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Question 1
Incorrect
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Anthrax is an infection caused by the bacterium Bacillus anthracis. Anthrax spores have been used as a biological warfare weapon. What is the drug of choice in treating anthrax infection?
Your Answer: Clindamycin
Correct Answer: Ciprofloxacin
Explanation:Early antibiotic treatment of anthrax is essential. A delay may significantly lessen the chances for survival of the patient. Treatment for anthrax infection include large doses of intravenous and oral antibiotics, such as fluoroquinolones (ciprofloxacin), doxycycline, erythromycin, vancomycin, or penicillin.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 2
Correct
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A 26-year-old woman presents with right iliac fossa pain and history of some bloodstained vaginal discharge. On examination, she has diffuse lower abdominal tenderness and is afebrile with a heart rate of 97 bpm and blood pressure of 120/70 mmHg. Considering these signs and symptoms, what should be the most appropriate course of action?
Your Answer: Abdominal and pelvic USS
Explanation:The history of bloodstained vaginal discharge and lower abdominal tenderness makes ectopic pregnancy a strong possibility. Therefore, a pregnancy test (for beta hCG) and abdominal and pelvic USS should be performed. If the beta HCG is high, that is an indication for intrauterine pregnancy. If it is not, then an ectopic pregnancy is likely, and surgery should be considered.
Generally, the differential diagnosis of right iliac fossa (RIF) pain includes:
1. Appendicitis
2. Crohn’s disease
3. Mesenteric adenitis
4. Diverticulitis
5. Meckel’s diverticulitis
6. Perforated peptic ulcer
7. Incarcerated right inguinal or femoral hernia
8. Bowel perforation secondary to caecal or colon carcinoma
9. Gynaecological causes—pelvic inflammatory disease/salpingitis/pelvic abscess/ectopic pregnancy/ovarian torsion/threatened or complete abortion
10. Urological causes—ureteric colic/urinary tract infection/Testicular torsion
11. Other causes—tuberculosis/typhoid/ infection with herpes zoster -
This question is part of the following fields:
- Generic Surgical Topics
- The Abdomen
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Question 3
Incorrect
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A 24-year-old man presents with a six-day history of bloody diarrhoea along with passage of mucus. He has been defecating about eight to nine times per day. Digital rectal examination is carried out in which no discrete abnormality is felt. However, some blood-stained mucus is seen on the glove. What could be the most likely diagnosis?
Your Answer: Rectal cancer
Correct Answer: Ulcerative colitis
Explanation:Passage of bloody diarrhoea together with mucus and a short history makes this a likely presentation of inflammatory bowel disease. Rectal malignancy in a young age would be a very unlikely event. Furthermore, the history is too short to be consistent with solitary rectal ulcer syndrome.
Rectal bleeding is a common cause for patients to be referred to the surgical clinic. In the clinical history, it is important to try and localise the anatomical source of the bleeding. Bright red blood is usually of rectal origin, whereas, dark red blood is more suggestive of a proximally located bleeding source. Blood which has entered the gastrointestinal tract from a gastroduodenal source will typically resemble melaena due to the effects of the digestive enzymes on the blood itself.
PR bleeding in ulcerative colitis (UC) is usually bright red and often mixed with stool. It is mostly associated with the passage of mucus as well. Other clinical features reported on history include diarrhoea, weight loss, and nocturnal incontinence. Proctitis is the most marked finding on examination and perianal disease is usually absent. Colonoscopy is carried out which shows continuous mucosal lesions.
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This question is part of the following fields:
- Colorectal Surgery
- Generic Surgical Topics
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Question 4
Incorrect
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A 14 year old boy is taken to the emergency room after complaining of sudden onset of pain in the left hemiscrotum despite not having any other urinary symptoms. The superior pole of the testis is tender on examination and the cremasteric reflex is particularly marked. What would be the underlying diagnosis?
Your Answer: Epididymo-orchitis
Correct Answer: Torsion of a testicular hydatid
Explanation:Answer: Torsion of a testicular hydatid
The appendix testis (or hydatid of Morgagni) is a vestigial remnant of the Müllerian duct, present on the upper pole of the testis and attached to the tunica vaginalis. It is present about 90% of the time. The appendix of testis can, occasionally, undergo torsion (i.e. become twisted), causing acute one-sided testicular pain and may require surgical excision to achieve relief. One third of patients present with a palpable blue dot discoloration on the scrotum. This is nearly diagnostic of this condition. If clinical suspicion is high for the serious differential diagnosis of testicular torsion, a surgical exploration of the scrotum is warranted. Torsion of the appendix of testis occurs at ages 0-15 years, with a mean at 10 years, which is similar to that of testicular torsion.
Occasionally a torsion of the hydatid of Morgagni can produce symptoms mimicking those created by a testicular torsion; a torsion of the hydatid, however, does not lead to any impairment of testicular function.
Absence of the cremasteric reflex is a sign of testicular torsion. This therefore confirms that the diagnosis is Torsion of a testicular hydatid. -
This question is part of the following fields:
- Generic Surgical Topics
- Urology
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Question 5
Incorrect
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A 27-year-old HIV patient started on an antifungal agent. Which antifungal agent that inhibits the biosynthesis of fungal ergosterol was given to the patient?
Your Answer: B Flucytosine
Correct Answer: Ketoconazole
Explanation:Ketoconazole is a synthetic imidazole antifungal drug used primarily to treat fungal infections. It inhibits the biosynthesis of ergosterol by blocking demethylation at the C14 site of the ergosterol precursor. Amphotericin B and Nystatin impair permeability of the cell membrane. Flucytosine interferes with DNA synthesis, while the target of griseofulvin is the microtubules
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 6
Incorrect
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A 78-year-old woman was brought to the emergency department with decreased consciousness, weakness and dehydration. Which serum electrolyte would most likely be low in this patient?
Your Answer: PO4 −
Correct Answer: Na+
Explanation:Hyponatremia is a sodium level below 135 mEq/L. Signs and symptoms may include: nausea with vomiting, fatigue, headache or confusion, cramps or spasm, irritability and restlessness and severe cases may lead to seizures and comma.
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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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A 30 year old lawyer presented with a history of pleural effusions, pericarditis, arthralgia without joint deformity and episodes of myalgia for the past 12 months. Blood tests reveal a normocytic anaemia. Which of the following tests should be performed to investigate this condition further?
Your Answer: Antinuclear antibody test
Explanation:These non specific findings are suggestive of autoimmune disease. Antinuclear antibody (ANA) is the first test that should be performed when autoimmune diseases are suspected and later on more specific tests should be performed. This tests aids in the diagnosis of SLE, scleroderma, Sjogren’s syndrome, Raynaud’s disease, juvenile chronic arthritis, rheumatoid arthritis and antiphospholipid antibody syndrome etc. To confirm the disease a history, physical examination along with specific tests are required.
CPK is more specific for acute conditions.
ESR is a non specific test for inflammation. -
This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 8
Correct
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A CT-scan of the lung shows a tumour crossing the minor (horizontal) fissure. This fissure separates:
Your Answer: The middle lobe from the upper lobe
Explanation:The horizontal fissure separates the upper lobe from the middle lobe. The oblique fissure on the other hand separates the lower lobe from both the middle and upper lobes. The lingula is found only on the left lung.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 9
Incorrect
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A 29-year-old man with gunshot to the abdomen is transferred to the operating theatre, following his arrival in the A&E department. He is unstable and his FAST scan is positive. During the operation, extensive laceration to the right lobe of the liver and involvement of the IVC are found, along with massive haemorrhage. What should be the most appropriate approach to blood component therapy?
Your Answer: Use Factor VIII concentrates early
Correct Answer:
Explanation:There is strong evidence to support haemostatic resuscitation in the setting of massive haemorrhage due to trauma. This advocates the use of 1:1:1 ratio.
Uncontrolled haemorrhage accounts for up to 39% of all trauma-related deaths. In the UK, approximately 2% of all trauma patients need massive transfusion. Massive transfusion is defined as the replacement of a patient’s total blood volume in less than 24 hours or the acute administration of more than half the patient’s estimated blood volume per hour. During acute bleeding, the practice of haemostatic resuscitation has been shown to reduce mortality rates. It is based on the principle of transfusion of blood components in fixed ratios. For example, packed red cells, FFP, and platelets are administered in a ratio of 1:1:1.
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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 10
Incorrect
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A 25-year-old male is found to have a 5cm carcinoid tumour of the appendix. Imaging and diagnostic workup show no distant diseases. What is the best course of action?
Your Answer: Appendicectomy
Correct Answer: Right hemicolectomy
Explanation:Carcinoid tumours are of neuroendocrine origin and derived from primitive stem cells in the gut wall, especially the appendix.
Signs and symptoms of carcinoid tumours vary greatly. Carcinoid tumours can be non-functioning presenting as a tumour mass or functioning. The sign and symptoms of a non-functioning tumour depend on the tumour location and size as well as on the presence of metastases. Therefore, findings range from no tumour-related symptoms (most carcinoid tumours) to full symptoms of carcinoid syndrome (primarily in adults).
– Periodic abdominal pain: Most common presentation for a small intestinal carcinoid; often associated with malignant carcinoid syndrome
– Cutaneous flushing: Early and frequent (94%) symptom
– Diarrhoea and malabsorption (84%)
– Cardiac manifestations (60%): Valvular heart lesions, fibrosis of the endocardium; may lead to heart failure with tachycardia and hypertension
– Wheezing or asthma-like syndrome (25%)
– Pellagra
– Carcinoid crisis can be the most serious symptom of carcinoid tumours and can be life-threatening. It can occur suddenly, after stress, or following chemotherapy and anaesthesia.Two surgical procedures can be applied to treat appendiceal Neuroendocrine Neoplasm (NEN): simple appendicectomy and oncological right-sided hemicolectomy.
– For T1 (ENETS) or T1a (UICC/AJCC) NEN (i.e. <1 cm), generally simple appendicectomy is curative and sufficient.
– For NEN >2 cm with a T3 stage (ENETS) or higher and T2 (UICC/AJCC) or higher respectively, a right-sided hemicolectomy is advised due to the increased risk of lymph node metastasis and long-term tumour recurrence and/or distant metastasis. The right-sided hemico- lectomy should be performed either as the initial surgical intervention should the problem be overt at that time, or during a second intervention. -
This question is part of the following fields:
- Colorectal Surgery
- Generic Surgical Topics
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Question 11
Incorrect
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Calculate the cardiac output in an adult male with the following parameters: Heart rate 70 beats/min, Arterial [O2] 0.24 ml O2/min, Venous [O2] 0.16 ml O2/min, Whole body O2 consumption 500 ml/min, Pulmonary diastolic pressure 15 mmHg, Pulmonary systolic pressure 25 mmHg, Wedge pressure 5 mmHg.
Your Answer: 1.65 l/min
Correct Answer: 6.25 l/min
Explanation:As per Fick’s principle, VO2 = (CO × CAO2) – (CO × CVO2) where VO2 = oxygen consumption, CO = cardiac output, CAO2 = oxygen concentration of arterial blood and CVO2 = oxygen concentration of venous blood. Thus, CO = VO2/CAO2– CVO2, CO = 500/0.24 – 0.16, CO = 500/0.8, CO = 6.25 l/min.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 12
Incorrect
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A 37 year old woman presents to the clinic with signs of lymphoedema that has occurred after a block dissection of the groin for malignant melanoma several years ago. She has persistent lower limb swelling despite having used pressure stockings. This has impaired her daily life activities. Currently there is no evidence of a recurrent malignancy. Lymphoscintigraphy shows significant occlusion of the groin lymphatics. However, examination reveals the distal lymphatic system to be healthy. Which of the following options would be most helpful in this case?
Your Answer: Loop diuretic therapy long term
Correct Answer: Lymphovenous anastomosis
Explanation:Lymphovenous anastomosis – Identifiable lymphatics are anastomosed to sub dermal venules. Usually indicated in 2% of patients with proximal lymphatic obstruction and normal distal lymphatics.
Causes of lymphoedema:
Primary:
Sporadic, Milroy’s disease, Meige’s disease
Secondary:
Bacterial/fungal/parasitic infection (filariasis)
Lymphatic malignancy
Radiotherapy to lymph nodes
Surgical resection of lymph nodes
DVT
ThrombophlebitisOther options given:
Homans operation – Reduction procedure with preservation of overlying skin (which must be in good condition). Skin flaps are raised and the underlying tissue excised. Limb circumference typically reduced by a third.Charles operation – All skin and subcutaneous tissue around the calf are excised down to the deep fascia. Split skin grafts are placed over the site. May be performed if overlying skin is not in good condition. Larger reduction in size than with Homans procedure.
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This question is part of the following fields:
- Generic Surgical Topics
- Vascular
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Question 13
Correct
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The following branch of the aorta is unpaired:
Your Answer: Coeliac artery
Explanation:Branches that stem from the abdominal aorta can be divided into three: the visceral branches, parietal branches and terminal branches. Of the visceral branches, the suprarenal, renal, testicular and ovarian arteries are paired while the coeliac artery and superior and inferior mesenteric arteries are unpaired. Of the parietal branches the inferior phrenic and lumbar arteries are paired while the middle sacral artery is unpaired. The terminal branches i.e. the common iliac arteries are paired.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 14
Incorrect
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A 62 year old retired teacher is diagnosed as having a malignant lesion in the inferior aspect of her left breast. On examination, there is palpable axillary lymphadenopathy. Which of the following is the best course of action?
Your Answer: Mastectomy and axillary node clearance
Correct Answer: Image guided fine needle aspiration of the axillary nodes
Explanation:Fine-needle aspiration (FNA) cytology of axillary lymph nodes is a simple, minimally invasive technique that can be used to improve preoperative determination of the status of the axillary lymph nodes in patients with breast cancer, thereby serving as a tool with which to triage patients for sentinel versus full lymph node dissection procedures. FNA of axillary lymph nodes is a sensitive and very specific method with which to detect metastasis in breast cancer patients. Because of its excellent positive predictive value, full axillary lymph node dissection can be planned safely instead of a sentinel lymph node dissection when a preoperative positive FNA result is rendered.
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This question is part of the following fields:
- Breast And Endocrine Surgery
- Generic Surgical Topics
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Question 15
Incorrect
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Which of the following cytokines produced by the T cell induce MHC-II proteins?
Your Answer: Tumour necrosis factor
Correct Answer: γ-Interferon
Explanation:Interferons elicit a non-specific antiviral activity by inducing specific RNA synthesis and expression of proteins in neighbouring cells. Common interferon inducers are viruses, double-stranded RNA and micro-organisms. INF-γ is produced mainly by CD4+, CD8+ T cells and less commonly by B cells and natural killer cells. INF-γ has antiviral and antiparasitic activity but its main biological activity appears to be immunomodulatory. Among its many functions are activation of macrophages and enhanced expression of MHC-II proteins or macrophages.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 16
Incorrect
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Urine specific gravity allows the assessment of which of the following renal functions?
Your Answer: Secretion
Correct Answer: Concentration
Explanation:Concentrating ability of kidneys is assessed by measuring the urine specific gravity. Normal values of urine specific gravity fall between 1.002 and 1.030 g/ml.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 17
Incorrect
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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: Neurocranium and the periosteal layer of the dura mater
Correct 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 18
Incorrect
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A patient with testicular seminoma has the following tumour markers: LDH 1.3 times the reference levels, β-hCG 4500 mIU/ml and AFP 875 ng/ml. What's the serum tumour marker stage in this case?
Your Answer: S0
Correct Answer: S1
Explanation:According to AJCC guidelines, the serum tumour marker staging is the following:
S0: marker studies within normal limits
S1: lactate dehydrogenase (LDH) less than 1.5 times the reference range, beta-human chorionic gonadotrophin (β-hCG) <5000 mIU/ml, and alpha-fetoprotein (AFP) <1000 ng/ml
S2: LDH 1.5–10 times the reference range, β-hCG 5000–50,000 mIU/ml or AFP 1000–10,000 ng/ml
S3: LDH greater than 10 times the reference range, β-hCG >50,000 mIU/ml or AFP >10,000 ng/ml.
According to this, the patient’s tumour belongs to the S1 stage. -
This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 19
Incorrect
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A 40-year old gentleman, who is a known with ulcerative colitis, complains of recent-onset of itching and fatigue. On examination, his serum alkaline phosphatase level was found to be high. Barium radiography of the biliary tract showed a 'beaded' appearance. What is the likely diagnosis?
Your Answer: Cholesterosis
Correct Answer: Sclerosing cholangitis
Explanation:Primary sclerosing cholangitis is characterised by patchy inflammation, fibrosis and strictures in intra- and extra-hepatic bile ducts. It is a chronic cholestatic condition with 80% patients having associated inflammatory bowel disease (likely to be ulcerative colitis). Symptoms include pruritus and fatigue. ERCP (endoscopic retrograde cholangiopancreatography) or MRCP (magnetic resonance cholangiopancreatography) are diagnostic. Disease can lead to complete obliteration of ducts, which can result in liver failure. Cholangiocarcinoma is also a recognised complication..
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 20
Incorrect
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A 1 week old baby boy is taken to the A&E department after a right sided groin swelling had been noticed. An examination is done and the testes are correctly located but there is a right sided inguinal hernia that is soft and easily reduced. Which of the following is the most appropriate management?
Your Answer: Reassure and discharge
Correct Answer: Surgery over the next few days
Explanation:Answer: Surgery over the next few days
Inguinal hernia is a type of ventral hernia that occurs when an intra-abdominal structure, such as bowel or omentum, protrudes through a defect in the abdominal wall. Inguinal hernias do not spontaneously heal and must be surgically repaired because of the ever-present risk of incarceration. Generally, a surgical consultation should be made at the time of diagnosis, and repair (on an elective basis) should be performed very soon after the diagnosis is confirmed.
The infant or child with an inguinal hernia generally presents with an obvious bulge at the internal or external ring or within the scrotum. The parents typically provide the history of a visible swelling or bulge, commonly intermittent, in the inguinoscrotal region in boys and inguinolabial region in girls.
The swelling may or may not be associated with any pain or discomfort. -
This question is part of the following fields:
- Generic Surgical Topics
- Paediatric Surgery
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Question 21
Incorrect
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A 54 year old man fell off his bicycle. He felt a severe pain in his hand and wasn't able to move it. It was found that a carpal bone in the distal row was fractured. Which is the most likely bone?
Your Answer: Pisiform
Correct Answer: Trapezium
Explanation:There are eight carpal bones which are arranged in two rows, proximal and distal; scaphoid, lunate, triquetral and pisiform are of proximal row. Trapezium, trapezoid, capitate and hamate are of the distal row.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 22
Correct
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Which of the following is the source of blood supply to the artery of the round ligament at the head of the femur?
Your Answer: Obturator artery
Explanation:The posterior branch of the obturator artery provides an articular branch to the head of the femur.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 23
Incorrect
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A 16 year old girl fractured a bone in her left foot. Upon examination the clinician discovered that the fracture affected the insertion of the peroneus brevis muscle. Which of the following bones was most likely affected?
Your Answer: Base of the first metatarsal
Correct Answer: Base of the fifth metatarsal
Explanation:The peroneus brevis muscle originates from the lower two-thirds of the lateral body of the fibula and has inserts at the base of the fifth metatarsal. Fractures to this bone are common and can be due to infection, trauma, overuse and repetitive use.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 24
Incorrect
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A 40-year old woman with portal hypertension has impaired venous drainage of the anal canal above the pectinate line. Thus, there might be an increase in blood flow downward to the systemic venous system via anastomoses with the inferior rectal vein. This is a tributary of?
Your Answer: External iliac vein
Correct Answer: Internal pudendal vein
Explanation:The inferior rectal vein drains into the internal pudendal vein. In addition the external iliac vein is one of the two branches of the common iliac vein however the internal iliac vein and it’s tributaries (including the pudendal vein) are much more important in draining the pelvic structures.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 25
Correct
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Which of the following will show decreased hearing when tested by air conduction but normal hearing when tested by bone conduction?
Your Answer: Fibrosis causing fixation of the ossicles
Explanation:As the cochlea is embedded into bone, the vibrations from the bone are transmitted directly to the fluid in the cochlea. Hence, any damage to the ossicles or tympanic membrane will not show an abnormal result on bone conduction test.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 26
Incorrect
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What will the destruction of endoplasmic reticulum stop?
Your Answer: Glycosylation of protein and carbohydrate moieties
Correct 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 27
Correct
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A 20-year old boy presented with low grade fever, night sweats and weakness over two months. On examination, he had multiple, non-tender, cervical, supraclavicular and axillary adenopathy. Microscopy of lymph node biopsy showed the presence of Reed-Sternberg cells. He is likely suffering from:
Your Answer: Hodgkin’s lymphoma
Explanation:Hodgkin’s lymphoma is a disease characterized by malignant proliferation of cells of the lymphoreticular system. It can be localized or disseminated, and can involve the nodes, spleen, liver and marrow. Symptoms of the disease include non-tender lymphadenopathy, fever, night sweats, weight loss, itching and hepatosplenomegaly. Histologically, the involved nodes show the presence of Reed-Sternberg cells, which are large, binucleated cells, in a heterogenous cellular infiltrate of histiocytes, lymphocytes, monocytes, plasma cells and eosinophils.
