Clinical SBAs
Clinical General Surgery: (68 questions)

Questions

• 1
  A 32-year old woman presents with severe abdominal pain and collapse. Which of these diagnoses should be excluded first?
  Difficulty: Easy     Topic: Abdo pain and collapse
  a

  Acute pancreatitis

  b

  Perforated duodenal ulcer

  c

  Oesophageal rupture

  d

  Bowel perforation

  e

  Ruptured ectopic pregnancy
  Explanation: In abdominal pain and shock, the most rapidly life-threatening diagnoses should be excluded: ruptured AAA, ruptured ectopic pregnancy, oesophageal rupture and MI, for example. In a 32-year old woman, pregnancy must be excluded as a ruptured ectopic can cause exsanguination and death in minutes. Oesophageal rupture (Boerhaave's syndrome) is unlikely to be the cause here because the pain is abdominal, rather than in the chest. Perforation of the oesophagus following a history of forceful vomiting and a pleural effusion may be seen on CXR. Bowel and DU perforation are emergencies that require surgery but death within an hour is unlikely. Acute pancreatitis needs supportive management and monitoring.
• 2
  A 43-year old man is listed for a laproscopic repair of a direct inguinal hernia. Where does the neck of his hernia lie?
  Difficulty: Medium     Topic: Inguinal hernias
  a

  Adjacent to the spermatic cord

  b

  At the mid-inguinal point

  c

  At the mid-point of the inguinal ligament

  d

  Inferior to the inguinal ligament

  e

  Medial to the inferior epigastric artery
  Explanation: All inguinal hernias arise superior to the inguinal ligament as they pass through (indirect) or push into (direct) the inguinal canal. Direct inguinal hernias push into the canal through a defect in the posterior wall, an area called Hesslebach's triangle which is bound inferiorly by the inguinal ligament, medially by abdominus rectus and laterally by the inferior epigastric artery. The neck of inguinal hernias lie lateral to the inferior epigastric vessels, and enter the canal at the deep inguinal ring, which is at the mid-point of the inguinal ligament, adjacent to the spermatic cord. The mid-inguinal point is from the pubic symphysis to ASIS and is the location of the femoral pulse.
• 3
  Which of the following statements is true?
  Difficulty: Medium     Topic: Acute abdomen
  a

  Irritable bowel syndrome causes urgency and pain relieved by passing bloody stools

  b

  A restless patient is unlikely to have obstruction of a hollow viscus

  c

  Meckel’s diverticulitis mimics appendicitis

  d

  Familial Mediterranean fever (FMF) is an infective cause of intermittent abdominal pain

  e

  Its more common for gastric ulcers to perforate than duodenal ulcers
  Explanation: Meckel's diverticulum is a vestigial remnant of the vitelline duct and lies within 30cm of the ileocaecal valve therefore inflammation closely mimics appendicitis and diagnosis may only be made on laparotomy. Blood in the stool is not a feature of IBS and prompts investigation even if there is a previous diagnosis of IBS. Patients with colic are likely to be restless, in contrast to those with peritonitis. FMF is a genetic condition that causes recurrent bouts of peritonitis with fever that is non-infectious. DU perforate more frequently than GU because the stomach wall is much thicker than the duodenal wall.
• 4
  A 42-year old woman presents to A&E apyrexial with 1 hour of severe constant right upper quadrant pain. CRP, ALT, ALP and bilirubin are normal. What is the most likely diagnosis?
  Difficulty: Easy     Topic: Constant RUQ pain
  a

  Acute cholecystitis

  b

  Ascending cholangitis

  c

  Obstructive jaundice

  d

  Biliary colic

  e

  Pancreatitis
  Explanation: The pain from biliary colic is usually constant with intermittent increases, unlike renal colic that may completely go between contractions of the ureter. There isn't infection associated with biliary colic and there is no obstruction to bile flow so blood tests are normal. Acute cholecystitis presents similarly plus fever, raised CRP and mildly raised ALP & ALT. Cholangitis causes obstructive jaundice, RUQ and rigors (Charcot's triad). Pancreatitis would have a raised CRP.
• 5
  This man has acromegaly. Diagnosis uses OGTT, demonstrating failure of glucose to suppress GH release. Pituitary adenomas cause bitemporal hemianopia therefore fields are assessed. Best treatment is resection, via a transphenoidal approach. Octreotide (a somatostatin analogue) can be used to antagonise the effects of excess GH while awaiting surgery. Radiotherapy has got some effect but it takes up to 2 years to have an effect therefore is least important of the options given.
  Difficulty: Easy     Topic: Epigastric pain with OA
  a

  Perforated gastric ulcer

  b

  Perforated duodenal ulcer

  c

  Perforated diverticulum

  d

  Acute pancreatitis

  e

  Ruptured abdominal aortic aneurysm
  Explanation: Board-like rigidity is reflex abdominal contraction, which signifies generalised peritonitis - often from perforation. Pancreatitis usually causes localised peritonitis (often in the epigastrum or left upper quadrant), not generalised. The duodenum is retroperitoneal therefore pain is more likely to radiate to the back than for the stomach, also duodenal ulcers are more common than gastric ulcers. Osteoarthritis may mean she has been taking regular NSAIDs, which increase the risk of upper GI ulceration due to a reduction in mucous production. Diverticulitis causes lower abdominal pain and a history of bleeding PR or diarrhoea. Ruptured AAA presents with shock and vomiting is less prominent.
• 6
  A 51-year old man complains of passing bright red blood PR and feeling something coming down from his anus during defecation, which returns by itself. No masses are felt on PR. What degree should this man’s condition be described as?
  Difficulty: Easy     Topic: Bright red blood PR
  a

  1st

  b

  2nd

  c

  3rd

  d

  4th

  e

  5th
  Explanation: This man has haemorrhoids, which are engorged and hypertrophied venous tissues that line the anus and may prolapse. They are normally not palpable on rectal examination, unless thrombosed. 1st degree bleed but do not prolapse. 2nd degree prolapse and reduce spontaneously after defecation. 3rd degree require physical reduction after they prolapse. 4th degree are permanently prolapsed and will not reduce. (There is no 5th degree.) Treatment involves: sclerosants, band-ligation and cryotherapy but there is no consensus on the best treatment.
• 7
  A 55-year old man is recovering from necrotizing pancreatitis caused by gallstones that he suffered from 2 weeks ago. He is found to have an epigastric mass that is difficult to localise and does not move with respiration. Amylase is 327IU/L. What is the most likely diagnosis?
  Difficulty: Easy     Topic: Epigastric masses
  a

  Hepatocellular carcinoma

  b

  Gastric carcinoma

  c

  Alcoholic liver disease (ALD)

  d

  Pseudocyst

  e

  Splenomegaly
  Explanation: A pseudocyst is a collection of fluid in the lesser sac, a complication of necrotizing pancreatitis. It is a retroperitoneal mass therefore is difficult to localise and is a cause of a persistently raised amylase. Hepatocellular carcinoma is the most common malignant primary liver tumour however it almost always occurs with a history of cirrhosis or hepatitis B infection. His pancreatitis was caused by gallstones, which is not a risk factor for cirrhosis or HCC. Gastric carcinoma presenting as a mass will be more easily localised. It causes symptoms of gastric outlet obstruction and does not result in a grossly raised amylase unless there is complete bowel obstruction. Splenomegaly moves with respiration and amylase is not raised. ALD presents as acute liver failure (due to alcoholic hepatitis), decompensation of cirrhosis or asymptomatically with signs of chronic disease.
• 8
  A 50-year old woman presents with intermittent right iliac fossa pain that has lasted 3 hours. She has severe nausea. What is the most likely diagnosis?
  Difficulty: Easy     Topic: Intermittent RIF pain
  a

