Surgery EMQs (solved just to have the answer)

Theme:PolypsAAdenocarcinomaBAdenomatous polypsCDysplasticDFibroepithelialEHamartomasFMetaplasticGVillous adenoma

The following patients have all presented with colonic polyps. Please choose the most appropriate answer from the list above.

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

Incorrect - The correct answer is Adenomatous polyps

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

Incorrect - The correct answer is Villous adenoma

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

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

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

Peutz-Jeghers syndrome is a dominant hereditary condition, which comprises

Dysplastic

Dysplastic

Fibroepithelial

circumoral pigmentation, and intestinal hamartomas that can occur from the stomach to the rectum. Left untreated these hamartomas can occasionally become dysplastic and eventually cancerous.

Theme:Body FluidsAIntracellular fluid depletionBExtracellular fluid depletionCIntravascular depletionDThird space lossETotal body fluid loss

The following dehydrated patients have all presented to the A&E department. Please choose the most appropriate answer from the list above.

A 25-year-old male presents with severe upper abdominal pain following an alcohol binge. On examination he is tachycardic and hypotensive. Following catherisation he has a urine output of less than 15 mls per hour. His serum amylase is 2432.

Incorrect - The correct answer is Third space loss

This man has acute pancreatitis. Sequestration of fluid from his pancreas has resulted in a third space loss. This explains the elusive loss of extracellular fluid.

A 22-year-old female has recently undergone a total colectomy and formation of end ileostomy for Ulcerative Colitis refractory to medical treatment. She complains of an output from her ileostomy in excess of 3 litres daily. She is clinically dehydrated.

Incorrect - The correct answer is Extracellular fluid depletion

ECF depletion is the most common abnormality of body fluids. It results from excessive or abnormal fluid loses with diminished intake. Decreased urine output and increased specific gravity are the best simple indicators.

A 34-year-old female with known polycystic kidneys has presented with right flank pain. On examination she is pale and clammy, has a tachycardia and is hypotensive. A full blood count reveals haemoglobin of 7.1 g/dl with an MCV within the normal range.

Extracellular f luid depletion

Intravascular depletion

Incorrect - The correct answer is Intravascular depletion

This woman has had a spontaneous haemorrhage into a renal cyst. Bleeding has been extensive and has resulted in a decrease in the intra-vascular volume.

Theme:Hazards of laser surgeryAabnormal skin pigmentationBatmospheric contaminationCeye damageDfire riskEorgan perforationFvenous gas embolismGvessel perforation

For each of the following theatre precautions, which potential hazard of laser surgery is it intending to provide protection against?

Highly efficient 'N95' masks should be used in association with plume evacuators.

Incorrect - The correct answer is atmospheric contamination

N95 masks filter 95% of 0.3 micron paricles. Laser surgery causes tissue vapourisation which can cause alveolar damage and is possibly mutagenic.

Patients undergoing laser surgery to the perianal area should have moistened drapes or a radiopaque, saline-soaked rectal swab.

Incorrect - The correct answer is fire risk

Methane gas (flatus) may be ignited by laser surgery and cause a localised burn. It is important that drapes are not dry and unintentional leakage of gas avoided.

Prominent signs should be placed on theatre doors indicating that lasers are being used.

Extracellular f luid depletion

eye damage

eye damage

venous gas embolism

Incorrect - The correct answer is eye damage

Other theatre staff should be aware of the possibility of laser surgery and wear the appropriate eye goggles before entering.

Theme:Renal calculiAcalcium oxylateBcystineCUric acidDtriple phosphateEpure oxylateFpapillary necrosis

For each case below, choose the SINGLE most likely type of renal calculus from the above list of options. Each option may be used once, more than once, or not at all.

These calculi represent a quarter of all patients who develop gout. They have an acidic urine and the management involves reducing purine intake and alkalinising the urine and taking allopurinol.

Incorrect - The correct answer is calcium oxylate

A 60-year-old lady presents with a renal colic. Sher urinalysis reveals proteus splitting organisms and an alkaline urine. Ultrasound scan and intravenous pyelogram reveal a staghorn calculus.

Incorrect - The correct answer is triple phosphate

A pathologist is sent a stone retrieved from the urine. It is laminated and has areas of black staining. Urinalysis reveals hypercalciuria.

Incorrect - The correct answer is calcium oxylate

The patient has the presence of lysine, arginine, ornithine and cystine in the urine. The disorder is autosomal recessive. The treatment includesurinary alkalinisation and penicillamine.

Incorrect - The correct answer is cystine

cystine

pure oxylate

cystine

Uric acid

A 19 year patient attends her GP with a renal colic. She informs her GP that she has a hereditary disease and that her mother had this problem.

CorrectMost patients have no underlying abnormality to account for stone formation. The abnormalities that cause stones to form involve, abnormal constituents in the urine, stasis or infection. In the first case this is an infective stone - triple phosphate stone. The second case has an herditary condition producing stones suggesting cystinuria. The third case has hypercalciuria and so calcium stones would be expected i.e. calcium oxylate. The fourth case has a hereditary problem which is most likely to be cystinuria rather than primary oxaluria which is an extremely rare condition and presents in young children. By adolesence, renal failure has developed.

Theme:Management of co-existent disease prior to surgeryAantibiotic prophylaxisBBeta blockersCConversion to heparin infusionDdiazepamEthromboembolic deterrent stockingsFMonoamine oxidase inhibitorsGNo medication requiredHphenoxybenzamineIproton pump inhibitorsJSliding scale insulin infusion

For each of the following patients select the most appropriate management from the above list for their co-existent disease process prior to their surgery.

