Revision Flashcards
1
Q
A 56-year-old man is having a spinal anaesthetic for a lower limb operation
as he has been told he is not fit enough for a general anaesthetic.
Which would be the most appropriate local anaesthetic agent?
A. Bupivacaine alone
B. Lidocaine
C. Lidocaine/prilocine mixture
D. Lidocaine with adrenaline
E. Prilocaine
A
A – Bupivacaine alone
Bupivacaine is a longer-acting anaesthetic that can be used without
adrenaline for spinal or epidural anaesthesia. Bupivacaine can also be
injected into surgical wounds with adrenaline to reduce post-operative
pain for up to 20 hours.
2
Q
when does pancreatic pseudocyst form?
A
4weeks after acute pancreatitis
3
Q
A 33-year-old man is brought into the emergency department following
an assault with a baseball bat. He has bruising over the abdomen and
right loin and complains of abdominal pain. On examination, his chest is
clear with good air entry but his abdomen is rigid. On arrival, his heart
rate is 140/min and blood pressure 90/60 mmHg. He is given O-negative
blood in the resuscitation room but his observations remain unchanged.
What would be the next step in his management?
A. Diagnostic peritoneal lavage
B. Laparotomy
C. Urgent CT scan
D. Urgent intravenous urogram
E. Urgent ultrasound scan
A
B – Laparotomy
This patient has suffered blunt abdominal trauma and is haemodynami-
cally unstable despite blood resuscitation. This is an indication for an
urgent laparotomy, to identify and manage the site of bleeding. From the
history there are no obvious sites of blood loss, so it can only be assumed
that it is being lost into the abdomen.
4
Q
What is boerhaave syndrome?
A
Boerhaave syndrome describes spontaneous transmural rupture of the
oesophagus, often associated with forceful vomiting.
common site : left posteolateral wall of the lower third of the oesoph-
agus.
SX (Mackler’s triad:) vomiting, lower thoracic pain subcutaneous emphysema -common abdominal pain -chest pain -SOB.
5
Q
How many types of jaundice ?
A
3 types
- pre hepatic
- hepatic
- post hepatic
6
Q
what will you see in pre hepatic jaundice?
A
inability of the liver to handle an excess amount of bilirubin being produced; Associated with -hereditary sphero- cytosis - Gilbert syndrome
INV
- serum bilirubin +
- urine bilirubin +
- conjugated bilirubin (normal)
- unconjugated bilirubin +/-
- AST/ALT = normal
- ALP = normal
- Gamma GT- normal
- urine color= normal
- stool color = normal
7
Q
What will you see in hepatic jaundice ?
A
caused by a primary failure of the hepatocytes to metabolise or excrete bilirubin;
Associated:
- viral hepatitis
-liver metastasis
INV
- -serum bilirubin +
- urine bilirubin +/-
- conjugated bilirubin (normal or low)
- unconjugated bilirubin (normal or reduce)
- AST/ALT = ++
- ALP =+/-
- Gamma GT- ++
- urine color= normal / dark
- stool color = normal
8
Q
What will you see in post-hepatic jaundice?
A
caused by the obstruction of bile ducts. Associated -gallstone -carcinoma on head of pancrease
INV
- serum bilirubin +
- urine bilirubin +
- conjugated bilirubin +
- unconjugated bilirubin (normal)
- AST/ALT = normal/ +
- ALP = ++
- Gamma GT- normal/ +
- urine color= dark
- stool color =pale
9
Q
A 37-year-old woman presents to the GP with a 3-week history of frequent,
loose motions. She is very tired and complains of muscle weakness. A subsequent colonoscopy demonstrates a 1.5 cm sessile growth that has
multiple projections. The remainder of the colon was unremarkable.
What is the most likely diagnosis?
A. Adenomatous polyp
B. Colorectal carcinoma
C. Infective colitis
D. Pseudomembranous colitis
E. Villous adenoma
A
E – Villous adenoma
Villous adenomas are large polyps which look like sea anemones. Villous
adenomas secrete mucus and potassium, hence they can present with
diarrhoea and features of hypokalaemia (muscle weakness, myalgia and
arrhythmias). Of all the rectal polyps, the villous adenoma has the high-
est potential for malignant change, so it must be removed.
10
Q
What is the ASA grading system ?
A
Grade I = normal, healthy individual (0.05% anaesthetic mortality)
Grade II = mild systemic disease that does not limit activity (0.4%
mortality)
Grade III = severe systemic disease that limits activity but is not incapacitating
(4.5% mortality)
Grade IV = incapacitating systemic disease that is constantly life-threatening
(25% mortality)
Grade V = moribund, not expected to survive over 24 hours with or
without surgery (50% mortality)
11
Q
A mother brings her 5-week-old son to the paediatric outpatient clinic.
She is concerned as he has been having episodes of forceful vomiting after
feeds for the last 2 weeks. She says her son always seems hungry and now
is beginning to appear lethargic. Examination of the child reveals mild
dehydration and the presence of a smooth, firm, non-tender mass in the
right upper quadrant of the abdomen. Blood tests are sent.
What biochemical abnormalities would you expect to find?
A. Hyperchloraemic, respiratory alkalosis
B. Hypernatraemic, hyperkalaemic, metabolic alkalosis
C. Hypochloraemic, hyperkalaemic, metabolic alkalosis
D. Hypochloraemic, hypokalaemic, metabolic alkalosis
E. Hyponatraemic, metabolic acidosis
A
D – Hypochloraemic, hypokalaemic, metabolic alkalosis
12
Q
A 53-year-old man presents to the GP with a deep, painful ulcer over the
big toe. He gives a 3-month history of severe calf pain on walking which is
only eased on resting. Examination shows cool peripheries with reduced
distal pulses.
Which ulcer does the patient most likely have?
A. Arterial ulcer
B. Curling ulcer
C. Marjolin ulcer
D. Neuropathic ulcer
E. Venous ulcer
A
A – Arterial ulcer
Arterial ulcers are typically painful, deep, well demarcated and occur
on the heels, toes and over bony prominences
13
Q
A 45-year-old man has walked into the emergency department follow-
ing his involvement in a road traffic collision. On arrival at the hospital
he is anxious, but otherwise fine. Later, he suddenly becomes faint. He is taken into the resuscitation room where he is found to have a heart rateof 46/min and a blood pressure of 80/48 mmHg. Primary examination is
unremarkable and the patient has warm peripheries.
Which of the following is the most likely cause of his symptoms?
A. Cardiogenic shock
B. Haemorrhagic shock
C. Hypovolaemic shock
D. Neurogenic shock
E. Spinal shock
A
D – Neurogenic shock
Neurogenic shock is caused by sudden disruption or injury to the sympathetic
nervous pathways, resulting in the loss of vasomotor tone and
pooling of blood in the peripheries. This leads to profound hypotension.
14
Q
modified Glasgow criteria for pancreas ?
A
Mnemonic PANCREAS P =p02 < 8kPa A= age >55 yr N= neutrophil WCC >15x10 C= calcium =<2.0mmol/l R= urea >16 mmol/l E= enzyme (AST, LDH > 600mmol/l) A= albumin <32mmol/l S-sugar >19mmol/l
Severe disease is present if three or more of the criteria are present
within 48 hours.
15
Q
A 50-year-old woman with known gallstones presents to the emergency
department with severe epigastric pain radiating to the back together
with nausea and vomiting. Examination reveals localized epigastric peri-
tonitis and investigations reveal an amylase of 650 μ/L.
Which of the following would indicate a poor prognosis in this condition? A. Amylase of 650 μ/L B. Arterial pO2 of 7.0 kPa C. Patient age of 50 years D. Pyrexia of 38.5°C E. White cell count of 10 × 103 /μL
A
B – Arterial pO2 of 7.0 kPa
16
Q
Malunion of supracondylar fractures = ?
A
cubitus varus deformity (‘gunstock deformity’).
17
Q
What will you see in volkmann ischaemic contracture ?
A
a flexion
contracture of the hand and wrist, caused by circulatory compromise
and ischaemia leading to fibrosis of the forearm compartment. It
is a recognized complication of supracondylar fractures, 2nd in compartment syndrome
Treatment of
Volkmann ischaemic contracture involves surgery to release the contracted
muscles.
18
Q
A 6-year-old boy who had a fracture above the left elbow and was treated
in a plaster cast is brought into the GP practice by his mother a few days
after plaster removal. She is worried due to the abnormal positioning of
his forearm. On examination, his left forearm appears to be shortened
and held in flexion at the wrist and the fingers.
Which of the following complications has led to this appearance?
A. Brachial artery injury
B. Lack of physiotherapy
C. Malunion at fracture site
D. Median nerve injury
E. Ulnar nerve injury
A
A – Brachial artery injury
This boy has presented with Volkmann ischaemic contracture, a flexion
contracture of the hand and wrist, caused by circulatory compromise
and ischaemia leading to fibrosis of the forearm compartment
19
Q
A 40-year-old man presents to the GP complaining of increasing diffi-
culty in swallowing over the last few months. He tells you he has been
working in Mexico for the last two years with a new business. He is other-
wise well and denies any other symptoms.
Which of the following is the most likely cause of his symptoms? A. Chagas disease B. Gastro-oesophageal reflux disease C. Myasthenia gravis D. Plummer-Vinson syndrome E. Zenker diverticulum
A
A – Chagas disease
Chagas disease is a parasitic disease of the tropics caused by the protozoan
Trypanosoma cruzi
20
Q
A 30-year-old woman presents with multiple bilateral breast swell-
ings which cause her discomfort, particularly just before her periods.
They have been present for several years but appear to be getting worse. What is the most likely diagnosis? A. Duct ectasia B. Fat necrosis C. Fibroadenoma D. Fibrocystic disease E. Peau d’orange
A
D – Fibrocystic disease
Fibrocystic disease of the breast is a common benign condition affecting
more than half of women, commonly between the ages of 30 and 50.
