RECALLS 2 Flashcards
A patient suffered an injury to his thumb finger while gardening. He is now complaining of a
fluctuant swelling in the palp space of his thumb. What is the causative organism?
A. Streptococcus pyogenes
B. Klebsiella
C. Staphylococcus aureus
D. Pseudomonas
E. MRSA
The most likely causative organism is C. Staphylococcus aureus.
Explanation:
The patient has a fluctuant swelling in the palmar (palp) space of the thumb, which suggests an abscess or deep space infection, likely due to a felon or deep space infection of the hand. These infections commonly result from puncture wounds, minor trauma, or gardening-related injuries.
• Staphylococcus aureus is the most common cause of hand infections, particularly abscesses and deep space infections.
• MRSA (Methicillin-Resistant Staphylococcus aureus) is also a possibility, but MSSA (Methicillin-Sensitive Staphylococcus aureus) is more common in community-acquired infections unless there is a history of MRSA exposure.
• Streptococcus pyogenes can cause cellulitis and necrotizing infections but is less commonly associated with abscess formation.
• Pseudomonas is associated with puncture wounds involving soil but is less common in isolated thumb infections.
• Klebsiella is rare in this context, mostly seen in immunocompromised patients.
Thus, the best answer is Staphylococcus aureus (C).
During major trauma what important factor that is increased and
important in coagulopathy + hyperfibrinolysis?
a. TNF
b. Plasmin activator inhibitor
c. Activated protein C
d. Tissue plasminogen
During major trauma, an important factor that is increased and plays a significant role in coagulopathy and hyperfibrinolysis is:
c. Activated protein C
Activated protein C (APC) is a key player in the regulation of coagulation and fibrinolysis. In the context of major trauma, the body’s response to injury can lead to a state of systemic inflammation and coagulation disturbances. Activated protein C has anticoagulant properties by inactivating factors Va and VIIIa, which are necessary for thrombin generation. Additionally, APC has profibrinolytic effects by inhibiting plasminogen activator inhibitor-1 (PAI-1), thereby promoting the breakdown of clots.
In trauma-induced coagulopathy, there is often an imbalance between coagulation and fibrinolysis, leading to either excessive clotting or bleeding. The increase in activated protein C can contribute to this dysregulation by enhancing fibrinolysis and inhibiting coagulation, which can exacerbate bleeding in trauma patients.
While other factors like TNF (a pro-inflammatory cytokine) and tissue plasminogen activator (tPA, which promotes fibrinolysis) are also involved in the inflammatory and coagulative response to trauma, activated protein C is particularly significant in the context of coagulopathy and hyperfibrinolysis.
Hip injury at psoas tendon insertion at lesser trochanter. Most likely
vessel injured here is -
a. Femoral artery
b. Femoral vein
c. Transverse circumflex artery
d. External iliac artery
In the case of a hip injury at the psoas tendon insertion at the lesser trochanter, the most likely vessel injured is:
c. Transverse circumflex artery
The lesser trochanter is the insertion site of the psoas tendon, and the surrounding anatomy includes branches of the medial circumflex femoral artery and lateral circumflex femoral artery. These arteries are part of the deep femoral artery (profunda femoris) system and supply the hip joint and surrounding muscles.
- The transverse branch of the lateral circumflex femoral artery runs near the lesser trochanter and is particularly vulnerable to injury in this region due to its proximity to the psoas tendon insertion.
- a. Femoral artery: The femoral artery is located more anteriorly in the femoral triangle and is not typically near the lesser trochanter.
- b. Femoral vein: The femoral vein accompanies the femoral artery and is also not in close proximity to the lesser trochanter.
- d. External iliac artery: The external iliac artery is located higher in the pelvis and is not near the lesser trochanter.
Thus, the transverse circumflex artery is the most likely vessel to be injured in this scenario.
internal iliac artery getting compressed by
some external structure. Then - Which is the correct anatomical relation?
a. Vein is anterior to artery
b. Vein is lateral to artery
c. Ureter is anterior to artery
d. Artery is anterior to vein
e. Artery is posterior to vein
The correct anatomical relation in the case of the internal iliac artery being compressed by an external structure is:
e. Artery is posterior to vein
In the pelvic region, the internal iliac artery and internal iliac vein have a specific anatomical relationship:
- The internal iliac vein lies anterior to the internal iliac artery.
- Therefore, the internal iliac artery is posterior to the internal iliac vein.
This relationship is important in understanding how structures in the pelvis interact and how compression or other external forces might affect these vessels.
- a. Vein is anterior to artery: This is correct, but the question asks for the relationship of the artery relative to the vein, not the vein relative to the artery.
- b. Vein is lateral to artery: Incorrect. The vein is anterior, not lateral.
- c. Ureter is anterior to artery: While the ureter does cross anterior to the internal iliac artery, this is not the relationship being asked about in the context of compression.
- d. Artery is anterior to vein: Incorrect. The artery is posterior to the vein.
Thus, the correct answer is e. Artery is posterior to vein.
Most likely amyloid composition in heart -
a. AA
b. AL
c. Attr
d. Beta 2
The most likely amyloid composition in the heart is:
b. AL (amyloid light chain)
Cardiac amyloidosis is most commonly associated with AL amyloidosis (primary amyloidosis), which is caused by the deposition of misfolded immunoglobulin light chains produced by plasma cell dyscrasias, such as multiple myeloma. AL amyloidosis is the most frequent type of amyloidosis affecting the heart.
- a. AA (amyloid A): This type is associated with chronic inflammatory diseases (e.g., rheumatoid arthritis, tuberculosis) and typically affects the kidneys, liver, and spleen, but rarely the heart.
- c. ATTR (transthyretin amyloidosis): This type can also affect the heart and is caused by the deposition of misfolded transthyretin protein. It can be hereditary (mutated transthyretin) or wild-type (senile amyloidosis). While ATTR is a significant cause of cardiac amyloidosis, it is less common than AL amyloidosis.
- d. Beta-2 microglobulin: This type is associated with dialysis-related amyloidosis and typically affects joints and bones, not the heart.
The most likely amyloid composition in the heart is AL amyloidosis (b). However, ATTR amyloidosis is also an important consideration in cardiac amyloidosis, particularly in older adults.
A 70-year-old ex-sailor presents with a crusty, exophytic ulcer over his left cheek that has been present for 6 months. On examination, the ulcer has an everted edge with basoloid features. A few enlarged lymph nodes are palpable in his neck.
Question:
What is the most likely diagnosis?
Options:
a. Squamous cell carcinoma (SCC)
b. Basal cell carcinoma (BCC)
c. Keratoacanthoma
d. Malignant melanoma
e. Merkel cell tumor
Correct Answer: a. Squamous cell carcinoma (SCC)
Rationale:
- Squamous cell carcinoma (SCC) is the most likely diagnosis given the clinical features:
- Crusty, exophytic ulcer: SCC often presents as an ulcerated lesion with an everted edge.
- Everted edge: This is a classic feature of SCC.
- Basaloid features: SCC can sometimes have basaloid differentiation, especially in high-risk or aggressive variants.
- Enlarged lymph nodes: SCC is more likely to metastasize to regional lymph nodes compared to other skin cancers like BCC.
- Risk factors: Chronic sun exposure (as in an ex-sailor) is a significant risk factor for SCC.
Why not the other options?
- b. Basal cell carcinoma (BCC): BCC typically presents as a pearly, nodular lesion with rolled edges and telangiectasia. It rarely metastasizes to lymph nodes.
- c. Keratoacanthoma: This is a rapidly growing, dome-shaped lesion that often resolves spontaneously. It is less likely to present with an everted edge or lymph node involvement.
- d. Malignant melanoma: Melanoma usually presents as a pigmented lesion with irregular borders and color variation. It is less likely to present as a crusty, exophytic ulcer.
- e. Merkel cell tumor: This is a rare neuroendocrine tumor of the skin that typically presents as a rapidly growing, painless nodule. It is less likely to have an everted edge or crusty appearance.
Conclusion:
The most likely diagnosis is Squamous cell carcinoma (SCC) due to the clinical features and risk factors.
Patient with refractory hypertension and diagnosed of Conn’s what you
think the cause of hypertension?
a. Increase plasma volume
b. Increase renin
c. Increase ACTH
d. Decrease aldosterone
e. Increase cortisol
In a patient with refractory hypertension diagnosed with Conn’s syndrome (primary hyperaldosteronism), the cause of hypertension is:
a. Increased plasma volume
Conn’s syndrome is characterized by excessive production of aldosterone from the adrenal glands, independent of the renin-angiotensin-aldosterone system (RAAS). This leads to:
- Increased sodium reabsorption in the kidneys, which causes water retention.
- Increased plasma volume, leading to hypertension.
- Suppression of renin due to the negative feedback from high aldosterone levels.
- b. Increased renin: Renin levels are typically decreased in Conn’s syndrome because the high aldosterone levels suppress renin production via negative feedback.
- c. Increased ACTH: ACTH is not directly involved in the pathophysiology of Conn’s syndrome. ACTH regulates cortisol production, not aldosterone.
- d. Decreased aldosterone: In Conn’s syndrome, aldosterone levels are elevated, not decreased.
- e. Increased cortisol: Cortisol levels are not typically affected in Conn’s syndrome. This condition is specific to aldosterone overproduction.
The primary cause of hypertension in Conn’s syndrome is increased plasma volume due to excessive aldosterone-driven sodium and water retention. Thus, the correct answer is a. Increased plasma volume.
Patient with urinary bladder cancer and made an operation for resection
of urinary bladder and then new bladder is formed from small intestine
mainly ileum, creatinine is high. What is the electrolyte disturbance
a. Hyperkalemia
b. Hypokalemia
c. Hyperchloremia
d. Hypochloremia
e. Hypocalcemia
In a patient who has undergone urinary bladder resection and formation of a new bladder (neobladder) using the ileum, the most likely electrolyte disturbance is:
a. Hyperkalemia
When a segment of the small intestine (typically the ileum) is used to create a neobladder, the intestinal mucosa can lead to electrolyte imbalances due to its absorptive and secretory properties. The ileum normally absorbs electrolytes, but when exposed to urine, it can lead to:
- Hyperkalemia: The ileal mucosa may absorb potassium from the urine, leading to elevated serum potassium levels.
- Hyperchloremic metabolic acidosis: The ileum can also absorb chloride and secrete bicarbonate, leading to acidosis and hyperchloremia.
- b. Hypokalemia: This is unlikely because the ileal mucosa tends to absorb potassium, not lose it.
- c. Hyperchloremia: While hyperchloremia can occur due to chloride absorption, it is often accompanied by metabolic acidosis and is not the primary electrolyte disturbance in this context.
- d. Hypochloremia: This is unlikely because the ileum tends to absorb chloride, not lose it.
- e. Hypocalcemia: Hypocalcemia is not typically associated with ileal neobladder formation. Calcium disturbances are more common in conditions like chronic kidney disease or hypoparathyroidism.
The most likely electrolyte disturbance in this patient is hyperkalemia due to potassium absorption from the urine by the ileal mucosa. Thus, the correct answer is a. Hyperkalemia.
A 12-year-old boy presents with fever, localized pain, and swelling in the upper thigh. Blood
tests reveal elevated white cell count, CRP, and ESR. X-rays show lytic lesions in the femoral
bone. Which part of the femur is most commonly affected in osteomyelitis in children?
Options:
1. Metaphysis.
2. Diaphysis.
3. Epiphysis.
4. Periosteum.
5 . Cortex
The most common site for osteomyelitis in children is the metaphysis of long bones. Therefore, the correct answer is:
1. Metaphysis.
- Metaphysis: This is the most common site for osteomyelitis in children due to its rich blood supply and unique vascular anatomy. The slow blood flow in the metaphyseal capillaries makes it susceptible to bacterial seeding.
- Diaphysis: This is the shaft of the bone and is less commonly affected in children compared to the metaphysis.
- Epiphysis: This is the end of the bone and is less commonly involved in osteomyelitis.
- Periosteum: This is the outer covering of the bone and is not typically the primary site of infection.
- Cortex: This is the dense outer layer of the bone and is not the primary site of infection in osteomyelitis.
In this case, the boy’s symptoms (fever, localized pain, swelling, elevated inflammatory markers, and lytic lesions on X-ray) are consistent with osteomyelitis, and the metaphysis of the femur is the most likely site of involvement.
A 72-year-old male on long-term warfarin for atrial fibrillation is scheduled for an elective
hip replacement in 7 days. His INR is 3.2. What is the best approach for managing his
anticoagulation prior to surgery?
Options:
1. Stop warfarin and give prothrombin complex concentrate (PCC).
2. Stop warfarin and administer vitamin K 10 mg.
3. Switch to low molecular weight heparin (LMWH) and discontinue it 24 hours
before surgery.
4. Continue warfarin but reduce the dose to normalize INR.
5. Perform surgery without altering anticoagulation therapy.
The best approach for managing this patient’s anticoagulation prior to elective hip replacement is:
3. Switch to low molecular weight heparin (LMWH) and discontinue it 24 hours before surgery.
- Warfarin has a long half-life (typically 2–5 days), and stopping it 7 days before surgery allows sufficient time for the INR to normalize (target INR < 1.5 for most surgeries).
- Low molecular weight heparin (LMWH) is used as a “bridge therapy” in patients at high risk of thromboembolism (e.g., atrial fibrillation with a CHA₂DS₂-VASc score ≥ 2). LMWH is stopped 24 hours before surgery to minimize bleeding risk while providing continued anticoagulation until closer to the procedure.
- Prothrombin complex concentrate (PCC) (Option 1) is used for urgent reversal of warfarin in cases of bleeding or emergency surgery, not for elective surgery.
- Vitamin K 10 mg (Option 2) is used for warfarin reversal but takes 24–48 hours to lower the INR. It is not ideal for elective surgery planning.
- Continuing warfarin (Option 4) or not altering anticoagulation (Option 5) would increase the risk of bleeding during surgery.
- Stop warfarin 7 days before surgery.
- Start LMWH as bridge therapy.
- Discontinue LMWH 24 hours before surgery.
- Check INR on the day of surgery to ensure it is < 1.5.
A 72-year-old male on long-term warfarin for atrial fibrillation presents for emergency hip
surgery following a fracture. His INR is 3.2, and the surgery cannot be delayed. What is the
best approach for managing his anticoagulation?
Options:
A. Prothrombin complex concentrate (PCC).
B. Administer vitamin K. 10 mg orally.
C. Continue warfarin but lower the dose.
D. Bridge with low molecular weight heparin (LMWH) and stop LMWH 24 hours before
s u r g e r y.
E. Perform surgery without altering anticoagulation.
In this emergency scenario, the best approach for managing the patient’s anticoagulation is:
A. Prothrombin complex concentrate (PCC).
- Prothrombin complex concentrate (PCC) is the fastest and most effective way to reverse warfarin anticoagulation in an emergency. It rapidly lowers the INR and reduces the risk of bleeding during surgery. PCC is preferred over fresh frozen plasma (FFP) because it works faster and does not require blood type matching or thawing.
- Vitamin K 10 mg orally (Option B) is not appropriate for emergency reversal because it takes 6–24 hours to lower the INR, which is too slow for urgent surgery.
- Continuing warfarin (Option C) or not altering anticoagulation (Option E) would leave the patient at high risk of bleeding during surgery.
- Bridging with LMWH (Option D) is not suitable for emergency surgery because it does not immediately reverse the effects of warfarin and takes time to discontinue.
- Administer PCC to rapidly reverse warfarin anticoagulation.
- Consider giving intravenous vitamin K (1–2 mg) as an adjunct to PCC to sustain the reversal effect, though this is secondary to PCC administration.
- Proceed with surgery once the INR is corrected to a safe range (typically < 1.5).
A 35-year-old male presents with a bite wound on his hand from a cat sustained two
days ago. The wound is swollen, erythematous, and tender. He reports mild fever and
regional lymphadenopathy. What is the most likely causative organism?
Options:
A. Bacteroides species
B. Bartonella henselae
C. Eikenella corrodens
D. Pasteurella multocida
E. Staphylococcus aureus
The most likely causative organism for a bite wound infection from a cat is Pasteurella multocida. This Gram-negative coccobacillus is commonly found in the oral flora of cats and can cause rapidly progressing soft tissue infections, characterized by swelling, erythema, tenderness, and lymphadenopathy
Answer:
D. Pasteurella multocida
A 25-year-old male presents with otitis externa. What is the least effective treatment for this condition?
Options:
1. Amoxicillin.
2. Ciprofloxacin ear drops.
3. Steroid ear drops.
4. Cleaning the ear canal
5. Analgesics.
The least effective treatment for otitis externa is Amoxicillin.
Explanation:
Otitis externa is most commonly caused by Pseudomonas aeruginosa and Staphylococcus aureus, both of which are resistant to Amoxicillin (a beta-lactam antibiotic targeting Gram-positive bacteria and some Gram-negative bacteria, but ineffective against Pseudomonas).
Effective treatments include:
• Ciprofloxacin ear drops: Effective against Pseudomonas and Staphylococcus.
• Steroid ear drops: Reduce inflammation and pain.
• Cleaning the ear canal: Removes debris and improves medication penetration.
• Analgesics: Provide symptomatic relief.
Answer:
- Amoxicillin (Least effective).
A 60-year-old male presents with lower limb paralysis, but upper limb and facial movements
are unaffected. A CT scan shows an ischemic stroke. Which cerebral artery is most likely
involved?
Options:
A. Anterior cerebral artery (ACA).
B. Middle cerebral artery (MCA).
C. Posterior cerebral artery (PCA).
D. Basilar artery.
E. Vertebral artery
C o r r e c t A n s w e r :
A. Anterior cerebral artery (ACA).
Explanation:
The anterior cerebral artery (ACA) supplies the medial portions of the frontal and parietal
lobes, which control motor and sensory functions of the lower limbs. Ischemia in this artery
typically results in contralateral lower limb weakness or paralysis, while sparing the upper
limbs and face, which are supplied by the middle cerebral artery (MCA).
A 40-year-old man is unable to abduct his shoulder beyond 90 degrees after a traumatic
injury. Which muscle is most likely responsible for this limitation?
Options:
1. Trapezius.
2. Deltoid.
3. Supraspinatus.
4. Infraspinatus.
5. Subscapularis.
Answer: Trapezius.
Explanation:
• Abduction of the shoulder involves a coordinated action of several muscles:
• 0-15 degrees: Primarily performed by the supraspinatus, part of the rotator
cuff.
• 15-90 degrees: Mainly performed by the deltoid, a strong abductor.
Beyond 90 degrees: Requires the action of the trapezius and serratus
anterior to rotate the scapula upward and stabilize it.
A patient presents with loss of sensation in the lateral two and a half fingers of the hand
following a fall on an outstretched hand. Examination reveals tenderness over the wrist.
Which investigation is best to identify the cause?
Options:
A. True lateral X-ray view.
B. MRI of the wrist.
C. Nerve conduction study.
D. AP X-ray view of the wrist.
E. Ultrasound of the wrist.
Correct Answer: A
Explanation:
Loss of sensation in the lateral two and a half fingers may indicate compression or injury of
the median nerve, commonly associated with fractures or dislocations of carpal bones, such
as the lunate or scaphoid. A true lateral X-ray view is essential to assess alignment and
identify fractures or carpal instability, particularly lunate dislocation, which can compress the
median nerve. MRI may be considered if soft tissue injury is suspected, but X-ray is the first-
line investigation in trauma cases.
During a dissection class, a student is asked to identify the muscle forming the lower border
of the scapula. Which muscle is this?
Options:
1. Teres major.
2. Teres minor.
3. Latissimus dorsi.
4. Subscapularis.
5. Rhomboid major.
The muscle forming the lower border of the scapula is the Teres major.
Explanation:
- The Teres major originates from the inferior angle (lower border) of the scapula and inserts into the medial lip of the intertubercular sulcus of the humerus. It helps in medial rotation, adduction, and extension of the arm.
- The other muscles listed are not directly associated with the lower border of the scapula:
- Teres minor: Located on the lateral border of the scapula, superior to the teres major.
- Latissimus dorsi: A large back muscle that does not attach to the scapula.
- Subscapularis: Located on the anterior surface of the scapula.
- Rhomboid major: Attaches to the medial border of the scapula, not the lower border.
Thus, the correct answer is 1. Teres major.
A 30-year-old male presents with difficulty everting his foot. Examination reveals sensory
loss over the dorsum of the foot. Which nerve is most likely affected?
Options:
A. Superficial peroneal nerve.
B. Deep peroneal nerve.
C. Tibial nerve.
D. Sural nerve.
E. Sciatic nerve.
The superficial peroneal nerve innervates the muscles responsible for foot eversion
(fibularis longus and fibularis brevis) and provides sensory supply to most of the dorsum of
the foot. Damage to this nerve typically results in impaired eversion and sensory loss over the
dorsum.
• The deep peroneal nerve primarily controls dorsiflexion and provides sensory supply
to the first web space.
• The tibial nerve innervates the posterior leg and sole of the foot.
The sural nerve provides sensory innervation to the lateral aspect of the foot.
The sciatic nerve affects both tibial and peroneal distributions and is unlikely to
cause isolated symptoms.
A 40-year-old male presents with a sensation of numbness along the medial aspect of his
thigh and leg after a motor vehicle accident. Examination reveals intact motor strength but
diminished pinprick sensation along the medial knee and down to the medial malleolus.
Which dermatome is most likely involved?
Options:
A. LI.
B. L2.
C. L3.
D. L4.
E. S1
The L4 dermatome covers the medial aspect of the knee, leg, and malleolus. Isolated
sensory loss in this distribution points to L4 involvement, likely due to trauma affecting the
femoral nerve or its branch, the saphenous nerve, which carries L4 fibers. Dermatomes L2
and L3 supply more proximal areas of the medial thigh, while S1 supplies the lateral foot and
Ll the inguinal region.
A 73-year-old man is admitted to ITU with an attack of severe gallstone pancreatitis. He requires ventilatory support for ARDS. Over the past few days, he has become more unwell and a CT scan is organized. This demonstrates an enhancement of the pancreatic tail.His CRP is 400 and WBC 25.1. What is the most accepted diagnosis?
A. Peripancreatic fluid collection
B. Pancreatic cancer
C. Pancreatic necrosis
D. Pancreatic abscess
E. Pancreatic pseudocyst
The most accepted diagnosis in this case is C. Pancreatic necrosis.
- Clinical Context: The patient has severe gallstone pancreatitis complicated by ARDS, requiring ventilatory support. This indicates a severe inflammatory process.
- CT Findings: Enhancement of the pancreatic tail suggests areas of non-viable tissue, which is characteristic of pancreatic necrosis.
- Inflammatory Markers: The elevated CRP (400) and WBC (25.1) indicate a significant systemic inflammatory response, consistent with necrotizing pancreatitis.
- Timing: Pancreatic necrosis typically develops over several days to weeks after the onset of acute pancreatitis, which aligns with the patient’s clinical course.
- A. Peripancreatic fluid collection: This is common in acute pancreatitis but does not explain the systemic inflammatory response or the CT findings of pancreatic enhancement.
- B. Pancreatic cancer: This is unlikely in the context of acute pancreatitis and does not explain the systemic inflammation or rapid clinical deterioration.
- D. Pancreatic abscess: This typically occurs later (4–6 weeks after pancreatitis) and is associated with infected necrosis, which is not indicated here.
- E. Pancreatic pseudocyst: This also develops later (usually >4 weeks) and is not associated with systemic inflammation or necrosis.
Thus, C. Pancreatic necrosis is the most appropriate diagnosis.
A 56 year old lady reports incontinence mainly when walking the dog. A bladder diary is inconclusive. What is the most appropriate investigation?
Intravenous urography
Urodynamic studies
Flexible cystoscopy
Micturating cystourethrogram
Rigid cystoscopy
The most appropriate investigation for this patient is B. Urodynamic studies.
- Clinical Presentation: The patient reports incontinence mainly during physical activity (walking the dog), which is suggestive of stress urinary incontinence (SUI). This is often caused by increased intra-abdominal pressure during activities, leading to leakage of urine.
- Bladder Diary Inconclusive: A bladder diary is a useful tool to assess urinary patterns, but it may not always provide a definitive diagnosis, especially in cases of stress incontinence.
- Urodynamic Studies: This is the gold standard investigation for diagnosing the type and cause of urinary incontinence. It assesses bladder function, pressure, and flow during filling and voiding, and can confirm stress incontinence by demonstrating leakage of urine with increased abdominal pressure (e.g., coughing or straining) in the absence of detrusor contraction.
- A. Intravenous urography: This is used to evaluate the upper urinary tract (kidneys and ureters) for structural abnormalities, not for diagnosing incontinence.
- C. Flexible cystoscopy: This is used to visualize the bladder and urethra for structural abnormalities (e.g., tumors, stones) but does not assess bladder function or incontinence.
- D. Micturating cystourethrogram: This is used to evaluate for vesicoureteral reflux or urethral abnormalities, not typically for stress incontinence.
- E. Rigid cystoscopy: Similar to flexible cystoscopy, this is used for structural evaluation and is more invasive than flexible cystoscopy.
Thus, B. Urodynamic studies is the most appropriate investigation to confirm the diagnosis of stress urinary incontinence.
Which of the following inhibits the secretion of insulin?
Adrenaline
Lipids
Gastrin
Arginine
Vagal cholinergic activity
The correct answer is A. Adrenaline.
- Adrenaline (Epinephrine): This is a catecholamine released by the adrenal medulla during stress or sympathetic nervous system activation. Adrenaline inhibits insulin secretion by acting on alpha-2 adrenergic receptors on pancreatic beta cells. This is part of the “fight or flight” response, where energy mobilization (e.g., glycogenolysis and lipolysis) is prioritized over energy storage.
- B. Lipids: Free fatty acids and other lipids can stimulate insulin secretion by providing substrates for ATP production in beta cells, which enhances insulin release.
- C. Gastrin: This is a hormone secreted by the stomach that primarily stimulates gastric acid secretion. It does not have a direct role in regulating insulin secretion.
- D. Arginine: This is an amino acid that stimulates insulin secretion by depolarizing beta cells and increasing intracellular calcium levels.
- E. Vagal cholinergic activity: Parasympathetic (vagal) stimulation enhances insulin secretion via acetylcholine acting on muscarinic receptors on pancreatic beta cells.
Thus, A. Adrenaline is the only option that inhibits insulin secretion.
A 47 year old lady is diagnosed as suffering from a phaeochromocytoma. From which of the following amino acids are catecholamines primarily derived?
Aspartime
Glutamine
Arginine
Tyrosine
Alanine
The correct answer is D. Tyrosine.
-
Catecholamines (such as adrenaline/epinephrine, noradrenaline/norepinephrine, and dopamine) are primarily derived from the amino acid tyrosine. The biosynthesis pathway involves the following steps:
- Tyrosine is converted to L-DOPA by the enzyme tyrosine hydroxylase.
- L-DOPA is converted to dopamine by the enzyme DOPA decarboxylase.
- Dopamine is converted to noradrenaline by the enzyme dopamine beta-hydroxylase.
- Noradrenaline is converted to adrenaline by the enzyme phenylethanolamine N-methyltransferase.
- A. Aspartame: This is an artificial sweetener and not involved in catecholamine synthesis.
- B. Glutamine: This is an amino acid involved in various metabolic processes but not in catecholamine synthesis.
- C. Arginine: This is an amino acid involved in nitric oxide synthesis and the urea cycle but not in catecholamine synthesis.
- E. Alanine: This is an amino acid involved in glucose metabolism (alanine cycle) but not in catecholamine synthesis.
Thus, D. Tyrosine is the amino acid from which catecholamines are primarily derived.
A 43 year old lady is recovering on the intensive care unit following a Whipples procedure. She has a central venous line in situ. Which of the following will lead to the y descent on the waveform trace ?
Ventricular contraction
Emptying of the right atrium
Emptying of the right ventricle
Opening of the pulmonary valve
Cardiac tamponade
The y descent on the central venous pressure (CVP) waveform represents the emptying of the right atrium. It occurs during diastole when the tricuspid valve opens, allowing blood to flow from the right atrium into the right ventricle oai_citation:0‡(A & L LANGE SERIES) Kim E. Barrett, Susan M. Barman, Heddwen L. Brooks, Jason Yuan, Scott Boitano - Ganong’s Review of Medical Physiology-McGraw-Hill Medical _ Education (2019).pdf.
Answer:
Emptying of the right atrium
Explanation:
• The CVP waveform consists of several characteristic waves:
• a wave: Atrial contraction.
• c wave: Bulging of the tricuspid valve into the atrium during ventricular contraction.
• x descent: Atrial relaxation.
• v wave: Venous filling of the atrium.
• y descent: The atrium empties as the tricuspid valve opens.
In cardiac tamponade, the y descent is blunted due to impaired atrial emptying caused by external compression of the heart oai_citation:1‡(A & L LANGE SERIES) Kim E. Barrett, Susan M. Barman, Heddwen L. Brooks, Jason Yuan, Scott Boitano - Ganong’s Review of Medical Physiology-McGraw-Hill Medical _ Education (2019).pdf.
Which of the following is not a feature of normal cerebrospinal fluid?
It has a pressure of between 10 and 15 mmHg.
It usually contains a small amount of glucose.
It may normally contain up to 5 red blood cells per mm3.
It may normally contain up to 3 white blood cells per mm3.
None of the above
Let me think about this step by step:
- CSF Pressure:
- Normal CSF pressure is 10-15 mmHg when measured by lumbar puncture
- This is a correct feature of normal CSF - Glucose content:
- Normal CSF does contain glucose
- The level is typically about 2/3 of blood glucose
- This is a correct feature - Red blood cells (RBCs):
- Normal CSF should not contain any RBCs
- The presence of RBCs indicates either a traumatic tap or pathology
- Up to 5 RBCs per mm3 is NOT a normal feature - White blood cells (WBCs):
- Normal CSF can contain 0-5 WBCs per mm3
- 3 WBCs per mm3 falls within this range
- This is a correct feature
Therefore, the statement that “It may normally contain up to 5 red blood cells per mm3” is NOT a feature of normal CSF. This is the answer.
The presence of any RBCs in CSF is abnormal and should prompt investigation for:
- Traumatic tap during collection
- Subarachnoid hemorrhage
- Other pathological conditions
Mechanism of bradycardia in Cushing triad?
A. Increased activity from carotid body
B. Increase activity from aortic body
C. Decreased activity from carotid sinus
D. Decreased activity from cardiopulmonary receptors
E. Increased activity from aortic sinus
The Cushing triad is a clinical syndrome associated with increased intracranial pressure (ICP). It consists of three main components: hypertension, bradycardia, and irregular respiration. The bradycardia in Cushing triad is primarily due to the body’s response to increased ICP, which involves the autonomic nervous system.
Here’s the mechanism:
- Increased Intracranial Pressure (ICP): As ICP rises, it compresses the brainstem, including the medulla oblongata, which houses the cardiovascular and respiratory centers.
- Cushing Reflex: The body responds to the decreased cerebral perfusion caused by the increased ICP. The initial response is systemic vasoconstriction to increase blood pressure (hypertension) to ensure adequate blood flow to the brain.
- Baroreceptor Response: The increased blood pressure is detected by baroreceptors located in the carotid sinus and aortic arch. These baroreceptors send signals to the medulla oblongata to decrease heart rate (bradycardia) as a compensatory mechanism to reduce the blood pressure.
- Parasympathetic Activation: The medulla oblongata increases parasympathetic (vagal) outflow to the heart, leading to bradycardia.
Given this mechanism, the correct answer is:
C. Decreased activity from carotid sinus
Explanation: The baroreceptors in the carotid sinus detect the elevated blood pressure and decrease their firing rate, which leads to increased parasympathetic activity and subsequent bradycardia. This is a reflex response to the hypertension caused by the Cushing reflex.
The other options are incorrect because:
- A. Increased activity from carotid body: The carotid body responds to changes in oxygen, carbon dioxide, and pH levels, not directly to blood pressure changes.
- B. Increased activity from aortic body: Similar to the carotid body, the aortic body responds to chemical changes in the blood, not directly to blood pressure.
- D. Decreased activity from cardiopulmonary receptors: These receptors are involved in regulating blood volume and pressure but are not the primary mechanism in the Cushing triad.
- E. Increased activity from aortic sinus: The aortic sinus contains baroreceptors that respond to increased blood pressure by decreasing heart rate, but the primary site for this reflex in the context of Cushing triad is the carotid sinus.
A patient with pharyngeal diverticulum. What is the site of diverticulum?
A. Above superior constrictor
B. Between superior and middle constrictor
C. Between medial and inferior constrictor
D. Above the inferior constrictor
E. Through inferior constrictor muscles
The pharyngeal diverticulum you are referring to is most likely a Zenker’s diverticulum, which is a type of esophageal diverticulum. This condition occurs due to a weakness in the pharyngeal musculature, specifically at Killian’s dehiscence, which is an anatomical area of potential weakness in the posterior pharyngeal wall.
- Killian’s dehiscence is located between the inferior constrictor muscle and the cricopharyngeus muscle (which is the upper esophageal sphincter).
- This area is above the inferior constrictor muscle but below the middle constrictor muscle.
D. Above the inferior constrictor
- The diverticulum forms in the posterior pharyngeal wall, specifically in the area of Killian’s dehiscence, which is located above the inferior constrictor muscle but below the middle constrictor muscle.
- This is the most common site for a Zenker’s diverticulum to develop.
- A. Above superior constrictor: This is not the site of Zenker’s diverticulum.
- B. Between superior and middle constrictor: This is not the site of weakness where Zenker’s diverticulum typically forms.
- C. Between medial and inferior constrictor: This is not anatomically correct.
- E. Through inferior constrictor muscles: The diverticulum does not form through the inferior constrictor muscles but rather above them at Killian’s dehiscence.
Thus, the correct answer is D. Above the inferior constrictor.
Which is true about left coronary artery?
A. Arises from posterior aortic sinus
B. Arises from below anterior aortic valve
C. Passes behind pulmonary trunk
D. Situated in posterior interventricular groove
E. Arises from anterior ascending aorta
The correct answer is:
C. Passes behind the pulmonary trunk.
Explanation:
• The left coronary artery (LCA) arises from the left posterior aortic sinus, also known as the left coronary sinus oai_citation:0‡Anatomy Questions for the MRCS.pdf.
• It passes forward from its origin, behind the pulmonary trunk, and then courses anterior to the left auricle oai_citation:1‡Anatomy Questions for the MRCS.pdf.
• It then bifurcates into the left anterior descending (LAD) artery and the circumflex artery oai_citation:2‡Anatomy Questions for the MRCS.pdf.
Why Other Options Are Incorrect:
• A. Arises from posterior aortic sinus – Incorrect, as it arises from the left posterior aortic sinus, not the general “posterior aortic sinus” oai_citation:3‡Anatomy Questions for the MRCS.pdf.
• B. Arises from below anterior aortic valve – Incorrect, as it arises from the left posterior aortic sinus, not below the valve oai_citation:4‡Anatomy Questions for the MRCS.pdf.
• D. Situated in posterior interventricular groove – Incorrect, as the posterior interventricular groove contains the posterior interventricular artery, which is usually a branch of the right coronary artery or the circumflex artery in left-dominant hearts oai_citation:5‡Anatomy Questions for the MRCS.pdf.
• E. Arises from anterior ascending aorta – Incorrect, as it arises from the left posterior aortic sinus, which is not directly from the ascending aorta oai_citation:6‡Anatomy Questions for the MRCS.pdf.
Thus, the left coronary artery passes behind the pulmonary trunk before dividing into its branches.
A 53 year old man is on the intensive care unit following an emergency abdominal aortic aneurysm repair. He develops abdominal pain and diarrhoea and is profoundly unwell. His abdomen has no features of peritonism. Which of the following arterial blood gas pictures is most likely to be present?
pH 7.45, pO2 10.1, pCO2 3.2, Base excess 0, Lactate 0
pH 7.35, pO2 8.0, pCO2 5.2, Base excess 2, Lactate 1
pH 7.20, pO2 9.0, pCO2 3.5, Base excess -10, Lactate 8
pH 7.29, pO2 8.9, pCO2 5.9, Base excess -4, Lactate 3
pH 7.30, pO2 9.2 pCO2 4.8, Base excess -2, lactate 1
The patient in question is a 53-year-old man who has undergone emergency abdominal aortic aneurysm repair and is now in the intensive care unit. He has developed abdominal pain and diarrhea and is profoundly unwell, though his abdomen does not show signs of peritonism. This clinical scenario is concerning for mesenteric ischemia, a condition where blood flow to the intestines is compromised, leading to tissue hypoxia, acidosis, and elevated lactate levels.
Let’s analyze the arterial blood gas (ABG) options:
-
pH 7.45, pO2 10.1, pCO2 3.2, Base excess 0, Lactate 0
- This ABG shows a slightly alkalotic pH, low pCO2 (respiratory alkalosis), and normal lactate. This is unlikely in a profoundly unwell patient with suspected mesenteric ischemia.
-
pH 7.35, pO2 8.0, pCO2 5.2, Base excess 2, Lactate 1
- This ABG is within normal limits, with no acidosis or elevated lactate. This is inconsistent with the clinical picture of mesenteric ischemia.
-
pH 7.20, pO2 9.0, pCO2 3.5, Base excess -10, Lactate 8
- This ABG shows a significant metabolic acidosis (low pH, low bicarbonate/base excess, and elevated lactate). The elevated lactate (8 mmol/L) is a key finding, as it indicates tissue hypoxia and anaerobic metabolism, which is consistent with mesenteric ischemia. The low pCO2 suggests a compensatory respiratory alkalosis.
-
pH 7.29, pO2 8.9, pCO2 5.9, Base excess -4, Lactate 3
- This ABG shows a mild metabolic acidosis with a moderately elevated lactate. While this could be seen in early or less severe mesenteric ischemia, it is less likely in a profoundly unwell patient.
-
pH 7.30, pO2 9.2, pCO2 4.8, Base excess -2, Lactate 1
- This ABG shows a mild acidosis with a normal lactate. This is not consistent with the severe clinical picture described.
The most likely ABG in this patient is:
pH 7.20, pO2 9.0, pCO2 3.5, Base excess -10, Lactate 8
This reflects a severe metabolic acidosis with elevated lactate, which is characteristic of mesenteric ischemia.
A 64-year-old man presents to the emergency department with abdominal pain. He is normally fit and well, with no known history of malignancy. Routine blood tests are performed, and the biochemistry laboratory contacts the ward urgently regarding a corrected calcium result of 3.6 mmol/L (normal range: 2.2–2.6 mmol/L).
What is the medication of choice to treat this abnormality?
A) IV Pamidronate
B) Oral Alendronate
C) Dexamethasone
D) Vitamin D
E) Resonium salts
Correct Answer: A) IV Pamidronate
Hypercalcemia (corrected calcium >3.0 mmol/L) is a medical emergency and requires urgent treatment to prevent complications such as nephrocalcinosis, arrhythmias, and neurological deterioration.
Stepwise Management of Severe Hypercalcemia (>3.0 mmol/L):
1. Aggressive IV Fluid Resuscitation – 0.9% Normal Saline to correct dehydration and enhance renal calcium excretion.
2. IV Bisphosphonates (Pamidronate or Zoledronate) – Pamidronate is the first-line choice as it inhibits osteoclastic bone resorption, lowering calcium levels within 2–4 days.
3. Calcitonin (if needed for rapid lowering) – Acts quicker but is short-lived.
4. Consider Steroids (Dexamethasone) if hypercalcemia is due to granulomatous disease or lymphoma.
Why not the other options?
• Oral Alendronate (B) – Used for osteoporosis, not for acute hypercalcemia.
• Dexamethasone (C) – Can help in some malignancy-related cases but is not the first-line treatment.
• Vitamin D (D) – Would worsen hypercalcemia, especially in vitamin D toxicity or sarcoidosis.
• Resonium salts (E) – Used for hyperkalemia, not hypercalcemia.
Thus, IV Pamidronate is the treatment of choice for severe hypercalcemia in this patient.
A 22 year old man is undergoing a daycase excision of a sebaceous cyst. He is needle phobic and as the surgeon approaches with the needle the patient begins to hyperventilate. He soon develops circumoral parasthesia and muscular twitching. Which of the following is the most likely explanation for this event?
Temporal lobe epilepsy
Reduction in ionised calcium levels
Increase in ionised calcium levels
Fall in serum PTH levels
Rise in serum PTH levels
Correct Answer: B) Reduction in ionised calcium levels
Mechanism:
• Hyperventilation causes respiratory alkalosis due to excessive CO₂ exhalation.
• This leads to a rise in blood pH, causing increased binding of calcium to albumin.
• As a result, ionised (free) calcium levels fall, leading to neuromuscular excitability (tetany, paraesthesia, twitching).
• This is why the patient develops circumoral paraesthesia and muscle twitching—classic signs of acute hypocalcaemia due to alkalosis.
Why not the other options?
• A) Temporal lobe epilepsy – Epilepsy would cause altered consciousness, automatisms, or seizures, not selective paraesthesia/twitching due to hyperventilation.
• C) Increase in ionised calcium levels – Hyperventilation leads to reduced ionised calcium, not an increase.
• D) Fall in serum PTH levels – PTH regulation takes time and does not cause immediate symptoms like this.
• E) Rise in serum PTH levels – PTH increases in chronic hypocalcaemia but does not contribute to the acute symptoms seen here.
Thus, hyperventilation-induced respiratory alkalosis leads to a fall in ionised calcium levels, causing neuromuscular excitability, making option B the correct answer.
A 22 year old lady presents with symptoms and signs of hyperthyroidism. Her diagnostic work up results in a diagnosis of Graves disease. Which of these statements best describes the pathophysiology of the condition?
Formation of IgG antibodies to the TSH receptors on the thyroid gland
Formation of IgG antibodies to the TRH receptors on the anterior pituitary
Formation of IgM antibodies to the TSH receptors on the thyroid gland
Formation of IgA antibodies to the TSH receptors on the thyroid gland
Formation of IgM antibodies to the TRH receptors on the anterior pituitary
Correct Answer: A) Formation of IgG antibodies to the TSH receptors on the thyroid gland
Pathophysiology of Graves’ Disease:
• Graves’ disease is an autoimmune disorder in which the body produces thyroid-stimulating immunoglobulins (TSI).
• These are IgG antibodies that bind to and activate the TSH receptors on the thyroid gland, leading to excess thyroid hormone production (hyperthyroidism).
• This continuous stimulation leads to thyroid gland enlargement (goitre) and systemic effects of excessive thyroid hormones.
Why not the other options?
• B) Formation of IgG antibodies to TRH receptors on the anterior pituitary – Graves’ disease does not affect TRH receptors; the pathology is at the level of the thyroid gland.
• C) Formation of IgM antibodies to TSH receptors on the thyroid gland – The antibodies in Graves’ disease are IgG, not IgM.
• D) Formation of IgA antibodies to TSH receptors on the thyroid gland – IgA is mainly involved in mucosal immunity, not autoimmune thyroid disease.
• E) Formation of IgM antibodies to TRH receptors on the anterior pituitary – Again, Graves’ disease does not involve TRH receptors or IgM antibodies.
Key Learning Points:
• Graves’ disease is caused by IgG autoantibodies against TSH receptors, leading to hyperthyroidism.
• Exophthalmos and pretibial myxoedema occur due to antibody-mediated stimulation of fibroblasts in the orbit and skin.
• TSH levels are low due to negative feedback from excess T3 and T4.
Thus, option A is the correct answer.
Which of the following inhibits gastric acid secretion?
Histamine
Nausea
Calcium
Parasympathetic vagal stimulation
Gastrin
Nausea inhibits gastric acid secretion.
Explanation:
• Histamine: Stimulates gastric acid secretion by binding to H₂ receptors on parietal cells.
• Nausea: Generally inhibits gastric acid secretion, likely due to the activation of inhibitory pathways in the brainstem that reduce gastric motility and secretion.
• Calcium: Can stimulate acid secretion by increasing gastrin release.
• Parasympathetic vagal stimulation: Increases gastric acid secretion via acetylcholine acting on parietal cells.
• Gastrin: Strongly stimulates gastric acid secretion by directly acting on parietal cells and indirectly by stimulating histamine release.
So, the correct answer is nausea.