A 43 year lady is planned for a femoral hernia repair. She has noticed the swelling over the last 2 years and in the last 6 months she experiences mild discomfort in the left groin

Incorrect - The correct answer is thromboembolic deterrent stockings

A 36-year-old lady admitted for right mastectomy. She has a strong family history of breast cancer. Staging of the disease revealed no evidence of metastatic disease. She has a known history of deep venous thrombosis following a plane flight 4 years previously

cystine

Conversion to heparin infusion

Conversion to heparin infusion

Incorrect - The correct answer is thromboembolic deterrent stockings

A 40-year-old lady with a body mass index of 30 . She is otherwise completely fit, without any past medical history or medication and is planned for day-case in-grown toe nail excision

Incorrect - The correct answer is No medication required

This woman has no real risks for thromboembolism particularly the toe nail removal.

A 65-year-old insulin dependant diabetic male undergoing high saphenous ligation, stripping and avulsions. He has known diabetic nephropathy with microalbuminuria and back ground diabetic retinopathy.

Incorrect - The correct answer is Sliding scale insulin infusion

This patient is insulin dependent and will need sliding scale insulin during and after the procedure.

A 54 year man was admitted following fresh rectal bleeding. He was taking warfarin on admission and was told by his cardiac surgeon that it was vital to continue on the anticoagulant. The day after admission there is no further evidence of bleeding and he undergoes flexible sigmoidoscopy. A large polyp is found in the sigmoid and his bowel is prepared for full colonoscopy with Sodium picosulphate

Incorrect - The correct answer is Conversion to heparin infusionSurgery on the prepared gastrointestinal tract produces an incidence of wound infection of 6-9%. When dealing with unprepared bowel the incidence rises to 40%. In all gastrointestinal surgery targeted antibiosis is essential. Patients with previous histories of DVT require the use of Thromboembolic deterrent stockings (TEDS) to improve venous return and stasis which occur during immobility. Pelvic surgery and surgery of malignancy increase the risks of developing DVT even higher. Patients with arterial disease in the lower limbs should not be prescribed TEDS because the compression can produce distal ischaemia. Patients undergoing endoscopic polpectomy have a significant risk of bleeding and perforation. Where patients are warfarinised, such as following cardiac valvular surgery, the anticoagulation should be only for the immediate perioperative period. Thus use of heparin infusions facilitates control due to its short half life.

diazepam

diazepam

No medication required

Theme:AmputationABelow knee amputationBTransmetatarsal amputationCSyme's amputationDRay amputation with "racket incision"ESupracondylar amputationFTarsal amputationGHindquarter amputationHChopart's amputationIAbove knee amputation

For each case below, choose the SINGLE most appropriate operation from the above list of options. Each option may be used once, more than once, or not at all.

A 64-year-old man with a tumour of the upper femur.

Incorrect - The correct answer is Hindquarter amputation

A 85-year-old man with pain and deformity of the left knee due to congenital malformation. He was able to walk up to the last 5 years when the pain became unbearable.

Incorrect - The correct answer is Above knee amputation

A gangrenous toe due to peripheral vascular disease with superimposed infection in a 70-year-old diabetic

Incorrect - The correct answer is Ray amputation with "racket incision"

Ischaemic gangrene of the lower leg with ulceration over the medial malleolus and spreading infection proximally

Incorrect - The correct answer is Below knee amputation

A 90-year-old lady who is immobile due to severe osteoartritis in the hips and knees. She has developed marked arterial ulceration in the right lower limb. She is requires full nursing care.

Chopart's amputation

Ray amputation w ith "racket incision"

Hindquarter amputation

Chopart's amputation

Incorrect - The correct answer is Above knee amputationThe indications for amputation are ischaemia, tumours, pain and deformity. 80-90% of amputations are performed for ischaemic gangrene secondary to peripheral vascular disease. Diabetics have large and small vessel disease and a ray amputation of the toes is often the first stage of a series of amputation levels. Where pain and deformity cannot be alleviated by medical means, amputation is the final option. Supracondylar amputations have the advantage of a longer stump which allows the patient to turn in bed, however the stump is usually not long enough to fit an internal knee mechanism prosthesis and thus is unpopular. Where the patient is already immobile, it is may be a practical option.

Theme:Renal calculiAcalcium oxalateBcystineCUric acidDtriple phosphateEpure oxalate

For each case below, choose the SINGLE most appropriate diagnosis from the above list of options. Each option may be used once, more than once, or not at all.

A 60-year-old lady presents with a renal colic. Her urinalysis reveals proteus splitting organisms and an alkaline urine. Ultrasound scan and intravenous pyelogram reveal a staghorn calculus

Incorrect - The correct answer is triple phosphate

A 19 year patient attends her GP with a renal colic. She informs her GP that she has a hereditary disease and that her mother had this problem

Incorrect - The correct answer is cystine

These calculi represent a quarter of all patients who develop gout. They have an acidic urine and the management involves reducing purine intake and alkalinising the urine and taking allopurinol

Incorrect - The correct answer is Uric acid

Tarsal amputation

cystine

calcium oxalate

calcium oxalate

A pathologist is sent a stone retrieved from the urine. It is laminated and has areas of black staining. Urinalysis reveals hypercalciuria

Correct

The patient has the presence of lysine, arginine, ornithine and cystine in the urine. The disorder is autosomal recessive. The treatment includesurinary alkalinisation and penicillamine

CorrectAbout 80% of calculi in the UK are composed of Ca, mainly calcium oxalate; 5% are uric acid; 2% are cystine; and the remainder are magnesium ammonium phosphate (or infection calculi). Most patients have no underlying abnormality to account for stone formation. The abnormalities that cause stones to form involve, abnormal constituents in the urine, stasis or infection. Oxalate and cystine stones are radio-opaque and urate stones are lucent. Primary oxaluria may present with familial renal calculi but this disorder is extremely rare and is associated with childhood renal colic and failure in adolescence. However, familial cystinuria may present with renal colic in young patients and is a familial cause of renal colic. The patient with aminoaciduria has cystinuria which is autosomal recessive.