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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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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/μL. Which of the following organisms is most likely to be responsible?
Your Answer: Clostridium difficle
Correct 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 180–200/μL may be asymptomatic or develop self-limiting diarrhoeal illness. However, patients with advanced AIDS (CD4 cell counts <50/μL) 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 29
Incorrect
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An old man was diagnosed with squamous cell carcinoma with axillary lymph node metastasis. The doctor said he will excise the tumour and remove all axillary lymph nodes medial to the edge of the pectoralis minor muscle. One of the following axillary lymph nodes won't be removed by this procedure. Which is it?
Your Answer: Central
Correct Answer: Apical
Explanation:The apical lymph node group won’t be removed which include 20 to 30 lymph nodes. They are grouped according to location. The lateral group, the anterior to pectoral group, the posterior or subscapular group, the central group, and the medial or apical group. The lateral, pectoral, and subscapular groups are found lateral to the pectoralis minor muscle. The central group is situated directly under that muscle. Thus, if all lymph nodes lateral to the medial edge of the pectoralis minor muscle are removed, all the above four groups will be removed. The apical group won’t be removed which is situated medial to the medial edge of the pectoralis minor muscle.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 30
Incorrect
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A 32-year-old woman is vomiting persistently following a laparoscopic appendicectomy for a perforated gangrenous appendicitis. Imaging shows some dilated small bowel loops. What should be the most appropriate course of action?
Your Answer: Arrange a laparotomy
Correct Answer: Insertion of wide bore nasogastric tube
Explanation:This patient is likely to have paralytic ileus and the administration of antiemetic drugs, in this situation, will have no effect. It is, therefore, important to decompress the stomach with a wide bore nasogastric tube.
Paralytic ileus is the obstruction of the intestine due to paralysis of the intestinal muscles. It commonly occurs after an abdominal surgery. Irrespective of the cause, paralytic ileus causes constipation, abdominal distention, nausea, and vomiting. It is a severe condition because if left untreated, an ileus can cut off blood supply to the intestines and cause tissue death.
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This question is part of the following fields:
- Generic Surgical Topics
- The Abdomen
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Question 31
Incorrect
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During a splenectomy procedure of a 45-year old male patient with a bleeding ruptured spleen, the surgeon decided to clamp the splenic artery near the coeliac trunk to stop the bleeding. Which of the following organ/s parts will be least affected by the clamping?
Your Answer: Greater curvature of the stomach
Correct Answer: Duodenum
Explanation:The duodenum is the only organ in the list that would not be affect by the clumping of the splenic artery as it is supplied by common hepatic artery (through the gastroduodenal artery) and the superior mesenteric artery (through the inferior pancreaticoduodenal artery). The splenic artery is the artery that supplies the spleen with oxygenated blood. The splenic artery before reaching the spleen also gives off branches that supply the stomach and the pancreas. The greater curvature and the fundus of the stomach is supplied the short gastric artery which branches off from the splenic artery. The left portion of the greater curvature of the stomach together with the greater omentum is supplied by the left gastro-omental artery of the splenic artery. The body and tail of the pancreas is supplied by branches of the splenic artery through the dorsal and superior pancreatic arteries and the caudal pancreatic arteries respectively.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 32
Incorrect
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A 6 week old preterm infant is scheduled for an inguinal hernia repair. Which of the following fluids should be ideally administered to him while he is on NPO?
Your Answer: Hartmann's solution
Correct Answer: 10% dextrose
Explanation:There is a substantial risk of hypoglycaemia in neonates following surgery, therefore 10% dextrose should be administered to them to avoid the complications associated with hypoglycaemia.
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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 33
Correct
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Perforin are present in the granules of which cell?
Your Answer: Natural killer cell
Explanation:Perforins are characteristically found In the granules of CD8+ T cells and natural killer cells. They are cytolytic proteins that insert into the target plasma membrane forming a hole and resulting in lysis. They along with granzyme B induce apoptosis in the target cell.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 34
Incorrect
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A 30-year-old man who is a known case of hepatitis C presents with pain and swelling in the right groin. On examination, a large, pulsatile swelling is noted in the right groin. There is no cough impulse. What is the most likely diagnosis?
Your Answer: True aneurysm of the femoral artery
Correct Answer: False aneurysm of the femoral artery
Explanation:Based on the history and examination findings, the correct diagnosis is false aneurysm of the femoral artery. It may occur following arterial trauma in intravenous drug users.
A false aneurysm, or pseudoaneurysm of the vessels, occurs when a blood vessel wall is injured and the leaking blood collects in the surrounding tissue. It is not an enlargement of any of the layers of the vessel wall. Pseudoaneurysms usually present as a painful, tender, pulsatile mass. Diagnostic options include duplex scan, and CT angiogram or a conventional angiogram.
In a true aneurysm, the artery or vessel weakens and bulges, usually forming a blood-filled sac.
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This question is part of the following fields:
- Generic Surgical Topics
- Vascular
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Question 35
Incorrect
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Which nerve lies immediately medial to the psoas major muscle?
Your Answer: Coccygeal
Correct Answer: Obturator
Explanation:The obturator nerve is formed from the ventral divisions of the 2nd, 3rd and 4th lumbar nerves. It courses through the fibres of the psoas major and emerges from the medial border near the pelvic brim.
The iliohypogastric nerve comes from the first lumbar nerve and emerges from the upper part of the lateral border of psoas major.
The ilioinguinal nerve arises with the iliohypogastric nerve from the first lumbar nerve and also emerges from the lateral border of the psoas major muscle.
The lateral femoral cutaneous nerve comes from the posterior division of the 2nd and 3rd lumbar nerves to emerge from the lateral border of the psoas major muscle near its middle.
The femoral nerve also arises from the dorsal divisions, but of the 2nd, 3rd and 4th lumbar nerves and courses through the muscle fibres to emerge at the lower part of the lateral border.
The coccygeal nerve doesn’t arise from the lumbar plexus but from the sacral plexus. -
This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 36
Incorrect
-
During an operation to repair an aortic coarctation in a neonate, a surgeon accidentally cuts the first aortic intercostal arteries as he mobilised the descending aorta. Which one of the following structure might be deprived of its primary source of blood supply following this injury?
Your Answer: First anterior intercostal space
Correct Answer: Right bronchus
Explanation:The right bronchus is supplied by one right bronchial artery that may branch from one of the left bronchial arteries or from the right 3rd posterior intercostal artery (this is the first intercostal artery that arises from the aorta). Damage to this artery might stop blood supply to the main bronchus. Intercostal arteries that go to the first and the second interspaces originate from the highest intercostal artery such that blood supply to either of these spaces would not be interfered with.
The left bronchus receives blood from 2 left bronchial arteries which are direct branches from the descending aorta.
Fibrous pericardium is the sac that contains the heart. Its blood supply is not a major concern.
Visceral pericardium receives its blood supply from the coronary vessels. -
This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 37
Incorrect
-
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: Use of suction drains in the abdominal wall
Correct 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 38
Incorrect
-
A 33-year old lady presented to the gynaecology clinic with amenorrhoea for 6 months and a recent-onset of milk discharge from her breasts. She was not pregnant or on any medication. On enquiry, she admitted to having frequent headaches the last 4 months. Which of the following findings would you expect to see in her condition?
Your Answer: Lack of growth hormone suppression
Correct Answer: Hyperprolactinaemia
Explanation:Excessively high levels of prolactin in the blood is called hyperprolactinaemia. Normally, prolactin levels are less than 580 mIU/l in females and less than 450 mIU/l in men. The biologically inactive macroprolactin can lead to a false high reading. However, the patient remains asymptomatic. Dopamine down-regulates prolactin whereas oestrogen upregulates it. Hyperprolactinaemia can be caused due to lack of inhibition (compression of pituitary stalk or low dopamine levels), or increased production due to a pituitary adenoma (prolactinoma). Either of these causes can lead to a prolactin level of 1000-5000 mIU/l. However, levels more than 5000mIU/l are usually associated due to an adenoma and >100,000 mIU/l are seen in macroadenomas (tumours < 1cm in diameter). Increased prolactin causes increased dopamine release from the arcuate nucleus of hypothalamus. This increased dopamine in turn, inhibits the GnRH (Gonadotrophin Releasing Hormone) thus blocking gonadal steroidogenesis resulting in the symptoms of hyperprolactinaemia. In women, it includes hypoestrogenism, anovulatory infertility, decreased or irregular menstruation or complete amenorrhoea. It can even cause production of breast milk, loss of libido, vaginal dryness and osteoporosis. In men, the symptoms include impotence, decreased libido, erectile dysfunction and infertility. In men, treatment can be delayed due to late diagnosis as they have no reliable indicator such as menstruation that might indicate a problem. Most of the male patients seek help only when headaches and visual defects start to surface.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 39
Incorrect
-
A 60-year-old female has sudden onset of high-grade fever associated with cough with productive rusty-coloured sputum. Chest x-ray showed left-sided consolidation. What is the most accurate test for the diagnosis of this patient?
Your Answer: Blood culture
Correct Answer: Sputum culture
Explanation:Sputum culture is used to detect and identify the organism that are infecting the lungs or breathing passages.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 40
Incorrect
-
A 63 year old woman reports colicky abdominal pain and foul smelling diarrhoea on the 4th day following a cholecystectomy for acute cholecystitis. Her surgery was complicated as the gallbladder spilled stones intraoperatively. She has been on ciprofloxacin therapy ever since her surgery. Which of the following organisms is most likely responsible for her symptoms?
Your Answer: Campylobacter
Correct Answer: Clostridium difficile
Explanation:Clostridioides difficile (C. difficile; formerly known as Clostridium difficile) is a gram-positive rod-shaped bacillus that is commonly involved in antibiotic-associated diarrhoea. As the bacterial spores are difficult to eradicate and easily transmitted (via faecal-oral transmission), the C. difficile infection rate is particularly high among hospitalized patients and residents in long-term care facilities.
Colonization with C. difficile occurs following antibiotic treatment of other diseases, as the bacteria is particularly resistant to antibiotics. The resulting damage to the intestinal flora promotes infection, which may be accompanied by high fever, abdominal pain, and characteristically foul-smelling diarrhoea. The most severe form of C. difficile infection is pseudomembranous colitis, which may lead to ileus, sepsis, and toxic megacolon. In most cases, however, colonization results in asymptomatic carriage rather than symptomatic infection.
Diagnosis is usually made via detection of the C. difficile toxin and/or corresponding genes in stool samples. C. difficile infections are treated with oral vancomycin or oral fidaxomicin. Following diagnosis, strict adherence to hygiene measures and patient isolation is essential, especially in hospitals and other healthcare settings. -
This question is part of the following fields:
- Clinical Microbiology
- Principles Of Surgery-in-General
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Question 41
Correct
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T lymphocytes that express the MCH type II antigen are most likely to produce which of the following cytokines?
Your Answer: Gamma interferon
Explanation:Interferon gamma is a soluble cytokine previously known as the macrophage activating factor. It is the only member belonging to the type II class of the interferons. It is secreted by a number of cells taking part in the immune reaction including: T-helper cells (CD-4), cells with immunological memory (CD45PA), killer cells (CD8), dendrite cells (CD23,35), natural killer cells (CD16) and B lymphocytes (CD22,CD23). It has both a defending as well as a pathological effect. It induces differentiation in the myeloid cell in the bone marrow. If macrophages are infected by parasites it activates the macrophages to destroy them. IFN-γ strengthens the anti-tumour activities of the cytotoxic lymphocytes. Together with CD4 or CD8 toxins, produced by lymphocytes, it suppresses the growth of the tumour cells. along with these functions it increases the non specific response of the natural killer cells, causing changes in the cell membrane surface to prevent adhesion and penetration of a virus. It can either increase or decrease B cell response and it activates osteoclasts which increases bone resorption.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 42
Incorrect
-
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 suction 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 43
Correct
-
Inside the palatoglossal arch is a muscle. Which nerve innervates this muscle?
Your Answer: X
Explanation:The palatoglossal arch contains the palatoglossal muscle which is innervated by the vagus nerve which is the tenth cranial nerve. So the correct answer is X
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 44
Incorrect
-
A 9 year old boy is admitted with right iliac fossa pain and an appendicectomy is to be performed.Which of the following incision is the best for this procedure?
Your Answer: Midline abdominal
Correct Answer: Lanz
Explanation:Answer: Lanz
The Lanz and Gridiron incisions are two incisions that can be used to access the appendix, predominantly for appendectomy.
Both incisions are made at McBurney’s point (two-thirds from the umbilicus to the anterior superior iliac spine). They involve passing through all of the abdominal muscles, transversalis fascia, and then the peritoneum, before entering the abdominal cavity.
The Lanz incision is a transverse incision, whilst the Gridiron incision is oblique (superolateral to inferomedial). Due to its continuation with Langer’s lines, the Lanz incision produces much more aesthetically pleasing results with reduced scarring.
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This question is part of the following fields:
- Generic Surgical Topics
- The Abdomen
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Question 45
Incorrect
-
The circle of Willis is one of the cerebrovascular safeguards comprised of the left and the right posterior communicating artery. Which of the following arteries in the brain is connected to the posterior cerebral artery by these posterior communicating arteries?
Your Answer: Anterior communicating artery
Correct Answer: Internal carotid artery
Explanation:The Circle of Willis is an anastomosis of cerebral arteries that are located at the base of the brain. The Circle of Willis is one of the important safeguards that ensure back up of blood supply to parts of the brain in case of any cerebrovascular accident. The Circle of Willis is made up of an anterior portion of arteries including; the anterior cerebral arteries. The anterior cerebral arteries are connected to the posterior portion of the circle of Willis by the anterior communicating artery. The posterior portion is made up of the posterior cerebral artery which branch off from the basilar artery. The posterior cerebral artery are connected to the anterior portion of the circle of Willis by the posterior communicating artery. The posterior communicating artery connects the posterior cerebral artery to the internal carotid artery. The circle of Willis receives blood supply from the left and right internal carotid arteries that continues as the middle cerebral artery and posteriorly from the two vertebral arteries that join to form the basilar artery.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 46
Correct
-
A 63 year old man presents with recurrent colicky abdominal pain. A CT scan demonstrates a hernia lateral to the rectus muscle at the level of the arcuate line. What type of hernia would this be classified as?
Your Answer: Spigelian
Explanation:A Spigelian hernia (or lateral ventral hernia) is a hernia through the Spigelian fascia, which is the aponeurotic layer between the rectus abdominis muscle medially, and the semilunar line laterally. These are generally interparietal hernias, meaning that they do not lie below the subcutaneous fat but penetrate between the muscles of the abdominal wall; therefore, there is often no notable swelling.
Spigelian hernias are usually small and therefore risk of strangulation is high. Most occur on the right side. (4th–7th decade of life.) Compared to other types of hernias they are rare.
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This question is part of the following fields:
- Generic Surgical Topics
- The Abdomen
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Question 47
Incorrect
-
A 30-year-old female was alarmed when she started to experience hair loss and balding, however, she also noted increased hair on her face and body and developed an acne breakout. Deepening of her voice also became prominent. She was referred to an oncologist and was diagnosed with a hormone-producing tumour. What is the most likely diagnosis ?
Your Answer: Seminoma
Correct Answer: Arrhenoblastoma
Explanation:Arrhenoblastoma, known as ‘Sertoli–Leydig tumour’ is a rare ovarian stromal neoplasm that secretes testosterone. It is mostly seen in women in the reproductive years. The key clinical features of this tumour is due to excessive production of testosterone which leads to progressive masculinisation in a woman who was typical normal beforehand. The lesion tends to grow slowly and rarely metastasises. Treatment is surgical removal of the tumour and the prognosis is generally good.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 48
Incorrect
-
Hormones of the anterior pituitary include which of the following?
Your Answer: Vasopressin
Correct 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 49
Incorrect
-
Which of the following mediators of inflammation requires arachidonic acid for synthesis?
Your Answer: Interleukin-1
Correct Answer: Prostaglandins
Explanation:Arachidonic acid is normally present in the phospholipids that make up the cell membrane and is cleaved by phospholipase A2 from the phospholipid. Arachidonic acid is a precursor for the production of eicosanoids which include: 1) prostaglandins, prostacyclins and thromboxane, 2) leukotrienes and 3) anandamides. The production of these products along with their action on the body is called the arachidonic acid cascade.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 50
Incorrect
-
Which among the following vertebrae marks the lowest extent of the superior mediastinum?
Your Answer: Third thoracic
Correct Answer: Fourth thoracic
Explanation:The superior mediastinum lies between the manubrium anteriorly and the upper vertebrae of the thorax posteriorly. Below, it is bound by a slightly oblique plane that passes backward from the sternal angle to the lower part of the body of T4 and laterally by the pleura.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 51
Incorrect
-
A patient who complained of pain on the lower left side of the back had an x-ray done which confirmed a hernia passing posterolaterally, just superior to the iliac crest. Where is this hernia passing through?
Your Answer: Triangle of Calot
Correct Answer: Lumbar triangle
Explanation:The lumber triangle is bound medially by the border of the latissimus dorsi, laterally by the external abdominal oblique and by the iliac crest inferiorly. This is exactly where the hernia that is described is located.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 52
Incorrect
-
What is correct regarding the obturator artery?
Your Answer: It enters the thigh immediately deep to the inguinal ligament
Correct Answer: It is found in the medial compartment of the thigh
Explanation:The obturator artery is a branch of the internal iliac artery, which passes antero-inferiorly on the lateral wall of the pelvis, to the upper part of the obturator foramen. The posterior branch follows the posterior margin of the foramen and turns forward on the inferior ramus of the ischium. It also supplies an articular branch, which enters the hip joint through the acetabular notch, sending a branch along the ligamentum teres to the head of the femur. It is the main source of arterial supply to the medial compartment of the thigh
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 53
Incorrect
-
A 60 year-old patient being treated for hypertension presents to the ED with swelling of the left upper limb due to poor venous return. On examination, it is found that an aneurysm of the ascending aorta is impinging on a large vein lying immediately anterosuperior to it. Which vein is it likely to be?
Your Answer: Left superior intercostal
Correct Answer: Left brachiocephalic
Explanation:Among the veins listed, only the left brachiocephalic vein is anterosuperior to the ascending aorta. The right brachiocephalic vein being on the right side would not be affected by the aortic aneurysm.
The azygos vein lies deep in the chest on the right side.
The internal thoracic vein lies interior to the anterior wall of the chest.
The left superior intercostal vein is close to the aortic arch, crossing it laterally. This vein drains the 2nd to 4th interspaces on the left side.
The Right internal jugular vein joins the right brachiocephalic vein which would not be affected by the aneurysm. -
This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 54
Incorrect
-
A 14-year old girl presented with a 2cm, mobile, cystic mass in the midline of her neck. Fine needle aspiration of the mass revealed clear fluid. This is most likely a case of:
Your Answer: Lymph node metastasis of follicular carcinoma
Correct Answer: Thyroglossal duct cyst
Explanation:Thyroglossal cyst is the most common congenital thyroid anomaly which is clinically significant and affects women more than men. It is a vestigial remnant of developing thyroid. Although the thyroglossal cyst can develop anywhere along the thyroglossal duct, the most common site is in the midline between the isthmus of thyroid and hyoid bone, or just above the hyoid. Thyroglossal cysts are also associated with ectopic thyroid tissue. Clinically, the cyst moves upward with protrusion of the tongue. Rarely, the persistent duct can become malignant (thyroglossal duct carcinoma) where the cancerous cells arise in the ectopic thyroid tissue that are deposited along the duct. Exposure to radiation is a predisposing factor.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 55
Incorrect
-
A 59 year old woman presents to the hospital with a 2.1cm mobile breast mass. A mammogram is indeterminate (M3), an ultrasound scan shows benign changes (U2), and clinical examination is also indeterminate (P3). What is the next best course of action?
Your Answer: Re-assure and discharge
Correct Answer: Image guided core biopsy
Explanation:Image guided core biopsy (US-directed biopsy) is performed for lesions that are palpable, but also for non-palpable, mammogram-detected lesions with a corresponding abnormality visualized on US. US-guided core biopsy is technically easier than stereotactic-guided biopsy as real-time imaging allows the surgeon to visualize the biopsy as it occurs. Using sterile technique and local anaesthesia, a small puncture is made with an 11-knife blade and the needle is placed near the edge of the lesion and fired, which inserts it into the lesion for a sample to be retrieved. When placed parallel to the needle the position of the needle can be visualized on US.
