ABSTRACT
In these questions candidates must select one answer only.
A lump is situated above and medial to the pubic tubercle and is felt on the tip of the finger when the patient coughs on scrotal invagination. The most likely diagnosis is:
Indirect inguinal hernia
Direct inguinal hernia
Saphena varix
Psoas abscess
Femoral hernia
A 50-year-old man presents with a groin lump. The lump disappears when the man lies down. He has marked varicose veins. The lump has a fluid thrill. The most likely diagnosis is:
Psoas abscess
Direct inguinal hernia
Saphena varix
Femoral artery aneurysm
Femoral hernia
A 48-year-old woman complains of lower back pain radiating down the buttock, back of thigh and lateral side of the leg to the foot. She also complains of altered perianal sensation and urinary incontinence. The most appropriate management would be:
Bedrest
Lumbosacral corset
Surgical decompression
NSAIDs
Physiotherapy
A 58-year-old man presents with progressive dysphagia to liquids. Of note he has a left recurrent laryngeal nerve palsy. Appropriate management includes all of the following EXCEPT:
Chest radiograph
LFTs
Contrast swallow
Upper gastrointestinal (GI) endoscopy and biopsy
Total parenteral nutrition
154Acute pancreatitis may be caused by all of the following EXCEPT:
Diabetes mellitus
Alcoholism
Hyperparathyroidism
Cholelithiasis
Corticosteroids
Two days after a right total hip replacement, a 60-year-old obese woman develops shortness of breath. Temperature is 37°C, blood pressure 140/85 and respiratory rate 35/min. On examination she has a swollen right leg. The most likely diagnosis is:
Lymphoedema
Deep venous thrombosis
Pleurisy
Pulmonary embolus
Haematoma
Appropriate measures include all of the following EXCEPT:
Intravenous heparin bolus followed by heparin infusion
Subcutaneous fragmin
Oxygen
Pulmonary angiogram
Chest radiograph
A 55-year-old man complains of rectal bleeding. He is noted to have freckles on his lips. His father also has freckles on the lips and underwent bowel surgery but he is not sure why. The most likely diagnosis is:
Crohn’s disease
Ulcerative colitis
Peutz – Jeghers syndrome
Hereditary haemorrhagic telangiectasia
Familial adenomatous polyposis
On preoperative examination, you find a brown, raised, 1-cm lesion on a patient’s calf, with irregular borders and ulceration. The next most appropriate step would be:
Palpate the groin for inguinal lymphadenopathy
Take an incisional biopsy of the lesion
Rebook the patient for excisional biopsy
Arrange for a chest radiograph
Notify your senior colleague
155Calot’s triangle is important to visualize in the following surgical procedure:
Abdominal aortic aneurysm repair
Abdominoperineal resection
Mastectomy
Laparoscopic cholecystectomy
Renal transplantation
A tall 20-year-old man presents with marked dyspnoea and chest pain. On chest auscultation, there are no breath sounds on the left side, with hyperresonance on percussion. He has just returned from a trans-Atlantic trip to the USA. He is on 100% oxygen and is turning blue. The most likely diagnosis is:
Subcutaneous emphysema
Tension pneumothorax
Pulmonary embolus
Bacillus anthracis
Status asthmaticus
The most appropriate management would be:
Obtain a chest radiograph
Insert an intercostal chest tube and attach to underwater seal
Intravenous heparinization
Administer ciprofloxacin i.v.
Needle decompression
A 40-year-old man presents with haematemesis. He smells of alcohol. After resuscitation with oxygen, intravenous fluids and blood products, what is the next most important step in management?
Contrast swallow
Upper GI series
Endoscopy
Blood for LFTs
Chest radiograph
A 30-year-old man presents with a painless swollen right testicle. Appropriate management would include all of the following EXCEPT:
Blood for hCG and α-fetoprotein
Scrotal ultrasonography
CT scan of the abdomen
Chest radiograph
A 12-lead ECG
156A 36-year-old woman presents with cyclical bilateral breast pain. Appropriate management after excluding sinister causes includes all of the following EXCEPT:
Evening primrose oil
Oral contraceptive pill
Danazol
Gamolenic acid
Bromocriptine
A 32-year-old woman presents with a right breast lump and right breast pain. On examination she has a tender 1-cm breast lump. The most appropriate management in the clinic would be:
Fine-needle aspiration
Ultrasonography of the breasts
Mammogram
Tru-Cut biopsy
List for excisional biopsy
A 40-year-old man on high-dose steroids and azathioprine for acute exacerbation of his Crohn’s disease now presents with severe upper abdominal pain and vomiting. The most likely diagnosis is:
Small bowel obstruction
Perforated peptic ulcer
Acute cholecystitis
Toxic megacolon
Ischaemic colitis
The most useful initial investigation would be:
Upright chest radiograph
Abdominal radiograph
Endoscopy
Contrast swallow
Abdominal ultrasonography
A mammogram shows microcalcifications. The most appropriate management would be:
Repeat mammogram immediately
Breast ultrasonography
Needle-guided breast biopsy
Nil
Repeat mammogram in 1 year
157Two days after coronary artery bypass graft, a 50-year-old man complains of severe abdominal pain, distension and vomiting. The serum amylase is elevated with high leucocytosis. Plain abdominal radiograph shows an ileus. The most likely diagnosis is:
Acute mesenteric ischaemia
Ruptured abdominal aortic aneurysm
Acute pancreatitis
Perforated peptic ulcer
Small bowel obstruction
The definitive investigation to confirm the suspected diagnosis is:
Barium enema
Colonoscopy
Angiography
CT scan of the abdomen
Abdominal ultrasonography
A 70-year-old woman falls onto her outstretched hand. A radiograph reveals a proximal humeral fracture. The most likely nerve to be damaged secondary to her fracture is:
Ulnar nerve
Radial nerve
Axillary nerve
Tibial nerve
Median nerve
The patient will be unable to carry out the following manoeuvres:
Abduct her shoulder
Supinate her forearm
Pronate her forearm
Make a fist
Adduct her wrist
The following statements about the treatment of breast cancer are true EXCEPT:
Locoregional breast cancer may be treated with wide local excision + radiotherapy
Locoregional breast cancer may be treated with mastectomy and radiotherapy to the flaps
If the sentinel node biopsy is positive, proceed to axillary node clearance
Primary chemotherapy may be used to treat inflammatory breast cancer
Postmenopausal women with breast cancer and positive oestrogen receptors should be offered tamoxifen
