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Question 1
Correct
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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: 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 2
Correct
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Which of the following structures, is the area in which the superior cerebral veins drain into?
Your Answer: Superior sagittal sinus
Explanation:The superior cerebral veins are predominantly located on the superior aspect of the brain. They are 8 to 12 in number and they drain the lateral, medial and superior aspects of the cerebral hemispheres.
These veins drain into the superior sagittal sinus, also known as the superior longitudinal sinus – which is located along the attached margin of the falx cerebri. -
This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 3
Correct
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A 76-year-old woman is diagnosed with diabetes mellitus after a urine test revealed she has glucosuria. Glucosuria may occur due to inadequate glucose reabsorption at:
Your Answer: Proximal convoluted tubule
Explanation:Glucose is reabsorbed almost 100% via sodium–glucose transport proteins (apical) and GLUT (basolateral) in the proximal convoluted tubule. Glycosuria or glucosuria is a condition of osmotic diuresis typical in those suffering from diabetes mellitus. Due to a lack of insulin, plasma glucose levels are above normal. This leads to saturation of receptors in the kidneys and glycosuria usually at plasma glucose levels above 11 mmol/l. Rarely, glycosuria is due to an intrinsic problem with glucose reabsorption within the kidneys (such as Fanconi syndrome), producing a condition termed renal glycosuria.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 4
Incorrect
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A man came to the hospital complaining of a sensation of pins and needles in the dorsum of the thumb and digits 1 and 2. On further examination they found that he had weakness in wrist dorsiflexion and finger extension. Which nerve do you think is injured in this case?
Your Answer: Musculocutaneous
Correct Answer: Radial
Explanation:The radial nerve can be injured in multiple sites along its course in the upper limb, and each site has its own presentation. The major complaint is wrist drop which if high above the elbow, can cause numbness of the forearm and hand. It can last for several days or weeks. The most common site of compression for the radial nerve is at the proximal forearm in the area of the supinator muscles.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 5
Correct
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A 39-year old female patient was diagnosed with a tumour of the left adrenal gland. The tumour, which is metastasizing to the adjacent tissues, has already extended to the left suprarenal vein. If the tumour is still spreading, which of the following veins will most likely be affected after the involvement of the left suprarenal vein?
Your Answer: Left renal vein
Explanation:The suprarenal veins or also known as the veins of Warshaw, are the veins that receive blood from the suprarenal glands. These veins receive blood from the medullary venous plexus and the cortex of the adrenal glands (suprarenal glands). They are two in number – the left and the right suprarenal veins. The right suprarenal vein drains into the inferior vena cava while the left suprarenal vein drains into the left renal vein. This therefore means that in the case of a metastasizing tumour involving the left suprarenal vein, the tumour will most likely extend from the left suprarenal vein to the left renal vein into which it drains.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 6
Correct
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A 7-year-old boys undergoes a testicular biopsy after a tumour is found in his right testis. Elements similar to hair and teeth are found in it. What kind of tumour is this?
Your Answer: Teratoma
Explanation:A teratoma is a tumour containing tissue elements that are similar to normal derivatives of more than one germ layer. They usually contain skin, hair, teeth and bone tissue and are more common in children, behaving as a benign tumour. After puberty, they are regarded as malignant and can metastasise.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 7
Correct
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Below which level of the spinal cord will the inferior gluteal nerve be unaffected?
Your Answer: S3
Explanation:The inferior gluteal nerve arises from the dorsal divisions of the fifth lumbar and first and second sacral nerves. According to this fact any lesion at or below the S3 will not affect the inferior gluteal nerve.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 8
Correct
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Which muscle in the neck divides the neck into two large triangles?
Your Answer: Sternocleidomastoid
Explanation:The sternocleidomastoid muscle is an important landmark in the neck as it divides the neck into two; anterior and posterior triangles. These triangles help in the location of the structures of the neck including the carotid artery, head and neck lymph nodes, accessory nerve and the brachial plexus. It originates from the manubrium and medial portion of the clavicle and inserts on the mastoid process of the temporal bone, superior nuchal line. The sternocleidomastoid receives blood supply from the occipital artery and the superior thyroid artery. It is innervated by the accessory nerve (motor)
and cervical plexus (sensory). -
This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 9
Correct
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A 55 year-old construction worker is diagnosed with malignant melanoma. He was exposed to what substance which increased his risk in developing mesothelioma?
Your Answer: Asbestos
Explanation:Mesothelioma is a rare, aggressive form of cancer that develops in the lining of the lungs, abdomen or heart. It is linked to inhalation of asbestos commonly used in ship building and the insulation industry. It has no known cure and has a very poor prognosis.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 10
Correct
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A 41-year-old man presents with a newly pigmented lesion on his right shin, which has been increasing in size. On examination, the lesion has regular borders and normal-appearing skin appendages.What should be the best course of action?
