Q_USMLE Surgery/Management 2018 S_V

A detailed surgical scene in an operating room, featuring a surgeon and surgical staff working collaboratively on a patient under general anesthesia, with surgical instruments and monitors visible. Bright and professionally lit atmosphere.

Surgical Management Quiz

Test your knowledge in the field of surgery with our comprehensive quiz designed for medical professionals and students alike. This quiz includes a variety of challenging questions covering surgical techniques, patient management, and postoperative care.

Key Features:

134 carefully crafted questions.
Multiple choice format for easy engagement.
Focus on real-world surgical scenarios.

134 Questions34 MinutesCreated by SuturingSurgeon512

1. You are asked to assist the lead surgeon with a midline laparotomy in theatre. The patient has small bowel obstruction confrmed by CT imaging. Before the start of the operation, you are asked what layers, from superficial to deep, would be cut through during a midline laparotomy incision. Which of the following is the most likely answer?

Skin, subcutaneous fat, Scarpa's fascia, external oblique, internal oblique, transversalis fascia, extraperitoneal fat and peritoneum

Scarpa's fascia, skin, linea alba, transversalis fascia, extraperitoneal fat, subcutaneous fat and peritoneum

Skin, Scarpa's fascia, linea alba, transversalis fascia, extraperitoneal fat, subcutaneous fat and peritoneunal

Linea alba, Scarpa's fascia, skin, external oblique, internal oblique, transversalis fascia, extraperitoneal fat, subcutaneous fat and peritoneum

Skin, subcutaneous fat, Scarpa's fascia, linea alba, transversalis fascia, extraperitoneal fat and peritoneum

2. You are asked to review a 45-year-old man on the surgical ward by the nursing staff. Checking through the notes, you observe that he is 1 day following an open anterior resection for rectal carcinoma. He describes severe central abdominal pain associated with dyspnoea. The abdomen is soft but generally tender throughout. His symptoms have occurred despite an epidural that was inserted prior to surgery. What is the most effective form of analgesia in this setting?

Four-hourly inu·amuscular morphine

Patient-controlled opiate analgesia (PCA)

Intravenous paracetamol

Per rectum diclofenac

Intravenous oxycodeine hydrochloride

3. A 64-year-old man undergoes a laparoscopic gastric bypass for obesity. His baseline blood pressure is 150/80 mmHg. Intraoperatively, there was a small serosal tear which was sutured laparoscopically. The patient had some bleeding during the dissection of the lesser omentum, which was controlled with diathermy. The patient did not require intraoperative transfusion. Postoperatively on return to the high dependency unit, the patient is mechanically ventilated and his blood pressure is 80/40 mmHg. His urine output is 15 ml,/h. Which of the following is the best means of improving his urine output?

Commence an infusion of furosemide

A trial of dobutamne

0-negative blood transfusion

Insert a Swan-Ganz catheter

Give a fluid challenge and monitor the clinical response

4. You are called urgently to see a 67-year-old man who is 24 hours following uncomplicated laparoscopic cholecystectomy. The patient is human immunodeficiency virus-positive and has a past history of thrombocytopenia and at pre-assessment his platelet count was 60 x 109/L. He is complaining of chest pain and breathlessness and his abdomen is noticeably more distended than in the initial postoperative period with signifcant peri-umbilical tenderness. His postoperative electrocardiogram shows lateral ischaemia and his current haemoglobin level is 7.5 g/dL. He is tachycardic and his blood pressure is 115/75 mmHg. The next appropriate step is?

Bleep the on-call cardiologist

Start treatment dose heparin

Start an infusion of glyceryl trinitrate

Start blood transfusion

Return the patient to operating theatre for re-look laparoscopy

5. A 22-year-old woman with known Crohn's disease is about to 11ndergo an emergency subtotal colectomy with ileostomy. Prior to surgery the patient has been on 30 mg of prednisolone daily for more than 3 months. The best management to prevent an addisonian crisis would be?

Additional steroid cover is not required

Usual preoperative dose only (30 mg oral prednisolone)

50 mg of hydrocortisone intravenously preoperatively, followed by 50 1ng of hydroco1iisone intravenously 8- hourly for 72 hours

25 mg of hydrocortisone i11travenously preoperatively, then resume the nornal steroid dose postoperatively

25 mg of hydrocortisone intravenously preoperatively, followed by 25 mg of hydrocortisone intravenously for 24 hours

6. You are asked to assist your consultant who is operating on a 43-year-old human immunodeficiency virus positive man involved in a road traffic accident. The following precautions have been shown to decrease risk of HIV transmission, with the exception of?

7. A 62-year-old man is about to undergo an elective abdominoperineal resection for a low rectal carcinoma. He usually takes 5 mg warfarin per day for atrial fibrillation. His most recent international normalized ratio (INR) is 2.9. Which of the following is the best preoperative strategy?

Ad1nit the patient 1 day prior to surgery to stop waifarin and check the INR

Admit the patient 3 - 5 days prior to surgery to stop tl1e warfai·in and check the INR <1.5

Admit the patient 3-5 days prior to surgery to stop the warfarin, check the INR <1.5 and stai·t aspirin

Admit the patient 3-5 days prior to surgery to stop the warfarin, check the INR <1.5 and stai·t heparin infusion

Admit the patient 1 day prior to surgery to stop waifarin, cl1eck the INR <1.5 and start low-molecular-weight hepai·in

8. A 34-year-old man is about to undergo a left hemicolectomy for colorectal carcinoma. He is an insulin-dependent diabetic. The most appropriate perioperative management is?

Preoperatively commence 0.9% normal saline (3 Lin 3 hours), along with 20 units of i11tramuscular Actrapid insulin to 6 units per hour thereafter along with potassit1m supplementation

Preoperatively start 50 units of insulin in 500 mLof normal saline and continue through to postoperative period, then restart normal subcutaneous insulin when the patient is eating and drinking normally

Start an intravenous infusion of 5% or 10% dextrose (500 mL bags) over 4-6 hours and add insulin and potassium chloride to each bag, titrated to blood glucose and potassium levels

Continue usual subcutaneous insulin until and including the day of surgery. Place first on the list and monitor blood glucose preoperatively, intraoperatively and in recovery

None of the above

9. A 62-year-old man is awaiting an elective femoropopliteal bypass for peripheral vascular disease. He is a smoker of 60 pack years and is being treated for hypertension and hypercholesterolaemia with ramipril 5 mg each morning and simvastatin 10 mg orally at night. Three weeks ago he was admitted following an ST elevation myocardial infarction. His current blood pressure is 170/110 mmHg. Which of the following best describes the preoperative strategy?

Preoperative control of blood pressure with nifedipine is mandatory

Preoperative unfractionated hepaiin should be started, with 4-hourly monito1ing of the patient's activated paitial thromboplastin time

Intensive chest physiotherapy three times a day is vital postoperatively

A preoperative echocardiogram is required

None of the above, as the surgery should be deferred for 6 months

10. A 37-year-old man is admitted with abdominal pain and treated for pancreatitis; 48 hours following his admission you are asked to assess the patient as he has become increasingly confu.sed and aggressive. Observations are not possible, but you note he appears to be breathing hard, he is tremulous and has pruritus. Choose an appropriate management strategy?

Septic screen; urine dip, chest radiograph and blood cultures

Chlordiazepoxide 20 1ng intravenously, four times daily for 1 week

Haloperidol 2 mg intramusculai·ly and confine to side room

Lorazepam infusion

Oral chlordiazepoxide-reducing regimen with 48 hours intravenous thiamne

11. A 70 kg patient is 1 day following total hip replacement. He has not started eating and drinking. He is being rehydrated with dextrose/saline (4% dextrose and 0.18% saline). Which one of the following best describes this type of ﬂuid therapy?

