SBA MCQ Flashcards
A 25-year-old man presents to the emergency department with a stab wound to the left chest. He is tachycardic, hypotensive and has decreased breath sounds on the left side. What is the most appropriate initial management?
A) Insert a chest drain in the fifth intercostal space in the mid-axillary line
B) Insert a chest drain in the second intercostal space in the mid-clavicular line C) Perform a needle decompression in the second intercostal space in the mid-clavicular line
D) Perform a needle decompression in the fifth intercostal space in the mid-axillary line
E) Perform a pericardiocentesis
The correct answer is C. This patient has a tension pneumothorax, which is a life-threatening condition that requires immediate decompression of the pleural cavity. A needle decompression in the second intercostal space in the mid-clavicular line is the preferred method of initial management, as it is quick and effective. A chest drain can be inserted afterwards to prevent recurrence. A chest drain in the fifth intercostal space in the mid-axillary line is the standard treatment for a simple pneumothorax, but it is not suitable for a tension pneumothorax. A chest drain in the second intercostal space in the mid-clavicular line is not recommended, as it may cause injury to the internal mammary artery or the lung apex. A needle decompression in the fifth intercostal space in the mid-axillary line is an alternative site for decompression, but it is less reliable and more difficult to access. A pericardiocentesis is indicated for a cardiac tamponade, which is a different condition that may also result from a penetrating chest injury.
A 45-year-old woman undergoes a total thyroidectomy for a multinodular goitre. On the first postoperative day, she complains of tingling sensations in her fingers and toes. She also has muscle cramps and twitching of her facial muscles. What is the most likely diagnosis?
A) Hypocalcaemia
B) Hypokalaemia
C) Hypomagnesaemia
D) Hypophosphataemia
E) Hypothyroidism
The correct answer is A. This patient has symptoms of hypocalcaemia, which is a common complication of total thyroidectomy, due to inadvertent damage or removal of the parathyroid glands1. Hypocalcaemia can cause neuromuscular irritability, such as paraesthesia, tetany, Chvostek’s sign (facial muscle twitching elicited by tapping the facial nerve), and Trousseau’s sign (carpopedal spasm induced by inflating a blood pressure cuff above the systolic pressure)2. Hypocalcaemia is treated with oral or intravenous calcium supplementation, and sometimes vitamin D or calcitriol3. The other options are less likely to cause the patient’s symptoms, and can be ruled out by measuring the serum electrolyte levels and thyroid function tests.
A 65-year-old man undergoes a right hemicolectomy for colon cancer. On the third postoperative day, he develops fever, tachycardia, and abdominal pain. On examination, he has rebound tenderness and guarding in the right lower quadrant. His white blood cell count is 15 x 109/L and his C-reactive protein is 120 mg/L. What is the most likely diagnosis?
A) Anastomotic leak
B) Bowel obstruction
C) Incisional hernia
D) Surgical site infection
E) Urinary tract infection
The correct answer is A. This patient has signs of peritonitis, which is a serious complication of bowel surgery. The most common cause of peritonitis after a hemicolectomy is an anastomotic leak, which occurs when the connection between the two ends of the bowel breaks down1. This allows the bowel contents to spill into the peritoneal cavity, causing inflammation, infection, and sepsis2. The diagnosis of an anastomotic leak can be confirmed by a contrast enema or a CT scan3. The treatment involves drainage of the abscess, antibiotics, and sometimes reoperation. The other options are less likely to cause the patient’s symptoms, and can be ruled out by further investigations, such as abdominal X-ray, ultrasound, or urine culture.
A 55-year-old man presents with a two-month history of progressive dysphagia, weight loss, and retrosternal pain. He has a history of gastro-oesophageal reflux disease and Barrett’s oesophagus. An endoscopy reveals a 4 cm ulcerated mass in the lower third of the oesophagus. A biopsy confirms adenocarcinoma of the oesophagus. A CT scan shows no evidence of distant metastasis. What is the most appropriate management?
A) Chemoradiotherapy followed by surgery
B) Chemotherapy alone
C) Endoscopic mucosal resection
D) Palliative stent insertion
E) Surgery alone
The correct answer is A. This patient has a locally advanced adenocarcinoma of the oesophagus, which is associated with Barrett’s oesophagus1. The treatment of choice for this stage of disease is chemoradiotherapy followed by surgery, which has been shown to improve survival and quality of life compared to surgery alone2. Chemotherapy alone is not curative and is usually reserved for metastatic disease. Endoscopic mucosal resection is only suitable for early-stage tumours that are confined to the mucosa. Palliative stent insertion is indicated for patients who are unfit for surgery or have unresectable disease, to relieve dysphagia and improve nutrition. Surgery alone is not recommended, as it has a high morbidity and mortality rate and does not address the risk of local recurrence or distant spread3.
A 70-year-old man presents with a six-month history of progressive dyspnoea, orthopnoea, and peripheral oedema. He has a history of hypertension, diabetes, and coronary artery disease. On examination, he has a raised jugular venous pressure, a displaced apex beat, a pansystolic murmur at the apex, and bilateral crackles in the lungs. His chest X-ray shows cardiomegaly and pulmonary congestion. His electrocardiogram shows left ventricular hypertrophy and atrial fibrillation. His echocardiogram shows a dilated left ventricle with an ejection fraction of 30%. What is the most likely diagnosis?
A) Aortic stenosis
B) Aortic regurgitation
C) Mitral stenosis
D) Mitral regurgitation
E) Tricuspid regurgitation
The correct answer is D. This patient has signs and symptoms of heart failure, which is a condition where the heart is unable to pump enough blood to meet the body’s needs1. The most common cause of heart failure is ischaemic heart disease, which can damage the heart muscle and impair its contractility2. This patient has a history of coronary artery disease, which increases his risk of developing heart failure. The most likely valve lesion that is associated with ischaemic heart disease and heart failure is mitral regurgitation, which occurs when the mitral valve does not close properly and allows blood to leak back into the left atrium during systole3. This causes a volume overload on the left ventricle, leading to dilation, hypertrophy, and reduced ejection fraction. Mitral regurgitation also causes a pansystolic murmur at the apex, which is best heard with the bell of the stethoscope. The other options are less likely to cause the patient’s presentation, and can be ruled out by the echocardiogram findings. Aortic stenosis causes a pressure overload on the left ventricle, leading to concentric hypertrophy and a reduced stroke volume. It also causes a systolic ejection murmur at the right second intercostal space. Aortic regurgitation causes a volume overload on the left ventricle, leading to dilation and increased stroke volume. It also causes a diastolic decrescendo murmur at the left third intercostal space. Mitral stenosis causes a pressure overload on the left atrium, leading to dilation and atrial fibrillation. It also causes a diastolic rumbling murmur at the apex. Tricuspid regurgitation causes a volume overload on the right ventricle, leading to dilation and reduced ejection fraction. It also causes a pansystolic murmur at the left lower sternal edge.
