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Question 1
Incorrect
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A 45-year-old-female is suspected to have a pulmonary mass. Supposing that she has a neoplasm, which of the following are most commonly found to involve the lung:
Your Answer: Small-cell anaplastic carcinomas in smokers
Correct Answer: Pulmonary metastases
Explanation:Lung metastases occur when a cancer started in another part of the body (primary site) spreads to the lungs. The lungs are among the most common site where cancer can spread due to its rich systemic venous drainage, almost every type of cancer can spread to the lung. The most common types of cancer that spread to the lung are breast, colorectal, kidney, testicular, bladder, prostate, head and neck cancers.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 2
Incorrect
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In the human body, veins often run a course parallel to the artery that has the same name. Which of the following listed veins doesn't run parallel to the artery of the same name?
Your Answer: Superior rectal
Correct Answer: Inferior mesenteric
Explanation:The inferior mesenteric artery and inferior mesenteric vein don’t run in tandem because the vein is part of the portal venous system-draining into the splenic vein which drains into the hepatic portal vein. The inferior mesenteric artery is a branch of the descending aorta at the level of L3. The inferior mesenteric vein and artery, however, drain the same region i.e. the descending and sigmoid colon and rectum.
Superior epigastric vessels course together and are the continuation of the internal thoracic artery and vein.
Superficial circumflex iliac vessels course together in the superficial fat of the abdominal wall.
Superior rectal vessels are the terminal ends of the inferior mesenteric vessels, located on the posterior surface of the rectum.
The ileocolic artery and vein are branches off the superior mesenteric vessels. Both course in the mesentery, supplying/draining the caecum, appendix, terminal portion of the ileum. The inferior epigastric vessels run together. -
This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 3
Correct
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Which foramen contains the vertebral artery?
Your Answer: Foramen magnum
Explanation:The foramen magnum is found in the most inferior part of the posterior cranial fossa. It is traversed by vital structures including the medulla oblongata. Its contents include the following: medulla oblongata, meninges, spinal root of the accessory nerve, vertebral arteries, anterior and posterior spinal arteries, tectorial membrane and alar ligaments.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 4
Correct
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A sudden loud sound is more likely to result in cochlear damage than a slowly developing loud sound. This is because:
Your Answer: There is a latent period before the attenuation reflex can occur
Explanation:On transmission of a loud sound into the central nervous system, an attenuation reflex occurs after a latent period of 40-80 ms. This reflex contracts the two muscles that pull malleus and stapes closer, developing a high degree of rigidity in the entire ossicular chain. This reduces the ossicular conduction of low frequency sounds to the cochlea by 30-40 decibels. In this way, the cochlea is protected from damage due to loud sounds (these are low frequency sounds) when they develop slowly.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 5
Correct
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Which of the following structures carry part of the right bundle branch of the AV bundle?
Your Answer: Moderator band (septomarginal trabecula)
Explanation:The moderator band extends from the base of the anterior papillary muscle to the ventricular septum. It is the structure which carries part of the right AV bundle. Its role it to prevent overdistention of the ventricle.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 6
Correct
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A 20 year old is brought to the A&E after he fell from a moving cart. The boy has sustained blunt abdominal injury, and the there is a possibility of internal bleeding as the boy is in shock. An urgent exploratory laparotomy is done in the A&E theatre. On opening the peritoneal cavity, the operating surgeon notices a torn gastrosplenic ligament with a large clot around the spleen. Which artery is most likely to have been injured in this case?
Your Answer: Short gastric
Explanation:The short gastric arteries branch from the splenic artery near the splenic hilum to travel back in the gastrosplenic ligament to supply the fundus of the stomach. Therefore, these may be injured in this case.
The splenic artery courses deep to the stomach to reach the hilum of the spleen. It doesn’t travel in the gastrosplenic ligament although it does give off branches that do.
The middle colic artery is a branch of the superior mesenteric artery that supplies the transverse colon.
Gastroepiploic artery is the largest branch of the splenic artery that courses between the layers of the greater omentum to anastomose with the right gastroepiploic.
Left gastric artery, a branch of the coeliac trunk. It supplies the left half of the lesser curvature. -
This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 7
Correct
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The primary somatosensory cortex is located in the:
Your Answer: Postcentral gyrus
Explanation:The primary somatic sensory cortex is located in the postcentral gyrus and is the largest cortical receiving area for information from somatosensory receptors. Through corticocortical fibres, it then sends the information to other areas of the neocortex and further analysis takes place in the posterior parietal association cortex.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 8
Incorrect
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A 26-year-old man sustains a Holstein-Lewis fracture of the left arm. Which of the following nerves is at risk of damage?
Your Answer: Musculocutaneous
Correct Answer: Radial
Explanation:Holstein-Lewis fracture is a fracture of the distal third of the humerus resulting in entrapment of the radial nerve. The radial nerve is one of the major peripheral nerves of the upper limb. It innervates all the muscles in the extensor compartments of the arm.
Conservative treatment for this fracture includes reduction and use of a functional brace. However, vascular injury may require open surgery.
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This question is part of the following fields:
- Generic Surgical Topics
- Orthopaedics
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Question 9
Correct
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When conducting an exploratory laparotomy procedure of a patient diagnosed with a bleeding ulcer of the lesser curvature of the stomach, which artery in this patient are you most likely to ligate to control the bleeding?
Your Answer: Left gastric
Explanation:The lesser curvature of the stomach is supplied by the left gastric artery along with the right gastric artery. These two arteries are the ones to most likely be ligated if bleeding was to be stopped at the lesser curvature of the stomach. The splenic artery branches from the celiac branch and supplies the spleen. The left gastro-omental, the right and left gastroepiploic arteries supply the greater curvature.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 10
Correct
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A 32-year-old man presented with a metabolic acidosis and increased anion gap. What is the most likely cause of the changes of the anion gap in this patient?
Your Answer: Lactic acidosis
Explanation:High anion gap in metabolic acidosis is caused generally by the elevation of the levels of acids like ketones, lactate, sulphates in the body, which consume the bicarbonate ions. Other causes of a high anion gap include overdosing on salicylates, uraemia, rhabdomyolysis, hypocalcaemia, hypomagnesaemia, or ingestion of toxins such as ethylene glycol, methanol, propyl alcohol, cyanide and iron.
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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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A 28-year old lady comes to the surgical clinic with a recently detected lump in her right breast. On examination, the lump is found to be 1cm, rubbery, mobile with no palpable axillary nodes. Mammography reveals no microcalcifications and the opposite breast appears normal. What is the likely diagnosis?
Your Answer: Fibroadenoma
Explanation:A benign breast tumour, fibroadenoma is common below the age of 30 years and occurs due to oestrogenic excess. It is characterised by proliferation of both glandular and stromal elements. Fibroadenomas are usually solitary and are mobile, not fixed to surrounding structures. The tumour is elastic, nodular and encapsulated with a grey-white cut surface. The two main histological types include intracanalicular and pericanalicular types, with both types often present in the same tumour. In the intracanalicular type, the stromal proliferation component predominates causing compression of ducts making them appear slit-like. In pericanalicular type, the fibrous stroma dominates around the ductal spaces so that they remain oval on cross section.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 12
Correct
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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 13
Correct
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After a cerebral infarction, which of these histopathogical findings is most likely to be found?
Your Answer: Liquefactive necrosis
Explanation:The brain has a high lipid content and typically undergoes liquefaction with ischaemic injury, because it contains little connective tissue but high amounts of digestive enzymes.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 14
Incorrect
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A lad involved in a road traffic accident is rushed to casualty where physical examination reveals that he has limited extension of his right humerus. Which of the following nerves is most likely to have been injured?
Your Answer: Suprascapular nerve
Correct Answer: Thoracodorsal nerve
Explanation:Extension of the humerus is a function of the latissimus dorsi. This muscle is supplied by the thoracodorsal nerve which is a branch of the posterior cord of the plexus whose fibres are derived from cranial nerves V, VI and VII.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 15
Correct
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Which of the following tumours is very radiosensitive?
Your Answer: Seminoma
Explanation:Seminoma is the most radiosensitive tumour and responds well to radiation therapy after unilateral orchidectomy. The ipsilateral inguinal areas are routinely not treated however, depending on the stage, the mediastinum and the left supraclavicular regions may also be irradiated.
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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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Atrial septal defect (ASD) is most likely to be due to incomplete closure of which one of the following structures:
Your Answer: Sinus venarum
Correct Answer: Foramen ovale
Explanation:Atrial septal defect is a congenital heart defect that results in a communication between the right and left atria of the heart and may involve the interatrial septum. It results from incomplete closure of the foramen ovale which is normally open during fetal life and closes just after birth.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 17
Incorrect
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Biopsy of a neoplastic mass was performed. Histologic examination of the specimen showed spindle shaped cells with high nuclear/cytoplasm ratio on immunohisto chemical staining. These pleomorphic cells were vimentin positive, cytokeratin negative and cd45 negative. This type of neoplasm is most commonly found in which patient?
Your Answer: A 35-year-old woman with a left breast mass and enlarged axillary lymph nodes
Correct Answer: A 15-year-old boy with a mass in the left femur and lung metastases
Explanation:A histology report that describes spindle shaped cells which are vimentin positive suggests osteosarcoma and hematogenous spread to the lungs.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 18
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 19
Correct
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The dilator pupillae muscle is innervated by postganglionic sympathetic fibres. Where do the postganglionic sympathetic fibres originate?
Your Answer: Superior cervical ganglion
Explanation:The postganglionic sympathetic axons are derived from the superior cervical ganglion and innervate the eye and lacrimal gland allowing for vasoconstriction of the iris and sclera, pupillary dilation, widening of the palpebral fissure, and a reduction in tear production.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 20
Correct
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A 64 year old diabetic man presents with a deep laceration of his lateral thigh which measures 3cm in depth by 7cm in length, that penetrates to the bone. There are no signs of fracture. His diabetes is diet controlled and is on low dose prednisolone therapy for polymyalgia rheumatica. Which of the following options should be employed most safely for the wound management of this patient?
Your Answer: Delayed primary closure
Explanation:Delayed primary closure is often intentionally applied to lacerations that are not considered clean enough for immediate primary closure. The wound is left open for 5-10 days; then, it is sutured closed to decrease the risk of wound infection. Improved blood flow at the wound edges, which develops increasingly over the first few days, is another benefit of this style of wound healing and can be associated with progressive increases in resistance to infections. The combination of diabetes and steroids makes wound complications more likely. Despite his high risk, a primary skin graft or flap is unlikely to be a safer option.
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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 21
Incorrect
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The periphery of a haematoma is infiltrated by fibroblasts, collagen and new vasculature. This process is best described as?
Your Answer: Recanalization
Correct 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 22
Correct
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An 18 year old military recruit complains of sudden onset of severe pain in the forefoot after several weeks of training exercises. Examination shows tenderness along the second metatarsal and an x-ray done indicates the presence of callus surrounding the shaft of the second metatarsal. What is his diagnosis?
Your Answer: Stress fracture
Explanation:Answer: Stress fracture
A stress fracture is caused by repetitive and submaximal loading of the bone, which eventually becomes fatigued and leads to a true fracture. The typical presentation is a complaint of increasing pain in the lower extremity during exercise or activity. The patient’s history usually reveals a recent increase in either training volume or intensity. Stress fractures result from recurrent and repetitive loading of bone. The stress fracture differs from other types of fractures in that in most cases, no acute traumatic event precedes the symptoms.
Normal bone remodelling occurs secondary to increased compressive or tensile loads or increased load frequency. In the normal physiologic response, minor microdamage of the bone occurs. This is repaired through remodelling. Stress fractures develop when extensive microdamage occurs before the bone can be adequately remodelled.
Common findings on physical examination may include tenderness or pain on palpation or percussion of the bone. Erythema or oedema may be present at the site of the stress fracture. Loading or stress of the affected bone may also produce symptoms.A stress fracture can be difficult to see on an X-ray, because the bone often appears normal in the X-ray, and the small cracks can’t be seen. X-rays may not help diagnose a stress fracture unless it has started to heal. When the bone starts to heal, it creates a callus, or lump, that can be seen on X-rays. The doctors may recommend a bone scan or magnetic resonance imaging (MRI), which is more sensitive than an X-ray and can spot stress fractures early.
Freiberg disease is a degenerative process involving the epiphyses resulting in osteonecrosis of subchondral cancellous bone. If the process is altered in such a way as to restore normal physiology, this may be followed by regeneration or recalcification. If not, the process continues to subchondral collapse and eventual fragmentation of the joint surface.
Patients who have Freiberg disease typically present with complaints of activity-related forefoot pain. Walking alone is often sufficient to cause pain. Some patients describe an extended (months to years) history of chronic forefoot pain with episodic exacerbation, whereas others present with pain of recent onset that is related to a specific injury or event. A history of trauma may not be noted. Patients may present with stiffness and a limp. The pain is often vague and poorly localized to the forefoot. Some patients describe the sensation of a small, hard object under the foot.Physical examination typically reveals a limited range of motion (ROM), swelling, and tenderness with direct palpation of the metatarsophalangeal (MTP) joint. In early stages of the disease, MTP tenderness may be the only finding. In later stages, crepitus or deformity may be present. A skin callus may be seen on the plantar surface of the affected metatarsal head.
Radiography
Depending on the stage of the disease, radiographs may show only sclerosis and widening of the joint space (early), with complete collapse of the metatarsal head and fragmentation later. Osteochondral loose bodies may be seen late in the disease as well. Oblique views may be especially useful for achieving a full appreciation of subtle changes early in the disease. One study advocated the use of radiographs to assess musculoskeletal foot conditions in women related to poorly fitting shoes.
Occasionally, patients are completely asymptomatic, with changes noted on radiographs taken for other reasons. Whether these patients later develop symptomatic Freiberg disease is not known. -
This question is part of the following fields:
- Generic Surgical Topics
- Orthopaedics
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Question 23
Correct
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A 30-year-old woman feels thirsty. This thirst is probably due to:
Your Answer: Increased level of angiotensin II
Explanation:Thirst is the basic need or instinct to drink. It arises from a lack of fluids and/or an increase in the concentration of certain osmolites such as salt. If the water volume of the body falls below a certain threshold or the osmolite concentration becomes too high, the brain signals thirst. Excessive thirst, known as polydipsia, along with excessive urination, known as polyuria, may be an indication of diabetes. Angiotensin II is a hormone that is a powerful dipsogen (i.e. it stimulates thirst) that acts via the subfornical organ. It increases secretion of ADH in the posterior pituitary and secretion of ACTH in the anterior pituitary.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 24
Correct
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An 8 year old boy presents with a history of repeated bacterial/pyogenic infections. He had a normal recovery from chickenpox and measles and shows normal antibody response. A decrease in which of the cell types can best explain this history of repeated pyogenic infections?
Your Answer: Neutrophils
Explanation:A decrease in the number of granulocytes, particularly neutrophils is known as agranulocytosis and it increases the susceptibility of an individual towards recurrent infections. Neutropenia can be either due to decreased production or increased elimination of neutrophils.
Ineffective agranulopoiesis is seen in: 1. myeloid stem cell suppression, 2. disease conditions associated with granulopoiesis such as megaloblastic anaemia and myelodysplastic syndromes, 3. rare genetic diseases, 4. splenic sequestration and 5. increased peripheral utilization. -
This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 25
Correct
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A 46-year-old male is involved in a polytrauma and requires a massive transfusion of packed red cells and fresh frozen plasma. Three hours later he develops marked hypoxia and his CVP is noted to be 10mm Hg. A chest x-ray shows bilateral diffuse pulmonary infiltrates. What is the most likely diagnosis?
Your Answer: Transfusion associated lung injury
Explanation:A massive blood transfusion is defined as the replacement of a patient’s total blood volume in <24 h
The abnormalities which result include effects upon coagulation status, serum biochemistry, acid-base balance and temperature homeostasis.
One of the complications is Transfusion-related acute lung injury
(TRALI) which is the most common cause of major morbidity and death after transfusion. It presents as an acute respiratory distress syndrome (ARDS) either during or within 6 h of transfusion.Clinical features
Hypoxaemia, dyspnoea, cyanosis, fever, tachycardia and hypotension result from non-cardiogenic pulmonary oedema. The radiographic appearance is of bilateral pulmonary infiltration, characteristic of pulmonary oedema. It is important to differentiate TRALI from other causes of ARDS such as circulatory overload or myocardial or valvular heart disease. Invasive monitoring in TRALI demonstrates normal intracardiac pressuresPathogenesis
Two different mechanisms for the pathogenesis of TRALI have been identified: immune (antibody-mediated) and non-immune. Immune TRALI results from the presence of leucocyte antibodies in the plasma of donor blood directed against human leucocyte antigens (HLA) and human neutrophil alloantigens (HNA) in the recipient. Antibodies present in the recipient only rarely cause TRALI. In up to 40% of patients, leucocyte antibodies cannot be detected in either donor or recipient. In these cases, it is possible that reactive lipid products released from the membranes of the donor blood cells act as the trigger. This is known as non-immune TRALI.
The target cell in both forms of TRALI is the neutrophil granulocyte. On activation of their acute phase cycle, these cells migrate to the lungs where they become trapped within the pulmonary microvasculature. Oxygen-free radicals and other proteolytic enzymes are then released which destroy the endothelial cells of the lung capillaries. A pulmonary capillary leak syndrome develops with the exudation of fluid and protein into the alveoli resulting in pulmonary oedema. The majority of reactions are severe, and often life-threatening; 70% require mechanical ventilation and 6ā9% are fatal. A definitive diagnosis requires antibody detection. The mortality in non-immune TRALI is lower, and the syndrome is encountered predominantly in critically ill patients.
Other Complications of blood transfusion
Early:
– Haemolytic reactions
Immediate
Delayed
– Non-haemolytic febrile reactions
– Allergic reactions to proteins, IgA
– Reactions secondary to bacterial contamination
– Circulatory overload
– Air embolism
– Thrombophlebitis
– Hyperkalaemia
– Citrate toxicity
– Hypothermia
– Clotting abnormalities (after massive transfusion)
Late:
– Transmission of infection
– Viral (hepatitis A, B, C, HIV, CMV)
– Bacterial (Treponeum pallidum, Salmonella)
– Parasites (malaria, toxoplasma)
– Graft-vs-host disease
– Iron overload (after chronic transfusions)
– Immune sensitization (Rhesus D antigen) -
This question is part of the following fields:
- Post-operative Management And Critical Care
- Principles Of Surgery-in-General
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Question 26
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 27
Correct
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Which of the following key features will be seen in an organ undergoing atrophy?
Your Answer: A greater number of autophagic vacuoles
Explanation:Atrophy is characterised by the breakdown of intracellular components along with organelles and packing them into vacuoles known as autophagic vacuoles. This is an adaptive response that separates the damaged cellular structures from the rest of the cells.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 28
Incorrect
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Rapid Eye Movement (REM) sleep is typically associated with:
Your Answer: Night terrors
Correct Answer: Penile erections
Explanation:Normal sleep comprises of alternate cycles between slow-wave sleep (non-REM sleep) and REM sleep. REM sleep is characterized by increased metabolic brain activity and EEG desynchronization. Somnambulism (sleepwalking), enuresis (bedwetting) and night terrors all occur during slow-wave sleep or during arousal from slow-wave sleep. In comparison, REM sleep is characterized by hypotonia of major muscle groups (excluding ocular muscles), dreams, nightmares and penile erection.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 29
Incorrect
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A 22-year-old male is diagnosed with an intersphincteric fistula-in-ano during an examination under anaesthetic. Which is the most appropriate treatment?
Your Answer: Insertion of a ācuttingā seton
Correct Answer: Insertion of a ālooseā seton
Explanation:An anal fistula is an abnormal tract between the anal canal and the skin around the anus.
