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Flashcards in Mixed IV Deck (18):
1

A 46-year-old lady who suffers from rheumatoid arthritis presents to the emergency department with carpal dislocation (confirmed radiologically) after she sustained a fall while out shopping.
On examination, she is unable to lift her thumb up towards the ceiling and has loss of sensation over the thumb, index and middle fingers.
Which nerve is the most likely to be injured?
(Please select 1 option)
Median nerve
Musculocutaneous nerve
Posterior interosseous nerve
Radial nerve
Ulnar nerve

Median nerve

The signs and symptoms are suggestive of a median nerve injury. In adults, the median nerve is commonly injured near the wrist, although it can be injured anywhere along the arm or the forearm. Low lesions may be caused by lacerations in front of the wrist or by carpal dislocation.

Median nerve injuries at the wrist cause sensory loss over the thumb, index, middle, and occasionally ring finger (lateral half). Motor loss includes all thenar muscles (except adductor pollicis) and the lateral two lumbricals.

If the injury is at the level of the elbow, there is paralysis of the pronators of the forearm and flexors of the wrist and fingers, with the exception of flexor carpi ulnaris and the medial part of flexor digitorum profundus.

2

A 71-year-old woman who lives in residential care presents with a 12 hour history of severe generalised abdominal pain associated with nausea and vomiting.
Her blood pressure is 100/70 mmHg and her heart rate is 102/min. She is in atrial fibrillation and examination of her abdomen reveals absent bowel sounds.
Choose the single most appropriate diagnosis.
(Please select 1 option)
Crohn's disease
Diverticular disease
Mesenteric infarction
Mittelschmerz
Ulcerative colitis

Mesenteric infarction

The history and clinical features in this patient are very suggestive of mesenteric infarction.

Although any of the three anterior abdominal aortic branches (coeliac, superior and the inferior mesenteric vessels) may occlude, it is the occlusion of the superior mesenteric artery (SMA) which commonly causes mesenteric infarction.

Despite the presence of collateral vessels for SMA, they may not be able to dilate sufficiently and swiftly enough to overcome the acute reduction in blood flow. The occlusion may be due to a thrombus or an embolus, and is seen in elderly patients who are in atrial fibrillation.

Clinical features include persistent, severe and generalised abdominal pain.

This condition is a surgical emergency as the patient rapidly becomes toxic and may die from septic shock unless the infracted bowel is removed.

3

A 39-year-old electrical engineer presents to the emergency department with a sudden onset of agonising pain in his left shoulder. He states that the pain started the night before as a dull ache but has now become quite intense.
All shoulder movements are painful and restricted, especially abduction. On examination, there is tenderness at the greater tuberosity just beneath the acromion process.
Choose the single most appropriate diagnosis.
(Please select 1 option)
Acute supraspinatus tendinitis
Frozen shoulder
Painful arc syndrome
Rotator cuff tear
Subdeltoid bursitis

Acute supraspinatus tendinitis

The history and clinical findings in this patient are very suggestive of acute supraspinatus tendonitis. This condition commonly affects young individuals between the ages of 25 and 45. The pain is dull aching to begin with but soon becomes agonising.

Practically, all the shoulder movements are painful and limited, especially abduction.

On examination, there is pain at the insertion of supraspinatus (on the greater tuberosity just beneath the acromion process).

This condition is usually treated with rest and anti-inflammatory agents.

4

The paediatric surgeons are asked to review a new-born baby boy with mild abdominal distension, bilious vomiting, and failure to pass meconium after 24 hours.
Plain abdominal x ray reveals dilated loops of bowel with fluid levels. Barium enema demonstrates a 'conical appearance' in a segment of the colon.
Choose the single most appropriate diagnosis.
(Please select 1 option)
Hirschsprung's disease
Infantile hypertrophic pyloric stenosis
Intestinal atresia
Intussusception
Meckel's diverticulum

Hirschsprung's disease

Hirschsprung's disease is an absence of ganglion cells in the neural plexus of the intestinal wall.

