Surgery_2-Diagnostic-Surgery

You are assisting a bypass grafting procedure in theatre. Your senior colleague asks you to show him from where the common femoral artery arises. From the list below, choose the statement that best describes the anatomical landmark and course of the common femoral artery?

The nursing staff asks you to review an erect chest radiograph of a 60-year-old woman who has undergone open colonic surgery for a pelvic mass 3 days ago. She is comfortable at rest. Her abdomen is distended, with absent bowel sounds. Free air under the hemi-diaphragms is likely to be due to?

You have been asked to see a 72-year-old Caucasian woman who is 52 hours following uncomplicated laparoscopic cholecystectomy for gallstone disease. She was found unconscious on the ward with generalized tonic-clonic seizures, requiring 20 mg diazepam. Her sodium level is 112 mmoVL. During surgery she received 3 L of 5 o/o dextrose with 20 mmoi/L potassium chloride. Her potassium and urea and creatinine are within normal limits. There are no signs of heart failure. Her plasma osmolality is 265 mOsmlkg and her urinary osmolality is 566 mOsm/kg. Which of the following is the most likely cause for her low sodium?

The patient in Question 6 had a central line inserted and was transferred to the highdependency unit. Her observations remained the same and in the last hour only 5 mL of urine is passed. Her saturations remain poor. Her central venous pressure initially is 11 cmH20. You attempt a fluid bolus of 250 mL of colloid, following which her central venous pressure increases and remains at 15 cmH20. Her urine output over the next hour is 10 mL. Which one of the following statements is the most correct?

You are asked to see a 45-year-old African Caribbean female patient on the ward. She is approximately 30 minutes following the insertion of a left internal jugular vein catheter sited for total parenteral nutrition. A plain film chest radiograph has not yet been performed following the procedure. The nursing staff is concerned as the patient is breathless. On arrival, the patient's airway is patent, but she is breathless at rest. Her respiratory rate is 30breaths/min. The trachea is central. Her pulse is 110 beats/min and blood pressure is 160/90 mmHg. There are reduced breath sounds on the left and the left chest is hyper-resonant to percussion. Select the most appropriate diagnosis and management strategy?

A 39-year-old lady is having a diagnostic laparoscopy to investigate her symptoms of right iliac fossa pain. The procedure lasts 50 minutes and following the removal of the endotracheal tube, the patient is taken to the recovery room where she develops sudden onset shortness of breath, tachycardia and hypotension. Following rapid assessment, she is found to have a tension pneumothorax which is decompressed by needle thoracocentesis. From the list below, choose the clinical sign which is not a feature of tension pneumothorax? !

You review a patient on the ward who has suspected cardiac tamponade following insertion of a pacemaker. You are asked to perform a rapid initial assessment of the patient. Which one of the following clinical signs from the list below would you expect to see in a patient with cardiac tamponade? !

You are asked to review a 30-year-old man who has sustained chest trauma. He has a p02 of7.9 kPa and a pC02 of 7.0 kPa. From his arterial blood gas reading (taken on 5 L 02 per minute), this patient has type 2 respiratory failure. Which of the following is not associated with type 2 (hypercapnic) respiratory faiJure?

A patient is admitted following an assault. On assessment, he has a stab wound to his chest. Clinically, he has a massive haemothorax and his Glasgow Coma Scale score is 4/15. Without further management this patient will succumb to which cause of death first?

A 35-year-old man is admitted after severing his arm on industrial machinery. His airway is patent and there is no identifiable hindrance to breathing. His pulse is 110 beats/min, blood pressure is 130/105 mmHg, and respiratory rate is 25 breaths/min. Which stage of shock is this patient in?

A 35-year-old butcher is admitted after stabbing himself with a knife inadvertently. His airway is patent and there are no identifiable hindrances to breathing. His pulse is 110 beats/min, BP is 130/105 mmHg, and respiratory rate is 25 breaths/min. Assuming a body mass of 70 kg, what is the best estimated volume of blood lost?

A male patient is admitted following a fall from height. On arrival his Glasgow Coma Scale score is 5/15 and he is therefore intubated. During primary resuscitation a chest film is taken which shows a widened mediastinum and right-sided deviation of the trachea. The diagnosis is?

A 20-year-old woman was resuscitated in the emergency department and required the insertion of a chest drain. The drain was removed 2 days later before she was discharged. She re-presents 10 days later complaining of chest pain associated with high fever and sweats. An empyema is suspected and a chest radiograph confirms a collection. The most appropriate next course of action is?