Anal fistulas can be classified according to their relationship with the external sphincter. A fistula may be complex, with several openings onto the perianal skin. Intersphincteric fistulas are the most common type and cross only the internal anal sphincter. Trans-sphincteric fistulas pass through both the internal and external sphincters.The aim is to drain the infected material and encourage healing.
For simple intersphincteric and low trans-sphincteric anal fistulas, the most common treatment is a fistulotomy or laying open of the fistula tract.
For high and complex (deeper) fistulas that involve more muscle, with a high risk of faecal incontinence or recurrence, surgery aims to treat the fistula and preserve sphincter-muscle function. Techniques include a 1āstage or 2āstage seton (suture material or rubber sling) either alone or in combination with fistulotomy, ligation of an intersphincteric fistula tract, creating a mucosal advancement flap, injecting glue or paste, or inserting a fistula plug . -
This question is part of the following fields:
- Colorectal Surgery
- Generic Surgical Topics
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Question 30
Correct
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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: 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 31
Correct
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The dural venous sinuses are venous channels that drain blood from the brain. This sinuses are located between which structures?
Your Answer: Meningeal and periosteal layers of the dura mater
Explanation:The dural venous sinuses lies between the periosteal and meningeal layer of the dura mater. Dural venous sinuses is unique because it does not run parallel with arteries and allows bidirectional flow of blood intracranially as it is valve-less.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 32
Correct
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Which name is given to the inferior fascia of the urogenital diaphragm?
Your Answer: Perineal membrane
Explanation:The urogenital fascia is mostly commonly referred to as the perineal membrane. This term refers to an anatomical fibrous membrane in the perineum. It is triangular in shape, and thus at times referred to as the triangular ligament. It is about 4 cm in depth. Its The perineal membrane’s apex is anterior and is separated from the arcuate pubic ligament by an oval opening for the passage of the deep dorsal vein of the penis. The lateral marginas of this triangular ligament are attached on either side to the inferior rami of the pubis and ischium, above the crus penis. Its base faces the rectum, and connects to the central tendinous point of the perineum. The pelvic fascia and Colle’s fascia is fused to the base of this triangle.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 33
Correct
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A chest X-ray in a healthy, non-smoker, asymptomatic 48-year-old woman reveals a 2cm left lower lobe well-defined round opacity. Which of the following conditions is most probably responsible for this finding?
Your Answer: Pulmonary hamartoma
Explanation:An asymptomatic healthy patient with no history of smoking and a lesion of small size most probably has a benign lung lesion. Hamartomas are one of the most common benign tumours of the lung that accounts for approximately 6% of all solitary pulmonary nodules. Pulmonary hamartomas are usually asymptomatic and therefore are found incidentally when performing an imaging test for other reasons.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 34
Correct
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After being admitted to the hospital, a 60-year-old man is administered sodium nitroprusside. Which class of drugs does nitroprusside belong to?
Your Answer: Vasodilators
Explanation:Sodium nitroprusside is a potent peripheral vasodilator that affects both arterioles and venules. It is often administered intravenously to patients who are experiencing a hypertensive emergency. It reduces both total peripheral resistance as well as venous return, so decreasing both preload and afterload. For this reason it can be used in severe cardiogenic heart failure where this combination of effects can act to increase cardiac output. It is administered by intravenous infusion. Onset is typically immediate and effects last for up to ten minutes. The duration of treatment should not exceed 72 hours.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 35
Correct
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A 16-year old boy was brought in an unconscious state to the emergency department. Clinical evaluation pointed in favour of acute adrenal insufficiency. On enquiry, it was revealed that he was suffering from a high grade fever 24 hours prior. On examination, extensive purpura were noted on his skin. The likely diagnosis is:
Your Answer: Meningococcaemia
Explanation:Findings described are suggestive of Waterhouse-Friderichsen syndrome which develops secondary to meningococcaemia. The reported incidence of Addison’s disease is 4 in 100,000. It affects both sexes equally and is seen in all age groups. It tends to show clinical symptoms at the time of metabolic stress or trauma. The symptoms are precipitated by acute infections, trauma, surgery or sodium loss due to excessive perspiration.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 36
Correct
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During an OSCE exam a medical student is asked to locate the sternal angle. The sternal angle is a land mark for locating the level of the:
Your Answer: Second costal cartilage
Explanation:The sternal angle, a key landmark used in the clinic for auscultating for heart sounds, is the point of attachment of the costal cartilage of rib 2 to the sternum. It thus corresponds to the location of the second rib. A horizontal plane through the sternal angle traverses the T4/T5 intervertebral disc and marks the inferior boundary of the superior mediastinum.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 37
Correct
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A 24-year old patient diagnosed with a direct inguinal hernia was scheduled for surgery to have the hernia repaired. The hernia was discovered to be protruding through the Hesselbach's triangle (inguinal triangle). Which of the following blood vessels that is a branch of the external iliac artery forms the lateral border of this triangle?
Your Answer: Inferior epigastric
Explanation:The inguinal triangle is formed by the following structures; inguinal ligamentĀ at the base; inferior epigastric vesselsĀ laterally and the lateral border of theĀ rectus sheath medially. This triangle (also known as Hesselebach’s triangle) is where direct inguinal hernias protrude. The inferior epigastric artery is this the branch of the external iliac artery being referred to. All the other blood vessels are branches of the internal iliac artery.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 38
Correct
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Which is the correct statement regarding gonadal venous drainage:
Your Answer: The left ovarian vein drains into the left renal vein
Explanation:Spermatic or testicular veins arise from the posterior aspect of the testis and receive tributaries from the epididymis. Upon uniting, they form the pampiniform plexus that makes up the greater mass of the spermatic cord. The vessels that make up this plexus rise up the spermatic cord in front of the ductus deferens. They then unite, below the superficial ring, to form three or four veins that traverse the inguinal canal and enter the abdomen through the deep inguinal ring. They further unite to form 2 veins that ascend up the psoas major muscle behind the peritoneum each lying on either side of the testicular artery. These further unite to form one vein that empties on the right side of the inferior vena cava at an acute angle and on the left side into the renal vein, at a right angle. The left testicular vein courses behind the iliac colon and is thus exposed to pressure from the contents of this part of the bowel. The ovarian vein is the equivalent of the testicular vein in women. They form a plexus in the broad ligament near the ovary and uterine tube and communicate with the uterine plexus. They drain into similar vessels as in a man.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 39
Correct
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Which lymph nodes are most likely to enlarge due to the spread of infection through the lymphatic channels in a patient with a boil on his scrotum?
Your Answer: Superficial inguinal nodes
Explanation:The superficial inguinal nodes drain the perineum and the external genitalia which include the scrotum and the labia majora. The testes, however, drain to the lumbar nodes.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 40
Incorrect
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Electrophoresis is used to detect antibodies (immunoglobulins) in a blood sample from the umbilical artery of a new born. Which antibodies have the highest percentage in a new-born?
Your Answer: IgM
Correct Answer: IgG
Explanation:IgG is a monomeric immunoglobulin. It is formed by two heavy chains and two light chains and has two binding sites. Its is the most abundant antibody that is equally distributed in the blood and the tissues. It is the only antibody that can pass through the placenta and thus the only antibody present in the baby after it is born. There are four subclasses: IgG1 (66%), IgG2 (23%), IgG3 (7%) and IgG4 (4%). IgG1, IgG3 and IgG4 cross the placenta easily
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 41
Correct
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A 39 year old female presents with a 4 day history of a painful purple lesion on her ring finger. A tender red/purple lesion is seen on her ring finger on examination and medical history states that she has systemic lupus erythematosus (SLE). Which of the following would be her diagnosis?
Your Answer: Oslers nodes
Explanation:Osler nodes are small, usually raised, purplish red lesions, which are always tender, appear suddenly, and last 4 to 5 days. Painful fingers may be the earliest complaint or the chief complaint as with this patient. The nodes can appear on the dorsa of the feet and elsewhere. Osler nodes sometimes also accompany bacteraemia without endocarditis as well as septic endarteritis, typhoid fever, gonococcemia, systemic lupus erythematosus, and nonbacterial thrombotic endocarditis.
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This question is part of the following fields:
- Generic Surgical Topics
- Orthopaedics
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Question 42
Correct
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A recognised side-effect of prefrontal leukotomy is:
Your Answer: Confusion
Explanation:Used previously as a treatment for psychiatric disorders, prefrontal leucotomy severs the connection between the prefrontal cortical association area and the thalamus. This leads to functional isolation of the prefrontal and orbitofrontal association cortex. Thus, along with the desired reduction in anger and frustration, undesirable side effects included changes in mood and affect, as well as confusion.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 43
Correct
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During uterogrowth, the second branchial arch gives rise to which structures?
Your Answer: Stylohyoid muscle
Explanation:The second pharyngeal arch or hyoid arch, is the second of six pharyngeal arches that develops in fetal life during the fourth week of development and assists in forming the side and front of the neck. Derivatives:
Skeletal – From the cartilage of the second arch arises:
Stapes,
Temporal styloid process,
Stylohyoid ligament, and
Lesser cornu of the hyoid bone.
Muscles:
Muscles of face
Occipitofrontalis muscle
Platysma
Stylohyoid muscle
Posterior belly of Digastric
Stapedius muscle
Auricular muscles
Nerve supply: Facial nerve -
This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 44
Incorrect
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A biopsy taken from the respiratory passage of a 37 year old male, chronic smoker will mostly likely show which cellular adaptation?
Your Answer: Mucous hyperplasia
Correct Answer: Stratified squamous metaplasia
Explanation:Metaplasia is a change in the cell type caused in part due to an extrinsic stress on the organ. It involves a change in the surface epithelium from one cell type to the another, most commonly squamous to columnar. This is a reversible process, and removal of the stress should theoretically reverse the surface epithelium back to normal morphology. Respiratory tract metaplasia is a classic example, in which the normal pseudostratified columnar epithelium is replaced by stratified squamous epithelium to better cope with the stress. Under continuous stress metaplasia can progress to dysplasia which is a disordered growth of cells eventually leading to the development of carcinoma.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 45
Incorrect
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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: Stress urinary incontinence
Correct 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 46
Correct
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A 65-year-old man complains of headaches, weakness, cramps, and confusion; blood tests reveal he has severe hyponatremia. The most likely cause is:
Your Answer: Severe diarrhoea or vomiting
Explanation:Hyponatraemia occurs when the sodium level in the plasma falls below 135 mmol/l. Hyponatraemia is an abnormality that can occur in isolation or, more commonly as a complication of other medical illnesses. Severe hyponatraemia may cause osmotic shift of water from the plasma into the brain cells. Typical symptoms include nausea, vomiting, headache and malaise. As the hyponatraemia worsens, confusion, diminished reflexes, convulsions, stupor or coma may occur. The cause of hyponatremia is typically classified by a person’s fluid status into low volume, normal volume, and high volume. Low volume hyponatremia can occur from diarrhoea, vomiting, diuretics, and sweating.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 47
Incorrect
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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: Hydrocele
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 48
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 49
Incorrect
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Calculate the resistance of the artery if the pressure at one end is 60 mmHg, pressure at the other end is 20 mm Hg and the flow rate in the artery is 200 ml/min.
Your Answer: 0.5
Correct Answer: 0.2
Explanation:Flow in any vessel = Effective perfusion pressure divided by resistance, where effective perfusion pressure is the mean intraluminal pressure at the arterial end minus the mean pressure at the venous end. Thus, in the given problem, resistance = (60 ā 20)/200 = 0.2 mmHg/ml per min.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 50
Correct
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Which of the following over-the-counter drugs can cause a prolonged bleeding time?
Your Answer: Acetylsalicylic acid
Explanation:Acetylsalicylic acid, or aspirin, is a nonsteroidal anti-inflammatory drug that is widely used as an analgesic and antipyretic. Aspirin is as a cyclo-oxygenase inhibitor that leads to decreased prostaglandin production. Decreased platelet aggregation is another effect of this drug, achieved by long-lasting use of aspirin.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 51
Incorrect
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A 58 year old woman is scheduled for the exploration of the common bile duct and insertion of a T tube. Which of the following devices would be most appropriately used in this patient?
Your Answer: Polypropylene T Tube on passive drainage
Correct Answer: Latex T tube on passive drainage
Explanation:The special part of the equipment is the T tube itself. As the name refers, it is a special tube in the shape of T with a shorter transverse part (20 cm) that stays inside the CBD (after trimming) and a long longitudinal part (60 cm) that extends from the middle of the transverse part to an end that connects with a drainage bag. This portion extends from the CBD to outside the abdominal cavity when applied. It comes with different circumference sizes (10, 12, 14, 16, 18 Fr). T tube can be made of different materials like latex, silicone, red rubber and polyvinyl chloride (PVC). PVC is very inert causing the least tissue reaction with lack of tissue tract formation making it the least favourable material for T tube placement purposes. Silicon has many favourable physical properties, but it can disintegrate with poor handling making it not a practical option for long-term placement. Latex has the desired properties to be the most commonly used. Red rubber is an alternative if latex can not be used or is not available.
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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 52
Incorrect
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A patient came into the emergency in a state of shock. His blood group is not known, but on testing it clotted with anti B antibodies when mixed with A +ve blood. Which blood should be transfused?
Your Answer: A-ve
Correct Answer: B +ve
Explanation:Group A ā has only the A antigen on red cells (and B antibody in the plasma)
Group B ā has only the B antigen on red cells (and A antibody in the plasma)
Group AB ā has both A and B antigens on red cells (but neither A nor B antibody in the plasma)
Group O ā has neither A nor B antigens on red cells (but both A and B antibody are in the plasma). Many people also have a Rh factor on the red blood cellās surface. This is also an antigen and those who have it are called Rh+. Those who have not are called Rhā. A person with Rhā blood does not have Rh antibodies naturally in the blood plasma (as one can have A or B antibodies, for instance) but they can develop Rh antibodies in the blood plasma if they receive blood from a person with Rh+ blood, whose Rh antigens can trigger the production of Rh antibodies. A person with Rh+ blood can receive blood from a person with Rhā blood without any problems. The patientās blood group is B positive as he has antigen B, antibody A and Rh antigens -
This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 53
Correct
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A patient had sudden complete loss of vision of the right eye. Fundoscopy showed the distinct cherry red spot on the retina. Which of the following arteries was occluded?
Your Answer: Central artery of the retina
Explanation:The central retinal artery supplies all the nerve fibres that form the optic nerve, which carries the visual information to the lateral geniculate nucleus of the thalamus. Thus if the central retinal artery gets occluded, there is complete loss of vision in that eye and the entire retina (with the exception of the fovea) becomes pale, swollen and opaque while the central fovea still appears reddish (this is because the choroid colour shows through). This is the basis of the famous Cherry red spot seen on examination of the retina on fundoscopy of a central retinal artery occlusion (CRAO).
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 54
Incorrect
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A 77-year-old woman's renal function is tested. The following results were obtained during a 24-h period: Urine flow rate: 2. 0 ml/min, Urine inulin: 0.5 mg/ml, Plasma inulin: 0.02 mg/ml, Urine urea: 220 mmol/l, Plasma urea: 5 mmol/l. What is the urea clearance?
Your Answer: 22 ml/min
Correct Answer: 88 ml/min
Explanation:Urea is reabsorbed in the inner medullary collecting ducts of the nephrons. The clearance (C) of any substance can be calculated as follows: C = (U Ć V)/P, where U and P are the urine and plasma concentrations of the substance, respectively and V is the urine flow rate. So, glomerular filtration rate = (0.220 Ć 2. 0)/0.005 = 88 ml/min.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 55
Correct
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A 60-year old man with a left-sided indirect inguinal hernia underwent emergency surgery to relieve large bowel obstruction resulting from a segment of the bowel being strangulated in the hernial sac. The most likely intestinal segment involved is:
Your Answer: Sigmoid colon
Explanation:The sigmoid colon is the most likely segment involved as it is mobile due to the presence of the sigmoid mesocolon. The descending colon, although on the left side, is a bit superior and is also retroperitoneal. The ascending colon and caecum are on the right side of the abdomen. The rectum is too inferior to enter the deep inguinal ring and the transverse colon is too superior to be involved.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 56
Correct
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During an operation to repair an indirect inguinal hernia, it is noticed that the hernial sac is protruding out of the superficial inguinal ring. The superficial inguinal ring is an opening in which structure?
Your Answer: External abdominal oblique aponeurosis
Explanation:The superficial inguinal ring is an opening in the aponeurosis of the external oblique just above and lateral to the pubic crest. The opening is oblique and corresponds to the fibres of the aponeurosis. It is bound inferiorly by the pubic crest, on either side by the margins of the opening in the aponeurosis and superiorly by the curved intercrural fibres.
The inferior crus is formed by the portion of the inguinal ligament that is inserted into the pubic tubercle.
The falx inguinalis is made of arching fibres of the transversalis fascia and the internal abdominal oblique muscle. It forms the posterior wall of the inguinal canal.
The internal abdominal oblique forms the root of the inguinal canal.
Scarpa’s and Camper’s fascia are the membranous and fatty layers, respectively of subcutaneous fascia.
Transversalis fascia covers the posterior surface of the rectus abdominis muscle inferior to the arcuate line. -
This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 57
Incorrect
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The renal tubule is the portion of the nephron that contains the fluid that has beenĀ filtered by the glomerulus. Which of the following substances is actively secreted into the renal tubules?
Your Answer: Sodium
Correct 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 HenlĆ© 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 65ā70% 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 58
Incorrect
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Which of the following coagulation factors is responsible for the formation of a complex with tissue factor to activate factors IX and X?
Your Answer: Prothrombin
Correct Answer: Factor VII
Explanation:Factor VII, also known as proconvertin or stable factor, is a vitamin Kādependent protein that plays a central role in haemostasis and coagulation. Tissue factor is a protein that is normally not exposed on the surface of intact blood vessels. Damage to the vascular lumen leads to tissue factor exposure. The exposed tissue factor binds to factor VII. This facilitates the activation of factor VII to factor VIIa.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 59
Incorrect
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A 27-year-old professional tennis player presents to the A&E department with a swollen, painful right arm. On examination, his fingers are dusky. Out of the following, which is the most appropriate investigation?
Your Answer: CT angiogram
Correct Answer: Venous duplex scan
Explanation:This patient has an axillary vein thrombosis. It classically presents with pain and swelling of the affected limb. Venous duplex scan is needed to exclude a thrombus.
Primary proximal upper-extremity deep vein thrombosis (UEDVT) is less common than its secondary forms. The most common primary form is effort-related thrombosis, also called Paget-Schroetter syndrome. It usually occurs in, otherwise, healthy young men who report, before the onset of thrombosis, vigorous arm exercise such as lifting weights, playing badminton/tennis, pitching a baseball, or performing repetitive overhead activities, such as painting or car repair. Most patients with effort-related UEDVT have an underlying venous thoracic outlet syndrome (VTOS). Secondary causes of UEDVT include central line insertion, malignancy, or pacemakers.
Patients with UEDVT typically present with heaviness, discomfort, pain, paraesthesia, and swelling of the affected arm. Physical examination may reveal pitting oedema, redness, or cyanosis of the involved extremity; visible collateral veins at the shoulder or upper arm; and fever.
Diagnosis is made by:
1. FBC: platelet function
2. Coagulation profile
3. Liver function tests
4. Venous duplex scan: investigation of choice, provides information relating to flow and characteristics of the vessels.
5. D-dimer testing
6. CT scan: for VTOSTreatment options for primary UEDVT are as follows:
1. Anticoagulation therapy should be undertaken with a once-daily regimen of LMWH or fondaparinux for at least five days, followed by vitamin K antagonists for at least three months. Unfractionated heparin instead of LMWH is recommended for patients with renal failure or for those treated with CDT.2. Early thrombus removal and restoration of venous patency aim should be done immediately after starting the patient on heparin. Catheter-based therapy is recommended for patients with proximal UEDVT of recent onset and severe symptoms, low risk for bleeding complications, and good functional status.