A 35-year-old woman presents with a three-month history of a painless lump in her right breast. She has no family history of breast cancer. On examination, she has a 2 cm firm, mobile, and well-defined mass in the upper outer quadrant of her right breast. There is no nipple discharge, skin changes, or axillary lymphadenopathy. She undergoes a core needle biopsy of the mass, which reveals a benign fibroepithelial lesion. What is the most likely diagnosis?
A) Fibroadenoma
B) Phyllodes tumour
C) Intraductal papilloma
D) Fibrocystic change
E) Ductal carcinoma in situ
The correct answer is A. This patient has a fibroadenoma, which is the most common benign breast tumour in young women1. It is composed of fibrous and glandular tissue, and it is usually well-circumscribed, rubbery, and mobile2. It does not increase the risk of breast cancer, and it may regress spontaneously or with hormonal changes3. The treatment options include observation, excision, or percutaneous ablation. The other options are less likely to cause the patient’s presentation, and can be ruled out by the biopsy findings. A phyllodes tumour is a rare fibroepithelial lesion that can be benign or malignant, and it usually grows rapidly and forms a large mass. An intraductal papilloma is a benign proliferation of epithelial cells within a duct, and it usually presents with nipple discharge. Fibrocystic change is a common condition that causes breast pain, tenderness, and cysts, especially in premenopausal women. Ductal carcinoma in situ is a non-invasive form of breast cancer that originates from the ductal epithelium, and it usually presents as microcalcifications on mammography.
A 50-year-old man presents with a two-week history of a painless, hard, and fixed lump in his left testis. He has no other symptoms or risk factors. He undergoes an ultrasound scan of the scrotum, which confirms a solid mass within the left testis. A serum tumour marker panel shows elevated levels of alpha-fetoprotein (AFP) and human chorionic gonadotropin (hCG). What is the most likely diagnosis?
A) Seminoma
B) Teratoma
C) Leydig cell tumour
D) Sertoli cell tumour
E) Lymphoma
The correct answer is B. This patient has a teratoma, which is a type of germ cell tumour that can arise from the testis. It is composed of various types of tissue, such as hair, teeth, bone, and cartilage. It can secrete alpha-fetoprotein (AFP) and human chorionic gonadotropin (hCG), which are useful tumour markers for diagnosis and monitoring. The treatment of choice is radical orchiectomy, which involves removal of the entire testis and spermatic cord. The other options are less likely to cause the patient’s presentation, and can be ruled out by the ultrasound and tumour marker findings. A seminoma is a type of germ cell tumour that is usually pure and does not secrete AFP or hCG. A Leydig cell tumour is a type of sex cord-stromal tumour that can secrete testosterone and cause gynaecomastia. A Sertoli cell tumour is another type of sex cord-stromal tumour that is usually benign and does not secrete any hormones. A lymphoma is a type of haematological malignancy that can affect the testis, especially in older men, and can cause systemic symptoms such as fever, night sweats, and weight loss.
A 40-year-old woman presents with a one-week history of a painful, red, and swollen right leg. She has no history of trauma, surgery, or immobilisation. She is otherwise healthy and takes no medications. On examination, she has a temperature of 38.5°C, a pulse of 110 beats per minute, and a blood pressure of 150/90 mmHg. Her right leg is warm, erythematous, and tender, with a circumference of 45 cm at the mid-thigh level, compared to 40 cm on the left side. There is no evidence of skin breakdown, ulceration, or lymphangitis. A Doppler ultrasound scan of the right leg shows a thrombus in the femoral vein. A blood test shows a white blood cell count of 12 x 109/L, a haemoglobin of 14 g/dL, a platelet count of 300 x 109/L, and an erythrocyte sedimentation rate of 60 mm/h. What is the most likely diagnosis?
A) Cellulitis B) Deep vein thrombosis C) Lymphoedema D) Necrotising fasciitis E) Superficial thrombophlebitis
The correct answer is B. This patient has a deep vein thrombosis (DVT), which is a condition where a blood clot forms in a deep vein, usually in the lower limbs. It can cause pain, swelling, redness, and warmth in the affected leg, and it can also lead to serious complications such as pulmonary embolism and post-thrombotic syndrome. The risk factors for DVT include trauma, surgery, immobilisation, cancer, pregnancy, oral contraceptives, smoking, obesity, and inherited or acquired thrombophilia. The diagnosis of DVT can be confirmed by a Doppler ultrasound scan, which shows the presence and location of the thrombus. The treatment of DVT involves anticoagulation therapy, such as heparin or warfarin, to prevent the clot from growing or breaking off. The other options are less likely to cause the patient’s presentation, and can be ruled out by the clinical and radiological findings. Cellulitis is a bacterial infection of the skin and subcutaneous tissue, which causes erythema, warmth, tenderness, and fever, but it usually affects only one area of the leg and is associated with skin breakdown, ulceration, or lymphangitis. Lymphoedema is a chronic swelling of the limb due to impaired lymphatic drainage, which causes a non-pitting oedema, skin thickening, and fibrosis, but it is usually painless and bilateral. Necrotising fasciitis is a rare and severe infection of the fascia and subcutaneous tissue, which causes severe pain, fever, crepitus, and systemic toxicity, but it is usually preceded by trauma, surgery, or immunosuppression. Superficial thrombophlebitis is an inflammation of a superficial vein, which causes a palpable, tender, and erythematous cord along the course of the vein, but it is usually mild and self-limiting.