If the core biopsy result is benign and is concordant with imaging findings, continued surveillance is acceptable. If the result is indeterminate or image-discordant, surgical excision is indicated to rule out malignancy. In order to determine the appropriate management and surveillance of a lesion, the histologic, imaging, and clinical findings must be taken into account for an assessment of concordance to be performed. In addition, surgical excision is indicated for a core biopsy that demonstrates atypical hyperplasia (lobular or ductal) or lobular carcinoma in situ or neoplasia as the incidence of coexisting ductal carcinoma in situ or invasive carcinoma may be as high as 30% due to potential sampling error.
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This question is part of the following fields:
- Breast And Endocrine Surgery
- Generic Surgical Topics
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Question 56
Incorrect
-
A 30-year-old female undergoes a renal transplant for focal segmental glomerulosclerosis. Within hours of the operation, the patient becomes unwell with features consistent with severe systemic inflammatory response syndrome. The patient is immediately taken back to the theatre and the transplanted kidney is removed. What type of immunoglobulins is responsible for graft rejection?
Your Answer: IgM
Correct Answer: IgG
Explanation:Rejection is related primarily to activation of T cells, which, in turn, stimulate specific antibodies against the graft. Various clinical syndromes of rejection can be correlated with the length of time after transplantation.
Hyperacute rejection
Hyperacute rejection of the renal allograft happens in the operating room within hours of the transplant, when the graft becomes mottled and cyanotic. This type of rejection is due to unrecognized compatibility of blood groups A, AB, B, and O (ABO) or to a positive T-cell crossmatch (class I human leukocyte antigen [HLA] incompatibility).
It is thought that IgG antibodies from the host bind to HLA-1 antigen of the donated organ.
No treatment exists, and nephrectomy is indicated.Acute rejection
Acute rejection appears within the first 6 months after transplantation and affects approximately 15% of transplanted kidneys. Rejection is secondary to prior sensitization to donor alloantigens (occult T-cell crossmatch) or a positive B-cell crossmatch.
Acute tubular interstitial cellular rejection is the most common type of rejection reaction, with an incidence of approximately 20-25%. Typically, it occurs between 1 and 3 months after transplantation. It is T-cell mediated, and injury is directed to the renal tubules. The standard for diagnosis is renal allograft biopsy. Mild rejections may be successfully reversed with corticosteroids alone, whereas moderate or severe rejections may require the use of anti–T-cell antibodies, either polyclonal or monoclonal.
Late acute rejection is strongly correlated with the scheduled withdrawal of immunosuppressive therapy 6 months after transplantation.Chronic rejection
Chronic rejection occurs more than 1 year after transplantation and is a major cause of allograft loss. It is a slow and progressive deterioration in renal function characterized by histologic changes involving the renal tubules, capillaries, and interstitium. Its precise mechanism is poorly defined and is an area of intense study. Diagnosis is by renal biopsy, and treatment depends on the identified cause if any. Application of conventional antirejection agents (e.g., corticosteroids or anti–T-cell antibodies) does not appear to alter the progressive course. -
This question is part of the following fields:
- Generic Surgical Topics
- Organ Transplantation
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Question 57
Incorrect
-
A 46 year old politician with chronic hepatitis for several years visits the clinic for a review. Recently, his AFP is noted to be increased and an abdominal ultrasound demonstrates a 2.2cm lesion in segment V of the liver. What is the most appropriate course of action?
Your Answer: USS guided liver biopsy
Correct Answer: Liver MRI
Explanation:In patients with liver tumours, it is crucial to detect and stage the tumours at an early stage (to select patients who will benefit from curative liver resection, and avoid unnecessary surgery). Therefore, an optimal preoperative evaluation of the liver is necessary, and a contrast-enhanced MRI is widely considered the state-of-the-art method. Liver MRI without contrast administration is appropriate for cholelithiasis but not sufficient for most liver tumour diagnoses.
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This question is part of the following fields:
- Generic Surgical Topics
- Hepatobiliary And Pancreatic Surgery
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Question 58
Correct
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Normally, the O2 transfer in the lungs from alveolar to capillary is perfusion-limited. In which of the following situations does it become a diffusion-limited process?
Your Answer: Pulmonary oedema
Explanation:Normally, the transfer of oxygen from air spaces to blood takes place across the alveolar-capillary membrane by simple diffusion and depends entirely on the amount of blood flow (perfusion-limited process). Diseases that affect this diffusion will transform the normal process to a diffusion limited process. Thus, the diseases which cause a thickened barrier (such as pulmonary oedema due to increased extravascular lung water or asbestosis) will limit the diffusion of oxygen. Chronic obstructive lung diseases will have little effect on diffusion. Inhaling hyperbaric gas mixtures might overcome the diffusion limitation in patients with mild asbestosis or interstitial oedema, by increasing the driving force. Strenuous (not mild) exercise might also favour diffusion limitation and decrease passage time. Increasing the rate of ventilation will not have this affect but will only maintain a high oxygen gradient from air to blood.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 59
Incorrect
-
A 47 year-old woman was admitted for elective cholecystectomy, with a past history of easy bruising and heavy menstrual periods. The patient was also diagnosed with Willebrand's disease. Willebrand's disease is:
Your Answer: Y-linked
Correct Answer: Autosomal dominant
Explanation:von Willebrand disease is an autosomal dominant disorder marked by the deficiency of vWF, a large protein synthesized by the endothelial cells and megakaryocytes. It mediates adhesion of platelets to the subendothelium at site of vascular injury. Disease characteristics include impaired platelet adhesion, prolonged bleeding time and a functional deficiency of factor VIII (vWF is its carrier protein).
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 60
Correct
-
A 34 year old man is suffering from septic shock and receives an infusion of Dextran 70. Which of the following complications may potentially ensue?
Your Answer: Anaphylaxis
Explanation:Dextran 40 and 70 have a higher rate of causing anaphylaxis than either gelatins or starches.
Dextrans are branched polysaccharide molecules, with dextran 40 and 70 available. The high-molecular-weight dextran 70 may persist for up to eight hours. They inhibit platelet aggregation and leucocyte plugging in the microcirculation, thereby, improving flow through the microcirculation. They are primarily used in sepsis.
Unlike many other intravenous fluids, dextrans are a recognised cause of anaphylaxis. -
This question is part of the following fields:
- Peri-operative Care
- Principles Of Surgery-in-General
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Question 61
Incorrect
-
During a case presentation, a 26 year old is said to have fractured his pelvis and shattered his coccyx following a motorbike accident. It is mentioned that he is likely to have lacerated his middle sacral artery from this kind of injury. Where does the middle sacral artery branch from?
Your Answer: External iliac artery
Correct Answer: Abdominal aorta
Explanation:The middle sacral artery arises from behind the aorta a little above the point of its bifurcation to descend down in front of L4,5, the sacrum and coccyx.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 62
Incorrect
-
A 35 year-old female developed food poisoning 24H after eating canned food. She complained of abdominal cramps, with nausea and vomiting. Shortly after she suddenly developed weakness, blurring of vision, difficulty in swallowing and breathing. Which of the following organisms is most likely associated with fatal food poisoning?
Your Answer: Vibrio cholerae
Correct Answer: Clostridium botulinum
Explanation:C. botulinum is a Gram-positive, rod-shaped, spore-forming bacterium. It is an obligate anaerobe, meaning that oxygen is poisonous to the cells. Only botulinum toxin types A, B, E, and F cause disease in humans. Types A, B, and E are associated with foodborne illness. Botulism poisoning can occur due to preserved or home-canned, low-acid food that was not processed using correct preservation times and/or pressure. Signs and symptoms of foodborne botulism typically begin between 18 and 36 hours after the toxin gets into the body, but can range from a few hours to several days, depending on the amount of toxin ingested. Botulinum that is produced by Clostridium botulinum can cause respiratory and muscular paralysis.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 63
Incorrect
-
A 5 year old boy is taken to the doctor with symptoms of dysuria and frequency in urination. Blood and nitrites are shown positive on urine dipstick. A urinary tract infection is suspected. Which follow up strategy is the most appropriate?
Your Answer: DMSA scan
Correct Answer: Watchful waiting
Explanation:In a child 3 months to 12 years of age who is afebrile and well-appearing, it is reasonable to consider withholding empiric treatment if urine analysis (UA) is mildly positive or equivocal e.g.: leukocyte esterase (LE0 only, low WBC count) while awaiting culture results. Conversely, if the history is very consistent with UTI and positive UA, start treatment empirically.
Positive leukocyte esterase: very sensitive, but less specific for true infection (false positives are common)
Note: if no WBC on microscopy, more likely to be a false positive
Positive nitrite: high specificity for UTI, but lower sensitivity i.e. positive nitrite means likely UTI, but negative nitrite does not rule out UTICan also see positive nitrite in contaminated specimen if left at room temperature for too long
• Positive blood and protein: not specific for UTI
• Microscopy:>10 WBC/mm3 is suggestive of UTIManagement
– A single isolated UTI (in girls) may be managed expectantly.
– > 2 UTI’s (or 1 in males) in a 6 month period should prompt further testing.
– Voiding cystourethrograms show the greatest anatomical detail and is the ideal first line test in males; isotope cystography has a lower radiation dose and is the first line test in girls.
– USS should also be performed.
– Renal cortical scintigraphy should be performed when renal scarring is suspected. -
This question is part of the following fields:
- Generic Surgical Topics
- Paediatric Surgery
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Question 64
Correct
-
A 30-year-old man is admitted to the hospital with an embolus in the brachial artery. A cervical rib is suspected as being the underlying cause. From which of the following vertebral levels does the cervical rib arise?
Your Answer: C7
Explanation:A cervical rib in humans is an extra rib which arises from the C7 vertebra. Its presence is a congenital abnormality located above the normal first rib, and it consists of an anomalous fibrous band that often originates from C7 and may arc towards but rarely reaches the sternum. It is estimated to occur in 0.2% to 0.5% of the population. People may have a cervical rib on the right, left, or both sides.
Most cases of cervical ribs are not clinically relevant and do not have symptoms; cervical ribs are generally discovered incidentally. However, they vary widely in size and shape, and in rare cases, they may cause problems such as contributing to thoracic outlet syndrome due to compression of the lower trunk of the brachial plexus or subclavian artery.
Compression of the brachial plexus may be identified by weakness of the muscles near the base of the thumb. Compression of the subclavian artery is often diagnosed by finding a positive Adson’s sign on examination, where the radial pulse in the arm is lost during abduction and external rotation of the shoulder.
Treatment is most commonly undertaken when there is evidence of neurovascular compromise. A transaxillary approach is the traditional operative method for excision of the cervical rib.
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This question is part of the following fields:
- Generic Surgical Topics
- Vascular
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Question 65
Incorrect
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An ultrasound report of a 35-year old female patient revealed that she had cancer of the pancreas and presented with subsequent severe obstructive jaundice. In which part of this was woman's pancreas was the tumour most likely located?
Your Answer: Tail
Correct Answer: Head
Explanation:The pancreas is divided into five parts; the head, body, neck, tail, and the uncinate process. Of the five parts, tumours located at the head of the pancreas in most instances cause obstruction of the common bile duct more often than tumours in the other parts of the pancreas. This is because the common bile duct passes through the head of the pancreas from the gallbladder and the liver (it is formed where the cystic and the hepatic bile duct join) to empty bile into the duodenum. This biliary obstruction leads to accumulation of bile in the liver and a consequent bilirubinaemia (raised levels of blood bilirubin). This results in jaundice. The pancreas is not divided into lobes.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 66
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 67
Incorrect
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A 35-year-old ultra marathon runner becomes severely dehydrated and collapses. This patient most likely has:
Your Answer: Decreased plasma osmolarity
Correct Answer: Decreased baroreceptor firing rate
Explanation:Baroreceptors are sensors located in the blood vessels of all vertebrate animals. They sense the blood pressure and relay the information to the brain, so that a proper blood pressure can be maintained. Acute dehydration results in decreased plasma volume and increased plasma osmolarity, since more water than salt is lost in sweat. The decrease in plasma volume leads to an inhibition of the baroreceptors and a lower firing rate. The increase in plasma osmolarity leads to increased ADH secretion and high plasma ADH levels, which increases water permeability of collecting duct cells. Therefore more water is reabsorbed by the kidneys and renal water excretion is low.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 68
Incorrect
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Which foramen contains the vertebral artery?
Your Answer: Foramen spinosum
Correct 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 69
Incorrect
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A 33 year old man with fulminant ulcerative colitis underwent a subtotal colectomy. Which type of stoma would most likely be fashioned?
Your Answer: End jejunostomy
Correct Answer: End ileostomy
Explanation:Subtotal colectomy is resection of the entire right, transverse, left and part of the sigmoid colon. The rectal stump is closed and an end ileostomy fashioned in the right iliac fossa.
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This question is part of the following fields:
- Generic Surgical Topics
- The Abdomen
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Question 70
Incorrect
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A 46 year old woman is taken to the A&E department with a full thickness burn on her chest which is well circumscribed. Her saturation was reduced to 92% on 15L of Oxygen, blood pressure of 104/63 mmHg and HR 106 bpm. What is the best management step?
Your Answer: Haemodialysis
Correct Answer: Escharotomy
Explanation:Answer: Escharotomy
Escharotomy is the surgical division of the nonviable eschar, which allows the cutaneous envelope to become more compliant. Hence, the underlying tissues have an increased available volume to expand into, preventing further tissue injury or functional compromise.
Full-thickness circumferential and near-circumferential skin burns result in the formation of a tough, inelastic mass of burnt tissue (eschar). The eschar, by virtue of this inelasticity, results in the burn-induced compartment syndrome. This is caused by the accumulation of extracellular and extravascular fluid within confined anatomic spaces of the extremities or digits. The excessive fluid causes the intracompartmental pressures to increase, resulting in collapse of the contained vascular and lymphatic structures and, hence, loss of tissue viability. The capillary closure pressure of 30 mm Hg, also measured as the compartment pressure, is accepted as that which requires intervention to prevent tissue death.
The circumferential eschar over the torso can lead to significant compromise of chest wall excursions and can hinder ventilation. Abdominal compartment syndrome with visceral hypoperfusion is associated with severe burns of the abdomen and torso. (A literature review by Strang et al found the prevalence of abdominal compartment syndrome in severely burned patients to be 4.1-16.6%, with the mean mortality rate for this condition in these patients to be 74.8%). Similarly, airway patency and venous return may be compromised by circumferential burns involving the neck.
Performing an escharotomy will therefore improve ventilation.
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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 71
Incorrect
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A young male was diagnosed with hepatitis A, which clinically resolved in 2 weeks. What will his liver biopsy done after 6 months show?
Your Answer: Lobular fibrosis
Correct Answer: Normal architecture
Explanation:Hepatitis A is the most common acute viral hepatitis, more common in children and young adults. It is caused by Hepatitis A virus, which is a single-stranded RNA picornavirus. The primary route of spread of Hepatitis A is the faecal-oral route. Consumption of contaminated raw shellfish is also a likely causative factor. The shedding of the virus in faecal matter occurs before the onset of symptoms and continues a few days after. Hepatitis A does not lead to chronic hepatitis or cirrhosis, and there is no known chronic carrier state. Hence, a biopsy performed after recovery will show normal hepatocellular architecture.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 72
Incorrect
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A 5 year old boy is taken to the doctor by his father. He has had an earache for the past day and he is constantly pulling and touching his ear. His father noticed a foul smelling discharge leaking from his ear after which the earache resolved. Which of the following is the most likely cause?
Your Answer: Mastoiditis
Correct Answer: Acute otitis media
Explanation:Acute otitis media (AOM) is a painful type of ear infection. It occurs when the area behind the eardrum, the middle ear, becomes inflamed and infected.
The following behaviours in children often mean they have AOM:
– fits of fussiness and intense crying (in infants)
– clutching the ear while wincing in pain (in toddlers)
– complaining about a pain in the ear (in older children).Perforation of the tympanic membrane is not unusual as the process advances, most frequently in posterior or inferior quadrants. Before or instead of a single perforation, an opaque serum like exudate is sometimes seen oozing through the entire tympanic membrane.
With perforation and in the absence of a coexistent viral infection, the patient generally experiences rapid relief of pain and fever. The discharge initially is purulent, though it may be thin and watery or bloody; pulsation of the otorrhea is common. Otorrhea from acute perforation normally lasts 1-2 days before spontaneous healing occurs. Otorrhea may persist if the perforation is accompanied by mucosal swelling or polypoid changes, which can act as a ball valve.
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This question is part of the following fields:
- Generic Surgical Topics
- Head And Neck Surgery
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Question 73
Incorrect
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Which of the following diseases is caused by intra-articular and/or extra-articular deposition of calcium pyrophosphate dihydrate (CPPD) crystals, due to unknown causes?
Your Answer: Calcium oxalate crystal deposition disease
Correct Answer: Pseudogout
Explanation:Pseudogout or chondrocalcinosis is a rheumatological disease caused by the accumulation of crystals of calcium pyrophosphate dihydrate (CPPD) in the connective tissues. It is frequently associated with other conditions, such as trauma, amyloidosis, gout, hyperparathyroidism and old age, which suggests that it is secondary to degenerative or metabolic changes in the tissues. The knee is the most commonly affected joint. It causes symptoms similar to those of rheumatoid arthritis or osteoarthritis.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 74
Incorrect
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A 21 year old intravenous drug abuser is recovering following surgical drainage of a psoas abscess. She is found collapsed and unresponsive in the bathroom with pinpoint pupils. Which of the following is the best step in immediate management?
Your Answer: Intravenous glycopyrrolate
Correct Answer: Intravenous naloxone
Explanation:Answer: Intravenous naloxone
Naloxone is a medication approved by the Food and Drug Administration (FDA) to prevent overdose by opioids such as heroin, morphine, and oxycodone. It blocks opioid receptor sites, reversing the toxic effects of the overdose. Naloxone is administered when a patient is showing signs of opioid overdose. The medication can be given by intranasal spray, intramuscular (into the muscle), subcutaneous (under the skin), or intravenous injection.
Several conditions and drugs can cause pinpoint pupils, including:
Prescription opioids or narcotics
Some medications have opioids or narcotics in them. Opioids, including morphine, are drugs commonly used for pain relief. Opioids can affect a person psychologically and are highly addictive.People often take prescription opioids in pill form to treat severe post-surgical pain, such as from dental surgery, or for long-term pain, as with some cancers.
Prescription opioids that may cause pinpoint pupils include:
oxycodone
morphine
hydrocodone
codeine
methadone -
This question is part of the following fields:
- Emergency Medicine And Management Of Trauma
- Principles Of Surgery-in-General
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Question 75
Correct
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A 30 year old gym coach presented to the surgical out patient clinic with a lump in the inguinal region. He was booked for surgery, during which, the surgeon opened the inguinal region and found a hernial sac with a small segment of intestine projecting through the abdominal wall. It was located just above the inguinal ligament and lateral to the inferior epigastric vessels. What type of hernia was this?
Your Answer: An indirect inguinal hernia
Explanation:An indirect inguinal hernia exits the abdominal cavity lateral to the inferior epigastric vessels and enters the inguinal canal through the deep inguinal ring. These are the most common types of hernias often caused by heavy weigh lifting. Direct inguinal hernias exit the abdominal cavity medial to the inferior epigastric vessels through weak fascia.
Congenital inguinal hernias are indirect hernias that occur due to persistence of the processus vaginalis.
Femoral hernias occur when abdominal viscera push through the femoral ring in the femoral canal.
Incisional hernia occurs after surgery when the omentum or organ protrudes through a previous site of incision.
Obturator hernia are a very rare type of hernia where the pelvic or abdominal contents protrude through the obturator foramen. -
This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 76
Incorrect
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A 45-year-old man presented to the doctor complaining of a flank pain and episodes of haematuria. Abdominal ultrasound revealed a left renal mass and the patient underwent a nephrectomy. Histopathological pattern was triphasic with blastemal, epithelial, and stromal components. The pathologist suggested the tumour resulted from the lack of a tumour suppressor gene on chromosome 11. Which of the following tumours is the pathologist most likely suggesting?
Your Answer: Transitional cell carcinoma
Correct Answer: Wilms’ tumour
Explanation:Wilms’ tumour is one of the most common malignant tumours of childhood but it can also rarely be found in adults. In biopsy, classical histopathological findings include the triphasic pattern composed by blastemal, epithelial, and stromal elements. First symptoms in children include an abdominal palpable mass, while in adults pain and haematuria are the most common complaints. Deletions of tumours’ suppressor genes on chromosome 11 are usually associated with Wilms’ tumour.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 77
Incorrect
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If a catheter is placed in the main pulmonary artery of a healthy 30-year-old woman, which of the following will be its mean pulmonary arterial pressure?