Which one of the following statements regarding diagnostic peritoneal lavage is not true?

Which of the following is not an independent indication for laparotomy following trauma?

A patient is admitted to the emergency department with a reduced level of consciousness, smelling of alcohol. A boggy haematoma is noted on the posterior aspect of his skull. The patient's eyes open to voice, but he makes no attempt to vocalize. A sternal rub causes the patient to open his eyes, moan and extend his arms and legs. His Glasgow Coma Scale score is?

A patient is admitted into the emergency department following a head injury at work. He is resuscitated and stabilized, but a computed tomography scan shows significant brain contusion. He is intubated and cared for on the intensive care unit. You attempt to evaluate his Glasgow Coma Scale score; there is no response to voice, but pressing a pen into his fingernail causes the patient to open his eyes and attempt to withdraw his hand from you. His Glasgow Coma Scale score is therefore?

A 31-year-old man is admitted foUowing an assault outside a nightclub. During the fight, he was hit by a blunt object across the side of the head. On admission his Glasgow Coma Scale score is initially 12/15 but falls to 8/15 during his evaluation. The decision is taken to perform a computed tomography head scan, which identifies a lens-shaped space-occupying lesion within the cranial vault. The diagnosis is?

Which of the following is not a recognized complication of severe burn injury?

A 27 -year-old patient presents with a 3-month history of increasing difficulty in swallowing. He first noticed the problem when drinking fluids, but is now commonly experiencing it when eating food as well. He has presented as regurgitation of food is becoming a problem and he has noticed unintentional weight loss. A chest radiograph shows a widened mediastinum. What is the most likely diagnosis?

A 45-year-old man presents to the emergency department with a history of coffee-ground vomiting. He also reports that for 2 days his stool appeared darker than usual. Which of the following gives the most sensitive guide as to the severity of his gastrointestinal haemorrhage?

A 45-year-old patient presents in shock complaining of sudden-onset generalized upper abdominal pain radiating to the right iliac fossa and the tip of his right shoulder. He reports one episode of vomiting, but none since. He has no past medical problems. On examination, his abdomen is rigid and bowel sounds are absent. The diagnosis is? [

Which of the following syndromes is associated with multiple duodenal ulcers not amenable to conventional medical therapy?

A patient presents with a short history of perfuse, projectile vomiting without bile staining. He has a history of peptic ulceration and chronic dyspepsia and has noticed increased bloating over the preceding 9 months. On examination, there is distension in the epigastric region and a succession splash. The abdominal radiograph shows a grossly distended stomach and collapsed bowel. The most likely cause is? [

A 62-year-old patient is admitted with jaundice. His stool is pale and urine dark red. On examination he has a palpable gallbladder. The most likely cause is? [

A 32-year-old female patient presents with a 6-week history of bloody bowel motions. She has noticed significant weight loss over the preceding 6 weeks with increasing lethargy and fatigue. She has previously had constipation and admits to regular laxative use. What is the most likely diagnosis?

You are called to see an 85-year-old female patient as the nursing staff is concerned that the patient has not passed stool for 4 days. The patient has been admitted after family members became increasingly concerned regarding her general deterioration in health and level of function. She is orientated but frail and complains of increasing abdominal discomfort. On examination bowel sounds are increased. The abdomen is distended with generalized tenderness, but no rebound or guarding. There is a firm palpable mass in the left iliac fossa. Digital rectal examination shows an empty rectum. What diagnosis must be excluded?

A 78-year-old patient is admitted with a short history of sudden onset colicky abdominal pain and bleeding per rectum. On assessment his blood pressure is 110/55 mmHg, respiratory rate is 30 breaths/min and he is in atrial fibrillation with a ventricular response of 130 beats/min. He is known to you as he has previously presented in the outpatients department and been investigated for intermittent abdominal pain associated with food associated with a 2 stone weight loss. He had a colonoscopy and upper GI endoscopy 3 months ago which was normal. Whilst you are investigating his pain, it changes to a constant central ache. The diagnosis is?

A 60-year-old homosexual man presents with a 6-month history of passing fresh blood per rectum and anal pain. His presentation has been precipitated by the recent loss of continence to faeces. The blood coats the stool and he had noticed it on the paper after wiping. On rectal examination the patient has an empty rectum. You identify a third-degree haemorrhoid in the 11 o'clock position, as well as two further second-degree haemorrhoids. No other masses are palpable. The diagnosis is?