158A fine-needle aspirate cytology is sufficient to diagnose all of the following EXCEPT:
Papillary thyroid carcinoma
Follicular thyroid carcinoma
Medullary thyroid carcinoma
Anaplastic thyroid carcinoma
Lymphoma
Complications of steroid therapy include all of the following EXCEPT:
Avascular necrosis of the hip
Adrenal hyperplasia
Peptic ulceration
Acute pancreatitis
Osteoporosis
On routine preoperative examination, a 55-year-old man is found to have a pulsatile midline abdominal mass. The most useful investigation would be:
CT scan of the abdomen
Digital subtraction angiography
Ultrasonography of the abdomen
Abdominal radiograph
MRI of the abdomen
The following statements regarding testicular tumours are correct EXCEPT:
Seminomas usually present in men in their 40s
Teratomas are radiosensitive
Cryptorchism is a risk factor
The contralateral testicle should be biopsied, if there is a history of infertility
After orchidectomy the disease is staged by chest and abdominal CT scans
A parotid mass is most likely to be malignant if the following feature is present:
Facial nerve palsy
Pain
Recent enlargement
Foul duct discharge
Stenosed ductal meatus
159A 65-year-old man presents with a 2-month history of vague lower abdominal pain, alternating diarrhoea with constipation and 4-kg weight loss. He has passed a small amount of dark red blood per rectum. There is anaemia. The most likely diagnosis is:
Diverticular disease
Crohn’s disease
Ulcerative colitis
Angiodysplasia
Carcinoma of the colon
A 65-year-old woman presents with blood per rectum and weight loss. The most useful investigation would be:
Barium enema
Sigmoidoscopy
Colonoscopy
Endoscopy
Proctoscopy
A 20-year-old woman presents with a wrist laceration. To test the function of the median nerve, you ask her to:
Extend the thumb
Palmar abduct the thumb against resistance
Pinch paper between the thumb and index finger leading to flexion of the DIP (distal interphalangeal) joint
Extend the fingers completely and spread them apart
Adduct the thumb
Charcot’s triad is:
Epigastric pain, jaundice and fever with rigors
Enlarged liver, jaundice and fever with rigors
Palpable gallbladder, jaundice and fever with rigors
Fever, right upper quadrant pain and a palpable mass
Fever with rigors, jaundice and right upper quadrant pain
Courvoisier’s law states that ‘if in the presence of jaundice the gallbladder is palpable, then the jaundice is …’:
Attributable to gallstones
Unlikely to be due to a stone
Likely to be due to a tumour of the head of the pancreas
Due to cholangitis
Likely to be due to carcinoma of the bile duct arising above the origin of the cystic duct
160What is the first diagnostic test for suspected gallstones?
Serum bilirubin
Abdominal radiograph
Ultrasonography
ERCP (endoscopic retrograde cholangiopancreatography)
HIDA (hepatobiliary iminodiacetic acid) scan
The following are causes of acute pancreatitis EXCEPT:
Alcoholism
Biliary tract disease
Oestrogens
Loop diuretics
Mumps
Risk factors for DVT include all of the following EXCEPT:
Total hip replacement
Caesarean section
Malignancy
Cardiac failure
Osteoporosis
What is the definitive investigation for DVT?
Duplex scanning
Doppler ultrasonography
Venous plethysmography
Venography
Ventilation – perfusion scan
What is the most common cause of postoperative renal failure?
Pre-existing renal disease
Hypertension
Renal artery stenosis
Diabetes mellitus
Hypovolaemia
A 60-year-old man has a temperature of 38.5°C without rigors 24 hours postoperatively. The most likely cause of the pyrexia is:
DVT
Pneumonia
Thrombophlebitis
Urinary tract infection
Atelectasis
161A 50-year-old man post-nephrectomy 3 days ago now presents with fever and confusion. On examination there are no breath sounds in the right lung base and no bowel sounds. The most likely diagnosis is:
Aspiration pneumonia
Pulmonary embolus
Atelectasis
Pneumonia
Pneumothorax
A 55-year-old man presents with diarrhoea 3 days after an abdominal aortic aneurysm repair. On examination the abdomen is distended, very tender, with no active bowel sounds. The most likely diagnosis is:
Pseudomembranous colitis
Mesenteric ischaemia
Bowel viscus perforation
Shigella dysentery
Faecal impaction
A 30 year old who is a cyclist is involved in an RTA. He sustains multiple injuries and undergoes open reduction and internal fixation of the right femur. On postoperative day 3 he becomes acutely short of breath. The most useful investigation is:
Arterial blood gas
Chest radiograph
FBC
Blood cultures
A 12-lead ECG
The most likely diagnosis is:
Acute myocardial infarction
Pulmonary embolus
Hypovolaemia due to blood loss
Septicaemia
Chest infection
A 60-year-old man is diagnosed with a tumour of the head of the pancreas. The patient should be offered:
Distal pancreatectomy
Pancreaticojejunostomy
Whipple’s procedure (pancreaticoduodenectomy)
Total pancreatectomy
Multiple drug chemotherapy with radiation
162A 35-year-old woman presents with a 1-month history of a painless firm but mobile 2-cm lump in the upper outer quadrant of her breast. No other abnormalities detected. Initial investigation should be:
Mammogram
Ultrasonography
Fine-needle aspiration cytology
Tru-Cut biopsy
Assessment for BRCA-1 and -2 mutations with sentinel node biopsy
The five ‘Ps’ of arterial insufficiency include all of the following EXCEPT:
Pallor
Paraesthesia
Paralysis
Painless
Pulseless
McBurney’s point is located:
At the outer third of a line joining the umbilicus to the anterosuperior iliac spine
At the outer third of a line joining the umbilicus to the anteroinferior iliac spine
At the inner third of a line joining the anterosuperior iliac spine to the pubic tubercle
At the inner third of a line joining the umbilicus to the anterosuperior iliac spine
At the outer third of a line joining the anterosuperior iliac spine to the pubic tubercle
The borders of Hesselbach’s triangle include the epigastric vessels, the edge of the rectus sheath and the following structure:
Poupart’s ligament (the reflected inguinal ligament)
The internal oblique aponeurosis
The external oblique aponeurosis
Transversalis fascia
The conjoint tendon
A 45-year-old man with a history of ulcerative colitis now presents with nausea, vomiting and abdominal distension. Plain abdominal films show dilatation of the entire colon. The most likely diagnosis is:
Volvulus
Diverticular disease of the colon
Toxic megacolon
Paralytic ileus
Carcinoma
163Medical management of ulcerative colitis includes all of the following EXCEPT:
Methylcellulose