  Salpingitis

  b

  Meckel's diverticulitis

  c

  Appendicitis

  d

  Nephrolithiasis

  e

  Small bowel obstruction (SBO)
  Explanation: Intermittent pain suggests colic from obstruction of a hollow viscus. Renal colic characteristically causes severe nausea such that analgesia may have to be given PR (indomethacin or other NSAID). SBO causes colicky pain but it would be central with constipation and bloating. 'A-C' are inflammatory in origin therefore tend to cause iliac fossa pain that gradually worsens up to a maximum intensity.
• 9
  Which of the following statements about management of the acute abdomen is incorrect?
  Difficulty: Medium     Topic: Acute abdomen 2
  a

  Laparotomy may be performed without perforation of a viscera

  b

  AXR is required to exclude perforation

  c

  Antibiotics should wait until blood cultures have been taken

  d

  Resuscitation should use crystalloid, not colloid

  e

  Chailaiditi syndrome may mimic bowel perforation
  Explanation: An erect CXR is the imaging method used to look for pneumoperitoneum, which suggests perforation. Laparotomy is performed before perforation in appendicitis and may also have a diagnostic role. Giving antibiotics before taking blood cultures may affect the organisms present and the true sensitivities will not be known. Current research demonstrates no difference between crystalloid and colloid. There are also more adverse effects of colloid e.g. anaphylactoid reactions or pulmonary oedema. Chailaiditi syndrome is the presence of bowel above the liver, which mimics pneumoperitoneum.
• 10
  A 35-year old man presents with acute pancreatitis. Which is the most likely finding on abdominal X-ray?
  Difficulty: Medium     Topic: Abdominal X-ray
  a

  Apple-core sign

  b

  Sentinel loop of bowel

  c

  Coffee bean sign

  d

  Microcalcification throughout the pancreatitis

  e

  Pneumobilia
  Explanation: A sentinel loop of bowel demonstrates a section of ileus that results from localised inflammation with pancreatitis, cholecystitis or appendicitis. The apple core sign shows a stenosing tumour on barium enema. The coffee-bean sign occurs in sigmoid volvulus - a dilated section of large bowel rising out the pelvis. In chronic pancreatitis there may be microcalcification. Pneumobilia is air in the biliary tree, which may be from cholangitis with gas-forming organisms or post-ERCP.
• 11
  A 71-year old lady presents with a 3 month history of intermittent, cramping left iliac fossa pain that is followed by bloody diarrhoea the next day. What is the most likely diagnosis?
  Difficulty: Medium     Topic: Cramping LIF pain
  a

  Angiodysplasia

  b

  Diverticulitis

  c

  Ischaemic colitis

  d

  Microscopic colitis

  e

  Ulcerative colitis
  Explanation: Chronic ischaemia of the colon most commonly affects the splenic flexure and may also cause systemic features of illness (fever & raised WCC). Barium enema characteristically shows a 'thumb print' from swelling of the submucosa. It can lead to strictures or gangrene, requiring emergency surgery. Revascularisation or angioplasty are the main treatments. Diverticulitis is unlikely to have a temporal delay between pain and bloody diarrhoea. Microscopic colitis less frequently causes bleeding.
• 12
  A 70-year old man presents with acute mesenteric ischaemia. Which of the following is least likely to be present?
  Difficulty: Medium     Topic: Acute mesenteric ischaemia
  a

  Peripheral vascular disease (PVD)

  b

  An irregularly irregular pulse

  c

  A raised HbA1c

  d

  Generalised peritonitis

  e

  Hypotension
  Explanation: Acute mesenteric ischaemia most commonly affects the superior mesenteric artery and can be thrombotic or embolic. Classical presentation is severe pain, shock and absence of abdominal signs (peritonitis). PVD is a risk factor for arterial disease in the mesenteric vessels. 'B' refers to atrial fibrillation, which may cause thromboembolism to the bowel. 'C' is an indicator (though not diagnostic) of diabetes, which is a risk factor for all arterial disease.
• 13
  A 59-year old diabetic man presents with weight loss, bloody stools and severe central abdominal pain after eating. What is the most likely diagnosis?
  Difficulty: Easy     Topic: Diabetic with bloody stools and weight loss
  a

  Mesenteric ischaemia

  b

  Chronic pancreatitis

  c

  Carcinoid syndrome

  d

  Zollinger-Ellison (Z-E) syndrome

  e

  Crohn's disease
  Explanation: Chronic small bowel ischaemia presents with weight loss due to malabsorption and fear of eating due to abdominal pain after meals with or without PR bleeding. Angioplasty is the treatment of choice. Chronic pancreatitis causes malabsorption, steatorrhoea and burning back pain with a history of excess alcohol intake. Carcinoid syndrome causes diarrhoea, flushing, CCF and weight loss (when advanced). Z-E syndrome presents with pain and upper GI bleeding. Crohn's causes diarrhoea and pain is not only associated with meals.
• 14
  A 38-year old man presents with 2 hours of severe upper abdominal pain and vomiting. He is apyrexial and sitting forwards on the bed. There is epigastric guarding and his sclera are icteric. What is the most likely diagnosis?
  Difficulty: Easy     Topic: Acute abdomen 5
  a

  Acute cholecystitis

  b

  Acute cholangitis

  c

  Acute pancreatitis

  d

  Acute hepatitis

  e

  Duodenal ulcer perforation
  Explanation: Acute pancreatitis occurs due to inflammation of the pancreas with autolysis due to release of its proteases. In 75% of cases a precipitant can be found of which the most common is gallstones, which is likely to be the case in this patient. A gallstone has impacted distal to the pancreatic duct, causing reflux of pancreatic juices that initiates pancreatitis. It also obstructs the flow of bile and this causes cholestasis. The pain of pancreatitis is worse if the patient lies down because the stomach (that is anterior to the pancreas) falls back and further irritates the inflamed organ. Acute cholecystitis and duodenal perforation do not cause jaundice. Cholangitis may develop later in this patient, however this man is currently apyrexial. Perforation of the duodenum would cause generalised guarding and the patient would be lying still rather than sitting forwards.
• 15
  A 52-year old woman with a history of Crohn’s disease presents with 2 days of diffuse colicky abdominal pain and swelling. She has been constipated for 5 days and began vomiting 1 day ago. What is the most likely diagnosis?
  Difficulty: Easy     Topic: Abdominal pain with Crohn's
  a

  Small bowel obstruction

  b

  Large bowel obstruction

  c

  Acute appendicitis

  d

  Richter's hernia

  e

  Acute pancreatitis
  Explanation: The four characteristic features of bowel obstruction are colicky abdominal pain, distension, vomiting and absolute constipation. The sequence in which these symptoms occurred may help to determine whether it is small or large bowel involved. This woman has had constipation followed by pain and distension with vomiting late, which suggests a distal obstruction. Whereas early vomiting and late constipation suggests upper (small bowel) obstruction. Acute appendicitis and pancreatitis cause inflammatory pain that is constant, not colicky. Nausea and anorexia tend to be more prominent in these conditions. Richter's hernia is one that involves the bowel wall only, not the lumen. Therefore these hernias may become strangulated without being obstructed.
• 16
  A 77-year old woman presents with 3 days of constant left lower quadrant abdominal pain. There is tenderness in the left iliac fossa and her temperature is 37.7 degrees. What is the most likely diagnosis?
  Difficulty: Easy     Topic: Acute abdomen 4
  a

  Rectal carcinoma

  b

  Sigmoid diverticulitis

  c

  Strangulated hernia

  d

  Salpingitis

  e

  Urolithiasis
  Explanation: Diverticulosis, the presence of multiple diverticula, is very common in the elderly population. If one of these diverticula becomes obstructed and infected then diverticulitis results. Lower abdominal pain, diarrhoea and blood per rectum are the most common symptoms. The diagnosis is also favoured by a mild pyrexia. Rectal carcinoma is most likely to cause a progressive change in bowel habit rather than acute abdominal pain. A strangulated hernia would cause colicky abdominal pain from obstruction. Salpingitis is a good differential diagnosis however it most commonly occurs in sexually active younger women and epidemiologically it is much less common than diverticulitis. Urolithiasis causes colicky abdominal pain from contraction of the ureter over the stone.
• 17
  A 61-year old man with a history of MI, CCF and atrial fibrillation presents with severe central abdominal pain. There is mild generalised abdominal tenderness but with no guarding or masses felt on examination. He is apyrexial, tachycardic and tachypnoeic. What is his acid-base status most likely to show?
  Difficulty: Easy     Topic: Acid-base state in acute abdomen
  a