A 74yo man who has been a smoker since he was 20 has recently been dx with SCLC. What serum electrolyte picture will confirm the presence of SIADH?
a. High serum Na, low serum osmolarity, high urine osmolarity
b. Low serum Na, high serum osmolarity, high urine osmolarity
c. High serum Na, low serum osmolarity, low urine osmolarity
d. Low serum Na, low serum osmolarity, high urine osmolarity
e. High serum Na, high serum osmolarity, low urine osmolarity
The correct answer is:
b. Low serum Na, high serum osmolarity, high urine osmolarity
This electrolyte profile is characteristic of Syndrome of Inappropriate Antidiuretic Hormone (SIADH) secretion, which can occur in patients with small cell lung cancer (SCLC) due to ectopic production of antidiuretic hormone (ADH) by the tumor cells. The low serum sodium (Na) level, combined with high serum osmolarity and high urine osmolarity due to water retention, reflects the dilutional hyponatremia typical of SIADH. This electrolyte imbalance is often seen in patients with SCLC, particularly in those with advanced disease. It’s crucial to recognize and manage SIADH promptly to prevent potentially serious complications.
A 67yo man after a stroke, presents with left sided ptosis and constricted pupil. He also has loss of pain and temp on the right side of his body and left side of his face. Which part of the brain is most likely affected?
a. Frontal cortex
b. Medulla
c. Cerebellum
d. Pons
e. Parietal cortex
The most likely affected part of the brain in this scenario is:
d. Pons
The symptoms described, including left-sided ptosis (drooping of the eyelid) and constricted pupil (miosis) on the same side, along with loss of pain and temperature sensation on the opposite side of the body and the same side of the face, are indicative of a classic presentation of a lateral medullary syndrome, also known as Wallenberg syndrome. This syndrome typically results from a lesion affecting the lateral portion of the medulla oblongata, which contains important structures involved in the pathway for sensation and autonomic control, including the descending sympathetic fibers responsible for maintaining normal pupil size.
A 47yo man has a temp of 39C and is delirious. He has developed blisters mainly on his trunk, which appeared a few hours ago. He is well and not on any medications. He last travelled 5 months ago to Italy. Which of the following is the most likely dx?
a. Shingles
b. Pemphigoid
c. Bullous pemphigus
d. Chicken pox
The most likely diagnosis in this scenario is:
d. Chicken pox
The combination of fever, delirium, and the development of blisters mainly on the trunk suggests a viral infection, with chickenpox (varicella-zoster virus) being the most likely cause. The patient’s recent travel to Italy is not relevant in this case, as chickenpox is a highly contagious viral infection that can occur worldwide. Additionally, the characteristic appearance of the rash with its distribution and timing aligns with chickenpox. It’s important to consider chickenpox, especially in adults who may not have been previously vaccinated or exposed to the virus. Prompt evaluation and appropriate management are essential to prevent complications and reduce transmission.
A 34yo alcoholic is found passed out in front of a local pub. The ambulance crew informs you that he was sweating when they found him and there were cans of cider lying empty around him. What is the initial stage of inv?
a. CT head
b. MRI head
c. Capillary blood sugar
d. ABG
e. MCV
The initial stage of investigation in this case would be:
c. Capillary blood sugar
Given the presentation of an alcoholic individual found passed out with sweating, the priority is to assess the blood sugar level to rule out hypoglycemia, which is common in individuals with alcohol use disorder. Hypoglycemia can result from alcohol-induced inhibition of gluconeogenesis and glycogenolysis, leading to decreased blood sugar levels. It’s essential to quickly assess and address any hypoglycemia to prevent complications and guide further management.
A young boy fell on his outstretched hand and has presented with pain around the elbow. He has absent radial pulse on the affected hand. What is the most likely dx?
a. Dislocated elbow
b. Undisplaced fx of radial head
c. Posterior dislocation of shoulder
d. Angulated supracondylar fx
The most likely diagnosis in this scenario is:
d. Angulated supracondylar fracture
The combination of pain around the elbow and an absent radial pulse suggests the possibility of an angulated supracondylar fracture. This type of fracture can cause compression or occlusion of the brachial artery, leading to compromised blood flow to the forearm and hand, resulting in an absent radial pulse. Prompt evaluation and management, including assessment of neurovascular status, are crucial to prevent complications such as compartment syndrome or ischemic injury to the hand.
A 32yo man presented with painless hematuria. He is hypertensive but the rest of the exam is unremarkable. What is the most likely dx?
a. TTP
b. Polycystic kidneys
c. Ca bladder
d. Ca prostate
e. HUS
The most likely diagnosis in this scenario is:
c. Bladder cancer
Painless hematuria in a hypertensive individual raises concern for underlying bladder cancer, especially considering the absence of significant findings on examination. While other conditions like polycystic kidneys and prostate cancer can also present with hematuria, bladder cancer is more commonly associated with painless hematuria, particularly in hypertensive patients. It’s important to further investigate with imaging studies and possibly cystoscopy to confirm the diagnosis and initiate appropriate management.
A 45yo female complains of pain in the inner side of her right thigh. She was dx with benign ovarian mass on the right. Which nerve is responsible for this pain?
a. Obturator nerve
b. Femoral nerve
c. Iliohypogastric nerve
d. Ovarian branch of splanchic nerve
e. Pudendal nerve
The nerve responsible for the pain in the inner side of the right thigh in this scenario is:
a. Obturator nerve
The obturator nerve innervates the inner thigh, and irritation or compression of this nerve can lead to pain in that region. The proximity of the ovarian mass to the obturator nerve can cause compression or irritation of the nerve fibers, resulting in referred pain to the inner thigh.
A 79yo stumbled and sustained a minor head injury 2 weeks ago. He has become increasingly confused, drowsy and unsteady. He has a GCS of 13. He takes warfarin for Afib. What is the most likely dx?
a. Subdural hemorrhage
b. Extradural hemorrhage
c. Subarachnoid hemorrhage
d. Cerebellar hemorrhage
e. Epidural hemorrhage
The most likely diagnosis in this case is:
a. Subdural hemorrhage
The patient’s history of a minor head injury, along with the onset of confusion, drowsiness, and unsteadiness, raises concern for a subdural hemorrhage. Subdural hemorrhages can occur following trauma, especially in older adults who may be on anticoagulant therapy like warfarin for conditions such as atrial fibrillation (Afib). The delayed onset of symptoms is characteristic of subdural hemorrhages, which can manifest days to weeks after the initial injury. Prompt evaluation and management, including neuroimaging, are crucial to assess the extent of the hemorrhage and initiate appropriate treatment.