Mesalazine
Predsol suppository
Azathioprine
Loperamide
A 20-year-old man presents with a cut over the right metacarpophalangeal joint. Appropriate management includes all of the following EXCEPT:
Obtain a hand radiograph
Close with sutures using aseptic technique
Prescribe broad-spectrum antibiotics
Debride and irrigate the wound
Swab the wound for culture and sensitivity
The following statements about skin carcinoma are true EXCEPT:
Basal cell carcinoma rarely metastasizes
Squamous cell carcinoma may occur in irradiated tissue
Keratoacanthoma is premalignant
Squamous cell carcinoma grows more rapidly than basal cell carcinoma
Actinic keratoses are premalignant
The different types of malignant melanoma include all of the following EXCEPT:
Superficial spreading
Lentigo maligna
Nodular
Acral lentiginous
Nodular sclerosing
A 60-year-old man presents with sudden, severe, colicky pain and bloody diarrhoea that began after lunch 3 hours ago. He has a history of two myocardial infarctions. On examination: temperature 39°C, BP 130/90, pulse 110/min regular. There is rebound tenderness in the lower left quadrant of his abdomen and there is fresh blood present in the rectum. There is a raised white cell count and mild anaemia. The most likely diagnosis is:
Colon carcinoma
Diverticular disease
Inferior mesenteric artery ischaemia
Superior mesenteric artery thromboembolism
Campylobacter infection
164Treatment options for prostatic adenocarcinomas include all of the following EXCEPT:
Local radiotherapy
Transurethral resection of the prostate (TURP)
Chemotherapy
Cyproterone acetate
Orchidectomy
Complications of burns include all of the following EXCEPT:
Stress ulcer
ARDS (acute respiratory distress syndrome)
Adynamic ileus
Sepsis
Hypoglycaemia
A 25-year-old woman presents with a 4-year history of intermittent bloody diarrhoea, abdominal pain and fever. Stool cultures are negative. Barium enema studies reveal loss of haustral markings in the colon. Sigmoidoscopy shows an erythematous and friable mucosa. The most likely diagnosis is:
Crohn’s disease
Diverticulosis
Peutz – Jeghers syndrome
Shigellosis
Ulcerative colitis
A 30-year-old man presents with a crush injury to the right anterior leg. The leg is swollen, painful and pulseless. The most appropriate management would be:
Fasciotomy
Arteriogram
Plain radiograph of the leg
Duplex scanning
Start heparin infusion
Indications for carotid endarterectomy include all of the following EXCEPT:
Recurrent transient ischaemic accidents (TIAs)
Non-stenotic atherosclerotic ulcers
Total occlusion of the internal carotid artery
Reduction in diameter of carotid artery by >70%
Symptomless patients with a high-grade stenosis as prophylaxis against stroke before cardiac bypass surgery
165Malignant melanoma occurring in the following sites are associated with a poorer prognosis stage for stage EXCEPT for:
Back
Neck
Scalp
Trunk
Leg
A 50-year-old man presents with haematuria. MSU reveals a sterile pyuria. This is suggestive of a diagnosis of:
Urinary calculi
Tuberculosis
Glomerulonephritis
Hydronephrosis
Neoplasm
A 55-year-old white man involved in an RTA is found to have blood at the urethral meatus. Management includes all of the following EXCEPT:
Retrograde urethrogram
Pelvic radiograph
Suprapubic catheter
Digital rectal examination
Foley catheterization
Painless haematuria is most likely to be associated with:
Urinary tract infection
Bladder tumour
Gonorrhoea
Sickle cell anaemia
Renal calculi
A 60-year-old woman after right hemicolectomy is found to have glycosuria. This is confirmed by an elevated serum glucose. Possible causes include all of the following EXCEPT:
Sepsis
Pre-existing diabetes mellitus
Parenteral nutrition
Concurrent use of steroids
Liver failure
166A 70-year-old woman presents with dysphagia and regurgitation to solids. She also has halitosis. There is a small lump on the left side of her neck. The most appropriate investigation is:
Barium swallow
Oesophagoscopy
Neck radiograph
Neck ultrasonography
Thyroid function tests
A 40-year-old woman undergoes rigid oesophagoscopy for the removal of a piece of chicken bone. She now presents with severe chest pain. The most likely diagnosis is:
Acute myocardial infarction
Pulmonary embolus
Oesophageal perforation
Boerhaave’s syndrome
Perforated peptic ulcer
Diagnosis is best confirmed on:
Plain, soft-tissue, neck radiograph
A 12-lead ECG
Upright chest radiograph
Gastrografin swallow
Barium swallow
A 20-year-old woman presents with a 5-day history of right iliac fossa (RIF) pain. On examination a mass is palpated in the RIF. The abdomen is soft with active bowel sounds. Possible causes include all of the following EXCEPT:
Ectopic pregnancy
Appendiceal mass
Acute appendicitis
Ovarian cyst
Crohn’s disease
A 19-year-old man presents with abdominal pain. On palpation of the left lower quadrant pain is felt in the right lower quadrant. This phenomenon is known as:
Rebound tenderness
Babinski’s response
Rovsing’s sign
Pemberton’s sign
Froment’s sign
167A 70-year-old woman presents with vomiting. On examination there is a tense and tender groin lump present below and lateral to the pubic tubercle. It is not reducible and there is no cough impulse. The most likely diagnosis is:
Strangulated indirect inguinal hernia
Strangulated direct inguinal hernia
Saphena varix
Psoas abscess
Strangulated femoral hernia
The most likely hernia to strangulate is:
Umbilical
Indirect
Direct
Femoral
Obturator
A 50-year-old obese woman presents with pyrexia, vomiting and upper abdominal pain. On examination there is a palpable mass in the right upper quadrant. The sclerae are white. The most likely diagnosis is:
Biliary colic
Acute cholecystitis
Typhoid fever
Stone in the common bile duct
Hiatus hernia
A 50-year-old man post-cholecystectomy now presents with jaundice. He is apyrexial. His urine is dark and his stools are pale. The most likely diagnosis is:
Carcinoma of the head of the pancreas
Mucocele
Common bile duct stone
Primary biliary cirrhosis
Cholangitis
The most useful investigation is:
ERCP
Ultrasonography
CT scan
Intravenous cholangiography
Barium meal
168Perioperative blood transfusion is detrimental in the following condition:
Aortic surgery
Colonic carcinoma
Total hip replacement
Coronary artery bypass graft
Pancreatic carcinoma
The following are absorbable sutures EXCEPT:
Catgut
Dexon
Vicryl
PDS
Prolene
A 60-year-old man post-TURP presents with convulsions. Blood pressure is 90/50. Laboratory results show hyponatraemia.