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This question is part of the following fields:
- Generic Surgical Topics
- Vascular
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Question 60
Incorrect
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A 40 year old teacher presents with a mass lesion in the upper outer quadrant of the right breast. Tests reveal that she has a 2cm mass lesion which on core biopsy is demonstrated to be invasive ductal carcinoma. A FNA of a bulky axillary lymph node contains malignant cells. What is the best course of action?
Your Answer: Radical mastectomy and axillary node clearance
Correct Answer: Wide local excision and axillary node clearance
Explanation:Axillary dissection is a surgical procedure that incises the axilla to identify, examine, or remove lymph nodes. Axillary dissection has been the standard technique used in the staging and treatment of the axilla in breast cancer.
Axillary dissection should be reserved for patients with proven axillary disease preoperatively or with a positive sentinel node biopsy.Axillary dissection is only therapeutic in patients who are node positive.
Wide local excision (Lumpectomy) is defined as complete surgical resection of a primary tumour with a goal of achieving widely negative margins (ideally a 1-cm margin around the lesion). It is applicable in most patients with stage I and stage II invasive carcinomas. This patient has a tumour size of 2cm which is small hence wide local excision should be done.
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This question is part of the following fields:
- Breast And Endocrine Surgery
- Generic Surgical Topics
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Question 61
Correct
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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: 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 62
Correct
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A 44 year old actor presents with an attack of mild acute pancreatitis. Imaging identifies gallstones but a normal calibre bile duct, and a peripancreatic fluid collection. Which management option would be the most appropriate?
Your Answer: Cholecystectomy once the attack has settled
Explanation:Pancreatitis is inflammation of the pancreas with variable involvement of regional tissues or remote organ systems. Acute pancreatitis (AP) is characterized by severe pain in the upper abdomen and elevation of pancreatic enzymes in the blood. In the majority of patients,
Biliary pancreatitis should always be treated eventually with a cholecystectomy after the process has subsided.
Feeding should be introduced enterally as the patientās anorexia and pain resolves.
The use of nasogastric aspiration offers no clear advantage in patients with mild AP, but is beneficial in patients with profound pain, severe disease, paralytic ileus, and intractable vomiting.
AP is a mild, self-limiting disease that resolves spontaneously without complications. Patients can be initiated on a low-fat diet initially and need not invariably start their dietary advancement using a clear liquid diet. Systematic reviews and meta-analyses have shown that administration of enteral nutrition may reduce mortality and infectious complications compared with parenteral nutrition. Although the ideal timing to initiate enteral feeding remains undetermined, administration within 48 hours appears to be safe and tolerated. -
This question is part of the following fields:
- Generic Surgical Topics
- Hepatobiliary And Pancreatic Surgery
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Question 63
Correct
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A 56-year-old man undergoes tests to determine his renal function. His results over a period of 24 hours were: Urine flow rate: 2. 0 ml/min, Urine inulin: 1.0 mg/ml, Plasma inulin: 0.01 mg/ml, Urine urea: 260 mmol/l, Plasma urea: 7 mmol/l. What is the glomerular filtration rate?
Your Answer: 200 ml/min
Explanation:Glomerular filtration rate (GFR) is the volume of fluid filtered from the renal (kidney) glomerular capillaries into the Bowman’s capsule per unit time. GFR is equal to the inulin clearance because inulin is freely filtered into Bowmanās capsule but is not reabsorbed or secreted. The clearance (C) of any substance can be calculated as follows: C = (U Ć V)/P, where U and P are the urine and plasma concentrations of the substance, respectively and V is the urine flow rate. Thus, glomerular filtration rate = (1.0 Ć 2. 0)/0.01 = 200 ml/min.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 64
Incorrect
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Under normal conditions, what is the major source of energy of cardiac muscles?
Your Answer: Glucose
Correct Answer: Fatty acids
Explanation:Under basal conditions, most of the energy needed by cardiac muscle for metabolism is derived from fats (60%), 35% by carbohydrates, and 5% by ketones and amino acids. However, after intake of large amounts of glucose, lactate and pyruvate are mainly used. During prolonged starvation, fat acts as the primary source. 50% of the used lipids are sourced from circulating fatty acids.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 65
Correct
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A young man undergoes a total thyroidectomy and develops respiratory stridor and a small haematoma in the neck, 5 hours after surgery. Which of the following is the most appropriate course of action?
Your Answer: Re-open the neck wound
Explanation:Answer: Re-open the neck wound
Thyroidectomy: complications
Airway obstruction (compressing hematoma, tracheomalacia)Incidence of hematoma is 1-2%, tracheomalacia incidence is <1%. Acute airway obstruction from hematoma may occur immediately postoperatively and is the most frequent cause of airway obstruction in the first 24 hours. Definitive therapy is opening the surgical incision to evacuate the hematoma. Re-intubation may be lifesaving for persistent airway obstruction. Consider awake fibreoptic intubation.
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This question is part of the following fields:
- Post-operative Management And Critical Care
- Principles Of Surgery-in-General
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Question 66
Incorrect
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Which of the following structures lying posterior to the ovary are at risk of injury in excision of a malignant tumour in the right ovary?
Your Answer: Obturator nerve
Correct Answer: Ureter
Explanation:The ovaries are two nodular structures situated one on either side of the uterus in relation to the lateral wall of the pelvis and attached to the back of the broad ligament of the uterus, lying posteroinferiorly to the fallopian tubes. Each ovary has a lateral and medial surface. The ureter is at greater risk of iatrogenic injury at this location.
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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 chloride sweat test was performed on a 13-year-old boy. Results indicated a high likelihood of cystic fibrosis. This diagnosis is associated with a higher risk of developing which of the following?
Your Answer: Bronchiectasis
Explanation:Cystic fibrosis is a life-threatening disorder that causes the build up of thick mucus in the lungs, digestive tract, and other areas of the body. It is a hereditary autosomal-recessive disease caused by mutations of the CFTR gene. Cystic fibrosis eventually results in bronchiectasis which is defined as a permanent dilatation and obstruction of bronchi or bronchioles.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 68
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 69
Correct
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A 76-year-old man with a urinary tract obstruction due to prostatic hyperplasia develops acute renal failure. Which of the following physiological abnormalities of acute renal failure will be most life threatening for this patient?
Your Answer: Acidosis
Explanation:Acute renal failure (ARF) is a rapid loss of renal function due to damage to the kidneys, resulting in retention of nitrogenous (urea and creatinine) and non-nitrogenous waste products that are normally excreted by the kidney. This accumulation may be accompanied by metabolic disturbances, such as metabolic acidosis and hyperkalaemia, changes in body fluid balance and effects on many other organ systems. Metabolic acidosis and hyperkalaemia are the two most serious biochemical manifestations of acute renal failure and may require medical treatment with sodium bicarbonate administration and antihyperkalaemic measures. If not appropriately treated these can be life-threatening. ARF is diagnosed on the basis of characteristic laboratory findings, such as elevated blood urea nitrogen and creatinine, or inability of the kidneys to produce sufficient amounts of urine.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 70
Correct
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A 69 Year old lady presented to the emergency department following a massive myocardial infarction. She was found to be in hypotensive shock with focal neurological signs. Unfortunately the patient demised. What would be the expected findings on the brain biopsy?
Your Answer: Liquefactive necrosis
Explanation:Liquefactive necrosis is often associated with bacterial or fungal infections. However, hypoxic death of cells within the central nervous system can also result in liquefactive necrosis. The focal area is soft with a liquefied centre containing necrotic debris and dead white cells. This may later be enclosed by a cystic wall
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 71
Correct
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What is the name of the cutaneous branch of the posterior primary ramus of C2?
Your Answer: Greater occipital nerve
Explanation:The dorsal primary ramus of the spinal nerve C2 is the greater occipital nerve which provides cutaneous innervation to the skin of the back of the head. The ventral primary ramus gives off the great auricular nerve, the lesser occipital nerve and the ansa cervicalis.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 72
Correct
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A 65-year-old man with no history of smoking complains of shortness of breath and persistent cough over the past 8 months. He reveals that in the 1960s he worked for several years as a boiler operator. Chest X-ray shows diffuse lung infiltrates. Which of the following is the most probable cause of these findings?
Your Answer: Asbestosis
Explanation:Asbestosis is a chronic lung disease which leads to long-term respiratory complications and is caused by the inhalation of asbestos fibres. Symptoms due to long exposure to asbestos usually appear 10 to 40 years after initial exposure and include shortness of breath, cough, weight loss, clubbing of the fingers and chest pain. Typical chest X-ray findings include diffuse lung infiltrates that cause the appearance of shaggy heart borders.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 73
Correct
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A 31 year old rugby player is brought to the ER after being crushed in a scrum. He briefly lost consciousness, regained it and collapsed again. On arrival, his GCS was noted to be 6/15 with dilatation of the left pupil. What would be the best definitive management in his case?
Your Answer: Parietotemporal craniotomy
Explanation:Epidural hematoma (EDH) is a traumatic accumulation of blood between the inner table of the skull and the stripped-off dural membrane. EDH results from a traumatic head injury, usually with an associated skull fracture and arterial laceration. The inciting event often is a focused blow to the head, such as that produced by a hammer or baseball bat. In 85-95% of patients, this type of trauma results in an overlying fracture of the skull. Blood vessels in close proximity to the fracture are the sources of the haemorrhage in the formation of an epidural hematoma. Because the underlying brain has usually been minimally injured, prognosis is excellent if treated aggressively. Outcome from surgical decompression and repair is related directly to patient’s preoperative neurologic condition.
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This question is part of the following fields:
- Generic Surgical Topics
- Surgical Disorders Of The Brain
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Question 74
Correct
-
Which of the following has the highest content of triglycerides?
Your Answer: Chylomicron
Explanation:Created by the small intestinal cells, chylomicrons are large lipoprotein molecules which transport lipids to the liver, adipose, cardiac and skeletal tissue. Chylomicrons are mainly composed of triglycerides (,85%) along with some cholesterol and cholesteryl esters. Apo B-48 is the main apolipoprotein content.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 75
Correct
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Mechanical distortion, and not K+ channels are responsible for distortion of which of the following structures?
Your Answer: Pacinian corpuscle
Explanation:Pacinian corpuscles are a type of mechanoreceptor, sensitive to deep pressure, touch and high-frequency vibration. The Pacinian corpuscles are ovoid and about 1 mm long. In the centre of the corpuscle is the inner bulb, which is a fluid-filled cavity with a single afferent unmyelinated nerve ending. Any deformation in the corpuscle causes the generation of action potentials by opening of pressure-sensitive sodium ion channels in the axon membrane. This allows influx of sodium ions, creating a receptor potential (independent of potassium channels).
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 76
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 āpopā 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 77
Incorrect
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The transmembrane proteins responsible for resting membrane potential of vascular smooth muscle cells was blocked by a drug. Which of the following transmembrane proteins were blocked by this drug?
Your Answer: Na+/K+ pump
Correct Answer: K+ channels
Explanation:The resting membrane potential is due to selective permeability of the membrane to potassium ions. The Na/K pump is responsible for the generation of a gradient across the membrane and it is due to the inherent ability of the K channels to allow diffusion back into the nerve at rest which charges the cells. In reality, the resting membrane potential is more positive because of small contributions by Na+ channels, Clā channels and non-selective cation channels.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 78
Correct
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A 15 year old girl is taken to the A&E after complaining of right iliac fossa pain which started suddenly. She is well other than having some right iliac fossa tenderness but no guarding. She has no fever and the urinary dipstick result is normal. Her last menstrual cycle was 14 days ago which was also normal and the pregnancy test done is negative. What is the most likely underlying condition?
Your Answer: Mittelschmerz
Explanation:Answer: Mittelschmerz
Mittelschmerz is midcycle abdominal pain due to leakage of prostaglandin-containing follicular fluid at the time of ovulation. It is self-limited, and a theoretical concern is treatment of pain with prostaglandin synthetase inhibitors, which could prevent ovulation. The pain of mittelschmerz usually occurs in the lower abdomen and pelvis, either in the middle or to one side. The pain can range from a mild twinge to severe discomfort and usually lasts from minutes to hours. In some cases, a small amount of vaginal bleeding or discharge might occur. Some women have nausea, especially if the pain is very strong.
Diagnosis of pelvic pain in women can be challenging because many symptoms and signs are insensitive and nonspecific. As the first priority, urgent life-threatening conditions (e.g., ectopic pregnancy, appendicitis, ruptured ovarian cyst) and fertility-threatening conditions (e.g., pelvic inflammatory disease, ovarian torsion) must be considered.
Many women never have pain at ovulation. Some women, however, have mid-cycle pain every month, and can tell by the pain that they are ovulating.
As an egg develops in the ovary, it is surrounded by follicular fluid. During ovulation, the egg and the fluid, as well as some blood, are released from the ovary. While the exact cause of mittelschmerz is not known, it is believed to be caused by the normal enlargement of the egg in the ovary just before ovulation. Also, the pain could be caused by the normal bleeding that comes with ovulation.
Pelvic inflammatory disease can be ruled out if the patient is not sexually active. -
This question is part of the following fields:
- Generic Surgical Topics
- The Abdomen
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Question 79
Correct
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A 54-year-old man is brought to the Emergency Department after being found collapsed in the street. He is known to have a history of alcoholic liver disease. Blood tests reveal the following:
Your Answer: 10ml of 10% calcium chloride over 10 minutes
Explanation:The clinical history combined with parathyroid hormone levels will reveal the cause of hypocalcaemia in the majority of cases
Causes
Vitamin D deficiency (osteomalacia)
Acute pancreatitis
Chronic renal failure
Hypoparathyroidism (e.g. post thyroid/parathyroid surgery)
Pseudohypoparathyroidism (target cells insensitive to PTH)
Rhabdomyolysis (initial stages)
Magnesium deficiency (due to end organ PTH resistance)Management
Acute management of severe hypocalcaemia is with intravenous replacement. The preferred method is with intravenous calcium chloride, 10ml of 10% solution over 10 minutes
ECG monitoring is recommended
Further management depends on the underlying cause
Calcium and bicarbonate should not be administered via the same route -
This question is part of the following fields:
- Emergency Medicine And Management Of Trauma
- Principles Of Surgery-in-General
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Question 80
Correct
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Where is the foramen ovale located?
Your Answer: Sphenoid
Explanation:The foramen ovale is an oval shaped opening in the middle cranial fossa located at the posterior base of the greater wing of the sphenoid bone, lateral to the lingula. It transmits the mandibular division of the trigeminal nerve (CN Vc), accessory meningeal artery, emissary veins between the cavernous sinuses and pterygoid plexus, otic ganglion, and occasionally the nervus spinosus and lesser petrosal nerve.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 81
Correct
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A 35 year old biker is rushed to the A&E department after he is knocked off his bike by a van. He has a 10cm open fracture of his tibia where no peripheral pulses are palpable. Intravenous antibiotics have been administered in the emergency department and the wound has been dressed. What is the most appropriate course of action?
Your Answer: Immediate vascular shunting, followed by temporary skeletal stabilisation and vascular reconstruction
Explanation:The Gustilo open fracture classification system is the most commonly used classification system for open fractures.
This system uses the amount of energy, the extent of soft-tissue injury and the extent of contamination for determination of fracture severity. Progression from grade 1 to 3C implies a higher degree of energy involved in the injury, higher soft tissue and bone damage and higher potential for complications.
Grade Injury
1 Low energy wound <1cm
2 Greater than 1cm wound with moderate soft tissue damage
3 High energy wound > 1cm with extensive soft tissue damage
3 A (sub group of 3) Adequate soft tissue coverage
3 B (sub group of 3) Inadequate soft tissue coverage
3 C (sub group of 3) Associated arterial injuryIt is important to recognize that a Gustilo score of grade 3C implies vascular injury as well as bone and connective-tissue damage. Grade 3C is defined as an open fracture associated with an arterial injury requiring repair, irrespective of degree of soft-tissue injury. The lack of peripheral pulses indicate arterial injury.
A less morbid damage control approach (compared with ligation) for patients with extremity vascular injury is vascular shunting, a technique that has been available for over 50 years. A vascular shunt is a synthetic tube that is inserted into the vessel and secured proximally and distally. Shunts were placed in the context of damage control to allow stabilization of Gustilo 3C fractures or limb replantation. Vascular shunts are typically used for larger, more proximal arteries and veins such as the femoral and popliteal arteries. Shunts can remain in place up to six hours, but definitive vascular reconstruction should be performed as soon as the patient is sufficiently stable to undergo the procedure. Once a fracture is identified, it is reduced as much as possible and splinted. If an open fracture is suspected, the patient should be taken to the operating room to debride and stabilize the fracture (usually with external fixation) either after life-threatening injuries have been managed or concurrently while less emergency chest, abdominal, or head injuries are being addressed. Revascularization ā Ischemia due to vascular injury is a major risk factor for amputation, and, ideally, the injury will be identified and treated within six hours to minimize ischemic nerve and muscle damage. -
This question is part of the following fields:
- Generic Surgical Topics
- Orthopaedics
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Question 82
Correct
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What will the destruction of endoplasmic reticulum stop?
Your Answer: Synthesis of proteins
Explanation:The rough endoplasmic reticulum is the factory for the manufacturing of proteins. It contains ribosomes attached to it and transports proteins that are destined for membranes and secretions. The rough ER is connected to the nuclear envelope and to the cisternae of the Golgi apparatus by vesicles that shuttle between the two compartments.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 83
Correct
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A 3 month old baby boy is taken to the hospital for recurrent colicky abdominal pain and intermittent intestinal obstruction. The transverse colon is herniated into the thoracic cavity, through a mid line defect and this is shown when imaging is done. What is the cause of this defect?
Your Answer: Morgagni hernia
Explanation:Morgagni hernias are one of the congenital diaphragmatic hernias (CDH), and are characterized by herniation through the foramen of Morgagni. When compared to Bochdalek hernias, Morgagni hernias are:
-anterior
-more often right-sided (,90%)
-small
-rare (,2% of CDH)
-at low risk of prolapseOnly ,30% of patients are symptomatic. Newborns may present with respiratory distress at birth similar to a Bochdalek hernia. Additionally, recurrent chest infections and gastrointestinal symptoms have been reported in those with previously undiagnosed Morgagni hernia.
The image of the transverse colon is herniated into the thoracic cavity, through a mid line defect and this indicates that it is a Morgagni hernia since the foramen of a Morgagni hernia occurs in the anterior midline through the sternocostal hiatus of the diaphragm, with 90% of cases occurring on the right side.Clinical manifestations of congenital diaphragmatic hernia (CDH) include the following:
Early diagnosis – Right-side heart; decreased breath sounds on the affected side; scaphoid abdomen; bowel sounds in the thorax, respiratory distress, and/or cyanosis on auscultation; CDH can often be diagnosed in utero with ultrasonography (US), magnetic resonance imaging (MRI), or bothLate diagnosis – Chest mass on chest radiography, gastric volvulus, splenic volvulus, or large-bowel obstruction
Congenital hernias (neonatal onset) – Respiratory distress and/or cyanosis occurs within the first 24 hours of life; CDH may not be diagnosed for several years if the defect is small enough that it does not cause significant pulmonary dysfunction
Congenital hernias (childhood or adult onset) – Obstructive symptoms from protrusion of the colon, chest pain, tightness or fullness the in chest, sepsis following strangulation or perforation, and many respiratory symptoms occur.
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This question is part of the following fields:
- Generic Surgical Topics
- The Abdomen
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Question 84
Incorrect
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A man in his sixties underwent surgery to remove a lump from his axilla. During removal, a nerve originating from the lateral cord of the brachial plexus was damaged. Which nerve is this referring to?
