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Flashcards in Mixed III Deck (40):

A 4-week-old boy born at 34 weeks gestation presents with a tender swelling in the right groin.

Indirect inguinal hernia
An indirect inguinal hernia travels down the inguinal canal on anterio-lateral side of the spermatic cord. Indirect inguinal hernias occur in 2% of full term infants and 10% of preterm infants. The male to female ratio is 10:1 with the right side being affected twice as often as the left. They usually present as a bulge in the groin when the baby cries. These hernias frequently present with irreducibility. The infant appears to be distressed with the distress worsening when the lump is examined. Most paediatric surgeons practise taxis (reduction under sedation) followed by herniotomy soon after.


A 62-year-old woman presents with a left groin swelling. On examination the lump is lateral to the femoral pulse.

Lymph node
Inguinal lymph nodes are frequently confused with an irreducible inguinal or femoral hernia. They are usually multiple and associated with constitutional symptoms of fever and malaise and may be an early manifestation of lymphoma. The surgeon can be confident that the lump is a lymph node if lateral to the femoral pulse as inguinal and femoral hernias are medial.


A 56-year-old man with moderately severe chronic obstructive airways disease presents with an easily reducible left groin swelling. On examination the cough impulse is not controlled by pressure over the internal ring.

Direct inguinal hernia
A direct inguinal hernia comes out directly forwards through the weakened posterior wall of the inguinal canal. The neck of an indirect hernia is lateral to the epigastric vessels while a direct hernia emerges medial to these vessels. Inguinal hernias have a peak incidence in the sixth decade with 65% being indirect. Direct inguinal hernias occur in the middle aged or elderly as an acquired condition. Clinically they present as a diffuse bulge.


A 52-year-old female presents with severe painful swelling of the right parotid gland five days after a hernia repair.

Acute postoperative parotitis may occur, particularly in the elderly. It is usually caused by S. aureus. Culture of the parotid duct and blood cultures should be performed.

If there is no clinical improvement in 48 to 72 hours it may be because an abscess has formed. This can be diagnosed by ultrasound, CT or MRI. The treatment of an abscess is ultrasound guided aspiration. Incision and drainage risks damage to the facial nerve. If required this needs a formal parotid exposure, no muscle paralysis, and facial nerve stimulation. The incision should be in line with the facial nerve branches.


A 40-year-old obese female presents with sudden dyspnoea and chest pain two days after a total abdominal hysterectomy. Bilateral expiratory wheezes are audible. Chest x ray shows a wedge-shaped area of hypovascularity and a small pleural effusion.

CT pulmonary angiogram
This woman presents with chest pain and breathlessness after major abdominal surgery. With the additional risk factor of obesity, a PE seems likely. As the chest x ray is abnormal and suggestive of a PE, a CT angiogram is indicated. This should provide better information on the extent of the PE than a V/Q scan.


A 36-year-old male presents with sudden onset of diarrhoea after every meal. He also has eructation of foul gas. He underwent gastroenterostomy about six months previously.

Barium enema
Gastrocolic fistula is a late complication of gastroenterostomy. This condition may cause diarrhoea, weight loss, belching of foetid gas or, very rarely, vomiting of faeculant material. Diagnosis is primarily by history, but barium enema will add weight to the suspected diagnosis.


A 58-year-old female presents with breathlessness and chest pain approximately 10 hours after a carotid endarterectomy.

Ten hours postendarterectomy is too soon for a PE, so this is more likely to be cardiac ischaemia. Patients with carotid disease also have a high incidence of coronary artery disease. An ECG is the most appropriate initial investigation here.


A 43-year-old woman presents with continuous vaginal urine leakage three weeks after a radical hysterectomy.

Intravenous indigo carmine
A vesico-vaginal fistula may be present in this 43-year-old woman. The appearance of indigo carmine in the vaginal discharge after IV administration may confirm this finding. Cystourethroscopy and EUA may then be required to confirm the site and size of the fistula.


A 70-year-old man presents with insidious onset of jaundice with some weight loss. On examination the gallbladder was palpable in the right upper quadrant. Liver function tests show a raised bilirubin, grossly raised alkaline phosphatase and a mildly raised AST.