53 year old man is recovering from a right lung lobectomy to treat a malignant pulmonary nodule. A chest drain is in situ and is swinging and it is suddenly noticed that there has been an output of approximately 1600ml of fresh blood into the drain. Of the parameters listed below, which is unlikely to decrease in such circumstances?
Cardiac output
Renin secretion
Firing of carotid baroreceptors
Firing of aortic baroreceptors
Blood pressure
In this scenario, the patient is experiencing massive postoperative hemorrhage (1600 mL of fresh blood loss). This will lead to hypovolemic shock, triggering compensatory mechanisms. Let’s analyze the listed parameters:
1. Cardiac output → Decreases
• Severe blood loss reduces preload (venous return), leading to a drop in stroke volume and cardiac output.
2. Renin secretion → Increases
• The loss of blood volume activates the renin-angiotensin-aldosterone system (RAAS) in an attempt to restore blood pressure.
3. Firing of carotid baroreceptors → Decreases
• Baroreceptors (in the carotid sinus) respond to arterial stretch. With hemorrhage-induced hypotension, there is less stretch, leading to reduced firing.
4. Firing of aortic baroreceptors → Decreases
• Similar to the carotid baroreceptors, aortic baroreceptors (located in the aortic arch) respond to stretch. Blood loss reduces arterial pressure, leading to decreased firing.
5. Blood pressure → Decreases
• Massive blood loss reduces circulating volume, causing a drop in blood pressure.
Answer:
Renin secretion is unlikely to decrease—it actually increases in response to hypovolemia.
Which of the following drugs causes hyperkalaemia?
Heparin
Ciprofloxacin
Salbutamol
Levothyroxine
Codeine phosphate
The correct answer is heparin.
Explanation:
Hyperkalemia (elevated potassium levels) can occur due to various mechanisms, including reduced renal excretion, increased potassium release from cells, or altered hormonal regulation. Let’s analyze each drug:
1. Heparin → Can cause hyperkalemia
• Heparin inhibits aldosterone secretion, leading to reduced potassium excretion by the kidneys, which can result in hyperkalemia.
2. Ciprofloxacin → Does not typically cause hyperkalemia
• Fluoroquinolones like ciprofloxacin are not strongly associated with potassium disturbances.
3. Salbutamol → Causes hypokalemia
• Salbutamol (a β₂-agonist) stimulates Na⁺/K⁺ ATPase, driving potassium into cells and reducing serum potassium.
4. Levothyroxine → No significant effect on potassium levels
• Thyroid hormones generally do not have a direct impact on potassium homeostasis.
5. Codeine phosphate → No significant effect on potassium levels
• Opioids do not typically influence potassium balance in a way that causes hyperkalemia.
Answer:
Heparin causes hyperkalemia due to its inhibitory effect on aldosterone secretion.
Which one of the following would cause a rise in the carbon monoxide transfer factor (TLCO)?
Emphysema
Pulmonary embolism
Pulmonary haemorrhage
Pneumonia
Pulmonary fibrosis
The correct answer is pulmonary haemorrhage.
Explanation:
The carbon monoxide transfer factor (TLCO) measures the ability of the lungs to transfer carbon monoxide (CO) from alveolar air to the blood. It is influenced by factors such as alveolar surface area, capillary blood volume, and haemoglobin concentration.
• Emphysema → Decreased TLCO
• Destruction of alveolar walls reduces the surface area for gas exchange, leading to a lower TLCO.
• Pulmonary embolism → Decreased TLCO
• Reduced perfusion due to blocked pulmonary arteries decreases effective gas exchange.
• Pulmonary haemorrhage → Increased TLCO
• Alveolar haemorrhage increases the amount of haemoglobin in the alveoli, which binds CO more readily, artificially elevating TLCO.
• Pneumonia → No consistent effect on TLCO
• Localized inflammation and consolidation may mildly reduce TLCO, but this varies depending on severity and extent.
• Pulmonary fibrosis → Decreased TLCO
• Thickening of the alveolar-capillary membrane impairs gas diffusion, reducing TLCO.
Thus, pulmonary haemorrhage is the only condition in this list that increases TLCO.
45 year old female is diagnosed as having a carcinoma of the caecum. She undergoes a CT scan which shows a tumour invading the muscularis propria with some regional lymphadenopathy. What is the most appropriate initial treatment?
Right hemicolectomy
External beam radiotherapy
Chemotherapy
Combined long course chemo radiotherapy
Referral for palliative care
The most appropriate initial treatment for a 45-year-old female diagnosed with carcinoma of the caecum, where the tumour invades the muscularis propria with some regional lymphadenopathy, is right hemicolectomy.
Explanation:
• Right hemicolectomy: This is the standard treatment for a localized right-sided colon cancer, particularly when the tumor has invaded the muscularis propria and there is regional lymphadenopathy. Surgical resection is essential to remove the tumor and involved lymph nodes.
• External beam radiotherapy: This is generally not the first-line treatment for colon cancer. It’s more commonly used in rectal cancer or for palliative purposes.
• Chemotherapy: While chemotherapy is important for treating metastatic disease or as adjuvant therapy after surgery (if the tumor has spread to lymph nodes), it is not the initial treatment for localized colon cancer.
• Combined long course chemo-radiotherapy: This is typically reserved for rectal cancer, not colon cancer, and is not the first-line treatment for a cecal carcinoma.
• Referral for palliative care: This would only be appropriate if the cancer were metastatic or the patient were not a surgical candidate, which is not indicated in the given scenario.
Thus, right hemicolectomy is the most appropriate initial treatment for this patient.
A 4 year old girl is admitted with lethargy and abdominal pain. On examination, she is febrile, temperature 38.1oC, pulse rate is 150 and blood pressure is 100/60. Her abdomen is soft but there is some right sided peritonism. Her WCC is 14 and urinanalysis is positive for leucocytes but is otherwise normal. What is the best course of action?
Manage as urinary tract infection with oral antibiotics
Manage as urinary tract infection with intravenous antibiotics
Take to theatre for appendicectomy within 6 hours
Undertake ultrasound scan
Admit for serial clinical examination
The best
The best course of action in this case would be to undertake an ultrasound scan.
Explanation:
This 4-year-old girl presents with lethargy, abdominal pain, fever, and signs of right-sided peritonism, which raises concern for conditions such as appendicitis or a urinary tract infection (UTI). Let’s break down the options:
• Manage as urinary tract infection with oral antibiotics: Although the urinanalysis is positive for leucocytes, which can suggest a UTI, the clinical signs of abdominal pain, fever, and peritonism are more concerning for an acute abdominal condition, such as appendicitis, which needs further investigation.
• Manage as urinary tract infection with intravenous antibiotics: Given the patient’s clinical findings, an IV antibiotic approach might be appropriate if the patient were to be diagnosed with a serious UTI or sepsis. However, the primary concern here is still appendicitis, so antibiotics alone would not address the underlying issue without further evaluation.
• Take to theatre for appendicectomy within 6 hours: This is premature without confirming the diagnosis of appendicitis. Although appendicitis is a strong possibility, a thorough diagnostic workup (like an ultrasound) is necessary before proceeding to surgery.
• Undertake ultrasound scan: Ultrasound is the best initial diagnostic tool to assess for appendicitis, especially in children. It can help confirm the presence of an inflamed appendix or reveal other causes of abdominal pain, such as inflammatory bowel disease or urinary tract issues.
• Admit for serial clinical examination: While serial examination might help monitor the patient’s progress, the clinical picture is concerning enough to warrant prompt imaging to rule out conditions like appendicitis before the situation worsens.
Given the combination of peritonism, fever, and abdominal pain, an ultrasound scan should be performed urgently to evaluate for appendicitis or any other abdominal pathology.
As a busy surgical trainee on the colorectal unit you are given the unenviable task of reviewing the unit’s histopathology results for colonic polyps. Which of the polyp types described below has the greatest risk of malignant transformation?
Hyperplastic polyp
Tubular adenoma
Villous adenoma
Hamartomatous polyp
Pseudopolyp
The polyp type with the greatest risk of malignant transformation is villous adenoma.
Explanation:
• Hyperplastic polyp: These are generally considered benign and have a very low risk of malignant transformation. They are often found in the rectum and are typically not a concern for malignancy.
• Tubular adenoma: This is the most common type of adenomatous polyp and is considered precancerous. However, its malignant potential is relatively lower compared to villous adenomas, particularly if it is small and has a tubular architecture.
• Villous adenoma: These have the highest risk of malignant transformation among the polyp types listed. They are typically large, have a villous architecture, and have a higher propensity for dysplasia, which can progress to cancer. The malignant transformation rate is significantly higher, especially as they grow in size.
• Hamartomatous polyp: These are benign growths composed of disorganized tissue. They do not have a significant risk of malignant transformation but can be associated with certain genetic syndromes, such as Peutz-Jeghers syndrome or Juvenile Polyposis Syndrome.
• Pseudopolyp: These are non-neoplastic lesions that typically result from inflammatory bowel disease (IBD), such as ulcerative colitis or Crohn’s disease. They have no malignant potential but can be associated with dysplasia in the background of IBD.
Thus, villous adenomas carry the greatest risk of malignant transformation due to their larger size, villous structure, and higher likelihood of dysplasia.
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A 56 year old man requires long term parenteral nutrition and the decision is made to insert a PIC line for long term venous access. This is inserted into the basilic vein at the region of the elbow. As the catheter is advanced, into which venous structure is the tip of the catheter most likely to pass from the basilic vein?
Subclavian vein
Axillary vein
Posterior circumfex humeral vein
Cephalic vein
Superior vena cava
The correct answer is Axillary vein.
When a peripherally inserted central catheter (PICC) line is inserted into the basilic vein at the elbow and advanced, it most commonly passes into the axillary vein. The basilic vein continues proximally and becomes the axillary vein at the lower border of the teres major muscle. From there, the catheter will typically proceed into the subclavian vein, then into the brachiocephalic vein, and finally into the superior vena cava, where the catheter tip is ideally placed for central venous access oai_citation:0‡EMRCS and pas test MCQs -1.pdf.
23 year old male presents with bright red rectal bleeding that occurs post defecation onto the toilet paper. He has been suffering from severe pain associated with this. On external anal examination there is a skin tag located at the 6 O’clock position. Which of the treatments listed below is most likely to be helpful?
Topical GTN
Rubber band ligation
Injections of oily phenol
Milligan Morgan haemorrhoidectomy
Lords anal dilatation
The correct answer is Topical GTN (Glyceryl trinitrate).
Explanation:
This patient’s symptoms—bright red rectal bleeding post-defecation, severe pain, and a skin tag at the 6 o’clock position—are highly suggestive of a chronic anal fissure. Chronic anal fissures commonly occur in the posterior midline (6 o’clock position) and may be associated with a sentinel skin tag.
Management:
• First-line treatment: Topical GTN (0.2%) is commonly used as it helps to relax the internal anal sphincter, improving blood flow to the area and promoting healing.
• Other conservative options: Stool softeners, dietary modifications (high-fiber diet), sitz baths, and topical local anesthetics.
• Second-line options: If medical therapy fails, lateral internal sphincterotomy or Botox injections may be considered.
Why not the other options?
• Rubber band ligation – Used for internal hemorrhoids, not anal fissures.
• Injections of oily phenol – Used for hemorrhoids, not fissures.
• Milligan Morgan haemorrhoidectomy – A surgical procedure for severe hemorrhoids, not indicated here.
• Lords anal dilatation – Outdated treatment for anal fissures, associated with incontinence risk.
Thus, Topical GTN is the most appropriate treatment in this case.
74 year old gentleman presents with an obstructing carcinoma of the splenic flexure. Attempts at placement of a colonic stent have failed. Which of the operative options listed below offers the best solution to this problem?
Sub total colectomy
Extended right hemicolectomy
Standard right hemicolectomy
Standard left hemicolectomy
Transverse colectomy
The correct answer is Subtotal colectomy.
Explanation:
This patient has an obstructing carcinoma of the splenic flexure, and colonic stenting has failed, meaning an urgent surgical solution is required.
Why subtotal colectomy is the best option:
1. Oncological clearance – A subtotal colectomy ensures removal of the entire colon up to the rectosigmoid junction, including the tumor and potential synchronous lesions or polyps.
2. Preventing future obstruction – Patients with left-sided colonic obstruction are at risk of having synchronous or metachronous lesions in other parts of the colon. Removing most of the colon prevents future obstruction.
3. Safe anastomosis – A subtotal colectomy with ileorectal anastomosis is preferable to avoid tension and ischemia, which can be problematic in an isolated left hemicolectomy.
Why not the other options?
• Extended right hemicolectomy – This includes the right colon, transverse colon, and splenic flexure, but does not adequately address descending and sigmoid colon disease, which could be problematic.
• Standard right hemicolectomy – Does not address the splenic flexure.
• Standard left hemicolectomy – While this removes the splenic flexure, it may leave behind the proximal colon, which could be poorly prepared and at risk for further obstruction.
• Transverse colectomy – Rarely performed as a standalone procedure due to poor vascular supply and higher anastomotic failure rates.
Conclusion:
Subtotal colectomy with ileorectal anastomosis is the best approach for an obstructing splenic flexure cancer when stenting has failed, as it provides oncological clearance, reduces risk of future obstruction, and allows for a safer anastomosis.
A 75 year old lady is admitted with a 12 hour history of absolute constipation, vomiting and colicky abdominal pain. On examination, her abdomen is distended and she has right sided tenderness. Imaging demonstrates an obstructing hepatic flexure tumour with a caecal diameter of 11cm. What is the best course of action?
Undertake an immediate laparotomy
Commence resuscitation with intravenous fluids and then undertake a laparotomy 2-4 hours later
Administer antibiotics and intravenous fluids and schedule surgery for the following day
Arrange a colonoscopy
Administer oral sodium picosulphate
The correct answer is:
Commence resuscitation with intravenous fluids and then undertake a laparotomy 2-4 hours later.
Explanation:
This 75-year-old lady presents with large bowel obstruction (LBO) secondary to a hepatic flexure tumour, with a caecal diameter of 11 cm on imaging. This is a surgical emergency because:
• The caecum is at risk of perforation when it exceeds 10-12 cm due to increased intraluminal pressure.
• Large bowel obstruction can lead to bowel ischemia, necrosis, or perforation, requiring urgent surgical intervention.
Best Approach:
1. Immediate resuscitation
• Intravenous fluids to correct dehydration and electrolyte imbalances.
• Nasogastric tube decompression if vomiting persists.
• Broad-spectrum antibiotics (to cover gut flora in case of perforation).
2. Urgent surgery within 2-4 hours
• Options include right hemicolectomy (standard oncological resection for hepatic flexure tumours) with primary anastomosis or stoma creation if the bowel is unhealthy.
Why not the other options?
• Immediate laparotomy – Without prior resuscitation, the patient is at higher risk of perioperative complications due to dehydration and electrolyte imbalances.
• Delay surgery to the next day – This is unsafe as there is a high risk of perforation, leading to peritonitis and sepsis.
• Colonoscopy – Not appropriate in an acute obstruction with a massively dilated caecum; could risk perforation.
• Oral sodium picosulphate – A laxative is contraindicated in bowel obstruction and could worsen the condition by increasing intraluminal pressure.
Conclusion:
This patient requires urgent resuscitation followed by laparotomy within 2-4 hours to prevent caecal perforation and sepsis.
66 year old man is admitted as an emergency with torrential rectal bleeding. Following resuscitation, an upper GI endoscopy is undertaken and it is normal. However, he continues to bleed. What is the most appropriate course of action?
Arrange a CT angiogram
Arrange a laparotomy and sub total colectomy
Undertake a colonoscopy
Perform a laparoscopy and on table colonoscopy
Arrange a capsule endoscopy
The correct answer is:
Arrange a CT angiogram.
Explanation:
This 66-year-old man presents with massive lower gastrointestinal (GI) bleeding, which has persisted despite a normal upper GI endoscopy. In cases of severe lower GI bleeding, it is essential to identify the source before considering definitive treatment.
Why CT angiography (CTA)?
• First-line investigation for hemodynamically significant lower GI bleeding when the source is unclear.
• Can localize the bleeding site if the bleeding rate is ≥ 0.3–0.5 mL/min.
• Can help guide endovascular intervention (e.g., embolization) or surgical management if required.
Why not the other options?
• Laparotomy and subtotal colectomy – A last resort if the bleeding is uncontrollable and no clear source is identified. Subtotal colectomy is highly morbid and should be avoided unless life-threatening bleeding persists despite all interventions.
• Colonoscopy – Can be done electively but is usually not helpful in massive bleeding because poor visualization limits its diagnostic and therapeutic potential. It is better suited for stable or slower bleeding cases.
• Laparoscopy with on-table colonoscopy – Rarely used in emergencies. Requires a well-prepared colon, which is not feasible in this scenario.
• Capsule endoscopy – Used mainly for small bowel bleeding when colonoscopy and upper GI endoscopy are inconclusive. However, it is not useful in massive bleeding as it cannot provide immediate localization or treatment.
Conclusion:
CT angiogram is the best next step to localize the bleeding source and guide either interventional radiology (embolization) or surgery if needed.
65 year old lady is admitted with large bowel obstruction. On investigation with CT, she is found to have a tumour of the mid rectum with no evidence of metastatic disease. What is the most appropriate course of action?
Formation of a loop colostomy
Laparotomy and Hartmanns procedure
Pan proctocolectomy and end ileostomy
Low anterior resection and covering loop ileostomy
Low anterior resection and end colostomy
The correct answer is:
Laparotomy with Low Anterior Resection (LAR) and Covering Loop Ileostomy.
Explanation:
This 65-year-old lady has a large bowel obstruction secondary to a mid-rectal tumor without metastatic disease. The goal of treatment is to provide curative resection while ensuring safe recovery from obstruction.
Why Low Anterior Resection (LAR) with Covering Loop Ileostomy?
• LAR is the standard surgical treatment for mid and upper rectal cancers when an oncological resection is feasible.
• A covering loop ileostomy is typically formed to protect the low pelvic anastomosis and reduce the risk of anastomotic leakage, which is high in rectal surgery.
• This approach preserves bowel continuity, improving long-term quality of life.
Why not the other options?
• Formation of a loop colostomy – This is only a temporary palliative measure for unresectable or frail patients. It does not provide curative intent.
• Laparotomy and Hartmann’s procedure – Reserved for emergencies (e.g., perforation, sepsis) or in patients unfit for anastomosis. It results in a permanent colostomy with difficult future reversal.
• Pan-proctocolectomy and end ileostomy – Only indicated in familial conditions (e.g., FAP or IBD) or extensive multifocal disease, not for isolated mid-rectal tumors.
• LAR with end colostomy – This would be an abdominoperineal resection (APR), which is needed for low rectal tumors involving the anal sphincter, but not for mid-rectal tumors, where sphincter preservation is possible.
Conclusion:
Low Anterior Resection (LAR) with Covering Loop Ileostomy is the best option, allowing curative resection, preservation of bowel continuity, and protection against anastomotic leaks.
Debate: Key says A
62 year old man is identified as having a rectal cancer. Following diagnostic work up no metastatic disease is identified. The tumour is 2cm from the anal verge. On MRI, lesion is T2, N0. Which of the following represents the correct course of action?
Proceed to abdomino-perineal excision of the colon and rectum (ELAPE)
Undertake a low anterior resection and loop ileostomy
Undertake a Hartmanns procedure
Offer radical external beam radiotherapy followed by abdomino-perineal excision of the colon and rectum (ELAPE)
Offer radical radiotherapy followed by low anterior resection and loop ileostomy
The correct answer is:
Proceed to abdominoperineal excision of the rectum (ELAPE).
Explanation:
This 62-year-old man has a T2N0 rectal cancer located 2 cm from the anal verge. The key factor here is the tumor’s proximity to the anal verge, which makes sphincter-preserving surgery (like Low Anterior Resection, LAR) unfeasible due to the lack of a sufficient distal margin.
Why ELAPE (Extralevator Abdominoperineal Excision)?
• Tumors ≤ 4 cm from the anal verge often require abdominoperineal excision (APE) because a safe oncological margin cannot be achieved while preserving the sphincters.
• ELAPE (extralevator APE) is a modified technique of APE that provides a more radical excision with better oncological clearance and reduced local recurrence rates.
• Since the tumor is T2N0 (localized, no nodal spread), there is no need for neoadjuvant radiotherapy, and immediate surgery is recommended.
Why not the other options?
• Low Anterior Resection (LAR) + Loop Ileostomy – Not suitable because LAR requires a distal margin of at least 1–2 cm, which is not feasible with a tumor only 2 cm from the anal verge.
• Hartmann’s Procedure – Typically used in emergency settings like perforation or obstruction. It is not a standard treatment for low rectal cancer.
• Radical Radiotherapy + ELAPE – Neoadjuvant chemoradiotherapy is not necessary for a T2N0 tumor, as the goal is curative resection.
• Radical Radiotherapy + LAR – Again, LAR is not an option due to the low position of the tumor, and radiotherapy is not required in T2N0 disease.
Conclusion:
For a T2N0 rectal cancer located 2 cm from the anal verge, abdominoperineal excision of the rectum (ELAPE) is the best approach, ensuring complete oncological clearance while avoiding inadequate sphincter preservation attempts.
A 20 year old man is admitted with bloody diarrhoea. He has been passing 10 stools per day, Hb-8.0, albumin-20. Stool culture negative. Evidence of colitis on endoscopy. He has been on intravenous steroids for 5 days and has now developed megacolon. His haemoglobin is falling and inflammatory markers are static. What is the most appropriate course of action?
Double the steroid dose
Undertake a loop ileostomy
Undertake a sub total colectomy and end ileostomy
Undertake a sub total colectomy and ileo-rectal anastomosis
Undertake a pan proctocolectomy
The correct answer is:
Undertake a subtotal colectomy and end ileostomy.
Explanation:
This 20-year-old man presents with severe ulcerative colitis (UC) complicated by toxic megacolon, which is a life-threatening condition requiring urgent surgical intervention.
Why subtotal colectomy with end ileostomy?
• Toxic megacolon is a surgical emergency, and the goal is to remove the diseased colon while minimizing perioperative morbidity.
• Subtotal colectomy with end ileostomy is preferred in the acute setting because:
• It removes the majority of the diseased colon, eliminating the immediate inflammatory burden.
• It preserves the rectum, which can be managed later with either:
• Completion proctectomy with ileal pouch-anal anastomosis (IPAA) (J-pouch) if the patient desires sphincter preservation.
• Completion proctectomy with permanent end ileostomy if pouch formation is unsuitable.
Why not the other options?
• Double the steroid dose – The patient has failed medical therapy (5 days of IV steroids) and has now developed megacolon, meaning surgery is needed. Increasing steroids will delay necessary intervention and increase the risk of perforation and sepsis.
• Loop ileostomy – This is not sufficient in toxic megacolon, as it does not remove the diseased, inflamed colon.
• Subtotal colectomy with ileorectal anastomosis – The rectum remains inflamed, and an anastomosis in an inflamed field risks breakdown. In acute colitis, rectal preservation is only temporary.
• Panproctocolectomy (PPC) with end ileostomy – Too extensive in an unstable patient. It is safer to perform a staged approach, starting with a subtotal colectomy, and then removing the rectum later when the patient is stable.
Conclusion:
For toxic megacolon in severe ulcerative colitis, subtotal colectomy with end ileostomy is the safest option, allowing stabilization before deciding on a definitive restorative or permanent procedure.
55 year old man is found to have an anal cancer. His staging investigations show a T2 lesion with no metastatic disease. What is the most appropriate treatment?
Radical abdominoperineal excision of the anus and rectum
Radical chemoradiotherapy
Excision proctectomy
External beam irradiation alone
Chemotherapy alone
The correct answer is:
Radical chemoradiotherapy.
Explanation:
This 55-year-old man has a T2 anal cancer with no metastatic disease. The standard first-line treatment for localized anal squamous cell carcinoma (SCC) is radical chemoradiotherapy (CRT), which has been shown to be highly effective for organ preservation and oncological control.
Why Radical Chemoradiotherapy?
• The Nigro Protocol (5-fluorouracil + mitomycin C + radiotherapy) is the standard treatment for T1–T3 anal SCC and achieves high cure rates (~80%) while preserving the anal sphincter.
• Chemoradiotherapy is curative in the majority of cases and avoids the need for a permanent colostomy.
• Surgery is reserved for persistent or recurrent disease.
Why Not the Other Options?
• Radical abdominoperineal excision of the anus and rectum (APE) – This is a salvage procedure for persistent or recurrent disease after chemoradiotherapy. It is not first-line treatment for T2 anal cancer.
• Excision proctectomy – This is not a standard treatment for anal SCC. Local excision is only considered in very small T1 tumors without nodal involvement.
• External beam irradiation alone – Inferior to chemoradiotherapy, as chemotherapy enhances the radiosensitivity of the tumor, leading to better outcomes.
• Chemotherapy alone – Ineffective as a primary treatment; requires radiotherapy for curative intent.
Conclusion:
For T2N0M0 anal cancer, radical chemoradiotherapy (Nigro protocol) is the most appropriate treatment, achieving excellent oncological control while preserving sphincter function.
3 year old man from Greece presents with colicky right upper quadrant pain, jaundice and an urticarial rash. He is initially treated with ciprofloxacin, but does not improve. What is the most likely diagnosis?
Infection with Wucheria bancrofti
Infection with Echinococcus granulosus
Type III hypersensitivity reaction
Allergy to ciprofloxacin
Common bile duct stones
The most likely diagnosis is:
Infection with Echinococcus granulosus (Hydatid disease).
Explanation:
This 30-year-old man from Greece presents with:
• Colicky right upper quadrant (RUQ) pain – Suggestive of hepatobiliary involvement.
• Jaundice – Indicates possible biliary obstruction.
• Urticarial rash – Suggests an immune response, possibly to parasite rupture.
• No response to ciprofloxacin – Suggests a non-bacterial cause.
Given the geographic background (Greece), hydatid disease (Echinococcus granulosus) is highly likely. This parasite is endemic in Mediterranean countries, and humans acquire it from contact with infected dogs or contaminated food/water.
Why Echinococcus granulosus?
• Hydatid cysts commonly affect the liver (~70%), causing RUQ pain and biliary compression.
• If the cyst ruptures into the biliary tree, it can cause jaundice, biliary obstruction, and anaphylactic reactions (urticaria, eosinophilia).
• Secondary bacterial infection of a cyst can mimic a liver abscess but will not respond well to ciprofloxacin.
Why Not the Other Options?
• Wuchereria bancrofti infection – Causes lymphatic filariasis, presenting with lymphoedema, elephantiasis, and chyluria, not RUQ pain and jaundice.
• Type III hypersensitivity reaction – Can cause urticarial rash, but does not explain RUQ pain and jaundice.
• Allergy to ciprofloxacin – Would typically cause rash, angioedema, or anaphylaxis, but not jaundice or persistent RUQ pain.
• Common bile duct (CBD) stones – Can cause biliary colic and jaundice, but do not explain the urticarial rash or lack of response to ciprofloxacin.
Conclusion:
This patient’s presentation is highly suggestive of hydatid disease (Echinococcus granulosus), likely due to rupture of a hepatic cyst into the biliary tree. Serology and imaging (CT/MRI) can confirm the diagnosis, and treatment involves albendazole and surgical or percutaneous cyst management (PAIR procedure).
A 4 year old presents with sudden onset of dysphagia. He undergoes an upper GI endoscopy and a large bolus of food is identified in the mid oesophagus. He has no significant history, other than a tracheo-oesophageal fistula repair soon after birth. What is the most likely diagnosis?
Barretts oesophagus
Benign oesophageal stricture
Squamous cell carcinoma of the oesophagus
Oesophageal adenocarcinoma
Achalasia
The most likely diagnosis in this case is benign oesophageal stricture.
- History of tracheo-oesophageal fistula (TOF) repair: This is a key clue. TOF repair in infancy is often associated with oesophageal atresia, which can lead to complications such as oesophageal strictures later in life. Strictures can develop due to scarring or narrowing of the oesophagus after surgical repair.
- Sudden onset of dysphagia with a food bolus impaction: This is a classic presentation of an oesophageal stricture. The stricture narrows the oesophageal lumen, making it difficult for food to pass, leading to impaction.
- Age and lack of significant history: Squamous cell carcinoma and oesophageal adenocarcinoma are extremely rare in a 4-year-old child. Barrett’s oesophagus is also unlikely in this age group and is typically associated with chronic gastro-oesophageal reflux disease (GORD).
- Achalasia: While achalasia can cause dysphagia, it is less likely in this context. Achalasia typically presents with progressive dysphagia for both solids and liquids, and it is not associated with a history of TOF repair.
The most likely diagnosis is benign oesophageal stricture, likely secondary to scarring from the previous TOF repair.
Patients with suspected temporal arteritis are often sent for temporal artery biopsy. Which statement is true?
Temporal artery biopsy is only diagnostic if there is visual loss
Biopsy is typically taken from the non-symptomatic side to avoid the risk of blindness
Pre-operative localisation with duplex is mandatory
Biopsies may be non diagnostic in over 50% of cases
Biopsies are usually performed under general anaesthesia
The correct statement is:
Biopsies may be non-diagnostic in over 50% of cases.
- Temporal artery biopsy is only diagnostic if there is visual loss: This is incorrect. Temporal artery biopsy can be diagnostic even in the absence of visual loss. Visual loss is a severe complication of temporal arteritis but is not a prerequisite for diagnosis.
- Biopsy is typically taken from the non-symptomatic side to avoid the risk of blindness: This is incorrect. The biopsy is usually taken from the symptomatic side (the side with tenderness, swelling, or other signs of inflammation) to maximize the chance of detecting pathology. The risk of blindness is not related to the side of the biopsy but to the disease itself.
- Pre-operative localisation with duplex is mandatory: This is incorrect. While duplex ultrasound can be helpful in identifying areas of inflammation or stenosis in the temporal artery, it is not mandatory before a biopsy. The biopsy is often guided by clinical findings.
- Biopsies may be non-diagnostic in over 50% of cases: This is correct. Temporal arteritis can involve the artery in a segmental or patchy manner, leading to “skip lesions.” As a result, even if the disease is present, the biopsy may miss the affected segment, leading to a false-negative result in a significant proportion of cases.
- Biopsies are usually performed under general anaesthesia: This is incorrect. Temporal artery biopsies are typically performed under local anaesthesia, as it is a relatively simple and quick procedure.
The most accurate statement is that biopsies may be non-diagnostic in over 50% of cases due to the segmental nature of the disease.
A 40 year old woman is admitted to the emergency department following a
road traffic accident, she sustains a complete transection of the spinal cord at
C7, which of the following reflexes is the earliest to recover following the spinal shock stage?
A. Plantar reflex
B. Ankle deep tendon reflex
C. Biceps deep tendon reflex
D. Delayed plantar Reflex
E. Bulbocavernosus reflex
The correct answer is:
E. Bulbocavernosus reflex
- Spinal shock: This is a temporary loss of spinal reflexes, motor function, and sensation below the level of a spinal cord injury. It typically lasts from a few hours to several weeks.
- Bulbocavernosus reflex: This is the earliest reflex to recover after spinal shock. It is a polysynaptic reflex mediated by the S2-S4 spinal cord segments. The reflex involves contraction of the bulbocavernosus muscle in response to squeezing the glans penis or clitoris or tugging on an indwelling Foley catheter. Its return signifies the end of spinal shock.
-
Other reflexes:
- Plantar reflex (A): This is a superficial reflex that tests the integrity of the corticospinal tract. It is not the earliest to recover.
- Ankle deep tendon reflex (B): This reflex tests the S1 nerve root and is not the first to recover.
- Biceps deep tendon reflex (C): This reflex tests the C5-C6 nerve roots and is not relevant in a C7 spinal cord injury.
- Delayed plantar reflex (D): This is not a recognized reflex.
- Why the bulbocavernosus reflex recovers first: It is a primitive reflex that does not depend on higher cortical input, making it the first to return after spinal shock.
The bulbocavernosus reflex is the earliest to recover following the spinal shock stage.
A 55 year old man with a long history of achalasia is successfully treated by a Hellers Cardiomyotomy. Several years later he develops an oesophageal malignancy. Which of the following lesions is most likely to be present?
Adenocarcinoma
Gastrointestinal stromal tumour
Leiomyosarcoma
Rhabdomyosarcoma
Squamous cell carcinoma
The most likely lesion to be present in this patient is:
Squamous cell carcinoma
- Achalasia and oesophageal malignancy: Patients with long-standing achalasia are at an increased risk of developing oesophageal cancer, particularly squamous cell carcinoma. The risk is estimated to be 10-30 times higher than in the general population.
- Pathophysiology: Chronic stasis of food in the oesophagus due to achalasia leads to irritation, inflammation, and mucosal damage, which can predispose to the development of squamous cell carcinoma.
- Adenocarcinoma (A): This type of cancer is more commonly associated with Barrett’s oesophagus, which results from chronic gastro-oesophageal reflux disease (GORD), not achalasia.
- Gastrointestinal stromal tumour (B): These are rare mesenchymal tumours that can occur anywhere in the gastrointestinal tract but are not specifically associated with achalasia.
- Leiomyosarcoma (C): This is a rare malignant smooth muscle tumour that can occur in the oesophagus but is not specifically linked to achalasia.
- Rhabdomyosarcoma (D): This is a rare malignant tumour of skeletal muscle origin and is extremely uncommon in the oesophagus.
Given the patient’s history of long-standing achalasia, the most likely oesophageal malignancy is squamous cell carcinoma.
A 32 year old lady presents with dysphagia. She has a 10 year history of anaemia secondary to menorrhagia and has been strongly resistant to treatment. What is the most likely underlying cause?
Candidiasis
Globus
Squamous cell carcinoma of the oesophagus
Adenocarcinoma of the oesophagus
Plummer Vinson syndrome
The most likely underlying cause in this case is:
Plummer-Vinson syndrome
- Clinical presentation: The patient is a 32-year-old woman with dysphagia and a long history of iron deficiency anaemia secondary to menorrhagia. These are classic features of Plummer-Vinson syndrome (also known as Paterson-Kelly syndrome).
-
Plummer-Vinson syndrome:
- Characterized by the triad of dysphagia, iron deficiency anaemia, and oesophageal webs.
- The oesophageal webs are thin mucosal folds that can cause obstruction, leading to dysphagia, particularly for solids.
- It is more common in middle-aged women and is strongly associated with iron deficiency.
-
Other options:
- Candidiasis (A): This typically occurs in immunocompromised individuals and presents with odynophagia (painful swallowing) rather than dysphagia. It is not associated with iron deficiency anaemia.
- Globus (B): This is a sensation of a lump in the throat without true dysphagia or structural abnormality. It is not associated with anaemia.
- Squamous cell carcinoma of the oesophagus (C): This is more common in older individuals with risk factors such as smoking, alcohol use, or long-standing achalasia. It is not typically associated with iron deficiency anaemia.
- Adenocarcinoma of the oesophagus (D): This is associated with Barrett’s oesophagus and chronic gastro-oesophageal reflux disease (GORD), not iron deficiency anaemia.
Given the patient’s history of iron deficiency anaemia and dysphagia, the most likely diagnosis is Plummer-Vinson syndrome.
From which of the following cell types do giant cells most commonly originate?
Neutrophils
Myofibroblasts
Fibroblasts
Macrophages
Goblet cells
The correct answer is:
Macrophages
- Giant cells: These are large, multinucleated cells that form through the fusion of monocytes or macrophages. They are typically seen in response to chronic inflammation, infections, or foreign bodies.
-
Macrophages (D): Giant cells most commonly originate from macrophages. When macrophages encounter persistent stimuli (e.g., pathogens, foreign material, or chronic inflammation), they can fuse together to form multinucleated giant cells. Examples include:
- Langhans giant cells (seen in tuberculosis).
- Foreign body giant cells (seen in response to foreign material).
- Touton giant cells (seen in xanthomas and fat necrosis).
-
Other cell types:
- Neutrophils (A): These are involved in acute inflammation and do not form giant cells.
- Myofibroblasts (B): These are involved in wound healing and fibrosis but do not form giant cells.
- Fibroblasts (C): These are responsible for producing extracellular matrix and collagen but do not form giant cells.
- Goblet cells (E): These are specialized epithelial cells that secrete mucus and are not involved in giant cell formation.
Giant cells most commonly originate from macrophages.
6 year old child has suffered a displaced supracondylar humeral fracture. On examination, he has a cold and insensate hand with absent pulses. What is the most likely underlying cause?
Clot embolus
Compartment syndrome
Steal syndrome
Direct arterial injury
Vasospasm
The most likely underlying cause in this case is:
Direct arterial injury
- Clinical scenario: A displaced supracondylar humeral fracture in a child is a serious injury that can lead to vascular compromise. The presence of a cold and insensate hand with absent pulses strongly suggests disruption of the brachial artery, which runs near the fracture site.
-
Direct arterial injury (D):
- The brachial artery is particularly vulnerable to injury in supracondylar fractures due to its proximity to the distal humerus.
- A displaced fracture can stretch, compress, or lacerate the artery, leading to acute ischemia of the forearm and hand.
- This is a surgical emergency requiring immediate reduction of the fracture and assessment of vascular integrity.
-
Other options:
- Clot embolus (A): While possible, this is less likely in the context of acute trauma and a displaced fracture. Emboli typically occur in the setting of atrial fibrillation or other cardiovascular conditions.
- Compartment syndrome (B): This can occur secondary to ischemia or swelling but is not the primary cause of the absent pulses and cold hand. Compartment syndrome would present with severe pain, pallor, paresthesia, and paralysis.
- Steal syndrome (C): This is a chronic condition seen in patients with arteriovenous fistulas and is not relevant in this acute traumatic setting.
- Vasospasm (E): While vasospasm can occur after trauma, it is unlikely to cause complete loss of pulses and a cold, insensate hand in the absence of direct arterial injury.
The most likely cause of the cold, insensate hand with absent pulses in this child is direct arterial injury due to the displaced supracondylar humeral fracture. Immediate intervention is required to restore blood flow and prevent permanent damage.
A 40 year old lady presents with a gastric carcinoma of the greater curvature of the stomach. Her staging investigations are negative for metastatic disease. What is the most appropriate treatment option?
Radical radiotherapy
Sub total gastrectomy, D2 lymphadenectomy and Roux en Y reconstruction
Sub total gastrectomy, D2 lymphadenectomy and anterior gastrojejunostomy
Oesophagogastrectomy
Sleeve gastrectomy
The most appropriate treatment option for this patient is:
Subtotal gastrectomy, D2 lymphadenectomy, and Roux-en-Y reconstruction
- Gastric carcinoma of the greater curvature: This is a localized gastric cancer, and the goal of treatment is curative resection.
- Staging investigations negative for metastatic disease: This indicates that the cancer is potentially resectable with curative intent.
-
Subtotal gastrectomy, D2 lymphadenectomy, and Roux-en-Y reconstruction:
- Subtotal gastrectomy: This involves removing the affected portion of the stomach, including the greater curvature, while preserving as much of the stomach as possible.
- D2 lymphadenectomy: This is the standard surgical procedure for gastric cancer and involves removing the perigastric lymph nodes (D1) as well as additional lymph nodes along the major arteries supplying the stomach (D2). This is crucial for accurate staging and reducing the risk of recurrence.
- Roux-en-Y reconstruction: This is a common method of restoring gastrointestinal continuity after gastrectomy. It involves creating a Y-shaped anastomosis between the remaining stomach, the jejunum, and the duodenum, which helps prevent bile reflux and improves postoperative function.
-
Other options:
- Radical radiotherapy (A): This is not typically used as primary treatment for localized gastric cancer. It may be used in palliative settings or in combination with chemotherapy (chemoradiation) in certain cases.
- Subtotal gastrectomy, D2 lymphadenectomy, and anterior gastrojejunostomy (C): Anterior gastrojejunostomy is not the standard reconstruction method for gastric cancer surgery. Roux-en-Y is preferred due to its advantages in reducing bile reflux.
- Oesophagogastrectomy (D): This is used for tumors involving the gastroesophageal junction or distal esophagus, not for tumors of the greater curvature of the stomach.
- Sleeve gastrectomy (E): This is a bariatric surgery procedure and is not appropriate for the treatment of gastric cancer.
The most appropriate treatment for this patient is subtotal gastrectomy, D2 lymphadenectomy, and Roux-en-Y reconstruction. This approach offers the best chance for curative resection and long-term survival.
A 63 year old man finds that he has to stop walking after 100 yards due to bilateral calf pain. He finds that bending forwards and walking up hill helps. He is able to ride a bike without any pain. What is the most likely underlying cause?
Lumbar canal stenosis
Diabetic neuropathy
Aorto-iliac occlusion
Occlusion of the superficial femoral artery
Pelvic rheumatoid arthritis
The most likely underlying cause in this case is:
Lumbar canal stenosis
-
Clinical presentation: The patient describes neurogenic claudication, which is characterized by:
- Bilateral calf pain after walking a certain distance (e.g., 100 yards).
- Relief with bending forward (e.g., leaning on a shopping cart or walking uphill), which increases the space in the lumbar spinal canal and reduces pressure on the nerves.
- Ability to ride a bike without pain, as cycling involves a flexed posture that relieves nerve compression.
-
Lumbar canal stenosis (A):
- This condition involves narrowing of the spinal canal in the lumbar region, leading to compression of the nerve roots.
- It is a classic cause of neurogenic claudication, which is often mistaken for vascular claudication (due to peripheral arterial disease).
- Symptoms are typically relieved by sitting or bending forward and worsened by standing or walking.
-
Other options:
- Diabetic neuropathy (B): This typically causes symmetric sensory symptoms (e.g., numbness, tingling, or burning) rather than positional claudication.
- Aorto-iliac occlusion (C): This would cause vascular claudication, which is not relieved by bending forward and is typically associated with absent or diminished pulses in the lower limbs.
- Occlusion of the superficial femoral artery (D): This would also cause vascular claudication, typically in the calf, but it would not be relieved by bending forward.
- Pelvic rheumatoid arthritis (E): This is rare and would not typically present with claudication symptoms. It would more likely cause pain and stiffness in the pelvic joints.
The patient’s symptoms are most consistent with lumbar canal stenosis, a condition that causes neurogenic claudication due to nerve root compression in the lumbar spine.
63 year old man has a history of claudication that has been present for many years. He is recently evaluated in the clinic and a duplex scan shows that he has an 85% stenosis of the superficial femoral artery. Two weeks later he presents with a 1 hour history of severe pain in his leg. On examination, he has absent pulses in the affected limb and it is much cooler than the contra-lateral limb. Which process best accounts for this presentation?
Thrombosis
Embolus
Atheroma growth
Sub intimal dissection
Anaemia
The process that best accounts for this presentation is:
Thrombosis
- Clinical scenario: The patient has a known history of claudication and an 85% stenosis of the superficial femoral artery (SFA). He now presents with acute severe pain, absent pulses, and a cool limb, which are classic signs of acute limb ischemia.
-
Thrombosis (A):
- The severe stenosis in the SFA creates turbulent blood flow, which predisposes to the formation of a thrombus (blood clot) at the site of the stenosis.
- The thrombus can acutely occlude the already narrowed artery, leading to sudden cessation of blood flow and acute limb ischemia.
- This is consistent with the patient’s presentation of severe pain, absent pulses, and a cool limb.
-
Other options:
- Embolus (B): An embolus typically originates from a proximal source (e.g., the heart or aorta) and lodges in a distal artery. While it can cause acute limb ischemia, it is less likely in this case given the pre-existing severe stenosis in the SFA.
- Atheroma growth (C): Growth of an atheroma (plaque) is a gradual process and would not cause sudden onset of symptoms.
- Subintimal dissection (D): This is a rare complication of endovascular procedures and is unlikely to occur spontaneously in this context.
- Anaemia (E): Anaemia does not cause acute limb ischemia or the described symptoms.
The most likely process accounting for this presentation is thrombosis of the superficial femoral artery at the site of pre-existing stenosis, leading to acute limb ischemia. This is a vascular emergency requiring urgent intervention (e.g., thrombectomy or thrombolysis).
A 20 year old lady presents with a thyroid cancer, she is otherwise well with no significant family history. On examination, she has a nodule in the left lobe of the thyroid, with a small discrete mass separate from the gland itself. Which of the following is the most likely cause?
