MRTMR Flashcards
Charlie is a 12-year-old boy referred by his GP with abdominal pain and fever. His GP suspects acute appendicitis. Which is true regarding the appendix?
A-The appendix receives its arterial supply from the SMA
B-The most common position of the appendix is retrocecal
C-The appendix is identified intraoperatively by following the convergence of the taenia coli
D-The appendix is rich in lymphoid tissue
E-All the above
The appendix is a blind tube (approx. 10 cm long) emerging from the base of the caecum. It is fully intraperitoneal and rich in lymphoid tissue. It receives its blood supply from the Appendicular branch of ileocolic artery (branch of SMA). The location of the appendix is highly variable in the abdomen, the most common location being retrocecal.
Other common positions of the appendix: -
• Pre-ileal
• Post-ileal
• Sub-ileal
• Pelvic
• Subcecal
• Para-cecal
Intraoperatively, the appendix is identified by tracing the taenia coli of the large bowel to their point of convergence at the tip of the appendix.
A 37-year-old man with a history of alcohol consumption for 20 years was diagnosed with CA pancreas. Prophylactic surgery must be done to reduce the risk of cancer in which condition?
A-Pancreas divisum
B-Annular pancreas
C-Anomalous pancreaticobiliary ductal junction
D-Ectopic pancreas
E-Ansa pancreatica
Anomalous pancreaticobiliary ductal junction: union of the pancreatic duct and common bile duct that occurs outside the duodenal wall to form a long common channel (>15 mm). Biliary drainage is not under the control of the sphincter of Oddi so reflux can happen and damage the biliary tree. Once diagnosed, prophylactic surgical correction is recommended to reduce the risk of developing biliary cancer.
A patient goes in for carpopedal spasm while measuring the blood pressure and his calcium levels are found to be very low and correction is being started.All of the following decrease renal calcium excretion except?
Decreased ECF volume
Increased plasma phosphate
Metabolic alkalosis
Vitamin D
Hypertension
The correct answer to the question “Which of the following does not decrease renal calcium excretion?” is Hypertension.
Explanation:
1. Decreased extracellular fluid (ECF) volume: This stimulates calcium reabsorption in the proximal tubule, thereby decreasing calcium excretion.
2. Increased plasma phosphate: Elevates the levels of parathyroid hormone (PTH), which reduces renal calcium excretion by increasing calcium reabsorption in the distal tubules.
3. Metabolic alkalosis: Enhances renal calcium reabsorption, reducing excretion.
4. Vitamin D: Promotes calcium reabsorption in the kidneys, lowering excretion.
However, Hypertension does not have a direct effect in reducing renal calcium excretion and may actually increase it.
Mr.Ashwin is on chemotherapy for carcinoma oral cavity.Which of the following drugs is an antimetabolite?
A 5FU
B Paclitaxel
C Cisplatin
D Cetuximab
E All of the above
The correct answer is A. 5FU (5-Fluorouracil).
Explanation:
• 5-Fluorouracil (5FU): This is an antimetabolite that inhibits thymidylate synthase, interfering with DNA synthesis. It is commonly used in the treatment of various cancers, including carcinoma of the oral cavity.
• Paclitaxel: A taxane that stabilizes microtubules and inhibits their depolymerization, disrupting cell division.
• Cisplatin: A platinum-based alkylating agent that forms DNA cross-links, leading to apoptosis.
• Cetuximab: A monoclonal antibody targeting the epidermal growth factor receptor (EGFR), used in certain head and neck cancers.
Thus, only 5FU is classified as an antimetabolite
What is the lymphatic drainage of caecum?
lleocolic
Inferior mesenteric
Internal iliac
Inguinal
All of the above
The correct answer is Ileocolic.
Explanation:
The caecum is primarily drained by lymph nodes associated with the ileocolic artery. The lymphatic drainage pathway is as follows:
1. Primary drainage: Lymph from the caecum flows into the ileocolic lymph nodes, located near the terminal branches of the ileocolic artery.
2. Secondary drainage: From the ileocolic nodes, lymph travels to the superior mesenteric lymph nodes.
Other options like the inferior mesenteric, internal iliac, and inguinal nodes do not contribute to the direct lymphatic drainage of the caecum
Mrs Nelson is being planned for distal pancreatectomy. What is the arterial supply to the distal pancreas?
A)Superior Mesenteric artery
B)Common Hepatic artery
c) Gastroduodenal artery
D)Pancreaticoduodenal artery
E) Splenic artery
The correct answer is E) Splenic artery.
Explanation:
The distal pancreas (tail and body) primarily receives its blood supply from branches of the splenic artery, which runs along the superior border of the pancreas. Key points:
• Splenic artery: Supplies the distal pancreas via its pancreatic branches, including the dorsal pancreatic artery, great pancreatic artery, and caudal pancreatic artery.
Other options:
• Superior mesenteric artery: Supplies parts of the small intestine and pancreas (head) via inferior pancreaticoduodenal branches.
• Common hepatic artery: Gives off the gastroduodenal artery but does not directly supply the distal pancreas.
• Gastroduodenal artery: Supplies the pancreas head and duodenum.
• Pancreaticoduodenal arteries: Primarily supply the head of the pancreas
Mr. Peter Robbins, a 27 year old gentleman, was admitted to ICU following right limb infection and sepsis. His vitals deteriorated progressively. He was diagnosed as having distributive shock. What is false regarding distributive shock?
A-Low systemic vascular resistance
B-High cardiac output
C-High venous pressure
D-High mixed venous saturation
D-High base deficit
The correct answer is C - High venous pressure.
Explanation:
Distributive shock (e.g., septic shock) is characterized by a significant reduction in systemic vascular resistance due to widespread vasodilation, leading to inadequate perfusion despite a relatively normal or high cardiac output. Let’s analyze each option:
1. Low systemic vascular resistance (A): True. Vasodilation causes a drop in systemic vascular resistance.
2. High cardiac output (B): True. As a compensatory mechanism, cardiac output is often elevated in early distributive shock.
3. High venous pressure (C): False. Venous pressure is typically low or normal due to decreased preload caused by vasodilation and capillary leakage.
4. High mixed venous saturation (D): True. Poor oxygen extraction by tissues leads to elevated mixed venous oxygen saturation.
5. High base deficit (D): True. Lactic acidosis from tissue hypoperfusion results in a high base deficit (metabolic acidosis).
Thus, high venous pressure is not a feature of distributive shock
A 34 year old male patient with a history of fever is diagnosed with infective endocarditis.The Duke ‘major’ criteria for the diagnosis of infective endocarditis include which one of the following?
Change in murmur
One positive blood culture
Raised C-reactive protein (CRP)
Roth spots
Vegetation detected on echocardiogram
The correct answer is Vegetation detected on echocardiogram.
Explanation:
The Duke Criteria are used to diagnose infective endocarditis and are divided into major and minor criteria. The major criteria include:
1. Positive blood cultures for typical organisms of infective endocarditis.
2. Evidence of endocardial involvement on echocardiography:
• Presence of vegetation.
• Abscess formation.
• New dehiscence of a prosthetic valve.
• New valvular regurgitation.
The options:
• Change in murmur: Not part of the Duke criteria.
• One positive blood culture: A major criterion requires persistent bacteremia with multiple positive blood cultures.
• Raised CRP: A minor criterion.
• Roth spots: A minor criterion.
• Vegetation detected on echocardiogram: A major criterion, as it indicates direct evidence of endocardial involvement
You are the core trainee and have just reviewed the case of a 30-year-old patient on the ward who has died following an emergency operation for a bowel perforation. You are required to fill in the death certificate in the bereavement office as soon as you are able.
Cases that should be referred to the coroner in England include which one of the following?
Death from a bowel perforation
Death from a notifiable disease such as meningitis
Death from AIDS or an HIV related ilnesses
Death in a patient under 50 years of age
Death related to industrial or occupational disease in former employment
Any death thought to have been caused by an industrial disease or industrial poisoning should be referred to the coroner. Recent surgery should also be referred to the coroner, particularly if it relates to the patient’s death.
The cause of death from a bowel perforation is known, explained and not unnatural. Assuming the patient has been seen by a doctor during their final illness and had no surgery this would not need to be referred to the coroner. Notifiable diseases have to be reported to the Consultant in Communicable Disease Control (CCDC). They do not need to be referred to the coroner. Age does not affect whether a case should or should not be referred to the coroner.
Deaths from AIDS or an HIV-related illnesses do not need to be reported to the coroner unless they meet another reason for reporting like an unknown cause of death, violent or unnatural death.
Deaths reported to a Coroner
A death is reported to a Coroner in the following situations:
• a doctor did not treat the person during their last illness
• a doctor did not see or treat the person for the condition from which they died within 28 days of death
• the cause of death was sudden, violent or unnatural such as an accident, or suicide
• the cause of death was murder
• the cause of death was an industrial disease of the lungs such as asbestosis
• the death occurred in any other circumstances that may require investigation
A death in hospital should be reported if:
• there is a question of negligence or misadventure about the treatment of the person who died
• they died before a provisional diagnosis was made and the general practitioner is not willing to certify the cause
• the patient died as the result of the administration of an anaesthetic
A death should be reported to a Coroner by the police, when:
• a dead body is found
• death is unexpected or unexplained
• a death occurs in suspicious circumstances
A death should be reported by the Governor of a prison immediately following the death of a prisoner no matter what the cause of death is.
Mr Singh is a 37-year-old construction worker brought to ED after a piece of construction equipment fell on his lower leg. Plain X ray excluded a fracture and he was given opioid analgesics for the pain and kept for overnight observation. During the night he has worsening pain requiring increased analgesic dose. The duty doctor found his leg to be red, swollen and severely tender. Pain increased on extending the foot or great toe passively. In which compartment of the leg is pressure likely to be elevated?
A Anterior compartment
B Lateral compartment
c Posterior superficial compartment
D Posterior deep compartment
E Medial compartment
The most likely compartment with elevated pressure in Mr. Singh’s case is the A) Anterior compartment.
-
Clinical Features:
- Severe pain out of proportion to the injury.
- Redness, swelling, and severe tenderness in the leg.
- Pain on passive extension of the foot or great toe: This is a key finding, as it suggests involvement of the muscles in the anterior compartment (tibialis anterior, extensor hallucis longus, extensor digitorum longus, and peroneus tertius), which are responsible for dorsiflexion of the foot and toes.