Carcinoma of the pancreas
Courvoisier's law states that if in the presence of jaundice the gallbladder is palpable, then the jaundice is unlikely to be due to a stone. If the obstruction is due to a stone then the gallbladder is likely to be thick, fibrotic and does not distend. The most likely cause here would be a pancreatic carcinoma.


A 35-year-old woman presents with sudden onset of jaundice, fever, rigors and severe pain. She is tender in the right upper quadrant but the gall bladder is not palpable. Liver function tests reveal grossly elevated bilirubin, AST and alkaline phosphatase.


The triad of jaundice, fever and severe pain is indicative of cholangitis. It is seen more commonly in the Far East.


A 35-year-old woman on routine medical examination and biochemical screening is found to have a mildly raised bilirubin and alkaline phosphatase. She has had one episode of right hypochondrial pain following a cheese and wine party the previous Christmas. Ultrasound examination showed the presence of multiple small stones in the gallbladder and a common bile duct with a diameter just over the upper normal limited, but no abnormalities.

Gallstone in the common bile duct

The final patient has an asymptomatic stone in the CBD and if laparoscopic cholecystectomy is undertaken there is a high chance of finding a stone in the CBD on cholangiography.


One of your patients suffers from a cardiac arrhythmia that gives rise to syncope.
He continues to drive despite your having made all reasonable efforts to explain to him that this is unsafe.
Which of the following should your response be?
(Please select 1 option)
As the patient has a right to confidentiality you may not take the matter any further
Inform the DVLA
Inform the patient's solicitor
Inform the police
It is the legal obligation of the patient to inform the authorities of his disability; hence you are not obliged to take any further action

Inform the DVLA

In such a situation your duty to society overrides any right of an individual to confidentiality.

The ultimate responsibility is yours and you have to inform the DVLA. Of course, it would be important to inform the patient's next of kin first to try to get the patient to stop driving voluntarily.

On the DVLA website there is a document on medical reasons for being unfit to drive and when patients can start driving again after a medical event. This include the size of aortic aneurysms as well as obvious reasons such as epilepsy.


A 32-year-old female patient has had multiple resections of the bowel on account of recurrent Crohn's disease.
This has resulted in intestinal failure and she is dependent on home parenteral nutrition. She has a Broviac catheter inserted for central venous access.
She presents with fever accompanied by chills and rigors. No physical signs are demonstrable. Cultures taken both centrally and peripherally demonstrate the presence of methicillin-sensitive Staphylococcus aureus.
Your next course of action would be which of the following?
(Please select 1 option)
Determine the antibiotic sensitivity prior to commencing antibiotic treatment
Do not use the intravenous line until the infection has been successfully eradicated.
Remove the intravenous line
Treatment with intravenous teicoplanin for 14 days followed by repeat cultures
Treatment with intravenous vancomycin for 14 days followed by repeat cultures

Remove the intravenous line

One of the main complications of parenteral nutrition is infection of the central line.

Educating the patient and carers may reduce this.

However, line infections do occur and infection with Staphylococcus aureus and Candida are indications for line removal.


A 55-year-old male is admitted as an emergency with severe abdominal pain.
He smokes 30 cigarettes a day and takes approximately 30 units of alcohol per week but admits to exceeding this amount sometimes.
He also complains of sudden deterioration in vision. Ophthalmoscopy shows multiple micro infarcts (cotton wool spots).
What investigation would best confirm your diagnosis and guide treatment?
(Please select 1 option)
Blood glucose
CT scan abdomen
Mesenteric angiogram
Upper GI endoscopy

CT scan of the abdomen

Ischaemic retinopathy, which causes retinal oedema and micro infarcts, causes acute visual loss.

This is a complication of acute pancreatitis.

CT scanning will be useful in diagnosis and evaluation of pancreatitis.


The surgical registrar on duty calls you to ask for advice.
A 24-year-old female patient was admitted under their care the previous night and underwent a diagnostic laparoscopy for investigation of abdominal pain. The examination was normal, the pain has subsided and the plan is to discharge the patient.
The patient is from abroad and wants to travel back to her home country. She would like to know how soon after laparoscopy she might undertake an airline flight.
What would your reply be?
(Please select 1 option)
48 hours
After five days
After one week
Ten days


Modern aircraft normally cruise at between 35,000 to 43,000 feet.