Your Answer: 5 mmHg
Correct Answer: 15 mmHg
Explanation:The pulmonary artery pressure (PA pressure) is a measure of the blood pressure found in the main pulmonary artery. The hydrostatic pressure of the pulmonary circulation refers to the actual pressure inside pulmonary vessels relative to atmospheric pressure. Hydrostatic (blood pressure) in the pulmonary vascular bed is low compared with that of similar systemic vessels. The mean pulmonary arterial pressure is about 15 mmHg (ranging from about 13 to 19 mmHg) and is much lower than the average systemic arterial pressure of 90 mmHg.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 78
Incorrect
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A 35 year old woman with uncontrolled hypertension presents with a thyroid nodule. Family history is significant for total thyroidectomies of both sisters. Which of the following would be the most likely underlying pathology of her thyroid lesion?
Your Answer: Lymphoma of the thyroid
Correct Answer: Medullary thyroid cancer
Explanation:Multiple endocrine neoplasia type 2 (MEN2) is a hereditary condition associated with 3 primary types of tumours: medullary thyroid cancer, parathyroid tumours, and pheochromocytoma. MEN2 is classified into subtypes based on clinical features. Virtually all patients with classical MEN2A develop medullary thyroid carcinoma (MTC), which is often the first manifestation of the disease and usually occurs early in life. Pheochromocytomas (PHEOs) tend to be diagnosed several years later or simultaneously with the MTC.
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This question is part of the following fields:
- Breast And Endocrine Surgery
- Generic Surgical Topics
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Question 79
Incorrect
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A 35-year-old woman in her 37th week of pregnancy complains of urinary incontinence. She is most likely to have:
Your Answer: Functional incontinence
Correct Answer: Stress incontinence
Explanation:Urinary incontinence is the involuntary excretion of urine from one’s body. It is often temporary and it almost always results from an underlying medical condition. Several types include:
– Stress incontinence is the voiding of urine following increased abdominal pressure e.g. laughing, coughing, pregnancy etc. It is the most common form of incontinence in women, most commonly due to pelvic floor muscle weakness, physical changes from pregnancy, childbirth and menopause. In men it is a common problem following a prostatectomy. Most lab results such as urine analysis, cystometry and postvoid residual volume are normal.
– Urge incontinence is involuntary loss of urine occurring for no apparent reason while suddenly feeling the need or urge to urinate. The most common cause of urge incontinence are involuntary and inappropriate detrusor muscle contractions.
– Functional incontinence – occurs when a person does not recognise the need to go to the toilet, recognise where the toilet is or get to the toilet in time. The urine loss may be large. Causes of functional incontinence include confusion, dementia, poor eyesight, poor mobility, poor dexterity or unwillingness. t
– Overflow incontinence – sometimes people find that they cannot stop their bladders from constantly dribbling or continuing to dribble for some time after they have passed urine. -
This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 80
Incorrect
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A patient who following 20 years of working in the asbestos industry develops malignant mesothelioma and is scheduled for pleuropneumonectomy to remove the entire pleura and lung on the affected side. Which layer would provide a natural cleavage plane for surgical separation of the costal pleura from the thoracic wall?
Your Answer: Visceral pleura
Correct Answer: Endothoracic fascia
Explanation:The endothoracic fascia is connective tissue that is between the costal parietal pleura and the inner aspect of the chest wall. Removing this layer of connective tissue would make it easy to separate the costal pleura from the thoracic wall.
Deep fascia: is not found around the lungs. It is a layer of connective tissue that invests a muscle or a group of muscles.
Parietal pleura: part of the pleura that lines the inner surface of the chest/thoracic cavity.
Visceral pleura: is the serous membrane that lines the surface of the lungs.
Transversus thoracis muscle fascia is associated only with the muscle transversus thoracis.
Peritracheal fascia: a layer of connective tissue that invests the trachea. It is not associated with the thoracic wall or the costal pleura. -
This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 81
Correct
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Hyperplastic arteriosclerosis with fibrinoid necrosis, petechial haemorrhages, microinfarcts in the kidneys and elevated plasma renin are common findings in which of the following patients?
Your Answer: A 45-year-old woman with scleroderma
Explanation:Scleroderma, also known as systemic sclerosis, is a chronic disease of the connective tissue. Involvement of the kidneys occurs in patients with diffuse scleroderma, causing rapid onset of high blood pressure with hyperreninemia, thrombotic microangiopathy, and progressive renal failure.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 82
Incorrect
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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: Raised blood pressure
Correct 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 83
Correct
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What is the normal duration of the ST segment?
Your Answer: 0.08 s
Explanation:The ST segment lies between the QRS complex and the T-wave. The normal duration of the ST segment is 0.08 s. ST-segment elevation or depression may indicate myocardial ischaemia or infarction.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 84
Incorrect
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What is the nerve supply to the muscles of the lateral compartment of the leg ?
Your Answer: Common peroneal nerve
Correct Answer: Superficial peroneal nerve
Explanation:The peroneus longus and peroneus brevis in the lateral compartment of the leg take nerve supply from the superficial peroneal nerve.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 85
Incorrect
-
A young girl who presented with a clinical picture of type I hypersensitivity reaction with eosinophilia is most likely to have?
Your Answer: Amyloidosis
Correct 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 86
Incorrect
-
A 40-year-old male pedestrian is brought to the A&E department after being hit by a car. On examination, he is found to be dyspnoeic and hypoxic despite administration of high flow oxygen therapy. Moreover, his pulse is 115bpm and blood pressure is 110/70 mmHg. The right side of his chest is hyper-resonant on percussion and has decreased breath sounds. His trachea is deviated to the left. What is the most likely underlying diagnosis?
Your Answer: Fat embolism
Correct Answer: Tension pneumothorax
Explanation:This patient has developed a tension pneumothorax following a blunt trauma.
Tension pneumothorax is a life-threatening condition that develops when air is trapped in the pleural cavity under positive pressure, displacing mediastinal structures and compromising cardiopulmonary function. Blunt or penetrating chest trauma that creates a flap-type defect on the surface of the lung can result in this life-threatening condition.
Signs and symptoms of tension pneumothorax include:
1. Chest pain that usually has a sudden onset, is sharp, and may lead to feeling of tightness in the chest
2. Dyspnoea and progressive hypoxia
3. Tachycardia
4. Hyperventilation
5. Cough
6. FatigueOn examination, hyper-resonant percussion note and tracheal deviation are typically found. Treatment is immediate without waiting for the CXR result and includes needle decompression and chest tube insertion.
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This question is part of the following fields:
- Emergency Medicine And Management Of Trauma
- Principles Of Surgery-in-General
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Question 87
Incorrect
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A 52-year-old male who is a known case of leukaemia visits the day unit for a blood transfusion. Five days later, he presents to the emergency department with a temperature of 38.5°C, and erythematous cutaneous eruptions.What is the most likely explanation?
Your Answer: Acute haemolytic transfusion reaction
Correct Answer: Graft-versus-host disease
Explanation:This is transfusion-associated graft-versus-host disease (GvHD) occurring in an immunosuppressed patient. It can occur 4–30 days after a transfusion and follows a subacute pathway. Patients may also have diarrhoea and abnormal liver function tests. Management involves steroid therapy.
Acute transfusion reactions present during or within 24 hours of a blood transfusion. The most frequent clinical features are fever, chills, pruritus, or urticaria, which typically resolve promptly without specific treatment or complications. Other signs occurring in temporal relationship with a blood transfusion such as severe dyspnoea, pyrexia, or loss of consciousness may be the first indication of a more severe, potentially fatal reaction.
Transfusion reactions may be immune-mediated and non-immune-mediated. GvHD is a condition that might occur after an allogeneic transplant. The donated blood cells view the recipient’s body as foreign and attacks it. Immunosuppressed patients who receive white blood cells from another person are at increased risk of developing GvHD.
There are two forms of the disease:
1. Acute graft-versus-host disease (aGvHD): usually presents with skin and/or liver and/or gut involvement.
2. Chronic graft-versus-host disease (cGvHD).The diagnosis is clinical and usually one of exclusion; however, biopsy of affected tissues may be helpful in unclear cases.
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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 88
Correct
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A 58 year old lady who has had a mastectomy undergoes a breast reconstruction surgery. The breast implant is placed just anterior to her pectoralis major muscle. Which of the following methods of wound closure would be the most appropriate in this case?
Your Answer: Use of a pedicled myocutaneous flap
Explanation:The latissimus dorsi myocutaneous flap (LDMF) is one of the most reliable and versatile flaps used in reconstructive surgery. It is known for its use in chest wall and postmastectomy reconstruction and has also been used effectively for coverage of large soft tissue defects in the head and neck, either as a pedicled flap or as a microvascular free flap.
The latissimus dorsi may be transferred as a myofascial flap, a myocutaneous flap, or as a composite osteomyocutaneous flap when harvested with underlying serratus anterior muscle and rib. For even greater reconstructive flexibility, the latissimus can be harvested for free tissue transfer in combination with any or all of the other flaps based on the subscapular vessels (the so-called subscapular compound flap or “mega-flap”), including serratus anterior, scapular, and parascapular flaps
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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 89
Incorrect
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Causes of metabolic acidosis with a normal anion gap include:
Your Answer: Lactic acidosis
Correct Answer: Diarrhoea
Explanation:Excess acid intake and excess bicarbonate loss as in diarrhoea, are causes of metabolic acidosis with a normal anion gap. The other conditions all result in an increased anion gap.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 90
Correct
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In the glomerulus of the kidney, the mesangium is a structure associated with the capillaries. It has extraglomerular mesangial cells that:
Your Answer: Form the juxtaglomerular apparatus in combination with the macula densa and juxtaglomerular cells
Explanation:The mesangium is an inner layer of the glomerulus, within the basement membrane surrounding the glomerular capillaries. The mesangial cells are phagocytic and secrete the amorphous basement membrane-like material known as the mesangial matrix. They are typically separated from the lumen of the capillaries by endothelial cells. The other type of cells in the mesangium are the extraglomerular mesangial cells which form the juxtaglomerular apparatus in combination with two other types of cells: the macula densa of the distal convoluted tubule and juxtaglomerular cells of the afferent arteriole. This apparatus controls blood pressure through the renin–angiotensin–aldosterone system.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 91
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 92
Correct
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When exposing the right saphenofemoral junction for flush-ligation of the saphenous vein, which of the following is the most likely to be seen passing through this opening?
Your Answer: Superficial external pudendal artery
Explanation:The saphenous opening is an oval opening in the fascia lata. It is covered by the cribriform fascia and It is so called because it is perforated by the great saphenous vein and by numerous blood and lymphatic vessels and the superficial external pudendal artery pierces it.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 93
Correct
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A 25 year-old female medical student presents with fever, lack of appetite, rashes, sore throat and lymphadenopathy. Peripheral smear shows atypical lymphocytes. Which is the most likely organism responsible for this patient's condition?
Your Answer: Epstein–Barr virus
Explanation:Epstein-Barr virus is in the herpes family of viruses and most people will become infected with EBV sometime during their lives. EBV commonly causes infectious mononucleosis, or mono, a contagious viral illness that initially attacks the lymph nodes in the neck and throat. When these tissues become less effective in fighting infection, sore throats, swelling of the nodes and fever may result.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 94
Incorrect
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A 40 year old man suffered severe trauma following an MVA. His BP is 70/33 mmhg, heart rate of 140 beats/mins and very feeble pulse. He was transfused 3 units of blood resulting in his BP returning to 100/70 and his heart rate to 90 beats/min. What decreased following transfusion?
Your Answer: Pulmonary artery pressure
Correct Answer: Total peripheral resistance
Explanation:The patient is in hypovolemic shock, he is transfused with blood to replace the volume lost. It is important not only to replace fluids but stop active bleeding in resuscitation. Fluid replacement will result in a decreased sympathetic discharge and adequate ventricular filling thus reducing total peripheral resistance and increasing cardiac output and cardiac filling pressures.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 95
Incorrect
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A 33 year old mechanic presents to the A&E department with epigastric pain. An endoscopy is done which shows that he has a punched out ulcer on the anterior wall of the stomach which is shallow and measures 0.8cm in diameter. What is the most likely diagnosis?
Your Answer: Dieulafoy lesion
Correct Answer: Acute peptic ulcer
Explanation:Peptic ulcer disease can involve the stomach or duodenum. Gastric and duodenal ulcers usually cannot be differentiated based on history alone, although some findings may be suggestive. Epigastric pain is the most common symptom of both gastric and duodenal ulcers, characterized by a gnawing or burning sensation and that occurs after meals—classically, shortly after meals with gastric ulcers and 2-3 hours afterward with duodenal ulcers.
Upper gastrointestinal (GI) endoscopy is the preferred diagnostic test in the evaluation of patients with suspected peptic ulcer disease. At endoscopy, gastric ulcers appear as discrete mucosal lesions with a punched-out smooth ulcer base, which often is filled with whitish fibrinoid exudate. Ulcers tend to be solitary and well circumscribed and usually are 0.5-2.5 cm in diameter.
Treatment of peptic ulcers varies depending on the aetiology and clinical presentation. The initial management of a stable patient with dyspepsia differs from the management of an unstable patient with upper gastrointestinal (GI) haemorrhage. In the latter scenario, failure of medical management not uncommonly leads to surgical intervention.Treatment options include empiric antisecretory therapy, empiric triple therapy for H pylori infection, endoscopy followed by appropriate therapy based on findings, and H pylori serology followed by triple therapy for patients who are infected. Breath testing for active H pylori infection may be used.
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This question is part of the following fields:
- Generic Surgical Topics
- Upper Gastrointestinal Surgery
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Question 96
Incorrect
-
A 15-year-old girl was diagnosed with bacterial meningitis. Gram staining of the spinal fluid shows numerous polymorphonuclear neutrophils and Gram-positive cocci. Which is the empiric drug of choice to be given to the patient until the antibiotic sensitivity report is available?
Your Answer: Ceftriaxone
Correct Answer: Methicillin
Explanation:Bacterial meningitis (including meningococcal meningitis, Haemophilus influenzae meningitis, and staphylococcal meningitis) is a neurologic emergency that is associated with significant morbidity and mortality. Initiation of empiric antibacterial therapy is therefore essential for better outcomes. The patient appears to be suffering from meningitis caused by Staphylococcus aureus. Methicillin would be the drug of choice . It is bactericidal and unlike streptomycin and chloramphenicol it is not associated with toxicity
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 97
Incorrect
-
Which of the following will be a seen in a patient with a plasma thyroid-stimulating hormone (TSH) level of 14 mU/l (normal < 5 mU/l) and a low T3 resin uptake of 19% (normal 25–35%)?
Your Answer: Tachycardia
Correct Answer: Periorbital swelling and lethargy
Explanation:Low T3 resin uptake combined with raised TSH is indicative of hypothyroidism. Signs and symptoms include dull expression, facial puffiness, lethargy, periorbital swelling due to infiltration with mucopolysaccharides, bradycardia and cold intolerance. Anxiety, palpitations, tachycardia, raised body temperature, heat intolerance and weight loss are all seen in hyperthyroidism.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 98
Correct
-
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 99
Incorrect
-
A 32 year old woman who works as a teacher presents with a swollen, oedematous leg. She hails from Africa, from an area that is poorly sanitized and prevalent with mosquitoes. She travelled to England two weeks back. Which of the following is the most likely diagnosis?
Your Answer: Milroy's disease
Correct Answer: Filariasis
Explanation:Lymphatic filariasis, commonly known as elephantiasis, is a painful and profoundly disfiguring disease. In communities where filariasis is transmitted, all ages are affected. While the infection may be acquired during childhood its visible manifestations may occur later in life, causing temporary or permanent disability. The disease is caused by three species of thread-like nematode worms, known as filariae – Wuchereria bancrofti, Brugia malayi and Brugia timori. Male worms are about 3–4 centimetres in length, and female worms 8–10 centimetres. The male and female worms together form “nests” in the human lymphatic system.
Filarial infection can cause a variety of clinical manifestations, including lymphoedema of the limbs, genital disease (hydrocele, chylocele, and swelling of the scrotum and penis) and recurrent acute attacks, which are extremely painful and are accompanied by fever. The vast majority of infected people are asymptomatic, but virtually all of them have subclinical lymphatic damage and as many as 40% have kidney damage, with proteinuria and haematuria.
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This question is part of the following fields:
- Generic Surgical Topics
- Vascular
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Question 100
Incorrect
-
A surgeon ligates the left superior suprarenal artery whilst preforming a left adrenalectomy. Where does the left superior suprarenal artery originate?
Your Answer: Renal artery
Correct Answer: Left inferior phrenic artery
Explanation:The superior suprarenal arteries arises from the inferior phrenic artery on either side.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 101
Incorrect
-
A 20-year old college student was diagnosed with meningitis that had developed due to an acute cavernous sinus thrombosis from an ear infection. Which of the following superficial venous routes is the usual path that an infected blood clot takes to reach the cavernous sinus?
Your Answer: Superficial temporal vein
Correct Answer: Facial vein
Explanation:The facial vein is the usual communication between the cavernous sinus and the pterygoid sinus. It is through this vein that an infected clot can travel to the cavernous sinus and cause infection. The pterygoid plexus is a venous plexus that is situated between the temporalis muscle and lateral pterygoid muscle, and partly between the two pterygoid muscles. The pterygoid plexus is connected to the facial vein by the deep facial vein. This connection is what makes this area where this sinus and the facial vein are located a danger zone. The danger zone or triangle of the face is the area from the corners of the mouth to the nose bridge. The sinus connection in this area makes it possible for infection to reach the cavernous sinus and at times cause meningitis.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 102
Incorrect
-
A 11 year girl presents to the A&E department with a full thickness burn to her right arm, which she got when a firework that she was playing with exploded. Which statement is not characteristic of the situation?
Your Answer: Absence of, or few, blisters
Correct Answer: The burn area is extremely painful until skin grafted
Explanation:Answer: The burn area is extremely painful until skin grafted
Third-degree burns destroy the epidermis and dermis. Third-degree burns may also damage the underlying bones, muscles, and tendons. The burn site appears white or charred. There is no sensation in the area since the nerve endings are destroyed. These are not normally painful until after skin grafting is done since the nerve endings have been destroyed.
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This question is part of the following fields:
- Emergency Medicine And Management Of Trauma
- Principles Of Surgery-in-General
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Question 103
Incorrect
-
Which of the following is a true statement regarding the pupil?
Your Answer: Atropine causes pupil constriction
Correct Answer: Phentolamine causes pupil constriction
Explanation:A balance between the sympathetic tone to the radial fibres of the iris and parasympathetic tone to the pupillary sphincter muscle determines the pupil size. Phentolamine (α-adrenergic receptor blocker) causes pupillary constriction. Dilatation of the pupil occurs with increased sympathetic activity, decreased parasympathetic activity during darkness or block of muscarinic receptors by atropine.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 104
Incorrect
-
A 30-year-old man with Crohn's disease has undergone a number of resections. His BMI is currently 18 kg/m2 and his albumin levels are 2.5 g/dL. He generally feels well but does have a small localised perforation of his small bowel. The gastroenterologists are giving him azathioprine. What should be the most appropriate advice regarding feeding?
Your Answer: Enteral feeding
Correct Answer: Parenteral feeding
Explanation:This patient is malnourished. Although surgery is imminent, it is best for him to be nutritionally optimised first. As he may have reduced surface area for absorption and has a localised perforation, total parenteral nutrition (TPN) is likely the best feeding modality.
The National Institute for Health and Care Excellence (NICE) has laid down guidelines for identifying patients as malnourished or at risk of malnourishment, in order to start oral, enteral, or parenteral nutrition support, alone or in combination.
Following patients are identified as malnourished:
1. BMI <18.5 kg/m2
2. Unintentional weight loss of >10% within the last 3–6 months
3. BMI <20 kg/m2 and unintentional weight loss of >5% within the last 3–6 monthsFollowing patients are at risk of malnutrition:
1. Eaten nothing or little for >5 days and/or likely to eat little or nothing for the next 5 days or longer
2. Poor absorptive capacity and/or
3. High nutrient loss and/or
4. High metabolic rateConsidering the method of parenteral nutrition:
1. For feeding <14 days, consider feeding via a peripheral venous catheter
2. For feeding >30 days, use a tunnelled subclavian line,
continuous administration in severely unwell patients
3. If feed needed for >2 weeks, consider changing from continuous to cyclical feeding
4. Do not give >50% of daily regime to unwell patients in the first 24–48 hours
5. In surgical patients, if malnourished with unsafe swallow or a non-functional GI tract or perforation, consider perioperative parenteral feeding. -
This question is part of the following fields:
- Post-operative Management And Critical Care
- Principles Of Surgery-in-General
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Question 105
Incorrect
-
A 40 year old man from Japan was diagnosed with cancer of the oesophagus. He is to undergo esophagectomy. While mobilizing the oesophagus in the neck, for resection and anastomosis with the stomach tube on the left side, the surgeon must be cautious not to injure a vital structure. Which of the following is it?