  Metabolic acidosis with normal anion gap

  b

  Metabolic acidosis with raised anion gap

  c

  Metabolic alkalosis

  d

  Normal pH and arterial blood gases

  e

  Metabolic acidosis with respiratory alkalosis
  Explanation: This man has presented with an acute abdomen but from history and examination it is difficult to determine the cause. A differential diagnosis would include: acute mesenteric ischaemia, appendicitis, pancreatitis and bowel obstruction. His past medical history and lack of findings on abdominal exam are most suggestive of mesenteric infarction. This typically causes a raised anion gap metabolic acidosis due to ischaemic bowel producing lactate. Acidosis with normal anion gap may occur in acute renal failure with bowel obstruction. Metabolic alkalosis results from severe vomiting or high-output ileostomies. Many conditions would present with normal ABGs, but it is reasonable to investigate in ill patients. Aspirin poisoning causes metabolic acidosis with respiratory alkalosis.
• 18
  A 81-year old man dies in minutes due to massive haematemesis and haematochezia. Past history: osteoarthritis, AAA repair, atrial fibrillation. What is the most likely diagnosis?
  Difficulty: Medium     Topic: Massive GI bleed
  a

  Anti-coagulation

  b

  Oesophageal varices

  c

  Gastric ulcer

  d

  Aortoduodenal fistula

  e

  Mesenteric ischaemia
  Explanation: Massive GI bleed in a patient with previous AAA repair is suggestive of an aortoduodenal fistula, which are fatal unless treated immediately. Anti-coagulation increases the risk of GI bleeds but it is unlikely to cause fatal blood loss in minutes without a major second pathology being present. There is no history of liver disease or risk factors for varices. Perforation of a gastric ulcer will cause peritonitis and moderate haematemesis but not massive volume. Mesenteric ischaemia presents with abdominal pain and small-volume bleeding.
• 19
  A 50-year old woman presents with intermittent right iliac fossa pain that has lasted 3 hours. She has severe nausea. What is the most likely diagnosis?
  Difficulty: Easy     Topic: Intermittent RIF pain
  a

  Salpingitis

  b

  Meckel's diverticulitis

  c

  Appendicitis

  d

  Nephrolithiasis

  e

  Small bowel obstruction (SBO)
  Explanation: Intermittent pain suggests colic from obstruction of a hollow viscus. Renal colic characteristically causes severe nausea such that analgesia may have to be given PR (indomethacin or other NSAID). SBO causes colicky pain but it would be central with constipation and bloating. 'A-C' are inflammatory in origin therefore tend to cause iliac fossa pain that gradually worsens up to a maximum intensity.
• 20
  Which of the following statements about management of the acute abdomen is incorrect?
  Difficulty: Medium     Topic: Acute abdomen 2
  a

  Laparotomy may be performed without perforation of a viscera

  b

  AXR is required to exclude perforation

  c

  Antibiotics should wait until blood cultures have been taken

  d

  Resuscitation should use crystalloid, not colloid

  e

  Chailaiditi syndrome may mimic bowel perforation
  Explanation: An erect CXR is the imaging method used to look for pneumoperitoneum, which suggests perforation. Laparotomy is performed before perforation in appendicitis and may also have a diagnostic role. Giving antibiotics before taking blood cultures may affect the organisms present and the true sensitivities will not be known. Current research demonstrates no difference between crystalloid and colloid. There are also more adverse effects of colloid e.g. anaphylactoid reactions or pulmonary oedema. Chailaiditi syndrome is the presence of bowel above the liver, which mimics pneumoperitoneum.
• 21
  A 32-year old woman presents with severe abdominal pain and collapse. Which of these diagnoses should be excluded first?
  Difficulty: Easy     Topic: Abdo pain and collapse
  a

  Acute pancreatitis

  b

  Perforated duodenal ulcer

  c

  Oesophageal rupture

  d

  Bowel perforation

  e

  Ruptured ectopic pregnancy
  Explanation: In abdominal pain and shock, the most rapidly life-threatening diagnoses should be excluded: ruptured AAA, ruptured ectopic pregnancy, oesophageal rupture and MI, for example. In a 32-year old woman, pregnancy must be excluded as a ruptured ectopic can cause exsanguination and death in minutes. Oesophageal rupture (Boerhaave's syndrome) is unlikely to be the cause here because the pain is abdominal, rather than in the chest. Perforation of the oesophagus following a history of forceful vomiting and a pleural effusion may be seen on CXR. Bowel and DU perforation are emergencies that require surgery but death within an hour is unlikely. Acute pancreatitis needs supportive management and monitoring.
• 22
  A 71-year old lady presents with a 3 month history of intermittent, cramping left iliac fossa pain that is followed by bloody diarrhoea the next day. What is the most likely diagnosis?
  Difficulty: Medium     Topic: Cramping LIF pain
  a

  Angiodysplasia

  b

  Diverticulitis

  c

  Ischaemic colitis

  d

  Microscopic colitis

  e

  Ulcerative colitis
  Explanation: Chronic ischaemia of the colon most commonly affects the splenic flexure and may also cause systemic features of illness (fever & raised WCC). Barium enema characteristically shows a 'thumb print' from swelling of the submucosa. It can lead to strictures or gangrene, requiring emergency surgery. Revascularisation or angioplasty are the main treatments. Diverticulitis is unlikely to have a temporal delay between pain and bloody diarrhoea. Microscopic colitis less frequently causes bleeding.
• 23
  A 70-year old man presents with acute mesenteric ischaemia. Which of the following is least likely to be present?
  Difficulty: Medium     Topic: Acute mesenteric ischaemia
  a

  Peripheral vascular disease (PVD)

  b

  An irregularly irregular pulse

  c

  A raised HbA1c

  d

  Generalised peritonitis

  e

  Hypotension
  Explanation: Acute mesenteric ischaemia most commonly affects the superior mesenteric artery and can be thrombotic or embolic. Classical presentation is severe pain, shock and absence of abdominal signs (peritonitis). PVD is a risk factor for arterial disease in the mesenteric vessels. 'B' refers to atrial fibrillation, which may cause thromboembolism to the bowel. 'C' is an indicator (though not diagnostic) of diabetes, which is a risk factor for all arterial disease.
• 24
  A 59-year old diabetic man presents with weight loss, bloody stools and severe central abdominal pain after eating. What is the most likely diagnosis?
  Difficulty: Easy     Topic: Diabetic with bloody stools and weight loss
  a

  Mesenteric ischaemia

  b

  Chronic pancreatitis

  c

  Carcinoid syndrome

  d

  Zollinger-Ellison (Z-E) syndrome

  e

  Crohn's disease
  Explanation: Chronic small bowel ischaemia presents with weight loss due to malabsorption and fear of eating due to abdominal pain after meals with or without PR bleeding. Angioplasty is the treatment of choice. Chronic pancreatitis causes malabsorption, steatorrhoea and burning back pain with a history of excess alcohol intake. Carcinoid syndrome causes diarrhoea, flushing, CCF and weight loss (when advanced). Z-E syndrome presents with pain and upper GI bleeding. Crohn's causes diarrhoea and pain is not only associated with meals.
• 25
  A 76-year old woman with aortic stenosis presents with intermittent, painless haematochezia. She has no other symptoms, OGD and colonoscopy are normal. What investigation is most likely to confirm the diagnosis?
  Difficulty: Hard     Topic: Intermittent GI bleeds
  a

  CT angiography

  b

  Tc-99 labelled RBC scan

  c

  Double-contrast barium enema

  d

  CT colonoscopy

  e

  Magnetic resonance angiography
  Explanation: Intermittent GI bleeds with normal endoscopy is typical of angiodysplasia; a condition with abnormal vessels in the submucosa. There is an association with aortic stenosis (known as Heyde's syndrome). MR or CT angiography may show angiodysplasia however it needs a higher rate of active bleeding that labelled RBC scan. Barium enema and CT colonoscopy won't demonstrate angiodysplasia.
• 26
  A 19-year old man presents with extremely painful defecation. He also describes bright red blood on the paper. What is the most likely diagnosis?
  Difficulty: Easy     Topic: Painful daefecation
  a