Your Answer: Excision biopsy
Explanation:Lesions bearing normal dermal appendages and regular borders are likely to be benign pigmented naevi. Therefore diagnostic and not radical excision is indicated. Incision biopsy should not be done.
Melanocytic naevi are pigmented moles. Some moles are present at birth or appear within the first two years of life. These are known as congenital melanocytic naevi. Most develop during childhood and early adult life and are, consequently, called acquired melanocytic naevi. The number of moles increase up to the age of 30–40. Thereafter, the number of naevi tend to decrease. New moles appearing in adulthood need to be monitored and checked if growing or changing. Moles can be found anywhere on the skin, including on the hands and feet, genitals, eyes, and scalp.
There are three main types of acquired melanocytic naevi:
1. Junctional melanocytic naevi: flat and usually circular.
2. Compound melanocytic naevi: raised brown bumps most of which are hairy, some have a slightly warty surface.
3. Intradermal melanocytic naevi: raised and often hairy bumps, similar to compound naevi but more pale coloured (often skin-coloured). -
This question is part of the following fields:
- Generic Surgical Topics
- Skin Lesions
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Question 11
Correct
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Nephrotic syndrome is a condition that causes proteinuria, hypoalbuminemia and oedema. Which of the following is the cause of the oedema in these patients?
Your Answer: Decreased oncotic pressure
Explanation:The glomeruli of the kidneys are the parts that normally filter the blood. They consist of capillaries that are fenestrated and allow fluid, salts and other small solutes to flow through, but normally not proteins. In nephrotic syndrome, the glomeruli become damaged allowing small proteins, such as albumin to pass through the kidneys into urine. Oedema usually occurs due to salt and water retention by the diseased kidneys as well as due to the reduced colloid oncotic pressure (because of reduced albumin in the plasma). Lower serum oncotic pressure causes fluid to accumulate in the interstitial tissues.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 12
Correct
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Which nodes are most likely to be enlarged in a patient complaining of a boil located on the labia majora?
Your Answer: Superficial inguinal
Explanation:The perineum, external genitalia, the labia majora and scrotum drain to the superficial inguinal lymph nodes. In a man, the testes do not drain to the superficial inguinal lymph nodes but rather travel in the spermatic cord and drain into the lumbar nodes. The lumbar nodes drain the internal pelvic organs. The sacral nodes drain the prostrate gland, uterus, vagina, rectum and posterior pelvic wall and the external iliac nodes in turn drain the lower limb. The internal iliac nodes drain the pelvis and gluteal region.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 13
Correct
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A 58 year old man presents to the clinic complaining of lower backache refractory to medicine. He is a known case of metastatic prostate carcinoma, with spinal involvement. However, up until recently, he has had no problems with pain control. He takes 1g qds paracetamol daily. Neurological examination is unremarkable. Which of the following is the most appropriate next step in management?
Your Answer: Add non steroidal anti inflammatory drug
Explanation:Acetaminophen, NSAIDs, and opiates are recommended in the basic approach to cancer pain associated with bone metastases. They should provide patients with adequate analgesia when used appropriately. NSAIDs including COX2 inhibitors are especially useful for patients with bone pain. Acetaminophen is an effective analgesic but is a weak anti-inflammatory agent. Ketorolac tromethamine is a potent NSAID capable of relieving moderate to severe acute bone pain.
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This question is part of the following fields:
- Oncology
- Principles Of Surgery-in-General
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Question 14
Correct
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After total thyroidectomy, which of the following investigations is recommended in the immediate post-operative period?
Your Answer: Serum calcium
Explanation:Total thyroidectomy might sometimes result in inadvertent excision or damage of parathyroid glands, leading to hypoparathyroidism. Monitoring serum calcium levels in the post-operative period to detect hypocalcaemia is essential to diagnose and prevent this condition.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 15
Correct
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What is the normal amount of oxygen that is carried in the blood?
Your Answer: 20 ml oxygen/100 ml blood
Explanation:Normally, 100 ml of blood contains 15g haemoglobin and a single gram of haemoglobin can bind to 1.34 ml oxygen when 100% saturated. Thus, 15 × 1.34 = 20 ml O2/100 ml blood. The haemoglobin in venous blood that is leaving the tissues is about 75% saturated with oxygen, and hence it carries about 15 ml O2/100 ml venous blood. This implies that for each 10 ml of blood, 5 ml oxygen is transported to the tissues. With a p(O2) > 100 mm Hg, only 3 ml of oxygen is dissolved in every one litre of plasma. By increasing the pA(O2) by breathing 100% oxygen, one can add an extra amount of oxygen in the plasma, but the amount of oxygen carried by haemoglobin will not increase significantly as it is already > 95% saturated.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 16
Correct
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A 50 year old woman presented with excessive bleeding after an inguinal hernia repair. Labs are suggestive of a primary haemostasis defect. Deficiency of which of the following is most likely to cause it?