It is an inapprop1iate fluid therapy for a postoperative patient

It contains 120 mmol of Na+ ions

Potassium supplementation is not required

Its osmolality is almost isotonic with plasma (286 mOsm/kg)

It has a pH of 7.35

12. A 22-year-old man is admitted foilowing a stab injury to the right groin. He is bleeding profusely from the wound. His blood pressure is 80/40 mmHg and his pulse is 140 beats/min. He is agitated and mildly confused. His skin is cool and mottled. In this scenario, which is the best mode of ﬂuid delivery?

Left subclavian central line

Long saphenous vein cut down

Right internal jugular approach central line

Left femoral long line

Two wide-bore cannulae inserted bilaterally to the antecubital fossae

13. A 22-year-old man is admitted following a stab injury to the right groin. He is bleeding profusely from the wound. His blood pressure is 80/40 mmHg and his pulse is 140 beats/min. He is agitated and mildly confused. His skin is cool and mottled, which one of the following statements regarding ﬂuid resuscitation is most correct?

Hartmann's solution should not be used

It is mandatory to use colloid over crystalloid

The best fluid replacement is cross-matched blood

Colloids are preferable to expand the intracellular volume

Crystalloids should be avoided as they may cause anaphylaxis

14. A 40-year-old man weighing approximately 70 kg is being kept nil by mouth due to small bowel obstruction. He is afebrile at 36.7 °C. Which of the following regimens best describe the patient's requirements over the first 24 hours?

1 - 2 mmol/kg of sodium is required

0.5-1 mmol/kg of potassium is required

At least 100-1000 kcal/kg/day are required

2700 mL of water is required

None of the above

15. A 68-year-old man is 6 days following open anterior resection with defunctioning ileostomy. The patient is afebrile at 36.7 °C. He is eating and drinking normally. The nursing staff informs you the stoma output is 3 L/day. His mucous membranes are dry and the patient feels thirsty. Which one of the following statements regarding ﬂuid therapy is most correct?

Continue to push oral fluids

5% dextrose is most appropriate given nutritional content

0.9% normal saline with potassium supplementation is most appropriate

Potassium supplementation is not required

None of the above

16. A 45-year-old patient is 1 week following an attack of severe acute pancreatitis. He has been unable to start eating as this precipitates severe pain. Physical examination reveals a soft abdomen with epigastric tenderness. Bowel sounds are scanty. He is afebrile. His amylase in normal and C-reactive protein is 200 mg/L. Which of the following statements regarding management of nutrition is correct?

No supplementary nutrition is required

Total parenteral nutrition should be commenced

Nasogastric feeding should be commenced

Nasojejunal feeding should be commenced

None of the above

17. After a multidisciplinary review, a 55-year-old patient is commenced on enteral feeding. After 24 hours, he complained of severe diarrhoea. What is the most appropriate step in managing this patient?

Speed up enteral feed

Stop the enteral feed

Slow down the enteral feed

Continue the enteral feeding at current rate and exclude other causes

None of the above

18. A 75-year-old Caucasian man is on the intensive care unit following an emergency Hartmann's procedure for an obstructing sigmoid carcinoma. He is currently 6 days post-procedure. His past history includes chronic obstructive pulmonary disease. The nursing staff report high nasogastric aspirates despite slow enteral feeding at 10 mL/hour. On examination, his abdomen is mildly distended, and generally tender with no peritonism. His stoma looks healthy, but has not started to work yet. His bowel sounds are absent. What is the best way to manage this patient's nutrition?

Continue nasogastric feeding

Site nasojejunal tube and start feeding

Commence total parenteral nutiition

Site a percutaneous gastrostomy tube

None of the above

19. A 30-year-old man is on the surgical ward following an assault resulting in severe head injury. The speech and language therapist is unhappy with the patient's swallow as he regurgitates ﬂuid and is at risk of aspiration. Which of the following is the best long-term strategy for addressing this patient's nutritional requirements?

20. You see a patient on the Intensive Care Unit who has been admitted with severe pancreatitis. He is having a central venous catheter inserted for intravenous fluid monitoring. Other than using a central venous cannula to measure central venous pressure during fluid resuscitation, from the list below choose the answer which correctly describes a long-term use of a central venous cannula?

21. You see an 18-year-old lady in the theatre admission lounge who is due to have a removal of a right breast fibroadenoma under general anaesthesia. You ask her whether she has had anything to eat or drink after midnight on the same day as the operation. From the list below, which of the following correctly applies to preoperative starvation in adults?

Patients should not eat solid food for 6 hours prior to a general anaesthetic

Patients may eat solid food up to 4 hours before a gen.era! anaesthetic

Patients should not eat solid food for 12 hours prior to a general anaesthetic

Patients may eat solid food up to 2 hours before a general anaesthetic

None of the above

22. You are asked to see a patient one day post total thyroidectomy who has a serum calcium of 2.0 and is complaining of muscular cramps. Which of the following is the most appropriate next step in this patient's management?

Prescribe a bisphosphonate infusion

Prescribe calcitonin

Establish cardiac monitoring

Administer high dose steroids

Contact the Surgical Registrar in light of taking this patient back to theatre

23. A 45-year-old lady is having an elective wide local excision of a right breast carcinoma followed by right axillary sentinel node biopsy under general anaesthesia. After 2 - 3 minutes of injecting the blue dye at the breast tumour site, you notice that the skin overlying the patient's chest has become erythematous. The anaesthetist alerts the surgeon that the patient has become tachycardic. Which of the following is the most appropriate next step to take in the anaesthetized patient?

Administer intravenous chlorpheniramine

Maintaining intravascular volume with intravenous fluids

Endotracheal tube removal and waking the patient

Continue with the surgery as this is not a serious condition

Administer intravenous hydrocortisone

24. A 25-year-old man is blue-lighted into the emergency department following an accident at work. A pan of hot cooking oil had spilled over half of his back and over both his legs and he has sustained extensive burns in this distribution. He weighs 70 kg. Calculate the additional volume of crystalloid this patient will require in the first 8 hours (from the time of his burn) of his treatment using the Parkland formula and the Wallace Rule of Nines?

25. As well as measuring oxygen saturation, a pulse oximeter also gives useful information regarding what other factor, used in initial assessment of the traumatized patient?

26. A patient is admitted in haemorrhagic shock following a road traffc accident. A final year medical student places an intravenous cannula; they have inserted a pink (20 G) cannula in the antecubital fossa. What rate of ﬂow into the patient will this allow?

27. A patient is admitted to the emergency department following an assault. You note a penetrating wound on the anterior chest wall. On examination, his blood pressure is 80/65 mmHg, pulse is thready and respiratory rate is 38breaths/min. His jugular venous pulse is unrecognizable as the neck veins are grossly distended. Breath sounds are equal bilaterally. During your evaluation the patient's output becomes undetectable. The next course of action should be?

28. A 42-year-old construction worker is admitted following a crush injury. The patient is in great distress and complaining of chest pain. The patient is working hard to breathe, however there is some paradoxical movement of her chest wall. Arterial blood gases show hypoxia with p02 7.5 and pC02 8.2. A chest radiograph shows multiple rib fractures. The life-saving intervention is?

29. A 35-year-old man was involved in a motor vehicle collision where he was thrown against the steering column. He sustained a blunt trauma injury to his left upper abdomen. On arrival at the emergency department, he complains of abdominal pain, but is haemodynamically stable. Computed tomography (CT) scanning shows a splenic tear and retained intra-abdominal haematoma. The tear extends through the splenic capsule, but not to the hilum. Which one of the following treatment options is not indicated in this case?

