other

Question 1

A 36 year old previously healthy man is to be admitted to the intensive care unit from A&E with hyper-acute liver failure following an overdose of paracetamol. He is conscious but incoherent and restless. You are asked by your consultant to examine him and document your findings in the notes.

Which of the following signs are most likely in this patient?

Answer 1

Asterixis

Asterixis, also known as hepatic flap, is a sign of grade II or III hepatic encephalopathy which is a cardinal feature of liver failure. Incoherency and restlessness are features of grade III hepatic encephalopathy and we can therefore assume that it is likely that this patient would also have a flap

Question 2

what is mirrizizis syndrome

Answer 2

This is the correct answer. Mirrizi’s syndrome causes an obstructive jaundice due to compression of the common bile duct secondary to the present of gallstones in the cystic duct. The symptoms described by the patient suggest an obstructive cause for her jaundice, producing a conjugated hyperbilirubinaemia

Question 3

This is the only obstructive cause of jaundice listed. Absent urobilinogen and bilirubinuria are indicative of a posthepatic cause of conjugated hyperbilirubinaemia. Conjugated bilirubin is water soluble and therefore enters the urine, making urine darker

what causes of obstructive jaundice are we looking fo

Answer 3

pancreatic adenocarcinoma

Question 4

post op pf small intestine. Patients suffer from diarrhoea, abdominal pain and malabsorption due to lack of a fully functioning gastrointestinal tract what codntion

Answer 4

short bowel syndrome

Question 5

A 5-year-old girl presents to the GP as her mother is concerned about her short stature. On examination, in addition to her short stature, the girl also has a round face and short 4th and 5th metacarpals. The GP requests tests of parathyroid function which are all normal. Which of the following is the most likely cause of this patient’s presentation?

Answer 5

Pseudopseudohypoparathyroidism

This condition presents with the morphological features of pseudohypoparathyroidism but with normal biochemistry

jut one pseudo
In this condition, there is a failure of target cell response to parathyroid hormone (PTH). This results in a round face, short metacarpals (especially 4th and 5th), short stature and a low IQ. Bloods would reveal low serum calcium with raised PTH. The answer is pseudopseudohypoparathyroidism, which presents with the morphological features of pseudohypoparathyroidism but with normal biochemistry

Question 6

A 70-year-old gentleman presents with difficulty passing urine. He has experienced increasingly poor flow over the past few months. His medication list includes Bisoprolol, Warfarin, Tamsulosin and Finasteride. Bladder scan shows 770mls of urine and a catheter is inserted. Blood tests are unremarkable and urine dip is negative.

What is the next step in management for this patient?

Answer 6

turp

Question 7

angulated fracture in the mid-diaphysis of the right radius. The fracture is incomplete as it goes through the cortex on the convex side of a bone that has been bent while the opposite cortex (concave surface) remains intact.

Answer 7

greenstick

Greenstick fractures occur in paediatric patients when force is applied to a bone and it bends in such way that the structural integrity of the cortex surface is overcome. However, the bending force applied does not break the bone completely, breaking only the convex part of the bone whilst the concave surface remains intact

bowing
Greenstick fractures occur in paediatric patients when force is applied to a bone and it bends in such way that the structural integrity of the cortex surface is overcome. However, the bending force applied does not break the bone completely, breaking only the convex part of the bone whilst the concave surface remains intact

Question 8

comminuted fracture

Answer 8

Comminuted fractures are complete fractures where more than two bone components are created. They usually occur as a result of high-impact trauma

Question 9

spiral fractures

Answer 9

Spiral fractures are complete fractures of long bones that result from a rotational force being applied along the axis of a bone while the other extremity is planted. They are a common sign of physical abuse because they are a result of forceful jerking or twisting of a limb

Question 10

A 25 year old man returns from a trip to Malawi and presents to his GP. He is worried as he swam in snail-infested fresh water and has now developed symptoms of abdominal pain, diarrhoea and haematuria.