Theme:Prophylaxis of wound infectionAConventional sterile technique onlyB1 week course of antibiotics rather than 3 dosesCante-grade colonic lavageD2 sachets of Sodium Picosulphate 24 hours pre-opEchlorhexidine shower pre-operativelyFuse of double layer gloves and face masksGuse of laminar air flow in the operating theatreHthe wearing of gas extraction suits for the surgeonsIapplication of topical antibioticsJuse of monofilament suture material

For each case below, choose the SINGLE most important intervention from the above list of options. Each option may be used once, more than once, or not at all.

A 62-year-old lady with jaundice and a pyrexia with suspected stones present in the biliary tree undergoing endoscopic retrograde cholangiopancreatography with the intention to remove the stones with a retrieval basket. Her white blood count is elevated and her bilirubin serum level is five times normal.

calcium oxalate

cystine

Correct

A 56-year-old gentleman admitted for an anterior resection of the rectum for adenocarcinoma of the mid-rectum. He was diagnosed with colonoscopy and has no evidence of metastases. He had subacute bacterial endocarditis 5 years ago and is diabetic.

Correct

A 78-year-old lady with osteoarthritis admitted for elective total hip replacement.

Incorrect - The correct answer is use of laminar air flow in the operating theatre

A 23 year lady undergoing excision of a lipoma from the right forearm. She has no coexistant medical problems and is to be discharged the same day.

Correct

An 80-year-old previously fit gentleman who has been admitted as an emergency with an acute abdomen. He was found to have marked diverticulosis on a barium enema X-ray taken 2 years previously but had been asymptomatic for the last year. On this admission he has peritonitis and is taken to theatre for a Hartmann's procedure.

Incorrect - The correct answer is 1 week course of antibiotics rather than 3 dosesThere is no evidence that sterile adhesive drapes, bowel preparation, prolonged antibiotic prophylaxis, laminar flow theatres or anterogradecolonic lavage reduce the incidence of wound infections in bowel surgery. The organisms that are responsible for wound infections in surgery of the gastrointestinal tract are endogenous (Escherichia coli, Bacterloides fragilis etc.) and not from the skin. Recent evidence implicates bacterial translocation through the bowel wall into the lymphovascular circulation to the wound. In orthopaedic operations the high flow of air in laminar air flow theatres combined with prophylactic antibiotics produces wound infection rates

1 w eek course of antibiotics rather than 3 doses

2 sachets of Sodium Picosulphate 24 hours pre-op

chlorhexidine show er pre-operatively

Conventional sterile technique only

the w earing of gas extraction suits for the surgeons

comparable with the wearing of gas extraction suits by the surgeons and no touch techniques.

Theme:Thyroid cancersAPapillaryBfollicularCteratomaDmedullaryElymphomaFsarcomaGanaplasticHMelanoma

For each case below, choose the SINGLE most appropriate diagnosis from the above list of options. Each option may be used once, more than once, or not at all.

A 44-year-old lady with a family history of Multiple Endocrine Neoplasia type 2a develops a lump palpable in the thyroid gland. She has experienced diarrhoea and undergoes total thyroidectomy with ipsilateral modified block dissection of the neck.

Incorrect - The correct answer is medullary

A 75-year-old lady with a long history of Hashimoto's thyroiditis develops a rapidly growing goitre.

Incorrect - The correct answer is lymphoma

A 45-year-old lady from an endemic goiterous region has a solitary tumour of the thyroid that has spread haematogenously to the lung and bone. Histological examination of the tumour reveals capsular invasion and vascular spread. No nodes are involved.

Incorrect - The correct answer is follicular

A 70-year-old lady presents to her GP with a hard fixed mass in the neck with hoarseness of her voice. A local debulking procedure is performed and a tracheostomy sited.

anaplastic

follicular

anaplastic

teratoma

Incorrect - The correct answer is anaplastic

A 25 year lady presents to his GP with a 2 lumps in her neck which she has noticed in the last 2 weeks. The most prominent lump is palpable in the lateral margin of the anterior triangle of the neck. She is investigated fully by a thyroid specialist who informs her that there requires surgery. She undergoes a total lobectomy with "berry picking" of individual lymph nodes.

Incorrect - The correct answer is PapillaryThyroid neoplasms   may present as a solitary nodule and must be distinguished from benign conditions by performing a history, examination, ultrasound scan and fine needle aspiration cytology. The commonest benign tumours are follicular adenomas whilst papillary represent 70% of all thyroid cancers. Follicular carcinoma represents 15% of all thyroid malignancies but occur at an older age group. Medullary cancers arise from the parafollicular C cells and synthesize calcitonin. Lymphomas are rare, whilst squamous and sarcoma are even rarer with a poor prognosis. Anaplastic tend to occur in the elderly and have a rapid progression with death ensuing within 1 year.

Theme:Soft tissue swellingsANeuromaBDesmoid tumoursCLipomaDBaker's cystEGanglionFNeurofibromaGLeiomyomaHKaposi's sarcomaIRhabdomyosarcoma

For each case below, choose the SINGLE most appropriate diagnosis from the above list of options. Each option may be used once, more than once, or not at all.

These lesions previously used to occur most commonly in Eastern Europeans. They are purple in colour and tend to be multiple. With the increase in AIDS they have been found increasingly on mucosal surfaces.

Correct

lymphoma

Kaposi's sarcoma

The lesions arise from skeletal muscle. They most commonly affect children and can be found in the head, neck, trunk and limbs.

Incorrect - The correct answer is Rhabdomyosarcoma

These lesions are very common and rarely become malignant. They are usually asymptomatic but may be multiple and painful.

Incorrect - The correct answer is Lipoma

These are rare tumours which may be part of a genetic syndrome. They are composed of highly vascularized fibrous tissue and they are not malignant. Reccurrence is common and most frequently found in the abdominal wall.