21
Q
You are called to see a 56-year-old man who is one day post appendicec-
tomy because he became acutely short of breath. He has just been given his
first dose of cyclizine to relieve nausea. On arrival, the patient is breath-
less with the following observations: heart rate 122/min, blood pressure
86/48 mmHg and saturations 85% in air. Which of the following would you administer first? A. Adrenaline B. Chlorphenamine C. Fluids D. Hydrocortisone E. Salbutamol
A
A – Adrenaline
This patient is in anaphylactic shock, an acute life-threatening emergency
which can rapidly cause death if untreated.
22
Q
A 43-year-old man presents to the GP with a 2-month history of wors-
ening headaches. The headaches are almost constant and are worse in
the morning. On examination, his skin is thick and greasy and he is
hypertensive.
A 43-year-old man presents to the GP with a 2-month history of wors-
ening headaches. The headaches are almost constant and are worse in
the morning. On examination, his skin is thick and greasy and he is
hypertensive.
A
A – Acromegaly
The headache is characteristic of an intracranial space-occupying lesion.
This, along with the features of greasy skin and hypertension, suggests acromegaly as the most likely cause from the given list. Acromegaly is caused
by a growth hormone-secreting tumour of the anterior pituitary gland. The
functions of growth hormone include lipolysis, protein synthesis and gluconeogenesis
– in other words it is anabolic. Patients with acromegaly may present
with headaches, excessive sweating, thick/oily skin, hypertrophy of soft
tissues (large nose/lips/tongue, ‘spade-like’ hands), big viscera, prognathism
(protruding lower jaw) and prominent supraorbital ridges.
23
Q
A 55-year-old man presents to the emergency department with increasing
itching and upper abdominal discomfort. His wife has noticed that he is
looking ‘yellow’. On examination, there is a non-tender mass in the right
upper quadrant. The patient has a history of ulcerative colitis, which is
currently in remission.
What is the most likely diagnosis?
A. Cholangiocarcinoma
B. Gallstones
C. Haemolysis
D. Hepatitis
E. Pancreatic carcinoma
A
A – Cholangiocarcinoma
Cholangiocarcinoma is an adenocarcinoma of the biliary tree and is
associated with ulcerative colitis, primary sclerosing cholangitis and to a
lesser extent Crohn disease. It usually presents between the ages of 50 and
70 poor prognosis with an average survival of 6 months
24
Q
A 27-year-old man presents to the emergency department after being
stabbed in the back. He is now unable to move his right leg. On exami-
nation, you note that he cannot feel pain on the left leg, although motor
function in this limb is preserved. What is the most likely diagnosis? A. Anterior cord syndrome B. Brown-Séquard syndrome C. Central cord syndrome D. Posterior cord syndrome E. Syringomyelia
A
B – Brown-Séquard syndrome
Brown-Séquard syndrome describes the features of unilateral transection
(hemisection) of the spinal cord
25
A 70-year-old woman presents with a 2-month history of anal pain and
itching. More recently she had been having some fresh bleeding and
mucous discharge per rectum. On examination, there is an irregular ten-
der ulceration at the anal margin which appears to be extending into the
```
anal canal.
What is the most likely diagnosis?
A. Anal carcinoma
B. Anal fissure
C. Anal warts
D. Fistula-in-ano
E. Primary syphilis
```
A – Anal carcinoma
The symptoms of anal carcinoma may initially be non-specific, including
pain, discomfort, itching, intermittent bleeding and inguinal lymphadenopathy,
and as a result it is a diagnosis which may easily be missed in
the early stages, particularly as many patients may not have a palpable
lesion.
26
How to calculate sensitivity ?
Sensitivity = number of true positives/(number of true positives +
number of false negatives) × 100
27
how to calculate specificity
Specificity = number of true negatives/(number of true negatives
+ number of false positives) × 100
28
How to calculate positive predictive value (PPV)
PPV = (number of true positives/total number of positives) × 100
29
How to calculate negative predictive value (NPV)
NPV = (number of true negatives/total number of negatives) × 100
30
A newborn baby boy is found to have visible intestine emerging from his
abdomen. There is no covering to the contents.
Which of the following is the most likely diagnosis?
A. Epigastric hernia
B. Exomphalos
C. Gastroschisis
D. Paraumbilical hernia
E. Umbilical hernia
C – Gastroschisis
Gastroschisis is a congenital defect in the anterior abdominal wall adjacent
to the umbilicus. Abdominal contents, such as the liver and intestines,
can herniated through this defect, but there is no sac covering the
contents. Management of gastroschisis is by immediately covering the
exposed viscera with clingfilm, followed by operative repair.
Exomphalos similar congenital abdominal wall defect where contents
of the gut, such as the intestines and liver, lie outside of the body
protruding through the umbilicus.
31
A 27-year-old woman is undergoing a routine surveillance colonoscopy
for ulcerative colitis. The endoscopist notes multiple small projections
throughout the bowel that are of a similar colour to the normal bowel
mucosa.
What is the most likely morphology of the polyps?
A. Adenomatous polyp
B. Hamartomatous polyp
C. Juvenile polyp
D. Metaplastic polyp
E. Pseudopolyp
E – Pseudopolyp
Pseudopolyps are found with inflammatory bowel disease. In an area of
oedematous, swollen bowel surrounded by ulcerations, it looks as if the
oedema is protruding from the walls of the bowel wall as a polyp. In reality,
these ‘polyps’ are merely areas of swollen bowel mucosa.
32
A 45-year-old woman presents to the orthopaedic clinic with a 6-week
history of shooting pains in her right foot, radiating to her toes, only
experienced when wearing her shoes. On examination, there is tenderness
between the third and fourth metatarsal heads. Foot X-rays are reported
as normal.
Which of the following is the most likely diagnosis?
A. Bunion
B. Gout
C. March fracture
D. Morton neuroma
E. Plantar fasciitis
D – Morton neuroma
Morton neuroma is a neuroma of the digital nerve of the foot that is most
common between the third and fourth metatarsals. It is a common cause
of foot pain and typically presents in women from the age of 40.
33
A 38-year-old woman presents to the GP with pain in the subareolar
region of the left breast associated with occasional blood-stained nipple
discharge. Apart from being extremely anxious she has no other associ-
ated symptoms. Examination is unremarkable.
```
What is the most likely diagnosis?
A. Duct ectasia
B. Galactocoele
C. Intraductal papilloma
D. Paget disease
E. Prolactinoma
```
C – Intraductal papilloma
Intraductal papillomas are benign tumours of the lactiferous glands
that usually occur in pre-menopausal women. They commonly present
with pain within the nipple or areola, associated with discharge which
may be blood-stained.
34
A 76-year-old man presents to the GP with a rapidly growing lump in his
neck. It is now causing him difficulty swallowing. Examination reveals a
4 cm hard mass in the front of the neck that is fixed to the overlying skin.
What is the most likely diagnosis?
A. Anaplastic carcinoma
B. Follicular carcinoma
C. Graves disease
D. Papillary carcinoma
E. Toxic multinodular goitre
A – Anaplastic carcinoma
Anaplastic carcinoma is a rare subtype of thyroid cancer (3%) but its incidence
increases with age. It is an aggressive carcinoma which often presents
with a short history of a lump in the neck with local invasion causing
compression of surrounding structures leading to dysphagia, stridor and
hoarseness (recurrent laryngeal nerve involvement).
35
Etiology of acute pancreatitis
mnemonic GET SMASHED:
Gallstones
Ethanol
Trauma
Steroids
Mumps
Autoimmune
Scorpion venom (Tityus trinitatis scorpion of Trinidad and Tobago)
Hyperlipidaemia, Hypercalcaemia, Hypothyroidism
Embolism, ERCP
Drugs (azathioprine, steroids, thiazide diuretics and the contraceptive pill)
36
A 32-year-old woman presents to the GP with a 1-month history of panic
attacks. She says the attacks are associated with sweating and the feeling
of her heart thumping in her chest. She cannot always think of a precipita-
tor to these attacks, but they are increasing in frequency. Examination is
unremarkable.
Which of the following investigations will be the most helpful in con-
firming the diagnosis?
```
A. 17-hydroxyprogesterone levels
B. 24-hour urinary vanillylmandelic acid
C. 24-hour urinary 5-hydroxyindole acetic acid
D. Serum calcitonin
E. Short synacthen test
```
B – 24-hour urinary vanillylmandelic acid
This woman presents with attacks of anxiety, sweating and palpitations.
Along with facial flushing and headaches these are classic presenting features
of phaeochromocytomas.
37
A 22-year-old woman presents to the GP practice with a scaly, well-
defined red rash on her cheeks. She has also noticed its appearance on her
```
scalp. There is some associated hair loss.
What is the most likely diagnosis?
A. Acne vulgaris
B. Discoid lupus
C. Erysipelas
D. Impetigo
E. Rosacea
```
B – Discoid lupus
Discoid lupus erythematosus (DLE) is a chronic inflammatory condition
with an autoimmune aetiology which results in cutaneous manifestations
38
An 18-year-old boy is brought into the emergency department follow-
ing an epileptic seizure. On recovery he complains of pain in the right
shoulder. Examination reveals the arm to be held adducted and internally
rotated with a fullness at the posterior aspect of the shoulder. There is
resistance to passive external rotation.
Which of the following injuries is the patient most likely to have
sustained?
A. Acromioclavicular dislocation
B. Anterior dislocation of the shoulder
C. Inferior dislocation of the shoulder
D. posterior dislocation of shoulder
E. Sternoclavicular dislocation
D. posterior dilocation of shoulder
common in epileptic seizures, electric shocks and
following a direct blow to the front of the shoulder. The arm will be held
internally rotated and adducted, and there is resistance to external rotation.