  Anal cancer

  b

  Haemorrhoids

  c

  Anal fissure

  d

  Perianal Crohn's disease

  e

  Ulcerative colitis
  Explanation: Anal fissures are very painful and can lead to constipation due to fear of defecation. A little blood may be present on the outside of the stool or on the paper. Anal cancer causes a change in bowel habit, pruritis ani and aren't as painful as a fissure; they are more likely in patients who are HIV-positive. Haemorrhoids may also cause blood on the paper but are not painful unless thrombosed. Perianal Crohn's may be accompanied by other features of Crohn's with ulcers/fistulae. Ulcerative colitis causes bloody diarrhoea and systemic upset.
• 27
  A 41-year old man presents with severe right upper quadrant pain and a temperature of 38.5 degrees. He appears unwell and his sclera are icteric. What is the most likely diagnosis?
  Difficulty: Easy     Topic: RUQ pain and pyrexia
  a

  Acute cholecystitis

  b

  Chronic cholecystitis

  c

  Pancreatic cancer

  d

  Ascending cholangitis

  e

  Duodenal obstruction
  Explanation: Ascending cholangitis occurs due to infection of the biliary tree above an obstruction. Charcot's triad: right upper quadrant pain, rigors and obstructive jaundice is characteristic of ascending cholangitis. It can be distinguished from cholecystitis because the patient is more unwell and, importantly, cholestatic. There may be a mild rise in transaminases and bilirubin in cholecystitis but patients with cholangitis will have a markedly raised bilirubin. Pancreatic cancer causes a painless obstructive jaundice and whilst it may predispose to ascending cholangitis it would be very rare in a 41-year old.
• 28
  A 32-year old lady has a breast cyst aspirated and a residual firm lump is found immediately. What is the most appropriate series of investigations?
  Difficulty: Medium     Topic: Investigation of breast lump 2
  a

  Examination, USS & FNAC

  b

  Examination, mammography & FNAC

  c

  Examination, MRI and FNAC

  d

  Examination, USS & excision biopsy

  e

  Examination, MRI and excision biopsy
  Explanation: If a lump is found to be still be present after aspiration of the breast lump then it should undergo triple assessment. As this patient is <35yrs, USS is the imaging modality of choice due to higher breast density. Mammography would be used for patients >35yrs.
• 29
  A 67-year old woman is assessed at the MDT for carcinoma of the breast. It is 3.5cm wide, ER+, does not involve the nipple and there are no signs of further spread. What is the most appropriate treatment for the primary mass?
  Difficulty: Hard     Topic: Treatment of breast carcinoma
  a

  Mastectomy and adjuvant radiotherapy

  b

  WLE and adjuvant chemotherapy

  c

  WLE and adjuvant radiotherapy

  d

  WLE and adjuvant hormone therapy

  e

  WLE, adjuvant radiotherapy and chemotherapy followed by hormone therapy
  Explanation: For early disease (that which can be completely resected), best therapy includes surgery ± radiotherapy (RT), chemotherapy and hormone therapy (if ER+). Mastectomy is indicated if the tumour is: >4cm, multifocal, there is nipple involvement or patient choice. Axillary staging determines need for RT post-mastectomy; all WLE requires adjuvant RT. Chemotherapy is beneficial to almost all patients with early disease. Hormone therapy is given for 5 years. The best hormone therapy for pre-menopausal women is the combination of a LRHR-agonist and tamoxifen. Optimum hormone therapy for post-menopausal women is anastrazole alone.
• 30
  A 19-year old woman presents with a regular, discrete lump in her breast. It is highly mobile and firm. What is the most likely diagnosis?
  Difficulty: Easy     Topic: Investigation of breast lump
  a

  Lipoma

  b

  Fibroadenoma

  c

  Fibrocystic change

  d

  Fat necrosis

  e

  Abscess
  Explanation: Fibroadenomas are the most common cause of breast lumps in young women and require reassurance. Excision biopsy may be performed for fibroadenomas >35yrs. Lipomas are soft though usually are fairly mobile and can occur almost anywhere on the body. Fibrocystic change presents as irregular masses that are cystic and may change through the menstrual cycle. Abscesses are most common when breastfeeding and present with pain.
• 31
  A 32-year old presents with intermittent dysphagia and regurgitation, especially with fluids. There is a bird’s beak appearance on barium swallow. Which statement about this presentation is not true?
  Difficulty: Hard     Topic: Intermittent dysphagia and regurgitation
  a

  There is increased risk of cancer

  b

  It may be caused by cancer

  c

  An air-fluid level may be seen on CXR

  d

  It can result from trypanosomiasis infection (Chagas' disease)

  e

  Botulinium toxin is a highly effective treatment
  Explanation: This patient has achalasia: oesophageal dysmotility with failure of relaxation of the lower oesophageal sphincter. Bird's beak appearance is characteristic. It increases the risk of oesophageal carcinoma. Carcinoma can cause achalasia by invasion of the myenteric plexus. If severe an air-fluid level may be seen behind the heart. Botulinium toxin is tried but it is rarely effective - endoscopic dilatation is the 1st line treatment.
• 32
  A 3-year old boy presents with a large lump at the base of the lateral aspect of the neck which transilluminates well. What is the most likely diagnosis?
  Difficulty: Medium     Topic: Neck lumps in children
  a

  Cystic hygroma

  b

  Branchial cyst

  c

  Thyroglossal cyst

  d

  Dermoid cyst

  e

  Sebaceous cyst
  Explanation: Cystic hygromas are lymphatic malformations found at the base of the neck and can be large. Branchial cysts are remnants of the branchial cleft and present as anterior masses in the upper half of the neck. Thyroglossal cysts are thyroglossal duct remnants and present as midline cysts that elevate on tongue protrusion. Dermoid cysts are benign teratomas that grow in the midline or periorbitally. Sebaceous cysts are intradermal, have a punctum and do not transilluminate; contrary to their name, they are not from sebaceous glands.
• 33
  A 23-year old woman presents with a painless mass in the anterior triangle of her neck. Which set of investigations is most likely to be appropriate?
  Difficulty: Medium     Topic: Investigation of neck lump
  a

  TSH and T4

  b

  FBC and ultrasound

  c

  FNAC and chest X-ray

  d

  Excision biopsy

  e

  Examination under anaesthesia
  Explanation: FBC and USS are the only investigations of those listed that is appropriate for all lumps in the anterior triangle. TSH & T4 are done for any midline lumps that could of thyroid origin but may not be done for lateral lumps that are clearly lymph nodes. FNAC and CXR is part of the work-up for suspected lymphoma but would not be performed on a simple thyroid goitre. Excision biopsy will help confirm neoplastic or benign origin of a lymph node. EUA is unlikely to be used for a neck lump but is important for pelvis masses.
• 34
  Which of the following statements about scars is not true?
  Difficulty: Easy     Topic: Abdominal scars
  a

  A Lanz scar indicates an open appendicectomy

  b

  A roof-top scar would be left following Whipple’s procedure

  c

  Emergency laparotomy often leaves a midline scar

  d

  Kocher’s scar is a vertical scar in the RUQ from cholecystectomy

  e

  Pfannelstiel scar is a consequence of pelvic surgery
  Explanation: Kocher's incision follows the costal margin, therefore is not a vertical scar. It is used for open cholecystectomy however most are now performed laparoscopically given that there aren't contraindications e.g. previous surgery with adhesions. A Lanz scar is horizontal whereas a McBurney's scar is oblique - both for open appendicectomy. Roof-top scars are bilateral across the costal margin and can also be used for liver resection/transplantation. A Pfannelstiel scar is horizontal in the suprapubic region and is used for pelvic access.
• 35
  A previously well 69-year old man presents with fatigue and anaemia; is found to have irregular hepatomegaly. Which of the following blood tests is most likely to be raised?
  Difficulty: Medium     Topic: Causes of hepatomegaly
  a

