What is the most likely diagnosis?
Your Answer: Inflammatory bowel disease
Explanation:A history of weight loss and intermittent diarrhoea makes inflammatory bowel disease (IBD) the most likely diagnosis. Conditions such as appendicitis and infections have a much shorter history. Although Meckel’s diverticulum can bleed and cause inflammation, it seldom causes marked weight loss. Irritable bowel syndrome (IBS) presents with alternating episodes of constipation and diarrhoea along with abdominal pain, bloating, and gas.
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This question is part of the following fields:
- Generic Surgical Topics
- The Abdomen
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Question 44
Correct
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A butcher accidentally cut himself on his right index finger. Which of the following substances when in contact with the basement membrane of the injured vasculature will activate the coagulation cascade as well as the kinin system in a first response to this injury?
Your Answer: Hageman factor
Explanation:Hageman factor/factor XII in the intrinsic pathway activates prekallikrein and factor XI. Deficiency will not cause excessive bleeding as other coagulation factors will be utilized but the PTT will be greater than 200 seconds.
Thromboxane promotes platelet aggregation and causes vasoconstriction.
Plasmin, which is cleaved from plasminogen acts as an anticoagulant which breaks down thrombi.
Platelet activating factor promotes platelet aggregation and is also chemotactic to neutrophils.
Histamine acts as a vasodilator.
Platelet inhibiting factor acts an anticoagulant.
Renin is a hormone released from the kidney that causes vasoconstriction and water retention. -
This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 45
Correct
-
A 39-year old female patient was diagnosed with a tumour of the left adrenal gland. The tumour, which is metastasizing to the adjacent tissues, has already extended to the left suprarenal vein. If the tumour is still spreading, which of the following veins will most likely be affected after the involvement of the left suprarenal vein?
Your Answer: Left renal vein
Explanation:The suprarenal veins or also known as the veins of Warshaw, are the veins that receive blood from the suprarenal glands. These veins receive blood from the medullary venous plexus and the cortex of the adrenal glands (suprarenal glands). They are two in number – the left and the right suprarenal veins. The right suprarenal vein drains into the inferior vena cava while the left suprarenal vein drains into the left renal vein. This therefore means that in the case of a metastasizing tumour involving the left suprarenal vein, the tumour will most likely extend from the left suprarenal vein to the left renal vein into which it drains.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 46
Correct
-
A 33 year old man presents with an injured forearm after falling from a scaffolding. Examination reveals a radial fracture and dislocated distal radio-ulnar joint. Which of the following options is synonymous with this presentation?
Your Answer: Galeazzi
Explanation:The Galeazzi fracture is a fracture of the middle to distal one-third of the radius associated with dislocation or subluxation of the distal radioulnar joint. It presents with pain, swelling and deformity. Physical examination reveals point tenderness over the fracture site. Isolated fracture of radius is rare and there usually is an associated injury.
Other fractures:
– Colles’ fracture (dinner fork deformity): fall onto extended outstretched hand. Classical Colles’ fractures have 3 features:
1. Transverse fracture of the radius
2. 1 inch proximal to the radio-carpal joint
3. Dorsal displacement and angulation– Smith’s fracture (reverse Colles’ fracture): volar angulation of distal radius fragment (Garden spade deformity). Caused by falling backwards onto the palm of an outstretched hand or falling with wrists flexed
– Bennett’s fracture: Intra-articular fracture of the first carpometacarpal joint. Impact on flexed metacarpal, caused by fist fights
– Monteggia’s fracture: dislocation of the proximal radioulnar joint in association with an ulna fracture. Caused by a fall on outstretched hand with forced pronation.
– Pott’s fracture: Bimalleolar ankle fracture from forced foot eversion
– Barton’s fracture: Distal radius fracture (Colles’/Smith’s) with associated radiocarpal dislocation from a fall onto extended and pronated wrist
– Holstein Lewis Fracture: fracture of the distal third of the humerus resulting in entrapment of the radial nerve.
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This question is part of the following fields:
- Generic Surgical Topics
- Orthopaedics
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Question 47
Correct
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When inserting a chest drain anteriorly into the second intercostal space, one must identify the second costal cartilage by palpating which landmark?
Your Answer: Sternal angle
Explanation:The sternal angle is the site for identification of the second rib as the second rib is attached to the sternum at this point.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 48
Correct
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A 70-year old man had had a large indirect inguinal hernia for 3 years. He presents at the out patient clinic complaining of pain in the scrotum. There is, however, no evidence of obstruction or inflammation. You conclude that the hernial sac is most probably compressing the:
Your Answer: Ilioinguinal nerve
Explanation:The ilioinguinal nerve arises together with the iliohypogastric nerve from the first lumbar nerve to emerge from the lateral border of the psoas major muscle just below the iliohypogastric and passing obliquely across the quadratus lumborum and iliacus muscles. It perforates the transversus abdominis, near the anterior part of the iliac crest and communicates with the iliohypogastric nerve between the internal oblique and the transversus. It then pierces the internal oblique to distribute filaments to it and accompanying the spermatic cord through the subcutaneous inguinal ring, is distributed to the skin of the upper and medial parts of the thigh, the skin over the root of the penis and the upper part of the scrotum in man and to the skin covering the mons pubis and labium majus in the woman. As the ilioinguinal nerve runs through the inguinal canal, it could easily be compressed by a hernial sac.
The femoral branch of genitofemoral nerve provides sensory innervation of the upper medial thigh.
The femoral nerve innervates the compartment of the thigh and also has some cutaneous sensory branches to the thigh.
The iliohypogastric nerve innervates the skin of the lower abdominal wall, upper hip and upper thigh. The subcostal nerve innervates the skin of the anterolateral abdominal wall and the anterior scrotal nerve is a terminal branch of the ilioinguinal nerve. -
This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 49
Correct
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Which of the following coagulation factors cross-links fibrin?
Your Answer: Factor XIII
Explanation:Factor XIII, also known as fibrin stabilizing factor, is an enzyme of the coagulation cascade that crosslinks fibrin. Deficiency of FXIII may cause bleeding tendency but paradoxically, it may also predispose to thrombosis.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 50
Correct
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Which of the following diseases affects young adults, causing pain in any bone -particularly long bones- which worsens at night, and is typically relieved by common analgesics, such as aspirin?
Your Answer: Osteoid osteoma
Explanation:Osteoid osteoma, which tends to affect young adults, can occur in any bone but is most common in long bones. It can cause pain (usually worse at night) that is typically relieved by mild analgesics, such as non-steroidal anti-inflammatory drugs. X-ray findings include a small radiolucent zone surrounded by a larger sclerotic zone.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 51
Correct
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The left lateral pterygoid muscle is one of the muscles of mastication. When acting alone, it will shift the mandible towards which direction?
Your Answer: Laterally, to the right
Explanation:The lateral pterygoid or external pterygoid is a muscle of mastication with two heads. It lies superiorly to the medial pterygoid. When acting alone, it will shift the mandible laterally and to the right.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 52
Correct
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A 50-year-old man presents with unilateral facial paralysis after being hit on the head. On examination, he has a right-sided facial nerve palsy and watery discharge from the nose. What is the most likely underlying cause?
Your Answer: Petrous temporal fracture
Explanation:Nasal discharge of clear fluid and a recent head injury makes basal skull fracture the most likely underlying cause for facial nerve palsy.
Facial palsy is a neurological condition in which function of the facial nerve (cranial nerve VII) is partially or completely lost. It is often idiopathic (Bell’s palsy) but in some cases, specific causes such as trauma (e.g. temporal bone fracture), infections, or metabolic disorders can be identified. Two major types are distinguished:
1. Central facial palsy—lesion occurs between cortex and nuclei in the brainstem
2. Peripheral facial palsy—lesion occurs between nuclei in the brainstem and peripheral organsDiagnosis can usually be made clinically while patient’s history often helps in evaluating the underlying aetiology.
Patients with basal skull fracture following head injury (as in this case) exhibit Battle’s sign on examination. It is an indication of fracture of middle cranial fossa of the skull and consists of bruising over the mastoid process as a result of extravasation of blood along the path of the posterior auricular artery. Clinical presence of CSF leak further supports the diagnosis.Assessment options for basal skull fracture include CT and MRI scan. Idiopathic facial nerve palsy is treated with oral glucocorticoids and, in severe cases, with antivirals. Treatment of the other types depends on the underlying cause. Prophylactic antibiotics are given in cases of CSF leak.
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This question is part of the following fields:
- Generic Surgical Topics
- Head And Neck Surgery
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Question 53
Correct
-
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: 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 54
Incorrect
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A male teenager is taken to the A&E department with lower abdominal discomfort. For the last several months, he has been having intermittent right iliac fossa pain. A negative colonoscopy and gastroscopy for iron deficiency anaemia are seen in his past medical history notes. He states that the pain is worse after eating. Tests show that his inflammatory markers are normal. What is the likely diagnosis?
Your Answer: Peptic ulcer disease
Correct Answer: Meckel's diverticulum
Explanation:Answer: Meckel’s diverticulum
Meckel’s diverticulum is the most common congenital malformation of the gastrointestinal tract (present in 2%-4% of population) due to persistence of the congenital vitello-intestinal duct. Bleeding from Meckel’s diverticulum due to ectopic gastric mucosa is the most common clinical presentation, especially in younger patients, but it is rare in the adult population. This is due to the persistence of the proximal part of the congenital vitello-intestinal duct. It is a true diverticulum, typically located on anti-mesenteric border, and contains all three coats of intestinal wall with its separate blood supply from the vitelline artery. Meckel’s diverticulum is lined mainly by the typical ileal mucosa as in the adjacent small bowel. However, ectopic gastric, duodenal, colonic, pancreatic, Brunner’s glands, hepatobiliary tissue and endometrial mucosa may be found, usually near the tip. The main mechanism of bleeding is the acid secretion from ectopic mucosa, leading to ulceration of adjacent ileal mucosa. It is possible that the recurrent intussusception may cause trauma, inflammation, mucosal erosion and bleeding. The pathogenic role of Helicobacter pylori in the development of gastritis and bleeding in the ectopic gastric mucosa is still debatable. NSAIDs’ effect on the ectopic gastric mucosa is yet to be proved. Bleeding from Meckel’s diverticulum can cause the iron deficiency anaemia, but it may also cause megaloblastic anaemia due to the bacterial overgrowth and vitamin B12 deficiency as a result of the dilatation and stasis in adjacent obstructed ileal loop. The presence of bleeding with hypoalbuminemia and low ferritin due to ongoing slow unrecognized bleeding may lead to the diagnosis of inflammatory bowel disease.
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This question is part of the following fields:
- Generic Surgical Topics
- The Abdomen
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Question 55
Correct
-
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 56
Correct
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Which of the following arteries, that runs on the superior aspect of the first part of the duodenum, forms the lower boundary of the epiploic foramen (also known as the foramen of Winslow)?
Your Answer: Hepatic
Explanation:The epiploic foramen is an important anatomical opening that allows for the communication between the greater peritoneal sac and the lesser peritoneal sac. Its boundaries are formed; superiorly by the caudate lobe of the liver, anteriorly by the hepatoduodenal ligament (containing the components of the portal triad), inferiorly by the first part of the duodenum and posteriorly by the peritoneum covering the inferior vena cava. The superior aspect of the first part of the duodenum, which forms the inferior boundary of the foramen of Winslow, forms the course of the hepatic artery before it ascends to the porta hepatis where it divides into its right and left branches.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 57
Correct
-
Which of the following variables are needed to calculate inspiratory reserve volume of a patient?
Your Answer: Tidal volume, vital capacity and expiratory reserve volume
Explanation:Vital capacity = inspiratory reserve volume + tidal volume + expiratory reserve volume. Thus, inspiratory reserve volume can be calculated if tidal volume, vital capacity and expiratory reserve volume are known.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 58
Correct
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A patient sustained an injury to the facial nerve after it emerges from the stylomastoid foramen. What is the clinical impact of this injury?
Your Answer: Facial expression
Explanation:The facial nerve is the seventh of the twelve paired cranial nerves. It emerges from the brainstem between the pons and the medulla. It controls the muscles of facial expression and supplies taste fibres to the anterior two-thirds of the tongue. It also supplies preganglionic parasympathetic fibres to several head and neck ganglia. Its branches and distribution are as follows:
Inside the facial canal (proximal to the stylomastoid foramen):
– Greater petrosal nerve – provides parasympathetic innervation to the lacrimal gland, as well as special taste sensory fibres to the palate via the nerve of pterygoid canal
– Nerve to stapedius – provides motor innervation for the stapedius muscle in the middle ear
– Chord tympani – provides parasympathetic innervation to the submandibular and sublingual glands and special sensory taste fibres for the anterior two-thirds of the tongue
Outside the skull (distal to the stylomastoid foramen):
– Posterior auricular nerve – controls the movements of some of the scalp muscles around the ear
– Five major facial branches (in the parotid gland), from top to bottom: temporal branch, zygomatic branch, buccal branch, marginal mandibular branch and cervical branch. From the description given above it is obvious that injury to the facial nerve distal to the stylomastoid foramen will affect facial expression. -
This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 59
Correct
-
An ECG of a 30 year old woman revealed low voltage QRS complexes. This patient is most probably suffering from?
Your Answer: Pericardial effusion
Explanation:The QRS complex is associated with current that results in the contraction of both the ventricles. As ventricles have more muscle mass than the atria, they result in a greater deflection on the ECG. The normal duration of a QRS complex is 10s. A wide and deep Q wave depicts myocardial infarction. Abnormalities in the QRS complex maybe indicative of a bundle block, ventricular tachycardia or hypertrophy of the ventricles. Low voltage QRS complexes are characteristic of pericarditis or a pericardial effusion.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 60
Correct
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Which type of thyroid tumour represents 75 - 80% of thyroid cancer cases? This type is predominant in children and in patients who have had a previous history of head or neck radiation.
Your Answer: Papillary carcinoma
Explanation:Papillary thyroid carcinoma is the most common thyroid cancer. This cancer has a high cure rate with 10-year survival rates for all patients with papillary thyroid cancer estimated at 80% to 90%.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 61
Correct
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Regarding the posterior compartment of the leg, which is correct?