Anterior dislocation caused by fall onto outstretched
arm or the shoulder itself. The arm will be held in external
rotation and abduction
acromioclavicular dislocation caused by a direct fall onto
the shoulder and may be associated with a fractured clavicle. A step
may be felt at the point of separation,
Inferior dislocation caused by hyperabduction injuries
39
A 60-year-old Asian woman presents to the GP having noticed a dark brown lesion on the palm of her left hand which has been present for 2 months. She initially thought it was a bruise but it has been slowly enlarging.What is the most likely diagnosis?A. Acral lentiginous melanomaB. Amelanocytic melanomaC. Lentigo maligna melanomaD. Nodular melanomaE. Superficial spreading malignant melanoma
A – Acral lentiginous melanoma
40
A 12-year-old girl is brought to the GP by her mother having noticed a painless swelling on the left side of her neck following a recent cold. On examination, there is a smooth, fluctuant, non-tender swelling anterior to the sternocleidomastoid muscle.What is the most likely diagnosis?A. Branchial cystB. Cervical ribC. Cystic hygromaD.Sternocleidomastoid tumourE. Thyroglossal cyst
A branchial cyst is a smooth, nontender,
fluctuant swelling in the anterior triangle, anterior to the border
of the sternocleidomastoid muscle at the junction of its upper and middle
thirds
41
A 27-year-old man who was the driver of a car involved in a high speed col-lision with a truck is brought into the resuscitation room. On arrival, he is complaining of severe left-sided chest pain. You note that he is breathless, tachycardic and hypotensive. He has reduced air entry on the left side of the chest and the trachea is deviated to the right.What would you do next?A. Insert a chest drain into the fifth intercostal spaceB. Insert a wide bore cannula into the second intercostal spaceC. Request an urgent chest X-rayD. Request an urgent ECGE.Perform a pericardiocentesis
B – Insert a wide-bore cannula into the
second intercostal space
This patient has a tension pneumothorax. Air entering the pleural cavity
during inspiration cannot escape during expiration due to the pleura
acting as a one-way valve Decompression is by
insertion of a large bore cannula into the second intercostal space in the
mid-clavicular line of the affected side.
42
A 72-year-old man comes to see you in the GP practice complaining ofa 6-month history of urinary hesitancy, poor stream and occasional incon-tinence. He is increasingly troubled by his symptoms. Blood test results show a prostate specific antigen of 30 ng/mL.Which of the following is the most appropriate next step?A.AntibioticsB. Medical management with alpha-blockersC. Referral for transurethral resection of prostateD. Urgent referral for renal tract ultrasoundE. Urgent referral for transrectal ultrasound and prostate biopsy
E – Urgent referral for transrectal ultrasound
and prostate biopsy
normal PSA value < 5
43
A 64-year-old woman presents with a 2-day history of increasing left-sided abdominal pain with fever. On examination, she has localized peritonism
in the left iliac fossa. Her blood tests reveal a raised white cell count and C-reactive protein.Which of the following is the most likely diagnosis?A.ConstipationB. Diverticular diseaseC.DiverticulitisD. DiverticulosisE. Irritable bowel syndrome
C – Diverticulitis
A diverticulum is an outpouching of a hollow structure. Colonic diverticula
are examples of false diverticula – the walls are made up only of
the inner mucosal layer of the bowel.
44
A 14-year-old boy who has been complaining of pain and a localized ten-der swelling above his right knee for a month has been sent for X-rays by his GP. The X-ray shows an ill-defined breach in the lower end of the cor-tex of the femur with periosteal elevation and calcification.What is the most likely diagnosis?A. ChondrosarcomaB. Ewing sarcomaC. LipomaD. OsteomaE. Osteosarcoma
E – Osteosarcoma
Osteosarcomas are the second most common primary bone tumours after
multiple myeloma. Osteosarcomas occur most often in young adults, in
which case they may be associated with a history of retinoblastoma, and
in older people with Paget disease
Osteosarcomas present with a warm, painful swelling, usually
around the knee (50%).pain tends to be worse at night
X-ray features
are characteristic, showing cortical destruction, periosteal elevation
(Codman’s triangle) and calcification within the tumour but outside of the
bone (sunray spicules).
45
A 4-week-old baby girl is brought to the paediatrics clinic with swelling of both legs which the parents feel has been present since birth. On exami-nation there is oedema, which is non-pitting and firm to touch, of both lower limbs to the knee.What is the most likely diagnosis?A.ElephantiasisB.Hereditary angioedemaC. Lymphoedema praecoxD. Lymphoedema tardaE. Milroy disease
E – Milroy disease
Milroy disease – an inherited autosomal dominant congenital
lymphoedema, caused by a failure of lymph vessels to develop in
utero
46
An 8-year-old boy is brought to the emergency department with a 3-day history of left-sided flank and abdominal pain, fevers and reduced appe-tite. On examination, he has minimal left-sided flank and lower abdomi-nal tenderness, and there is a fluctuant, non-tender swelling in the child’s groin. You note that the child is walking with a limp and there is pain in the hip region on straight leg raising against resistance.How would this child be best managed?A.AppendicectomyB. Arthroscopic hip washoutC.Exploration of testesD. Incision and drainage with intravenous antibioticsE.Intravenous antibiotics alone
D – Incision and drainage with intravenous antibiotics
This boy has presented with the symptoms and signs of a psoas abscess.
A psoas abscess may be primary (and commonly caused by Staphylococcus
aureus) or secondary to spread of infection from structures adjacent to
the muscle,
47
A 74-year-old man presents to the emergency department with a 6-hour history of colicky lower abdominal pain accompanied by gross abdominal distension. He has had similar episodes in the past that have been relieved by opening his bowels. Today he is not even able to pass flatus. Abdominal X-ray shows a grossly dilated loop of large bowel.Which of the following is the most likely diagnosis?A.AdhesionsB.Faecal impactionC.IntussusceptionD.Sigmoid volvulusE.Strangulated inguinal hernia
D – Sigmoid volvulus
| A volvulus is the twisting of a bowel loop around its mesenteric axis.
48
A 56-year-old man is having a spinal anaesthetic for a lower limb opera-tion as he has been told he is not fit enough for a general anaesthetic.Which would be the most appropriate local anaesthetic agent?A.Bupivacaine aloneB.LidocaineC.Lidocaine/prilocine mixtureD.Lidocaine with adrenalineE.Prilocaine
A – Bupivacaine alone
Bupivacaine is a longer-acting anaesthetic that can be used without
adrenaline for spinal or epidural anaesthesia. Bupivacaine can also be
injected into surgical wounds with adrenaline to reduce post-operative
pain for up to 20 hours. The maximum dose of bupivacaine is 2 mg/kg
49
A 68-year-old man presents with acute lower chest and upper abdominal pain following an episode of vomiting. On examination, he has marked tenderness in the epigastrium and you note the presence of subcutaneous emphysema. ECG shows a sinus tachycardia with no ST segment changes, and a chest X-ray demonstrates mediastinal air.Which of the following is the most likely diagnosis?A. Boerhaave syndromeB. Chest infectionC. Mallory-Weiss tearD. Myocardial infarctionE.Pulmonary embolus
A – Boerhaave syndrome
Boerhaave syndrome describes spontaneous transmural rupture of the
oesophagus, often associated with forceful vomiting
Boerhaave syndrome is characterized by Mackler’s triad: vomiting,
lower thoracic pain and subcutaneous emphysema
50
A 45-year-old man presents with episodic upper abdominal pain, severe heartburn, episodes of dark vomitus and diarrhoea. He has been tak-ing over-the-counter indigestion medication with no relief. On endos-copy, he has multiple ulcers throughout the duodenum, some of which are large.Which of the following is most likely to have caused this?A.AlcoholB. Aspirin useC. Gastrinoma D.Helicobacter pylori infectionE.Smoking
C – Gastrinoma
Peptic ulcers result from an imbalance between gastric acid secretion
and mucosal barrier protection.
51
What is Maydl hernia?
contains a ‘W’ loop of intestine, where the
| middle segment is liable to become strangulated.
52
What is amyand hernia ?
contains the appendix within its sac
53
What is gluteal hernia ?
protrudes through the greater sciatic foramen
54
What is littre hernia ?
contains a Meckel diverticulum
55
What is obturator hernia ?
protrudes through the obturator canal pass through the obturator canal in the upper thigh,
especially in older women
56
What is sciatic hernia ?
protrudes through the lesser sciatic foramen
57
What is spigelian hernia ?
protrudes through the semilunar line
58
Type 1 hypersensitivity
Type I hypersensitivity (anaphylactic) reactions occur when exposure
to certain allergens results in IgE-mediated secretion of inflammatory
mediators by basophils and mast cells.
allergic asthma, hay fever (allergic rhinitis), and
peanut allergies.
59
Type II hypersensitivity
cytotoxic antibody mediated
60
Type III hypersensitivity
(complex) mediated by immune complexes
(antigen-antibody complexes). Immune complexes can deposit in various
sites in the body and result in localized tissue damage via complement
activation
glomerulonephritis
following a streptococcal throat infection, rheumatic fever and
systemic lupus erythematosus.
61
Type IV hypersensitivity
delayed type reactions
as features can take days to develop. contact dermatitis
(e.g. to nickel) and transplant rejection.
62
Type V hypersensitivity
describe the presence
of antibodies that bind to cell receptors and either stimulate or prevent
stimulation of the receptor
Graves disease (a stimulatory
response of autoantibodies binding to the TSH receptor of the
thyroid gland) and myasthenia gravis (an inhibitory response from
autoantibodies that bind to acetylcholine receptors at the neuromuscular
junction).
63
A 39-year-old man presents to the emergency department with a painful lump in the groin. He tells you that this lump has been present on and off for a few months and has previously been asymptomatic. Today, the lump has become painful. On examination, there is an erythematous, tender, irreducible lump above and medial to the pubic tubercle. The patient denies abdominal pain, vomiting or constipation.Which is the best descriptive term for the hernia above?A.Incarcerated herniaB.Perforated herniaC.Richter herniaD.Sliding herniaE.Strangulated hernia
C – Richter hernia
This man has a direct inguinal hernia that shows features of a Richter hernia.
A Richter hernia describes strangulation of one sidewall of the bowel
within a hernia sac
64
A 65-year-old woman presents to the emergency department with right wrist pain following a fall onto an outstretched hand. An X-ray shows a fracture of the distal radius with volar displacement of the distal frag-ment. There is no intra-articular involvement.Which of the following would be the most appropriate term to describe this fracture?A. Barton fractureB.Colles fractureC.Galeazzi fractureD.Monteggia fractureE. Smith fracture
E – Smith fracture
| fracture of the distal radius with volar displacement of the distal frag-ment.
