Mixed

Question 1

A 65-year-old man presents with a history of pain in the calf for the last two years. In last six months he was able to walk 300 yards and now is only able to achieve 50 yards. He rests for five minutes between periods of walking.

Answer 1

Intermittent claudication
Atherosclerosis affects the entire circulation. Disease in one anatomical region suggests that other regions are also diseased and therefore if a patient has carotid stenosis he may well have intermittent claudication, angina pectoris and an aortic aneurysm.

When taking a history and performing an examination of patients, all vascular regions should be examined. Symptomatic stenosis of greater than 70% in the carotids requires operative intervention with a carotid endarterectomy.

Patients with abdominal aortic aneurysms greater than 5-5.5 cm require inlay grafting, and patients with critical ischaemia in their limbs or rapidly deteriorating claudication distance require angioplasty or bypass surgery.

Clearly patients should be assessed for their fitness for surgery, since many have multiple co-existing diseases.

Question 2

A 56-year-old diabetic attends his GP complaining of an ulcer on the heel of his foot. He has had diabetes for 20 years and is known to be poorly compliant with his medication. The GP examines his lower limb and elicits a reduction in sensation to vibration and light touch.

Answer 2

Neuropathic ulcer

Question 3

A 76-year-old man presents to the hospital with an episode of amaurosis fugax. The physician finds a bruit in the left carotid artery and he is sent for duplex colour flow Doppler imaging.

Answer 3

Carotid stenosis

Question 4

A 66-year-old man has undergone an anterior resection of the rectum and is making a slow recovery. He complains that in the middle of the night he has pain in the left calf. On examination he has a tender left calf which is slightly swollen and red. He has been given subcutaneous heparin throughout his hospital stay.

Answer 4

Deep venous thrombosis

Question 5

A 22-year-old man presents to the Emergency department following an accident at work. A piece of scaffolding fell from two metres above him and trapped his left leg. His peripheral pulses are present on arrival in hospital two hours after the accident. He is admitted for observation when he becomes hypotensive with a poor urine output.

Answer 5

Rhabdomyolysis

Question 6

A 64-year-old man with a tumour of the upper femur.

Answer 6

Hindquarter amputation

Question 7

A 85-year-old man with pain and deformity of the left knee due to congenital malformation. He was able to walk up until the last five years when the pain became unbearable.

Answer 7

Above knee amputation

Question 8

A gangrenous toe due to peripheral vascular disease with superimposed infection in a 70-year-old diabetic.

Answer 8

Ray amputation with “racket incision”

Question 9

Ischaemic gangrene of the lower leg with ulceration over the medial malleolus and spreading infection proximally.

Answer 9

Below knee amputation

Question 10

A 90-year-old lady who is immobile due to severe osteoarthritis in the hips and knees. She has developed marked arterial ulceration in the right lower limb. She is requires full nursing care.

Answer 10

Above knee amputation
The indications for amputation are ischaemia, tumours, pain and deformity. 80-90% of amputations are performed for ischaemic gangrene secondary to peripheral vascular disease.

Diabetics have large and small vessel disease and a ray amputation of the toes is often the first stage of a series of amputation levels. Where pain and deformity cannot be alleviated by medical means, amputation is the final option.

Supracondylar amputations have the advantage of a longer stump which allows the patient to turn in bed, however the stump is usually not long enough to fit an internal knee mechanism prosthesis and thus is unpopular. Where the patient is already immobile, it is may be a practical option.

Question 11

Performed where other investigations have failed to identify whether a lump is malignant or benign.

Answer 11

Excision biopsy

Question 12

Can be used in symptomatic and asymptomatic patients. It is 80-95% accurate and part of the United Kingdom screening programme.

Answer 12

Mammography

Question 13

Usefully identifies cysts and is able to study abnormal tumour circulation.

Answer 13

Ultrasound

Question 14

Used in the histological diagnosis of impalpable lesions which are suspicious of malignancy. Requires a general anaesthetic.

Answer 14

Wire-guided biopsy

Question 15

Very helpful in establishing the presence and extent of metastatic disease.

Answer 15

Bone scan

The management of a patient with breast cancer requires the achievement of a diagnosis and staging of the disease.

Examination identifies palpable characteristics
Ultrasound reveals if the lump is solid or cystic, thin or thick
Mammography identifies changes in architecture and calcification and
Spiculation, cytology or histological examination confirms the presence of malignancy, the type, and hormone receptor status.
Metastatic spread can be identified by CT, MRI and bone scans.