-
Compartment Syndrome:
- Compartment syndrome occurs when increased pressure within a closed fascial space compromises blood flow, leading to ischemia and muscle necrosis.
- The anterior compartment is the most commonly affected in the leg due to its relatively tight fascial boundaries and vulnerability to trauma.
-
Why Not Other Compartments:
- B) Lateral compartment: Involves the peroneal muscles (evert the foot). Pain would be elicited with passive inversion, not extension.
- C) Posterior superficial compartment: Involves the gastrocnemius and soleus (plantarflex the foot). Pain would be elicited with passive dorsiflexion, not extension of the toes.
- D) Posterior deep compartment: Involves the tibialis posterior, flexor digitorum longus, and flexor hallucis longus (invert the foot and flex the toes). Pain would be elicited with passive extension of the toes, but this compartment is less commonly affected.
- E) Medial compartment: Not a recognized compartment of the leg.
The findings of severe pain, swelling, and pain on passive extension of the foot or great toe strongly suggest anterior compartment syndrome. This is a surgical emergency, and prompt fasciotomy is required to prevent permanent muscle and nerve damage.
A young woman who had collapsed in the airport was rushed to your A&E. Her friend reports that she has no known medical illnesses. Your examination revels that she is slightly obese and has a swollen left leg. What will her ASA grade be?
Grade 1
Grade 2
Grade 3
Grade 4
Grade 5
Solution
This is likely to be a case of pulmonary embolism. The patient is obese - a mild to moderate systemic condition - but is otherwise in good health (no functional impairment). The American Society of Anesthesiologists (ASA) classification is used to assess the preoperative physical status of patients. Based on the provided scenario:
• The patient is slightly obese.
• She has a swollen left leg, which could indicate deep vein thrombosis (DVT) or another vascular issue.
• No other medical illnesses are known.
ASA Classification:
• ASA I: A normal, healthy patient.
• ASA II: A patient with mild systemic disease (e.g., obesity, controlled hypertension).
• ASA III: A patient with severe systemic disease but not incapacitating.
• ASA IV: A patient with severe systemic disease that is a constant threat to life.
• ASA V: A moribund patient who is not expected to survive without the operation.
Given that obesity is considered a mild systemic disease and a swollen leg (potentially DVT) may indicate a vascular issue but not necessarily a life-threatening condition at this stage, ASA Grade II is the most appropriate classification .
Mr. Johnathan presented to your clinic with a complaint of a funny gait. Based on your clinical assessment, you suspect weakness of the superior gluteal nerve. Which muscle will be spared in this case?
A Gluteus maximus
B Gluteus medius
C Gluteus minimus
D Tensor fascia lata
E Both A and D
The superior gluteal nerve innervates the gluteus medius, gluteus minimus, and tensor fascia lata. If there is a lesion affecting this nerve, these muscles will be weakened, leading to a Trendelenburg gait. However, the gluteus maximus is spared because it is innervated by the inferior gluteal nerve .
Correct answer:
A. Gluteus maximus
An eight-year old female fell down while playing. She was complaining of pain and swelling of the left elbow. She had diffuse swelling of the left elbow without any external wound. The radial pulse was well palpated. There was wrist, thumb and fingers drop associated with hypoesthesia over the first web space indicating radial nerve palsy. Plain X-ray of the left elbow showed fracture of the lateral condyle (type I| Milch) and avulsed fracture of the medial epicondyle.Which of the following muscles originates from the medial epicondyle?
Brachioradialis
Extensor carpi ulnaris
Extensor digiti minimi
Anconeus
Pronator teres
The medial epicondyle of the humerus serves as the common origin for the muscles of the flexor compartment of the forearm, primarily those innervated by the median nerve (except for flexor carpi ulnaris and part of flexor digitorum profundus, which are supplied by the ulnar nerve).
Among the given options, Pronator teres is the only muscle that originates from the medial epicondyle.
Explanation of the options:
• Brachioradialis – Originates from the lateral supracondylar ridge.
• Extensor carpi ulnaris – Originates from the lateral epicondyle.
• Extensor digiti minimi – Originates from the lateral epicondyle.
• Anconeus – Originates from the lateral epicondyle.
• Pronator teres – Originates from the medial epicondyle.
Correct answer:
Pronator teres
You are examining a patient with discomfort during swallowing in the clinic.Examination reveals a swelling in the posterior tongue in the midline.What is the most likely tissue of origin of this swelling?
A Filiform papillae
B Fungiform papillae
C Lymphoid tissue
D Palatine tonsil
E Circumvallate papillae
A midline swelling in the posterior tongue is most likely arising from lymphoid tissue, specifically the lingual tonsils. The posterior third of the tongue contains lymphoid aggregates that are part of Waldeyer’s ring, which can become hypertrophied or inflamed, leading to discomfort during swallowing.
Explanation of the options:
• Filiform papillae – These are the most numerous papillae on the anterior tongue and lack taste buds. They are not located in the posterior tongue.
• Fungiform papillae – Found on the anterior part of the tongue, especially at the tip and sides, and are involved in taste sensation.
• Lymphoid tissue – Correct answer; the posterior third of the tongue contains lingual tonsils, which can enlarge and present as a midline swelling.
• Palatine tonsil – Located laterally in the oropharynx, not in the midline of the posterior tongue.
• Circumvallate papillae – Large papillae arranged in a V-shape at the posterior tongue but not typically forming a prominent swelling.
Correct answer:
C. Lymphoid tissue
A 57-Year-Old Heart Transplant Recipient Is Keen To Join The Cardiac Rehabilitation Programme. Which Of The Following Factors Is Most Likely To Increase Cardiac Output In This Patient During Moderate Exercise?
A Decreased Negative Intrathoracic Pressure
B Decreased Venous Tone
C Decreased Ventricular Compliance
D Increased Atrial Filling
E None of the above
Increased atrial filling enhances cardiac output during exercise, especially in patients with heart transplants. In a heart transplant recipient, the heart is denervated, meaning it lacks autonomic nervous system regulation. This has significant effects on how cardiac output (CO) increases during exercise.
How does a transplanted heart increase cardiac output?
1. Loss of autonomic control – The transplanted heart does not respond to direct sympathetic stimulation or vagal inhibition.
2. Cardiac output mainly increases via the Frank-Starling mechanism, which relies on increased venous return to enhance stroke volume.
3. Increased atrial filling (preload) leads to increased stroke volume, as the transplanted heart responds mainly to changes in preload rather than neural control.
Analysis of the options:
• A. Decreased negative intrathoracic pressure – This would reduce venous return, decreasing cardiac output (incorrect).
• B. Decreased venous tone – This would reduce preload and lower cardiac output (incorrect).
• C. Decreased ventricular compliance – This would limit ventricular filling, reducing cardiac output (incorrect).
• D. Increased atrial filling – Correct; increased venous return (preload) enhances stroke volume via the Frank-Starling mechanism, which is the primary way a denervated heart increases cardiac output.
• E. None of the above – Incorrect, as increased atrial filling is a valid mechanism.
Correct answer:
D. Increased Atrial Filling
What is the pharmacological basis behind prescribing a thiazide and loop diuretic together?
A Antagonism
B Synergism
C Agonism
D None of the above
E All of the above
The correct answer is:
B. Synergism
Pharmacological Basis:
• Loop diuretics (e.g., furosemide, bumetanide, torsemide) act on the Na⁺-K⁺-2Cl⁻ symporter in the thick ascending limb of the loop of Henle, leading to potent diuresis by preventing sodium and water reabsorption.
• Thiazide diuretics (e.g., hydrochlorothiazide, chlorthalidone, metolazone) act on the Na⁺-Cl⁻ symporter in the distal convoluted tubule (DCT) to promote sodium and water excretion.
Why are they used together?
1. Sequential nephron blockade:
• Loop diuretics cause increased sodium delivery to the DCT, where the thiazide diuretics further inhibit sodium reabsorption.
• This leads to an enhanced diuretic effect (synergism).
2. Overcoming diuretic resistance:
• In conditions like heart failure or chronic kidney disease (CKD), the kidney adapts to long-term loop diuretic use by increasing sodium reabsorption in the DCT.
• Adding a thiazide diuretic blocks this compensatory mechanism, enhancing diuresis.
3. Enhanced natriuresis (sodium excretion):
• This combination leads to greater sodium and water loss, making it effective in treating severe edema and fluid overload.
Incorrect options explained:
• A. Antagonism – Incorrect, as they do not work against each other.
• C. Agonism – Incorrect, as they do not act on the same receptor.
• D. None of the above – Incorrect, as synergism is the correct explanation.
• E. All of the above – Incorrect, since only synergism applies.
A patient with vomiting and abdomen pain and has been diagnosed with annular pancreas.Where is the site of obstruction in this patient?
A The first part of the duodenum
в The second part of the duodenum
c The fourth part of the duodenum
D The third part of the duodenum
E The duodeno-jejunal flexure
The pancreas develops from two foregut outgrowths (ventral and dorsal). During rotation the ventral bud and adjacent gallbladder and bile duct lie together and fuse. When the pancreas fails to rotate normally it can compress the duodenum with development of obstruction. Usually occurring as a result of associated duodenal malformation. The second part of the duodenum is the commonest site.
A new test to screen for COVID 19 was trialled in 800 patients.The test was positive in 30 of the 60 patients shown to have COVID 19 by a gold standard test. It was also positive in 10 patients who were shown not to have COVID. What is the positive predictive value of the test?
A-66
B-75
C-50
D-33
E-80
Positive predictive value: proportion of those who have a positive test who actually have the disease.
Positive Predictive Value = number of true positives / (number of true positives + number of false positives)
True positive = 30, False positive = 10
PPV = 30/ (30+10) × 100
= 30 / 40 × 100 = 75
You are performing a diagnostic endoscopy on a 50 year old male patient which reveals gastric polyps.The most common type of gastric polyps are:
A Hyperplastic polyps
B Fundic polyps
C Inflammatory polyps
D Neoplastic polyps
E None.
The most common type of gastric polyps found during diagnostic endoscopy are fundic gland polyps. These polyps are typically benign and are associated with the use of proton pump inhibitors (PPIs) or, less commonly, with familial adenomatous polyposis (FAP).
B. Fundic polyps
- Fundic gland polyps are the most common type of gastric polyps, accounting for 47-77% of all gastric polyps in some studies.
- They arise from the fundus and body of the stomach and are often discovered incidentally during endoscopy.