65
Colles fracture
a fracture of the distal 2.5 cm of the
radius with dorsal and radial displacement of the distal fragment (leading
to the classic ‘dinner fork’ deformity)
66
What will you see in osteoarthiritis X-ray ?
1. Narrowing of joint space (due to cartilage loss)
2. Osteophytes
3. Subchondral sclerosis (laying down of new bone)
4. Cyst formation
67
What will you see in rheumatoid arthritis X-ray ?
1. Narrowing of joint space
2. Soft tissue swelling
3. Juxta-articular erosions
4. Joint subluxation
68
An 81-year-old woman from a nursing home is brought into the emer-gency department following a fall. She is complaining of pain in her left hip. On examination, her left leg is shortened and externally rotated. The home tells you this woman has dementia but is able to mobilize indepen-dently with a frame. An X-ray shows a displaced intracapsular femoral neck fracture.Which of the following would be the most suitable management option?A. Allow the patient to try to mobilizeB. Dynamic hip screwC.HemiarthroplastyD. Open reduction and internal fixationE. Total hip replacement
```
C – Hemiarthroplasty
The blood supply to the femoral head comprises the intramedullary vessels,
the vessels in the retinaculum of the joint capsule and through the
ligamentum teres (although at this age this may be obsolete).
```
69
A 56-year-old man presents to the emergency department with a 3-hour history of severe abdominal pain and vomiting. On examination, the abdomen is rigid. A CT scan confirms free air in the peritoneum and a perforation of a sigmoid diverticulum.What is the most appropriate operation?A.Abdominoperineal resectionB. Extended right hemicolectomyC. Hartmann procedureD.Left hemicolectomyE.Right hemicolectomy
C – Hartmann procedure
Hartmann procedure involves resection
of the rectosigmoid colon with closure of the rectal stump and formation
of a colostomy.
70
Staging of tumor ?
```
Duke system of grading CRC
Dukes A → confined to the bowel wall
Dukes B → invade through the bowel wall but there is no lymph node
involvement
Dukes C →→→
invade the bowel wall and involve lymph nodes
C1 = apical node not involved
C2 = apical node involved
Dukes D → distal metastases present
```
71
```
A 27-year-old man is admitted to the high dependency ward having sus-tained a significant head injury. Two days later he starts vomiting blood.Which of the following is the most likely cause?
A.Curling ulcer
B.Cushing ulcer
C. Decubitus ulcer
D. Dendritic ulcer
E. Martorell’s ulcer
```
B – Cushing ulcer
A Cushing ulcer is the development of acute peptic ulceration in the setting
of raised intracranial pressure, e.g. after intracranial bleed or traumatic
brain injury. These ulcers most commonly develop within the
antrum of the stomach, although the first part of the duodenum may also
be affected.
72
A 65-year-old man presents to the GP surgery complaining of increas-ing pain in his back and lower left leg. His mobility is now very limited. On examination, he has a marked kyphosis of the spine and bowing of the left lower limb. Locally the leg is markedly warm. Blood tests are taken.Which of the following biochemical abnormalities would one expect to find?A. Hypercalcaemia and hyperphosphataemiaB. Hypocalcaemia and hypophosphataemiaC. Hypocalcaemia and raised alkaline phosphataseD. Raised alkaline phosphatase and normal calciumE. Reduced parathyroid hormone levels and normal calcium
D – Raised alkaline phosphatase and normal calcium
This patient has presented with features of Paget bone disease.
Paget disease is a disorder of bone remodelling,
characterized by excessive bone reabsorption by osteoclasis, followed by a
compensatory increase in bone formation by osteoblasts
73
A 33-year-old woman presents to the surgical outpatient clinic with increasing dysphagia for solids and liquids, retrosternal chest pain on eating, regurgitation of undigested food and weight loss. Oesophageal and gastric biopsy at endoscopy was normal. Oesophageal manometry showed impaired relaxation of the lower oesophageal sphincter and barium swallow revealed a dilated proximal oesophagus with distal narrowing.Which of the following surgical procedures would be indicated?A. Billroth IB. Billroth IIC.Heller myotomyD.Ramstedt procedureE.Whipple procedure
C – Heller myotomy
This patient has presented with the symptoms and signs of oesophageal
achalasia, a condition where there is failure of relaxation of the lower end
of the oesophagus, due to a loss of ganglion cells in the myenteric plexus
Ramstedt pyloromyotomy is a similar procedure performed for pyloric
stenosis.
Whipple procedure is used in resecting pancreatic carcinomas
Billroth I is a partial gastrectomy and Billroth II is partial gastrectomy
with anastomosis of the stomach to the jejunum. These procedures have
been used in the treatment of gastric ulcers and malignancies.
74
Burn score wallace rule of 9?
```
Head + neck → 9%
Upper limb → 9% each
Anterior torso → 18%
Posterior torso → 18%
Lower limb → 18% each
Perineum → 1%
```
75
An 18-year-old boy is attacked in a bar fight, during which he is stabbed in the right groin. He attends the emergency department as he is unable to extend his knee afterwards. On examination, the right knee jerk is absent and there is loss of sensation over the front of the thigh and medial aspect of the leg.Which nerve has most likely been affected?A.Common peroneal nerveB.Femoral nerveC.Obturator nerveD.Sciatic nerveE.Tibial nerve
Femoral nerve
palsies result in a loss of knee extension and loss of sensation over the
anterior thigh and medial leg.
76
A 56-year-old woman presents with progressive difficulty swallowing. She has also noticed increased difficulty in articulating her speech. On examination, you notice that her tongue is small and stiff. She has an exaggerated gag reflex.Which of the following is the most likely cause of her symptoms?A.Bulbar palsyB. Myasthenia gravisC. Paralysis of the vocal cordsD.Pseudobulbar palsyE.Scleroderma
A pseudobulbar palsy is the result of a bilateral upper motor neurone
lesion affecting the 9th to 12th cranial nerves inclusively.spasticity,
hyperreflexia, weakness without muscle wasting)
bulbar palsy is caused by a bilateral lower motor neurone lesion of the 9th
to 12th cranial nerves inclusively. It may also present with dysphagia and
dysarthria. Other features include a wasted fasciculating tongue, drooling
and an absent gag reflex.
77
A 58-year-old woman is brought to the emergency department hav-ing been found unresponsive by her husband at home. On examina-tion, you note that she is overweight with coarse features. Observations include heart rate 42/min, blood pressure 100/68 mmHg and tempera-ture 34.6°C.
Which of the following would be the most appropriate next step in your management?A.Intravenous thyroxineB.Intravenous propranololC.Oral propylthiouracilD.Oral thyroxineE.Thyroidectomy
A – Intravenous thyroxine
This patient has presented in a myxoedema coma, a medical emergency
with a mortality of up to 50%.
Myxoedema coma is more common in those with
undiagnosed/untreated hypothyroidism and following thyroid surgery.
It may also be precipitated by cold, infections, trauma and drugs such
as amiodarone. Physical findings are those of severe hypothyroidism,
namely hypothermia, hypotensive shock, non-pitting oedema, lethargy
and reduced consciousness.
78
A 13-year-old girl presents to the emergency department following a fall on the outstretched hand. An X-ray of the affected upper limb shows a fracture of the upper ulna with dislocation of the radial head.Which of the following would be the most appropriate term to describe this fracture?A. Barton fractureB.Colles fractureC.Galeazzi fractureD.Monteggia fractureE. Smith fracture
D – Monteggia fracture
A Monteggia fracture dislocation is caused by a fall with forced pronation
of the forearm.
proximal ulna fracture with associated dislocation
of the radial head.
Galeazzi fracture dislocation is a fracture
of the radial shaft, at the junction of its middle and lower thirds, with
dislocation of the distal ulna.
79
Which term best fits the description of the hernia given below?A hernia that has two parts, each lying either side of the inferior epi-gast ric a r ter y.A.GlutealB.LumbarC. MaydlD.ObturatorE.Pantaloon
E – Pantaloon
A pantaloon hernia is a type of direct inguinal hernia where the hernia
sac straddles the inferior epigastric vessels. Normally, a direct inguinal
hernia passes medial to the inferior epigastric vessels, whereas an indirect
hernia lies lateral to these.
80
A 48-year-old-woman presents with a long-standing, painless swelling on her right thigh which disappears on lying flat. She is otherwise well. On examination, the swelling is bluish and non-pulsatile. It lies below and lateral to the pubic tubercle.What is the most likely diagnosis?A.Femoral herniaB.Inguinal herniaC. Psoas abscessD. Saphena varixE. Sebaceous cyst
D – Saphena varix
A saphena varix is a dilatation of the long saphenous vein that occurs due
to valvular incompetence at the saphenofemoral junction (which is an
inch below and lateral to the pubic tubercle, just medial to the femoral
pulse).
Features
- bluish tinge
- soft
- compressible
- disappear on lying down
- got cough impulse
- fluid thrill
81
A 27-year-old man presents to the emergency department with sudden-onset pain and swelling in his right knee which occurred while walking. He denies any trauma to the knee. The man describes his knee ‘locking’ at the time, although this sensation is not present now.What is the most likely diagnosis?A. Anterior cruciate ligament injuryB.Chondromalacia patellaeC.Osgood–Schlatter diseaseD.Osteochondritis dissecansE.Pre-patellar bursitis
D – Osteochondritis dissecans
Osteochondritis dissecans is characterized by local ischaemic necrosis of a
segment of the articular surface of a bone and its overlying cartilage the patient experiences sudden
‘locking’ of the knee associated with severe pain and swelling
82
A 46-year-old woman attends a follow-up appointment at the endocrine surgery outpatient clinic. She had an operation for Cushing disease in the past. She complains that her skin is becoming darker and denies sun bed use or excess sunlight exposure.What is the most likely diagnosis?A.AcromegalyB.Carcinoid syndromeC. Conn syndromeD.HypoparathyroidismE. Nelson syndrome
Nelson syndrome results in skin hyperpigmentation via the
| secretion of melanocyte stimulating hormone.