Follicular carcinoma
Anaplastic carcinoma
Medullary carcinoma
Papillary carcinoma
B Cell Lymphoma
The most likely cause in this case is:
Papillary carcinoma
- Clinical presentation: The patient is a 20-year-old woman with a thyroid nodule and a small discrete mass separate from the thyroid gland. This is highly suggestive of papillary thyroid carcinoma, which is the most common type of thyroid cancer, particularly in young women.
-
Papillary carcinoma (D):
- Accounts for 80-85% of all thyroid cancers.
- Often presents as a solitary thyroid nodule.
- Can spread to regional lymph nodes, which may present as discrete masses separate from the thyroid gland (as in this case).
- Has an excellent prognosis, especially in young patients.
-
Other options:
- Follicular carcinoma (A): This is the second most common type of thyroid cancer but is less likely to present with lymph node involvement. It is more common in older patients.
- Anaplastic carcinoma (B): This is a rare, aggressive form of thyroid cancer that typically occurs in older patients and presents with rapid growth and local invasion. It is unlikely in a 20-year-old.
- Medullary carcinoma (C): This is a rare type of thyroid cancer that arises from parafollicular C cells. It can be sporadic or familial (associated with multiple endocrine neoplasia [MEN] syndromes). However, it is less common than papillary carcinoma and would typically present with elevated calcitonin levels.
- B-cell lymphoma (E): This is a rare cause of thyroid masses and is typically seen in older patients with a history of Hashimoto’s thyroiditis.
The most likely diagnosis in this young patient with a thyroid nodule and a discrete mass separate from the gland is papillary carcinoma. This is the most common thyroid cancer in this age group and often presents with regional lymph node involvement.
62 year old man presents with dyspepsia and a tumour of the gastric cardia is diagnosed. He has no evidence of metastatic disease. What is the most appropriate treatment option?
Sub total gastrectomy and Roux en Y reconstruction
Total gastrectomy and Roux en Y reconstruction
Total gastrectomy and loop jejunostomy reconstruction
Proximal gastrectomy and gastric pull up
External beam radical radiotherapy
The most appropriate treatment option for this patient is:
Total gastrectomy and Roux-en-Y reconstruction
- Tumour of the gastric cardia: The gastric cardia is the region of the stomach that connects to the esophagus. Tumors in this location are often adenocarcinomas and require aggressive surgical management due to their proximity to the esophagus and the risk of local spread.
- No evidence of metastatic disease: This indicates that the tumor is potentially resectable with curative intent.
-
Total gastrectomy and Roux-en-Y reconstruction:
- Total gastrectomy: This involves complete removal of the stomach, including the cardia, to ensure clear margins and reduce the risk of local recurrence.
- Roux-en-Y reconstruction: This is the standard method of restoring gastrointestinal continuity after total gastrectomy. It involves creating a Y-shaped anastomosis between the esophagus, the jejunum, and the duodenum, which helps prevent bile reflux and improves postoperative function.
-
Other options:
- Subtotal gastrectomy and Roux-en-Y reconstruction (A): This is not appropriate for tumors of the gastric cardia, as it does not provide adequate margins for resection.
- Total gastrectomy and loop jejunostomy reconstruction (C): This is not a standard reconstruction method and is less effective than Roux-en-Y in preventing bile reflux.
- Proximal gastrectomy and gastric pull-up (D): This is rarely performed due to the high risk of complications, such as reflux and anastomotic strictures.
- External beam radical radiotherapy (E): This is not a primary treatment for resectable gastric cancer. It may be used in palliative settings or in combination with chemotherapy (chemoradiation) in certain cases.
The most appropriate treatment for this patient with a tumor of the gastric cardia is total gastrectomy and Roux-en-Y reconstruction. This approach offers the best chance for curative resection and long-term survival.
A 34-year-old man is taken immediately to theatre with aortic dissection. You note he is tall with pectus excavatum and arachnodactyly. His condition is primarily due to a defect in which one of the following proteins?
Polycystin-1
Fibrillin
Type IV collagen
Type I collagen
Elastin
The condition described in this patient is most likely Marfan syndrome, and the primary defect is in:
Fibrillin
-
Clinical features:
- Tall stature, pectus excavatum (sunken chest), and arachnodactyly (long, slender fingers and toes) are classic features of Marfan syndrome.
- Aortic dissection is a life-threatening complication of Marfan syndrome due to weakening of the aortic wall.
-
Marfan syndrome:
- This is an autosomal dominant connective tissue disorder caused by mutations in the FBN1 gene, which encodes the protein fibrillin-1.
- Fibrillin-1 is a key component of microfibrils in the extracellular matrix, which provide structural support to tissues, including the aorta.
- Defective fibrillin-1 leads to abnormal connective tissue, resulting in the characteristic features of Marfan syndrome and an increased risk of aortic dissection.
-
Other proteins:
- Polycystin-1 (A): Mutations in this protein are associated with autosomal dominant polycystic kidney disease (ADPKD), not Marfan syndrome.
- Type IV collagen (C): Defects in type IV collagen are associated with Alport syndrome, a condition affecting the kidneys and ears.
- Type I collagen (D): Mutations in type I collagen are seen in osteogenesis imperfecta, a condition characterized by brittle bones.
- Elastin (E): While elastin is important for tissue elasticity, defects in elastin are not the primary cause of Marfan syndrome.
The primary defect in this patient’s condition is in fibrillin, which is the underlying cause of Marfan syndrome and its associated complications, such as aortic dissection.
A 72 year old man has a CT scan for abdominal discomfort and the surgeon suspects abdominal aortic disease. It reveals a 6.6cm aneurysm with a 3.5cm neck and it continues to involve the right common iliac. The left iliac is occluded. He is hypertensive and has Type 2 DM which is well controlled. What is the best course of action?
Abdominal aortic aneurysm repair in next 48 hours
Abdominal aortic aneurysm repair in 6 weeks time
Review in outpatients in 3 months
Endovascular aortic aneurysm repair in 48 hours
Discharge the patient
Given the scenario of a 72-year-old man with a 6.6 cm abdominal aortic aneurysm (AAA) involving the right common iliac artery and an occluded left iliac artery, along with comorbidities of hypertension and well-controlled Type 2 diabetes mellitus, the best course of action is typically determined by the size and risk of rupture of the aneurysm.
- Size of Aneurysm: A 6.6 cm AAA is considered large and has a significant risk of rupture. Generally, aneurysms larger than 5.5 cm are considered for repair due to the increased risk of rupture.
- Urgency: Given the size, repair should be considered urgently, but not necessarily emergently unless there are signs of impending rupture.
- Type of Repair: The choice between open surgical repair and endovascular aortic repair (EVAR) depends on several factors, including the patient’s overall health, anatomy of the aneurysm, and surgical risks. EVAR is less invasive and often preferred for patients with suitable anatomy and higher surgical risk.
Given these considerations, the most appropriate option would likely be:
- Endovascular aortic aneurysm repair in 48 hours: This approach allows for a less invasive procedure, which may be beneficial given the patient’s age and comorbidities. The urgency reflects the need to address the aneurysm promptly due to its size.
However, the final decision should be made by the vascular surgery team based on a comprehensive evaluation of the patient’s condition, aneurysm characteristics, and available treatment options.
32 year old man is diagnosed as having a carcinoma of the caecum. On questioning, his mother developed uterine cancer at the age of 39 and his maternal uncle died from colonic cancer aged 38. His older brother developed a colonic cancer with micro satellite instability aged 37. What is the most appropriate operative treatment?
Limited ileocaecal resection
Right hemicolectomy
Extended right hemicolectomy
Panproctocolectomy
Sub total colectomy
The most appropriate operative treatment is Extended right hemicolectomy.
Here’s why:
* Strong Family History: This patient has a very strong family history of young-onset colorectal and related cancers. This raises a high suspicion for Hereditary Non-Polyposis Colorectal Cancer (HNPCC), also known as Lynch syndrome. The brother’s diagnosis of MSI-high (microsatellite instability) colorectal cancer further strengthens this suspicion, as MSI is a hallmark of Lynch syndrome.
* Lynch Syndrome Implications: Lynch syndrome significantly increases the risk of synchronous (occurring at the same time) and metachronous (occurring later) colorectal cancers, as well as other cancers (endometrial, ovarian, stomach, etc.). Because of this increased risk throughout the colon, a more extensive resection is warranted.
* Extended Right Hemicolectomy Rationale: A standard right hemicolectomy removes the cecum, ascending colon, and a portion of the transverse colon. An extended right hemicolectomy removes even more of the transverse colon, which is important in this case because of the Lynch syndrome risk. This wider resection aims to reduce the risk of future cancers developing in the remaining colon.
Why other options are less suitable:
* Limited ileocaecal resection: This is insufficient given the strong family history and risk of Lynch syndrome. It only removes a small portion of the bowel.
* Right hemicolectomy: While better than a limited resection, it doesn’t address the increased risk in the more distal colon due to Lynch syndrome.
* Panproctocolectomy: This involves removing the entire colon and rectum. While it would eliminate the risk of future colorectal cancer, it’s a more radical procedure with significant long-term consequences (requiring an ileostomy or ileoanal pouch). It’s generally reserved for cases with rectal involvement or other specific indications, and not typically the first-line approach for a right-sided caecal cancer in this context.
* Subtotal colectomy: This removes most of the colon but leaves the rectum. While it might be considered in some situations, an extended right hemicolectomy is more appropriate in this case because it addresses the location of the current cancer while also accounting for the Lynch syndrome risk in the remaining colon.
32 year old lady presents with a 1.5cm pigmented lesion on her back. The surgeon is concerned that this may be a melanoma. What is the most appropriate course of action?
2mm punch biopsy from the centre of the lesion
4mm punch biopsy from the centre of the lesion
Wide excision of the lesion with 3cm margins
Excisional biopsy of the lesion
Wide excision of the lesion with 1cm margins
The most appropriate course of action is Excisional biopsy of the lesion.
Here’s why:
* Concern for Melanoma: The surgeon’s concern for melanoma necessitates complete removal of the lesion for accurate diagnosis and staging. Punch biopsies, while sometimes useful for initial characterization, are generally not the best approach for suspected melanomas. They may miss crucial information about the depth of invasion and other features that are critical for prognosis.
* Excisional Biopsy Technique: An excisional biopsy involves removing the entire lesion, including a small margin of normal-appearing skin. This provides the pathologist with the entire lesion to examine, allowing for accurate diagnosis, Breslow thickness measurement (depth of invasion), and other important prognostic factors.
* Margins: The appropriate margins for an excisional biopsy of a suspected melanoma are generally narrower than those used for definitive melanoma excision after diagnosis. A 1-3mm margin of normal skin is usually sufficient for the initial diagnostic excisional biopsy. The other options of 1cm or 3cm margins are generally not needed for the initial biopsy and would result in unnecessarily large scars.
Why other options are incorrect:
* 2mm or 4mm punch biopsy from the centre of the lesion: As mentioned above, punch biopsies are not ideal for suspected melanomas as they may not provide enough information for accurate diagnosis and staging. The entire lesion needs to be examined.
* Wide excision of the lesion with 3cm or 1cm margins: Wide excision with larger margins is the treatment after a melanoma has been diagnosed, not for the initial diagnostic biopsy. Performing a wide excision before a diagnosis is confirmed is unnecessary and could lead to excessive scarring.
A 28 year old man develops an acute paronychia and subsequent spreading sepsis. The tissue exudate has a higher protein content than normal tissue because?
Breakdown of tissue cells release protein
Capillary walls are more permeable
Increased blood flow transports more protein into the area
Intracapillary pressure is raised
Plasma cells release gamma globulin
The correct answer is Capillary walls are more permeable.
Here’s why:
* Increased Permeability in Inflammation: Paronychia and spreading sepsis represent an inflammatory response. A key characteristic of inflammation is increased permeability of capillary walls. This allows proteins and other large molecules, which normally remain within the bloodstream, to leak into the interstitial space (the tissue surrounding the capillaries). This leakage is what causes the higher protein content in the tissue exudate.
Why the other options are less accurate:
* Breakdown of tissue cells release protein: While tissue damage does release some proteins, this is not the primary reason for the increased protein content in exudate. The main source is leakage from the capillaries.
* Increased blood flow transports more protein into the area: Increased blood flow delivers more everything to the area, including proteins, but it’s the increased permeability that allows the proteins to leave the bloodstream and enter the tissue. Simply having more blood flow doesn’t explain the disproportionately higher protein content in the exudate.
* Intracapillary pressure is raised: While intracapillary pressure can be elevated in inflammation, it’s not the primary mechanism causing the protein leakage. Increased permeability is the key factor.
* Plasma cells release gamma globulin: Plasma cells do release gamma globulins (antibodies), but this is a more specific and later part of the immune response. While it contributes to the overall protein content, it’s not the main reason for the increased protein in acute exudate. The increased capillary permeability is the immediate and most significant factor.
A 38 year old lady who smokes heavily presents with recurrent episodes of infection in the right breast. On examination she has an indurated area at the lateral aspect of the nipple areaolar complex. Imaging shows no mass lesions. What is the most likely diagnosis?
Duct ectasia
Periductal mastitis
Pagets disease of the nipple
Mondors disease of the breast
Radial scar
The most likely diagnosis is Periductal mastitis.
Here’s why:
* Recurrent Infections and Smoking: Recurrent breast infections, especially in smokers, are highly suggestive of periductal mastitis (also known as plasma cell mastitis or mammary duct ectasia complex). Smoking is a known risk factor.
* Indurated Area at Nipple-Areolar Complex: The location of the induration (firmness) at the lateral aspect of the nipple-areolar complex is characteristic of periductal mastitis. This is where the ducts converge.
* No Mass Lesions on Imaging: The absence of mass lesions makes other diagnoses less likely. Periductal mastitis is primarily an inflammatory process, not a tumor.
Why the other options are less likely:
* Duct ectasia: While duct ectasia can be a component of periductal mastitis, it refers more specifically to the dilation of the milk ducts. The recurrent infections and induration point more towards the inflammatory process (periductal mastitis) itself.
* Paget’s disease of the nipple: Paget’s disease is a rare form of breast cancer that presents with nipple changes (eczema-like rash, scaling, itching). It’s less likely given the recurrent infections and the indurated area away from the nipple itself. It also usually presents with more obvious nipple changes.
* Mondor’s disease: Mondor’s disease is a rare condition involving thrombophlebitis (inflammation and clotting) of a superficial vein in the breast or chest wall. It typically presents as a palpable, tender cord, not an indurated area.
* Radial scar: Radial scars are benign breast lesions that can sometimes mimic cancer on imaging. However, they are not typically associated with recurrent infections. They are also usually not located directly at the nipple-areolar complex.
A 32 year old lady undergoes a thyroidectomy for a mild goitre. The resected specimen shows an intense lymphocytic infiltrate with acinar destruction and fibrosis. What is the underlying lesion?
Anaplastic carcinoma
Rhadomyosarcoma
Lymphoma
Hashimotos thyroiditis
Graves’ disease
The underlying lesion is Hashimoto’s thyroiditis.
Here’s why:
* Lymphocytic Infiltrate, Acinar Destruction, and Fibrosis: These are the classic histological hallmarks of Hashimoto’s thyroiditis. The lymphocytic infiltrate (mainly lymphocytes and plasma cells) attacks the thyroid follicles (acini), leading to their destruction and subsequent fibrosis (scarring).
* Mild Goitre: Hashimoto’s thyroiditis often presents with a goitre (enlarged thyroid gland), which can be mild.
* Autoimmune Nature: Hashimoto’s is an autoimmune disease, where the body’s immune system attacks the thyroid gland. This explains the lymphocytic infiltrate and destruction of thyroid tissue.
Why the other options are incorrect:
* Anaplastic carcinoma: This is a very aggressive form of thyroid cancer. It would not typically present with the described histological features. Anaplastic carcinomas are usually much more undifferentiated and aggressive looking under the microscope.
* Rhabdomyosarcoma: This is a rare malignant tumor of skeletal muscle. It does not arise in the thyroid gland.
* Lymphoma: While lymphoma can affect the thyroid, the description of “acinar destruction” points strongly towards Hashimoto’s. Lymphoma would typically present as a more diffuse infiltrate of lymphocytes without such prominent acinar destruction.
* Graves’ disease: Graves’ disease is another autoimmune thyroid condition, but it is characterized by hyperthyroidism (overactive thyroid), not the destruction and fibrosis seen in Hashimoto’s. Histologically, Graves’ disease shows features of increased follicular activity, not destruction.
46 year old lady presents with symptoms of diarrhoea, weight loss of 10 Kg and a skin rash of erythematous blisters involving the abdomen and buttocks. The blisters have an irregular border and both intact and ruptured vesicles. What is the most likely diagnosis?
Colonic adenocarcinoma
Pancreatic adenocarcinoma
Tropical sprue
Glucagonoma
Insulinoma
The most likely diagnosis is Glucagonoma.
Here’s why:
* Diarrhoea, Weight Loss, and Skin Rash: These three symptoms together are highly suggestive of a glucagonoma. The skin rash is particularly characteristic; it’s called necrolytic migratory erythema (NME). It often presents as erythematous (red), blistering lesions, especially on the face, groin, and extremities. The lesions can be irregular, with both intact and ruptured vesicles, as described.
* Glucagonoma and NME: Glucagonomas are rare neuroendocrine tumors of the pancreas that produce excess glucagon. The elevated glucagon levels are responsible for the diabetes-like symptoms (which can include diarrhea), weight loss, and the distinctive NME rash.
Why the other options are less likely:
* Colonic adenocarcinoma: While colonic cancer can cause weight loss and sometimes diarrhea, it wouldn’t typically present with the characteristic NME skin rash.
* Pancreatic adenocarcinoma: Pancreatic cancer can also cause weight loss and sometimes diarrhea (due to malabsorption). However, like colon cancer, it wouldn’t typically cause the NME rash. Also, pancreatic cancer often presents with abdominal pain and jaundice (if it obstructs the bile duct), which aren’t mentioned here.
* Tropical sprue: This is a malabsorption syndrome caused by an infection. It can cause diarrhea and weight loss, but it doesn’t typically cause the specific NME skin rash. Tropical sprue also usually responds to antibiotic treatment.
* Insulinoma: This is a tumor that produces excess insulin, leading to hypoglycemia (low blood sugar). The symptoms are typically related to this, such as sweating, tremors, confusion, and seizures. It would not cause diarrhea, weight loss, or the NME rash.
A 12 year old male is investigated for swallowing difficulties and is found to have dysphagia lusoria. Which of the diagnostic modalities described below is most likely to demonstrate the cause?
CT angiogram
Upper GI endoscopy
Barium swallow
Capsule endoscopy
Oesophageal manometry
The most likely diagnostic modality to demonstrate the cause of dysphagia lusoria is CT angiogram.
Here’s why:
* Dysphagia Lusoria Cause: Dysphagia lusoria is caused by an aberrant right subclavian artery, which arises from the aorta distal to the left subclavian artery and then courses behind the esophagus to reach the right arm. This abnormal artery can compress the esophagus, leading to swallowing difficulties.
* CT Angiogram’s Role: A CT angiogram is specifically designed to visualize blood vessels. It will clearly show the origin and course of the aberrant right subclavian artery, confirming the diagnosis of dysphagia lusoria.
Why the other options are less suitable:
* Upper GI endoscopy: Endoscopy visualizes the inside of the esophagus. While it might show indirect signs of external compression (like a pulsating indentation), it won’t directly visualize the aberrant vessel itself.
* Barium swallow: A barium swallow can also show indirect signs of compression on the esophagus, but it’s not as sensitive or specific as a CT angiogram for visualizing the blood vessel. It’s better for assessing the lumen of the esophagus.
* Capsule endoscopy: This is primarily used to visualize the small intestine. It’s not helpful for diagnosing esophageal compression.
* Oesophageal manometry: This measures the pressure and motor function of the esophagus. It can detect abnormalities in esophageal motility, but it won’t directly show the cause of external compression like an aberrant artery.
73 year old man develops sudden onset abdominal pain and collapses. On examination he has a tender pulsatile mass in his upper abdomen. He has a blood pressure of 90/60mmHg and pulse rate of 105 beats per minute. Which of the following intravenous fluid regimens is most appropriate, whilst waiting for operative repair?
1 Litre of pentastarch over 15 minutes
1 litre of Hartmans solution over 4 hours
1 litre of gelofusin over 30 minutes
1 litre of Hartmans solution over 30 minutes
1 litre of blood over 15 minutes
The clinical scenario described suggests a ruptured abdominal aortic aneurysm (AAA), which is a surgical emergency. The patient is in hypovolemic shock, as indicated by the low blood pressure (90/60 mmHg) and tachycardia (pulse rate of 105 beats per minute). The priority in this situation is rapid fluid resuscitation to restore circulating volume and maintain perfusion to vital organs while awaiting definitive surgical repair.
Among the options provided, the most appropriate intravenous fluid regimen would be the one that allows for rapid volume expansion.
- 1 Litre of pentastarch over 15 minutes: This is a colloid solution that can rapidly expand plasma volume. However, colloids like pentastarch can have side effects such as anaphylactoid reactions and may not be the first choice in this emergency setting.
- 1 litre of Hartmans solution over 4 hours: This is a crystalloid solution, but the infusion rate is too slow for this emergency situation.
- 1 litre of gelofusin over 30 minutes: Gelofusin is another colloid solution, but similar to pentastarch, it may not be the first choice due to potential side effects.
- 1 litre of Hartmans solution over 30 minutes: This is a crystalloid solution and can be given rapidly to restore circulating volume. Hartmann’s solution is balanced and less likely to cause electrolyte imbalances compared to normal saline.
- 1 litre of blood over 15 minutes: Blood transfusion would be ideal as it replaces lost blood volume and improves oxygen-carrying capacity. However, crossmatching and availability might delay administration.
Given the options, 1 litre of Hartmans solution over 30 minutes is the most appropriate choice for rapid volume resuscitation while waiting for operative repair. It allows for quick administration of a balanced crystalloid solution to stabilize the patient’s hemodynamics. However, in a real clinical setting, blood transfusion would be the preferred option if immediately available.
A 23 year old woman presents with greenish nipple discharge on one occasion. Clinical examination of the breast is normal. Ultrasound report is U1. What is the best course of action?
Arrange a mammogram
Undertake a total duct excision
Undertake a microdochectomy
Reassure and discharge
Express duct fluid for cytology
The best course of action is Reassure and discharge.
Here’s why:
* Greenish Nipple Discharge, Normal Exam, U1 Ultrasound: Greenish nipple discharge, especially if it’s non-bloody and occurs only once, is often benign. A normal clinical breast exam and a U1 ultrasound (which indicates a normal ultrasound) further support a benign process. In this age group, it is very likely to be physiological.
* Reassurance: Reassurance is key in this situation. The patient should be informed that the discharge is likely benign given the normal examination and ultrasound.
Why other options are not the best course of action:
* Arrange a mammogram: Mammograms are generally not indicated in women under 40 unless there are specific high-risk factors or concerning clinical findings. A single episode of greenish discharge with a normal exam and ultrasound does not warrant a mammogram in this age group.
* Undertake a total duct excision: This is a major surgical procedure and is only indicated for persistent, troublesome nipple discharge, especially if it is bloody or associated with other concerning findings. It is far too invasive for a single episode of greenish discharge with normal clinical and ultrasound findings.
* Undertake a microdochectomy: This is a less extensive procedure than total duct excision, involving removal of a single duct. However, it is still an invasive procedure and is not indicated for this presentation.
* Express duct fluid for cytology: Cytology of nipple discharge is sometimes performed, especially if the discharge is bloody or there are other concerning features. However, in this case, the discharge is described as greenish, and the clinical examination and ultrasound are normal. Therefore, cytology is not necessary at this point. Reassurance is the most appropriate step.
A pale 65-year-old man collapsed at home. He is a known hypertensive. On
examination his blood pressure is 70/30 mmHg, and his heart rate is 120
beats/minute. A pulsatile mass is noted in his epigastrium. Which of the following is
the most appropriate management?
A. 2 liters of 0.9% saline
B. 2 liters of ringer lactate
C. 2 units of group O negative red cells
D. 6 packs of platelets
E. Prothrombin complex concentrate (octaplex or beriplex)
The most appropriate management in this scenario is B. 2 liters of ringer lactate.
Here’s why:
* Suspected Ruptured AAA: The combination of collapse, low blood pressure, high heart rate, and a pulsatile epigastric mass strongly suggests a ruptured abdominal aortic aneurysm (AAA). This is a life-threatening emergency.
* Initial Management: The immediate priority is to stabilize the patient by restoring circulating volume and blood pressure. This is best achieved with rapid infusion of crystalloid fluids.
* Ringer Lactate: Ringer lactate (also known as Hartmann’s solution) is a balanced crystalloid solution that is commonly used for initial fluid resuscitation in trauma and surgical emergencies. It helps to restore fluid volume and electrolytes.
* Why not other options:
* 0.9% saline: While saline can be used, Ringer lactate is generally preferred due to its more balanced electrolyte composition.
* Group O negative red cells: Blood transfusion is essential, but it shouldn’t be the initial management. Fluid resuscitation should be started first to restore some circulating volume before blood products are given. Uncrossmatched O-negative blood can be used in dire situations, but crystalloid is the first step.
* Platelets: Platelets are not indicated in this situation unless there is evidence of significant coagulopathy.
* Prothrombin complex concentrate: This is used to reverse the effects of anticoagulants, which is not relevant in this acute scenario.
Which of the following is the most common childhood brain tumour?
Glioblastoma multiforme
Astrocytoma
Medulloblastoma
Ependymoma
Meningioma
The most common childhood brain tumor among the options provided is Medulloblastoma.
Medulloblastoma is a type of embryonal tumor that typically arises in the cerebellum, which is the part of the brain responsible for coordinating movement. It is most commonly diagnosed in children, particularly between the ages of 3 and 8, though it can occur in adults as well.
Here’s a brief overview of the other options for context:
- Glioblastoma multiforme: This is a highly aggressive brain tumor that is more common in adults than in children.
- Astrocytoma: This is a type of glioma that can occur in both children and adults, but it is not the most common childhood brain tumor.
- Ependymoma: This tumor arises from the ependymal cells lining the ventricles of the brain and the central canal of the spinal cord. It can occur in children but is less common than medulloblastoma.
- Meningioma: This is a tumor that arises from the meninges, the protective layers surrounding the brain and spinal cord. It is more common in adults and is rare in children.
Thus, Medulloblastoma is the most common childhood brain tumor among the listed options.
55 year old lady presents with a neck mass. On examination, there is a swelling of the neck and enlarged deep cervical lymph nodes. A biopsy is taken from the nodes and is noted to be CD20 positive. What is the most likely diagnosis?
Hashimotos thyroiditis
Thyroid gland lymphoma
Papillary thyroid cancer
Follicular thyroid cancer
Anaplastic thyroid cancer
The most likely diagnosis in this case is Thyroid gland lymphoma.
Here’s why:
- CD20 positivity: CD20 is a marker expressed on B-cells, and its presence suggests a B-cell lymphoma. Thyroid gland lymphoma is a type of non-Hodgkin lymphoma that arises from B-cells within the thyroid gland.
- Clinical presentation: The patient is a 55-year-old woman with a neck mass and enlarged deep cervical lymph nodes, which is consistent with lymphoma. Thyroid lymphomas often present with rapid enlargement of the thyroid gland and may be associated with symptoms of compression, such as difficulty swallowing or breathing.
- Association with Hashimoto’s thyroiditis: Thyroid lymphoma is frequently associated with Hashimoto’s thyroiditis, a chronic autoimmune thyroiditis. Patients with Hashimoto’s thyroiditis have an increased risk of developing thyroid lymphoma.
Let’s briefly consider the other options:
- Hashimoto’s thyroiditis: This is an autoimmune condition that can cause thyroid enlargement (goiter), but it does not typically present with CD20-positive lymph nodes or rapid neck mass enlargement.
- Papillary thyroid cancer: This is the most common type of thyroid cancer, but it is not associated with CD20 positivity. It typically presents as a thyroid nodule rather than diffuse thyroid enlargement with lymphadenopathy.
- Follicular thyroid cancer: This is another type of thyroid cancer that presents as a thyroid nodule, but it is not associated with CD20 positivity.
- Anaplastic thyroid cancer: This is a rare and aggressive form of thyroid cancer that can present with rapid thyroid enlargement and lymphadenopathy, but it is not CD20 positive.
Given the CD20 positivity and the clinical presentation, Thyroid gland lymphoma is the most likely diagnosis.
32-year-old male patient fell on an outstretched hand injuring his distal forearm 2 cm above the wrist. On examination, he can’t lift his thumb off the table while palm is facing downwards. On fixing the proximal phalanx, the patient cannot move his interphalangeal joint. Which is the most likely responsible?
A. Radial nerve injury
B. Posterior interosseous nerve injury
C. Abductor policis brevis tendon tear
D. Extensor policis longus tendon tear
E. Extensor policis brevis tendon tear
The clinical scenario described involves a 32-year-old male who sustained an injury to his distal forearm after falling on an outstretched hand. The key findings on examination are:
- Inability to lift the thumb off the table while the palm is facing downward.
- Inability to move the interphalangeal joint of the thumb when the proximal phalanx is fixed.
These findings suggest a loss of function in the extensor pollicis longus (EPL) tendon, which is responsible for extending the interphalangeal joint of the thumb and assisting in thumb abduction. The EPL tendon is particularly vulnerable to injury in distal forearm trauma, especially near the wrist.
- A. Radial nerve injury: A radial nerve injury would typically cause weakness in wrist extension and finger extension, not just isolated thumb dysfunction. This is less likely given the specific findings.
- B. Posterior interosseous nerve injury: This would affect multiple extensor muscles in the forearm but would not selectively spare other functions while causing isolated thumb dysfunction.
- C. Abductor pollicis brevis tendon tear: This muscle is innervated by the median nerve and is involved in thumb abduction, not extension. It does not explain the inability to extend the interphalangeal joint.
- D. Extensor pollicis longus tendon tear: This is the most likely cause. The EPL tendon is responsible for extending the interphalangeal joint of the thumb and is commonly injured in distal forearm trauma.
- E. Extensor pollicis brevis tendon tear: The EPB tendon assists in thumb extension but primarily acts on the metacarpophalangeal joint, not the interphalangeal joint.
D. Extensor pollicis longus tendon tear
Following a supraclavicular LN dissection, a 43-year-old male patient is unable to shrug his left shoulder. Which of the following deformities would be expected?
A. Loss of neck flexion
B. Inability to rotate the face towards the right side
C. Inability to rotate the face towards the left side
D. Loss of sensation over upper lateral shoulder
E. Inability to shrug the other shoulder
The clinical scenario involves a 43-year-old male who is unable to shrug his left shoulder following a supraclavicular lymph node (LN) dissection. This suggests injury to the accessory nerve (cranial nerve XI), which innervates the trapezius muscle. The trapezius muscle is primarily responsible for elevating the shoulder (shrugging) and stabilizing the scapula.
- A. Loss of neck flexion: Neck flexion is primarily controlled by the sternocleidomastoid muscle (also innervated by the accessory nerve) and other cervical muscles. However, the inability to shrug the shoulder is more specific to trapezius dysfunction.
- B. Inability to rotate the face towards the right side: The sternocleidomastoid muscle (innervated by the accessory nerve) is responsible for rotating the face to the opposite side. If the left sternocleidomastoid is affected, the patient would have difficulty rotating the face to the right side.
- C. Inability to rotate the face towards the left side: This would occur if the right sternocleidomastoid muscle were affected, which is not the case here.
- D. Loss of sensation over upper lateral shoulder: This would suggest injury to the supraclavicular nerves (branches of the cervical plexus), not the accessory nerve.
- E. Inability to shrug the other shoulder: The accessory nerve innervates the trapezius muscle on the same side. Injury to the left accessory nerve would not affect the right shoulder.
B. Inability to rotate the face towards the right side
This is because the left sternocleidomastoid muscle, innervated by the left accessory nerve, is responsible for rotating the face to the right side. Injury to the left accessory nerve during supraclavicular LN dissection would impair this function.
A 23-year-old male with a four-day history of abdominal pain has an ultrasound showing a complicated appendicular mass with purulent content.
Which of the following organisms would likely be found under microscopy?
A. Streptococcus pyogenes
B. Bacteroides
C. Clostridium difficile
D. Staphylococcus aureus
E. Salmonella
The clinical scenario describes a complicated appendicular mass with purulent content, which is highly suggestive of acute appendicitis with abscess formation. The most likely organisms involved in such infections are polymicrobial, typically including Gram-negative enteric bacteria and anaerobes.
- A. Streptococcus pyogenes: This is a Gram-positive bacterium that causes pharyngitis, skin infections, and other conditions but is not typically associated with appendicitis or intra-abdominal abscesses.
- B. Bacteroides: This is a genus of anaerobic Gram-negative bacteria that is commonly found in the gastrointestinal tract and is a frequent contributor to intra-abdominal infections, including appendicitis and abscesses.
- C. Clostridium difficile: This is an anaerobic Gram-positive bacterium that causes antibiotic-associated diarrhea and colitis, not appendicitis or abscesses.
- D. Staphylococcus aureus: This is a Gram-positive bacterium that causes skin and soft tissue infections, but it is not typically associated with appendicitis or intra-abdominal infections.
- E. Salmonella: This is a Gram-negative bacterium that causes gastroenteritis and enteric fever but is not a common cause of appendicitis or abscess formation.
B. Bacteroides
Bacteroides species, along with other anaerobes (e.g., Prevotella, Fusobacterium) and facultative Gram-negative rods (e.g., Escherichia coli), are the most likely organisms found in a complicated appendicular mass with purulent content. These organisms are part of the normal gut flora and are commonly implicated in intra-abdominal infections.
A 43-year-old man was diagnosed with bacterial infective endocarditis.
Culture revealed sensitivity to amoxicillin, but the patient has an active penicillin allergy. Which antibiotic would be appropriate?
Amoxycillin
Linezolid
Cefuroxime
Gentamicin
Cephalosporin
In a patient with bacterial infective endocarditis and a penicillin allergy, the choice of antibiotic must avoid cross-reactivity with penicillin while effectively treating the infection. The culture revealed sensitivity to amoxicillin, which is a penicillin-class antibiotic, so alternatives must be carefully selected.
- Amoxicillin: This is a penicillin-class antibiotic and is contraindicated in patients with a penicillin allergy due to the risk of hypersensitivity reactions.
- Linezolid: This is an oxazolidinone antibiotic effective against Gram-positive bacteria, including streptococci and staphylococci. It is not related to penicillin and is a reasonable alternative in penicillin-allergic patients.
- Cefuroxime: This is a second-generation cephalosporin. While cephalosporins are generally safe in patients with a non-severe penicillin allergy, there is a 5-10% cross-reactivity risk with penicillin. Therefore, it should be avoided in patients with a documented penicillin allergy unless the allergy is mild (e.g., rash only).
- Gentamicin: This is an aminoglycoside antibiotic often used in combination with other antibiotics for synergistic effects in endocarditis. However, it is not typically used as monotherapy for endocarditis.
- Cephalosporin: This is a broad class of antibiotics, and like cefuroxime, there is a risk of cross-reactivity with penicillin. It should be avoided in patients with a penicillin allergy unless the allergy is mild.
Linezolid
Linezolid is a safe and effective alternative for treating Gram-positive bacterial infections, including infective endocarditis, in patients with a penicillin allergy. It does not cross-react with penicillin and is effective against many of the organisms responsible for endocarditis (e.g., streptococci and staphylococci).
- If the patient has a severe penicillin allergy (e.g., anaphylaxis), vancomycin is another alternative that is commonly used for endocarditis caused by Gram-positive organisms.
- Always consider consulting an infectious disease specialist for complex cases like infective endocarditis.
patient is suspected of having a pharyngeal pouch, what is the most appropriate investigation?
Upper GI endoscopy with flexible endoscope
Upper GI endoscopy with rigid endoscope
Upper GI fluoroscopic swallowing study
Oesophageal manometry
CT scan of the neck
A pharyngeal pouch (also known as Zenker’s diverticulum) is an outpouching of the mucosa through the Killian’s dehiscence, a weak area in the posterior pharyngeal wall. It typically presents with symptoms such as dysphagia, regurgitation of undigested food, and sometimes a palpable neck mass. The most appropriate investigation for diagnosing a pharyngeal pouch is one that allows visualization of the pouch and its relationship to the surrounding structures.
- Upper GI endoscopy with flexible endoscope: This is not ideal for diagnosing a pharyngeal pouch because the flexible endoscope may miss the pouch or even inadvertently enter it, increasing the risk of perforation.
- Upper GI endoscopy with rigid endoscope: Rigid endoscopy can be used to visualize the pharyngeal pouch, but it carries a higher risk of complications, such as perforation, and is not the first-line investigation.
- Upper GI fluoroscopic swallowing study (barium swallow): This is the most appropriate investigation for diagnosing a pharyngeal pouch. It allows dynamic visualization of the swallowing process and can clearly show the pouch, its size, and its relationship to the esophagus.
- Oesophageal manometry: This measures pressure within the esophagus and is used to evaluate motility disorders, not structural abnormalities like a pharyngeal pouch.
- CT scan of the neck: While a CT scan can provide detailed anatomical information, it is not the first-line investigation for a pharyngeal pouch. It may be used in complex cases or to assess complications.
Upper GI fluoroscopic swallowing study (barium swallow)
This is the gold standard for diagnosing a pharyngeal pouch. It is non-invasive, provides dynamic imaging, and clearly demonstrates the pouch and its relationship to the esophagus.
A 24 year old lady from Western India presents with symptoms of lethargy and dizziness, worse on turning her head. On examination, her blood pressure is 176/128. Her pulses are impalpable at all peripheral sites. Auscultation of her chest reveals a systolic heart murmur. What is the most likely diagnosis?
Subclavian steal syndrome
Aortic coarctation
Patent ductus arteriosus
Aortic dissection
Takayasu’s arteritis
The clinical scenario describes a 24-year-old woman from Western India with hypertension (176/128 mmHg), absent peripheral pulses, a systolic heart murmur, and symptoms of lethargy and dizziness worsened by head movement. These findings are highly suggestive of Takayasu’s arteritis, a chronic inflammatory disease affecting the large arteries, particularly the aorta and its branches.
- Subclavian steal syndrome: This occurs when there is stenosis or occlusion of the subclavian artery proximal to the vertebral artery, leading to reversed flow in the vertebral artery. It can cause dizziness, but it does not typically present with hypertension, absent peripheral pulses, or a systolic murmur.
- Aortic coarctation: This is a congenital narrowing of the aorta, usually distal to the left subclavian artery. It causes hypertension in the upper extremities and weak or absent pulses in the lower extremities. However, it does not typically present with systemic symptoms like lethargy or dizziness.
- Patent ductus arteriosus: This is a congenital condition where the ductus arteriosus fails to close after birth, leading to a left-to-right shunt. It causes a continuous murmur, not a systolic murmur, and does not present with hypertension or absent pulses.
- Aortic dissection: This is a life-threatening condition where there is a tear in the aortic wall. It typically presents with severe, tearing chest pain and asymmetric blood pressures, not the chronic symptoms described here.
- Takayasu’s arteritis: This is a large-vessel vasculitis that primarily affects young women, particularly those of Asian descent. It causes inflammation and stenosis of the aorta and its branches, leading to hypertension, absent peripheral pulses, bruits, and systemic symptoms like lethargy and dizziness. The systolic murmur is due to turbulent flow through stenotic vessels.
Takayasu’s arteritis
This is the most likely diagnosis given the patient’s demographic (young woman from Western India), symptoms (lethargy, dizziness), and clinical findings (hypertension, absent peripheral pulses, systolic murmur). Takayasu’s arteritis is a chronic condition that requires prompt diagnosis and treatment to prevent complications such as stroke, heart failure, or organ damage.
A 73 year old lady presents with severe abdominal pain and a laparotomy is performed. At operation there is widespread necrosis of the small bowel and right colon. What is the most likely explanation for this finding?
Mesenteric vein thrombosis
Acute embolism affecting the superior mesenteric artery
Acute on chronic thrombus of the superior mesenteric artery
Sub intimal dissection of the superior mesenteric artery
Proximal migration of abdominal aortic aneurysm
The clinical scenario describes a 73-year-old woman with severe abdominal pain and findings of widespread necrosis of the small bowel and right colon during laparotomy. This pattern of bowel necrosis is most consistent with acute mesenteric ischemia, which is typically caused by a sudden interruption of blood supply to the intestines. The most likely explanation for this finding is acute embolism affecting the superior mesenteric artery (SMA).
- Mesenteric vein thrombosis: This causes venous congestion and ischemia but typically progresses more slowly than arterial occlusion. It is less likely to cause sudden, widespread necrosis of the small bowel and right colon.
- Acute embolism affecting the superior mesenteric artery: This is the most likely explanation. An embolus (often from a cardiac source, such as atrial fibrillation) can acutely occlude the SMA, leading to sudden and severe ischemia of the small bowel and right colon, which are supplied by this artery.
- Acute on chronic thrombus of the superior mesenteric artery: This refers to a sudden thrombus forming on top of a pre-existing chronic stenosis. While it can cause acute ischemia, it is less common than an embolic event and typically occurs in patients with a history of chronic mesenteric ischemia (e.g., postprandial pain, weight loss).
- Subintimal dissection of the superior mesenteric artery: This is a rare cause of mesenteric ischemia and is more likely to occur in patients with underlying vascular pathology (e.g., fibromuscular dysplasia). It is not the most likely explanation in this case.
- Proximal migration of abdominal aortic aneurysm: This is not a recognized cause of acute mesenteric ischemia. An abdominal aortic aneurysm (AAA) can cause complications such as rupture or distal embolization, but it would not explain the widespread bowel necrosis described here.
Acute embolism affecting the superior mesenteric artery
Acute embolism to the SMA is the most common cause of acute mesenteric ischemia and fits the clinical scenario of sudden, severe abdominal pain and widespread bowel necrosis. The SMA supplies the small bowel and right colon, making it the most likely vessel involved in this case.
A 66 year old lady presents with pain in her right hip. It has been increasing over the previous three weeks and waking her from sleep. On examination, she is tender on internal rotation. Blood tests reveal a markedly elevated serum calcium and alkaline phosphatase levels. What is the likely cause?
Metastatic breast cancer
Chondrosarcoma
Osteoporosis
Pagets disease
Rickets
The clinical scenario describes a 66-year-old woman with hip pain, tenderness on internal rotation, and markedly elevated serum calcium and alkaline phosphatase levels. These findings are highly suggestive of a bone pathology with increased bone turnover. The most likely cause in this context is metastatic breast cancer.
- Metastatic breast cancer: This is the most likely cause. Breast cancer commonly metastasizes to bone, leading to osteolytic lesions that cause pain, elevated calcium levels (due to bone resorption), and elevated alkaline phosphatase (due to increased bone turnover). The hip is a common site for metastatic disease.
- Chondrosarcoma: This is a primary bone tumor that typically presents with pain and swelling. However, it does not usually cause systemic biochemical changes like elevated calcium and alkaline phosphatase levels.
- Osteoporosis: This condition causes reduced bone density and an increased risk of fractures but does not typically cause elevated calcium or alkaline phosphatase levels. It also does not cause localized pain or tenderness unless a fracture has occurred.
- Paget’s disease: This is a chronic bone disorder characterized by increased bone remodeling, which can lead to elevated alkaline phosphatase levels. However, it rarely causes hypercalcemia unless the patient is immobilized. It also typically affects multiple bones and is less likely to present with isolated hip pain.
- Rickets: This is a childhood condition caused by vitamin D deficiency, leading to defective bone mineralization. It is not relevant in a 66-year-old woman.
Metastatic breast cancer
This is the most likely diagnosis given the patient’s age, gender, clinical presentation (hip pain, tenderness on internal rotation), and biochemical findings (elevated calcium and alkaline phosphatase levels). Breast cancer is a common malignancy in women and frequently metastasizes to bone, causing osteolytic lesions and systemic biochemical changes. Further imaging (e.g., X-ray, MRI, or bone scan) and biopsy would be needed to confirm the diagnosis.
A 23 year old man fractures his right tibia in a sporting accident. At which point in the healing process is fracture callus first visible radiologically?