A young college student is found in his dorm unconscious. He has tachyarrhythmia and high fever. He also seems to be bleeding from his nose, which on examination shows a perforated nasal septum. What is the most likely dx?
a. Marijuana OD
b. Heroin OD
c. Alcohol OD
d. CO poisoning
e. Cocaine OD
The most likely diagnosis in this case is:
e. Cocaine overdose
The combination of tachyarrhythmia, high fever, nasal septal perforation, and bleeding from the nose strongly suggests cocaine overdose. Cocaine can cause significant cardiovascular effects, including tachyarrhythmias such as ventricular tachycardia or fibrillation. Fever can result from the stimulant effects of cocaine, and nasal septal perforation is a characteristic finding associated with chronic cocaine use due to its vasoconstrictive properties leading to tissue necrosis. Prompt medical intervention, including supportive care and management of complications such as arrhythmias, is essential in cases of cocaine overdose.
In CRF, main cause of Vit D deficiency is the failure of:
a. Vit D absorption in intestines
b. 1 alpha hydroxylation of Vit D
c. 25 alpha hydroxylation of Vit D
d. Excess Vit D loss in urine
e. Availability of Vit D precursors
The main cause of vitamin D deficiency in chronic renal failure (CRF) is:
b. 1 alpha hydroxylation of vitamin D
In chronic renal failure, impaired renal function leads to reduced conversion of vitamin D into its active form, calcitriol, by the kidneys. This process occurs through the 1-alpha hydroxylation of vitamin D. Therefore, decreased synthesis of calcitriol contributes significantly to the development of vitamin D deficiency in individuals with chronic renal failure.
A woman who returned from abroad after 3 weeks of holiday complains of severe diarrhea of 3 weeks. She also developed IDA and folic acid def. What condition best describes her situation?
a. Malabsorption
b. Jejunal villous atrophy
c. Chronic diarrhea secretions
d. Increased catabolism
e. Increased secretions of acid
The condition that best describes the woman’s situation is:
a. Malabsorption
The combination of severe diarrhea lasting for three weeks, along with iron deficiency anemia (IDA) and folic acid deficiency, suggests malabsorption. Malabsorption syndromes can lead to inadequate absorption of nutrients, including iron and folic acid, resulting in deficiencies. The prolonged diarrhea further supports the possibility of malabsorption, as it can impair nutrient absorption in the intestines. Further evaluation would be needed to determine the specific cause of malabsorption, such as jejunal villous atrophy, but malabsorption is the overarching condition underlying her symptoms.
A man presented with cellulitis and swelling. He was started on flucloxacillin. What other medication do you want to add?
a. Vancomycin
b. Metronidazole
c. Ceftriaxone
d. Penicillin
e. Amoxicillin
In a case of cellulitis, especially if there’s a concern for methicillin-resistant Staphylococcus aureus (MRSA) infection, adding another antibiotic such as vancomycin would be prudent. Therefore, the additional medication to consider adding is:
a. Vancomycin
A 35yo man who has served in the army presents with lack of interest in enjoyable activities and feeling low. He doesn’t feel like reading the news or watching movies as he believes there is violence everywhere. What is the most appropriate first line therapy?
a. Citalopram
b. CBT
c. Lofepramine
d. Chlordiazepoxide
e. Desensitization
Given the symptoms described, particularly the lack of interest in enjoyable activities and the belief that there is violence everywhere, along with the patient’s history of military service, the most appropriate first-line therapy would likely involve addressing the underlying depressive symptoms with therapy rather than medication. Therefore, the most appropriate option is:
b. CBT (Cognitive Behavioral Therapy)
CBT is an evidence-based psychotherapy that focuses on identifying and challenging negative thought patterns and behaviors associated with depression. It can be particularly effective in addressing symptoms related to trauma and negative cognitions. Considering the patient’s concerns about violence and his history of military service, CBT could help him reframe his thoughts and cope with his symptoms more effectively.
A 12yo child with episodes of sudden bluish discoloration and brief loss of consciousness. Exam:
clubbing, central cyanosis, systolic thrill with systolic ejection murmur in 2nd left ICS. What is the most probable dx?
a. ASD
b. VSD
c. TOF
d. PDA
e. CoA
Based on the symptoms and examination findings described, the most probable diagnosis is:
c. TOF (Tetralogy of Fallot)
Tetralogy of Fallot is a congenital heart defect characterized by four abnormalities: pulmonary stenosis, overriding aorta, ventricular septal defect (VSD), and right ventricular hypertrophy. The episodes of sudden bluish discoloration (cyanotic spells or “tet” spells) and brief loss of consciousness (syncope) are classic presentations of TOF. The presence of clubbing, central cyanosis, and a systolic thrill with a systolic ejection murmur in the second left intercostal space further support this diagnosis.
Pt with hx of alcoholism, ataxic gait, hallucinations and loss of memory. He is given acamprosate. What other drug can you give with this?
a. Chlordiazepoxide
b. Diazepam
c. Disulfiram
d. Haloperidol
e. Thiamine
In a patient with a history of alcoholism experiencing symptoms such as ataxic gait, hallucinations, and loss of memory, the combination of acamprosate with another medication is often aimed at managing alcohol withdrawal symptoms and preventing relapse. Therefore, the most appropriate additional medication would be:
e. Thiamine
Thiamine supplementation is essential in patients with alcohol use disorder to prevent or treat Wernicke’s encephalopathy, a potentially serious neurological complication characterized by confusion, ataxia, and ophthalmoplegia. Thiamine deficiency is common in individuals with chronic alcoholism and can exacerbate neurological symptoms. Therefore, combining acamprosate with thiamine supplementation is a common and appropriate approach in the management of alcohol use disorder.
A 22yo woman with longstanding constipation has severe ano-rectal pain on defecation. Rectal exam: impossible due to pain and spasm. What is the most probable dx?
a. Anal hematoma
b. Anal abscess
c. Protalgia fugax
d. Anal fissure
e. Hemorrhoids
The most probable diagnosis in this case is:
d. Anal fissure
The symptoms of severe ano-rectal pain on defecation, along with the inability to perform a rectal exam due to pain and spasm, are highly suggestive of an anal fissure. Anal fissures are small tears or cracks in the lining of the anal canal, often caused by trauma during bowel movements, and they can result in intense pain, especially during defecation. The spasm of the anal sphincter muscles further exacerbates the pain and makes examination difficult. Anal fissures are a common cause of ano-rectal pain, particularly in individuals with longstanding constipation.