83
A 56-year-old woman presents with a lump on the left side of her neck which has been slowly enlarging over the last few months. On examina-tion, there is a 2 cm firm, painless, mobile lump near the angle of the left jaw. She is still able to move her facial muscles.What is the most likely diagnosis?A.ChemodectomaB.Pleomorphic adenomaC. Salivary duct carcinomaD. Salivary duct stoneE.Sternocleidomastoid tumour
The pleomorphic adenoma is the most common benign
tumour of the salivary glands. It is most common in the 40s to 50s and the
only known risk factor is exposure to radiation.
84
What is Enchondromas?
common benign bone lesions of cartilaginous
origin. They develop from aberrant cartilage left within a bone and are
usually found in the metaphysis.
85
A 56-year-old woman is brought into the resuscitation room. Three days ago she suffered an insect bite to the abdomen which has now spread, causing redness across the whole of her abdomen. On examination, she is confused, with a temperature of 38.3°C, heart rate 106/min and blood pressure 100/56 mmHg.Which of the following is specific to the treatment of this type of shock?A.AntibioticsB.AntihistaminesC.AtropineD.FluidsE.Inotropes
A – Antibiotics
The mainstay of treatment, in addition
to supportive measures, is systemic antibiotics
86
A 72-year-old woman presents to the emergency department with a 5-hour history of abdominal pain, bloating and vomiting. On examination, the abdomen is distended and auscultation reveals intermittent high-pitched sounds. An abdominal X-ray shows air in the biliary tree.What is the most likely diagnosis?A.Emphysematous cholecystitisB.Gallstone ileusC. Paralytic ileusD.Perforated gallbladderE.Pyogenic cholecystitis
B – Gallstone ileus
This patient has presented with the symptoms and signs of small bowel
obstruction. Gallstone ileus is a rare cause of small bowel obstruction
(5% of cases) but is most common in elderly women.
87
A 52-year-old man presents to the GP complaining of an enlarging lump on his face. On examination, he has a 1 cm pigmented, raised lesion on his left cheek that has a shiny rolled edge.What is the most likely diagnosis?A. Basal cell carcinomaB. Bowen diseaseC. KeratoacanthomaD. Seborrhoeic keratosisE. Squamous cell carcinoma
A
| appearance is of a ‘pearly’ lesion with a rolled edge and telangiectasia.
88
```
A 62-year-old man presents to the GP with a lump in the left groin which has been present for over 2 months. On examination, the lump is above the inguinal ligament. It is reducible and has a cough impulse, but does not extend into the scrotum.Which of the following is the most likely diagnosis?
A. Direct inguinal hernia
B.Femoral hernia
C.Gluteal hernia
D. Indirect inguinal hernia
E. Obturator hernia
```
A
Direct inguinal hernias protrude straight out of the abdominal wall
through a weakened area of the transversalis fascia without travelling
down the inguinal canal.
An indirect hernia is one that travels down the inguinal canal and into
the scrotum. Indirect inguinal hernias are the most common type of hernias
and occur most often in young, active men and premature babies
89
A 67-year-old woman presents to the emergency department with a 1-month
history of malaise, weight loss, worsening cough and haemoptysis. You notice
her saturations are 92% on air and perform a blood gas test with the follow-
ing results: pH 7.37, pO2 6.7, pCO2 7.4, bicarbonate 35, saturations 91.7%.
Reference ranges: pO2 >11.0 kPa, pCO2 4.6–6.0 kPa, bicarbonate 22–28
mmol/L, pH 7.35–7.45.
What blood gas picture does this represent?
A. Fully compensated metabolic acidosis
B. Fully compensated metabolic alkalosis
C. Fully compensated respiratory acidosis
D. Type I respiratory failure
E. Venous sample
C – Fully compensated respiratory acidosis
90
A 56-year-old man presents to the pre-assessment clinic prior to an elec-
tive knee operation. He tells you he smokes 20 cigarettes a day and suffers
```
from occasional angina.
Which of the following best describes his preoperative morbidity?
A. ASA grade I
B. ASA grade II
C. ASA grade III
D. ASA grade IV
E. ASA grade V
```
B – ASA grade II
91
A 43-year-old man is brought into the resuscitation room having been
involved in a house fire. On arrival you estimate him to have 20% burns.
The man is around 80 kg in weight.
How much fluid should the patient have over the next 12 hours?
A. 300 mL
B. 600 mL
C. 1200 mL
D. 2400 mL
E. 3000 mL
```
D = 2400ml
Fluid per period (mL) = weight (kg) × % burn area/2
The periods are as follows:
Every 4 hours for the first 12 hours
then Every 6 hours for the next 12 hours
then Over 12 hours for the next 12 hours
```
92
A 64-year-old woman who was conservatively treated in plaster for a
Colles fracture re-presents to the fracture clinic 2 weeks after plaster
removal complaining of a burning pain in the whole hand. On examina-
tion, the hand is slightly swollen, red and shiny. There is a reduction in all
hand and finger movements.
Which of the following is most likely to be the cause of her symptoms?
A. Carpal tunnel syndrome
B. Compartment syndrome
C. Malunion of the fracture
D. Rupture of the extensor pollicis longus
E. Sudeck atrophy
Sudeck atrophy is a reflex sympathetic dystrophy that can affect any limb after injury and can occur in up to 30% of people with Colles
fracture.
Features
- presistent burning pain associated with redness, swelling, warmth of the affected limb
- late = pale and atrophied.
93
A 26-year-old man has been referred to the fracture clinic with instabil-
ity of the left knee. His symptoms followed a football injury in which he
heard a ‘pop’ in his knee while being tackled. He tells you that he attended
the emergency department immediately and a large amount of blood was
drained from the knee.
On examination which of the following would you expect to find?
A. Positive Lachman test
B. Positive McMurray test
C. Positive Simmonds test
D. Positive patellar apprehension test
E. Valgus instability of the knee joint
A
Injury to the knee associated with an acute haemarthrosis is typical of a cruciate ligament injury
Anterior (ACL) prevent forward displacement of tibia
posterior (PCL) prevent backward displacement
investigate with lachment test
94
A 32-year-old man is involved in a high speed car accident. On arrival
at the resuscitation room he complains of chest pain and is short of
breath and tachycardic. He has an area of paradoxical movement of the
chest wall.
Which of the following would be the most appropriate management
measure?
A. Analgesia and respiratory support
B. Chest drain insertion
C. Needle thoracocentesis
D. Pericardiocentesis
E. Thoracotomy
A – Analgesia and respiratory support
The cause of this patient’s respiratory distress is a flail chest. A flail chest
is a life-threatening injury caused by high impact trauma resulting in two
or more consecutive ribs being broken in two or more places.
95
A 62-year-old smoker presents with a 2-week history of worsening short-
ness of breath, haemoptysis and weight loss. On examination, he appears
cachexic and his liver is enlarged with an irregular border.
Which of the following is the most likely cause of his hepatomegaly?
A. Budd-Chiari syndrome
B. Hepatocellular carcinoma
C. Liver cirrhosis
D. Metastatic liver disease
E. Riedel lobe
D – Metastatic liver disease
This patient has presented with symptoms suggestive of lung cancer. It is
likely that the cause of his hepatomegaly is metastatic spread of the cancer.
96
A 42-year-old woman is taken to theatre after fracturing her left hip in a
road traffic collision. Postoperatively, it is noticed that she is unable to flex
or extend her left foot. There is no sensation present below the left knee
except over the medial aspect of the leg.
Which nerve has most likely been affected?
A. Common peroneal nerve
B. Femoral nerve
C. Sciatic nerve
D. Sural nerve
E. Saphenous nerve
C – Sciatic nerve
The sciatic nerve can be damaged with fracture dislocations of the hip or
by misplaced gluteal injections. Sciatic nerve palsy results in paralysis of
the hamstrings and all the muscles of the leg and foot.
97
A 33-year-old man comes to see you at the GP surgery complaining of
increasing difficulty passing urine with poor flow. He has previously been treated for gonorrhoea on three separate occasions.
Which of the following investigations would be most useful in estab-
lishing the cause of his symptoms?
```
A. Intravenous urogram
B. Ultrasound of the renal tract
C. Urethral swabs
D. Urethrography
E. Urinary flow rates
```
D – Urethrography
This patient has presented with obstructive urinary symptoms, the likely
cause being a urethral stricture.
98
A 31-year-old man presents with episodic perianal pain for more than
a year. He has occasionally noticed some discharge. On examination,
a pit is seen in the lower natal cleft. It is filled with hair and a mini-
mal amount of discharge is produced when pressure is applied to the
```
region.
What is the most likely diagnosis?
A. Perianal abscess
B. Perianal haematoma
C. Pilonidal sinus
D. Proctalgia fugax
E. Rectal prolapse
```
C – Pilonidal sinus
A pilonidal sinus is a sinus that contains a tuft of hair. It is typically found
within the natal cleft and is associated with dark hair, hirsutism and obesity.
Pilonidal sinuses are most common in men. They may also occur
in the web spaces of the fingers of barbers and farmers
99
A 68-year-old man attends the emergency department following two epi-
sodes of weakness in the left side of his face, each lasting 2 hours. These
resolve spontaneously and completely. Examination is unremarkable
except for a left carotid bruit.
Which of the following steps would you take next?
A. Start aspirin, advise smoking cessation and refer for outpatient CT head
B. Start aspirin, advise smoking cessation and refer for outpatient carotid
Doppler
C. Start aspirin and refer for urgent inpatient assessment
D. Start aspirin and refer to ophthalmology
E. Start steroids, advise smoking cessation and refer for CT head
C – Start aspirin and refer for urgent inpatient assessment
This patient has presented with a history of transient ischaemic attacks
(TIAs), a focal neurological deficit of vascular origin that resolves completely
within 24 hours
Any patient presenting with a TIA should be risk stratified using the
ABCD2 score as follows:
A Age >65 (1 point)
B Blood pressure >140 systolic or >90 diastolic (1 point)
C Unilateral weakness (2 points), speech disturbance (1 point)
D Duration >60 minutes (2 points), 10–59 minutes (1 point)
E Diabetes (1 point)
Of a total score of 7, patients with a score of 4 or more require admission
for inpatient assessment regarding suitability for carotid endarterectomy
100
A 65-year-old woman attends the GP practice. Yesterday, while garden-
ing, she experienced sudden-onset pain in her right shoulder. On exami-
nation, there is some bruising of the upper arm, and on flexion of the
```
elbow a bulge is seen in the upper arm.