Your Answer: The muscles plantarflex the foot and are innervated by the tibial nerve
Explanation:The muscles of the back of the leg are subdivided into two groups: superficial and deep. Superficial muscles include gastrocnemius, soleus and plantaris. Deep muscles include tibialis posterior, flexor hallucis longus, flexor digitorum longus and popliteus. The superficial ( calf muscles) which are responsible for plantarflexion of the foot are supplied by the tibial nerve as follows: the gastrocnemius and soleus muscles are supplied by the first and second sacral nerves and the plantaris by the fourth and fifth lumbar and first sacral nerve (the tibial nerve).
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 62
Correct
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A 47-year old-woman diagnosed with pancreatitis presented to the emergency department complaining of a worsening shortness of breath, fever, agitation and cough. Oxygen saturation was 67% in room air. Her respiratory status continued to deteriorate therefore she was intubated. She was admitted to the intensive care unit for management. Chest X-ray demonstrated bilateral perihilar opacities. The patient failed conventional treatment and died several days later. At autopsy, the lung shows growth of type 2 pneumocytes and thickened alveolar walls. What is the most probable diagnosis?
Your Answer: Adult respiratory distress syndrome
Explanation:Acute (or adult) respiratory distress syndrome (ARDS) is a life-threatening lung condition characterised by a non-cardiogenic pulmonary oedema that leads to acute respiratory failure. The most common risk factors for ARDS include trauma with direct lung injury, sepsis, pneumonia, pancreatitis, burns, drug overdose, massive blood transfusion and shock. Acute onset of dyspnoea with hypoxemia, anxiety and agitation is typical. Chest X ray most commonly demonstrates bilateral pulmonary infiltrates. Histological changes include the exudative, proliferative and fibrotic phase. ARDS is mainly a clinical diagnosis.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 63
Correct
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A 45-year old male patient with a long history of alcoholism developed liver cirrhosis that has led to portal hypertension. Which of the following plexuses of veins is most likely dilated in this patient?
Your Answer: Haemorrhoidal plexus
Explanation:The haemorrhoidal plexus or also known as the rectal plexus is a venous plexus that surrounds the rectum. This venous plexus in males communicates anteriorly with the vesical plexus and uterovaginal plexus in females. This venous plexus forms a site of free communication between the portal and systemic venous systems. In the case of portal hypertension this plexus would most likely dilate due to the increased pressure.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 64
Correct
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A 55-year-old woman died 3 years after a cardiac transplant due to worsening congestive heart failure. Autopsy revealed diffuse hyperplasia of the vascular intima involving the entire length of the coronary arteries. The most probable cause of deterioration of the cardiac function is:
Your Answer: Coronary atherosclerosis
Explanation:Allograft coronary artery disease (CAD) can begin right after the transplant and is the major cause of later death in cardiac transplant recipients. This form of atherosclerosis progresses quickly resulting in allograft failure. Due to lack of premonitory symptoms CAD may lead to sudden death.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 65
Correct
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Paracentesis of ascetic fluid in a 45-year old woman revealed the following : clear, yellow fluid with protein 2.0 g/dl and a few mesothelial and mononuclear cells seen. No malignant cells seen. What is the likely diagnosis?
Your Answer: Micronodular cirrhosis
Explanation:Cirrhosis is disease of the liver that is characterized by fibrosis leading to disorganization of the hepatic architecture. It shows the development of regenerative nodules surrounded by dense fibrotic tissue. Cirrhosis shows non-specific symptoms initially, which include fatigue, anorexia and weight loss. It can later progress to portal hypertension, ascites and liver failure.
Micronodular cirrhosis is named so, due to the uniformly small nodules (<3 mm in diameter) and thick regular bands of connective tissue. These nodules lack lobular organization with distortion of central hepatic venules and portal triads. Over a period of time, macronodular cirrhosis develops, with bigger nodules (3 mm to 5 cm in diameter) surrounded by broad fibrous bands, and some amount of lobular organization. Mixed cirrhosis combines features of both micronodular and macronodular cirrhosis. -
This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 66
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 67
Correct
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A 51-year-old man is brought to the A&E department following a road traffic accident. He complains of lower abdominal pain. On examination, fracture of the pelvis along with distended, tender bladder is observed. What is the most likely diagnosis?
Your Answer: Urethral injury
Explanation:Pelvic fractures may cause laceration of the urethra. Urinary retention, blood at the urethral meatus, and a high-riding prostate on digital rectal examination are the typical features of urethral injury.
Up to 10% of male pelvic fractures are associated with urethral or bladder injuries. Urethral injury occurs mainly in males. It has two types.
1.Bulbar rupture:
a. most common
b. mostly associated with straddle-type injury, e.g. from bicycles
c. presentation with a triad of urinary retention, perineal haematoma, and blood at the meatus2. Membranous rupture:
a. can be extra- or intraperitoneal
b. occurs commonly due to pelvic fracture
c. symptomology may include penile or perineal oedema/haematoma
d. prostate displaced upwards (high-riding prostate)Ascending urethrogram is carried out in patients of suspected urethral injury. Suprapubic catheter is surgically placed and is indicated in:
1. External genitalia injuries (i.e. the penis and the scrotum)
2. Injury to the urethra caused by penetration, blunt trauma, continence- or sexual pleasure–enhancing devices, and mutilation. -
This question is part of the following fields:
- Generic Surgical Topics
- Urology
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Question 68
Correct
-
Which is a feature of the action of insulin?
Your Answer: Promotes protein synthesis
Explanation:Insulin is produced by the beta-cells of the islets of Langerhans in the pancreas. Its actions include:
– promoting uptake of glucose into cells
– glycogen synthesis (glycogenesis)
– protein synthesis
– stimulation of lipogenesis (fat formation).
– driving potassium into cells – used to treat hyperkaelamia.
Parathyroid hormone and activated vitamin D are the principal hormones involved in calcium/phosphate metabolism, rather than insulin. -
This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 69
Correct
-
Mallory bodies are characteristic of which of the following conditions?
Your Answer: Alcoholic hepatitis
Explanation:Mallory bodies (or ‘alcoholic hyaline’) are inclusion bodies in the cytoplasm of liver cells, seen in patients of alcoholic hepatitis; and also in Wilson’s disease. These pathological bodies are made of intermediate keratin filament proteins that are ubiquinated or bound by proteins like heat chock protein. Being highly eosinophilic, they appear pink on haematoxylin and eosin staining.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 70
Correct
-
A young female in the 15th week of pregnancy presented to the emergency department with the passage of grape-like masses per vagina. Dilatation and curettage was done and microscopy revealed large avascular villi with trophoblastic proliferation. Which one of the following investigations is best recommended for her follow-up?
Your Answer: Serum β-hCG
Explanation:Trophoblast is the layer of cells surrounding the blastocyst and that later develops into the chorion and amnion. Gestational trophoblastic disease is a tumour arising from this trophoblast. It can occur during or after either an intrauterine or ectopic pregnancy. If it occurs in a pregnant woman, it usually leads to spontaneous abortion, eclampsia or fetal death. It can be either malignant or benign.
In suspected cases, investigations include measurement of serum beta subunit of human chorionic gonadotrophin (β-hCG) and pelvic ultrasound. Confirmatory test is a biopsy. Post-removal, the disease is classified clinically to assess further treatment. To assess the presence of metastases, further work-up includes computed tomography of the brain, chest, abdomen and pelvis. Chemotherapy is usually needed for persistent disease. If at least three consecutive, weekly serum β-hCG measurements are normal, treatment is considered successful. Follow-up is also done by measuring β-hCG. -
This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 71
Correct
-
Hepatomegaly with greatly increased serum alpha-fetoprotein is seen in which of the following conditions?
Your Answer: Hepatocellular carcinoma
Explanation:Hepatocellular carcinoma or hepatoma affects people with pre-existing cirrhosis and is more common in areas with higher prevalence of hepatitis B and C. Diagnosis include raise alpha-fetoprotein levels, imaging and liver biopsy if needed. Patients at high-risk for developing this disease can undergo screening by periodic AFP measurement and abdominal ultrasonography. The malignancy carries poor prognosis (see also Answer to 10.4).
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 72
Correct
-
A 4-year-old child was brought to a paediatrician for consult due to a palpable mass in his abdomen. The child has poor appetite and regularly complains of abdominal pain. The child was worked up and diagnosed with a tumour. What is the most likely diagnosis ?
Your Answer: Nephroblastoma
Explanation:Nephroblastoma is also known as Wilms’ tumour. It is a cancer of the kidneys that typically occurs in children. The median age of diagnose is approximately 3.5 years. With the current treatment, approximately 80-90% of children with Wilms’ tumour survive.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 73
Correct
-
Action potentials are used extensively by the nervous system to communicate between neurones and muscles or glands. What happens during the activation of a nerve cell membrane?
Your Answer: Sodium ions flow inward
Explanation:During the generation of an action potential, the membrane gets depolarized which cause the voltage gated sodium channels to open and sodium diffuses inside the neuron, resulting in the membrane potential moving towards a positive value. This positive potential will then open the voltage gated potassium channels and cause more K+ to move out decreasing the membrane potential and restoring the membrane potential to its resting value.
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This question is part of the following fields:
- Basic Sciences
- Physiology
-
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Question 74
Correct
-
Which of the following is a potential cause of a positive D-dimer assay?
Your Answer: Deep venous thrombosis
Explanation:A D-dimer test is performed to detect and diagnose thrombotic conditions and thrombosis. A negative result would rule out thrombosis and a positive result although not diagnostic, is highly suspicious of thrombotic conditions like a deep vein thrombosis, pulmonary embolism as well as DIC.
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This question is part of the following fields:
- Basic Sciences
- Physiology
-
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Question 75
Incorrect
-
A 22-year-old man undergoes incision and drainage of an axillary abscess. How should the wound be managed?
Your Answer: Packing with gauze
Correct Answer: Packing with alginate dressing
Explanation:The wound of this patient should be packed with alginate dressing. Abscess wounds should not undergo primary closure. Moreover, use of gauze is inappropriate and would be difficult to redress.
Alginate dressings are absorbent wound care products that contain sodium and calcium fibres derived from seaweed. An individual dressing is able to absorb up to 20 times its own weight. These dressings, which are easy to use, mold themselves to the shape of the wound, which helps ensure that they absorb wound drainage properly. In abscesses requiring incision and drainage, alginate dressings are well-tolerated and their removal causes minimal pain.
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This question is part of the following fields:
- Principles Of Surgery-in-General
- Surgical Technique And Technology
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Question 76
Correct
-
Which tumour site is more commonly involved in adults than in children?
Your Answer: Lung
Explanation:In adults, the most common primary site of tumour is in the lungs, compared to children wherein the most common primary site is the blood.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 77
Correct
-
A 64 year old woman with metastatic breast cancer presents with bone pain. Radiological reports show a metastatic lytic lesion in her femoral shaft. The lesion occupies 75 percent of the bone diameter. Which of the following would be the most appropriate step in the management of this patient?
Your Answer: Fixation with intramedullary nail
Explanation:The role of surgery for bone metastasis can be divided into (i) prophylactic fixation to prevent impending pathological fractures, (ii) stabilization of a pathological fractures, (iii) segmental resection of tumours, and (iv) arthroplasty for replacing joints that have been destroyed by a tumour. To this end, orthopaedic surgeons have a vast array of surgical devices and implants in their surgical armamentarium at their disposal. These include plates and screws, intramedullary fixation devices, and tumour endoprostheses.
Even with surgical fixation only 30% of pathological fractures unite. -
This question is part of the following fields:
- Oncology
- Principles Of Surgery-in-General
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Question 78
Incorrect
-
A growing tumour is impinging on the lingual artery in the floor of the mouth. Which structure will experience decreased blood flow?
Your Answer: The genioglossus muscle
Correct Answer: The sublingual gland
Explanation:The paired sublingual glands are major salivary glands in the mouth. They are the smallest, most diffuse, and the only unencapsulated major salivary glands. They provide only 3-5% of the total salivary volume. The gland receives its blood supply from the sublingual and submental arteries. The sublingual artery is a branch of the lingual artery, thus damage to the lingual artery will decrease the blood flow to the sublingual gland.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 79
Correct
-
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 80
Correct
-
A 34 year old athlete presents to the clinic after receiving a hard blow to his palm that has resulted into a painful swelling over the volar aspect of his hand. On examination, pain is felt on wrist movement and longitudinal compression of the thumb. Which of the following is the most likely injury?
Your Answer: Scaphoid fracture
Explanation:The scaphoid bone is the most commonly fractured carpal bone. Fractures are most often localized in the middle third of the scaphoid bone.
Generally, scaphoid bone fractures result from indirect trauma when an individual falls onto the outstretched hand with a hyperextended and radially deviated wrist. Pain when applying pressure to the anatomical snuffbox is highly suggestive of a scaphoid bone fracture.
X-ray is the initial test of choice for diagnosis. Computer tomography and magnetic resonance imaging may be indicated, if x-ray findings are negative but clinical suspicion is high.
Treatment can be conservative (e.g., wrist immobilization) or in certain cases surgical (e.g., proximal pole fracture). Complications include non-union and avascular necrosis. -
This question is part of the following fields:
- Generic Surgical Topics
- Orthopaedics
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Question 81
Correct
-
A 31 -year-old female patient had a blood gas done on presentation to the emergency department. She was found to have a metabolic acidosis and decreased anion gap. The most likely cause of these findings in this patient would be?
Your Answer: Hypoalbuminemia
Explanation:A low anion gap might be caused by alterations in serum protein levels, primarily albumin (hypoalbuminemia), increased levels of calcium (hypercalcaemia) and magnesium (hypermagnesemia) or bromide and lithium intoxication. However, the commonest cause is hypoalbuminemia, thus if the albumin concentration falls, the anion gap will also be lower. The anion gap should be corrected upwards by 2.5 mmol/l for every 10g/l fall in the serum albumin.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 82
Correct
-
Staphylococcus aureus can be identified in the laboratory based on the clotting of plasma. Which microbial product is responsible for this activity?
Your Answer: Coagulase
Explanation:Staphylococcus aureus is the most pathogenic species and is implicated in a variety of infections. S. aureus can be identified due to its production of coagulase. The staphylococcal enzyme coagulase will cause inoculated citrated rabbit plasma to gel or coagulate. The coagulase converts soluble fibrinogen in the plasma into insoluble fibrin.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 83
Incorrect
-
A 32-year-old male is admitted overnight, following a road traffic accident. He has an open tibial fracture with a 20 cm wound and extensive periosteal stripping. He is neurovascularly intact; IV antibiotics and wound dressing have been administered in the emergency department. What is the most appropriate course of action?