  Alpha-feto protein (AFP)

  b

  Beta-human chorionic gonadotrophic (B-HCG)

  c

  Carcinoembryonic antigen (CEA)

  d

  CA125

  e

  CA15-3
  Explanation: The most common causes of hepatomegaly are: early alcoholic liver disease or fatty liver disease, right-sided heart failure and colorectal metastases. She most likely has colorectal cancer, which can be asymptomatic unlike late. CEA is raised in most CRC and is used for monitoring (not diagnosis). AFP is raised in hepatocellular carcinoma, which is rare in the absence of cirrhosis or hepatitis B. B-HCG is raised in testicular teratomas and pregnancy. CA125 is raised in ovarian carcinoma, an unlikely cause of hepatic metastases in a man. Unlike most other cancer markers, CA125 may have a role in diagnosis of pelvic masses. CA15-3 is a cancer maker most specifically raised in breast cancer, which can be used to detect relapse following treatment.
• 36
  What abdominal operation typically results in formation of an ileostomy?
  Difficulty: Medium     Topic: Ileostomy
  a

  Gastric outlet bypass

  b

  Hartmann's procedure

  c

  Oesophagectomy

  d

  Panproctocolectomy without anal reconstruction

  e

  Whipple's resection
  Explanation: UC and Crohn's may result in permanent ileostomy following pancolectomy or as a diversion when primary anastamosis has been performed. Gastric outlet obstruction may be treated surgically with a gastro-ileal bypass. Hartmann's procedure is an emergency operation for sigmoid pathology, resulting in a colostomy. Oesophagectomy may involve a defunctioning pharyngostomy but primary anastamosis, plus use of a chest drain is common practice. Whipple's resection is used for carcinoma of the pancreatic head. The operation involves a partial gastrectomy and duodenectomy with anastamosis onto the jejunum, which also connects to the common bile duct via a Roux loop but there is no ileostomy.
• 37
  A 70-year old man with previously resected oesophageal cancer presents with epigastric pain and vomiting. It is not possible to pass a NG tube. A double fluid-level is visible on erect CXR. What is the most likely diagnosis?
  Difficulty: Hard     Topic: Inability to pass NGT
  a

  Recurrence of oesophageal carcinoma

  b

  Achalasia

  c

  Gastric volvulus

  d

  Gastric carcinoma

  e

  Pyloric stenosis secondary to ulceration
  Explanation: Gastric volvulus occurs when the stomach twists, causing obstruction and ischaemia that may lead to infarction and perforation. It is more common in patients who have had gastric or oesophageal surgery. An inability to place a NGT is characteristic, as is a double fluid-level on CXR. Gastric carcinoma and pyloric stenosis may give symptoms of gastric outlet obstruction but an NGT could be passed. Achalasia may show a single fluid-level on CXR behind the heart. Vomiting is a less common feature of oesophageal carcinoma, it presents with dysphagia. Achalasia results in regurgitation and dysphagia.
• 38
  A 60-year old man with varicose veins presents with a groin lump that lies inferior and lateral to the pubic tubercle. What clinical feature is most consistent with the diagnosis?
  Difficulty: Easy     Topic: Lump with varicose veins
  a

  It disappears on lying flat

  b

  Cough impulse is absent

  c

  It is resonant to percussion

  d

  It is non-fluctuant

  e

  It is very painful
  Explanation: This man has a saphena varix, a dilatation of the junction between the femoral vein and the great saphenous vein. It may be a cause of incompetence in varicose veins or associated with other levels of incompetent valves. A saphena varix appears to disappear on pressure or when lying down therefore appears to reduce. The other features may be present with a femoral hernia, which are more common in women but lie in a similar anatomical position to a saphena varix. Femoral hernias are resonant due to the presence of bowel but if they obstruct then a cough impulse may not be present. A strangulated femoral hernia may lose fluctuance as it becomes inflamed and will be extremely painful.
• 39
  A 62-year old woman presents with a firm lump immediately lateral to the mid-point between the ASIS and the pubic symphysis. What is the most likely diagnosis?
  Difficulty: Easy     Topic: Firm inguinal lump
  a

  Inguinal hernia

  b

  Psoas abscess

  c

  Femoral artery aneurysm

  d

  Femoral neuroma

  e

  Inguinal lymphadenopathy
  Explanation: The mid-inguinal point is the position of the femoral pulse. (The mid-point of the inguinal ligament is the position of the deep ring.) Immediately lateral the artery is the femoral nerve and a firm lump suggests a neuroma. An inguinal hernia will be superomedial to the pubic tubercle. A psoas abscess would be more lateral and fluctuant; it causes pain on passive hip flexion. Femoral artery aneurysm is expansile and pulsatile. Inguinal lymph nodes are medial to the femoral vein.
• 40
  A 46-year old man presents with fever, pain on hip flexion and a fluctuant swelling immediately medial to the anterior superior iliac spine. What is the most likely diagnosis?
  Difficulty: Medium     Topic: Fluctuant inguinal swelling
  a

  Femoral hernia

  b

  Femoral aneurysm

  c

  Saphena varix

  d

  Psoas abscess

  e

  Ectopic testis
  Explanation: Psoas major passes lateral to the femoral nerve before it inserts on the lesser trochanter. Abscesses are most commonly due to TB and may be related to lumbar infection (Pott's disease of the spine). Other features include: systemic upset, weight loss, swinging fever and pain on passive hip flexion. None of the other pathologies lie immediately medial to the ASIS, they lie further towards the midline. A femoral hernia and saphena varix lie inferolateral to the pubic tubercle. An aneurysm is expansile, pulsatile and medial to the femoral nerve. Ectopic testis is most likely to be in the abdomen or the inguinal canal therefore superomedial to the femoral nerve.
• 41
  A 58-year old man presents with a gradual onset constipation and fatigue. Which of the following is least likely to be helpful in establishing a diagnosis?
  Difficulty: Medium     Topic: Constipation and fatigue
  a

  Ask about a history of anti-psychotic use

  b

  Measuring TSH and T4 levels

  c

  Measuring 24-hour urinary 5HIAA levels

  d

  Asking about family history of ovarian and endometrial cancers

  e

  Performing colonoscopy
  Explanation: 24-hour urinary 5-HIAA (a breakdown product of monoamines) detects raised monoamines from a carcinoid tumour, which causes diarrhoea, not constipation. Anti-psychotics have anti-muscarinic effects therefore can be constipating and sedating. TSH and T4 are important to exclude hypothyroidism, which presents insidiously including constipation and fatigue. Ovarian & endometrial cancers are associated with Lynch II syndrome (hereditary non-polyposis colorectal cancer), therefore he may be at increased risk of colorectal cancer without having a family history. Colonoscopy is appropriate for men >50yrs presenting with persistent change of bowel habit lasting >6 weeks even in the absence of blood.
• 42
  A 72-year old man with who underwent radical resection for colon cancer 3 years ago is found to have a 2cm mass in the right lobe of his liver. Biopsy demonstrates adenocarcinoma. What is the most appropriate management?
  Difficulty: Medium     Topic: Metastases to the liver
  a

  Radiofrequency ablation (RFA)

  b

  Referral to hepatic surgeon

  c

  Palliative chemo-radiotherapy

  d

  Transarterial chemo-embolisation (TACE)

  e

  Palliative radiotherapy
  Explanation: Hepatic metastases can be resected for many primaries, CRC is the most common indication. Prognosis is better if they are heterochronous (in this case) and in these patients resection may be curative. Refer if 1 lobe involved and <4 metastases. RFA and TACE are more commonly used for non-resectable hepatocellular carcinoma whereas resection is the best treatment for CRC metastases. It is possible to treat this patient with curative intent therefore palliative radiotherapy or chemo-therapy are not appropriate at this stage.
• 43
  A 25-year old man presents with 30minutes of acute abdominal pain, what is the least likely diagnosis?
  Difficulty: Easy     Topic: Medical acute abdomen
  a