A 32yo had a normal vaginal delivery 10 days ago. Her uterus has involuted normally. Choose the single most likely predisposing factor for PPH?
a. Retained product
b. Uterine infection
c. DIC
d. Von Willebrand disease
e. Primary PPH
The single most likely predisposing factor for postpartum hemorrhage (PPH) in this case would be:
a. Retained product
Retained products of conception, such as placental fragments or membranes, can lead to postpartum hemorrhage by preventing the uterus from contracting adequately and achieving proper hemostasis. In this scenario, if the uterus has involuted normally but the patient still experiences postpartum hemorrhage, retained products of conception are a likely cause. Prompt identification and management of retained products are crucial to prevent complications associated with postpartum hemorrhage.
A butcher stabbed accidently his groin. He bled so much that the towel was soaked in blood and BP=80/50mmHg, pulse=130bpm. What % of circulatory blood did he lose?
a. <15%
b. 15-30%
c. 30-40%
d. 40-50%
e. >50%
Based on the given scenario of significant bleeding and the patient’s vital signs, the estimated blood loss can be categorized as follows:
BP=80/50 mmHg, pulse=130 bpm
These vital signs indicate hypotension and tachycardia, which are signs of compensatory mechanisms in response to significant blood loss.
Based on the clinical signs and symptoms, the estimated blood loss would likely fall within the range of:
e. >50%
The patient’s condition with significant hypotension and tachycardia suggests a massive hemorrhage, indicating a loss of more than 50% of circulatory blood volume. This level of blood loss is severe and requires urgent medical attention and resuscitation to prevent further complications and improve outcomes.
An old alcoholic presents with cough, fever, bilateral cavitating consolidation. What is the most probable cause?
a. AFB
b. Gram +ve diplococcic
c. Gram –ve cocci
d. Coagulase +ve cocci
e. Coagulase –ve cocci
The most probable cause of cough, fever, and bilateral cavitating consolidation in an old alcoholic is:
a. AFB (acid-fast bacilli)
This presentation is highly suggestive of tuberculosis, especially in an older alcoholic individual. Tuberculosis commonly presents with cough, fever, and pulmonary infiltrates, which can progress to cavitation, particularly in individuals with risk factors such as alcoholism. Acid-fast bacilli (AFB) are characteristic of Mycobacterium tuberculosis, the causative agent of tuberculosis, and are typically seen on sputum microscopy or culture in affected individuals. Therefore, AFB is the most probable cause in this case.
A 67yo man had successful thrombolysis for an inf MI 1 month ago and was discharged after 5days. He is now readmitted with pulmonary edema. What is the most probable dx?
a. Pulmonary stenosis
b. Aortic regurgitation
c. Ischemic mitral regurgitation
d. Mitral valve prolapse
e. Rheumatic mitral valve stenosis
The most probable diagnosis in this case is:
c. Ischemic mitral regurgitation
Ischemic mitral regurgitation occurs as a complication of myocardial infarction, particularly involving the papillary muscles or chordae tendineae. The dysfunction of these structures leads to incomplete closure of the mitral valve, resulting in regurgitation of blood from the left ventricle into the left atrium during systole. Pulmonary edema is a common manifestation of severe mitral regurgitation, as the backward flow of blood increases the volume and pressure within the left atrium and pulmonary vasculature, leading to pulmonary congestion and edema. Therefore, ischemic mitral regurgitation is the most probable diagnosis in this scenario, given the patient’s history of recent myocardial infarction and presentation with pulmonary edema.
A 3yo child who looks wasted on examination has a hx of diarrhea on and off. The mother describes the stool as bulky, frothy and difficult to flush. What is the single inv most likely to lead to dx?
a. Sweat chloride test
b. LFT
c. US abdomen
d. Anti-endomysial antibodies
e. TFT
The single investigation most likely to lead to the diagnosis in this case is:
a. Sweat chloride test
The presentation of a wasted appearance in a 3-year-old child with a history of chronic diarrhea, bulky, frothy stools, and difficulty flushing suggests the possibility of cystic fibrosis (CF). The sweat chloride test is the gold standard for diagnosing CF, as elevated chloride levels in sweat are characteristic of the condition. Therefore, performing a sweat chloride test would be the most appropriate initial investigation to confirm or rule out the diagnosis of CF in this child.
A girl with hx of allergies visited a friend’s farm. She got stridor, wheeze and erythematous rash. What is the most appropriate tx?
a. 0.25ml PO adrenaline
b. 0.25ml IM adrenaline
c. 0.25ml IV adrenaline
d. IV chlorphearamine
The most appropriate treatment for anaphylaxis, as described in this scenario, is:
b. 0.25ml IM adrenaline
Anaphylaxis is a severe allergic reaction that can lead to life-threatening symptoms such as stridor, wheezing, and erythematous rash. The first-line treatment for anaphylaxis is adrenaline (epinephrine) administered intramuscularly (IM). Adrenaline acts rapidly to reverse the symptoms of anaphylaxis by constricting blood vessels, relaxing bronchial smooth muscle, and improving cardiac output. Therefore, administering 0.25ml of IM adrenaline is the most appropriate immediate treatment in this case.
A 25yo had an LSCS 24h ago for fetal distress. She now complains of intermittent vaginal bleeding. Observations: O2 sat=98% in air, BP=124/82mmHg, pulse=84bpm, temp=37.8C. The midwife tells you that she had a retained placenta, which required manual removal in the OT. Choose the most appropriate C-Section complication in this case?
a. Uterine rupture
b. Retained POC
c. Aspiration pneumonitis
d. Endometritis
e. DIC
The most appropriate C-Section complication in this case, given the history of retained placenta requiring manual removal in the operating theater and the current presentation of intermittent vaginal bleeding, is:
e. DIC (Disseminated Intravascular Coagulation)
Disseminated intravascular coagulation (DIC) can occur as a complication of retained products of conception (POC), such as retained placenta. Manual removal of the placenta can lead to excessive bleeding and disruption of normal clotting mechanisms, resulting in DIC. The intermittent vaginal bleeding in this case may be indicative of ongoing bleeding secondary to DIC. Therefore, DIC is the most appropriate complication to consider in this scenario.