Your Answer: Thoracodorsal
Correct Answer: Lateral pectoral
Explanation:The only branch of the lateral cord of brachial plexus in the options given, is the lateral pectoral nerve. It supplies the pectoralis major muscle and sends a branch to join the medial pectoral nerve forming a loop in front of the first part of the axillary artery.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 85
Correct
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Which is the correct order of tendons passing from medial to lateral-posterior to the medial malleolus?
Your Answer: Posterior tibial, flexor digitorum longus, flexor hallucis longus
Explanation:The correct order of structures is the tendon of tibialis posterior, tendon of flexor digitorum longus, posterior tibial artery (and vein), tibial nerve and tendon of flexor hallucis longus.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 86
Correct
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A 55-year old gentleman presented to the doctor with worsening dysphagia for both solids and liquids over 6 months. This was associated with regurgitation of undigested food and occasional chest pain. Barium swallow revealed distal oesophageal dilatation with lack of peristalsis in the distal two-third oesophagus. The likely diagnosis is:
Your Answer: Achalasia
Explanation:Achalasia is an oesophageal motility disorder where inappropriate contractions in the oesophagus lead to reduced peristalsis and failure of the lower oesophageal sphincter to relax properly in response to swallowing. Classical triad of symptoms include dysphagia to fluids followed by solids, chest pain and regurgitation of undigested food. Other symptoms include belching, hiccups, weight loss and cough. Diagnosis is by:
– X-ray with a barium swallow or oesophagography : narrowing at the gastroesophageal junction (ābird/parrot beakā or ārat tailā appearance) and various degrees of mega-oesophagus (oesophageal dilatation) as the oesophagus is gradually stretched by retained food. Effectiveness of treatment can be measured with a 5-minute timed barium swallow.
– Manometry ā probe measures the pressure waves in different parts of oesophagus and stomach while swallowing.
– Endoscopy
– CT scan to exclude other causes like malignancy
– Pathological examination showing defect in the nerves which control oesophageal motility (myenteric plexus).
In Chagas disease, there is destruction of ganglion cells by Trypanosoma cruzi. -
This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 87
Correct
-
A 45 year old women has a 4 cm non tender mass in her right breast which is fixed to the chest wall. Another 2cm non-tender mass is palpable in the left axilla. Chest x ray reveals multiple nodules ranging from 0.5 - 0.2 cm in both the lungs. What is the stage of her disease?
Your Answer: T4 N1 M1
Explanation:This woman has an invasive primary tumour mass with axillary node and lung metastases, making this stage T4 N1 M1. Looking at the other stems, T1 N1 M0 signifies a small primary cancer with nodal metastases but no distant metastases; T1 N0 M1 signifies a small primary cancer with no lymph node metastases but with distant metastases; T2 N1 M0 signifies a larger primary cancer with nodal metastases but no distant metastases; and T3 N0 M0 indicates a larger primary cancer with no metastases to either lymph nodes or to distant sites.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 88
Correct
-
A patient with chronic renal disease, missed a day of his dialysis schedule., His serum potassium was 7.6 mmol/L when his electrolytes were checked. What is the ECG finding expected in this patient?
Your Answer: Tented T waves
Explanation:ECG characteristics of hyperkalaemia may show the following changes: P-waves are widened and of low amplitude due to slowing of conduction, widened QRS complex, QRS-T fusion, loss of ST segment and tall tented T waves.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 89
Incorrect
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An 26-year-old man sought admission due to persistent non-bloody diarrhoea. The patient is HIV-positive. Examination of stool sample showed numerous acid-fast cysts. Which of the following organism is the most likely cause of diarrhoea?
Your Answer: Entamoeba histolytica
Correct Answer: Cryptosporidium parvum
Explanation:Cryptosporidium parvum is one of several species that causes cryptosporidiosis, a parasitic disease of the mammalian intestinal tract. Primary symptoms of C. parvum infection are acute, watery, and non-bloody diarrhoea. C. parvum infection is of particular concern in immunocompromised patients, where diarrhoea can reach 10ā15 l per day.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 90
Correct
-
A 35 year old woman with dysphagia undergoes oesophageal manometry. She is found to have a hypertensive lower oesophageal sphincter that does not completely relax on swallowing. Which of the following is the most likely diagnosis?
Your Answer: Achalasia
Explanation:Achalasia is a failure of the lower oesophageal sphincter (LES) to relax that is caused by the degeneration of inhibitory neurons within the oesophageal wall. It is classified as either primary (idiopathic) or secondary (in the context of another disease). In patients with achalasia, the chief complaint is dysphagia to both solids and liquids, although regurgitation, retrosternal pain, and weight loss may also occur. Upper endoscopy, barium esophagram, and oesophageal manometry play complementary roles in the diagnosis of achalasia. While upper endoscopy and/or barium esophagram are often obtained initially, manometry usually confirms the diagnosis, and upper endoscopy is indicated to rule out a malignant underlying cause. In good surgical candidates, achalasia is usually treated with pneumatic dilation or myotomy. In most other cases, an injection of botulinum toxin is attempted. If these measures fail to provide relief, medical therapy (e.g., nifedipine) is indicated.
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This question is part of the following fields:
- Generic Surgical Topics
- Upper Gastrointestinal Surgery
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Question 91
Correct
-
A patient with this condition has extracellular fluid volume expansion:
Your Answer: Nephrotic syndrome
Explanation:Nephrotic syndrome is a syndrome comprising of signs of nephrosis, including proteinuria, hypoalbuminemia, and oedema. It is a component of glomerulonephritis, in which different degrees of proteinuria occur. Essentially, loss of protein through the kidneys leads to low protein levels in the blood , which causes water to be drawn into soft tissues (oedema). Severe hypoalbuminemia can also cause a variety of secondary problems, such as water in the abdominal cavity (ascites), around the heart or lung (pericardial effusion, pleural effusion), high cholesterol, loss of molecules regulating coagulation (hence increased risk of thrombosis). The most common sign is excess fluid in the body due to the serum hypoalbuminemia. Lower serum oncotic pressure causes fluid to accumulate in the interstitial tissues. Sodium and water retention aggravates the oedema.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 92
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: Bone marrow biopsy
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 93
Incorrect
-
Which type of contractions are responsible for the propulsion of chyme along the small intestine?
Your Answer: Peristaltic waves
Correct Answer: Segmentation
Explanation:Two major types of intestinal contractions are segmentation and peristalsis:
Segmentation occurs most frequently and primarily involves circular muscle. It is essentially a contraction of 2- or 3-cm long intestinal segments while the muscle on either side of it relaxes. Chyme in the segment is displaced in both orad and aborad directions. As the contracted segment relaxes, the previously relaxed segments on either side may contract. This efficiently mixes the chyme with the digestive secretions and exposes the mucosal absorptive surface to the luminal contents. It also serves a propulsive function and contributes to the aborad movement of chyme.
Peristalsis is a propulsive wave of contraction that is initiated by intestinal distension. It is short lived and travels only a few centimetres before dying out. The combined effects of intestinal peristalsis and segmentation provide for both adequate mixing of the intestinal contents and slow, steady movement of chyme. -
This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 94
Incorrect
-
Which of the following is the most likely cause of prolonged thrombin clotting time?
Your Answer: Factor VIII deficiency
Correct Answer: Hypofibrinogenemia
Explanation:Thrombin clotting time, also called thrombin time (TT), is test used for the investigation of possible bleeding or clotting disorders. TT reflects the conversion of fibrinogen to fibrin and it’s also very sensitive to the presence of the anticoagulant heparin. A prolonged thrombin time may indicate the presence of hypofibrinogenemia (decreased fibrinogen level ), dysfibrinogenaemia, disseminated intravascular coagulation (DIC), end stage liver disease or malnutrition.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 95
Correct
-
Which of the following has the least malignant potential?
Your Answer: Hyperplastic polyp
Explanation:Non-neoplastic (non-adenomatous) colonic polyps include hyperplastic polyps, hamartomas, juvenile polyps, pseudopolyps, lipomas, leiomyomas and others.
An autosomal dominant condition, PeutzāJeghers syndrome is a disease that is characterized by multiple hamartomatous polyps in the stomach, small bowel and colon. Symptoms of this syndrome include hyperpigmentation of the skin and mucous membranes, especially of the lips and gums.
Juvenile polyps develop in children, and once they outgrow their blood supply, they autoamputate around puberty. In cases of uncontrolled bleeding or intussusception, treatment is needed.
Inflammatory polyps and pseudopolyps occur in chronic ulcerative colitis and Crohnās disease. There is an increased risk of cancer with multiple juvenile polyps (not with sporadic polyps). -
This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 96
Correct
-
A 30-year-old male patient is undergoing an open appendicectomy. The surgeons extend the incision medially and suddenly encounter troublesome bleeding. What should be the best course of action?
Your Answer: Ligate the bleeding vessel
Explanation:Medial extension of an appendicectomy incision carries a risk of injury to the inferior epigastric artery which can bleed briskly. It is best managed by ligation.
Bleeding is a complication encountered in all branches of surgery. The decision as to how best to manage the bleed, depends upon its site, vessel, and circumstances.
1. Superficial dermal bleeding:
This will usually cease spontaneously. If not, then direct use of a monopolar or a bipolar cautery device will usually control the situation. Scalp wounds are a notable exception and bleeding from them may be brisk. In this situation, use of a mattress suture as a wound closure method will usually address the problem.2. Superficial arterial bleeding:
If the vessel can be safely identified in superficial arterial bleeding, then the easiest method is to apply a haemostatic clip and ligate the vessel.3. Major arterial bleeding:
If the vessel can be clearly identified and is accessible, then it may be possible to apply a clip and ligate the vessel. If the vessel is located in a pool of blood, then blind application of haemostatic clips is highly dangerous and may result in collateral injury. In this situation, evacuating the clot and packing the area is often safer. The pack can then be carefully removed when the required instruments are available. Some vessels may retract and bleeding may then be controlled by dissection of surrounding structures or underrunning the bleeding point.4. Major venous bleeding:
The safest initial course of action is to apply digital pressure to the bleeding point. To control the bleeding, thereafter, the surgeon will need a working suction device. Divided veins may require ligation.5. Bleeding from raw surfaces:
This may be mixed bleeding and can be troublesome. Spray diathermy and argon plasma coagulation are both useful agents. Certain topical haemostatic agents, such as surgicel, are useful in encouraging clot formation and may be used in conjunction with, or instead of, the above agents. -
This question is part of the following fields:
- Principles Of Surgery-in-General
- Surgical Technique And Technology
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Question 97
Incorrect
-
A 34 year old opera singer undergoes a thyroidectomy. Post-operatively, it is discovered that he is only able to make a gargling noise. On examination, his voice sounds breathy. What is the best explanation for this symptom?
Your Answer: Unilateral superior laryngeal nerve injury
Correct Answer: Unilateral inferior laryngeal nerve injury
Explanation:Unilateral vocal fold paralysis (UVFP) occurs from a dysfunction of the recurrent laryngeal (inferior laryngeal nerve) or vagus nerve innervating the larynx. It causes a characteristic breathy voice often accompanied by swallowing disability, a weak cough, and the sensation of shortness of breath. This is a common cause of neurogenic hoarseness. When this paralysis is properly evaluated and treated, normal speaking voice is typically restored. Specifically, thyroidectomy, carotid endarterectomy, anterior cervical spine surgery, thoracic, or mediastinal surgery most often result in a presentation of UVFP.
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This question is part of the following fields:
- Generic Surgical Topics
- Head And Neck Surgery
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Question 98
Correct
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A 25-year-old woman is undergoing an appendicectomy for perforated appendicitis. What is the single most important modality for reducing the risks of postoperative wound infection?
Your Answer: Perioperative administration of antibiotics
Explanation:Perioperative administration of antibiotics is very important for reducing the risks of postoperative wound infection. Clips make infections easier to manage but do not reduce the risks. Drains have no effect on the skin wounds in these cases.
Surgical site infections (SSI) comprise up to 20% of all healthcare-associated infections and at least 5% of patients undergoing surgery will develop an SSI as a result. SSIs may occur following a breach in tissue surfaces and allow normal commensals and other pathogens to initiate infection. The organisms are mostly derived from the patient’s own body.
SSIs are a major cause of morbidity and mortality.
Some preoperative measures that may increase the risk of SSI include:
1. Shaving the wound using a razor (disposable clipper preferred)
2. Tissue hypoxia
3. Delayed administration of prophylactic antibiotics in tourniquet surgerySSIs can be prevented by taking certain precautionary steps pre-, intra-, and postoperatively.
1. Preoperatively:
a. Do not remove body hair routinely
b. If hair needs removal, use electrical clippers (razors increase the risk of infection)
c. Antibiotic prophylaxis if:
– placement of prosthesis or valve
– clean-contaminated surgery
– contaminated surgery2. Intraoperatively:
a. Prepare the skin with alcoholic chlorhexidine (Lowest incidence of SSI)
b. Cover surgical site with dressing3. Postoperatively:
a. Prevention of incisional infection by appropriate cleansing, skin care, and moisture management
b.Tissue viability advice for management of surgical wound healing by secondary intention -
This question is part of the following fields:
- Principles Of Surgery-in-General
- Surgical Technique And Technology
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Question 99
Correct
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A victim of road traffic accident presented to the emergency department with a blood pressure of 120/90 mm Hg, with a drop in systolic pressure to 100 mm Hg on inhalation. This is known as:
Your Answer: Pulsus paradoxus
Explanation:Weakening of pulse with inhalation and strengthening with exhalation is known as pulsus paradoxus. This represents an exaggeration of the normal variation of the pulse in relation to respiration. It indicates conditions such as cardiac tamponade and lung disease. The paradox refers to the auscultation of extra cardiac beats on inspiration, as compared to the pulse. Due to a decrease in blood pressure, the radial pulse becomes impalpable along with an increase in jugular venous pressure height (Kussmaul sign). Normal systolic blood pressure variation (with respiration) is considered to be >10 mmHg. It is >100 mmHg in Pulsus paradoxus. It is also predictive of the severity of cardiac tamponade.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 100
Correct
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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 101
Correct
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A 37 year old female is admitted after she vomited blood. An upper gastrointestinal endoscopy is performed and a large ulcer in the first part of the duodenum is noted. Attempts are made to endoscopically clip and inject the ulcer which is bleeding profusely but they are unsuccessful. What is the most appropriate management option?
Your Answer: Laparotomy and underrunning of the ulcer
Explanation:Ulcer bleeding stops spontaneously in about 80% of patients. Only a small percentage require specific measures to stop bleeding. surgery remains the most definitive method of controlling ulcer haemorrhage, and is indicated when endoscopic haemostasis fails to control the bleeding, or when rebleeding occurs. The morbidity and mortality of emergency surgery for ulcer bleeding is high. In principle, the operation performed should be the minimum compatible with permanent haemostasis. The choice of operations is determined by the site and size of the ulcer as well as the experience and preference of the surgeon. Most bleeding duodenal ulcers may be managed by underrunning the bleeding vessel together with vagotomy and pyloroplasty.
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This question is part of the following fields:
- Generic Surgical Topics
- Upper Gastrointestinal Surgery
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Question 102
Incorrect
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A sexually active 21 year old man presents with the history of dysuria for the past 3 days. Urine culture confirmed Neisseria gonorrhoeae and smear showed abundant neutrophils. Which of the following mediators is responsible for causing diapedesis of the neutrophils to reach the site of infection?
Your Answer: Prostaglandin
Correct Answer: Complement C5a
Explanation:C5a is part of the complement cascade and is released frim the complement C5. It acts as a chemotactic factor for neutrophils. Other chemotactic mediators are TNF, leukotrienes and bacterial products.
Bradykinin is associated with the production of pain and vasodilation.
Hageman factor is a clotting factor.
Histamine causes vasodilation.
C3B causes opsonisation.
IL-6 and IL-12 are inflammatory mediators causing B cell maturation and mediating inflammation and prostaglandins are involved with pain, increasing cell permeability and vasodilation. -
This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 103
Correct
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A young girl who presented with a clinical picture of type I hypersensitivity reaction with eosinophilia is most likely to have?
Your Answer: Liver flukes
Explanation:Usually a parasitic infection will be associated with a type I hypersensitivity reaction.
Amyloid deposition will not cause an immune reaction.
Organic dust will lead to a type III hypersensitivity reaction.
Cell mediated as well as humoral immune mechanism play a part in syphilis, but they are do not specifically cause a type I reaction.
Malaria is cause by plasmodium and is not cause of a hypersensitivity reaction.
Atopic dermatitis will not be accompanied by eosinophilia. -
This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 104
Correct
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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: 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 āCLAM SHELLā 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 105
Incorrect
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Gastric acid secretion is stimulated by which of the following?
Your Answer: Secretin
Correct Answer: Gastrin
Explanation:Gastric acid secretion is stimulated by three factors:
– Acetylcholine, from parasympathetic neurones of the vagus nerve that innervate parietal cells directly
– Gastrin, produced by pyloric G-cells
– Histamine, produced by mast cells.
Gastric acid is inhibited by three factors:
– Somatostatin
– Secretin
– Cholecystokinin -
This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 106
Correct
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A patient who has used NSAIDS for many years presents to the A&E with symptoms of acute haemorrhagic shock. An emergency endoscopy is done that shows that a duodenal ulcer has perforated the posterior wall of the first part of the duodenum. Which artery is most likely to be the cause of the haemorrhage?
Your Answer: Gastroduodenal
Explanation:The gastroduodenal artery is a branch of the hepatic artery and descends near the pylorus between the first part of the duodenum and the neck of the pancreas to divide at the lower border of the duodenum into the right gastroepiploic and pancreaticoduodenal arteries. Before it divides, it gives off a few branches to the pyloric end of the stomach and to the pancreas. The artery that is most likely involved in this situation is the gastroduodenal artery since it is posterior to the first part of the duodenum.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 107
Incorrect
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A 41 year old women presents with a history of carcinoma involving the right breast with enlarged axillary nodes on the same side. She underwent mastectomy and axillary node clearance. These were sent for histopathological examination. They showed no signs of metastasis. What could be cause of this enlargement in the lymph nodes?
Your Answer: Paracortical lymphoid hyperplasia
Correct Answer: Sinus histiocytosis
Explanation:Sinus histiocytosis also referred to as reticular hyperplasia, refers to the enlargement, distention and prominence of the sinusoids of the lymph nodes. This is a non-specific form of hyperplasia characteristically seen in lymph nodes that drain tumours. The endothelial lining of the lymph node becomes markedly hypertrophied, along with an increase in the number of macrophages which results in the distortion, distention and enlargement of the sinus. In this scenario there is no evidence that an infection or another malignancy could account for the enlargement. Paracortical lymphoid hyperplasia is caused by an immune response.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 108
Incorrect
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A 40-year old lady presented to the hospital with fever and mental confusion for 1 week. On examination, she was found to have multiple petechiae all over her skin and mucosal surfaces. Blood investigations revealed low platelet count and raised urea and creatinine. A platelet transfusion was carried out, following which she succumbed to death. Autopsy revealed pink hyaline thrombi in myocardial arteries. What is the likely diagnosis?
Your Answer: Disseminated intravascular coagulopathy
Correct Answer: Thrombotic thrombocytopenic purpura
Explanation:Hyaline thrombi are typically associated with thrombotic thrombocytopenic purpura (TTP), which is caused by non-immunological destruction of platelets. Platelet transfusion is contraindicated in TTP. Platelets and red blood cells also get damaged by loose strands of fibrin deposited in small vessels. Multiple organs start developing platelet-fibrin thrombi (bland thrombi with no vasculitis) typically at arteriocapillary junctions. This is known as ‘thrombotic microangiopathy’. Treatment consists of plasma exchange.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 109
Incorrect
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A 4-year-old boy suffers 20% burns to the torso. On examination, there is fixed pigmentation and the affected area has a white and dry appearance. Which of the following options represents the best management plan?