Correct

These lumps arise following trauma. The cells regenerate in a disorganized manner. They are often found in amputation stumps and are may produce pain.

Incorrect - The correct answer is NeuromaWhen examining lumps   , the site, size, consistency and colour are important to assess. The regional lymph must also be examined since malignant tumours may have spread along its lymphatic drainage. Lipomas are characterised by soft rubbery tissue and can transilluminate. Associated with Dercum's syndrome when multiple. Kaposi's sarcoma used to be found more frequently in Eastern Europeans but are now recognised as an AIDS defining illness. They are purple papaular lesions and can be found on the mucosal surfaces. Of the lesions suggested, rhabdomyosarcoma arises from muscle, and neuromas from neurones following regeneration at amputated stumps.

Theme:Skin tumoursAsuperficial spreading malignant melanomaBacral lentiginous malignant melanomaCnodular malignant melanomaDsquamous cell carcinomaEBowen's carcinoma in situFLentigo maligna melanoma

Ganglion

Neuroma

Desmoid tumours

Neurofibroma

GBasal cell carcinomaHChloasmaIMelanocytic naevus

For each case below, choose the SINGLE most likely skin lesion from the above list of options. Each option may be used once, more than once, or not at all.

A 46-year-old lady with a pigmented lesion on her legs. It is irregular in shape with brown and blue discolouration. There is peripheral extension with central regression. Mild inflammation is noted and mild nodularity.

Incorrect - The correct answer is superficial spreading malignant melanoma

A GP noticed an erythematous plaque on the trunk of a retired builder. Biopsy revealed very large keratinocytes with large nuclei and mitotic figures.

Incorrect - The correct answer is Bowen's carcinoma in situ

A 32-year-old lady presents with increasing pigmentation of her skin. She is 4 months pregnant and has no previous medical history.

Incorrect - The correct answer is Chloasma

A 76 year man presents with a skin lesion on his face. It is hyperkeratotic with ulceration. The nodular area on the edge has been noted to be rapidly expanding.

Incorrect - The correct answer is squamous cell carcinoma

A 90-year-old lady has noted that she had developed a pearly nodule on her nose. On examination telangiectasia was noted and at the ulcerated margin the edges were rolled upward.

squamous cell carcinoma

squamous cell carcinoma

acral lentiginous malignant melanoma

nodular malignant melanoma

Chloasma

Incorrect - The correct answer is Basal cell carcinoma

Theme:Perioperative managementAabdominal ultrasound scanBcervical spine X-rayCChest X-rayDCoagulation screenEEchocardiogramFElectrocardiogramGendoscopic retrograde cholangiopancreatographyHexercise stress testIFull blood countJspirometry

For each case below, choose the SINGLE most important investigation from the above list of options. Each option may be used once, more than once, or not at all.

A 55-year-old smoker with a productive cough. He is planned for a high tie and long saphenous strip to the left leg varicose veins

Incorrect - The correct answer is Chest X-ray

Varicose vein surgery requires no specific investigations. However where there is evidence for a chest infection a chest X-ray would be required, especially in a longstanding smoker.

A 35-year-old lady for elective laparoscopic cholecystectomy for cholelithiasis with deranged liver function tests. The alkaline phosphatase is significantly elevated and during her previous acute admission she was investigated with ultrasound scan which revealed multiple calculi in the gallbladder with no bile duct dilatation.

Incorrect - The correct answer is endoscopic retrograde cholangiopancreatography

Patients with calculus cholecystitis routinely undergo delayed cholecystectomy. Abdominal ultrasound is used to assist diagnosis of cholecystitis and may indicate biliary obstruction when jaundice is present. Those with evidence of obstructive jaundice, require either pre-operative endoscopic retrograde cholangiopancreatography or

endoscopic retrograde cholangiopancreatography

Echocardiogram

Intraoperative cholangiogram to identify any stones or biliary sludge persistent in the ducts.

A 58-year-old man undergoing arthroscopy on the right knee for intermittent locking His medication includes warfarin, following a DVT two months ago

Correct

Patients on Warfarin require assessment of their anticoagulant status.

A 75-year-old lady with rheumatoid arthritis admitted for left total hip replacement. Her rheumatoid arthritis has been in remission for 2 years and has never taken immunosuppressants

Incorrect - The correct answer is cervical spine X-ray

This is to screen for cervical spine subluxation.

A 46-year-old lady undergoing Dilatation and Curettage following many years of menorrhagia. She has no known cardiac or respiratory illness, but was a cigarette smoker for 5 years in her twenties

Incorrect - The correct answer is Full blood count

A full blood count should be performed prior to surgery due to the risk of anaemia.Preoperative tests should be performed where clinically indicated, and the results should be available before the patient goes to theatre.

Urea, creatinine, electrolytes, full blood count and blood glucose BM testing shold be carried out in most patients

Crossmatch or Group and Save blood as required by the operation. Specific blood tests:

Liver function tests in Jaundice, alcohol abuse or malignancy Amylase in acute abdominal pain Blood Glucose in diabetic patients Clotting studies in liver disease or if on anticoagulants Thyroid function tests in thyroid disease Sickle cell tests in those from at-risk groups

Chest X ray - if indicated ECG - if indicated Theme:Surgical access to the abdomen

Coagulation screen

Chest X-ray

exercise stress test

Amidline incisionBparamedian incisionCright subcostal incisionDPfannenstiel incisionEUmbilical incisionFFlank (oblique) incisionGRoof top incisionHTransverse incisionISkin crease incision

For each case below, choose the SINGLE most appropriate surgical incision from the above list of options. Each option may be used once, more than once, or not at all.