Your Answer: Immediate skeletal stabilisation and application of negative pressure dressing
Correct Answer: Combined skeletal and soft tissue reconstruction on a scheduled operating list
Explanation:The patient has Gustilo-Anderson Grade IIIb.
Options for wound closure in the treatment of open fractures include primary closure of the skin, split-thickness skin grafting, and the use of either free or local muscle flaps. The timing of open wound closure has proponents in the immediate, early, and delayed categories
Gustilo-Anderson classification
Type I – Open fracture with a wound less than 1 cm in length, and clean
Type II – Open fracture with a laceration more than 1 cm in length, without extensive soft-tissue damage, flaps, or avulsions
Type III – Either an open segmental fracture, an open fracture with extensive soft-tissue damage, or a traumatic amputation
The description of type III fractures was subsequently further refined and described by Gustilo et al in 1984, [6] as follows:
Type IIIa – Severe comminution or segmental fractures, but with adequate coverage of bone and a wound that is closable by simple means
Type IIIb – Extensive soft-tissue damage in association with the open fracture, with significant bone exposure and periosteal stripping, typically requiring tissue rotation or free tissue transfer for closure
Type IIIc – Any open fracture with an arterial injury that requires repair -
This question is part of the following fields:
- Generic Surgical Topics
- Orthopaedics
-
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Question 84
Correct
-
Which of the following morphological features is most characteristic of hyaline degeneration?
Your Answer: Homogeneous, ground-glass, pink-staining appearance of cells
Explanation:The characteristic morphological features of hyaline degeneration is ground-glass, pinking staining cytoplasm with an intact cell membrane. The accumulation of lipids, calcium salts, lipofuscin and an amorphous cytoplasm with an intact cell membrane are all characteristically found in different situations.
Pyknotic nucleus and orphan Annie eye nucleus are not seen in hyaline degeneration. -
This question is part of the following fields:
- Basic Sciences
- Pathology
-
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Question 85
Correct
-
Identify which of the following muscles acts on two joints?
Your Answer: Sartorius
Explanation:The sartorius muscle, the longest muscle in the body, is one of the two jointed or biarticular muscles. It originates from the anterior superior iliac spine and part of the notch between the anterior superior iliac spine and anterior inferior iliac spine and crosses both the hip joint and the knee joint. At the hip joint the sartorius flexes and rotates the thigh at the hip joint and flexes the leg at the knee joint.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 86
Correct
-
A 40-year old gentleman, known with past peptic ulcer disease, was brought to the clinic in a dehydrated state with persistent vomiting. His blood investigations revealed sodium = 142 mmol/l, potassium = 2.6 mmol/l, chloride = 85 mmol/l, pH = 7.55, p(CO2) = 50 mmHg, p(O2) = 107 mmHg and standard bicarbonate = 40 mmol/l. This patient had:
Your Answer: Metabolic alkalosis
Explanation:High pH with high standard bicarbonate indicates metabolic alkalosis. The pa(CO2) was appropriately low in compensation. This is hypokalaemia hypochloraemic metabolic acidosis due to prolonged vomiting. Treatment includes treating the cause and intravenous sodium chloride with potassium.
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This question is part of the following fields:
- Basic Sciences
- Physiology
-
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Question 87
Incorrect
-
A 24-year-old rugby player sustains a fracture of the distal radius after falling on his outstretched right hand during the game. X-ray shows a dorsally angulated comminuted fracture. What is the most appropriate management?
Your Answer: Reduce under haematoma block and place in plaster cast
Correct Answer: Admit for open reduction and internal fixation
Explanation:This is a case of a high-velocity injury and, therefore, requires surgical fixation.
Bony injury resulting in a fracture may occur due to trauma (excessive force applied to bone), stress (repetitive low-velocity injury), or underlying pathology (abnormal bone which fractures during normal use or following minimal trauma).
Diagnosis involves not just evaluating the fracture, such as the site and type of injury, but also other associated injuries and distal neurovascular status. This may entail not just clinical examination but radiographs of proximal and distal joints. When assessing x-rays, it is important to assess for changes in the length of the bone, the angulation of the distal bone, rotational effects, and the presence of a foreign body such as glass.
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This question is part of the following fields:
- Generic Surgical Topics
- Orthopaedics
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Question 88
Correct
-
Glucose is the most important source of energy for cellular respiration. The transport of glucose in the renal tubular cells occurs via:
Your Answer: Secondary active transport with sodium
Explanation:In 1960, Robert K. Crane presented for the first time his discovery of the sodium-glucose cotransport as the mechanism for glucose absorption. Glucose transport through biological membranes requires specific transport proteins. Transport of glucose through the apical membrane of renal tubular as well as intestinal epithelial cells depends on the presence of secondary active Na+–glucose symporters, SGLT-1 and SGLT-2, which concentrate glucose inside the cells, using the energy provided by co-transport of Na+ ions down their electrochemical gradient.
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This question is part of the following fields:
- Basic Sciences
- Physiology
-
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Question 89
Correct
-
Muscles and tendons in the planter region of the foot mainly take blood supply from:
Your Answer: Posterior tibial artery
Explanation:The posterior tibial artery is the main source of blood supply to the posterior compartment of the leg.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 90
Correct
-
A patient at the time of her second delivery opted for a bilateral pudendal nerve block. In order to inject the anaesthetic agent near the pudendal nerve a anaesthetic consultant had to insert a finger into the vagina and press laterally to palpate which landmark?
Your Answer: Ischial spine
Explanation:The ischial spine is always palpated through the walls of the vagina when performing a transvaginal pudendal nerve block and can easily be palpated on the lateral wall of the vagina.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 91
Correct
-
A surgical registrar performing an adrenalectomy procedure on the left suprarenal gland of a 25 - year old male patient, accidentally jabbed and injured a vital structure that lies anterior to the left suprarenal organ. Which of the following was the structure most likely injured?
Your Answer: Pancreas
Explanation:The adrenal (suprarenal) glands are organs of the endocrine system located on top of each of the kidneys. The left suprarenal gland, in question, is crescent in shape and slightly larger than the right suprarenal gland. It is posteriorly located to the lateral aspect of the head of the pancreas which is thus the most likely to be injured. The other organs like the duodenum, liver and the inferior vena cava are related to the right suprarenal gland. The spleen and the colon are not in close proximity with the left suprarenal gland and are not likely to be the organs injured.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
-
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Question 92
Correct
-
During a street fight a boy sustained a laceration below the elbow. It was a deep cut that led to profuse bleeding from an artery situated on the supinator muscle immediately below the elbow. The vessel most likely to have been injured is?
Your Answer: Radial recurrent artery
Explanation:The radial recurrent artery is situated on the supinator muscle then passing between the brachialis and the brachioradialis muscles. It originates from the radial artery and ends by anastomosing with the terminal part of the Profunda brachii.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
-
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Question 93
Correct
-
Which of the following is a fact worth noting about the development of the spleen?
Your Answer: It develops in the dorsal mesogastrium
Explanation:The spleen in the human embryo arises in week 5 of intrauterine life. It appears as a proliferating mesenchyme above the pancreas. The spleen is one the organs that develops in the dorsal mesogastrium. When the stomach changes its position during development, the spleen is made to move behind the stomach and stays in contact with the left kidney. The spleen is found within the peritoneum of the abdominal cavity thus it is an intraperitoneal organ.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 94
Correct
-
A 64 year old woman received midazolam before a colonoscopy. During the procedure her respiratory rate slows down and she becomes hypoxic. The anaesthetist decides to reverse her sedation. Which of the following drugs should be administered?
Your Answer: Flumazenil
Explanation:Reversal of the central effects of midazolam by intravenous flumazenil after general anaesthesia. Since many benzodiazepines have longer half lives than flumazenil patients still require close monitoring after receiving the drug. Other drugs provided in the options would not characteristically be used for the reversal of midazolam.
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This question is part of the following fields:
- Peri-operative Care
- Principles Of Surgery-in-General
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Question 95
Correct
-
A 13-year-old boy's mother notices he has a lump in his arm, near his right shoulder. An X-ray reveals a lateral projection in the metaphyseal region of his humerus. The lesion is removed and it is found to be composed of bony cortex, capped by cartilage. What's the most likely diagnosis in this case?
Your Answer: Osteochondroma
Explanation:Osteochondromas, or osteocartilaginous exostoses, are the most common benign bone tumours, and tend to appear near the ends of long bones. The overgrowth can occur in any bone where cartilage forms bone, and they are capped by cartilage. They are most common in people between the ages of 10-20 years old.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 96
Incorrect
-
Which of the following is the most likely cause of massive splenomegaly in a 35-year old gentleman?
Your Answer: Infectious mononucleosis
Correct Answer: Myelofibrosis
Explanation:Causes of massive splenomegaly include chronic myelogenous leukaemia, chronic lymphocytic leukaemia, lymphoma, hairy cell leukaemia, myelofibrosis, polycythaemia vera, sarcoidosis, Gaucher’s disease and malaria.
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This question is part of the following fields:
- Basic Sciences
- Pathology
-
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Question 97
Incorrect
-
A 50-year-old female has a metallic heart valve and requires a paraumbilical hernia repair. Perioperatively, she is receiving intravenous unfractionated heparin. To perform the surgery safely a normal coagulation state is required. Which of the following strategies is a routine standard practice?
Your Answer: Stopping the heparin infusion 6 hours pre operatively and administration of intravenous protamine sulphate on commencing the operation
Correct Answer: Stopping the heparin infusion 6 hours pre operatively
Explanation:In performing noncardiac surgery on patients on anticoagulation, the major concern is when it is safe to perform surgery without increasing the risk of haemorrhage or increasing the risk of thromboembolism (e.g., venous, arterial) after discontinuing treatment.
Any patient who is on long-term anticoagulation and is to undergo a major surgery needs proactive management.
Heparin is discontinued 6-12 hours before surgery and restarted at 200-400 U/h at 4-6 hours after surgery. Coumadin is restarted as soon as tolerated by the patient. Stop oral anticoagulants at least 5 days preoperatively, and do not perform the procedure until the PT is in the reference range. -
This question is part of the following fields:
- Peri-operative Care
- Principles Of Surgery-in-General
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Question 98
Correct
-
A 30-year-old man is brought to the emergency department suffering from extreme dehydration, and subsequent hypotension and tachycardia. Which part of the kidney will compensate for this loss?
Your Answer: Collecting ducts
Explanation:The collecting duct system of the kidney consists of a series of tubules and ducts that physically connect nephrons to a minor calyx or directly to the renal pelvis. The collecting duct system is the last component of the kidney to influence the body’s electrolyte and fluid balance. In humans, the system accounts for 4–5% of the kidney’s reabsorption of sodium and 5% of the kidney’s reabsorption of water. At times of extreme dehydration, over 24% of the filtered water may be reabsorbed in the collecting duct system.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 99
Incorrect
-
A 35 year old woman presents to her family physician complaining of perianal discomfort. She is diagnosed with pruritis ani. Which of the following would not be associated with this condition?
Your Answer: Hyperbilirubinemia
Correct Answer: Tuberculosis
Explanation:Tuberculosis is least likely to be associated with this condition. Anal pruritus affects up to 5% of the population. It is often persistent and the constant urge to scratch the area can cause great distress. Although usually caused by a combination of irritants, particularly faecal soiling and dietary factors, it can be a symptom of serious dermatosis, skin or generalised malignancy or systemic illness.
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This question is part of the following fields:
- Colorectal Surgery
- Generic Surgical Topics
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Question 100
Correct
-
The periphery of a haematoma is infiltrated by fibroblasts, collagen and new vasculature. This process is best described as?
Your Answer: Organisation of the haematoma
Explanation:Formation of granulation tissue at the periphery of the hematoma is a normal process leading to resolution. This granulation tissue is composed of new capillaries, fibroblasts and collagen. Lysis of a blood clot can occur, but the actual process of this response is known as organization, wherein the scar tissue will become part of the vessels. This is followed by recanalization and embolization which can lead to eventual complications. Proliferation of a clot will occur due to an imbalance in the clotting and lysing systems. Thrombosis has nothing to do with the process described above.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 101
Correct
-
Anthrax is an infection caused by the bacterium Bacillus anthracis. Anthrax spores have been used as a biological warfare weapon. What is the drug of choice in treating anthrax infection?
Your Answer: Ciprofloxacin
Explanation:Early antibiotic treatment of anthrax is essential. A delay may significantly lessen the chances for survival of the patient. Treatment for anthrax infection include large doses of intravenous and oral antibiotics, such as fluoroquinolones (ciprofloxacin), doxycycline, erythromycin, vancomycin, or penicillin.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 102
Correct
-
A 33 year old African woman presents with complaints of continuous dribbling of urine after the birth of her second child. The woman denies any complications associated with her pregnancies except for prolonged labour. She is otherwise healthy and feels well. Which of the following is the most likely diagnosis?
Your Answer: Vesicovaginal fistula
Explanation:Vesicovaginal fistula (VVF) is an abnormal opening between the bladder and the vagina that results in continuous and unremitting urinary incontinence. It is one of the most distressing complications of gynaecologic and obstetric procedures. Vesicovaginal fistulae should be suspected in patients with continuous dribbling incontinence after prolonged labour.
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This question is part of the following fields:
- Generic Surgical Topics
- Urology
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Question 103
Correct
-
A 55-year-old male undergoes a laparotomy for perforated bowel after a colonoscopy. 2 days after surgery the nursing staff report there is pink, serous fluid discharging from the wound. What is the next most appropriate management step?
Your Answer: Examine the wound for separation of the rectus fascia
Explanation:Surgical wound dehiscence (SWD) is the separation of the margins of a closed surgical incision that
has been made in the skin, with or without exposure or protrusion of underlying tissue, organs or implants. Separation may occur at single or multiple regions, or involve the full length of the incision, and may affect some or all tissue layers. A dehisced incision may, or may not, display clinical signs and symptoms of infection.
SWD can occur without warning. Incisions at risk of dehiscence may show signs of inflammation beyond the time and extent expected for normal healing, e.g. more exaggerated incisional redness, swelling, warmth and pain that extend beyond postoperative day 5. Palpation of the incision and surrounding area may reveal the warmth and a collection of fluid under some or all of the incision (a seroma, haematoma or abscess). A sudden increase in pain or discharge of serosanguineous fluid from the incision may herald SWD.Prior to assessment of SWD, the events, if any, leading to the dehiscence, e.g. coughing, vomiting, trauma, suture/clip removal, purulent drainage, should be ascertained. The duration of the dehiscence should also be determined: SWD occurring very soon after surgery and of very recent occurrence may be suitable for re-suturing.
