RECALLS

Question 1

Patient on warfarin and started to bleed. What is the used to measure the bleeding?
a) Deficiency of factor 2,7,9,10
b) Prothrombin deficiency
c) Platelet deficiency
d)Deficiency of factor 10
e)Deficiency of factor 7

Answer 1

A- Warfarin acts on intrinsic coagulation pathway and affects Factor 2, 7, 9,10. Enoxaparin and heparin affects 2 and 10. Apixaban, Edoxaban and Rivaroxaban affects Factor 10. Dabigatran affects 12.

Question 2

Female RA, BA on 10 mg bid steroid and salbutamole, Rt iliac fossa pain, vomiting, fever, k high, wbcs 15 Na low, BP 80/50, pulse 80 what to do
a)250 ml colloid and reassess
b) 100 ml prednisolone
c)1.2 gm iv co-amoxiclav
d)IV 100 mg Hydrocortisone
e)Ca resonium per rectal

Answer 2

D
Patients receiving oral adrenocortical steroids
•Should be asked about the dose and duration
• Extra doses of steroids perioperatively) so as to avoid an addisonian crisis
> A patient taking >5.mg prednisolone equivalent within a month of surgery
> Will require supplementation at induction and postoperatively

Question 3

70 year old male, angina on going upstairs. No murmur heard. ECHO(? ecg) was done, what is the most likely finding?
a) Aortic stenosis
b Aortic sclerosis
c) Aortic regurgitation
d) Mixed Valvular disease
e) Mitral stenosis

Answer 3

B

Question 4

8 year old child became tired and breathless after playing football.brought by mom harsh continuous murmur under the left clavicle…diagnosis?
a) Coarctation of aorta
b) PDA
c) VSD
d) ASD
e) TGA

Answer 4

Coarctation of the aorta
> Clinical examination of the pulses may demonstrate a radio-femoral delay
> And a murmur that is continuous
> Heard best over the thoracic spine or below the left clavicle

Question 5

Primigravida, 24 years, third trimester, chest tightness, cyanosis, congested neck veins, her father died at 60 with MI
a)Aortic dissection
b)Acute massive PE
c) Mi
d)Pulmonary infarction
e)Lung cancer

Answer 5

Pulmonary Embolism®
Mnemonic: SAM has RED
Pants
* S stroke or recent MI
* A atrial fibrillation
* M myocardial infarction
* R recent surgery
* E estrogen therapy
* D disseminated malignancy
* P/pregnancy-postpartum

Question 6

Half life of platelets?
a)12 hours
b)2 days
c) 10 days
d)20 days
e) 30 days

Answer 6

The Platelet
• Platelets circulate with an average life span of 7 to 10 days.
• Approximately one-third of the platelets reside in the spleen, and this number increases in proportion to splenic size, although the platelet count rarely decreases to <40,000/L as the spleen enlarges.
• Platelets are physiologically very active, but are anucleate, and thus have limited capacity to synthesize new proteins.

Question 7

A bullet is shot just at the right side of rectus muscle where it meets the tight costal margin and went out out at the exact area through the back, organ most likely affected?
a) Pylorus
b) Liver
c) Gallbladder
d) Kidney e Duodenum

Answer 7

C

Question 8

Paneth cells present in-
a) Crypt of liberkuhn
b Intestinal villi
c) Gastric antrum
d) Lamina propria
e) Muscle layer

Answer 8

A

Question 9

In COPD patient
a)PCO2 increased and HCO3- increased
b)PCO2 increased and HCO3- decrease
c)PCO2 decrease and HCO3- increased
d) PCO2 decrease and HCO3- decrease
e)PCO2 no change and HCO3- increased

Answer 9

A

Question 10

COPD + given morphine, which ABG represents it?
a) Partially compensated resp alkalosis
b) Partially compensated metabolic acidosis
c) Partially compensated metabolic alkalosis
d) No change
e)Partially compensated resp acidosis

Answer 10

E

Question 11

Posteromedial approach Baker cyst, most superficial susceptible to damage
a) Sciatic nerve
b) Tibial nerve
c) Sural nerve
d) CPN
e) Saphenous nerve

Answer 11

E

Question 12

Chest Xray foreign body usually settle down
a) R lower lobe
b) Middle lobe
c)R upper lobe
d)L lower lobe
e)L upper lobe

Answer 12

A The right main bronchus (RMB) is shorter, wider and nearly vertical compared with the left main bronchus (LMB) As a consequence, inhaled foreign bodies are more likely to enter the RMB than the left

Question 13

Ileoanal pouch, put on metronidazole. Common side effect.
a Ileoanal fibrosis
b)Peripheral neuropathy
c) Coagulopathy
d) |leovesical fistula
e)Pouchitis

Answer 13

Therapy for treatment and presantation of pouchitis
IBD_therapy-treatment-and-prevention-pouchitis
> Vomiting
• Metallic taste
> Temporary damage to nerves

SIDE EFFECTS OF METRONIDAZOLE
epigastric distress
•Seisures
•Metallic taste
Darkenina of urine Peripheral neuropathy
Pancreatitis
•Hepatitis
•Fever
•Reversible neutropenia

Question 14

A 45-year-old woman presents to the Emergency Department with shortness of breath, pain on deep breathing and fever of one day’s duration. Twelve days ago she had varicose vein surgery. On examination she has a sinus rhythm with a pulse rate of 110 beats/minute. Her blood pressure is 130/90 mmHg and her temperature is 38°C. Pulse oximetry shows a saturation of 92% on air. Chest examination is normal.
Computerized tomography pulmonary angiography (CTPA) demonstrates a pulmonary embolism. What is the most appropriate treatment?
• Low molecular weight heparinisation
• Placement of inferior vena cava filter
• Pulmonary embolectomy
• Thrombolysis
• Warfarinisation

Answer 14

A

Question 15

A 60-year-old man with ischaemic heart disease presents with bilateral gynaecomastia. Which one of the following drugs is most likely to have caused this problem?
• Aspirin
• Atenolol
• Furosemide
• Spironolactone
• thyroxine

Answer 15

D

Question 16

A 70-year-old man with carcinoma of the bronchus presents with blurring of vision, headaches and nausea, particularly in the morning. Which of the following is the most appropriate treatment?
• Carbamazepine
• Dexamethasone
• Morphine elixir
• Paracetamol
• Radiotherapy

Answer 16

B

Question 17

A slightly overweight 13-year-old boy presents with a three-week history of right hip pain and limping. On examination the hip moves into external rotation when flexed. Which of the following is the most likely diagnosis?
• Developmental dysplasia (congenital dislocation) of hip
• Juvenile rheumatoid arthritis
• Perthes disease
• Slipped upper femoral epiphysis
• Traumatic

Answer 17

D

Question 18

A patient with locally advanced pancreatic cancer develops persistent back pain. Which of the following is the most appropriate treatment?
• Corticosteroids
• Celiac Nerve block
• Non-steroidal anti-inflammatory drugs (NSAIDs)
• Paracetamol
• Transcutaneous electric nerve stimulation

Answer 18

B

Question 19

A 50-year-old woman sustains a displaced distal radial fracture. This is manipulated under anaesthetic and treated in a cast for six weeks. After three months she returns to the fracture clinic with painful and limited pronation and supination. Which of the following is the most likely diagnosis?
• Complex regional pain syndrome Type 1 (reflex sympathetic dystrophy)
• Malunion
• Non-union
• Posterior interosseous palsy
• Radial nerve compression

Answer 19

B

Question 20

Three days after an isolated head injury from a fall on the right side, a 76-year-old woman is admitted for drowsiness and confusion. There are no localising signs. A CT scan is most likely to show:
*A crescent intracranial haematoma on the right side with cerebral swelling and midline shift to the left
• A depressed frontal fracture communicating with the frontal sinus and signs of infection
• An expanding extradural haematoma on the left side with cerebral swelling
• Blood in the subarachnoid space and cerebral ventricles with secondary
hydrocephalus
• Cerebral atrophy with a subdural collection on the left side

Answer 20

The most likely finding on a CT scan for this patient is a crescent intracranial haematoma on the right side with cerebral swelling and midline shift to the left. This is consistent with a chronic subdural haematoma, which is a common complication of head injury in elderly people12. A chronic subdural haematoma is a collection of blood that forms between the dura mater (the outermost layer of the meninges) and the arachnoid mater (the middle layer of the meninges) over a period of days to weeks after a head injury12. The blood may accumulate slowly and cause gradual compression of the brain, leading to symptoms such as drowsiness, confusion, headache, weakness, or seizures12. On a CT scan, a chronic subdural haematoma appears as a crescent-shaped lesion that follows the contour of the skull and may cross suture lines12. The haematoma may also cause cerebral swelling and midline shift, which are signs of increased intracranial pressure12.
The other options are less likely for this patient, based on the clinical scenario and the CT scan appearance:
A depressed frontal fracture communicating with the frontal sinus and signs of infection would be more likely in a patient with a history of blunt trauma to the forehead, and would show a bony defect and air-fluid levels in the frontal sinus on a CT scan3.
An expanding extradural haematoma on the left side with cerebral swelling would be more likely in a patient with a history of a temporal bone fracture or a tear of the middle meningeal artery, and would show a lens-shaped lesion that does not cross suture lines on a CT scan4.
Blood in the subarachnoid space and cerebral ventricles with secondary hydrocephalus would be more likely in a patient with a history of a ruptured aneurysm or a traumatic subarachnoid haemorrhage, and would show a diffuse pattern of blood in the basal cisterns, sulci, and ventricles on a CT scan5.
Cerebral atrophy with a subdural collection on the left side would be more likely in a patient with a history of dementia or chronic alcoholism, and would show a diffuse loss of brain volume and a thin layer of blood on the opposite side of the head injury on a CT scan.

Question 21

A 40-year-old man develops a high output fistula following multiple jejunal stricturoplasties and an ileal resection for crohn disease. Which of the following is the most appropriate form of nutritional support?
• Elemental diet.
• High nutrition oral fluids
• Multibitamin supplements
• Percutaneous endoscopic gastrostomy feeding
• Total parenteral nutrition

Answer 21

E

Question 22

A 3-month-old boy, who was born prematurely, presents with a tender irreducible swelling in the right groin. Which of the following is the most likely diagnosis?
• Direct inguinal hernia
• Femoral hernia.
• Indirect inguinal hernia
• Inguinal lymphadenitis
• Torsion of testis

Answer 22

The most likely diagnosis for this patient is indirect inguinal hernia. This is a type of hernia that occurs when a part of the intestine protrudes through the inguinal canal, a passage in the lower abdominal wall that connects the abdomen and the scrotum. Indirect inguinal hernias are more common in males than females, and are often present at birth or develop in infancy. Premature babies have a higher risk of developing indirect inguinal hernias.
Some of the signs and symptoms of an indirect inguinal hernia include:
A bulge or swelling in the groin or scrotum that may increase in size when the baby cries, coughs, or strains
Pain, tenderness, or discomfort in the groin or scrotum
Redness or discoloration of the skin over the hernia
Vomiting, fever, or poor feeding, which may indicate a complication such as strangulation or incarceration of the hernia
The other options are less likely for this patient, based on the clinical scenario and the web search results:
A direct inguinal hernia is a type of hernia that occurs when a part of the intestine pushes through a weak spot in the abdominal wall near the inguinal canal. Direct inguinal hernias are more common in older men and are rarely seen in children.
A femoral hernia is a type of hernia that occurs when a part of the intestine protrudes through the femoral canal, a passage in the upper thigh that connects the abdomen and the leg4. Femoral hernias are more common in women than men and are also rare in children4.
Inguinal lymphadenitis is an inflammation of the lymph nodes in the groin, which may be caused by an infection or an injury in the lower extremities. Inguinal lymphadenitis may cause swollen, tender, or warm lymph nodes in the groin, but not a bulge or swelling in the scrotum5.
Torsion of testis is a condition that occurs when the spermatic cord, which supplies blood to the testicle, twists and cuts off the blood flow6. Torsion of testis is a medical emergency that requires immediate surgery to prevent permanent damage to the testicle6. Torsion of testis may cause severe pain, swelling, and redness of the scrotum, but not a bulge or swelling in the groin6.

Question 23

An otherwise healthy 5-year-old boy presents with a six-week history of minor, painless, intermittent, bright red rectal bleeding with no associated disturbance of bowel habit. Which of the following is the most likely diagnosis?
• Anal fissure
• Haemorrhoids.
• Intussusception
• Juvenile rectal polyp
• Meckel diverticulum

Answer 23

D Juvenile polyp: Present at 2-5 yrs.
• Most common (80%)
• Bleeding per rectum or prolapsed polyp
• Diagnosis by history, examination and colonoscopy.
• Treatment is polypectomy
• Histological examination is vital

Question 24

A 56-year-old woman ventilated in intensive care has increasing oxygen requirements one day after elective aortic aneurysm repair. Her pulmonary capillary wedge pressure (PCWP) is 20 mmHg (normal range 8-12 mmHg) and she has obvious bilateral diffuse opacities on chest X-ray.
Which of the following is the most likely diagnosis?
• Acute respiratory distress syndrome (ARDS)
• Aspiration pneumonia.
• Lobar pneumonia
• Pulmonary embolus.
• Pulmonary edema secondary to heart failure

Answer 24

E

Based on the clinical presentation of a 56-year-old woman ventilated in intensive care with increasing oxygen requirements, elevated pulmonary capillary wedge pressure (PCWP), and bilateral diffuse opacities on chest X-ray, the most likely diagnosis is:

Pulmonary edema secondary to heart failure.

Here’s a breakdown of the options:

1.	Acute respiratory distress syndrome (ARDS): ARDS typically presents with acute onset of hypoxemia, bilateral opacities on chest imaging, and absence of elevated PCWP. The PCWP in ARDS is usually normal or low.
2.	Aspiration pneumonia: This can lead to bilateral opacities on chest X-ray but usually does not present with elevated PCWP unless there’s an underlying cardiac issue.
3.	Lobar pneumonia: While lobar pneumonia can cause bilateral opacities on chest X-ray, it doesn’t typically lead to elevated PCWP.
4.	Pulmonary embolus: Pulmonary embolism can cause hypoxemia and may present with chest pain and hemoptysis. It usually doesn’t result in elevated PCWP or diffuse bilateral opacities on chest X-ray unless there’s concurrent heart failure.
5.	Pulmonary edema secondary to heart failure: Heart failure can lead to elevated PCWP due to left ventricular dysfunction. Elevated PCWP can cause pulmonary edema with bilateral diffuse opacities on chest X-ray.

Given the elevated PCWP and bilateral diffuse opacities on chest X-ray in the context of a patient with increasing oxygen requirements post-operatively, pulmonary edema secondary to heart failure is the most likely diagnosis.

Source:

•	Murray, J. F., & Matthay, M. A. (2015). Acute respiratory distress syndrome (ARDS). Annals of internal medicine, 142(10), 764-772. Link
•	Braunwald, E. (2019). Heart failure and cardiomyopathies. In Harrison’s Principles of Internal Medicine (20th ed.). McGraw-Hill Education.

Question 25

A 75-year-old man is scheduled for abdominoperineal resection for a rectal carcinoma. As part of the enhanced recovery programme, he was given a carbohydrate drink the night before surgery. How does preoperative carbohydrate loading p to improve the outcome of surgery? • It decreases the utilization of fat resources • It improves abdominal muscle function • It improves nitrogen balance and reduces insulin resistance • It improves respiratory muscle function • It improves sugar levels in the perioperative period

Answer 25

The correct answer is: It improves nitrogen balance and reduces insulin resistance. Preoperative carbohydrate loading is a strategy that involves drinking a clear carbohydrate beverage up to 2 hours before surgery1. It is part of the enhanced recovery programme, which aims to reduce postoperative stress and improve the recovery process2. Preoperative carbohydrate loading has several benefits for the outcome of surgery, such as12: It modifies insulin resistance, which is a known risk factor of postoperative complications. Insulin resistance is a condition in which the body does not respond well to insulin, a hormone that regulates blood sugar levels. Insulin resistance can lead to hyperglycaemia, inflammation, and impaired wound healing. Preoperative carbohydrate loading can reduce insulin resistance by providing glucose to the cells and preventing the breakdown of muscle protein. It improves nitrogen balance, which is a measure of the balance between protein synthesis and breakdown. A positive nitrogen balance means that more protein is being built than broken down, which is essential for tissue repair and recovery. A negative nitrogen balance means that more protein is being lost than gained, which can lead to muscle wasting and weakness. Preoperative carbohydrate loading can improve nitrogen balance by sparing muscle protein and stimulating protein synthesis. It improves patient comfort and well-being, by reducing preoperative thirst, hunger, anxiety, and fatigue. It also minimizes protein losses, which can affect the immune system and the ability to fight infections. It improves postoperative muscle function, by preserving muscle strength and endurance. It reduces hospital stays, by facilitating early mobilization and oral intake. The other options are incorrect or not supported by the web search results: It decreases the utilization of fat resources: This is not a benefit of preoperative carbohydrate loading. In fact, preoperative carbohydrate loading may increase the utilization of fat resources, as glucose is preferentially used as an energy source over fat. However, this does not have a negative impact on the outcome of surgery, as fat is not a major contributor to the metabolic and immune response to injury1. It improves abdominal muscle function: This is not a benefit of preoperative carbohydrate loading. There is no evidence that preoperative carbohydrate loading improves abdominal muscle function specifically. However, it may improve general muscle function, as explained above12. It improves respiratory muscle function: This is not a benefit of preoperative carbohydrate loading. There is no evidence that preoperative carbohydrate loading improves respiratory muscle function specifically. However, it may improve general muscle function, as explained above12. It improves sugar levels in the perioperative period: This is not a benefit of preoperative carbohydrate loading. Preoperative carbohydrate loading does not improve sugar levels in the perioperative period, as it does not affect the blood glucose levels during or after surgery. However, it does reduce insulin resistance, which is a more important factor for the outcome of surgery12.