It is more common in boys.

The delayed passage of meconium together with distension of abdomen following feeds and bilious vomiting are the usual clinical features.

Plain abdominal x ray may demonstrate dilated loops of bowel with fluid levels.

Barium enema demonstrates a 'conical appearance' in the affected part due to the dilated ganglionic proximal colon and the distal aganglionic bowel failing to distend.

5

A 39-year-old man walks into the emergency department after being assaulted with a baseball bat. He had a momentary loss of consciousness but feels fine at present.
Skull x ray reveals a linear fracture over his right parietal area. While in casualty, he suddenly becomes confused and later unconscious with a Glasgow coma scale of 8. His right pupil is dilated.
Which one of the following is the correct diagnosis?
(Please select 1 option)
Diffuse axonal injury
Extradural haematoma
Subaponeurotic haematoma
Subarachnoid haemorrhage
Subdural haematoma

Extradural haematoma

Acute extradural haematoma should be suspected after a head injury where the patient has a fluctuating level of consciousness (though not always). The patient may briefly lose consciousness, but soon recovers (lucid interval). They are usually associated with trauma and are seen in the young.

Extradural bleeds are commonly due to fractured temporal or parietal bones causing injury to the middle meningeal artery or vein.

With increasing bleed (haematoma), lateralising signs develop including an ipsilateral dilated pupil and contralateral hemiparesis. This eventually leads to a bilateral fixed pupil and coma which culminates in respiratory arrest.

6

A 32-year-old woman presents to the surgical outpatient clinic with intermittent dysphagia for solids and liquids, which is exacerbated by stress. She also gives a history of delayed regurgitation of food.
There is no gastric air bubble seen on plain radiography, and chest x ray reveals a double right heart border.
Choose the single most appropriate diagnosis.
(Please select 1 option)
Achalasia cardia
Pharyngeal palsy
Plummer-Vinson syndrome (pharyngeal web)
Retrosternal goitre
Syringomyelia

Achalasia cardia

The history and findings in this patient are very suggestive of achalasia cardia, a condition where there is a neuromuscular failure of relaxation at the lower end of the oesophagus due to loss of ganglia from the Auerbach's plexus. It affects more females than males (3 : 2) and is common during the third decade of life.

There is progressive dysphagia to solids and liquids, chest pain and regurgitation of old food from the dilated oesophageal sac.

There is no gastric air bubble because the dilated oesophagus never completely empties and therefore swallowed air cannot pass into the stomach.

Chest x ray shows air or fluid level behind the heart and the expanded oesophagus gives the appearance of a 'double right heart border'.

7

A 69-year-old gentleman presents to his GP with hoarseness of voice of three months' duration. He is known to have COPD for which he is on steroid inhalers and he smokes 20 cigarettes per day.
On examination, the throat appears inflamed with white patches. In addition, the larynx and vocal cords also appear red and beefy.
Choose the single most appropriate diagnosis.
(Please select 1 option)
Candidiasis of the larynx
Chronic laryngitis
Laryngeal carcinoma
Laryngeal papillomata
Sicca syndrome

Candidiasis of the larynx

Candidiasis of the larynx is common in patients using steroid inhalers. Those at an increased risk include:

Very young or old
Diabetics
Immunosuppressed (cytotoxics, steroids, haematological malignancies, AIDS).
These lesions appear as creamy white patches on the mucosa, surrounded by a thin margin of erythema. Patches are hard to remove and they bleed if scraped.

Antifungal agents such as nystatin or amphotericin B are useful to treat this condition.

If possible, antibiotics should be withdrawn.

8

An 8-month-old male baby with haemophilia is referred by his GP to the surgical outpatient clinic with history of intermittent episodes of inconsolable crying and vomiting. The parents say the baby's stools are mixed with blood.
On examination, a mass is palpable over the right side of the abdomen.
Choose the single most appropriate diagnosis.
(Please select 1 option)
Ano-rectal atresia
Intussusception
Meconium ileus
Mid-gut malrotation
Volvulus neonatorum

Intussusception

This baby is most likely to have intussusception, which is caused due to invagination of a segment of bowel into its adjoining lower segment.