The entire length of an incision with SWD should be fully assessed: the factors that led to the SWD may also be affecting other regions of the incision that remain closed. -
This question is part of the following fields:
- Post-operative Management And Critical Care
- Principles Of Surgery-in-General
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Question 104
Correct
-
When the pitch of a sound increases, what is the physiological response seen in the listener?
Your Answer: The location of maximal basilar membrane displacement moves toward the base of the cochlea
Explanation:An increase in the frequency of sound waves results in a change in the position of maximal displacement of the basilar membrane in the cochlea. Low pitch sound produces maximal displacement towards the cochlear apex and greatest activation of hair cells there. With an increasing pitch, the site of greatest displacement moves towards the cochlear base. However, increased amplitude of displacement, increase in the number of activated hair cells, increased frequency of discharge of units in the auditory nerve and increase in the range of frequencies to which such units respond, are all seen in increases in the intensity or a sound stimulus.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 105
Incorrect
-
An anatomy instructor is giving a demonstration of the right lung. Which of the statements about the right lung made by the demonstrator is correct?
Your Answer: Its upper lobar bronchus lies behind and below the right pulmonary artery
Correct Answer: Its upper lobar bronchus lies behind and above the right pulmonary artery
Explanation:The root of the lungs on both sides are similar in that the pulmonary veins are anterior and inferior while the bronchus is posterior. However, on the right side, the pulmonary arteries are anterior to the bronchus while on the left side the pulmonary arteries are superior to the bronchus. The lingual is only found on the left lung. The mediastinum is the space in the thorax between the two pleural sacs and does not contain any lung. The right lung, having three lobes, is slightly larger than the left lung. On both sides, the phrenic nerves passes in front of the root of the lung.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 106
Correct
-
A 30 year old man suffered severe blood loss, approx. 20-30% of his blood volume. What changes are most likely seen in the pulmonary vascular resistance (PVR) and pulmonary artery pressure (PAP) respectively following this decrease in cardiac output?
Your Answer: Increase Decrease
Explanation:Hypovolemia will result in the activation of the sympathetic adrenal discharge resulting is a decrease pulmonary artery pressure and an elevated pulmonary vascular resistance.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 107
Correct
-
A 19-year-old female presents to the oncology clinic after noticing a painless neck lump. On examination, she is noted to have bilateral thyroid masses and multicentric nodules near the base of the thyroid. Her corrected calcium level is 2.18 mg/dL. Which of the following is the most likely diagnosis?
Your Answer: Medullary carcinoma of the thyroid associated with multiple endocrine neoplasia
Explanation:Based on the aforementioned findings in this case, the most likely diagnosis is medullary carcinoma of the thyroid associated with multiple endocrine neoplasia (MEN).
Medullary thyroid cancer is a tumour of the parafollicular cells (C cells) of the thyroid and is neural crest in origin. It may be familial and occur as part of the MEN 2A disease spectrum. Less than 10% of thyroid cancers are of this type with patients typically presenting as children or young adults. Diarrhoea occurs in 30% of the cases. In association with MEN syndromes, medullary thyroid cancers are always bilateral and multicentric. Spread may either be lymphatic or haematogenous, and as these tumours are not derived primarily from thyroid cells, they are not responsive to radioiodine.
Toxic nodular goitre is very rare. In sporadic medullary carcinoma of the thyroid, patients typically present with a unilateral solitary nodule and it tends to spread early to the lymph nodes in neck.
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This question is part of the following fields:
- Generic Surgical Topics
- Head And Neck Surgery
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Question 108
Incorrect
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Dysarthria, nystagmus and a tremor worsening with directed movement are likely to be seen in:
Your Answer: Parkinsonism
Correct Answer: Cerebellar disease
Explanation:The given symptoms are seen in diseases affecting the cerebellum. A cerebellar tremor is a slow tremor that occurs at the end of a purposeful movement. It is seen in cerebellar disease, such as multiple sclerosis or some inherited degenerative disorders and chronic alcoholism. Classically, tremors are produced in the same side of the body as a one-sided lesion. Cerebellar disease can also result in a wing-beating’ type of tremor called rubral or Holmes’ tremor – a combination of rest, action and postural tremors. Other signs of cerebellar disease include dysarthria (speech problems), nystagmus (rapid, involuntary rolling of the eyes), gait problems and postural tremor of the trunk and neck.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 109
Correct
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A 36 year old man with severe treatment refractory ulcerative colitis arrives at the clinic in a state of hypotension and tachycardia with peritonitis. Which of the following is the most appropriate treatment strategy for this patient?
Your Answer: Emergency subtotal colectomy and ileostomy
Explanation:Subtotal colectomy with ileostomy remains a safe and effective treatment for patients requiring urgent surgery for severe inflammatory bowel disease. As the patient is not hemodynamically stable, any anastomosis like ileorectal or ileoanal should not be done. The patient should be fully resuscitated and given antibiotics and thromboprophylaxis preoperatively.
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This question is part of the following fields:
- Colorectal Surgery
- Generic Surgical Topics
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Question 110
Correct
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Lateral medullary syndrome, also known as Wallenberg's syndrome is a neurological condition caused by ischaemia in the lateral part of the medulla oblongata and is commonly associated with numerous neurological symptoms. Which of the following arteries when occluded leads to this condition?
Your Answer: Posterior inferior cerebellar
Explanation:The lateral medullary syndrome or Wallenberg’s disease is also known as posterior inferior cerebellar artery syndrome (PICA). This syndrome is a clinical manifestation of the occlusion of the posterior cerebellar artery that results in symptoms of infarction of the lateral medullary oblongata. Other arteries that contribute to blood flow in to this region such are the vertebral artery, superior middle cerebellar and inferior medullary arteries can also result to this syndrome when occluded.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 111
Correct
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Which of these foramen is located at the base of the skull and transmits the accessory meningeal artery?
Your Answer: Foramen ovale
Explanation:At the base of the skull the foramen ovale is one of the larger of the several holes that transmit nerves through the skull. The following structures pass through foramen ovale: mandibular nerve, motor root of the trigeminal nerve, accessory meningeal artery, lesser petrosal nerve, a branch of the glossopharyngeal nerve, emissary vein connecting the cavernous sinus with the pterygoid plexus of veins and occasionally the anterior trunk of the middle meningeal vein.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 112
Correct
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A 26-year-old female patient had the following blood report: RBC count = 4. 0 × 106/μl, haematocrit = 27% and haemoglobin = 11 g/dl, mean corpuscular volume (MCV) = 90 fl, mean corpuscular haemoglobin concentration (MCHC) = 41 g/dl. Further examination of blood sample revealed increased osmotic fragility of the erythrocytes. Which of the following is the most likely cause of this patient’s findings?
Your Answer: Spherocytosis
Explanation:Spherocytes are small rounded RBCs. It is due to an inherited defect of the RBC cytoskeleton membrane tethering proteins. Membrane blebs form that are lost over time and cells become round instead of biconcave. As it is a normochromic anaemia, the MCV is normal. it is diagnosed by osmotic fragility test which reveals increased fragility in a hypotonic solution.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 113
Correct
-
A 30-year-old professional footballer is admitted to the emergency department. During a tackle, his leg is twisted with his knee flexed. He hears a loud crack and his knee rapidly becomes swollen. Which of the following is the main site of injury?
Your Answer: Anterior cruciate ligament
Explanation:Anterior cruciate ligament (ACL) injuries are most often a result of low-velocity, noncontact, deceleration injuries and contact injuries with a rotational component. Contact sports also may produce injury to the ACL secondary to twisting, valgus stress, or hyperextension all directly related to contact or collision.
Symptoms of an acute ACL injury may include the following:
– Feeling or hearing a “pop” sound in the knee
– Pain and inability to continue the activity
– Swelling and instability of the knee
– Development of a large hemarthrosisDifferential Diagnoses
A- Medial Collateral Knee Ligament Injury
Contact, noncontact, and overuse mechanisms are involved in causing MCL injuries.
Contact injuries involve a direct valgus load to the knee. This is the usual mechanism in a complete tear.
Noncontact, or indirect, injuries are observed with deceleration, cutting, and pivoting motions. These mechanisms tend to cause partial tears.
Overuse injuries of the MCL have been described in swimmers. The whip-kick technique of the breaststroke has been implicated. This technique involves repetitive valgus loads across the knee.B- Posterior Cruciate Ligament Injury
Knowledge of the mechanism of injury is helpful. The following 4 mechanisms of PCL injury are recognized:
– A posteriorly directed force on a flexed knee, e.g., the anterior aspect of the flexed knee striking a dashboard, may cause PCL injury.
– A fall onto a flexed knee with the foot in plantar flexion and the tibial tubercle striking the ground first, directing a posterior force to the proximal tibia, may result in injury to the PCL.
– Hyperextension alone may lead to an avulsion injury of the PCL from the origin. This kind of injury may be amenable to repair.
– An anterior force to the anterior tibia in a hyperextended knee with the foot planted results in combined injury to the knee ligaments along with knee dislocation.In chronic PCL tears, discomfort may be experienced with the following positions or activities:
– A semi flexed position, as with ascending or descending stairs or an incline
– Starting a run
– Lifting a load
– Walking longer distances
– Retro patellar pain symptoms may be reported as a result of posterior tibial sagging.
– Swelling and stiffness may be reported in cases of chondral damage.
– Individuals may describe a sensation of instability when walking on uneven ground
– Medial joint line pain may be reported. -
This question is part of the following fields:
- Generic Surgical Topics
- Orthopaedics
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Question 114
Correct
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A 3 year old girl is taken to the clinic with a 3 day history of feeling unwell and having a sore throat. When examined by the doctor, marked cervical lymphadenopathy is observed and the oropharynx is covered with a thick grey membrane which bleeds following attempted removal. Which of the following is the most likely diagnosis?
Your Answer: Diphtheria
Explanation:Diphtheria is an infection caused by the bacterium Corynebacterium diphtheriae. Signs and symptoms may vary from mild to severe. They usually start two to five days after exposure. Symptoms often come on fairly gradually, beginning with a sore throat and fever. In severe cases, a grey or white patch develops in the throat. This can block the airway and create a barking cough as in croup. The neck may swell in part due to enlarged lymph nodes.
The disease may remain manageable, but in more severe cases, lymph nodes in the neck may swell, and breathing and swallowing are more difficult. People in this stage should seek immediate medical attention, as obstruction in the throat may require intubation or a tracheotomy. Abnormal cardiac rhythms can occur early in the course of the illness or weeks later, and can lead to heart failure. Diphtheria can also cause paralysis in the eye, neck, throat, or respiratory muscles. Patients with severe cases are put in a hospital intensive care unit and given a diphtheria antitoxin (consisting of antibodies isolated from the serum of horses that have been challenged with diphtheria toxin). Since antitoxin does not neutralize toxin that is already bound to tissues, delaying its administration increases risk of death. Therefore, the decision to administer diphtheria antitoxin is based on clinical diagnosis, and should not await laboratory confirmation.
Antibiotics are used in patients or carriers to eradicate C. diphtheriae and prevent its transmission to others. The Centres for Disease Control and Prevention recommends either:
Metronidazole
Erythromycin is given (orally or by injection) for 14 days (40 mg/kg per day with a maximum of 2 g/d), or
Procaine penicillin G is given intramuscularly for 14 days (300,000 U/d for patients weighing <10 kg and 600,000 U/d for those weighing >10 kg); patients with allergies to penicillin G or erythromycin can use Rifampicin or clindamycin. -
This question is part of the following fields:
- Generic Surgical Topics
- Head And Neck Surgery
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Question 115
Correct
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A 25-year-old intravenous drug user is found to have a femoral abscess. He is also febrile with a temperature of 39°C and has a pansystolic murmur loudest at the left sternal edge in the 4th intercostal space. Which of the following is the most likely underlying lesion?
Your Answer: Tricuspid regurgitation
Explanation:Intravenous drug users are at a high risk of right-sided cardiac valvular endocarditis. The character of the murmur described in the scenario fits with the diagnosis of tricuspid valve endocarditis.
Other listed options are ruled out because:
1. Aortic regurgitation—Early diastolic murmur
2. Mitral regurgitation—Pansystolic murmur
3. Aortic valve stenosis—Ejection systolic murmur
4. Tricuspid valve stenosis—Mid-diastolic murmur -
This question is part of the following fields:
- Generic Surgical Topics
- Vascular
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Question 116
Correct
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A 32-year-old lady presents with a six-month history of an offensive discharge from the anus. She is otherwise well but is annoyed at the need to wear pads. On examination, she has a small epithelial defect in the five o'clock position, approximately three centimetres from the anal verge. Out of the following, which is the most likely cause?
Your Answer: Fistula-in-ano
Explanation:This patient is a case of fistula-in-ano.
A fistula-in-ano is an abnormal hollow tract or cavity that is lined with granulation tissue and that connects a primary opening inside the anal canal to a secondary opening in the perianal skin; secondary tracts may be multiple and can extend from the same primary opening. Fistulae usually occur following previous ano-rectal sepsis. The discharge may be foul smelling and troublesome.
Fistula-in-ano is classified into two groups based on its anatomical location.
1. Low fistula: relatively close to the skin and passes through a few or no sphincter muscle fibres, crosses <30% external sphincter
2. High fistula: passes through a large amount of muscleAssessment of fistula-in-ano includes:
1. Examination of the perineum
2. Digital rectal examination (DRE)
Low, uncomplicated fistulas may not require any further assessment. Other groups will usually require more detailed investigation.
3. Endo-anal USS
4. Ano-rectal MRI scanTreatment options include:
1. Seton suture
2. Fistulotomy: Low fistulas that are simple should be treated by fistulotomy once the acute sepsis has been controlled. Fistulotomy (where safe) provides the highest healing rates.
3. Anal fistula plugs and fibrin glue
4. Ano-rectal advancement flaps: primarily for high fistulae -
This question is part of the following fields:
- Colorectal Surgery
- Generic Surgical Topics
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Question 117
Correct
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A 42-year-old woman is admitted with sepsis and right flank pain. Twenty-four hours ago, she was started on trimethoprim, by the GP, for a urinary tract infection (UTI).Which of the following organisms is the most likely causative agent?
Your Answer: E. coli
Explanation:Ascending infection of the urinary tract is most commonly caused by Escherichia coli (E.coli). Other organisms may be accountable. However, these are less common.