Your Answer: Full thickness skin graft
Correct Answer: Split thickness skin graft
Explanation:Burn depth is classified as first, second, third, or fourth degree, as follows:
First-degree burns are usually red, dry, and painful. Burns initially termed first-degree are often actually superficial second-degree burns, with sloughing occurring the next day.
Second-degree burns are often red, wet, and very painful. Their depth, ability to heal, and propensity to form hypertrophic scars vary enormously.
Third-degree burns are generally leathery in consistency, dry, insensate, and waxy. These wounds will not heal, except by contraction and limited epithelial migration, with resulting hypertrophic and unstable cover. Burn blisters can overlie both second- and third-degree burns. The management of burn blisters remains controversial, yet intact blisters help greatly with pain control. Debride blisters if infection occurs.
Fourth-degree burns involve underlying subcutaneous tissue, tendon, or bone. Usually, even an experienced examiner has difficulty accurately determining burn depth during an early examination. As a general rule, burn depth is underestimated upon initial examination.The management plan for patients with large burns that require inpatient care is usually determined by the physiology of the burn injury.
Hospitalization is divided into 4 general phases, including (1) initial evaluation and resuscitation, (2) initial wound excision and biologic closure, (3) definitive wound closure, and (4) rehabilitation and reconstruction.Early excision and closure of full-thickness wounds change the natural history of burn injury, avoiding the otherwise common occurrence of wound sepsis. Wound size is the most important factor in determining the need for early operation
Medications
See the list below:
– Silver sulfadiazine – Broad antibacterial spectrum; painless application
– Aqueous 0.5% silver nitrate – Broad-spectrum coverage, including fungi; leeches electrolytes
– Mafenide acetate – Broad antibacterial spectrum; penetrates eschar best
– Petrolatum – Bland and nontoxic
– Various debriding enzymes – Useful in selected partial-thickness wounds
– Various antibiotic ointments – Useful in many superficial partial-thickness wounds
Membranes
See the list below:
– Porcine xenograft – Adheres to wound coagulum and provides excellent pain control
– Split-thickness allograft – Vascularizes and provides durable temporary closure of wounds
– Various hydrocolloid dressings – Provide vapour and bacteria barrier while absorbing wound exudate
– Various impregnated gauzes – Provide vapour and bacteria barrier while allowing drainage
– Various semipermeable membranes – Provide vapour and bacteria barrier
– Acticoat (Westhaim Biomedical, Saskatchewan, Canada) – Nonadherent wound dressing that delivers a low concentration of silver for antisepsis
– Biobrane (Dow-Hickman, Sugarland, Tex) – Synthetic bilaminate that facilitates fibrovascular tissue growth into the inner layer and provides temporary vapour and bacteria barrier
– Transcyte (Smith and Nephew, Largo, Fla) – Synthetic bilaminate that facilitates fibrovascular tissue growth into the inner layer populated with allogenic fibroblasts and overlying layer that provides temporary vapour and bacteria barrier
– AlloDerm R – Consists of cell-free allogenic human dermis; requires an immediate thin overlying autograft
– Integra R – Provides scaffold for neodermis; requires delayed thin autograft -
This question is part of the following fields:
- Principles Of Surgery-in-General
- Surgical Technique And Technology
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Question 110
Incorrect
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A 43-year-old female with liver cirrhosis is recovering following an emergency paraumbilical hernia repair. She has been slow to resume oral intake and has been receiving regular boluses of normal saline for oliguria. Which of the following intravenous fluids should be considered?
Your Answer: 5% dextrose with 20mmol KCL
Correct Answer: Human albumin solution 4.5%
Explanation:In a surgical patient, hepatic dysfunction translates into an increased risk of infection, haemorrhage, thrombosis, and a prolonged half-life of numerous drugs (e.g., opioids and benzodiazepines). The associated imbalance of neuroendocrine mediators (e.g., vasopressin, renin-angiotensin-aldosterone system, and nitric oxide) also potentiates sodium and fluid retention, resulting in a background hyperdynamic circulation with splanchnic venous congestion and systemic vasodilation.
In emergency surgery, stress response to the underlying condition, anaesthesia, and surgical trauma increase the risk of hepatic decompensation and associated multi-system failure. Changes in hepatic perfusion with shock and fluid shifts further compromise hepatocellular synthetic and excretory functions. In addition, endotoxemia from gram-negative sepsis potentiates platelet aggregation and creates a state of low-grade disseminated intravascular coagulation.
Activation of the renin-angiotensin-aldosterone system with hypersecretion of vasopressin acts as compensatory mechanisms to preserve arterial pressure and replenish effective circulating volume when blood is pooled in the splanchnic territory. With the progression of cirrhosis, avidity for water and sodium increases, and dilutional hyponatremia results from water retention. In advanced cases, exacerbation of these abnormalities leads to hepatorenal syndrome (HRS). HRS is characterized by a rapid decline in renal function with low urinary excretion of sodium due to severe renal vasoconstriction and diminished or absent cortical perfusion. This syndrome is potentially reversible but carries an extremely poor prognosis.Owing to raised intra-abdominal pressure due to ascites and muscle weakness from decreased muscle mass and malnutrition, umbilical and inguinal hernia incidence is higher in patients with cirrhosis.
If the patient with cirrhosis has umbilical hernia with obstructive symptoms such as intermittent incarceration or trophic skin changes, surgical repair should be considered.Euvolemia and electrolyte homeostasis should be maintained under strict clinical and laboratory monitoring. Acute kidney injury in the absence of hemodynamic instability, use of nephrotoxic drugs, or parenchymal renal disease suggests the diagnosis of hepatorenal syndrome. Additional diagnostic criteria include no improvement in renal function after volume expansion with albumin and diuretic withdrawal. Treatment of hepatorenal syndrome requires the use of splanchnic vasoconstrictors (terlipressin, noradrenalin, or midodrine) and albumin infusion. Improved renal function has been demonstrated with medical treatment, but a mortality benefit is only ultimately achieved with liver transplantation. TIPS placement and renal and hepatic replacement therapies can be indicated as bridging strategies.
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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 111
Correct
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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 112
Incorrect
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A 48-year-old man smoker presented to the doctor complaining of a persistent cough and shortness of breath. A chest X-ray indicated the presence of a right upper lung mass. Biopsy of the mass revealed the presence of pink cells with large, irregular nuclei. What is the most probable diagnosis?
Your Answer: Small cell anaplastic carcinoma
Correct Answer: Squamous cell carcinoma
Explanation:Squamous cell carcinoma, is a type of non-small cell lung cancer that accounts for approximately 30% of all lung cancers. The presence of squamous cell carcinoma is often related with a long history of smoking and the presence of persistent respiratory symptoms. Chest radiography usually shows the presence of a proximal airway lesion. Histological findings include keratinisation that takes the form of keratin pearls with pink cytoplasm and cells with large, irregular nuclei.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 113
Incorrect
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Which of the following conditions of the breast is most often associated with use of oral contraceptives?
Your Answer: Hypertrophy
Correct Answer: Cyst formation
Explanation:Breast cysts are common and are smooth, firm, mobile lumps that can sometimes be tender. Cysts can also be bilateral and are known to recur in 10% of cases. They are more common in women in the third and fourth decades and most often disappear after menopause. Cysts are filled with fluid from the breast which occurs due to the normal menstrual cycle of a woman. The end of the menstrual cycle causes breast cells to swell. After the menses, the cells shrink and the released fluid disappears. However, in some cases this fluid forms a cyst. Incidence of cysts was also linked to use of oral contraceptives.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 114
Correct
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A 39-year-old homosexual is admitted with diarrhoea of three-month duration. He is found to be HIV positive with a CD4 cell count <50/Ī¼L. Which of the following organisms is most likely to be responsible?
Your Answer: Cryptosporidium
Explanation:Based on the history and findings, the most likely causative organism is cryptosporidium. It can cause severe, chronic, and possibly fatal diarrhoea in immunocompromised patients.
In patients with HIV/AIDS, clinical manifestations of cryptosporidiosis vary with the degree of immune compromise. Those with CD4 cell counts above 180ā200/Ī¼L may be asymptomatic or develop self-limiting diarrhoeal illness. However, patients with advanced AIDS (CD4 cell counts <50/Ī¼L) can have severe diarrhoea that can persist for several months, resulting in severe dehydration, weight loss and malnutrition, extended hospitalizations, and mortality. In addition, patients with advanced AIDS are at greater risk of developing extraintestinal infection, particularly of the biliary, pancreatic, and respiratory tracts.
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This question is part of the following fields:
- Clinical Microbiology
- Principles Of Surgery-in-General
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Question 115
Correct
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The histological exam of a tuberculous granuloma shows a periphery of multinuclear giant cells, with a central area of:
Your Answer: Caseous necrosis
Explanation:Granulomas with necrosis tend to have an infectious cause. The chronic infective lesion in this case typically presents with a central area of caseous (cheese-like) necrosis. Foam cells are the fat-laden M2 macrophages seen in atherosclerosis
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 116
Correct
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A 12 year old girl is admitted with severe (35%) burns following a fire at home. She was transferred to the critical care unit after the wound was cleaned and dressed. She became tachycardic and hypotensive one day after skin grafts were done. She has vomited three times and blood was seen in it. What is the most likely diagnosis?
Your Answer: Curling's ulcers
Explanation:Answer: Curling’s ulcers
Curling’s ulcer is an acute gastric erosion resulting as a complication from severe burns when reduced plasma volume leads to ischemia and cell necrosis (sloughing) of the gastric mucosa. The most common mode of presentation of stress ulcer is the onset of acute upper GI bleed like hematemesis or melena in a patient with the acute critical illness.
A similar condition involving elevated intracranial pressure is known as Cushing’s ulcer. Cushing’s ulcer is a gastro-duodenal ulcer produced by elevated intracranial pressure caused by an intracranial tumour, head injury or other space-occupying lesions. The ulcer, usually single and deep, may involve the oesophagus, stomach, and duodenum. Increased intracranial pressure may affect different areas of the hypothalamic nuclei or brainstem leading to overstimulation of the vagus nerve or paralysis of the sympathetic system. Both of these circumstances increase secretion of gastric acid and the likelihood of ulceration of gastro-duodenal mucosa.
Mallory-Weiss syndrome is characterized by upper gastrointestinal bleeding secondary to longitudinal mucosal lacerations (known as Mallory-Weiss tears) at the gastroesophageal junction or gastric cardia. However, Mallory-Weiss syndrome may occur after any event that provokes a sudden rise in the intragastric pressure or gastric prolapse into the oesophagus, including antecedent transoesophageal echocardiography. Precipitating factors include retching, vomiting, straining, hiccupping, coughing, primal scream therapy, blunt abdominal trauma, and cardiopulmonary resuscitation. In a few cases, no apparent precipitating factor can be identified. One study reported that 25% of patients had no identifiable risk factors.
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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 117
Correct
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A 29-year-old man who plays social rugby presents with recurrent anterior dislocation of the right shoulder. Which of the following abnormalities is most likely to be present?
Your Answer: Bankart lesion
Explanation:This patient has a Bankart lesion which is the most common underlying abnormality in recurrent anterior dislocation of the shoulder.
Bankart lesion is an injury of the anterior (inferior) glenoid labrum of the shoulder due to anterior shoulder dislocation. When this happens, a pocket at the front of the glenoid forms that allows the humeral head to dislocate into it. It is usually visualised by CT and MRI scanning and is often repaired arthroscopically.
Shoulder fractures and dislocations usually result from low-energy falls in predominantly elderly females or from high-energy trauma in young males. They can be associated with nerve injury (commonly axillary), and fracture-dislocation of the humeral head. Anterior shoulder dislocation (glenohumeral dislocation) is the most common type of shoulder dislocation (>90%) and is usually traumatic in nature.
Early assessment of shoulder dislocation:
Careful history, examination, and documentation of neurovascular status of the upper limb, in particular the axillary nerve, is important. This should be re-assessed after manipulation. Early radiographs should also be done to confirm the direction of the dislocation.Initial management of anterior dislocation:
It consists of emergent closed reduction (to prevent lasting chondral damage) under Entonox and analgesia, but often requires conscious sedation. The affected arm should then be immobilised in a polysling. Initial management requires emergent reduction to prevent lasting chondral damage. -
This question is part of the following fields:
- Emergency Medicine And Management Of Trauma
- Principles Of Surgery-in-General
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Question 118
Correct
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Which one of the following is a derivative of the midgut?
Your Answer: Caecum
Explanation:The primary intestinal loop is formed from the midgut which gives rise to the distal half of the duodenum, the jejunum, ascending colon, proximal two thirds of the transverse colon and the ileum.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 119
Incorrect
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Calculate the cardiac output of a patient with the following measurements: oxygen uptake 200 ml/min, oxygen concentration in the peripheral vein 7 vol%, oxygen concentration in the pulmonary artery 10 vol% and oxygen concentration in the aorta 15 vol%.
Your Answer: 2000 ml/min
Correct Answer: 4000 ml/min
Explanation:The Fickās principle states that the uptake of a substance by an organ equals the arteriovenous difference of the substance multiplied by the blood flowing through the organ. We can thus calculate the pulmonary blood flow with pulmonary arterial (i.e., mixed venous) oxygen content, aortic oxygen content and oxygen uptake. The pulmonary blood flow, systemic blood flow and cardiac output can be considered the same assuming there are no intracardiac shunts. Thus, we can calculate the cardiac output. Cardiac output = oxygen uptake/(aortic ā mixed venous oxygen content) = 200 ml/min/(15 ml O2/100 ml ā 10 ml O2/100 ml) = 200 ml/min/(5 ml O2/100 ml) = 200 ml/min/0.05 = 4000 ml/min.
It is crucial to remember to use pulmonary arterial oxygen content and not peripheral vein oxygen content, when calculating the cardiac output by Fickās method. -
This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 120
Correct
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Intravenous diazepam was administered to a man who was brought to the emergency department with status epilepticus. He was administered 15 l/min oxygen via a reservoir bag mask. Blood investigations showed sodium = 140 mmol/l, potassium = 4 mmol/l and chloride = 98 mmol/l. His arterial blood gas analysis revealed pH 7.08, p(CO2)= 61.5 mmHg, p(O2) = 111 mmHg and standard bicarbonate = 17 mmol/l. This patient had:
Your Answer: Mixed acidosis
Explanation:Acidosis with high p(CO2) and low standard bicarbonate indicates mixed acidosis. Lower p(O2) is due to breathing of 70% oxygen. The prolonged seizures lead to lactic acidosis and the intravenous diazepam is responsible for the respiratory acidosis. Treatment includes airway manoeuvres and oxygen, assisted ventilation if needed, and treatment with fluids.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 121
Correct
-
A 35-year-old woman in her 37th week of pregnancy complains of urinary incontinence. She is most likely to have:
Your Answer: Stress incontinence
Explanation:Urinary incontinence is the involuntary excretion of urine from oneās body. It is often temporary and it almost always results from an underlying medical condition. Several types include:
– Stress incontinence is the voiding of urine following increased abdominal pressure e.g. laughing, coughing, pregnancy etc. It is the most common form of incontinence in women, most commonly due to pelvic floor muscle weakness, physical changes from pregnancy, childbirth and menopause. In men it is a common problem following a prostatectomy. Most lab results such as urine analysis, cystometry and postvoid residual volume are normal.
– Urge incontinence is involuntary loss of urine occurring for no apparent reason while suddenly feeling the need or urge to urinate. The most common cause of urge incontinence are involuntary and inappropriate detrusor muscle contractions.
– Functional incontinence ā occurs when a person does not recognise the need to go to the toilet, recognise where the toilet is or get to the toilet in time. The urine loss may be large. Causes of functional incontinence include confusion, dementia, poor eyesight, poor mobility, poor dexterity or unwillingness. t
– Overflow incontinence – sometimes people find that they cannot stop their bladders from constantly dribbling or continuing to dribble for some time after they have passed urine. -
This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 122
Correct
-
Which of the following terms best describes the movement of leukocytes towards a specific target?
Your Answer: Chemotaxis
Explanation:The movement of leukocytes towards a chemical mediator is termed chemotaxis and the mediators likewise called chemoattractants.
Diapedesis is the squeezing of the leukocytes from the capillary wall into the intercellular space.
Endocytosis is engulfing of a small substance by the cells e.g. glucose, protein, fats.
Margination is lining of the WBC along the periphery of the blood vessel.
Adhesion is attachment with the vessel wall.
Phagocytosis is described as engulfing the bacteria or the offending substance. -
This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 123
Incorrect
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A 60-year old patient having a history of cholelithiasis that led to recurrent pain, bloating, nausea and vomiting, was scheduled for surgery to have the gallbladder removed. During the cholecystectomy, the SHO conducting the procedure accidentally punctured a blood vessel that lied immediately posterior to the omental foramen and blood filled the operating field. Which of the following blood vessels was the one likely punctured?
Your Answer: Portal vein
Correct Answer: Inferior vena cava
Explanation:The omental foramen is the pathway that connects the greater peritoneal sac and the lesser peritoneal sac. The omental foramen is bordered posteriorly by the inferior vena cava. This is the blood vessel that would most likely be punctured. The aorta and its branch, the renal artery, lie postero-lateral to the omental foramen and are deeper than the inferior vena cava hence making them less likely to be injured. The hepatic portal vein, the hepatic artery and the superior mesenteric vein borders the omental foramen anteriorly and would not be injured by a jab on the posterior border of the omental foramen. Finally, the splenic artery is found in the splenorenal ligament that borders the omental foramen laterally to the left.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 124
Correct
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A three week old baby is referred to surgery by his paediatrician because she has a painful area of macerated tissue at the site of the umbilicus. When he cries, a clear-yellowish fluid is seen to be draining from the umbilicus. Which of the following would be the correct diagnosis?
Your Answer: Patent urachus
Explanation:A patent urachus is one of the spectrum of congenital urachal anomalies. It has occasionally been termed urachal fistula. In an open (or patent) urachus, there is an opening between the bladder and the belly button (navel). The urachus is a tube between the bladder and the belly button that is present before birth. In most cases, it closes along its full length before the baby is born. An open urachus occurs mostly in infants. A patent urachus is often diagnosed in neonates when urine is noted leaking from the umbilicus. The umbilicus may also have an abnormal appearance on physical exam.
A patent urachus predisposes to infection. If the urachal disorder presents with an infection, the infection is treated first. This requires antibiotics, possible admission for intravenous antibiotics, and occasional surgical drainage of any infected cyst or poorly draining cavity. Once the infection is under control, excision of the urachus is usually performed. This can usually be done laparoscopically or with a small incision on the lower abdomen. Patients usually stay in the hospital 1-2 days after the surgery. The urachus can be excised because in normal development it usually obliterates anyway. The umbilicus is not removed.
Omphalitis is an infection of the umbilicus and/or surrounding tissues, occurring primarily in the neonatal period. Omphalitis is primarily a disease of the neonate and is characterized by tenderness, erythema, and induration of the umbilicus and surrounding tissues. Early on, patients may only have superficial cellulitis but, if untreated, this can progress to involve the entire abdominal wall. Patients may also have purulent drainage or be bleeding from the umbilical cord stump. Foul-smelling drainage should raise the suspicion of anaerobic infection.
Patent vitellointestinal or persistent omphalomesenteric duct is a very unusual congenital anomaly which occurs in 2% of population related with the embryonic yolk stalk. A persistent vitellointestinal duct can induce abdominal pain, bowel obstruction, intestinal haemorrhage and umbilical sinus, fistula or hernia which commonly occurs in children.
An umbilical granuloma is a moist, red lump of tissue that can form on a baby’s navel (belly button). It can be seen in the first few weeks of life, after the umbilical cord has dried and fallen off. It’s usually a minor problem that looks worse than it is. An umbilical granuloma does not cause pain. It may ooze a small amount of fluid that can make the skin around it red and irritated.