A 60-year-old diabetic patient presents with an 8-hour history of being unable to pass urine. On taking his history, he reports a 3-day history of pyrexia and throbbing pain around the back passage. He is also concerned as he has also noticed he has been passing urine increasingly frequently and worries that his diabetes is getting worse since increased urinary frequency was how his condition was initially diagnosed. On examination of his abdomen there is no evidence of peritonism. On digital rectal examination there are no abnormalities visible in the perianal area; the procedure is extremely painful. However, the prostate feels normal and is in the normal position. The diagnosis is?

A 55-year-old man, with a 2-year history of dyspepsia, is brought to the emergency department following a sudden onset of severe epigastric pain. The pain is made worse on movement and the patient has also experienced one episode of haematemesis. On examination, the patient is cold, sweating profusely and taking shallow breaths. The abdomen is rigid and bowel sounds are absent. A plain film chest radiograph reveals free air under the diaphragm. The most likely diagnosis is?

You see a 55-year-old woman in the emergency department, who was admitted with central colicky abdominal pain and multiple episodes of vomiting. She last opened her bowels 4 hours ago. On examination she appears dehydrated and is in pain. The abdomen is generally tender and slightly distended. Bowel sounds are increased. Yon suspect a bowel obstruction and decide to order some investigations. What is the most valuable initial investigation that will support your suspected diagnosis?

A 45-year-old Asian man is brought in with an acute onset of epigastric pain, nausea and severe vomiting. The pain is worse with movement and is only relieved slightly by leaning forward. The patient is an alcoholic and has been admitted to the emergency department on several occasions for alcohol intoxication. On examination the patient is tachycardic, pyrexial and dehydrated. The abdomen is diffusely tender and soft, and bowel sounds are normal. The patient's serum amylase is raised by six times the upper limit of normal. The most likely diagnosis is?

A 75-year-old man, who suffers from chronic atrial fibrillation, is admitted to the emergency department with a sudden onset of severe central colicky abdominal pain and vomiting. The patient has been bleeding from the rectum. The blood is dark in colour and has an altered consistency. On examination the patient is pale, has cold peripheries and is tachycardic. The abdomen is diffusely tender and bowel sounds are decreased. What is the likely diagnosis?

A 50-year-old woman presents with an acute episode of epigastric pain, vomiting and fever. The registrar, who has already clerked and examined the patient, tells you that 'Murphy's sign is positive'. Despite not having seen the patient, from the information conveyed to you, what is the most likely top differential diagnosis that is running through your mind?

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 likely diagnosis?

You are asked to see a 48-year-old woman who has been admitted to the emergency department with sudden onset of right upper quadrant pain. Your registrar liaises with you, after having seen this patient, and tells you that the patient has 'Charcot's triad'. From the information conveyed to you, what is the most likely diagnosis that you should be thinking of?

A 57 -year-old man presents with acute colicky pain in the suprapubic area. He has been constipated over the last 2 days and has been feeling bloated. He feels nauseous, but he has not vomited. On examination of the abdomen you notice marked abdominal distension, and increased bowel sounds. What is the most likely diagnosis?

What is the least number of factors that must be present from the modified Glasgow criteria for acute pancreatitis to be classified as severe within 48 hours of admission?

A 28-year-old man with a 10-year history of ulcerative colitis presents to the emergency department with an acute severe episode of abdominal pain, nausea and vomiting and bloodstained, watery diarrhoea. On examination you notice that the patient has fever and tachycardia and that the abdomen is markedly distended. An abdominal plain film radiograph shows that the transverse colon is dilated at approximately 6.5 em. What is the most likely diagnosis?

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 most likely diagnosis?

A 55-year-old woman presents to the emergency department with severe epigastric and left upper quadrant pain. Since admission, the patient has vomited. On examination you notice the patient is retching (which is non-productive), tachycardic and hypotensive. There is marked tenderness in the upper abdomen and bowel sounds are slightly raised. There is failure to pass a nasogastric tube. A chest radiograph reveals a dilated stomach and large fluid level behind the heart. Which is the most likely diagnosis?

A 49-year-old postmenopausal woman is admitted to the emergency department following severe attacks of abdominal pain, nausea and vomiting. The pain is colicky in nature, starts from the left flank of the abdomen and radiates to the left groin. You are unable to take a history from the patient as she is writhing in pain. On examination you notice that the patient is sweating profusely. The abdomen is soft and non-tender and bowel sounds are normal. What is the most likely diagnosis?