An 18 year lady undergoing Caesarean section

Incorrect - The correct answer is Pfannenstiel incision

A 21 year man undergoing urgent appendicectomy. He has local peritonism, a pyrexia and a raised white count.

Incorrect - The correct answer is Skin crease incision

A patient with a perforated duodenal ulcer admitted for emergency laparotomy

Incorrect - The correct answer is midline incision

A 61 year lady undergoing a Whipples procedure for carcinoma of the pancreas

Incorrect - The correct answer is Roof top incision

A patient under going insertion of the first port for a laparoscopic cholecystectomy

Roof top incision

Umbilical incision

Umbilical incision

paramedian incision

Transverse incision

Incorrect - The correct answer is Umbilical incision The choice of incision for any surgical procedure is determined by its ability to

gain access to the organs involved, the ability for the incision to be extended, its ease of closure and its cosmetic appearance. The midline laparotomy incision allows access to most of the abdominal organs with incision through the linea alba and safe en-masse closure.

Theme:Types of HerniasAdirect inguinal herniaBepigastric herniaCfemoral herniaDGilmore's groinEincisional herniaFindirect inguinal herniaGinterparietal herniaHlumbar herniaIobtruator herniaJparaumbilical herniaKSpigelean herniaLumbilical hernia

For each case below, choose the SINGLE most probable diagnosis from the above list of options. Each option may be used once, more than once, or not at all.

A 79-year-old man presents with pain in the right iliac fossa and a palpable mass. He had an appendicectomy as a small boy. He has not noted any change in bowel habit. He was investigated 1 year previously for a rectal bleeding when a colonoscopy was performed. It was reported as normal and he underwent sclerosant therapy for piles.

Incorrect - The correct answer is incisional hernia

This patient has a mass in the right iliac fossa following a grid iron incision. The diagnosis is an incisional hernia.

A 45 year lady presents with a painful groin. She is unable to feel a mass at present and there is no cough impulse. She experiences the pain on lifting heavy weights and on one occasion she felt a small lump which vanished on lying horizontal.

Gilmore's groin

paraumbilical hernia

Incorrect - The correct answer is indirect inguinal hernia

It is important here to distinguish between a direct and indirect inguinal hernia. Features that suggest the latter are the fact that this is commoner in females and it reduces in this patient on lying down as suggested by the examination findings.

A 68-year-old retired builder with a painful groin. He has noticed the pain for the last 8 years and that the swelling is increasing in size. He is able to reduce the lump easily.

Incorrect - The correct answer is direct inguinal hernia

This patient who is a retired builder has a lump that is easy to decompress and is suggestive of a direct inguinal hernia due to elevated intra-abdominal pressure.

A 4-year-old boy with an easily reducible protuberance through the umbilicus

Incorrect - The correct answer is umbilical hernia

This is a typical umbilical hernia which does not obliterate following birth and is more common in the black population than caucasian. Surgery should be avoided in children less than 2 years old as it usually obliterates.

A 30-year-old man presents to casualty with lower abdominal pain which radiates to the groin. He has no findings on examination tenderness over the mid inguinal point.

Incorrect - The correct answer is Gilmore's groin

This is a typical story thought to be an early direct inguinal hernia and is more common in sport's people.

Theme:Treatment of peptic ulcerationAProton pump inhibitorsBTruncal vagotomyCSelective vagotomyDHighly selective vagotomy

epigastric hernia

paraumbilical hernia

Spigelean hernia

EGastroenterostomyFUnder-runningGNissen fundoplicationHTotal gastrectomyIOmental patch

For each case below, choose the SINGLE most appropriate treatment from the above list of options. Each option may be used once, more than once, or not at all.

A 64-year-old man attends the outpatient department with a long history of peptic ulcer disease. He has been treated with H2 antagonists and proton pump inhibitors without success. He is dependent on NSAIDs for pain relief. He has continued to have symptoms and now is unable to tolerate the pain.

Incorrect - The correct answer is Highly selective vagotomy

A 29-year-old man, previously fit and well, presents to the casualty department with sudden onset of epigastric pain. On examination he has board-like rigidity of the abdomen and absent bowel sounds. Erect chest x ray reveals a cresenteric area of free gas beneath the left hemidiaphragm.

Incorrect - The correct answer is Omental patch

This is a likely perforation and emergency surgery is required. An omental patch would be used to cover the perforation.

An 82-year-old lady presents to the surgeons with haematemesis. She is hypotensive on admission and despite resuscitation, her blood pressure continues to drop. Endoscopy reveals a bleeding duodenal ulcer which is actively bleeding. Attempts at injection with adrenaline fail.

Incorrect - The correct answer is Under-running

The active bleeding ulcer, which has failed to respond to injection, now requires surgical intervention. Laparotomy with underruming of the ulcer should be performed to stem the haemorrhage

Proton pump inhibitors

Selective vagotomy

Selective vagotomy

A 63-year-old man has been medically treated for a duodenal ulcer for 15 years with good relief of his symptoms. He complains to his GP that he has been feeling bloated and is referred to the hospital. On attending, starts to vomit profusely. He becomes dehydrated and is admitted for rehydration and nasogastric aspiration. The drainage remains high in volume and a contrast x ray reveals a tight stenosis around the site of his duodenal ulcer.

Incorrect - The correct answer is Gastroenterostomy

He has a pyloric stenosis. Gastroenterostomy is the treatment of choice.

A 39-year-executive complains of a short history of epigastric pain. He undergoes upper GI endoscopy and a small duodenal ulcer is found. Gastric biopsy for H Pylori is negative.

Incorrect - The correct answer is Proton pump inhibitors

PPIs are the mainstay of treatment for peptic ulceration. If H Pylori were positive then eradication therapy with PPIs and antibiotics would be required.

Peptic ulceration is now no longer the commonest finding on endoscopic examination of the upper GI tract, it has been overtaken by gastro-oesophageal reflux disease.