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This question is part of the following fields:
- Generic Surgical Topics
- Paediatric Surgery
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Question 125
Correct
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A 50-year old gentleman was recently diagnosed with hypertension, with no other abnormality on physical examination. Further investigations revealed the following : Na+ 144 mmol/l, K+ 3.0 mmol/l, Cl- 107 mmol/l, Bicarbonate 25 mmol/l. Blood glucose 5.8 mmol/l. What is the likely diagnosis?
Your Answer: Conn syndrome
Explanation:Overproduction of aldosterone (a mineralocorticoid) by the adrenal glands is known as Conn’s syndrome. It can be either due to an aldosterone-secreting adrenal adenoma (50-60% cases) or adrenal gland hyperplasia (40-50% cases). Excess aldosterone leads to sodium and water retention, along with potassium excretion. This leads to arterial (non-essential) hypertension. Conn’s syndrome is the commonest cause of primary hyperaldosteronism. Other symptoms include muscle cramps, headache (due to hypokalaemia) and metabolic alkalosis, which occurs due to increased secretion of H+ ions by the kidney. The raised pH of the blood traps calcium leading to symptoms of hypocalcaemia, which can be mimicked by liquorice ingestion and Liddle syndrome. To diagnose Conn’s syndrome, the ratio of renin and aldosterone is measured. Due to suppression of renin secretion, there is low renin to aldosterone ratio (<0.05). However, anti-hypertensives may affect the test results and should be withdrawn for 6 weeks. Computed tomography can also be done to detect the presence of adrenal adenoma.
Cushingās syndrome does not cause hypokalaemia with normal serum glucose levels. Nelsonās syndrome refers to increased ACTH secretion due to pituitary adenoma. Pheochromocytoma will not lead to hypokalaemia even though hypertension can be seen. -
This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 126
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 127
Correct
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A 52 year old man undergoes a renal transplant from a living related donor. He is well for the first five months, but on review in the renal clinic, he is noted to have persistent hypertension and a slight deterioration in renal function. What is the best explanation for this?
Your Answer: Renal artery stenosis
Explanation:Transplant renal artery stenosis (TRAS) is a well-recognized vascular complication after kidney transplant. It occurs most frequently in the first 6 months after kidney transplant, and is one of the major causes of graft loss and premature death in transplant recipients. Transplant renal artery stenosis (TRAS) is the narrowing of the transplant renal artery, impeding blood flow to the allograft. It accounts for 1ā5% cases of post-transplant hypertension. Patients with TRAS have activated RAAS and usually present with worsening or refractory hypertension, fluid retention and/or allograft dysfunction without evidence of rejection.
Percutaneous transluminal angioplasty with stent placement is generally the first-line therapy to correct hemodynamically significant stenosis in TRAS, especially for lesions that are short, linear and distal to the anastomosis. -
This question is part of the following fields:
- Generic Surgical Topics
- Organ Transplantation
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Question 128
Correct
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All the following arteries contribute to the blood supply of the hip joint except:
Your Answer: Pudendal
Explanation:The blood supply to the hip joint is from two main arteries, the medial circumflex femoral and lateral circumflex femoral arteries. These are branches of the deep artery of the thigh, which itself is a branch of the femoral artery. There is contribution of blood supply from the inferior gluteals, foveal and obturator arteries.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 129
Correct
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Coagulation in the body (in vivo) is a process in which several proteins known as coagulation factors are activated in a cascade effect to stop bleeding. Which of the following initiates this cascade effect?
Your Answer: Tissue factor
Explanation:Tissue factor (TF), also known as ‘factor III’ or ‘thromboplastin’, is an anti-coagulation protein that initiates the extrinsic coagulation. TF acts as a transmembrane receptor for Factor VII/VIIa . It is expressed by endothelial cells but also certain tissues, such as the heart and brain.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 130
Correct
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A medical student is asked to calculate the net pressure difference in a capillary wall, considering: Interstitial fluid hydrostatic pressure = ā3 mmHg, Plasma colloid osmotic pressure = 28 mmHg, Capillary hydrostatic pressure = 17 mmHg, Interstitial fluid colloid osmotic pressure = 8 mmHg, and Filtration coefficient = 1. Which is the correct answer?
Your Answer: 0 mmHg
Explanation:The rate of filtration at any point along a capillary depends on a balance of forces sometimes called Starlingās forces after the physiologist who first described their operation in detail. The Starling principle of fluid exchange is key to understanding how plasma fluid (solvent) within the bloodstream (intravascular fluid) moves to the space outside the bloodstream (extravascular space). Fluid movement = k[(pcā pi)ā(Ī cā Ī i)] where k = capillary filtration coefficient, pc = capillary hydrostatic pressure, pi= interstitial hydrostatic pressure, Ī c = capillary colloid osmotic pressure, Ī i = interstitial colloid osmotic pressure. Therefore: 1 Ć [capillary hydrostatic pressure (17) ā interstitial fluid hydrostatic pressure (ā3)] ā [plasma colloid osmotic pressure (28) ā interstitial fluid colloid osmotic pressure (8)] = 0 mmHg
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 131
Correct
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A 30-year-old male is playing tennis when he suddenly collapses and has a GCS of 4 when examined. What is the most likely cause?
Your Answer: Subarachnoid haemorrhage
Explanation:The term subarachnoid haemorrhage (SAH) refers to extravasation of blood into the subarachnoid space between the pial and arachnoid membranes. SAH constitutes half of all spontaneous atraumatic intracranial haemorrhages; the other half consists of bleeding that occurs within the brain parenchyma.
Intracranial saccular aneurysms (āberry aneurysmsā) represent the most common aetiology of nontraumatic SAH; about 80% of cases of SAH result from ruptured aneurysms. -
This question is part of the following fields:
- Generic Surgical Topics
- Surgical Disorders Of The Brain
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Question 132
Correct
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A 65 year old man with a history of diabetes and hypertension presented with a stroke a few months ago severely affecting his speech and movement in the right arm and leg. A cerebral angiogram revealed a middle cerebral artery occlusion. A recent CT scan was done which revealed a 5 cm cystic space in his left parietal lobe. This lesion is a result of which of the following forms of resolution?
Your Answer: Liquefactive necrosis
Explanation:Characteristically, the brain will undergo liquefactive necrosis following ischaemic injury. This leaves a cystic space in that region which would show up on a CT scan. Atrophy would result in a generalized decrease in the brain size. Coagulative necrosis typically occurs in parenchymal organs e.g. the spleen or kidney which have a lower lipid content. Caseous necrosis is typical in granulomatous tuberculosis infection. Apoptosis will not form a cystic area as it is programmed cell death involving a individual cells. Gangrenous necrosis is characteristic of ischaemic injury of the lower limb and GI tract. Fibrinous necrosis results from necrotic damage to the blood vessels with the leaking of proteins into the vessel, appearing bright pink on H & E staining.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 133
Correct
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While conducting a physical examination of a patient, the GP passed a finger down the edge of the medial crus of the superficial inguinal ring and felt a bony prominence deep to the lateral edge of the spermatic cord. What was this bony prominence?
Your Answer: Pubic tubercle
Explanation:At the superficial inguinal ring, the pubic tubercle would be felt as a bony prominence lateral to the edge of the spermatic cord. This tubercle is the point of attachment of the inguinal ligament that makes up the floor of the inguinal canal.
Pecten pubis is the ridge on the superior surface of the superior pubic ramus and the point of attachment of the pectineal ligament.
The pubic symphysis is the joint between the two pubic bones and the iliopubic eminence is a bony process on the pubis found near the articulation of the pubis and the ilium.
The iliopectineal line is formed by the arcuate line of the ilium and the pectineal line of the pubis. It is the line that marks the transition between the abdominal and pelvic cavity.
The sacral promontory is found on the posterior wall of the pelvis and would not be felt through the inguinal ring. -
This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 134
Correct
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During thyroidectomy, the recurrent laryngeal nerves are vulnerable to injury. Which of the following muscles will not be affected in cases where the recurrent laryngeal nerve is severed?
Your Answer: Cricothyroid
Explanation:All muscles of the larynx are supplied by the recurrent laryngeal nerve except for the cricothyroid which is supplied by the vagus nerve.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 135
Correct
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Which of the given options best describes the metabolic changes which occur following a severe soft tissue injury sustained after a PVA?
Your Answer: Mobilisation of fat stores
Explanation:The following metabolic responses occur following trauma as part of a coping mechanism for the additional stress. These include acid base changes (metabolic acidosis or alkalosis), decrease urine output and osmolality, reduced basal metabolic rate (BMR), gluconeogenesis with amino acid breakdown and shunting, hyponatraemia as a result of impaired functioning of sodium pumps, hypoxic injury, coagulopathies, decreased immunity, increase extracellular fluid and hypovolemic shock, increase permeability leading to oedema, break down and mobilization of fat reserves, pyrexia and reduced circulating levels of albumin.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 136
Correct
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A 62 year old man presents with sudden onset of palpitations. ECG shows broad complex tachycardia at a rate of 150 beats per minute. The blood pressure is 120/82 mmHg and there is no evidence of heart failure. The doctor wants to prescribe a rate controlling medication. Which of the following should be avoided in this case?
Your Answer: Verapamil
Explanation:The use of intravenous diltiazem or verapamil is contraindicated in patients with ventricular tachycardia. The IV administration of a calcium channel blocker can precipitate cardiac arrest in such patients.
Marked hemodynamic deterioration and ventricular fibrillation have occurred in patients with wide-complex ventricular tachycardia (QRS >= 0.12 seconds) treated with IV verapamil. -
This question is part of the following fields:
- Emergency Medicine And Management Of Trauma
- Principles Of Surgery-in-General
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Question 137
Incorrect
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A 4-year-old boy is brought to the clinic with symptoms of urinary hesitancy and poor stream. Which of the following is the most likely underlying diagnosis?
Your Answer: Hypospadias
Correct Answer: Posterior urethral valves
Explanation:In children, more common causes of Urinary tract obstruction include the following:
UPJ or UVJ obstruction
Ectopic ureter
Ureterocoele
Megaureter
Posterior urethral valvesPosterior urethral valves:
During the early stages of embryogenesis, the most caudal end of the wolffian duct is absorbed into the primitive cloaca at the site of the future verumontanum in the posterior urethra. In healthy males, the remnants of this process are the posterior urethral folds, called plicae colliculi. Histologic studies suggest that PUVs are formed at approximately 4 weeks’ gestation, as the wolffian duct fuses with the developing cloaca.
Congenital obstructing posterior urethral membrane (COPUM) was first proposed by Dewan and Goh and was later supported by histologic studies by Baskin. This concept proposes that instead of a true valve, a persistent oblique membrane is ruptured by initial catheter placement and, secondary to rupture, forms a valve like configuration.
Indicators of possible PUVs later in childhood include the following:
Urinary tract infection (UTI)
Diurnal enuresis in boys older than 5 years
Secondary diurnal enuresis
Voiding pain or dysfunction
Abnormal urinary stream -
This question is part of the following fields:
- Generic Surgical Topics
- Paediatric Surgery
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Question 138
Correct
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A 62 year old alcoholic man presents with worsening confusion over the last two weeks. He has felt weakness of the left side of the body. Which of the following explanations would be the least likely?
Your Answer: Extra dural haematoma
Explanation:Extradural haematoma (EDH) is defined as an acute bleed between the dura mater and the inner surface of the skull. This then causes increased intracranial pressure, which puts vital brain structures at risk. The question asks for the least likely cause, and extradural hematoma would be acute in onset.
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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 139
Incorrect
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Which nuclei of the posterior grey column of the spinal cord are likely affected in a patient who has lost the sensation of pain and temperature?
Your Answer: Nucleus dorsalis
Correct Answer: Substantia gelatinosa
Explanation:Substantia gelatinosa is one of the nuclei in the posterior grey column along side other posterior grey column nuclei like the nucleus dorsalis, nucleus proprius, and posteromarginal nucleus. These nuclei are a collection of cells in the posterior grey area found in throughout the spinal cord. The substantia gelatinosa receives direct input from the dorsal nerve roots (sensory), especially from thermoreceptors and nociceptors (receptors for temperature and pain).
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 140
Correct
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A 17 year old girl is taken to the hospital with a 10 hour history of pelvic pain. Her last normal menstrual cycle was 14 days ago and she is otherwise well. Her abdomen was soft with mild suprapubic pain on examination. What is the underlying cause?
Your Answer: Mittelschmerz
Explanation:Answer: Mittelschmerz
Mittelschmerz is midcycle abdominal pain due to leakage of prostaglandin-containing follicular fluid at the time of ovulation. It is self-limited, and a theoretical concern is treatment of pain with prostaglandin synthetase inhibitors, which could prevent ovulation. The pain of mittelschmerz usually occurs in the lower abdomen and pelvis, either in the middle or to one side. The pain can range from a mild twinge to severe discomfort and usually lasts from minutes to hours. In some cases, a small amount of vaginal bleeding or discharge might occur. Some women have nausea, especially if the pain is very strong.
Diagnosis of pelvic pain in women can be challenging because many symptoms and signs are insensitive and nonspecific. As the first priority, urgent life-threatening conditions (e.g., ectopic pregnancy, appendicitis, ruptured ovarian cyst) and fertility-threatening conditions (e.g., pelvic inflammatory disease, ovarian torsion) must be considered.
Many women never have pain at ovulation. Some women, however, have mid-cycle pain every month, and can tell by the pain that they are ovulating.
As an egg develops in the ovary, it is surrounded by follicular fluid. During ovulation, the egg and the fluid, as well as some blood, are released from the ovary. While the exact cause of mittelschmerz is not known, it is believed to be caused by the normal enlargement of the egg in the ovary just before ovulation. Also, the pain could be caused by the normal bleeding that comes with ovulation.
Pelvic inflammatory disease can be ruled out if the patient is not sexually active. -
This question is part of the following fields:
- Generic Surgical Topics
- The Abdomen
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Question 141
Correct
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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: 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 142
Correct
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A 45-year old farmer was referred to the surgical clinic with complaints of pain in his right hypochondrium. Investigations confirmed the diagnosis of hepatocellular carcinoma with malignant ascites. According to you, what is the most likely cause of HCC in this patient?
Your Answer: Aflatoxin
Explanation:Aflatoxins are naturally occurring toxins produced by the Aspergillus fungus (most often, A. flavus and A. parasiticus). These organisms are common and their native habitat is soil, decaying vegetation and grains. They can contaminate the grain before harvest or after storage, more likely in high-humidity (at least 7%) or high temperature environment of after stressful conditions like drought. Aflatoxins are mycotoxins and also carcinogenic. They get metabolized in the liver to an epoxide, aflatoxin M1. High exposure can lead to acute necrosis, cirrhosis or liver carcinoma. These substances can cause haemorrhage, acute liver damage, oedema, and alteration in digestion, absorption and/or metabolism of nutrients. Although humans are susceptible to these toxins like all other animals, they have a high tolerance level and hence, rarely develop acute aflatoxicosis. However, children are particularly susceptible to exposure leading to growth impairment and delayed development. Chronic exposure carries a high risk of hepatic cancer, due to intercalation of its metabolite aflatoxin M1 into the DNA and alkylation of the bases because of its epoxide moiety.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 143
Incorrect
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Which of the following muscles attaches to the pterygomandibular raphe?
Your Answer: Lateral pterygoid muscle
Correct Answer: Superior pharyngeal constrictor muscle
Explanation:The pterygomandibular raphƩ (pterygomandibular ligament) provides attachment on its posterior border to the superior pharyngeal constrictor and on its anterior border to the buccinator muscle.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 144
Correct
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The vagus nerve passes through which of the following foramen?
Your Answer: Jugular foramen
Explanation:The jugular foramen is a large foramen in the base of the skull. It is located behind the carotid canal and is formed in front by the petrous portion of the temporal bone, and behind by the occipital bone. Cranial nerves IX, X, and XI and the internal jugular vein pass through the jugular foramen.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 145
Correct
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A 60 year old woman develops an enterocutaneous fistula which is high output following a recent stricturoplasty. Her medical history shows that she has been suffering from small bowel Crohn's disease for the past 17 years. A small bowel follow through shows it to be 14 cm from the DJ flexure and her overlying skin is becoming excoriated. What is the most appropriate course of action?
Your Answer: Commence TPN and octreotide
Explanation:Total parenteral nutrition (TPN) is usually indicated with suspected gastric, duodenal, or small-bowel fistula. When the fistula output is very high, discontinuance of oral intake is recommended because oral intake stimulates further losses of fluids, electrolytes, and protein via the fistula. A decrease in fistula output frequently occurs with the initiation of TPN.
Volume depletion from a proximal high-output fistula can be controlled with the use of the long-acting somatostatin analogue octreotide, which acts by inhibiting GI hormones. The administration of octreotide reportedly diminishes fistula output, but whether it shortens the time required for fistula closure remains to be determined.
Draus et al recommended a 3-day trial of octreotide, maintaining that if the fistula output is reduced during this time, then administration of the drug should be continued. Two meta-analyses showed that somatostatin and its analogues decreased the time for fistula closure and increased the closure rate. -
This question is part of the following fields:
- Generic Surgical Topics
- The Abdomen
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Question 146
Correct
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A 40-year-old man is brought to the A&E department in an unconscious state, following a car collision. He was driving at a high speed of 140 km/hr, wearing a seat belt, when his car collided with a brick wall. CT scan of the brain appears to be normal. However, he remains in a persistent vegetative state. What is the most likely underlying cause?
Your Answer: Diffuse axonal injury
Explanation:This is a case of diffuse axonal injury (DAI) which occurs when the head is rapidly accelerated or decelerated.
DAI is a form of traumatic brain injury which occurs when the brain rapidly shifts inside the skull as an injury is occurring. The long connecting fibres in the brain called axons are sheared as the brain rapidly accelerates and decelerates inside the hard bone of the skull. There are two components of DAI:
1. Multiple haemorrhages
2. Diffuse axonal damage in the white matterUp to two-thirds of the changes occurs at the junction of the grey and white matter due to the different densities of the tissue. These are mainly histological and axonal damage is secondary to biochemical cascades. Often, there are no signs of a fracture or contusion. DAI typically causes widespread injury to the brain leading to loss of consciousness. The changes in the brain are often very tiny and can be difficult to detect using CT or MRI scans.
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This question is part of the following fields:
- Generic Surgical Topics
- Surgical Disorders Of The Brain
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Question 147
Correct
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An 18 year old man is admitted to the intensive care unit with severe meningococcal sepsis. He is on maximal inotropic support and a CT scan of his chest and abdomen is performed. The adrenal glands show evidence of diffuse haemorrhage. Which of the following is the best explanation?
Your Answer: Waterhouse- Friderichsen syndrome
Explanation:Answer: Waterhouse- Friderichsen syndrome
Waterhouse-Friderichsen syndrome is a condition characterized by the abrupt onset of fever, petechiae, arthralgia, weakness, and myalgias, followed by acute haemorrhagic necrosis of the adrenal glands and severe cardiovascular dysfunction. The syndrome is most often associated with meningococcal septicaemia but may occur as a complication of sepsis caused by other organisms, including certain streptococcal species. This disorder may be associated with a history of splenectomy.
Fulminant infection from meningococcal bacteria in the bloodstream is a medical emergency and requires emergent treatment with vasopressors, fluid resuscitation, and appropriate antibiotics. Benzylpenicillin was once the drug of choice with chloramphenicol as a good alternative in allergic patients. Ceftriaxone is an antibiotic commonly employed today. Hydrocortisone can sometimes reverse the adrenal insufficiency. Amputations, reconstructive surgery, and tissue grafting are sometimes needed as a result of tissue necrosis (typically of the extremities) caused by the infection.