It is more common in boys and usually occurs under the age of 1.

Intussusception is associated with haemophilia, Henoch-Schönlein purpura, haemangiomas and gastrointestinal lymphomas.

Clinical features include severe colicky abdominal pain (causing intermittent inconsolable cries with the child drawing up the legs) and vomiting. The infant may pass 'redcurrant jelly' stools and a sausage-shaped mass is palpable on abdominal examination. Rectal examination may reveal blood.

9

Which one of the following is smoking related?
(Please select 1 option)
Astrocytoma
Bladder cancer
Coeliac disease
Thyroid cancer
Ulcerative colitis

Bladder cancer

There is a two- to fourfold increased risk of developing bladder cancer in those who smoke.

Astrocytomas are the commonest form of brain glioma (brain connective tissue) tumours. They are of an uncertain aetiology, which is not thought to be linked to smoking.

Cigarette smoking, or a factor closely linked to it, seems to exert a major protective effect against the development of symptomatic adult onset coeliac disease.

Aetiological causes of thyroid cancer include

Pre-existing goitre
Exposure to radiation
Genetic causes (for example, medullary).
Ulcerative colitis is also of an uncertain aetiology and appears to be slightly less common in patients who smoke.

10

Which of the following is not a differential diagnosis of femoral hernia?
(Please select 1 option)
Cyst of canal of Nuck
Ectopic testis
Psoas abscess
Saphena varix
Virchow's node

Virchow's node This is the correct answerThis is the correct answer
Femoral hernias lie in the femoral canal which is the medial compartment of the femoral sheath, the opening to which is the femoral ring.

The femoral canal contains lymphatics, and therefore causes enlarged lymph nodes which form part of the differential diagnosis (that is, lymphoma, infection).

However, Virchow's node (Troisier's sign) is a supraclavicular lymph node, associated with intra-abdominal malignancy (that is, gastric) and does not form part of the differential.

The intermediate compartment of the sheath contains the femoral veins and therefore a saphena varix may be mistaken for a hernia due to the close proximity.

The femoral artery lies in the lateral compartment. The walls of the sheath are formed by a continuation of the fascia transversalis interiorly and posterior iliacus/psoas fascia. A psoas abscess will therefore track along the fascia, under the ligament into the groin, lying in a similar position to a femoral hernia.

11

Which of the following is true in hypothermia?
(Please select 1 option)
A metabolic alkalosis is a common finding
Hypertension is often seen during re-warming
Pancreatitis is a recognised complication
Passive re-warming is advised for all patients
The oxygen dissociation curve is shifted to the right

Pancreatitis is a recognised complication

Hypothermia is defined as a core temperature less than 35°C, and is associated with

hypopituitarism
hypothyroidism
spinal cord trauma
alcohol
drug overdose.
In hypothermic patients the oxygen dissociation curve is shifted to the left.

A metabolic acidosis is commonly seen in hypothermia, and is exacerbated by a reduction in hepatic clearance and renal excretion of hydrogen ions and lactic acid.

Other complications include

acute pancreatitis
hyperglycaemia
thrombocytopaenia
a coagulopathy.
Passive re-warming is appropriate when the core temperature is above 33°C (not all patients), but active measures are required when the temperature is lower.

Hypotension may be seen as the core temperature rises, as hypovolaemia is revealed and will usually require fluid resuscitation.

12

Which of the following is a congenital neck mass in infants?
(Please select 1 option)
Branchial cyst
Carotid body tumour
Cavernous haemangioma
Parotid myxoma
Thyroid adenoma

Branchial cyst

Congenital neck masses in infants include

Cystic hygroma (lymphangiomas)
Thyroglossal cysts
Haemangioma
Dermoid cysts
Branchial cysts.
Parotid myxomas, carotid body tumours and thyroid adenomas are acquired and not congenital, and a cavernous haemangioma - as found in Sturge-Weber syndrome - is not on the neck.