- These polyps are usually small, multiple, and benign, though they may rarely undergo dysplastic changes, especially in patients with FAP.
- A. Hyperplastic polyps: These are the second most common type of gastric polyps. They are often associated with chronic gastritis, Helicobacter pylori infection, or bile reflux. However, they are not as common as fundic gland polyps.
- C. Inflammatory polyps: These are rare and are associated with chronic inflammation or injury to the gastric mucosa.
- D. Neoplastic polyps: These include adenomas and other potentially malignant polyps. They are less common than fundic gland polyps and hyperplastic polyps.
- E. None: Incorrect, as fundic gland polyps are the most common.
Thus, the correct answer is B. Fundic polyps.
Mrs.Jones, a 56 year old patient diagnosed with hepatocellular carcinoma now has malignant ascites. Which among the following Investigations would you perform to visualise her biliary system?
CT
MRI
Ultrasound
Hepatobiliary scintigraphy
PET СТ
The best investigation to visualize the biliary system in
The best investigation to visualize the biliary system in a patient with malignant ascites and hepatocellular carcinoma would be:
MRI (Magnetic Resonance Imaging), specifically MRCP (Magnetic Resonance Cholangiopancreatography).
Explanation:
• MRI (MRCP) is the gold standard for non-invasive imaging of the biliary tree and pancreatic ducts. It provides detailed images of biliary obstruction, strictures, and masses without the need for contrast.
• CT scan is useful for detecting hepatic tumors and metastases, but it does not provide clear imaging of the biliary tree unless contrast is used (CT cholangiography).
• Ultrasound is a good initial test for assessing liver lesions and ascites, but it is limited in evaluating the biliary system.
• Hepatobiliary scintigraphy (HIDA scan) is mainly used for functional assessment of the biliary system (e.g., gallbladder dyskinesia, bile leaks) but is not preferred for anatomical visualization.
• PET-CT is useful for detecting metastatic disease, but it is not the best choice for detailed biliary imaging.
Best Answer: MRI (MRCP)
DEBATE: Mortimer cevabı sintigrafi: Cancer patients may have intra-abdominal fluid or malignant ascites that complicates interpretation of pericholecystic fluid or gallbladder wall thickening on ultrasound or CT imaging. Hepatobiliary scintigraphy may be required to confirm the diagnosis of cholecystitis.
You are seeing a 17 year old male patient with type 1 diabetes at the clinic.All of the following are true about type 1 diabetes except?
A Age at onset is < 20 years
B Insulin is low or absent
C Glucagon is high and resistant to suppression
D Insulin sensitivity is normal
E All are true
The statement that is not true about type 1 diabetes is:
C. Glucagon is high and resistant to suppression
In type 1 diabetes, glucagon levels are often normal or slightly elevated, but they are not typically resistant to suppression. Glucagon is a hormone that works to raise blood glucose levels, and in type 1 diabetes, the primary issue is the lack of insulin production by the pancreas, leading to hyperglycemia. The other statements (A, B, and D) are generally accurate descriptions of type 1 diabetes.
A renal transplant patient has developed pure red cell aplasia following intake of immunosuppressants.Which of the following drugs might be responsible for this?
Sirolimus
Mycophenolate
Azathioprine
Tacrolimus
Cyclosporine
• The principal toxicities of Mycophenolate mofetil are Gl and hematologic: leuko- penia, pure red cell aplasia, diarrhea, and vomiting. There also is an increased incidence of some infections, especially sepsis associated with cytomegalovirus.
• The use of sirolimus in renal transplant patients is associated with a dose-dependent increase in serum cholesterol and triglycerides that may require treatment. Although immunotherapy with sirolimus per se is not considered nephrotoxic, patients treated with cyclosporine plus sirolimus have impaired renal function compared to patients treated with cyclosporine alone.Lymphocele, a known surgical complication associated with renal transplantation, is increased in a dose-dependent fashion by sirolimus, requiring close postoperative follow-up.Other adverse effects include anemia, leukopenia, thrombocytopenia, mouth ulcer, hypokalemia, and GI effects.
• Nephrotoxicity; neurotoxicity (e.g., tremor, headache, motor disturbances, seizures); Gl complaints; hypertension; hyperkalemia; hyperglycemia; and diabetes all are associated with tacrolimus use.
• The major side effect of azathioprine is bone marrow suppression, including leukopenia (common), thrombocytopenia (less common), or anemia (uncommon). Other important adverse effects include increased susceptibility to infections (especially varicella and herpes simplex viruses), hepatotoxicity, alopecia, Gl toxicity, pancreatitis, and increased risk of neoplasia.
• The principal adverse reactions to cyclosporine therapy are renal dysfunction and hypertension; tremor, hirsutism, hyperlipidemia, and gum hyperplasia also are frequently encountered. Hypertension occurs in about 50% of renal transplant and almost all cardiac trans- plant patients. Hyperuricemia may lead to worsening of gout, increased P-glycoprotein activity, and hypercholesterolemia. Nephrotoxicity occurs in the majority of patients and is the major reason for cessation or modification of therapy. Combined use of calcineurin inhibitors and glucocorticoids is particularly diabetogenic, although this seems more problematic in patients treated with tacrolimus. Cyclosporine, as opposed to tacrolimus, is more likely to produce elevations in LDL cholesterol.
A new technique of rectus closure is designed to prevent the risk of dehiscence is undergoing clinical trials. 100 patients are subjected to the new technique. During a three week period 20 of the patients have an episode of dehiscence. In the control group there are 200 patients who are subjected to the usual method of closure. In this group 50 people have dehiscence during the same time period. What is the relative risk of having a dehiscence when the new technique is used?
A 0.4
B 0.8
C 0.7
D 0.35
E 0.23
B 0.8
Relative risk (RR) = Incidence among exposed/ Incidence among non-exposed
Incidence among exposed = 20/100 = 0.2
Incidence among non exposed = 50/200 = 0.25
RR = 0.2/0.25 =0.8
A 40 year old male sustains extraperitoneal bladder rupture following a road traffic accident.Which among the following is true about the urinary bladder?
A The apex of the bladder faces anteriorly
B Apex is attached to medial umbilical ligament
C The base lies above the level of the rectovesical pouch
D The inferolateral surfaces are the lowest part of the bladder
E Superior surface is devoid of peritoneum
The correct answer is: A. The apex of the bladder faces anteriorly
Explanation:
To understand this question, let’s clarify some anatomical details of the urinary bladder:
• Apex: The apex of the bladder indeed faces anteriorly and is attached to the median umbilical ligament (not medial). This ligament is a remnant of the urachus, which connected the bladder to the umbilicus in the fetus.
• Base: The base (or posterior surface) of the bladder lies below the level of the rectovesical pouch in males (a peritoneal reflection between the bladder and rectum).
• Inferolateral surfaces: These surfaces are not the lowest; instead, the neck of the bladder is the lowest part, especially in males.
• Superior surface: This surface is covered with peritoneum, especially when the bladder is distended.
So, the correct and true statement is A.
The empty bladder is situated entirely within the pelvic cavity. As the bladder distends it domes up into the abdominal cavity. The empty bladder is a flattened three-sided pyramid, with the sharp apex pointing forwards to the top of the pubic symphysis and a triangular base facing backwards in front of the rectum or vagina. There are two inferolateral surfaces cradled by the anterior parts of levator ani, a neck where the urethra opens, and a superior surface on which the small intestine and sigmoid colon or uterus lie.
The apex has the remains of the urachus attached to it, the latter forming the median umbilical ligament which runs up the midline of the anterior abdominal wall in the median umbilical fold of peritoneum.
Most of the base, or posterior surface, lies below the level of the rectovesical pouch and only the uppermost portion is covered by peritoneum between the vas deferens on each side Each inferolateral surface slopes downwards and medially to meet its fellow, lying against the front part of the pelvic diaphragm and obturator internus.
The lowest part of the bladder is its neck, where the base and inferolateral surfaces meet and which is pierced by the urethra at the internal urethral orifice.
The superior surface is covered by peritoneum which sweeps upwards onto the anterior abdominal wall.
You are working in a colorectal clinic where you have seen several patients at risk of bowel malignancy. Which of these conditions does not warrant regular colonoscopies?
A Familial Adenomatous Polyposis
B Hereditary Non-Polyposis Colorectal Cancer
C Family history of colonic cancer
D Long standing Crohn’s disease
E Previous history of colorectal malignancy
The correct answer is:
While a family history of colorectal cancer increases an individual’s risk, it does not automatically warrant regular colonoscopies unless specific high-risk criteria are met (e.g., first-degree relative with early-onset cancer, multiple affected relatives, or known hereditary syndromes).
In contrast, the other options do require regular colonoscopic surveillance due to their significantly increased risk of malignancy:
- A. Familial Adenomatous Polyposis (FAP) → Mandatory surveillance due to near-universal development of hundreds to thousands of adenomatous polyps with a 100% lifetime risk of colorectal cancer if untreated.
- B. Hereditary Non-Polyposis Colorectal Cancer (HNPCC/Lynch Syndrome) → High lifetime risk (up to 80%) of colorectal cancer, requiring colonoscopy every 1–2 years starting at age 20–25.
- D. Long-standing Crohn’s disease → Increased risk of colorectal cancer after 8–10 years of disease, especially with extensive colonic involvement (similar to ulcerative colitis).
- E. Previous history of colorectal malignancy → High risk of recurrence/metachronous cancers, requiring regular surveillance (e.g., colonoscopy at 1, 3, and 5 years post-resection).
A general family history of colorectal cancer (C) alone does not necessitate routine colonoscopies unless additional risk factors are present (e.g., early age at diagnosis or multiple affected relatives). The other conditions (A, B, D, E) are well-established high-risk scenarios requiring regular endoscopic surveillance.
Those with a strong family history of colonic cancer are advised to undergo genetic testing. In the absence of a genetic condition (such as FAP or Lynch syndrome), a colonoscopy is advised between the ages of 35 and 45. Further routine colonoscopy is only indicated in the presence of polyps or other suspicious pathology.
Genetic conditions like FAP or HNPCC (aka Lynch syndrome) are associated with high risk of bowel cancer and hence managed with annual colonoscopies.
Patients with IBD are also at higher risk of colonic malignancy, though the exact risk depends on a variety of factors (age, duration and severity of illness, sites affected, etc.) The screening usually starts 10 years after onset of the condition with routine colonoscopies every 1 to 5 years (depending on the risk).