30. A patient is admitted following a fall from 4 m. He has sustained an injury to the posterior aspect of his head and has a Glasgow Coma Scale score of 12/15. On primary and secondary survey you identify a fracture of the left tibia but no focal neurology. You wish to remove the cervical spine collar and spinal board and so you review the cervical spine films; they show no abnormalities, but the lateral and swimmer's view films do not show the C7-Tl junction. Which one of the following is the most appropriate next step?

Clear the cervical spine clinically, askin.g whether neck pain is felt and assessing for neurology

Flexion and extension views

Continue management on a spinal board and collar until clinical assessment is possible

Ask senior clinician/radiologist to review films

Clear the cervical spine using computed tomography

31. A 32-year-old woman is admitted following a house fire. She has no obvious injuries save for some partial thickness burning to her back and legs. On initial assessment she appears confused, Glasgow Coma Scale score 14/15, and complains of nausea and headache. Her blood pressure is 165/110 mmg, pulse rate is 105 beats/min and respiratory rate is 23 breaths/min. Oxygen saturation is 98oo on room air. Arterial blood gases reveal respiratory alkalosis and a normal P02. The next stage of management is?

High-flow oxygen via non-rebreathable mask

Intubate and ventilate

Computed tomography head scan

Focused assessment with sonography for trauma (FAST) scan of the abdomen

100% oxygen via rebreathing bag

32. A 48-year-old man is admitted with a burn over his arm and anterior chest. The involved tissue includes the entire circumference of his upper arm. Following initial resuscitation, he is admitted for observation. You are called to assess him as he is beginning to complain of increasing pain and tightness in his forearm. On examination you note weak peripheral pulses, paraesthesia and pain on active movement of the fingers, hand and wrist. The next stage in management is?

33. A homeless man is admitted unresponsive after being found by police on a park bench. He has no external signs of injury. An oesophageal temperature probe records his core body temperature to be 34 °C. Which of the following management options is not routinely indicated in this case?

34. A 58-year-old builder is referred to outpatients with a long history of retrosternal chest pain associated with food. Oesophagogastroduodenoscopy was performed which showed grade 2 oesophagitis with a hiatus hernia. The stomach and duodenum were normal. What is the most appropriate management?

35. Which one of the following is not a recognized long-term complication of partial/total gastrectomy?

36. A 51-year-old patient is brought into the emergency department following a large-volume haematemesis. The patient is a known cirrhotic and previously survived variceal haemorrhage. The patient is haemodynamically stabilized and an emergency endoscopy is performed which identifies actively bleeding varices, and banding is attempted. Shortly following the procedure the patient again has a large-volume haematemesis and becomes haemodynamically compromised. The next step is?

Oesophageal transection

Transjugular intrahepatic portal-systemic stent shunting

Sengstaken-Blakemore tube

Repeat endoscopy

Angiographic arterial embolizatio

37. A 63-year-old patient is admitted with intermittent, colicky right upper quadrant pain and jaundice. Abdominal ultrasound shows a thickened gallbladder, but no identifiable stones. He is treated for biliary colic with fluids and analgesia but fails to improve. His serum bilirubin continues to rise and after 24 hours his C-reactive protein level and white cell count become elevated. Two days after initial presentation he develops a pyrexia of 39.2 °C and his pain is now constant. The next step in management is?

Cholecystectomy

Endoscopic retrograde cholangiopancreatography

Open stone removal with T-tube drainage

Magnetic resonance cholangiopancreatography

Lithotripsy

38. A postoperative patient has been moved to a side room after developing diarrhoea following the start of a course of antibiotics. Faecal samples test positive for Clostridium difcile toxin and metronidazole is started. After 10 days the antibiotic course is fmished and nursing staﬀ repeat the toxin assay on a formed stool sample, which is again positive. What is the most appropriate next management step?

No further action required

Continue metronidazole for a further 10 days

Start intravenous va11comycin

Start oral vancomycin

Urgent colonoscopy as this patient is at significant risk of pseudomembranous colitis

39. A 60-year-old patient is being treated for colonic carcinoma. The primary lesion has been excised and chemotherapy started. However, computed tomography (CT) scanning identifies a 1 cm metastasis in the right lobe of the liver. The patient has no history of alcohol misuse or viral hepatitis. CT chest and CT brain show no abnormalities. The most appropriate next stage of management would be?

Liver resection

Gadolinium-enhanced liver magnetic resonance imaging

CT/ultrasound-guided biopsy

Referral to a palliative care setting with appropriate counseling and support

Monitor lesion - If size exceeds 1.5 cm, add irinotecan to 5-fluorouracil and folinic acid chemotherapy

40. On colonoscopy a malignant lesion is identified 5 cm proximal to the splenic flexure. There are no contraindications to resection and the decision is made to operate with curative intent. The most appropriate procedure would be?

41. An 85-year-old male patient with a history of chronic constipation presents with acute severe colicky abdominal pain and absolute constipation. Plain abdominal film shows a grossly dilated oval of large bowel arising from the left lower quadrant. A diagnosis of sigmoid volvulus is made. The next step in management is?

42. A 27-year-old patient is seen in outpatients, as part of the follow-up for his ulcerative colitis. His current maintenance drugs include mesalazine and azathioprine, but he has not been tolerating azathioprine, and complains of malaise, nausea and vomiting. The next treatment option is?

43. An 18-year-old patient presents with a 12-day history of abdominal pain and pyrexia. On examination bowel sounds are present and the abdomen is soft with no rebound. A mass in the right iliac fossa is palpable. Abdominal computed tomography confrms the diagnosis of an appendix mass with an associated abscess. The patient is started on cefuroxime and metronidazole and admitted for observation and conservative management. After 2 days the mass has not reduced in size and the temperature remains raised. The next stage in management is?

44. A patient with a previous anal abscess presents with persistent discharge from the anus and perianal discomfort. On examination a sinus is identifable at the 6 o'clock position with the patient in the lithotomy position. A fistula is diagnosed and the patient is booked for theatre. What procedure is the surgeon most likely to perform?

45. An 85-year-old patient is admitted to the emergency department in shock with a short history of large-volume fresh bleeding per rectum. You resuscitate the patient with blood and ﬂuids. There is no identifable source on rectal examination. However, the patient continues to be unstable and you suspect continued bleeding. Her bowels open and pass an additional large volume of blood. Your next stage of management is?

46. A 45-year-old woman with a history of previous gynaecological surgery is admitted through the emergency department with central colicky abdominal pain, vomiting and absolute constipation. She is ﬂuid resuscitated and a nasogastric tube is placed. Abdominal radiograph demonstrates dilated loops of bowel with valvulae conniventes clearly identifable. Over the next 48 hours she fails to improve. The next stage of management is?

47. A 26-year-old woman arrives at the emergency department with unbearable intense right iliac fossa pain. Earlier that day, she was experiencing 'on and off moderate pain in the umbilical area which gradually moved over to the right iliac fossa. Associated symptoms include anorexia, nausea and vomiting. On examination, the patient is pyrexial and there is rebound tenderness and guarding over the right iliac fossa. A beta-human chorionic gonadotrophin test is negative. What should you do next?

Send the patient to the emergency operating theatre for an appendicectomy

Alert the obstetrics and gynaecology team, suspecting that she may have a ruptured ectopic pregnancy

Manage the patient medically in the emergency department

Order an ultrasot1nd scan of the abdomen

Send the patient for a plain film radiograph of the abdomen

48. A 12-year-old boy is admitted to the emergency department with sudden onset of severe right testicular and lower abdominal pain during athletic training. He has had one episode of vomiting and constantly feels nauseous. On examination, the patient is sweating and in unbearable pain. There is marked tenderness and swelling of the right testicle which is observed to be lying horizontally. What is the most appropriate next step in this patient's management?