As this environment would be non-physiological, the aircraft cabin is pressurised to a maximum cabin altitude of 8,000 feet. This reduced atmospheric pressure would cause gas in body cavities to expand by 30 - 40%.

Hence, air travel should be delayed for 48 hours after laparoscopy to allow all gas to be absorbed.


A 72-year-old female presents with a longstanding leg ulcer.
Which of the following minerals is most important in wound healing?
(Please select 1 option)

Zinc This is the correct answerThis is the correct answer
Certain supplements are important in wound healing particularly zinc, vitamin C and arginine.

Zinc is a component of many of the enzymes responsible for wound healing.


A 63-year-old male with a long history of alcohol abuse presents after haematemesis at home. He is stable and the bleeding appears to have stopped.
He is known to have oesophageal varices.
Which of the following would be the most appropriate treatment for this patient?
(Please select 1 option)
Sengstaken-Blakemore tube
Transjugular intrahepatic portosystemic shunt (TIPS)


Endoscopy and sclerotherapy or band ligation are used to treat varices.

In the acute situation vasopressin has been extensively used for the initial control of variceal haemorrhage (20 units in 10 mls of 5% dextrose IV over 10 minutes). Nitroglycerine may be as effective.

Octreotide the long acting somatostatin analogue has recently been evaluated and may have an important role.

A Sengstaken-Blakemore tube may stop bleeding through compression.

In the long term a shunt procedure may also be tried, for example, TIPS.


Which one of the following statements is true regarding inguinal hernias in children?
(Please select 1 option)
50% develop a contralateral hernia
50% of hernias are bilateral
Are more common in preterm infants
Girls are more commonly affected than boys
Incarceration is uncommon in infants

Are more common in preterm infants

Inguninal hernias are the commonest surgical condition of childhood. Approximately 2% of male infants will develop an inguinal hernia and 99% will be indirect.

The male:female ratio is 9:1.

Inguinal hernias are more common on the right and 10% are bilateral.

Prematurity is a significant risk factor.

The risk of incarceration is increased in infants and therefore a hernia presenting before 1 year of age requires urgent surgical assessment.

Approximately 20% will develop a contralateral hernia.

The role of contralateral groin exploration at the time of a unilateral herniotomy is controversial.


Normal sexual function but persistent azoospermic sample in a man who suffers from recurrent urinary tract infections.

Retrograde ejaculation


Azoospermia in a 58-year-old businessman three years after prostate surgery.

Retrograde ejaculation


Oligospermia and scrotal swelling in a 24-year-old.



Erectile failure in a smoker of 40 cigarettes per day.

Peripheral vascular disease


Erectile dysfunction in a 44-year-old hypertensive.

Beta-blocker medication
Retrograde ejaculation leds to azoospermia and may follow lower urinary tract surgery or scarring.

Varicocele can usually be detected by palpating a soft scrotal swelling.

Peripheral vascular disease associated with buttock claudication and impotence (known as Leriche syndrome) is commonest in heavy smokers.

Drugs such as beta-blockers (and alcohol) may lead to erectile failure.


A 79-year-old male with critical ischaemia of his foot is awaiting below knee amputation and has lower limb pain.
He is awake and lucid with normal observations.
His full blood count shows:
Haemoglobin 12.0 g/dL (13.0-18.0)
White cell count 14.0 ×109/L (4-11)
Platelets 67 ×109/L (150-400)
Which of the following is the best option for pain relief?
(Please select 1 option)
Diclofenac 50 mg per oram
Epidural analgesia
Fermoral nerve block
Morphine 10 mg intravenously
Tramadol 50 mg per oram

Tramadol 50 mg per oram This is the correct answerThis is the correct answer
Of the options given, tramadol is the best.

In a 79-year-old arteriopath diclofenac is best avoided for fear of renal damage. It is now contraindicated for use in those with heart disease which must be assumed in a patient with limb ischaemia.

Epidural analgesia may confer benefits, especially pre-operatively for below knee amputation and would be appropriate if the operation were to be delayed. However with platelets of 67 most anaesthetists would be reluctant to site one.

Femoral nerve block is a relatively simple procedure which may help, but will give incomplete cover and runs the risk of damaging the femoral artery.