Previous history of colorectal malignancy also predisposes to a subsequent cancer and requires screening every few years.
57 year old male patient presented with altered bowel habit, abdominal pain and distension.Colonoscopy Reveals narrowing and thickening at distal left colon of about 4 cm segment. Biopsy revealed Adenocarcinoma of colon. Which is the Most insidious site of colon cancer?
Cecum
Ascending colon
Descending colon
Transverse colon
Sigmoid colon
Correct Answer: Cecum
Explanation:
The cecum is the most insidious site for colon cancer because:
• Tumors in the cecum and ascending colon can grow large before causing symptoms due to the wide lumen and liquid stool content.
• Patients often present late with iron deficiency anemia from chronic occult bleeding rather than obstructive symptoms.
• Right-sided colon cancers are often diagnosed at advanced stages compared to left-sided tumors, which cause earlier symptoms like obstruction or altered bowel habits.
Why Not the Other Options?
• Ascending Colon – Similar to the cecum, but cecal tumors are usually more insidious.
• Descending Colon – Left-sided tumors tend to present earlier with obstruction, tenesmus, or rectal bleeding.
• Transverse Colon – Intermediate presentation, but not as silent as the cecum.
• Sigmoid Colon – More common site for cancer, but presents earlier with obstructive symptoms due to narrower lumen.
Conclusion:
Cancers in the cecum grow silently for a long time, making it the most insidious site for colon cancer.
Mr Thomas Cook is a 65-year-old man who has come to the GP. He is very concerned about having bowel cancer, as he has been suffering from diarrhoea for a week, and has also suddenly lost weight. He reports that he is using the bathroom 5 to 6 times a day, and has noticed that the stools are hard to flush as they float on the water. He gives a history of recently returning from a holiday 2 weeks ago, where he says he spent a lot of time swimming at the hotel pool. He claims he only drank bottled water and did not eat any raw/uncooked food. What infectious agent is likely to be the cause of his diarrhoea?
Enterotoxigenic E.coli
Shigella sonnei
Salmonella typhi
Rotavirus
GiGiardia lamblia
Giardia lamblia, also known as Giardia intestinalis and Giardia duodenalis, is a flagellated, anaerobic protozoon, which is an important cause of persistent diarrhoea or malabsorption.
Giardia has an outer membrane that makes it possible to retain life even when outside of the host body which can make it tolerant to chlorine disinfection. There are multiple transmission methods including drinking infected water, which is the most common method of transmission for this parasite. It is also common in day-care centers (among children) where poor/undeveloped hygiene practices lead to feco-oral transmission.
Suspect diarrhea when :
• Acute diarrhea lasts more than a week
• Traveller’s diarrhea that has not resolved in over 10 days, and the symptoms started after return, with associated weight loss.
• Diarrhea in day-care centers/ palliative care facilities.
Investigation is usually via stool microscopy OC&P (ova, cysts and parasites).
Superficial spreading melanoma differentiates from Paget’s disease of breast by
S-100 positive
CEA positive
CA19-1 positive
Cytokeratin 19 positive
Pathognomonic of Paget’s disease is the presence of large, pale, vacuolated cells (Paget cells) in the rete pegs of the epithelium. Paget’s disease may be confused with superficial spreading melanoma. Differentiation from pagetoid intrepithelial melanoma is based on the presence of S-100 antigen immunostaining in melanoma and carcinoembryonic antigen immunostaining in Paget’s disease. Surgical therapy for Paget’s disease may involve lumpectomy or mastectomy, depending on the extent of involvement of the nipple-areolar complex and the presence of DCIS or invasive cancer in the underlying breast parenchyma.
None of the above
A 46 year old lean woman is referred to you by the Dermatologist after he diagnosed her with necrolytic migratory erythema. She gives you a history of anticoagulation therapy for recurrent episodes of DVT and long standing Diabetes Mellitus. What according to you is the most likely diagnosis in this patient?
Insulinoma
Gastrinoma
VIPoma
Glucagonoma
Somatostatinoma
Glucagonoma syndrome is a rare syndrome, with a classic presentation of the “4 D’s”: diabetes, dermatitis, deep vein throm-bosis, and depression. It is also characterised by a severe catabolic state with weight loss, depletion of fat and protein stores, and associated vitamin deficiencies. The characteristic skin lesion, a necrolytic migrating erythema, is noted in approximately two thirds of patients and often appears before other symptoms of the syndrome
Mrs Meenakshi has been diagnosed with Parkinson’s disease.She is on a drug which inhibits catechol-o-methyltransferase.Which among the following drugs acts by the above mentioned mechanism?
A Levodopa
B Trihexyphenidyl
C Amantadine
D Tolcapone
E Ropinirole
D Tolcapone
• Levodopa is the single most effective agent in the treat- ment of PD.The effects of levodopa result from its decarboxylation to
DA. In clinical practice, levodopa is almost always administered in combination with a peripherally acting inhibitor of AADC, such as carbidopa or benserazide, drugs that do not penetrate well into the CNS. If levodopa is administered alone, the drug is largely decarboxylated by enzymes in the intestinal mucosa and other peripheral sites so that relatively little unchanged drug reaches the cerebral circulation, and probably less than 1% penetrates the CNS.
• Dopamine receptor agonists are proposed to have the potential to modify the course of PD by reducing endogenous release of
DA as well as the need for exogenous levodopa, thereby reducing free-radical formation. Two orally administered DA receptor agonists are commonly used for treatment of PD: ropinirole and pramipexole.Ropinirole,pramipexole and rotigotine may produce hallucinosis or confusion, similar to that observed with levodopa, and may cause nausea and orthostatic hypotension. They should be initiated at low dose and titrated slowly to minimize these effects.
• COMT inhibitors block this peripheral conversion of levodopa to 3-O-methylDOPA, increasing both the plasma t1/2 of levodopa and the fraction of each dose that reaches the CNS.The COMT inhibitors tolcapone and entacapone reduce significantly the
“wearing off” symptoms in patients treated with levodopa/carbidopa. Common adverse effects of both agents include nausea, orthostatic hypotension, vivid dreams, confusion, and hallucinations. An important adverse effect associated with tolcapone is hepatotoxicity.
• Selective MAO-B inhibitors are used for the treatment of PD: selegiline and rasagiline. These agents selectively and irreversibly inactivate MAO-B. Both agents exert modest beneficial effects on the symptoms of PD. Selegiline can lead to the development of stupor, rigidity, agitation, and hyperthermia when administered with the analgesic meperidine
• Amantadine, an antiviral agent used for the prophylaxis and treatment of influenza A, has antiparkinsonian activity. Amantadine appears to alter DA release in the striatum, has anticholinergic properties, and blocks NMDA glutamate receptors. It is used as initial therapy of mild PD. It also may be helpful as an adjunct in patients on levodopa with dose-related fluctuations and dyskinesias. Dizziness, lethargy, anticholinergic effects, and sleep disturbance, as well as nausea and vomiting, side effects are mild and reversible.
• Antimuscarinic drugs currently used in the treatment of PD include trihexyphenidyl and benztropine mesylate, as well as the antihistaminic diphenhydramine hydrochloride, which also interacts at central muscarinic receptors. The biological basis for the therapeutic actions of muscarinic antagonists is not completely understood. Adverse effects result from their anticholinergic properties. Most troublesome are sedation and mental confusion. All anti- cholinergic drugs must be used with caution in patients with narrow-angle glaucoma, and in general anticholinergics are not well tolerated in the elderly
A football player sustains an injury to his right foot and there is a 2 x0.5cm laceration over the dorsum of the foot.WHich among the following pathological changes will not be present at the site of injury?
A Vasodilation
B Increased permeability of vessel wall
C Chemotaxis of leukocytes
D Granuloma formation
E None of the above
Acute inflammation has three major components:
• Dilation of small vessels leading to an increase in blood flow
• Increased permeability of the microvasculature enabling plasma proteins and leukocytes to leave the circulation; and
• Emigration of leukocytes from the microcirculation, their accumulation in the focus of injury, and their activation to eliminate the offending agent
Granuloma formation is a feature of chronic inflammation.
Nina Foster is a 78 year old woman who is being moved from her own residence to a nursing care home, as she is unable to manage her day-to-day activities independently. You are the doctor who attends the nursing home and have been asked to give her a general check-up. While she is generally in good health, you note that she has some hard nodules on her fingers in the proximal interphalangeal joint. What is the likely diagnosis?
A Osler’s nodes secondary to Lupus
B Osler’s nodes secondary to endocarditis
C Heberden’s nodes secondary to osteoarthritis
D Bouchard’s nodes secondary to osteoarthritis
E Ganglion cyst
This is a Bouchard node. The hard, bony growths in the PIP joint are exostoses, and are usually asymptomatic. They can occasionally cause finger tip deviation. Usually, Bouchard nodes are indicative of severe systemic osteoarthritis.
Your paediatric urology consultant is fond of named signs.Blue dot sign is found in?
A Testicular torsion
B Epididymo Orchitis
c Testicular appendage torsion
D Idiopathic scrotal edema
All of the above
C. Torsion of a testicular or epididymal appendage characteristically affects boys just before puberty, possibly because of enlargement of the hydatid in response to gonadotropins. A hydatid of Morgagni is an embryological remnant found on the upper pole of the testis or epididymis. The pain often increases over a day or two. Occasionally, the torted hydatid can be felt or seen (blue dot sign). Excision of the appendage leads to rapid resolution of symptoms.
A patient with alternating bowel habits and family history of Ibd is found to have ulcerative colitis.Which among the following pathological mechanisms underlies the disease?
A Production of IgE antibodies
B Antibody mediated cellular dysfunction
C Antibody mediated phagocytosis and opsonization
D Antigen-antibody complex deposition
E Inflammation mediated by Th1 and Thi7 cytokines
The correct answer is:
E. Inflammation mediated by Th1 and Th17 cytokines
Explanation:
Ulcerative colitis (UC) is an idiopathic chronic inflammatory condition of the colon, and although the exact cause remains unclear, the pathogenesis is believed to involve a dysregulated immune response to intestinal flora in genetically susceptible individuals. The disease mechanism in UC is primarily associated with inflammatory responses mediated by Th2 and Th17 cells, though more recent research also highlights the role of Th1 and Th17 cytokines particularly in the broader category of IBD (including Crohn’s disease).
• Th17 cells produce interleukin-17 (IL-17), a cytokine implicated in the recruitment of neutrophils and promotion of inflammation.