A 20yo man has a head on collision in a car. On presentation his is breathless, has chest pain and fx of 5-7th rib. CXR confirms this. What is the most appropriate initial action in this pt?
a. Antibiotics
b. Analgesia
c. O2 by mask
d. Physiotherapy
e. Refer to surgeon
The most appropriate initial action in this patient, who presents with breathlessness, chest pain, and confirmed rib fractures on CXR after a head-on collision, is:
c. O2 by mask
Given the potential for underlying lung injury or pneumothorax secondary to rib fractures and the patient’s symptoms of breathlessness, providing oxygen by mask is crucial to optimize oxygenation and prevent hypoxia. This action takes priority in the initial management of trauma patients with suspected chest injuries. After ensuring adequate oxygenation, further assessment and management, including analgesia and referral to a surgeon if necessary, can be initiated. However, oxygen therapy is the most immediate and appropriate initial action in this scenario.
A 30yo man presents with deep penetrating knife wound. He said he had TT when he left school.
What will you do for him now?
a. Human Ig and full course of tetanus vaccine
b. Antibiotic
c. Human Ig and TT
d. Human Ig only
e. Full course of tetanus vaccine only
The most appropriate action for the 30-year-old man with a deep penetrating knife wound who reports having received tetanus toxoid (TT) vaccination when he left school is:
b. Antibiotic
While tetanus prophylaxis is important in cases of penetrating wounds, if the patient has received a complete primary vaccination series and a booster within the past 10 years, additional tetanus toxoid vaccination may not be necessary. However, administering antibiotics is crucial to prevent wound infection and other potential complications. Therefore, providing antibiotics would be the most appropriate immediate action for this patient.
A mother comes with her 15m child. Which of the following will bother you?
a. Shies away from strangers
b. She can’t make a sentence
c. Can walk but not run
d. Vocabulary consists of only 2 meaningless words
e. None
The option that would likely be of concern is:
b. She can’t make a sentence
At 15 months of age, most children should be able to make basic sentences consisting of a few words. The inability to form sentences could be a developmental red flag and may indicate a language delay or other developmental issue. Therefore, this option would be the one that raises concern.
A 46yo man, known case of chronic GN presents to OPD. He feels well. BP = 140/90mmHg. Urine dipstick: protein ++, blood ++ and serum creatinine=106mmol/L. Which medication can prevent the progression of this dx?
a. Diuretics
b. ACEi
c. Cytotoxic meds
d. Longterm antibiotics
e. Steroids
The medication that can help prevent the progression of chronic glomerulonephritis (GN) in this case is:
b. ACEi (Angiotensin-Converting Enzyme inhibitor)
ACE inhibitors have been shown to be effective in slowing the progression of chronic kidney disease, including chronic glomerulonephritis. They help by reducing intraglomerular pressure and proteinuria, thereby protecting the kidneys from further damage and slowing the decline in kidney function. Therefore, prescribing an ACE inhibitor would be a suitable choice to help manage this patient’s condition and prevent progression.
A 78yo lady on warfarin for atrial fibrillation lives in a care home. She presents with hx of progressive confusion for three days. She was also noticed to have bruises on her arms. INR = 7. What is the most probable dx?
a. Alzheimers
b. Delirium
c. Vascular dementia
d. Subdural hemorrhage
e. Pick’s dementia
The most probable diagnosis in this case is:
d. Subdural hemorrhage
The presentation of progressive confusion, bruises on the arms, and an elevated INR level in a patient on warfarin suggests the possibility of a subdural hemorrhage. Warfarin predisposes patients to bleeding events, and an elevated INR increases the risk of hemorrhage, including subdural hemorrhage, which can present with symptoms such as confusion and bruising. Therefore, subdural hemorrhage is the most probable diagnosis in this scenario.
Mrs. A, a 32-year-old woman of African descent, presents to the clinic with complaints of recurrent episodes of severe pain in her joints and abdomen. She reports a long history of similar episodes since childhood. She mentions experiencing fatigue, shortness of breath, and occasional dizziness. Her medical history reveals frequent hospitalisations for pain management.
⚠️ Clinical Examination:
Pallor
Jaundice
Splenomegaly
Tenderness over long bones
Limited range of motion due to pain
📋 Investigations:
Haemoglobin: 70 g/L
Reticulocyte Count: 8%
Serum Bilirubin: 43.4 µmol/L
Blood Smear: Presence of Howell-Jolly bodies
❓ Question: What do you think this condition is?
Sickle Cell Anemia
Thalassemia
Hemophilia
Polycythemia Vera
The clinical presentation and investigation results are highly suggestive of:
Sickle Cell Anemia
Explanation:
• Recurrent episodes of severe pain in the joints and abdomen: These pain crises are characteristic of sickle cell anemia due to vaso-occlusion. • Fatigue, shortness of breath, and occasional dizziness: These symptoms are consistent with chronic hemolytic anemia, common in sickle cell disease. • Pallor and jaundice: These signs indicate hemolysis. • Splenomegaly and tenderness over long bones: Splenomegaly is common in children with sickle cell anemia due to sequestration crises, though the spleen may become fibrotic and reduce in size over time. Bone pain and tenderness are frequent due to bone infarctions. • Limited range of motion due to pain: This is typical during pain crises. • Haemoglobin: 70 g/L: This is indicative of severe anemia. • Reticulocyte Count: 8%: Elevated reticulocyte count reflects increased red blood cell production in response to hemolysis. • Serum Bilirubin: 43.4 µmol/L: Elevated bilirubin is a result of increased breakdown of red blood cells. • Blood Smear: Presence of Howell-Jolly bodies: Howell-Jolly bodies indicate asplenia or hyposplenia, often seen in sickle cell anemia due to repeated splenic infarctions.
Therefore, the correct diagnosis is:
Sickle Cell Anemia
A 70-year-old woman presents with painless obstructive jaundice and a distended gallbladder. Ultrasound has shown a solid 3 cm mass arising from the head of the pancreas.
Which part of the extrahepatic biliary tree is being compressed by the mass?