Peptic disease may present with mild symptoms or as an emergency with perforation. The vast majority of acute perforations have no previous known history of peptic ulcer disease. NSAIDs are often involved in the aetiopathology.

The advent of proton pump inhibitors has radically changed the treatment of ulcer disease. Surgery is now uncommon and only of use in selected cases where medical treatment has been unsuccessful, e.g. a highly selective vagotomy where medical therapy has failed, is sometimes used. Similarly, with perforation or failure to stop bleeding, surgery is often required.

Theme:Colorectal diseaseAFaecal occult blood testsBColonoscopyCInstant watersoluble contrast enemaDFull blood count

Selective vagotomy

Under-running

ELiver function testsFFlexible sigmoidoscopyGProctoscopyHRectal inspection and digital examinationIStool microscopy and cultureJCLO test

For each case below, choose the SINGLE most appropriate investigation from the above list of options. Each option may be used once, more than once, or not at all.

A 38-year-old man attends his GP with no symptoms. He informs his GP that he has perfect health but has heard that colorectal cancer can be hereditary. His father and grandfather had cancer of the colon at the age of 42 and 46 respectively.

Correct

This patient has a particularly strong family history of premature bowel cancer. The most appropriate for this disorder is colonoscopy. Currently, recommendations suggest that in the presence of two first degree relatives with colon cancer then screening with colonoscopy beginning at age 35 (or five years younger than the earliest case in the family) then every five years thereafter along with yearly fecal occult blood testing (FOBT) should be performed.

A 19-year-old student who complains of a change in bowel habit with bloody diarrhoea following an elective period in Brazil. He has no family history of bowel diseases.

Incorrect - The correct answer is Stool microscopy and culture

This youth has returned from a tropical climate with bloody diarrhoea. Disorders such as shigella or amoebiasis should be considered, and hence stool microscopy with culture should be performed.

A 19-year-old woman complains of three months of rectal pain which occurs during bowel opening. She has noticed hard stools and occasional bright red blood found on the toilet paper.

Colonoscopy

Flexible sigmoidoscopy

Full blood count

Incorrect - The correct answer is Rectal inspection and digital examination

This sounds like simple constipation with anal tears. Inspection and digital examination would suffice.

A 52-year-old businessman presents with a two month history of diarrhoea and weight loss. He has travelled throughout the world during work. He was examined by his general practitioner and underwent stool culture and flexible sigmoidoscopy. He was given a report of his investigation which revealed no abnormality. He has continued with his diarrhoea.

Incorrect - The correct answer is Colonoscopy

The change in bowel habit with weight loss should be considered as sinister, particularly as he has had normal stool cultures and a flexible sigmoidoscopy. A colonoscopy should be performed to look for neoplasia or other colonic disease - IBD etc.

A 68-year-old gentleman with a six month hstory of intermittent diarrhoea and constipation. He reports a 10 kg weight loss over the last three months. The diarrhoea has small flecks of blood present. He is examined in the outpatients and no abnormality found.

Incorrect - The correct answer is Flexible sigmoidoscopy

Again, the history is sinister with weight loss and some flecks of blood. The first investigation, as this patient has undergone examination, should be sigmoidoscopy but if this is normal, colonoscopy is appropriate. There is no point in performing FoB if blood is obviously present.

Theme:Groin swellingADirect inguinal herniaBEncysted hydroceleCFemoral artery aneurysmDFemoral herniaEIndirect inguinal herniaFLymph nodeGMalposition of the testesHSaphena varix

Instant w atersoluble contrast enema

Stool microscopy and culture

The following patients have presented with a groin swelling. Please choose the most appropriate association from the list above.

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

Incorrect - The correct answer is Indirect inguinal hernia

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

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

Incorrect - The correct answer is Lymph node

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

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

Incorrect - The correct answer is Direct inguinal hernia

A direct inguinal hernia comes out directly forwards through the weakened posterior wall of the inguinal canal. The neck of an indirect hernia is lateral to the epigastric vessels while a direct hernia emerges medial to these vessels. Inguinal hernias have a peak incidence in the

Direct inguinal hernia

Malposition of the testes

Malposition of the testes

sixth decade with 65% being indirect. Direct inguinal hernias occur in the middle aged or elderly as an acquired condition. Clinically they present as a diffuse bulgeTheme:Hepatobiliary diseaseACarcinoma of the pancreasBCholangiocarcinomaCCholangitisDGallstone in the common bile ductEInfective hepatitisFMirizzi's syndrome

For each of the following presentations select the most likely diagnosis:

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

Correct

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

Incorrect - The correct answer is Cholangitis

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

Incorrect - The correct answer is Gallstone in the common bile duct

Courvoisier's law states that if in the presence of jaundice the gallbladder is palpable then the jaundice is unlikely to be due to a stone. If the obstruction is due to a stone then the gallbladder is likely

Carcinoma of the pancreas

Cholangiocarcinoma

Infective hepatitis

to be thick, fibrotic and does not distend. The most likely cause here would be a pancreatic carcinoma.

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

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

Theme:Peripheral vascular diseaseAIntermittent claudicationBCarotid stenosisCVaricose veinsDRhabdomyolysisESaphena varixFSturge-Weber syndromeGNeuropathic ulcerHSpinal stenosisISaddle embolusJDeep venous thrombosis

For each case below, choose the SINGLE most likely diagnosis from the above list of options. Each option may be used once, more than once, or not at all.

A 65-year-old man presents with a history of pain in the calf for the last two years. In last six months he was able to walk 300 yards and now is only able to achieve 50 yards. He rests for five minutes between periods of walking.

Incorrect - The correct answer is Intermittent claudication

A 56-year-old diabetic attends his GP complaining of an ulcer on the heal of his foot. He has had diabetes for 20 years and is known to be poorly compliant with his medication. The GP examines his lower limb and elicits a reduction in sensation to vibration and light touch.