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This question is part of the following fields:
- Breast And Endocrine Surgery
- Generic Surgical Topics
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Question 148
Correct
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After finding elevated PSA levels, a 69-year-old man undergoes a needle biopsy and is diagnosed with prostatic cancer. What is the stage of this primary tumour?
Your Answer: T1c
Explanation:The AJCC uses a TNM system to stage prostatic cancer, with categories for the primary tumour, regional lymph nodes and distant metastases:
TX: cannot evaluate the primary tumour T0: no evidence of tumour
T1: tumour present, but not detectable clinically or with imaging T1a: tumour was incidentally found in less than 5% of prostate tissue resected (for other reasons)
T1b: tumour was incidentally found in more than 5% of prostate tissue resected
T1c: tumour was found in a needle biopsy performed due to an elevated serum prostate-specific antigen
T2: the tumour can be felt (palpated) on examination, but has not spread outside the prostate
T2a: the tumour is in half or less than half of one of the prostate glandās two lobes
T2b: the tumour is in more than half of one lobe, but not both
T2c: the tumour is in both lobes
T3: the tumour has spread through the prostatic capsule (if it is only part-way through, it is still T2)
T3a: the tumour has spread through the capsule on one or both sides
T3b: the tumour has invaded one or both seminal vesicles
T4: the tumour has invaded other nearby structures.
In this case, the tumour has a T1c stage. -
This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 149
Incorrect
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In order to arrest sudden bleeding during pericardiectomy that started after accidental injury to a major vasculature in the pericardium; the surgeon inserted his left index finger through the transverse pericardial sinus, pulled forward on the two large vessels lying ventral to his finger, and compressed these vessels with his thumb to control the bleeding. Which vessels were these?
Your Answer: Pulmonary trunk and brachiocephalic trunk
Correct Answer: Pulmonary trunk and aorta
Explanation:Transverse pericardial sinus: located behind two great vessels (aorta and pulmonary trunk) and in front of the superior vena cava and is accessed from above as in this case. The brachiocephalic trunk is located above the pericardium and the right pulmonary artery is above the pericardial reflections.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 150
Incorrect
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A 49-year-old man, smoker, complains of a persisting and worsening cough over the past few months. He also has noted blood in his sputum. The patient has no other major health conditions. Which of the following investigative procedures should be done first?
Your Answer: Bronchoalveolar lavage
Correct Answer: Sputum cytology
Explanation:Sputum cytology is a diagnostic test used for the examination of sputum under a microscope to determine if abnormal cells are present. It may be used as the first diagnostic procedure to help detect a suspected lung cancer or certain non-cancerous lung conditions.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 151
Correct
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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: 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 152
Correct
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A 27-year old lady is shot in the chest. The bullet enters superior to the upper edge of the clavicle. She had difficulty in breathing which is interpreted by the A&E physician as a likely indicator of a collapsed lung. If that is the case, what portion of the pleura is most likely to have been punctured?
Your Answer: Cupola
Explanation:The cupola is part of the pleura that extends above the first rib into the root of the lung. Most likely to injured in a stab above the level of the clavicle.
Costodiaphragmatic recess: the lowest extent of the pleural sac.
Pulmonary ligament: is a fold of pleura located below the root of the lung.
Mediastinal pleura: part of the pleura that lines the mediastinal cavity.
Hilar reflection is the part of the pleura where the visceral pleura of the lung reflects to become continuous with the parietal pleura. -
This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 153
Correct
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Which of the following features is indicative of poor prognosis in a case of breast carcinoma?
Your Answer: Axillary lymph node metastases
Explanation:Lymphatic spread indicates poor prognosis. Presence of family history is not a prognostic factor despite being linked to higher incidence. Aneuploidy is a poor prognostic factor. A breast tumour positive for oestrogen receptors is a good prognostic factor as it increases the responsiveness of the tumour to certain therapies. In-situ tumours carry the best prognosis.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 154
Incorrect
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A 53 year old women with a history of atrial fibrillation developed an acute abdomen. On laparoscopic examination her bowels appeared to be dusky to red-purple in colour and her mesenteric veins appeared to be patent. Which of the following is most likely to occur in this situation?
Your Answer: Coagulative necrosis
Correct Answer: Wet gangrene
Explanation:Infarction of the small bowel following a sudden and complete occlusion of the mesenteric artery can involve any portion of the bowel, whether small or a large. The splenic flexure is at most risk for infarction as it is the watershed area between the superior and inferior mesenteric vessels. Regardless of whether the arterial or the venous blood vessels are occluded, because of the blood reflow into the damaged portion, it will appear haemorrhagic. The bowel appearing congested at first and then becoming oedematous. If the artery is occluded then there will be a clear cut demarcation and in venous occlusion the dusky colour fades with the rest of the normal bowel. Wet gangrene is characteristic of ischaemic injury to the gut.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 155
Incorrect
-
What is the pH of freshly formed saliva at ultimate stimulation?
Your Answer: 4.4
Correct Answer: 8
Explanation:Saliva has four major components: mucus (lubricant), Ī±-amylase (enzyme that initiates digestion of starch), lingual lipase (enzyme that begins fat digestion), and a slightly alkaline electrolyte solution for moistening food. As the secretion rate of saliva increases, its osmolality increases. Moreover, the pH changes from slightly acidic (at rest) to basic (pH 8) at ultimate stimulation. This occurs due to increase of HCO3-. Amylase and mucus also increase in concentration after stimulation.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 156
Incorrect
-
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: Cephalic
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 157
Incorrect
-
A histopathological analysis of a specimen showed loss of individual cell structure with karyorrhexis and fragmentation. The overall integrity of the tissue structure is preserved. This is typical of which of the following pathologies?
Your Answer: Carcinoma insitu
Correct Answer: Viral hepatitis
Explanation:Viral infections will cause necrosis of the hepatocytes with characteristic changes of karyorrhexis and cell fragmentation.
Brown atrophy of the heart is due to accumulation of lipofuscin in the myocardium.
Tissue destruction associated with transplant rejection leads to widespread loss of structural integrity.
Single cell necrosis is not characteristically seen in chronic alcoholic liver.
Barbiturate overdose will result in hypertrophy of the smooth endoplasmic reticulum.
Carcinoma insitu will cause dysplastic cells without the overall structural integrity being disrupted.
Atrophy is due to apoptosis with ordered cellular fragmentation and phagocytosis and will not induce an inflammatory process unlike necrosis. -
This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 158
Correct
-
A 39 year old woman returns from a holiday trip in Nepal and presents to her doctor with painless jaundice. On examination there is no organomegaly and she is not deeply jaundiced. What is most likely cause of her illness?
Your Answer: Hepatitis A infection
Explanation:Hepatitis A is a viral liver disease that can cause mild to severe illness. The hepatitis A virus (HAV) is transmitted through ingestion of contaminated food and water or through direct contact with an infectious person.
The risk of hepatitis A infection is associated with a lack of safe water, and poor sanitation and hygiene (such as dirty hands). Unlike hepatitis B and C, hepatitis A does not cause chronic liver disease and is rarely fatal, but it can cause debilitating symptoms and fulminant hepatitis (acute liver failure), which is often fatal.
Prodrome
In the prodrome, patients may have mild flulike symptoms of anorexia, nausea and vomiting, fatigue, malaise, low-grade fever (usually < 39.5Ā°C), myalgia, and mild headache. Smokers often lose their taste for tobacco, like persons presenting with appendicitis. Icteric phase
In the icteric phase, dark urine appears first (bilirubinuria). Pale stool soon follows, although this is not universal. Jaundice occurs in most (70%-85%) adults with acute HAV infection; it is less likely in children and is uncommon in infants. The degree of icterus also increases with age. Abdominal pain occurs in approximately 40% of patients. Itching (pruritus), although less common than jaundice, is generally accompanied by jaundice.Arthralgias and skin rash, although also associated with acute HAV infection, are less frequent than the above symptoms. Rash more often occurs on the lower limbs and may have a vasculitic appearance.
Relapsing hepatitis A
Relapsing hepatitis A is an uncommon sequela of acute infection, is more common in elderly persons, and is characterized by a protracted course of symptoms of the disease and a relapse of symptoms and signs following apparent resolution. -
This question is part of the following fields:
- Clinical Microbiology
- Principles Of Surgery-in-General
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Question 159
Incorrect
-
A 35 year old male patient sustained a traumatic head injury. The patient had loss of consciousness, woke up momentarily when he was in the emergency room but became drowsy and comatose a few hours after. CT scan of the brain showed accumulation of blood between the dura and the cranial bone on the left side of his head. What type of haemorrhage did the patient have?
Your Answer: Subdural
Correct Answer: Epidural
Explanation:Epidural hematoma, also known as epidural bleeding, is a type of traumatic brain injury (TBI) in which a build-up of blood occurs between the dura mater (the tough outer membrane of the central nervous system) and the skull. The spinal cord is also covered by a layer of dura mater, so epidural bleeds may also occur in the spinal column. Often due to trauma, the condition is potentially deadly because the build-up of blood may increase pressure in the intracranial space, compressing delicate brain tissue, and causing brain shift. The condition is present in one to three percent of head injuries. Around 15ā20% of epidural hematomas are fatal.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 160
Correct
-
A 43-year-old diabetic man complains of headaches, palpitations, anxiety, abdominal pain and weakness. He is administered sodium bicarbonate used to treat:
Your Answer: Metabolic acidosis
Explanation:Sodium bicarbonate is indicated in the management of metabolic acidosis, which may occur in severe renal disease, uncontrolled diabetes, circulatory insufficiency due to shock or severe dehydration, extracorporeal circulation of blood, cardiac arrest and severe primary lactic acidosis. Bicarbonate is given at 50-100 mmol at a time under scrupulous monitoring of the arterial blood gas readings. This intervention, however, has some serious complications including lactic acidosis, and in those cases, should be used with great care.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 161
Correct
-
Regarding the coagulation cascade, Factor VII:
Your Answer: Is mainly synthesised by the vascular endothelium
Explanation:Factor VII is an important part of the coagulation cascade. Deficiency causes haemophilia A. It is synthesised predominantly by the vascular endothelium and is not affect by liver disease. In the circulation it is bound to von Willebrand factor and it forms a stable complex. It is activated by thrombin or factor Xa and acts as a co-factor to factor IXa to activate factor X.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 162
Correct
-
During a radical mastectomy for advanced breast cancer, the surgeon injured the long thoracic nerve. Which among the following muscles is likely to be affected?
Your Answer: Serratus anterior
Explanation:The long thoracic nerve innervates the serratus anterior muscle which holds the scapula forward and balances the rhomboids and the trapezius muscles which retract the scapula. Injury to this nerve results in a ‘winged scapula’ with a posterior protrusion.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 163
Correct
-
Routine evaluation of a 38 year old gentleman showed a slightly lower arterial oxygen [pa(O2)] than the alveolar oxygen [pA(O2)]. This difference is:
Your Answer: Is normal and due to shunted blood
Explanation:Blood that bypasses the ventilated parts of lung and enters the arterial circulation directly is known as shunted blood. It happens in normal people due to mixing of arterial blood with bronchial and some myocardial venous blood (which drains into the left heart). Diffusion limitation and reaction velocity with haemoglobin are immeasurably small. CO2 unloading will not affect the difference between alveolar and arterial p(O2). A large VSD will result in much lower arterial O2 as compared to alveolar O2.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 164
Correct
-
Hormones of the anterior pituitary include which of the following?
Your Answer: Prolactin
Explanation:The anterior pituitary gland (adenohypophysis or pars distalis) synthesizes and secretes:
1. FSH (follicle-stimulating hormone)
2. LH (luteinizing hormone)
3. Growth hormone
4. Prolactin
5. ACTH (adrenocorticotropic hormone)
6. TSH (thyroid-stimulating hormone).
The posterior pituitary gland (neurohypophysis) stores and secretes 2 hormones produced by the hypothalamus:
1. ADH (antidiuretic hormone or vasopressin)
2. Oxytocin -
This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 165
Correct
-
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 166
Correct
-
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: 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 167
Correct
-
Cancer of the testis most likely metastases to which set of lymph nodes?
Your Answer: Aortic
Explanation:The lymphatic drainage of an organ is related to its blood supply. The lymphatic drainage of the testis drains along the testicular artery to reach the lymph nodes along the aorta.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 168
Incorrect
-
A 30-year-old female presents with a painless lump in the upper outer quadrant of her left breast. Ultrasound is indeterminate (U3). Two core biopsies show normal breast tissue (B1). What is the most appropriate course of action?
Your Answer: Reassure the patient and discharge
Correct Answer: Undertake an excision biopsy of the lump
Explanation:Discrete masses graded P3 or R3/M3 or U3 and above should be triple assessed using core biopsy rather than FNAC unless core biopsy is not feasible.
When cytology or biopsy has been reported as C1 or B1 it will require a further biopsy to delineate the pathology in most instances.
The exceptions are when the lesion is suspected to be a lipoma or hamartoma following imaging and discussion. Following triple assessment, if there is non-concordance by more than one grade then further biopsy and or investigations should be undertaken.
In this case, Excisional biopsy is the next required biopsy to delineate the pathology. -
This question is part of the following fields:
- Breast And Endocrine Surgery
- Generic Surgical Topics
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Question 169
Incorrect
-
A 45 year-old male, with behavioural changes developed euvolemic hyponatraemia. Which of the following conditions most likely predisposed the patient to develop euvolemic hyponatraemia?
Your Answer: Salt-losing nephropathy
Correct Answer: Psychosis
Explanation:In euvolemic hyponatraemia, there is volume expansion in the body, there is no oedema, but hyponatremia occurs. Causes include: state of severe pain or nausea, psychosis, brain trauma, SIADH, hypothyroidism and glucocorticoid deficiency.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 170
Incorrect
-
Prostatectomy carries a risk of loss of penile erection due to injury to the prostatic plexus responsible for an erection. From which nerves do these fibres originate?
Your Answer: Pudendal
Correct Answer: Pelvic splanchnics
Explanation:Erection is a function of the parasympathetic nerves. Of the nerves listed, only the pelvic splanchnic nerves have parasympathetic fibres that innervate the smooth muscles and glands of the pelvic viscera.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 171
Correct
-
During an operation to repair a hiatal hernia, the coeliac branch of the posterior vagal trunk is injured. This damage would affect muscular movements as well as some secretory activities of the gastrointestinal tract. Which gastrointestinal segment is LEAST likely to be affected?
Your Answer: Sigmoid colon
Explanation:The vagus nerve supplies the parasympathetic fibres to the abdominal structures that are receive arterial supply from the coeliac trunk or superior mesenteric artery i.e. up to the transverse colon. The end of the transverse colon and the gastrointestinal structures distal to this point receive parasympathetic innervation from the pelvic splanchnic nerves and blood from the inferior mesenteric artery(IMA). The ascending colon, caecum, jejunum and ileum would all, thus, be affected by this damage. Sigmoid colon would not be affected.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 172
Correct
-
An intern is attempting to put in an arterial line in an ICU patients left foot. Which is the best site to feel for the pulsation of the dorsalis pedis artery in the foot?
Your Answer: Just lateral to the tendon of extensor hallucis longus
Explanation:The dorsalis pedis artery is the continuation of the anterior tibial artery. The pulse of the posterior tibial artery, which comes from the posterior compartment of the leg, may be felt behind the medial malleolus just lateral to the tendon of the extensor hallucis longus.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 173
Correct
-
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: 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 174
Correct
-
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%ā90% 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 82ā85% 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 175
Incorrect
-
A 33 year old man presents to the clinic complaining of a tender mass in the right groin area. Red streaks are also noted on the thigh that are extending from a small abrasion. Which of the following would be the most likely explanation?
Your Answer: Abscess
Correct Answer: Lymphadenitis
Explanation:Lymphadenitis is the inflammation or enlargement of a lymph node. Lymph nodes are small, ovoid nodules normally ranging in size from a few millimetres to 2 cm. They are distributed in clusters along the course of lymphatic vessels located throughout the body. The primary function of lymph nodes is to filter out microorganisms and abnormal cells that have collected in lymph fluid. Lymph node enlargement is a common feature in a variety of diseases and may serve as a focal point for subsequent clinical investigation of diseases of the reticuloendothelial system or regional infection. The majority of cases represent a benign response to localized or systemic infection. The red streaks that are noted along the line of lymphatics are indicative of lymphadenitis.
Groin masses are common and include:
Herniae
Lipomas
Lymph nodes
Undescended testis
Femoral aneurysm
Saphena varix -
This question is part of the following fields:
- Generic Surgical Topics
- Vascular
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Question 176
Correct
-
A 55-year-old man is recovering following an elective right hemicolectomy for carcinoma of the caecum. His surgery is uncomplicated, when should oral intake resume?
Your Answer: Within 24 hours of surgery
Explanation:It has been well established that any delay in the resumption of normal oral diet after major surgery is associated with increased rates of infectious complications and delayed recovery. Early oral diet is safe 4 h after surgery in patients with a new non-diverted colorectal anastomosis. Some report that low residue diet, rather than a clear liquid diet, after colorectal surgery is associated with less nausea, faster return of bowel function, and a shorter hospital stay without increasing postoperative morbidity when administered in association with prevention of postoperative ileus. Spontaneous food intake rarely exceeds 1200ā1500 kcal/day. To reach energy and protein requirements, additional oral nutritional supplements are useful.
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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 177
Correct
-
During pregnancy the uterus enlarges however after delivery it regresses to its original size. Which of the following organelles is responsible for this regression?
Your Answer: Lysosomes
Explanation:Lysosomes are formed by budding of the Golgi apparatus and contain enzymes which digest macromolecules. They are found in both plants and animals and are active in autophagic cell death, digestion after phagocytosis and for the cells own recycling process. They fuse with the molecules and release their content resulting in digestion.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 178
Correct
-
QT interval in the electrocardiogram of a healthy individual is normally:
Your Answer: 0.40 s
Explanation:QT interval extends from beginning of the QRS complex till the end of he T-wave and normally lasts for 0.40 s. It is important in the diagnosis of long-QT and short-QT syndrome. The QT interval varies on the basis of heart rate and may need to be corrected.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 179
Correct
-
A 35-year-old male presents with recurrent episodes of knife-like pain within his rectum. On examination, there is no abnormality to find on either proctoscopy or palpation. What is the most likely diagnosis?
Your Answer: Proctalgia fugax
Explanation:Proctalgia fugax or functional recurrent anorectal pain is part of a spectrum of functional gastrointestinal disorders defined by the Rome III diagnostic criteria as episodes of sharp fleeting pain that recur over weeks, are localized to the anus or lower rectum, and last from seconds to several minutes with no pain between episodes. There is no diurnal variation. There are numerous precipitants including sexual activity, stress, constipation, defecation and menstruation, although the condition can occur without a trigger. It should be differentiated from chronic proctalgia, a functional anorectal pain disorder with a vague, dull ache or pressure sensation high in the rectum, often worse when sitting than when standing or lying down, and lasts at least 20 minutes.