A Common hepatic duct
B Infraduodenal common bile duct
C Left extrahepatic duct
D Right extrahepatic duct
E Supraduodenal common bile duct
The mass arising from the head of the pancreas is most likely compressing the supraduodenal common bile duct.
This is because the head of the pancreas lies closely adjacent to the common bile duct, specifically the supraduodenal part, which is the portion of the common bile duct that runs above the duodenum before it enters and runs behind the pancreas. Compression of this duct by a pancreatic head mass is a common cause of obstructive jaundice.
Therefore, the correct answer is:
E Supraduodenal common bile duct
A 45-year-old man presents with a lump protruding from his abdomen into his groin and the upper part of the scrotum.
Through which one of the following spaces would the lump have extruded out of the peritoneal cavity?
A Deep inguinal ring
B Femoral ring
C Inguinal triangle
D Interparietal space
E Superficial inguinal ring
The description of a lump protruding from the abdomen into the groin and upper part of the scrotum suggests an inguinal hernia. Specifically, for the hernia to reach the scrotum, it must pass through the inguinal canal. The entrance to the inguinal canal from the abdominal cavity is the deep inguinal ring.
Therefore, the correct answer is:
A Deep inguinal ring
A 55-year-old woman has been diagnosed with an advanced carcinoma of the stomach. She complains of a discharging swelling over her belly button.
Which one of the following intra abdominal ligaments is the portal of cause of this ulcer?
A Coronary ligament of the liver
B Left triangular ligament
C Lesser omentum
D Ligamentum teres
E Urachus
The discharging swelling over the belly button (umbilicus) in a patient with advanced carcinoma of the stomach suggests a Sister Mary Joseph nodule, which is a metastatic tumor deposit at the umbilicus. The pathway through which such metastases can occur is often related to the ligamentum teres, which is a remnant of the umbilical vein and runs from the umbilicus to the liver.
Therefore, the correct answer is:
D Ligamentum teres
A 25-year-old man, a cyclist, presents after being hit on the left side of his lower chest when involved in a collision with a car. He complains of pain in his left lower chest, left upper abdomen and left shoulder tip. He has full range of movements of his left upper limb. A FAST (focused abdominal sonography in trauma) scan shows free fluid under the left hemidiaphragm.
Which one of the following anatomical factors is the most likely cause of his left shoulder tip pain?
A Diaphragmatic rupture causing pain through the intercostobrachial nerve
B Left acromion fracture causing pain through the long thoracic nerve
C Left kidney rupture causing pain through the vagus nerve
D Left lower rib fractures causing pain from the lower six intercostal nerves
E Splenic rupture causing pain through the phrenic nerve
The patient’s presentation with pain in the left shoulder tip, left lower chest, and left upper abdomen, along with free fluid under the left hemidiaphragm on a FAST scan, strongly suggests splenic injury. The referred pain to the left shoulder tip is characteristic of Kehr’s sign, which occurs due to irritation of the diaphragm. The phrenic nerve, which innervates the diaphragm, originates from cervical nerves C3-C5 and can refer pain to the shoulder tip.
Therefore, the correct answer is:
E Splenic rupture causing pain through the phrenic nerve
A 30-year-old woman is to have postoperative analgesia by means of a nerve block following an operation for a fistula-in-ano.
Which one of the following nerves is the anaesthetist going to block by local anaesthetic?
A Common peroneal nerve
B Lumbosacral trunk
C Nerve to levator ani and external anal sphincter
D Obturator nerve
E Pudendal nerve
For postoperative analgesia following an operation for a fistula-in-ano, the most appropriate nerve to block is the pudendal nerve. The pudendal nerve provides sensory innervation to the perineum and the external genitalia, as well as motor innervation to the external anal sphincter and other pelvic floor muscles. Blocking this nerve will provide effective pain relief for procedures involving the anal and perineal region.
Therefore, the correct answer is:
E Pudendal nerve
The pudendal nerve (S2, S3 and S4) in the perineum is the one that can be blocked by local anaesthetic. The nerve is accessed through the lateral wall of the vagina
to produce anaesthesia to the perineal and anal skin. The nerve is formed by the anterior divisions of the ventral rami of the 2nd, 3rd and 4th sacral nerves. After its origin, it leaves the pelvis through the greater sciatic foramen to enter the gluteal region near the ischial spine. The nerve accompanies the internal pudendal vessels into the pudendal (Alcock’s) canal on the lateral wall of the ischiorectal fossa. In the posterior part of the canal it gives off its branches – inferior rectal nerve, the perineal nerve and the dorsal nerve of clitoris or penis.
The common peroneal nerve is formed by L4, L5 and S1 and S2. The lumbosacral trunk is constituted by L4 and L5, and joins the sacral plexus. S4 contributes to the nerve supplying the levator ani and external anal sphincter. The obturator nerve arises from the lumbar plexus from the anterior divisions of L2, L3 and L4. None of these nerves is the target of the caudal block.
A 42-year-old man, a labourer, while at work, suddenly develops severe pain in his lower back radiating to the buttocks, back of thigh, lower leg and sole of foot. He cannot feel when he sits as he has diminished sensation on his buttocks.
Which one of the following nerves is most likely affected?
A L5
B S1
C S2
D S3
E S4
The S3 nerve root is responsible for the sensation of the sitting area of buttock. It is a constituent of the sacral plexus. The most important nerve arising from the sacral plexus is the sciatic nerve. It arises from L4, L5, S1, S2 and S3 roots of the sacral plexus. At its origin it is 2 cm wide and is the thickest nerve in the body. It enters the gluteal region from the pelvis through the greater sciatic foramen. At a variable level in the back of the thigh proximal to the popliteal fossa it divides into the common peroneal (fibular, L4, L5, S1, S2 and tibial, L4, L5, S1, S2, S3) nerves. The surface anatomy is an imaginary line drawn from the midpoint of the ischial tuberosity and greater trochanter to the apex of the popliteal fossa formed by the junction of the semimembranosus and semitendinosus medially and biceps femoris laterally. As an aid to remember the dermatome levels, we stand mainly on S1 (sole of foot), sit on S3 (buttocks) and wipe S4 (immediate perianal area).