You see a 50-year-old woman, admitted with colicky central abdominal pain, and passing bloodstained diarrhoea and mucus per rectum. She has a marked fever and tachycardia. Abdominal plain film radiography appears normal. The white cell count is raised and stool analysis reports reveal the presence of Clostridium difficile cytotoxins. What is the most likely diagnosis?

A worried 23-year-old woman, who started taking the combined contraceptive pill 3 months ago, presents with a 1-day history of discovering a painless lump in the right breast. The patient states that the lump was not there a month ago. On examination, a slightly mobile, discrete, welldefined, non-tender, firm 1 em diameter lump is found. There is no lymphadenopathy. The most likely diagnosis here is?

A 36-year-old nulliparous woman attends your clinic with a 7-day history of left breast pain after being involved in a car accident. On examining her breast, you notice a hard, irregular 3 em, immobile, tender lump. You also notice some skin tethering and overlying bruising in the region of the lump. Ultrasound features suggest a benign pathology. The most likely diagnosis at this point is?

A 33-year-old, non-smoking, breastfeeding woman is 10 days postpartum. She has a 4-day history of a slight crack on the surface of her left nipple. She presents with a 2-day history of severe continuous pain in the left breast, spiking pyrexia up to 38.8 with rigours which has prevented her from sleeping. On examination, you find the outer quadrants of the left breast to be red, warm and tender with a hard 3 em lump at the edge of the left nipple. The most likely diagnosis is?

A 65-year-old nulliparous woman presents to your clinic with a lump in her left breast, which was discovered 7 months ago. On examination you find a hard, ill-defined, non-tender, 3.5 em lump behind the left nipple. The patient has also had bloody, non-purulent discharge from a single duct on the left nipple for over 3 months. The most likely diagnosis here is?

A 43-year-old woman presents to your clinic with a 2-month history of localized dull pain in the right breast. The pain intensifies just before her period. On examination, you find a discrete 2.5 em mobile, tense, tender, fluctuant lump in the lower inner quadrant of the right breast. The most likely diagnosis here is?

A 47-year-old perimenopausal woman presents with a 3-week history of green discharge from the right nipple. On examination, the right nipple is non-tender, has a 'slit-like' appearance and is retracted. The most likely diagnosis is?

A 67-year-old woman, with a 25-year smoking history, on hormone replacement therapy, presents to clinic expressing concerns regarding an increase in the size of her right breast over the last 4 months. On examination, you find a non-tender, mobile, lobulated 10 em mass with relatively smooth edges in the right breast. The right breast is significantly larger than the left and has a 'teardrop' appearance and the skin looks normal. The most likely diagnosis here is?

A 21-year-old nulliparous woman presents to your clinic with a 1-month history of bilateral breast pain. The pain, which is dull and achy in nature, is poorly localized and widespread across both breasts. The pain gradually increases in severity and is worse just before her menses. The pain usually starts to get better once her menses start. On examination, both breasts are tender. There are no lumps, skin changes or obvious swellings. The most likely diagnosis here is?

You are attending a breast multidisciplinary team (MDT) meeting where the core biopsy histology results of a suspicious breast lesion are being discussed in a 55-year-old woman presenting with a right side breast lump. The histopathologist states that the breast lesion possesses 'B5b' histology features. What is the most likely diagnosis?

You are asked to see a 67-year-old woman admitted with severe limb ischaemia. Your senior colleague asks you to examine the patient and report your findings. What are the two most likely clinical features that suggest the patient has severe limb ischaemia?

A 65-year-old man presents for the first time to your clinic with a painless wound in his right leg, which has been present for over 2 months. On examination you notice a 3 em x 4 em leg ulcer in the gaiter area of the right leg, covering the medial malleolus. The shallow bed of the ulcer is covered with granulation tissue, which is surrounded by sloping edges. There is no history of trauma. From the list below, choose the most likely diagnosis?

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 likely diagnosis?

You are told by your colleague that a 44-year-old woman, who underwent elective right hip replacement, is suspected of having deep vein thrombosis of the left calf. You are asked to carry out a pretest clinical probability score (Wells score) and a D-dimer test. Which is the most likely scenario where deep vein thrombosis can be excluded from your list of differential diagnoses?

You are told that a 45-year-old woman, who presented to the vascular surgery clinic, has a positive tourniquet test in the left leg. On the basis of the information conveyed to you, choose the most likely diagnosis that is associated with a positive tourniquet test?

Your colleague consults you with regard to a 56-year-old patient who has suffered an episode of amaurosis fugax. From the list below, choose the most likely site of pathology which may give rise to amaurosis fugax?