Schistosomiasis
tx

Answer 10

Two doses of Praziquantel

Question 11

ARDS after RTA what do you give

Answer 11

Low tidal volume mechanical ventilation

This is the correct answer. The patient presents with clinical features consistent with acute respiratory distress syndrome (ARDS), most likely secondary to transfusion-related lung injury. Large randomised trials have shown that low tidal volume ventilation reduces mortality in ARDS

Question 12

for the past month. The pain is worse when he takes the first few steps in the morning and is relieved by rest. He also notices that walking barefoot worsens the pain. There is no history of trauma to the foot. His job as a chef requires him to stand most of the time.

On examination, he has a BMI of 32 and a left-sided antalgic gait. There is no visible swelling in the foot. There is pain with palpation of the plantar medial aspect of the heel and with passive dorsiflexion of the ankle and toes.

A provisional diagnosis of plantar fasciitis is made. Which of the following is the most suitable advice to give this patient at this point of time?

tx

Answer 12

Advise weight loss and recommend a suitable weight loss program

Plantar fasciitis is the most common cause of heel pain and risk factors include running, obesity and prolonged standing. His BMI of 32 puts him in the obese category of weight. Raised BMI not only is a risk factor but also a predictor of functional loss reported by patients. Recommending a suitable weight loss program would be ideal as first-line management of his condition alongside avoidance of activities that worsen the pain

Question 13

A 35-year-old man presents to the surgical outpatient clinic complaining of severe anal pain during and around the time of defecation for the past 6 months. In addition, he has occasionally noticed a small amount of fresh blood on the toilet paper after passing bowel motions. On questioning, he confirms that he has been straining and requiring significant effort to pass bowel motions. He mentions having tried laxatives, fibre, lubricants plus topical nifedipine and lignocaine on the advice of a general practitioner. None of these has reduced his pain.

On inspecting the perianal area, there appears to be a sizeable ‘split’ in the mucosa just proximal to the anal verge. A digital rectal exam is attempted but terminated due to intolerable discomfort. He denies any other changes to his bowel habits and is generally well. Past medical and family history are non-contributory.

Given the above information, which of the following is the most appropriate management of this patient?

Answer 13

anal fissuer

sphincterotomy last line

Question 14

benefit of epidurals

Answer 14

faster return of normal bowel function

Question 15

Pneumaturia sign of what

Answer 15

UTI
FISTULA - ENTEROVESICAL

Question 16

if colovesical fistula has formed what should you do

Answer 16

abdo CT scan

Question 17

stricture

Answer 17

laparotomy

Question 18

do diverticular bleeds often settle spontaneously

Answer 18

yes

Question 19

An 18-year-old man with a previous history of constipation presents with bright red rectal bleeding and diarrhoea. He has suffered episodes of faecal incontinence, which have occurred randomly throughout the day and night.

Answer 19

proctitis
Nocturnal diarrhoea and incontinence are typical of inflammatory bowel disease.

Question 20

A 56-year-old man presents with episodes of pruritus ani and bright red rectal bleeding. On examination there is a mass in the ano rectal region and biopsies confirm squamous cell cancer.

Answer 20

These are features of anal cancer. Anal cancers arise from the cutaneous epithelium and are therefore typically squamous cell. They are usually sensitive to chemoradiotherapy.

Question 21

A 19-year-old man presents with bright red rectal bleeding. He has a longstanding history of irritable bowel syndrome. At flexible sigmoidoscopy a lesion is biopsied and reported as showing ‘fibromuscular obliteration’.

Answer 21

Solitary rectal ulcer syndrome

This is the typical presentation of SRUS. These patients require careful diagnostic work up to elicit the underlying cause of their altered bowel habit. The histological appearances of solitary rectal ulcers are characteristic and extensive collagenous deposits are often seen. This is usually termed fibromuscular obliteration.

Question 22

triad of vomiting, pain and failed attempts to pass an NG tube

Answer 22

gastric volvulus