The commonest cause of damage to the sciatic nerve is iatrogenic misplaced
gluteal injection. It may be affected in pelvic disease, severe hip trauma (7% of dislocations and 16% of fracture dislocations), or after total hip replacement (1%). Complete sciatic nerve palsy is rare and results in a flail foot and severe difficulty in walking. Because of its anatomical location in close proximity to the fibular head, the common peroneal nerve is the commonest nerve to be damaged in the lower limb. This results in a foot drop, high stepping gait and sensory loss over the lower lateral part of the leg and dorsum of the foot.
A 65-year-old woman presents with severe pain on the inside of her thigh, which began 1 week ago. The pain radiates along the inside of the thigh to the knee. It is relieved by bending the hip and rotating it outwards. In that position a soft lump is palpable.
Which one of the following nerves is causing the pain?
A Femoral
B Genitofemoral
C Ilioinguinal
D Lateral femoral cutaneous
E Obturator
The symptoms described suggest that the obturator nerve is causing the pain. Here’s the reasoning:
• Pain location and radiation: The obturator nerve supplies sensation to the inner thigh and knee area. • Pain relief by hip position: Bending the hip and rotating it outwards, which relieves the pain, indicates involvement of the obturator nerve. • Palpable lump: A palpable lump in this area could be associated with a hernia or other mass compressing the obturator nerve.
Answer:
E. Obturator
The obturator nerve is causing this patient’s pain. She has the clinical features of
an obturator hernia. The pain is referred to the knee by the geniculate branch of the obturator nerve (anterior divisions of L2, L3 and L4). The pain is much more pronounced in a strangulated hernia. Arising from the lumbar plexus, the obturator nerve lies on the psoas muscle and enters the obturator foramen. In the obturator canal it divides into anterior and posterior branches.
In an obturator hernia, a swelling is not often palpable unless the hip is abducted, flexed and externally rotated. The hernia can sometimes be felt as a tender swelling on rectal or vaginal examination.
Explanation:
The obturator nerve provides sensory innervation to the medial aspect of the thigh. Pain along the inner thigh to the knee, which is relieved by specific hip movements, is characteristic of obturator nerve involvement. The palpable lump further suggests a mass effect on this nerve.
A 30-year-old man presents with left ureteric colic. A spiral CT scan shows a stone impacted at the pelvic brim.
At which of the following anatomical sites would the stone be impacted?
A Common iliac artery bifurcation
B Fifth lumbar transverse process
C Ischial spine
D Pelviureteric junction
E Vas deferens crossing above the ureter
In the context of left ureteric colic with a stone impacted at the pelvic brim, the anatomical site where the stone is likely impacted is the common iliac artery bifurcation.
Answer:
A. Common iliac artery bifurcation
Explanation:
The ureter has several natural points of narrowing where stones are commonly impacted. One of these points is where the ureter crosses over the bifurcation of the common iliac artery at the pelvic brim. This anatomical feature makes it a common site for ureteral stones to become lodged, leading to ureteric colic symptoms.
The stone is impacted at the bifurcation of the common iliac artery where it leaves the psoas muscle. This is one of the points of natural narrowing where a stone may get arrested. The other points of natural narrowing are: pelviureteric junction, where it is crossed by the vas deferens or broad ligament and at the ureterovesical junction.
Knowledge of the relationships of the ureter is very important, so as to prevent iatrogenic damage. On the left it underlies the apex of the sigmoid mesocolon.
It then runs over the external iliac artery and vein and then down the side wall of the pelvis in front of the internal iliac artery and behind the ovary. On the right it will be in close proximity to a pelvic appendix. Further distally at the level of the ischial spine it travels forwards and medially to enter the bladder base. Here the vas deferens in the male crosses above the ureter and in the female it crosses the lateral vaginal fornix.
A 35-year-old woman is undergoing a hysterectomy with preservation of ovaries.
During the operation which one of the following anatomical structures is vulnerable to iatrogenic damage?
A Fallopian tubes
B Ovaries
C Rectum
D Ureters
E Urinary bladder
During a hysterectomy with preservation of the ovaries, the ureters are particularly vulnerable to iatrogenic damage.
Answer:
D. Ureters
Explanation:
The ureters are at risk during a hysterectomy because they run close to the uterine arteries, which need to be ligated during the procedure. The ureters pass underneath the uterine arteries (“water under the bridge”) and are at risk of being inadvertently cut, clamped, or ligated. This is a well-known complication of gynecological surgeries, including hysterectomy.
A 25-year-old man presents following a straddle injury to his perineum having fallen astride on the beam in the gymnasium. Clinically there is a perineal haematoma with blood on his external urinary meatus.
Which anatomical structure is most likely to be injured?
A Bladder neck
B Bulbar urethra
C Membranous urethra
D Prostatic urethra
E Urinary bladder
Given the presentation of a perineal hematoma and blood at the external urinary meatus following a straddle injury, the anatomical structure most likely to be injured is the bulbar urethra.
Answer:
B. Bulbar urethra
Explanation:
A straddle injury often results in trauma to the bulbar (or bulbous) part of the urethra, which is located in the perineum. This part of the urethra is vulnerable to direct trauma when a person falls astride an object. The presence of blood at the external urinary meatus is a typical sign of urethral injury, and in this context, the bulbar urethra is the most commonly affected segment.
This patient has injured his bulbar urethra (sometimes referred to as the anterior urethra) in the perineum. This injury involves the junction of the membranous with the bulbar portion of the urethra. The anatomy of this region is such that extravasation of urine occurs, unless recognition of the injury and treatment
is carried out promptly. Urine leaks between the perineal membrane and the membranous layer of the perineal fascia (Colles’ fascia). As both these layers are firmly attached to the ischiopubic rami posteriorly, urine extravasates anteriorly into the loose connective tissue around the scrotum, penis and anterior abdominal wall. Should the posterior urethra be injured, urine leaks into the pelvic extraperitoneal tissues. Tear of the perineal membrane results in extravasation in the perineum.
Anatomically, the membranous urethra is the shortest (1.5 cm) and least dilatable part of the male urethra (which is 18–20 cm long). The anterior urethra (16 cm) has a proximal perineal and a distal penile component. The posterior urethra is subdivided into preprostatic, prostatic and membranous parts. The female urethra is 4 cm long and 6 mm wide.
Injury to the bladder neck, membranous and prostatic urethra can occur in fractures of the pelvis. Bladder rupture, extra- or intraperitoneal, is highly unlikely with such an injury. The clinical findings are not those of a bladder rupture.