• Th1 cells release interferon-gamma (IFN-γ), contributing to cellular immunity and inflammation.
This immune-mediated inflammatory response leads to mucosal damage in the colon, characteristic of ulcerative colitis.
The other options describe mechanisms associated with different immune conditions:
• A. IgE antibodies – typical of type I hypersensitivity (e.g., allergies).
• B. Antibody-mediated cellular dysfunction – seen in diseases like myasthenia gravis.
• C. Antibody-mediated phagocytosis and opsonization – related to type II hypersensitivity.
• D. Antigen-antibody complex deposition – hallmark of type III hypersensitivity (e.g., systemic lupus erythematosus).
A patient has been admitted with SIRS to the medical ward. His peripheral smear reveals the presence of Dohle bodies.Which organelle are these bodies derived from?
A Mitochondria
B Lysosomes
c Endoplasmic reticulum
D Nucleus
E None of the above
The correct answer is:
C. Endoplasmic reticulum
Explanation:
Döhle bodies are small, pale blue, cytoplasmic inclusions found in neutrophils. They are remnants of rough endoplasmic reticulum (RER) and are often seen in conditions involving increased neutrophil turnover or toxic granulation, such as in systemic inflammatory response syndrome (SIRS), sepsis, burns, or after administration of certain medications.
These inclusions indicate accelerated neutrophil production in the bone marrow, with immature or toxic changes.
Here’s why the other options are incorrect:
• A. Mitochondria – do not form cytoplasmic inclusions like Döhle bodies.
• B. Lysosomes – may contribute to toxic granules but not Döhle bodies.
• D. Nucleus – Döhle bodies are cytoplasmic, not nuclear.
• E. None of the above – incorrect because they specifically originate from RER.
A 27-year-old woman was thrown from a horse and has sustained a transverse mid humerus fracture. She is unable to actively extend her wrist or index/long fingers or thumb and notes numbness in her first dorsal web space. What is the most likely cause of her nerve dysfunction?
A Laceration by fracture fragment
B Direct blow from landing on the ground
C Crush injury from impact with the ground
D Vascular injury from interruption of the blood supply
E Stretch injury from the fracture displacement
The correct answer is:
E. Stretch injury from the fracture displacement
Explanation:
This patient presents with a classic radial nerve palsy:
• Wrist drop (inability to extend the wrist),
• Loss of extension of fingers and thumb,
• Numbness in the first dorsal web space (a key sensory distribution of the superficial branch of the radial nerve).
The radial nerve travels in the radial (spiral) groove of the humerus, making it particularly vulnerable to injury in mid-shaft humeral fractures.
Among the listed mechanisms:
• Stretch injury from fracture displacement is the most common mechanism of radial nerve palsy in this context. The nerve gets stretched or entrapped by the displaced bone fragments, not necessarily cut or compressed.
• Laceration by fracture fragment (A) is possible but less common than stretch injuries in closed fractures.
• Direct blow (B) and crush injuries (C) might cause nerve injury but are less likely in this typical scenario.
• Vascular injury (D) is unrelated to the specific nerve symptoms described.
Within physiological limits, the heart pumps all the blood that returns to it by way of the veins.What is the name of this law?
A Frank Starling law
B Laplace law
C Poiseuille law
D Bernoulli principle
E None of the above
The correct answer is:
A. Frank-Starling law
Explanation:
The Frank-Starling law of the heart states that the stroke volume of the heart increases in response to an increase in the volume of blood filling the heart (the end-diastolic volume). This is due to the increased stretch of the ventricular myocardium, which optimizes the alignment of actin and myosin filaments, resulting in a stronger contraction.
In simpler terms: the more the heart fills with blood during diastole, the greater the force of contraction during systole, up to a physiological limit. This ensures that the heart pumps out all the blood it receives, maintaining balance between venous return and cardiac output.
Here’s why the others are incorrect:
• B. Laplace law: Describes the relationship between pressure, wall tension, and radius in hollow organs.
• C. Poiseuille law: Governs flow through a cylindrical vessel based on radius, viscosity, and pressure.
• D. Bernoulli principle: Relates pressure and velocity in fluid dynamics.
There is a patient with DCIS posted for wide local excision.Which histologic type of DCIS is most likely to progress to invasive ductal cancer?
A Comedo
B Micropapillary
C Papillary
D Cribriform
E All of the above
The correct answer is:
A. Comedo
Explanation:
Ductal carcinoma in situ (DCIS) is a non-invasive breast cancer confined to the ductal system. Among its various histological subtypes, the comedo type is considered the most aggressive and most likely to progress to invasive ductal carcinoma if left untreated.
Comedo DCIS is characterized by:
• High nuclear grade,
• Central necrosis (often calcified and visible on mammography),
• Rapid proliferation.
The other types—micropapillary, papillary, and cribriform—tend to be lower grade and less likely to become invasive, though all forms of DCIS carry some risk.
E. All of the above is incorrect because not all subtypes carry the same risk; comedo specifically stands out as the highest-risk histologic type for progression.
A newly graduated F1 doctor who was administering local anaesthesia to a patient is concerned that she forgot to draw back the syringe before oushing LA in. She is worried about possible intravascular injection of LA. Which is not an appropriate action?
A She should ask the patient to be on the lookout for perioral tingling, ringing in the ears or excessive drowsiness.
B She should inform the ward nurse to observe for any sudden collapse, seizures or apnoea.
c If the patient collapses, she should immediately infuse IV fluids and shift to an ICU setting
D Anaesthetist team should be informed as intubation may be necessary
E She must fill an incident report
The correct answer is:
A. She should ask the patient to be on the lookout for perioral tingling, ringing in the ears or excessive drowsiness.
Explanation:
Lignocaine toxicity can develop in case of accidental intravascular injection or loosening of a tourniquet during regional block.
Symptoms include drowsiness, headache, perioral tingling, tinnitus and anxiety.
Toxicity can lead to seizures, cardiovascular collapse, arrhythmias, and apnoea. If this develops, initial treatment should always follow ABC protocol - intubation may be necessary and IV fluids should be started. Treatment is mainly symptomatic and inotropic support may be needed.
Incident Reports must always be filled when any avoidable error occurs in the hospital. These are used to document any problems faced in the workplace, including statements of how the problem came about and what corrective actions were taken. This is a standard procedure in hospitals in the UK.
While it is crucial to monitor patients for signs of local anaesthetic systemic toxicity (LAST)—which includes symptoms like perioral tingling, tinnitus, metallic taste, dizziness, and in severe cases, seizures or cardiovascular collapse—it is not appropriate to rely on the patient to self-monitor for these signs, especially if they are sedated, anxious, or not medically trained.
The appropriate course of action includes:
• B. Informing nursing staff to closely observe the patient for any signs of toxicity.
• C. Preparing for emergency management, including IV fluids and ICU transfer if needed.
• D. Informing the anaesthetics team, as advanced airway support or lipid emulsion therapy may be required.
• E. Completing an incident report, which is essential for patient safety, documentation, and reflective learning.
A patient who had sustained a severe road traffic accident undergoes massive blood transfusion.Which of the following is not a complication of massive transfusion?
A Hypothermia
B Coagulopathy
C Hyperkalemia
D Hypercalcemia
E None of the above
The correct answer is:
D. Hypercalcemia
Explanation:
Massive transfusion—typically defined as the replacement of a patient’s total blood volume within 24 hours or transfusion of more than 10 units of packed red blood cells—can lead to several complications. Let’s review them:
• A. Hypothermia – Stored blood is cold, and large volumes can cause hypothermia if not warmed properly.
• B. Coagulopathy – Due to dilutional effects and consumption of clotting factors and platelets.
• C. Hyperkalemia – Stored red cells can leak potassium, especially in older blood, which can lead to elevated serum potassium levels.
• D. Hypercalcemia – This is not a complication. In fact, the opposite is true: hypocalcemia may occur because citrate used in blood products binds to calcium, reducing ionized calcium levels.
So, hypercalcemia is not a complication—that makes D the correct answer here.
Complications from a single transfusion
It includes:
• Incompatibility, haemolytic transfusion reaction;
• Febrile transfusion reaction
• Allergic reaction
• Infection
• Bacterial infection (usually due to faulty storage)
• Hepatitis
• HIV
• Malaria
• Air embolism
• Thrombophlebitis
• Transfusion-related acute lung injury (usually from FFP).
Complications from massive transfusion:
• Coagulopathy
• Hypocalcaemia
• Hyperkalaemia
• Hypokalaemia
• Hypothermia.
Ref: Bailey & Love’s Short Practice of Surgery, 27th Edition, Chapter 2.
Henry suffered an Ml and underwent an angioplasty. He has been receiving 120 mg/day morphine by subcutaneous pump while in the hospital. He is now being discharged home on oral medications. What is the equivalent dose of oral opioid?
A 40 mg immediate release morphine every 4 hours
B 120 mg sustained release oxycodone OD
C 16 mg sustained release hydromorphone BD
D Both A and B
E A, B, and C
The correct answer is:
E. A, B, and C
Explanation:
To determine equivalent oral doses of different opioids from subcutaneous morphine, you need to consider both opioid equivalence and bioavailability.
Step 1: Calculate the total daily oral morphine equivalent.
• Subcutaneous morphine has higher bioavailability than oral morphine.
• The usual conversion ratio is: subcutaneous morphine : oral morphine = 1 : 2.
• So, 120 mg/day subcutaneous morphine = ~240 mg/day oral morphine.
Step 2: Match oral alternatives.
Let’s break down the options:
• A. 40 mg immediate release morphine every 4 hours:
• 6 doses/day → 40 mg × 6 = 240 mg/day oral morphine. Correct.
• B. 120 mg sustained release oxycodone OD:
• Oral oxycodone is approximately 1.5–2 times as potent as oral morphine.
• So 120 mg oxycodone ≈ 180–240 mg morphine. Correct.
• C. 16 mg sustained release hydromorphone BD:
• Oral hydromorphone is ~5–7 times as potent as oral morphine.
• 16 mg BD = 32 mg/day hydromorphone × 5–7 = 160–224 mg morphine. Correct.
So, all three regimens are reasonable equivalents to 240 mg/day oral morphine, making the best answer:
E. A, B, and C
Which of the following is related to the Farabeuf’s triangle?