1 day
7 days
8 weeks
6 weeks
3 weeks
Fracture healing is a complex process that involves several stages, including inflammation, soft callus formation, hard callus formation, and remodeling. The fracture callus is the new bone tissue that forms at the fracture site, bridging the gap between the broken bone ends. It becomes visible on radiographs during the soft callus formation stage.
- 1 day: At this early stage, the fracture site is in the inflammatory phase, and no callus is visible on radiographs.
- 7 days: By this time, the soft callus begins to form, but it is not yet visible on radiographs.
- 3 weeks: This is the most likely time when the fracture callus first becomes visible radiologically. The soft callus (composed of cartilage and fibrous tissue) starts to mineralize, forming a visible bridge on X-rays.
- 6 weeks: By this stage, the hard callus is well-formed and clearly visible on radiographs.
- 8 weeks: The callus is fully mature, and the bone is in the remodeling phase, where the callus is gradually replaced by mature bone.
3 weeks
The fracture callus typically becomes visible on radiographs around 2-3 weeks after the injury, during the transition from soft callus to hard callus formation. This corresponds to the mineralization of the soft callus, making it detectable on X-rays.
A 40 year old man presents with obstructive jaundice and dysphagia. Twenty years previously he underwent a right hemicolectomy for a mucinous right sided colonic carcinoma. He was subsequently diagnosed as having Lynch syndrome. A recent colonoscopy was normal. What is the most likely cause of his jaundice?
Hepatocellular carcinoma
Liver metastasis from colonic cancer
Pancreatic carcinoma
Duodenal carcinoma
Metastatic gastric carcinoma
The clinical scenario describes a 40-year-old man with a history of Lynch syndrome (hereditary non-polyposis colorectal cancer, HNPCC) and a previous mucinous right-sided colonic carcinoma treated with a right hemicolectomy. He now presents with obstructive jaundice and dysphagia. Given his history of Lynch syndrome, which predisposes him to various cancers, the most likely cause of his jaundice is duodenal carcinoma.
- Hepatocellular carcinoma (HCC): HCC typically presents with symptoms of liver dysfunction (e.g., jaundice, ascites) but is not associated with dysphagia. It is also less likely in a patient without chronic liver disease or cirrhosis.
- Liver metastasis from colonic cancer: While liver metastases are common in colorectal cancer, they typically cause jaundice by compressing the biliary tree. However, they do not explain the dysphagia, and the recent normal colonoscopy makes recurrent colonic cancer less likely.
- Pancreatic carcinoma: Pancreatic cancer can cause obstructive jaundice due to compression of the common bile duct. However, it does not typically cause dysphagia unless it involves the stomach or esophagus, which is less common.
- Duodenal carcinoma: This is the most likely cause. Lynch syndrome is associated with an increased risk of duodenal and small bowel cancers. A duodenal carcinoma can cause obstructive jaundice by compressing the ampulla of Vater and dysphagia by extending into the stomach or esophagus.
- Metastatic gastric carcinoma: Gastric cancer can cause dysphagia and, if it metastasizes to the liver, jaundice. However, the recent normal colonoscopy and the absence of gastric symptoms make this less likely.
Duodenal carcinoma
Lynch syndrome is associated with an increased risk of duodenal and small bowel cancers. A duodenal carcinoma can cause both obstructive jaundice (by compressing the biliary tree) and dysphagia (by invading or compressing adjacent structures). Further investigations, such as upper endoscopy and imaging, would be needed to confirm the diagnosis.
14 year old develops abdominal pain and anaemia and a colonoscopy and terminal ileal intubation are performed. The terminal ileum shows normal mucosa but quite a lot of fresh blood. An OGD is normal. Which of these pathological processes is likely to be present within the causative lesion?
Heterotopia
Metaplasia
Dysplasia
Anaplasia
Atrophy
The most likely pathological process present in the causative lesion is heterotopia.
Here’s why:
* Heterotopia: This refers to the presence of tissue in an abnormal location. In the context of the terminal ileum, gastric or pancreatic heterotopia can occur. This misplaced tissue can be a source of bleeding, even if the surrounding mucosa looks normal on colonoscopy. The presence of fresh blood without an obvious mucosal lesion points towards a submucosal or less visible source, which heterotopic tissue could explain.
Why the other options are less likely:
* Metaplasia: This is a reversible change from one mature cell type to another. It’s often a response to chronic irritation. While it can occur in the GI tract, it’s less likely to cause significant fresh bleeding in the terminal ileum without other more noticeable endoscopic findings.
* Dysplasia: This refers to disordered cell growth and is a precursor to cancer. While it can bleed, it usually presents with more visible mucosal abnormalities (e.g., polyps, ulcerations) rather than just fresh blood in a seemingly normal-looking terminal ileum.
* Anaplasia: This is a characteristic of malignant cells, representing a loss of differentiation. Like dysplasia, it would typically be associated with more obvious endoscopic changes.
* Atrophy: This is a decrease in cell size. While it can sometimes lead to subtle changes in the mucosa, it’s not a common cause of fresh bleeding.
Therefore, the most likely explanation for fresh blood in the terminal ileum with normal mucosa and a normal OGD in a 14-year-old is heterotopic tissue.
thyroidectomy specimen from a 45 year old man shows a mass with prominent oxyphil cells and scanty thyroid colloid. What is the underlying cause?
Papillary carcinoma
Lymphoma
Follicular carcinoma
Thyroiditis
Graves’ disease
This is for informational purposes only. For medical advice or diagnosis, consult a professional.
The underlying cause is Follicular carcinoma.
Here’s why:
* Oxyphil cells: These are also known as Hürthle cells, which are thyroid follicular cells with abundant granular, eosinophilic cytoplasm due to a high number of mitochondria.
* Scanty thyroid colloid: Colloid is a substance stored in the thyroid follicles that contains thyroglobulin, the precursor to thyroid hormones. A decrease in colloid suggests less hormone production or storage.
These features are commonly associated with follicular carcinoma, a type of thyroid cancer that often exhibits these characteristics.
Let’s look at why the other options are less likely:
* Papillary carcinoma: This is the most common type of thyroid cancer, but it typically presents with distinct features like papillary structures and psammoma bodies, not prominent oxyphil cells.
* Lymphoma: This is a cancer of the lymphatic system and would likely involve other signs and symptoms related to the lymphatic system, such as enlarged lymph nodes.
* Thyroiditis: This is inflammation of the thyroid gland and can have various causes. While oxyphil cells might be present in some types of thyroiditis, it wouldn’t be the dominant feature.
* Graves’ disease: This is an autoimmune disorder that causes hyperthyroidism. While it can lead to changes in the thyroid gland, it wouldn’t primarily present with a mass of oxyphil cells and scanty colloid.
Important Note: This is a simplified explanation based on the information provided. A definitive diagnosis would require a thorough pathological examination of the thyroid specimen.
24 year old lady presents with a history of severe epigastric pain that is worse post prandially. On examination, the abdomen is soft and non tender with no palpable masses, there is a bruit in the epigastrium. Imaging with USS shows no gallstones and an OGD is normal. What is the most likely diagnosis?
Sphincter of oddi dysfunction
Irritable bowel syndrome
Median arcuate ligament syndrome
Mesenteric vein thrombosis
GORD
This is for informational purposes only. For medical advice or diagnosis, consult a professional.
The most likely diagnosis is Median arcuate ligament syndrome (MALS). Here’s why:
* Severe epigastric pain worse postprandially: This is a hallmark symptom of MALS. The pain occurs after eating because the stomach and intestines require more blood flow for digestion. In MALS, the median arcuate ligament compresses the celiac artery (which supplies blood to these organs) during exhalation, restricting blood flow and causing pain.
* Soft, non-tender abdomen with no palpable masses: This suggests that the pain is not due to an acute abdominal issue like appendicitis or bowel obstruction.
* Bruit in the epigastrium: A bruit is an abnormal sound heard over an artery, often indicating turbulent blood flow due to a narrowing or blockage. In MALS, the bruit is caused by the compression of the celiac artery.
* Normal USS and OGD: These tests rule out gallstones and upper gastrointestinal issues, respectively, further supporting the diagnosis of MALS.
Why other options are less likely:
* Sphincter of Oddi dysfunction: This condition involves problems with the valve controlling the flow of bile and pancreatic juices into the duodenum. It can cause abdominal pain, but it’s less likely to be associated with a bruit.
* Irritable bowel syndrome (IBS): IBS is a functional gastrointestinal disorder that causes abdominal pain and changes in bowel habits. However, it typically doesn’t present with severe postprandial pain or a bruit.
* Mesenteric vein thrombosis: This is a blood clot in the mesenteric vein, which supplies blood to the intestines. It can cause severe abdominal pain, but it’s usually associated with other symptoms like fever, nausea, vomiting, and bloody stools.
* GORD (Gastro-oesophageal reflux disease): GORD is a condition where stomach acid flows back into the esophagus, causing heartburn and other symptoms. While it can cause epigastric pain, it’s not typically associated with a bruit.
Important Note: This is a simplified explanation based on the information provided. A definitive diagnosis of MALS often requires further investigations, such as a CT angiogram or mesenteric angiography, to visualize the celiac artery and confirm the compression.
A 38 year old sheep farmer presents to the clinic with a 3 month history of malaise and right upper quadrant pain. On examination, he is mildly jaundiced. His liver function tests demonstrate a mild elevation in bilirubin and transaminases, his full blood count shows an elevated eosinophil level. An abdominal x-ray is performed by the senior house officer and demonstrates a calcified lesion in the right upper quadrant of the abdomen. What is the most probably underlying diagnosis?
Mesenchymal hamartoma
Clonorchiasis
Fasciolopsiasis
Liver cell adenoma
Hydatid cyst
This is for informational purposes only. For medical advice or diagnosis, consult a professional.
The most likely diagnosis is Hydatid cyst. Here’s why:
* Sheep farmer: This occupation puts him at risk for exposure to Echinococcus granulosus, the tapeworm that causes hydatid cysts. Dogs are the definitive hosts, and sheep are common intermediate hosts.
* Malaise and right upper quadrant pain: These are common symptoms of hydatid cysts in the liver, which is the most common location for these cysts.
* Mild jaundice: This can occur if the cyst compresses or obstructs the bile ducts.
* Elevated eosinophil level: This is a characteristic finding in parasitic infections, including hydatid cysts.
* Calcified lesion in the right upper quadrant: Hydatid cysts often have calcified walls, which can be seen on abdominal x-rays.
Let’s look at why the other options are less likely:
* Mesenchymal hamartoma: This is a benign liver tumor that typically occurs in young children, not adults.
* Clonorchiasis and Fasciolopsiasis: These are parasitic infections that can cause liver and biliary disease, but they are less common in sheep farmers and don’t typically present with calcified lesions.
* Liver cell adenoma: This is a benign liver tumor that can occur in women taking oral contraceptives or anabolic steroids. It’s not typically associated with calcified lesions or eosinophilia.
Important Note: This is a simplified explanation based on the information provided. A definitive diagnosis of hydatid cyst often requires further investigations, such as an ultrasound or CT scan of the abdomen, and serological tests for Echinococcus antibodies.
A 70 year old lady who has never smoked is identified as having a peripherally sited mass in her left lung. What is the most likely underlying diagnosis?
Small cell lung cancer
Gastric cancer metastasis
Adenocarcinoma
Squamous cell carcinoma
Lymphoma
This is for informational purposes only. For medical advice or diagnosis, consult a professional.
The most likely diagnosis is Adenocarcinoma. Here’s why:
* Never smoked: Adenocarcinoma is the most common type of lung cancer in non-smokers, accounting for the majority of cases.
* Peripherally sited mass: Adenocarcinomas often arise in the outer regions of the lung, making them more likely to present as peripheral masses.
Let’s look at why the other options are less likely:
* Small cell lung cancer: This type of lung cancer is strongly associated with smoking and typically presents as a centrally located mass.
* Gastric cancer metastasis: While gastric cancer can metastasize to the lungs, it’s less likely to present as a solitary peripheral mass. Metastatic lung lesions are often multiple and located in the lower lobes.
* Squamous cell carcinoma: This type of lung cancer is also more strongly associated with smoking and tends to arise in the central airways of the lung.
* Lymphoma: While lymphoma can affect the lungs, it usually presents with more diffuse infiltrates or multiple nodules rather than a solitary peripheral mass.
Important Note: This is a simplified explanation based on the information provided. A definitive diagnosis of lung cancer requires a biopsy or surgical resection of the mass for pathological examination.
Which of the tumour types listed below is found most frequently in a person with aggressive fibromatosis?
Medullary thyroid cancer
Basal cell carcinoma of the skin
Desmoid tumours
Dermoid tumours
Malignant melanoma
This is for informational purposes only. For medical advice or diagnosis, consult a professional.
The tumor type found most frequently in a person with aggressive fibromatosis is Desmoid tumors.
Here’s why:
* Desmoid tumors are actually another name for aggressive fibromatosis. They are benign but locally aggressive tumors that arise from connective tissue.
Let’s look at why the other options are less likely:
* Medullary thyroid cancer: This is a type of thyroid cancer that arises from C cells, which produce calcitonin. It’s not associated with aggressive fibromatosis.
* Basal cell carcinoma of the skin: This is the most common type of skin cancer and is typically caused by sun exposure. It’s not related to aggressive fibromatosis.
* Dermoid tumors: These are benign tumors that typically occur in the ovaries or testicles. They are not associated with aggressive fibromatosis.
* Malignant melanoma: This is a type of skin cancer that arises from melanocytes, the cells that produce melanin. It’s not related to aggressive fibromatosis.
Important Note: This is a simplified explanation based on the information provided. A definitive diagnosis of aggressive fibromatosis requires a biopsy or surgical resection of the tumor for pathological examination.
53 year old man is due to undergo a splenectomy as a treatment for refractory haemolytic anaemia. The underlying pathological basis for haemolytic anaemia is thought to be a Type 2 hypersensitivity response. Which of the following mechanisms best describes this process
Deposition of immune complexes
Cell mediated immune response
IgE mediated response
Formation of autoantibodies against cell surface antigens
None of the above
The correct answer is Formation of autoantibodies against cell surface antigens.
Here’s why:
* Type II hypersensitivity reactions are characterized by the formation of antibodies (usually IgG or IgM) that bind to antigens on the surface of cells. In the case of autoimmune hemolytic anemia, these antibodies are directed against the individual’s own red blood cell antigens (hence, “autoantibodies”). This antibody binding leads to:
* Complement activation: The complement system is triggered, leading to the destruction of the red blood cells (hemolysis).
* Antibody-dependent cell-mediated cytotoxicity (ADCC): Immune cells (like macrophages and natural killer cells) with receptors for the antibody bind to the antibody-coated red blood cells and kill them.
Let’s look at why the other options are less likely:
* Deposition of immune complexes (Type III hypersensitivity): This involves the formation of antigen-antibody complexes that circulate in the blood and deposit in tissues, causing inflammation. While immune complexes can sometimes be involved in hemolytic anemia, the primary mechanism in autoimmune hemolytic anemia is autoantibody formation.
* Cell-mediated immune response (Type IV hypersensitivity): This involves T cells directly attacking target cells. While T cells can play a role in some hemolytic anemias, the classic mechanism of autoimmune hemolytic anemia is antibody-mediated (Type II).
* IgE-mediated response (Type I hypersensitivity): This involves IgE antibodies binding to mast cells, which then release histamine and other inflammatory mediators upon encountering the antigen. This is typically associated with allergic reactions, not autoimmune hemolytic anemia.
59 year old lady is referred from the NHS breast screening program. A recent mammogram is reported as showing linear, branching microcalcification with coarse granules. Which disease process is the most likely underlying cause of these appearances?
Invasive lobular cancer
Lobular carcinoma in situ
Cribriform type ductal carcinoma in situ
Comedo type ductal carcinoma in situ
Fibroadenosis
The most likely underlying cause of linear, branching microcalcifications with coarse granules on a mammogram is Cribriform type ductal carcinoma in situ (DCIS).
Here’s why:
* Cribriform DCIS: This type of DCIS often presents with linear or branching microcalcifications, which correspond to the calcifications within the abnormal ducts. The “coarse granules” description further supports this, as it reflects the irregular calcifications within the cribriform (sieve-like) pattern of the cancerous cells.
Let’s look at why the other options are less likely:
* Invasive lobular carcinoma (ILC): ILC often presents with more subtle mammographic findings, sometimes with architectural distortion or a vague mass. Microcalcifications are not as typical a feature as with DCIS.
* Lobular carcinoma in situ (LCIS): LCIS is usually an incidental finding and often does not produce mammographic abnormalities like microcalcifications. It’s more often detected through biopsy of an area suspicious for other reasons.
* Comedo type ductal carcinoma in situ (DCIS): Comedo DCIS is also associated with microcalcifications, but they tend to be more clustered and linear, often described as “casting” or “rod-like,” reflecting the necrotic debris within the ducts. It’s less likely to be described as having “coarse granules.”
* Fibroadenosis: This is a common benign breast condition. While it can sometimes cause microcalcifications, they are usually more scattered and less likely to have the linear, branching pattern with coarse granules seen in cribriform DCIS.
Important Note: While cribriform DCIS is the most likely diagnosis given the mammographic description, a definitive diagnosis requires a biopsy and histological examination of the breast tissue. Mammographic features can be suggestive, but they are not always specific.
43 years old diagnosed hyperparathyroidism, PTH elevated, surgically removed parathyroid gland, how long it takes for serum PTH level to fall if functioning edenoma has been successfully removed?
A.24 hrs
B. 2 hrs
C.10 mints
D.6 hrs
E.1 hr
The serum parathyroid hormone (PTH) level falls rapidly after successful removal of a functioning parathyroid adenoma. Typically, the PTH level drops significantly within 10 minutes postoperatively, as the hyperfunctioning gland is no longer secreting excess hormone oai_citation:0‡Endocrine-Pastest.pdf.
Thus, the correct answer is:
C. 10 minutes.
Dry cornea and affection of lacrimation which nucleusis affected in the brain
A. Superior salivatory nucleus
B. Inferior salivatory nucleus
C. Edenger wistiphal nucleus
D. ambigous nucleus
E. Dorsal vagal nucleus
The superior salivatory nucleus is responsible for parasympathetic innervation to the lacrimal gland, submandibular gland, and sublingual gland via the facial nerve (CN VII). Damage to this nucleus can lead to impaired lacrimation, resulting in dry cornea.
Thus, the correct answer is:
A. Superior salivatory nucleus.
A 20-year-old rugby player falls to the ground with severe pain in his right knee after being hit by a hockey stick. When seen a week later at the orthopedic clinic, he is found to have an effusion in his right knee, with persistent tenderness 2.5 cm above the joint line on the medial side. What is the possible cause?
A. Anterior cruciate ligament injury
B. Lateral collateral ligament injury
C. Unhappy triad injury
D. Medial collateral ligament injury
E. Posterior horn medial meniscus injury
The most likely cause of the persistent tenderness 2.5 cm above the joint line on the medial side is an injury to the medial collateral ligament (MCL). The MCL is located on the medial side of the knee, and injury typically occurs due to a direct blow to the lateral side of the knee, causing valgus stress. The presence of an effusion and localized tenderness suggests ligamentous damage rather than an isolated meniscal tear.
Correct answer:
D. Medial collateral ligament injury.
- A 13-year-old boy presented with a focal swelling at the distal end of his left thigh. Investigations revealed an osteoid-forming tumor in the lower distal femur. What is the most likely diagnosis?
A. Osteosarcoma
B. Ewing sarcoma
C. Chondrosarcoma
D. Osteoblastoma
E. Benign bone cyst
The most likely diagnosis is osteosarcoma.
Explanation:
• Osteosarcoma is the most common primary malignant bone tumor in children and adolescents, typically affecting the metaphysis of long bones (e.g., distal femur, proximal tibia).
• It is characterized by osteoid formation (bone matrix production).
• Common symptoms: Localized bone pain, swelling, and sometimes pathological fractures.
• Radiological features: Sunburst appearance and Codman’s triangle on X-ray.
Other options:
• Ewing sarcoma: Usually affects the diaphysis of long bones and presents with a more systemic illness (fever, leukocytosis).
• Chondrosarcoma: More common in older adults and arises from cartilaginous tissue.
• Osteoblastoma: A benign tumor that typically occurs in the spine or long bones but is less aggressive.
• Benign bone cyst: Fluid-filled lesion, often in younger children, without aggressive features like osteoid formation.
Correct answer:
A. Osteosarcoma.
22 year man suffer blunt head injury, he is drowsy and gcs of 7 on admission, which is major determinant of cerebral blood flow in this situation?
A. systematic BP
B. Mean artrial pressure
C. acidosis
D. Hypoxemia
E. Intracranial pressure
The major determinant of cerebral blood flow (CBF) in this scenario is intracranial pressure (ICP).
Explanation:
• Cerebral blood flow (CBF) is primarily regulated by cerebral perfusion pressure (CPP), which is calculated as:
CPP = Mean Arterial Pressure (MAP) - Intracranial Pressure (ICP)
• In traumatic brain injury (TBI), increased ICP due to cerebral edema, hemorrhage, or mass effect can reduce CPP, leading to cerebral ischemia.
• If ICP increases to the level of MAP, CBF can cease, causing brain herniation and death.
• While factors like systemic BP, acidosis, and hypoxemia influence CBF, ICP is the key determinant in a patient with brain injury and raised intracranial pressure.
Correct answer:
E. Intracranial pressure.
- A 32-year-old athlete presented to the ED after a fall. Examination revealed a bruised knee. X-ray showed a multi-fragmented fracture of the patella. What is the most appropriate management?
A. Patellectomy
B. Wire binding
C. Open reduction and internal fixation
D. Open reduction and external fixation
E. Casting
The most appropriate management for a multi-fragmented (comminuted) patellar fracture is wire binding (B. Wire binding), commonly performed using tension band wiring (TBW).
Explanation:
• Patella fractures can be treated based on the degree of displacement and comminution.
• Tension band wiring (TBW) is the preferred technique for comminuted fractures that can still be reconstructed. It converts tensile forces into compressive forces, promoting healing.
• Patellectomy (A) is generally reserved for severely comminuted fractures where reconstruction is not possible.
• Open reduction and internal fixation (C) is used for displaced transverse fractures but is often supplemented with TBW.
• Open reduction and external fixation (D) is not typically used for patellar fractures.
• Casting (E) is only suitable for non-displaced fractures.
Correct answer:
B. Wire binding (Tension Band Wiring).
What is the structure behind the 2nd and 3rd part of duodenum
A. Ureter
B. Gonadal vessels
C. Kidney
D. IVC
E. Aorta
The structure located behind the 2nd and 3rd parts of the duodenum is the Inferior Vena Cava (IVC) and Aorta.
Explanation:
• The 2nd part of the duodenum (descending part) runs adjacent to the IVC on its right side.
• The 3rd part of the duodenum (horizontal part) crosses anterior to the aorta and IVC.
• Other related structures:
• Kidney (C) is located posteriorly but laterally, rather than directly behind.
• Ureter (A) and Gonadal vessels (B) are also posterior but do not primarily lie behind the duodenum.
Correct answer:
D. IVC (also, the Aorta is located slightly to the left).
Paget’s disease of the nipple ismost likely associated with which of the following?
A. Invasive lobular carcinoma
B. Invasive ductal carcinoma
C. DCIS
D. LCIS
E. Inflammatory breast carcinoma
Paget’s disease of the nipple is most strongly associated with ductal carcinoma in situ (DCIS).
Explanation:
• Paget’s disease of the nipple presents with eczema-like changes (redness, scaling, and ulceration) of the nipple and is often associated with underlying breast malignancy.
• DCIS (Ductal Carcinoma In Situ) is the most common underlying malignancy, found in 85–95% of cases.
• Mechanism: Malignant ductal cells migrate from the underlying DCIS into the epidermis of the nipple.
Other options:
• Invasive ductal carcinoma (B): Can be present in some cases, but DCIS is more strongly associated.
• Invasive lobular carcinoma (A) & LCIS (D): These typically do not involve the nipple.
• Inflammatory breast carcinoma (E): Causes skin thickening and peau d’orange but is not directly linked to Paget’s disease.
Correct answer:
C. DCIS (Ductal Carcinoma In Situ).
An 83 year old lady is admitted with a fractured neck of femur and is managed with surgical fixation. On the day following surgery, she is noted to have a dense hemiparesis. Several days later, an MRI scan of the brain is performed which demonstrates a 3cm area of devitalised tissue within the right frontal lobe. Which of the pathological processes described below is most likely to account for these appearances?
Coagulative necrosis
Colliquative necrosis
Caseous necrosis
Fibrinoid necrosis
Apoptosis
The most likely pathological process in this scenario is colliquative necrosis (liquefactive necrosis).
Explanation:
• The patient, an elderly woman with a fractured neck of femur, has developed dense hemiparesis postoperatively, suggesting a stroke.
• MRI shows a 3 cm area of devitalized tissue in the right frontal lobe, which is characteristic of an ischemic stroke leading to brain infarction.
• In the brain, ischemic injury results in liquefactive necrosis (colliquative necrosis) rather than coagulative necrosis, due to the high lipid content and action of hydrolytic enzymes breaking down the tissue into a cystic cavity.
Other options:
• Coagulative necrosis: Typical of ischemia in solid organs like the heart and kidneys, but not the brain.
• Caseous necrosis: Seen in tuberculosis, not stroke.
• Fibrinoid necrosis: Found in vasculitis or severe hypertension, not brain infarction.
• Apoptosis: A regulated process of programmed cell death, not the main mechanism in ischemic stroke.
Correct answer:
B. Colliquative necrosis (Liquefactive necrosis).
Which of the following is not found on a blood film post splenectomy?
Pappenheimer bodies
Stipple cells
Erythrocyte containing siderotic granules
Howell-Jolly bodies
Target cells
The correct answer is:
B. Stipple cells
Explanation:
After splenectomy, the spleen’s filtering function is lost, leading to the presence of abnormal red blood cell inclusions in the peripheral blood. The following are typically seen on a blood film post-splenectomy:
1. Howell-Jolly bodies – Small nuclear remnants normally removed by the spleen.
2. Pappenheimer bodies – Iron-containing granules in RBCs.
3. Erythrocytes containing siderotic granules – RBCs with iron deposits, similar to Pappenheimer bodies.
4. Target cells – RBCs with a bullseye appearance due to altered membrane structure.
However, stipple cells (basophilic stippling) are associated with lead poisoning, thalassemia, and megaloblastic anemia, not specifically with splenectomy.
Correct answer:
B. Stipple cells
66 year old man is referred via the aneurysm screening programme with an abdominal aortic aneurysm measuring 4.5 cm. Apart from well controlled type 2 DM he has no other co-morbidities. What is the best course of action?
AAA repair during next 48 hours
USS in 3 months
CT aortic angiogram
MRI aortic angiogram
Discharge from the programme
The best course of action is USS in 3 months
Here’s why:
* AAA repair during next 48 hours: This is too aggressive for a 4.5cm AAA. Surgery is generally recommended for aneurysms larger than 5.5cm or those that are rapidly growing or causing symptoms.
* CT aortic angiogram: While CTAs are useful for detailed imaging, they are not the first-line investigation for a 4.5cm AAA. Ultrasound is sufficient for initial assessment and surveillance.
* MRI aortic angiogram: MRI is not typically used for AAA surveillance due to cost and availability.
* Discharge from the programme: This is not appropriate as the patient has an AAA that requires ongoing monitoring.
Surveillance:
* Ultrasound is the preferred method for monitoring AAA size.
* Repeat ultrasound in 3 months is recommended to assess for growth.
* If the aneurysm grows or becomes symptomatic, further investigation and intervention may be necessary.
Which of the following pathological explanations best describes the initial pathological processes occurring in an abdominal aortic aneurysm in an otherwise well 65 year old, hypertensive male?
Loss of elastic fibres from the adventitia
Loss of collagen from the adventitia
Loss of collagen from the media
Loss of elastic fibres from the media
Decreased matrix metalloproteinases in the adventitia
This is for informational purposes only. For medical advice or diagnosis, consult a professional.
The best answer is Loss of elastic fibres from the media.
Here’s why:
* Media: The tunica media is the middle layer of the arterial wall, composed primarily of elastic fibers and smooth muscle cells. These elastic fibers are crucial for the aorta’s ability to expand and recoil with each heartbeat, maintaining blood pressure and flow.
* Elastic fibers: These fibers provide the aorta with its elasticity and resilience. Their loss leads to weakening of the aortic wall and progressive dilation, which is the hallmark of an abdominal aortic aneurysm (AAA).
Other options:
* Adventitia: The adventitia is the outermost layer of the arterial wall, composed mainly of collagen and fibroblasts. While it provides structural support, it’s not the primary site of initial pathological changes in AAA.
* Collagen: Collagen provides tensile strength to the arterial wall. While collagen loss does occur in AAA, it’s a later stage process, not the initial event.
* Matrix metalloproteinases (MMPs): MMPs are enzymes that degrade the extracellular matrix, including elastin and collagen. Increased MMP activity contributes to AAA development, but it’s not the primary pathological explanation for the initial process.
A 78 year old lady presents to the surgical clinic with symptoms of both dysphagia and dyspnoea. On examination, there is a large mass in the neck that moves on swallowing. CT scanning of the neck shows a locally infiltrative lesion arising from the thyroid and invading the strap muscles. What is the most likely diagnosis?
Lymphoma
Follicular carcinoma
Multinodular goitre
Anaplastic carcinoma
Papillary carcinoma
The most likely diagnosis is Anaplastic carcinoma. Here’s why:
* Rapid Growth and Invasion: Anaplastic carcinoma is a highly aggressive and undifferentiated thyroid cancer known for its rapid growth and local invasion. The description of a “locally infiltrative lesion arising from the thyroid and invading the strap muscles” strongly suggests this characteristic.
* Symptoms: The presence of both dysphagia (difficulty swallowing) and dyspnea (difficulty breathing) indicates that the mass is compressing or invading nearby structures, such as the esophagus and trachea. This is consistent with the aggressive nature of anaplastic carcinoma.
* Age: While anaplastic carcinoma can occur at any age, it is more common in older individuals, such as this 78-year-old patient.
Why other options are less likely:
* Lymphoma: Thyroid lymphoma is less common than anaplastic carcinoma and often presents with more generalized lymphadenopathy.
* Follicular carcinoma: Follicular carcinoma is usually slow-growing and less likely to cause compressive symptoms like dysphagia and dyspnea unless it is a large, neglected tumor.
* Multinodular goitre: While multinodular goiters can grow large and cause compressive symptoms, they are typically benign and do not exhibit the rapid invasion described in this case.
* Papillary carcinoma: Papillary carcinoma is the most common type of thyroid cancer, but it is generally slow-growing and less likely to present with rapidly progressive compressive symptoms.
Important Note: A definitive diagnosis requires a biopsy and histopathological examination of the lesion.
Which of the following renal stone types is most radiodense on a plain x-ray?
Calcium phosphate
Calcium oxalate
Uric acid
Struvite
Cystine
This is for informational purposes only. For medical advice or diagnosis, consult a professional.
The most radiodense renal stone type on a plain x-ray is Calcium oxalate.
Here’s why:
* Calcium oxalate: These stones are composed of calcium oxalate crystals, which are highly dense and readily absorb x-rays. This makes them appear bright white on a plain x-ray.
* Calcium phosphate: While also containing calcium, calcium phosphate stones are generally less dense than calcium oxalate stones and may appear slightly less bright on x-ray.
* Uric acid: Uric acid stones are radiolucent, meaning they do not show up well on plain x-ray. They can sometimes be visualized on ultrasound or CT scan.
* Struvite: Struvite stones, composed of magnesium ammonium phosphate, have moderate radiodensity. They are often associated with urinary tract infections.
* Cystine: Cystine stones, formed from the amino acid cystine, have variable radiodensity. They may be faintly visible on plain x-ray.
Key takeaway: Calcium oxalate stones are the most common type of renal stone and are also the most radiodense, making them easily detectable on plain x-ray.
72 year old man presents with haematuria which is recurrent. On investigation, a retrograde pyelogram shows multiple ureteric filling defects and the renal pelvis is irregular. What is the most likely cause?
Squamous cell carcinoma of the renal pelvis
Transitional cell carcinoma
Adenocarcinoma of the kidney
Retroperitoneal sarcoma
Retroperitoneal fibrosis
The most likely cause is Transitional cell carcinoma (TCC), also known as urothelial carcinoma. Here’s why:
* Haematuria (recurrent): Painless haematuria is the most common presenting symptom of TCC.
* Multiple ureteric filling defects and irregular renal pelvis: These findings on a retrograde pyelogram are highly suggestive of TCC. TCC can occur anywhere in the urothelium, from the renal pelvis down to the bladder. The filling defects represent the tumor within the ureter or renal pelvis, and the irregularity suggests involvement of the lining of the renal pelvis.
Why other options are less likely:
* Squamous cell carcinoma of the renal pelvis: While squamous cell carcinoma can occur in the renal pelvis, it’s less common than TCC and is often associated with chronic irritation or infection. It wouldn’t typically present with multiple filling defects.
* Adenocarcinoma of the kidney (Renal cell carcinoma - RCC): RCC typically presents as a solitary mass within the kidney itself, not as multiple filling defects in the ureters and renal pelvis. While haematuria can be a symptom, the pyelogram findings are not typical for RCC.
* Retroperitoneal sarcoma: These are rare tumors that arise in the retroperitoneum (the area behind the abdominal cavity). They are unlikely to cause the specific pyelogram findings described. They usually present as a palpable mass.
* Retroperitoneal fibrosis: This is a rare condition characterized by the formation of fibrous tissue in the retroperitoneum. It can cause ureteric obstruction, but it typically presents with smooth narrowing or obstruction of the ureters, not multiple filling defects.
In summary: The combination of recurrent haematuria and the specific findings on the retrograde pyelogram strongly points to transitional cell carcinoma as the most likely diagnosis.
15 year old boy develops sudden onset of pain in the left hemiscrotum. He has no other urinary symptoms. On examination, the superior pole of the testis is tender and the cremasteric reflex is particularly marked. What is the most likely underlying diagnosis?
Epididymo-orchitis
Torsion of the testis
Torsion of a testicular hydatid
Viral orchitis
Testicular malignancy
The most likely diagnosis is Torsion of the testis.
Here’s why:
* Sudden onset of pain: Testicular torsion typically presents with sudden, severe pain in the scrotum.
* No other urinary symptoms: While urinary symptoms can sometimes accompany other scrotal conditions, their absence is more suggestive of torsion.
* Tender superior pole of the testis: This is a key finding in torsion. The tenderness is localized to the area where the spermatic cord is twisted.
* Marked cremasteric reflex: While the cremasteric reflex can be variable in torsion, a present or even exaggerated reflex doesn’t rule it out. The absence of the reflex is more concerning, but its presence doesn’t exclude torsion. The key here is the tenderness at the superior pole.
Why other options are less likely:
* Epididymo-orchitis: This usually presents with more gradual onset of pain, swelling, and redness of the scrotum. Urinary symptoms are often present. The tenderness would typically be more diffuse, not just at the superior pole.
* Torsion of a testicular hydatid: This can also cause sudden scrotal pain, but the tenderness is usually localized to the appendix testis (a small appendage on the testis), not the superior pole.
* Viral orchitis: This is more commonly associated with mumps and typically presents with bilateral testicular swelling and tenderness.
* Testicular malignancy: Testicular cancer is usually painless and presents as a firm, non-tender mass in the testis.
Key point: Testicular torsion is a surgical emergency. Prompt diagnosis and treatment are crucial to salvage the testicle. The history and exam findings are highly suggestive, and immediate surgical consultation is warranted.
22 year old man is involved in a road traffic accident. He is found to have a pelvic fracture. While on the ward the nursing staff report that he is complaining of lower abdominal pain. On examination, you find a distended tender bladder and blood at the urethral meatus. What is the best management?
10 Ch foley urethral catheter
Suprapubic catheter
16 Ch foley urethral catheter
18 Ch coude tip urethral catheter
Pain relief and review in 1 hour
The best management is a Suprapubic catheter.
Here’s why:
* Suspected Urethral Injury: The combination of a pelvic fracture, lower abdominal pain, a distended tender bladder, and blood at the urethral meatus strongly suggests a urethral injury. Attempting to pass a urethral catheter in this situation is contraindicated as it can worsen the injury and cause further damage.
* Suprapubic Catheter as the Safest Option: A suprapubic catheter is inserted directly into the bladder through a small incision in the abdomen, bypassing the urethra altogether. This is the safest way to drain the bladder in the presence of a suspected urethral injury.
Why other options are incorrect:
* 10 Ch, 16 Ch, or 18 Ch Foley Urethral Catheter: As mentioned above, passing a urethral catheter is contraindicated in suspected urethral injuries. The size of the catheter is irrelevant in this context.
* 18 Ch Coude Tip Urethral Catheter: A coude tip catheter is designed to navigate bends in the urethra, but it’s still a urethral catheter and therefore contraindicated.
* Pain relief and review in 1 hour: Delaying intervention in this scenario is dangerous. A distended bladder can cause significant discomfort and potentially lead to further complications. Immediate bladder drainage is necessary.
In summary: In a patient with a pelvic fracture, signs of a potential urethral injury, and a distended bladder, the priority is to avoid urethral catheterization and establish bladder drainage via a suprapubic catheter. This should be done in consultation with a urologist.
A 56 year old man presents with lethargy, haematuria and haemoptysis. On examination, he is hypertensive and has a right loin mass. A CT scan shows a lesion affecting the upper pole of the right kidney, it has a small cystic centre. Which of the options below is the most likely diagnosis?
Squamous cell carcinoma of the kidney
Nephroblastoma
Renal adenocarcinoma
Transitional cell carcinoma of the kidney
Polycystic kidney disease
The most likely diagnosis is Renal adenocarcinoma (Renal Cell Carcinoma - RCC).
Here’s why:
* Classic Triad: The combination of haematuria, flank pain (represented by the loin mass), and a palpable abdominal mass is the classic triad of symptoms for renal cell carcinoma. While not all patients present with all three, their presence together is highly suggestive.
* Other Symptoms: Lethargy and haemoptysis can also be associated with RCC. Lethargy can be due to paraneoplastic syndromes (hormone-like substances produced by the tumor), and haemoptysis can occur if the tumor metastasizes to the lungs.
* CT Scan Findings: A lesion in the upper pole of the kidney with a small cystic center is a common appearance of RCC on CT scan. While other kidney lesions can have cystic components, this description fits well with RCC.
* Age: RCC is most common in adults, typically between 50 and 70 years old, which aligns with the patient’s age.
Why other options are less likely:
* Squamous cell carcinoma of the kidney: This is a rarer type of kidney cancer and is often associated with chronic kidney stones or infections. It’s less likely to present with the classic triad and the described CT findings.
* Nephroblastoma (Wilms tumor): This is a childhood cancer, typically presenting in children under the age of 5. It’s highly unlikely in a 56-year-old man.
* Transitional cell carcinoma of the kidney: This cancer arises from the lining of the renal pelvis and ureters. While it can cause haematuria, it’s less likely to present with a loin mass and the specific CT findings described. It would more likely cause filling defects in the renal pelvis/ureter.
* Polycystic kidney disease (PKD): PKD is a genetic disorder characterized by multiple cysts throughout both kidneys. While it can cause haematuria and abdominal masses (due to enlarged kidneys), it typically presents with bilateral involvement and wouldn’t have a single dominant lesion with a cystic center like described. It also wouldn’t typically cause haemoptysis.
Therefore, the combination of clinical presentation and CT scan findings makes renal adenocarcinoma the most likely diagnosis in this case.
A 43 year old lady with episodes of recurrent urinary tract sepsis presents with a staghorn calculus of the left kidney. Her urinary pH is 7.8. A KUB x-ray shows a faint outline of the calculus. What is the most likely stone composition?
Struvite
Calcium phosphate
Calcium oxalate
Uric acid
Cystine
The most likely stone composition is Struvite. Here’s why:
* Staghorn Calculus: Staghorn calculi are large stones that fill the renal pelvis and calyces, taking on a branched, “staghorn” shape. They are most commonly composed of struvite.
* Recurrent Urinary Tract Sepsis: Struvite stones are often associated with urinary tract infections (UTIs) caused by urease-producing bacteria (such as Proteus species). These bacteria split urea into ammonia, which raises the urinary pH and promotes the precipitation of struvite crystals. The recurrent UTIs in this patient strongly suggest a role for these bacteria and, therefore, struvite stones.
* High Urinary pH (7.8): Struvite stones form in alkaline urine (pH > 7.0). A urinary pH of 7.8 is consistent with struvite stone formation.
* Faint Outline on KUB X-ray: Struvite stones have a relatively low density compared to calcium oxalate stones and may appear fainter on plain x-ray.
Why other options are less likely:
* Calcium phosphate: While calcium phosphate stones can also form in alkaline urine, they are less commonly associated with staghorn calculi and recurrent UTIs.
* Calcium oxalate: Calcium oxalate stones are the most common type of kidney stones overall, but they typically form in acidic or neutral urine and are not associated with urease-producing bacteria. They are also usually more radiopaque (denser) on x-ray.
* Uric acid: Uric acid stones form in acidic urine and are radiolucent (not visible) on plain x-ray.
* Cystine: Cystine stones are associated with a genetic disorder and are not typically associated with recurrent UTIs or a high urinary pH. They can be faintly visible on x-ray, but the clinical picture is more suggestive of struvite.
In summary: The combination of a staghorn calculus, recurrent UTIs, and a high urinary pH strongly points towards struvite as the most likely stone composition.
A 30 year old male presents with a painless swelling of the testis. Histologically the stroma has a lymphocytic infiltrate. The most likely diagnosis is :
Differentiated teratoma
Malignant undifferentiated teratoma
Classical seminoma
Spermatocytic seminoma
Anaplastic seminoma
The most likely diagnosis is Classical seminoma.
Here’s why:
* Painless Swelling: Painless testicular swelling is a common presentation of testicular cancer.
* Lymphocytic Infiltrate: A prominent lymphocytic infiltrate within the stroma is a characteristic feature of classical seminoma. This is a key histological finding that distinguishes it from other types of testicular tumors.
* Age: Seminoma is the most common type of testicular cancer, and it typically occurs in men aged 20-40, which aligns with the patient’s age.
Why other options are less likely:
* Differentiated teratoma: Teratomas contain various differentiated tissues (e.g., hair, teeth, skin). While they can be benign or malignant, they don’t typically have the prominent lymphocytic infiltrate seen in seminomas.
* Malignant undifferentiated teratoma: Similar to differentiated teratomas, undifferentiated teratomas don’t characteristically have the dense lymphocytic infiltrate.
* Spermatocytic seminoma: This is a less common variant of seminoma that usually occurs in older men (over 50) and has a different histological appearance (smaller cells, no lymphocytic infiltrate).
* Anaplastic seminoma: This is a more aggressive variant of seminoma, but the key distinguishing feature remains the prominent lymphocytic infiltrate, which is seen in both classical and anaplastic seminomas. Since “classical” is an option and is more common, it’s the better answer. Anaplastic would be considered if the question stem mentioned features of rapid growth or spread.
Therefore, the combination of painless swelling, lymphocytic infiltrate, and the patient’s age strongly suggests classical seminoma as the most likely diagnosis.
A 42 year old man underwent a vasectomy at the surgical clinic. He is reviewed at the request of his general practitioner. On examination he has a small rounded nodule adjacent to the vas. What is the most likely underlying diagnosis?
Haematoma
Sperm granuloma
Varicocele
Hydrocele
Epididymal cyst
The most likely diagnosis is Sperm granuloma.
Here’s why:
* Location: The nodule is described as being adjacent to the vas, which is the location where a sperm granuloma is most likely to occur after a vasectomy.
* Mechanism: A sperm granuloma forms when sperm leaks from the cut end of the vas deferens and elicits an inflammatory response. It’s essentially a reaction to the leaked sperm.
* Timing: It’s common to find these after a vasectomy, as this disrupts the normal flow of sperm.
* Appearance: They are typically small, firm nodules.
Why other options are less likely:
* Haematoma: While a hematoma (collection of blood) can occur after any surgical procedure, it would usually be more diffuse and would likely resolve over time. It wouldn’t typically persist as a small, rounded nodule.