Order a Doppler ultrasound of the testicular arteries @

Send the patient immediately for emergency surgical exploration of the scrotum

Perform urine dipstick

Manage the patient with analgesia and observe

Obtain a second opinion from your senior colleague, who will only be able to see the patient in an hour

49. A 48-year-old woman is admitted with severe epigastric pain and vomiting. The pain is continuous in nature and is made worse on movement. On examination you notice the patient is lying still, taking shallow breaths and sweating. There is marked tenderness in the epigastric and right upper quadrant of the abdomen. Murphy's sign is positive and the patient is slightly pyrexial. You suspect acute cholecystitis. What is the next best step in managing this patient?

Keep nil by mouth, administer parenteral analgesia and systemic antibiotics

Send patient for emergency laparoscopic cholecystectomy

Request a plain film abdominal radiograph

Administer analgesia and seek the opinion of a superior colleague

Request an ultrasound of the abdomen

50. A 65-year-old man is admitted to the emergency department following an acute episode of abdominal pain and collapse. The pain is intermittent and radiates to the back and iliac fossae. On examination, the patient appears confused, is sweating and has tachycardia. On inspection, the abdomen appears normal, but on palpation, you discover a pulsatile, expansile swelling in the midline of the abdomen. You suspect a ruptured abdominal aortic aneurysm. What is the most important next step?

Establish intravenous access and begin fluid resuscitation with a colloid

Send for a computed tomography scan of the abdomen

Obtain blood to determine haemoglobin and amylase levels

Request an abdominal plain film radiograph

Perform electrocardiography

51. A patient has been sent to theatre for emergency surgery with suspected appendicitis. He is given three doses of intravenous cefuroxime and metronidazole in a timely fashion. When is the best time to administer the first dose of antibiotics?

52. An elderly man with chronic constipation experiences acute-onset left iliac fossa pain and tenderness. On examination, the patient has fever and is slightly tachycardic. There is marked tenderness and guarding in the left iliac fossa. Full blood count results reveal a raised. What is the most appropriate treatment plan?

Keep nil by mouth and send for emergency laparotomy

Give analgesia and antibiotics

Keep nil by mouth, administer antibiotics and analgesia

Keep nil by mouth, achninister intravenous fluids, antibiotics and analgesia

Keep nil by mouth, administer intravenous fluids and analgesia

53. A 78-year-old African Caribbean man presents to the emergency department with severe pain arising from his hernia in the left groin. The patient is also experiencing central colicky abdominal pain. On examination, the abdomen is generally tender and distended and bowel sounds are raised. Examination of the hernial orifices reveals a left-sided, irreducible, tense and extremely tender inguinal hernia. The overlying skin of the hernia is warm and erythematou.s. What is the most appropriate course of action in managing this patient?

Alert theatre and send patient for emergency surgery

Request a computed tomography scan of the abdomen

Request an ultrasound

Attempt to reduce the hernia

None of the above

54. A 75-year-old man is admitted to the emergency department with acute-onset suprapubic pain and inability to pass urine for 2 days. On examination, the patient is in discomfort, neurologically intact, and the abdomen is particularly tender in the suprapubic region. A digital rectal examination reveals a smooth, enlarged prostate. What is the next step in management?

Ask the urology registrar to see the patient

Request an abdominal plain film radiograph

Btain blood for urea and electrolytes sampling

Urinary catheterization

Request an intravenous urogram

55. You see an 11-year-old boy in the emergency department who is admitted with an acute onset of abdominal pain, nausea and vomiting. There is diffuse pain around the central abdomen and right iliac fossa and is continuous in nature. On examination, the patient is febrile and there is marked tenderness and rebound in the right iliac fossa. The patient's mother tells you that he has recently had a sore throat. You suspect mesenteric adenitis and request an ultrasound scan which is inconclusive. What is the best next step to take in managing this patient?

Start the patient on analgesia and intraveno·us antibiotics

Send for a computed tomography scan of the abdomen

Observe patient for the next 2 hours and reassess

Send for emergency explorative laparotomy

None of the above

56. A 13-month-old girl is diagnosed with intussusception. She was admitted to the emergency department 2 hours ago with vomiting, passing red mucus-like stools and persistent crying. You are asked by your consultant about the first line treatment for this condition. What is the most likely first line treatment option?

Laparotomy and reduction

Barium enema per rectum and abdominal plain film radiography

Analgesia and observation for 24 hours

Intravenous fluids and antibiotics

Laparotomy and resection

57. A 25-year-old woman presents to your clinic after discovering, for the first time, two lumps in the inner lower quadrant of her left breast. On examination you fnd these lumps to be 2 cm in size, solid, discrete, mobile and non-tender. The right breast is normal and there is no lymphadenopathy. The most appropriate course of management is?

58. A 25-year-old woman is diagnosed with a 1.5 cm palpable area of fat necrosis of the left breast by core biopsy following a traumatic injury 14 days earlier. She has slight bruising of the lower outer quadrant of the left breast with moderate tenderness. What would be the most appropriate course of management?

Reassurance and discharge

Follow-t1p appointment for ultrasound in 3 months

Wide local excision

Left m.astectomy

Follow-up appointment for ultrasound in 6 months

59. A 38-year-old woman, and mother of two healthy children, is diagnosed with a fluid-flled simple cyst after triple assessment. On ultrasound the inner surface of the cyst looks entirely smooth. The woman does not have any significant family history of carcinoma and the cyst is located in the outer-lower quadrant of the right breast. What would be the most appropriate course of action?

60. A 30-year-old woman who is 12 days postpartum and breastfeeding is diagnosed with acute mastitis of the left breast. Four days earlier, she discovered a painful crack in the region of the left nipple and noticed that the surrounding skin was tender, warm and red in colour. The patient is not allergic to penicillin and you decide to prescribe a course of antibiotics. What would be the most appropriate antibiotic for treating this condition?

61. After a triple assessment, including core biopsy, a 28-year-old woman is diagnosed with a fibroadenoma of the left breast. The patient has a significant family history of breast carcinoma. The non-tender lump is situated in the inner lower quadrant of the left breast. The lump is approximately 1.5 cm x 1.5 cm. What is the most appropriate course of management?

Excision of the lump

Reassure and follow-up after 3 months

The patient should be given the choice of excision or not and if not she could be discharged

Fine needle aspiration

Perfor11 triple assessment again in 6 weeks

62. A 45-year-old perimenopausal woman is diagnosed with mammary duct ectasia of the right breast after having had small and infrequent amounts of milky green discharge from multiple ducts of the right nipple for over 2 months. The patient has no signifcant family history and mammography fmdings are normal. What is the most appropriate course of management?

Reassure and discharge

Surgical resection of the duct system of the right breast (Hadfield's operation)

Cormnence antibiotic therapy

Perform mamnography of the right breast in 3 months

Mastectomy of the 1ight breast

63. A 60-year-old woman was found to have one focal area of microcalcifcation (approximately 20 mm in diameter) in the left breast. A stereotactic core biopsy of this area was taken for histological assessment, which revealed low-grade ductal carcinoma in situ. In light of this, what would be the most appropriate treatment modality for this patient?