Question 26

In the UK, the National Institute for Health and Care Excellence guidance recommends that if a person has had a blood transfusion they should be informed that they can • Donate blood after a period of six months • Donate blood after a period of 12 montns • Donate blood only if tested negative for blood-borne viruses • Donate blood when haemoglobin is more than 135 g/L • No longer be a blood donor

Answer 26

The correct answer is: No longer be a blood donor. According to the web search results, the UK has a rule that anyone who has had a blood transfusion or blood products anytime since 01 January 1980 cannot be a blood donor in the future1234. This is one of the safety measures in place to protect people who receive a blood transfusion from the risk of infection or adverse reactions12. The other options are incorrect or not applicable for the UK: Donate blood after a period of six months: This is not a valid option for the UK. Some countries may have different rules for blood donation after a transfusion, but the UK does not allow it at all12. Donate blood after a period of 12 months: This is not a valid option for the UK. Some countries may have different rules for blood donation after a transfusion, but the UK does not allow it at all12. Donate blood only if tested negative for blood-borne viruses: This is not a valid option for the UK. Although all blood donations are tested for blood-borne viruses, such as HIV, hepatitis B, hepatitis C, and syphilis, there is still a small risk of transmitting an infection that is not detected by the tests. Therefore, the UK does not allow blood donation after a transfusion, regardless of the test results12. Donate blood when haemoglobin is more than 135 g/L: This is not a valid option for the UK. Haemoglobin is a protein in red blood cells that carries oxygen. The normal range of haemoglobin for men is 135 to 180 g/L and for women is 115 to 165 g/L. However, having a normal haemoglobin level does not mean that a person can donate blood after a transfusion. The UK does not allow blood donation after a transfusion, regardless of the haemoglobin level12.

Question 27

A 50-year-old woman presents with a 1 cm diameter pigmented, crusting, bleeding lesion on her back, clinically suggestive of a malignant melanoma. Which of the following is the most appropriate diagnostic procedure to be performed ? • Curettage • Excisional biopsy • Incisional biopsy • Punch biopsy • Wide local excision with a 2 cm margin

Answer 27

The most appropriate diagnostic procedure for a suspected malignant melanoma is excisional biopsy12. This is a technique that involves removing the entire lesion and a small margin of normal skin around it, and sending it to a laboratory for histopathological analysis12. Excisional biopsy is the gold standard for melanoma diagnosis, as it allows for the accurate assessment of the thickness, margins, and other features of the tumor12. The other options are not recommended for a suspected malignant melanoma, based on the web search results: Curettage: This is a technique that involves scraping off the surface of the lesion with a sharp instrument, and sending it to a laboratory for cytological analysis3. Curettage is not suitable for melanoma diagnosis, as it does not provide enough tissue for histopathological analysis, and may miss the deeper parts of the tumor3. Incisional biopsy: This is a technique that involves removing a part of the lesion, usually the thickest or most abnormal area, and sending it to a laboratory for histopathological analysis4. Incisional biopsy is not preferred for melanoma diagnosis, as it may not represent the whole lesion, and may underestimate the thickness and margins of the tumor4. Punch biopsy: This is a technique that involves removing a small, circular piece of skin using a special tool, and sending it to a laboratory for histopathological analysis5. Punch biopsy is not ideal for melanoma diagnosis, as it may not capture the entire lesion, and may distort the shape and margins of the tumor5. Wide local excision with a 2 cm margin: This is a technique that involves removing the lesion and a large margin of normal skin around it, and sending it to a laboratory for histopathological analysis. Wide local excision with a 2 cm margin is not a diagnostic procedure, but a treatment option for confirmed melanoma cases. It is not necessary to remove such a large margin of normal skin for diagnosis, as it may cause unnecessary scarring and morbidity.

Question 28

A 23-year-old asthmatic man is admitted with a bilateral fracture of fibula and tibia following a road traffic accident. He is on 15 mg of prednisolone daily and is to undergo surgery the following day. Which of the following regimes should beimplemented? • Continue normal steroids in the perioperative period • Omit steroids on day of surgery, then continue normal steroids • Reduce steroids on day of surgery then continue normal steroids • Increase steroids on day of surgery and for one month following surgery • Increase steroids on day of surgery and for three days postoperatively

Answer 28

Very debatable but E For a 23-year-old asthmatic man with a bilateral fracture of the fibula and tibia who is on 15 mg of prednisolone daily and scheduled for surgery, the appropriate perioperative steroid management would be to increase steroids on the day of surgery and for three days postoperatively. This recommendation is based on the general guidelines for managing patients who are on chronic steroid therapy undergoing surgery. These patients are at risk for adrenal suppression, and thus, it is crucial to provide additional steroid coverage to cope with the stress of surgery. In the context of the provided search results, while specific perioperative steroid management protocols for orthopedic surgeries are not detailed, the general principle of increasing steroid dosage during significant surgical stress to prevent adrenal insufficiency is well-established in clinical practice. Patients who have been on systemic corticosteroids for more than two weeks in the past six months should be considered at risk for adrenal suppression and would need intraoperative supplementation of steroids[1]. This is typically managed by administering 1–2 mg/kg of hydrocortisone intravenously every 8 hours on the day of surgery, followed by a gradual tapering off to the usual preoperative dosage[1]. Therefore, the most suitable option for this patient would be to increase steroids on the day of surgery and for three days postoperatively to ensure adequate physiological response to the surgical stress and to prevent potential adrenal crisis.

Question 29

A 72-year-old woman, who was treated for breast cancer 20 years ago, presents with tiredness, constipation, back and chest pain. Examination reveals localized tenderness over thoracic vertebrae and anterior ribs. Her pulse is 110 beats/minute and blood pressure 90/60mmHg. An ECG shows a shortened QT interval. Her biochemistry results are: Finding Sodium 137 mmol/L (135-145) Potassium 4.3 mmol/L (3.5-5.0) Corrected calcium 3.8 mmol/L (2.2-2.6) Phosphate 0.8 mmol/L (0.8-14) Chest X-ray shows lytic lesions in the left anterior third rib and fifth thoracic vertebra. Which of the following treatments should be administered first? • 0.9% sodium chloride • Calcitonin • Cinalcalcet • Pamidronate • Prednisolone

Answer 29

The patient presents with symptoms of hypercalcemia, including tiredness, constipation, back and chest pain, and localized tenderness over the thoracic vertebrae and anterior ribs. The biochemistry results show a corrected calcium level of 3.8 mmol/L, which is above the normal range of 2.2-2.6 mmol/L. The patient's ECG shows a shortened QT interval, which is a common finding in hypercalcemia. The mainstays of treatment for hypercalcemia are IV hydration, bisphosphonates, and calcitonin. In this case, the patient should be administered IV hydration with 0.9% sodium chloride to help reduce the serum calcium level and alleviate symptoms. This is the first line of treatment for hypercalcemia, as it helps to increase calciuresis and decrease bone resorption. Calcitonin can be used as a second-line treatment, as it helps to decrease bone resorption and increase calcium excretion. However, it is not the first choice in this case, as the patient's calcium level is already elevated, and IV hydration is more effective in reducing serum calcium levels quickly. Cinacalcet is a medication that helps to decrease the production of parathyroid hormone (PTH), which can contribute to hypercalcemia. However, it is not the first choice in this case, as the patient's calcium level is already elevated, and IV hydration and calcitonin are more effective in reducing serum calcium levels quickly. Pamidronate is a bisphosphonate that can be used to treat hypercalcemia, but it is not the first choice in this case, as IV hydration is the first line of treatment. Pamidronate can be used if the patient's calcium level does not respond to IV hydration. Prednisolone is a corticosteroid that can be used to treat hypercalcemia, but it is not the first choice in this case. Corticosteroids can help to reduce the production of PTH, but they are not as effective as IV hydration and bisphosphonates in reducing serum calcium levels quickly. In summary, the patient should be administered IV hydration with 0.9% sodium chloride as the first line of treatment for hypercalcemia.

Question 30

A previously fit 21-year-old man collapses while running a marathon. Resuscitation is unsuccessful. A post-mortem examination shows an intracranial haemorrhage. What is the most likely site of the haemorrhage? • Extradural • Intracerebral • Intraventricular • Subarachnoid • Subdural

Answer 30

The most likely site of the hemorrhage in this case is Subarachnoid. It’s commonly associated with sudden, severe headaches and can result from conditions like aneurysms or arteriovenous malformations. life-threatening type of stroke caused by bleeding into the space surrounding the brain. caused by a ruptured aneurysm, AVM arteriovenous malformation, or head injury. 1/3 survive with good recovery 1/3 will survive with a disability 1/3 will die. Symptoms : sudden onset of a severe headache ("the worst headache of my life") + Meningism It causes Raised ICP CSF Circ. Block > Hydrocephalus & Seizures

Question 31

A 40-year-old woman presents with a two-week history of flank pain and episodic frank haematuria. An ultrasound demonstrates a 10 cm renal mass without hydronéphroses. What is the most appropriate investigation? • Computerized tomography (CT) scan • Intravenous pyelogram • Isotope bone scan • Magnetic resonance imaging (MRI) • Renal biopsy

Answer 31

CT is the frist line for kidney stones or renal mases, unless in some cases such as pregnancy or young aged child e.g.: 1 years old child or teenager girl for risk of infertility we do US or IVU initially

Question 32

A previously fit young man is admitted after a road traffic accident. He is satisfactorily intubated because of a head injury. He has a Glasgow coma score of 8 (E2. V2. M4). There are no other external injuries and initial cardiorespiratory stability is achieved during the primary survey. He suddenly becomes hypoxic after log-rolling to examine the back. What is the most likely cause of his deterioration? • Cardiac tamponade. • Ongoing major haemorrhage • Spinal injury • Tension pneumothorax. • Tracheal tube displacement.

Answer 32

Given the scenario provided, the most likely cause of the patient’s sudden hypoxia after log-rolling to examine the back is tracheal tube displacement. This complication is particularly common during patient movement and positioning, such as log-rolling, especially in situations involving trauma patients who are intubated. Tracheal tube displacement can result in airway obstruction, leading to hypoxia and potentially respiratory arrest. It’s crucial to ensure proper positioning and securement of the endotracheal tube to prevent this complication. Other causes such as tension pneumothorax or spinal injury could also lead to respiratory compromise, but in this case, given the context of the patient’s recent movement, tracheal tube displacement is the most likely culprit. Source: • Tracheal Intubation: Complications and Management: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3230495/

Question 33

A A 21-year-old man has been hit by a cricket ball on the side of the head. Initially he has a Glasgow coma score (GCS) of 15 (E4. V5. M6). Four hours after arrival in hospital, while on the observation ward, his GCS drops to 7 (E1. V2. M4). His left pupil dilates, and he begins to demonstrate extensor posturing of the limbs. What are the most likely changes to his vital signs since injury? Blood pressure: Decreased Heart rate: Decreased Blood pressure : Decreased Heart rate: Increased Blood pressure : Decreased Heart rate: Normal Blood pressure: Increased. Heart rate: Decreased Blood pressure: Increased. Heart rate: Increased

Answer 33

Cushing’s triad is a set of three classic signs indicating increased intracranial pressure (ICP). These signs include: 1. Hypertension: This refers to elevated blood pressure. Increased ICP can compress blood vessels in the brain, leading to hypertension as the body tries to maintain cerebral perfusion pressure. 2. Bradycardia: Bradycardia, or a slow heart rate, is another component of Cushing’s triad. It occurs because increased ICP can stimulate the vagus nerve, which leads to a decrease in heart rate. 3. Irregular respirations: Irregular breathing patterns, such as Cheyne-Stokes respirations or periods of apnea, can occur due to the brain’s attempt to regulate oxygen levels in response to increased pressure. Cushing’s triad is often seen in severe cases of head injury, intracranial hemorrhage, or brain tumors where there is significant brain swelling or mass effect. It indicates a critical condition requiring immediate medical attention to prevent further neurological deterioration and potential herniation of brain structures. Source: • Cushing’s Triad: https://www.ncbi.nlm.nih.gov/books/NBK542246/

Question 34

A 78-year-old man, who is a smoker with a long history of Barrett oesophagus, presents with dysphagia and weight loss. Endoscopy confirms the presence of a malignant stricture. Which of the following is the most likely histological diagnosis • Adenocarcinoma • Adenosquamous carcinoma. • Lymphoma • Mucoepidermoid carcinoma • Squamous cell carcinoma

Answer 34

Given the patient’s history of Barrett esophagus, dysphagia, and weight loss, the most likely histological diagnosis for the malignant stricture is adenocarcinoma. Adenocarcinoma is the most common type of esophageal cancer in Western countries, especially in individuals with Barrett esophagus, which is a precancerous condition characterized by changes in the lining of the esophagus. Adenosquamous carcinoma is a less common subtype of esophageal cancer and typically presents differently. Lymphoma, while it can affect the esophagus, is less common than adenocarcinoma in this age group and clinical context. Mucoepidermoid carcinoma is more commonly found in the salivary glands rather than the esophagus. Squamous cell carcinoma is another type of esophageal cancer, but it is less likely in this patient given the history of Barrett esophagus, which predisposes to adenocarcinoma. Source: • Esophageal Cancer: https://www.cancer.gov/types/esophageal/patient/esophageal-treatment-pdq#section/_15

Question 35

24 hours after a routine aortic valve replacement for a heavily calcified valve the patient's heart rate abruptly falls to 40 beats/minute. The systolic pressure, which was 140 mmHg, is now 110 mmHg and the right atrial pressure, which was 7 mmHg, is now averaging 15 mmg. Which of the following is the most likely diagnosis? • Atrial fibrillation • Cardiac tamponade • Digoxin toxicity • Heart block • Left ventricular failure

Answer 35

Given the scenario described, the most likely diagnosis is heart block, specifically a type of heart block called “complete heart block” or “third-degree heart block.” Complete heart block occurs when there is complete dissociation between the atria and ventricles, leading to an independent rhythm of the atria and ventricles. This can result in a slow ventricular rate, leading to bradycardia (heart rate of 40 beats/minute). The decreased cardiac output due to the slow heart rate can result in a decrease in systolic blood pressure. The elevation in right atrial pressure (from 7 mmHg to averaging 15 mmHg) suggests impaired filling of the right ventricle, which can occur due to the slow heart rate associated with heart block. While atrial fibrillation can cause a rapid and irregular heart rate, it typically presents with tachycardia rather than bradycardia. Cardiac tamponade typically presents with signs of hemodynamic compromise such as hypotension, elevated jugular venous pressure, and distant heart sounds. Digoxin toxicity can cause bradycardia, but the clinical presentation would typically involve other signs and symptoms such as nausea, vomiting, visual disturbances, and possibly arrhythmias. Left ventricular failure may lead to symptoms such as dyspnea and signs such as pulmonary congestion on examination, but it’s less likely to cause the abrupt bradycardia described in the scenario. Source: • Complete Heart Block: https://www.ncbi.nlm.nih.gov/books/NBK560867/

Question 36

A 67-year-old man is admitted with a history of fresh rectal bleeding, preceded by the left- sided abdominal pain on two occasions in the past 36 hours. The blood was both bright red and dark plum coloured mixed with a loose motion. He is on atenolol for hypertension. Examination shows frank blood per rectum. There is slight abdominal tenderness in the left upper quadrant and left iliac fossa. He is normotensive with a haemoglobin of 106g/L. Which of the following is the most likely diagnosis? • Anal carcinoma • Ischaemic colitis • Meckel diverticulum • Oesophageal varices • Ulcerative colitis

Answer 36

The most likely diagnosis in this case is Ischaemic colitis. The clinical presentation of fresh rectal bleeding, left-sided abdominal pain, and the presence of blood mixed with loose motions are indicative of ischemic colitis. It’s essential for the patient to receive prompt medical attention to determine the severity and initiate appropriate management.

Question 37

A 25-year-old man became constipated after taking opiate analgesics for back pain. Which of the following is the most likely description of his rectal bleed? • Bright red, associated with severe perianal pain • Bright red, short lasting episodes of profuse bleeding • Dark red, associated with profuse watery stools • Dark red. mixed in with bowel motions. • Dark red, profuse bleeding associated with strong smell

Answer 37

A

Question 38

A 50-year-old man with type 1 diabetes and an autonomic neuropathy undergoes an inguinal bernia repair as a day case. Which of the following is most likely to be a problem for him as a day case? • Constipation • Orthostatic hypotension. • Peripheral neuropathy • Reduced pulse rate variability • Sinus tachycardia

Answer 38

The most likely problem for the 50-year-old man with type 1 diabetes and autonomic neuropathy undergoing inguinal hernia repair as a day case would be Orthostatic hypotension. Autonomic neuropathy can affect blood pressure regulation, leading to orthostatic hypotension, especially when moving from a lying to a standing position.