Your Answer: Sympathetic chain
Correct Answer: Thoracic duct
Explanation:The oesophagus is divided into 3 portions: cervical (part that is in the neck), thoracic portion and the abdominal portion. The cervical part is bordered by the trachea anteriorly and the prevertebral fascia covering the bodies of the 6,7 and 8th vertebra posteriorly. The thoracic duct lies on the left side at the level of the sixth cervical vertebra. The carotid sheath with its contents and lower poles of the lateral lobes of thyroid gland are lateral. The thoracic duct is the structure most likely to be injured.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 106
Incorrect
-
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: 0.1
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 − 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 107
Incorrect
-
Which of the given options best describes the metabolic changes which occur following a severe soft tissue injury sustained after a PVA?
Your Answer: Inhibition of gluconeogenesis
Correct 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 108
Incorrect
-
A mechanic sustained a deep laceration to his right cubital fossa which resulted in him unable to move the proximal radioulnar joint of his right arm. Which muscles was affected?
Your Answer: Brachialis
Correct Answer: Pronator teres
Explanation:The correct answer is the pronator teres muscle. This muscle arises from 2 heads of origin: the humerus and ulnar. Between the 2 heads is the site of entrance of median nerve to the forearm. This muscle acts on the proximal radio-ulnar joint to rotate the radius on the ulna, otherwise known as pronation. It also assists in forearm flexion if the radius is fixed.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 109
Incorrect
-
A patient is brought to the accident and emergency department. He is said to have been involved in a mall explosion. Chest imaging reveals metal fragments in his thoracic cavity. He also has a pericardial effusion suggestive of a pericardial tear. An emergency thoracotomy is done which revealed a tear of the pericardium inferiorly. The surgeon began to explore for fragments in the pericardial sac with his hand from below the apex. He slips his fingers upward and to the right within the sac until they were stopped by the cul-de-sac formed by the pericardial reflection near the base of the heart. His finger tips were now in the:
Your Answer: Sulcus terminalis
Correct Answer: Oblique pericardial sinus
Explanation:Transverse sinus: part of pericardial cavity that is behind the aorta and pulmonary trunk and in front of the superior vena cava separating the outflow vessels from the inflow vessels.
Oblique pericardial sinus: is behind the left atrium where the visceral pericardium reflects onto the pulmonary veins and the inferior vena cava. Sliding a finger under the heart will take you to this sinus.
Coronary sinus: large vein that drains the heart into the right atrium. Located on the surface of the heart.
Coronary sulcus: groove on the heart demarcating the atria from the ventricles.
Costomediastinal recess: part of the pleural sac where the costal pleura transitions to become the mediastinal pleura.
Sulcus terminalis: a groove between the right atrium and the vena cava. -
This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 110
Correct
-
A 40-year-old man has been diagnosed with anal fissure, which has failed to respond to first-line treatment. What should be the next most appropriate treatment?
Your Answer: 15–30 units of botulinum toxin injected into the internal anal sphincter
Explanation:The next appropriate step would be to perform an examination under anaesthesia and inject 15–30 units of botulinum toxin into the internal anal sphincter.
Anal fissures are commonly seen in the colorectal clinic and are a common cause of painful, bright red rectal bleeding. Most fissures are idiopathic and present as a painful mucocutaneous defect in the posterior midline (90% cases). Fissures are more likely to be anteriorly located in females, particularly if they are multiparous. Diseases associated with fissure-in-ano include:
1. Crohn’s disease
2. Tuberculosis
3. Internal rectal prolapseDiagnostic options are as follows:
In most cases, the defect can be visualised as a posterior midline epithelial defect. Where symptoms are highly suggestive of the condition and examination findings are unclear, an examination under anaesthesia may be helpful. Atypical disease presentation should be investigated by colonoscopy and EUA, with biopsies of the area.For management of anal fissure:
1. Stool softeners are important as hard stools may tear the epithelium and result in recurrent symptoms (however, up to 25% of the patients fail to respond). The most effective first-line agents are topically applied GTN (0.2%) or Diltiazem (2%) paste.
2. Resistant cases may benefit from injection of botulinum toxin or lateral internal sphincterotomy. Advancement flaps may be used to treat resistant cases. -
This question is part of the following fields:
- Colorectal Surgery
- Generic Surgical Topics
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Question 111
Incorrect
-
In a splenectomy procedure, special care is emphasized on the preservation of the tail of the pancreas that is closely associated with the spleen to avoid post operative pancreatic fistula. As a general surgeon conducting a splenectomy where are you most likely to find the tail of the pancreas in the abdominal cavity?
Your Answer: Falciform ligament
Correct Answer: Splenorenal ligament
Explanation:The tail of the pancreas is the only intraperitoneal part of the pancreas and is found contained in the splenorenal ligament of the peritoneal cavity. The splenorenal ligament is derived from the peritoneum where the wall of the general peritoneal cavity connects to the omental bursa between the spleen and the left kidney. This ligament contains the splenic vessels and the tail of the pancreas.
The gastrocolic ligament stretches from the greater curvature of the stomach to the transverse colon, connecting the two.
The gastrosplenic ligament is derived from the greater omentum and is the structure that connects the stomach to the hilum of the spleen. The gastrosplenic ligament continues from the splenic flexure of the colon to the diaphragm and acts as a support to the spleen.
The transverse colon is connected to the abdominal wall by the mesocolon ligament.
The falciform ligament on the other hand, attaches the liver to the ventral wall of the abdomen.
The hepatoduodenal ligament connects the porta hepatis of the liver to the superior part of the duodenum. -
This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 112
Incorrect
-
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: Wernicke's encephalopathy and CVA
Correct 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 113
Incorrect
-
Thalamic syndrome will most likely result in:
Your Answer: Increased sexual drive
Correct Answer: Hyperaesthesia
Explanation:Signs and symptoms of thalamic syndrome include contralateral hemi anaesthesia, burning or aching sensation in one half of a body (hyperaesthesia), often accompanied by mood swings.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 114
Incorrect
-
A 40-year old woman presents with tightening of the skin over her fingers which makes movement of her fingers difficult.. She also gives a history of her fingers turning blue on exposure to low temperatures. She admits to gradual weight loss. Investigations reveal negative rheumatoid factor, negative antinuclear antibody and a positive anticentromere body. Which of the following conditions is she likely to have?
Your Answer: Zollinger-Ellison syndrome
Correct Answer: Oesophageal stricture
Explanation:Scleroderma is a connective tissue disorder that ranges in severity and progression. The disease could show generalised skin thickening with rapid, fatal, visceral involvement; or only cutaneous involvement (typically fingers and face). The slow progressive form is also known as ‘limited cutaneous scleroderma’ or CREST syndrome (calcinosis cutis, Raynaud’s phenomenon, (o)oesophageal dysmotility, sclerodactyly, and telangiectasia).
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 115
Incorrect
-
A 20-year-old woman had profuse watery diarrhoea for 2 days. She felt dizzy and weak, and thus decided to seek medical attention. At the emergency room her BP was 80/60 mmHg with a pulse of 118/min. What is the most appropriate intravenous treatment that should be given?
Your Answer: D5NM solution
Correct Answer: Isotonic saline
Explanation:Normal saline is typically the first fluid used when hypovolemia is severe enough to threaten the adequacy of blood circulation. It is isotonic and has long been believed to be the safest fluid to give quickly in large volumes.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 116
Incorrect
-
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: Arterial occlusion
Correct 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 117
Incorrect
-
A 67 year old man brought to the emergency department with acute pancreatitis is immediately intubated and put on a ventilator. His intra-abdominal pressure is measured using a bladder catheter connected to manometry. Which of the following would most likely represent the pressure effect seen in abdominal compartment syndrome?
Your Answer: Bladder pressure of > 35 mmHg does not cause anuria
Correct Answer: Bladder pressure of 16–25 mmHg does not require decompression
Explanation:Bladder pressures below 5mm Hg are expected in healthy patients. Pressures between 10 to 15 mmHg can be expected following abdominal surgery and in obese patients. Bladder pressures over 25 mmHg are highly suspicious of abdominal compartment syndrome and should be correlated clinically. It is recommended that pressure measurements be trended to show and recognize the worsening of intra-abdominal hypertension. Recommended management at this stage includes fluid resuscitation and if the pressure rises beyond the critical threshold of 25 mmHg, abdominal decompression is required.
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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 118
Correct
-
If the blood flow is constant, oxygen extraction by tissues will show the greatest decrease due to which of the following interventions?
Your Answer: Tissue cooling
Explanation:With a constant blood flow to a given tissue bed, there will be an increase in oxygen extraction by the tissue with the following; an increase in tissue metabolism and oxygen requirements: warming (or fever), exercise, catecholamines and thyroxine. With cooling, the demand for oxygen decreases, leading to decreased oxygen extraction.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 119
Correct
-
A 37 year old woman has recently undergone a mastectomy along with axillary node clearance for an invasive ductal carcinoma. Histological analysis show a completely excised grade III lesion measuring 3.5cm. Two of the axillary nodes are significant for metastatic spread. The tumour is found to be oestrogen receptor negative. Which of the following would be the next best step in the management of this patient?
Your Answer: Administration of cytotoxic chemotherapy
Explanation:Chemotherapy is offered to patients to help downstage advanced lesions to facilitate breast conserving surgery i.e. in grade 3 tumours with axillary node metastasis.
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This question is part of the following fields:
- Breast And Endocrine Surgery
- Generic Surgical Topics
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Question 120
Incorrect
-
Where does the ejaculatory duct open into?
Your Answer: Spongy urethra
Correct Answer: Prostatic urethra
Explanation:There are two ejaculatory ducts, one on either side of the midline. Each ejaculatory duct is formed by the union of the duct from the seminal vesicles with the ductus deferens. They start at the base of the prostate and run forward and downward between the middle and lateral lobes and along the side of the prostatic utricle to end in the prostatic urethra.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 121
Incorrect
-
A woman with type II diabetes is undergoing a bilateral hernia repair as a day-case procedure under general anaesthetic. Which of the following is most appropriate?
Your Answer: Their usual diabetic medication should be omitted on the evening following surgery
Correct Answer: They should be placed first on the operating list whenever possible
Explanation:Answer: They should be placed first on the operating list whenever possible
Patients with diet controlled diabetes are all
suitable for day case surgery if the procedure itself
is suitable for day surgery and all other criteria are
fulfilled.
People with diabetes controlled by oral or injected
medication are suitable for day case surgery if:
• They fulfil all day case criteria
• They can be first / early on a morning or afternoon
list.
Prioritise patients with diabetes on the list. This reduces the starvation time and hence the likelihood of the patient requiring a VRIII.Insulin should never be stopped in people with Type 1 diabetes because this will lead to ketoacidosis. If the starvation period is expected to require omission of more than one meal, a variable rate intravenous insulin infusion (VRIII) with concomitant glucose and electrolyte infusion will be required. Insulin requirements are increased by:
• Obesity
• Prolonged or major surgery
• Infection
• Glucocorticoid treatment.
When a VRIII is used, insulin and substrate should be infused continuously. If the infusion is stopped, there will be no insulin present in the circulation after 3-5 minutes leading to immediate catabolism. -
This question is part of the following fields:
- Peri-operative Care
- Principles Of Surgery-in-General
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Question 122
Incorrect
-
An abnormal opening of the urethra on the under surface of the penis (ventral surface) is known as:
Your Answer: Exstrophy
Correct Answer: Hypospadias
Explanation:Hypospadias is the condition where the urethra opens along the underside or ventral aspect of penile shaft. First-degree hypospadias is seen in 50-75% cases, where the urethra open on the glans penis. Second-degree hypospadias is seen in 20% cases where the urethra opens on the shaft, and third-degree in 30% cases with the urethra opening on the perineum. The severe cases are usually associated with undescended testis (cryptorchidism) or chordee, where the penis is tethered downwards and not completely separated from the perineum.
It is a common male genital birth defect but varying incidences are noted in different countries. There is no obvious inheritance pattern noted. No exact cause has been determined, however several hypotheses include poor response to androgen, or interference by environmental factors. -
This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 123
Incorrect
-
A 24 year old man hits his head during a fall whilst he is intoxicated. He is taken to the doctor and is disorientated despite opening his eyes in response to speech and being able to talk. He is also able to obey motor commands. What would be his Glasgow coma score?
Your Answer: 15
Correct Answer: 13
Explanation:Answer: 13
Eye Opening Response
Spontaneous–open with blinking at baseline – 4 points
Opens to verbal command, speech, or shout – 3 points
Opens to pain, not applied to face – 2 point
None – 1 pointVerbal Response
Oriented – 5 points
Confused conversation, but able to answer questions – 4 points
Inappropriate responses, words discernible – 3 points
Incomprehensible speech – 2 points
None – 1 pointMotor Response
Obeys commands for movement – 6 points
Purposeful movement to painful stimulus – 5 points
Withdraws from pain – 4 points
Abnormal (spastic) flexion, decorticate posture – 3 points
Extensor (rigid) response, decerebrate posture – 2 points
None – 1 pointHe is seen to be disorientated despite opening his eyes in response to speech and being able to talk. He is also able to obey motor commands. His score is therefore 13: 3 for eye opening response, 4 for verbal response and 6 for motor response.
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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 124
Incorrect
-
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: Berylliosis
Correct 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 125
Incorrect
-
A 24-year-old rugby player sustains a fracture of the distal radius after falling on his outstretched right hand during the game. X-ray shows a dorsally angulated comminuted fracture. What is the most appropriate management?
Your Answer: Discharge home with arm sling and review in fracture clinic
Correct Answer: Admit for open reduction and internal fixation
Explanation:This is a case of a high-velocity injury and, therefore, requires surgical fixation.
Bony injury resulting in a fracture may occur due to trauma (excessive force applied to bone), stress (repetitive low-velocity injury), or underlying pathology (abnormal bone which fractures during normal use or following minimal trauma).
Diagnosis involves not just evaluating the fracture, such as the site and type of injury, but also other associated injuries and distal neurovascular status. This may entail not just clinical examination but radiographs of proximal and distal joints. When assessing x-rays, it is important to assess for changes in the length of the bone, the angulation of the distal bone, rotational effects, and the presence of a foreign body such as glass.
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This question is part of the following fields:
- Generic Surgical Topics
- Orthopaedics
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Question 126
Incorrect
-
A 42 year old lawyer is rushed to the emergency room after she was found lying unconscious on her left arm with an empty bottle of Diazepam beside her. Her left arm has red and purple marks and is swollen. Her hand is stiff and insensate. Which of the following substances would be expected to be present in her urine in increased quantities?
Your Answer: Protein
Correct Answer: Myoglobin
Explanation:Answer: Myoglobin
When muscle is damaged, a protein called myoglobin is released into the bloodstream. It is then filtered out of the body by the kidneys. Myoglobin breaks down into substances that can damage kidney cells.
Compartment syndrome is a painful condition that occurs when pressure within the muscles builds to dangerous levels. This pressure can decrease blood flow, which prevents nourishment and oxygen from reaching nerve and muscle cells.Compartment syndrome can be either acute or chronic.
Acute compartment syndrome is a medical emergency. It is usually caused by a severe injury. Without treatment, it can lead to permanent muscle damage.
Chronic compartment syndrome, also known as exertional compartment syndrome, is usually not a medical emergency. It is most often caused by athletic exertion. Compartments are groupings of muscles, nerves, and blood vessels in your arms and legs. Covering these tissues is a tough membrane called a fascia. The role of the fascia is to keep the tissues in place, and, therefore, the fascia does not stretch or expand easily.
Compartment syndrome develops when swelling or bleeding occurs within a compartment. Because the fascia does not stretch, this can cause increased pressure on the capillaries, nerves, and muscles in the compartment. Blood flow to muscle and nerve cells is disrupted. Without a steady supply of oxygen and nutrients, nerve and muscle cells can be damaged.In acute compartment syndrome, unless the pressure is relieved quickly, permanent disability and tissue death may result. This does not usually happen in chronic (exertional) compartment syndrome.
Compartment syndrome most often occurs in the anterior (front) compartment of the lower leg (calf). It can also occur in other compartments in the leg, as well as in the arms, hands, feet, and buttocks.
Acute compartment syndrome usually develops after a severe injury, such as a car accident or a broken bone. Rarely, it develops after a relatively minor injury.
Conditions that may bring on acute compartment syndrome include:
A fracture.
A badly bruised muscle. This type of injury can occur when a motorcycle falls on the leg of the rider, or a football player is hit in the leg with another player’s helmet.
Re-established blood flow after blocked circulation. This may occur after a surgeon repairs a damaged blood vessel that has been blocked for several hours. A blood vessel can also be blocked during sleep. Lying for too long in a position that blocks a blood vessel, then moving or waking up can cause this condition. Most healthy people will naturally move when blood flow to a limb is blocked during sleep. The development of compartment syndrome in this manner usually occurs in people who are neurologically compromised. This can happen after severe intoxication with alcohol or other drugs.
Crush injuries.
Anabolic steroid use. Taking steroids is a possible factor in compartment syndrome.
Constricting bandages. Casts and tight bandages may lead to compartment syndrome. If symptoms of compartment syndrome develop, remove or loosen any constricting bandages. -
This question is part of the following fields:
- Emergency Medicine And Management Of Trauma
- Principles Of Surgery-in-General
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Question 127
Correct
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During work up for a 29 year-old lady who complained of chest pain, a computed tomography showed a large mass in the posterior mediastinum. Which among the following structures could be involved?
Your Answer: Lymph glands
Explanation:Boundaries of the posterior mediastinum include:
Superior: a plane through the sternal angle and T4/5
Inferior: the diaphragm
Anterior: the middle mediastinal structures
Posterior the spinal cord.
Structures in the posterior mediastinum include the descending thoracic aorta, the azygos system, oesophagus, thoracic duct and lymph nodes. The great vessels and structures at the root of the lung are part of the middle mediastinum. In this case, the lymph nodes is the correct answer. -
This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 128
Incorrect
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Which portion of the renal tubule absorbs amino acids and glucose?
Your Answer: Distal convoluted tubule
Correct Answer: Proximal convoluted tubule
Explanation:In relation to the morphology of the kidney as a whole, the convoluted segments of the proximal tubules are confined entirely to the renal cortex. Glucose, amino acids, inorganic phosphate and some other solutes are reabsorbed via secondary active transport in the proximal renal tubule through co-transport channels driven by the sodium gradient.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 129
Incorrect
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A patient with this type of tumour is advised to follow up regularly for monitoring of tumour size as there is a strong correlation with malignant potential and tumour size. Which of the following is the most likely tumour in this patient?
Your Answer: Colon adenocarcinoma
Correct Answer: Renal adenocarcinoma
Explanation:The distinction between a benign renal adenoma and renal adenocarcinoma is commonly made on the basis of size. Tumours less than 2 cm in size rarely become malignant as opposed to those greater than 3 cm.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 130
Incorrect
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A 34 year old mechanic suffers from a Gustilo and Anderson type IIIA fracture of the femoral shaft after being hit by a fork lift truck. What would be the most suitable step in the management of this patient?
Your Answer: Debridement and placement of long leg plaster cast
Correct Answer: Debridement and external fixation
Explanation:Perhaps the most important aspect in the treatment of open fractures is the initial surgical intervention with irrigation and meticulous debridement of the injury zone. Irrigation, along with debridement, is absolutely crucial in the management of open fractures.
Early stabilization of open fractures provides many benefits to the injured patient. It protects the soft tissues around the zone of injury by preventing further damage from mobile fracture fragments. It also restores length, alignment, and rotation—all vital principles of fracture fixation. Skeletal traction and external fixation are the quickest fixation constructs to employ. The use of skeletal traction should be reserved only for selected open fracture types (i.e., pelvis fractures and very proximal femur fractures) and if used, it should only be for a short selected time. External fixation is a valuable tool in the surgeon’s arsenal for acute open fracture management. Indications for external fixation are grossly contaminated open fractures with extensive soft-tissue compromise, the Type IIIA-C injuries, and when immediate fixation is needed for physiologically unstable patients. -
This question is part of the following fields:
- Generic Surgical Topics
- Orthopaedics
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Question 131
Incorrect
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Selective destruction of which of the following cells will affect antibody synthesis?
Your Answer: Reticulocytes
Correct Answer: Plasma cells
Explanation:Plasma cell are memory cells. After the antigen Is engulfed by the B cells it is presented to the CD4+ helper cells via the MCH II receptor and this leads to their activation which in turn stimulates the B cells to form antibodies against that specific antigen. Some B cells differentiate into plasma cells also called memory cells that get activated after subsequent infection.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 132
Incorrect
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A 55-year-old male presents with tearing central chest pain. On examination, he has an aortic regurgitation murmur. An ECG shows ST elevation in leads II, III and aVF. What is the likely explanation?