Mastectomy

Mastectomy+ postoperative radiotherapy

Wide local excision+ postoperative radiotherapy

Mastectomy+ axillary cleai·ance+ postoperative radiotherapy

Wide local excision + axillary clearance+ postoperative radiotherapy

64. A 47-year-old woman is diagnosed with an unofficial 2.5 cm Grade 3 invasive ductal carcinoma of the right breast. Following MDT discussion the consultant sees the patient in clinic to convey management options. Which of the following would be the most appropriate management plan for this patient?

Wide local excision

Wide local excision and axillary clearance

Mastectomy and sentinel node biopsy

Wide local excision and sentinel node biopsy

Mastectomy and axillary clearance

65. A 46-year-old man is diagnosed with an oestrogen receptor positive invasive ductal carcinoma of the right breast after having discovered a lump 3 months before. The patient is found to have multiple involved axillary lymph nodes and the tumour is of an aggressive phenotype. The most appropriate treatment option for this patient is?

Cytotoxic chemotherapy and Tam.oxife11 but no surgery

Mastectomy+ axillary clearance+ systemic chemotherapy+ radiotherapy and tamoxifen

Wide local excision and Tamoxifen only

Mastectomy+ postoperative radiotherapy only

Palliative care programme

66. A 28-year-old woman, who was hospitalized 2 months ago following a head injury, attends the outpatient clinic with a 6-week history of polyuria and polydipsia and no other symptoms. Her blood pressure is 117 /83 mmHg and her heart rate is 68 beats/min. From the list below, select the most appropriate management option?

67. During a ward round, you are asked by your surgical registrar about the management of a phaeochromocytoma. Select from the list below the most appropriate management plan for a phaeochromocytoma?

Surgical resection, followed by p blockade, followed by a blockade

Lifelong p and a blockade

Surgical resection

P blockade, followed by a blockade, followed by surgical resectio.n

A blockade, followed by p blockade followed by surgical resection

68. A 58-year-old postmenopausal woman has been seen in clinic following discovery of a 3 cm, nontender, irregular, firm lump in the upper outer quadrant of the left breast. Mammography and ultrasound imaging respectively reveal that the lump has areas of calcification and is a solid mass. The most appropriate course of action is?

Repeat mammography and ultrasound scans in 6 months

Reassure and discharge

Repeat mammography and ultrasound scans in 3 months

Fine needle aspiration to e11sure that the lump is not really fluid filled

Core biopsy

69. You assess a patient with a plantar ulcer who has poorly controlled diabetes. From the list of options below, select the most likely management plan?

70. A 60-year-old woman has been diagnosed as having claudication of the lower limbs which does not impair her lifestyle. The patient is a smoker and has hyperlipidaemia for which she is taking a 'statin'. You are asked to discuss with the patient the treatment options available to her. From the list below, choose the recommended treatment option for this patient?

Angioplasty

Amputation

Lower limb bypass

Start an antiplatelet, increase exercise and quit smoking

Continue with the cholesterol-lowering 1edication and follow up in outpatients in 3 months

71. You are asked to see a 56-year-old homeless man who presented to the emergency department with a severe pain in his right leg, which started over 12 hours ago. On examination, the right leg is pale in colour in comparison with the left leg from below the knee to the toes and has fixed mottling. The right leg is cold and the popliteal, posterior tibial and dorsalis pedis pulses are absent. There is no sensation in the right leg and the patient is unable to flex the knee or move the toes due to fixed flexion deformities. In addition, the patient is apyrexial and heart rate is 85 beats per minute and regular. What is the most appropriate treatment option for this patient?

Percutaneous transluminal angioplasty

Revasculai·ization through endarterectomy

Revascularization through bypass grafting

Endoluminal stent grafting

Amputation

72. You see a SO-year-old woman with a history of atrial fbrillation, who presents to the emergency department with a sudden onset of pain in the left forearm. The pain started 3 hours ago, and has been increasing in intensity since. On examination, the left forearm is cold and pale. The left axillary pulse is present, but distal pulses are absent. Movement and sensation are intact in the left hand. There is no history of trauma. What is the most appropriate next step in this patient's management?

Commence a hepaiin infusion and send the patient to theatre for vascular intervention

Give analgesia and manage the patient in the emergency depai·tment

Administer oral aspirin and send the patient to theatre for vasculai· intervention

Request an a11giogram

Request anteroposterior and lateral plain radiographs of the left forearm

73. A 41-year-old woman, diagnosed with varicose veins in the left leg, presents to your clinic with a 2-month history of severe pain in the left leg on prolonged standing. The patient is obese and the pain has aﬀected her working and social lifestyle and she asks you about the most effective treatment option. From the list below, choose the most effective treatment option that you would discuss with this patient?

74. A 55-year-old woman, who is obese and has a positive smoking history, is to have varicose vein surgery in the next 12 hours. Your senior colleague asks you to ensure that deep vein thrombosis prophylaxis is commenced. From the list below, choose the most appropriate form of deep vein thrombosis prophylaxis that you would use?

75. You are in the vascular surgery outpatient clinic explaining the indications forbundergoing carotid endarterectomy to a patient. From the list below, select the most likely scenario where carotid endarterectomy is likely to be indicated?

Symptomatic carotid ai·tery stenosis of greater than 50%

Asymptomatic carotid artery stenosis of between 70% and 80%

Asympton1atic cai·otid artery stenosis of between 50%and 60%

Symptomatic carotid ai·tery stenosis of less than 50%

None of the above

76. You see a 26-year-old woman in clinic presenting with lower limb lymphoedema. Which of the following conditions is associated with lymphoedema?

77. A 19-year-old Caucasian woman attends the outpatient clinic with a 2-day history of left-sided earache. The pain has worsened in the past 24 hours and she describes some seepage from the affected ear. Over the past few weeks her left ear has felt 'blocked' and she has been using cotton wool buds to clean them. Her hearing is not impaired. She is afebrile (36.7°C). On examination, the pain is worsened on superior movement of the auricle. There is a scanty discharge emerging from the left ear. Due to undergo treatment for her 2-day history of ear pain. Which of the following is most appropriate therapy?

Discharge with advice to stop using cotton wool buds

Discharge with combination of acidifying and antibiotic ear drops

Discharge with oral analgesics

Refe1ral to ENT specialist for myringotomy

None of tl1e above as the ear canal is 'self-cleaning'

78. A 6-year-old Asian boy is brought to the paediatric emergency department by his mother. She is worried because the boy is lethargic and has been complaining of right-sided earache all day. There have been no similar attacks in the past. On examination, he looks unwell, and his temperature is 39.0°C, pulse rate is llObeats/min and blood pressure is 90/40 mmHg. There is no cervical lymphadenopathy. Otoscopic examination reveals a bright red right tympanic membrane. You decide to take a microbiology swab. Due to treatment for his ear infection, which one of the following options is most appropriate therapy?

Immediate myringotomy

Advice on hygiene and antipyretics

Refer to ENT for tympanostomy tube

Oral antibiotics (amoxicillin) for 5 days

Antibiotic (amoxicillin) ear drops

79. You are asked to review a 34-year-old Caucasian male patient in the clinic. He describes a long history of problems in his right ear as a child. He also describes a 10-day history of pain in and behind the same ear. There has been a continuous discharge from the ear and he has been feeling 'under the weather'. He has a low-grade fever (37.5°C). Clinical examination reveals tenderness behind the right ear. Otoscopic examination reveals a bulging, red tympanic membrane. Select the most appropriate statement regarding the management of this patient from the list below?