Question 39

A 62-year-old man presents with a painful, pale right lower limb. He underwent right femoro- popliteal (below knee) bypass 18 months ago using in-situ vein. On duplex examination the graft is blocked. What is the most likely histological feature of the graft? • Aneurysmal dilatation • Atheromatous plaques • Neointimal hyperplasia • Smooth muscle hyperplasia • Varicose dilatation of the vein wall

Answer 39

The most likely histological feature of the blocked graft in this case would be Neointimal hyperplasia. This is a common cause of graft failure in vascular procedures, leading to narrowing or occlusion of the graft over time.

Question 40

A 63-year-old woman with a caecal cancer is booked for an elective right hemicolectomy. She is otherwise fit and well. In the pre-assessment clinic she asks about the benefits of the enhanced recovery programme. Which of the following is a potential benefit? • Reduced length of hospital stay • Reduced likelihood of chronic pain • Routine use of abdominal drains • Routine use of nasogastric tube • Use of morphine-based analgesia

Answer 40

A potential benefit of the enhanced recovery programme for a patient undergoing right hemicolectomy is Reduced length of hospital stay. Enhanced recovery protocols aim to optimize the perioperative care, leading to quicker recovery and shorter hospital stays. An Enhanced Recovery Programme (ERP), also known as Enhanced Recovery After Surgery (ERAS), is a multidisciplinary approach to patient care aimed at optimizing the perioperative period to enhance recovery following surgery. The goal is to improve outcomes, reduce complications, shorten hospital stays, and facilitate earlier return to normal function and activities. Key components of an ERP typically include: 1. Preoperative optimization: This involves patient education, preoperative counseling, nutritional optimization, smoking cessation, and physical conditioning to prepare patients for surgery and aid in their recovery. 2. Minimally invasive techniques: Utilizing minimally invasive surgical approaches whenever possible to reduce surgical trauma, postoperative pain, and recovery time. 3. Multimodal pain management: Implementing a combination of analgesic techniques, such as regional anesthesia, non-opioid medications, and patient-controlled analgesia, to minimize postoperative pain and opioid consumption. 4. Early oral intake: Encouraging early resumption of oral intake following surgery to maintain hydration and prevent ileus, typically starting with clear fluids and advancing as tolerated. 5. Early mobilization: Initiating early mobilization and ambulation to prevent complications such as deep vein thrombosis, pneumonia, and muscle deconditioning, and to promote faster recovery. 6. Avoidance of routine interventions: Avoiding unnecessary interventions such as prolonged fasting, bowel preparation, urinary catheterization, and routine use of nasogastric tubes, unless clinically indicated. 7. Continuous quality improvement: Implementing protocols for data collection, audit, and feedback to continuously monitor outcomes and refine the ERP process. ERPs are tailored to specific surgical procedures and patient populations, and their implementation requires collaboration among surgeons, anesthesiologists, nurses, physiotherapists, and other healthcare professionals. Overall, ERPs have been shown to significantly improve patient outcomes, reduce healthcare costs, and enhance patient satisfaction in various surgical specialties. Source: • ERAS Society: https://erassociety.org/

Question 41

A 45-year-old woman feels a sudden pain in her left leg and feels as if she has been hit in the back of the ankle as she starts to cross the road before she falls. Which of the following is the most appropriate clinical test? • An impingement sign • Apleys grinding test • Phalen's manoeuvre • Simmonds' squeeze test • Thomas test

Answer 41

Rupture of the Achilles tendon usually occurs in middle-aged men. The history frequently follows the pattern of tendon rupture following a trivial stumble. Dorsiflexion is exaggerated as it is normally limited by the Achilles tendon. Plantar flexion is limited and the patient is unable to stand on tiptoe, but some plantar flexion is still possible owing to the action of the long flexors of the toes, tibialis posterior and peronei. Thompson test (also known Simmond’s squeeze test) is positive in Achillis tendon rupture, which is lack of plantar flexion when calf is squeezed. The Thompson test, also known as the calf squeeze test, is a physical examination maneuver used to assess the integrity of the Achilles tendon. It is primarily employed to diagnose Achilles tendon rupture, although it can also help evaluate for other Achilles tendon pathologies. Here’s how the Thompson test is performed: 1. The patient is positioned prone or lying face down on the examination table with their feet hanging over the edge. 2. The examiner squeezes the calf muscle of the affected leg with their fingers or thumbs while observing the movement of the foot and ankle. 3. In a normal Thompson test, squeezing the calf muscle should result in plantar flexion (pointing downward) of the foot. This occurs because the calf muscle contraction normally causes the Achilles tendon to pull on the heel, leading to plantar flexion. 4. If there is an Achilles tendon rupture, there will be no movement of the foot in response to calf muscle squeezing. This lack of movement is indicative of a positive Thompson test and suggests a complete rupture of the Achilles tendon. It’s important to note that a positive Thompson test indicates a complete rupture of the Achilles tendon, but a negative test does not necessarily rule out a partial tear or other Achilles tendon injuries. Imaging studies such as ultrasound or MRI may be needed for further evaluation in cases where there is clinical suspicion of Achilles tendon pathology. The Thompson test is a simple and quick bedside maneuver that can provide valuable diagnostic information for clinicians evaluating patients with suspected Achilles tendon injuries. Source: • Thompson Test: https://www.ncbi.nlm.nih.gov/books/NBK499992/ The impingement sign, also known as the Hawkins-Kennedy test, is a physical examination maneuver used to assess for subacromial impingement syndrome in the shoulder. Subacromial impingement occurs when the tendons of the rotator cuff muscles become compressed or irritated as they pass through the subacromial space, resulting in pain and decreased range of motion. Here’s how the impingement sign/Hawkins-Kennedy test is performed: 1. The patient is typically seated or standing comfortably. 2. The examiner raises the affected arm to shoulder height and then flexes the elbow to 90 degrees. 3. With the patient’s arm in this position, the examiner then forcibly internally rotates the arm by bringing the forearm across the body, while stabilizing the scapula. 4. A positive impingement sign is indicated by the reproduction of pain in the subacromial space, typically felt over the top and front of the shoulder. The impingement sign/Hawkins-Kennedy test is thought to provoke symptoms by narrowing the subacromial space and compressing the inflamed structures, including the rotator cuff tendons and subacromial bursa. It’s important to note that while a positive impingement sign is suggestive of subacromial impingement syndrome, it is not specific to this condition and may also be positive in other shoulder pathologies. Therefore, it is often used in combination with other clinical tests and imaging studies to make a diagnosis. Apley’s grinding test is a physical examination maneuver used to assess for meniscal injury or pathology in the knee joint. It is named after the British orthopedic surgeon Alan Graham Apley, who described the test. Here’s how Apley’s grinding test is performed: 1. The patient is typically positioned prone or lying face down on an examination table. 2. The examiner flexes the affected knee to approximately 90 degrees. 3. The examiner then places one hand on the patient’s heel to stabilize the lower leg, while the other hand grasps the patient’s ankle or foot. 4. With the knee in flexion, the examiner applies downward pressure on the patient’s foot while simultaneously rotating the tibia (lower leg) internally and externally. 5. During this rotation, the examiner applies axial compression to the tibia by pushing down on the foot. 6. The test is considered positive if the patient experiences pain or reproduces the symptoms of meniscal injury, such as clicking, popping, or grinding sensations, especially when combined with compression and rotation. Apley’s grinding test is thought to reproduce symptoms of meniscal injury by placing stress on the meniscus, particularly the inner (medial) or outer (lateral) meniscus, depending on the direction of rotation. The test may provoke pain or mechanical symptoms (e.g., clicking or locking) if there is a tear or other pathology affecting the meniscus. It’s important to note that while Apley’s grinding test can provide valuable clinical information, it is not specific to meniscal pathology and may also be positive in other knee conditions. Therefore, it is often used in conjunction with other physical examination maneuvers, imaging studies (such as MRI), and clinical judgment to make a diagnosis. Source: • Apley’s Grinding Test: https://www.physio-pedia.com/Apley’s_Grinding_Test • Hawkins-Kennedy Test: https://www.physio-pedia.com/Hawkins-Kennedy_Test Phalen’s maneuver, also known as Phalen’s test, is a physical examination maneuver used to assess for carpal tunnel syndrome, a common condition characterized by compression of the median nerve as it passes through the carpal tunnel in the wrist. Here’s how Phalen’s maneuver is performed: 1. The patient is asked to flex both wrists maximally and press the dorsal surfaces of the hands together, with the fingers pointing downward and the wrists in full flexion. 2. The position is typically held for 60 seconds or until symptoms are reproduced. 3. The test is considered positive if the patient experiences numbness, tingling, or pain in the distribution of the median nerve, which includes the thumb, index finger, middle finger, and half of the ring finger. Phalen’s maneuver is thought to exacerbate symptoms of carpal tunnel syndrome by increasing pressure within the carpal tunnel and compressing the median nerve. The flexed wrist position reduces the space within the carpal tunnel, leading to compression of the nerve against the transverse carpal ligament. It’s important to note that while Phalen’s maneuver can help diagnose carpal tunnel syndrome, it is not specific and may also be positive in other conditions affecting the median nerve or wrist joint. Therefore, it is often used in conjunction with other clinical tests, such as Tinel’s sign and median nerve compression test, as well as imaging studies and electrodiagnostic tests, to confirm the diagnosis. Source: • Phalen’s Test: https://www.ncbi.nlm.nih.gov/books/NBK513295/ The Thomas test is a physical examination maneuver used to assess for hip flexion contracture and tightness of the hip flexor muscles, specifically the iliopsoas muscle. It is named after Dr. Hugh Owen Thomas, a British orthopedic surgeon who described the test. Here’s how the Thomas test is performed: 1. The patient lies supine (on their back) on an examination table with both legs fully extended. 2. The examiner stands at the side of the table and passively flexes one of the patient’s hips, bringing the knee towards the chest until the thigh is fully flexed against the abdomen. 3. While maintaining the flexed position of the hip, the examiner observes the position of the contralateral (opposite) leg. 4. If the contralateral thigh lifts off the table or if the knee flexes, it indicates that the hip being tested is unable to fully extend due to tightness of the hip flexors, particularly the iliopsoas muscle. 5. To assess for tightness of the rectus femoris muscle, the examiner can also observe whether the knee of the contralateral leg remains fully extended or if it flexes during the test. The Thomas test is particularly useful in evaluating for hip flexion contracture, a condition where the hip joint is unable to fully extend due to tightness of the hip flexor muscles. It can be performed as part of a musculoskeletal examination to assess for various hip and pelvic conditions, including hip impingement, labral tears, and iliopsoas tendonitis. Interpretation of the Thomas test results should take into account the patient’s symptoms, clinical history, and findings from other physical examination maneuvers and imaging studies. Source: • Thomas Test: https://www.physio-pedia.com/Thomas_Test

Question 42

After returning to the United Kingdom from a business trip to China, a 35-year-old woman is admitted to hospital with a painful swollen right leg and a palpable dorsalis pedis pulse. Duplex ultrasound sonography of the right femoral vein shows extensive mobile thrombus. The most appropriate immediate management would be • Aspirin • Exploration of the femoral vein • Heparin • Leg compression stockings • Thrombolysis.

Answer 42

The most appropriate immediate management for a 35-year-old woman with a painful swollen right leg and extensive mobile thrombus in the femoral vein after returning from a business trip would be Heparin. Heparin is commonly used as an anticoagulant to prevent the extension of venous thrombosis. Source: American College of Chest Physicians - Antithrombotic Therapy for VTE Disease

Question 43

A 68-year-old woman Presents with a two-month history of intermittent, bloodstained nipple discharge from her right breast. There is no significant past history. Clinical examination confirms presence of a bloodstained nipple discharge but shows no palpable abnormality. A mammogram and ultrasound scan are normal. What is the most appropriate next step in management? • Clinical follow-up in three months • Ductogram • Reassure patient and discharge • Surgical excision of affected ducts • Tamoxifen

Answer 43

Given the clinical presentation of a 68-year-old woman with a two-month history of intermittent bloodstained nipple discharge from her right breast, and normal findings on mammogram and ultrasound scan, the most appropriate next step in management would be a ductogram. A ductogram, also known as a galactogram or ductography, is a diagnostic imaging procedure specifically used to evaluate the breast ducts and ductal system. It involves injecting a contrast dye into the affected duct or ducts followed by imaging with X-rays or other imaging modalities. This procedure can help identify abnormalities within the ductal system, such as intraductal papillomas or ductal carcinoma in situ (DCIS), which may not be visualized on mammography or ultrasound. In this case, since the patient has a bloodstained nipple discharge with no palpable abnormality and normal findings on mammogram and ultrasound, a ductogram would be the most appropriate next step to further evaluate the cause of the discharge and assess the ductal system for any abnormalities. Clinical follow-up in three months may be considered if initial imaging studies are inconclusive or if the discharge resolves spontaneously. However, given the persistent nature of the symptoms, further investigation with a ductogram is warranted. Reassuring the patient and discharging her without further investigation may not be appropriate, as the presence of bloodstained nipple discharge requires thorough evaluation to rule out underlying pathology, including malignancy. Surgical excision of affected ducts or initiating tamoxifen therapy would be premature without a definitive diagnosis or identification of the underlying cause of the nipple discharge. Therefore, the most appropriate next step in management would be to proceed with a ductogram to further evaluate the cause of the bloodstained nipple discharge and assess the ductal system for abnormalities. Source: • Breast Ductography: https://radiopaedia.org/articles/ductography?lang=us

Question 44

A 24-year-old man with a history of Crohn disease presents with generalised bone pains and tenderness in his thighs. He also has increasing muscle weakness, increasing difficulty in walking and a change of gait. Serum calcium and phosphate levels are low but alkaline phosphate and parathyroid hormone levels are elevated. A bone biopsy shows increase in non- mineralised osteoid. What is the most likely diagnosis? • Osteitis fibrosa cystica • Osteomalacia. • Osteoporosis. • Paget disease of the bone • Multiple myeloma

Answer 44

Based on the presented clinical findings and laboratory results, the most likely diagnosis is osteomalacia. Osteomalacia is a condition characterized by softening of the bones due to impaired mineralization of the osteoid matrix, which is the non-mineralized component of bone. It often results from vitamin D deficiency or malabsorption, leading to inadequate calcium and phosphate absorption and subsequent impaired bone mineralization. The symptoms described, including generalized bone pains, tenderness in the thighs, muscle weakness, difficulty walking, and a change in gait, are consistent with osteomalacia. The laboratory findings of low serum calcium and phosphate levels indicate mineral deficiencies, while elevated alkaline phosphatase and parathyroid hormone levels are compensatory responses to the mineralization defect. The bone biopsy showing an increase in non-mineralized osteoid further supports the diagnosis of osteomalacia. Osteitis fibrosa cystica, characterized by bone cysts and fibrous tissue replacement due to hyperparathyroidism, typically presents with bone pain, fractures, and deformities, but it is not associated with vitamin D deficiency or impaired mineralization of the osteoid matrix. Osteoporosis is a condition characterized by decreased bone density and increased risk of fractures, but it does not involve impaired mineralization of the bone matrix as seen in osteomalacia. Paget’s disease of the bone is a disorder characterized by abnormal bone remodeling, leading to bone enlargement, deformities, and fractures. It typically presents with localized bone pain and deformities, rather than the generalized bone pains and mineralization defects seen in osteomalacia. Multiple myeloma is a cancer of plasma cells that typically presents with bone pain, fractures, and skeletal lesions, but it is not associated with vitamin D deficiency or impaired mineralization of the osteoid matrix as seen in osteomalacia. Therefore, among the options provided, osteomalacia is the most likely diagnosis based on the clinical presentation, laboratory findings, and bone biopsy results. Source: • Osteomalacia: https://www.ncbi.nlm.nih.gov/books/NBK532269/ Vit D deficiency should be treated with Vit D supplements in patients with crohn's disease to prevent

Question 45

A 32-year-old woman, with a recent diagnosis of Graves disease, underwent incision and drainage of a breast abscess three hours ago. She has become agitated, confused and is noted to be jaundiced and sweaty. Her temperature is 39°C. pulse 152 beats/minute and blood pressure 95/60 mmHg. An ECG shows an irregular ventricular rate with absent p waves. After resuscitation what is the most appropriate next step in management? • B-adrenoceptor blockers and iodides • B-adrenoceptor blockers and thionamides • Bile acid sequestrants and glucocorticoids • lodides and bile acid sequestrants. • Thionamides and thyroidectomy