Most treatments for proctalgia fugax (e.g., oral diltiazem, topical glyceryl nitrate, nerve blocks) act by relaxing the anal sphincter spasm, but the effectiveness of these treatments are supported only by case reports or case series, with the exception of a single randomized controlled trial of salbutamol, making the value of most treatment options, including salbutamol, difficult to judge. -
This question is part of the following fields:
- Colorectal Surgery
- Generic Surgical Topics
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Question 180
Correct
-
A 25-year-old female had a painful abdomen and several episodes of vomiting. She was severely dehydrated when she was brought to the hospital. Her ABG showed a pH 7.7, p(O2) 75 mmHg, p(CO2) 46 mmHg and bicarbonate 48 mmol/l. The most likely interpretation of this ABG report would be:
Your Answer: Metabolic alkalosis
Explanation:Metabolic alkalosis is a primary increase in bicarbonate (HCO3ā) with or without compensatory increase in carbon dioxide partial pressure (Pco2); pH may be high or nearly normal. Metabolic alkalosis occurs as a consequence of a loss of H+ from the body or a gain in HCO3 -. In its pure form, it manifests as alkalemia (pH >7.40). As a compensatory mechanism, metabolic alkalosis leads to alveolar hypoventilation with a rise in arterial carbon dioxide tension p(CO2), which diminishes the change in pH that would otherwise occur. Normally, arterial p(CO2) increases by 0.5ā0.7 mmHg for every 1 mmol/l increase in plasma bicarbonate concentration, a compensatory response that occurs very rapidly. If the change in p(CO2) is not within this range, then a mixed acidābase disturbance occurs. Likewise, if the increase in p(CO2) is less than the expected change, then a primary respiratory alkalosis is also present. However an elevated serum bicarbonate concentration can also occur due to a compensatory response to primary respiratory acidosis. A bicarbonate concentration greater than 35 mmol/l is almost always caused by metabolic alkalosis (as is the case in this clinical scenario). Calculation of the serum anion gap can also help to differentiate between primary metabolic alkalosis and the metabolic compensation for respiratory acidosis. The anion gap is frequently elevated to a modest degree in metabolic alkalosis because of the increase in the negative charge of albumin and the enhanced production of lactate. However, the only definitive way to diagnose metabolic alkalosis is by performing a simultaneous blood gases analysis, which reveals elevation of both pH and arterial p(CO2) and increased calculated bicarbonate.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 181
Correct
-
After having donated a unit of blood. The blood bank will prefer to use which of the following anticoagulants to store the blood?
Your Answer: Citrate
Explanation:Calcium is necessary for coagulation to occur. Citrate being a chelator and combining with calcium ions to form un-ionised compound will prevent coagulation. Following transfusion the citrate is removed by the liver with in a few minutes. Oxalate also works on the same principle but it is toxic to the body.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 182
Correct
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Question 183
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 184
Correct
-
A 40 year old patient with an history of obesity has been diagnosed with meralgia parasthetica. The condition was discovered to be caused by the pinching of the lateral femoral cutaneous nerve. Injuries at what spinal levels usually affect this nerve?
Your Answer: L2, L3
Explanation:The lateral femoral cutaneous nerve of the thigh arises from the dorsal division of the lumbar plexus of the second and the third lumbar nerves (L2 – L3). Spinal injuries at this level are likely to affect the lateral femoral cutaneous nerve. The lateral femoral cutaneous nerve innervates the skin on the lateral aspect of the thigh.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 185
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 186
Correct
-
Following a posterolateral thoracotomy, a surgeon may wish to infiltrate local anaesthetic above and below the incision to block the nerves supplying the thoracic wall. This wall is innervated by?
Your Answer: Intercostal nerves
Explanation:Intercostal nerves are the ventral primary rami of spinal nerves T1āT11. They give branches which supply the thoracic wall.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 187
Incorrect
-
Which nerve mediates the sensation to itch from the skin that is just over the base of the spine of your scapula?
Your Answer: Ventral root of T2
Correct Answer: Dorsal primary ramus of C7
Explanation:The first branches off spinal nerves are called the dorsal and ventral rami. The dorsal rami mediate sensation of the skin over the back and motor supply to the true muscles of the back whilst the ventral rami gives sensation to the skin over the limbs and the skin that is over the ventral side of the trunk. It also gives motor supply to the skeletal muscles of the neck, the trunk and extremities. Hence, itchiness of the part of the skin that is over the spine of the scapula would be mediated by the primary ramus of C7. Accessory nerve doesn’t have any sensory innervation.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 188
Incorrect
-
The passage of leukocytes through the wall of the blood vessels is best described by which of the following terms?
Your Answer: Chemotaxis
Correct Answer: Diapedesis
Explanation:The steps involved in leukocyte arrival and function are:
1. margination: cells migrate from the centre to the periphery of the vessel
2. rolling: selectins are upregulated on the vessel walls
3. adhesion: upregulation of the adhesion molecules ICAM and VCAM on the endothelium interact with integrins on the leukocytes, interaction of these results in adhesion
4. diapedesis and chemotaxis: diapedesis is the transmigration of the leukocyte across the endothelium of the capillary and towards a chemotactic product
5. phagocytosis: engulfing the offending substance/cell. -
This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 189
Correct
-
A 33 year old woman presents to the ER after being involved in a road traffic accident. Her knee has hit the dashboard. Examination reveals a posteriorly displaced tibia. Injury to which of the following structures has resulted in this presentation?
Your Answer: Posterior cruciate ligament
Explanation:The posterior drawer test is a physical exam technique that is done to assess the integrity of the posterior cruciate ligament (PCL). The PCL is attached to the posterior intercondylar area of the tibia and passes anteriorly, medially, and upward to attach to the lateral side of the medial femoral condyle.
This ligament prevents backward displacement of the tibia or forward sliding of the femur. Injury to the ligament allows displacement of the tibia -
This question is part of the following fields:
- Generic Surgical Topics
- Orthopaedics
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Question 190
Incorrect
-
Which of the following brings about a reduction in gastric blood flow?
Your Answer: Acetylcholine
Correct Answer: Vasopressin
Explanation:Gastric blood flow is increased by vagal stimulation, gastrin, histamine and acetylcholine as they stimulate gastric section and the production of vasodilator metabolites. Acetylcholine and histamine also have a direct action on the gastric arterioles. Similarly, gastric blood flow is reduced by inhibitors of secretion ā catecholamines, secretin and vasopressin.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 191
Correct
-
A 56-year-old woman complains of back pain, muscle spasms, weakness, and a burning sensation that radiates from her left hip to her toes. What's the most likely diagnosis?
Your Answer: Herniated nucleus pulposus
Explanation:A herniated disk will produce sensory disturbances, causing pain that radiates along the course of the sciatic nerve which is typically burning or stabbing, with or without back pain. The herniation is usually caused by age-related degeneration although trauma, injuries, or straining may also trigger it.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 192
Incorrect
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A 59 year old man presents with septicaemia 48 hours after undergoing a difficult colonoscopy to assess the extent of a caecal carcinoma. His abdomen is soft and non tender. Blood cultures grow gram positive cocci. Which of the following organisms is likely responsible for this condition?
Your Answer: Staphylococcus epidermidis
Correct Answer: Streptococcus bovis
Explanation:Streptococcus bovis (S. bovis) bacteria are associated with colorectal cancer and adenoma. S. bovis is currently named S. gallolyticus. 25-80% of patients with S. bovis/gallolyticus bacteraemia have concomitant colorectal tumours. Colonic neoplasia may arise years after the presentation of bacteraemia or infectious endocarditis of S. bovis/gallolyticus. The presence of S. bovis/gallolyticus bacteraemia and/or endocarditis is also related to the presence of villous or tubular-villous adenomas in the large intestine.
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This question is part of the following fields:
- Clinical Microbiology
- Principles Of Surgery-in-General
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Question 193
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 194
Correct
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A 50-year-old man presents with bright red rectal bleeding that occurs post defecation and is noted on the toilet paper. It is also associated with severe pain. On external anal examination, a skin tag is identified at 6 o'clock position.Which of the following treatment options is most likely to be helpful?
Your Answer: Topical GTN
Explanation:Since the most likely diagnosis is anal fissure, the correct treatment is topical nitrates.
Anal fissures are a common cause of painful, bright red rectal bleeding. Most fissures are idiopathic and present as a painful mucocutaneous defect in the posterior midline (90% cases). Fissures are more likely to be anteriorly located in females, particularly if they are multiparous. Diseases associated with fissure-in-ano include:
1. Crohn’s disease
2. Tuberculosis
3. Internal rectal prolapseDiagnostic options are as follows:
In most cases, the defect can be visualised as a posterior midline epithelial defect. Where symptoms are highly suggestive of the condition and examination findings are unclear, an examination under anaesthesia may be helpful. Atypical disease presentation should be investigated by colonoscopy and EUA, with biopsies of the area.For management of anal fissure:
1. Stool softeners are important as hard stools may tear the epithelium and result in recurrent symptoms. The most effective first-line agents are topically applied GTN (0.2%) or Diltiazem (2%) paste.
2. Resistant cases may benefit from injection of botulinum toxin or lateral internal sphincterotomy. Advancement flaps may be used to treat resistant cases. -
This question is part of the following fields:
- Colorectal Surgery
- Generic Surgical Topics
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Question 195
Correct
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A 41 year old paediatrician presents with right upper quadrant pain and a sensation of abdominal fullness. A 6.7 cm hyperechoic lesion in the right lobe of the liver is detected when an ultrasound scan is done. Tests show that the serum AFP is normal. What is the most likely underlying lesion?
Your Answer: Haemangioma
Explanation:A cavernous liver haemangioma or hepatic haemangioma is a benign tumour of the liver composed of hepatic endothelial cells. It is the most common liver tumour, and is usually asymptomatic and diagnosed incidentally on radiological imaging. Liver haemangiomas are thought to be congenital in origin. Several subtypes exist, including the giant hepatic haemangioma, which can cause significant complications. This large, atypical haemangioma of the liver may present with abdominal pain or fullness due to haemorrhage, thrombosis or mass effect. It may also lead to left ventricular volume overload and heart failure due to the increase in cardiac output which it causes. Further complications are Kasabach-Merritt syndrome, a form of consumptive coagulopathy due to thrombocytopaenia, and rupture.
As one of the benign neoplasms, the AFP level of hepatic cavernous haemangioma patients is not usually outside the normal range.
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This question is part of the following fields:
- Generic Surgical Topics
- Hepatobiliary And Pancreatic Surgery
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Question 196
Correct
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A 35 year old IV drug abuser arrives at the clinic with localized spinal pain. It is worse on movement and has been occurring for the last 2 months. The pain is refractory to analgesic treatment and is felt excruciatingly at rest too. He has no history of tuberculosis. Which of the following is the most likely diagnosis?
Your Answer: Osteomyelitis
Explanation:Complications of intravenous drug abuse, such as subcutaneous abscess, joint infections, osteomyelitis, overdose, hepatitis, and infective endocarditis, account for an increasing number of admissions in accident and emergency departments throughout the UK. The organisms that usually cause chronic osteomyelitis in intravenous drug users are Gramānegative rods such as Pseudomonas aeruginosa and Gramāpositive cocci such as staphylococci. Early treatment is essential to prevent progressive bone destruction. TB tends to affect the thoracic spine and in other causes of osteomyelitis the lumbar spine is affected.
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This question is part of the following fields:
- Generic Surgical Topics
- Orthopaedics
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Question 197
Correct
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A 23-year-old male presents with a persistent and unwanted erection that has been present for the previous 7 hours. On examination, the penis is rigid and tender. Aspiration of blood from the corpus cavernosa shows dark blood. Which of the following is the most appropriate initial management?
Your Answer: Aspirate further blood from the corpus cavernosa in an attempt to decompress
Explanation:Priapism is defined as a prolonged penile erection lasting for >4 h in the absence of sexual stimulation and remains despite orgasm.
The classification of priapism is conventionally divided into three main groups. The commonest classification is into nonāischaemic (high flow), ischaemic (low flow), and stuttering (recurrent) subtypes.
The EAU guidelines refer to the subtypes as ischaemic (low flow, venoāocclusive) and arterial (high flow, nonāischaemic). Of these, ischaemic priapism is the commonest, with refractory cases at risk of smooth muscle necrosis in the corpus cavernosum leading to sequelae of corporal fibrosis and erectile dysfunction (ED).
One of the key considerations in the management of priapism is the duration of the erection at presentation.
The EAU guidelines do differentiate the periods such that the intervention varies accordingly, which is particularly important for prolonged episodes that are refractory to pharmacological interventions and allow a stepāwise intervention.Ischaemic priapism is a medical emergency as the progressive ischaemia within the cavernosal tissue is associated with timeādependent changes in the corporal metabolic environment, which eventually leads to smooth muscle necrosis. As the duration of the penile erection becomes pathologically prolonged, as in the case of lowāflow priapism, the partial pressure of oxygen (pO2) progressively falls as the closed compartment prevents replenishment of stagnant blood with freshly oxygenated arterial blood.
Investigations using corporal blood aspiration, that in itself can be a therapeutic intervention leading to partial or complete penile detumescence, helps to differentiate ischaemic from nonāischaemic priapism subtypes based on the pO2, pCO2 and pH levels. The AUA guidelines state that typically the blood gas analysis would give a pO2 of <30 mmHg and pCO2 of >60 mmHg and a pH of <7.25 in ischaemic priapism, whereas nonāischaemic blood gas analysis would show values similar to venous blood. Once the diagnosis of priapism has been made, the initial management involves corporal blood aspiration followed by instillation of Ī±āagonists directly into the corpus cavernosum.
The EAU guidelines recommend several possible agents for intracavernosal injection, as well as oral terbutaline after intracavernosal injection.
Phenylephrine ā 200 Ī¼g every 3ā5 min to a maximum of 1 mg within 1 h.
Etilephrine ā 2.5 mg diluted in 1ā2 mL saline.
Adrenaline ā 2 mL of 1/100 000 solution given up to 5 times in a 20āmin period.
Methylene blue ā 50ā100 mg intracavernosal injection followed by aspiration and compression.Shunt surgery allows diversion of blood from the corpus cavernosum into another area such as the corpus spongiosum (glans or urethra) or the venous system (saphenous vein). Both the EAU and AUA guidelines recommend surgical intervention using firstly distal shunts and then proximal shunts in cases where aspiration and instillation of pharmacological agents fails to achieve penile detumescence. The EAU guidelines recommend that distal shunts should be attempted before proximal shunts, although the specific technique is left to the individual surgeon’s preference. The EAU guidelines also define a time point (36 h) when shunt surgery is likely to be ineffective in maintaining longāterm erectile function and may serve to reduce pain only. This is an important consideration when contemplating early penile prosthesis placement.
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This question is part of the following fields:
- Generic Surgical Topics
- Urology
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Question 198
Correct
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A 41 year old librarian undergoes a gastric bypass surgery and she returns to the clinic complaining that she develops vertigo and crampy abdominal pain after eating. Which of the following is the underlying cause?
Your Answer: Dumping syndrome
Explanation:Dumping syndrome is the effect of altered gastric reservoir function, abnormal postoperative gastric motor function, and/or pyloric emptying mechanism. Clinically significant dumping syndrome occurs in approximately 10% of patients after any type of gastric surgery and in up to 50% of patients after laparoscopic Roux-en-Y gastric bypass. Dumping syndrome has characteristic alimentary and systemic manifestations. It is a frequent complication observed after a variety of gastric surgical procedures, such as vagotomy, pyloroplasty, gastrojejunostomy, and laparoscopic Nissan fundoplication. Dumping syndrome can be separated into early and late forms, depending on the occurrence of symptoms in relation to the time elapsed after a meal.
Postprandially, the function of the body of the stomach is to store food and to allow the initial chemical digestion by acid and proteases before transferring food to the gastric antrum. In the antrum, high-amplitude contractions triturate the solids, reducing the particle size to 1-2 mm. Once solids have been reduced to this desired size, they are able to pass through the pylorus. An intact pylorus prevents the passage of larger particles into the duodenum. Gastric emptying is controlled by the fundic tone, antropyloric mechanisms, and duodenal feedback. Gastric surgery alters each of these mechanisms in several ways.The late dumping syndrome is suspected in the person who has symptoms of hypoglycaemia in the setting of previous gastric surgery, and this late dumping can be proven with an oral glucose tolerance test (hyperinsulinemic hypoglycaemia), as well as gastric emptying scintigraphy, which shows the abnormal pattern of initially delayed and then accelerated gastric emptying.
The clinical presentation of dumping syndrome can be divided into GI symptoms and vasomotor symptoms. GI symptoms include early satiety, crampy abdominal pain, nausea, vomiting, and explosive diarrhoea. Vasomotor symptoms include diaphoresis, flushing, dizziness, palpitations, and an intense desire to lie down.
The expression of these symptoms varies in different individuals. Most patients with early dumping have both GI and vasomotor symptoms, while patients with late dumping have mostly vasomotor symptoms. Patients with severe dumping often limit their food intake to avoid symptoms. This leads to weight loss and, over time, malnutrition.
Early dumping syndrome generally occurs within 15 minutes of ingesting a meal and is attributable to the rapid transit of food into the small intestine, whereas late dumping syndrome occurs later and may be attributed to hypoglycaemia with tremors, cold sweats, difficulty in concentrating, and loss of consciousness.
Early dumping systemic symptoms are as follows:
Desire to lie down
Palpitations
Fatigue
Faintness
Syncope
Diaphoresis
Headache
FlushingEarly dumping abdominal symptoms are as follows:
Epigastric fullness
Diarrhoea
Nausea
Abdominal cramps
BorborygmiLate dumping symptoms are as follows:
Perspiration
Shakiness
Difficulty to concentrate
Decreased consciousness
Hunger -
This question is part of the following fields:
- Generic Surgical Topics
- Upper Gastrointestinal Surgery
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Question 199
Correct
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A 22-year old man presented with a mass in his left scrotum which was more prominent when standing and felt like a 'bag of worms'. Examination revealed a non-tender mass along the spermatic cord. Also, the right testis was larger than the left testis. What is the likely diagnosis?
Your Answer: Varicocele
Explanation:Varicocele refers to dilatation and increased tortuosity of the pampiniform plexus ā which is a network of veins found in spermatic cord that drain the testicle. Defective valves or extrinsic compression can result in outflow obstruction and cause dilatation near the testis. Normal diameter of the small vessels ranges from 0.5 ā 1.5mm. A varicocele is a dilatation more than 2mm.
The plexus travels from the posterior aspect of testis into the inguinal canal with other structures forming the spermatic cord. They then form the testicular veins out of which the right testicular vein drains into the inferior vena cava and the left into the left renal vein.
It affects 15-20% men, and 40% of infertile males. Usually diagnosed in 15-25 years of age, they are rarely seen after 40 years of age. Because of the vertical path taken by the left testicular vein to drain into left renal vein, 98% idiopathic varicoceles occur on the left side. It is bilateral in 70% cases. Right-sided varicoceles are rare.
Symptoms include pain or heaviness in the testis, infertility, testicular atrophy, a palpable mass, which is non-tender and along the spermatic cord (resembling a ābag of wormsā). The testis on the affected side might be smaller.
Diagnosis can be made by ultrasound. Provocative measures such as Valsalva manoeuvre or making the patient stand up to increase the dilatation by increasing the intra-abdominal venous pressure. -
This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 200
Correct
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A 45-year-old male undergoes a distal gastrectomy for cancer. He is slightly anaemic and therefore receives a transfusion of 4 units of packed red cells to cover both the existing anaemia and associated perioperative blood loss. He is noted to develop ECG changes that are not consistent with ischaemia. What is the most likely cause?
Your Answer: Hyperkalaemia
Explanation:The patient suffers from hyperkalaemia as an adverse effect of RBCs transfusion, which causes his ECG changes.
The potassium concentration of blood increases during storage, by as much as 5ā10 mmol uā1. After the transfusion, the RBC membrane Na+āK+ ATPase pumping mechanism is re-established and cellular potassium reuptake occurs rapidly. Hyperkalaemia rarely occurs during massive transfusions unless the patient is also hypothermic and acidotic.
The total extracellular potassium load, which is <0.5 mmol for fresh RBC units and only 5-7 mmol for units at expiration, rarely causes problems in the recipient because of rapid dilution, redistribution into cells, and excretion. An abnormally high potassium level (>5 mmol/l or ā„1.5 mmol/l net increase) within an hour of transfusion is classified as transfusion-associated hyperkalaemia.
Irradiation enhances potassium leakage. -
This question is part of the following fields:
- Post-operative Management And Critical Care
- Principles Of Surgery-in-General
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SESSION STATS - PERFORMANCE PER SPECIALTY