Your Answer: Distal aortic dissection
Correct Answer: Proximal aortic dissection
Explanation:The patient’s ECG indicates Inferior myocardial infarction. However, the tearing central chest pain is more suggestive of Aortic Dissection.
Patients with acute aortic dissection typically present with the sudden onset of severe chest pain, although this description is not universal.
The location of the pain may indicate where the dissection arises. Anterior chest pain and chest pain that mimics acute myocardial infarction usually are associated with the anterior arch or aortic root dissection. This is caused by the dissection interrupting flow to the coronary arteries, resulting in myocardial ischemia. Pain in the neck or jaw indicates that the dissection involves the aortic arch and extends into the great vessels.High-probability ECG features of MI are the following:
ST-segment elevation greater than 1 mm in two anatomically contiguous leads
The presence of new Q wavesIntermediate-probability ECG features of MI are the following:
ST-segment depression
T-wave inversion
Other nonspecific ST-T wave abnormalities
Low-probability ECG features of MI are normal ECG findings. However, normal or nonspecific findings on ECGs do not exclude the possibility of MI.Localization of the involved myocardium based on the distribution of ECG abnormalities in MI is as follows:
– Inferior wall – II, III, aVF
– Lateral wall – I, aVL, V4 through V6
– Anteroseptal – V1 through V3
– Anterolateral – V1 through V6
– Right ventricular – RV4, RV5
– Posterior wall – R/S ratio greater than 1 in V1 and V2, and – T-wave changes in V1, V8, and V9
– True posterior-wall MIs may cause precordial ST depressions, inverted and hyperacute T waves, or both. ST-segment elevation and upright hyperacute T waves may be evident with the use of right-sided chest leads. -
This question is part of the following fields:
- Peri-operative Care
- Principles Of Surgery-in-General
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Question 133
Incorrect
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The line which divides the perineum into two triangles is connected to the?
Your Answer: Coccyx
Correct Answer: Ischial tuberosities
Explanation:The perineum has it’s deep boundaries in front of the pubic arch and the arcuate ligament of the pubis, behind the tip of the coccyx and on either side of the inferior rami of the pubis and ischium and the sacrotuberous ligament. It also corresponds to the outlet of the pelvis. A line drawn transversely across, in front of the ischial tuberosities divides the space into two portions, the posterior contains the termination of the anal canal and the anterior, contains the external urogenital organs.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 134
Incorrect
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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: Lymphangiectasis
Correct 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 135
Incorrect
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A patient is diagnosed with lung cancer. His physician told him that his lung cancer type is aggressive. It can grow rapidly and may undergo early metastasis, however it is very sensitive to chemotherapy and radiotherapy. Which lung cancer type is most likely present
Your Answer: Adenocarcinoma
Correct Answer: Small-cell carcinoma
Explanation:Small-cell lung carcinoma (SCLC) is a type of highly malignant cancer that most commonly arises within the lung. SCLC usually metastasizes widely very early on in the natural history of the tumour, and in nearly all cases responds dramatically to chemotherapy and/or radiotherapy. Surgery has no role in the treatment of this disease.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 136
Incorrect
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An elderly, diabetic man has firm, tender nodules at the base of his left middle and ring fingers, which he can't extend fully. What's the most likely diagnosis?
Your Answer: Giant-cell tumour of the tendon sheath
Correct Answer: Fibromatosis
Explanation:This case is suggestive of Dupuytren’s contracture due to palmar fibromatosis. Its incidence is higher in men over the age of 45 years, and it increases in patients with diabetes, alcoholism, or epilepsy. These nodules are benign, usually appearing as a tender nodule in the palm which becomes painless. The disease has an aggressive clinical behaviour and recurs frequently.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 137
Correct
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A 65-year old patient with altered bowl movement experienced the worsening of shortness of breath and exertional chest pains over the course of 8 weeks. Examination shows pallor and jugular venous distension. Furthermore, a test of the stool for occult blood is positive. Laboratory studies show: Haemoglobin 7.4 g/dl, Mean corpuscular volume 70 fl, Leukocyte count 5400/mm3, Platelet count 580 000/mm3, Erythrocyte sedimentation 33 mm/h.A blood smear shows hypochromic, microcytic RBCs with moderate poikilocytosis. Which of the following is the most likely diagnosis?
Your Answer: Iron deficiency anaemia
Explanation:Iron deficiency anaemia is the most common type of anaemia. It can occur due to deficiency of iron due to decreased intake or due to faulty absorption. An MCV less than 80 will indicated iron deficiency anaemia. On the smear the RBC will be microcytic hypochromic and will also show piokilocytosis. iron profiles tests are important to make a diagnosis. Clinically the patient will be pale and lethargic.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 138
Incorrect
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An old man fell and fractured a carpal bone articulating with the pisiform bone. Which bone was most likely fractured?
Your Answer: Trapezium
Correct Answer: Triquetral
Explanation:The pisiform bone has an oval facet for articulation with the triquetral bone. The pisiform bone is a sesamoid bone, and is anterior to the other carpal bones.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 139
Incorrect
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What is the result of maltase deficiency in the brush border of the small intestine?
Your Answer: Results in lack of absorption of lactose
Correct Answer: Results in increased passage of maltose in stool
Explanation:Maltase is an enzyme produced from the surface cells of the villi, lining the small intestine and aids in hydrolysing the disaccharide maltose, which splits into two molecules of α-glucose. It is done by breaking the glycosidic bond between the ‘first’ carbon of one glucose and the ‘fourth’ carbon of the other (a 1–4 bond). Hence, a deficiency of enzyme maltase will result in the increased passage of maltose in the stool.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 140
Correct
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A previously healthy 40-year-old housewife suddenly complains of a headache and loses consciousness. A CT scan reveals subarachnoid haemorrhage. Which of the following is the most probable cause?
Your Answer: Ruptured berry aneurysm
Explanation:Saccular aneurysms, also known as berry aneurysms, appear as a round outpouching and are the most common form of cerebral aneurysm. They are a congenital intracranial defect, and haemorrhage can occur at any age, but is most common between the ages of 40-65 years. A second rupture (rebleeding) sometimes occurs, most often within about 7 days of the first bleed.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 141
Correct
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A medical student is told a substance is freely filtered but is not metabolised, secreted, or stored in the kidney. It has a plasma concentration of 1000 mg/l and its urine excretion rate is 25 mg/min, and the inulin clearance is 100 ml/min. What is the rate of tubular reabsorption of the substance?
Your Answer: 75 mg/min
Explanation:Reabsorption or tubular reabsorption is the process by which the nephron removes water and solutes from the tubular fluid (pre-urine) and returns them to the circulating blood. To calculate the reabsorption rate of substance Z we use the following equation: excretion = (filtration + secretion) – reabsorption. As this substance is freely filtered, its filtration rate is equal to that of inulin. So 25 = (100 + 0) – reabsorption. Reabsorption = 100 – 25 therefore reabsorption = 75 mg/min.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 142
Incorrect
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A 27-year-old woman, who had been taking a combined oral contraceptive for 6 months, presented with inguinal pain and oedema of the left leg. Which of the following investigations would you recommend to help confirm the diagnosis?
Your Answer: Complete blood count
Correct Answer: Duplex scan
Explanation:Oral combined contraceptive pill (OCCP) is a drug used for birth control and treating a number of other conditions. Women who take the OCP have a higher risk of developing deep vein thrombosis (DVT), usually in the legs. Duplex ultrasonography is a safe and non-invasive technique which is used for diagnosing the presence of lower extremity thrombi.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 143
Incorrect
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A 56 year old man presents to the emergency with a type IIIc Gustilo and Anderson fracture of distal tibia after being involved in a road traffic accident. He was trapped under the wreckage for about 7 hours and had been bleeding profusely from the fracture site during this time. He is found to have an established neurovascular deficit. Which of the following is the most appropriate course of action?
Your Answer: Insertion of intramedullary nail and arterial reconstruction
Correct Answer: Amputation
Explanation:A below-knee amputation (“BKA”) is a transtibial amputation that involves removing the foot, ankle joint, and distal tibia and fibula with related soft tissue structures. In general, a BKA is preferred over an above-knee amputation (AKA), as the former has better rehabilitation and functional outcomes. There are three major categories of indications for proceeding with a BKA. These include:
– Urgent cases where source control of necrotizing infections or haemorrhagic injuries outweighs limb preservation.
– Less acutely, urgent BKAs may be performed for chronic nonhealing ulcers or significant infections with the risk of impending systemic infection or sepsis.
– Urgent BKAs may be performed where limb salvage has failed to preserve a mangled lower extremity. Adequate resuscitation and stabilization must always have occurred before such a decision, as judged by vital signs, lactate, base deficit, and the management of concomitant injuries.
This man is hemodynamically unstable and the limb is likely to be non-viable after so many hours of entrapment. Hence, the safest option would be primary amputation of the injured limb. -
This question is part of the following fields:
- Emergency Medicine And Management Of Trauma
- Principles Of Surgery-in-General
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Question 144
Incorrect
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A 1 year old baby is taken to the A&E with colicky abdominal pain and an ileo-ileal intussusception is found on investigation. What is the most appropriate course of action?
Your Answer: Attempt hydrostatic reduction with barium enema
Correct Answer: Undertake a laparotomy
Explanation:Answer: Undertake a laparotomy
Intussusception, which is defined as the telescoping or invagination of a proximal portion of intestine (intussusceptum) into a more distal portion (intussuscipiens), is one of the most common causes of bowel obstruction in infants and toddlers.
Intussusception may be ileoileal, colocolic, ileoileocolic, or ileocolic (the most common type).
Most infants with intussusception have a history of intermittent severe cramping
or colicky abdominal pain, occurring every 5-30 minutes. During these attacks, the infant screams and flexes at the waist, draws the legs up to the abdomen, and may appear pale. These episodes may last for only a few seconds and are separated by periods of calm normal appearance and activity. However, some infants become quite lethargic and somnolent between attacks.
Infants with intussusception require surgical correction. Prompt laparotomy following diagnosis is crucial for achieving better outcomes. Primary anastomosis can be performed successfully, and stomas can be created in the critically ill patients or those with late detection and septicaemia. -
This question is part of the following fields:
- Generic Surgical Topics
- Paediatric Surgery
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Question 145
Correct
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A 5 year old boy presents with an abnormal gait. On examination, his WCC was found to be 12 and ESR was 31. Past medical history shows a recent viral illness. Which of the following is the cause of these symptoms?
Your Answer: Transient synovitis
Explanation:Transient synovitis (TS) is the most common cause of acute hip pain in children aged 3-10 years. The disease causes arthralgia and arthritis secondary to a transient inflammation of the synovium of the hip. Biopsy reveals only nonspecific inflammation and hypertrophy of the synovial membrane. Ultrasonography demonstrates an effusion that causes bulging of the anterior joint capsule. Synovial fluid has increased proteoglycans.
Unilateral hip or groin pain is the most common symptom reported; however, some patients with transient synovitis (TS) may report medial thigh or knee pain. Transient synovitis has the highest incidence rate among causes of nontraumatic hip pain in children. Guidelines for chronic hip pain have been established.Causes
No definitive cause of transient synovitis is known, although the following have been suggested:
– Patients with transient synovitis often have histories of trauma, which may be a cause or predisposing factor.
– One study found an increase in viral antibody titres in 67 of 80 patients with transient synovitis.
– Postvaccine or drug-mediated reactions and an allergic disposition have been cited as possible causes.The following studies may be indicated in transient synovitis (TS):
– CBC count: The white blood cell (WBC) count may be slightly elevated.
– Erythrocyte sedimentation rate (ESR) may be slightly elevated. One study found that the combination of an ESR greater than 20 mm/h and/or a temperature greater than 37.5°C identified 97% of individuals with septic hip. -
This question is part of the following fields:
- Generic Surgical Topics
- Orthopaedics
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Question 146
Incorrect
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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: Patella tendon
Correct 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 147
Correct
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A 7-year-old boy with facial oedema was brought to the hospital by his parents. Renal function is normal and urinalysis revealed the presence of a profound proteinuria. Which of the following is the most probable cause of these findings?
Your Answer: Minimal-change disease
Explanation:Minimal-change disease (MCD) refers to a histopathologic glomerular lesion, typically found in children, that is almost always associated with nephrotic syndrome. The most noticeable symptom of MCD is oedema, which can develop very rapidly. Due to the renal loss of proteins muscle wasting and growth failure may be seen in children. Renal function is usually not affected and a proteinuria of more than 40 mg/h/m2 is the only abnormal finding in urinalysis.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 148
Correct
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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 149
Incorrect
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Which of the following can occur even in the absence of brainstem co-ordination?
Your Answer: Vomiting
Correct Answer: Gastric emptying
Explanation:Although gastric emptying is under both neural and hormonal control, it does not require brainstem co-ordination. Increased motility of the orad stomach (decreased distensibility) or of the distal stomach (increased peristalsis), decreased pyloric tone, decreased duodenal motility or a combination of these, all increase the rate of gastric emptying. The major control mechanism for gastric emptying is through duodenal gastric feedback. The duodenum has receptors for the presence of acid, carbohydrate, fat and protein digestion products, osmolarity different from that of plasma, and distension. Activating these receptors decreases the rate of gastric emptying. Neural mechanisms involve both enteric and vagal pathways and a vagotomy impairs the gastric emptying regulation. CCK (cholecystokinin) slows gastric emptying at physiological levels of the hormone. Gastrin, secretin and glucose-1-phosphate also slow gastric emptying, but require higher doses.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 150
Incorrect
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Which of the following clinical signs will be demonstrated in a case of Brown-Séquard syndrome due to hemisection of the spinal cord at mid-thoracic level?
Your Answer: Ipsilateral spastic paralysis, contralateral loss of vibration and proprioception (position sense) and contralateral loss of pain and temperature sensation beginning one or two segments below the lesion
Correct Answer: Ipsilateral spastic paralysis, ipsilateral loss of vibration and proprioception (position sense) and contralateral loss of pain and temperature sensation beginning one or two segments below the lesion
Explanation:Brown–Séquard syndrome results due to lateral hemisection of the spinal cord and results in a loss of motricity (paralysis and ataxia) and sensation. The hemisection of the cord results in a lesion of each of the three main neural systems: the principal upper motor neurone pathway of the corticospinal tract, one or both dorsal columns and the spinothalamic tract. As a result of the injury to these three main brain pathways the patient will present with three lesions. The corticospinal lesion produces spastic paralysis on the same side of the body (the loss of moderation by the upper motor neurons). The lesion to fasciculus gracilis or fasciculus cuneatus results in ipsilateral loss of vibration and proprioception (position sense). The loss of the spinothalamic tract leads to pain and temperature sensation being lost from the contralateral side beginning one or two segments below the lesion. At the lesion site, all sensory modalities are lost on the same side, and an ipsilateral flaccid paralysis.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 151
Incorrect
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Which organ is responsible for the secretion of enzymes that aid in digestion of complex starches?
Your Answer: Stomach
Correct Answer: Pancreas
Explanation:α-amylase is secreted by the pancreas, which is responsible for hydrolysis of starch, glycogen and other carbohydrates into simpler compounds.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 152
Incorrect
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Where would you insert the needle when drawing blood from a patient's median cubital vein?
Your Answer: Femoral triangle
Correct Answer: Anterior aspect of the elbow
Explanation:The correct answer is to insert it into the anterior aspect of the elbow. If you look at the venous drainage of the upper limb, you will find that there are two main veins, the basilic and the cephalic vein; the connecting branch between these two veins is the median cubital vein. and this vein passes via the cubital fossa which is on the anterior aspect of the forearm.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 153
Incorrect
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Which is the site of action of the drug omeprazole?
Your Answer: Active H+ and Cl– co-transport
Correct Answer: H+/K+ ATPase
Explanation:H+/K+-ATPase or ‘proton pump’ located in the canalicular membrane plays a major role in acid secretion. The ATPase here is magnesium-dependent. Omeprazole is a proton pump inhibitor and blocks H+/K+- ATPase.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 154
Incorrect
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A man had an injury to his right brachial plexus. After examination by the doctor they found that the diaphragm and the scapula were unaffected however the patient could not abduct his arm. When helped with abducting his arm to 45 degrees he was able to continue the movement. This means that he was unable to initiate abduction. Where is the likely site of injury?
Your Answer: Axillary nerve
Correct Answer: Suprascapular nerve
Explanation:The loss of ability to initiate abduction means paralysis of the supraspinatus muscle. This muscle is supplied by the supraclavicular nerve.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 155
Incorrect
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If your EEG shows waves with a frequency range of 8-12 Hz, the waves most likely to be seen are:
Your Answer: Beta
Correct Answer: Alpha
Explanation:Electroencephalography (EEG) is the neurophysiological measurement of the electrical activity of the brain. It is done by placing electrodes on the scalp or subdurally. In reality, the electrical currents are not measured, but rather the voltage differences between different parts of the brain. Four major types of EEG activity are recognized, which are alpha, beta, delta and theta.
Alpha waves, also known as Berger’s waves ranges in frequency from 8-12 Hz. Best detected with eyes closed, alpha waves are characteristic of a relaxed, alert state of consciousness. An alpha-like normal variant called mu is sometimes seen over the motor cortex (central scalp) and attenuates with movement or, rather, with the intention to move. -
This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 156
Incorrect
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A 39 year old lady presents with a mass in the upper outer quadrant of her left breast. Imaging, histology and clinical examination confirm a 1.4cm malignant mass lesion with no clinical evidence of axillary nodal disease. Which treatment would be the most appropriate?
Your Answer: Wide local excision and axillary node sampling
Correct Answer: Wide local excision and sentinel node biopsy
Explanation:Sentinel lymph node biopsy has become the gold standard for axillary staging for patients with clinically and radiologically node negative axilla. The recommended technique is the dual technique of blue dye/radioisotope and this is associated with high sentinel node identification rates (> 95 %). However, in centres where radioisotope is not available, blue dye guided four node sampling appears to be a reasonable alternative. Sentinel node biopsy was shown to be an accurate technique for axillary node staging in the ALMANAC Trial with less associated morbidity and strong health economic arguments for its use.
The tumour in this patient is small so a wide local excision should be done.
Lumpectomy or breast wide local excision is a surgical removal of a discrete portion or lump of breast tissue, usually in the treatment of a malignant tumour or breast cancer. It is considered a viable breast conservation therapy, as the amount of tissue removed is limited compared to a full-breast mastectomy, and thus may have physical and emotional advantages over more disfiguring treatment. Sometimes a lumpectomy may be used to either confirm or rule out that cancer has actually been detected. A lumpectomy is usually recommended to patients whose cancer has been detected early and who do not have enlarged tumours. -
This question is part of the following fields:
- Breast And Endocrine Surgery
- Generic Surgical Topics
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Question 157
Correct
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A 30-year-old woman presents with a history of severe epigastric pain that worsens post prandially. On examination, the abdomen is soft and non tender with no palpable mass felt. However, a bruit is heard in the epigastrium, on auscultation. Imaging with USS shows no gallstones and OGD is normal as well. What is the most likely diagnosis?
Your Answer: Median arcuate ligament syndrome
Explanation:The most likely diagnosis is median arcuate ligament syndrome (MALS).
MALS, also known as coeliac artery compression syndrome, is a condition characterized by abdominal pain attributed to compression of the coeliac artery and the coeliac ganglia by the median arcuate ligament. The pain may be related to meals, may be accompanied by weight loss, and may be associated with an abdominal bruit.
The diagnosis of MALS is one of exclusion, as many healthy patients demonstrate some degree of coeliac artery compression in the absence of symptoms. Consequently, a diagnosis of MALS is typically only entertained after more common conditions have been ruled out. Once suspected, screening for MALS can be done with USS and confirmed with CT or MRI scan.
Treatment is generally surgical, the mainstay being open or laparoscopic division or separation of the median arcuate ligament combined with removal of the celiac ganglia. The majority of patients benefit from surgical intervention. Poorer responses to treatment tend to occur in patients of older age, those with a psychiatric condition or who use alcohol, have abdominal pain unrelated to meals, or who have not experienced weight loss.
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This question is part of the following fields:
- Generic Surgical Topics
- Vascular
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Question 158
Correct
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A 16 year-old boy was stabbed in the right supraclavicular fossa. The sharp object punctured the portion of the parietal pleura that extends above the first rib. What is the name of this portion of the parietal pleura?
Your Answer: Cupola
Explanation:Endothoracic fascia: the connective tissue (fascia) that is between the costal parietal pleura and the inner wall of the chest wall.
Costomediastinal recess: the point where the costal pleura becomes mediastinal pleura.
Costodiaphragmatic recess: is the lowest point of the pleural sac where the costal pleura becomes diaphragmatic pleura.
Cupola: the part of the parietal pleura that extends above the first rib level into the root of the neck.
Costocervical recess: this is a made-up term.