Answer 45

B Based on the clinical presentation and recent diagnosis of Graves’ disease, the most appropriate next step in management after resuscitation would be administering beta-adrenoceptor blockers and thionamides. Graves’ disease is an autoimmune disorder characterized by hyperthyroidism, which can lead to symptoms such as agitation, confusion, jaundice, diaphoresis (sweating), fever, tachycardia, and hypertension. The patient’s symptoms, including an irregular ventricular rate with absent p waves on ECG, are consistent with thyroid storm, a severe and life-threatening complication of untreated or undertreated hyperthyroidism. Beta-adrenoceptor blockers (such as propranolol) are used to manage symptoms of hyperthyroidism, including tachycardia and hypertension. They can help stabilize the patient’s heart rate and blood pressure. Thionamides (such as propylthiouracil or methimazole) are used to inhibit the production of thyroid hormones and block the synthesis of new thyroid hormone in Graves’ disease. They are essential for controlling thyroid hormone levels and mitigating the hyperthyroid state. While iodides may temporarily reduce thyroid hormone release, they are not typically used as initial therapy in thyroid storm due to the risk of exacerbating thyrotoxicosis and potentially worsening the patient’s condition. Bile acid sequestrants and glucocorticoids are not indicated as first-line treatments for thyroid storm and would not address the underlying cause of hyperthyroidism. Thyroidectomy may be considered as a definitive treatment for Graves’ disease in some cases, but it is not appropriate as an immediate intervention in the acute management of thyroid storm. Therefore, the most appropriate next step in management after resuscitation of the patient with thyroid storm due to Graves’ disease is administering beta-adrenoceptor blockers and thionamides to stabilize thyroid function and alleviate symptoms. Source: • Thyroid Storm: https://www.ncbi.nlm.nih.gov/books/NBK482257/

Question 46

A 1-year-old girl presents with shortness of breath. Her parents have also noticed that her eyes no longer look symmetrical. The right pupil is smaller than the left and the right eyelid appears droopy. A chest X-ray shows increased opacification in the right hemithorax, particularly in the right upper zone. Which one of the following is the most likely diagnosis? Select one: A community acquired pneumonia A congenital diaphragmatic hernia A congenital pulmonary airway malformations Lymphoma Neuroblastoma

Answer 46

The clinical features point to a right sided Horner syndrome, secondary to a right apical tumour compressing the sympathetic chain. In this age group the most likely cause is neuroblastoma. A community acquired pneumonia - although a pneumonia can present with shortness of breath, the Horner syndrome is not in keeping A congenital diaphragmatic hernia - although late presenting congenital diaphragmatic hernia can present with shortness of breath, the Horner syndrome is not in keeping A congenital pulmonary airway malformations - although late presenting congenital pulmonary airway malformation can present with shortness of breath (usually because of infection in the CPAM), the Horner syndrome is not in keeping Lymphoma - lymphoma causes lymph node enlargement. The chest X-ray may typically show a mediastinal mass Neuroblastoma - correct The correct answer is: Neuroblastoma

Question 47

A 25-year-old woman presents with sensory symptoms in the upper limbs and a headache that is worse on coughing. An MRI scan shows a Chiari malformation of the hindbrain and syringomyelia in the cervical spine. Which one of the following nerve tracts are most vulnerable to damage in this condition? Select one: Corticospinal Posterior columns Spinocerebellar Spinothalamic Sympathetic trunks

Answer 47

In Chiari malformation with associated syringomyelia, the most vulnerable nerve tract to damage is the spinothalamic tract. Syringomyelia is a condition characterized by the development of a fluid-filled cyst (syrinx) within the spinal cord. This cyst can disrupt the normal transmission of sensory information within the spinal cord, particularly affecting the crossing fibers of the spinothalamic tract, which carries pain and temperature sensation. The Chiari malformation, in which the cerebellar tonsils herniate through the foramen magnum into the spinal canal, can exacerbate the compression of the spinal cord and worsen the symptoms associated with syringomyelia. Therefore, in this condition, the spinothalamic tract, which transmits pain and temperature sensation, is the most vulnerable nerve tract to damage. The other nerve tracts mentioned may also be affected to some extent, but the spinothalamic tract is particularly vulnerable due to its location and the disruption caused by the syrinx within the spinal cord. Source: • Syringomyelia: https://www.ncbi.nlm.nih.gov/books/NBK526016/

Question 48

An elderly patient with an intra-capsular fractured neck of femur is due to have a hip hemiarthroplasty performed. Which of the following describe anatomical steps to access the hip joint during the most commonly used approach for a hemiarthroplasty? Select one: Detaching the anterior aspect of gluteus medius and minimus from the greater trochanter Detaching piriformis and the short external rotators from their femoral insertion Developing a plane between the gracilis and adductor longus muscles Developing a superficial plane between sartorius and tensor fasciae latae Elevation of vastus lateralis

Answer 48

The most commonly used approach for hip hemiarthroplasty is the antero - lateral (modified hardinge) approach to the hip. During this approach the gluteus medius and minimus are detached as one or separate layers from the greater trochanter anteriorly to gain access to the hip joint. The correct answer is: Detaching the anterior aspect of gluteus medius and minimus from the greater trochanter

Question 49

An 80-year-old woman is admitted with a pulsatile mass in the abdomen, guarding and tenderness. An ultrasound demonstrates an intact abdominal aortic aneurysm at the level of the origin of the superior mesenteric artery. You suspect bowel ischaemia of which of the following structures? Select one: The jejunum, ileum and ascending colon The kidneys and spleen The liver and pancreas The stomach and duodenum The transverse and descending colon

Answer 49

The celiac trunk supplies the foregut (the liver, stomach and spleen); the SMA supplies the midgut (small intestine and ascending colon) and the IMA supplies the hindgut (transverse, descending and sigmoid colon). The correct answer is: The jejunum, ileum and ascending colon

Question 50

A 73-year-old man is admitted with severe abdominal pain and guarding. He also has painful tips of the radial 2 digits which are dusky. He is haemodynamically stable but has untreated atrial fibrillation. You suspect an underlying arterioembolic cause and organise an urgent CT angiogram of the bowel, which shows that the inferior mesenteric artery is occluded. Which one of the following will result from the occluded artery? Select one: Ischaemia of the descending colon & sigmoid colon Ischaemia of the duodenum Ischaemia of the jejunum Ischaemia of the jejunum and ileum Ischaemia of the terminal ileum and ascending colon

Answer 50

This patient is is suffering with arterial emboli which has led to ischaemia in both the upper limb and bowel. The inferior mesenteric artery supplies the left side of the colon and sigmoid and branches include: left colic ascending branch that joins the middle colic descending branch that joins the highest sigmoid branch sigmoid arteries (2-3) superior sigmoid branch join the left colic inferior sigmoid branch joins the superior rectal The superior mesenteric artery supplies the small bowel and right side of the colon. The correct answer is: Ischaemia of the descending colon & sigmoid colon

Question 51

A patient who was involved in a road traffic accident suffers a penetrating trauma to the infra-clavicular area and is found to have a pulsatile mass at the level of pectorals minor. You suspect an injury to the axillary artery and the lateral cord of the brachial plexus due to loss of function of which of the following nerves? Select one: Axillary and median nerves Median and musculocutaneous nerves Musculocutaneous and radial nerves Posterior interosseous and anteriorinterosseous nerves Ulnar and median nerves

Answer 51

The median and musculocutaneous nerves both arise from the lateral cord of the brachial plexus. The axillary nerve arises from the posterior cord, as does the posterior interosseous branch of the radial nerve. The anterior interosseous is a branch of the median nerve. The correct answer is: Median and musculocutaneous nerves

Question 52

A 9-year-old boy presents with a non-retractile foreskin. He does not currently have any urinary symptoms. On examination the foreskin is thickened, white and stiff. Which one of the following is the most appropriate next step? Select one: A circumcision A preputioplasty Oral steroids Topical betnovate cream Waiting until post puberty to reassess

Answer 52

The history points to balanitis xerotica obliterans. This is a progressive scarring condition and requires a circumcision for definitive treatment. A - correct B - this loosens the foreskin but does not remove the disease process C - oral steroids have no place in the management of this localised disease D - Betnovate may control the symptoms for a short period but is not definitive. E - there is no advantage in waiting and there is a small risk of urinary symptoms progressing to the point of urinary retention The correct answer is: A circumcision

Question 53

The morning following a successful right carotid endarterectomy under general anaesthesia, a 65-year-old man complains of severe hoarseness. Which one of the following is the most likely diagnosis? Select one: The hypoglossal nerve has been damaged during surgery The larynx has been traumatised during anaesthesia The patient has sustained a post operative stroke The recurrent laryngeal nerve has been damaged during surgery There has been bleeding from the endarterectomy site

Answer 53

A number of cranial nerves are at risk during carotid surgery and hoarseness secondary to recurrent laryngeal nerve palsy is one of the more common complications. The recurrent laryngeal nerve is at risk during exposure and endarterectomy of the carotid bifurcation due to proximity of the vagus nerve. The correct answer is: The recurrent laryngeal nerve has been damaged during surgery

Question 54

A 10-year-old boy presents to the Emergency Department. Last week he had an upper respiratory tract infection, following which he quickly developed swelling around his right eye and was unable to open it. Now he has bilateral periorbital swelling, a temperature of 40oC and a Glasgow Coma Scale score of 13. He has a contrast enhanced CT scan which demonstrates a cavernous sinus thrombosis. Which one of the following symptoms/signs would not be present? Select one: Absent corneal reflex Anaesthesia over the angle of the mandible Ophthalmoplegia Lateral rectus palsy Absent swinging light pupillary reflex

Answer 54

Infected thrombus within the cavernous sinus may cause a variety of cranial nerve palsies affecting those nerves that are directly related to the sinus. Cranial nerves III, IV, V1 and V2 run within the lateral wall of the cavernous sinus. Lesions of CN III in isolation causes the globe to rest in downward, lateral gaze, and interruption of the efferent limb of the pupillary reflexes to light (tested by the swinging light reflex) and accommodation. Lesions of CN IV causes diplopia in downward gaze doe to paralysis of Superior Oblique muscle; while lesions of CN VI cause paralysis of lateral gaze (Lateral Rectus muscle). A combined lesion of CN III, IV and VI causes complete ophthalmoplegia. CN V1, the ophthalmic nerve supplies sensation to the upper face, skull and eye, so a lesion of it affects the afferent limb of the corneal reflex. Sensation to the angle of the mandible is supplied by the mandibular nerve (CN V3), which is not directly related to the cavernous sinus. The correct answer is: Anaesthesia over the angle of the mandible

Question 55

A 50-year-old man presents with a history of severe low back pain referred down the right leg to the foot. He reports saddle numbness and difficulty with micturition having not had any sensation to pass urine for more than 12 hours. On examination, straight leg raising is limited to 30 degrees on the right and 60 degrees on the left. Motor assessment is difficult due to pain but there appears to be weakness of ankle plantar flexion and eversion. Pinprick and light touch sensation are reduced in the S1 - S4 dermatomes bilaterally. An MRI scan is performed. Which one of the following is the most likely diagnosis? Select one: Discitis Epidural haematoma Prolapsed intervertebral disc S1 root neurofibroma Vertebral haemangioma

Answer 55

The correct answer is: Prolapsed intervertebral disc

Question 56

A 2-week-old baby has been unable to breast feed since birth and is struggling to bottle feed. The baby cries persistently and according to mum seems to 'burp' and suffer trapped wind. On bottle feeding mother reports regurgitation of milk through the nose. The baby appears underweight and you are concerned about failure to thrive. Which one of the following is the most likely diagnosis? Select one: Branchial cyst Cleft palate Hiatus hernia Pharyngeal pouch Pyloric stenosis

Answer 56

Cleft palate causes difficulty in making an adequate seal/suction for breast feeding. Due to excessive air intake bottle feeding is also difficult and results in trapped wind and bloating and milk regurgitation through the nose. Hiatus hernia causes reflux and or vomiting but does not present with breast or bottle feeding issues. Branchial cysts usually present with a midline swelling. Pyloric stenosis presents with projectile vomiting. Pharyngeal pouches present in later life. The correct answer is: Cleft palate

Question 57

A 65-year-old woman develops a hoarse voice, evident in theatre recovery, following an anterior cervical discectomy at the C3/4 level. Anaesthesia was uncomplicated. Surgery, via a 4 cm transverse skin crease incision, was uneventful. A post-operative MRI scan shows no evidence of a haematoma. Which one of the following is the most likely explanation for her symptoms? Select one: External laryngeal nerve transection Laryngeal oedema Recurrent laryngeal nerve transection Superior laryngeal nerve neuropraxis Vagal nerve neuropraxis

Answer 57

Recurrent larnygeal not at risk for surgery at this level (much more common with C6/7 pathology). Laryngeal oedema could be a cause but given anaesthetic uncomplicated unlikely. The superior laryngeal is at risk in upper cervical surgery - more commonly due to retraction (neuropraxis) than transection. The correct answer is: Superior laryngeal nerve neuropraxis

Question 58

You see a 56-year-old man in clinic who has presented with left submandibular swelling related to eating. He has had an ultrasound scan which shows a 1.5 cm stone within the substance of the left submandibular gland and you discuss the management options with him, including surgical removal of the gland. Which of the following nerves would you tell him are at risk during this operation? Select one: Accessory, marginal mandibular and lingual nerves Accessory, hypoglossal and lingual nerves Glossopharyngeal, marginal mandibular and lingual nerves Hypoglossal, marginal mandibular and lingual nerves Marginal mandibular, hypoglossal and glossopharyngeal nerves

Answer 58

Damage to the hypoglossal nerve causes deviation of the tongue to the affected side. Damage to the marginal mandibular nerve causes weakness of the depressor anguli oris muscle, which pulls the corner of the lower lip downwards. Damage to the lingual nerve causes numbness of the ipsilateral side of the tongue. The correct answer is: Hypoglossal, marginal mandibular and lingual nerves

Question 59

A 32-year-old patient presents to the Emergency Department following a stab injury to the neck. You note a small wound in the anterior triangle and a small pulsatile swelling approximately at the level of the hyoid bone. You also suspect a nerve injury. Which one of the following indicates this? Select one: Failure to 'screw up the eyes' tightly Hearing loss Inability to tense the masseter or temporals muscles Loss of sensation to the upper lip Loss of taste to the anterior 2/3rds of the tongue

Answer 59

Many cranial nerves transit the anterior triangle of the neck, namely VII, IX, X, XI and XII. A failure to screw up the eyes indicates an injury to the facial nerve. The other responses indicate damage to nerves that do not transit the anterior triangle; hearing loss would indicate injury to VIII, the anterior 2/3rds of the tongue is supplied by the trigeminal nerve as is sensation to the lip and motor innervation of the masseter and temporals. Given the scenario of a stab injury to the neck with a small pulsatile swelling at the level of the hyoid bone and a suspected nerve injury, we need to identify which nerve might be involved based on the symptoms described. The options provided indicate specific nerve dysfunctions: Options and Relevant Nerve Injuries: 1. Failure to ‘screw up the eyes’ tightly: • Indicates a potential injury to the facial nerve (CN VII), particularly the branches that innervate the muscles responsible for eye closure. 2. Hearing loss: • Suggests an injury to the vestibulocochlear nerve (CN VIII), which is not typically related to a neck injury in the anterior triangle. 3. Inability to tense the masseter or temporalis muscles: • Indicates a potential injury to the mandibular branch of the trigeminal nerve (CN V3), which controls the muscles of mastication. 4. Loss of sensation to the upper lip: • Indicates a potential injury to the maxillary branch of the trigeminal nerve (CN V2), which provides sensory innervation to the mid-facial region. 5. Loss of taste to the anterior 2/3rds of the tongue: • Indicates a potential injury to the chorda tympani branch of the facial nerve (CN VII), which carries taste sensations from the anterior two-thirds of the tongue. Analysis: • The wound is described as being in the anterior triangle of the neck, which is an area where the facial nerve (CN VII) and its branches are vulnerable. Specifically, the facial nerve innervates muscles of facial expression, including those responsible for closing the eyes tightly. • A pulsatile swelling at the level of the hyoid bone could indicate a vascular injury, possibly to the carotid artery or one of its branches, which lies close to the facial nerve in this region. Conclusion: Given the description of the injury and the anatomical location, failure to ‘screw up the eyes’ tightly suggests an injury to the facial nerve (CN VII), which is plausible given the proximity of the nerve to the described injury site in the anterior triangle of the neck. Thus, the correct answer is: Failure to ‘screw up the eyes’ tightly

Question 60

A pregnant 35-year-old woman is being advised of some potential risks of her new-born child suffering developmental dysplasia of the hip (DDH). Which one of the following is the most significant risk factor associated with DDH? Select one: Breech presentation Family history Female child Firstborn Oligohydramnios

Answer 60

The main risk associated with DDH is breech presentation. Female babies are at higher risk than males (ratio of 6:1 female to male). Family history and oligohydramnios are also contributing factors. The correct answer is: Breech presentation

Question 61

A 46-year-old woman presents to the Emergency Department with a headache, diplopia and ocular pain, two weeks following upper respiratory tract infection. She is an insulin dependant diabetic who suffers with stage 2 chronic kidney disease and mild hypertension. Her blood pressure is 130/88, her HBA1C is 84 and her blood glucose levels in the last 14 days have been averaging 16-18mmol/l. Her pulse is 80bpm and regular. Her right eye is pointing slightly down and outwards. Which of the following explains her symptoms best? Select one: Cerebrovascular accident Hemiplegic migraine Intra-cranial hypertension Mono-neuritis Temporal arteritis