* Varicocele: A varicocele is an enlargement of the veins within the scrotum. It feels like a “bag of worms” and is located above and behind the testicle, not specifically adjacent to the vas.
* Hydrocele: A hydrocele is a collection of fluid around the testicle, causing scrotal swelling. It wouldn’t present as a small, rounded nodule adjacent to the vas.
* Epididymal cyst: These are fluid-filled cysts within the epididymis (a structure behind the testicle). They are usually located away from the vas deferens, though close by, and are typically smooth and mobile.
In summary: A small, rounded nodule adjacent to the vas deferens after a vasectomy is most consistent with a sperm granuloma.
48 year old woman presents with recurrent loin pain and fevers. Investigation reveals a staghorn calculus of the left kidney. Infection with which of the following organisms is most likely?
Staphylococcus saprophyticus
Proteus mirabilis
Klebsiella
E-Coli
Staphylococcus epidermidis
The most likely organism is Proteus mirabilis.
Here’s why:
* Staghorn Calculus: Staghorn calculi, as mentioned before, are large stones that fill the renal pelvis and calyces. They are strongly associated with Proteus mirabilis infections.
* Urease Production: Proteus mirabilis is a urease-producing organism. Urease breaks down urea into ammonia, which alkalinizes the urine. This alkaline environment favors the formation of struvite stones, which are the most common component of staghorn calculi.
* Recurrent Loin Pain and Fevers: These symptoms suggest recurrent urinary tract infections (UTIs), which are common with struvite stones and Proteus infections.
Why other options are less likely:
* Staphylococcus saprophyticus: While S. saprophyticus is a common cause of UTIs, particularly in young women, it’s not typically associated with staghorn calculi formation.
* Klebsiella: Klebsiella can cause UTIs, but it’s less strongly associated with staghorn calculi compared to Proteus.
* E. coli: E. coli is the most common cause of UTIs overall, but it’s less likely to produce staghorn calculi unless there is some other complicating factor.
* Staphylococcus epidermidis: S. epidermidis is more commonly associated with infections of indwelling medical devices (like catheters) and is less likely to cause staghorn calculi.
Key takeaway: The combination of a staghorn calculus, recurrent loin pain and fevers (suggestive of recurrent UTIs), and the known association of Proteus mirabilis with struvite stones makes Proteus the most likely causative organism.
Which of the following does not cause red urine?
Rifampicin
Phosphaturia
Beetroot
Rhubarb
Blackberries
Phosphaturia does not cause red urine. It can make urine appear cloudy or milky, but it doesn’t change the color to red.
The others can cause red urine:
* Rifampicin: This antibiotic can turn urine (and other bodily fluids) reddish-orange.
* Beetroot: Eating beetroot can cause red or pink urine (beeturia) in some people.
* Rhubarb: Rhubarb can also cause red or pink urine.
* Blackberries: Eating a large quantity of blackberries can sometimes lead to red or purplish discoloration of the urine.
A 32 year old male presents with a swollen, painful right scrotum after being kicked in the groin area. There is a painful swelling of the right scrotum and the underlying testis cannot be easily palpated. What is the best course of action?
Inguinal orchidectomy
Scrotal orchidectomy
Scrotal exploration
Testicular USS
The best course of action is Testicular USS (ultrasound).
Here’s why:
* Need for Assessment: The patient has sustained trauma to the scrotum, and you can’t adequately examine the testis due to swelling. You need to know what’s going on inside. Ultrasound is the best way to do this.
* What Ultrasound Will Show: The ultrasound will help determine if there is:
* Testicular rupture: This is a surgical emergency.
* Hematocele: A collection of blood around the testis.
* Testicular torsion: Twisting of the spermatic cord, also a surgical emergency.
* Other injuries: Such as epididymitis or soft tissue injury.
* Guiding Further Management: The ultrasound findings will dictate the next steps. If there’s a rupture or torsion, surgery (exploration and likely repair/orchidectomy) will be needed urgently. If it’s a hematocele or other less serious injury, conservative management might be appropriate.
Why other options are not the best initial course of action:
* Inguinal orchidectomy/Scrotal orchidectomy: These are treatment options, not diagnostic ones. You don’t know yet if the testis needs to be removed. Orchidectomy would only be considered if the testis is non-viable (e.g., due to severe trauma or torsion).
* Scrotal exploration: Surgery without knowing what you’re dealing with is not the best approach. Ultrasound is non-invasive and provides valuable information that will guide surgical decisions, if surgery is even needed. Going straight to exploration could potentially cause more harm.
In short: Ultrasound is the essential first step to assess the extent of the injury and determine the appropriate treatment.
40 year old woman is being investigated for haematuria. She was living with her sister who has just died from a sub arachnoid haemorrhage. The haematuria is painless and she has mild renal impairment. What is the most likely cause?
Adenocarcinoma of the bladder
Bladder stones
Polycystic kidney disease
Renal cancer
Pyelonephritis
The most likely cause is Polycystic kidney disease (PKD).
Here’s why:
* Family History: The sister’s subarachnoid hemorrhage raises a strong suspicion for PKD. PKD is a hereditary condition, and the most common type (autosomal dominant PKD) often presents with kidney cysts and can also be associated with intracranial aneurysms (which can lead to subarachnoid hemorrhage).
* Painless Haematuria: Painless haematuria is a common symptom of PKD. The bleeding is usually microscopic, but it can sometimes be visible (gross haematuria).
* Mild Renal Impairment: PKD is a progressive condition that can lead to chronic kidney disease and renal impairment.
Why other options are less likely:
* Adenocarcinoma of the bladder/Renal cancer: While these cancers can cause haematuria, they are less likely to be associated with a family history of subarachnoid hemorrhage. Renal cell carcinoma typically presents as a solitary mass, not with the diffuse cystic changes of PKD. Bladder cancer would not cause renal impairment.
* Bladder stones: Bladder stones can cause haematuria, but they are usually associated with other symptoms like pain, dysuria (painful urination), and urgency. Also, they would not explain the renal impairment.
* Pyelonephritis: Pyelonephritis (kidney infection) usually presents with fever, flank pain, and other signs of infection. While it can cause haematuria, the lack of these symptoms makes it less likely. It would not explain the family history.
Key takeaway: The combination of painless haematuria, mild renal impairment, and a strong family history of subarachnoid hemorrhage (suggestive of PKD) makes PKD the most likely diagnosis. Further investigation, such as a renal ultrasound or CT scan, would be needed to confirm the diagnosis.
A 56 year old man is involved in a road traffic accident. He is found to have a pelvic fracture. He reports that he has some lower abdominal pain. He has peritonism in the lower abdomen. The nursing staff report that he has not passed any urine. A CT scan shows evidence of free fluid. What is the most likely diagnosis?
Membranous urethral injury
Bladder rupture
Bladder contusion
Bulbar urethral injury
Urinary tract infection
The most likely diagnosis is Bladder rupture.
Here’s why:
* Pelvic Fracture: Pelvic fractures are commonly associated with bladder injuries.
* Lower Abdominal Pain and Peritonism: These signs suggest peritoneal irritation, which is a strong indicator of bladder rupture (urine leaking into the abdominal cavity). Peritonism is a sign of inflammation of the peritoneum (lining of the abdomen) and is characterized by abdominal pain, tenderness, rigidity, and guarding.
* No Urine Output: This suggests that urine is not draining from the bladder, which is consistent with a rupture.
* Free Fluid on CT Scan: This confirms that there is fluid outside of the bladder, likely urine, which has leaked into the abdomen due to the rupture.
Why other options are less likely:
* Membranous/Bulbar Urethral Injury: While urethral injuries can occur with pelvic fractures, they wouldn’t typically cause peritonism (unless there’s also a bladder injury). Urethral injuries would also present with blood at the urethral meatus, which isn’t mentioned here.
* Bladder Contusion: A contusion is a bruise. While it can cause pain and possibly some blood in the urine (hematuria), it wouldn’t lead to free fluid in the abdomen or an inability to pass urine.
* Urinary Tract Infection (UTI): A UTI would not be associated with trauma, pelvic fracture, inability to pass urine, free fluid, or peritonism.
In summary: The combination of a pelvic fracture, lower abdominal pain with peritonism, no urine output, and free fluid on CT scan strongly points to a bladder rupture. This is a serious injury requiring prompt surgical intervention.
During a game of football, Andrew experienced a twisted injury. The next day emergency
house officer found a positive patellar tap. He cannot extend his knee. What is your diagnosis?
a. Anterior cruciate ligament injury
b. Knee Dislocation
c. Dislocated patella
d. Bucket handle meniscal tear
e. lateral collateral ligament injury
The most likely diagnosis in this case is dislocated patella (option C).
Explanation:
• The positive patellar tap suggests a significant effusion, indicating intra-articular injury.
• Inability to extend the knee suggests disruption of the extensor mechanism, which is commonly seen in patellar dislocations.
• Mechanism of injury (twisting) is a classic cause of patellar dislocation, often seen in sports injuries.
Why not the other options?
• Anterior cruciate ligament (ACL) injury (A): Would present with instability and a positive anterior drawer or Lachman test, but usually allows some degree of extension.
• Knee dislocation (B): A much more severe injury that typically involves multiple ligament ruptures and potential neurovascular compromise.
• Bucket handle meniscal tear (D): Can cause locking of the knee but does not typically cause an effusion large enough for a positive patellar tap.
• Lateral collateral ligament injury (E): Would not explain the large effusion or inability to extend the knee.
This matches findings from MRCS recall questions, where dislocated patella is often associated with acute swelling and inability to extend the knee oai_citation:0‡MCQs_for_the_MRCS_Part_A.pdf.
A 42-year-old tall patient presents with sudden sharp abdominal pain radiating to the groin. He has a history of chest pain and TIA. What is the most likely diagnosis?
A. Aortic dissection
B. Pulmonary embolism
C. Myocardial infarction
D. Ruptured abdominal aortic aneurysm
E. Perforated abdominal viscus
The most likely diagnosis in this case is Aortic dissection (option A).
Explanation:
• Tall patient: This could indicate Marfan syndrome or another connective tissue disorder, which increases the risk of aortic dissection.
• Sudden sharp abdominal pain radiating to the groin: Aortic dissection can extend along the aorta and cause pain radiating to different regions, including the abdomen and groin.
• History of chest pain and TIA:
• Chest pain is a classic symptom of aortic dissection, often described as tearing or ripping.
• TIA (Transient Ischemic Attack): Suggests prior arterial embolization, which can be a complication of dissection if it affects blood flow to the brain.
Why not the other options?
• Pulmonary embolism (B): Typically presents with pleuritic chest pain, shortness of breath, and hypoxia, but not abdominal pain radiating to the groin.
• Myocardial infarction (C): Causes chest pain but does not typically present with groin pain or a history of TIA.
• Ruptured abdominal aortic aneurysm (D): Can cause sudden abdominal pain but is more common in elderly male smokers and presents with hypotension and shock.
• Perforated abdominal viscus (E): Causes generalized peritonitis with fever and guarding, but does not explain the patient’s history of TIA and chest pain.
Takeaway:
Aortic dissection should be suspected in tall patients with sudden sharp pain (often tearing in nature) radiating along the aorta and a history suggestive of connective tissue disorders or arterial embolization. Immediate CT angiography or transesophageal echocardiography is needed for diagnosis.
Hit in the knee by a hockey stick. On examination, his knee is tense and swollen. X-ray shows
no fractures. what next definitive investigation?
a. CT
b. MRI
c. Bone scan
d. Aspiration
e. Arthroscopic
The best next definitive investigation in this case is MRI (option B).
Explanation:
• Mechanism of injury (direct trauma with a hockey stick) suggests a soft tissue injury rather than a fracture.
• Tense and swollen knee indicates a hemarthrosis (blood in the joint), which is often seen in ligamentous injuries (ACL tear, PCL tear) or chondral injuries.
• X-ray shows no fracture, so a bony injury is ruled out, making soft tissue assessment (ligaments, menisci, cartilage) the priority.
Why not the other options?
• CT (A): Better for bony injuries, but X-ray already ruled out fractures.
• Bone scan (C): Used for stress fractures or infections, which are not suggested by the history.
• Aspiration (D): Can confirm hemarthrosis, but does not define the extent of ligament or meniscal damage.
• Arthroscopy (E): Invasive and used for treatment rather than initial diagnosis.
Takeaway:
For a soft tissue knee injury (tense, swollen knee with no fracture on X-ray), MRI is the best next definitive investigation to assess ligaments, menisci, and cartilage damage.
A patient is diagnosed with multiple myeloma and presents with a pink, fleshy lesion. What is the diagnosis?
A. Metaplasia
B. Dysplasia
C. AL amyloidosis
D. AA amyloidosis
E. Beta 2 micro amyloidosis
The correct answer is:
C. AL amyloidosis
Explanation:
• Multiple myeloma is strongly associated with AL (Amyloid Light-chain) amyloidosis.
• Pink, fleshy lesion is suggestive of amyloid deposition, which can occur in the skin, tongue (macroglossia), or other soft tissues.
• AL amyloidosis is caused by the deposition of monoclonal light chains (lambda or kappa) produced by plasma cells, often in the setting of multiple myeloma.
Why not the other options?
• Metaplasia (A): A reversible change in cell type (e.g., Barrett’s esophagus), not typically associated with multiple myeloma.
• Dysplasia (B): Refers to disordered cellular growth, a precancerous change seen in epithelial tissues, not in multiple myeloma.
• AA amyloidosis (D): Associated with chronic inflammatory conditions (e.g., rheumatoid arthritis, tuberculosis), not multiple myeloma.
• Beta-2 microglobulin amyloidosis (E): Occurs in long-term hemodialysis patients, due to β2-microglobulin accumulation in joints and bones, not soft tissue lesions in multiple myeloma.
Takeaway:
• AL amyloidosis is the most common type of amyloidosis in multiple myeloma, often presenting with soft tissue deposits, cardiac involvement, nephrotic syndrome, or macroglossia.
• Diagnosis is confirmed by Congo red staining with apple-green birefringence under polarized light.
A 55-year-old man fell from the stairs. His wife reports that he lost consciousness for 15 seconds but has fully recovered now. What should you do next?
A. Admit for 6 hours and observe
B. Immediate CT
C. CT after 1 hour
D. Call a neurosurgeon
E. Discharge and instruct on warning signs
The correct answer is:
A. Admit for 6 hours and observe
Explanation:
• This patient had a brief loss of consciousness (LOC) after a fall, which raises concern for minor traumatic brain injury (TBI) or concussion.
• According to NICE guidelines for head injury, patients with a brief LOC but no high-risk features should be observed for at least 6 hours in a medical setting.
• Observation helps detect delayed deterioration due to a slowly evolving intracranial hemorrhage (e.g., subdural hematoma).
Why not the other options?
• Immediate CT (B): Indicated if there are red flag signs such as:
• GCS < 13 on initial assessment
• Persistent vomiting
• Focal neurological deficit
• Signs of skull fracture
• Post-traumatic seizure
• Coagulopathy or age >65
(Since this patient is alert and recovered, an immediate CT is not required.)
• CT after 1 hour (C): There is no guideline recommending a 1-hour delay; observation is the correct approach unless high-risk features develop.
• Call a neurosurgeon (D): Neurosurgical consultation is necessary only if CT shows a significant brain injury requiring intervention.
• Discharge and instruct on warning signs (E): While patient education is important, immediate discharge is inappropriate because a delayed bleed (e.g., subdural hematoma) can develop.
Takeaway:
For a patient with a brief LOC after trauma but no immediate red flags, the correct approach is 6 hours of observation in a medical setting. If symptoms worsen, a **CT
A patient fell onto their chin, causing their teeth to become separated. They have reduced mouth opening, malalignment of the jaws, and tenderness in the pre-auricular area. Which part of the mandible is affected?
A. Body of the mandible
B. Ramus
C. Coronoid process
D. Condyle
E. Angle of the mandible
The correct answer is:
D. Condyle
Explanation:
• Fall onto the chin can transmit force to the temporomandibular joint (TMJ) and cause a condylar fracture.
• Symptoms suggestive of a condylar fracture:
• Teeth become separated → Indicates malocclusion (misalignment of the jaws).
• Reduced mouth opening → Suggests involvement of the TMJ.
• Tenderness in the pre-auricular area → The condyle is located near the TMJ, making this a key finding.
Why not the other options?
• Body of the mandible (A): Fractures here cause localized pain and swelling along the jawline, not pre-auricular tenderness or TMJ dysfunction.
• Ramus (B): Rarely fractured in isolation and does not cause significant malocclusion or TMJ pain.
• Coronoid process (C): Rarely fractures unless due to direct trauma, does not affect occlusion significantly.
• Angle of the mandible (E): More commonly fractured by lateral blows, often leading to pain at the fracture site but not TMJ symptoms.
Takeaway:
A fall onto the chin with pre-auricular tenderness, malalignment, and reduced mouth opening strongly suggests a condylar fracture of the mandible. Panoramic X-ray (OPG) or CT scan can confirm the diagnosis.
A 33-year-old female with a BRCA1 mutation presents with a firm painless
mass in the right breast. What is the next step?
A. MRI
B. Ultrasound
C. Mammography
D. FNAC
E. True cut biopsy
The correct answer is:
E. True cut biopsy
Explanation:
• A firm, painless mass in a BRCA1-positive patient is highly suspicious for breast cancer.
• True cut biopsy (core needle biopsy) is the best next step because:
• It provides histological diagnosis, differentiating between benign and malignant lesions.
• It allows for hormone receptor and HER2 status assessment, which is crucial for treatment planning.
• It is more accurate than FNAC (fine-needle aspiration cytology), which may not provide sufficient tissue architecture.
Why not the other options?
• MRI (A):
• MRI is the most sensitive imaging modality for BRCA1 carriers but is used for screening and staging rather than as a first-line investigation for a palpable mass.
• Ultrasound (B):
• Useful in younger women (dense breasts) and to differentiate cystic vs. solid masses but does not confirm malignancy.
• Mammography (C):
• Important for screening, but in younger patients (<40), breast tissue is dense, limiting sensitivity.
• Can be used alongside biopsy but is not the next best step alone.
• FNAC (D):
• Can confirm malignancy but does not provide tissue architecture for receptor status assessment.
• Higher risk of false negatives than core biopsy.
Takeaway:
In a BRCA1-positive patient with a suspicious breast lump, a true cut biopsy is the next best step to confirm malignancy and guide treatment. Imaging (US/Mammogram/MRI) can be done afterward for staging.
A 50-year-old female with a history of Hashimoto thyroiditis presents with a rapidly enlarging thyroid gland and difficulty swallowing. Pathology shows bland cells and CD 20+ phenotype. What is your diagnosis?
A. Lymphoma
B. Medullary thyroid carcinoma
C. Follicular thyroid carcinoma
D. Papillary thyroid carcinoma
E. Anaplastic carcinoma
The correct answer is:
A. Lymphoma
Explanation:
• Rapidly enlarging thyroid gland with dysphagia suggests an aggressive thyroid pathology.
• History of Hashimoto’s thyroiditis is a major risk factor for primary thyroid lymphoma (PTL).
• CD20+ phenotype confirms a B-cell origin, which is characteristic of thyroid lymphoma.
• Bland cells suggest a low-grade malignancy, which is typical of MALT lymphoma (a subtype of PTL).
Why not the other options?
• Medullary thyroid carcinoma (B):
• Arises from parafollicular C-cells, not lymphoid tissue.
• Associated with calcitonin elevation, not CD20 positivity.
• Follicular thyroid carcinoma (C):
• More common in iodine-deficient areas and spreads hematogenously.
• Does not present with rapid enlargement or CD20 positivity.
• Papillary thyroid carcinoma (D):
• The most common thyroid cancer but slow-growing.
• Shows Orphan Annie nuclei, psammoma bodies, and is not CD20 positive.
• Anaplastic carcinoma (E):
• Rapidly enlarging and highly aggressive, but typically CD20 negative.
• Shows pleomorphic, undifferentiated cells, not bland cells.
Takeaway:
Primary thyroid lymphoma (PTL) should be suspected in a patient with Hashimoto thyroiditis, a rapidly enlarging thyroid mass, and CD20 positivity. Biopsy confirms the diagnosis, and treatment involves chemotherapy and radiation, not surgery.
A patient with Graves disease returns after 12 months with a relapse. What
should be given now?
A. Propylthiouracil
B. Propranolol
C. Steroids
D. Carbimazole
E. Thyroxine
The correct answer is:
D. Carbimazole
Explanation:
• Graves’ disease is an autoimmune hyperthyroidism often treated initially with antithyroid drugs (ATDs) like carbimazole or propylthiouracil (PTU).
• Relapse after 12 months suggests persistent disease, and the usual next step is to restart antithyroid medication or consider definitive treatment (radioactive iodine or surgery).
• Carbimazole is preferred over PTU due to better safety profile and once-daily dosing.
Why not the other options?
• Propylthiouracil (A):
• Used in pregnancy (first trimester) or in thyroid storm, but not the first choice due to risk of hepatotoxicity.
• Propranolol (B):
• Beta-blockers relieve symptoms (tachycardia, tremors) but do not treat the underlying cause.
• Steroids (C):
• Used in thyroid eye disease, not for relapse of hyperthyroidism.
• Thyroxine (E):
• Used in hypothyroidism, not hyperthyroidism.
Takeaway:
For a Graves’ disease relapse, the first step is to restart carbimazole. If relapse happens again after prolonged treatment, consider radioactive iodine or thyroidectomy for definitive management.
A 19-year-old skier fell, injuring her left knee. She felt severe pain, and the knee became swollen instantly. Aspiration revealed a large hemarthrosis. What is the most likely diagnosis?
A. Patellar tendon rupture
B. Meniscal damage
C. ACL tear
D. PCL tear
E. Injury to the medial collateral ligament
The correct answer is:
C. ACL tear (Anterior Cruciate Ligament tear)
Explanation:
• Mechanism of injury: A 19-year-old skier suggests a non-contact twisting injury, common in ACL tears.
• Severe pain and immediate swelling:
• Instant swelling (hemarthrosis) is highly suggestive of an ACL tear due to the vascular supply of the ACL.
• Other causes of hemarthrosis: Patellar dislocation, tibial plateau fracture, or PCL injury.
• Aspiration shows large hemarthrosis:
• ACL tears cause 70-80% of acute traumatic hemarthroses in young athletes.
• Meniscal and collateral ligament injuries do not typically cause immediate large effusions.
Why not the other options?
• Patellar tendon rupture (A):
• Causes inability to extend the knee, but does not usually lead to large hemarthrosis.
• Meniscal damage (B):
• Causes delayed swelling (over 24 hours) due to synovial fluid accumulation, not hemarthrosis.
• PCL tear (D):
• Often caused by a direct blow to the anterior tibia (dashboard injury) rather than a twisting mechanism.
• Hemarthrosis can occur but is less common than in ACL injuries.
• Medial collateral ligament (MCL) injury (E):
• Causes localized medial pain and valgus instability, but does not cause significant hemarthrosis.
Takeaway:
A young athlete with a twisting knee injury, immediate swelling, and hemarthrosis likely has an ACL tear. Diagnosis is confirmed with Lachman test, anterior drawer test, and MRI.
A 45-year-old man is involved in a car accident. On admission, he is in hypovolemic shock, and radiographs show a displaced anterior pelvic fracture. On rectal examination, the prostate gland cannot be felt in its usual position. What is the possible cause?
A. The bladder is ruptured
B. The bulbar part of the urethra is ruptured
C. The membranous urethra is ruptured
D. The prostatic urethra is ruptured
E. None of the above
The answer is C. The membranous urethra is ruptured.
Here’s why:
* High-riding prostate: A high-riding or non-palpable prostate on rectal exam in the context of pelvic fracture and hypovolemic shock is a strong indicator of posterior urethral injury. This typically involves the membranous urethra. The prostate is displaced superiorly by the pelvic fracture fragments.
* Membranous vs. Bulbar Urethra: The bulbar urethra is more anterior and injuries to it are less likely to cause a high-riding prostate. Bulbar urethral injuries are more commonly associated with straddle injuries.
* Bladder Rupture: While bladder rupture can occur with pelvic fractures, it doesn’t directly cause a high-riding prostate. Bladder injuries are often diagnosed with cystography.
* Prostatic Urethra: Prostatic urethral injuries are less common than membranous urethral injuries in pelvic fractures. They might also present with a high-riding prostate, but the membranous urethra is more frequently involved.
Therefore, the most likely cause given the presented scenario is a ruptured membranous urethra.
A 22-year-old sickle cell anemia patient presented with painful priapism for which he underwent aspiration and showed no improvement. What is the best next step?
A. Cavernosal aspiration
B. Phenylephrine
C. Surgical exploration
D. Intracavernous injection
E. Analgesia and follow-up
The best next step is D. Intracavernous injection.
Here’s the reasoning:
* Aspiration Failure: The patient has already undergone aspiration without improvement. This indicates a more persistent and likely higher-flow priapism.
* Intracavernosal Injection: This is the next line of treatment for priapism that fails aspiration. It typically involves injecting a sympathomimetic agent like phenylephrine directly into the corpora cavernosa. This constricts the penile arteries, reducing blood flow and hopefully resolving the priapism.
* Phenylephrine Systemically: While phenylephrine is used, it’s more effective when injected directly into the corpora cavernosa. Systemic administration isn’t as targeted and may have more side effects.
* Surgical Exploration: Surgery is usually reserved for refractory cases of priapism that fail all other treatments. It’s a more invasive procedure and not the next best step after failed aspiration.
* Analgesia and Follow-up: While pain management is important, simply providing analgesia and following up without attempting to actively resolve the priapism is not appropriate. Prolonged priapism can lead to significant complications, including erectile dysfunction. Active intervention is required.
Therefore, intracavernous injection is the most appropriate next step after aspiration has failed in this patient with sickle cell-related priapism.
A 43-year-old schizophrenic patient is on selective serotonin reuptake inhibitors (SSRIs) for 3 years. He presented today with a 6-hour painful priapism. What is the best initia! management option?
A. Intracavernosal aspiration V
B. Analgesia
C. Surgical shunting
D. Phenylephrine
E. Intracavernous injection
The best initial management option is A. Intracavernosal aspiration.
Here’s the breakdown:
* SSRI-Associated Priapism: Priapism is a known, though rare, side effect of SSRIs. While the exact mechanism isn’t fully understood, it’s thought to involve changes in neurotransmitter levels.
* Initial Management: The first-line treatment for priapism, regardless of the cause, is typically intracavernosal aspiration. This involves inserting a needle into the corpora cavernosa and draining the trapped blood. This can often relieve the pressure and resolve the priapism.
* Other Options:
* Analgesia: While pain management is important, it doesn’t address the underlying issue of the priapism itself. Aspiration is the priority.
* Surgical Shunting: This is a more invasive procedure reserved for cases of priapism that are refractory to other treatments. It’s not a first-line option.
* Phenylephrine: While phenylephrine (or other alpha-adrenergic agonists) can be used, it’s usually the next step if aspiration is unsuccessful. Aspiration is simpler and less invasive as a first attempt.
* Intracavernous Injection: This refers to injecting medications (like phenylephrine) into the corpora cavernosa. While this is a valid treatment, aspiration is generally tried first.
Therefore, intracavernosal aspiration is the most appropriate initial management option for this patient with SSRI-associated priapism.
A 45-year-old man with a history of chronic pancreatitis presents to the clinic complaining of persistent, severe pain in his mid-back, radiating to the abdomen. He describes the pain as deep, gnawing, and worse after meals. He has tried over-the-counter analgesics with minimal relief. What is the MOST appropriate next step in the management of his pain?
a. Non-steroidal anti-inflammatory drugs (NSAIDs)
b. Nerve block (e.g., celiac plexus block)
c. Opioids
d. Pancreatic enzyme replacement therapy (PERT) adjustment
e. Endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy
The most appropriate next step in the management of this patient’s pain is b. Nerve block (e.g., celiac plexus block).
Here’s why:
* Chronic Pancreatitis Pain: Chronic pancreatitis often causes severe, debilitating pain that is difficult to manage. It’s characterized by inflammation and damage to the pancreas, leading to both abdominal and back pain (due to the pancreas’s retroperitoneal location).
* Why not the other options?
* NSAIDs: While NSAIDs might be used for mild pain, they are unlikely to provide sufficient relief for the severe, persistent pain described in this case. Long-term NSAID use also carries risks, especially in patients with chronic conditions.
* Opioids: Opioids can be effective for pain management, but they are generally not the first-line treatment for chronic pancreatitis pain due to the risks of dependence, tolerance, and other side effects. They might be considered if other options fail.
* PERT Adjustment: While pancreatic enzyme replacement therapy (PERT) is crucial for managing maldigestion and malabsorption in chronic pancreatitis, it primarily addresses those issues, not directly the pain itself. It’s an important part of the overall management but not the most appropriate next step for pain relief.
* ERCP with Sphincterotomy: ERCP is a procedure used to visualize and treat the pancreatic and bile ducts. While it can be helpful in certain situations (e.g., strictures, stones), it’s not the primary approach for managing chronic pancreatitis pain. It’s more invasive and carries its own risks.
* Celiac Plexus Block: A celiac plexus block involves injecting local anesthetic into the celiac plexus, a network of nerves that innervates the upper abdominal organs, including the pancreas. This can provide significant pain relief for some patients with chronic pancreatitis. It’s a less invasive procedure than surgery and can be repeated if necessary. It is often considered before moving on to stronger pain medications like opioids.
Patient presented by Hypovolemia and oliguria and after correction with
fluid challenge, it still oliguric. What is the character finding in this patient?
A. Urine to plasma osmolarity ratio 1:1
B. Urine specific gravity 1010
C. Urine osmolarity 250
D. Urine sodium 10
E. All of the above
This medical question appears to be testing knowledge about differentiating between prerenal and intrinsic renal failure in a patient with oliguria.
To solve this, I need to analyze each option and determine which finding would be characteristic of a patient who remains oliguric after adequate fluid resuscitation.
Let’s analyze each option:
A. Urine to plasma osmolarity ratio 1:1
In prerenal azotemia, this ratio would typically be >1.5:1 as the kidneys try to conserve water. A ratio of 1:1 suggests the kidneys have lost concentrating ability, indicating acute tubular necrosis (ATN) or intrinsic renal failure.
B. Urine specific gravity 1010
Normal urine specific gravity ranges from 1.003-1.030. A fixed specific gravity around 1.010 (isosthenuric) indicates loss of concentrating ability, consistent with ATN.
C. Urine osmolarity 250
Normal urine osmolarity ranges from 300-900 mOsm/L. A value of 250 mOsm/L (close to plasma osmolarity) indicates loss of concentrating ability, consistent with ATN.
D. Urine sodium 10
In prerenal azotemia, urine sodium is typically <20 mEq/L as the kidneys try to conserve sodium. A value of 10 mEq/L suggests prerenal causes rather than intrinsic renal failure.
E. All of the above
Since the patient remains oliguric after fluid challenge, this suggests progression from prerenal to intrinsic renal failure (likely ATN).
The characteristic findings would be:
- Urine:plasma osmolarity ratio close to 1:1
- Fixed urine specific gravity around 1.010
- Urine osmolarity close to plasma (around 250-300)
- Urine sodium typically >20 mEq/L in ATN
Since option D (urine sodium 10) is more consistent with prerenal failure rather than intrinsic renal failure after fluid challenge, not all findings listed are characteristic.
The answer is not E.
The most likely answer is A, as a urine to plasma osmolarity ratio of 1:1 is highly characteristic of intrinsic renal failure when a patient remains oliguric after fluid challenge.
Patient in RTA presented by fracture ribs 5 and 6 then after 3 days suffered
from Dyspnea, Tachycardia 90, blood pressure 170/9, sweating and on
examination; there is poor air entry and no abnormal sounds
A. Ineffective analgesia
B. Pneumonia
C. Pulmonary embolism
D. ARDS
E. COPD
The patient’s presentation is concerning for a pulmonary embolism (PE). Here’s why:
- History: The patient was in a road traffic accident (RTA) and sustained fractures of ribs 5 and 6. This immobility and trauma increase the risk of deep vein thrombosis (DVT) and subsequent PE.
- Timing: The onset of dyspnea and other symptoms 3 days after the injury is consistent with the timeline for PE development.
- Symptoms: Dyspnea, tachycardia (HR 90), and sweating are classic signs of PE.
- Examination: Poor air entry without abnormal sounds (e.g., crackles or wheezes) suggests a ventilation-perfusion mismatch, which is common in PE.
- Blood pressure: The elevated blood pressure (170/9) could be due to pain or stress, but it does not rule out PE.
- A. Ineffective analgesia: While pain could contribute to tachycardia and hypertension, it does not explain the dyspnea or poor air entry.
- B. Pneumonia: Pneumonia typically presents with fever, cough, and abnormal lung sounds (e.g., crackles), which are absent here.
- D. ARDS (Acute Respiratory Distress Syndrome): ARDS usually develops over hours to days in the setting of severe systemic illness or trauma, but it is less likely in this case without hypoxia or bilateral infiltrates on imaging.
- E. COPD: COPD exacerbation would typically present with wheezing, prolonged expiration, and a history of chronic lung disease, which is not mentioned here.
-
Immediate investigations:
- Arterial blood gas (ABG) to assess for hypoxia and elevated alveolar-arterial gradient.
- CT pulmonary angiogram (CTPA) to confirm PE.
- D-dimer (if low clinical probability).
- ECG to look for signs of right heart strain (e.g., S1Q3T3 pattern).
-
Management:
- Start anticoagulation (e.g., low molecular weight heparin) if PE is suspected.
- Oxygen therapy if hypoxic.
- Consider thrombolysis if hemodynamically unstable.
This patient requires urgent evaluation and treatment for suspected PE.
A 46-year-old woman underwent laparoscopic cholecystectomy for chronic calculous cholecystitis. Three days later, she presents with progressive jaundice, pale stools, and dark urine. What is the most probable diagnosis?
A Bile duct injury
B Collection at the surgical site
C. Residual CBD stone M
D. Acute pancreatitis
E Cholangitis
Let’s analyze this case carefully:
A 46-year-old woman underwent laparoscopic cholecystectomy for chronic calculous cholecystitis. Three days after surgery, she presents with:
- Progressive jaundice
- Pale stools
- Dark urine
These symptoms strongly suggest biliary obstruction. Let’s evaluate each option:
A. Bile duct injury
This is a known complication of laparoscopic cholecystectomy, occurring in 0.3-0.7% of cases. The timing (3 days post-op) and symptoms (jaundice, pale stools, dark urine) are classic for bile duct injury. The pale stools indicate lack of bile reaching the intestine, while dark urine suggests bilirubin being excreted renally instead.
B. Collection at the surgical site
While a biloma (bile collection) can occur after cholecystectomy, it typically causes pain, fever, and sometimes a palpable mass. It wouldn’t typically cause obstructive jaundice with pale stools this quickly unless it was compressing the bile duct externally, which is less common.
C. Residual CBD stone
Retained stones in the common bile duct are possible, especially with pre-existing gallstones. However, these stones would have been present before surgery. The new onset of complete biliary obstruction symptoms after surgery makes this less likely than bile duct injury.
D. Acute pancreatitis
Post-ERCP pancreatitis can occur, but post-cholecystectomy pancreatitis typically presents with severe epigastric pain radiating to the back, nausea, vomiting, and elevated lipase/amylase. The clinical picture doesn’t suggest pancreatitis as the primary issue.
E. Cholangitis
Cholangitis typically presents with Charcot’s triad (fever, jaundice, right upper quadrant pain) or Reynolds’ pentad (plus hypotension and altered mental status). The absence of fever or pain in the case description makes cholangitis less likely.
The most probable diagnosis is:
A. Bile duct injury
This best explains the complete biliary obstruction picture (progressive jaundice, pale stools, dark urine) developing in the days following laparoscopic cholecystectomy. Bile duct injuries often become apparent 1-7 days after surgery as biliary obstruction develops, matching this timeline perfectly.
You notice a nurse practicing a minor procedure without evidence or references. What should you do?
A. Risk assessment
B. Medical audit
C. Report to GMC
D. Health and safety
E. Incident report
The most appropriate action in this scenario is:
E. Incident report
- Incident report: If you observe a nurse practicing a minor procedure without evidence or references, it is important to document the incident. This ensures that the situation is formally recorded and can be reviewed by the appropriate authorities within the healthcare facility. Reporting the incident allows for an investigation to determine if there was a breach of protocol and helps prevent future occurrences.
- A. Risk assessment: While a risk assessment might be part of the follow-up process, it is not the immediate action to take when observing the incident.
- B. Medical audit: A medical audit is a systematic review of clinical practices, but it is not the immediate response to an observed incident.
- C. Report to GMC: Reporting to the General Medical Council (GMC) would be premature unless the incident involves a serious breach of professional standards or harm to a patient. The first step is to report internally.
- D. Health and safety: This is not directly relevant to the situation unless the procedure poses an immediate health and safety risk.
By filing an incident report, you ensure that the situation is addressed appropriately and that patient safety and professional standards are upheld.
A 25 year old man is admitted with left sided loin pain that radiates to his groin. His investigations demonstrate a 9mm left sided calculus within the proximal ureter. His renal function is normal. What is the most appropriate course of action?
Arrange a percutaneous nephrolithotomy
Arrange extra corporeal shock wave lithotripsy
Review the patient in 4 weeks with KUB x-ray on arrival
Arrange for ureteroscopy and stent insertion
Arrange for open ureteric stone extraction
The most appropriate course of action for this patient is:
Arrange extracorporeal shock wave lithotripsy (ESWL).
- The patient is a 25-year-old man with a 9mm left-sided proximal ureteric calculus, normal renal function, and no signs of infection or obstruction. For a stone of this size in the proximal ureter, ESWL is often the first-line treatment. ESWL is a non-invasive procedure that uses shock waves to break the stone into smaller fragments, which can then pass naturally through the urinary tract.
- Percutaneous nephrolithotomy (PCNL): This is typically reserved for larger stones (>20mm) or complex cases, such as staghorn calculi. It is not necessary for a 9mm stone.
- Review in 4 weeks with KUB x-ray: While conservative management with monitoring might be considered for smaller stones (<5mm), a 9mm stone is unlikely to pass spontaneously and requires active intervention.
- Ureteroscopy and stent insertion: Ureteroscopy is an option, but it is more invasive than ESWL and is usually reserved for cases where ESWL has failed or is contraindicated.
- Open ureteric stone extraction: This is rarely used nowadays due to the availability of less invasive techniques like ESWL and ureteroscopy.
For a 9mm proximal ureteric stone in a patient with normal renal function, ESWL is the most appropriate and least invasive first-line treatment.
A 25 yr. old man has a 6-month history of mild Jaundice. He mentioned That his urine become darker, and he had mild itching. What is the most likely diagnosis?
A. Carcinoma of the duodenum
B. Choledocholithiasis
C. Gilbert syndrome
D. Hepatitis C
E. Primary biliary cirrhosis
obstructine Jandice
The most likely diagnosis for this patient is:
E. Primary biliary cholangitis (formerly known as primary biliary cirrhosis).
- The patient is a 25-year-old man with a 6-month history of mild jaundice, dark urine, and mild itching. These symptoms are suggestive of cholestatic liver disease.
-
Primary biliary cholangitis (PBC) is an autoimmune condition that primarily affects the small bile ducts in the liver, leading to cholestasis (impaired bile flow). It is more common in middle-aged women but can occur in men and younger individuals. Key features include:
- Jaundice
- Pruritus (itching)
- Dark urine (due to bilirubinuria)
- Elevated alkaline phosphatase (ALP) and gamma-glutamyl transferase (GGT) levels.
- A. Carcinoma of the duodenum: This is unlikely in a 25-year-old without other symptoms such as weight loss, abdominal pain, or vomiting.
- B. Choledocholithiasis: This typically presents with acute symptoms such as biliary colic (severe right upper quadrant pain), fever, and jaundice. It is less likely to cause a 6-month history of mild jaundice and itching.
- C. Gilbert syndrome: This is a benign condition characterized by intermittent mild jaundice due to unconjugated hyperbilirubinemia. It does not cause dark urine, itching, or cholestasis.
- D. Hepatitis C: While hepatitis C can cause jaundice, it is usually associated with acute hepatitis (e.g., fatigue, nausea, elevated transaminases) or chronic liver disease. It does not typically present with isolated cholestatic features like itching and dark urine over 6 months.
The patient’s symptoms of jaundice, dark urine, and itching over 6 months are most consistent with primary biliary cholangitis (PBC), a chronic cholestatic liver disease. Further investigations, such as liver function tests (elevated ALP and GGT), antimitochondrial antibodies (AMA), and imaging, would help confirm the diagnosis.
A 58 year old man has an episode of painless frank haematuria whilst undergoing a 24 urine collection for investigation of hypertension. What is the most likely cause?
Renal adenocarcinoma
Neuroblastoma
Transitional cell carcinoma of the ureter
Squamous cell carcinoma of the bladder
Phaeochromocytoma
The most likely cause of painless frank haematuria in a 58-year-old man is:
Transitional cell carcinoma (TCC) of the bladder.
- Painless frank haematuria is a classic presentation of transitional cell carcinoma (TCC) of the bladder, which is the most common type of bladder cancer. Risk factors include smoking, exposure to certain chemicals (e.g., aniline dyes), and older age.
- Bladder cancer typically presents with intermittent, painless haematuria, and the patient may also have irritative voiding symptoms (e.g., urgency, frequency) if the tumor is located near the bladder neck.
- Renal adenocarcinoma (renal cell carcinoma): While renal cell carcinoma can cause haematuria, it is often associated with flank pain, a palpable abdominal mass, or systemic symptoms (e.g., weight loss, fever). Painless haematuria is more characteristic of bladder cancer.
- Neuroblastoma: This is a tumor of the sympathetic nervous system that primarily occurs in children. It is extremely rare in adults and would not present with isolated haematuria.
- Squamous cell carcinoma of the bladder: This is a rare type of bladder cancer, usually associated with chronic irritation (e.g., long-term indwelling catheter or schistosomiasis infection). It is less common than TCC and would not be the first consideration in this case.
- Phaeochromocytoma: This is a tumor of the adrenal medulla that secretes catecholamines, leading to episodic hypertension, palpitations, and headaches. It does not cause haematuria.
In a 58-year-old man with painless frank haematuria, the most likely diagnosis is transitional cell carcinoma (TCC) of the bladder. Further investigations, such as cystoscopy and imaging (e.g., CT urogram), would be required to confirm the diagnosis.
A 73 year old man has previously undergone a prostatectomy to treat prostate cancer. On review, his PSA has risen to 55 and he has developed pain in his lower back. Imaging shows osteosclerotic lesions in L4 and L3. What is the best treatment strategy?
Posterior spinal fusion
Vertebral body reconstruction
Bisphosphonates and radiotherapy
Androgen suppression, bisphosphonates and radiotherapy
Radiotherapy alone
Based on the clinical information provided, this 73-year-old man has several concerning findings:
- History of prostatectomy for prostate cancer
- Significantly elevated PSA (55)
- Lower back pain
- Osteosclerotic lesions in L3 and L4 vertebrae
These findings are consistent with metastatic prostate cancer to the spine. The osteosclerotic (bone-forming) lesions are typical of prostate cancer metastasis, and the rising PSA after prostatectomy strongly suggests recurrent disease.
The best treatment strategy for this patient would be:
Androgen suppression, bisphosphonates and radiotherapy
This multifaceted approach addresses several aspects of the disease:
- Androgen suppression therapy (also called hormone therapy or ADT - androgen deprivation therapy) remains the backbone of treatment for metastatic prostate cancer, as most prostate cancers are hormone-sensitive. This can be achieved through medications like LHRH agonists/antagonists (e.g., leuprolide, goserelin) and/or anti-androgens.
-
Bisphosphonates (such as zoledronic acid) help manage bone metastases by:
- Reducing skeletal-related events
- Decreasing bone pain
- Potentially slowing progression of bone metastases
- Reducing risk of pathological fractures
-
Radiotherapy to the affected vertebrae can:
- Provide pain relief
- Control local disease
- Prevent pathological fractures
- Reduce risk of spinal cord compression
The other options are less appropriate:
- Posterior spinal fusion or vertebral body reconstruction would be overly invasive as first-line treatment and don’t address the systemic nature of the disease
- Bisphosphonates and radiotherapy alone, without addressing the hormonal driver of the disease, would be insufficient
- Radiotherapy alone wouldn’t address the systemic nature of the disease or provide bone support
This patient should also be evaluated for other systemic therapies depending on disease characteristics, including possibly chemotherapy, immunotherapy, or targeted therapies if appropriate.
