emrcs questions Flashcards
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Which of the following signs is seen in patients who have a significant retroperitoneal haemorrhage?
Bruising of the flank is described as Grey Turners sign
abdominal signs
rovsings sign?
boas sign?
Murphys sign?
Cullens sign?
grey-turners sign
Rovsings sign- appendicitis
Boas sign -cholecystitis
Murphys sign- cholecystitis
Cullens sign- pancreatitis (other intraabdominal haemorrhage)
Grey-Turners sign- pancreatitis (or other retroperitoneal haemorrhage)
In which of the conditions listed below is Cullens sign most likely to be seen?
Ruptured ectopic pregnancy
Appendicitis
Intestinal malrotation
Perforated peptic ulcer
Incarcerared femoral hernia
Ruptured ectopic pregnancy
Explanation Cullens sign is seen with significant intra peritoneal haemorrhage.
In which of the conditions described below is Rovsing’s sign most likely to be absent?
Locally advanced caecal cancer
Para ileal appendicitis
Right sided colonic diverticulitis
Retrocaecal appendicitis
Severe terminal ileal Crohns disease
Retrocaecal appendicitis
Explanation Any advanced right iliac fossa pathology can result in a positive Rovsings sign. However, in retrocaecal appendicitis, it may be absent and this fact can contribute to a delayed diagnosis if undue weight is placed on the presence of the sign in making the diagnosis.
Which of the following is commonest cause of acute abdominal pain in acute unselected surgical ‘take’?
Non specific abdominal pain
Biliary colic
Acute appendicitis
Ureteric colic
Pancreatitis
non specific abdominal pain
A 28 year old female has suffered from diffuse abdominal pain for the past 2 weeks since she was started on the contraceptive pill. The pain has increased significantly over the past 10 hours and has been associated with vomiting. A pregnancy test is negative. What is the most likely diagnosis?
Mesenteric venous thrombosis
Acute mesenteric embolus
Chronic mesenteric ischaemia
Ruptured ectopic pregnancy
The abdomen
Inflammatory bowel disease
Mesenteric venous thrombosis is the likely underlying cause and an angiogram is the sensible step as it will also facilitate the identification of areas of infarcted bowel , similar to that which may occur in the leg when massive DVT is present.
An 8 year-old boy of Caribbean descent presents with periumbilical abdominal pain. He has vomited twice and is refusing fluids. His temperature is 38.1 o C and blood tests are as follows: Haemoglobin 8 g/dl, WCC 13 x 10 9 /l, with a neutrophilia. What is the most likely diagnosis?
Pancreatitis
Sickle cell crisis
Appendicitis
Intussusception
Spontaneous bacterial peritonitis
Anaemia is seldom seen in appendicitis and if present should prompt a search for an alternative underlying diagnosis.
Sickle cell anaemia is characterised by severe chronic haemolytic anaemia resulting from poorly formed erythrocytes. Painful crises result from vaso-occlusive episodes, which may occur spontaneously or may be precipitated by infection. Consider this diagnosis in all children of appropriate ethnic background.
A 15-month-old girl presents with a three day history of periorbital oedema. She is brought to hospital. On examination she has facial oedema and a tender distended abdomen. Her temperature is 39 o C and her blood pressure is 90/45 mmHg. There is clinical evidence of poor peripheral perfusion. What is the most likely diagnosis?
Sickle cell crisis
Intussusception
Spontaneous bacterial peritonitis
Henoch Schonlein purpura
Appendicitis
Spontaneous bacterial peritonitis
Explanation The 15-month-old girl is a patient with nephrotic syndrome. Patients with this condition are at risk of septicaemia and peritonitis from Streptococcus pneumonia, due to the loss of immunoglobulins and opsonins in the urine.
A 53 year old man undergoes a reversal of a loop colostomy. He recovers well and is discharged home. He is readmitted 10 days later with symptoms of vomiting and colicky abdominal pain. On examination, he has a swelling of the loop colostomy site and it is tender. What is the most likely underlying diagnosis?
Haematoma
Intra abdominal adhesions
Anastomotic leak
Anastomotic stricture
Obstructed incisional hernia
n this scenario the most likely diagnosis would be obstructed incisional hernia. The tender swelling coupled with symptoms of obstruction point to this diagnosis. Prompt surgical exploration is warranted. Loop colostomy reversals are at high risk of this complication as the operative site is at increased risk of the development of post operative wound infections.
Acute incisional hernia
Any surgical procedure involving entry into a cavity containing viscera may be complicated by post operative hernia
The abdomen is the commonest site
The deep layer of the wound has usually broken down, allowing internal viscera to protrude through
Management is dictated by the patients clinical status and the timing of the hernia in relation to recent surgery
Bowel obstruction or tenderness at the hernia site both mandate early surgical intervention to reduce the risk of bowel necrosis
Mature incisional hernias with a wide neck, and no symptoms, may be either left or listed for elective repair
Risk factors for the development of post operative incisional hernias include; post operative wound infections, long term steroid use, obesity and chronic cough
A 72 year old lady is suspected of having a femoral hernia. At which of the following sites is it most likely to be identifiable clinically?
Mid inguinal point
Above and medial to the pubic tubercle
Below and lateral to the pubic tubercle
Mid point of the inguinal ligament
3 cm superomedially to the superficial inguinal ring
Below and lateral to the pubic tubercle
Explanation Femoral hernias exit the femoral canal below and lateral to the pubic tubercle. Femoral hernia occur mainly in women due to their difference in pelvic anatomy. They are at high risk of strangulation and therefore should be repaired.