Incorrect - The correct answer is Neuropathic ulcer

A 76-year-old man presents to the hospital with an episode of amaurosis fugax. The physician finds a bruit in the left carotid artery and he is sent for duplex colour flow Doppler imaging.

Varicose veins

Varicose veins

Incorrect - The correct answer is Carotid stenosis

A 66-year-old man has undergone an anterior resection of the rectum and is making a slow recovery. He complains that in the middle of the night he has pain in the left calf. On examination he has a tender left calf which is slightly swollen and red. He has been given subcutaneous heparin throughout his hospital stay.

Incorrect - The correct answer is Deep venous thrombosis

A 22 year man presents to the casualty department following an accident at work. A piece of scaffolding fell from 2 metres above him and trapped his left leg. His peripheral pulses are present on arrival in hospital 2 hours after the accident. He is admitted for observation when he becomes hypotensive with a poor urine output.

Incorrect - The correct answer is Rhabdomyolysis

Atherosclerosis affects the entire circulation. Disease in one anatomical region suggests that other regions are also diseased and therefore if a patient has carotid stenosis he may well have intermittent claudication, angina pectoris and an aortic aneurysm.

When taking a history and performing an examination of patients, all vascular regions should be examined. Symptomatic stenosis of greater than 70% in the carotids requires operative intervention with a carotid enarterectomy. Patients with abdominal aortic aneurysms greater than 5-5.5 cm require inlay grafting, and patients with critical ischaemia in their limbs or rapidly deteriorating claudication distance require angioplasty or bypass surgery.

Clearly patients should be assessed for their fitness for surgery, since many have multiple co-existing diseases.

Theme:Clinical audit 2AData analysisBData collectionCIdentify standardsDImplement change

Sturge-Weber syndrome

Sturge-Weber syndrome

Deep venous thrombosis

ENeeds assessmentFRe-audit

Select the most appropriate next step from the list above for the following teams who are undertaking audits:

A vascular team assessing the mortality of patients in ITU/HDU following surgery for abdominal aortic aneurysm have retrospectively collected data over the last five years on 133 patients.

Incorrect - The correct answer is Data analysis

At a recent directorate meeting an ENT consultant has been nominated to undertake the next clinical audit.

Incorrect - The correct answer is Needs assessment

A team presented their audit of post-operative analgesia for GI surgery approximately one year ago from which a number of recommendations were made and changes implemented.

Incorrect - The correct answer is Re-audit

The audit cycle comprises an initial needs assessment where the requirements of the department/section/individual are determined and the actual audit itself determined. Then when what is to be audited is decided upon, it is important to identify the standards against which the audit will be compared. These can be national standards or clinical guidelines determined by the national bodies or even comparisons can be made within the department. Once the standards are set, data collection is undertaken with selection of retrospective or prospective data followed by data analysis. The results can then be presented, compared with the standards and from this recommendations for improvements/implementation of change are/is made. Finally, to assess how effectively these recommendations have been implemented, a re-audit is suggested for some stage in the future. In the case of the ENT team nominated to take on an audit, they have to decide what needs to be audited. The vascular team having collected data on AAA procedures needs to analyse and then present their data. Finally, having presented their data, the a re-audit of post-operative

Data collection

Identify standards

Implement change

pain control is now required to see if the recommendations have been implemented.Theme:Clinical Audit 1AData analysisBData collectionCIdentify standardsDImplement changeENeeds assessmentFRe-audit

Select the most appropriate next step from the list above for the following teams who are undertaking audits:

A surgical team presented their data demonstrating an increased rate of post-surgical wound infection in following GI surgery compared with published standards from the Royal College of surgoens.

Incorrect - The correct answer is Implement change

This group have collected, analysed their data and found a problem. Changes need to be implemented then re-auditted.

A vascular tems intend to compare their results for aortic aneurysm repair with national standards.

Correct

They have specified the standards and can now collect their data

A team wish to audit their departmental results on the use of anticoagulation in patients with atrial fibrillation.

Incorrect - The correct answer is Identify standards

The standards against which the audit should be compared need to be identified.The audit cycle comprises an initial needs assessment where the requirements of the department/section/individual are determined and the actual audit itself determined. Then what is to be audited is decided upon, it is important to identify the standards against which the audit will be compared. These can be national standards or clinical guidelines determined by the national bodies or even comparisons can be

Data analysis

Data collection

Re-audit

made within the department. Once the standards are set, data collection is undertaken with selection of retrospective or prospective data followed by data analysis. The results can then be presented, compared with the standards and from this recommendations for improvements/implementation of change are/is made. Finally, to assess how effectively these recommendations have been implemented, a re-audit is suggested for some stage in the future

Theme:Male infertilityAVaricoceleBHistory of Hodgkin's LymphomaCPeripheral vascular diseaseDMultiple sclerosisEAuto-antibodiesFRetrograde ejaculationGBeta-blocker medicationHDepression

For each case of male infertility choose the SINGLE most likely diagnosis from the list of options.

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

Incorrect - The correct answer is Retrograde ejaculation

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

Incorrect - The correct answer is Retrograde ejaculation

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

Incorrect - The correct answer is Varicocele

Erectile failure in a smoker of 40 cigarettes per day.

Incorrect - The correct answer is Peripheral vascular disease

Erectile dysfunction in a 44-year-old hypertensive.

Varicocele

Peripheral vascular disease

Peripheral vascular disease

Retrograde ejaculation

Correct

Retrograde ejaculation leds to azoospermia and may follow lower urinary tract surgery or scarring.

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

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

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

Theme:Metabolic response to traumaAIncreased utilisation of non-esterified fatty acidsBIncreased nitrogen lossCAnaerobic metabolismDIncreased lung complianceEIncreased Adrenaline levels in the serumFBradycardiaGEndothelial damageHReduced VLDL uptake

For each case below, choose the SINGLE most important physiological change from the above list of options. Each option may be used once, more than once, or not at all.