The patient shot1ld be discharged on high-dose oral antibiotics for 7 days

Admit the patient for intravenous antibiotics and investigation

The condition cannot be treated by myringotomy and a tympanostomy tube

Mastoidectomy shot1ld be performed as soon as practically possible

None of the above

80. A 60-year-old Caucasian woman presents to the emergency department complaining of newonset 'dizziness'. She noticed it in the morning when she turned her head around to talk to her children. She felt the room was spinning around her for a few minutes and she had to go and rest in bed. She denies any deafness, tinnitus, otalgia or otorrhoea. She describes a less severe attack happening two months earlier. On examination she appears comfortable at rest, her pulse is 90 beats/min, blood pressure is 133/68 mmHg and respiratory rate is 12 beats/min. Otoscopic assessment is within normal limits. What will you do next?

Request a head computed tomography scan

Request magnetic resonance imaging of the brain

Perform positional testing

Prescribe betahistine

Prescribe cyclizine

81. A 4-year-old girl is brought to the paediatric emergency department by her father. He is concerned that she is fmding it painful to swallow her saliva. She describes a 1-week history of sore throat and feeling unwell. On examination she is febrile (39.0°C) and dribbling her saliva. A faint high-pitched sound is heard on inspiration from the end of the bed. What will you do next?

Call for senior help and an ENT specialist

Immediately set up an adrenaline nebulizer

Start oral third-generation cephalosporins

Request a neck radiograph

Site a surgical airway

82. A 40-year-old Caucasian man presents to the outpatient clinic complaining of progressively severe nasal obstruction. His wife has noticed that he has started to snore at night. He also describes a recent history of clear discharge from his nose. He suffers from recurrent attacks of sinusitis. Physical examination does not reveal any tenderness across the paranasal sinuses. What will you do next?

Request magnetic resonance imaging

Request allergy testing

Request plain radiographs of the sinuses

Examine the nose with a light and mirror

Refer for rhinomanometry

83. A SO-year-old Asian woman attends the emergency department complaining of a nose bleed that has persisted for more than 10 minutes at home. She is pinching her nose tightly and placed a towel under her mouth to catch any blood. A friend is holding an ice pack on her forehead. She describes several previous attacks which have resolved spontaneously. She is not in any respiratory distress. Her pulse rate is 100 beats/min, blood pressure is 130/70 mmHg and respiratory rate is 12 breaths/min. Physical assessment reveals an anterior bleeding point. What is the next procedure to control the bleeding? I

84. You review a 33-year-old Afro-Caribbean woman in the minors bay of the emergency department. She describes a 4-day history of a sore throat (being worse on the right side) and pain on swallowing. Today, she is unable to even swallow her own saliva. She feels unwell and describes 'ache' in all her muscles and joints. On examination she is febrile (37.9°C), pulse rate is 100 beats/min, blood pressure is 144/90 mmHg and respiratory rate is 12 breaths/min. She is reluctant to open her mouth due to pain. Examination of the oropharynx reveals asymmetric tonsillar enlargement (right more than left) with marked tonsillar exudate. The uvula is deviated to the left. She has bilateral cervical lymphadenopathy. Which one of the following is the most appropriate management?

Oral amoxicillin 500 mg four times daily

Aspiration of abscess in the emergency depart1nent

Chlorhexidine mouthwash four times daily

Regular oral analgesia and discharge to general practitioner

None of the above

85. A 9-year-old boy is brought to the hospital by his father because he noticed that his right eye was 'red, bulging and not moving very well'. The boy describes a headache and pain on moving his right eye. He has had multiple previous attacks of sinusitis. On examination, his temperature is 39.0°C, blood pressure 100/60 mmHg, pulse 94 beats/min, and respiratory rate 20 breaths/min. Physical assessment reveals proptosis and ophthalmoplegia of the right eye with pain to gentle palpation. The sinuses are tender, his eyelids are erythematous and the conjunctiva is markedly injected, but visual acuity is intact bilaterally. A purulent nasal discharge is additionally noted by the examining clinician. What is the most appropriate next step?

Needle aspiration of the orbit

Oral amoxicillin 500 mg four times daily for 10 days

Topical steroid eye drops

Admit for high-dose intravenous antibiotics

None of the above

86. A 40-year-old Caucasian man presents complaining of pain in his left eye. Earlier that day he was working in his house, attempting to put up a shelf with nails. He felt a sensation of 'some material entering his eye'. He does not wear contact lenses. His eye has been extremely watery and he has been 11nable to open it properly. All of the following statements regarding assessment are correct, except?

It is vital to assess visual acuity

The use of fluorescein is required to exclude an abrasion

Local anaesthesia may be required to formally assess the eye

Laceration to the margin of the eyelid can be sutured in the emergency room

It is important to identify and remove any foreign bodies

87. A 40-year-old Caucasian man presents complaining of pain in his left eye. Earlier that day he was working in his house, attempting to put up a shelf with nails. He felt a sensation of 'some material entering his eye'. He does not wear contact lenses. His eye has been extremely watery and he has been unable to open it properly, fluorescein assessment under the blue light slit lamp reveals a discrete green region at the lateral corneal margin. Which one of the foilowing statements best describes the management for corneal abrasion following foreign body injury?

An eye pad should not be prescribed

Topical steroids should be prescribed

Chloramphenicol may help prevent infection

Cycloplegic drops may speed healing

Surgery has no role in the management

88. A 48-year-old Caucasian man presents to the emergency department complaining of suddenonset loss of vision in his left eye which has now resolved. A few hours ago, he experienced the sensation of a 'curtain falling down over his left eye'. He is a smoker with a 40 pack year history and also has a past history of transient ischaemic attacks and angina. Fundoscopy reveals retinal infarcts and a cherry-red spot at the macula. The most appropriate management for this patient is?

89. You are asked to see a 77-year-old Caucasian woman on the ward by the admitting medical team. She describes a 1-week history of a constant ache on the right side of her head. This area is especially tender when she touches it or combs her hair. She describes suffering a similar series of symptoms approximately a year before the present admission on the left side, which resulted in complete blindness in her left eye. She has no visual disturbance in the right eye and acuity is normal. What would you recommend the team to do next?

Refer immediately to an ophthalmologist

Start high-dose steroids immediately

Perform a temporal artery biopsy

Perform erythrocyte sedimentation rate

None of the above

90. You are asked to assess a 25-year-old patient who returned from theatre 2 hours ago following a thyroidectomy for a large, hyperplastic goitre and is now complaining of diﬀiculty swallowing sips of water. On examination you note that she is very short of breath with a respiratory rate of 30 breaths/min, using her accessory muscles of respiration and only able to answer your questions in two or three words. In addition, there appears to be a fluctuant mass in the midline of the neck underlying the surgical clips. Immediate management of this patient would be?

High-flow oxygen via Hudson mask

Removal of surgical clips at the bedside

Intravenous access witl1 two large-bore cannulae and fluid resuscitation

Removal of surgical clips in theatre under general anaesthesia

Call your senior and wait for him/her to remove the clips

91. A 39-year-old man of Italian origin presents complaining of an exquisitely tender area over his right buttock, which has been present for several weeks. Within the past few days, the area has begun to weep profusely and his temperature at home prior to admission was 38°C. He reports having had this problem previously and was operated on during a previous admission. On examination you note that the man is extremely hairy and that there is an irregular, erythematous, warm and exquisitely tender shallow lump overlying the top of the right buttock. A small scar is seen over the lump and, on palpation, it is fluctuant and discharges purulent ﬂuid. A pilonidal abscess is suspected. Definitive management would consist of?

Advising to shave the affected area

Intravenous antibiotics

Drainage of the abscess under local anaesthesia

Drainage of the abscess under general anaesthesia

Oral antibiotics

92. A 55-year-old man with known atrial fibrillation presents to his general practitioner with a 3- month history of gynaecomastia. Which of his following medications is not associated with gynaecomastia?