Which of the following is the most likely diagnosis?
A. Distal rupture of biceps tendon
B. Proximal rupture of biceps tendon
C. Rotator cuff tear
D. Rupture of triceps
E. Supraspinatus tendonitis
```
B – Proximal rupture of biceps tendon
Rupture of the biceps
most commonly occurs proximally, at the site of origin of the long head,
and presents with acute pain and the sensation of a ‘snap’.
101
A 27-year-old man presents to the emergency department with a 2-hour
history of severe left-sided loin pain which woke him from sleep. The pain
is constant but occasionally dulls. He has been feeling sick with the pain
and vomited twice. On examination, the patient is writhing in agony and has mild tenderness in the left loin only. His temperature is 36.9°C. Urine
dipstick shows 2+ of blood.
What is the most likely diagnosis?
A. Biliary colic
B. Dissecting aortic aneurysm
C. Pyelonephritis
D. Renal cell carcinoma
E. Renal colic
E – Renal colic
| Renal colic is a common presenting condition in the emergency department.
102
A 64-year-old woman presents to the GP complaining of pain and dif-
ficulty in swallowing. It is becoming progressively worse and now she
```
complains it is even hard to drink water. On examination, she appears
cachexic.
Which of the following is the most likely diagnosis?
A. Oesophageal candidiasis
B. Oesophageal carcinoma
C. Oesophageal spasm
D. Oesophageal stricture
E. Oesophageal web
```
B – Oesophageal carcinoma
A history of rapidly progressive dysphagia with weight loss in a patient
of this age (60–80 years) suggests a diagnosis of oesophageal carcinoma.
103
A 32-year-old man presents to the GP with pain in the right foot which
is exacerbated by weight bearing. He tells you he jogs on a daily basis.
On examination, he has a tender swelling over the second metatarsal. An
X-ray of his foot shows a periosteal reaction over the neck of the second
metatarsal.
What is the most likely diagnosis?
A. Gout
B. Hallux rigidus
C. Jones fracture
A 32-year-old man presents to the GP with pain in the right foot which
is exacerbated by weight bearing. He tells you he jogs on a daily basis.
On examination, he has a tender swelling over the second metatarsal. An
X-ray of his foot shows a periosteal reaction over the neck of the second
metatarsal.
What is the most likely diagnosis?
A. Gout
B. Hallux rigidus
C. Jones fracture
E – March fracture
March fractures are undisplaced hairline fractures caused by repetitive
stress, e.g. marching or running. They commonly occur near the neck
of the second or third metatarsal.
104
A 27-year-old woman presents to the GP with a 2-month history of wors-
ening swelling in both legs. On examination, her lower legs and thighs
```
are very oedematous and firm. The skin is thick, hard and grey in colour.
What is the most likely diagnosis?
A. Filariasis
B. Hereditary angioedema
C. Lymphoedema praecox
D. Lymphoedema tarda
E. Milroy disease
```
A – Filariasis
Filariasis is a cause of secondary lymphoedema. Filariasis (a.k.a. elephantiasis)
is characterized by thickening of the skin and subcutaneous tissues,
often of the legs and genitals. It is caused by infection and obstruction of
lymph vessels by the parasite Wuchereria bancrofti in tropical countries.
The infection is transmitted by mosquito bites.
105
A 36-year-old man presents to the emergency department following a
road traffic collision. He has fractured his right tibia and also complains
of pain in his neck. On examination, he is unable to lift his right arm,
which is medially rotated and extended at the elbow. There is a loss of
sensation on the lateral side of the right arm and forearm.
Which nerve has most likely been affected?
A. Lower brachial plexus
B. Median nerve
C. Radial nerve
D. Ulnar nerve
E. Upper brachial plexus
E – Upper brachial plexus
Upper brachial plexus injuries, also known as Erb’s palsy, involve the C5
and C6 nerve roots (the brachial plexus is made up of the roots C5 to T1).
They are commonly caused by traction injuries, e.g. motorcycle accidents
or birth injuries (due to pulling on the baby’s arm). There is flaccid paralysis
of the arm abductors, lateral rotators of the shoulder and supinators,
so the affected arm hangs limp, is medially rotated, extended at the elbow
and pronated with the hand pointing backwards – the waiter’s tip position.
Paralysis is accompanied by loss of sensation over the lateral arm
and forearm.
Lower brachial plexus injuries, also known as Klumpke’s palsy, involve
the C8 and T1 nerve roots. They are often caused by breech birth injuries
(when the baby’s arm remains above its head) and motorcycle accidents.
Patients present with a claw hand in all digits (from paralysis of the
intrinsic muscles of the hand) and sensory loss along the ulnar border of
the forearm and hand.
106
A 34-year-old man has presented to the emergency department following a
large haematemesis. On examination, the patient appears agitated. His pulse
is 120/min, blood pressure 122/84 mmHg and respiratory rate 22/ min.
How would you classify the patient’s current condition?
A. Class I haemorrhagic shock
B. Class II haemorrhagic shock
A 34-year-old man has presented to the emergency department following a
large haematemesis. On examination, the patient appears agitated. His pulse
is 120/min, blood pressure 122/84 mmHg and respiratory rate 22/ min.
How would you classify the patient’s current condition?
A. Class I haemorrhagic shock
B. Class II haemorrhagic shock
B – Class II haemorrhagic shock
| find shock image
107
A 54-year-old man presents with a 2-day history of upper abdominal and
shoulder tip pain on the right side. He also complains of difficulty breath-
ing and episodes of fever and sweats. He underwent a laparotomy 2 weeks
```
ago following a perforated appendix.
What is the most likely diagnosis?
A. Appendix abscess
B. Cholecystitis
C. Diverticular abscess
D. Polycystic liver disease
E. Subphrenic abscess
```
E – Subphrenic abscess
A subphrenic abscess is a localized collection of pus beneath the diaphragm.
It most commonly occurs on the right side. It develops 2–3 weeks
following a peritonitic event and apart from the symptoms described
above, there may be complaints of shoulder tip pain, hiccups (secondary
to diaphragmatic irritation), and respiratory difficulty caused by pulmonary
collapse and effusions.
108
An 18-year-old has been physically assaulted outside a bar. On arrival at
the emergency department she appears drowsy and there is gross swell-
ing to the right side of her face. On examination, she is making groaning
```
sounds but is not verbally interactive. She is unable to obey commands
but withdraws to pain and opens her eyes only to painful stimulus.
What is her Glasgow coma score?
A. 3
B. 6
C. 8
D. 10
E. 13
```
C – 8
109
A 24-year-old man, who has been suffering from intermittent fresh bleed-
ing per rectum, presents to the emergency department with a 6-hour history of right-sided abdominal pain, fevers and nausea. On examination, he has
tenderness and guarding in the right iliac fossa. His temperature is 38.2°C.
What is the most likely diagnosis?
A. Appendicitis
B. Haemorrhoids
C. Meckel diverticulitis
D. Renal colic
E. Shigella infection
C – Meckel diverticulitis
110
Which term best fits the description of the hernia given below?
This hernia arises from a triangle bounded by the external oblique
muscle, the latissimus dorsi and the iliac crest below.
A. Amyand
B. Littre
C. Lumbar
D. Obturator
E. Sciatic
C– Lumbar hernia
There are two types of lumbar hernia. A Petit hernia (as in this question)
passes through the inferior lumbar triangle of the posterolateral wall,
which is bounded by external oblique, latissimus dorsi and the iliac crest
below. A Grynfeltt hernia passes through the superior lumbar triangle, a
space bounded by the 12th rib above, sacrospinalis muscle medially and
the internal oblique muscle laterally.
111
A 27-year-old man presents to the GP practice having noticed a painless
swelling of his right testicle. He is otherwise well. On examination, the
testis is enlarged, firm and has a nodular texture.
What is the most likely diagnosis?
A. Epididymal cyst
B. Gumma
C. Haematocele
D. Orchitis
E. Testicular cancer
E – Testicular cancer
Testicular cancer is the most common cancer affecting men between the
ages of 20 and 40.
112
A 37-year-old man presents to the GP with a 2-month history of thirst
and frequency of urination. He has no significant past medical history
and examination is unremarkable. Routine bloods demonstrate the fol-
lowing: random glucose 5.6 mmol/L, sodium 142 mmol/L and potassium
```
2.9 mmol/L.
What is the most likely diagnosis?
A. Addison disease
B. Congenital adrenal hyperplasia
C. Conn syndrome
D. Multiple endocrine neoplasia
E. Phaeochromocytoma
```
C – Conn syndrome
This man presents with polyuria and polydipsia associated with high
sodium, low potassium and normal glucose
113
```
A 58-year-old woman presents with itchy, dry skin around the left areola.
On examination, the skin is dry and cracked, and there appears to be a 1 cm
nodule underlying the affected area.
What is the most likely diagnosis?
A. Atopic dermatitis
B. Fibrocystic disease
C. Mondor disease
D. Paget disease
E. Peau d’orange
```
D– Paget disease
Paget disease of the nipple is an eczema-like (i.e. dry and itchy) condition
of the nipple which persists despite local treatment and is associated with
an underlying breast carcinoma.
114
A 6-year-old girl is referred by her GP to the paediatric clinic with preco-
cious puberty. On examination, she is found to have clitoromegaly and
some pubic hair. She is on the 98th centile for height and weight.
Which of the following will be most helpful in determining the under-
lying diagnosis?