The most likely complication is:
Clot retention
Haemorrhage
TURP syndrome
ABO incompatibility
ARDS
Types of staging include all of the following EXCEPT:
Clinical
Radiological
Surgical
Pathological
Historical
Operative treatment for carcinoma of the descending colon is:
Right hemicolectomy
Transverse colectomy
Left hemicolectomy
Hartmann’s procedure
Total colectomy
Investigations in the assessment of a patient with a history of TIAs include all of the following EXCEPT:
FBC
A 12-lead ECG
CT scan of the head
Carotid digital subtraction angiogram
Positron emission tomography (PET)
169The most common cause of mechanical small bowel obstruction is:
Crohn’s disease
Hernias
Carcinoma
Adhesions
Gallstone ileus
A 50-year-old man presents with severe flank pain and haematuria. Appropriate analgesia would be:
Diclofenac
Pethidine
Diamorphine
Co-proxamol
Tramadol
An intravenous urogram reveals a 3-cm stone in the left renal pelvis with dilatation of the calyces. Initial treatment would be:
Percutaneous nephrostomy
Extracorporeal shock wave lithotripsy
Nephrolithotomy
Partial nephrectomy
Extraction using a Dormia basket
Appropriate prophylactic antibiotic for total hip replacement surgery would be:
Penicillin
Cefuroxime
Metronidazole
Amoxicillin
Flucloxacillin
Prophylactic antibiotic of choice for appendectomy is:
Cefuroxime
Penicillin
Metronidazole
Vancomycin
Gentamicin
Management for splenectomy patients includes all of the following EXCEPT:
Preoperative Pneumovax
Preoperative meningococcal vaccine
Preoperative Hib vaccine
Life-long amoxicillin
Life-long penicillin
170Prophylactic antibiotic of choice for cardiac valve replacement operations is:
Penicillin
Cefuroxime
Co-amoxiclav
Vancomycin
Flucloxacillin
Components of an audit cycle include all of the following EXCEPT:
Implementing change
Selecting a topic
Observing practice
Comparing practice with standards
Managing risk
The best investigation of choice for assessing the severity of acute pancreatitis is:
Dynamic CT scan
Serum amylase
Abdominal ultrasonography
Urinary amylase
ERCP
Which specific blood test should be requested for a patient with suspected DVT?
FBC
PT
D-dimers
APTT
Bleeding time
A 75-year-old man presents with urinary retention. On examination he has an enlarged prostate. Blood tests reveal a normal prostate-specific antigen (PSA). Appropriate management includes any of the following EXCEPT:
α Blocker
TURP
Anti-androgen finasteride
Antimuscarinic
Parasympathomimetic
171A 10-year-old boy falls off his bicycle and presents with contusion of the right hand. On examination he has a swollen thenar eminence. He is tender in the anatomical snuffbox. He has weakness of opponens pollicis and normal abductor pollicis brevis function. What is your suspected diagnosis?
Radial nerve palsy
Median nerve palsy
Fracture of the scaphoid
Colles’ fracture
Fracture of the metacarpal bone
A 22 year old who is an intravenous drug abuser has injected into the anatomical snuffbox and is now unable to extend his wrist. What is his diagnosis?
Median nerve palsy
Radial nerve palsy
Ulnar nerve palsy
Scaphoid fracture
Colles’ fracture
A 70-year-old man is noted to have a BP of 170/100. Before starting his medication, the following blood tests should be requested EXCEPT:
FBC
U&Es
Lipids
TFTs
Clotting screen
A 60-year-old man complains of recurrent TIAs. Initial diagnosis is made by:
A 12-lead ECG
CT scan of the head
Intravenous digital subtraction arteriogram of the carotids
Duplex scan of the carotids
Intra-arterial digital subtraction angiography (IADSA)
Complications that can occur with a tracheostomy include all of the following EXCEPT:
Tracheal stenosis
Posterior wall erosion
Displaced tube
Acquired tracheo-oesophageal fistula
Infection with Pseudomonas aeruginosa
172Complications of massive blood transfusions include all of the following EXCEPT:
Depletion of clotting factors
Hypocalcaemia
Hypothermia
Hypokalaemia
Thrombocytopenia
A 60-year-old man on day 1 postoperatively after a Hartmann’s procedure presents with a temperature of 40°C and a BP of 80/50. Urine output is now only 10 mL/h. The most likely diagnosis is:
Septicaemic shock
Cardiogenic shock
Hypovolaemic shock
Neurogenic shock
Anaphylactic shock
Appropriate measures for this man include all of the following EXCEPT:
Blood cultures
Wound culture
Start intravenous cefuroxime and metronidazole
Start dopamine
Start furosemide
Patients who have undergone a gastrectomy may need to take a supplement of the following vitamin:
Vitamin K
Vitamin B12
Vitamin B6
Vitamin C
Vitamin E
A 49-year-old woman presents with confusion. She is noted to have a serum calcium of 3.2 mmol/L. On examination a 3-cm lump is palpated in her left breast. Management should include the following EXCEPT:
Intravenous fluids
Oxygen
Calcitonin
Bisphosphonates
Tamoxifen
173A 55-year-old woman presents with disfiguring varicose veins. She reports that her legs ache by the end of the day. Examination should include all of the following EXCEPT:
Perform Brodie – Trendelenburg tourniquet test
Check for cough impulse over saphenofemoral junction
Percuss over varix
Check peripheral pulses
Inspect for ankle flare and eczema
Diagnostic investigations include all of the following EXCEPT:
Doppler ultrasonography
Duplex ultrasonic Doppler scan
Varicography
Radionuclide venography
Bipedal ascending plethysmography
A 40-year-old man presents with fever, anal pain and perianal inflammation. On examination you confirm a perianal abscess. The most appropriate management is:
EUA (explore under anaesthetic), investigate and identify (I&D)±biopsy
Conservative treatment with metronidazole
Bedrest and analgesia
Wide local excision with healing by primary suture
Lateral sphincterotomy
Complications of below-knee amputations include all of the following EXCEPT:
Neuroma
Gas gangrene
Osteomyelitis
Contracture
Phantom pain
Signs of inoperable breast cancer include all of the following EXCEPT:
Peau d’orange
Skin ulceration
5-cm breast lump
Satellite nodules
Chest fixity
174A 55-year-old woman with metastatic breast disease now has a pathological fracture of the right femur. The most appropriate management would be:
Intramedullary nail
Internal fixation with plate and screws
Radiotherapy
Skin traction