A IJV
B Common facial vein
C Hypoglossal nerve
D Jugulodigastric node
E All of the above
The correct answer is:
E. All of the above
Explanation:
Farabeuf’s triangle is an important anatomical landmark in neck surgery, particularly in vascular and lymph node dissections. It is bounded by:
• Medially: Common facial vein
• Laterally: Internal jugular vein (IJV)
• Superiorly: Hypoglossal nerve (cranial nerve XII)
Within or near this triangle, you’ll also find:
• Jugulodigastric lymph node (a prominent lymph node in the upper deep cervical chain),
• And the carotid bifurcation, which makes this area surgically significant.
So, each structure listed:
• IJV (A) – forms the lateral boundary,
• Common facial vein (B) – forms the medial boundary,
• Hypoglossal nerve (C) – forms the superior boundary,
• Jugulodigastric node (D) – is located near/within this triangle,
are indeed all related to Farabeuf’s triangle.
Hence, the answer is E. All of the above.
A 13 year old boy is diagnosed with acute left tonsillitis.He is complaining of pain in the left ear. Examination of the ear is unremarkable.
Referred pain from which nerve is most likely to be responsible for these symptoms?
A Facial nerve
B Glossopharyngeal nerve
C Hypoglossal nerve
D Lesser palatine nerve
E Superior laryngeal nerve
The correct answer is:
B. Glossopharyngeal nerve
Explanation:
This is a classic case of referred otalgia (ear pain) in a patient with acute tonsillitis. The glossopharyngeal nerve (cranial nerve IX) provides sensory innervation to:
• The posterior third of the tongue,
• The tonsils,
• The oropharynx,
• And importantly, the middle ear via the tympanic branch (Jacobson’s nerve).
Because of this shared sensory pathway, inflammation or infection in the tonsillar region (as in tonsillitis) can refer pain to the ear, even if the ear exam is normal.
Let’s rule out the others:
• A. Facial nerve – primarily motor to muscles of facial expression; not involved in oropharyngeal sensation.
• C. Hypoglossal nerve – motor to the tongue; no sensory role.
• D. Lesser palatine nerve – sensory to soft palate, but not connected to the ear.
• E. Superior laryngeal nerve – branch of the vagus nerve; sensory to the larynx above vocal cords, not the ear.
So, glossopharyngeal nerve is responsible for the referred ear pain in tonsillitis.
A 50 year old female patient has been listed for PCNL and you have been asked to brief her about the procedure. Which is not a complication of PCNL?
A Renal parenchymal haemorrhage
B Avulsion of ureter
C Rupture of the collecting system
D Sepsis
E Pneumothorax
The correct answer is:
B. Avulsion of ureter
Explanation:
Percutaneous nephrolithotomy (PCNL) is a minimally invasive surgical procedure used to remove kidney stones through a small incision in the back. While it is generally safe, several complications can occur:
Common complications of PCNL include:
• A. Renal parenchymal haemorrhage – due to vascular injury during access or dilation.
• C. Rupture of the collecting system – can occur with high-pressure irrigation or traumatic instrumentation.
• D. Sepsis – due to bacteria released from infected stones or urine.
• E. Pneumothorax – especially if upper pole access is attempted through the 10th or 11th intercostal space.
B. Avulsion of ureter – This is not a complication of PCNL. It is typically associated with ureteroscopic procedures, especially when retrieving large or impacted stones, or during forceful stent placement.
So, avulsion of the ureter is not a known risk of PCNL, making B the correct answer.
You have been called to provide a surgical consult on a patient admitted to the geriatric ward for pneumonia. Her left arm has purple patches with subcutaneous nodules. She gives a previous history of mastectomy with axillary irradiation 15 years ago. What is the likely diagnosis?
A Lymphoedema
B Thrombophlebitis
C Deep vein thrombosis
D Lymphangiosarcoma
E Granulomas
The correct answer is:
D. Lymphangiosarcoma
Explanation:
This clinical scenario is classic for Stewart-Treves syndrome, which refers to the development of lymphangiosarcoma, a rare but aggressive malignant vascular tumor arising in the setting of chronic lymphoedema, often following mastectomy with axillary lymph node dissection and/or radiotherapy.
Key features include:
• History of breast cancer treatment (mastectomy + irradiation).
• Long-standing lymphoedema in the upper limb.
• Development of purple patches, nodules, or plaques on the edematous limb.
• May be mistaken for bruises or hematomas initially.
Let’s rule out other options:
• A. Lymphoedema – is the predisposing condition but not the diagnosis in this case.
• B. Thrombophlebitis – usually involves tender cords and erythema over veins.
• C. DVT – uncommon in the upper limb and doesn’t present with nodules or purple patches.
• E. Granulomas – are more associated with chronic inflammatory or infectious conditions, not post-radiation malignancy.
Lymphangiosarcoma is a surgical emergency, as it is highly malignant and often necessitates radical surgery (like limb amputation) and/or chemotherapy.
Marcus West is a young man who was driving under the influence of alcohol and was involved in a car crash. He was brought to the emergency where his GCS remained 3 despite all resuscitative efforts. His CT scan showed no gross abnormalities. What is the likely diagnosis?
A Concussion
B Subarachnoid haemorrhage
C Intraventricular bleed
D Diffuse axonal injury
E Alcohol induced coma
The correct answer is:
D. Diffuse axonal injury (DAI)
Explanation:
Diffuse axonal injury is a severe form of traumatic brain injury caused by shearing forces during rapid acceleration-deceleration, such as in high-speed motor vehicle accidents. It leads to widespread microscopic damage to axons, especially at the grey-white matter junction, corpus callosum, and brainstem.
Key clues in this case:
• High-impact trauma (car crash),
• Persistent GCS of 3 despite resuscitation,
• Normal CT scan initially (DAI may not show up clearly on CT; MRI is more sensitive),
• No evidence of major hemorrhage or mass lesion.
Why others are incorrect:
• A. Concussion – usually has transient symptoms and GCS should improve.
• B. Subarachnoid haemorrhage – would likely be visible on CT.
• C. Intraventricular bleed – also visible on CT.
• E. Alcohol induced coma – possible, but persistent GCS of 3 after resuscitation in trauma makes DAI more likely.
So, the clinical picture fits diffuse axonal injury, making D the most likely diagnosis.
Which of the following statements is false with regard to immunohistochemistry?
A This is just a special staining method.
B It relies on the use of a specific antibody.
C It helps to determine cell type and differentiation.
D It has a role in the determination of treatment and prognosis.
E It has no role in infectious diseases
The correct answer is:
E. It has no role in infectious diseases — this statement is false.
Explanation:
This technique is a special staining method. It detects a specific antigen using a specific antibody which is labelled with a dye and, when bound to its target antigen, is seen as a coloured stain.
It determines cell type and differentiation and site of origin. The method has a role in the selection of treatment and in the prediction of prognosis. It also has a role in infections. There are antibodies to many infectious agents such as cytomegalovirus (CMV), Epstein-Barr virus (EBV), herpes virus and hepatitis B. Immunohistochemistry (IHC) is a powerful diagnostic tool that uses antibodies to detect specific antigens in tissue sections, making it valuable in both pathology and research.
Let’s review each statement:
• A. This is just a special staining method – True, though “just” understates its importance; IHC is a special stain using antibody-antigen interaction.
• B. It relies on the use of a specific antibody – True, that’s fundamental to IHC.
• C. It helps to determine cell type and differentiation – True, it’s commonly used to distinguish tumour subtypes (e.g., lymphoma vs carcinoma).
• D. It has a role in the determination of treatment and prognosis – True, e.g., HER2 in breast cancer affects treatment decisions.
• E. It has no role in infectious diseases – False. IHC can detect pathogens (like CMV, HSV, tuberculosis, fungi) in tissue by targeting their antigens, and is especially useful when cultures are negative or slow.
Thus, E is the false statement, and therefore the correct answer.
Mrs. Leanne Richards suffered a minor burn over her arm while cooking. After meeting her GP, she is prescribed an NSAID. Which step of pain sensation does this act on?
A Perception
B Transmission
C Modulation
D Transduction
E None of the above
The correct answer is:
D. Transduction
Explanation:
NSAIDs (Non-Steroidal Anti-Inflammatory Drugs) primarily act at the transduction phase of the pain pathway. Here’s how it works:
Pain Pathway Steps:
1. Transduction – Conversion of a noxious stimulus (e.g., thermal or chemical from a burn) into an electrical signal at the peripheral nerve ending. NSAIDs act here by inhibiting cyclooxygenase (COX) enzymes, reducing prostaglandin production, which in turn lowers nociceptor sensitivity.
2. Transmission – The signal travels via peripheral nerves to the spinal cord and then the brain.
3. Modulation – The central nervous system modulates the pain signal through inhibitory or excitatory pathways.
4. Perception – Conscious awareness and interpretation of pain in the brain.
So, NSAIDs reduce the generation of pain signals at the site of injury, specifically during transduction.
A patient with knee injury is seen by his GP.He is clinically suspecting displacement of the patella and is examining him.The oblique placement of the femur and/or line of pull of the quadriceps femoris muscle relative to the axis of the patellar tendon and tibia is assessed clinically as the_angle.
A-T
B-Q
C-R
D-K
E-Alpha
B. Q-angle
Explanation:
The Q-angle (Quadriceps angle) is a clinical measurement used to assess the alignment and biomechanics of the knee, particularly in relation to the patella and quadriceps muscle pull. The patellar ligament is the anterior ligament of the knee joint. Laterally, it receives the medial and lateral patellar retinaculum, aponeurotic expansions of the vastus medialis and lateralis and overlying deep fascia. The retinacula make up the joint capsule of the knee on each side of the patella and play an important role in maintaining alignment of the patella relative to the patellar articular surface of the femur. The oblique placement of the femur and/or line of pull of the quadriceps femoris muscle relative to the axis of the patellar tendon and tibia, assessed clinically as the Q-angle, favors lateral displacement of the patella.
Key points about the Q-angle:
• It represents the angle formed by:
1. A line drawn from the anterior superior iliac spine (ASIS) to the center of the patella.
2. A line from the center of the patella to the tibial tuberosity.
• It reflects the lateral force vector applied by the quadriceps muscle on the patella.
• Normal Q-angle:
• Males: ~13°
• Females: ~18° (due to wider pelvis)
• Increased Q-angle can predispose to patellar subluxation/dislocation, especially laterally.
Clinical relevance:
This measurement is important in assessing patellofemoral pain syndrome, knee malalignment, and risk of patellar dislocation.