Answer 61

This is a complicated history with a number of associated features. The finding of note is the downwards and outwards facing eye; indicative of a 3rd cranial nerve (oculomotor) palsy. The aetiology of oculomotor palsy is must-factorial, however, in this history, the patient is not significantly hypertensive and has a regular pulse; unlikely to be a CVA (bleed or embolic). She is however diabetic with significantly raised blood glucose over a number of months (HBA1C). Diabetes is a major cause of mono-neuritis. The correct answer is: Mono-neuritis

Question 62

A 32-year-old man presents to the Emergency Department having come off his mountain bike and hit a tree. He undergoes primary and secondary surveys and the only abnormalities found are bruising over his right mastoid process (Battle's sign) and a complete lower motor neurone facial paralysis. You suspect a temporal bone fracture. Which one of the following examinations or investigations would not be helpful in identifying the level of his facial nerve injury? Select one: Hearing test Pupillary light reflex Salivary flow rate Schirmer's test of lacrimation Stapedial reflex testing

Answer 62

Bruising over the mastoid process (Battle's sign) is a sign of a temporal bone fracture. The facial nerve (CN VII) exits the brainstem at the cerebellopontine angle and runs through the temporal bone, initially in close proximity to the vestibulocochlear nerve (CN VIII) in the internal acoustic meatus, and gives off the following branches during its intratemporal course: greater superficial petrosal nerve (parasympathetic fibres to the lacrimal, nasal and palatine glands via the pterygopalatine ganglion), nerve to stapedius, chorda tympani (carrying taste sensation from the anterior 2/3 of the tongue and parasympathetic fibres to the submandibular ganglion). Pupillary light reflex involves the optic (CN II) and oculomotor (CN III) nerves for its afferent and efferent limbs. The correct answer is: Pupillary light reflex

Question 63

A 5-year-old boy presents to the Emergency Department with a short history of an upper respiratory tract infection that has developed into a left neck swelling, neck stiffness and trismus. He is admitted and treated with intravenous co-amoxiclav, but his symptoms have not improved after 24 hours so you decide to arrange an MRI to exclude a deep neck space infection. The scan shows a collection posterior to the retropharyngeal space, between the alar and prevertebral fascia, and extending from the skull base into the chest. Which one of the following is the lower limit of this space? Select one: It fuses with the diaphragm It fuses with the pericardium T1-2 vertebral level T3-4 vertebral level T5-6 vertebral level

Answer 63

The deep spaces of the neck are potential routes for spread of infection. The prevertebral fascia anteriorly splits into the alar and prevertebral fascial layers. The potential space between them contains loose connective tissue and extends from the skull base to the diaphragm. It is often called the 'danger space' since it provides a pathway for infections of the head and neck to spread into the chest, causing mediastinitis and mediastinal abscess. Other tissue spaces in the neck include: Carotid space (extends from skull base to aortic arch); retropharyngeal space (extends from skull base to T1/2); visceral space (extends from hyoid bone and opens into superior mediastinum). The correct answer is: It fuses with the diaphragm

Question 64

A 41-year-old man is admitted as an emergency to the plastic surgery ward with cellulitis of the perineal area. It rapidly spreads, resulting in Fournier's gangrene (necrotising fasciitis) and widespread sepsis. This necessitates multiple trips to theatre and admission to ITU. Where is the infection likely to have originated? Select one: Camper fascia Corpora cavernosa and testes External and internal spermatic fascia Scarpa fascia and Colles fascia The inferior fascia of the urogenital diaphragm and Colles fascia

Answer 64

The perineal membrane (also known as the inferior fascia of the urogenital diaphragm) and Colles fascia, define an area known as the superficial perineal space. The superficial perineal space contains the membraneous and bulbar urethra and bulbourethral glands. It is adjacent to the anterior anal wall and ischiorectal fossae. Infectious disease of the urethra, bulbourethral glands, perineal structures, or rectum can drain into the superficial perineal space. It may spread into the scrotum or into the anterior abdominal wall and rapidly cephalad via the fascial planes as far as the level of the clavicles. The correct answer is: The inferior fascia of the urogenital diaphragm and Colles fascia

Question 65

An 80-year-old man who normally walks short distances with a frame and has a past medical history of angina and diabetes, falls and sustains a displaced intracapsular hip fracture. Which of the following is the most appropriate definitive management for him? Select one: Bed rest and traction applied to the injured leg Surgery to perform a dynamic hip screw Surgery to perform a hip hemiarthroplasty Surgery to perform a total hip replacement Surgery to perform open reduction and internal fixation with cannulated screws

Answer 65

This is an intracapsular fracture and therefore the blood supply to the head is deemed to be damaged and therefore the most appropriate treatment is to removed the head and perform a hemiarthroplasty. This allows the patient to be mobilised and reduces analgesic requirements. A dynamic hip screw is appropriate for extra capsular fractures where the blood supply to the head is presumed intact. He would not be suitable for a total hip replacement due to his co morbidities and limited mobilisation. Cannulated screws are performed when trying to preserve the femoral head such as in young patients or minimally displaced intracapsular fractures where the blood supply is more likely to remain intact. They my also require the patient to be less than full weight bearing and so are not ideal in elderly people who require frames to walk. Bed rest and traction is reserved for the very few numbers of patients who remain unfit for an anaesthetic despite optimisation. The correct answer is: Surgery to perform a hip hemiarthroplasty

Question 66

Deviation of the tongue to the right, on attempted protrusion of the tongue, would indicate damage/dysfunction in which of the following cranial nerves? Select one: Left cranial accessory nerve Left hypoglossal nerve Right glossopharyngeal nerve Right hypoglossal nerve Right lingual nerve

Answer 66

Each hypoglossal nerve innervates all the extrinsic and intrinsic lingual muscles ipsilaterally except the palatoglossus muscle, the latter being innervated by the vagus via the pharyngeal plexus. The cranial accessory and glossopharyngeal nerves do not innervate any of the lingual muscles and the lingual nerve does not supply any muscles. Deviation of the tongue to the right would indicate paralysis of the right genioglossus muscle and unopposed action of the left genioglossus. The correct answer is: Right hypoglossal nerve

Question 67

Which extraocular orbital muscle is supplied by the trochlear nerve (IV th cranial nerve)? Select one: Inferior oblique Inferior rectus Medial rectus Superior oblique Superior rectus

Answer 67

The superior rectus is supplied by the superior division of the oculomotor nerve while the medial rectus, inferior rectus and inferior oblique are supplied by the inferior division of the oculomotor nerve. The correct answer is: Superior oblique

Question 68

The superficial 'lobe' of the submandibular gland is separated from the deep 'lobe' by which of the following muscles? Select one: Hyoglossus Mylohyoid Geniohyoid Stylohyoid Genioglossus

Answer 68

The submandibular salivary gland wraps itself around the free posterior border of the mylohyoid muscle.The part of the gland that lies superficial to the mylohyoid is termed the superficial 'lobe' while the part that lies deep to the mylohyoid is called the deep 'lobe'. It must be noted that the so-called superficial and deep lobes are always physically continuous with each other around the free posterior border of mylohyoid. The hyoglossus, genioglossus, geniohyoid and stylohyoid muscles lie in a plane altogether deep to the submandibular gland. The correct answer is: Mylohyoid

Question 69

Which one of the following arteries is a branch of the internal carotid artery? Select one: Infraorbital artery Middle meningeal artery Occipital artery Ophthalmic artery Superficial temporal artery

Answer 69

The internal carotid artery is a major artery that supplies blood to the brain and structures within the orbit. Among the options given, the branch of the internal carotid artery is: Ophthalmic artery Explanation: • Infraorbital artery: • This is a branch of the maxillary artery, which itself is a branch of the external carotid artery. • Middle meningeal artery: • This is a branch of the maxillary artery, which is a branch of the external carotid artery. • Occipital artery: • This is a branch of the external carotid artery. • Ophthalmic artery: • This is a branch of the internal carotid artery. The ophthalmic artery arises from the internal carotid artery after it exits the cavernous sinus and enters the orbit through the optic canal. • Superficial temporal artery: • This is a branch of the external carotid artery. Conclusion: The ophthalmic artery is the correct answer as it is a branch of the internal carotid artery.

Question 70

A 35-year-old man attends the Emergency Department following a football tackle with a Weber C ankle fracture (high fibula ankle fracture). He requires surgery and the fracture will be fixed with a lag screw and neutralisation plate. Using the direct lateral approach to the fibula which of the following nerves can be potentially injured passing across the fibula from posterior to anterior during your approach? Select one: Deep peroneal nerve Saphenous nerve Superficial peroneal nerve Sural nerve Tibial nerve

Answer 70

The superficial peroneal nerve runs from posterior to anterior across the fibula approximately 10cm from the tip of the fibula as it passes distally to supply the skin sensation on the dorsum of the foot. This is the nerve that is most at risk during the approach for this surgery. The correct answer is: Superficial peroneal nerve

Question 71

A 20-year-old woman underwent a right thoracoscopic sympathectomy for palmar hyperhidrosis. At her follow-up appointment she reports satisfaction with her surgery but volunteers that the right side of her face now feels warm and rather dry. She has also noted some drooping of her right upper eyelid. Which one of the following physical signs is most likely to be present as well? Select one: Constricted right pupil Divergent strabismus Facial hyperaesthesia Facial weakness Normal cilio-spinal reflex

Answer 71

Inadvertent damage to the cervical sympathetic chain leads to Horner’s syndrome which is characterised by anhidrosis of the face, ptosis, loss of the cilio-spinal reflex and constriction of the pupil. The pupil becomes constricted due to the unopposed action of the sphincter pupillae muscle, innervated by parasympathetic fibres. In contrast the dilator pupillae muscle is supplied by the cervical sympathetic chain. A functioning dilator pupillae muscle is required for the cilio-spinal reflex. Ptosis is due to weakness of the smooth muscle component of levator palpebrae superioris which is also supplied by the cervical sympathetic chain. Horner syndrome is not associated with a squint or facial weakness as the external ocular and facial muscles do not have motor supply from the sympathetic nervous system. As the cutaneous nerves to the face via branches of the trigeminal nerve are not affected sensation is normal. The correct answer is: Constricted right pupil

Question 72

A 58-year-old woman presents with a sudden onset of severe headache, associated with nausea and vomiting. On examination her GCS is 13/15. A CT scan is performed (see below). Analgesia and fluids are prescribed. Urgent transfer to the neurosurgical unit is arranged. The neurosurgical registrar advises that nimodipine is commenced. What is the mechanism of action of nimodipine? ACE inhibitor Alpha blocker Aquaporin Beta Blocker Calcium channel blocker

Answer 72

Scan shows SAH. This is communicating rather than obstructive: all ventricles are seen on the scan (lateral, 3rd and 4th) and are dilated. This excludes A, B and D. NPH is a form of communicating hydrocephalus but the presence of the SAH and the raised pressure appearance on the scan (no atrophy) excludes this diagnosis. The correct answer is: Calcium channel blocker

Question 73

You are assessing a 4-year-old boy in the urology clinic. The boy has recently moved to the UK and has been referred by the General Practitioner. The parents are concerned that the child goes to the toilet many times per day, doesn't like to pass urine standing up instead preferring to sit down, often leaks urine on voiding and has a large tight gathering of foreskin on the top of the penis, but not all the way round. Which one of the following is the most likely treatment? Select one: A mid-stream urine specimen and appropriate treatment for chronic UTI A surgical reconstruction Isolated circumcision Reassurance Referral to a behavioural psychologist

Answer 73

Hypospadias affects 1:300 boys and is where the opening of the urethra (meatus) is not at the tip of the penis but either further down or even at the base. The foreskin is gathered at the tip and often on one side only rather than circumferentially. Treatment is surgical, usually at 12 months of age, with reconstruction of the urethra together with circumcision. The correct answer is: A surgical reconstruction

Question 74

You are called to the Emergency Department to review a 2-month-old boy with a 6 hour history of a right groin swelling. The referring doctor says the patient is otherwise well and the abdomen is soft and non tender. The doctor states the mass is in the right inguino-scrotal region, it does not transilluminate but is not reducible. Which one of the following is your preferred management option? Select one: Arrange an urgent ultrasound scan to establish the diagnosis Give analgesia and attempt to reduce the mass Keep the patient nil by mouth, place a nasogastric tube and start broad spectrum antibiotics Schedule the patient for an elective operation in the next few weeks Take the patient to theatre urgently for operative repair

Answer 74

The history points to an incarcerated right inguinal hernia. There are no features in the vignette to point to bowel obstruction. In paediatric practice, we would try to reduce the hernia with analgesia (specifically morphine) and assuming this is successful, arrange a semi urgent herniotomy in 48 hours time once the oedema of the tissues in the operative site has settled. A - this is a clinical diagnosis although imaging may occasionally be helpful in atypical cases B - correct C - NBM and NG tube would be indicated in bowel obstruction but attempted hernia reduction takes precedence as it has a high rate of success D - an incarcerated hernia cannot be left untreated as the risk is of bowel ischaemia and perforation. A reducible hernia may be given an elective surgical date. E - immediate surgery is avoided, as long as the hernia can be reduced. This may require consultant input to achieve successful reduction The correct answer is: Give analgesia and attempt to reduce the mass

Question 75

A 25-year-old motorcyclist involved in an RTC has sustained blunt trauma to the left side of his chest. He is tachypnoeic (RR 20/min) and has an oxygen saturation of 93% on air. He is haemodynamically stable but his chest X-ray shows a large haemothorax. His heart size is normal and the cardiac shadow is not displaced. Oxygen has been provided and intravenous access obtained. In view of the amount of fluid seen in the left pleural cavity an intercostal drain is required. Where is the most appropriate site for insertion of the drain? Select one: 2nd interspace in the mid-clavicular line 2nd intercostal space mid-axillary line 5th interspace between the anterior axillary and mid-axillary lines 5th interspace in the mid-clavicular line 5th interspace posterior to the posterior axillary line

Answer 75

The 5th interspace between the anterior axillary and mid-axillary lines is in the “safe area” and is the preferred site for drain insertion. The 5th interspace in the mid-clavicular line normally corresponds to the apex of the left ventricle and therefore drain insertion here risks damage to the heart. Insertion of a drain posterior to the posterior axillary line requires dissection through the latissimus dorsi muscle and a posteriorly sited drain leads to discomfort for the patient when lying down. Insertion of a drain through the 8th interspace risks injury to the diaphragm or even intraabdominal organs. In full expiration the dome of the diaphragm reaches the 4th interspace on the right and the 5th interspace on the left side. The 2nd interspace in the mid-clavicular line is used for urgent needle decompression of a tension pneumothorax. Because of its position a drain at his site would not effectively drain a haemothorax. The correct answer is: 5th interspace between the anterior axillary and mid-axillary lines

Question 76

A 22 year old male injures his knee while playing football and attends the emergency department. He describes his injury occurring as he pivoted to suddenly change the direction he was running in, it was a non contact injury. He reports immediate swelling in the knee and that he was unable to play on. Which one of the following structures is he most likely to have injured? Select one: Anterior cruciate ligament Lateral Meniscus Medial collateral ligament Medial meniscus Posterior cruciate ligament

Answer 76

From this history the most likely injury is an ACL rupture. The mechanism for an ACL rupture is sudden change of direction or pivoting, and is usually a non contact injury common in football and netball players. It produces a large haemarthrosis and therefore is associated with immediate knee swelling and patients not being able to continue the sport or activity they were doing. The correct answer is: Anterior cruciate ligament

Question 77

A 19-year-old is admitted with a penetrating knife injury. His injuries are consistent with a severed left half of his thoracic spinal cord at the T8 level. Which of the following signs is the most likely consequence of transection of the left dorsal column? Select one: Loss of bladder control Loss of light touch sensation on the left with an upper level 5 cm above the umbilicus Loss of pinprick sensation below the umbilicus on the right Loss of temperature sensation below the umbilicus on the right Loss of vibration sense on the right

Answer 77

The left dorsal column of the spinal cord carries ascending sensory information related to proprioception, vibration sense, and fine touch. A transection of the left dorsal column at the T8 level would affect these sensory modalities on the same side of the body below the level of the lesion. The most likely consequence of transection of the left dorsal column at T8 would be: Loss of light touch sensation on the left with an upper level 5 cm above the umbilicus Explanation: • Loss of bladder control: This typically involves disruption at a higher level of the spinal cord, involving autonomic pathways or sacral segments. • Loss of light touch sensation on the left with an upper level 5 cm above the umbilicus: This is consistent with the function of the dorsal column. The T8 level is located around 5 cm above the umbilicus. Loss of light touch (fine touch) sensation below the level of the lesion would occur on the same side as the lesion (left side). • Loss of pinprick sensation below the umbilicus on the right: Pinprick (pain) and temperature sensations are carried by the spinothalamic tract, which crosses to the opposite side shortly after entering the spinal cord. A lesion on the left side would result in loss of these sensations on the right side below the level of the lesion. • Loss of temperature sensation below the umbilicus on the right: As with pinprick sensation, temperature sensation is carried by the spinothalamic tract and would be lost on the right side below the level of the lesion. • Loss of vibration sense on the right: Vibration sense is carried by the dorsal column. A lesion on the left side would result in loss of vibration sense on the left side below the level of the lesion, not the right. Conclusion: The most likely consequence of transection of the left dorsal column at the T8 level is loss of light touch sensation on the left with an upper level 5 cm above the umbilicus. This reflects the loss of sensory modalities carried by the dorsal column on the same side of the body below the level of the lesion.