```
A. 17-hydroxyprogesterone levels
B. 24-hour urinary vanillylmandelic acid
C. 24-hour urinary 5-hydroxyindole acetic acid
D. Serum calcitonin
E. Short synacthen test
```
A – 17-hydroxyprogesterone levels
The presentation of clitoromegaly, precocious puberty and accelerated
growth in this young girl is indicative of congenital adrenal hyperplasia.
autosomal recessive deficiency
of the enzyme 21-hydroxylase
115
A 42-year-old man presents to the GP with a slowly enlarging mass in the
left side of his neck which has been present for 3 months. On examina-
tion, the mass is 2 cm in diameter, non-tender, pulsatile and can be moved
```
from side to side, but not up or down.
What is the most likely diagnosis?
A. Branchial cyst
B. Cervical rib
C. Chemodectoma
D. Pleomorphic adenoma
E. Virchow node
```
C – Chemodectoma
A chemodectoma is a tumour of carotid body chemoreceptors arising in
the carotid bifurcation. It is usually benign. Chemodectoma presents as
a slowly enlarging neck mass which demonstrates a transmitted carotid
pulsation. It characteristically mobilizes side to side but not up and down
116
A 23-year-old man presents to the emergency department with a nose
bleed. He tells you this has been a recent recurrent problem and that
his father was the same. On examination, you note that he has multiple
dilated blood vessels around the nose and mouth.
Which of the following is the most likely cause of his epistaxis?
A. Haemophilia B
B. Hypertension
C. Osler-Weber-Rendu syndrome
D. Septal polyps
E. Sturge-Weber syndrome
Osler-Weber-Rendu syndrome is an autosomal dominant condition
characterized by telangiectasia and arteriovenous (AV) malformations
at multiple sites.
117
A 33-year-old man presents to the emergency department with an acutely
painful swollen right knee. On examination, he has a swollen, red hot
knee with minimal range of movement. Aspiration of the joint shows tur-
bulent fluid with a raised neutrophil count and no crystals.
```
What is the most likely diagnosis?
A. Gout
B. Pseudogout
C. Reiter’s syndrome
D. Rheumatoid arthritis
E. Septic arthritis
```
E – Septic arthritis
Gout more commonly affects the big toe and is diagnosed by
finding negatively birefringent, needle-shaped crystals (sodium urate).
Pseudogout is caused by deposition of calcium pyrophosphate dihydrate
crystals in the joint space. These are positively birefringent on microscopy.
Reiter’s syndrome is the triad of seronegative arthritis, conjunctivitis
and urethritis.
118
An 18-year-old boy is brought into the emergency department hav-
ing fallen down a flight of stairs outside his flat. His cervical spine is immobilized by the attending paramedics. The patient is saying he does
not have neck pain and wants the collar removed.
In which of the following circumstances is it appropriate to remove the
collar?
A. He has been drinking alcohol
B. He has lost consciousness for only 5 minutes
C. He has no cervical spine tenderness
D. He is in shock with a splenic injury which requires a laparotomy
E. He has no peripheral neurological signs
C – He has no cervical spine tenderness
The cervical spine may only be ‘cleared’ clinically if all the following
apply: the patient is fully alert and orientated, not under the influence
of drugs or alcohol, there is no head injury, no neck pain, no abnormal
neurology and no distracting injuries together with no C-spine tenderness,
deformity or external evidence of injury on clinical examination. If
any of these are present, imaging must be obtained. Remember that life threatening
treatment takes precedence over clearing the spine and can
be carried out while the` patient is immobilized
119
You are called to see a 62-year-old man on the ward who was admitted
earlier in the day with frank haematuria with the passage of clots. He is
now complaining of lower abdominal pain and an inability to pass urine.
On examination the bladder is distended.
Which of the following would you perform in the first instance?
A. Catheterization using a Foley catheter
B. Catheterization using a three-way catheter
C. Cystoscopy
D. Suprapubic catheterization
E. Ultrasound of the bladder
B – Catheterization using a three-way catheter
This patient has developed urinary retention, most likely secondary to
clot retention. He will require catheterization for relief of his symptoms.
Although this could be done using a standard Foley catheter, it is best to
use a three-way catheter as irrigation of the bladder with normal saline
can be performed simultaneously to allow the clearance of clots and
prevent blockage of the catheter. Three-way catheters are often inserted
routinely in the presence of frank haematuria to prevent clot retention;
120
A 65-year-old woman with a past medical history of hypertension and sta-
ble angina presents to the GP practice complaining of episodes of severe
central abdominal pain. They occur around half an hour after meals and
can last up to an hour. She is becoming reluctant to eat because of the pain
and as a result she has lost nearly a stone in weight over the past 2 months.
Examination is unremarkable.
Which of these investigations would be the most informative?
A. Barium follow through
B. CT scan
C. Colonoscopy
D. Exercise tolerance test
E. Mesenteric angiography
E – Mesenteric angiography
This patient has presented with symptoms typical of mesenteric angina:
severe, griping abdominal pain 15–45 minutes after eating. The pain
reflects mesenteric ischaemia and occurs as a result of vascular stenosis
in the mesenteric arteries (commonly the superior mesenteric artery).
It is comparable to angina and intermittent claudication. The risk factors
for the development of mesenteric angina are the same as those for atherosclerosis
in general. It typically occurs in those over the age of 60 and
is three times more common in females. The treatment is largely surgical,
options being endarterectomy, bypass and stenting. Medical management
includes anticoagulation with warfarin. Acute or acute-on-chronic
mesenteric occlusion presents with ischaemic bowel.
121
A 65-year-old man presents to the vascular outpatient clinic with a history
of severe cramping pains in the right calf on walking. The pain has been
so severe that he has had to stop his activities. Over the last few months he
has also had pain at rest, particularly at night, which is relieved on hang-
ing his leg off the bed. Examination of the right leg shows it is cool and
```
there is difficulty palpating the pulses. There are no gangrenous changes
or ulcers.
Which of the following ankle brachial pressure index results would
you expect?
A. 0.1
B. 0.3
C. 0.7
D. 1.0
E. 1.4
```
B – 0.3
The ankle brachial pressure index (ABPI) is calculated by taking the
greatest of the systolic pressures in either the posterior tibial artery or
the dorsalis pedis, and dividing this by the systolic pressure in the brachial
artery on the same side. A normal reading should be 1.0 or above.
Calcification of arteries, as can occur in diabetes, can give abnormally
high readings (>1.3) even in the presence of significant peripheral vascular
disease. These patients should be referred for further investigation.
Intermittent claudication will give a reading of 0.5 to 1.0, and readings
of between 0.3 and 0.5 are expected in those with rest pain. Readings of
below 0.2 occur in the acutely ischaemic leg, and those with gangrene and
ulcers.
122
A 34-year-old man presents to the emergency department with a 6-hour
history of abdominal pain and vomiting. On examination, the abdomen
is distended and tympanic. He tells you that for the last 6 months he has
been having episodes of cramping right-sided abdominal pain with inter-
mittent episodes of blood in his stools.
```
Which of the following complications has resulted in his presentation
today?
A. Abscess formation
B. Fistula formation
C. Primary sclerosing cholangitis
D. Stricture formation
E. Toxic megacolon
```
D – Stricture formation
This patient has presented with the signs and symptoms of bowel
obstruction, however his background history is suggestive of Crohn
disease. Crohn disease is a non-specific inflammatory bowel disease,
thought to be of autoimmune pathogenesis. It is characterized histologically
by full-thickness inflammation of the bowel and non-caseating
granulomas. Mucosal ulceration along with the intermittent oedema
that occurs in Crohn disease results in a cobblestone appearance of the
bowel.
123
A 72-year-old man presents to the emergency department with a 3-hour
history of a painful, cold right leg. He has a past medical history of atrial
fibrillation. On examination, the right leg is cold and tender. The pedal
pulses on the right are not palpable.
What would be the most appropriate initial management?
A. Amputation
B. Aorto-bifemoral bypass graft
C. Conservative management
D. Embolectomy
E. Fasciotomy
D – Embolectomy
124
A 33-year-old man presents to the emergency department having hit the
end of his finger with a hammer while at work. He is now unable to lift the
end of his finger. On examination, the index finger is flexed at the distal
interphalangeal joint.
Which of the following is the most likely diagnosis?
A. Boutonniere deformity
B. Duck bill deformity
C. Mallet finger
D. Swan neck deformity
E. Trigger finger
C – Mallet finger
Mallet finger (or baseball finger) occurs when sudden passive flexion of a
distal interphalangeal (DIP) joint (like a ball striking the tip of the finger)
ruptures the extensor tendon at the point of its insertion into the base
of the distal phalanx.
125
A 27-year-old man with a long history of constipation presents with a
history of severe pain on defaecation and bright red blood on the tissue
paper. On examination, you see a skin tag at the anal verge. Per rectum
examination is not possible due to severe pain.
Which of the following treatments would you suggest?
A. Analgesic suppositories
B. Excision of skin tag
C. Haemorrhoidectomy
D. Incision and drainage
E. Topical GTN ointment
E – Topical GTN ointment
This patient has presented with an anal fissure. Anal fissures are longitudinal
tears in the anal mucosa, with exposure of the underlying circular
muscle, and they typically occur on the passage of a constipated
stool. Patients present with a stinging pain that can last up to 2 hours
on defaecation.
126
A 34-year-old builder comes to see you in the GP practice complaining of
a 3-week history of lower back ache. The pain is worst at the end of the day
and partially relieved by lying down. He has no other associated symp-
toms of note. Examination is unremarkable.
What would be the most suitable management option in the first
instance?
A. Blood tests for ESR and bone profile
B. Lumbar X-ray
C. Refer for MRI of the spine
D. Simple analgesia and bed rest
E. Simple analgesia and gentle mobilization
E – Simple analgesia and gentle mobilization
This patient has presented with mechanical back pain which is characteristically
worse at the end of the day. He has no other symptoms that
would suggest serious pathology, such as neurological symptoms, fever
or weight loss.
127
A 25-year-old woman has been investigated with lower gastrointestinal
endoscopy and biopsy following complaints of frequent bloody diarrhoea
which is still continuing. The results show diffuse superficial inflamma-
tion with ulceration in the rectum only.
```
Which of the following treatment options would be most suitable in
the first instance?
A. Azathioprine
B. Colectomy
C. Mesalazine
D. Prednisolone
E. Surveillance colonoscopy
```
C – Mesalazine
| This patient has presented with ulcerative colitis (UC).