Thus, the correct answer is B. Q-angle.
A child is brought to the ER with complaints of abdomen pain and passage of blood mixed with mucus per rectum.A diagnosis of intussusception is made.Which among the following is the most common pathological lead point?
A Meckel’s diverticulum
B Polyp
C Lymphoma
D Duplication cyst
E None of the above
The correct answer is:
A. Meckel’s diverticulum
Explanation:
In older children, the incidence of a pathologic lead point is up to 12%, and Meckel diverticulum is found to be the most common lead point for intussusception. However, other causes, such as intestinal polyps, an inflamed appendix, submucosal haemorrhage associated with Henoch-Schönlein purpura, a foreign body, ectopic pancreatic or gastric tissue, and intestinal duplication, must also be considered. Intussusception is a condition in which a segment of the intestine “telescopes” into an adjacent distal segment, leading to obstruction, ischemia, and bleeding. It is most common in infants and young children, presenting with:
• Intermittent colicky abdominal pain
• “Red currant jelly” stools (blood and mucus)
• Palpable abdominal mass
Pathological lead points:
In most cases (especially under 2 years), intussusception is idiopathic and may be associated with Peyer’s patches hypertrophy (after viral infections).
However, when a pathological lead point is identified, the most common cause in children is:
• A. Meckel’s diverticulum – A remnant of the vitelline duct, often located in the ileum, and may contain ectopic gastric or pancreatic tissue.
Other less common lead points include:
• Polyps (B) – e.g., juvenile polyps, more common in older children.
• Lymphoma (C) – more typical in older children and adolescents.
• Duplication cyst (D) – rare congenital anomalies of the gut.
So, the most common lead point in children is Meckel’s diverticulum.
When the pH falls, the oxygen-haemoglobin dissociation curve shifts to the right. Which of the following phenomena best describes this shift?
A Haldane effect
B Bohr effect
C Pasteur effect
D Rebound effect
E Breuer effect
B. Bohr effect
Explanation:
The Bohr effect describes the rightward shift of the oxygen-haemoglobin dissociation curve in response to a decrease in pH (acidosis) or an increase in carbon dioxide (CO₂). This shift facilitates the release of oxygen from haemoglobin in tissues where it is most needed (e.g., active muscles producing CO₂ and H⁺).
Key features of the Bohr effect:
• Lower pH (more acidic) → rightward shift
• Increased CO₂ → rightward shift
• Promotes oxygen unloading in tissues.
Let’s look at the other options:
• A. Haldane effect – Describes how oxygenation of blood in the lungs displaces CO₂ from haemoglobin, enhancing CO₂ removal.
• C. Pasteur effect – Refers to the inhibition of glycolysis by oxygen.
• D. Rebound effect – A general term not specific to respiratory physiology.
• E. Breuer effect – Possibly referring to the Hering–Breuer reflex, which prevents lung overinflation.
Thus, the Bohr effect is the best explanation for the rightward shift due to a fall in pH.
A 56 year old female patient is posted for coronary artery bypass graft.Which is the preferred conduit for the bypass?
A Great saphenous vein
B Short saphenous vein
C Internal thoracic artery
D Radial artery
E Axillary vein
The correct answer is:
C. Internal thoracic artery
Explanation:
In coronary artery bypass grafting (CABG), the preferred and most durable conduit is the internal thoracic artery (ITA)—specifically the left internal thoracic artery (LITA).
Reasons:
• Superior long-term patency rates compared to vein grafts.
• Resistant to atherosclerosis.
• Most commonly anastomosed to the left anterior descending artery (LAD), which is often the most critical artery in terms of myocardial perfusion.
The other options:
• A. Great saphenous vein – Frequently used as a secondary conduit, especially for multiple grafts, but has lower patency than ITA.
• B. Short saphenous vein – Rarely used due to smaller size and variable anatomy.
• D. Radial artery – A good alternative arterial conduit, used when additional arterial grafts are needed.
• E. Axillary vein – Not used for CABG.
So, the internal thoracic artery is the gold standard conduit for CABG.
In earlier coronary artery bypass operations, a suitable length of great saphenous vein was anastomosed at one end to the ascending aorta and at the other to the appropriate coronary vessel distal to the site of blockage. The vein, of course, must be turned upside down so that any valves in the chosen segment do not obstruct the arterial flow. Current opinion now often favours the use of the internal thoracic artery, particularly for the left anterior descending artery; the proximal end remains intact at its subclavian origin and the cut lower end is anastomosed to the coronary vessel. Three or four coronary arteries may be bypassed in the same patient utilizing both internal thoracic arteries and vein grafts or free arterial segments (such as from the radial artery).
Which of these is considered as the most important reasons to remove thyroglossal cyst?
A Recurrent inflammation
B Malignancy
C Aberrant tissues
D Hyperthyroidism
E None of the above
The correct answer is:
A. Recurrent inflammation
Explanation:
The most important and common reason to remove a thyroglossal duct cyst is recurrent infection or inflammation. These cysts often present in childhood or adolescence as a midline neck swelling that may become tender, enlarge, or drain during episodes of infection.
Why the others are incorrect:
• B. Malignancy – While possible, malignancy in a thyroglossal cyst (usually papillary carcinoma) is rare (~1%).
• C. Aberrant tissues – Thyroglossal cysts may contain ectopic thyroid tissue, but this alone isn’t a primary reason for removal.
• D. Hyperthyroidism – Unrelated; thyroglossal cysts typically don’t secrete thyroid hormones.
Surgical removal:
The standard procedure is the Sistrunk operation, which involves excising the cyst, the tract, and the central portion of the hyoid bone to reduce recurrence.
A 56 year old male patient is diagnosed with parotid sialadenitis.There is a calculi in the parotid duct. Which among the following is true about the parotid duct?
A Has an opening located on the floor of the mouth next to the frenulum
B Has an opening opposite the first lower molar
C Is approximately 1 cm long
D Lies in the middle third of a line between the intertragic notch of the auricle and the midpoint of the philtrum
E Runs between mylohyoid and hyoglossus
The correct answer is:
D. Lies in the middle third of a line between the intertragic notch of the auricle and the midpoint of the philtrum
Explanation:
The parotid (Stensen’s) duct is about 5 cm long, not 1 cm. It arises from the anterior border of the parotid gland, passes over the masseter muscle, and then pierces the buccinator muscle to open opposite the second upper molar tooth, not the first lower molar (which is the submandibular duct’s location).
Importantly, it lies in the middle third of a line drawn from the intertragic notch (just below the ear) to the midpoint of the philtrum of the upper lip, which is a classic anatomical landmark used in clinical assessment and procedures involving the duct.
Let’s quickly go through the other options:
• A refers to the submandibular (Wharton’s) duct, not the parotid duct.
• B is incorrect; the opening is opposite the second upper molar, not the first lower.
• C is incorrect; the duct is approximately 5 cm long.
• E is incorrect; the parotid duct does not run between the mylohyoid and hyoglossus—that’s the course of the submandibular duct.
You have been called to see an abnormal ECG in the ER.An enthusiastic medical student starts asking you doubts on the cardiac action potential.Phase 0 of the cardiac action potential relates to which one of the following options?
A Rapid efflux of potassium
B Rapid influx of calcium
C Influx of potassium
D Rapid influx of sodium
E None of the above
A 45 year old male patient has been admitted at the CCU following acute myocardial infarction. Which of these is not a risk factor for ischaemic heart disease?
A Obesity.
B Female gender.
C Advancing age.
D Reduced physical activity.
E Smoking
The correct answer is:
B. Female gender
Explanation:
Female gender is not considered a risk factor for ischaemic heart disease (IHD); in fact, pre-menopausal women are relatively protected due to the cardioprotective effects of estrogen. However, this protection diminishes after menopause, and the risk eventually becomes similar to that in men.
Here’s how the other options relate to IHD risk:
• A. Obesity: Increases risk due to its association with hypertension, diabetes, and dyslipidemia.
• C. Advancing age: A well-established non-modifiable risk factor.
• D. Reduced physical activity: A modifiable risk factor.
• E. Smoking: A major modifiable risk factor that damages vascular endothelium and accelerates atherosclerosis.
At what level of brainstem injury does damage to the vagus and hypoglossal nerve nuclei occur?
A Pons
B Medulla
C Cerebrum
D Midbrain
E Any of the above
The correct answer is:
B. Medulla
The vagus nerve (CN X) and the hypoglossal nerve (CN XII) nuclei are located in the medulla oblongata of the brainstem.
- The dorsal motor nucleus of the vagus and the nucleus ambiguus (which contributes motor fibers to the vagus nerve) are found in the medulla.
- The hypoglossal nucleus (which controls tongue movement via CN XII) is also located in the medulla.
- A. Pons – Contains nuclei for CN V, VI, VII, and VIII, but not X or XII.
- C. Cerebrum – Not part of the brainstem; does not contain cranial nerve nuclei.
- D. Midbrain – Contains nuclei for CN III and IV, but not X or XII.
- E. Any of the above – Incorrect, as only the medulla houses these nuclei.
Thus, damage to the medulla can affect the vagus and hypoglossal nerve nuclei.
A pathologist finds “ smudge cells” in a peripheral smear.What is the most likely diagnosis?
A CML
B AML
C ALL
D CLL
E Hodgkin’s lymphoma
The correct answer is:
D. CLL (Chronic Lymphocytic Leukemia)
Smudge cells (also called basket cells) are a hallmark finding in CLL. They are fragile, ruptured lymphocytes that appear as smudged or broken cells on a peripheral blood smear due to their fragility during slide preparation.
- A. CML (Chronic Myeloid Leukemia) – Typically shows myeloid precursors (e.g., myelocytes, metamyelocytes) and basophilia, not smudge cells.
- B. AML (Acute Myeloid Leukemia) – Presents with myeloblasts and Auer rods, not smudge cells.
- C. ALL (Acute Lymphoblastic Leukemia) – Shows lymphoblasts, which are larger and more uniform, not smudge cells.
- E. Hodgkin’s lymphoma – Diagnosed by Reed-Sternberg cells in lymph nodes, not smudge cells in peripheral blood.
Smudge cells are most characteristic of CLL, where they result from the fragility of malignant B lymphocytes (CD5+/CD19+/CD23+). A high smudge cell count may correlate with disease burden.
Identify the true statement about clinical audit
A It is designed and conducted solely to define or judge current care.
B It involves randomisation
C It involves an intervention which is in use only
D It is designed to answer: “What standard does this service achieve?”