E. coli are gram-negative rods. They have a wide range of subtypes and some are normal gut commensals. Most varieties of E. coli are harmless or cause relatively brief diarrhoea. But a few nasty strains, such as E. coli O157:H7, can cause severe abdominal cramps, bloody diarrhoea, and vomiting. Some strains of E. coli are also resistant to a large number of antibiotics used to treat gram-negative infections.
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This question is part of the following fields:
- Clinical Microbiology
- Principles Of Surgery-in-General
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Question 118
Correct
-
Which of the following structures is derived from the dorsal mesogastrium of the stomach during the development of the gut?
Your Answer: Greater omentum
Explanation:In a developing foetus, the stomach has two mesogastria from which most of the abdominal ligaments develop. These two mesogastria are the; ventral mesogastrium and the dorsal mesogastrium. During the embryological development of the gut, different organs develop in each mesogastrium; the spleen and pancreas in the dorsal mesogastrium while the liver in the ventral mesogastrium (with their associated ligaments). In the dorsal mesogastrium the following structures develop; the greater omentum (containing the gastrophrenic ligament and the gastrocolic ligament), gastrosplenic ligament, mesentery, splenorenal ligament and phrenicocolic ligament. The structures that develop from the ventral mesogastrium include the; lesser omentum (containing the hepatoduodenal ligament and the hepatogastric ligament) in association with the liver; the coronary ligament (left triangular ligament, right triangular ligament and hepatorenal ligament) and the falciform ligament (round ligament of liver and ligamentum venosum within).
There are also folds that develop from the dorsal mesogastrium which include; umbilical folds, supravesical fossa, medial inguinal fossa, lateral umbilical fold, lateral inguinal fossa and Ileocecal fold. -
This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 119
Correct
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A 45-year-old man complains of shortness of breath, cough and chest pain. Chest X ray revealed a perihilar mass with bronchiectasis in the left mid-lung. Which of the following is most probably associated with these findings?
Your Answer: Bronchial carcinoid
Explanation:Bronchial carcinoids are neuroendocrine tumours that arise from Kulchitsky’s cells of the bronchial epithelium. Kulchitsky’s cells belong to the diffuse endocrine system. Patients affected by this tumour may be asymptomatic or may present with symptoms of airway obstruction, like dyspnoea, wheezing, and cough. Other common findings are recurrent pneumonia, haemoptysis, chest pain and paraneoplastic syndromes. Chest radiographs are abnormal in the majority of cases. Peripheral carcinoids usually present as a solitary pulmonary nodule. For central lesions common findings include hilar or perihilar masses with or without atelectasis, bronchiectasis, or consolidation. Bronchial carcinoids most commonly arise in the large bronchi causing obstruction.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 120
Correct
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A 40 year old woman has a full thickness burn on her foot after being trapped in a burning building. The limb has no fractures but the burn is well circumscribed. She starts complaining of tingling of her foot which has a dusky look after 3 hours. Which of the following is the best management step?
Your Answer: Escharotomy
Explanation:Answer: Escharotomy
Escharotomy is the surgical division of the nonviable eschar, which allows the cutaneous envelope to become more compliant. Hence, the underlying tissues have an increased available volume to expand into, preventing further tissue injury or functional compromise.
Full-thickness circumferential and near-circumferential skin burns result in the formation of a tough, inelastic mass of burnt tissue (eschar). The eschar, by virtue of this inelasticity, results in the burn-induced compartment syndrome. This is caused by the accumulation of extracellular and extravascular fluid within confined anatomic spaces of the extremities or digits. The excessive fluid causes the intracompartmental pressures to increase, resulting in collapse of the contained vascular and lymphatic structures and, hence, loss of tissue viability. The capillary closure pressure of 30 mm Hg, also measured as the compartment pressure, is accepted as that which requires intervention to prevent tissue death.
The circumferential eschar over the torso can lead to significant compromise of chest wall excursions and can hinder ventilation. Abdominal compartment syndrome with visceral hypoperfusion is associated with severe burns of the abdomen and torso. (A literature review by Strang et al found the prevalence of abdominal compartment syndrome in severely burned patients to be 4.1-16.6%, with the mean mortality rate for this condition in these patients to be 74.8%). Similarly, airway patency and venous return may be compromised by circumferential burns involving the neck.
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This question is part of the following fields:
- Emergency Medicine And Management Of Trauma
- Principles Of Surgery-in-General
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Question 121
Correct
-
Dicloxacillin is an antibiotic; the subclass that dicloxacillin belongs to is:
Your Answer: Penicillin
Explanation:Dicloxacillin is a narrow-spectrum beta-lactam antibiotic. It is used to treat infections caused by susceptible Gram-positive bacteria and most effective against beta-lactamase-producing organisms such as Staphylococcus aureus. To decrease the development of resistance, dicloxacillin is recommended to treat infections that are suspected or proven to be caused by beta-lactamase-producing bacteria.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 122
Incorrect
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Blood supply to the posterior compartment of the thigh is supplied by which artery?
Your Answer:
Correct Answer: Perforating
Explanation:There are usually 3 perforating arteries:
The first gives branches to the adductor brevis and magnus, biceps femoris and gluteus maximus and anastomoses with the inferior gluteal, medial and lateral femoral circumflex.
The second artery supplies the posterior femoral muscles and anastomose with the first and third perforating vessels.
The third supplies the posterior femoral muscles. -
This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 123
Incorrect
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A drug abuser developed an infection which spread from the dorsum of the hand to the medial side of the arm along the course of the large cutaneous vein. Which vein is involved?
Your Answer:
Correct Answer: Basilic
Explanation:The basilic vein is one of two veins found in the forearm, the other is the cephalic vein. These veins originate from the deep venous arch of the hand. The cephalic vein ascends along the lateral side of the forearm, and the basilic vein runs up the medial side of the forearm.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 124
Incorrect
-
A 47-year-old male smoker, who had been self-medicating with oral steroids for the last two years due to persistent breathlessness presented to the doctor complaining of a productive cough, fever and chest pain. A chest X-ray revealed bilateral patchy opacities. He was diagnosed with bilateral bronchopneumonia. Which of these organisms is most probably causing these findings?
Your Answer:
Correct Answer: Nocardia asteroides
Explanation:Nocardia is a Gram-positive aerobic actinomycete. Several species have been identified but the most common human pathogen is Nocardia asteroides. The predominant clinical finding in the majority of patients affected by nocardiosis is pulmonary disease. Predisposing factors for pulmonary nocardiosis include leukaemia, human immunodeficiency virus (HIV) infection, organ transplantation, diabetes and receiving prolonged corticosteroids.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 125
Incorrect
-
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:
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 126
Incorrect
-
A 63-year-old woman complains of a new, persisting headache. She is diagnosed with vasculitis and the histopathological sample revealed giant-cell arteritis. What is the most probable diagnose?
Your Answer:
Correct Answer: Temporal arteritis
Explanation:Giant cell arteritis (GCA), also known as temporal arteritis, is the most common systemic inflammatory vasculitis that occurs in adults. It is of unknown aetiology and affects arteries large to small however the involvement of the superficial temporal arteries is almost always present. Other commonly affected arteries include the ophthalmic, occipital and vertebral arteries, therefore GCA can result in systemic, neurologic, and ophthalmologic complications. GCA usually is found in patients older than 50 years of age and should always be considered in the differential diagnosis of a new-onset headache accompanied by an elevated erythrocyte sedimentation rate. Diagnosis depends on the results of artery biopsy.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 127
Incorrect
-
A 55-year-old male presents with central chest pain. On examination, he has a mitral regurgitation murmur. An ECG shows ST elevation in leads V1 to V6. There is no ST elevation in leads II, III and aVF. What is the diagnosis?
Your Answer:
Correct Answer: Anterior myocardial infarct
Explanation:High-probability ECG features of MI are the following:
ST-segment elevation greater than 1 mm in two anatomically contiguous leads
The presence of new Q wavesIntermediate-probability ECG features of MI are the following:
ST-segment depression
T-wave inversion
Other nonspecific ST-T wave abnormalities
Low-probability ECG features of MI are normal ECG findings. However, normal or nonspecific findings on ECGs do not exclude the possibility of MI.Special attention should be made if there is diffuse ST depression in the precordial and extremity leads associated with more than 1 mm ST elevation in lead aVR, as this may indicate stenosis of the left main coronary artery or the proximal section of the left anterior descending coronary artery.
Localization of the involved myocardium based on the distribution of ECG abnormalities in MI is as follows:
– Inferior wall – II, III, aVF
– Lateral wall – I, aVL, V4 through V6
– Anteroseptal – V1 through V3
– Anterolateral – V1 through V6
– Right ventricular – RV4, RV5
– Posterior wall – R/S ratio greater than 1 in V1 and V2, and – T-wave changes in V1, V8, and V9
– True posterior-wall MIs may cause precordial ST depressions, inverted and hyperacute T waves, or both. ST-segment elevation and upright hyperacute T waves may be evident with the use of right-sided chest leads.Hyperacute (symmetrical and, often, but not necessarily pointed) T waves are frequently an early sign of MI at any locus.
The appearance of abnormalities in a large number of ECG leads often indicates extensive injury or concomitant pericarditis.
The characteristic ECG changes may be seen in conditions other than acute MI. For example, patients with previous MI and left ventricular aneurysm may have persistent ST elevations resulting from dyskinetic wall motion, rather than from acute myocardial injury. ST-segment changes may also be the result of misplaced precordial leads, early repolarization abnormalities, hypothermia (elevated J point or Osborne waves), or hypothyroidism.
False Q waves may be seen in septal leads in hypertrophic cardiomyopathy (HCM). They may also result from cardiac rotation.
Substantial T-wave inversion may be seen in left ventricular hypertrophy with secondary repolarization changes.
The QT segment may be prolonged because of ischemia or electrolyte disturbances.
Saddleback ST-segment elevation (Brugada epsilon waves) may be seen in leads V1-V3 in patients with a congenital predisposition to life-threatening arrhythmias. This elevation may be confused with that observed in acute anterior MI.
Diffuse brain injuries and haemorrhagic stroke may also trigger changes in T waves, which are usually widespread and global, involving all leads.
Convex ST-segment elevation with upright or inverted T waves is generally indicative of MI in the appropriate clinical setting. ST depression and T-wave changes may also indicate the evolution of NSTEMI.
Patients with a permanent pacemaker may confound recognition of STEMI by 12-lead ECG due to the presence of paced ventricular contractions.
To summarize, non-ischemic causes of ST-segment elevation include left ventricular hypertrophy, pericarditis, ventricular-paced rhythms, hypothermia, hyperkalaemia and other electrolyte imbalances, and left ventricular aneurysm. -
This question is part of the following fields:
- Emergency Medicine And Management Of Trauma
- Principles Of Surgery-in-General
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Question 128
Incorrect
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A 13 year old boy is admitted to the surgical ward with appendicitis. Medical history shows that he has been taking Metoclopramide. He is normally fit and well. However, he is reported to be acting strange and on examination, he is agitated with a clenched jaw and eyes are deviated upwards. What is his diagnosis?
Your Answer:
Correct Answer: Oculogyric crisis
Explanation:Answer: Oculogyric crisis
Oculogyric crisis is an acute dystonic reaction of the ocular muscles characterized by bilateral dystonic elevation of visual gaze lasting from seconds to hours. This reaction is most commonly explained as an adverse reaction to drugs such as antiemetics, antipsychotics, antidepressants, antiepileptics, and antimalarials. Metoclopramide is a benzamide selective dopamine D2 receptor antagonist that is used as an antiemetic, with side effects that are seen frequently in children.1 The most common and most important side effects of metoclopramide are acute extrapyramidal symptoms, which require immediate treatment. Acute dystonic reactions occur as contractions of the muscles, opisthotonos, torticollis, dysarthria, trismus, and oculogyric crisis.
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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 129
Incorrect
-
Which of the following conditions causes an elevation of the pH in the tissues with elevated arterial CO2 content?
Your Answer:
Correct Answer: Metabolic alkalosis
Explanation:Metabolic alkalosis is a metabolic condition in which the pH of tissue is elevated beyond the normal range (7.35-7.45). This is the result of decreased hydrogen ion concentration, leading to increased bicarbonate, or alternatively a direct result of increased bicarbonate concentrations. Normally, arterial pa(CO2) increases by 0.5–0.7 mmHg for every 1 mEq/l increase in plasma bicarbonate concentration, a compensatory response that is very quick. If the change in pa(CO2) is not within this range, then a mixed acid–base disturbance occurs.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 130
Incorrect
-
Which of the following substances brings about a dilatation of the gastrointestinal resistance vessels?
Your Answer:
Correct Answer: Vasoactive intestinal peptide
Explanation:Gastric vasoconstrictors include catecholamines, angiotensin II and vasopressin. Vasodilators include vasoactive intestinal peptide and the hormones; gastrin, cholecystokinin and glucagon.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 131
Incorrect
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Work of breathing (WOB) is the energy expended to inhale and exhale a breathing gas. Normally, maximal amount of work of breathing is required to overcome:
Your Answer:
Correct Answer: Elastic lung compliance
Explanation:The forces of elastance (compliance), frictional resistance and inertia have been identified as the forces that oppose lung inflation and deflation. The normal relaxed state of the lung and chest is partially empty. Further exhalation requires muscular work. Inhalation is an active process requiring work. About 60–66% of the total work performed by the respiratory muscles is used to overcome the elastic or compliance characteristics of the lung–chest cage, 30–35% is used to overcome frictional resistance and only 2–5% of the work is used for inertia.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 132
Incorrect
-
A 4-year-old boy is referred to the clinic with a scrotal swelling. On examination, the mass does not transilluminate and it is impossible to palpate normal cord above it. What is the most likely diagnosis?
Your Answer:
Correct Answer: Indirect inguinal hernia
Explanation:An inguinal hernia is a common condition requiring surgical repair in the paediatric age group.
The infant or child with an inguinal hernia generally presents with an obvious bulge at the internal or external ring or within the scrotum. The parents typically provide the history of a visible swelling or bulge, commonly intermittent, in the inguinoscrotal region in boys and inguinolabial region in girls.
The swelling may or may not be associated with any pain or discomfort. More commonly, no pain is associated with a simple inguinal hernia in an infant. The parents may perceive the bulge as being painful when, in truth, it causes no discomfort to the patient.