A 40-year-old office executive presents with a 4-hour history of excruciating left loin pain radiating to the groin. The pain has been constant with short spells of more severe pain every 30-40 minutes. He informs you that his father has gout and has had similar pains in the past. A KUB and IVU confirm the presence of a radio-opaque stone in the left ureter, measuring approximately 4 mm in diameter. What type of stone is more likely to be present in this patient?

A 75-year-old man presents to the surgical unit with a 24-hour history of acuteonset left loin pain, which seems to worsen intermittently and has not settled with regular simple analgesia. He suffers from mild dementia and is unable to recall the details of his past medical history. The foundation year 2 doctor on call suspects that a urinary calculus is the cause of this man's pain and spots an old pathology report in the patient's notes showing the presence of negatively birefringent crystals in a synovial fluid aspirate. Which one of the following substances is likely to make up the majority of this man's calculus?

A 24-year-old sexually active medical student is diagnosed as having a urinary tract infection by her GP. Which one of the following organisms is most commonly associated with community acquired urinary tract infection?

A 40-year-old female lawyer is referred to the urology outpatient clinic with a history of multiple urinary tract infections over the preceding 10 years, which have required increasingly longer courses of antibiotics to treat. She also reports feeling more lethargic of late, despite leading a relatively active lifestyle. An ultrasound scan of this patient's renal tract indicates chronic pyelonephritis. Which of the following sonographic features would be diagnostic of her condition?

A 28-year-old student presents with a 2-day history of dysuria and mucopurulent urethral discharge. He reports recently having had unprotected sex while on holiday in the Mediterranean. A urethral discharge smear inoculated into Thayer- Martin medium confirms infection with Neisseria gonorrhoeae and appropriate antibiotics are started. What type of organism is N. gonorrhoeae?

A 69-year-old diabetic man presents to the acute surgery unit with a 5-day history of mild dysuria, frequency and feeling generally unwell. On examination, he is found to be pyrexial and tachycardic. A genital examination reveals both the penis and the scrotum to be swollen, red and tender to touch, with erythema also extending into the groin bilaterally. Of note, the examining surgeon believes that there is palpable crepitus in the perineum. Routine bloods and cultures are taken (which later grow both aerobic and anaerobic organisms), and fluid resuscitation and broad-spectrum antibiotics are commenced. Following further discussion with a urologist, he is taken promptly into the operating theatre for definitive management. The most likely diagnosis in this patient is?

A 6-week-old boy presents with his parents to the specialist paediatric urology outpatients department. The families are Jewish and at the time of the boy's circumcision were told by their rabbi that the urethral meatus was not in the normal position. On examination, the meatus is on the ventral surface just below the glans penis. What is the most likely diagnosis?

A young girl presents to her GP with a 2-day history of fever and swelling on the left side of her abdomen. Examination confirms a raised temperature and left loin swelling extending into the mid-line. In addition, microscopic haematuria is found on a urine dipstick test. She is referred to the local hospital where an ultrasound scan of the abdomen and biopsy confirm Wilm's tumour (nephroblastoma). Which one of the following statements regarding Wilm's tumour is true?

You are asked to see a patient in the outpatient clinic. The patient has weakness in her left arm following a car accident 1 month ago when she fractured her left arm. On examination, there is weakness of extension of the fingers and wrist on the left side. However, the sensation is maintained in all distributions and there is no wrist drop. Which one of the following fractures classically associated with nerve damage is the most likely cause of this palsy?

Your registrar teUs you that his patient bas a boxer's fracture. From this, you know that the bone which is fractured is?

A patient presents to his GP surgery complaining of a swelling on his wrist. On examination, there is a focal swelling on the dorsal aspect of the wrist. It is smooth and non-tender. The overlying skin is normal and moves freely over the mass, however it seems to be fixed to the tendon. What is the likely diagnosis?

A patient presents to the outpatients department following referral for carpal tunnel syndrome. While taking the history and examining the patient you attempt to evaluate whether any permanent nerve injury has occurred. Which sign is often the first indicator of lasting nerve injury?

A 37-year-old patient presents to you having noticed a lump on the lateral aspect of his leg. The lump was first noticed while the patient was in the gym on a rowing machine. There is no associated pain. On examination when the patient tenses his quadriceps a smooth lump can be appreciated, which disappears when the leg is relaxed. With the leg relaxed, it is possible to identify a depression in the fascia lata. The diagnosis is?