Surgical Questions Flashcards
A 65 year old man presents with severe abdominal pain radiating to the back, abdominal distension and hypotension.
Which of the following is NOT a reasonable differential?
(a) Ruptured abdominal artery aneurysm
(b) Pancreatitis
(c) Appendicitis
(d) Mesenteric thrombosis
(e) Perforated peptic ulcer
The correct answer is (c) Appendicitis.
Appendicitis causes a localised peritonitis in the right iliac fossa and is unlikely to cause such abdominal distension, although perforation could cause shock. Additionally the differential of appendicitis is less appropriate in a 65 year old male as it is much more common in younger age groups.
Abdominal pain radiating to the back and presenting with shock symptoms is a leaking abdominal artery aneurysm(a) until proven otherwise. There’s often a history of collapse in these patients.
Pancreatitis (b), Mesenteric thrombosis (d) and perforated peptic ulcer (e) are all reasonable differentials, but it’s important to rule out myocardial infarction as well. Abdominal pain can be a presentation of MI, especially in a 65 year old male.
What are the four cardinal signs of intestinal obstruction?
Abdominal distension, colicky abdominal pain, absolute constipation and vomiting.
Which of the following is not a sign of a bowel obstruction becoming strangulated?
(a) Change in nature of pain from colicky to continuous
(b) A tender abdomen
(c) Increased bowel sounds
(d) Fever
(e) Tachycardia
The correct answer is (c) increased bowel sounds.
Instead, when a bowel obstruction progresses to become strangulated you hear reduced bowel sounds. In simple bowel obstruction bowel sounds are often increased (tinkling bowel sounds).
Which of the following is a non-depolarising muscle blocker?
(a) Suxamethonium
(b) Tubocurarine
(c) Succinylcholine
(d) Lidnocaine
(e) Edrophonium
The correct answer is (b) Tubocurarine.
Tubocurarine, like other non-depolarising blockers such as pancuronium, atracurium and vecuronium, is a reversible, compettive inhibitor which competes with acetylcholine at the neuromuscular junction. Their action is terminated by used of an anticholinesterase such as neostigmine or edrophonium (e).
Suxamethonium (a) and succinylcholine (c) are both depolarising blockers which are irreversible blockers that have an initial, stimulatory acting, meaning muscle fasciculation can be seen. Patients often complain of muscle pains after an operation where suxamethonium was used. Suxamethonium has a rapid onset and is short acting and is normally metabolised by pseudocholinesterase, however deficiences of this do occur and can have devastating consequences. Deficiencies are usually familiar so it’s important to take a good family history of any problems with anaesthesia in the family.
A 19 year old man was taken to A&E by ambulance after being stabbed in the chest.
Match the following nerves with the correct statement:
Long Thoracic nerve Intercostobrachial nerve Axillary nerve Thoracodorsal nerve Medial Pectoral nerve
- Damaging this nerve causes paralysis of Latissimus dorsi.
- Damage to this nerve leads to problems with shoulder abduction as it innervates the deltoid muscle.
- Injury to this nerve causes pain and tingling in the axilla.
- This nerve innervates serratus anterior which is responsible for protracting the scapula and holding it against the thoracic wall, damage to it causes “winging” of the scapula.
- Damage to this nerve would cause the shoulder joint to be abducted, laterally rotated, retracted and elevated.
The correct matches go as follows:
Long Thoracic nerve - This nerve innervates serratus anterior which is responsible for protracting the scapula and holding it against the thoracic wall, damage to it causes “winging” of the scapula.
Intercostobrachial nerve - Injury to this nerve causes pain and tingling in the axilla.
Axillary nerve - Damage to this nerve leads to problems with shoulder abduction as it innervates the deltoid muscle.
Thoracodorsal nerve - Damaging this nerve causes paralysis of Latissimus dorsi.
Medial Pectoral nerve -Damage to this nerve would cause the shoulder joint to be abducted, laterally rotated, retracted and elevated.
Define the boundaries of the anterior and posterior triangles of the neck respectively.
The anterior triangle of the neck’s boundaries are the anterior border of the sternocleidomastoid muscles posteriorly, the inferior border of the mandible superiorly and the anterior midline of the neck anteriorly. (Additionally the anterior triangle can be further subdivided into digastric triangle, carotid triangle and muscular triangle, though that’s probably too in-depth for finals!)
The posterior triangle of the neck’s boundaries are the posterior border of the sternocleidomastoid muscle anteriorly, the clavicle inferiorly, and the anterior border of the trapezius muscle posteriorly.
Define the boundaries of the inguinal canal.
- Superiorly the canal is formed by transversus abdominus and internal oblique
- Inferiorly by the inguinal and lacunar ligament, -Anteriorly by an aponeurosis of the internal and external oblique muscles
- Posteriorly by transversalis fascia and the conjoint tendon
A 35 year old woman presents to A&E with abdominal pain. She reports having foul-smelling, blood-tinged diarrhoea since three days ago, which is also when the pain started. This is the first time anything like this has happened. On examination there is a tender mass in the right lower quadrant, the patient is pyrexial at 38.1 and there is a bilateral, erythematous nodular rash over the anterior aspect of the patient’s legs.
What is the cause of this patient’s symptoms?
(a) Appendicitis
(b) Ectopic pregnancy
(c) Ulcerative colitis
(d) Yersinia enterocolitica infection
(e) Tuberculosis of the bowel
The correct answer is (d) Yersinia enterocolitica infection.
This patient has gasteroenteritis with erythema nodosum and a right lower quadrant tender mass. This odd combination points to a yersinia enterocolitica infection which can cause mesenteric lymphadenitis, which is sometimes referred to as pseudoappendicitis.
Appendicitis (a) wouldn’t cause a foul-smelling blood-tinged diarrhoea or erythema nodosum but would certainly be your secondary differential and something important to rule out, so an USS of the abdomen would be appropriate in this case.
An ectopic pregnancy (b) must always be ruled out as this can present with RIF mass and tenderness, and also a classic sign that’s often missed with ectopic pregnancy is diarrhoea! However it wouldn’t cause erythema nodosum so it loses out this time. A pregnancy test would be done routinely, as it should be in all women of childbearing age with any abdominal pathology, to rule out this important differential.
UC (c) would cause a similar pattern of disease and signs seen here so it’s a reasonable differential but given the patient had had no previous similar symptoms, UC that’s affecting the right, proximal colon is very unlikely. This is clearly a very acute case, so while a flare up of UC may cause similar symptoms, it’s unlikely to have presented like this with no previous symptoms.
TB of the bowel (e) is the least likely of the differentials here and would only be suspected with risk factors for TB and exclusion of the other differentials first.