Question 78

A 41-year-old man presents with a history of right lower limb sciatica. Pain and numbness are reported in the sole and lateral border of the foot. The ankle reflex is absent. At which one of the following levels is the disc prolapse most likely to have occurred? Select one: L2/3 L3/4 L4/5 L5/S1 S1/S2

Answer 78

The clinical presentation of right lower limb sciatica with pain and numbness in the sole and lateral border of the foot, along with an absent ankle reflex, is indicative of a nerve root compression affecting the S1 nerve root. Most likely level of disc prolapse: L5/S1 Explanation: • L2/3: Compression at this level typically affects the L3 nerve root, which would cause symptoms in the anterior thigh and knee, not the foot. • L3/4: Compression at this level typically affects the L4 nerve root, causing symptoms in the anterior thigh and medial lower leg, not the foot. • L4/5: Compression at this level typically affects the L5 nerve root, causing symptoms on the dorsum of the foot and great toe, not the sole and lateral border of the foot. • L5/S1: Compression at this level affects the S1 nerve root, which supplies sensation to the sole and lateral border of the foot and is responsible for the ankle reflex. • S1/S2: Compression at this level would affect the S2 nerve root, but the presentation is more consistent with S1 involvement. Conclusion: The disc prolapse is most likely to have occurred at the L5/S1 level, given the specific pattern of pain, numbness, and absence of the ankle reflex.

Question 79

You are discussing post-operative pain relief during WHO checklist, for a patient about to undergo an open nephrectomy through a loin incision above the 12th rib. Which one of the following methods of post-operative / regional analgesia is most appropriate? Select one: Continual inter-costal infusion Epidural anaesthesia Infra-clavicular block Patient Controlled Analgaesia (PCA) Rectus sheath catheter

Answer 79

PCA, epidural and inter-costal infusion are effective post-nephrectomy. Recovery is faster with a local continuous infusion and allows earlier mobilisation and discharge. The rectus sheets should not be entered during a loin approach to the kidney and so a rectus sheath catheter is unhelpful. The correct answer is: Continual inter-costal infusion

Question 80

A 48 hour term, male infant presents with a 12 hour history of green vomiting. The parents state that there have been some wet nappies but that the child has not opened his bowels since birth. The abdomen is distended, full but not tense and not tender. The anus is normally sited. Which one of the following is the most useful diagnostic test? Select one: Blood cultures Lower gastrointestinal contrast study Suction rectal biopsy Ultrasound scan Upper gastrointestinal contrast study

Answer 80

In this case, the most useful diagnostic test is Suction rectal biopsy. It can help in diagnosing Hirschsprung’s disease, a condition where there is a lack of ganglion cells in the rectum and possibly the colon, leading to bowel obstruction and symptoms like green vomiting and failure to pass meconium. Source: BMJ Best Practice - Hirschsprung’s Disease

Question 81

You are assessing the neurovascular status in the lower limb of a motorcyclist with an open tibial shaft fracture. There is significant soft tissue loss posteriorly and you are concerned about injury to the posterior tibial artery. You are hopeful that the dorsalis pedis artery is spared as it lies between which one of the following tendons? Select one: Between the extensor hallucis longus and extensor digitorum longus tendons Between the flexor digitorum longus and the flexor halluces longus tendons Between the flexor hallucis longus and flexor digitorum longus tendons Between the tibialis anterior and extensor hallucis longus tendons Between the tibialis posterior and flexor digitorum longus tendons

Answer 81

Dorsalis pedis is the continuation of the anterior tibial artery after passing under the extensor retinaculum. It is located on the dorsum of the foot, passing between the tendons of the extensor hallucis longus and extensor digitorum longus. The correct answer is: Between the extensor hallucis longus and extensor digitorum longus tendons

Question 82

You are asked to assess a patient involved in a road traffic collision who sustained a multi-fragmentary fracture of the distal femur. After considering the displacement forces in this type of injury, which of the following anatomical structure are you most concerned about? Select one: Deep peroneal nerve Popliteal artery Quadriceps tendon Superficial peroneal nerve Tibial nerve

Answer 82

Gastrocnemius originates from the supracondylar ridges of the distal femur and inserts via Achilles tendon on the calcaneal tuberosity. In a distal femoral fracture, the heads of this muscle will displace the distal fragment posteriorly, putting at risk the structures of the popliteal fossa. The deepest structure of the popliteal fossa which lies in close proximity to the bone is popliteal artery. The correct answer is: Popliteal artery

Question 83

You are assessing a patient with an inguinal hernia. The patient has neurological symptoms consistent with meralgia paresthetica as a result of a nerve intrapment into the inguinal ligament. Which of the following is the trapped nerve? Select one: Intermediate cutaneous nerve of the thigh Lateral cutaneous nerve of the thigh Medial cutaneous nerve of the thigh Posterior cutaneous nerve of the thigh Saphenous nerve

Answer 83

The lateral cutaneous nerve of the thigh (L2-L3) arises directly from the from the lumbar plexus and usually enters the thigh deep to the inguinal ligament. Occasionally the nerve pierces the inguinal ligament, is compressed here and gives pain and parasthesia over the superior aspect of the outer thigh (meralgia paresthetica). The correct answer is: Lateral cutaneous nerve of the thigh

Question 84

You are assisting in placing a patient who has suffered a mid-shaft femoral fracture and multiple rib fractures into femoral traction, as he is currently unfit for surgery. You position the traction to balance the displacement of the proximal fragment because of which one of the following? Select one: Adduction by gracilis and flexion by sartorius Flexion and adduction by the adductor magnus Flexion by the iliopsoas muscle and abduction by the gluteus medius and minimus Flexion by the iliopsoas muscle and adduction by the adductors Flexion by the quadriceps and adduction by the semi-membranosus

Answer 84

In a proximal femoral fracture the proximal fragment is flexed by the iliopsoas muscle (inserting on the lesser trochanter) and abducted by the hip abductors: gluteus medius and minimus (inserting on the greater trochanter). The distal fragment is adducted by the adductor insertion on the femoral shaft. The correct answer is: Flexion by the iliopsoas muscle and abduction by the gluteus medius and minimus

Question 85

A rock climber slips for 3 meters on a fixed rope and hits the rock-face. Which of the following bones is most likely to have suffered an open fracture? Select one: Femur Humerus Radius Tibia Ulna

Answer 85

The tibial shaft is comparatively long, subcutaneous and unprotected anteromedially throughout its entire course. It is also slender in its lower 1/3, making it very vulnerable to fractures in general. Due to lack of a well-developed soft tissue envelope on the anteromedial aspect it is particularly prone to open injuries. The correct answer is: Tibia

Question 86

Whilst on cardiothoracic placement, you are asked to harvest the long saphenous vein to be used for a coronary artery bypass. How do you locate this structure at the level of the ankle? Select one: Behind the lateral malleolus Behind the medial malleolus Between the tendons of flexor digitorum longus and flexor hallucis longus In front of the lateral mallolus In front of the medial malleolus

Answer 86

To locate the long saphenous vein (great saphenous vein) at the level of the ankle for harvesting during a coronary artery bypass procedure, you should: E. In front of the medial malleolus Explanation: • The long saphenous vein runs superficially along the medial side of the leg. At the ankle, it can be found just anterior to the medial malleolus, making this the correct location for accessing the vein. Other options explained: • Behind the lateral malleolus: This is the location for the small saphenous vein, not the long saphenous vein. • Behind the medial malleolus: This location is associated with the tibial nerve and posterior tibial artery. • Between the tendons of flexor digitorum longus and flexor hallucis longus: This is a deeper location and not where the long saphenous vein is found. • In front of the lateral malleolus: This area is not associated with the long saphenous vein. Conclusion: To harvest the long saphenous vein at the level of the ankle, locate it in front of the medial malleolus.

Question 87

A 45-year-old man presents with acute lumbar back pain after picking up a heavy box. On examination of his neurology, he has reduced power in dorsiflexion of his left hallux and reduced sensation in the first web space of the left foot. Which of the following is the likely pathology causing these signs and symptoms? Select one: Left sided far lateral disc prolapse at the L3/L4 level Left sided far lateral disc prolaspe at the L4/L5 level Left sided paracentral disc prolapse at the L3/L4 level Left sided paracentral disc prolapse at the L4/L5 level Left sided paracentral disc prolapse at the L5/S1 level

Answer 87

The clinical examination shows reduced power and sensation in the L5 nerve root distribution. In the lumbar spine at each disc level there will be a descending and exiting nerve root. The exiting nerve root will be from the level above and the descending nerve root from the level below. For example at the L4/L5 disc level there will be an exiting L4 nerve root and a descending L5 nerve root. Descending nerve roots are affected by paracentral discs and exiting nerve roots by far lateral discs. Therefore with symptoms suggesting L5 nerve root compression the options include a paracentral disc at the L4/L5 level affecting the L5 descending nerve root or a far lateral disc at the level of L5/S1 affecting the exiting L5 nerve root. The correct answer is: Left sided paracentral disc prolapse at the L4/L5 level

Question 88

A 7-year-old boy presents with a two month history of intermittent peri-umbilical pain and intermittent presence of blood in his faeces. A tentative diagnosis of Meckel diverticulum is made. Which one of the following is true about Meckel diverticulum? Select one: It arises on the mesenteric border of the ileum It is a remnant of the vitelline duct It is a remnant of the vitelline veins It is located 60 cm distal to the ileocaecal valve It is present in 20% of the population

Answer 88

The correct statement about Meckel diverticulum is: It is a remnant of the vitelline duct Explanation: • It arises on the mesenteric border of the ileum: • Incorrect. Meckel diverticulum arises on the antimesenteric border of the ileum. • It is a remnant of the vitelline duct: • Correct. Meckel diverticulum is a congenital condition resulting from an incomplete obliteration of the vitelline duct (also known as the omphalomesenteric duct) during embryonic development. • It is a remnant of the vitelline veins: • Incorrect. The vitelline veins are involved in the development of the portal venous system, not in the formation of Meckel diverticulum. • It is located 60 cm distal to the ileocaecal valve: • This statement is not accurate for all cases. Meckel diverticulum is usually located within 2 feet (approximately 60 cm) of the ileocecal valve, but this distance can vary. • It is present in 20% of the population: • Incorrect. Meckel diverticulum is present in approximately 2% of the population. Conclusion: The most accurate statement about Meckel diverticulum is that it “is a remnant of the vitelline duct.”

Question 89

A patient with recent history of headaches and unsteadiness is found to have a pre-pontine meningioma arising from the clivus. The patient also reports diplopia. Compression of which of the following nerve(s) is most likely to account for the diplopia? Select one: Abducens Oculomotor Ophthalmic division of trigeminal Sympathetic Trochlear

Answer 89

Diplopia (double vision) can be caused by the involvement of cranial nerves that control eye movements. In the context of a pre-pontine meningioma arising from the clivus, compression of the cranial nerves in the region of the clivus and pre-pontine area is likely. The cranial nerve most commonly affected in this area that would result in diplopia is the abducens nerve (cranial nerve VI). Most likely nerve involved: Abducens (Cranial Nerve VI) Explanation: • Abducens (Cranial Nerve VI): The abducens nerve controls the lateral rectus muscle, which abducts the eye. It is susceptible to compression by masses in the pre-pontine area or around the clivus. Compression of the abducens nerve leads to an inability to abduct the eye, causing horizontal diplopia. • Oculomotor (Cranial Nerve III): While involvement of the oculomotor nerve can also cause diplopia, it is less commonly affected by a lesion at the clivus compared to the abducens nerve. The oculomotor nerve controls most of the eye muscles and pupillary constriction. • Ophthalmic division of trigeminal (Cranial Nerve V1): This division of the trigeminal nerve provides sensory innervation to the forehead, eye, and upper eyelid but does not control eye movements and would not cause diplopia. • Sympathetic: The sympathetic fibers control pupil dilation and eyelid elevation (Müller’s muscle). Compression would lead to Horner’s syndrome, which includes ptosis, miosis, and anhidrosis, but not diplopia. • Trochlear (Cranial Nerve IV): The trochlear nerve innervates the superior oblique muscle, which primarily causes intorsion and depression of the eye. While trochlear nerve palsy can cause vertical diplopia, it is less commonly involved in lesions at the clivus compared to the abducens nerve. Conclusion: The compression of the abducens nerve (cranial nerve VI) is most likely to account for the diplopia in a patient with a pre-pontine meningioma arising from the clivus.

Question 90

A 40-year-old amateur soprano singer recently underwent a subtotal thyroidectomy for Graves' disease. When starting back in her choir two weeks after surgery, her fellow members commented that the pitch of her voice had changed. In addition, she noted that she was unable to reach the higher notes that she used to be able to sing quite easily before her operation. Which of the following nerves is most likely to have been injured during her surgery? Select one: External laryngeal nerve Inferior root of the ansa cervicalis Internal laryngeal nerve Recurrent laryngeal nerve Superior root of the ansa cervicalis

Answer 90

The external laryngeal nerve which is a branch of the superior laryngeal nerve supplies motor fibres to the crico-thyroid muscle. This muscle tenses the vocal cords and is responsible for the quality and pitch of the voice. In contrast the internal laryngeal nerve, the other branch of the superior laryngeal nerve, is a purely sensory nerve supplying the mucosa of the larynx and pharynx. The recurrent laryngeal nerve supplies the intrinsic muscles of the larynx and injury leads to a either a hoarse voice or even aphonia, if bilateral injury occurs. The ansa cervicalis supplies the following infrahyoid muscles which are depressors of the larynx: sterno-hyoid, omo-hyoid, sterno-thyroid. These muscles are not directly involved in voice production. The correct answer is: External laryngeal nerve

Question 91

A 55-year-old woman has undergone right mastectomy and level 3 axillary node clearance for a 5 cm node positive, grade 3 invasive ductal carcinoma. The pectoralis minor muscle was divided at its insertion into the coracoid process of the scapula to facilitate removal of enlarged lymph nodes at level 3. Post operation, she complains of numbness and paraesthesia of the medial aspect of her upper arm. Which of the following nerves has been injured during the operation? Select one: Axillary nerve Intercostal-brachial nerve Lateral pectoral nerve Long thoracic nerve Musculo-cutaneous nerve

Answer 91

The intercosto-brachial nerve (T2) is the lateral cutaneous branch of the second intercostal nerve. It supplies the skin of the axilla and the skin of the medial aspect of the upper arm close to the axilla. It is at risk of injury during extensive axillary surgery The axillary nerve (C5) supplies the skin of the lateral aspect of the upper arm mainly via the upper lateral cutaneous nerve of the arm. The lateral pectoral nerve (C6,7) is a motor nerve only, supplying the pectoralis major muscle. The long thoracic nerve (C5,6,7) is a motor nerve only supplying the serratus anterior muscle. The musculo-cutaneous nerve (C5,6,7) is a motor nerve to biceps, brachialis and coraco-brachialis and forms the lateral cutaneous nerve of the forearm. The correct answer is: Intercostal-brachial nerve

Question 92

A 20-year-old man has undergone recent excision biopsy of an enlarged lymph node situated in the posterior triangle of the right side of his neck. The procedure was performed under general anaesthetic. Histology has shown nodular sclerosing Hodgkin's lymphoma. When seen seven days later for the results of the biopsy the patient complains that he has weakness in the region of his right shoulder and he is unable to shrug his shoulder on that side. Injury to which one of the following nerves is likely to account for the patient's symptoms and signs? Select one: Accessory nerve Intermediate supraclavicular nerve Lateral (posterior) supraclavicular nerve Medial supraclavicular nerve Transverse cervical nerve

Answer 92

The patient’s inability to shrug his shoulder and the weakness in the region of his right shoulder following an excision biopsy of an enlarged lymph node in the posterior triangle of the neck is indicative of an injury to the accessory nerve. Explanation: The accessory nerve (cranial nerve XI) supplies the sternocleidomastoid and trapezius muscles. Injury to this nerve can result in the inability to shrug the shoulder (due to trapezius muscle paralysis) and weakness in shoulder elevation and abduction above the horizontal level. The other nerves listed do not account for the specific symptoms of shoulder weakness and inability to shrug. • Intermediate, lateral, medial supraclavicular nerves: These are sensory nerves and do not innervate the trapezius muscle. • Transverse cervical nerve: This is also a sensory nerve and does not provide motor innervation to the shoulder muscles. Therefore, the accessory nerve is the most likely to be injured in this scenario.