During the acute (EBB) phase following 40% deep dermal burns

Incorrect - The correct answer is Increased utilisation of non-esterified fatty acids

Where the patient's traumatic insult is overwhelming

Incorrect - The correct answer is Anaerobic metabolism

In the delayed (FLOW) phase, one week after multiple trauma

Incorrect - The correct answer is Increased nitrogen loss

Beta-blocker medication

Bradycardia

Increased lung compliance

Increased utilisation of non-esterif ied fatty acids

During the flight and fright early response to injury

Incorrect - The correct answer is Increased Adrenaline levels in the serum

A 42-year-old lady develops hypoxaemia unresponsive to oxygen therapy on the Intensive Care Unit following severe sepsis from pancreatitis

Incorrect - The correct answer is Endothelial damage

The early metabolic responses to trauma reflect the appreciation of danger with the flight, fright and fight response with predominantly adrenaline release.

Following injury the tissues become damaged and there is a change in the homeostatic mechanisms that compensate for fluid loss.

Plasma hormone levels change with mobilisation of energy reserves and alterations in fuel utilisation. Initiation of acute phase protein responses occur with elevation in ACTH, ADH and aldosterone.

During the more prolonged flow phase which can occur over weeks, increases in metabolic rate occur and insulin resistance, increased skeletal muscle breakdown and loss of lean body mass result in creating nitrogen loss.

During the recovery phase catabolism occurs with subsequent fat restoration.

If failure to appropriately respond to trauma occurs due to organ failure, loss of oxygen delivery and anaerobic metabolism ensues with necrobiosis and death.

Theme:Breast cancer investigationAUltrasoundBFine needle aspiration and cytologyCCore-biopsyDWire-guided biopsyEMammographyFBone scanGFull blood count

Anaerobic metabolism

Bradycardia

HCarcino-embyonic antigenIExcision biopsy

For each case below, choose the SINGLE investigation from the above list of options that is best described below. Each option may be used once, more than once, or not at all.

Performed where other investigations have failed to identify whether a lump is malignant or benign.

Correct

Can be used in symptomatic and asymptomatic patients. 80-95% accurate and part of UK screening programme.

Incorrect - The correct answer is Mammography

Usefully identifies cysts and is able to study abnormal tumour circulation.

Incorrect - The correct answer is Ultrasound

Used in the histological diagnosis of impalpable lesions which are suspicious of malignancy. Requires a general anaesthetic.

Incorrect - The correct answer is Wire-guided biopsy

Very helpful in establishing the presence and extent of metastatic disease.

Correct

The management of a patient with breast cancer requires the achievement of a diagnosis and staging of the disease.

Examination identifies palpable characteristics; ultrasound reveals if the lump is solid or cystic, thin or thick; mammography identifies

Excision biopsy

Wire-guided biopsy

Fine needle aspiration and cytology

Carcino-embyonic antigen

Bone scan

changes in architecture and calcification; and spiculation, cytology or histological examination confirms the presence of malignancy, the type, and hormone receptor status.

Metastatic spread can be identified by CT, MRI and bone scans.

Theme:Benign breast diseaseABenign mammary dysplasiaBCystic diseaseCMastitis neonatorumDLactational breast abscessENon-lactational abscessFDuct ectasiaGFat necrosisHNon-cyclical breast painIFibromatosis

For each case below, choose the single most appropriate diagnosis from the above list of options. Each option may be used once, more than once, or not at all.

A pre-menopausal 42-year-old lady experiences marked premenstrual breast nodularity and discomfort of the upper outer quadrant. Fine needle aspiration cytology is performed and no malignancy is found. A core-biopsy reveals multiple cysts, fibrosis and epitheliosis.

Incorrect - The correct answer is Benign mammary dysplasia

In this case the biopsy with multiple cysts, fibrosis and epitheliosis is characteristic of benign mammary dysplasia.

A 45-year-old lady, pre-menopausal, with a discreet smooth breast lump presents to her GP. Aspiration is attempted and reveals a yellow/brown/green fluid. There is absence of blood-staining. The GP refers her to a breast clinic where she has a mammogram and ultrasound. The lump is no longer present.

Correct

This woman is likely to have cystic breast disease.

Fat necrosis

Cystic disease

A 26-year-old lady presents with a hot, red, swollen lump in her left breast which is very tender. She is one month post partum of her first child.

Incorrect - The correct answer is Lactational breast abscess

The 26-year-old post partum woman has typical features of a breast abscess and this, of course, is likely to be lactational.

A 50-year-old lady describes an intermittent discharge of clear, cheese-like fluid with occasional blood staining. Her nipple has become retracted. Fine needle aspiration (FNA) cytology has been performed and reveals benign cells. Some coarse calcification is seen on her mammogram.

Incorrect - The correct answer is Duct ectasia

The FNA of the 50-year-old woman shows benign breast disease, but the calcification on mammography suggests duct ectasia.

A small lump from the upper outer quadrant of the breast is surgically removed as a day case in a 26-year-lady with no family history of breast cancer. Histological examination reveals proliferation of myelofibroblasts.

Incorrect - The correct answer is Fibromatosis

The 26-year-old with a FH of cancer has proliferation of myelofibroblasts on histology of the lump, and this is typical of fibromatosis.

The investigation of breast disease requires the taking of a history, performance of an examination and specific investigations. Within the history, the patient's characteristics of the complaint should be elicited: risk factors such as family history, menopausal status and hormonal medication.

Specific investigation of a lump requires the use of appropriate investigation which would include mammography, ultrasound and often needle biopsy.

Fat necrosis

Lactational breast abscess

Duct ectasia