  Familial Mediterranean fever

  b

  Pan-hypopituitarism

  c

  Henoch-Schonlein syndrome

  d

  Pneumonia

  e

  Angina
  Explanation: Angina very rarely causes abdominal pain and it would resolve on rest therefore does not last for 30min. Abdominal pain of cardiac-origin that has lasted 30minutes is most likely to be an inferior MI in a diabetic patient. FMF causes intermittent peritonitis, fever and malaise due to a genetic defect. Pan-hypopituitarism can cause an acute Addison's crisis with abdominal pain and shock. Henoch-Schonlein syndrome is a vasculitis most affecting teenage boys that often involves the bowel, causing abdominal pain and GI bleeds as well as haematuria and palpable purpura on the lower limbs. Basal pneumonia may present as upper quadrant pain with an absence of signs.
• 44
  A 28-year old man presents having stepped on a rusty nail, which has entered his foot. He completed his course of tetanus toxoid immunisation 10 years ago. What is the most appropriate course of action for tetanus prophylaxis?
  Difficulty: Medium     Topic: Tetanus prophylaxis
  a

  No further treatment needed

  b

  Booster dose of toxoid

  c

  Commence immunisation course

  d

  Booster dose of toxoid plus passive immunisation

  e

  Immunisation course plus passive immunisation
  Explanation: Wounds potentially contaminated with Clostridium tetani are those that are penetrating and dirty, therefore may become anaerobic. If a full course has previously been completed then a booster of toxoid should be given. If the course has not been completed then anti-tetanus immunoglobulin is given as passive immunisation and the full course of active immunisation is begun.
• 45
  A 37-year old woman presents with a 4 month history of diarrhoea, weight loss and abdominal pain. A tender, poorly defined right iliac fossa mass is found on examination. What is the most likely diagnosis?
  Difficulty: Medium     Topic: RIF masses
  a

  Crohn's mass

  b

  Tuberculous mass

  c

  Appendix mass

  d

  Caecal carcinoma

  e

  Carcinoid tumour
  Explanation: Diarrhoea, pain and weight loss in a 30-40yr old woman is highly suggestive of Crohn's. Inflammation of the terminal ileum results in a poorly defined, tender RIF mass that is known as a "Crohn's mass". TB causes 'cold', non-tender abscesses from previous infection that may form a sinus. Appendix mass forms post-appendicitis and unless an abscess develops it is mostly asymptomatic. Caecal carcinoma is insidious in presentation and causes anaemia but less commonly a change of bowel habit. Carcinoid tumour has similar features but is not tender.
• 46
  A thin 22-year old man presents with fatigue and pyrexia. A smooth, firm 5cm mass is palpable in his umbilical region. What is the most likely diagnosis?
  Difficulty: Medium     Topic: Smooth umbilical mass
  a

  Bowel cancer

  b

  Hodgkin's lymphoma

  c

  Non-Hodgkin's lymphoma

  d

  Dermoid cyst

  e

  Aortic aneurysm
  Explanation: This man has para-aortic lymphadenopathy. It would transmit a pulse because it is overlying the aorta however it will not be expansile, which would suggest an aneurysm. A dermoid cyst will be fluctuant, lies more superficially and does not cause fatigue. Bowel cancer could present with an abdominal mass however it would be very rare for bowel cancer to present with these symptoms, in a young man and in that anatomical location. Hodgkin's lymphoma peaks at 20-30yrs, whereas NHL increases with age.
• 47
  A 71-year old woman presents with a history of fatigue, anorexia and weight loss. She is found to have generalised abdominal swelling. Her whole abdomen feels firm and irregular. Shifting dullness is present. What is the most likely diagnosis?
  Difficulty: Easy     Topic: Firm, irregular abdomen
  a

  Ovarian carcinoma

  b

  Endometrial carcinoma

  c

  Hepatic cirrhosis

  d

  Gastric carcinoma

  e

  Ductal carcinoma of the breast
  Explanation: A firm and irregular abdomen with ascites suggests omental carcinomatosis, which are multiple small malignant deposits throughout the abdomen. In post-menopausal women this is most commonly from ovarian carcinoma and can be caused by endometrial and gastric less frequently. Cirrhosis would not give an irregular abdomen, though the ascites may be tense. Ductal carcinoma of the breast may metastasise to the peritoneum but it is rare.
• 48
  A 55-year old man is recovering from necrotizing pancreatitis caused by gallstones that he suffered from 2 weeks ago. He is found to have an epigastric mass that is difficult to localise and does not move with respiration. Amylase is 327IU/L. What is the most likely diagnosis?
  Difficulty: Easy     Topic: Epigastric masses
  a

  Hepatocellular carcinoma

  b

  Gastric carcinoma

  c

  Alcoholic liver disease (ALD)

  d

  Pseudocyst

  e

  Splenomegaly
  Explanation: A pseudocyst is a collection of fluid in the lesser sac, a complication of necrotizing pancreatitis. It is a retroperitoneal mass therefore is difficult to localise and is a cause of a persistently raised amylase. Hepatocellular carcinoma is the most common malignant primary liver tumour however it almost always occurs with a history of cirrhosis or hepatitis B infection. His pancreatitis was caused by gallstones, which is not a risk factor for cirrhosis or HCC. Gastric carcinoma presenting as a mass will be more easily localised. It causes symptoms of gastric outlet obstruction and does not result in a grossly raised amylase unless there is complete bowel obstruction. Splenomegaly moves with respiration and amylase is not raised. ALD presents as acute liver failure (due to alcoholic hepatitis), decompensation of cirrhosis or asymptomatically with signs of chronic disease.
• 49
  A 68-year old woman presents with 2 months of intermittent cramping lower left quadrant pain and diarrhoea, which partly relieves the pain. What is the most appropriate management?
  Difficulty: Medium     Topic: Cramping pain and diarrhoea
  a

  Reassurance and advice on IBS diet

  b

  Routine blood tests and reassurance

  c

  Routine blood tests and buscopan

  d

  Routine blood tests and sigmoidoscopy

  e

  Routine blood tests and colonoscopy
  Explanation: This woman has presented with symptoms consistent with IBS according to the Rome II criteria, however it is still appropriate to investigate for malignancy. Initial presentation of IBS at over 50 years is rare and the symptoms may be due to colorectal cancer. Though the majority of colon-rectal cancer can be seen on sigmoidoscopy, colonoscopy is required to exclude caecal carcinoma. 'A-C' may all be used to treat irritable bowel syndrome depending on appropriate history and examination findings.
• 50
  What is the best investigation to confirm a congenital remnant of the vitelline duct?
  Difficulty: Hard     Topic: Congenital malformation
  a

  CT scan

  b

  MRI

  c

  CT angiography

  d

  Radionucleotide scan

  e

  Colonoscopy
  Explanation: Meckel's diverticulum is the remnant of the vitelline duct that is present in the terminal ileum of 2% of the general population. It shows gastric heterotopia (gastric mucosa is present) and a Tc-99 labelled scan can be used to detect it. As it lies proximal to the ileo-caecal valve, colonoscopy will not visualise it. MRI and CT may show the diverticulum but are less likely to than nuclear imaging. CT angiography can be used for angiodysplasia or mesenteric ischaemia.
• 51
  For which of the following is a CT scan least appropriate?
  Difficulty: Medium     Topic: CT for the acute abdomen
  a

  Leaking AAA

  b

  Ruptured AAA

  c

  Ureteric colic

  d

  Splenic rupture

  e

  Necrotising pancreatitis
  Explanation: CT should only be used when a patient is stable and most patients with a ruptured AAA will go from resuscitation directly to theatre. Leaking AAA and ureteric colic can present similarly and diagnostic confusion is reported. CT excludes an aneurysm and is also highly sensitive for demonstrating nephrolithiasis. Patients with splenic rupture (from blunt trauma) are likely to be more stable than those with a AAA. CT can help to grade the severity of necrotising pancreatitis.
• 52
  A 71-year old woman with known diverticulosis presents with LIF pain and fever. In the next hour the pain intensifies, she develops generalised guarding and becomes hypotensive. After resuscitation, what is the most appropriate management?
  Difficulty: Hard     Topic: Diverticulitis surgery
  a