Chemotherapy with CMF (cyclophosphamide, methotrexate, 5-fluorouracil)
The UK National Breast Screening Programme currently advises mammography every 3 years to women aged between:
40 and 65
45 and 64
50 and 70
45 and 60
35 and 59
Lateral neck lumps include all of the following EXCEPT:
Cystic hygroma
Branchial cyst
Tuberculous cervical adenitis
Carotid body tumour
Dermoid cyst
A 20-year-old man is brought to A&E complaining of headache and drowsiness. On examination he has a boggy swelling over the left side of his skull. The left pupil is dilated and unresponsive to light. The most likely diagnosis is:
Cerebral malignancy
Extradural haemorrhage
Subdural haematoma
Meningitis
Subarachnoid haemorrhage
The most common site of diverticulitis in the colon is within the:
Ascending colon
Descending colon
Rectum
Sigmoid
Transverse colon
175A 17-year-old young man fell on to the crossbar of his bicycle and now complains of pain in his scrotum. On examination he has a haematoma in the perineum and scrotum, and blood from the urethral meatus. He has the urge to urinate but cannot due to pain. He has a palpable bladder. Initial measures may include all of the following EXCEPT:
Broad-spectrum antibiotics
Ascending urethrography using a water-soluble contrast
Passage of a urinary catheter per urethra
Insertion of a suprapubic catheter
Analgesia
Of the following list of complications, total hip replacement surgery has the highest risk of:
Death
DVT/PE
Wound infection
Urinary retention
Sciatic nerve damage
A 50-year-old man presents with severe abdominal pain radiating to his back. His blood pressure is 80/40 with a pulse rate of 120. The following measures should be taken EXCEPT:
CT scan of the abdomen
A 12-lead ECG
Type and crossmatch 10 units of blood
Give blood or plasma expanders via a central line
Crash induction of anaesthesia in the operating theatre
The patient is anaesthetized and on the table. You are a junior doctor on a busy vascular service at a district general hospital and the registrar informs the theatre that he is on his way but is delayed. There is no specialty registrar on duty and the consultant is at home. The anaesthetist is unable to sustain the patient’s BP. He tells you to open the patient. You decide to perform a long midline abdominal incision. You confirm a ruptured aortic aneurysm. You could buy time by all of the following EXCEPT:
Put your hand over the hole in the aorta
Place a clamp over the neck of the aneurysm
Insert a large Foley catheter on an introducer through the rupture and inflate the balloon
Place a clamp over the suprarenal aorta
Suction the blood from the abdominal cavity
176A 35-year-old woman presents with shortness of breath following a subtotal thyroidectomy. Likely causes include all of the following EXCEPT:
Laryngeal oedema
Haemorrhage into the paratracheal space
Aspiration of vomit
Unilateral or bilateral vocal fold palsy
Pulmonary embolus
Likely complications occurring after laparoscopic cholecystectomy include all of the following EXCEPT:
Bleeding
Jaundice
Biliary peritonitis
Umbilical hernia
Paralytic ileus
Initial investigations for jaundice should include all of the following EXCEPT:
LFTs
Hepatitis A, B and C virology
Urine for bilirubin and urobilinogen
ERCP
EBV and CMV serology
What is the best technique for managing retained common bile duct stones?
ERCP and sphincterotomy
Endoscopic removal or destruction of stones via a T-tube tract
Surgical exploration
Electrohydraulic or laser lithotripsy
Irrigation down a T tube with saline
A 22-year-old man presents with a gunshot wound to the right anterior thigh. You are unable to palpate any distal pulses and the leg is cold. You are also unable to detect any pulses by Doppler ultrasound probe. The next step should be:
Urgent fasciotomy
Urgent arteriography
Surgical exploration
Radiograph of leg
Ascending plethysmography
177A 55-year-old man presents with having lost a stone over the last 6 months. He has smoked three packs of cigarettes per day over the last 35 years. On examination he has distended neck veins and a puffy face. The most likely cause is:
Congestive heart failure
Enlargement of bullae
Obstruction of the superior vena cava
Pulmonary embolus
Thrombosis of the subclavian vein
Best management for pyloric stenosis is:
Hydrostatic reduction by barium enema
Ramstedt’s pyloromyotomy
Duodeno-duodenostomy
Exploratory laparotomy
Bedrest and intravenous fluids
A 16-year-old young man presents with acute onset of severe testicular pain and swelling. There is no history of trauma. The cord is thickened and the testis is tender, hot and swollen. Management should be:
Take urethral swabs and MSU
Give doxycycline and ciprofloxacin
Obtain consent and place on emergency list for possible orchidectomy and bilateral orchidopexy
Obtain ultrasonography of the testis
Take blood for serum βhCG and α-fetoprotein
The surgical procedure of choice for ulcerative colitis is:
Hartmann’s procedure
Panproctocolectomy
Subtotal colectomy and RIF end-ileostomy
Restorative proctocolectomy
Split-loop ileostomy
A 70-year-old man presents with profuse per rectum bleeding. He has a history of aortic valve replacement. Management may include all of the following EXCEPT:
Colonoscopy
Barium enema
Radiolabelled red cell scanning
Proctoscopy and sigmoidoscopy
Selective mesenteric angiography
178Treatment for angiodysplasia is:
Right hemicolectomy
Sigmoid colectomy
Subtotal colectomy
Colonoscopic laser or diathermy
Conservative treatment with blood transfusions
A 65-year-old woman presents with fever, vomiting and severe left lower abdominal pain. On examination she has rebound tenderness and left iliac fossa guarding. The most appropriate management would be:
Intravenous broad-spectrum antibiotics and barium enema
Flexible sigmoidoscopy
Laparotomy and Hartmann’s procedure (subtotal colectomy with ileostomy and closure of the sigmoid colon at the peritoneal reflection)
Drainage and proximal loop colostomy
Resection with primary anastomosis
The correct 5-year survival rate for Dukes’ stage B rectal carcinoma is:
68%
50%
40%
26.5%
16.4%
Stigmata of liver disease include all of the following EXCEPT:
Xanthomas
Palmar erythema
Gynaecomastia
Volkmann’s contracture
Clubbing
Cholangiocarcinoma is associated with which parasite?