Your Answer: Platelets
Explanation:Primary haemostatic control means the first line of defence against immediate bleeding. This is carried out by the platelets. They immediately form a haemostatic plug at the site of injury. Coagulation starts within 20s after an injury to the blood vessel which damage the endothelial cells. Secondary haemostasis follows which includes activation of the coagulation factors to form fibrin strands which mesh together forming the platelet plug. Platelets interact with platelet collagen receptor, glycoprotein Ia/IIa and to collagen fibres in the vascular endothelium. This adhesion is mediated by von Willebrand factor (vWF), which forms links between the platelet glycoprotein Ib/IX/V and collagen fibrils. The platelets are then activated and release the contents of their granules into the plasma, in turn activating other platelets and white blood cells.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 17
Correct
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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 18
Correct
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A 13 year old girl presents to the clinic with weight loss and bloody diarrhoea. Examination of the abdomen is unremarkable. What is the most likely diagnosis?
Your Answer: Inflammatory bowel disease
Explanation:Answer: Inflammatory bowel disease
The inflammatory bowel diseases (IBDs), including ulcerative colitis and Crohn disease, are chronic inflammatory disorders of the gastrointestinal tract most often diagnosed in adolescence and young adulthood, with a rising incidence in paediatric populations. Inflammatory bowel disease is caused by a dysregulated mucosal immune response to the intestinal microflora in genetically predisposed hosts. Although children can present with the classic symptoms of weight loss, abdominal pain, and bloody diarrhoea, many present with nonclassical symptoms of isolated poor growth, anaemia, or other extraintestinal manifestations.
Colorectal Carcinoma (CRC) is rare in patients less than 20 years of age.
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This question is part of the following fields:
- Generic Surgical Topics
- Paediatric Surgery
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Question 19
Correct
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Chronic obstructive pulmonary disease (COPD) is likely to result in:
Your Answer: Respiratory acidosis
Explanation:COPD leads to respiratory acidosis (chronic). This occurs due to hypoventilation which involves multiple causes, such as poor responsiveness to hypoxia and hypercapnia, increased ventilation/perfusion mismatch leading to increased dead space ventilation and decreased diaphragm function.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 20
Correct
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In a hypertensive patient with secondary hyperaldosteronism, aldosterone is released mainly in response to:
Your Answer: Angiotensin II
Explanation:Secondary hyperaldosteronism in hypertension is either due to primary renin overproduction by the kidneys or renin overproduction secondary to decreased renal blood flow. The main stimulus for aldosterone release are adrenocorticotrophic hormone (ACTH), angiotensin II and high plasma K+ levels. Low plasma Na+ might also stimulate the adrenal cortex. Fluid overload will reduce aldosterone secretion. Atrial natriuretic peptide is secreted under conditions of expanded extracellular volume and will not lead to aldosterone secretion.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 21
Correct
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Cyclophosphamide is used as a chemotherapy and immunosuppressant agent and is indicated in various diseases. One of the most severe complications of its use is cancer of the:
Your Answer: Urinary bladder
Explanation:Cyclophosphamide is used to treat various types of cancer and autoimmune disorders. The main use of cyclophosphamide is in combination with other chemotherapy agents in the treatment of lymphomas, some forms of leukaemia and some solid tumours. Side-effects include nausea and vomiting, bone marrow suppression, stomach ache, diarrhoea, darkening of the skin
ails, alopecia, lethargy, and haemorrhagic cystitis. Cyclophosphamide is itself carcinogenic, potentially causing transitional cell carcinoma of the bladder as a long-term complication. -
This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 22
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 23
Correct
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A 28 year old teacher is readmitted following a difficult appendicectomy. On examination, her wound is erythematous and, on incision, foul smelling pus is drained. Which of the following organisms is responsible?
Your Answer: Bacteroides fragilis
Explanation:Bacteroides species are anaerobic bacteria that are predominant components of the bacterial florae of mucous membranes and are therefore a common cause of endogenous infections. Bacteroides infections can develop in all body sites, including the CNS, the head, the neck, the chest, the abdomen, the pelvis, the skin, and the soft tissues. Inadequate therapy against these anaerobic bacteria may lead to clinical failure.
These bacteria are resistant to penicillins, mostly through the production of beta-lactamase. Anaerobic bacteria can infect deep wounds, deep tissues, and internal organs where there is little oxygen. These infections are characterized by abscess formation, foul-smelling pus, and tissue destruction. Anaerobes outnumber aerobes by 1000:1 in the large intestine; thus, they play an important role in almost all intra-abdominal infections.