A 39 year old man notices a swelling in his left hemiscrotum. On examination lying supine, he has a left sided varicocele. The ipsilateral testis is normal on palpation. What is the most appropriate course of action?
Scrotal exploration and ligation of the varicocele
Abdominal ultrasound
Scrotal ultrasound
Left orchidectomy
Discharge
Given the clinical scenario of a 39-year-old man with a left-sided varicocele and normal testis on palpation, the most appropriate next step would be:
Abdominal ultrasound
Here’s why this is the correct approach:
- While varicoceles are common and often benign, a new-onset varicocele in an adult male, particularly on the left side, raises concern for possible renal tumor with obstruction of the left renal vein. This is because:
- The left testicular vein drains directly into the left renal vein
- A renal tumor (especially renal cell carcinoma) can obstruct venous return, causing a varicocele
- This is known as the “Varicocele Sign”
- The abdominal ultrasound would allow visualization of the kidneys and retroperitoneum to rule out a renal mass or other abdominal pathology that could be causing venous obstruction.
Other options are less appropriate because:
- Scrotal ultrasound: While this would confirm the varicocele, it wouldn’t identify the potentially more serious underlying cause. It could be a reasonable second step if the abdominal ultrasound is negative.
- Scrotal exploration and ligation: This would be premature without first ruling out a more serious underlying cause. Surgical intervention for a varicocele is typically considered for pain, infertility, or testicular atrophy - none of which are mentioned in this case.
- Left orchidectomy: This is far too aggressive without evidence of testicular pathology, especially since the testis is normal on palpation.
- Discharge: This would miss a potentially serious underlying condition and is inappropriate without further investigation.
After the abdominal ultrasound, if a renal or retroperitoneal mass is identified, appropriate referral to urology/oncology would be indicated. If the ultrasound is negative, then a scrotal ultrasound could be considered as a next step to further evaluate the varicocele and testis.
soft fluctuant swelling in the right scrotum that cannot be separated from the testis. It transilluminates when a pen torch is held against it. What is the best course of action?
Ligation of patent processus vaginalis via inguinal approach
Ligation of patent processus vaginalis via a scrotal approach
Jaboulay procedure via scrotal approach
Lords procedure via scrotal approach
Aspiration
Based on the clinical description of a soft fluctuant scrotal swelling that cannot be separated from the testis and transilluminates with a pen torch, this is most consistent with a hydrocele. The best course of action would be:
Jaboulay procedure via scrotal approach
Here’s why this is the most appropriate management:
- The clinical findings (fluctuant, transilluminating, inseparable from testis) are classic for a simple hydrocele in an adult.
- The Jaboulay procedure is a standard surgical treatment for hydrocele in adults that involves:
- Scrotal approach to access the hydrocele
- Evacuation of the hydrocele fluid
- Excision of the redundant tunica vaginalis
- Plication (folding and suturing) of the remaining tunica behind the testis
- This prevents recurrence by eliminating the space where fluid can reaccumulate
The other options are less appropriate because:
- Ligation of patent processus vaginalis (via either inguinal or scrotal approach): This would be appropriate for a communicating hydrocele or indirect inguinal hernia, typically seen in children. The description doesn’t suggest communication with the peritoneal cavity, and the patient appears to be an adult.
- Lords procedure: While this is another hydrocele repair technique, it’s typically used for smaller hydroceles. The Lords procedure involves multiple small punctures in the hydrocele wall rather than excision and is generally less effective for larger hydroceles.
- Aspiration: This is only a temporary measure for hydroceles and has a high recurrence rate. It might be considered for temporary relief in poor surgical candidates or for diagnostic purposes, but is not definitive treatment.
Without knowing the patient’s age or other clinical details, the Jaboulay procedure remains the most appropriate definitive treatment for what appears to be a simple hydrocele in an adult patient.
3 month old boy is brought to the clinic by his mother who has noticed a swelling in the right hemiscrotum. On examination, there is a firm mass affecting the right spermatic cord distally, the testis is felt separately from it. What is the most likely diagnosis?
Inguino scrotal hernia
Rhabdomyosarcoma
Leydig cell tumour
Torsion of testicular hydatid
Hydrocele
The most likely diagnosis for this 3-month-old boy with a firm mass affecting the right spermatic cord distally, where the testis is felt separately, is:
Rhabdomyosarcoma.
- Rhabdomyosarcoma is a malignant tumor of mesenchymal origin and is the most common soft tissue sarcoma in children. It can occur in the genitourinary tract, including the spermatic cord, and often presents as a firm, painless mass.
- In this case, the mass is distinct from the testis, which suggests it arises from the spermatic cord rather than the testis itself. This is a classic presentation for paratesticular rhabdomyosarcoma.
- Inguino-scrotal hernia: This typically presents as a soft, reducible swelling in the scrotum that may extend into the inguinal canal. It is not firm, and the testis is not felt separately.
- Leydig cell tumor: This is a rare testicular tumor that arises from the testis itself, not the spermatic cord. The testis would not be felt separately from the mass.
- Torsion of testicular hydatid: This typically presents with acute pain and a tender, small nodule at the upper pole of the testis. It does not cause a firm mass in the spermatic cord.
- Hydrocele: This presents as a soft, fluid-filled swelling around the testis. It is not firm, and the testis is not felt separately.
The firm mass affecting the spermatic cord with the testis felt separately is most consistent with rhabdomyosarcoma. Further investigations, such as ultrasound and biopsy, would be required to confirm the diagnosis. Early referral to a pediatric oncologist is essential for appropriate management.
On a physical examination, a 28 years old man was found unable to lift his thumb from table while palm facing upwards. What is the expected nerve lesion causing this deformity?
A. Radial nerve
B. Posterior interosseous nerve
C. Median nerve
D. Anterior interosseous nerve
E. Ulnar nerve
The expected nerve lesion causing this deformity is:
D. Anterior interosseous nerve.
- The anterior interosseous nerve is a branch of the median nerve that innervates the flexor pollicis longus (FPL), flexor digitorum profundus (FDP) to the index and middle fingers, and the pronator quadratus.
- Inability to lift the thumb from the table while the palm is facing upwards (loss of flexion at the interphalangeal joint of the thumb) suggests weakness or paralysis of the flexor pollicis longus (FPL), which is supplied by the anterior interosseous nerve. This condition is known as anterior interosseous nerve syndrome or Kiloh-Nevin syndrome.
- A. Radial nerve: The radial nerve primarily innervates the extensor muscles of the wrist and fingers. A radial nerve lesion would cause wrist drop and inability to extend the fingers, not loss of thumb flexion.
- B. Posterior interosseous nerve: This is a branch of the radial nerve that innervates the extensor muscles of the forearm. A lesion would result in weakness of finger and wrist extension, not thumb flexion.
- C. Median nerve: A proximal median nerve lesion would cause weakness in thumb abduction and opposition (due to thenar muscle involvement) and sensory loss in the lateral palm and fingers. However, the specific inability to flex the thumb suggests an isolated anterior interosseous nerve lesion.
- E. Ulnar nerve: The ulnar nerve innervates the intrinsic muscles of the hand (e.g., interossei, hypothenar muscles) and the flexor digitorum profundus to the ring and little fingers. A lesion would cause claw hand deformity and weakness in finger abduction/adduction, not isolated thumb flexion loss.
The inability to lift the thumb from the table (loss of thumb flexion) is most consistent with a lesion of the anterior interosseous nerve, a branch of the median nerve. This condition is known as anterior interosseous nerve syndrome.
A 56 year old man presents with urinary symptoms and on investigation is found to have a 2cm nodule in the left lobe of the prostate. Imaging with whole body MRI and pelvic CT/MRI demonstrates a likely cancer with no distant disease and no nodal metastasis. What is the most appropriate course of action?
Robotic prostatectomy
Open prostatectomy
Transvesical prostatectomy
Prostatic biopsy
Radical pelvic radiotherapy
Based on the clinical information provided, this 56-year-old man has a 2cm nodule in the left lobe of the prostate that is suspected to be cancer, with no evidence of metastasis on comprehensive imaging. The most appropriate next step would be:
Prostatic biopsy
Here’s why this is the correct approach:
-
Diagnostic confirmation is essential: Despite the suspicious nodule and imaging findings suggesting cancer, definitive tissue diagnosis is absolutely required before proceeding with any definitive treatment. Without a biopsy:
- We don’t have confirmation that the nodule is actually malignant
- We don’t know the Gleason score/Grade Group, which is crucial for treatment planning
- We can’t determine other histological features that might influence treatment decisions
-
Treatment planning requires histopathology: The choice between surgery, radiation, active surveillance, or other approaches depends heavily on:
- Gleason score/Grade Group
- Percentage of positive cores
- Perineural invasion
- Other histological features
- Patient counseling and informed consent: To properly discuss treatment options with the patient, we need the pathology results to provide accurate information about prognosis and treatment success rates.
The other options would be premature at this stage:
- Robotic prostatectomy or Open prostatectomy: These are definitive surgical treatments that should only be performed after tissue diagnosis and proper risk stratification.
- Transvesical prostatectomy: This approach is typically used for benign prostatic hyperplasia, not cancer, and would be inappropriate regardless.
- Radical pelvic radiotherapy: Like surgery, this definitive treatment should only be offered after tissue diagnosis and proper discussion of all treatment options.
After the biopsy results are available, then the patient can be appropriately counseled on treatment options, which might include radical prostatectomy (robotic or open), radiation therapy, or in some cases, active surveillance, depending on the risk classification of his cancer.
30 year old male presents with gynaecomastia. Clinically, he is noted to have a nodule in the left testis. What is the most likely diagnosis?
Oestrogen abuse
Seminoma with syncytiotrophoblast giant cells
Teratoma
Sarcoma
Leydig cell tumour
The most likely diagnosis for this 30-year-old male with gynaecomastia and a testicular nodule is:
Leydig cell tumour.
- Leydig cell tumours are rare testicular tumours that arise from the Leydig cells in the testis. They are often hormonally active and can secrete oestrogens, leading to gynaecomastia (breast enlargement in males) due to an imbalance in the oestrogen-to-testosterone ratio.
- These tumours typically present as a painless testicular mass and may be associated with hormonal symptoms such as gynaecomastia, decreased libido, or infertility.
- Oestrogen abuse: While exogenous oestrogen use can cause gynaecomastia, it would not explain the presence of a testicular nodule.
- Seminoma with syncytiotrophoblast giant cells: Seminomas are germ cell tumours that typically do not secrete hormones. Although syncytiotrophoblast giant cells can produce beta-hCG (human chorionic gonadotropin), this is less commonly associated with gynaecomastia compared to Leydig cell tumours.
- Teratoma: Teratomas are germ cell tumours that are usually hormonally inactive and do not cause gynaecomastia.
- Sarcoma: Testicular sarcomas are rare and are not typically associated with hormonal symptoms like gynaecomastia.
The combination of gynaecomastia and a testicular nodule in a young male is most suggestive of a Leydig cell tumour. Further evaluation with testicular ultrasound and hormonal assays (e.g., testosterone, oestradiol, LH, FSH) is necessary to confirm the diagnosis. Surgical excision (radical orchiectomy) is the definitive treatment.
59-year-old patient is prepared for elective hernia repair. In the recovery room, nurses found his temperature to be 35°C (hypothermia). How will you deal with the patient?
A. Ward transfer should be arranged until temperature is 36°C or above
B. IV warm saline
C. Make ambient temperature 19°C
D. Warm by Bair Hugger and do the operation under general anesthesia
E. Do the operation under local anesthesia
Here’s the breakdown of why the best answer is B and why the others are not:
A. Ward transfer should be arranged until temperature is 36°C or above: Transferring the patient without actively addressing the hypothermia is not appropriate. Hypothermia can lead to serious complications, and the patient needs immediate intervention.
B. IV warm saline: This is a good initial step. Warming the patient from the inside out is a basic hypothermia management strategy. Warmed IV fluids help increase the core body temperature.
C. Make ambient temperature 19°C: This would actually worsen the hypothermia. A cold room will further draw heat away from the patient.
D. Warm by Bair Hugger and do the operation under general anesthesia: The patient has already had the operation. While a Bair Hugger (forced-air warming device) is an excellent method for warming, it’s being suggested in the context of re-doing the surgery, which is unnecessary.
E. Do the operation under local anesthesia: The patient has already had the operation. Changing the anesthesia type is not relevant to the current situation.
Therefore, the most appropriate initial intervention is B. IV warm saline.
Additional steps to consider (beyond the options given):
Assess the patient: Check vital signs (heart rate, blood pressure, respiratory rate, oxygen saturation), level of consciousness, and look for any other signs of complications.
Oxygen: Administer supplemental oxygen to help with oxygen delivery to tissues.
Warm blankets: Apply warm blankets to the patient’s skin.
Monitor core temperature: Continuously monitor the patient’s temperature to assess the effectiveness of warming interventions.
Investigate the cause: Try to determine why the patient became hypothermic in the first place (e.g., prolonged anesthesia, cold operating room, inadequate warming measures during surgery).
Consider other warming methods: If IV fluids and blankets are not sufficient, consider other active warming methods like a Bair Hugger, radiant warmers, or warm water immersion.
A 28-year-old male presents with severe abdominal pain, vomiting, and swelling at the stoma site three months after colostomy reversal. What is the most likely cause?
A. Wound dehiscence
B. Intestinal obstruction
C. Incarcerated incisional hernia
D. Wound infection
E. None of the above
The most likely cause of severe abdominal pain, vomiting, and swelling at the stoma site three months after colostomy reversal is C. Incarcerated incisional hernia.
- Incarcerated incisional hernia: After colostomy reversal, the site where the stoma was created is a potential weak point in the abdominal wall. An incisional hernia can develop at this site, and if the hernia becomes incarcerated (trapped), it can lead to bowel obstruction, severe pain, and swelling. This is a surgical emergency.
- Wound dehiscence (A): This typically occurs early in the postoperative period, not three months later.
- Intestinal obstruction (B): While possible, it would not specifically explain the swelling at the stoma site unless it is related to a hernia.
- Wound infection (D): This would present with redness, warmth, and discharge, but not typically with severe pain and vomiting unless it has progressed to an abscess or systemic infection.
- None of the above (E): This is less likely given the clinical presentation.
The symptoms strongly suggest an incarcerated incisional hernia, which requires urgent surgical evaluation and management.
A 30-year-old motorcyclist suffers a closed fracture of the mid shaft of the tibia. Anterior
compartment syndrome is best assessed by pain on passive:
A. Ankle dorsiflexion
B. Ankle plantar flexion
C. Mid foot eversion
D. Mid foot inversion
E. None of the above
The correct answer is:
B. Ankle plantar flexion
Explanation:
Anterior compartment syndrome occurs when increased pressure within the anterior compartment of the leg compromises circulation and function of the enclosed tissues. The anterior compartment contains the tibialis anterior, extensor hallucis longus, extensor digitorum longus, and peroneus tertius muscles, all of which are primarily responsible for dorsiflexion of the ankle and extension of the toes.
One of the key clinical signs of anterior compartment syndrome is severe pain on passive stretching of the affected muscles. Since the anterior compartment muscles are dorsiflexors, passive plantar flexion of the ankle (opposite movement) stretches these muscles, exacerbating the pain oai_citation:0‡Emergency-Pastest.pdf.
Key points:
• Early sign: Severe pain, particularly on passive muscle stretch.
• Late signs: Paraesthesia (deep peroneal nerve involvement), muscle weakness, and potential ischemic damage.
• Diagnosis: Primarily clinical, supported by compartment pressure measurements (>30-35 mmHg or a delta pressure <30 mmHg).
• Management: Urgent fasciotomy if compartment syndrome is suspected. Delayed treatment can lead to irreversible muscle and nerve damage.
A defect in Type 1 collagen leads to abnormal bone formation and mineralization. Which of the following radiographic findings is most characteristic of this condition?
A) Irregular patches of ossification
B) Wormian bones
C) Multiple fractures
D) Dense metaphyseal bands
E) Bone within bone appearance
The answer is B) Wormian bones.
Here’s why:
* Type 1 collagen is a crucial component of bone, skin, tendons, and other connective tissues. A defect in Type 1 collagen leads to Osteogenesis Imperfecta (OI), a group of genetic disorders characterized by brittle bones.
* Wormian bones are extra, small bones that can appear within the sutures of the skull. They are often seen in OI and are a characteristic radiographic finding.
Let’s look at why the other options are less likely:
* A) Irregular patches of ossification: While OI can affect bone formation, “irregular patches” isn’t the most specific or characteristic finding. This description is too general and could apply to various conditions.
* C) Multiple fractures: While multiple fractures are a consequence of OI due to bone fragility, they aren’t the most characteristic radiographic finding. Fractures are a symptom, not the underlying skeletal abnormality visualized on x-ray.
* D) Dense metaphyseal bands: These are more commonly associated with other conditions, such as lead poisoning or rickets.
* E) Bone within bone appearance: This is a classic radiographic finding of osteopetrosis, a different condition involving abnormally dense bones, not brittle bones like in OI.
12 year-old boy who is small for his age presents to the clinic with poor muscular development and hyper-mobile fingers. His x-rays show multiple fractures of the long bones and irregular patches of ossification. What is the most likely diagnosis?
Osteogenesis imperfecta
Osteoporosis
Scurvy
Osteopetrosis
Osteomalacia
The most likely diagnosis for this 12-year-old boy with poor muscular development, hyper-mobile fingers, multiple fractures, and irregular ossification is Osteogenesis Imperfecta.
Explanation:
• Osteogenesis Imperfecta (OI) is a genetic disorder characterized by brittle bones that fracture easily due to defective collagen formation.
• Clinical features include:
• Frequent fractures with minimal trauma
• Blue sclerae (though not always present)
• Hypermobile joints
• Poor muscle development
• Irregular ossification on X-rays
• X-ray Findings:
• Multiple fractures of long bones
• Wormian bones (small irregular bones in the skull)
• Thin cortices of bones with variable density
Other options:
• Osteoporosis: More common in the elderly; unlikely in a child without underlying causes.
• Scurvy (Vitamin C deficiency): Causes bone pain, gingival bleeding, and perifollicular hemorrhages, but not hypermobility.
• Osteopetrosis: Characterized by overly dense bones due to defective osteoclast function, leading to fractures, anemia, and cranial nerve compression oai_citation:0‡(A & L LANGE SERIES) Kim E. Barrett, Susan M. Barman, Heddwen L. Brooks, Jason Yuan, Scott Boitano - Ganong’s Review of Medical Physiology-McGraw-Hill Medical _ Education (2019).pdf.
• Osteomalacia: Affects adults with vitamin D deficiency and is more associated with bone softening rather than frequent fractures in childhood oai_citation:1‡LibraryFile_151638_59.pdf.
Thus, Osteogenesis Imperfecta is the most appropriate diagnosis based on the clinical and radiological findings.
Which nerve is injured during supracondylar femur fracture?
A. Sciatic nerve
B. Common peroneal nerve
C. Tibial nerve
D. Sural nerve
E. Saphenous nerve
The correct answer is:
B. Common peroneal nerve
A supracondylar femur fracture can potentially injure the common peroneal nerve, which is a branch of the sciatic nerve. The common peroneal nerve wraps around the neck of the fibula and is relatively superficial, making it vulnerable to injury during trauma or fractures in the distal femur or proximal tibia/fibula region. Injury to this nerve can result in foot drop (inability to dorsiflex the foot) and sensory deficits on the lateral leg and dorsum of the foot.
The other nerves listed are less likely to be directly affected by a supracondylar femur fracture:
- A. Sciatic nerve: While the sciatic nerve is in the vicinity, it is less commonly injured in this type of fracture.
- C. Tibial nerve: This nerve is deeper and less likely to be injured in this fracture.
- D. Sural nerve: A sensory nerve that is not typically affected by this fracture.
- E. Saphenous nerve: A branch of the femoral nerve, which is not typically injured in this fracture.
A 65-year-old male smoker with a history of ischemic heart disease and previous endovascular repair (EVAR) of an abdominal aortic aneurysm presents with acute onset of a cold, painful, and pale left foot. On examination, pulses are palpable in the affected limb. What is the most likely cause of his “trash foot”?
A. Thrombosed EVAR graft
B. Popliteal aneurysm
C. Atrial fibrillation
D. Ruptured abdominal aortic aneurysm
The most likely cause of this patient’s “trash foot” is:
A. Thrombosed EVAR graft
Explanation:
• “Trash foot” (also known as embolic or microembolization syndrome) occurs due to cholesterol embolization or thromboembolic debris showering into the distal arterial circulation.
• The patient has a history of EVAR, making thrombosis or embolization from the graft the most probable etiology.
• Palpable pulses in the affected limb suggest that the major arteries are still patent, making a proximal large vessel occlusion (like popliteal aneurysm thrombosis or atrial fibrillation embolism) less likely.
• Cholesterol embolization from the aortic graft can lead to digital ischemia, cyanosis, and pain, characteristic of “blue toe syndrome” or “trash foot”.
Why not the other options?
• B. Popliteal aneurysm: This can cause acute limb ischemia but usually presents with absent pulses distal to the occlusion, which is not seen in this patient.
• C. Atrial fibrillation: AF can cause large embolic events leading to sudden arterial occlusion, but it typically results in a non-palpable pulse distal to the occlusion, unlike the scenario given.
• D. Ruptured AAA: A ruptured AAA leads to hemodynamic instability, severe abdominal/back pain, and shock, which this patient does not have.
What is the lymphatic drainage of endometrial cancer?
A. External iliac lymph nodes
B. Para-aortic lymph nodes
C. Superficial inguinal lymph nodes
D. Deep inguinal lymph nodes
E. Internal iliac lymph nodes
1) The endometrium is part of the uterus, and its lymphatic drainage follows specific patterns that are important for cancer spread.
2) The lymphatic drainage of the uterus primarily occurs in three directions:
- Laterally along the broad ligament
- Along the round ligament
- Along the uterosacral ligaments
3) The primary lymphatic drainage of endometrial cancer follows this pattern:
- First to the pelvic lymph nodes (external and internal iliac nodes)
- Then to the para-aortic nodes
- The superficial and deep inguinal nodes are not in the primary drainage pathway
4) Between the external and internal iliac nodes, the primary drainage is to the:
EXTERNAL ILIAC LYMPH NODES
5) The para-aortic nodes are typically involved as secondary drainage, after the pelvic nodes.
Therefore, the answer is A. External iliac lymph nodes.
This represents the primary and most common lymphatic drainage pathway for endometrial cancer. While other nodes can become involved (particularly para-aortic nodes) as the disease progresses, the external iliac nodes are the primary drainage site.
A 34-year-old man has an aneurysm of a tortuous artery above the pancreas. After its ligation, which structure is most likely affected other than the spleen?
A. Head of pancreas
B. Fundus of stomach
C. Colon
D. Duodenum
E. Small bowel
The correct answer is:
B. Fundus of stomach
The scenario describes a splenic artery aneurysm, which is the most common aneurysm of the visceral arteries. The splenic artery runs along the upper border of the pancreas and is often tortuous. Ligation of the splenic artery can lead to ischemia of the spleen and potentially other structures supplied by its branches.
The fundus of the stomach is at risk because it receives blood supply from the short gastric arteries, which are branches of the splenic artery. Ligation of the splenic artery can compromise blood flow to these vessels, affecting the fundus of the stomach.
- A. Head of pancreas: The head of the pancreas is primarily supplied by the superior pancreaticoduodenal artery (from the gastroduodenal artery) and the inferior pancreaticoduodenal artery (from the superior mesenteric artery), not the splenic artery.
- C. Colon: The colon is supplied by the superior mesenteric artery (right and middle colic arteries) and the inferior mesenteric artery (left colic artery), not the splenic artery.
- D. Duodenum: The duodenum is supplied by the pancreaticoduodenal arteries, not the splenic artery.
- E. Small bowel: The small bowel is supplied by the superior mesenteric artery, not the splenic artery.
Thus, the fundus of the stomach (B) is the most likely structure to be affected after ligation of the splenic artery, other than the spleen.
A 50-year-old man falls at work and is unconscious for several minutes. At the ED, he complains of hyperacusis (increased sensitivity to sound). Which nerve is most likely injured?
A. Facial nerve
B. Mandibular branch of trigeminal
C. Maxillary branch of trigeminal
D. Ophthalmic branch of trigeminal
E. Vestibulocochlear nerve
The correct answer is:
A. Facial nerve
Explanation:
• Hyperacusis (increased sensitivity to sound) occurs due to paralysis of the stapedius muscle, which is normally responsible for dampening loud sounds.
• The stapedius muscle is innervated by the facial nerve (CN VII).
• If the facial nerve is injured, stapedius muscle paralysis results in an inability to modulate sound, leading to hyperacusis.
Why not the other options?
• B. Mandibular branch of the trigeminal nerve (V3) → Innervates the tensor tympani muscle, which also plays a role in sound modulation, but damage does not usually cause hyperacusis.
• C. Maxillary branch of the trigeminal nerve (V2) → Provides sensory innervation to the midface and maxillary sinus, not related to sound modulation.
• D. Ophthalmic branch of the trigeminal nerve (V1) → Provides sensory innervation to the forehead, cornea, and upper eyelid, unrelated to hearing.
• E. Vestibulocochlear nerve (CN VIII) → Responsible for hearing and balance, but its injury causes sensorineural hearing loss, vertigo, or tinnitus, not hyperacusis.
Key Learning Point:
• Hyperacusis → Think facial nerve (CN VII) injury affecting the stapedius muscle.
A bullet goes through the junction of the linea semilunaris and the costal
margin on the right side. Which structure will likely be injured?
A. Gall bladder fundus
B. Liver
C. Right kidney
D. Cecum
E. Appendix
Let me solve this step by step:
1) First, let’s identify the anatomical landmarks:
- Linea semilunaris is the lateral border of rectus abdominis muscle
- Costal margin is the lower border of the ribcage
- Their junction is in the right upper quadrant of the abdomen
2) At this specific junction point:
- It’s high in the abdomen (subcostal)
- It’s lateral (at the linea semilunaris)
- This puts us in the right hypochondriac region
3) Let’s consider which organs are in this region:
- Liver
- Gallbladder
- Part of right kidney (but more posterior)
- Cecum and appendix are much lower in the right iliac fossa
4) At this specific point:
- The gallbladder fundus is typically found at the intersection of the linea semilunaris and costal margin
- This is where the gallbladder projects beyond the liver’s edge
- This point is often used clinically as Murphy’s point
Therefore, the answer is A. Gall bladder fundus.
Rationale:
- The gallbladder fundus is specifically located at this anatomical landmark
- The liver, while nearby, is more superior and medial
- The kidney is more posterior
- The cecum and appendix are far too inferior to be involved
A 19 year old woman is admitted with a 48 hour history of worsening right iliac fossa pain.
She has been nauseated and vomited twice. On examination, she is markedly tender in the right
iliac fossa with localized guarding. Vaginal examination is unremarkable. Urine dipstick (including
beta HCG) is negative. Blood tests show a WCC of 13.5 and CRP 70. What is the most appropriate
course of action?
a. Open appendicectomy
b. Laparotomy
c. Abdominal ultrasound
d. Diagnostic Laparoscopy
e. Abdominal CT scan
The correct answer is:
D. Diagnostic Laparoscopy
Explanation:
• This 19-year-old woman presents with acute right iliac fossa (RIF) pain, nausea, vomiting, localized guarding, and elevated inflammatory markers (WCC 13.5, CRP 70).
• The most likely diagnosis is acute appendicitis, but in a young female, gynecological causes (e.g., ovarian cyst rupture, ectopic pregnancy, or pelvic inflammatory disease) must be ruled out.
• Beta-hCG is negative, excluding an ectopic pregnancy.
• Given the diagnostic uncertainty and the potential for gynecological pathology, diagnostic laparoscopy is the preferred approach.
Why not the other options?
• A. Open appendicectomy → Not the first-line approach if the diagnosis is uncertain. Minimally invasive techniques (laparoscopy) are preferred for both diagnosis and treatment.
• B. Laparotomy → Too invasive for an undifferentiated RIF pain case. It is typically reserved for complications like perforation or generalized peritonitis.
• C. Abdominal ultrasound → Less sensitive for appendicitis in adults, especially if bowel gas obscures the appendix. More useful in pediatric patients.
• E. Abdominal CT scan → While highly sensitive for appendicitis, CT is avoided in young women due to radiation exposure unless absolutely necessary.
Key Learning Point:
• Young female with RIF pain? Think gynecological causes!
• Diagnostic laparoscopy is the best diagnostic and therapeutic approach when appendicitis is suspected but uncertainty remains.
Most common thyroid cancer in 3 year old boy
Hurthle cell ca
Papillary ca
Follicular
Medullary anaplastic
The correct answer is Papillary thyroid carcinoma (PTC).
Explanation:
• Papillary thyroid carcinoma (PTC) is the most common thyroid cancer in children, including a 3-year-old boy.
• It accounts for >90% of pediatric thyroid cancers and has a good prognosis, even with lymph node involvement.
• Medullary thyroid carcinoma (MTC) is seen in children, but it is much rarer and usually associated with MEN2A or MEN2B syndromes.
• Follicular carcinoma is more common in older children and adults.
• Hurthle cell carcinoma is a rare variant of follicular carcinoma, very uncommon in young children.
• Anaplastic carcinoma is almost never seen in children; it is an aggressive cancer affecting older adults.
Correct answer: Papillary thyroid carcinoma (PTC)
The most commonly injured ligament in ankle injury is:
A. Posterior talofibular ligament
B. Anterior talofibular ligament
C. Deltoid ligament
D. Calcaneotalar ligament
E. None of the above
The correct answer is:
B. Anterior talofibular ligament (ATFL)
Explanation:
• The anterior talofibular ligament (ATFL) is the most commonly injured ligament in ankle sprains, especially in inversion injuries.
• It is part of the lateral ligament complex of the ankle and is the weakest of the three lateral ligaments.
• It is often injured when the foot is plantarflexed and inverted, which is a common mechanism in sports injuries.
Why not the other options?
• A. Posterior talofibular ligament: Less commonly injured, usually affected in severe ankle sprains or dislocations.
• C. Deltoid ligament: A strong medial ligament, more resistant to injury; sprains here occur with eversion injuries.
• D. Calcaneotalar ligament: Not commonly injured in typical ankle sprains.
• E. None of the above: Incorrect, as ATFL is the most frequently injured ligament.
This question has been seen in MRCS recall exams oai_citation:0‡MRCS RECALL ALL JAN EXAMS 2016 - 2021.pdf.
A 21-year-old man has been stabbed in the back of the knee, dividing the popliteal artery, and is
undergoing repair via a posterior approach. Which of the following structures is most likely to be
encountered first, when dissecting deep from the skin incision?
A. Popliteal artery
B. Popliteus muscle
C. Popliteal vein
( lateral ligament
D. Tibial nerve
E. Soleus muscle
This is a medical question about anatomy and surgical procedures. Here’s the breakdown of the answer:
Understanding the Posterior Approach to the Knee
A posterior approach to the knee means the surgeon is working from behind the knee. The popliteal fossa is the diamond-shaped area behind the knee, and it contains vital structures.
Layers of the Popliteal Fossa
When dissecting from the skin in the popliteal fossa, you encounter structures in layers. Here’s the general order from superficial to deep:
* Skin and superficial fascia: This is the outermost layer.
* Deep fascia: A tough layer of connective tissue.
* Nerve: The tibial nerve is typically the most superficial of the major structures within the popliteal fossa itself.
* Vein: The popliteal vein usually lies somewhat deeper than the nerve.
* Artery: The popliteal artery is the deepest of the major vessels in the popliteal fossa.
* Muscles: The popliteus muscle is encountered even deeper, as it forms part of the floor of the popliteal fossa.
The Answer
Given the layers, the tibial nerve (D) would be the first major structure encountered when dissecting deep from the skin incision in a posterior approach to the knee.
Important Note: This is a simplified explanation. Actual anatomy can vary, and surgeons must have a thorough understanding of the region’s anatomy to avoid complications.
A 55 years old undergo cholecystectomy and show multiple dark irregular small stones. The most
cause of theses stones is elevating blood test
A. Bile salts
B. Cholesterol
C. Conjugated bilirubin
D. Unconjugated bilirubin
E. None of the above
The presence of multiple dark irregular small stones after a cholecystectomy suggests the possibility of pigment stones, particularly if they are dark in color. These stones are primarily composed of bilirubin.
In this case, the elevation of conjugated bilirubin (Option C) is the most likely cause of the formation of these dark stones, as conjugated bilirubin is associated with the formation of pigment stones. Unconjugated bilirubin, while it does play a role in the formation of stones, typically does not lead to the formation of dark stones in the gallbladder.
Therefore, the correct answer is:
C. Conjugated bilirubin
Anterior surface gastric ulcer between the antrum and the body of stomach develops massive
bleeding, what is the most accepted artery to be affected?
A. short gastric a
B. left gastroepiploic a
C. right gastroepiploic a
D. left gastric a
E. None of the above
The most likely artery to be affected in the case of a massive bleeding gastric ulcer located between the antrum and the body of the stomach is:
D. Left gastric artery
- The left gastric artery is a major branch of the celiac trunk and supplies blood to the lesser curvature of the stomach, including the region between the antrum and the body of the stomach. This area is a common site for gastric ulcers, and bleeding from this region is often due to erosion of the left gastric artery or its branches.
- The other arteries listed (short gastric, left gastroepiploic, and right gastroepiploic) supply different regions of the stomach and are less likely to be involved in bleeding from an ulcer in this specific location.
Thus, the correct answer is D. Left gastric a.
Patient with congenital antithrombin3 came to do sigmoid colectomy, what will you prescribe for
her postoperative?
A. warfarin for 6 months
B. warfarin for 3 months
C. warfarin for life
D. heparin for 6 months
E. heparin for life
The best postoperative anticoagulation option for a patient with congenital antithrombin III (ATIII) deficiency undergoing sigmoid colectomy is lifelong heparin therapy (Option E).
Explanation:
• Congenital ATIII deficiency is a thrombophilic disorder that leads to an increased risk of venous thromboembolism (VTE), especially in surgical settings.
• Heparin works by enhancing the activity of antithrombin III, making it the most effective anticoagulant in this scenario.
• Warfarin alone is not sufficient as it inhibits vitamin K-dependent clotting factors but does not directly address the deficiency of ATIII.
• Duration: Lifelong anticoagulation is recommended for patients with severe congenital ATIII deficiency, as they are at high risk of recurrent thrombosis.
Thus, Option E (Heparin for life) is the correct answer.
A 45-year-old female came to the ER with shortness of breath, pleuritic chest pain, and fever after varicose vein surgery. CT angiography shows pulmonary embolism. What is the pathological finding in pulmonary embolism?
A. Increased PO2
B. Increased PCO2
C. Increased arterial 02
D. Increased ventilation-perfusion ratio
E. Increased diffusion
The pathological finding in pulmonary embolism is increased ventilation-perfusion (V/Q) ratio, making Option D the correct answer.
Explanation:
Pulmonary embolism (PE) occurs when a thrombus, typically from a deep vein thrombosis (DVT), lodges in the pulmonary vasculature, causing obstruction to blood flow. This results in the following pathophysiological changes:
1. Increased Ventilation-Perfusion (V/Q) Ratio:
• The embolism blocks blood flow to parts of the lung, causing areas where ventilation is maintained but perfusion is reduced, leading to an increased V/Q ratio.
• This results in inefficient gas exchange and hypoxemia.
2. Decreased Arterial PO₂ (Not Increased PO₂):
• Since perfusion is blocked, oxygen cannot effectively reach the bloodstream from the affected lung regions, leading to decreased arterial oxygen levels.
3. Decreased or Normal PCO₂ (Not Increased PCO₂):
• The hypoxemia from the embolism triggers hyperventilation, which leads to increased CO₂ elimination and decreased arterial PCO₂.
4. No Significant Increase in Diffusion:
• Pulmonary embolism primarily affects perfusion rather than the diffusion capacity of the alveolar membrane.
4 Month child with failure to thrive with recurrent chest infection and dyspnea increase with
lying flat in the night and awake him from sleep
A. TOF
B. Congenital diaphragmatic hernia
C. Asthma
D. GERD
E. None of the above
The most likely diagnosis in this 4-month-old child with failure to thrive, recurrent chest infections, and dyspnea that worsens when lying flat at night is gastroesophageal reflux disease (GERD), making Option D the correct answer.
Explanation:
1. Failure to Thrive (FTT):
• GERD can cause poor weight gain due to frequent vomiting and reduced oral intake.
2. Recurrent Chest Infections:
• GERD can lead to aspiration of gastric contents, causing recurrent respiratory infections and wheezing.
3. Dyspnea Worsening When Lying Flat (Orthopnea-like Symptoms in an Infant):
• When lying down, reflux is more likely to occur, leading to choking, coughing, and awakening from sleep.
Why Not the Other Options?
• Tetralogy of Fallot (TOF) (A):
• TOF presents with cyanotic episodes (Tet spells), usually triggered by crying or feeding. Murmur and echocardiography findings would confirm the diagnosis.
• Congenital Diaphragmatic Hernia (CDH) (B):
• CDH is usually diagnosed at birth due to severe respiratory distress. It would cause significant lung hypoplasia and be evident on imaging.
• Asthma (C):
• Rare in infants this young. Wheezing due to asthma would typically respond to bronchodilators and have an atopic history.
• None of the Above (E):
• GERD fits well with the described symptoms, making this choice unnecessary.
Next Steps:
• Diagnosis: Clinical history, pH monitoring, barium swallow study, or endoscopy if severe.
• Management:
• Conservative: Positioning therapy (keeping the infant upright after feeds), thickened feeds.
• Medical: Proton pump inhibitors (PPIs) or H2 blockers for severe cases.
• Severe cases may need fundoplication surgery.
Thus, GERD (D) is the best answer.
What portion of blood is present in the pulmonary circulation?
A. 10 to 15%
B. 20 to 25%
C. 25-30%
D. 50 to 60%
E. 60%
The portion of blood present in the pulmonary circulation is approximately 18% of the total blood volume oai_citation:0‡(A & L LANGE SERIES) Kim E. Barrett, Susan M. Barman, Heddwen L. Brooks, Jason Yuan, Scott Boitano - Ganong’s Review of Medical Physiology-McGraw-Hill Medical _ Education (2019).pdf.
Thus, the correct answer is B. 20 to 25%, as this is the closest range to the actual value.
A 35-year-old patient suffered from dyspnea and palpitation. On examination, there is a holosystolic murmur propagating to the axilla. What is the expected chamber enlargement in transesophageal echo?
A. Left atrium
B. Left ventricle
C. Right ventricle
D. Right atrium
E. Ventricle apex
The holosystolic murmur radiating to the axilla strongly suggests mitral regurgitation (MR). The expected chamber enlargement on transesophageal echocardiography would be the left atrium, making Option A (Left atrium) the correct answer.
Explanation:
1. Mitral regurgitation (MR) occurs due to incompetent closure of the mitral valve, leading to backflow of blood into the left atrium during systole.
2. Hallmark Murmur:
• Holosystolic murmur best heard at the apex and radiating to the axilla.
3. Effects on Cardiac Chambers:
• Left atrium enlarges due to chronic volume overload.
• Left ventricle may also dilate over time due to increased preload, but the left atrium is the first and most significantly affected chamber.
4. Confirmatory Test:
• Transesophageal echocardiography (TEE) would show left atrial dilation and possible mitral valve pathology.
Why Not the Other Options?
• Left ventricle (B): Enlarges later in chronic MR but is not the primary chamber affected first.
• Right ventricle (C) & Right atrium (D): These are more involved in tricuspid regurgitation or pulmonary hypertension, not MR.
• Ventricular apex (E): Not an anatomical term for chamber enlargement.
Thus, the correct answer is A. Left atrium.
During the injury of a nerve passing through the foramen ovale, which muscle will not be affected in closing the mouth?
A. Temporalis
B. Masseter
C. Buccinator
D. Medial pterygoid
E. Lateral pterygoid
The correct answer is C. Buccinator.
Explanation:
The foramen ovale transmits the mandibular nerve (V3), a branch of the trigeminal nerve (cranial nerve V). The muscles responsible for closing the mouth (elevation of the mandible) that are innervated by V3 include:
1. Temporalis (elevates and retracts the mandible)
2. Masseter (elevates the mandible)
3. Medial pterygoid (elevates the mandible)
The lateral pterygoid is responsible for jaw opening (depression of the mandible) and side-to-side movements, so it is not involved in closing the mouth.
Why is Buccinator (C) the correct answer?
• Buccinator is NOT involved in jaw closure; it functions in chewing by keeping food between the teeth but does not move the mandible.
• It is innervated by the facial nerve (CN VII), not the mandibular nerve (V3).
Thus, if the mandibular nerve (V3) is injured at the foramen ovale, all muscles of mastication will be affected except Buccinator, making C. Buccinator the correct choice.
A patient cannot ejaculate after abdominoperineal surgery involving retroperitoneal node clearance. What nerve was injured during surgery?
A. Pelvic splanchnic nerve
B. Lumber splanchnic nerve
C. Thoracic splanchnic nerve
D. Pudendal nerve
E. Iliolumbar nerve
The correct answer is B. Lumbar splanchnic nerve.
Explanation:
Ejaculation involves two main phases:
1. Emission (Sympathetic Control - Hypogastric Nerve, L1-L2)
• Involves contraction of the vas deferens, seminal vesicles, and prostate to propel semen into the urethra.
• Controlled by the lumbar splanchnic nerves (L1-L2), which contribute to the inferior hypogastric plexus.
2. Ejaculation (Somatic and Parasympathetic Control - Pudendal Nerve, S2-S4)
• Rhythmic contraction of the bulbospongiosus muscle via the pudendal nerve (S2-S4).
How Does Surgery Affect This?
• Retroperitoneal lymph node dissection (RPLND) or abdominoperineal surgery can injure the lumbar splanchnic nerves (L1-L2), leading to loss of emission (failure to transport sperm into the urethra), resulting in retrograde ejaculation or anejaculation.
Why Not the Other Options?
• Pelvic splanchnic nerve (A) (S2-S4): Controls parasympathetic erection, not ejaculation.
• Thoracic splanchnic nerve (C) (T5-T12): Primarily involved in abdominal visceral function, not ejaculation.
• Pudendal nerve (D) (S2-S4): Controls somatic ejaculation (muscle contraction) but does not control emission.
• Iliolumbar nerve (E): Primarily involved in sensory and muscular function in the lower back, unrelated to ejaculation.
Final Answer:
B. Lumbar splanchnic nerve (L1-L2) is responsible for emission, and its injury leads to ejaculation failure.
A young man with mid gut Volvulus has 250cm of small bowel left after massive resection. What is the best nutritional option?
A. Total parenteral nutrition
B. Can be fed orally
C. Feeding jejunostomy
D. Percutaneous endoscopic gastrostomy
E. Nasogastric tube
The best nutritional option for a young man with midgut volvulus and 250 cm of small bowel left after massive resection depends on several factors, including the functionality of the remaining bowel, the patient’s ability to tolerate oral intake, and the presence of any complications such as short bowel syndrome.
Here’s a breakdown of the options:
A. Total parenteral nutrition (TPN):
- TPN is used when the patient cannot absorb sufficient nutrients through the gastrointestinal tract. While it may be necessary initially after massive resection, it is not the best long-term option due to risks like infections, liver dysfunction, and metabolic complications.
B. Can be fed orally:
- If the remaining 250 cm of small bowel is functional and the patient can tolerate oral intake, this is the best option. The small intestine can adapt over time, and oral feeding is the most natural and least invasive method. However, the patient may need supplemental vitamins, minerals, and possibly specialized oral formulas to meet nutritional needs.
C. Feeding jejunostomy:
- A feeding jejunostomy is an option if oral intake is insufficient or not tolerated. It allows direct feeding into the jejunum, bypassing the stomach. This may be useful in the short term but is not ideal for long-term management if oral feeding is possible.