Question 16

A premenopausal 42-year-old lady experiences marked premenstrual breast nodularity and discomfort of the upper outer quadrant. Fine needle aspiration cytology is performed and no malignancy is found. A core-biopsy reveals multiple cysts, fibrosis and epitheliosis.

Answer 16

Benign mammary dysplasia

In this case the biopsy with multiple cysts, fibrosis and epitheliosis is characteristic of benign mammary dysplasia.

Question 17

A 45-year-old lady, premenopausal, with a discrete smooth breast lump presents to her GP. Aspiration is attempted and reveals a yellow/brown/green fluid. There is absence of blood staining. The GP refers her to a breast clinic where she has a mammogram and ultrasound. The lump is no longer present.

Answer 17

Cystic disease

This woman is likely to have cystic breast disease.

Question 18

A 26-year-old lady presents with a hot, red, swollen lump in her left breast which is very tender. She is one month post partum of her first child.

Answer 18

Lactational breast abscess

The 26-year-old post partum woman has typical features of a breast abscess and this is likely to be lactational.

Question 19

A 50-year-old lady describes an intermittent discharge of clear, cheese-like fluid with occasional blood staining. Her nipple has become retracted. Fine needle aspiration (FNA) cytology has been performed and reveals benign cells. Some coarse calcification is seen on her mammogram.

Answer 19

Duct ectasia
The FNA of the 50-year-old woman shows benign breast disease, but the calcification on mammography suggests duct ectasia.

Question 20

A small lump from the upper outer quadrant of the breast is surgically removed as a day case in a 26-year-lady with no family history of breast cancer. Histological examination reveals proliferation of myelofibroblasts.

Answer 20

Fibromatosis
The 26-year-old with no FH of cancer has proliferation of myelofibroblasts on histology of the lump, and this is typical of fibromatosis.

The investigation of breast disease requires a detailed history, clinical examination and specific investigations.

Information about the gynaecological and obstetric history, menopausal status and past and current hormonal medication are essential. The patient’s risk factors, such as family history, must also be established.

Specific investigation of a lump requires the use of appropriate investigation which would include ultrasound, mammography and often fine needle or ultrasound guided biopsy.

Question 21

A 38-year-old man attends his GP with no symptoms. He informs his GP that he has perfect health but has heard that colorectal cancer can be hereditary. His father and grandfather had cancer of the colon at the age of 42 and 46 respectively.

Answer 21

Colonoscopy
This patient has a particularly strong family history of premature bowel cancer. The most appropriate for this disorder is colonoscopy.

Currently, recommendations suggest that in the presence of two first degree relatives with colon cancer then screening with colonoscopy beginning at age 35 (or five years younger than the earliest case in the family), then every five years thereafter, along with yearly faecal occult blood testing (FOBT) should be performed.

Question 22

A 19-year-old student who complains of a change in bowel habit with bloody diarrhoea following an elective period in Brazil. He has no family history of bowel diseases.

Answer 22

Stool microscopy and culture
This youth has returned from a tropical climate with bloody diarrhoea. Disorders such as Shigella or amoebiasis should be considered, and hence stool microscopy with culture should be performed.

Question 23

A 19-year-old woman complains of three months of rectal pain which occurs during bowel opening. She has noticed hard stools and occasional bright red blood found on the toilet paper.

Answer 23

Rectal inspection and digital examination

This sounds like simple constipation with anal tears. Inspection and digital examination would suffice.

Question 24

A 52-year-old businessman presents with a two month history of diarrhoea and weight loss. He has travelled throughout the world during work.
He was examined by his general practitioner and underwent stool culture and flexible sigmoidoscopy. He was given a report of his investigation which revealed no abnormality. He has continued with his diarrhoea.

Answer 24

Colonoscopy
The change in bowel habit with weight loss should be considered as sinister; particularly as he has had normal stool cultures and a flexible sigmoidoscopy. A colonoscopy should be performed to look for neoplasia or other colonic disease - inflammatory bowel disease, etc.

Question 25

A 79-year-old man presents with pain in the right iliac fossa and a palpable mass. He had an appendicectomy as a small boy. He has not noted any change in bowel habit. He was investigated one year previously for a rectal bleeding when a colonoscopy was performed. It was reported as normal and he underwent sclerosant therapy for piles.

Answer 25

Incisional hernia

This patient has a mass in the right iliac fossa following a grid iron incision. The diagnosis is an incisional hernia.

Question 26

A 45-year-old lady presents with a painful groin. She is unable to feel a mass at present and there is no cough impulse. She experiences the pain on lifting heavy weights and on one occasion she felt a small lump which vanished on lying horizontal.