  Laparoscopic colectomy with primary anastamosis

  b

  Laparoscopic colectomy with primary anastamosis and defunctioning ileostomy

  c

  Open colectomy with primary anastamosis

  d

  Laparoscopic Hartmann's with end-colostomy

  e

  Open Hartmann's with end-colostomy
  Explanation: This woman has perforated during acute diverticulitis. She requires peritoneal wash-out and lavage and removal of the diseased bowel. Given the she has generalised peritonitis it is accepted by most that Hartmann's is more appropriate than primary anastamosis. Primary anastamosis following dehiscence is associated with a higher rate of complications. Surgery is more likely to be open as she has become hypotensive and laparotomy allows wash-out to be more thorough.
• 53
  A 41-year old woman presents with a skin lesion on her left thigh, which she said has bled a few times. It is 1cm in diameter and is irregularly black-brown. The edge is not smooth but lies flat with the skin. What is the most likely diagnosis?
  Difficulty: Medium     Topic: Bleeding skin lesion
  a

  Basal cell carcinoma (BCC)

  b

  Squamous cell carcinoma (SCC)

  c

  Malignant melanoma

  d

  Merkel cell carcinoma

  e

  Bowen's disease
  Explanation: Malignant melanoma present as either a change in an existing mole or a new pigmented lesion (especially >45years). They are irregular with respect to colour, border and shape. They show: elevation, crusting, bleeding and itching. Regional LN metastases may be palpable. They are excised and radiotherapy or adjuvant isolated limb chemotherapy may be given. BCC are slow growing papules with rolled edges and telangiectasia, usually on the face. SCC grow quickly, ulcerate with raised edges.
• 54
  A 62-year old woman undergoes total thyroidectomy for follicular carcinoma. Which of the following is she least likely to experience?
  Difficulty: Medium     Topic: Follicular carcinoma of thyroid
  a

  Airway compromise

  b

  Hypercalcaemia

  c

  Tachyarrhythmias

  d

  Pneumothorax

  e

  Hoarse voice
  Explanation: Hypocalcaemia occurs early post-thyroidectomy if the parathyroid glands have been damaged, which may cause tetany and arrhythmias. Intra-operatively, thyroidectomy can cause airway compromise from laryngeal oedema. Post-operatively an arterial haematoma can cause tracheal collapse. Release of T4 during surgery can cause a thyrotoxic storm with severe tachycardiac. Pneumothorax is a local complication of surgery. Damage to the recurrent laryngeal nerve causes hoarse voice.
• 55
  A 32-year old woman presents with green nipple discharge. She has a moderately painful lump below her areola with similar appearance bilaterally. What is the most likely diagnosis?
  Difficulty: Easy     Topic: Green nipple discharge
  a

  Ductal carcinoma

  b

  Lobular carcinoma

  c

  Ductal ectasia

  d

  Fibrocystic change

  e

  Cystosarcoma phylloides
  Explanation: Mammary duct ectasia occurs due to dilatation of the ducts, which then become blocked and recurrently infected. Green nipple discharge in a pre-menopausal woman is a common presentation and it is usually bilateral. Ducts can be excised if severe. Carcinoma presents with a fixed lump and may cause bloody discharge. Fibrocystic change presents with a history of multiple lumps, cysts and mastalgia with yellow discharge. Phylloides tumours are large but most are benign.
• 56
  A 63-year old woman awaiting repair for a femoral hernia presents with abdominal pain, vomiting and complete constipation. The hernia has always been irreducible but is now much more painful. What is the most appropriate management?
  Difficulty: Easy     Topic: Complication of hernias
  a

  NG tube and 5% dextrose IVI

  b

  Erect CXR

  c

  CT abdomen

  d

  Urgent surgery

  e

  Metoclopramide IV
  Explanation: This femoral hernia has obstructed and become strangulated. If the neck of the hernia becomes too tight, it leads to oedema and congestion in the bowel loop with eventual infarction and perforation. Surgery is required for suspected strangulation. Femoral hernias have the highest risk of strangulation. Obstruction requires fluid replacement with saline (or Hartmann's solution), not dextrose. Erect CXR or CT are unlikely to alter the management. Metoclopramide is a prokinetic that is contraindicated in mechanical bowel obstruction.
• 57
  A 41-year old man presents with a lump in his abdomen that appears when he coughs or stands up. There is a reducible fluctuant mass that protruding through the linea semiluminares. What is term given to this pathology?
  Difficulty: Medium     Topic: Hernias
  a

  Littré's hernia

  b

  Spigelian hernia

  c

  Richter's hernia

  d

  Maydl's hernia

  e

  Paraumbilical hernia
  Explanation: This is a spigelian hernia, the defect is in the linea semiluminares at the lateral edge of rectus abdominus. Littré's is a hernia containing Meckel's diverticulum, which often strangulates. A Richter's hernia may strangulate without obstructing because it only involves the bowel wall, not the lumen. Maydl's hernia has a double-loop passing through a single defect, which may cause strangulation of the internal section. Paraumbilical hernias are immediately superior or inferior to the umbilicus.
• 58
  A 55-year old woman presents to A&E with lower abdominal pain and has been vomiting for 1 day. She complains of feeling bloated and hasn’t opened her bowels in 4 days. Potassium 4.6mmol/L. What is the most appropriate immediate management?
  Difficulty: Easy     Topic: Abdominal pain and constipation
  a

  Measure serum amylase

  b

  Hartmann's solution alone and pass NGT

  c

  Hartmann's solution with potassium and pass NGT

  d

  5% dextrose with potassium and pass NGT

  e

  Erect CXR
  Explanation: This woman has large bowel obstruction; she has presented with lower abdominal pain and constipation came before vomiting, whereas in small bowel obstruction there is vomiting before absolute constipation. Obstruction requires IV fluid and a nasogastric tube to be placed. There is marked loss of electrolytes when obstructed (due to 3rd space losses), including potassium, so Hartmann's solution with potassium is best. It is important to measure potassium before adding potassium to the fluid therapy because this lady may be in acute renal failure with hyperkalaemia. A CXR will help to exclude perforation but would also be done to help confirm placement of the NGT therefore it is reasonable to treat for obstruction first.
• 59
  A 51-year old man complains of passing bright red blood PR and feeling something coming down from his anus during defecation, which returns by itself. No masses are felt on PR. What degree should this man’s condition be described as?
  Difficulty: Easy     Topic: Bright red blood PR
  a

  1st

  b

  2nd

  c

  3rd

  d

  4th

  e

  5th
  Explanation: This man has haemorrhoids, which are engorged and hypertrophied venous tissues that line the anus and may prolapse. They are normally not palpable on rectal examination, unless thrombosed. 1st degree bleed but do not prolapse. 2nd degree prolapse and reduce spontaneously after defecation. 3rd degree require physical reduction after they prolapse. 4th degree are permanently prolapsed and will not reduce. (There is no 5th degree.) Treatment involves: sclerosants, band-ligation and cryotherapy but there is no consensus on the best treatment.
• 60
  A 61-year old man presents with bleeding PR and altered bowel habit. He has a Duke’s B tumour in the proximal sigmoid colon. What is the most appropriate resection?
  Difficulty: Medium     Topic: Colorectal surgery
  a

  Abdomino-perineal excision

  b

  Anterior resection

  c

  Hartmann's procedure

  d

  Left hemi-colectomy

  e

  Right hemi-colectomy
  Explanation: Surgery for CRC depends on whether they are presenting as an emergency or if the resection is elective. this is not an emergency (bleeding, perforation, obstruction). High sigmoid tumours require removal of the descending colon therefore left hemi-colectomy is more appropriate than an anterior resection for low sigmoid tumours because the latter only takes part of the descending colon. Hartmann's procedure involves a permanent colostomy and is used in emergencies. Right hemi-colectomy is used for caecal and ascending tumours. A-P excision is used for low rectal tumours.
• 61
  A 34-year old man presents with severe nausea and constant epigastric pain that is relieved by sitting forwards. Which of the following is least likely to also be present?
  Difficulty: Easy     Topic: Nausea and constant epigastric pain
  a