Echinococcus granulosus
Entamoeba histolytica
Schistosoma mansonii
Giardia lamblia
Clonorchis sinensis
179A 55-year-old homeless man presents with profuse haematemesis. He is unkempt and smells of alcohol. On examination his BP is 85/50 and pulse 130, and he has tender hepatomegaly and spider naevi. The most likely diagnosis is:
Oesophageal varices
Perforated peptic ulcer
Mallory – Weiss tear
Gastric varices
Angiodysplasia
Appropriate management after resuscitation includes all of the following EXCEPT:
Arrange urgent endoscopy
Crossmatch 6 units of blood
Consider Sengstaken – Blakemore tube to tamponade bleed
Administer octreotide
Commence cimetidine
You are obtaining consent from a patient for partial gastrectomy and discuss the risk of dumping syndrome. Which symptom is NOT associated with this syndrome?
Palpitations
Diarrhoea
Diaphoresis
Faintness
Nausea after eating
Causes of sclerosing cholangitis include all of the following EXCEPT:
Ulcerative colitis
Crohn’s disease
Carcinoma
Gallstones
Previous biliary surgery
A 40-year-old woman undergoes laparoscopic cholecystectomy. This is converted to an open cholecystectomy on the table. Four days later she develops spiking temperatures to 40°C. Chest radiograph, MSU and blood cultures are clear. White cell count is raised with predominantly neutrophils. What is the next investigation?
CT scan of the abdomen
ERCP
Ultrasonography
Abdominal radiograph
Peritoneal tap
180The most likely diagnosis is:
DVT
Pulmonary atelectasis
Subphrenic abscess
Retained stones in the common biliary duct
Anaphylaxis
A 70-year-old man undergoes right total knee replacement; 12 hours postoperatively you are called for poor urine output of 100 mL in the last 8 hours. On examination, he is pale and dyspnoeic. His BP is 88/58 with a pulse of 110. His pulse oximeter reads 98%. His preoperative Hb was 11 g/dL. He has been on fragmin preoperatively and postoperatively. You check the position of the Foley catheter. The next step is?
Take blood for urgent FBC and crossmatch
Insert a central line
Perform a 12-lead ECG
Arrange a ventilation – perfusion scan
Give boluses of intravenous fluids
Associations with gastric cancer include all of the following EXCEPT:
Pernicious anaemia
Atrophic gastritis
Blood group O
Acanthosis nigricans
Sister Mary Joseph’s sign
A 50-year-old woman who is a secretary complains of tingling and numbness over the right thumb, index finger, middle finger and lateral half of the ring finger, worse at night. She also complains of weakness in holding a book. On examination there is weakness of the thumb abduction and wasting of the thenar muscles. The most likely diagnosis is:
Cervical spondylosis
Carpal tunnel syndrome
Multiple sclerosis
Rheumatoid arthritis
Myasthenia gravis
Treatment for carpal tunnel syndrome includes all of the following EXCEPT:
A splint
Diuretics
Depo-Medrone injection
Arthroscopic division of flexor retinaculum
Propranolol
181A 65-year-old man presents with low back pain and urinary incontinence. On digital rectal examination (DRE), a hard nodular prostate is palpated. Appropriate investigations include all of the following EXCEPT:
Prostate-specific antigen
Isotope bone scan
Transrectal biopsy
Serum acid phosphatase
Carcinoembryonic antigen
The carpal bone that is most likely to become necrotic following fracture is:
Capitate
Hamate
Scaphoid
Lunate
Trapezoid
Risk factors for carcinoma of the oesophagus include all of the following EXCEPT:
Alcohol
Smoking
Achalasia
Barrett’s oesophagus
Blood group A
Clinical findings with pneumothorax include all of the following EXCEPT:
Increased vocal fremitus
Increased vocal resonance
Raised percussion note
Whispering pectoriloquy
Tracheal shift to the same side
The following statements are true regarding blunt chest trauma EXCEPT:
A contused lung goes into pulmonary oedema rapidly
In a normal lung, bacteria are cleared in 4 hours
In a contused lung, bacteria clear in 24 hours
The first two ribs are the easiest to break
Fractured ribs may be repaired by wire fixation
182A 30-year-old woman presents with severe chest pain. She was a driver in a high-speed head-on collision. Her chest radiograph shows a widened mediastinum. The most likely diagnosis is:
Haemothorax
Pulmonary contusion
Mediastinal mass
Possible ruptured aorta
Aortic aneurysm
Your next step would be:
Arrange an urgent CT scan and then transfer the patient to a specialist centre
Transfer the patient directly to a specialist centre
Arrange urgent ultrasonography and then transfer the patient to a specialist centre
Take the patient directly to theatre
Treat the patient conservatively
The anatomy of the coronary arteries can be visualized by:
Cardiac catheterization
MUGA scan
Positron emission tomography (PET) scan
Thallium stress test
Transoesophageal echocardiography
The following statements regarding undescended testes are correct EXCEPT:
Undescended testes must be fixed by 1 year of age
Ultrasonography is a useful investigation in children
A CT scan is not indicated
Most cases are retractile
Surgery is offered to locate the testes via a high Jones’ approach and then to fix the testes
The following statements regarding adenocarcinoma of the stomach are correct EXCEPT:
The tumour is most commonly found in the fundus/cardia
Intestinal gastric carcinoma has a better prognosis than diffuse type
The investigation of choice is a double-contrast barium study + fibreoptic endoscopy
Surgical laparotomy is the best method of staging this tumour
Radical gastrectomy is offered for all stages of the tumour
183A 50-year-old man presents with dysphagia. Endoscopy and biopsies reveal adenocarcinoma at the gastric fundus. CT scan confirms hepatic metastasis. The most appropriate treatment is:
Radical gastrectomy