93. A 73-year-old woman is seen in the outpatients department. She complains of altered bowel habit and weight loss. A colonoscopy is performed which identifes a large polyp. Polypectomy was not possible due to the patient being on warfarin for a metal heart valve. You are asked to re-book the patient for definitive management. Which one of the following statements pertaining to this scenario is correct?

Admission is required to monitor the patient while warfarin is stopped

Warfarin should be replaced with therapeutic doses of lowmolecular-weight heparin for 5 days prior to the procedure

An echocardiogram is required prior to the procedure to exclude valve thrombus

Conversion to unfractionated heparin infusion is required

A computed tomography pneumocolon should be performed to identify/exclude further disease before a management decision is made

94. A patient who underwent an oesophagectomy in an attempt to cure stage 1 cancer becomes confused 4 days postoperatively and pulls out his nasogastric tube. What is the best course of action?

95. A 43-year-old patient is being managed following presentation with perfuse diarrhoea and profound dehydration secondary to an exacerbation of Crohn's colitis. Your initial bloods come back showing sodium 137 mmol/L, potassium 2.9 mmol/L, urea 9.2 mmol/L, creatinine 134 µmolL. He has a peripheral cannula in situ only. Which one of the following statements regarding potassium replacement in this patient is the most correct?

40 mmol potassium chloride can safely be given over 1 hour

Central line insertion is advisable

Bolus potassiu1n is safe, provided a central line is used

Maxim.um concentration of potassium to be given peripherally is 20 mmol/500 mL

Maxim.um rate of potassium infusion peripherally is 20 mm.ol every 4 hours

96. A postoperative patient is being managed on a high-dependency unit following a subtotal colectomy. Blood results show the phosphate level is 0.25 mmol/L. Which one of the following statements regarding intravenous phosphate is incorrect?

May cause hypercalcaemia

Should never be given at a rate greater than 30 mmol over 6 hours

Should preferentially be given via a central line

May cause metastatic calcification

Should be used even if the patient is asymptomatic

97. A 4-year-old child is admitted following a road traffic accident. She is tachycardic and you wish to administer fluid and blood. The child is peripherally shut down and it has not been possible to gain access after two attempts at peripheral cannulation. Your next option is?

98. A patient is admitted following a car accident where she was a restrained passenger. The patient is 32 weeks pregnant. She is shocked with a rigid and tender abdomen. An abdominal radiograph is performed which shows air under the diaphragm and the fetus's left leg appears extended. The most appropriate next course of action is?

99. A 29-year-old city worker is diagnosed with a duodenal ulcer which was visualized with upper gastrointestinal endoscopy. A tissue biopsy of the ulcer was taken and a Campylobacter-like organisms (CLO) test revealed the presence of Helicobacter pylori. Which one of the following treatment regimens will oﬀer the highest chance of cure?

Omeprazole, amoxicillin, clarithromycin

Raniticine, amoxicillin, metronidazole

Omeprazole, clarithromycin

Raniticline, amoxici11in

Amoxicillin, clarithromycin

100. A 45-year-old patient presents to the outpatient department following referral by his general practitioner for rectal bleeding. The patient reports that as well as the bleeding in the past few days he has experienced increased pain in the perianal area. On examination you identify thrombosed haemorrhoids. The appropriate management is?

Admit, analgesia, haem.orrhoidectomy

Oral and local analgesia and discharge with follow-up

Outpatient department banding

5% phenol in arachis oil injection above the dentate line

Discharge to general practitioner for management

101. A 46-year-old patient is seen in the outpatient department for follow-up of Crohn's disease. He reports intractable diarrhoea, but does not report any systemic symptoms or abdominal pain. Contrast follow-through fails to show any evidence of active disease or fistulation. He is otherwise well. His maintenance medications include mesalazine and 6-mercaptopurine. The most appropriate choice of drug is?

102. A patient with a perforation of the sigmoid colon, secondary to diverticulitis, is sent for an emergency colonic resection. From the list below, select the most appropriate colonic resection that should be performed in this patient?

103. An otherwise ft 65-year-old patient is admitted following an assault during which he was pushed to the ground and sustained a fractured hip. Your specialist registrar reviews the film and says the fracture is a Garden 2 intracapsular neck of femur fracture. The appropriate management is?

104. A 75-year-old woman is admitted following a fall at home. Her leg is shortened and externally rotated. Radiographs show a fracture line running through both the greater and the lesser trochanters. The appropriate management is?

105. A 38-year-old man is admitted after falling and sustaining fractures of his tibia and fibula. He is taken to theatre and plate fxation of the fractures is performed. You are called to the ward by the nursing staffs, who want you to prescribe morphine patient-controlled analgesia, as the patient's pain has not responded to a current rate of morphine analgesia. You examine the limb; it is in a cast with the forefoot exposed, the skin is warm, but sensation is reduced compared with the non-operative side. You attempt to move the toes, but the patient is in too much discomfort. Your first course of action should be?

106. A 72-year-old Asian man presents to his general practitioner with a neck lump noticed when shaving. Of note, he is a smoker of 50 pack years. He denies any symptoms from his ear, nose or throat. He has noticed feeling more tired recently and has lost a few pounds in weight over the last couple of months. He has no previous history of dental abscess or infection. Which one of the following is the most appropriate next management option?

107. A 40-year-old woman presents with a progressively enlarging midline swelling of her neck over many years. She complains about the cosmetic appearance and states that recently it feels like she is being 'strangled at night' when she lies ﬂat. She does not have dysphagia or dysphonia. Her appetite and weight are unchanged. Her periods are regular. On examination, she has a smoothly enlarged goitre. Which one of the following is the most appropriate management?

108. A 62-year-old Caucasian man presents to clinic complaining of a recent change in his voice. He has noticed that it is much more hoarse than normal. The symptoms have persisted for more than 4 weeks. He also describes a history of persistent dry cough lasting several months. He is a smoker of 60 cigarettes per day. ENT evaluation reveals an irregular swelling of the left vocal cord which is biopsied. Which one of the following is the best statement regarding laryngeal carcinoma?

Adenoid cystic carcinoma is the most common histological variant

Glottic laryngeal carcinoma is less common than supraglottic carcinoma

Surgical therapy is mandatory

In the absence of cervical nodes, total laryngectomy and radical neck dissection is advocated

None of the above

109. A 55-year-old Caucasian woman is referred to the clinic by her dentist. She noticed a painless white spot on her tongue a few months ago, which has failed to heal with topical therapy and is still present 3 weeks later. She smokes 30 cigarettes per day and drinks approximately 30 units of alcohol per week. On examination, she has a small ulcer on the tip of her tongue. Tongue movements are not affected. There is no palpable cervical lymphadenopathy. Which one of the following is the best statement regarding management/ diagnosis?

In the absence of tongue fixation, malignancy is unlikely

Any ulcer that has persisted for more than 3 weeks should be biopsied to exclude malignancy

Partial glossectomy is never required

Adenocarcinoma is most common

None of the above

110. A 62-year-old African man presents to his general practitioner in the well-man clinic for a routine check-up. His past medical history includes type 2 diabetes mellitus (diagnosed 20 years ago), hypercholesterolaemia and hypertension. He takes metformin 850 mg per day, but does not record his blood sugar regularly. He is additionally taking simvastatin and enalapril. Examination reveals no cardiovascular or respiratory abnormalities and a normal urine dipstick test. Fundoscopy reveals dot retinal haemorrhages, cotton wool spots and neovascularization. His visual acuity is not significantly impaired. Which one of the foilowing is the most appropriate management?