Secondary peritonitis and abdominal abscesses generally occur after entry of enteric organisms into the peritoneal cavity through perforation of the intestine or other viscus as a result of obstruction, infarction, or trauma.
Most visceral abscesses (e.g., hepatic), chronic cholecystitis, perforated and gangrenous appendicitis, postoperative wound infections and abscesses, diverticulitis, and any infection associated with faecal contamination of the abdominal cavity involve both aerobes and anaerobes.
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This question is part of the following fields:
- Clinical Microbiology
- Principles Of Surgery-in-General
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Question 24
Incorrect
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Renal function is an indication of the state of the kidney, measured by glomerular filtration rate (GFR). In a healthy person, GFR would be greatly increased by:
Your Answer: An increase in mean arterial pressure from 90 mmHg to 140 mmHg
Correct Answer: Substantial increases in renal blood flow
Explanation:An increase in the rate of renal blood flow (RBF) greatly increases the glomerular filtration rate (GFR). The more plasma available (from increased RBF), the more filtrate is formed. Glomerular filtration rate (GFR) is the volume of fluid filtered from the renal (kidney) glomerular capillaries into the Bowman’s capsule per unit time. Central to the physiologic maintenance of GFR is the differential basal tone of the afferent and efferent arterioles.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 25
Correct
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A 48-year-old woman has a mass in her right breast and has right axillary node involvement. She underwent radical mastectomy of her right breast. The histopathology report described the tumour to be 4 cm in its maximum diameter with four axillary lymph nodes with evidence of tumour. The most likely stage of cancer in this patient is:
Your Answer: IIB
Explanation:Stage IIB describes invasive breast cancer in which: the tumour is larger than 2 centimetres but no larger than 5 centimetres; small groups of breast cancer cells — larger than 0.2 millimetre but not larger than 2 millimetres — are found in the lymph nodes OR the tumour is larger than 2 centimetres but no larger than 5 centimetres; cancer has spread to 1 to 3 axillary lymph nodes or to lymph nodes near the breastbone (found during a sentinel node biopsy) OR the tumour is larger than 5 centimetres but has not spread to the axillary lymph nodes.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 26
Correct
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A 21-year-old woman presents with an episode of greenish discharge from the left nipple. Clinical examination of the breast is normal. Her breast USS report is U1 (normal). What should be the best course of action?
Your Answer: Reassure and discharge
Explanation:This is likely to be a case of simple duct ectasia. Normal USS report coupled with normal examination would favour discharge from the clinic. Mammography is generally not helpful in this age group.
Possible causes of nipple discharge include:
1. Abscess
2. Birth control pills
3. Breast cancer
4. Ductal carcinoma in situ (DCIS)
5. Endocrine disorders
6. Excessive breast stimulation
7. Fibrocystic breasts (lumpy or rope-like breast tissue)
8. Galactorrhoea
9. Injury or trauma to the breast
10. Intraductal papilloma (benign, wart-like growth in a milk duct)
11. Mammary duct ectasia
12. Mastitis (an infection in breast tissue that most commonly affects women who are breast-feeding)
13. Medication use
14. Menstrual cycle hormone changes
15. Paget’s disease of the breast
16. Periductal mastitis
17. Pregnancy and breast-feeding
18. ProlactinomaAssessment and management of non-malignant nipple discharge includes:
1. Exclude endocrine disease
2. Nipple cytology is not carried out as it would be unhelpful
3. Smoking cessation advice given for duct ectasia
4. Total duct excision may be warranted for duct ectasia with severe symptoms -
This question is part of the following fields:
- Breast And Endocrine Surgery
- Generic Surgical Topics
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Question 27
Correct
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What is the basic chemical reaction that takes place in the breakdown of complex foodstuffs?
Your Answer: Hydrolysis
Explanation:Breakdown of complex food into simpler compounds is achieved by hydrolysis, with the help of different enzymes specific for different compounds.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 28
Correct
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Which of these substances is secreted by pericytes in the juxtaglomerular cells?
Your Answer: Renin
Explanation:The juxtaglomerular cells synthesise, store and secrete the enzyme renin in the kidney. They are specialised smooth muscle cells in the wall of the afferent arteriole that delivers blood to the glomerulus and thus play a critical role in the renin– angiotensin system and so in renal autoregulation.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 29
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 30
Correct
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A 27-year-old woman has chronic low serum calcium levels. Which of the following conditions may be responsible for the hypocalcaemia in this patient?
Your Answer: Hypoparathyroidism
Explanation:Chronic hypocalcaemia is mostly seen in patients with hypoparathyroidism as a result of accidental removal or damage to parathyroid glands during thyroidectomy.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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SESSION STATS - PERFORMANCE PER SPECIALTY