Re-establish swallowing with recanalization with laser, intubation or bypass
Chemotherapy with epirubicin, cis-platinum and continuous 5FU
Radiotherapy
Palliative resection
The treatment for established ARDS is:
Intravenous broad-spectrum antibiotics
Endotracheal intubation and intermittent positive-pressure ventilation
Respiratory physiotherapy
Fluid replacement with plasma expanders
100% oxygen by facemask
The following statements regarding management of burns are correct EXCEPT:
Full-thickness burns are established by loss of sensation to pinprick
Treatment should include intravenous broad-spectrum antibiotics
Oral opiates are used for analgesia
Fluid replacement is crucial
Blood transfusion may be required
The most accurate investigation for diagnosing the site of a upper gastrointestinal bleed is:
Double-contrast radiography
Angiography
Endoscopy
Chest radiograph
CT scan of the chest
Recognized methods of controlling an upper GI bleed include all of the following EXCEPT:
Nd:YAG laser with endoscopy
Endoscopic diathermy
Endoscopic sclerotherapy
Balloon tamponade
Endoscopic intubation
184Acute osteomyelitis is most commonly associated with:
Streptococcus pneumoniae
Haemophilus influenzae
Salmonellae
Staphylococcus aureus
Streptococcus viridans
A 50-year-old overweight banker complains of retrosternal chest pain, worse on lying flat and stooping down. He smokes 20 cigarettes a day. He takes no medication. The most likely diagnosis is:
Gastric ulcer
Angina
Duodenal ulcer
Costochondritis
Gastro-oesophageal reflux disease
What is the recommended treatment for Helicobacter pylori eradication?
Proton pump inhibitor + amoxicillin + metronidazole for 1 week
H2-receptor blocker + amoxicillin + metronidazole for 2 weeks
Bismuth + amoxicillin + tetracycline for 6 weeks
Bismuth + clarithromycin + proton pump inhibitor for 2 weeks
Bismuth + amoxicillin + metronidazole for 2 weeks
Indications for surgery for duodenal ulcer include all of the following EXCEPT:
Pyloric stenosis
Perforation
Haemorrhage
Lack of patient compliance with medical treatment
Pain
Preoperative management of perforated duodenal ulcer includes all of the following EXCEPT:
Insert a nasogastric tube
Commence intravenous cefuroxime and metronidazole
Replete plasma volume with crystalloid
Insert a Foley catheter and maintain a urine output of 60 mL/h
Give diclofenac i.m. for analgesia
185A 60-year-old man on intravenous cefuroxime and metronidazole for acute diverticulitis now presents with swinging pyrexia and a white cell count of 183 × 109/L. He is tender in the left iliac fossa but does not have peritoneal signs at this stage. The next step should be:
Obtain an urgent abdominal radiograph to exclude bowel obstruction
Obtain an upright chest radiograph to exclude perforation of a diverticulum
Request an ultrasound scan to exclude pericolic abscess
Expeditious surgery
Continue to treat conservatively with intravenous antibiotics
A 60-year-old man presents with vomiting and severe upper abdominal pain radiating to the back. He is sitting forward. He has a history of alcoholism. On examination temperature is 39°C, BP 90/50 and pulse 135/min. His abdomen is rigid with generalized tenderness. Pulse oximeter reads 80% O2 saturation. Useful blood tests include all of the following EXCEPT:
FBC
Arterial blood gas
Serum amylase
Serum glucose
Clotting profile
Chest radiograph shows a small left-sided pleural effusion. Abdominal radiograph shows absent psoas shadow. Blood results are:
WBC
203 × 109/L
Hb
10 g/dL
Platelets
2503 × 109/L
Glucose
12 mmol/L
LDH
400 IU/L
AST
60 IU/L
γ-Glutamyltransferase
100 IU/L
Amylase
1200 IU/mL
The most likely diagnosis is:
Perforated peptic ulcer
Perforated gallbladder
Acute pancreatitis
Ruptured AAA (aortic abdominal aneurysm)
Alcoholic cirrhosis
186A 50-year-old woman returns for her mammogram results. The mammogram reveals spiculation and finely scattered microcalcification. Fine-needle aspiration cytology (FNAC) confirms breast cancer. Further investigations for this patient include all of the following EXCEPT:
LFTs
Chest radiograph
A 12-lead ECG
Bone scan
Ultrasonography of the liver
A 20-year-old man attempts suicide by drinking sulphuric acid. Management should include all of the following EXCEPT:
Total parenteral nutrition
Gastrostomy
Nil by mouth
Steroids
Gentle dilatation with bougies after 3 – 4 weeks
Preoperative management for thyroidectomy should include:
ENT referral for vocal fold check
Type and crossmatch 2 units of blood
Serum calcium level
Subcutaneous fragmin
CT scan of the neck
Indications for thyroidectomy include all of the following EXCEPT:
Retrosternal goitre
Unsightly goitre
Solitary nodule
Fear of radiation
Myxoedema
A 25-year-old obese woman complains of difficulty breathing and swallowing. On examination her breathing is laboured and her trachea is displaced. You ask her to raise her arms above her head. She develops facial congestion and stridor. The most likely diagnosis is:
Retrosternal goitre
Tension pneumothorax
Cervical rib
Oesophageal carcinoma
Globus pharyngeus
187The most appropriate initial investigation is:
Plain chest radiograph + thoracic inlet view of the neck
Ultrasonography of the neck
Endoscopy
Thyroid function tests
Technetium scintiscan
A 70-year-old man presents with left lower abdominal pain and change in bowel habits. A barium enema shows a filling defect in the sigmoid colon. The most likely diagnosis is:
Diverticulosis
Carcinoma
Crohn’s disease
Ulcerative colitis
Familial adenomatous polyposis
Signs of venous hypertension include all of the following EXCEPT:
Ankle flare
Lipodermatosclerosis
Varicose veins
Cellulitis
Shallow ulcers with sloping edges on the medial aspect of the leg