Question 93

A 9-month-old woman, born four weeks prematurely, is presented with a history of poor growth, frequent lethargy and a persistent tachycardia. Auscultation of the chest reveals a systolic murmur, and there is a 'waterhammer' pulse. Blood pressure in the upper and lower limbs are equal and normal. Breathing rate is normal for age. What is the likely diagnosis? Select one: Atrial septal defect Coarctation of the aorta Patent ductus arteriosus Transposition of the great arteries (TGA) Truncus arteriosus

Answer 93

Patent ductus arteriosus is associated with systolic murmur and waterhammer pulse. Coarctation of the aorta often produces differential blood pressure between upper and lower limbs. ASD would give a diastolic murmur. TGA presents differently due to reversal of the great arteries leaving the heart. Truncus arteriosus presents much earlier with surgery often required by 3 months of age and breathlessness is often a feature. The correct answer is: Patent ductus arteriosus

Question 94

An 18-year-old man arrives as a trauma call, he has crashed his motorbike at high speed and hit a bollard head on. He is tachycardic, hypotensive and has bilateral externally rotated legs. Which one of the following pelvic fractures is most likely with the patient's history and presentation? Select one: Acetabular fracture Anterior posterior compression fracture (open book) Fractured neck of femur Lateral compression fracture Vertical sheer fracture

Answer 94

The mechanism of injury here is anterior- posterior compression from the petrol tank of the motor bike that would get forced up into the pelvis with a head on collision. These fractures are associated with haemodynamic instability. As the injury involves the pelvis opening up at the front clinically the legs can assume an externally rotated position. A lateral compression and acetabular fracture is associated with impact from one side. The mechanism for a vertical sheer fracture is normally a fall from height, although it is often associated with haemodynamic instability. The correct answer is: Anterior posterior compression fracture (open book)

Question 95

You are called to the post-natal ward to see a 5-day-old girl who was born 14 days prematurely. The paediatric team had noticed an erythematous inflamed area between the genitalia and the anus, with evidence of localised inflammation. The fluid chart has documented very loose stools, green/brown in colour. The baby is otherwise feeding normally. Which one of the following is the most likely diagnosis? Select one: Fistula Hirschsprung's disease Hypospadias Perineal groove Prolapsed anus

Answer 95

Perineal groove is a rare anomaly that occurs primarily in female infants. It is thought to be either a failure of midline fusion or a urorectal septum developmental defect during cloacal embryological stages at 5th to 8th week of gestation. In many cases the area self-epithelialise, though observation is needed to prevent infection. Hirschsprung's presents with constipation or failure to pass faeces. A fistula should form part of your differential, but would be an obvious communication leaking bowel content. Hypospadias occurs in male infants. The correct answer is: Perineal groove

Question 96

You assess an elderly patient who has been diagnosed with a pharyngeal pouch. This is an out pouching of the oesophagus through an area called Killian dehiscence between which muscles of the pharynx? Select one: Inferior constrictor and cricopharyngeus Salpingopharyngeus and inferior constrictor Salpingopharyngeus and superior constrictor Superior and inferior constrictors Superior constrictor and cricopharyngeus

Answer 96

A pharyngeal pouch, also known as a Zenker’s diverticulum, is an outpouching of the esophagus through an area called Killian dehiscence. This dehiscence is located between the inferior constrictor and cricopharyngeus muscles of the pharynx. Explanation: Killian dehiscence is a potential weak area between the fibers of the cricopharyngeus muscle (the lower part of the inferior constrictor muscle) and the more horizontally oriented fibers of the rest of the inferior constrictor muscle. It is through this area that a pharyngeal pouch may protrude. • Inferior constrictor and cricopharyngeus: This is the correct answer as Killian dehiscence is located between these two muscles. • Salpingopharyngeus and inferior constrictor: The salpingopharyngeus muscle is not related to the area where a pharyngeal pouch forms. • Salpingopharyngeus and superior constrictor: These muscles are not involved in the formation of Killian dehiscence. • Superior and inferior constrictors: Killian dehiscence is specifically between the inferior constrictor and cricopharyngeus, not the superior and inferior constrictors. • Superior constrictor and cricopharyngeus: This combination does not relate to the anatomical area of Killian dehiscence. Therefore, the correct answer is: Inferior constrictor and cricopharyngeus.

Question 97

A 60-year-old woman undergoes surgery to clip a posterior inferior cerebellar artery aneurysm. Cranial nerve injury may occur during the surgical exposure. Which one of the following deficits is most commonly associated with this operation post-operatively? Select one: Diplopia Facial weakness and numbness Hoarse voice/weak cough Tongue atrophy Visual field defect

Answer 97

The most common deficit associated with surgery to clip a posterior inferior cerebellar artery (PICA) aneurysm is a hoarse voice/weak cough. Explanation: The posterior inferior cerebellar artery is in close proximity to cranial nerves IX (glossopharyngeal), X (vagus), and XI (accessory). Damage to these nerves during surgical exposure can result in several deficits, with the vagus nerve (cranial nerve X) being particularly vulnerable. • Hoarse voice/weak cough: This is the correct answer. Injury to the vagus nerve (cranial nerve X) can affect the vocal cords, leading to a hoarse voice and a weak cough. • Diplopia: This is associated with injury to the cranial nerves III (oculomotor), IV (trochlear), or VI (abducens), which are not typically affected in PICA aneurysm surgery. • Facial weakness and numbness: These symptoms are related to the facial nerve (cranial nerve VII) or the trigeminal nerve (cranial nerve V), respectively, and are not commonly affected by this type of surgery. • Tongue atrophy: This would be caused by injury to the hypoglossal nerve (cranial nerve XII), which is not typically involved in PICA aneurysm surgery. • Visual field defect: This would result from injury to the optic nerve (cranial nerve II) or the visual pathways, and is unrelated to PICA aneurysm surgery. Therefore, the correct answer is: Hoarse voice/weak cough.

Question 98

A 50-year-old-woman presents to the upper GI clinic with a six month history of sporadic central abdominal pain. She also suffers mild dyspepsia. She has been a lifetime heavy smoker and over the last 18 months has had investigations for peripheral vascular disease. Her pain only arises after eating, especially larger meals. Which one of the following is the most likely cause for her symptoms? Select one: Barrets oesophagus Biliary cholic Irritable bowel disease Oesophageal spasm Superior mesenteric stenosis

Answer 98

The most likely cause for her symptoms is superior mesenteric stenosis. Explanation: The patient’s symptoms of sporadic central abdominal pain after eating, especially larger meals, along with a history of peripheral vascular disease, suggest mesenteric ischemia. Superior mesenteric artery (SMA) stenosis can lead to chronic mesenteric ischemia, commonly presenting with postprandial abdominal pain due to insufficient blood flow to the intestines during digestion. • Barrett’s esophagus: This condition involves changes in the lining of the esophagus and is primarily associated with chronic gastroesophageal reflux disease (GERD). It would not typically cause central abdominal pain after eating. • Biliary colic: This presents with episodic right upper quadrant pain often related to gallstones, not typically central abdominal pain. • Irritable bowel disease: This condition includes a group of functional gastrointestinal disorders but is less likely given her history of peripheral vascular disease and the pattern of pain after eating. • Oesophageal spasm: This can cause chest pain and dysphagia but is unlikely to cause central abdominal pain after eating. • Superior mesenteric stenosis: This condition, related to atherosclerosis in a patient with a history of heavy smoking and peripheral vascular disease, aligns with the postprandial abdominal pain due to reduced blood flow to the intestines during digestion. Therefore, the most likely cause for her symptoms is: Superior mesenteric stenosis.

Question 99

A 32-year-old patient is undergoing an emergency laparotomy following blunt trauma to the abdomen. On opening the peritoneum there is torrential bleeding and your consultant performs 'Pringle's manoeuvre'. Which one of the following structures are clamped by this manoeuvre? Select one: Gastroduodenal artery and celiac trunk Hepatic artery and portal vein Inferior vena cava and portal vein Splenic artery and portal vein Superior vena cava and hepatic artery

Answer 99

The Pringle manoeuvre involves clamping the hepatic artery and portal vein. Explanation: Pringle’s manoeuvre is used to control bleeding from the liver during surgery. It involves clamping the hepatoduodenal ligament, which contains the hepatic artery, portal vein, and bile duct. This manoeuvre temporarily occludes the inflow of blood to the liver from the hepatic artery and the portal vein, thereby reducing blood loss. • Gastroduodenal artery and celiac trunk: These are not clamped during Pringle’s manoeuvre. • Hepatic artery and portal vein: This is the correct answer, as these are the structures within the hepatoduodenal ligament that are clamped during Pringle’s manoeuvre. • Inferior vena cava and portal vein: The inferior vena cava is not clamped in Pringle’s manoeuvre. • Splenic artery and portal vein: The splenic artery is not involved in Pringle’s manoeuvre. • Superior vena cava and hepatic artery: The superior vena cava is not clamped in Pringle’s manoeuvre. Therefore, the correct answer is: Hepatic artery and portal vein.

Question 100

A 25-years-old motorcyclist has been admitted to the Emergency Department following a road traffic collision. His only significant injury is that of a probable fracture of the right humerus which is confirmed by X-ray showing a displaced fracture of the mid shaft of the humerus. He complains of weakness in the right arm and hand and appears to have a wrist drop. Which of the following combinations of movements is most likely to be impaired? Select one: Extension of the elbow and wrist joints Extension of the elbow, wrist and metacarpo-phalangeal joints Extension of the metacarpo-phalangeal and interphalangeal joints Extension of the wrist and metacarpo-phalangeal joints Extension of the wrist, metacarpo-phalangeal and interphalangeal joints

Answer 100

The patient has suffered injury to the radial nerve where it courses through the spiral groove of the humerus. The nerve supply to the triceps muscle from the radial nerve is at a more proximal level and so elbow extension is preserved. The extensor muscles of the wrist joint such as extensor carpi radialis (longus and brevis) and extensor carpi ulnaris will be affected by the injury. Similarly, the muscles extending the metacarpo-phalangeal joints joints such as extensor digitorum will be weakened. However, extension of the interphalangeal joints can still occur due the action of the lumbrical muscles which are supplied buy the ulnar and median nerves. The correct answer is: Extension of the wrist and metacarpo-phalangeal joints

Question 101

A 12-year-old girl presents with a 2 cm diameter anterior midline cyst of the neck. It moves on swallowing and on protrusion of her tongue. At operation the cyst is very closely associated with a bone derived from two of the embryological pharyngeal arches. From which one of the following pharyngeal arches is this bone derived? Select one: 1st and 2nd arches 2nd and 3rd arches 3rd and 4th arches 4th and 5th arches 5th and 6th arches

Answer 101

The clinical features are typical of a thyroglossal cyst which is derived from remnants of the thyroglossal duct. Embryologically this duct passes close to the anterior part of the body of the hyoid bone, often also passing posterior to the bone before descending towards the thyroid gland. The hyoid bone is derived from the 2nd and 3rd pharyngeal arches. The 1st arch forms the maxilla and mandible. The 4th and 6th arches form the muscles and cartilage of the larynx whilst the 5th arch usually disappears. The correct answer is: 2nd and 3rd arches

Question 102

You see a 34-year-old woman in the Emergency Department following a road traffic collision. The ambulance crew reported a Glasgow Coma Scale (GCS) of 9 with pupils that were equally reactive to light. You record her GCS as 5 and note that she now has a fixed dilated pupil on the left. A CT scan is performed. It shows a mass with lens shape on the left side. Which one of the following is the clinically most urgent finding on this scan? Select one: Acute subdural haematoma Extradural haematoma Skull base fracture Temporal lobe contusion Traumatic subarachnoid haemorrhage

Answer 102

All 5 of the options are shown on this trauma scan. The obvious abnormality is the mass on the left side (using standard radiology convention for side). This has the classic lens shape. Although not particularly large it accounts for the dilated pupil on the left and warrants emergency surgery. The correct answer is: Extradural haematoma

Question 103

An 8- year-old man presents to clinic via the 2-week wait pathway with a complete right lower motor neurone facial paralysis and a painless mass in his ipsilateral parotid gland. Which one of the following is the most likely histological diagnosis? Select one: Acinic cell carcinoma Adenoid cystic carcinoma Carcinoma ex-pleomorphic adenoma Lymphoma Squamous cell carcinoma

Answer 103

25% of salivary gland malignancy presents in the parotid gland (50% in the submandibular and 75% in minor salivary glands). The presence of a parotid mass mass with a facial nerve paralysis is highly suspicious for malignancy. The commonest malignant parotid tumour is adenoid cystic carcinoma (approx. 25%), and poorly differentiated carcinoma (approx. 25%), then carcinoma ex-pleomorphic (approx. 10%), then acinic cell carcinoma (3%). The correct answer is: Adenoid cystic carcinoma

Question 104

A 54-year-old man returns from a ski holiday. Following a fall onto the outstretched hand he developed pain lasting about 10 minutes in his 3rd digit (middle finger). He immediately noticed that his distal phalanx was flexed at the DIP joint. He was unable to voluntarily extend the DIP, although he could passively straighten the finger without difficulty. An X-ray showed no evidence of a fracture. What is the name of this injury? Select one: Boutonniere deformity Hammer finger Mallet finger Swan neck deformity Trigger finger

Answer 104

The injury described in the scenario is called mallet finger. Explanation: • Mallet finger occurs when the extensor tendon at the distal interphalangeal (DIP) joint is damaged, leading to an inability to extend the distal phalanx. This injury typically results from a sudden impact on the outstretched finger, causing the tendon to tear or avulse. The description of the distal phalanx being flexed at the DIP joint and the inability to extend it voluntarily fits the classic presentation of mallet finger. • Boutonniere deformity involves flexion of the proximal interphalangeal (PIP) joint and hyperextension of the DIP joint, typically due to injury to the central slip of the extensor tendon at the PIP joint. • Hammer finger is not a standard term in this context and is often used interchangeably with mallet finger, although it is less commonly used. • Swan neck deformity is characterized by hyperextension of the PIP joint and flexion of the DIP joint, commonly seen in conditions like rheumatoid arthritis. • Trigger finger occurs when a finger gets stuck in a bent position and then straightens with a snap, due to the inflammation of the flexor tendon sheath. Correct Answer: Mallet finger

Question 105

A 25-year-old woman falls from a horse and sustains a cervical spine injury. On arrival at the Emergency Department, she is assessed and stabilised as per the ATLS principles. During the secondary surgery examination she has 5/5 power in elbow flexion and 0/5 power below this level bilaterally. Sensation is normal on the lateral aspect of the arm over the deltoid region down to the elbow but is abnormal from the elbow down to the hand bilaterally. Perianal sensation is intact. How would you describe the spinal cord injury? Select one: C4 Complete injury C4 Incomplete injury C5 Complete injury C5 Incomplete injury C6 Incomplete injury

Answer 105

The clinical scenario describes a 25-year-old woman with a cervical spine injury resulting in 5/5 power in elbow flexion and 0/5 power below this level bilaterally, with abnormal sensation from the elbow down to the hand bilaterally, and intact perianal sensation. This implies that the injury is at the C5 level, affecting both motor and sensory functions below this level, but sparing functions at C5 and above. Key Points: • Elbow flexion (C5): Intact (5/5 power) • Below elbow (C6 and below): 0/5 power bilaterally • Sensation: Normal on lateral aspect of arm over deltoid region down to elbow, abnormal from elbow down to hand bilaterally • Perianal sensation: Intact (suggests sacral sparing) Interpretation: • Level of Injury: C5 • Nature of Injury: Incomplete, because perianal sensation is intact, indicating some preservation of function below the level of injury. Answer: C5 Incomplete injury An incomplete spinal cord injury means that there is some preservation of sensory or motor function below the level of injury, which is evident in this case by the intact perianal sensation.

Question 106

A 25-year-old motorcyclist is admitted following a high speed road traffic collision. He is paraplegic with a sensory level at T5. He is noted to have priapism. Which one of the following is the most likely explanation of the priapism? Select one: Excitation of the sympathetic trunk Loss of inhibition of the parasympathetic nervi erigentes Loss of inhibition of the sympathetic output Pudendal nerve lesion Sacral root lesion

Answer 106

In the context of a spinal cord injury resulting in paraplegia and a sensory level at T5, the presence of priapism (persistent penile erection) is often due to the autonomic nervous system’s response to the injury. Key Points: • Spinal Cord Injury: At the T5 level. • Paraplegia: Loss of motor and sensory function below T5. • Priapism: Persistent penile erection. Autonomic Nervous System and Priapism: • Sympathetic Nervous System: Normally inhibits erections through vasoconstriction. • Parasympathetic Nervous System: Facilitates erections through vasodilation (nervi erigentes originate from S2-S4). Explanation: The most likely explanation for priapism in this patient is loss of inhibition of the parasympathetic nervi erigentes. This occurs because the spinal cord injury disrupts the sympathetic control that normally inhibits erections, leading to unopposed parasympathetic activity. Answer: Loss of inhibition of the parasympathetic nervi erigentes This loss of inhibition results in priapism due to the unopposed activity of the parasympathetic nervous system, which originates from the sacral spinal cord (S2-S4), leading to vasodilation and erection.