The bulge commonly occurs after crying or straining and often resolves during the night while the baby is sleeping.
Indirect hernias are more common on the right side because of delayed descent of the right testicle. Hernias are present on the right side in 60% of patients, on the left is 30%, and bilaterally in 10% of patients.
Physical examination of a child with an inguinal hernia typically reveals a palpable smooth mass originating from the external ring lateral to the pubic tubercle. The mass may only be noticeable after coughing or performing a Valsalva manoeuvre, and it should be reduced easily. Occasionally, the examining physician may feel the loops of intestine within the hernia sac. In girls, feeling the ovary in the hernia sac is not unusual; it is not infrequently confused with a lymph node in the groin region. In boys, palpation of both testicles is important to rule out an undescended or retractile testicle.
In boys, differentiating between a hernia and a hydrocele is not always easy. Transillumination has been advocated as a means of distinguishing between the presence of a sac filled with fluid in the scrotum (hydrocele) and the presence of bowel in the scrotal sac. However, in cases of inguinal hernia incarceration, transillumination may not be beneficial because any viscera that is distended and fluid-filled in the scrotum of a young infant may also transilluminate. A rectal examination may be helpful if intestine can be felt descending through the internal ring.
A femoral hernia can be very difficult to differentiate from an indirect inguinal hernia. Its location is below the inguinal canal, through the femoral canal. The differentiation is often made only at the time of operative repair, once the anatomy and relationship to the inguinal ligament are clearly visualized. The signs and symptoms for femoral hernias are essentially the same as those described for indirect inguinal hernias. -
This question is part of the following fields:
- Generic Surgical Topics
- Paediatric Surgery
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Question 133
Incorrect
-
A 9 year old boy is admitted with right iliac fossa pain and an appendicectomy is to be performed.Which of the following incision is the best for this procedure?
Your Answer:
Correct Answer: Lanz
Explanation:Answer: Lanz
The Lanz and Gridiron incisions are two incisions that can be used to access the appendix, predominantly for appendectomy.
Both incisions are made at McBurney’s point (two-thirds from the umbilicus to the anterior superior iliac spine). They involve passing through all of the abdominal muscles, transversalis fascia, and then the peritoneum, before entering the abdominal cavity.
The Lanz incision is a transverse incision, whilst the Gridiron incision is oblique (superolateral to inferomedial). Due to its continuation with Langer’s lines, the Lanz incision produces much more aesthetically pleasing results with reduced scarring.
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This question is part of the following fields:
- Generic Surgical Topics
- The Abdomen
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Question 134
Incorrect
-
The following branch of the aorta is unpaired:
Your Answer:
Correct Answer: Coeliac artery
Explanation:Branches that stem from the abdominal aorta can be divided into three: the visceral branches, parietal branches and terminal branches. Of the visceral branches, the suprarenal, renal, testicular and ovarian arteries are paired while the coeliac artery and superior and inferior mesenteric arteries are unpaired. Of the parietal branches the inferior phrenic and lumbar arteries are paired while the middle sacral artery is unpaired. The terminal branches i.e. the common iliac arteries are paired.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 135
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:
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
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Question 136
Incorrect
-
Which of the following muscles is solely contained in the anterior triangle of the neck and divides the anterior triangle into three smaller triangles?
Your Answer:
Correct Answer: Digastric
Explanation:The digastric muscle is a small muscle located under the jaw. It lies below the body of the mandible, and extends, in a curved form, from the mastoid process to the symphysis menti. The digastric divides the anterior triangle of the neck into three smaller triangles:
– The submaxillary triangle, bounded above by the lower border of the body of the mandible and a line drawn from its angle to the sternocleidomastoid, below by the posterior belly of the digastric and the stylohyoid and in front by the anterior belly of the digastric
– The carotid triangle, bounded above by the posterior belly of the digastric and stylohyoid, behind by the sternocleidomastoid and below by the omohyoid
– The suprahyoid or submental triangle, bounded laterally by the anterior belly of the digastric, medially by the midline of the neck from the hyoid bone to the symphysis menti and inferiorly by the body of the hyoid bone. -
This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 137
Incorrect
-
A 40-year-old male pedestrian is brought to the A&E department after being hit by a car. On examination, he is found to be dyspnoeic and hypoxic despite administration of high flow oxygen therapy. Moreover, his pulse is 115bpm and blood pressure is 110/70 mmHg. The right side of his chest is hyper-resonant on percussion and has decreased breath sounds. His trachea is deviated to the left. What is the most likely underlying diagnosis?
Your Answer:
Correct Answer: Tension pneumothorax
Explanation:This patient has developed a tension pneumothorax following a blunt trauma.
Tension pneumothorax is a life-threatening condition that develops when air is trapped in the pleural cavity under positive pressure, displacing mediastinal structures and compromising cardiopulmonary function. Blunt or penetrating chest trauma that creates a flap-type defect on the surface of the lung can result in this life-threatening condition.
Signs and symptoms of tension pneumothorax include:
1. Chest pain that usually has a sudden onset, is sharp, and may lead to feeling of tightness in the chest
2. Dyspnoea and progressive hypoxia
3. Tachycardia
4. Hyperventilation
5. Cough
6. FatigueOn examination, hyper-resonant percussion note and tracheal deviation are typically found. Treatment is immediate without waiting for the CXR result and includes needle decompression and chest tube insertion.
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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 138
Incorrect
-
A 41 year old lecturer is admitted with abdominal pain. He has suffered from repeated episodes of this colicky right upper quadrant pain. On examination, he has a fever with right upper quadrant peritonism. His blood tests show a white cell count of 22. An abdominal ultrasound scan shows multiple gallstones in a thick walled gallbladder, the bile duct measures 4mm. Tests show that his liver function is normal. What is the best course of action?
Your Answer:
Correct Answer: Undertake a laparoscopic cholecystectomy
Explanation:This individual has acute cholecystitis. This is demonstrated by well-localized pain in the right upper quadrant, usually with rebound and guarding; frequent presence of fever and peritonism. Ultrasonography is the procedure of choice in suspected gallbladder or biliary disease. A bile duct measuring 4mm is usually normal.
Once gallstones become symptomatic, definitive surgical intervention with cholecystectomy is usually indicated (typically, laparoscopic cholecystectomy is the first-line therapy at centres with experience in this procedure). -
This question is part of the following fields:
- Generic Surgical Topics
- Hepatobiliary And Pancreatic Surgery
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Question 139
Incorrect
-
A 55-year-old male chronic smoker is diagnosed with non-small-cell cancer. His right lung underwent complete atelectasis and he has a 7cm tumour involving the chest wall. What is the stage of the lung cancer of this patient?
Your Answer:
Correct Answer: T3
Explanation:Non-small-cell lung cancer is staged through TNM classification. The stage of this patient is T3 because based on the TNM classification the tumour is staged T3 if > 7 cm or one that directly invades any of the following: Chest wall (including superior sulcus tumours), diaphragm, phrenic nerve, mediastinal pleura, or parietal pericardium; or the tumour is in the main bronchus < 2 cm distal to the carina but without involvement of the carina, Or it is associated with atelectasis/obstructive pneumonitis of the entire lung or separate tumour nodule(s) in the same lobe.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 140
Incorrect
-
What occurs during cellular atrophy?
Your Answer:
Correct Answer: Cell size decreases
Explanation:Atrophy is the decrease in the size of cells, tissues, or organs. There are several causes including inadequate nutrition, poor circulation, loss of hormonal support or nerve supply, disuse, lack of exercise, or disease. An increase in cell size is termed hypertrophy which is distinguished from hyperplasia, in which the cells remain approximately the same size but increase in number.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 141
Incorrect
-
A 4-month-old boy is brought to the clinic by his mother who has noticed a swelling in the right hemiscrotum. On examination, there is a firm mass affecting the right spermatic cord distally, the testis is felt separately from it. What is the most likely diagnosis?
Your Answer:
Correct Answer: Rhabdomyosarcoma
Explanation:Rhabdomyosarcoma (RMS) is the most common soft tissue sarcoma in children.
Rhabdomyosarcoma usually manifests as an expanding mass. Tumours in superficial locations may be palpable and detected relatively early, but those in deep locations (e.g., retroperitoneum) may grow large before causing symptoms.
Symptoms depend on the location of the tumour, and pain may be present. Typical presentations of nonmetastatic disease, by location, are as follows:
Orbit: Proptosis or dysconjugate gaze
Paratesticular: Painless scrotal mass, testes are felt separately
Prostate: Bladder or bowel difficulties
Uterus, cervix, bladder: Menorrhagia or metrorrhagia
Vagina: Protruding polypoid mass (botryoid, meaning a grapelike cluster)
Extremity: Painless mass
Parameningeal (ear, mastoid, nasal cavity, paranasal sinuses, infratemporal fossa, pterygopalatine fossa): Upper respiratory symptoms or painIn the international classification of rhabdomyosarcoma, there are 5 recognized variants: embryonal, alveolar, botryoid embryonal, spindle cell embryonal and anaplastic. The most common variant is embryonal, most associated with tumours of the genitourinary tract and the head and neck. Histologically, the embryonal subtype resembles that of a 6- to an 8-week old embryo.
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This question is part of the following fields:
- Generic Surgical Topics
- Urology
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Question 142
Incorrect
-
The annular ligament in the forearm:
Your Answer:
Correct Answer: Encircles the head of the radius
Explanation:The annular ligament forms about four-fifths of the osseofibrous ring and is attached to the anterior and posterior margins of the radial notch. It is a strong band of fibres which encircles the head of the radius retaining it in contact with the radial notch of the ulna. When it comes to its upper border, it blends with the anterior and posterior ligament of the elbow.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 143
Incorrect
-
A 46-year-old male complains of sharp chest pain. He is due to have elective surgery to replace his left hip. He has been bed-bound for 3 months. He suddenly collapses; his blood pressure is 70/40mmHg, heart rate 120 bpm and his saturations are 74% on air. He is deteriorating in front of you. What is the next best management plan?
Your Answer:
Correct Answer: Thrombolysis with Alteplase
Explanation:The patient has Pulmonary embolism (PE).
PE is when a thrombus becomes lodged in an artery in the lung and blocks blood flow to the lung. Pulmonary embolism usually arises from a thrombus that originates in the deep venous system of the lower extremities; however, it rarely also originates in the pelvis, renal, upper extremity veins, or the right heart chambers. After travelling to the lung, large thrombi can lodge at the bifurcation of the main pulmonary artery or the lobar branches and cause hemodynamic compromise.
The classic presentation of PE is the abrupt onset of pleuritic chest pain, shortness of breath, and hypoxia. However, most patients with pulmonary embolism have no obvious symptoms at presentation. Rather, symptoms may vary from sudden catastrophic hemodynamic collapse to gradually progressive dyspnoea.
Physical signs of pulmonary embolism include the following:
Tachypnoea (respiratory rate >16/min): 96%
Rales: 58%
Accentuated second heart sound: 53%
Tachycardia (heart rate >100/min): 44%
Fever (temperature >37.8°C [100.04°F]): 43%
Diaphoresis: 36%
S3 or S4 gallop: 34%
Clinical signs and symptoms suggesting thrombophlebitis: 32%
Lower extremity oedema: 24%
Cardiac murmur: 23%
Cyanosis: 19%
Management
Anticoagulation and thrombolysis
Immediate full anticoagulation is mandatory for all patients suspected of having DVT or PE. Diagnostic investigations should not delay empirical anticoagulant therapy.
Thrombolytic therapy should be used in patients with acute pulmonary embolism who have hypotension (systolic blood pressure< 90 mm Hg) who do not have a high bleeding risk and in selected patients with acute pulmonary embolism not associated with hypotension who have a low bleeding risk and whose initial clinical presentation or clinical course suggests a high risk of developing hypotension.
Long-term anticoagulation is critical to the prevention of recurrence of DVT or pulmonary embolism because even in patients who are fully anticoagulated, DVT and pulmonary embolism can and often do recur.
Thrombolytic agents used in managing pulmonary embolism include the following:
– Alteplase
– ReteplaseHeparin should be given to patients with intermediate or high clinical probability before imaging.
Unfractionated heparin (UFH) should be considered (a) as a first dose bolus, (b) in massive PE, or (c) where rapid reversal of effect may be needed.
Otherwise, low molecular weight heparin (LMWH) should be considered as preferable to UFH, having equal efficacy and safety and being easier to use.
Oral anticoagulation should only be commenced once venous thromboembolism (VTE) has been reliably confirmed.
The target INR should be 2.0–3.0; when this is achieved, heparin can be discontinued.
The standard duration of oral anticoagulation is: 4–6 weeks for temporary risk factors, 3 months for first idiopathic, and at least 6 months for other; the risk of bleeding should be balanced with that of further VTE. -
This question is part of the following fields:
- Emergency Medicine And Management Of Trauma
- Principles Of Surgery-in-General
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Question 144
Incorrect
-
A 60-year-old woman complains of left sided headaches which have been recurring for several years. She recently suffered from a focal seizure for the first time a few days ago. A CT scan shows a mass in the left hemisphere of the brain. The most likely diagnosis is:
Your Answer:
Correct Answer: Meningioma
Explanation:Meningiomas are a common benign intracranial tumour, and their incidence is higher in women between the ages of 40-60 years old. Many of these tumours are asymptomatic and are diagnosed incidentally, although some of them may have malignant presentations (less than 2% of cases). These benign tumours can develop wherever there is dura, over the convexities near the venous sinuses, along the base of the skull, in the posterior fossa and, within the ventricles.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 145
Incorrect
-
A 7 year old boy is taken to the doctor by his mother after she observed a swelling in his right hemiscrotum. On examination, it transilluminates. What is the next best step in his management?
Your Answer:
Correct Answer: Division of the patent processus vaginalis via an inguinal approach
Explanation:The inguinal approach, with ligation of the processus vaginalis high within the internal inguinal ring, is the procedure of choice for paediatric hydroceles (typically, communicating). If a testicular tumour is identified on testicular ultrasonography, an inguinal approach with high control/ligation of the cord structures is mandated.
Approximately 10% of patients with testicular teratomas may present with a cystic mass that may transilluminate during the physical examination. Similarly, adults with testicular tumours may present with new-onset scrotal swelling. If this diagnosis is considered, measuring serum alpha-fetoprotein and human chorionic gonadotropin (hCG) levels is indicated to exclude malignant teratomas or other germ cell tumours.