A 60-year-old man presents with acute right leg pain. On examination the leg is white, cold, desensate and pulseless. On-table angiography stops at the adductor canal. The next step is:
Thrombolysis
Reverse saphenous vein graft for femoral – popliteal bypass
Primary stenting to the right iliac artery
Dacron graft for femoral – popliteal bypass
Reverse saphenous vein graft for femoral – posterior tibial bypass
A 50-year-old woman presents with pain and a cold right leg for 4 h. On examination her pulse is irregular with a rate of 120. She has a history of mitral valve disease. The most likely diagnosis is:
Femoral artery embolism
Popliteal aneurysm
Femoral aneurysm
Intermittent claudication
Deep venous thrombosis
Appropriate investigations for Crohn’s disease include all of the following EXCEPT:
FBC
Barium follow-through
Colonoscopy
ESR, CRP
Sigmoidoscopy
188A 50-year-old woman who underwent a thyroidectomy a week ago now presents with confusion. She also complains of perioral tingling. The most discriminating investigation is:
Serum glucose
LFTs
FBC and film
Thyroid function tests
Serum calcium
A 55-year-old man presents with a 2-day history of abdominal pain, flatulence and severe foul-smelling diarrhoea. He reports that he drank untreated water from a reservoir in the countryside. The most likely pathogen is:
Giardia
E. coli
Leishmania donovania
Pityrosporum ovale
Plasmodium falciparum
The patient was started on medications. He should be cautioned against drinking:
Lemonade
Grapefruit juice
Tea
Alcohol
Cranberry juice
A 30-year-old woman presents with drooping of the terminal phalanx of her middle right finger. She was making the bed at the time of injury. She is now unable to extend the tip of her finger. The most likely diagnosis is:
Bennett’s fracture
Ulnar nerve injury
Median nerve injury
Mallet finger
Flexor digitorum profundus injury
A 40-year-old woman is scheduled for an elective laparoscopic cholecystectomy. Shortly after induction of general anaesthesia she develops a tachycardia, pyrexia and hypotension, and is clenching her jaw. The most likely diagnosis is:
Anaphylaxis
Suxamethonium apnoea
Malignant hyperthermia
Cardiac arrest
Respiratory arrest
189The most likely causative agent is:
Atropine
Halogen
Oxygen
Suxamethonium
Propofol
The intracellular substance that is markedly raised in this condition is:
Calcium
Potassium
Hydrogen
Nitrogen
Sodium
A 30 year old who is a builder presents with a swelling in the upper arm that appears on elbow flexion. He says that he lifted a pile of bricks yesterday when he felt a snapping sensation in the upper arm region. The most likely diagnosis is:
Adhesive capsulitis
Rotator cuff injury
Shoulder dislocation
Rupture of long head of biceps
Rupture of short head of biceps
A 60-year-old woman presents with postoperative oliguria. Urine output is 10 mL/h. The central venous pressure (CVP) line reads 10 mmHg. On lung auscultation there are raˆles present. The most appropriate management would be:
Intravenous fluid bolus
Furosemide
Take blood for FBC
Obtain a portable chest radiograph
Commence intravenous broad-spectrum antibiotics
A 45-year-old man presents with right calf pain 1 week after a left hemicolectomy. On examination there is ankle oedema and positive Hoffman’s sign. Ultrasound scan shows a clot in the right femoral vein. The most appropriate management is:
Oral warfarin
Intravenous heparin
Oral aspirin
Intravenous tPA (tissue plasminogen activator)
Intravenous streptokinase
190A 70-year-old man presents with episodes of weakness in the right arm which last for several minutes. He is a long-standing smoker. On examination he is hypertensive and on auscultation a loud left carotid bruit is heard. The most appropriate management is:
Carotid endarterectomy
Cerebral arteriography
Duplex ultrasonography of the carotid arteries
Initiation of heparin therapy
Transoesophageal echocardiography
General factors that delay healing include all of the following EXCEPT:
Thiamine deficiency
Vitamin C deficiency
Chemotherapy
Zinc deficiency
Uraemia
A 65-year-old woman presents with a 4-week history of progressive painless jaundice. Her urine is dark and stools pale. The most likely diagnosis is:
Cholecystitis
Pancreatic carcinoma
Hepatitis
Wilson’s disease
Cirrhosis
A 55-year-old man presents to A&E after a night of drinking. He is unable to give a history as he is drunk but he complains of severe chest pain. On examination he is found to have surgical emphysema. The most likely diagnosis is:
Myocardial infarction
Pneumonia
Inhalation of foreign body
Ruptured oesophagus
Unstable angina
A 40-year-old man presents with a 1-month history of jaundice and malaise. His ferritin level is high and LFTs are elevated. The most likely diagnosis is:
Primary biliary cirrhosis
Pancreatic carcinoma
Haemochromatosis
Stomach carcinoma
Hepatitis
191The most discriminating investigation is:
ERCP
Liver biopsy
Liver ultrasonography
Viral serology
Serum mitochondrial antibodies
A positive Froment’s sign can be elicited in:
Median nerve lesion
Ulnar nerve lesion
Axillary nerve lesion
Radial nerve lesion
Accessory nerve lesion
Repair of an abdominal aortic aneurysm is advocated when the size of the aneurysm is:
>7 cm
>6.5 cm
>5.5 cm
<4 cm
<5.5 cm
A 20-year-old presents with a swollen, tender finger. A radiograph shows a transverse, undisplaced fracture of the proximal phalanx. The most appropriate treatment is:
Closed reduction and cast immobilization
Open reduction and plating
Buddy strapping
Sling
Open reduction and Kirschner wire fixation
An 80-year-old woman presents to A&E after a fall directly on to her hip; she is now unable to weight bear. The leg is shorter and externally rotated. She cannot lift her leg. The most likely diagnosis is:
Femoral shaft fracture
Fractured patella
Pelvic fracture
Fractured tibial spine
Intertrochanteric fracture