Ten mg morphine intravenously would be considered hazardous in a 79-year-old (in most people actually). IM morphine or a PCA would be alternatives.

Tramadol can have unpleasant side effects for the elderly.


Contains enzymes capable of digesting cells and cellular material.



'Reads' the mRNA and builds protein.



Modification of lipids and proteins with storage of material prior to export out of the cell.

Golgi apparatus
A knowledge of cellular organelles is a pre-requisite for the understanding of the function of the cell.

Different tissues have different quantities of organelles to correspond with their differing functions; for example, muscle is packed with mitochondria, the organelle associated with energy production from Krebs' cycle.

White cells have numerous lysosomes, which store enzymes that are capable of digesting cellular materials.

The Golgi apparatus receives material from the endoplasmic reticulum (protein having been synthesised by ribosomes from messenger ribonucleic acid [mRNAs]), alters and stores it prior to export from the cell.


An 18-year-old male is found to have multiple colonic polyps on screening.

Adenomatous polyps
Familial adenomatous polyposis (FAP) is a dominant hereditary condition characterised by the development of more than 100 colorectal adenomas in the teenage years. Left untreated these adenomas will become cancerous. It is recommended that they undergo panproctolectomy and formation of ileostomy or anal pouch.


A 72-year-old female presenting with excessive clear diarrhoea is found to have a large sessile polyp in the rectum.

Villous adenoma
A villous adenoma can occur anywhere in the gastrointestinal tract, but most frequently occurs in the rectum.
They produce excessive amounts of mucous, which is high in sodium and potassium. An alkalosis results due to the exchange of potassium and sodium for hydrogen ions. The patient may also complain of weakness due to the hypokalaemia. Left untreated they become dysplastic and eventually cancerous.


A 28-year-old female with circumoral pigmentation is found to have multiple polyps in the colon and small intestine.


Peutz-Jegher's syndrome is a dominant hereditary condition which comprises circumoral pigmentation, and intestinal hamartomas that can occur from the stomach to the rectum. Left untreated these hamartomas can occasionally become dysplastic and eventually cancerous.


Regarding leg ulcers, which of the following is true?
(Please select 1 option)
Diuretics have been shown to be of benefit in the treatment of associated oedema
In diabetic ulcers the dressing should be left in situ for no more than one week
Large gravitational ulcers are always painful
Treating superficial infection with antibiotics has been shown to be beneficial
Ulcers caused by arterial disease are typically treated by compression bandaging

In diabetic ulcers the dressing should be left in situ for no more than one week

Diabetics often have some element of neuropathy. This means that significant progression of ulceration/infection may not be noticed. Frequent checks of the ulcers are essential.

Diuretics are only used to treat oedema of general cause, for example, congestive cardiac failure. They do not accelerate healing.

Leg ulcers are not necessarily always painful and there is no evidence to indicate that treatment with antibiotics accelerates healing.

Arterial ulcers should not be treated with compression bandages.


With which of the following is gynaecomastia not associated?
(Please select 1 option)
Digoxin therapy
Klinefelter syndrome
Liver cirrhosis
Prepubescent boys

Prepubescent boys

Gynaecomastia can occur in association with:

Chromosomal abnormalities such as Klinefelter's (XXY)
Drugs such as digoxin, spironolactone and anti-prostate therapy
Diseases such as liver or renal disease, teratoma/seminoma and
Can be a transient phenomenon in young males.
This is associated with a decreased testosterone to oestradiol levels.

Gynaecomastia in liver cirrhosis occurs as a result of decreased metabolism of oestrogens.

The frequency is highly variable based on the criteria used for defining the condition. In one study, a figure of 38% was reported in boys aged 10-16 years using a definition of breast tissue greater than 5 cm in diameter. In another series, gynaecomastia was noted in approximately 10% of boys aged 12-17 years.


A 69-year-old man presents to his GP with difficulty in abducting his right shoulder after he injured it trying to lift a heavy object.
On examination, he is unable to initiate abduction of this shoulder. However, if the arm is lifted to 90 degrees, he is able to hold it in that position. There is tenderness under the acromion process.
Choose the most appropriate diagnosis.
(Please select 1 option)
Anterior dislocation of the shoulder
Rotator cuff tear
Rupture of the long head of biceps
Supraspinatus tendinitis
Torn supraspinatus tendon

Torn supraspinatus tendon This is the correct answerThis is the correct answer
Tear of the supraspinatus tendon is common in elderly patients. With advancing age the tendinous cuff of the shoulder degenerates and is liable to rupture if subjected to sudden movement or stress. Major tear in the tendon leads to a loss of action of the supraspinatus muscle (tendon).