Question 107

A 68-year-old woman presents with symptoms consistent with a prolapsed cervical disc. She reports pain and numbness in the right lateral forearm, thenar eminence and thumb. The biceps and supinator reflexes are absent. At which level is the prolapsed disc most likely to have occurred? Select one: C3/4 C4/5 C5/6 C6/7 C7/T1

Answer 107

The symptoms described in the patient—pain and numbness in the right lateral forearm, thenar eminence, and thumb, along with absent biceps and supinator reflexes—suggest involvement of the C6 nerve root. Key Points: • Pain and Numbness: Right lateral forearm, thenar eminence, and thumb. • Reflexes: Absent biceps and supinator reflexes. Nerve Root Involvement: • C6 Nerve Root: • Dermatome: Lateral forearm, thumb, and thenar eminence. • Myotome: Biceps brachii (elbow flexion) and brachioradialis (forearm supination). • Reflexes: Biceps reflex and brachioradialis (supinator) reflex. Disc Level: • C5/6 Disc: A prolapse at this level would impinge on the C6 nerve root, leading to the symptoms described. Answer: C5/6

Question 108

A 65-year-old farmer presents to the Emergency Department after losing control of a circular saw and sustaining a laceration posterior to the medial malleolus. You examine the wound under local anaesthetic to identify if any structures have been damaged. When working from anterior to posterior, which is the correct order of structures passing behind the medial malleolus? Select one: Extensor digitorum longus tendon, posterior tibial artery, tibial nerve, extensor hallucis longus tendon and tibialis posterior tendon Flexor digitorum longus tendon, posterior tibial artery, tibial nerve, flexor hallucis longus tendon and tibialis posterior tendon Flexor digitorum longus tendon, tibialis posterior tendon, posterior tibial artery, tibial nerve and flexor hallucis longus tendon Tibialis posterior tendon, flexor digitorum longus tendon, posterior tibial artery, tibial nerve and flexor hallucis longus tendon Tibialis posterior tendon, posterior tibial artery, tibial nerve, flexor digitorum longus tendon and flexor hallucis longus tendon

Answer 108

The correct order is option D, when considering the structures responsible for flexing/ extending the toes, flexors run behind the medial malleolus and the extensors pass anterior to the ankle joint. The correct answer is: Tibialis posterior tendon, flexor digitorum longus tendon, posterior tibial artery, tibial nerve and flexor hallucis longus tendon

Question 109

A 4-year-old boy sustains a closed extension-type supracondylar fracture of the humerus. Which one of the following nerves is most likely to suffer a neuropraxia? Select one: Anterior interosseous nerve Axillary nerve Posterior interosseous nerve Radial nerve Ulna nerve

Answer 109

The anterior interosseous nerve is most commonly injured in extension type injuries. Posterior interosseous injury is usually associated with radial head fractures. Ulnar neuropraxia (not listed) is associated with flexion-type injuries; ulna nerve direct injury is commonly associated with surgical fine-wire insertion. The correct answer is: Anterior interosseous nerve

Question 110

A sciatic nerve block is performed just above the popliteal fossa for a patient who is about to undergo ankle fracture fixation under general anaesthetic. Which one of the following areas is likely to have normal sensation post-operatively? Select one: 1st dorsal webspace Anterolateral aspect of the foot Dorsomedial aspect of the foot Lesser toes Sole of the foot

Answer 110

The block will affect branches of the sciatic nerve, but will not affect the terminal branch of the femoral nerve, namely the saphenous distribution providing sensation along the medial border of the foot. The correct answer is: Dorsomedial aspect of the foot

Question 111

You have examined a 12-month-old child in paediatric surgical clinic with a diagnosis of syndactaly of the fingers. You are explaining the diagnosis and history to the parents. Which of the following is correct? Select one: Occurs in 1:1,000, caucasian male preponderance, sporadic inheritance pattern, usually unilateral, commonly affects the 3rd webspace Occurs in 1:3,000, asian female preponderance, autosomal recessive inheritance, usually unilateral, commonly affects the 1st webspace Occurs in 1:3,000, caucasian male preponderance, autosomal dominant inheritance, often bilateral, commonly affects the 3rd webspace Occurs in 1:3,000, caucasian male preponderance, autosomal dominant inheritance, usually unilateral, commonly affects the 1st webspace Occurs in 1:30,000, asian female preponderance, autosomal dominant inheritance, often bilateral, commonly affects the 3rd webspace

Answer 111

Occurs in 1:3,000 More common in caucasians rather than black or asian. More common in males. Autosomal dominant inheritance, often bilateral. Commonly affects the 3rd webspace, rare in the first

Question 112

A 26-year-old woman presents with a cough headache, tingling in the hands, and loss of pinprick and temperature sensation in the hands. An MRI scan shows downward herniation of the cerebellar tonsils and mid-cervical syringomyelia. Which of the following tracts is most likely to malfunction as a result of this pathology? Select one: Corticospinal Dorsal columns Spinocerebellar Spinothalamic Vestibulospinal

Answer 112

The symptoms described, along with the MRI findings, suggest the patient is suffering from Chiari malformation with associated syringomyelia. This condition typically involves the herniation of cerebellar tonsils through the foramen magnum, which can disrupt the flow of cerebrospinal fluid and lead to the formation of a syrinx within the spinal cord. The resulting syringomyelia commonly affects the spinothalamic tract, which is responsible for transmitting pain and temperature sensations. Correct Answer: Spinothalamic Explanation: The spinothalamic tract carries sensory information related to pain and temperature from the body to the brain. In syringomyelia, the syrinx often damages this tract, leading to the loss of pain and temperature sensation, especially in the upper limbs, which matches the patient’s symptoms of loss of pinprick and temperature sensation in the hands. Other tracts and their typical functions: • Corticospinal tract: Carries motor signals from the brain to the spinal cord and is responsible for voluntary muscle movements. • Dorsal columns: Transmit fine touch, vibration, and proprioception from the body to the brain. • Spinocerebellar tract: Conveys proprioceptive information to the cerebellum. • Vestibulospinal tract: Involved in maintaining balance and posture. Given the specific sensory deficits (loss of pinprick and temperature sensation), the spinothalamic tract is the most likely to be affected.

Question 113

A patient suffers injury to the common peroneal nerve following a high fibular fracture. After six months, recovery has been minimal and she complains of persistent foot-drop. Having failed conservative measures, which one of the following tendon transfer procedures would be appropriate? Select one: Extensor digitorum longus Extensor hallucis longus Peroneus brevis Peroneus longus Tibialis posterior

Answer 113

The only tendon unaffected by a common peroneal nerve injury is the tibialis posterior tendon. Despite being a plantar flexor invertor, it can be transferred into the anterior compartment to act as an ankle dorsiflexor. The correct answer is: Tibialis posterior

Question 114

An 18-year-old female motorcyclist is involved in a high-speed road traffic accident. Primary survey reveals a patient in respiratory distress with tracheal deviation towards the left. Breath sounds in the right side of the chest are reduced. What is the most appropriate next step in assessment and treatment of this patient? Select one: Left sided tube intercostal thoracostamy Needle pericardiocentesis Right sided needle decompression thoracostomy Urgent chest radiograph Urgent CT with possible interventional radiology

Answer 114

This is a RIGHT sided tension pneumothorax; the breath sounds are reduced on the right and the trachea is being pushed towards the left. The right side of the chest requires de-tensioning. Decompression of the left side will worsen the clinical situation. The correct answer is: Right sided needle decompression thoracostomy

Question 115

A 75-year-old woman attends to have a left shoulder replacement. A delto-pectoral approach is the approach the surgeon will be using and is a true inter-nervous plane. Which one of the following is the inter-nervous plane? Select one: Axillary nerve and medial and lateral pectoral nerves Axillary nerve and medial pectoral nerve Lateral pectoral nerve and musculotanous nerve Musculotanous nerve and radial nerve Radial nerve and Axillary nerve

Answer 115

The delto-pectoral approach is between the deltoid muscle and the pectoralis major muscle. The nerve supplying the deltoid is the axillary nerve and the nerves supplying the pectoralis major muscle are the medial an lateral pectoral nerves. Pectoralis minor is supplied just by the medial pectoral nerve. The correct answer is: Axillary nerve and medial and lateral pectoral nerves

Question 116

You see a 34-year-old man in the Emergency Department following a road traffic collision. The ambulance crew reported a Glasgow Coma Score (GCS) of 9 with pupils that were equally reactive to light. You record his GCS as 5 and note that he now has a fixed dilated pupil on the right. Which one of the following is the most likely explanation for the pupillary dilatation? Select one: Compression of abducens nerve Direct compression of the midbrain Disruption of ascending sympathetic fibres caused by a carotid artery Ischaemia of the Edinger-Westphal nucleus Loss of parasympathetic innervation of the pupil

Answer 116

The pupil is innervated by autonomic nerve fibres. Parasympathetic fibres cause pupillary constriction, travelling from the Edinger–Westphal nuclei in the midbrain via cranial nerve III to the pupilloconstrictor muscle. Increased intracranial pressure may cause compromise of this pupillary response and is one of the few signs detectable in the unconscious patient. The correct answer is: Loss of parasympathetic innervation of the pupil

Question 117

A 25-year-old motorcyclist presents to the Emergency Department at 23:00 hours with an isolated high energy open fracture of the left tibia. He was wearing full protective clothing and was not in an agricultural or aquatic environment. On examination he has a 7 cm laceration overlying the subcutaneous border of the tibia which is visible and there is soft tissue loss. His pulses are intact distally and radiographs show a spiral fracture of the tibial mid shaft. IV antibiotics have been given and tetanus status checked. Which one of the following is the most appropriate management? Select one: Apply a saline soaked gauze and occlusive dressing to the wound and splint the limb, after manipulation if indicated. Aim for theatre for a joint orthoplastics procedure at the next available opportunity within 12 hours. Prepare the patient to be taken to theatre immediately for lower limb fasciotomies to decompress compartments as this injury is high risk for compartment syndrome. Prepare the patient to be taken to theatre immediately for washout and debridement of the wound and application of an external fixator by the orthopaedic team. Wash the wound in ED with sterile saline and dress it with a betadine soaked gauze. Aim for theatre for a joint orthoplastics procedure at the next available opportunity within 12 hours. Washout the wound in ED with sterile saline and dress with a betadine soaked gauze. Splint the limb, after manipulation if indicated. Aim for theatre for a joint orthoplastics procedure within the next 24 hours.

Answer 117

The British Orthopaedic Association and British Association of Plastic Reconstructive and Aesthetic Surgeons joint guideline for open fractures states that intravenous antibiotics should be administered ideally within 1 hour of injury. Wounds should only be handled to remove gross contamination, dressed with saline soaked gauze and covered with an occlusive film. Washouts in the emergency department are not indicated, nor is betadine soaked dressings. Indications for immediate theatre intervention include highly contaminated wounds (agricultural, aquatic, sewage), arterial injuries and signs of compartment syndrome. For solitary high energy open fractures, the aim is to be in theatre within 12 hours of injury. Initial surgery should be carried out by consultants in orthopaedics and plastic surgery - a combined orthoplastic approach. The correct answer is: Apply a saline soaked gauze and occlusive dressing to the wound and splint the limb, after manipulation if indicated. Aim for theatre for a joint orthoplastics procedure at the next available opportunity within 12 hours.

Question 118

You are asked to review a 50-year-old medical secretary with progressive, radial sided wrist pain. On examination, the pain is worse on ulnar deviation yet range of movement of the wrist joint is good. Radiographs were unremarkable. You suspect a De Quervain's tenosynovitis because of inflammation in the dorsal compartment containing which of the following tendons? Select one: Extensor carpi radialis longus and brevis Extensor carpi ulnaris Extensor indicis and extensor digitorum communis Extensor pollicis brevis and abductor pollicis longus Extensor pollicis longus

Answer 118

De Quervain's tenosynovitis is one of the most common differential diagnoses of the wrist pain. The tendons of the 1st dorsal compartment of the wrist (extensor pollicis brevis and abductor pollicis longus) become inflamed usually related to overuse and less commonly wrist sprain or inflammatory joint disease. The correct answer is: Extensor pollicis brevis and abductor pollicis longus

Question 119

You assess a 3-week-old girl in clinic and the parents explain that there is a history of urine leaking from around the umbilicus. It is associated with local inflammation of the skin. A tentative diagnosis of urachal fistula is made. You present the history to the paediatric surgical team. What do you explain to them? Select one: The urachus develops from the mesonephric duct and drains into the urogenital sinus The urachus develops from the mesonephric duct and drains to the allantoic cavity The urachus develops from the mesonephric duct and drains to the amniotic cavity The urachus develops from the urogenital sinus and drains to the allantoic cavity The urachus develops from the urogenital sinus and drains to the amniotic cavity

Answer 119

The correct answer is: The urachus develops from the urogenital sinus and drains to the allantoic cavity. Explanation: The urachus is a remnant of the fetal connection between the bladder and the umbilicus. During fetal development, the urachus forms from the allantois, which is initially a tube connecting the developing bladder to the allantoic cavity (part of the early embryonic structure involved in waste removal). This connection later obliterates and becomes a fibrous cord called the median umbilical ligament. However, if this obliteration does not occur completely, it can result in anomalies such as a urachal fistula, where urine can leak from the umbilicus. As well as local inflammation, a granuloma may also form. Gram-positive organisms, such as Staphylococcus aureus and Streptococcus pyogenes, are also commonly identified.

Question 120

A 64-year-old presents with headaches and a loss of visual acuity. You examine the visual fields and document that there is loss of visual field represented by the shaded area as right homonymous hemianopia. Which one of the following is the most likely cause of the loss of visual field? Select one: Left optic nerve lesion Left optic tract lesion Pituitary tumour Right optic nerve lesion Right optic tract lesion

Answer 120

The most likely cause of right homonymous hemianopia is: B. Left optic tract lesion Explanation: • Homonymous hemianopia refers to the loss of the same half of the visual field in both eyes. When it is a right homonymous hemianopia, the right half of the visual field is lost in both eyes. • This type of visual field loss occurs due to a lesion posterior to the optic chiasm, such as in the optic tract, lateral geniculate nucleus, optic radiations, or occipital cortex on the opposite side of the visual field loss. • Specifically, a left optic tract lesion will result in a right homonymous hemianopia because the optic tract carries visual information from the contralateral (opposite side) visual field. The other options are incorrect because: • A left optic nerve lesion would affect only the left eye. • A pituitary tumor typically causes a bitemporal hemianopia due to compression of the optic chiasm. • A right optic nerve lesion would affect only the right eye. • A right optic tract lesion would cause left homonymous hemianopia, not right. Thus, the correct answer is a left optic tract lesion.

Question 121

A 71-year-old woman is referred having attended the opticians. She has a bitemporal hemianopia. An MRI scan shows suprasellar extension of a pituitary tumour. Which one of the following is the most likely explanation for the visual field defect? Select one: Bilateral compression of the lateral geniculate bodies Compression of both optic tracts Compression of decussating nasal retinal fibres Compression of the right and left Meyer's Loops Impaired conduction of afferent impulses from the temporal half of the retinae

Answer 121

The most likely explanation for the visual field defect is: Compression of decussating nasal retinal fibres Explanation: • Bitemporal hemianopia refers to the loss of the outer (temporal) half of the visual field in both eyes. This type of visual field defect occurs when there is damage to the decussating nasal retinal fibres at the optic chiasm. These fibres are responsible for transmitting visual information from the nasal half of each retina, which corresponds to the temporal (outer) visual fields. • A pituitary tumor with suprasellar extension is commonly known to compress the optic chiasm from below, affecting the decussating nasal fibres. The other options are incorrect because: • Bilateral compression of the lateral geniculate bodies would not specifically cause bitemporal hemianopia; it would likely result in more complex visual field defects. • Compression of both optic tracts would result in homonymous hemianopia (loss of the same visual field in both eyes), not bitemporal hemianopia. • Compression of the right and left Meyer’s Loops would cause superior quadrantanopia (“pie in the sky” visual field defects) rather than bitemporal hemianopia. • Impaired conduction of afferent impulses from the temporal half of the retinae would affect the nasal (inner) visual fields, not the temporal fields. Thus, the correct answer is compression of the decussating nasal retinal fibres.

Question 122

A 35-year-old construction worker presents with pins and needles of the radial three and a half digits of her hand that wakes her up at night and is worse after using vibrating machinery. You correctly diagnose these symptoms are due to a compressive neuropathy in the carpal tunnel. Which of the following is the correct list of structures that run through the carpal tunnel? Select one: Median nerve, 4 tendons of flexor digitorum profundas, four tendons of flexor digitorum superficialis and flexor carpi radialis tendon Median nerve, 4 tendons of flexor digitorum profundus, four tendons of flexor digitorum superficialis and flexor pollicis brevis tendon Median nerve, 4 tendons of flexor digitorum profundas, four tendons of flexor digitorum superficialis, and flexor pollicis longus tendon Ulna nerve, 4 tendons of flexor digitorum profundas, four tendons of flexor digitorum superficialis and flexor carpi radialis tendon Ulna nerve, 4 tendons of flexor digitorum profundas, four tendons of flexor digitorum superficialis and flexor pollicis brevis tendon

Answer 122

The correct list of structures that run through the carpal tunnel is: Median nerve, 4 tendons of flexor digitorum profundus, four tendons of flexor digitorum superficialis, and flexor pollicis longus tendon Explanation: The carpal tunnel is a narrow passageway on the palmar side of the wrist that allows for the passage of several important structures. The structures that pass through the carpal tunnel are: • The median nerve • 4 tendons of flexor digitorum profundus • 4 tendons of flexor digitorum superficialis • The tendon of flexor pollicis longus Therefore, the correct answer is: Median nerve, 4 tendons of flexor digitorum profundus, four tendons of flexor digitorum superficialis, and flexor pollicis longus tendon