Answer 26

Indirect inguinal hernia
It is important here to distinguish between a direct and indirect inguinal hernia. Features that suggest the latter are the fact that this is commoner in females and it reduces in this patient on lying down as suggested by the examination findings.

Question 27

A 68-year-old retired builder with a painful groin. He has noticed the pain for the last eight years and that the swelling is increasing in size. He is able to reduce the lump easily.

Answer 27

Direct inguinal hernia
This patient who is a retired builder has a lump that is easy to decompress and is suggestive of a direct inguinal hernia due to elevated intra-abdominal pressure.

Question 28

A 4-year-old boy with an easily reducible protuberance through the umbilicus.

Answer 28

Umbilical hernia
This is a typical umbilical hernia which does not obliterate following birth and is more common in the black population than caucasian. Surgery should be avoided in children less than 2-years-old as it usually obliterates.

Question 29

A 30-year-old man presents to casualty with lower abdominal pain which radiates to the groin. He has no findings on examination tenderness over the mid inguinal point.

Answer 29

Gilmore’s groin

This is a typical story thought to be an early direct inguinal hernia and is more common in sporting people.

Question 30

An 18-year-old lady undergoing caesarean section.

Answer 30

Pfannenstiel incision

Question 31

A 21-year-old man undergoing urgent appendicectomy. He has local peritonism, a pyrexia and a raised white count.

Answer 31

Skin crease incision

Question 32

A patient with a perforated duodenal ulcer admitted for emergency laparotomy.

Answer 32

Midline incision

Question 33

A 61-year-old lady undergoing a Whipple’s procedure for carcinoma of the pancreas.

Answer 33

Roof top incision

Question 34

A patient under going insertion of the first port for a laparoscopic cholecystectomy.

Answer 34

Umbilical incision
The choice of incision for any surgical procedure is determined by:

Its ability to gain access to the organs involved
The ability for the incision to be extended
Its ease of closure, and
Its cosmetic appearance.
The midline laparotomy incision allows access to most of the abdominal organs with incision through the linea alba and safe en-masse closure.

Question 35

A 64-year-old man attends the outpatient department with a long history of peptic ulcer disease. He has been treated with H2 antagonists and proton pump inhibitors without success. He is dependent on non-steroidal anti-inflammatory drugs (NSAIDs) for pain relief. He has continued to have symptoms and now is unable to tolerate the pain.

Answer 35

Highly selective vagotomy

Question 36

A 29-year-old man, previously fit and well, presents to the casualty department with sudden onset of epigastric pain. On examination he has board-like rigidity of the abdomen and absent bowel sounds. Erect chest x ray reveals a cresenteric area of free gas beneath the left hemidiaphragm.

Answer 36

Omental patch

This is a likely perforation and emergency surgery is required. An omental patch would be used to cover the perforation.

Question 37

An 82-year-old lady presents to the surgeons with haematemesis. She is hypotensive on admission and despite resuscitation, her blood pressure continues to drop. Endoscopy reveals a bleeding duodenal ulcer which is actively bleeding. Attempts at injection with adrenaline fail.

Answer 37

Under-running
The active bleeding ulcer, which has failed to respond to injection, now requires surgical intervention. Laparotomy with under-running of the ulcer should be performed to stem the haemorrhage.

Question 38

A 63-year-old man has been medically treated for a duodenal ulcer for 15 years with good relief of his symptoms. He complains to his GP that he has been feeling bloated and is referred to the hospital. On attending, starts to vomit profusely. He becomes dehydrated and is admitted for rehydration and nasogastric aspiration. The drainage remains high in volume and a contrast x ray reveals a tight stenosis around the site of his duodenal ulcer.

Answer 38

Gastroenterostomy

He has a pyloric stenosis. Gastroenterostomy is the treatment of choice.

Question 39

A 39-year-executive complains of a short history of epigastric pain. He undergoes upper GI endoscopy and a small duodenal ulcer is found. Gastric biopsy for H.pylori is negative.

Answer 39

Proton pump inhibitors
PPIs are the mainstay of treatment for peptic ulceration. If H. pylori were positive then eradication therapy with PPIs and antibiotics would be required.

Peptic ulceration is now no longer the commonest finding on endoscopic examination of the upper gastrointestinal tract, it has been overtaken by gastro-oesophageal reflux disease.

Peptic disease may present with mild symptoms or as an emergency with perforation. The vast majority of acute perforations have no previous known history of peptic ulcer disease. Non-steroidal anti-inflammatory drugs (NSAIDs) are often involved in the aetiopathology.