Peritracheal fascia: a layer of connective tissue that invests the trachea. -
This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 159
Incorrect
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A 41 year old woman presents with discomfort in her left breast. On examination, she has a discrete, soft, fluctuant area in the upper outer quadrant of her left breast. A halo sign is observed on the mammogram. What is the most likely explanation for this process?
Your Answer: Ductal carcinoma in situ
Correct Answer: Breast cyst
Explanation:A breast cyst is a fluid-filled sac within the breast. They are often described as round or oval lumps with distinct edges. In texture, a breast cyst usually feels like a soft grape or a water-filled balloon, but can also feel firm.
Breast cysts can be painful and may be worrisome but are generally benign. They are most common in pre-menopausal women in their 30s or 40s. They usually disappear after menopause, but may persist or reappear when using hormone therapy. They are also common in adolescents. Breast cysts can be part of fibrocystic disease. The pain and swelling is usually worse in the second half of the menstrual cycle or during pregnancy.
The halo sign, described as a complete or partial radiolucent ring surrounding the periphery of a breast mass, has long been considered a mammographic sign indicating a benign process. The phenomenon is most frequently seen with cysts and fibroadenomas.
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This question is part of the following fields:
- Breast And Endocrine Surgery
- Generic Surgical Topics
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Question 160
Incorrect
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A 30-year-old male presents with a lump in his scalp. It is located approximately 4cm superior to the external occipital protuberance. It feels smooth and slightly fluctuant and has a centrally located small epithelial defect. What is the most likely underlying diagnosis?
Your Answer: Merkel cell tumour
Correct Answer: Sebaceous cyst
Explanation:Epidermoid cysts represent the most common cutaneous cysts. While they may occur anywhere on the body, they occur most frequently on the face, scalp, neck, and trunk.
Because most lesions originate from the follicular infundibulum, the more general term epidermoid cyst is favoured. The term sebaceous cyst should be avoided because it implies that the cyst is of sebaceous origin.
Epidermoid cysts are usually asymptomatic. Discharge of a foul-smelling “cheese like” material may be described. Less frequently, the cysts can become inflamed or infected, resulting in pain and tenderness. In the uncommon event of malignancy, rapid growth, friability, and bleeding may be reported.
Epidermoid cysts appear as flesh–coloured-to-yellowish, firm, round nodules of variable size. A central pore or punctum may be present.
Certain hereditary syndromes are associated with epidermoid cysts. Such syndromes include Gardner syndrome, basal cell nevus syndrome, and pachyonychia congenita. In addition, idiopathic scrotal calcinosis may actually represent an end-stage of dystrophic calcification of epidermoid cysts.
Epidermoid cysts may be removed via simple excision or incision with removal of the cyst and cyst wall through the surgical defect. If the entire cyst wall is not removed, the lesion may recur. Excision with punch biopsy technique may be used if the size of the lesion permits. Minimal-incision surgery, with reduced scarring, has been reported. An intraoral approach has been used to minimize facial scarring.
Incision and drainage may be performed if a cyst is inflamed. Injection of triamcinolone into the tissue surrounding the inflamed cyst results in a faster improvement in symptoms. This may facilitate the clearing of infection; however, it does not eradicate the cyst. -
This question is part of the following fields:
- Generic Surgical Topics
- Skin Lesions
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Question 161
Incorrect
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A 13 month old baby was taken to the hospital after his father saw that he had periorbital oedema for two days. He is seen by the doctor and noted to have facial oedema and a tender distended abdomen. His temperature is 39.1 and his blood pressure is 91/46 mmHg. There is also clinical evidence of poor peripheral perfusion. What is the diagnosis?
Your Answer: Sickle cell crisis
Correct Answer: Spontaneous bacterial peritonitis
Explanation:Answer: Spontaneous bacterial peritonitis
The presence of periorbital and facial oedema with normal blood pressure in this toddler indicates that he has nephrotic syndrome. Nephrotic syndrome can be associated with a series of complications that can affect an individual’s health and quality of life:
Spontaneous bacterial peritonitis can develop where there is ascites present. This is a frequent development in children but very rarely found in adults.Spontaneous bacterial peritonitis (SBP) is the development of a bacterial infection in the peritoneum, despite the absence of an obvious source for the infection. It is specifically an infection of the ascitic fluid – an increased volume of peritoneal fluid. Ascites is most commonly a complication of cirrhosis of the liver. It can also occur in patients with nephrotic syndrome. SBP has a high mortality rate.
The diagnosis of SBP requires paracentesis, a sampling of the peritoneal fluid taken from the peritoneal cavity. If the fluid contains large numbers of white blood cells known as neutrophils (>250 cells/µL), infection is confirmed and antibiotics will be given, without waiting for culture results. In addition to antibiotics, infusions of albumin are usually administered.
Signs and symptoms of spontaneous bacterial peritonitis (SBP) include fevers, chills, nausea, vomiting, abdominal pain and tenderness, general malaise, altered mental status, and worsening ascites. Thirteen percent of patients have no signs or symptoms. In cases of acute or chronic liver failure SBP is one of the main triggers for hepatic encephalopathy, and where there is no other clear causal indication for this, SBP may be suspected.
These symptoms can also be the same for a spontaneous fungal peritonitis (SFP) and therefore make a differentiation difficult. Delay of diagnosis can delay antifungal treatment and lead to a higher mortality rate.
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This question is part of the following fields:
- Generic Surgical Topics
- The Abdomen
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Question 162
Correct
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A 72 year old man suffered a MI. What is the approximate time needed by the scar tissue of the MI to recover and attain full strength?
Your Answer: Several months
Explanation:A week following a MI attack, a little collagen starts to form and deposit. By the end of the 2nd week, neovascularisation of the scar occurs, with some collagen being laid down in a haphazard fashion. By this time the scar attains some strength. During the next 6 months, collagen is constantly being laid down and is rearranged in order to shrink the scar. Most of the blood vessels by this time have regenerated, decreasing vascularity of the scar reaching full maturity.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 163
Incorrect
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A 55 year old man presented with a 4 day history of cough and fever. His sputum culture showed the presence of Strep pneumoniae. Which of the following substances produced by the inflammatory cells will result in effective clearance of this organism from the lung parenchyma?
Your Answer: Kallikrein
Correct Answer: Hydrogen peroxide
Explanation:Hydrogen peroxide is produced by myeloperoxidase to form a potent oxidant that eliminates bacteria, but is not effective in chronic granulomatous diseases.
Platelet activating factor will lead to the activation, adhesion and aggregation of platelets but will not directly kill bacteria.
Prostaglandins cause vasodilation but do not activate neutrophils.
Kallikrein promotes formation of bradykinin that leads to vasodilation.
Leukreines increase vascular permeability.
Cytokines are communicating molecules between immune cells but directly will not kill bacteria.
Interleukins will regulate the immune response. -
This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 164
Incorrect
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Which tumour site is more commonly involved in adults than in children?
Your Answer: Kidney
Correct Answer: Lung
Explanation:In adults, the most common primary site of tumour is in the lungs, compared to children wherein the most common primary site is the blood.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 165
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 166
Correct
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A 38-year old lady presented to the hospital with abnormal passing of blood per vagina. On examination, she was found to have an endocervical polypoidal mass. On enquiry, she gave history of oral contraceptive usage for 3 years. What finding is expected on the histopathology report of biopsy of the mass?
Your Answer: Microglandular hyperplasia
Explanation:Endocervical polyps or microglandular hyperplasia are benign growths occurring in the endocervical canal, in about 2-5% women and occur secondary to use of oral contraceptives. They are usually < 1cm in size, friable and reddish-pink. Usually asymptomatic, they can cause bleeding or become infected, leading to leucorrhoea (purulent vaginal discharge). They are usually benign but need to be differentiated from adenocarcinomas by histology.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 167
Correct
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Leakage from a silicone breast implant can lead to:
Your Answer: Pain and contracture
Explanation:Breast implants are mainly: saline-filled and silicone gel-filled. Complications include haematoma, fluid collections, infection at the surgical site, pain, wrinkling, asymmetric appearance, wound dehiscence and thinning of the breast tissue.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 168
Incorrect
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A 49 year old carpenter is rushed to the hospital after falling from the roof of a house. He has an open fracture of his tibia with a 14 cm wound and he is neurovascularly intact. What is the most appropriate course of action?
Your Answer: Combined skeletal and soft tissue reconstruction on a scheduled operating list
Correct Answer: Intravenous antibiotics, photography and application of saline soaked gauze with impermeable dressing
Explanation:The administration of antibiotics is best considered therapeutic, rather than prophylactic, because of the high risk of infection in the absence of antibiotics.
Although debate still surrounds some aspects of antibiotic administration for open fractures, the following generalizations can be made:
– All patients with open fractures should receive cefazolin or equivalent gram-positive coverage; this may be sufficient
– Type II or type III injuries likely benefit from the addition of adequate gram-negative coverage, typically with an aminoglycoside
– Injuries at risk for anaerobic infections (e.g., farm injuries, severe tissue necrosis) probably benefit from the addition of penicillin or clindamycin.Digital photos are helpful for documenting the initial appearance of the extremity and can be a valuable addition to the medical record. Digital imaging allows other members of the treatment team to see the wound preoperatively without repeated manipulations of the wound.
Gauze swabs soaked in normal saline are frequently used as dressing on open wounds.The Oxford Handbook for Medical school recommends that open fractures should be sealed with saline-soaked gauze and impermeable dressing after removal of gross contaminants.
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This question is part of the following fields:
- Generic Surgical Topics
- Orthopaedics
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Question 169
Incorrect
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The following organs would be expected to lie within the right lower quadrant of the abdomen, assuming that the gastrointestinal tract is rotated normally:
Your Answer: Distal duodenum and proximal jejunum
Correct Answer: Distal jejunum, caecum, vermiform appendix
Explanation:The abdomen is divided by theoretical anatomic lines into four quadrants. The median plane follows the linea alba and extends from the xiphoid process to the pubic symphysis and splits the abdomen in half. The transumbilical plane is a horizontal line that runs at the level of the umbilicus. This forms the upper right and left quadrants and the lower right and left quadrants. Structures in the right lower quadrant include: caecum, appendix, part of the small intestine, ascending colon, the right half of the female reproductive system, right ureter. Pain in this region is most commonly associated with appendicitis.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 170
Incorrect
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A 4-year-old boy inserts a crayon into his external auditory meatus. Attempts to remove it have not been successful. What is the best course of action?
Your Answer: Enlist the help of additional staff members to restrain the child before attempting to remove it again in the emergency department
Correct Answer: Operate on the next emergency operating list
Explanation:The removal of foreign bodies from the ear is a common procedure in the emergency department.
Abandon attempts to retrieve a foreign body if complications arise. If the object migrates farther into the canal or if bleeding, oedema, or increasing pain develops, consult an ENT specialist. Repeated attempts to remove a foreign body from the ear may result in infection, perforation, or another morbidity.
The presence of a tympanic membrane (TM) perforation, contact of a foreign body with the tympanic membrane, or incomplete visualization of the auditory canal are indications for urgent-emergent ENT consultation for removal by operative microscope and speculum.
Local anaesthesia is invasive and is not generally used for uncomplicated ear foreign body removal because of the complex innervations of the external ear canal. -
This question is part of the following fields:
- Generic Surgical Topics
- Paediatric Surgery
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Question 171
Incorrect
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Which of the following muscles attach to the hyoid bone?
Your Answer: Sternothyroid
Correct Answer: Middle pharyngeal constrictor
Explanation:The hyoid bone is a horseshoe-shaped bone situated in the anterior midline of the neck between the chin and the thyroid cartilage. A large number of muscles attach to the hyoid: Superiorly – the middle pharyngeal constrictor muscle, hyoglossus muscle, genioglossus, intrinsic muscles of the tongue and suprahyoid muscles. Inferiorly – the thyrohyoid muscle, omohyoid muscle and sternohyoid muscle.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 172
Incorrect
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A 27-year-old woman who is 32 weeks pregnant is struck by a car. On arrival in the emergency department, she has a systolic blood pressure of 105 mmHg and a pulse rate of 126 bpm. Abdominal examination demonstrates diffuse tender abdomen and some bruising of the left flank. The FAST scan is normal. What should be the most appropriate course of action?
Your Answer: Arrange a departmental abdominal USS
Correct Answer: Arrange an urgent abdominal CT scan
Explanation:The patient’s history and examination point towards a significant visceral injury. FAST scan is associated with a false-negative result in pregnancy which makes the normal result, in this scenario, less reassuring. CT scan of the abdomen remains the gold standard for diagnosis.
Sonography and FAST scanning are established in pregnancy and provide the advantage of avoiding ionising radiations. However, the sensitivity of the FAST scan is reduced in pregnancy especially with advanced gestational age. CT scan remains the first-line investigation in major trauma where significant visceral injury is suspected. The maximum permitted safe dose of radiation in pregnancy is 5 mSv.
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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 173
Incorrect
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A 40-year-old motorcyclist is involved in a road traffic accident. A FAST scan in the emergency department shows free intrabdominal fluid. A laparotomy is performed during which there is evidence of small liver laceration that has stopped bleeding and a tear to the inferior pole of the spleen. What is the best course of action?
Your Answer: Fully mobilise the spleen to inspect it
Correct Answer: Attempt measures to conserve the spleen
Explanation:Spleen injuries are among the most frequent trauma-related injuries. At present, they are classified according to the anatomy of the injury. The optimal treatment strategy, however, should take into consideration the hemodynamic status, the anatomic derangement, and the associated injuries. The management of splenic trauma patients aims to restore the homeostasis and the normal physiopathology especially considering the modern tools for bleeding management.
The trend in the management of splenic injury continues to favour nonoperative or conservative management. This varies from institution to institution but usually includes patients with stable hemodynamic signs, stable haemoglobin levels over 12-48 hours, minimal transfusion requirements (2 U or less), CT scan injury scale grade of 1 or 2 without a blush, and patients younger than 55 years.
Surgical therapy is usually reserved for patients with signs of ongoing bleeding or hemodynamic instability. In some institutions, CT scan–assessed grade V splenic injuries with stable vitals may be observed closely without operative intervention, but most patients with these injuries will undergo exploratory laparotomy for more precise staging, repair, or removal.A retrospective analysis by Scarborough et al compared the effectiveness of nonoperative management with immediate splenectomy for adult patients with grade IV or V blunt splenic injury. The study found that both approaches had similar rates of in-hospital mortality (11.5% in the splenectomy group vs 10.0%), however, there was a higher incidence of infectious complications in the immediate splenectomy group. The rate of failure in the nonoperative management was 20.1% and symptoms of a bleeding disorder, the need for an early blood transfusion, and grade V injury were all early predictors of nonoperative management failure.
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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 174
Incorrect
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An episiotomy is indicated for a woman during a difficult vaginal delivery. Whilst the registrar was performing this procedure she made a median cut too far through the perineal body cutting the structure immediately posterior. Which structure is this?
Your Answer: Ischiocavernosus muscle
Correct Answer: External anal sphincter
Explanation:An episiotomy is an incision that is made whenever there is a risk of a tear during vaginal deliver. A posterolateral incision, as opposed to a median incision is preferred. Of the options given, the external anal sphincter lies right posterior to the perineal body. The sacrospinous and the sacrotuberous ligaments are deep in the perineum that they should not be involved in this.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 175
Incorrect
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What is the chief ligament preventing posterior sliding of the tibia on the femur ?
Your Answer: Fibular collateral
Correct Answer: Posterior cruciate
Explanation:The posterior cruciate ligament is attached to the posterior intercondyloid fossa of the tibia and the lateral and front part of the medial condyle of the femur. It resists sliding of the tibia posteriorly.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 176
Incorrect
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A 42 year old female has a redo thyroidectomy for a multinodular goitre. She develops oculogyric crises and diffuse muscle spasm a day after completing surgery. Which of the following is the best course of action?
Your Answer: Return the patient to theatre for wound exploration
Correct Answer: Administration of intravenous calcium
Explanation:Tetany: A condition that is due usually to low blood calcium (hypocalcaemia) and is characterized by spasms of the hands and feet, cramps, spasm of the voice box (larynx), and overactive neurological reflexes. Tetany is generally considered to result from very low calcium levels in the blood. However, tetany can also result from reduction in the ionized fraction of plasma calcium without marked hypocalcaemia, as is the case in severe alkalosis (when the blood is highly alkaline).
Hypocalcaemic tetany (HT) is the consequence of severely lowered calcium levels (<2.0 mmol/l), usually in patients with chronic hypocalcaemia. The causal disease for hypocalcaemic tetany is frequently a lack of parathyroid hormone (PTH), (e. g. as a complication of thyroid surgery) or, rarely, resistance to PTH. HT due to severe and painful clinical symptoms requires rapid i. v. calcium replacement by central venous catheter on an intensive care unit.
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This question is part of the following fields:
- Breast And Endocrine Surgery
- Generic Surgical Topics
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Question 177
Correct
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The chest X-ray of an 10-year-old boy, that presented with low-grade fever and cough, revealed hilar enlargement and parenchymal consolidation in the middle lobes. These X-ray findings are more typical for which of the following diagnoses?
Your Answer: Pulmonary tuberculosis
Explanation:Primary pulmonary tuberculosis is seen in patients exposed to Mycobacterium tuberculosis for the firs time. The main radiographic findings in primary pulmonary tuberculosis include homogeneous parenchymal consolidation typically in the lower and middle lobes, lymphadenopathy, miliary opacities and pleural effusion.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 178
Incorrect
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A patient presents with loss of pain and temperature sensation in the left leg. He is likely to have a lesion involving:
Your Answer: Left anterior spinothalamic tract
Correct Answer: Right lateral spinothalamic tract
Explanation:The spinothalamic tract is a sensory pathway originating in the spinal cord that transmits information to the thalamus. There are two main parts of the spinothalamic tract: the lateral spinothalamic tract transmits pain and temperature and the anterior spinothalamic tract transmits touch (crude touch). The decussation of this pathway occurs at the level of the spinal cord. Hence, a unilateral lesion of the lateral spinothalamic tract causes contralateral loss of pain and temperature.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 179
Incorrect
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A 48 year old woman with episodes of recurrent urinary tract sepsis presents with a staghorn calculus of the right kidney. Her urinary pH is 7.8. An abdominal x-ray shows a faint outline of the calculus. What would be the most likely composition of the stone?
Your Answer: Calcium oxalate
Correct Answer: Struvite
Explanation:Staghorn calculi refer to branched stones that fill all or part of the renal pelvis and branch into several or all of the calyces. They are most often composed of struvite (magnesium ammonium phosphate) and/or calcium carbonate apatite. These stones are often referred to as ‘infection stones’ since they are strongly associated with urinary tract infections with urea splitting organisms. Small struvite and/or calcium carbonate apatite stones can grow rapidly over a period of weeks to months into large staghorn calculi involving the calyces and entire renal pelvis. If left untreated, this can lead to deterioration of kidney function and end-stage renal disease. In addition, since the stones often remain infected, there is a risk of developing sepsis. Thus, most patients require definitive surgical treatment.
Struvite stones account for 15% of renal calculi. They are associated with chronic urinary tract infection (UTI) with gram-negative, urease-positive organisms that split urea into ammonia, which then combines with phosphate and magnesium to crystalize into a calculus. Usual organisms include Proteus, Pseudomonas, and Klebsiella species. Escherichia coli is not capable of splitting urea and, therefore, is not associated with struvite stones. Because ammonia, a base, is produced during the catalytic process, the urine pH is typically greater than 7.
Underlying anatomical abnormalities that predispose patients to recurrent kidney infections should be sought and corrected. UTI does not resolve until the stone is removed entirely.
This patient has a urine pH of 7.8 which is very alkaline. -
This question is part of the following fields:
- Generic Surgical Topics
- Urology
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Question 180
Correct
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Painful erections along with deviation of the penis to one side when erect are seen in which of the following conditions?
Your Answer: Peyronie’s disease
Explanation:Peyronie’s disease leads to development of fibrous plaques in the penile soft tissue and occurs in 1% of men, most commonly affecting white males above 40 years age. It is a connective tissue disorder named after a French surgeon, François de la Peyronie who first described it. Symptoms include pain, hard lesions on the penis, abnormal curvature of erect penis, narrowing/shortening, painful sexual intercourse and in later stages, erectile dysfunction. 30% cases report fibrosis in other elastic tissues such as Dupuytren’s contractures of the hand. There is likely a genetic predisposition as increased incidence is noted among the male relatives of an affected individual.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 181
Incorrect
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A 4-year-old boy develops a persistent fever following an open appendicectomy for gangrenous appendicitis. On examination, he has erythema of the wound and some abdominal distension. What is the most appropriate course of action?
Your Answer: Arrange an abdominal CT scan
Correct Answer: Arrange an abdominal ultrasound scan
Explanation:Post-operative fever is very common.
It is known to occur after all types of surgical procedures, irrespective of the type of anaesthesia.