E It measures current service without reference to a standard
D. It is designed to answer: “What standard does this service achieve?”
Explanation:
A clinical audit is a quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria and the implementation of change. The key elements involve:
• Measuring current practice against a predetermined standard
• Identifying areas for improvement
• Implementing necessary changes
• Re-auditing to assess the effect of changes
Let’s review the other options:
• A: Incorrect. While audits assess current care, they are also about improving care, not just judging it.
• B: Incorrect. Randomisation is a feature of clinical trials, not audits.
• C: Incorrect. Clinical audits may involve existing interventions, but this isn’t the defining feature.
• E: Incorrect. An audit must compare current service against a set standard, not just describe it.
You are being shown an x-ray chest of a patient with descending thoracic aneurysm.The consultant wants to know at what vertebral level this major vessel begins.
A Lower border of T3
B Upper border of T4
C Lower border of T4
D Upper border of T5
E Upper border of T3
Descending thoracic aorta commences at the lower border of T4 vertebra, where the arch of the aorta ends. At first to the left of the midline, the vessel slants gradually to the midline and leaves the posterior mediastinum at the level of T12 vertebra by passing behind the diaphragm between the crura (i.e. behind the median arcuate ligament). It gives off nine pairs of posterior intercostal arteries, a pair of subcostal arteries, bronchial arteries, esophageal vessels and a few small pericardial and phrenic branches.
A 70-year-old man with known chronic obstructive pulmonary disease is admitted to the Emergency Department with severe shortness of breath. Blood gas analysis shows:
pH: 7.37 (7.35-7.45)
PaCO2: 10kPa (4.6-6 kPa)
Pa02: 10kPa (> 10.6 kPa)
HCO3-: 31 mmol/L (22-29 mmol/L)
What abnormality does his blood gas analysis show?
A Acute respiratory acidosis
B Chronic, compensated respiratory acidosis
C Acute exacerbation of chronic respiratory acidosis
D Acute respiratory alkalosis
E Severe metabolic acidosis
The correct answer is:
B. Chronic, compensated respiratory acidosis
Here’s why:
Let’s interpret the blood gases step by step:
• pH: 7.37 — This is within the normal range, but on the acidic side, suggesting compensation.
• PaCO₂: 10 kPa — This is very high, indicating respiratory acidosis.
• HCO₃⁻: 31 mmol/L — This is elevated, indicating renal compensation by retaining bicarbonate to buffer the acidosis.
• PaO₂: 10 kPa — Slightly low, consistent with COPD.
Conclusion:
This patient with known COPD has:
• A high PaCO₂, consistent with chronic CO₂ retention.
• A normal pH, maintained by a raised bicarbonate, indicating the kidneys have compensated.
• This is a typical picture of chronic, compensated respiratory acidosis.
Other options:
• A: Acute respiratory acidosis would show low pH without time for renal compensation.
• C: In acute-on-chronic, you’d usually see a drop in pH due to the acute element.
• D: Respiratory alkalosis would show low PaCO₂.
• E: Metabolic acidosis would present with low HCO₃⁻ and low pH.
A 57-year-old non-small-cell lung cancer patient with a potentially resectable tumor found on computed tomography (CT) scan who can walk on a flat surface indefinitely without oxygen or stopping to rest, secondary to dyspnea will most likely tolerate
Lobectomy
Pneumonectomy
Single-lung ventilation
Wedge resection
None of the above
Solution
Lobectomy. Patients with potentially resectable tumors require careful assessment of their functional status and ability to tolerate either lobectomy or pneumonectomy. The surgeon should first estimate the likelihood of pneumonectomy, lobectomy, or possibly sleeve resection, based on the CT images. A sequential process of evaluation then unfolds. A patient’s history is the most important tool for gauging risk. Specific questions regarding performance status should be routinely asked. If the patient can walk on a flat surface indefinitely, without oxygen and without having to stop and rest secondary to dyspnea, he will be very likely to tolerate lobectomy. If the patient can walk up two lights on stairs (up two standard levels), without having to stop and rest secondary to dyspnea, he will likely tolerate pneumonectomy. Finally, nearly all patients, except those with carbon dioxide (CO2 ) retention on arterial blood gas analysis, will be able to tolerate periods of single-lung ventilation and wedge resection.
A 60-year-old man presents to his GP with a 2-day history of left iliac fossa pain (LIF) and fresh rectal bleeding. He has no history of weight loss or loss of appetite, but reveals a longstanding history of constipation. Physical examination reveals mild left iliac fossa tenderness with no signs of peritonism. Which of the following statements is not true about the most likely condition that this patient has presented with?
The underlying pathology occurs at sites of vascular entry into the bowel wall
The underlying pathology involves all layers of the bowel wall
The underlying pathology most commonly occurs in the descending and sigmoid colon
The condition is most common in Western populations
The underlying pathology almost never occurs in the rectum
The correct answer is:
B. The underlying pathology involves all layers of the bowel wall
Here’s why:
This patient presents with:
• Left iliac fossa (LIF) pain
• Fresh rectal bleeding
• Longstanding constipation
• No systemic symptoms like weight loss
These features are most consistent with diverticular disease, likely diverticulitis or bleeding from a colonic diverticulum.
Key facts about diverticular disease:
• Pathology: Diverticula are mucosal herniations through the muscular layer at points of weakness — typically where vessels penetrate the bowel wall. So, A is true.
• Layers involved: Diverticula are not full-thickness defects — they are false diverticula, involving mucosa and submucosa only, not all bowel layers. So, B is not true.
• Common location: Most often in the sigmoid and descending colon. So, C is true.
• Epidemiology: Common in Western populations, linked with low-fibre diets. So, D is true.
• Rectum: Almost never affected due to stronger longitudinal muscle layer. So, E is true.
Therefore:
B is not true, making it the correct answer to the “not true” question.
All of the following are causes of intravascular hemolysis except?
A Hereditary spherocytosis
B Prosthetic heart valves
C Thrombotic vessel
D Marathon running
E All of the above
The correct answer is:
A. Hereditary spherocytosis
Here’s why:
Intravascular hemolysis occurs when red blood cells (RBCs) are destroyed within the blood vessels, leading to the release of free hemoglobin into the plasma.
Let’s examine each option:
• A. Hereditary spherocytosis:
• This is primarily a cause of extravascular hemolysis, where spherocytes are removed by the spleen.
• It does not typically cause intravascular hemolysis, hence this is the correct answer to the “except” question.
• B. Prosthetic heart valves:
• Can cause mechanical destruction of RBCs in circulation — a classic cause of intravascular hemolysis.
• C. Thrombotic vessel (e.g., microangiopathic hemolytic anemia):
• RBCs get sheared as they pass through narrowed or damaged vessels — another cause of intravascular hemolysis.
• D. Marathon running:
• Known to cause foot strike hemolysis, a mild form of intravascular hemolysis due to mechanical trauma.
• E. All of the above:
• Incorrect, as A is not a cause of intravascular hemolysis.
Summary:
Hereditary spherocytosis causes extravascular, not intravascular, hemolysis — making A the correct choice.
You are being shown an x-ray chest of a patient with descending thoracic aneurysm.The consultant wants to know at what vertebral level this major vessel begins.
A Lower border of T3
B Upper border of T4
c Lower border of T4
D Upper border of T5
E Upper border of T3
Solution
Descending thoracic aorta commences at the lower border of T4 vertebra, where the arch of the aorta ends. At first to the left of the midline, the vessel slants gradually to the midline and leaves the posterior mediastinum at the level of T12 vertebra by passing behind the diaphragm between the crura (i.e. behind the median arcuate ligament). It gives off nine pairs of posterior intercostal arteries, a pair of subcostal arteries, bronchial arteries, esophageal vessels and a few small pericardial and phrenic branches.
A cohort study is being designed to look at the relationship between duration of hospitalisation in the patient and mucormycosis. What is the usual outcome measure in a cohort study?
A Odds ratio
B Experimental event rate
c Relative risk
D Absolute risk increase
E Numbers needed to harm
• Strength of association in a cohort study is evaluated by Relative risk (RR), Attributable risk (AR) and Population attributable risk
(PAR)
• Relative risk (RR) = Incidence among exposed/ Incidence among non-exposed
• Interpretation of RR: Incidence of lung disease among exposed IS SO MANY TIMES HIGHER as compared to that among non-exposed
• Attributable risk (AR) = (Incidence among exposed - Incidence among non- exposed) / Incidence among exposed × 100
• Interpretation of AR: So much disease can be attributed to exposure
• Population attributable risk (PAR) = (Incidence among total - Incidence among non- exposed) / Incidence among total × 100
• Interpretation of PAR: If risk factor is modified or eliminated, there will be so much annual reduction in incidence of disease in the given population
A 31-year-old male rock climber spent the day climbing outdoors with a partner. They hiked to the base of the climb carrying their gear in backpacks. After hiking 2.5 hours back to his vehicle, while carrying approximately 9 kg of gear in this manner, he realized he was unable to shrug his right shoulder The foramen magnum is one of several openings at the base of the skull. Which important neurological structure/s pass through the foramen magnum?
A Facial nerve VII
B Hypoglossal nerve XII
C Optic nerve |I
D The medulla oblongata and the spinal accessory nerve
E Vestibulocochlear nerve VIII.
The structures passing through the foramen magnum include: the medulla oblongata; meninges; spinal parts of the accessory nerves; meningeal branches of the upper cervical nerves; the vertebral arteries; and the anterior and posterior spinal arteries.
The correct answer is:
D. The medulla oblongata and the spinal accessory nerve
Explanation:
The foramen magnum is the largest opening in the base of the skull and serves as a passage for several critical structures:
• The medulla oblongata, which continues as the spinal cord.
• The spinal root of the accessory nerve (cranial nerve XI), which ascends through the foramen magnum to join its cranial component before exiting the skull via the jugular foramen.
• Vertebral arteries and meninges also pass through.
This question links to the clinical scenario: the inability to shrug the shoulder suggests spinal accessory nerve (CN XI) damage, which innervates the trapezius muscle. Compression or traction injury from carrying a heavy backpack could lead to this.
Other nerves listed pass through different foramina:
• Facial nerve (VII): stylomastoid foramen.
• Hypoglossal nerve (XII): hypoglossal canal.
• Optic nerve (II): optic canal.
• Vestibulocochlear nerve (VIII): internal acoustic meatus.