D. Percutaneous endoscopic gastrostomy (PEG):
- PEG is typically used for long-term enteral feeding when oral intake is not possible. However, it is less suitable for patients with short bowel syndrome, as the stomach and duodenum may not be the primary sites of nutrient absorption.
E. Nasogastric tube:
- A nasogastric tube is a short-term solution for feeding or decompression. It is not suitable for long-term nutritional support due to discomfort and risks like aspiration or tube displacement.
Best Answer:
B. Can be fed orally
- If the patient can tolerate oral intake and the remaining small bowel is functional, oral feeding is the best option. The patient may require dietary modifications, supplements, and close monitoring to ensure adequate nutrition. If oral intake is insufficient, a combination of oral feeding and supplemental enteral nutrition (e.g., via a feeding jejunostomy) may be considered. TPN should only be used if enteral feeding is not feasible.
A 51-year-old patient with Crohn’s disease undergoes surgery for
postoperative nutrition?
A. Start oral
B. Start oral with special formula
C. Nasogastric tube
D. TPN with a peripheral line
E. TPN at home
The best answer here is C. Nasogastric tube.
Here’s the reasoning:
* Post-operative nutrition after bowel surgery in a patient with Crohn’s disease requires careful consideration. The bowel needs time to heal, and oral intake may not be immediately tolerated.
* A. Start oral: This is unlikely to be appropriate immediately after bowel surgery, especially with Crohn’s disease, as it could irritate the healing bowel.
* B. Start oral with special formula: While a special formula might be used later, it’s not the first-line choice immediately post-op. The gut needs a rest.
* C. Nasogastric tube: This allows for enteral feeding (feeding directly into the gut) which is preferred over parenteral nutrition (TPN) whenever possible. It provides nutrition while bypassing the surgical site and allowing the bowel to rest and heal. It’s a less invasive option than TPN.
* D. TPN with a peripheral line: TPN (Total Parenteral Nutrition) is a method of providing nutrition intravenously, bypassing the gut entirely. While TPN is sometimes necessary, it carries more risks (infection, blood clots) than enteral feeding and is generally reserved for situations where the gut cannot be used. A peripheral line isn’t ideal for long-term TPN and is more suitable for short-term nutritional support.
* E. TPN at home: TPN at home is a long-term solution. It’s not the immediate course of action post-operatively.
Therefore, a nasogastric tube for enteral feeding is the most appropriate initial approach for post-operative nutrition in this patient. TPN would be considered if enteral feeding is not tolerated or feasible.
The radial nerve course is mainly posterior all through its course. At which anatomical spot does the radial nerve travel from the posterior group to the anterior group?
• A. Spiral groove
• B. Cubital tunnel
• C. 10 cm above radio capitular joint
• D. 1 cm above the insertion of biceps
• E. None of the above
The correct answer is:
C. 10 cm above the radio-capitellar (radio-capitular) joint
Explanation:
• The radial nerve originates from the posterior cord of the brachial plexus and primarily courses posteriorly through the arm.
• It travels through the spiral groove of the humerus but remains in the posterior compartment.
• Around 10 cm above the radio-capitellar joint, the radial nerve pierces the lateral intermuscular septum and moves from the posterior to the anterior compartment.
• It then continues anteriorly in the forearm, where it divides into the superficial (sensory) and deep (motor) branches at the level of the elbow.
Why not the other options?
• A. Spiral groove – The radial nerve is still in the posterior compartment at this point.
• B. Cubital tunnel – This is related to the ulnar nerve, not the radial nerve.
• D. 1 cm above the insertion of biceps – This is too distal; by this point, the radial nerve has already moved anteriorly.
• E. None of the above – Incorrect, as option C is correct.
Thus, the correct answer is C. 10 cm above the radio-capitellar joint.
Which structure is the deepest in the posterior compartment of the leg?
• A. Tibial artery
• B. Fibular artery
• C. Tibial nerve
• D. Saphenous nerve
• E. Tibialis posterior muscle
The correct answer is:
E. Tibialis posterior muscle
Explanation:
In the posterior compartment of the leg, structures are arranged from superficial to deep as follows:
1. Superficial layer – Gastrocnemius, soleus, plantaris
2. Deep layer – Popliteus, tibialis posterior (deepest), flexor digitorum longus, flexor hallucis longus
3. Neurovascular structures – The tibial nerve and posterior tibial artery run superficial to tibialis posterior.
Why not the other options?
• A. Tibial artery – Lies superficial to tibialis posterior.
• B. Fibular artery – A branch of the posterior tibial artery, but still not as deep as tibialis posterior.
• C. Tibial nerve – Runs with the posterior tibial artery, also superficial to tibialis posterior.
• D. Saphenous nerve – This is a superficial cutaneous nerve in the leg, not in the deep posterior compartment.
Thus, the deepest structure in the posterior compartment of the leg is the tibialis posterior muscle (E).
A patient cannot hold a piece of paper between the thumb and index fingers without flexion. The described deformity is a result of injury to which nerve?
• A. Recurrent branch of the median nerve
• B. Superficial ulnar nerve
• C. Deep ulnar nerve
• D. Deep branch of the radial nerve
• E. Posterior interosseous nerve
The inability to hold a paper between the thumb and index finger without the thumb flexing indicates that the patient is compensating for weakness of the adductor pollicis muscle. Normally, the adductor pollicis—innervated by the deep branch of the ulnar nerve—helps to hold the thumb in the proper position during pinch grip. When this muscle is weakened due to an injury to the deep branch of the ulnar nerve, the patient compensates by flexing the thumb using the flexor pollicis longus (innervated by the median nerve), which is seen as abnormal thumb flexion during the pinch.
Thus, the described deformity is most consistent with an injury to the deep ulnar nerve.
Answer: C. Deep ulnar nerve
A 54-year-old female typist presented to the clinic with features of carpal tunnel syndrome. Which of the following muscles is most likely to be non-functioning?
• A. Flexor pollicis longus
• B. Flexor digitorum profundus
• C. Flexor pollicis brevis
• D. 4th lumbricals
• E. Flexor carpi ulnaris
The correct answer is:
C. Flexor pollicis brevis
Explanation:
Carpal Tunnel Syndrome (CTS) is caused by compression of the median nerve as it passes through the carpal tunnel at the wrist. The median nerve innervates several muscles in the hand, primarily those in the thenar eminence and lumbricals to the lateral two fingers (index and middle fingers).
Muscle Innervation and Function
Flexor pollicis longus (Option A) – Median nerve (anterior interosseous branch, C8-T1)
Involved in thumb flexion.
This muscle remains functional in CTS because its nerve branch (anterior interosseous) arises before the carpal tunnel.
Flexor digitorum profundus (Option B) – Dual innervation: median nerve (lateral part for index and middle fingers), ulnar nerve (medial part for ring and little fingers)
This muscle flexes the DIP joints of fingers.
Only the lateral half (index and middle fingers) is innervated by the median nerve, but it is not affected in CTS as it receives innervation proximal to the carpal tunnel.
Flexor pollicis brevis (Option C) – Thenar muscle
Superficial head: Innervated by the median nerve (via the recurrent branch), which gets compressed in CTS.
Deep head: Innervated by the ulnar nerve.
The superficial head is affected in CTS, leading to weak thumb flexion and opposition.
4th lumbrical (Option D) – Ulnar nerve (C8-T1)
The lumbricals to the ring and little fingers are supplied by the ulnar nerve, which is not affected in CTS.
Flexor carpi ulnaris (Option E) – Ulnar nerve
The flexor carpi ulnaris is exclusively ulnar nerve innervated, so it is not involved in CTS.
Why is Flexor Pollicis Brevis Most Likely to be Affected?
The recurrent branch of the median nerve, which supplies the thenar muscles (including flexor pollicis brevis, abductor pollicis brevis, and opponens pollicis), arises after the carpal tunnel.
Compression of the median nerve in CTS leads to thenar muscle weakness, causing difficulty in thumb opposition, flexion, and abduction.
This results in thenar muscle atrophy, seen in chronic CTS cases.
Key Clinical Features of Median Nerve Injury in CTS
Pain and numbness in the lateral 3.5 fingers (thumb, index, middle, and half of the ring finger).
Weakness of thumb opposition due to involvement of thenar muscles.
Sparing of the flexor pollicis longus and flexor digitorum profundus (as their innervating branches arise proximal to the carpal tunnel).
Wasting of the thenar eminence in chronic cases.
Final Answer:
C. Flexor pollicis brevis (superficial head) is most likely to be non-functional in carpal tunnel syndrome due to median nerve compression.
A 52-year-old female is in the postoperative clinic after a right mastectomy.
She complains of a weak right-hand grasp as she cannot lift her suitcase, but she can write with her thumb and index. What is the expected nerve injury?
• A. Posterior cord
• B. Anterior interosseous nerve
• C. Medial brachial plexus
• D. Recurrent median nerve
• E. Ulnar nerve
Here’s how to break down the scenario to find the correct answer:
* Right mastectomy: This surgery involves the breast and often the axillary lymph nodes, which are near the brachial plexus.
* Weak right-hand grasp: This points to motor weakness in the hand.
* Can write with thumb and index: This indicates that the median nerve function affecting the thenar muscles (used for fine motor skills like writing) is mostly intact.
* Cannot lift suitcase: This suggests weakness in stronger grasping motions.
Considering these points:
* A. Posterior cord: The posterior cord gives rise to the axillary and radial nerves. Radial nerve damage would cause wrist drop and weakness in extension, which isn’t the primary complaint here.
* B. Anterior interosseous nerve: The anterior interosseous nerve (a branch of the median nerve) affects the flexor pollicis longus, flexor digitorum profundus (index and middle fingers), and pronator quadratus. Damage would disrupt the “OK” sign (pinching index finger and thumb), which is not described.
* C. Medial brachial plexus: The medial brachial plexus gives rise to the medial cord, which gives rise to the medial pectoral, medial cutaneous nerve of the arm, medial cutaneous nerve of the forearm and the ulnar nerve. Damage to the medial brachial plexus would cause a wider range of symptoms than just a weak grip.
* D. Recurrent median nerve: The recurrent branch of the median nerve innervates the thenar muscles. The patient can write, showing that this nerve is relatively intact.
* E. Ulnar nerve: The ulnar nerve is responsible for the intrinsic muscles of the hand, which are crucial for grip strength. Damage to the ulnar nerve can cause weakness in grip and difficulty with fine motor movements. A weak grip, with the ability to write, is highly suggestive of ulnar nerve damage.
Therefore, the most likely answer is E. Ulnar nerve.
A 70-year-old male patient with a history of prostate cancer presents to the oncology clinic for a follow-up appointment: Over the past few months, he has experienced increasing back pain and discomfort, particularty in his lower spine and hips.
Imaging studies, including a bone scan, are performed to assess for possible bone metastases, a common site of spread for prostate cancer. The radiology report notes the presence of several areas of increased bone density. What is the most likely type of bone lesion associated with prostatic bone metastases?
A. Lytic lesion
B. Reactive sclerosis
C.Mixed lytic and sclerotic lesions
D.Bone cyst
E. Osteopenia
The most likely type of bone lesion associated with prostatic bone metastases is:
B. Reactive sclerosis
Explanation:
Prostate cancer commonly metastasizes to bones, particularly the axial skeleton (spine, pelvis, ribs). Unlike many other cancers that cause lytic (destructive) bone lesions, prostate cancer typically produces sclerotic (osteoblastic) lesions, leading to increased bone density on imaging studies such as X-rays and bone scans oai_citation:0‡Image-Pastest.pdf. These sclerotic lesions appear as areas of increased bone formation due to the osteoblastic activity stimulated by metastatic prostate cancer cells oai_citation:1‡EMRCS and pas test MCQs -1.pdf.
Why not the other options?
• Lytic lesions: More common in cancers like multiple myeloma, renal cell carcinoma, and lung cancer oai_citation:2‡EMRCS and pas test MCQs -1.pdf.
• Mixed lytic and sclerotic lesions: Seen in some malignancies like breast cancer but are not the dominant pattern in prostate cancer.
• Bone cysts: These are usually benign and not associated with prostate cancer metastases.
• Osteopenia: Represents decreased bone density, whereas prostate cancer metastases result in increased bone density (sclerosis).
Conclusion:
Prostate cancer metastases are characteristically sclerotic, making reactive sclerosis the best answer.
A 35-year-old male patient presents to the Emergency Department after sustaining a head injury. On examination, he has a depressed skull fracture. but he is conscious, alert, and oriented. His
Glasgow Coma Scale (GCS) score is 15, and his vital signs are stable. The medical team needs to determine the appropriate next step in managing this patient to ensure that any potential complications, such as intracranial hemorage or brain injury, are promptly identified and treated. What is the next step in the management of this patient?
A.Perform a CT scan in 8 hours
B.Perform a CT scan within 1 hour C.Monitor GCS and vital signs
D.Refer to a neurosurgeon
E. Discharge with instructions for home observation
The correct answer is:
B. Perform a CT scan within 1 hour.
Explanation:
According to NICE guidelines, an urgent CT scan within 1 hour is indicated in patients with a depressed skull fracture, regardless of their GCS score, due to the increased risk of intracranial injury. Other indications for an immediate CT scan include:
• GCS < 13 at any time
• GCS < 15 two hours after the injury
• Signs of basal skull fracture (e.g., Battle’s sign, haemotympanum)
• Post-traumatic seizure
• Focal neurological deficits
• More than one episode of vomiting oai_citation:0‡Neurology-Pastest.pdf.
Why not the other options?
• A. Perform a CT scan in 8 hours – Delaying imaging in a patient with a depressed skull fracture is inappropriate as early detection of potential complications (e.g., intracranial bleeding) is crucial.
• C. Monitor GCS and vital signs – While observation is important, imaging is necessary to rule out significant intracranial pathology.
• D. Refer to a neurosurgeon – While neurosurgical involvement is needed if there is an underlying brain injury, the first step is to confirm the diagnosis with a CT scan.
• E. Discharge with instructions for home observation – This is unsafe for a patient with a skull fracture, as they are at risk of delayed complications.
Thus, an immediate CT scan within 1 hour is the next best step in management.
A 40-year-old male presents to the clinic with a concern about an asymmetrical smile that he: noticed developing over the past few weeks, On examination, the patient is found to have a noticeable drop on one side of his mouth when attempting to smile, indicating facial nerve involvement. The medical team is assessing the likely cause and determining which specific branch of the facial nerve is responsible for the asymmetry in his smile. Which branch of the facial nerve most likely responsible for the asymmetrical smile?
Temporal branch
zygomatic branch
Buccal branch
Marginal mandibular branch
Cervical branch
The correct answer is:
D. Marginal mandibular branch
Explanation:
The marginal mandibular branch of the facial nerve supplies the depressor anguli oris, depressor labii inferioris, and mentalis muscles. Injury to this branch results in an asymmetrical smile because the patient cannot properly depress the corner of the mouth on the affected side oai_citation:0‡GET_THROUGH_MRCS_Anatomy.pdf.
Why not the other options?
• Temporal branch: Controls eyebrow movement and forehead muscles.
• Zygomatic branch: Responsible for eye closure (orbicularis oculi).
• Buccal branch: Involved in movements of the upper lip, such as blowing out cheeks.
• Cervical branch: Controls the platysma, which affects neck movement rather than the smile.
Since the marginal mandibular branch specifically affects lower lip movement and smiling, it is the best answer.
A 45-year-old male patient is brought to the emergency department after being found unresponsive at home. The patient has a history.of chronic pain and was recently prescribed morphine for pain management. On arrival, the patient is note to have shallow breathing, a decreased level of consciousness, and pinpoint pupils. Concerned about opioid overdose, the medical team performs an arterial blood gas (ABG) analysis, which reveals the following results:
pH: 7.28 (Low)
- pCO2: 60 mmHg (High)
HCO3-: 24 mEq/l (Normal)
What is your diagnosis based on the ABG results and the clinical scenario?
A.Uncompensated respiratory acidosis
B.Uncompensated metabolic acidosis
C. Compensated respiratory acidosis
D.Respiratory alkalosis
E. Compensated metabolic acidosis
The correct answer is:
A. Uncompensated respiratory acidosis
Explanation:
This patient has opioid overdose, which leads to respiratory depression and hypoventilation, causing CO₂ retention (hypercapnia). This results in a respiratory acidosis, as seen in the ABG findings:
• pH: 7.28 (Low) → Indicates acidosis.
• pCO₂: 60 mmHg (High) → Elevated CO₂ confirms respiratory cause.
• HCO₃⁻: 24 mEq/L (Normal) → No metabolic compensation has occurred yet.
Since the bicarbonate (HCO₃⁻) is still within the normal range, there is no renal compensation, meaning this is an acute (uncompensated) respiratory acidosis.
Why not the other options?
• B. Uncompensated metabolic acidosis → Would have low HCO₃⁻ and normal/low pCO₂, not high pCO₂.
• C. Compensated respiratory acidosis → Compensation involves increased HCO₃⁻, which is not seen here.
• D. Respiratory alkalosis → Would have high pH and low pCO₂, opposite to this case.
• E. Compensated metabolic acidosis → Would have low HCO₃⁻ with low pCO₂ (respiratory compensation), which is not the case here.
Conclusion:
This is an acute opioid-induced respiratory acidosis due to hypoventilation. Naloxone should be administered to reverse the opioid effects and restore normal respiration.
What feature is not seen in tetraology of Fallot (TOF)?
A. Large ventricular septal defect
B. Right ventricular outflow tract obstruction
C. Overriding aorta
D. Left ventricular hypertrophy
There are four main features in tetralogy of Fallot.
These include:
Right ventricular outflow tract (RVOT) obstruction, which may be narrowing at, below, or above the pulmonary valve
A large ventricular septal defect (VSD)
The aorta overriding the ventricular septal defect
Right ventricular hypertrophy (RVH)
Left ventricular hypertrophy is not typically a feature in tetralogy of Fallot, so D is correct.
A 62-year-old man with a 20-year history of gastroesophageal reflux disease (GERD) is undergoing surveillance endoscopy after a previous diagnosis of Barrett’s esophagus. He reports occasional heartburn despite being on proton pump inhibitor therapy. During endoscopy, a 3-cm segment of abnormal, salmon-colored mucosa is visualized in the distal esophagus with an area of nodularity. Targeted biopsies of the nodular region reveal high‐grade dysplasia. Which of the following is the most appropriate next step in management?
A-Repeat endoscopy in 12 months with continued PPI therapy
B-Endoscopic submocosal resection followed by radiofrequency ablation
C-Immediate esophagectomy
D-Radiofrequency ablation only
E-Photodynamic therapy
Correct Answer Explanation:
Correct Answer: Endoscopic mucosal resection (EMR) followed by radiofrequency ablation (RFA) is indicated for Barrett’s esophagus with high-grade dysplasia (HGD), particularly when a nodular area is present. EMR facilitates removal of the nodular lesion and permits histopathological evaluation to exclude invasive carcinoma. Subsequently, RFA is employed to eradicate the remaining dysplastic Barrett’s epithelium, thereby reducing the risk of progression to esophageal adenocarcinoma.
Incorrect Answer Explanations:
Surveillance with repeat endoscopy is appropriate for Barrett’s esophagus without dysplasia or with low-grade dysplasia under certain circumstances, but HGD necessitates more aggressive therapy rather than mere monitoring, even though proton pump inhibitor therapy is continued.
Immediate esophagectomy, while definitive, is reserved for cases where invasive carcinoma is confirmed or if endoscopic management fails. Given that the patient’s lesion is amenable to endoscopic evaluation and treatment, this approach is overly aggressive and associated with higher morbidity.
Radiofrequency ablation alone may be considered when there is no nodularity. In the presence of a nodular lesion, EMR is necessary to obtain tissue for definitive histological diagnosis to exclude invasive cancer prior to RFA.
Photodynamic therapy is an alternative ablation method for Barrett’s esophagus with dysplasia; however, it is less favored due to its adverse effects (such as photosensitivity and stricture formation) compared to the well tolerated RFA regimen.
A 58-year-old man with a 10-year history of gastroesophageal reflux disease (GERD) was diagnosed with Barrett’s esophagus 2 years ago. During routine surveillance, endoscopy revealed low-grade dysplasia, and he underwent radiofrequency ablation (RFA). One year later, repeat endoscopy confirms complete eradication of dysplasia. Considering current evidence on the cost-effectiveness and long-term outcomes of RFA for Barrett’s esophagus with dysplasia, which of the following best describes the expected long-term prognosis for this patient?
A-Sustained eradication of dysplasia with low recurrence rates over 3 to 5 year follow-up, especially in patients with low grade dysplasia
B-Frequent recurrence of dysplasiawithin one year requiring multiple sessions of ablation
C-Progression to high-grade dysplasia and esophageal adenocarcinoma despite the initial eradication
D-High incidence of strictures post RFA, that significantly compromise long-term outcomes and cost-effectiveness
E-Outcomes equivalent to those seen with esophagectomy, with comparable morbidity and mortality rates
Correct Answer Explanation:
Correct Answer: RFA in patients with Barrett’s esophagus and low-grade dysplasia leads to sustained eradication of dysplasia with low recurrence rates over a 3- to 5-year period. Multiple studies have shown that the effective elimination of dysplasia through RFA significantly reduces the progression to high-grade dysplasia or adenocarcinoma, especially in patients initially diagnosed with low-grade dysplasia. Continued surveillance is important, but the overall prognosis remains favorable.
Incorrect Answer Explanations:
This choice is incorrect because although recurrence of dysplasia can occur after RFA, frequent recurrences within one year requiring multiple ablation sessions are not typical, particularly in patients with low-grade dysplasia.
This option is incorrect as the progression to high-grade dysplasia and esophageal adenocarcinoma is significantly reduced following successful RFA in patients with low-grade dysplasia.
This option is incorrect because the incidence of strictures post-RFA is low and most strictures can be managed effectively with endoscopic dilation. They do not significantly compromise long-term outcomes or cost-effectiveness.
This answer is incorrect given that outcomes of RFA are not equivalent to those of esophagectomy. Esophagectomy is a more invasive procedure with higher morbidity and mortality, and it is generally reserved for more advanced disease.
A 32-year-old is brought to the emergency department after a fall.
Investigations revealed a distal radial fracture for which he underwent
casting. Two weeks later, he presents back with pain and an inability to
extend his thumb. What is the most likely diagnosis?
A. Extensor pollicis longus tendon rupture
B. Complex regional pain syndrome Type 1 (reflex sympathetic dystrophy)
C. Posterior interosseous nerve injury
D, Displaced fracture
E. Radial nerve injury
Correct Answer: A. Extensor pollicis longus tendon rupture
Explanation:
The extensor pollicis longus (EPL) tendon is particularly vulnerable to rupture following a distal radial fracture, even if the fracture is undisplaced. The rupture often occurs due to ischemia, mechanical attrition, or inflammation associated with the healing process. It is commonly seen around 2–6 weeks after the initial injury.
The classic presentation includes:
• Pain at the wrist
• Inability to extend the thumb (loss of EPL function)
• Intact sensation (helping differentiate it from nerve injuries)
Why not the other options?
• B. Complex regional pain syndrome (CRPS) Type 1 – This would present with burning pain, allodynia, swelling, and skin changes, rather than an isolated thumb extension deficit.
• C. Posterior interosseous nerve (PIN) injury – PIN injury causes finger and wrist drop but spares the sensory function. However, it typically results from direct trauma or compression rather than a simple cast immobilization.
• D. Displaced fracture – A displaced fracture would typically cause deformity, swelling, or malalignment, rather than an isolated tendon rupture.
• E. Radial nerve injury – A radial nerve injury would cause wrist drop and sensory deficits in the dorsal hand, which are absent in this case.
Takeaway:
EPL tendon rupture is a well-known complication of distal radial fractures and should be suspected when a patient presents with inability to extend the thumb weeks after injury. Surgical tendon transfer (e.g., Extensor indicis proprius to EPL) is often required for management.
Sympathetic relay on which part at spinal cord :
A. Anterior horn
B. Dorsal horn
C. lateral horn
D. medial horn
E. none of the above
The correct answer is:
C. lateral horn
The sympathetic relay occurs in the lateral horn of the spinal cord, specifically in the intermediolateral cell column (IML). This region is found in the thoracic and upper lumbar segments (T1-L2) of the spinal cord, where preganglionic sympathetic neurons are located. These neurons send their axons out through the ventral roots to synapse with postganglionic neurons in sympathetic ganglia.
Pancost tumor which nerve is affected
A. T1
B. C8
C. C7
D. C5
E. None of the above
The correct answer is:
A. T1
A Pancoast tumor (a type of lung cancer located at the apex of the lung) often affects the T1 nerve root and sometimes the C8 nerve root. The tumor can invade the brachial plexus, leading to symptoms such as pain, weakness, and atrophy in the affected arm, as well as Horner’s syndrome (ptosis, miosis, and anhidrosis) due to involvement of the sympathetic chain. The T1 nerve root is most commonly affected because of its proximity to the tumor location.
Patient with abdominal pain and Ca 3.7mmol/l (normal2-2.5mmol/l). management :
A. Calcium gluconate
B. I.V saline infusion
C. Zoledronates
D. Pamidronates
E. None of the above
The correct answer is:
B. I.V saline infusion
The patient has hypercalcemia (elevated calcium level of 3.7 mmol/L, normal range 2–2.5 mmol/L). The initial management of hypercalcemia, especially if symptomatic (e.g., abdominal pain, dehydration, or altered mental status), includes:
- Intravenous (I.V.) saline infusion: This is the first-line treatment to correct dehydration and promote calcium excretion through the kidneys (via forced diuresis).
- Loop diuretics (e.g., furosemide) may be added after rehydration to enhance calcium excretion.
- Bisphosphonates (e.g., zoledronate or pamidronate) are used for long-term control of hypercalcemia, particularly in cases of malignancy-related hypercalcemia, but they are not the first step in acute management.
- Calcium gluconate is used for hypocalcemia, not hypercalcemia.
Thus, the immediate management for this patient is I.V. saline infusion.
Maintenance Fluid in the postoperative period ???
A. 1 L of 0.9 % saline plus 1.5 L. of 4 % dextrose/0.18 % saline
B. 1 L of 0.9 % saline plus 1.5 L of 5 % dextrose
C. 1 L of 0.9 % saline plus 1.5 L of Hartmann’s solution
D. 2 L of 0.9% saline
E. 2 L of 4 % dextrose/0,18 % saline
The correct answer is:
B. 1 L of 0.9 % saline plus 1.5 L of 5 % dextrose
In the postoperative period, maintenance fluids are used to replace normal daily losses and maintain electrolyte balance. The standard maintenance fluid regimen typically includes:
- Water: 25–30 mL/kg/day (approximately 2–2.5 L for a 70 kg adult).
- Sodium: 1–2 mmol/kg/day.
- Potassium: 1 mmol/kg/day.
The choice of fluids should provide both electrolytes and glucose to meet these requirements.
- 0.9% saline provides sodium and chloride but no potassium or glucose.
- 5% dextrose provides free water and glucose but no electrolytes.
- Combining 1 L of 0.9% saline (to provide sodium) with 1.5 L of 5% dextrose (to provide free water and glucose) is a common and appropriate regimen for postoperative maintenance fluid therapy.
The other options are incorrect because:
- A: 4% dextrose/0.18% saline provides insufficient sodium.
- C: Hartmann’s solution is more commonly used for fluid resuscitation rather than maintenance.
- D: 2 L of 0.9% saline provides excessive sodium and no glucose.
- E: 4% dextrose/0.18% saline provides insufficient sodium and is not typically used for maintenance.
Flail chest, no pneumothorax but pain on inspiration Management plan ? A. Infiltration by 2% lignocaine B. Infiltration by 1% or 0.5 bupivacaine C. chest drains with suction D. chest drains without suction E. none of the above
The correct answer is:
B. Infiltration by 1% or 0.5% bupivacaine
In a patient with flail chest (a segment of the rib cage detached due to multiple rib fractures) and pain on inspiration, the primary management focuses on pain control to improve ventilation and prevent complications like atelectasis or pneumonia.
- Local anesthetic infiltration (e.g., 1% or 0.5% bupivacaine) is a good option for pain relief, as it provides longer-lasting analgesia compared to lignocaine.
- Epidural analgesia is another effective option for pain management in flail chest, but it is not listed here.
- Chest drains are not indicated in the absence of pneumothorax or hemothorax.
- Lignocaine (option A) provides shorter-lasting pain relief compared to bupivacaine.
Thus, the best choice among the options is B. Infiltration by 1% or 0.5% bupivacaine.
Preterm baby found drowsy & floppy immediately post-partum. what is your diagnosis?
A. Acute subdural hemorrhage
B. Extradural hemorrhage
C. Sub arachnoid hemorrhage
D. Intraventricular hemorrhage
E. None of the above
The correct answer is:
D. Intraventricular hemorrhage
A preterm baby who is drowsy and floppy immediately post-partum is most likely suffering from intraventricular hemorrhage (IVH). This condition is common in preterm infants, particularly those born before 32 weeks of gestation, due to the fragility of the germinal matrix vasculature in the developing brain.
- Intraventricular hemorrhage can lead to symptoms such as lethargy, hypotonia (floppiness), apnea, and seizures.
- Acute subdural hemorrhage (A) and extradural hemorrhage (B) are more commonly associated with traumatic deliveries, such as those involving forceps or vacuum extraction, and are less likely in preterm infants.
- Subarachnoid hemorrhage (C) can occur in newborns but is less common than IVH in preterm infants.
Thus, the most likely diagnosis in this scenario is D. Intraventricular hemorrhage.
25 years old man presented with a shiny tense palm skin after a displaced wrist fracture. What is the most likely cause? A. Regional pain syndrome B. Carpal tunnel syndrome C. Dupuytrens contracture D. Hemarthrosis
The most likely cause of a shiny, tense palm skin after a displaced wrist fracture is Regional Pain Syndrome (Complex Regional Pain Syndrome, CRPS).
Explanation:
CRPS is a condition that can develop after an injury, such as a wrist fracture, and is characterized by:
• Shiny, tense skin
• Pain out of proportion to the injury
• Swelling and stiffness
• Temperature changes (hot or cold)
• Hyperalgesia and allodynia (increased pain sensitivity)
This condition occurs due to dysregulated autonomic and inflammatory responses in the affected limb.
Answer: A. Regional Pain Syndrome (CRPS)
Other options:
• B. Carpal Tunnel Syndrome: Usually presents with numbness, tingling, and weakness in the median nerve distribution but does not typically cause shiny or tense skin.
• C. Dupuytren’s Contracture: Causes progressive palmar fibrosis and finger contractures, but it does not develop acutely after a fracture.
• D. Hemarthrosis: Involves bleeding into a joint, typically causing joint swelling rather than changes in the skin texture.
This scenario fits well with Complex Regional Pain Syndrome (CRPS), which can follow trauma such as a wrist fracture
A 23 years old patient was admitted after falling on his outstretched hand. His examination revealed that his thumb is extended and adducted with lost other thumb movements. What is the most accepted cause of this injury?
A. Hook of hamate fracture
B. Distal radial fracture
C. Lunate dislocation.
D. Scaphoid fracture
E. Montagea fracture
The most accepted cause of thumb extension and adduction with loss of other movements following a fall on an outstretched hand is lunate dislocation.
Answer: C. Lunate dislocation
Explanation:
Lunate dislocation can cause compression of the median nerve, leading to loss of opposition, flexion, and abduction of the thumb. The characteristic “spilled teacup sign” on lateral wrist X-ray is diagnostic of lunate dislocation. The dislocated lunate may impinge on the median nerve, affecting the thenar muscles except for the adductor pollicis (which is supplied by the ulnar nerve), leading to the described clinical picture.
Why not the other options?
• A. Hook of hamate fracture → Typically affects the ulnar nerve, leading to weakness of intrinsic hand muscles, not isolated thumb movement loss.
• B. Distal radial fracture → Could cause median nerve compression (e.g., in Colles’ fracture), but is less likely to cause complete loss of thumb movement.
• D. Scaphoid fracture → Presents with snuffbox tenderness and risks avascular necrosis, but does not typically cause the described motor deficit.
• E. Monteggia fracture → Affects the radial nerve, which controls wrist and finger extension, rather than thumb function.
This scenario is classic for median nerve compression secondary to lunate dislocation
49 years old man reported that he neglected his desire to urinate due to stressful condition.
After the situation passed, he felt no desire to urinate. On examination, he has abdominal
tenderness and distension with an empty foley catheter. What is the most accepted cause?
A. Blocked catheter
B. Hypovolemia
C. Bladder diverticulum
D. Ureteric stone
E. Bladder rupture
The most likely cause of this patient’s condition is bladder rupture (Option E).
Explanation:
• The patient initially ignored the desire to urinate due to stress, leading to prolonged bladder distension.
• After the stress resolved, he lost the urge to urinate, which suggests neurological or structural bladder dysfunction.
• Examination findings include abdominal tenderness, distension, and an empty Foley catheter, which indicates that urine is not collecting as expected.
• In the context of a previously distended bladder, a rupture is a serious concern, leading to urinary leakage into the peritoneal cavity.
• Bladder rupture is often associated with pelvic trauma, but can also occur due to chronic overdistension, as seen in this case .
Why Other Options Are Less Likely:
• A. Blocked catheter – Would result in a full bladder and catheter obstruction, but here the catheter is empty.
• B. Hypovolemia – Would not explain the empty bladder unless the patient was in severe shock, which is not described.
• C. Bladder diverticulum – Can cause urinary retention or infections, but does not usually lead to acute bladder rupture or an empty catheter.
• D. Ureteric stone – Would present with flank pain and hematuria, but not loss of bladder sensation or an empty catheter.
Thus, bladder rupture (E) is the best answer.
A 20 year old man is diagnosed with Meckel diverticulitis, histopathology of the resected specimen reveals ectopic pancreatic tissue, which of the following would be seen on microscopic examination?
A} Beta cells of islets of Langerhans
B} Basophilic acinar cells and ductal cells
C} Acidophilic acinar cells and ductal cells
D} All cell types found in Islets of Langerhans
E} None of the above
The correct answer is:
C) Acidophilic acinar cells and ductal cells
Explanation:
• Meckel’s diverticulum is a congenital anomaly that can contain heterotopic (ectopic) tissue, including gastric and pancreatic tissue.
• Ectopic pancreatic tissue is composed mainly of exocrine acinar cells, ductal structures, and occasionally endocrine islet cells.
• Acinar cells in the pancreas are acidophilic due to their high content of zymogen granules, which are rich in digestive enzymes like trypsinogen and amylase.
• Basophilic acinar cells are not characteristic of pancreatic tissue.
• Islets of Langerhans, which contain beta cells (insulin-secreting), are less commonly found in ectopic pancreatic tissue
Thus, C) Acidophilic acinar cells and ductal cells is the most accurate description of the microscopic features.
Ileoanal pouch, put on metronidazole. Common side effect.
• Ileoanal fibrosis
• Peripheral neuropathy
• Coagulopathy
• Ileovesical fistula
• Pouchitis
B) Peripheral neuropathy
Explanation:
• Metronidazole is commonly used to treat pouchitis in patients with an ileoanal pouch.
• A well-known side effect of long-term metronidazole use is peripheral neuropathy, which presents with paresthesia (numbness and tingling), weakness, and loss of sensation in the extremities.
• The mechanism is thought to involve mitochondrial toxicity and nerve damage.
Why Not the Other Options?
• A) Ileoanal fibrosis – This is related to chronic inflammation or ischemia, not metronidazole.
• C) Coagulopathy – Metronidazole does not significantly affect coagulation.
• D) Ileovesical fistula – This is a complication of Crohn’s disease or post-surgical complications, not a drug side effect.
• E) Pouchitis – This is an indication for metronidazole, not a side effect.
Thus, Peripheral neuropathy (B) is the correct answer.
A 70-year-old man presents to his general practitioner with back pain that has been worsening over the last six weeks. He also complains of slow urinary flow. Digital rectal examination reveals an irregular hard prostate. Prostate specific antigen is 300 ng/ml (normal <4). What should the first line of treatment be A. Bladder neck incision B. Hormonal manipulation C. Radical prostatectomy D. Transurethral resection of prostate E. Watchful waiting
Answer: B. Hormonal manipulation
Explanation:
This patient has metastatic prostate cancer, as indicated by:
• Back pain (suggesting bone metastases, common in prostate cancer)
• Irregular, hard prostate on DRE (suggestive of malignancy)
• Very high PSA (300 ng/ml) (normal is <4 ng/ml, indicating advanced disease)
The first-line treatment for metastatic prostate cancer is hormonal manipulation (androgen deprivation therapy - ADT). This involves:
• LHRH agonists (e.g., leuprolide, goserelin) or
• Bilateral orchidectomy (surgical castration)
• Anti-androgens (e.g., bicalutamide) may be added to prevent testosterone flare
Why not the other options?
• A. Bladder neck incision → Used for benign prostatic hyperplasia (BPH), not cancer.
• C. Radical prostatectomy → Only for localized prostate cancer; not suitable for metastatic disease.
• D. TURP (Transurethral Resection of Prostate) → Used for urinary obstruction in BPH, but not curative for prostate cancer.
• E. Watchful waiting → Not appropriate for metastatic prostate cancer with symptoms.
Hormonal therapy is the standard first-line treatment in patients with advanced/metastatic prostate cancer
40 years old lady with long-standing rhematpid arthritis presents with the dry mouth and bilateral parotid gland swelling. Her symptoms transiently improved following administration of a course of steroid for rheumatoid disease?
Adenoid cystic carcinoma
Sarcoidosis
Sjogrens syndrome
Answer: Sjögren’s Syndrome
Explanation:
This 40-year-old woman with long-standing rheumatoid arthritis (RA) presents with:
• Dry mouth (xerostomia)
• Bilateral parotid gland swelling
• Symptoms improving transiently with steroids
These features are highly suggestive of Sjögren’s syndrome, an autoimmune condition that commonly occurs in patients with rheumatoid arthritis. It primarily affects the exocrine glands, leading to dry mouth, dry eyes (keratoconjunctivitis sicca), and salivary gland enlargement.
Why not the other options?
• Adenoid cystic carcinoma → A malignant tumor of the salivary glands, usually presents with painful, persistent swelling and facial nerve involvement. It does not improve with steroids.
• Sarcoidosis → Can cause bilateral parotid gland swelling (Heerfordt syndrome) but is more associated with pulmonary symptoms, uveitis, and hypercalcemia. It is less likely in a patient with rheumatoid arthritis and dry mouth.
Conclusion:
Sjögren’s syndrome is the most likely diagnosis in this patient with RA, dry mouth, and bilateral parotid swelling. Steroids can temporarily improve symptoms but are not the mainstay of treatment.
34-year-old lady presents with a persistent offensive discharge from ear. on examination, she is noted to have a reduced in her hearing of 40 decibels compared to the opposite side. A. Acoustic neuroma B. Preauricular sinus C. Acute suppurative otitis media D. Cholesteatoma E. Otitis externa
Answer: D. Cholesteatoma
Explanation:
This 34-year-old woman presents with:
• Persistent offensive ear discharge
• Hearing loss (40 dB)
These features are highly suggestive of cholesteatoma, a destructive lesion of the middle ear caused by the abnormal growth of keratinizing squamous epithelium within the middle ear and mastoid.
Key Features of Cholesteatoma:
• Chronic ear discharge (foul-smelling, persistent, and often painless)
• Progressive conductive hearing loss (~40 dB loss is common)
• Complications: Can erode ossicles, leading to significant hearing loss, and may cause facial nerve palsy, labyrinthine fistula, or intracranial infections.
Why not the other options?
• A. Acoustic neuroma → Causes sensorineural hearing loss, usually unilateral, with associated tinnitus and sometimes imbalance.
• B. Preauricular sinus → Can cause recurrent localized infections, but does not lead to persistent ear discharge or hearing loss.
• C. Acute suppurative otitis media → Presents with fever, ear pain, and transient conductive hearing loss, but it does not cause persistent discharge or progressive hearing loss.
• E. Otitis externa → Causes ear pain, swelling, and discharge, but hearing loss is not usually significant (mild conductive loss due to canal blockage).
Conclusion:
Cholesteatoma is the best answer given the persistent offensive ear discharge and significant conductive hearing loss. Early referral to ENT is essential for surgical management to prevent complications.
A 23 years old athlete developed inability of plantar flexion due to pain after a prolonged period
of casting for fractured tibia. Where would you expect the sensory loss to be?
A. Dorsum of the foot
B. Plantar aspect of the foot
C. 1st web space
D. Dorsum of the foot except 1st web space
E. None of the above
The correct answer is:
B. Plantar aspect of the foot
Explanation:
The patient likely has compartment syndrome or nerve compression due to prolonged casting of the tibia, leading to tibial nerve dysfunction. The tibial nerve supplies the muscles responsible for plantar flexion (e.g., gastrocnemius, soleus, and tibialis posterior) and provides sensory innervation to the plantar aspect of the foot.
Thus, damage to the tibial nerve results in:
• Motor deficit: Weakness or inability to plantar flex.
• Sensory deficit: Loss of sensation on the plantar surface of the foot.
Let’s go through each option systematically:
A. Dorsum of the foot → Incorrect
• The dorsum of the foot is supplied by the superficial peroneal nerve, except for the 1st web space, which is supplied by the deep peroneal nerve.
• Since the tibial nerve is affected, the dorsum of the foot would not lose sensation, making this option incorrect.
C. 1st web space → Incorrect
• As explained earlier, the 1st web space is supplied by the deep peroneal nerve, not the tibial nerve.
• The patient’s main issue is plantar flexion weakness, which indicates tibial nerve involvement, ruling out this option.
D. Dorsum of the foot except the 1st web space → Incorrect
• The superficial peroneal nerve supplies most of the dorsum of the foot, except the 1st web space (deep peroneal nerve).
• Since the tibial nerve does not supply the dorsum of the foot, there will be no sensory loss in this region, making this answer incorrect.
E. None of the above → Incorrect
• There will be sensory loss, specifically on the plantar aspect of the foot, so this option is incorrect.
Final Answer: B. Plantar aspect of the foot (Correct)
• The tibial nerve supplies sensory innervation to the plantar surface of the foot and motor innervation to the muscles responsible for plantar flexion.
• Injury to the tibial nerve (e.g., compression from prolonged casting) leads to loss of plantar flexion and sensory loss in the plantar aspect of the foot.
A 70 year old lady falls from standing height and sustains displaced subcapital femoral neck fracture, this was managed by fixation via a screw, 2 years later she presents with hip pain and restricted hip movement, which of the following is responsible for her symptoms?
A) Avascular necrosis.
B) Osteoarthritis.
C) Hip dislocation.
D) Synovitis.
E) osteosarcoma
A) Avascular necrosis.
Explanation:
Avascular necrosis (AVN) is a well-known complication following fixation of a displaced subcapital femoral neck fracture. The blood supply to the femoral head is mainly provided by the medial circumflex femoral artery, which can be disrupted in such fractures. If the femoral head loses its blood supply, it undergoes necrosis, leading to collapse and subsequent arthritis, which presents with pain and restricted hip movement.
• Osteoarthritis (B) can occur as a late consequence of AVN but typically develops over a longer period.
• Hip dislocation (C) is uncommon following internal fixation of a femoral neck fracture.
• Synovitis (D) is an inflammatory process that usually follows an acute insult rather than a delayed complication.
• Osteosarcoma (E) is rare and unlikely in this scenario.
Thus, the delayed onset of pain and restricted movement strongly suggests AVN as the primary pathology.
osteoarthritis (OA) can develop as a secondary consequence of avascular necrosis (AVN), and a two-year timeframe is sufficient for degenerative changes to occur. However, the key factor in this scenario is the primary pathology leading to the symptoms.
Why Avascular Necrosis (AVN) is still the best answer:
1. AVN is a direct complication of femoral neck fracture fixation, especially in displaced subcapital fractures, due to disruption of the medial circumflex femoral artery.
2. Hip pain and restricted movement are hallmarks of AVN, which often progresses to joint collapse before osteoarthritis sets in.
3. Two years is within the typical timeframe for AVN progression, leading to secondary osteoarthritis, but the initial cause remains AVN.
Could it be Osteoarthritis (OA)?
• Yes, but OA in this case would likely be secondary to AVN, meaning AVN is still the primary pathology.