The patient is unable to initiate shoulder abduction, as the early phase of abduction requires the action of the supraspinatus muscle. However, the patient may be able to hold the arm in the abducted position (after passive abduction), since this is supported by the action of the deltoid.


A 30-year-old man felt a sudden pain in the lower back while he was weight training.
On examination, the paraspinal muscles are in spasm and he has an altered sensation down the back of both his legs. He is unable to pass urine. Plain radiography does not reveal any fractures.
Choose the single most appropriate diagnosis.
(Please select 1 option)
Lumbar intervertebral disc prolapse
Lumbar spinal stenosis
Multiple myeloma
Secondary metastatic deposit in the vertebrae
Spondylolisthesis L4/5

Lumbar intervertebral disc prolapse

Lumbar intervertebral disc prolapse usually affects men in their middle age. It is mainly caused by a sudden lifting of heavy weight, or it may be precipitated by trauma. L4/5 and L5/S1 discs account for about 90% of the cases.

The acute clinical presentation includes acute back pain, with radiating pain along the legs, paraesthesia and motor weakness in the event of nerve root compression. In severe bilateral nerve root compression there may be bowel and bladder incontinence and sexual dysfunction.

On examination, the paraspinal muscles may be in spasm and the patient may lean away from the side of the pain with the hip and knee flexed in an effort to reduce the leg pain.


A 40-year-old marketing executive presents to the surgical outpatient clinic with a lump in her right breast of about six weeks' duration. On examination, the lump is about 3 x 3 cm in size.
Mammogram reveals diffuse micro-calcifications and FNAC is suggestive of a malignancy. There are no palpable nodes or evidence of distant metastasis.
Choose the single most appropriate management in this patient.
(Please select 1 option)
Modified radical mastectomy with axillary dissection
Preoperative radiotherapy followed by modified radical mastectomy
Wide local excision and axillary dissection followed by adjuvant radiotherapy
Wide local excision followed by adjuvant radiotherapy
Wide local excision followed by observation

Modified radical mastectomy with axillary dissection

Modified radical mastectomy with axillary dissection should be recommended even for small tumours in patients with diffuse micro calcifications on mammography.

Wide local excision with sentinel biopsy might be appropriate if the area of calcification around the lump is small and well defined.

Adjuvant radiotherapy is not indicated after this procedure unless there are four or more positive axillary nodes, or evidence of lympho-vascular invasion.


An 81-year-old gentleman with dementia is brought to the emergency department with a right-sided hemiparesis.
His nursing home carer states he might have hit his head against a washing sink about two weeks ago. Since then he has complained of recurrent episodes of headaches and has been noticed to have variation in his conscious level. He is on warfarin for atrial fibrillation.
Choose the single most appropriate diagnosis.
(Please select 1 option)
Diffuse axonal injury
Extradural haematoma
Subarachnoid haemorrhage
Subdural haematoma

Subdural haematoma This is the correct answerThis is the correct answer
This patient is most likely to have a subdural haematoma. They are usually secondary to trauma, sometimes trivial, where the patient (or carer) does not recall the incident. Spontaneous subdural haematomas can occur in elderly patients with cerebral atrophy due to shearing of the subdural veins (venous plexus).

Alcoholics, epileptics and patients on anticoagulants are more susceptible. In chronic subdural haematomas, patients may not become symptomatic for many days or even weeks after injury.

If the haematoma continues to enlarge, headache, fluctuating level of consciousness, failing intellect and hemiparesis can all present.


Which one of the following vessels is an indirect branch of the abdominal aorta?
(Please select 1 option)
Gonadal artery
Inferior gluteal artery
Middle suprarenal artery
Renal artery
Superior mesenteric artery

Inferior gluteal artery

The direct branches of the aorta are described as anterior (coeliac axis, superior and inferior mesenteric arteries), lateral and dorsal (lumbar arteries).