The advent of proton pump inhibitors has radically changed the treatment of ulcer disease. Surgery is now uncommon and only of use in selected cases where medical treatment has been unsuccessful, for example, a highly selective vagotomy where medical therapy has failed, is sometimes used.

Similarly, with perforation or failure to stop bleeding, surgery is often required.

Question 40

A 55-year-old smoker with a productive cough. He is planned for a high tie and long saphenous strip to the left leg varicose veins.

Answer 40

Chest x ray
Varicose vein surgery requires no specific investigations. However, where there is suspicion of a chest infection a chest x ray would be required, especially in a long-standing smoker.

Question 41

A 35-year-old lady admitted for an elective laparoscopic cholecystectomy has moderately deranged liver function tests five days after her last episode of severe pain. During a previous acute admission she was investigated with an ultrasound scan which showed multiple calculi in the gallbladder with no bile duct dilatation.

Answer 41

Magnetic resonance cholangio-pancreatography (MRCP)
Patients with calculus cholecystitis routinely undergo delayed cholecystectomy. Abdominal ultrasound is used to assist diagnosis of cholecystitis and may indicate biliary obstruction when jaundice is present. A normal diameter bile duct does not exclude the presence of stones in the duct. Those with biochemical evidence of obstructive jaundice require either a repeat ultrasound and/or MRCP. If there is bile duct dilatation preoperative endoscopic retrograde cholangio-pancreatography (ERCP) may be required (which has an overall mortality of around 1%) or an intra-operative cholangiogram to identify any stones or biliary sludge persistent in the ducts.

Question 42

A 58-year-old man undergoing arthroscopy on the right knee for intermittent locking. His medication includes warfarin, following a DVT two months ago.

Answer 42

Coagulation screen

Patients on warfarin require assessment of their anticoagulant status.

Question 43

A 75-year-old lady with rheumatoid arthritis admitted for left total hip replacement. Her rheumatoid arthritis has been in remission for two years and she has never taken immunosuppressants.

Answer 43

Cervical spine x ray

This is to screen for cervical spine subluxation.

Question 44

A 46-year-old lady undergoing dilatation and curettage following many years of menorrhagia. She has no known cardiac or respiratory illness, but was a cigarette smoker for five years in her twenties.

Answer 44

Full blood count
A full blood count should be performed prior to surgery due to the risk of anaemia.

Patients do not require routine investigations prior to surgery unless there are specific indications.

Question 45

A 43-year-old lady with a BMI of 31 is admitted for a day case femoral hernia repair under general anaesthetic. She has noticed the swelling over the last two years and in the last six months she has experienced mild discomfort in the left groin.

Answer 45

Thromboembolic deterrent stockings (TED stockings)

Question 46

A 36-year-old lady admitted for right mastectomy. She has a strong family history of breast cancer. Staging of the disease revealed no evidence of metastatic disease. She has a known history of deep venous thrombosis following a plane flight four years previously.

Answer 46

Thromboembolic deterrent stockings (TED stockings)

Question 47

A 40-year-old lady with a body mass index of 37. She is otherwise completely fit, without any past medical history or medication and is planned for day-case in-growing toe nail excision.

Answer 47

No medication required
This woman has no real risks for thromboembolism. She is having a toenail excision which would be under local anaesthetic.

Question 48

A 65-year-old insulin dependant male with diabetes undergoing high saphenous ligation, stripping and avulsions. He has known diabetic nephropathy with microalbuminuria and background diabetic retinopathy.

Answer 48

Sliding scale insulin infusion

This patient is insulin dependent and will need sliding scale insulin during and after the procedure.

Question 49

A 54-year-old man was admitted following fresh rectal bleeding. He was taking warfarin on admission and was told by his cardiac surgeon that it was vital to continue on the anticoagulant.
The day after admission there is no further evidence of bleeding and he undergoes flexible sigmoidoscopy. A large polyp is found in the sigmoid and his bowel is prepared for full colonoscopy with sodium picosulphate.

Answer 49

Conversion to heparin infusion
Patients with a previous history of DVT require the use of thromboembolic deterrent stockings (TEDS) to improve venous return and stasis which occur during immobility. A BMI over 30 kg/m2 is also an indication for mechanical thromboprophylaxis.

Pelvic surgery and surgery for malignancy make the risk of developing DVT even higher.

Patients with arterial disease in the lower limbs should not be prescribed TEDS because the compression can produce distal ischaemia.

Where patients are warfarinised, such as following cardiac valvular surgery, the anticoagulation should be only for the immediate peri-operative period. Thus use of heparin infusions facilitates control due to its short half life.