Increased metformin dose and tight observation of glucose control

Vitrectomy

Early laser photocoagulation

Retinoscopy and deferred laser photocoagulation

Retinoscopy and deferred vitrectomy

111. A young couple of Jamaican origin present to the paediatric outpatient clinic with their 3- month-old son, concerned about the presence of a large lump overlying the umbilicus, which appears to enlarge when the child cries. The baby was born at term via an uncomplicated vaginal delivery. On examination, the lump is as described and the child appears otherwise healthy and developed as expected for his age. First-line management of this condition would be?

112. A 6-month-old boy presents with his parents to the paediatric outpatient clinic. The infant's parents have recently become aware that his scrotum appears to be small and underftlled. He was born prematurely at 30 weeks gestation. On examination, the scrotum appears small and hypoplastic, but there is no palpable abnormality within the inguinal regions. An ultrasound scan reports that two ovoid objects lie in the posterior abdominal wall and are consistent with the appearance of bilateral truly undescended testes. The infant's parents are advised that an orchidopexy is indicated to fix the testes in the scrotum. In which age range should this procedure ideally be undertaken to prevent irreparable testicular damage?

113. A 25-year-old woman presents to her general practitioner with redness overlying her left nipple and the skin su.rrounding it. She has been feeling generally unwell for the past several days and has 6 weeks previously given birth to a healthy girl, whom she is breastfeeding. On examination, the redness is confined to the left breast and painful to touch. There is no evidence of the nipple being cracked. The patient's general practitioner suspects that she has developed a lactational breast abscess. The most appropriate action would be to?

Prescribe an antibacterial agent, e.g. flucloxacillin

Advise the patient to stop breastfeeding and review in 2 - 3 weeks

Breast aspiration under local anaesthesia

Prescribe an antifungal agent, e.g. ketoconazole

Refer to hospital's general su1·gical team for formal drainage under general anaesthesia

114. A 67-year-old female ha.s been moved to the intensive care unit after undergoing a laparotomy and elective right hemicolectomy for a caecal tumour. The patient is placed on epidural analgesia. From the list below, choose the most likely associated systemic effect of epidural analgesia?

115. A 47-year-old male is admitted with acute renal failure. He is HIV positive and is on antiretroviral medications. He was recently recruited into a clinical trial and started on trial medication. He has been unwell since and has noticed blood in his urine and low urine output. His BMI is 20. He has been unable to eat properly for 1 week because of a poor appetite. The nutrition for this patient is?

Consider parenteral nutrition

High risk of refeeding synch·ome ai1d requiI·es slow calorie replacement

Increase oral/enteral nutrition

MUST score is low and the patient can be observed

MUST score is medium and repeat screen on a monthly basis

116. A 79-year-old female suffers from depression and long-standing arthritis. She used to weigh 66 kg 6 months ago and is now 62 kg. Her BMI is 22. The nutrition for this patient is?

Consider parenteral nutrition.

High risk of refeeding synch·ome and requires slow calorie replace1nent.

Increase oral/enteral nutrition

MUST score is low and the patient can be observed

MUST score is medium and repeat screen on a monthly basis.

117. A young man has undergone extensive bowel resection for Crohn's disease 2 days ago. He is in intensive care and his BMI is 25. Blood test shows Na 142 mmol/, K 3.7 mmol/, urea 8.9 mmol/ and creatinine 98 µmol/. The nutrition for this patient is?

Consider parenteral nutlition

High risk of refeeding syndrome and requires slow calorie replacement.

Increase oral/enteral nutrition

MUST score is low and the patient can be observed

MUST score is medium and repeat screen on a monthly basis

118. An 18-year-old girl presents to A&E having collapsed at home. She is very slim and has a BMI of 15. She is weak, thin and has poor dentition, nails and hair. Systemic examination is normal. Blood tests show Na 142 mmol/, K 2.2 mmol/, urea 6 mmol/, creatinine 50 µmol/ and glucose 6.7 mmol/. The nutrition for this patient is?

Consider parenteral nutrition

High risk of refeeding syndrome and requires slow calorie replacement.

Increase oral/enteral nutrition.

MUST score is low and the patieNt can be observed.

MUST score is medium and repeat screen on a monthly basis.

119. A 70-year-old female with a past history of large bowel cancer has recently moved to a care home and staff is concerned that she may be malnourished. Her BMI is 25. Her appetite is normal and there is no history of weight loss. The nutrition for this patient is?

Consider parenteral nutrition.

High risk of refeeding synch·o1ne and requires slow calorie replacement

Increase oral/enteral nutrition

MUST score is low and the patient can be observed

MUST score is medium and repeat screen on a monthly basis

120. An adolescent with Perthes' disease has a small area of collapse in the main load-bearing area of the femoral head. What is the best next step in management?

121. A 34-year-old man has isolated medial compartment osteoarthritis following a previous complex tibial plateau fracture. He has severe pain, but with a reasonable range of movement, and a varus deformity. What is the best next step in management?

122. A 49-year-old woman presents with advanced radiographic osteoarthritis of the knee, isolated to the medial compartment. What is the best next step in management? �

123. A 78-year-old man presents with severe right groin pain, regular night and rest pain and limiting his day-to-day activities. Radiographs of the hip demonstrate moderate to severe osteoarthritis of the right hip. What is the best next step in management?

124. A 67-year-old woman presents with severe left knee pain affecting her mobility and quality of life. Radiographs of the knee demonstrate tricompartmental idiopathic osteoarthritis of the knee. What is the best next step in management?

125. A 32-year-old woman twists her right ankle, sustaining an isolated Weber B undisplaced lateral malleolus fracture with no displacement of the ankle mortice. What is the best next step in management of this patient?

126. A 17-year-old boy falls and suffers a transverse displaced midshaft fracture of the left radius and ulna. It is a closed and neurovasculary intact injury. What is the best next step in management of this patient?

127. A 22-year-old man sustains an open fracture of his left distal radius following a heavy fall while playing football. There is 0.2 cm small puncture wound over the ulna aspect of his left wrist, with no evidence of contamination and is neurovascularly intact. What is the best next step in management of this patient?

Total hip arthroplasty

Traction

Wot1nd deb1idement and washout

Wound debridement with washout and closure, fracture fixation

Wound debridement, washout, leave wound open and fracture fixation

128. A 71-year-old man with carcinoma of the lung and metastases presents with a pathological fracture through the upper third of the femur. What is the best next step in management of this patient?

129. An 81-year-old woman presents following a simple mechanical fall, and on presentation her right leg is shortened and externally rotated. She has a past medical history of ischaemic heart disease and COPD. X-rays reveal a right intertrochanteric neck of femur fracture. What is the best next step in management of this patient?

130. A 4-year-old girl falls from a trampoline and sustains a displaced fracture of the left distal humerus (supracondylar). It is a closed and neurovasculary intact injury. What is the best next step in management of this patient?

31. One hour before surgery, oral administration of paracetamol and ibuprofen. General anaesthesia with spontaneous breathing, including a small dose of short-acting opiate, e.g., fentanyl. Local infiltration of long-acting local anaesthetic by surgeon to wound(s). What the best next step in management?

132. One hour before surgery, oral administration of paracetamol and Ibuprofen. General anaesthesic technique with ventilation, including intravenous morphine. Local infiltration of long-acting local anaesthetic by surgeon to wound(s). What the best next step in management?

133. A nerve block carried out by the anaesthetist or surgeon, using a mixture of short- and longacting local anaesthetic agents. What the best next step in management?

134. General anaesthesia, using a small dose of short-acting opiate, e.g., fentanyl. A nerve block using long-acting local anaesthetic carried out at the beginning of the procedure. What the best next step in management?

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