  Hypoglycaemia

  b

  Lipase of 643 IU/L

  c

  Hepatic steatosis

  d

  Positive Chvostek's sign

  e

  Hypercalcaemia
  Explanation: Nausea and anorexia are prominent features of pancreatitis. Lying back puts pressure from the stomach on the pancreas, which increases the pain. Hyperglycaemia is common though few patients need insulin. Lipase is a more sensitive marker of pancreatitis than amylase. Alcohol is the 2nd most common cause of acute pancreatitis, closely following gallstones. Alcohol induces hepatic steatosis, which is lipid deposition in hepatocytes that is usually asymptomatic but progress to steatohepatitis. Other causes of gallstones includes: hypercalcaemia, steroids, ERCP, trauma and a large proportion are idiopathic. Chvostek's sign is the presence of facial spasm on tapping the parotid gland due to hypocalcaemia, a complication of pancreatitis. Whereas hypercalcaemia may cause pancreatitis.
• 62
  A 62-year old man has stage 4 gastric carcinoma at the pylorus and suffers from severe outlet obstruction. What is the most appropriate treatment?
  Difficulty: Hard     Topic: Gastric cancer
  a

  Palliative gastrectomy

  b

  Laparoscopic gastroenterostomy

  c

  Chemotherapy

  d

  Laser therapy

  e

  Alcohol injection
  Explanation: Palliative treatment of non-resectable pyloric carcinoma involves removal of the gastric outlet obstruction. Gastroenterostomy joins the body of the stomach to the jejunum, which bypasses the obstruction. Gastrectomy is unlikely to be possible due to the position of the tumour, though would be an option if it were in a T2 (or T3) tumour in the fundus or corpus. Gastric carcinoma is moderately chemosensitive but chemotherapy will not give acute relief of the obstruction. Laser therapy is generally only used for oesophageal obstruction. Alcohol injection can be used for bleeding.
• 63
  A 45-year old man presents to the GP with new onset dyspepsia. An epigastric mass is palpable. What is the most appropriate management?
  Difficulty: Medium     Topic: New onset dyspepsia
  a

  Order a chest X-ray and follow up with GP in 4 weeks

  b

  Perform routine bloods and follow up with GP in 2 weeks

  c

  Order an abdominal X-ray and follow up with GP in 2 weeks

  d

  Urgent hepatobiliary surgeon referral

  e

  Urgent gastroenterology referral
  Explanation: A palpable upper abdominal mass is a criteria for urgent referral for suspected upper GI cancer. The other criteria are: new dysphagia, dyspepsia with 'alarm' symptoms, new dyspepsia at >55yrs, jaundice. The other investigations may be performed by the GP but a referral should be sent the same day so that this man is seen by a specialist in <2 weeks rather than followed-up by the GP. It is most likely that this man has gastric carcinoma but other causes of dyspepsia need to be excluded therefore referral to a gastroenterologist for an OGD is more appropriate than to a surgeon.
• 64
  A patient is in shock. Heart rate 110bpm with a bounding pulse, blood pressure 76/44mmHg, they are sweating and have warm peripheries and a patent airway. What is the most likely class of shock?
  Difficulty: Easy     Topic: Shock classes
  a

  Hypovolaemic

  b

  Cardiogenic

  c

  Septic

  d

  Anaphylactic

  e

  Neurogenic
  Explanation: Sepsis causes a similar picture to anaphylaxis but there is no compromisation of the airway. There is systemic vasodilatation, therefore they require aggressive fluid therapy, antibiotics and may need vasopressors if blood pressure remain low. Hypovolaemic and cardiogenic shock have cool peripheries due to vasoconstriction. Anaphylaxis causes occlusion of the airway due to laryngeal oedema and may also cause arrhythmias. Neurogenic shock shows peripheral vasodilatation and blood pooling below the level of injury due to loss of sympathetic supply for example, with a peripherally dilated lower limb and shunt-down upper limb.
• 65
  Which of the following is not part of the sepsis resuscitation bundle?
  Difficulty: Easy     Topic: Sepsis resuscitation bundle
  a

  Ranitidine for gastroprotection

  b

  SAG-M red blood cells for anaemia

  c

  IV hydrocortisone for septic shock

  d

  Diltiazem for hypertension

  e

  IV insulin for hyperglycaemia
  Explanation: The sepsis resuscitation bundle describes the treatment that should be implemented within 6hrs and 24hrs of diagnosing sepsis. Diltiazem is a rate-limiting calcium channel blocker that is negatively isotropic. For patients with sepsis this may reduce cardiac output and worsen their acidosis. If patients are hypertensive with sepsis then a dihydropyridine calcium channel blocker (e.g. nifedipine) is more appropriate. Histamine-blockers (ranitidine) or PPI should be given for gastro-protection. Packed red cells can be given for haemorrhage. IV steroids should be given within 24hrs for septic shock in accordance with local policy. IV insulin may be required as hyperglycaemia is known to give a poorer outcome.
• 66
  A 85-year old woman is on the ward table 1 day post-operation: 37.1 degrees, heart rate 92bpm, white cell count 6×10^9/L, respiratory rate 24/min. Examination is normal. What term best describes her condition?
  Difficulty: Medium     Topic: Systemic inflammation
  a

  SIRS

  b

  Sepsis

  c

  Septic shock

  d

  Severe sepsis

  e

  Acute respiratory distress syndrome
  Explanation: This woman has 2 features of the systemic inflammatory response syndrome (SIRS): respiratory rate >20/min and heart rate >90bpm. Other features are a white cell count <4x10^9/ml or >12x10^9/ml. SIRS is a non-specific response that can occur due to a number of stimuli. The most likely cause in this case is the stress from surgery. Sepsis requires the presence (or suspicious) of infection as the cause of SIRS, which is not described in this case. Severe sepsis describes sepsis with organ dysfunction, if this includes hypotension then it is called septic shock. A diagnosis of ARDS require poor oxygen saturation despite oxygen therapy and patients often require supported ventilation.
• 67
  A 50-year old man is recovering 2-hours after a laparotomy. Temperature 37.2 degrees, heart rate 102bpm, SaO2 92% and he is breathing with shallow breaths. What is the most likely cause?
  Difficulty: Medium     Topic: Post-op desaturation
  a

  Pneumonia

  b

  Poor analgesia

  c

  Pulmonary oedema

  d

  Excessive opiate analgesia

  e

  Raised intracranial pressure
  Explanation: This man is apyrexial, tachycardic and mildly desaturated, most likely due to basal atelectasis, which occurs to some degree during all operations. Good analgesia is required to allow ventilation of the lung bases. Tachycardia represents the pain response. Pneumonia would cause a raised temperature and takes 3-4 days to develop. Pulmonary oedema would cause respiratory distress with forceful breathing (not shallow). Opiate overdose causes slow, deep breaths. Raised ICP causes a bradycardia and irregular respirations.
• 68
  A 40-year old man is recovering from an emergency laparotomy for a perforated duodenal ulcer. 10 days later he develops an intermittent pyrexia, upper abdominal pain with localised guarding and hiccups. What is the most likely diagnosis?
  Difficulty: Easy     Topic: Intermittent pyrexia and hiccups
  a

  Spontaneous bacterial peritonitis

  b

  Anastamosis dehiscence

  c

  Subphrenic abscess

  d

  Mesenteric ischaemia

  e

  Empyema
  Explanation: An intermittent pyrexia (or 'swinging fever') is suggestive of an abscess. Hiccups result from: ileus, uraemia and irritation of the diaphragm e.g. subphrenic abscesses. Thorough wash-out is required after perforation to ensure that abscesses do not develop. Spontaneous bacterial peritonitis and anastamotic dehiscence present with generalised peritonitis and a constant fever. Mesenteric ischaemia would present with abdominal pain and an absence of signs, rarely fever. An empyema would cause chest pain and usually occurs post-pneumonia.