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This question is part of the following fields:
- Generic Surgical Topics
- Paediatric Surgery
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Question 146
Incorrect
-
The stomach is an organ that is divided into several important anatomical parts. These parts of the stomach have varied arterial blood supply that ensure that the whole organ receive oxygenated blood. Which of the following arteries if ligated, will not render any portion of the stomach ischaemic?
Your Answer:
Correct Answer: Superior mesenteric
Explanation:The blood supply to the stomach is through the following arteries:
– The superior mesenteric artery supplies blood to the lower part of the duodenum, pancreas and two-thirds of the transverse colon. Thus ligation of the superior mesenteric artery would not affect the stomach.
– The right and the left gastroepiploic arteries supply the greater curvature of the stomach – along its edges.
– The short gastric artery supplies blood to the upper portion of the of the greater curvature and the fundus of the stomach.
– The gastroduodenal artery supplies blood to the distal part of the stomach (the pyloric sphincter) and the proximal end of the duodenum.
– The left gastroepiploic and the short gastric are branches of the splenic artery and therefore ligation of the splenic artery would directly affect the stomach. -
This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 147
Incorrect
-
A 25-year-old man is involved in vigorous intercourse and suddenly feels a snap. His penis becomes swollen and painful immediately after. The admitting surgeon suspects a penile fracture. Which of the following is the most appropriate initial management?
Your Answer:
Correct Answer: Immediate surgical exploration
Explanation:Suspected penile fractures should be surgically explored and the injury repaired.
Penile fractures are a rare type of urological trauma. The injury is usually in the proximal part of the penile shaft and may involve the urethra. A classical history of a snapping sensation followed by immediate pain is usually given by the patient (usually during vigorous intercourse). On examination, a tense haematoma is most commonly noted, and if the urethra is injured, blood may be seen at the meatus.
The correct management involves surgical exploration and repair of the injury. A circumferential incision is made immediately inferior to the glans and the penile shaft is inspected. Injuries are usually sutured and the urethra is repaired over a catheter.
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This question is part of the following fields:
- Generic Surgical Topics
- Urology
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Question 148
Incorrect
-
Where is factor VIII predominantly synthesised?
Your Answer:
Correct Answer: Vascular endothelium
Explanation:Factor VIII is an important part of the coagulation cascade. Deficiency causes haemophilia A. It is synthesised predominantly by the vascular endothelium and is not affected by liver disease. In the circulation it is bound to von Willebrand factor and it forms a stable complex with it. It is activated by thrombin or factor Xa and acts as a co factor to factor IXa to activate factor X which is a co factor to factor Va. Thrombin cleaves fibrinogen in fibrin and forms a meshwork to trap RBC and platelets to form a clot.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 149
Incorrect
-
A 6 year-old boy is brought to you coughing. He is suspected to have aspirated a Lego piece which he was seen playing with. Where would you expect the piece to be?
Your Answer:
Correct Answer: Right main bronchus
Explanation:Inhaled objects are more likely to enter the right lung for several reasons. First the right bronchus is shorter, wider and more vertical than the left bronchus. Also, the carina (a ridge-like structure at the point of tracheal bifurcation) is set a little towards the left. The terminal bronchiole is a very small space and impossible for the seed to lodge here.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 150
Incorrect
-
A 47 year old accountant presents with symptoms of biliary colic and tests confirmed the diagnosis of gallstones. Which of the procedures listed below would most likely increase the risk of gallstone formation?
Your Answer:
Correct Answer: Ileal resection
Explanation:Ileal resection may lead to bile acid malabsorption and an altered biliary lipid composition. A “bile acid deficiency” in the enterohepatic circulation with a relative excess of cholesterol and cholesterol supersaturated bile might ensue, causing cholesterol gallstone formation.
In patients with Crohn’s disease involving the small
intestine, the prevalence of gall-bladder stones is higher
than that in the general population. One hypothesis
for this increased risk is that bile acid malabsorption,
secondary to impaired active bile acid transport as a
consequence of ileal disease/resection, leads to a
reduction in the total bile acid pool size and an increase
in biliary cholesterol saturation. In patients with
ulcerative or Crohn’s colitis, or who have undergone
colectomy, the bile acid malabsorption is less than that
in those with ileal dysfunction or resection, but the risk
of gallstone formation is still increased, allegedly by the
same mechanism. -
This question is part of the following fields:
- Generic Surgical Topics
- Hepatobiliary And Pancreatic Surgery
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Question 151
Incorrect
-
What is the most likely cause of bilateral gynaecomastia in a 55-year old male?
Your Answer:
Correct Answer: Hepatic failure
Explanation:Hypertrophy of breast tissue in males is known as gynaecomastia. It is normally due to proliferation of stroma and not of mammary ducts. Physiological gynaecomastia can occur during puberty and is often transient, bilateral, symmetrical and possibly tender. Gynaecomastia can occur during old age too, but is usually unilateral. Other causes include hepatic or renal failure, endocrinological disorders, drugs (anabolic steroids, antineoplastic drugs, calcium channel blockers, cimetidine, digitalis, oestrogens, isoniazid, ketoconazole, methadone, metronidazole, reserpine, spironolactone, theophylline), and marijuana. It should not be confused with malignancy which is often hard, asymmetric and fixed to the dermis or fascia. Treatment if indicated, includes withdrawal of the causative factor or treatment of the underlying disorder.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 152
Incorrect
-
A middle aged woman presents with a 4 day history of sore throat, malaise and fatigue and she is seen to have a large peritonsillar abscess on examination. Which of the following would most likely be the causative agent?
Your Answer:
Correct Answer: Streptococcus pyogenes
Explanation:Answer: Streptococcus pyogenes
Tonsillitis is inflammation of the pharyngeal tonsils. The inflammation usually extends to the adenoid and the lingual tonsils; therefore, the term pharyngitis may also be used. Most cases of bacterial tonsillitis are caused by group A beta-haemolytic Streptococcus pyogenes (GABHS).
Signs and symptoms
TonsillitisIndividuals with acute tonsillitis present with the following:
Fever
Sore throat
Foul breath
Dysphagia (difficulty swallowing)
Odynophagia (painful swallowing)
Tender cervical lymph nodesAirway obstruction may manifest as mouth breathing, snoring, sleep-disordered breathing, nocturnal breathing pauses, or sleep apnoea.
Peritonsillar abscess
Individuals with peritonsillar abscess (PTA) present with the following:
Severe throat pain
Fever
Drooling
Foul breath
Trismus (difficulty opening the mouth)
Altered voice quality (the hot-potato voice)Treatment of acute tonsillitis is largely supportive and focuses on maintaining adequate hydration and caloric intake and controlling pain and fever.
Corticosteroids may shorten the duration of fever and pharyngitis in cases of infectious mononucleosis (MN). In severe cases of MN, corticosteroids or gamma globulin may be helpful. GABHS infection obligates antibiotic coverage.
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This question is part of the following fields:
- Clinical Microbiology
- Principles Of Surgery-in-General
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Question 153
Incorrect
-
A Monospot test in a 17-year old boy presenting with fever, multiple palpable lymph nodes and mild icterus was positive. His blood investigation is likely to show which of the following?
Your Answer:
Correct Answer: Atypical lymphocytosis
Explanation:Epstein-Barr virus is the causative agent for infectious mononucleosis leading to presence of atypical lymphocytes in blood. Usually symptomatic in older children and adults, the incubation period is 30-50 days. Symptoms include fatigue, followed by fever, adenopathy and pharyngitis. Fatigue can last for months and is maximum in first few weeks. Fever spikes in the afternoon or early evening, with temperature around 39.5 – 40.5 °C. The ‘typhoidal’ form where fatigue and fever predominate has a low onset and resolution. Pharyngitis resemble that due to streptococcus and can be severe and painful. Lymphadenopathy is bilaterally symmetrical and can involve any nodes, specially the cervical ones. Mild splenomegaly is seen in 50% cases, usually in 2-3rd week. Mild tender hepatomegaly can occur. Less common manifestations include maculopapular eruptions, jaundice, periorbital oedema and palatal enanthema. Diagnostic tests include full blood count and a heterophil antibody test. Morphologically abnormal lymphocytes account for 80% cells and are heterogenous, unlike leukaemia.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 154
Incorrect
-
A 11 year girl presents to the A&E department with a full thickness burn to her right arm, which she got when a firework that she was playing with exploded. Which statement is not characteristic of the situation?
Your Answer:
Correct Answer: The burn area is extremely painful until skin grafted
Explanation:Answer: The burn area is extremely painful until skin grafted
Third-degree burns destroy the epidermis and dermis. Third-degree burns may also damage the underlying bones, muscles, and tendons. The burn site appears white or charred. There is no sensation in the area since the nerve endings are destroyed. These are not normally painful until after skin grafting is done since the nerve endings have been destroyed.
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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 155
Incorrect
-
The surgical registrar is doing an exploratory laparotomy on a 35 year old lady of African descent with tuberculous of the abdomen and suspected perforation. The small bowel is matted due to adhesions and it is difficult to differentiate the ileum from the jejunum. Which of the following features is typical of the jejunum?
Your Answer:
Correct Answer: It has sparse aggregated lymph nodules
Explanation:The jejunum has a wider diameter, is thicker and more vascularized, hence of a deeper colour compared to the ileum. The valvulae conniventes (circular folds) of its mucous membranes are large and thick and its villi are larger than those in the ileum. The jejunum also has sparse aggregates of lymph nodules and most of its part occupies the umbilical and left iliac regions whilst the ileum is mostly in the umbilical, hypogastric, right iliac and pelvic regions.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 156
Incorrect
-
Elevated mean corpuscular volume with hypersegmented neutrophils and low reticulocyte index is seen in on the blood count of a middle-aged lady about to undergo elective surgery. On enquiry, she mentions feeling tired for a few months. Which of the following investigations should be carried out in her to reach a diagnosis?
Your Answer:
Correct Answer: Serum vitamin B12 and folate
Explanation:Elevated levels of MCV indicates megaloblastic anaemia, which are associated with hypersegmented neutrophils. Likely causes include vitamin B12 or folate deficiency. Megaloblastic anaemia results from defective synthesis of DNA. As RNA production continues, the cells enlarge with a large nucleus. The cytoplasmic maturity becomes greater than nuclear maturity. Megaloblasts are produced initially in the marrow, before blood. Dyspoiesis makes erythropoiesis ineffective, causing direct hyperbilirubinemia and hyperuricemia. As all cell lines are affected, reticulocytopenia, thrombocytopenia and leukopenia develop. Large, oval blood cells (macro-ovalocytes) are released in the circulation, along with presence of hypersegmented neutrophils.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 157
Incorrect
-
A 66 year old woman undergoes an emergency hip hemiarthroplasty. The procedure is complicated by a fracture of the femoral shaft following the insertion of the prosthesis. She is seen postoperatively to be unsteady on her feet and she is depressed. She remains bedbound for 2 weeks and is slow to progress despite adequate physiotherapy. Which of the following physiological changes is not seen after prolonged immobilization?
Your Answer:
Correct Answer: Bradycardia
Explanation:Answer: Bradycardia
Prolonged bed rest and immobilization inevitably lead to complications. Such complications are much easier to prevent than to treat. Musculoskeletal complications include loss of muscle strength and endurance, contractures and soft tissue changes, disuse osteoporosis, and degenerative joint disease. Cardiovascular complications include an increased heart rate (tachycardia), decreased cardiac reserve, orthostatic hypotension, and venous thromboembolism.
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This question is part of the following fields:
- Peri-operative Care
- Principles Of Surgery-in-General
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Question 158
Incorrect
-
A young male was diagnosed with hepatitis A, which clinically resolved in 2 weeks. What will his liver biopsy done after 6 months show?
Your Answer:
Correct Answer: Normal architecture
Explanation:Hepatitis A is the most common acute viral hepatitis, more common in children and young adults. It is caused by Hepatitis A virus, which is a single-stranded RNA picornavirus. The primary route of spread of Hepatitis A is the faecal-oral route. Consumption of contaminated raw shellfish is also a likely causative factor. The shedding of the virus in faecal matter occurs before the onset of symptoms and continues a few days after. Hepatitis A does not lead to chronic hepatitis or cirrhosis, and there is no known chronic carrier state. Hence, a biopsy performed after recovery will show normal hepatocellular architecture.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 159
Incorrect
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Renal function is an indication of the state of the kidney, measured by glomerular filtration rate (GFR). In a healthy person, GFR would be greatly increased by:
Your Answer:
Correct Answer: Substantial increases in renal blood flow
Explanation:An increase in the rate of renal blood flow (RBF) greatly increases the glomerular filtration rate (GFR). The more plasma available (from increased RBF), the more filtrate is formed. Glomerular filtration rate (GFR) is the volume of fluid filtered from the renal (kidney) glomerular capillaries into the Bowman’s capsule per unit time. Central to the physiologic maintenance of GFR is the differential basal tone of the afferent and efferent arterioles.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 160
Incorrect
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Which organs would cause pain in a patient who complains of dull pain in her pelvis, along the midline starting from the pubic bone in the front to the sacrum at the back?
Your Answer:
Correct Answer: Urinary bladder, uterus/cervix/vagina, rectum
Explanation:The pain could have been caused by the urinary bladder, uterus/cervix/vagina or rectum as it involves the pelvic viscera.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 161
Incorrect
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An old man presented with atrophy of the thenar eminence despite the sensation over it still being intact. What is the injured nerve in this case?
Your Answer:
Correct Answer: Median nerve
Explanation:Atrophy of the thenar muscles means injury to the motor supply of these muscles. The nerve that sends innervation to it is the median nerve. But the median nerve does not provide sensory innervation to the overlying skin so sensation is spared.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 162
Incorrect
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A 15 month old boy has a history of repeated bacterial pneumonia, failure to thrive and a sputum culture positive for H.influenzea and S.pneumoniae. There is no history of congenital anomalies. He is most likely suffering from?
Your Answer:
Correct Answer: X-linked agammaglobulinemia
Explanation:Recurrent bacterial infections may be due to lack of B-cell function, consequently resulting in a lack of gamma globulins production. Once the maternal antibodies have depleted, the disease manifests with greater severity and is called x-linked agammaglobulinemia also known as ‘X-linked hypogammaglobulinemia’, ‘XLA’ or ‘Bruton-type agammaglobulinemia. it is a rare x linked genetic disorder that compromises the bodies ability to fight infections.
Acute leukaemia causes immunodeficiency but not so specific.
DiGeorge syndrome is due to lack of T cell function.