• If the question specifically mentioned chronic gradual worsening over many years (rather than a more sudden onset of symptoms after a fracture fixation), OA could be a stronger contender.
Conclusion:
The most precise answer remains AVN because it precedes OA in cases of post-fixation complications. If left untreated, AVN leads to secondary osteoarthritis, but the primary issue in this patient’s timeline is AVN itself.
Metabolic screening for a 32-year-old male with recurrent renal stones
was undertaken. Which of the following is the most probable diagnosis?
A. Hyperparathyroidism
B. Familial hyperoxaluria
C. Idiopathic cystinuria
D. Gout
E. Pseudogout
Correct Answer: A. Hyperparathyroidism
Explanation:
The most common metabolic cause of recurrent renal stones is primary hyperparathyroidism. This condition leads to hypercalcemia and hypercalciuria, which promote the formation of calcium-based kidney stones (typically calcium oxalate or calcium phosphate).
Key Features Suggesting Hyperparathyroidism:
• Recurrent renal stones (especially calcium oxalate)
• Elevated serum calcium levels
• Elevated or inappropriately normal parathyroid hormone (PTH) levels
• Reduced serum phosphate (due to PTH effects on the kidneys)
Why Not the Other Options?
• B. Familial hyperoxaluria – Rare genetic disorder causing excessive oxalate production, leading to severe early-onset renal stones and nephrocalcinosis. Usually diagnosed in childhood.
• C. Idiopathic cystinuria – A genetic disorder causing defective renal transport of cystine, leading to cystine stones. These stones are hexagonal and are diagnosed with the cyanide-nitroprusside test.
• D. Gout – Gout leads to uric acid stones, but the most common type of renal stone is calcium-based, making hyperparathyroidism the more likely answer.
• E. Pseudogout – Pseudogout is associated with calcium pyrophosphate deposition disease (CPPD), typically affecting joints rather than forming urinary stones.
Takeaway:
If a patient presents with recurrent renal stones, especially calcium-based, hyperparathyroidism should be suspected first and confirmed with calcium and PTH levels.
A 40 year old man undergoes liver resection, regeneration of the liver postoperatively occurs due to division of which cells?
Labile cells.
Stable cells.
Permenant cells.
Stem cells.
Stellate cells.
The correct answer is:
Stable cells.
Explanation:
Liver regeneration after resection occurs due to the proliferation of hepatocytes, which are classified as stable cells.
• Stable cells (also called quiescent cells) are normally in the G0 phase of the cell cycle but can re-enter the cell cycle in response to injury or loss of tissue, as seen in liver resection.
• Hepatocytes have a remarkable capacity for regeneration, allowing the liver to restore its mass after partial resection.
Why Not the Other Options?
• Labile cells: These continuously divide and are found in tissues like the skin, bone marrow, and gastrointestinal epithelium, but not in the liver.
• Permanent cells: These cannot regenerate (e.g., neurons, cardiac myocytes). Liver cells can regenerate, so this is incorrect.
• Stem cells: While liver stem cells (oval cells) exist, normal liver regeneration primarily occurs through hepatocyte proliferation, not stem cell activation.
• Stellate cells: These are involved in liver fibrosis and vitamin A storage, not regeneration.
Key Concept:
Liver regeneration is unique because it is primarily driven by mature hepatocytes (stable cells), unlike other organs that rely on stem cells for repair.
A 23 year old female develops anemia, on blood film stained with prussian stain, there is marked staining at the periphery of the RBC, which of the following is the most likely diagnosis?
Chronic iron defeciency anemia.
B12 deficiency anemia.
Sideroblastic anemia.
Aplastic anemia.
Myelofibrosis.
The correct answer is:
Sideroblastic anemia.
Explanation:
A Prussian blue stain is used to detect iron deposits in red blood cells. The characteristic finding of ringed sideroblasts (iron-laden mitochondria forming a ring around the nucleus of erythroblasts) is diagnostic of sideroblastic anemia.
Why Not the Other Options?
• Chronic iron deficiency anemia → Would show hypochromic, microcytic RBCs with no iron deposits on Prussian blue stain (iron is deficient).
• B12 deficiency anemia → Leads to megaloblastic anemia with hypersegmented neutrophils, not iron-stained sideroblasts.
• Aplastic anemia → Characterized by pancytopenia and a hypocellular bone marrow, but does not involve iron-laden RBCs.
• Myelofibrosis → Shows tear-drop RBCs and leukoerythroblastic blood picture, not sideroblasts.
Key Concept:
• Sideroblastic anemia can be hereditary (e.g., ALAS2 mutation) or acquired (e.g., alcohol, lead poisoning, myelodysplastic syndrome).
• Ringed sideroblasts are due to defective heme synthesis, leading to iron accumulation in mitochondria.
Thus, sideroblastic anemia is the most likely diagnosis in this case.
Tranexamic acid is an antifibrinolytic agent, it is an analogue of which of the following?
A) Glutamate.
B) Valine.
C) Lysine
D) Alanine.
The correct answer is:
C) Lysine
Explanation:
Tranexamic acid (TXA) is a synthetic analogue of lysine that works as an antifibrinolytic agent by competitively inhibiting the activation of plasminogen to plasmin, thereby preventing fibrin degradation and promoting clot stability.
Mechanism of Action:
• Plasminogen contains lysine-binding sites that help it bind to fibrin for clot breakdown.
• TXA competes with lysine for binding to plasminogen, blocking fibrinolysis and stabilizing clots.
Why Not the Other Options?
• Glutamate (A) → Important in neurotransmission and metabolism but not directly related to fibrinolysis.
• Valine (B) → A branched-chain amino acid involved in protein synthesis, not antifibrinolysis.
• Alanine (D) → Plays a role in gluconeogenesis but has no known antifibrinolytic properties.
Clinical Uses of TXA:
• Trauma and surgery (reduces bleeding)
• Postpartum hemorrhage
• Heavy menstrual bleeding
• Hereditary angioedema
Thus, TXA is a lysine analogue that prevents excessive bleeding by inhibiting fibrinolysis.
A 50 year old male is suffering from ischemic heart disease, which of the following is the most common form of cardiac amyloidosis?
A) AA amyloid.
B) AL amyloid.
C) Transthyretin.
D) B2 microglobulin.
The correct answer is:
Transthyretin (ATTR) amyloid.
Explanation:
In a 50-year-old male with ischemic heart disease, the most common form of cardiac amyloidosis is due to transthyretin (TTR) amyloid deposition.
Types of Cardiac Amyloidosis:
1. Transthyretin (ATTR) amyloidosis
• Can be wild-type (senile systemic amyloidosis) or hereditary (mutant TTR gene).
• Wild-type ATTR occurs in older adults and primarily affects the heart, leading to restrictive cardiomyopathy and heart failure with preserved ejection fraction (HFpEF).
• Mutant ATTR is inherited and can cause familial amyloid cardiomyopathy (FAC).
2. AL amyloidosis (Immunoglobulin Light Chain Amyloidosis)
• Caused by monoclonal plasma cell dyscrasia (e.g., multiple myeloma).
• Also affects the kidneys, liver, nerves, and heart (but less common than ATTR in isolated cardiac cases).
3. AA amyloidosis
• Due to chronic inflammatory conditions (e.g., rheumatoid arthritis, tuberculosis).
• Rarely affects the heart significantly.
4. B2-microglobulin amyloidosis
• Seen in patients on long-term dialysis.
• Mainly affects joints and bones, not the heart.
Why ATTR is the Most Common in This Case?
• Age (50 years old) suggests wild-type ATTR or early hereditary ATTR.
• Ischemic heart disease and restrictive cardiomyopathy are commonly associated with TTR amyloid deposition in the heart.
Conclusion:
Transthyretin amyloidosis (ATTR) is the most common form of cardiac amyloidosis, especially in older adults with ischemic heart disease or heart failure with preserved ejection fraction (HFpEF).
A 28 year old man is admitted to ICU, he has a subelavian line inserted and he is intubated, following removal of the subclavian line he suddently becomes hypoxic, which of the following is the best next step?
A) Put patient in prone position.
B) Put patient in left lateral decubitus position.
C) Put patient in Trendelenburg position.
D) Put patient on high flow oxygen.|
The scenario described suggests that the patient may have developed a pneumothorax following the removal of the subclavian line. This is a known complication of central line removal, particularly with subclavian lines, as air can enter the pleural space, leading to lung collapse and sudden hypoxia.
The best next step is:
B) Put the patient in the left lateral decubitus position.
- Left lateral decubitus position: If a pneumothorax is suspected, placing the patient in the left lateral decubitus position (if the subclavian line was on the right side) can help trap air in the apex of the lung, preventing further compromise of the mediastinum and cardiovascular collapse. This is a temporary measure while preparing for definitive treatment (e.g., chest tube insertion).
- A) Prone position: This is used for severe ARDS to improve oxygenation but is not appropriate for a suspected pneumothorax.
- C) Trendelenburg position: This position is used for hypotension or to facilitate central line insertion but is not helpful in a pneumothorax.
- D) High-flow oxygen: While oxygen supplementation is important, it does not address the underlying issue of a pneumothorax. Definitive treatment (e.g., chest tube) is required.
- Confirm the diagnosis with a chest X-ray or point-of-care ultrasound.
- Prepare for chest tube insertion if a pneumothorax is confirmed.
- Monitor the patient closely for signs of tension pneumothorax (e.g., hypotension, tracheal deviation, absent breath sounds), which is a life-threatening emergency.
A 69 year old man with advanced rectal cancer, has recently developed gangrenous appendicitis, following the operation the wound becomes erythematosus and foul smelling with skin blisters and crepitus, which of the following is the best initial course of action?
A) Antibiotic therapy.
B) Removal of the sutures.
C) Radical debridement.
D) Percutaneous drainage.
The correct answer is:
C) Radical debridement.
Explanation:
This patient has signs of necrotizing soft tissue infection (NSTI), likely necrotizing fasciitis, which presents with:
• Erythematous, foul-smelling wound
• Skin blisters (bullae) and crepitus (gas-producing organisms like Clostridium perfringens or polymicrobial infections)
• Rapid progression of infection
Best Initial Course of Action:
Radical surgical debridement (C) is the most important and life-saving intervention.
• Removes necrotic, infected tissue to control the spread of the infection.
• Delaying debridement increases mortality because NSTI progresses rapidly.
Why Not the Other Options?
• A) Antibiotic therapy → Essential but not sufficient as monotherapy. Antibiotics alone do not stop the spread of necrotic tissue.
• B) Removal of sutures → May expose the infection, but it does not treat the underlying necrotizing process.
• D) Percutaneous drainage → Not appropriate for deep soft tissue infections; radical debridement is required.
Additional Management:
• Empirical broad-spectrum IV antibiotics (e.g., carbapenem + clindamycin + vancomycin) after surgical debridement.
• Hemodynamic support if septic shock develops.
• Possible repeat debridements if needed.
• Hyperbaric oxygen therapy (HBO) in select cases.
Conclusion:
Immediate radical debridement (C) is the priority because necrotizing fasciitis is a rapidly progressive and life-threatening condition. Delaying surgery significantly increases mortality.
A young sexually active patient presents with a suspected septic knee joint. Which of the organisms likely to be responsible?
Staph aureus
Staph epidermidis
E. coli
N gonorrhoeae
Strep pneumoniae
The most likely organism responsible for septic arthritis in a young, sexually active patient is Neisseria gonorrhoeae. This bacterium is known to cause disseminated gonococcal infection, which can lead to septic arthritis.
Other common causes of septic arthritis include Staphylococcus aureus, which is the most frequent pathogen overall, and Streptococcus species. However, in the context of a sexually active patient, N. gonorrhoeae is the primary suspect.
A 12 years old boy suffered a supracondylar humeral fracture. Which nerve is at greatest risk?
A. Median nerve
B. Ulnar nerve
C. Posterior interosseus nerve
D. Deep branch of ulnar nerve
E. Anterior interosseus nerve
The correct answer is:
A. Median nerve
A supracondylar humeral fracture, particularly the extension type (which is more common), can result in injury to the median nerve. This nerve is at greatest risk due to its proximity to the fracture site and the potential for displacement of the fracture fragments. The median nerve can be compressed or stretched as it passes anteriorly near the elbow joint.
Other nerves, such as the ulnar nerve and radial nerve (including its branches like the posterior interosseous nerve), are less commonly injured in this type of fracture. The anterior interosseous nerve, a branch of the median nerve, can also be affected but is less likely compared to the main median nerve trunk.
Thus, the median nerve is the most at risk in a supracondylar humeral fracture.
A 30-year-old man is assaulted, sustaining blunt trauma to the head in the Emergency Department he is able to localize the pain to stimuli 5, open his eyes in response to pain 2 and make moaning sounds. His speech is incomprehensible. His heart rate is 80 beats/minute, blood pressure 130/80 mmHg and respiratory rate 12 beats/minute. Which of the following is his Glasgow coma score?
A. 5
B. 7
C. 9
D. 11
E. 13
The Glasgow Coma Score (GCS) is calculated based on three components:
• Eye Response (E):
• Opens spontaneously: 4
• Opens to verbal command: 3
• Opens to pain: 2
• No response: 1
• Verbal Response (V):
• Oriented: 5
• Confused: 4
• Inappropriate words: 3
• Incomprehensible sounds: 2
• No response: 1
• Motor Response (M):
• Obeys commands: 6
• Localizes pain: 5
• Withdraws from pain: 4
• Abnormal flexion (decorticate): 3
• Abnormal extension (decerebrate): 2
• No response: 1
For the given case:
• Eye response: Opens to pain → Score 2
• Verbal response: Incomprehensible sounds → Score 2
• Motor response: Localizes pain → Score 5
Total GCS = 2 + 2 + 5 = 9/15
Thus, the correct answer is C. 9
4 Month child with failure to thrive with recurrent chest infection and dyspnea increase
with lying flat in the night and awake him from sleep?
A. TOF
B. Congenital diaphragmatic hernia
C. Asthma
D. GERD
E. None of the above
The correct answer is:
D. GERD (Gastroesophageal Reflux Disease)
Explanation:
A 4-month-old child with failure to thrive, recurrent chest infections, and dyspnea that worsens when lying flat (nocturnal symptoms) strongly suggests gastroesophageal reflux disease (GERD).
• GERD in infants can lead to aspiration of refluxed gastric contents, which can cause recurrent chest infections and respiratory distress.
• Symptoms often worsen when lying flat, as gravity no longer helps keep stomach contents down.
• Nighttime reflux can cause disturbed sleep and frequent awakenings.
Why not the other options?
• Tetralogy of Fallot (TOF) (A): Presents with cyanotic spells, worsened with exertion, not specifically related to lying flat.
• Congenital diaphragmatic hernia (B): Usually diagnosed at birth or in the neonatal period with severe respiratory distress.
• Asthma (C): Can cause nocturnal symptoms, but failure to thrive is less common in early infancy.
Thus, GERD is the most likely diagnosis in this case.
At 36 weeks, a tall, slim 28-year-old primigravida presents in the Emergency
Department with history of sudden chest pain. Her father died at 42 years of
age of a “heart attack.” On examination there are no abnormal physical signs
other than a tachycardia of 90 beats/minute in keeping with her anxiety.
Which of the following is the most likely initial clinical diagnosis?
A. Aortic dissection
B. Myocardial infarction
C. Panic attack
D. Puerperal psychosis
E. Pulmonary thromboembolism
The correct answer is:
A. Aortic dissection
Explanation:
This case describes a pregnant woman (36 weeks gestation) with sudden chest pain and a family history of early cardiac death. Given her tall, slim build, this suggests a possible connective tissue disorder (e.g., Marfan syndrome), which is a major risk factor for aortic dissection.
Key Features Supporting Aortic Dissection:
1. Sudden onset chest pain – A classic symptom.
2. Pregnancy – Increases the risk of aortic dissection, particularly in the third trimester due to hormonal effects on vascular integrity.
3. Tall, slim habitus – Suggestive of Marfan syndrome, a known risk factor for aortic root dilatation and dissection.
4. Family history of sudden cardiac death – Could indicate a genetic predisposition to aortic pathology.
Why Not the Other Options?
• Myocardial infarction (MI) (B): Rare in young women without major risk factors (e.g., hypertension, diabetes, smoking). Also, pregnancy-related MI is more likely in the peripartum period.
• Panic attack (C): Could cause chest pain but wouldn’t explain the family history of sudden death or the association with pregnancy.
• Puerperal psychosis (D): Occurs postpartum, not during pregnancy.
• Pulmonary thromboembolism (E): While pregnancy increases venous thromboembolism (VTE) risk, there are no signs of dyspnea, hypoxia, or hemoptysis in this patient.
Final Thought:
Given the clinical context and risk factors, aortic dissection should be the primary concern until proven otherwise. Immediate imaging (e.g., echocardiography, CT angiography) is required to confirm the diagnosis.
A CT scan of a patient with head trauma reveals bilateral extradural hematomas (EDH). While on the operating table, the anesthetist notices that one pupil is dilated. Where should the first burr hole be placed?
A. Ipsilateral side (same side as the dilated pupil)
B. Contralateral side (opposite side to the dilated pupil)
C. Vertex
D. Midline suboccipital region
Correct Answer: A. Ipsilateral side (same side as the dilated pupil)
Explanation:
• A dilated pupil in the context of head trauma suggests uncal herniation, which occurs due to compression of the oculomotor nerve (CN III) by the expanding hematoma.
• Even though there are bilateral extradural hematomas, the one causing the herniation signs (pupil dilation) should be prioritized.
• Burr hole placement should begin on the ipsilateral side to rapidly decompress the mass effect and relieve pressure on the brainstem.
Why Not the Other Options?
• B. Contralateral side – The contralateral hematoma may also need evacuation, but the first priority is the side showing clinical signs of herniation.
• C. Vertex – The vertex is not a typical location for burr holes in extradural hematomas, which are mostly temporal or parietal.
• D. Midline suboccipital region – This approach is used for posterior fossa decompression, not for treating supratentorial EDH.
Key Takeaway:
In cases of bilateral extradural hematomas, the first burr hole should be placed on the side of the dilated pupil, as it indicates impending herniation and urgent decompression is needed.
T2-year-old man with carcinoma of the kidney develops pain at the
site of a secondary metastatic deposit in the mid-shaft of the left
humerus. Which of the following is the most appropriate treatment?
A. Nerve block
B. Non-steroidal anti-inflammatory drugs (NSAIDs)
C. Paracetamol
D. Radiotherapy
E. Slow-release morphine
The correct answer is:
D. Radiotherapy
Explanation:
This 72-year-old man with renal carcinoma and metastatic bone pain in the humerus requires effective pain relief and local tumor control. Radiotherapy is the most appropriate treatment for metastatic bone pain because:
1. Pain relief – Radiation reduces pain by decreasing tumor burden and inflammation.
2. Prevention of pathological fractures – By stabilizing the affected bone.
3. Long-term control – Helps in palliating symptoms effectively.
Why Not the Other Options?
• Nerve block (A): Used for localized, refractory pain but not first-line for bone metastases.
• NSAIDs (B) & Paracetamol (C): May provide mild relief but are insufficient for metastatic bone pain, which is often severe.
• Slow-release morphine (E): Used for cancer pain, but should be combined with radiotherapy for better long-term relief.
Final Thought:
Radiotherapy is the best first-line treatment for metastatic bone pain in this case, providing both pain relief and disease control.
52yr old smoker patient is due to undergoing an elective colon resection what is most appropriate method of thromboprophylaxis
A) lmwh and stockings
B) lmwh
C) ivc filter
D) oral anticoagulant
E) none of above
The correct answer is:
A) LMWH and stockings
Explanation:
This 52-year-old smoker undergoing elective colon resection is at high risk for venous thromboembolism (VTE) due to:
• Major abdominal surgery
• Smoking (a risk factor for hypercoagulability)
The most appropriate thromboprophylaxis in this case is a combination of Low Molecular Weight Heparin (LMWH) and graduated compression stockings.
Why this choice?
1. LMWH – Effectively reduces the risk of deep vein thrombosis (DVT) and pulmonary embolism (PE) in surgical patients.
2. Graduated compression stockings – Help improve venous return, reducing stasis in lower limbs.
3. Combination therapy is recommended – Especially for major abdominal surgeries per NICE guidelines.
Why Not the Other Options?
• LMWH alone (B): Good but adding stockings provides extra protection.
• IVC filter (C): Only indicated in patients with contraindications to anticoagulation or recurrent VTE despite anticoagulation.
• Oral anticoagulants (D): Not used for surgical thromboprophylaxis due to delayed onset of action and risk of bleeding.
• None of the above (E): Incorrect, as thromboprophylaxis is essential in major abdominal surgery.
Final Thought:
For elective colon resection, LMWH + stockings is the best evidence-based approach to prevent perioperative VTE.
Following a thoracotomy, a patient complains of numbness and loss
of fine control of the left hand. On examination It Is established that
the numbness is on the ulnar border of the hand and involves the little
finger and both sides of the ring finger. The hand Is weak, including
both the abductor pollicis brevis and the first dorsal interosseous
muscles. Which of the following Is the most likely site of neurological
injury?
A. Lower trunk of the brachia! plexus
B. Median nerve
C. Middle trunk of the brachia I plexus
D. Ulnar nerve
E. Upper trunk of the brachia I plexus
The correct answer is:
A. Lower trunk of the brachial plexus
Explanation:
This patient has numbness on the ulnar side of the hand (little finger + both sides of the ring finger) and weakness in the abductor pollicis brevis and first dorsal interosseous muscles. This suggests an injury affecting both the ulnar and median nerve distributions, which points to a lesion at the lower trunk of the brachial plexus (C8-T1 roots).
Key Features Supporting Lower Trunk Injury:
• Sensory loss: Ulnar border of the hand (C8-T1 dermatome).
• Motor weakness:
• First dorsal interosseous (ulnar nerve, C8-T1).
• Abductor pollicis brevis (median nerve, C8-T1).
• Mechanism of injury:
• Thoracotomy can cause traction or compression of the lower trunk of the brachial plexus.
Why Not the Other Options?
• Median nerve (B): Would not explain ulnar-sided sensory loss or first dorsal interosseous weakness (which is innervated by the ulnar nerve).
• Middle trunk of the brachial plexus (C): Involves C7, which primarily affects radial nerve muscles (e.g., triceps, wrist extensors), not the ulnar border of the hand.
• Ulnar nerve (D): Would cause weakness in the first dorsal interosseous muscle but not abductor pollicis brevis, which is supplied by the median nerve.
• Upper trunk of the brachial plexus (E): Affects C5-C6, causing shoulder abduction and elbow flexion weakness (Erb’s palsy-like features), not ulnar-sided sensory loss.
Final Thought:
This presentation is highly suggestive of a lower trunk (C8-T1) brachial plexus injury, most likely due to traction or compression during thoracotomy.
42-year-old multiparous woman attends her General Practitioner
with pelvic discomfort and the feeling of “something coming down “.
Which anatomical structure normally gives the most significant
direct support to the uterus?
A. Mesometrial part of the broad ligament
B. Mesosalpingial pa rt of the broad ligament
C. Round ligament
D. Transverse cervical ligaments
E. Transverse perinea! Muscles
The correct answer is D. Transverse cervical ligaments.
Here’s why:
* Transverse cervical ligaments (also known as cardinal ligaments): These are the primary supports for the uterus, preventing it from prolapsing. They extend from the cervix and upper vagina to the lateral pelvic walls.
* Mesometrial part of the broad ligament: While the broad ligament provides some support, the mesometrium (the part attached to the uterus) is relatively loose and doesn’t offer the same level of direct, rigid support as the cardinal ligaments.
* Mesosalpingial part of the broad ligament: This portion of the broad ligament supports the fallopian tubes, not primarily the uterus.
* Round ligament: These ligaments help maintain the anteverted position of the uterus, but they provide minimal vertical support.
* Transverse perineal muscles: These muscles support the pelvic floor, which indirectly aids in pelvic organ support, but they do not provide direct support to the uterus itself, like the cardinal ligaments do.
In a multiparous woman with pelvic discomfort and a feeling of “something coming down,” the most likely issue is uterine prolapse, which directly implicates the primary uterine supports, the cardinal ligaments.
During scrotal examination of a 3-year-old a unilateral scrotal
swelling is found that does not seem to be present all the time. Which
of the following is the most likely diagnosis?
A. Direct inguinal hernia
B. Epididymal cyst
C. Femora l hernia
D. Hydrocele
E. Varicocel
The correct answer is:
D. Hydrocele
Explanation:
A 3-year-old boy with intermittent unilateral scrotal swelling is most likely to have a communicating hydrocele.
Key Features of a Communicating Hydrocele:
• Fluctuating swelling – Appears and disappears due to fluid movement between the peritoneal cavity and tunica vaginalis.
• Transillumination positive – When light is shined through, it appears translucent.
• Associated with a patent processus vaginalis – This allows peritoneal fluid to move into the scrotum, making it intermittent.
Why Not the Other Options?
• Direct inguinal hernia (A): Rare in children. More common in adults due to weakened abdominal wall.
• Epididymal cyst (B): Usually occurs in older individuals, not in young children. It is also non-fluctuating.
• Femoral hernia (C): More common in women and presents as a groin swelling below the inguinal ligament, not in the scrotum.
• Varicocele (E): More common in adolescents, typically on the left side, and described as a “bag of worms” that does not fluctuate significantly.
Final Thought:
A communicating hydrocele is the most likely cause of intermittent scrotal swelling in a 3-year-old. It is due to a patent processus vaginalis and may resolve spontaneously, but persistent cases might require surgical repair (herniorrhaphy).
Witch single respiratory test parameter (FEVJ Forced expiratory volume in one second; FVC -
Forced vital capacity) is the best prediction for morbidity and mortality after surgery?
A. A. Confronted flow volume loop
B. FEV1 < 1L
C. FEV1/FVC > 90%.
D. tidal volume = 1500
E. increased residual volume
The correct answer is:
B. FEV1 < 1L
Explanation:
Forced Expiratory Volume in 1 second (FEV1) < 1L is the most important predictor of postoperative morbidity and mortality in patients undergoing surgery, particularly thoracic and major abdominal surgeries.
Why is FEV1 important?
• FEV1 < 1L is associated with high risk of respiratory complications such as pneumonia, prolonged ventilation, and respiratory failure.
• It is a strong predictor of postoperative respiratory function, especially in lung resection or general anesthesia.
• In patients undergoing lung surgery (e.g., lobectomy, pneumonectomy), FEV1 is used to determine if they have enough functional lung reserve to tolerate surgery.
Why Not the Other Options?
• A. Confronted flow volume loop: Not the best single predictor; mainly used to assess upper airway obstruction.
• C. FEV1/FVC > 90%: Suggests restrictive lung disease, but not a key predictor of surgical risk.
• D. Tidal volume = 1500: Tidal volume varies and is not a strong predictor of postoperative complications.
• E. Increased residual volume: Common in obstructive lung diseases (e.g., COPD) but does not predict postoperative mortality as well as FEV1 < 1L.
Final Thought:
For preoperative pulmonary risk assessment, FEV1 < 1L is the best predictor of poor surgical outcomes, especially in patients undergoing lung or major abdominal surgery.
33old man have been attacked by dog his nose has been bitten off and lost treatment is
A) microvascular free flap
B) stsg
C)ftsg
D) pedicle flap
E) secondaey intention
The correct answer is:
A) Microvascular free flap
Explanation:
A 33-year-old man with complete nasal loss due to a dog bite requires complex nasal reconstruction. The best option is a microvascular free flap, which provides:
1. Adequate tissue volume and vascular supply – Essential for functional and aesthetic reconstruction.
2. Best contour and durability – Helps restore nasal shape and structural integrity.
3. Long-term viability – Compared to skin grafts, free flaps integrate better and are less prone to contracture.
Why Not the Other Options?
• Split-thickness skin graft (STSG) (B): Too thin, lacks structural support, and prone to contraction.
• Full-thickness skin graft (FTSG) (C): May provide better coverage than STSG, but lacks volume and support.
• Pedicle flap (D): Limited mobility and may not provide sufficient tissue bulk for total nasal reconstruction.
• Secondary intention (E): Not appropriate for large tissue defects, as healing would be prolonged and cosmetically poor.
Final Thought:
For total nasal loss, a microvascular free flap (e.g., radial forearm, anterolateral thigh, or forehead flap) is the gold standard for functional and aesthetic nasal reconstruction.
- An 28 years old patient stabbed on right side posterior to axillary line, xray showing pneumothorax with fluid level, what is the best management?
A. Chest drain with suction
B. Needle Decompression
C thoracentesis
D. Chest drain without suction
E. None of the above
The best management for this patient, who has a pneumothorax with a fluid level (likely a hemopneumothorax due to the stab wound), is:
D. Chest drain without suction
- Pneumothorax with fluid level: This indicates the presence of both air and blood (or other fluid) in the pleural space, which is consistent with a traumatic injury like a stab wound.
- Chest drain (tube thoracostomy): This is the standard treatment for traumatic pneumothorax, especially when there is associated hemothorax (blood in the pleural space). The chest tube allows for the evacuation of both air and fluid, helping to re-expand the lung.
- Without suction: Initially, a chest drain is placed without suction, as suction is not routinely required and can sometimes worsen bleeding or cause re-expansion pulmonary edema. If the lung does not re-expand adequately, suction can be added later.
- A. Chest drain with suction: Suction is not typically used initially unless the lung fails to re-expand.
- B. Needle decompression: This is a temporary measure for tension pneumothorax, not for a stable pneumothorax with fluid.
- C. Thoracentesis: This is used for diagnostic or therapeutic removal of fluid but does not address the pneumothorax effectively.
- E. None of the above: A chest drain is the correct management.
Thus, the best answer is D. Chest drain without suction.
A patient on double anticoagulant therapy presents with swelling above the patella and an inability to fully extend the knee. What is the most likely diagnosis?
Options:
A. Quadriceps tendon rupture
B. Patellar tendon rupture
C. Prepatellar bursitis
D. Hemarthrosis
E. Meniscal tear
Correct Answer: A. Quadriceps tendon rupture
Explanation:
A quadriceps tendon rupture is a common injury in patients with anticoagulant therapy, chronic kidney disease, diabetes, or previous steroid use. It typically presents with:
• Swelling above the patella (suprapatellar region)
• Inability to fully extend the knee
• A palpable gap above the patella
• Patella baja (low-lying patella) on imaging
Since the quadriceps tendon is essential for active knee extension, rupture results in significant weakness or complete loss of extension.
Why Not the Other Options?
• B. Patellar tendon rupture – Would cause swelling below the patella and patella alta (high-riding patella) rather than suprapatellar swelling.
• C. Prepatellar bursitis – Causes localized anterior swelling but does not typically impair knee extension.
• D. Hemarthrosis – Common in anticoagulated patients but would cause generalized knee swelling without a specific loss of extension.
• E. Meniscal tear – Can cause joint swelling and pain, but does not typically result in sudden inability to extend the knee unless associated with a locked knee (bucket-handle tear).
Takeaway:
A quadriceps tendon rupture should be suspected in anticoagulated patients with suprapatellar swelling and an inability to extend the knee. Urgent orthopedic evaluation and surgical repair are usually required.
Following an open abdominal aortic aneurysm repair a 73 year old man develops cyanosis, arterial blood gas analysis reveals hypoxaemia, plain radiograph of the chest shows diffuse bilateral opacities in the lung fields, the following are measured:
Blood pressure: 100/60 mmHg
Heart rate: 130 beat per minute
Oxyhemoglobin concentration: 89% on room air and 100% oxygen by mask Pulmonary artery wedge pressure: 20 mmHg
Which of the following is the most accepted cause?
A. Adult respiratory distress syndrome
B. Heart failure
C. Pulmonary embolism D. Lobar pneumonia
E. Aspiration pneumonia
Correct Answer: A. Adult Respiratory Distress Syndrome (ARDS)
Explanation:
This patient presents with acute hypoxemia, tachycardia, hypotension, and bilateral pulmonary opacities following major surgery (abdominal aortic aneurysm repair). The most likely cause is Acute Respiratory Distress Syndrome (ARDS), a severe inflammatory lung injury often triggered by major surgery, sepsis, or shock.
Key Features of ARDS:
• Acute onset respiratory distress
• Severe hypoxemia (PaO₂ remains low despite high oxygen administration)
• Bilateral pulmonary infiltrates on chest X-ray (“white-out” lungs)
• Non-cardiogenic pulmonary edema (PAWP ≤ 18 mmHg, though some variation exists)
Why Not the Other Options?
• B. Heart failure – Would cause similar bilateral infiltrates but typically presents with elevated pulmonary artery wedge pressure (PAWP > 18 mmHg). This patient’s PAWP is borderline but not markedly elevated.
• C. Pulmonary embolism (PE) – Can cause hypoxia and tachycardia, but it rarely presents with diffuse bilateral lung infiltrates. A PE is more likely if there were sudden pleuritic chest pain and clear lung fields on X-ray.
• D. Lobar pneumonia – Would typically show a localized consolidation rather than diffuse opacities. Fever and productive cough would also be more prominent.
• E. Aspiration pneumonia – Would present with localized infiltrates, often in the dependent lung segments, and typically occurs after vomiting or altered consciousness.
Takeaway:
ARDS should be suspected in any critically ill post-surgical patient with hypoxemia, bilateral pulmonary infiltrates, and no clear signs of cardiogenic pulmonary edema. Prompt management includes lung-protective ventilation with low tidal volumes, PEEP, and supportive care.
A 65-year-old male underwent coronary artery bypass grafting (CABG). Postoperatively, he developed sternal dehiscence, which required wound debridement and muscle flap repair. Following this procedure, the primary blood supply to the sternum is now dependent on which of the following arteries?
A) Thoracoacromial artery
B) Internal thoracic artery
C) Intercostal arteries
D) Lateral thoracic artery
The correct answer is A) Thoracoacromial artery.
Here’s why:
* Sternal Dehiscence and CABG: Sternal dehiscence, a separation of the sternum after a median sternotomy (common in CABG), disrupts the primary blood supply to the sternum, which is normally provided by the internal thoracic arteries.
* Muscle Flap Repair: Muscle flap repair involves transferring a muscle with its blood supply to the affected area to provide vascularized tissue for healing. The pectoralis major muscle is frequently used in sternal wound repair. The blood supply of the pectoralis major muscle is the thoracoacromial artery. Therefore the blood supply to the sternum, after a muscle flap repair using the pectoralis major muscle, will be supplied by the thoracoacromial artery.
* Why the other options are incorrect:
* B) Internal thoracic artery: These arteries are the primary blood supply to the sternum but are often compromised during CABG and subsequent debridement.
* C) Intercostal arteries: While they provide some collateral blood supply to the chest wall, they are not the primary source after a muscle flap repair.
* D) Lateral thoracic artery: This artery supplies the lateral chest wall and is not the dominant blood supply to the sternum or the pectoralis major muscle.
A 45 year old man undergoes an upper gastrointestinal endoscopy for a benign oesophageal stricture. This is dilated and he suffers an iatrogenic perforation at the site. His imaging shows a small contained leak and a small amount of surgical emphysema. What is the most appropriate nutritional option?
a. Nil by mouth and intravenous fluids alone
b. Intravenous fluids and sips orally
c. Total parenteral nutrition
d. Nasogastric feeding
e. PEG tube feeding
Correct Answer: C) Total Parenteral Nutrition (TPN).
Explanation:
In the setting of a small contained oesophageal perforation, the primary concern is preventing further contamination while ensuring adequate nutrition. The approach to management depends on the severity of the perforation:
• Small contained leaks with minimal symptoms can sometimes be managed conservatively.
• Larger or uncontained leaks may require surgical intervention.
Nutritional Strategy:
• TPN (Total Parenteral Nutrition) is the best choice in this case because it allows complete bowel rest, preventing further oesophageal contamination and promoting healing.
• Nil by mouth (NBM) and IV fluids alone (Option A) would not provide adequate nutrition for healing.
• Sips orally (Option B) could worsen the leak by increasing intraoesophageal pressure.
• Nasogastric feeding (Option D) or PEG tube feeding (Option E) is contraindicated in acute oesophageal perforations, as they can exacerbate the leak and delay healing.
Conclusion:
TPN provides the safest and most appropriate nutrition in this case, allowing healing without further oesophageal stress.
A patient with a pituitary macroadenoma develops severe headache and vomiting. What is the most likely complication?
A) Hydrocephalus
B) Pituitary apoplexy
C) Meningitis
D) Cavernous sinus thrombosis
Correct Answer:
B) Pituitary apoplexy**
Explanation:
Pituitary apoplexy is caused by acute hemorrhage or infarction of a pituitary tumor, leading to:
- Sudden severe headache (due to meningeal irritation).
- Vomiting (increased ICP).
- Potential visual/ocular palsy (compression of optic chiasm/cavernous sinus).
Other options:
- A) Hydrocephalus: Rare with pituitary tumors unless obstructing 3rd ventricle.
- C) Meningitis: Would feature fever/nuchal rigidity.
- D) Cavernous sinus thrombosis: Presents with fever, proptosis, and cranial nerve palsies.
A 56-year-old alcoholic with a minor head injury and GCS 13 (improving to 15) should be managed with:
A) Immediate CT head
B) Admission for 24-hour observation
C) Discharge with a responsible adult
D) Routine neurosurgical referral
*Correct Answer:**
C) Discharge with a responsible adult
Explanation:
The patient has a mild head injury (GCS 13–15) with rapid improvement to GCS 15, indicating low risk for complications (e.g., intracranial hemorrhage). Discharge with supervision is appropriate if:
- No focal deficits.
- No worsening symptoms.
- Reliable follow-up.
Other options:
- A) CT head: Indicated if GCS <13, focal deficits, or high-risk features (e.g., vomiting, anticoagulation).
- B) Admission: Needed if GCS not improving or concerning symptoms persist.
- D) Neurosurgical referral: Reserved for significant pathology on imaging.
A 70-year-old with a subcapital femoral neck fracture should be managed with:
A) Dynamic hip screw (DHS)
B) Cemented hemiarthroplasty
C) Cemented total hip replacement (THR)
D) Cannulated screw fixation
Correct Answer:**
C) Cemented total hip replacement (THR)
Explanation:
For active, elderly patients with a subcapital femoral neck fracture, cemented THR is preferred due to:
- Better long-term function (compared to hemiarthroplasty).
- Lower revision rates (avoids acetabular wear from hemiarthroplasty).
Other options:
- A) DHS: Used for intertrochanteric fractures, not intracapsular fractures.
- B) Hemiarthroplasty: Reserved for less active patients.
- D) Cannulated screws: For non-displaced fractures in younger patients.
A 42 year old woman is admitted to surgery with acute cholecystitis. She is known to have hypertension, rheumatoid arthritis and polymyalgia rheumatica.You are called by the CT1 to assess this lady as she has become delirious and hypotensive 2 hours after surgery. Her blood results reveal: i. Na+ 132 mmol/l ii. K+ 5.3 mmol/l iii. Urea 7 mmol/l iv. Creatinine 108 umol/I v. Hb 12.4 g/dl vi. Platelets 178 * 109/I vii. WBC 15.4 * 109/I What is the diagnosis?
a) Addisons disease
b) Conns
c) Phaeochromocytoma
d) Graves
The most likely diagnosis in this case is Addison’s disease (acute adrenal insufficiency).
Explanation:
• The patient has a history of autoimmune conditions (rheumatoid arthritis and polymyalgia rheumatica), which increases the risk of adrenal insufficiency due to autoimmune adrenalitis.
• She develops delirium and hypotension postoperatively, which are classic signs of adrenal crisis.
• The blood results show:
• Hyponatremia (Na+ 132 mmol/L) → Common in adrenal insufficiency due to lack of aldosterone.
• Hyperkalemia (K+ 5.3 mmol/L) → Due to reduced aldosterone, leading to potassium retention.
• Leukocytosis (WBC 15.4 × 10⁹/L) → Can occur due to stress and inflammation.
• Normal hemoglobin and platelets → Rules out significant hemorrhage.
• The stress of surgery would have increased cortisol demand, and if she was on long-term steroids (for her autoimmune conditions), abrupt cessation or insufficient perioperative steroid cover could have precipitated an adrenal crisis.
Why not the other options?
• Conn’s syndrome (primary hyperaldosteronism) → Would present with hypertension, hypokalemia, and metabolic alkalosis, none of which are seen here.
• Phaeochromocytoma → Typically presents with paroxysmal hypertension, palpitations, and headaches, rather than postoperative hypotension and hyperkalemia.
• Graves’ disease (thyrotoxicosis) → Would cause tachycardia, heat intolerance, and hyperreflexia, but not hyponatremia or hyperkalemia.
Management:
• Immediate IV hydrocortisone (100 mg stat, then 50 mg every 6 hours)
• IV fluids (0.9% saline) to correct hypotension and electrolyte imbalance
• Monitor electrolytes and blood glucose
• Check cortisol levels and ACTH to confirm adrenal insufficiency
Thus, the correct answer is:
(a) Addison’s disease
During Recovery From Varicose Veins Surgery 35 Years Old Woman Complains Of Weakness Of Dorsiflexion and Eversion Of The Ankle Physical Examination Reveals Absent Sensation over The Dorsum Of The Foot. Which Of The Following Nerves Is Most Likely Injured?
a. Deep Peroneal Nerve
b. Saphenous Nerve
c. Superficial Peroneal Nerve
d. Sural Nerve
The correct answer is:
(c) Superficial Peroneal Nerve
Explanation:
The superficial peroneal nerve (a branch of the common peroneal nerve) is responsible for:
• Motor function: Eversion of the foot (via fibularis longus and fibularis brevis muscles).
• Sensory function: Provides sensation to most of the dorsum of the foot (except the first web space, which is supplied by the deep peroneal nerve).
Why is this the most likely nerve injured?
• Varicose vein surgery involves the great saphenous vein, which runs along the medial aspect of the leg. The superficial peroneal nerve, as it descends in the lateral compartment of the leg, becomes more superficial and can be injured during venous stripping or ligation procedures.
• The patient’s symptoms include:
• Weakness in dorsiflexion and eversion: The superficial peroneal nerve mainly affects eversion (fibularis longus/brevis), but it also contributes slightly to dorsiflexion.
• Loss of sensation over the dorsum of the foot: This matches the sensory distribution of the superficial peroneal nerve.
Why not the other options?
• Deep peroneal nerve (a): Primarily responsible for dorsiflexion (via tibialis anterior, extensor hallucis longus, extensor digitorum longus). However, it does not significantly affect eversion and only provides sensory innervation to the first web space.
• Saphenous nerve (b): Purely sensory, providing sensation to the medial aspect of the leg and foot—it does not control muscle movement.
• Sural nerve (d): Purely sensory, providing sensation to the lateral foot and ankle, and does not affect dorsiflexion or eversion.
Summary:
The combination of weakness in eversion and dorsiflexion along with sensory loss over the dorsum of the foot strongly suggests superficial peroneal nerve injury, making (c) Superficial Peroneal Nerve the correct answer.
Follow up in medullary thyroid cancer following thyroidectomy (Calcitonin not in option)
a. Thyroglobulin
b. CEA
c. TSH
d. TRH
e. T4
The correct answer is:
(b) CEA (Carcinoembryonic Antigen)
Explanation:
• Medullary Thyroid Cancer (MTC) arises from the parafollicular C-cells of the thyroid, which produce calcitonin.
• Calcitonin is the most important tumor marker for monitoring recurrence, but since it is not an option, we consider CEA (Carcinoembryonic Antigen).
• CEA is a secondary tumor marker that can be elevated in advanced or recurrent MTC, making it useful for follow-up.
Why not the other options?
• Thyroglobulin (a) → Used to monitor papillary and follicular thyroid cancers, but not MTC (as MTC arises from C-cells, which do not produce thyroglobulin).
• TSH (c) → Not relevant for MTC follow-up, as MTC is not dependent on TSH stimulation.
• TRH (d) → Not used in MTC follow-up; its role is in regulating TSH secretion.
• T4 (e) → Thyroid hormone levels are monitored after thyroidectomy, but they are not used for MTC-specific follow-up.
Summary:
Since calcitonin is not an option, the best available choice for MTC follow-up is CEA (Carcinoembryonic Antigen), making (b) CEA the correct answer.