13

Which one of the following conditions predisposes to malignancy?
(Please select 1 option)
Diverticular disease of the colon
Polycystic disease of the ovaries
Prolactinomas
Turcot syndrome
Turner's syndrome

Turcot syndrome

Turcot syndrome refers to adenomatous tumours of the colon and central nervous system.

Paget's disease is associated with an increased risk of osteosarcoma.

Prolactinomas do not predispose to either breast or pituitary malignancy.

14

Which of the following disinfectants is effective for skin?
(Please select 1 option)
Carbolic soap
Chloramphenicol drops
Chlorhexidine
Glutaraldehyde
Ethylene oxide

Chlorhexidine

Glutaraldehyde is used in the treatment of warts and calluses.

Chlorhexidine is a skin cleanser and antiseptic. It can also be used for bladder irrigation and catheter patency solutions.

Ethyl alcohol with povidone-iodine is a skin disinfectant but must be used with caution in pregnancy, breast-feeding, broken skin, and renal impairment.

Ethylene oxide is used to sterilise most dialysers.

Chloramphenicol is a potent broad-spectrum antibiotic.

15

Gynaecomastia is not associated with which one of the following conditions?
(Please select 1 option)
Digoxin therapy
Klinefelter syndrome
Liver cirrhosis
Teratoma
Two-thirds of pubescent boys

Two-thirds of pubescent boys This is the correct answerThis is the correct answer
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 up to 40% of male adolescents.

This is associated with a decreased testosterone to oestradiol levels.

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

16

Which one of the following is true of clinical audit?
(Please select 1 option)
Clinical audit is a quality improvement process and is best performed through the means of a randomised control trial
Clinical audit projects are best constructed and ran by junior doctors
Clinical audit requires a number of stages known as the 'audit cycle'
Clinical governance is the autonomy which individual clinicians have to decide the best treatment for a patient.
Only hospital clinicians should be involved in clinical audit

Clinical audit requires a number of stages known as the 'audit cycle'

Clinical audit is a quality improvement process that seeks to improve patient care and outcome through systemic review of care against explicit criteria and the implementation of change.

Clinical audit projects are best conducted within a structured programme, with effective leadership, participation by all staff, and an emphasis on team working and support. Adequate funding should also be put aside to run these projects properly.

Within the audit cycle there are stages which follow a systemic process of establishing best practice, measuring care against criteria, taking action to improve care, and monitoring to sustain improvement.

Clinical governance is framework through which the NHS is accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish.

The General Medical Council now advises all doctors 'must take part in regular and systematic medical and clinical audit'.

17

Which of the following is correct regarding foam dressings?
(Please select 1 option)
Are suitable for dry superficial wounds
Are suitable for exuding, granulating wounds
Are used for surgical packing
Form a gel in contact with exudates
Usually require a secondary dressing

Are suitable for exuding, granulating wounds

Foam dressings are suitable for exuding wounds where there is granulation tissue and do not require secondary dressings.

Alginates form a gel when in contact with exuding wounds.

18

Which one of the following is true of lung ventilation perfusion scanning in patients suspected of thromboembolism?
(Please select 1 option)
A normal perfusion scan virtually excludes pulmonary embolism
It is contraindicated in pregnancy
It is contraindicated in those with iodine hypersensitivity
The appearances of the scan in emphysema resemble those in pulmonary embolism
There is reduced perfusion in the upper lobes in mitral stenosis

A normal perfusion scan virtually excludes pulmonary embolism

Increased pulmonary venous pressure, especially secondary to mitral valve disease, causes increased flow to the upper lobes.

Chronic obstructive pulmonary disease (COPD) usually gives rise to matched defects. Radiation to fetus is small.

VQ scan is not contraindicated in pregnant women, although the perfusion only scan is adequate.

Xenon is used for imaging ventilation, whilst technetium labelled macroaggregated human serum albumin (MAA) is used to image perfusion.

A normal perfusion scan has a sensitivity of 98% but a specificity of only 40%.