Aplastic anaemia and EBV infection does not cause immunodeficiency. -
This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 163
Incorrect
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Infection to all of the following will lead to enlargement of the superficial inguinal lymph nodes, except for:
Your Answer:
Correct Answer: Ampulla of the rectum
Explanation:The superficial inguinal lymph nodes form a chain immediately below the inguinal ligament. They receive lymphatic supply from the skin of the penis, scrotum, perineum, buttock and abdominal wall below the level of the umbilicus.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 164
Incorrect
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A 59-year-old woman with hyperaldosteronism is prescribed a diuretic. Which of the following diuretics promotes diuresis by opposing the action of aldosterone?
Your Answer:
Correct Answer: Potassium-sparing diuretic
Explanation:The term potassium-sparing refers to an effect rather than a mechanism or location. Potassium-sparing diuretics act by either antagonising the action of aldosterone (spironolactone) or inhibiting Na+ reabsorption in the distal tubules (amiloride). This group of drugs is often used as adjunctive therapy, in combination with other drugs, for the management of chronic heart failure. Spironolactone, the first member of the class, is also used in the management of hyperaldosteronism (including Conn’s syndrome) and female hirsutism (due to additional antiandrogen actions).
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 165
Incorrect
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A 33 year old firefighter is recovering from an appendicectomy where the operation was complicated by the presence of perforation. On observation, he is seen to be vomiting and his urine output is decreasing. Which intravenous fluid should be initially administered, pending analysis of his urea and electrolyte levels?
Your Answer:
Correct Answer: Hartmann's solution
Explanation:Compound Sodium Lactate (Hartmann’s) is used:
• for intravenous fluid and electrolyte replacement
• as a source of bicarbonate in the treatment of mild to moderate metabolic acidosis associated with dehydration or associated with potassium deficiency
• as a vehicle for intravenous drug delivery, if the drugs are compatible with the solutionsThe total amount of electrolytes per litre are: sodium 131 mmol, potassium 5mmol, chloride 112 mmol, calcium 2mmol, bicarbonate (as lactate) 28 mmol.
The osmolality is approximately 255 mOsm/kg water. The solutions are isotonic, sterile, non-pyrogenic and do not contain antimicrobial agent or added buffers. The pH range is 5.0 to 7.0. Compound Sodium LactateRinger’s lactate solution (RL), also known as sodium lactate solution and Hartmann’s solution, is a mixture of sodium chloride, sodium lactate, potassium chloride, and calcium chloride in water. It is used for replacing fluids and electrolytes in those who have low blood volume or low blood pressure.
Hartmann’s solution is often preferred over normal saline as it contains both fluids and electrolytes. The solution is also associated with fewer adverse effects and it can be administered to both adults and children.
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This question is part of the following fields:
- Post-operative Management And Critical Care
- Principles Of Surgery-in-General
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Question 166
Incorrect
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Tumours derived from all three germ-cell layers in new-borns usually occur in which of the following sites?
Your Answer:
Correct Answer: Sacrococcygeal area
Explanation:A teratoma is a tumour with tissue or organ components resembling normal derivatives of more than one germ layer. It is derived from all three cell layers. The most common location of teratoma in new-born infants is in the sacrococcygeal area.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 167
Incorrect
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A 35 year old gardener presents to the clinic complaining of a lesion on the dorsum of his right hand that has been present for the last 10 days. He had been pruning rose bushes before the lesion occurred. Examination shows a raised ulcerated lesion that bleeds easily on contact. What is the most likely diagnosis?
Your Answer:
Correct Answer: Pyogenic granuloma
Explanation:Pyogenic granuloma is a vascular lesion that occurs on both mucosa and skin, and appears as an overgrowth of tissue due to irritation, physical trauma, or hormonal factors. It is often found to involve the gums, the skin and nasal septum, and has also been found far from the head such as in the thigh. Contact bleeding and ulceration are common.
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This question is part of the following fields:
- Generic Surgical Topics
- Skin Lesions
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Question 168
Incorrect
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A 39 year old woman is knocked off her bike on the way home and she is taken to the hospital. Her ankle is observed to be grossly deformed with bilateral malleolar tenderness, severe ankle swelling and tenting of the medial soft tissues. Which of the following would be the best option in initial management?
Your Answer:
Correct Answer: Immediate reduction and application of backslab
Explanation:Ankle fractures most often occur by rotational mechanisms with the external forces transmitted through the foot via the talus to the malleoli. The specific pattern of fracture and ligamentous injury depends on the position of the foot and the direction of the force at the time of injury.
Reduce the ankle fracture as soon as possible once informed consent provided to the patient. Assess the neurovascular status of the limb before and after manipulation. Have splinting materials ready and measured out (use the uninjured, contralateral leg for measuring). Either a short leg splint or cast is applied based on fracture type, patient, surgical urgency, and surgeon preference.
Ensure adequate analgesia for the patient including NSAIDs, IV medications, hematoma block, or procedural sedation. Once reduced and splinted in place, recheck neurovascular status, elevate the leg and obtain a post-reduction X-ray.
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This question is part of the following fields:
- Generic Surgical Topics
- Orthopaedics
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Question 169
Incorrect
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Which of the following is responsible for the activation of pepsinogen released in the stomach?
Your Answer:
Correct Answer: Acid pH and pepsin
Explanation:Pepsinogen is the inactive precursor of pepsin. Once secreted, it comes in contact with hydrochloric acid and pepsin, previously formed, and undergoes cleavage to form active pepsin.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 170
Incorrect
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A 42-year old woman presents to the doctor with jaundice. Her investigations show conjugated hyperbilirubinemia, raised urine bilirubin levels and low urine urobilinogen levels. What is the likely cause of her jaundice?
Your Answer:
Correct Answer: Blockage of the common bile duct
Explanation:The description of the patient here fits the diagnosis of obstructive jaundice or cholestasis, which results in conjugated hyperbilirubinemia. Cholestasis occurs due to impairment of bile flow, which can be anywhere from the liver cell canaliculus to the ampulla of Vater. Causes can be divided into intrahepatic and extrahepatic.
– Intrahepatic causes include hepatitis, drug toxicity, alcoholic liver disease, primary biliary cirrhosis, cholestasis of pregnancy and metastatic cancer.
– Extrahepatic causes include common duct stone, pancreatic cancer, benign stricture of the common duct, ductal carcinoma, pancreatitis and sclerosing cholangitis.
There is absence of bile constituents in the intestine, which causes spillage in the systemic circulation. Symptoms include pale stools, dark urine, pruritus, malabsorption leading to steatorrhea and deficiency of fat-soluble vitamins. Chronic cases can result in osteoporosis or osteomalacia due to vitamin D deficiency and Ca2+ malabsorption. Cholesterol and phospholipid retention produces hyperlipidaemia despite fat malabsorption (although increased liver synthesis and decreased plasma esterification of cholesterol also contribute); triglyceride levels are largely unaffected. The lipids circulate as a unique, low-density lipoprotein called lipoprotein X. -
This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 171
Incorrect
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Which is the CORRECT statement regarding the small intestine:
Your Answer:
Correct Answer: The superior mesenteric artery courses between the body and uncinate process of the pancreas before the artery supplies the jejunum and ileum
Explanation:The small intestine extends from the pylorus to the ileocecal valve where It ends in the large intestine. It is surrounded on the sides and above by the large intestine. It is related anteriorly with the greater omentum and abdominal wall. Is connected to the vertebral column by a fold of peritoneum or otherwise known as the mesentery. Is divided into three portions: the duodenum, jejunum and ileum. The jejunum and ileum are supplied by the superior mesenteric artery that courses between the body and uncinate process of the pancreas before it gives off intestinal branches.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 172
Incorrect
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A 32 year old woman who works as a teacher presents with a swollen, oedematous leg. She hails from Africa, from an area that is poorly sanitized and prevalent with mosquitoes. She travelled to England two weeks back. Which of the following is the most likely diagnosis?
Your Answer:
Correct Answer: Filariasis
Explanation:Lymphatic filariasis, commonly known as elephantiasis, is a painful and profoundly disfiguring disease. In communities where filariasis is transmitted, all ages are affected. While the infection may be acquired during childhood its visible manifestations may occur later in life, causing temporary or permanent disability. The disease is caused by three species of thread-like nematode worms, known as filariae – Wuchereria bancrofti, Brugia malayi and Brugia timori. Male worms are about 3–4 centimetres in length, and female worms 8–10 centimetres. The male and female worms together form “nests” in the human lymphatic system.
Filarial infection can cause a variety of clinical manifestations, including lymphoedema of the limbs, genital disease (hydrocele, chylocele, and swelling of the scrotum and penis) and recurrent acute attacks, which are extremely painful and are accompanied by fever. The vast majority of infected people are asymptomatic, but virtually all of them have subclinical lymphatic damage and as many as 40% have kidney damage, with proteinuria and haematuria.
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This question is part of the following fields:
- Generic Surgical Topics
- Vascular
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Question 173
Incorrect
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What is the nerve supply of the muscle that is inserted onto the crest of the lesser tubercle of the humerus?
Your Answer:
Correct Answer: Lower subscapular
Explanation:The muscle is the subscapularis muscle which is supplied by the lower subscapular nerve.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 174
Incorrect
-
An operation to remove a segment of the oesophagus through a right thoracotomy is complicated when a tear develops in a large venous structure in the posterior mediastinum that empties into the superior vena cava. Which of the following structures is likely to be injured?
Your Answer:
Correct Answer: Azygos vein
Explanation:The azygos vein is formed by the union of the right subcostal veins and the ascending lumbar veins at the level of the 12th thoracic vertebra. It enters the thorax through the aortic hiatus to ascend in the posterior mediastinum and arching over the right main bronchus posteriorly at the root of the right lung to join the superior vena cava before it pierces the pericardium.
The basilic vein is a vein on the medial aspect of the arm that ascends to become the axillary vein.
The cephalic vein is also a vein of the arm.
The external jugular and brachiocephalic vein are not in the posterior mediastinum.
The median cubital vein is found in the cubital fossa of the arm. -
This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 175
Incorrect
-
An old woman complains of a lack of sensation halfway down the anterior surface of the thigh. The cause of this:
Your Answer:
Correct Answer: Would result from damage to the nerve that innervates the pectineus muscle
Explanation:The pectineus is supplied by the second, third and fourth lumbar nerves through the femoral nerve and by the third lumbar through the accessory obturator when it exists. The anterior surface of the thigh receives its innervation from the femoral nerve as well, thus this is the nerve most likely to be injured
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 176
Incorrect
-
A lesion involving the lateral geniculate nucleus of the thalamus is likely to affect:
Your Answer:
Correct Answer: Vision
Explanation:The lateral geniculate nucleus (LGN) of the thalamus is the primary processor of visual information in the central nervous system. The LGN receives information directly from the retina and sends projections directly to the primary visual cortex. The LGN likely helps the visual system focus its attention on the most important information.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 177
Incorrect
-
A young lady is stabbed in the chest when she was leaving a party and she develops a cardiac arrest in the A&E department. What is the best course of action?
Your Answer:
Correct Answer: Thoracotomy
Explanation:Answer: Thoracotomy
Cardiac arrest after penetrating chest trauma may be an indication for emergency thoracotomy. A successful outcome is possible if the patient has a cardiac tamponade and the definitive intervention is performed within 10 minutes of loss of cardiac output.
EMERGENCY “CLAM SHELL” THORACOTOMYIndication:
Penetrating chest/epigastric trauma associated with cardiac arrest (any rhythm).
Contraindications:
Definite loss of cardiac output for greater than 10 minutes.Any patient who has a cardiac output, including hypotensive patients.
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This question is part of the following fields:
- Emergency Medicine And Management Of Trauma
- Principles Of Surgery-in-General
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Question 178
Incorrect
-
A 47-year-old male is recovering in hospital following a total hip replacement. He develops profuse and watery diarrhoea. Several other patients have been suffering from similar symptoms. Infection with which of the following is the most likely underlying cause?
Your Answer:
Correct Answer: Clostridium difficile
Explanation:Clostridioides difficile (formerly Clostridium difficile) colitis results from a disturbance of the normal bacterial flora of the colon, colonization by C difficile, and the release of toxins that cause mucosal inflammation and damage. Antibiotic therapy is the key factor that alters the colonic flora. C difficile infection (CDI) occurs primarily in hospitalized patients.
The diagnosis of C difficile colitis should be suspected in any patient with diarrhoea who has received antibiotics within the previous 3 months, has been recently hospitalized, and/or has an occurrence of diarrhoea within 48 hours or more after hospitalization. In addition, C difficile can be a cause of diarrhoea in community dwellers without previous hospitalization or antibiotic exposureThe following recommendations on Clostridium difficile infection (CDI) were released on February 2018 by the Infectious Diseases Society of America (ISDA) and Society for Healthcare Epidemiology of America (SHEA).
Diagnosis (adults)
Patients with unexplained and new-onset ≥3 unformed stools in 24 hours are the preferred target population for testing for CDI.
Use a stool toxin test as part of a multistep algorithm (i.e., glutamate dehydrogenase [GDH] plus toxin; GDH plus toxin, arbitrated by nucleic acid amplification test [NAAT]; or NAAT plus toxin) rather than NAAT alone for all specimens when there are no pre-agreed institutional criteria for patient stool submission.
Use NAAT alone or a multistep algorithm for testing (i.e., GDH plus toxin; GDH plus toxin, arbitrated by NAAT; or NAAT plus toxin) rather than a toxin test alone when there are pre-agreed institutional criteria for patient stool submission.
Do not perform repeat testing (within 7 days) during the same episode of diarrhoea and do not test stool from asymptomatic patients, except for epidemiologic studies -
This question is part of the following fields:
- Clinical Microbiology
- Principles Of Surgery-in-General
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Question 179
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:
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 180
Incorrect
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A 27-year-old woman, who had been taking a combined oral contraceptive for 6 months, presented with inguinal pain and oedema of the left leg. Which of the following investigations would you recommend to help confirm the diagnosis?
Your Answer:
Correct Answer: Duplex scan
Explanation:Oral combined contraceptive pill (OCCP) is a drug used for birth control and treating a number of other conditions. Women who take the OCP have a higher risk of developing deep vein thrombosis (DVT), usually in the legs. Duplex ultrasonography is a safe and non-invasive technique which is used for diagnosing the presence of lower extremity thrombi.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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SESSION STATS - PERFORMANCE PER SPECIALTY