The paired (and often multiple) direct branches arising from the lateral group include:

Suprarenal artery
Renal artery
Gonadal artery.
The suprarenal artery arises from the lateral aspect of the abdominal aorta, level with the superior mesenteric artery. It ascends slightly, where it anastamoses with the suprarenal branches of the phrenic and renal arteries.

The superior mesenteric artery arises directly from the anterior surface of the abdominal aorta. The renal arteries are two of the largest direct branches of the abdominal aorta and arise laterally from the vessel just below the origin of the superior mesenteric artery.

The inferior gluteal artery arises from the internal iliac artery and is, therefore, an indirect branch of the abdominal aorta.


A 37-year-old receptionist presents to the surgical outpatient clinic with a two week history of periareolar inflammatory mass with discharge in her right breast. There is slight retraction of the nipple.
It is diagnosed to be a mammary duct fistula.
Which one of the following is the most appropriate management in this patient?
(Please select 1 option)
Fine needle aspiration cytology
Mastectomy and axillary clearance
Radical mastectomy
Wide local excision and axillary node sampling


A mammary duct fistula is a communication between the skin (usually in the periareolar region) and a breast duct. The underlying pathology is usually a periductal mastitis or rarely, granulomatous mastitis.

The median age of women developing mammary duct fistula is around 35 years. Retraction of the nipple at the site of the involved duct is present in almost all the patients.

Excision of the involved duct and fistula alone (fistulotomy) or excision of the fistula combined with total duct excision (Hadfield's procedure - radical subareolar duct excision) under antibiotic cover, is the treatment of choice for this condition.


A 23-year-old electrician presents to the emergency department with a deep cut to his right distal forearm from a broken glass after he was involved in a fight at a nightclub.
On examination, he is unable to pinch by adducting his thumb or spread his fingers. His grip is weak. He also has loss of sensation over his little and ring fingers.
Which nerve is the most likely to have been damaged?
(Please select 1 option)
Anterior interosseous nerve
Median nerve
Posterior interosseous nerve
Radial nerve
Ulnar nerve

Ulnar nerve This is the correct answerThis is the correct answer
This patient is mostly likely to have an ulnar nerve injury.

Injury to the ulnar nerve at the level of the wrist produces hypothenar wasting and clawing of the hand, due to unopposed action of the long flexors.

There is loss of sensation over the little and ring fingers. Finger abduction is weak and the loss of thumb adduction makes pinch difficult. This is due to paralysis of the adductor pollicis and the first palmar interossei causing flexion of the thumb (due to flexor pollicis longus) when the patient is asked to grasp a card between his thumb and index finger (Froment's sign).


A 69-year-old gentleman is referred by the GP to the urology outpatient clinic with a two to three month history of painless haematuria, increased frequency of micturition and loss of weight. He also complains of generalised tiredness and lethargy.
He smokes about 20-25 cigarettes a day. On examination, he appears pale and anaemic. Abdominal examination is unremarkable. Per rectal examination is unremarkable.
Choose the single most appropriate diagnosis.
(Please select 1 option)
Carcinoma of the bladder
Carcinoma of the prostate
Renal cell carcinoma
Squamous cell carcinoma of the renal pelvis

Carcinoma of the bladder

The history of smoking and other pertinent signs and symptoms in this patient are very suggestive of a carcinoma of the bladder.

Carcinoma of the bladder epithelium is the most common tumour of the genitourinary tract. Some of the recognised risk factors for the development of carcinoma of the bladder include

Cigarette smoking (more than 20 cigarettes/day increases the risk of developing bladder cancer by 2-6 times)
Working in the:
Aniline dye industry
Rubber industry
Petrochemical industry
Schistosomiasis infestation of the bladder
Local radiation therapy
Some chemotherapeutic drugs
Longterm catheterisation in paraplegic patients.
Some recognised bladder carcinogens include

Aromatic amines
as well as various dyes and solvents.

Patients with carcinoma of the bladder may present with painless haematuria, dysuria, frequency and an urgency of micturition.

The patient may have symptoms of anaemia such as dry and pale tongue and generalised tiredness. Investigations include urine microscopy and culture (to rule out any infection) and cystoscopy.

Endoscopic resection of the mass followed by a four to six week course of radiotherapy to the bladder and the pelvic side walls is useful in treating a majority of the tumours.