Postoperative fever can occur after minor surgical procedures but is rare and depends on the type of procedure. Overall, both abdominal and chest procedures result in the highest incidence of postoperative fever.In this case:
Acute Fever
Fever occurs in the first week (1 to 7 POD)
POD 7 (5 to 10): Wound infection: Risk increases if the patient is immunocompromised (e.g., diabetic), abdominal wound, duration of surgery greater than 2 hours or contamination during surgery. Signs include erythema, warmth, tenderness, discharge.
Rule out abscess or collections by physical exam plus ultrasound if needed. If an abscess is present, drainage and antibiotics are needed. Prevention is by careful surgical technique and prophylactic antibiotics (e.g., intravenous cefazolin at the time of induction of anaesthesia as well as postoperatively if needed)Other causes of Postoperative fever:
An Immediate Fever
Fever occurs immediately after surgery or within hours on postoperative days (POD) 0 or 1.
– Malignant hyperthermia: high-grade fever (greater than 40 C), occurs shortly after inhalational anaesthetics or muscle relaxant (e.g., halothane or succinylcholine), may have a family history of death after anaesthesia. Laboratory studies will reveal with metabolic acidosis and hypercalcemia. If not readily recognized, it can cause cardiac arrest. The treatment is intravenous dantrolene, 100% oxygen, correction of acidosis, cooling blankets, and watching for myoglobinuria.
– Bacteraemia: High-grade fever (greater than 40 C) occurring 30 to 40 minutes after the beginning of the procedure (e.g., Urinary tract instrumentation in the presence of infected urine). Management includes blood cultures three times and starting empiric antibiotics.
– Gas gangrene of the wound: High-grade fever (greater than 40 C) occurring after gastrointestinal (GI) surgery due to contamination with Clostridium perfringens; severe wound pain; treat with surgical debridement and antibiotics.
– Febrile non-haemolytic transfusion reaction: Fevers, chills, and malaise 1 to 6 hours after surgery (without haemolysis). Management: Stop transfusion (rule out haemolytic transfusion reaction) and give antipyretics (avoid aspirin in the thrombocytopenic patient).B. Acute Fever
– Fever occurs in the first week (1 to 7 POD).
POD 1 to 3: atelectasis: After prolonged intubation, the presence of upper abdominal incision, inadequate postoperative pain control, lying supine. Should be prevented by incentive spirometry, semi-recumbent position, adequate pain control, early ambulation. Clinically may be asymptomatic or with increased work of breathing, respiratory alkalosis, chest x-ray with volume loss. Treatment includes spirometry, chest physiotherapy, semi-recumbent position (improves expansion of alveoli by preventing pressure from intra-abdominal organs on the diaphragm and hence improving functional residual capacity)
– POD 3: Unresolved atelectasis resulting in pneumonia (respiratory symptoms, Chest x-ray with infiltrate or consolidation, sputum culture, empiric antibiotics and modify according to culture result and sensitivity), or development of urinary tract infection (urine analysis and culture, treat with empiric antibiotics and modify according to culture result and sensitivity)
– POD 5: Thrombophlebitis (may be asymptomatic or symptomatic, diagnose with Doppler ultrasound of deep leg and pelvic veins and treat with heparin)
– POD 7: Pulmonary embolism (tachycardia, tachypnoea, pleuritic chest pain, ECG with right heart strain pattern (a low central venous pressure goes against diagnosis), arterial blood gas with hypoxemia and hypocapnia, confirm diagnosis with CT angiogram, and treat with heparin, if recurrent pulmonary embolism while anticoagulated with therapeutic INR, Inferior vena cava filter placement is the next stepC. Subacute Fever
Fever occurs between postoperative weeks 1 and 4.
– POD 10: Deep infection (pelvic or abdominal abscess and if abdominal abscess could be sub-hepatic or sub-phrenic). A digital rectal exam to rule out the pelvic abscess and CT scan to localize intra-abdominal abscess. Treatment includes re-exploration vs. radiological guided percutaneous drainage
Drugs: Diagnosis of exclusion includes rash and peripheral eosinophiliaD. Delayed Fever
Fever after more than 4 weeks.
Skin and soft tissue infections (SSTI)
Viral infections -
This question is part of the following fields:
- Principles Of Surgery-in-General
- Surgical Technique And Technology
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Question 182
Incorrect
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Question 183
Incorrect
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A 20-year-old woman is admitted with right upper quadrant pain. On examination, there is tenderness in the right upper quadrant region. Imaging shows signs of acute cholecystitis due to gallstones. The common bile duct appears normal and liver function tests are normal as well. What should be the most appropriate course of action?
Your Answer: Laparoscopic cholecystectomy 3 months following resolution of the attack
Correct Answer: Laparoscopic cholecystectomy during the next 24–48 hours
Explanation:In most cases, the treatment of choice for acute cholecystitis is cholecystectomy performed early in the illness. The procedure can be carried out laparoscopically even when acute inflammation is present. Delayed surgery particularly around five to seven days after presentation is much more technically challenging and is often best deferred.
Up to 24% of women and 12% of men may have gallstones. Of these, up to 30% may develop local infection and cholecystitis. The classical symptom of cholecystitis is colicky right upper quadrant pain that occurs postprandially. Others include swinging pyrexia, and general feeling of being unwell. They are usually worst following a fatty meal when cholecystokinin levels are highest and gallbladder contraction is maximal.
Murphy’s sign is positive on examination. The standard diagnostic work-up consists of abdominal ultrasound and liver function tests. For management, cholecystectomy should ideally be done within 48 hours of presentation. In patients unfit for surgery, percutaneous drainage may be considered.
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This question is part of the following fields:
- Generic Surgical Topics
- Hepatobiliary And Pancreatic Surgery
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Question 184
Incorrect
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A 19-year-old female presents to the oncology clinic after noticing a painless neck lump. On examination, she is noted to have bilateral thyroid masses and multicentric nodules near the base of the thyroid. Her corrected calcium level is 2.18 mg/dL. Which of the following is the most likely diagnosis?
Your Answer: Toxic nodular goitre
Correct Answer: Medullary carcinoma of the thyroid associated with multiple endocrine neoplasia
Explanation:Based on the aforementioned findings in this case, the most likely diagnosis is medullary carcinoma of the thyroid associated with multiple endocrine neoplasia (MEN).
Medullary thyroid cancer is a tumour of the parafollicular cells (C cells) of the thyroid and is neural crest in origin. It may be familial and occur as part of the MEN 2A disease spectrum. Less than 10% of thyroid cancers are of this type with patients typically presenting as children or young adults. Diarrhoea occurs in 30% of the cases. In association with MEN syndromes, medullary thyroid cancers are always bilateral and multicentric. Spread may either be lymphatic or haematogenous, and as these tumours are not derived primarily from thyroid cells, they are not responsive to radioiodine.
Toxic nodular goitre is very rare. In sporadic medullary carcinoma of the thyroid, patients typically present with a unilateral solitary nodule and it tends to spread early to the lymph nodes in neck.
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This question is part of the following fields:
- Generic Surgical Topics
- Head And Neck Surgery
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Question 185
Incorrect
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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: Hyperviscosity
Correct 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 186
Incorrect
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A 15-day old male baby was brought to the emergency department with sweating and his lips turning blue while feeding. He was born full term. On examination, his temperature was 37.9°C, blood pressure 75/45 mmHg, pulse was 175/min, and respiratory rate was 42/min. A harsh systolic ejection murmur could be heard at the left upper sternal border. X-ray chest showed small, boot-shaped heart with decreased pulmonary vascular markings. He most likely has:
Your Answer: Anomalous left coronary artery
Correct Answer: Tetralogy of Fallot
Explanation:The most common congenital cyanotic heart disease and the most common cause of blue baby syndrome, Tetralogy of Fallot shows four cardiac malformations occurring together. These are ventricular septal defect (VSD), pulmonary stenosis (right ventricular outflow obstruction), overriding aorta (degree of which is variable), and right ventricular hypertrophy. The primary determinant of severity of disease is the degree of pulmonary stenosis. Tetralogy of Fallot is seen in 3-6 per 10,000 births and is responsible for 5-7% congenital heart defects, with slightly higher incidence in males. It has also been associated with chromosome 22 deletions and DiGeorge syndrome. It gives rise to right-to-left shunt leading to poor oxygenation of blood. Primary symptom is low oxygen saturation in the blood with or without cyanosis at birth of within first year of life. Affected children ay develop acute severe cyanosis or ‘tet spells’ (sudden, marked increase in cyanosis, with syncope, and may result in hypoxic brain injury and death). Other symptoms include heart murmur, failure to gain weight, poor development, clubbing, dyspnoea on exertion and polycythaemia. Chest X-ray reveals characteristic coeur-en-sabot (boot-shaped) appearance of the heart. Treatment consists of immediate care for cyanotic spells and Blalock–Taussig shunt (BT shunt) followed by corrective surgery.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 187
Correct
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A young lady visited a doctor with complaints of fever and a dull, continuous pain in the right lumbar region for 6 days. On, enquiry, she recalled passing an increasing number of stools with occasional blood in last few months. Lower gastrointestinal endoscopic biopsy was taken 5 cm proximal to ileocaecal valve which showed transmural inflammation with several granulomas. Tissue section showed the absence of acid-fast bacillus. She denies any history of travel and her stool cultures were negative. What is the likely diagnosis?
Your Answer: Crohn’s disease
Explanation:Crohn’s disease is a chronic, inflammatory disease that can affect any part of the gastrointestinal tract but is usually seen in the distal ileum and colon. It is transmural and symptoms include chronic diarrhoea, abdominal pain, fever, anorexia and weight loss. On examination, there is usually abdominal tenderness with a palpable mass or fullness seen occasionally. Rectal bleeding is uncommon (except in isolated colonic involvement) which manifests like ulcerative colitis. Differential diagnosis includes acute appendicitis or intestinal obstruction. 25%-33% patients also have perianal disease in the form of fissure or fistulas.
Extra intestinal manifestations predominate in children, and include: arthritis, pyrexia, anaemia or growth retardation. Histologically, the disease shows crypt inflammation and abscesses initially, which progress to aphthoid ulcers. These eventually develop into longitudinal and transverse ulcers with interspersed mucosal oedema, leading to the characteristic ‘cobblestoned appearance’. Transmural involvement leads to lymphoedema and thickening of bowel wall and mesentery, leading to extension of mesenteric fat on the serosal surface of bowel and enlargement of mesenteric nodes. There can also be hypertrophy of the muscularis mucosae, fibrosis and stricture formation, which can cause bowel obstruction. Abscesses are common and the disease can also leas to development of fistulas with various other organs, anterior abdominal wall and adjacent muscles. Pathognomonic non-caseating granulomas are seen in 50% cases and they can occur in nodes, peritoneum, liver, and in all layers of the bowel wall. The clinical course does not depend on the presence of granulomas. There is sharp demarcation between the diseased and the normal bowel (skip areas).
35% cases show only the ileal involvement, whereas in 45% cases, both the ileum and colon are involved with a predilection for right side of colon. 20% cases show only colonic involvement, often sparing the rectum (unlike ulcerative colitis). In occasional cases, there is jejunoileitis – involvement of the entire small bowel. The stomach, duodenum and oesophagus are rarely involved, although there has been microscopic evidence of disease involving the gastric antrum in younger patients. The affected small bowel segments show increased rick of cancer. Moreover, patients with colonic disease show a long-term risk of cancer similar to that seen in ulcerative colitis. -
This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 188
Correct
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A 42-year-old female has undergone a total thyroidectomy for multinodular goitre. You are called to see her because of respiratory distress. On examination, she has marked stridor, her wound seems healthy but there is a swelling within the operative site. What is the most likely explanation for this problem?
Your Answer: Contained haematoma
Explanation:Airway obstruction: In the first 24 hours it is most likely from a compressive hematoma. After 24 hours consider laryngeal dysfunction secondary to hypocalcaemia.
In this patient, the most likely cause is a haematoma.
Definitive therapy is opening the surgical incision to evacuate the hematoma. Re-intubation may be lifesaving for persistent airway obstruction. Consider awake fibreoptic intubation. -
This question is part of the following fields:
- Peri-operative Care
- Principles Of Surgery-in-General
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Question 189
Incorrect
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A 37 year old man is reported to have a left-sided renal mass. Imaging reveals a renal tumour measuring 5 cm that has invaded the left renal vein. Which of the following is the most appropriate step in the management of this patient?
Your Answer: Neoadjuvant chemotherapy
Correct Answer: Radical nephrectomy
Explanation:In a radical nephrectomy, the surgeon removes the whole kidney, the fatty tissues surrounding the kidney and a portion of the tube connecting the kidney to the bladder (ureter). The surgeon may remove the adrenal gland that sits atop the kidney if a tumour is close to or involves the adrenal gland. Radical nephrectomy is the treatment of choice for localized renal cell carcinoma (RCC). Biopsy should not be performed when a nephrectomy is planned but is mandatory before any ablative therapies are undertaken.
Renal cell carcinoma comprise up to 85% of all renal malignancies. Males are more commonly affected than females and sporadic tumours typically affect patients in their sixth decade.
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This question is part of the following fields:
- Generic Surgical Topics
- Urology
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Question 190
Incorrect
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Which tumour occurs in young adults, affecting the epiphyses of the bones and sometimes extending to the soft tissues?
Your Answer: Osteoid osteoma
Correct Answer: Benign giant-cell tumour
Explanation:Benign giant-cell tumours tend to affect adults in their twenties and thirties, occur in the epiphyses and can erode the bone and extend into the soft tissues. These tumours have a strong tendency to recur.
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This question is part of the following fields:
- Basic Sciences
- Pathology
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Question 191
Incorrect
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A 68 year old woman who underwent a mastectomy with axillary node clearance for breast cancer is going to have a drain inserted to prevent seroma development. Which of the following devices should ideally be used?
Your Answer: Use of a VAC wound closure system
Correct Answer: A closed suction drainage system made of polypropylene
Explanation:A surgical drain is a tube used to remove pus, blood or other fluids from a wound. They are commonly placed by surgeons or interventional radiologists. Suction is applied through the drain to generate a vacuum and draw fluids into a bottle. Following breast surgery, it is standard practice to use a Redivac type system that is made of polypropylene.
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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 192
Incorrect
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Which of the following is the cause of flattened (notched) T waves on electrocardiogram (ECG)?
Your Answer: Myocardial infarction
Correct Answer: Hypokalaemia
Explanation:The T-wave is formed due to ventricular repolarisation. Normally, it is seen as a positive wave. It can be normally inverted (negative) in V1 (occasionally in V2-3 in African-Americans/Afro-Caribbeans). Hyperacute T-waves are the earliest ECG change of acute myocardial infarction. ECG findings of hyperkalaemia include high, tent-shaped T-waves, a small P-wave and a wide QRS complex. Hypokalaemia results in flattened (notched) T-waves, U-waves, ST-segment depression and prolonged QT interval.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 193
Incorrect
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What is the arterial sequence for an analgesic to reach the latissimus dorsi muscle assuming that your starting point is at the subclavian vein?
Your Answer: Subclavian – axillary – thyrocervical trunk – suprascapular
Correct Answer: Subclavian – axillary – subscapular – thoracodorsal
Explanation:Assuming our starting point is the subclavian artery, the analgesic continues in the same vessel into the axillary artery, as it passes into the axilla. The axillary artery at the lower border of the subscapularis gives rise to the subcapsular artery which is considered the largest branch of the axillary artery. This circumflex scapular branch distributes a serratus branch before entering the substance of the muscle as the thoracodorsal artery.
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This question is part of the following fields:
- Anatomy
- Basic Sciences
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Question 194
Correct
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A 79-year-old has been bedridden for 2 months after suffering from a stroke. She suddenly developed shortness of breath and chest pain, and was diagnosed with a pulmonary embolism. Which of the following is most likely to increase in this case?
Your Answer: Ventilation/perfusion ratio
Explanation:Pulmonary embolism (PE) is a blockage of an artery in the lungs by an embolus that has travelled from elsewhere in the body through the bloodstream. The change in cardiopulmonary function is proportional to the extent of the obstruction, which varies with the size and number of emboli obstructing the pulmonary arteries. The resulting physiological changes may include pulmonary hypertension with right ventricular failure and shock, dyspnoea with tachypnoea and hyperventilation, arterial hypoxaemia and pulmonary infarction. Consequent alveolar hyperventilation is manifested by a lowered pa(CO2). After occlusion of the pulmonary artery, areas of the lung are ventilated but not perfused, resulting in wasted ventilation with an increased ventilation/perfusion ratio – the physiological hallmark of PE – contributing to a further hyperventilatory state. The risk of blood clots is increased by cancer, prolonged bed rest, smoking, stroke, certain genetic conditions, oestrogen-based medication, pregnancy, obesity, and post surgery.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 195
Incorrect
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A drug abuser developed an infection which spread from the dorsum of the hand to the medial side of the arm along the course of the large cutaneous vein. Which vein is involved?
Your Answer: 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 196
Incorrect
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Signals pass through neuromuscular junctions via the neurotransmitter acetylcholine. After release from the skeletal neuromuscular junction, acetylcholine:
Your Answer: Activates presynaptic potassium channels
Correct Answer: Causes postsynaptic depolarisation
Explanation:Acetylcholine is released from the presynaptic membrane into the cleft where it binds to the ion gated channels on the post synaptic membrane, causing them to open. This results in sodium entering into the fibre and further depolarizing it, creating an action potential.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 197
Incorrect
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Ventricular filling follows a delay caused by?
Your Answer: Bundle branches
Correct Answer: AV node
Explanation:The AV node is a conducting tissue found between the atria and the ventricles of the heart. It conducts electrical signal from the atria to the ventricles and acts a delaying mechanism preventing the atria and the ventricles from contracting at the same time. This decremental conduction prevents premature ventricular contraction in cases such as atrial fibrillation. A delay in the AV node is the reason for the PR segment seen on the ECG. In certain types of supraventricular tachycardia, a person could have two AV nodes; this will cause a loop in electrical current and uncontrollably rapid heart beat. When this electricity catches up with itself, it will dissipate and return to a normal heart rate.
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This question is part of the following fields:
- Basic Sciences
- Physiology
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Question 198
Correct
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A 30-year-old male presents to the clinic with a recurrent thyroid cyst. It has been drained on three different occasions. Each time the cyst is aspirated and cytology is reassuring. What is the most appropriate course of action?
Your Answer: Resection of the ipsilateral thyroid lobe
Explanation:Aspiration is the treatment of choice in thyroid cysts, but the recurrence rates are high (60%–90% of patients), particularly with repeated aspirations and large-volume cysts.
Percutaneous ethanol injection (PEI) has been studied in several large randomized controlled studies, with reported success in 82–85% of the cases after an average of 2 sessions, with a volume reduction of more than 85% from baseline size.
PEI may also be considered for hyperfunctioning nodules, particularly if a large fluid component is present. It has a success rate ranging from 64% to 95%, with a mean volume reduction of 66%, but recurrences are more common and the number of sessions required to achieve good response is higher (about 4 sessions per patient). PEI is a safe procedure, with the most common reported adverse effects being local pain, dysphonia, flushing, dizziness, and, rarely, recurrent laryngeal nerve damage.
Surgery, Lobectomy is also a reasonable therapy for cystic lesions, as an alternative to the previously mentioned procedures. -
This question is part of the following fields:
- Breast And Endocrine Surgery
- Generic Surgical Topics
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Question 199
Incorrect
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A 32-year-old motorist was involved in a road traffic accident in which he collided head-on with another car at high speed. He was wearing a seatbelt and the airbags were deployed. When rescuers arrived, he was conscious and lucid but died immediately after. What could have explained his death?
Your Answer: Haemopericardium
Correct Answer: Aortic transection
Explanation:Aortic transection was the underlying cause of death in this patient.
Aortic transection, or traumatic aortic rupture, is typically the result of a blunt aortic injury in the context of rapid deceleration. This condition is commonly fatal as blood in the aorta is under great pressure and can quickly escape the vessel through a tear, resulting in rapid haemorrhagic shock and death. A temporary haematoma may prevent the immediate death. Injury to the aorta during a sudden deceleration commonly originates near the terminal section of the aortic arch, also known as the isthmus. This portion lies just distal to the take-off of the left subclavian artery at the intersection of the mobile and fixed portions of the aorta. As many as 80% of the patients with aortic transection die at the scene before reaching a trauma centre for treatment.
A widened mediastinum may be seen on the X-ray of a person with aortic rupture.
Other types of thoracic trauma include:
1. Tension pneumothorax and pneumothorax
2. Haemothorax
3. Flail chest
4. Cardiac tamponade
5. Blunt cardiac injury
6. Pulmonary contusion
7. Diaphragm disruption
8. Mediastinal traversing wounds -
This question is part of the following fields:
- Emergency Medicine And Management Of Trauma
- Principles Of Surgery-in-General
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Question 200
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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SESSION STATS - PERFORMANCE PER SPECIALTY