A 32 year old male is noted to have a tender mass in the right groin area. There are also red streaks on the thigh, extending from a small abrasion. What is the most likely explanation?
Lymphadenitis
Saphena varix
Femoral artery aneurysm
Abscess
Incarcerated hernia
The red streaks are along the line of the lymphatics, indicating infection of the lymphatic vessels. Lymphadenitis is infection of the local lymph nodes.
A 21 year old man is admitted with a tender mass in the right groin, fevers and sweats. He is on multiple medical therapy for HIV infection. On examination, he has a swelling in his right groin, hip extension exacerbates the pain. What is the most likely cause?
Septic arthritis
Psoas abscess
Infected lymph node
HIV related lymphadenopathy
Femoral hernia
Psoas abscesses may be either primary or secondary. Primary cases often occur in the immunosuppressed and may occur as a result of haematogenous spread. Secondary cases may complicated intra abdominal diseases such as Crohns. Patients usually present with low back pain and if the abscess is extensive a mass that may be localised to the inguinal region or femoral triangle . Smaller collections may be percutaneously drained. If the collection is larger, or the percutaneous route fails, then surgery (via a retroperitoneal approach) should be performed.
A 25 year-old lady presents to her GP complaining of a two day history of right upper quadrant pain, fever and a white vaginal discharge. She has seen the GP twice in 12 weeks complaining of pelvic pain and dyspareunia. What is the most likely cause?
Appendicitis
Adnexial torsion
Endometriosis
Pelvic inflammatory disease
Ruptured ectopic pregnancy
The most likely diagnosis is pelvic inflammatory disease. Right upper quadrant pain occurs as part of the Fitz Hugh Curtis syndrome in which peri hepatic inflammation occurs.
A 73 year old lady presents with peritonitis and tenderness of the left groin. At operation, she has a left femoral hernia with perforation of the anti mesenteric border of ileum associated with the hernia. What type of hernia is this?
Richters hernia
Littres hernia
Morgagni hernia
Spigelian hernia
Bochdalek hernia
Richters hernia
Explanation When part of the bowel wall is trapped in a hernia such as this it is termed a Richters hernia and may complicate any hernia although femoral and obturator hernias are most typically implicated
Richters hernia
Condition in which part of the wall of the small bowel (usually the anti mesenteric border) is strangulated within a hernia (of any type)
They do not present with typical features of intestinal obstruction as lumenal patency is preserved
Where vomiting is prominent it usually occurs as a result of paralytic ileus from peritonitis (as these hernias may perforate)
Spigelian hernia
Interparietal hernia occurring at the level of the arcuate line
Rare
May lie beneath internal oblique muscle. Usually between internal and external oblique
Equal sex distribution
Position is lateral to rectus abdominis
Both open and laparoscopic repair are possible, the former in cases of strangulation
incisional hernia
Occur through sites of surgical access into the abdominal cavity
Most common following surgical wound infection
To minimise following midline laparotomy Jenkins Rule should be followed and this necessitates a suture length 4x length of incision with bites taken at 1cm intervals, 1 cm from the wound edge
Repair may be performed either at open surgery or laparoscopically and a wide variety of techniques are described
bochdalek hernia
Bochdalek hernia is a diseases of 3 P’s and 3 B’s
1- Birth defect (congenital)
2- Posterior located
3- Big
4- Bad Prognosis
5- Pulmonary hyPoPlais is common
6- Placement of mesh may be needed to treat
A hernia is the most likely diagnosis given the abdominal findings. The large hernia may displace the heart although true dextrocardia is not present. The associated pulmonary hypoplasia will compromise lung developmen
A 1 day old infant is born with severe respiratory compromise. On examination, he has a scaphoid abdomen and an absent apex beat. Which of the following anomalies is most likely?
Situs inversus
Morgagni hernia
Necrotising enterocolitis
Bochdalek hernia
Cystic fibrosis
Bochdalek hernia
A 5 year old boy is found to have a Meckels diverticulum at an appendicectomy and it looks to be non inflamed. What type of epithelium is most likely to be found in the diverticulum?
Gastric mucosa
Non stratified squamous epithelium
Ileal mucosa
Stratified squamous epithelium
Jejunal mucosa
ileal mucosa
causes of GI Bleeding in peads
UPPER GI
newborn–hemorrhagic disease, swallowed maternal blood
1 mon to 1 yr–oseophagitis, gastritis
1-2 yrs—peptic ulcer disease
older than 2 yr- varices
LOWER GI
newborn–anal fissure/NEC
1 mont to 1 yr—anal fissure,intussusception
1yr-2yr–polyps/meckels diverticulum
older than 2 years-IBD/Polyps/intussusceptions
A 20 year old man is suspected of having an inflamed Meckels diverticulum. At which of the following locations is it most likely to be found?
Approximately 60 cm distal to the ileo-caecal valve
Approximately 60 cm proximal to the ileocaecal valve
Approximately 200cm distal to the ileocaecal valve
Approximately 200cm proximal to the ileocaecal valve
50cm distal to the DJ flexure
Approximately 60 cm proximal to the ileocaecal valve
Explanation
Rule of 2’s
2% of population 2 inches (5cm) long 2 feet (60 cm) from the ileocaecal valve 2 x’s more common in men 2 tissue types involved
They are typically found 2 feet proximal to the ileocaecal valve (or approximately 60cm).