128
A 46-year-old pre-menopausal woman has a 5 cm lump over her right
breast which has been confirmed to be an invasive tumour. She is other-
wise fit and well.
```
Which is the next most appropriate course of action?
A. Mastectomy
B. Radiotherapy
C. Tamoxifen
D. Trastuzumab
E. Wide local excision
```
A – Mastectomy
a mastectomy is required if the tumour is >4 cm in size
if patient dont want can try do chemo to reduce size then perform wide local excision instead.
129
A 36-year-old woman presents to the GP with a 2-month history of
tremors. This is interfering with her work as a typist and the worry has
caused her to lose over a stone in weight over the last few weeks. On
examination, the thyroid appears normal although a bruit can be heard
overlying it.
What is the most likely diagnosis?
A. De Quervain thyroiditis
B. Graves disease
C. Thyroid adenoma
D. Thyroid storm
E. Toxic multinodular goitre
B – Graves disease
This woman demonstrates features of thyrotoxicosis with a thyroid bruit.
The presence of hyperthyroidism with a bruit indicates a likely diagnosis
of Graves disease
130
`SALTER–HARRIS FRACTURES
The Salter–Harris classification describes fractures that involve the
growth plate in children. The classification can be remembered using the
initials SALTeR:
I Slipped Fracture across the physis with no other fragment
II Above Fracture across the physis with a metaphyseal fragment
III Lower Fracture across the physis with an epiphyseal fragment
IV Through Fracture through the physis with metaphyseal +
epiphyseal fragments
V Rammed Crush injury to the physis
Remember that the metaphysis is the area of bone on the inside of the
physis (growth plate) and the epiphysis is the outermost part of the bone.
131
A 6-year-old boy has a fall onto his outstretched hand. On examination,
he is tender over the distal radius. An X-ray confirms a fracture through
the distal radius growth plate which includes a metaphyseal and epiphy-
seal fragment.
```
What classification is most suitable for this fracture?
A. Salter–Harris I
B. Salter–Harris II
C. Salter–Harris III
D. Salter–Harris IV
E. Salter–Harris V
```
D – Salter–Harris IV
| IV Through Fracture through the physis with metaphyseal +epiphyseal fragments
132
A 46-year-old woman has been involved in a road traffic collision. Her
right knee hit the dashboard of the car. On arrival at the emergency
department she is unable to flex her toes on the right side. Examination
reveals an absence of the ankle jerk and loss of sensation over the sole of
the right foot.
Which of the following nerves is most likely to have been affected?
A. Femoral nerve
B. Obturator nerve
C. Sciatic nerve
D. Sural nerve
E. Tibial nerve
E – Tibial nerve
The tibial nerve is particularly vulnerable to damage during posterior
dislocations of the knee. It can also be compressed in the posterior tarsal
tunnel behind the medial malleolus.
tibial nerve supplies the flexor compartment of the leg (calf muscles). It
also gives rise to the medial and lateral plantar nerves which supply the
intrinsic muscles of the foot as well as plantar sensation. Tibial nerve palsy
results in loss of toe flexion, ankle inversion and the ankle jerk
133
An 8-year-old boy is brought into the emergency department by his father
with a 1-day history of fever, right-sided abdominal pain and diarrhoea.
He has no past medical history of note, but has recently recovered from a
cold. On examination, he has a temperature of 39°C and is tender, but not
guarding, in the right iliac fossa.
What is the most likely diagnosis?
A. Appendicitis
B. Crohn disease
C. Coeliac disease
D. Gastroenteritis
E. Mesenteric adenitis
E – Mesenteric adenitis
Mesenteric adenitis is the term given to the non-specific inflammation
of mesenteric lymph nodes, resulting in mild peritoneal irritation.
Mesenteric adenitis usually follows a viral infection
Mesenteric adenitis is rare after the age of 30 and is most common in
children following an upper respiratory tract infection. The presentation
of mesenteric adenitis often mimics acute appendicitis; features that may
be helpful in differentiating the two are a high grade fever (greater than
38.5ºC), shifting tenderness, lack of rebound tenderness and absence of
anorexia in mesenteric adenitis.
diagnosis may sometimes only be made after laparotomy
or laparoscopy, on finding a normal appendix and enlarged mesenteric
lymph nodes.
self-limiting condition and
treatment is conservative and symptomatic (analgesia, anti-pyretics).
134
Whtat is monteggia fracture ?
| which nerve will be injured ?
1/3 proximal fracture of ulna and anterior disolocation of head of radius and injure radial nerve
135
Wrist drop = what nerve?
radial nerve
136
foot drop = what nerve?
common peronal nerve or sciatic nerve
137
claw hand = which nerve?
ulnar nerve
138
fibular neck fracture injure which nerve?
common peronal nerve
139
femur neck fracture injure which nerve?
sciatic nerve
140
Acetabulum fracture injure which nerve
sciatic nerve
141
humeral shaft fracture injure which nerve
radial nerve
142
humeral neck fracture injuere which nerve
axillary nerve
143
unable to flex proximal interphalangeal joint and metacarpophalangeal joint
flexor digitorium superficialis
144
unable to flex distal interphalangeal joint and metacarpophalangeal joint
flexor profundus superficialis
145
what happend if bicep tendon rupture ?
muscle will be at distal arm
| "popeye" appearance
146
De Quervain disease
pain under thumb
147
tennis elbow
lateral epicondylitis
| affected wrist extension
148
golfer elbow
medial epicondylitis
149
loss sensation in medial part of foot
saphenous nerve
150
loss sensation in lateral foot
sural nerve
151
where u put chest drain ?
5th intercostal slightly anterior and mid-axillary line
152
what are the boundaries of the safety triangle?
anterior: pectoralis major
posterior latassimus dorsi
superirly: base of axilla
inferiorly: 5th intercostal space
153
where ovary and testis lymph drainage
para-aortic lymph node
154
where perineum, scrotum, vulva lymph drainage ?
superficial inguinal LN
155
Where the tip of tongue lymph drainage ?
submental LN
156
where the anterior 2/3 of tongue lymph drainage?
submandibular LN
157
Where the posterior 1/3 of tongue lymph drainage?
deep cervical lymph
158
Temporal lobe stroke?
memory impairment
| superior homonymous quadrantinopias
159
Parietal lobe stroke?
inferior homonymous quadrantinopias
160
Frontal lobe?
change of behavior, personality, social, BUT NO VISUAL DEFECT
161
common peroneal nerve
PED
peroneal nearve
eversion of foot and dorsiflex
162
Tibial nerve
TIP
tibial nerve
inversion and plantar flexion of foot.
163
Deep inguinal
above and midpoint of inguinal ligament
164
Lacunar infract ?
ataxic hemiparesis (same side) + dysarthria (difficulty speaking)
165
cerebral infract?
contralateral hemiplegia/sensory loss + dysphasia + homonymous hemianopia
166
Brainstem
lock in syndrome
quadriplegia
vertigo
diplopia
167
Unilateral recurrent laryngeal nerve damage ?
Hoarsness of voice
recurrent laryngal nerve branch of Vagus nerve (10th CN)
168
Bilateral recurrent laryngeal nerve damage ?
aphonia and airway obstruction
recurrent laryngal nerve branch of Vagus nerve (10th CN)
169
external branch of superior aryngealnerve
loss of high pitch sound = dysphonia
170
Which anatomical landmark for IVC (inferior vena cava)
T8
| IOA) → I Opened A door → IVC, Oesophagus, Aorta (T8, 10, 12
171
Which anatomical landmark for oesophagus
T10
| IOA) → I Opened A door → IVC, Oesophagus, Aorta (T8, 10, 12
172
Which anatomical landmark for arota
T12
| IOA) → I Opened A door → IVC, Oesophagus, Aorta (T8, 10, 12
173
Which anatomical landmark for umbilicus level
L3/L4
174
Which anatomical landmark for iliac crest ?
L4
175
transpyloric plane is in which anatomical landmark ?
L1
```
9 Costal Cartilage,
• GB fundus,
• Stomach pylorus,
• Kidney hilum,
• SMA (Superior mesenteric artery),
• Celiac trunk.
```
176
How to diagnose paget disease ?
Punch Biopsy
177
Fat necrosis of breast
Hx of Trauma to the Breast (redness or bruises around the lump) + firm,
round, solitary and localized lump
178
20-40YO woman bleeding on 1 nipple+/- skin change
Ductal pailloma
do GALACTOGRAM
179
15-30YO woman, firm, non-tender, and mobile mass on breast
fibroadenoma
TRIPLE ASSESSMENT
- Clinical
- US
- FNA
180
childbearing age woman, pain breast and increase size, lumpiness (nodularity) can be felt, this occur before mensturation and disappear after
Fibroadenosis
181
Fixed, irregular, hard, painless lump +/- nipple retraction +/- fixed of skin (peau d orange) or muscle + local, fixed, firm, axillary LN
breast cancer
Do core biopsy
182
Hx of abscess around breast area, yellow discharge near nipple
Ductal fistula (mamillary fistula)
183
Prolonged Redness around the areola. Hx of using antibiotics which may
improve symptoms slightly. greenish fluid is aspirated from the breast.
Periductal mastitis.
184
Pt with dysphagia + regurgiatation of food+ chronic cough at night time + halitosis + aspiration + gurgling sound in chest on drinking ?
pharyngeal pouch =zenker diverticulum
185
Pharyngeal pouch do what investigation?
Barium swallow
endoscopy is contraindicated because it can perforate the pouch
186
A 35 years old construction worker is diagnosed with indirect inguinal hernia. Which statement below best describes it?
A. Passes through the superficial inguinal ring only
B. Lies above and lateral to the pubic tubercle
C. Does not pass through the superficial inguinal ring
D. Passes through the deep inguinal ring
D. Passes through the deep inguinal ring
187
Common location of renal tract calculus
3 most common location from proximal to distal within the renal tract
1. pelvic-ureteric junction (PUJ)
2. within the ureter at pelvic brim
3. vesicoureteric junction (VUJ) (most common site)
