New USMLE Surgery STD

A 70-year-old man of ASA anaesthetic category 3, underwent an emergency closure of a perforated duodenal ulcer. The anaesthetic and operation were uneventful. On the first postoperative day, he complained of feeling very unwell with a systolic blood pressure of 80 mm Hg with no unusual signs in his abdomen; there was impaired conscious level and peripheral vasoconstriction. The diagnostic of this patient is?

A 56-year-old lady is having a total thyroidectomy for Graves’ disease. During the operation she develops thyroid storm and the anaesthetist informs you that the patient has developed a tachycardia. From the list below, please choose a feature not likely to be associated with thyroid storm?

A 10-year-old African Caribbean boy is referred to the orthopaedic team with an acutely painful arm. On examination, there is a notable swelling of the limb above and around the elbow joint. There is no reduced range of passive movement of the joint, but the boy is holding his arm very still and will not actively move the limb. Investigations include haemoglobin 8.3 g/dL, white cell count 10.5 × 109/L, and C-reactive protein 12 mg/L. The child is apyrexial with a blood pressure of 110/75 mmHg, and a pulse rate of 85 beats/min?

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?

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

A patient is admitted following a road traffic accident. He has sustained significant blunt injury to his head, chest and abdomen and has a Glasgow Coma Scale score of 8/15. His saturations are poor at 89% on 15 L of oxygen via a rebreathing mask. You note bruising around both eyes and blood-stained fluid issuing from his left ear, which forms concentric circles when dripped on a white sheet. You wish to support his airway to improve oxygenation. The first choice of airway adjunct would be?

You are assessing the nutritional status of a patient in the Intensive Care Unit who has been admitted with polytrauma. The Consultant has advised the team that this patient will require a period of total parenteral nutrition (TPN). You are discussing the essential elements which the TPN feed should contain. Which of the following is referred to as a fat-soluble vitamin involved in cell membrane stabilisation and retinal function?

An otherwise well 57-year-old male is 45 minutes post transurethral resection of the prostate gland for benign prostatic hyperplasia. The procedure was performed under general anaesthesia and lasted one and a half hours. You are asked to see the patient due to the fact that he has become acutely confused and drowsy. Initial observation showed an oxygen saturation of 98% on 2 litres of oxygen per minute, respiratory rate of 18 breaths per minute, pulse rate of 40 beats per minute, blood pressure of 90/70 mmHg and temperature of 37.30C. From the list below, choose the most likely cause for this patient's deterioration?

A 28-year-old man is trapped under a collapsed building for 18 hours. His right arm and leg were crushed under a beam. When he is finally freed, he is confused, his pulse is faint but regular and his right arm and leg are cold, pale and pulseless. He does not appear to be able to feel or move either of them. What is the best diagnosis of this patient?

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 34-year-old thin female undergoes a diagnostic laparoscopy for unexplained pelvic pain. The woman collapses after the introduction of the first trocar. The surgeon could not visualize any structures in the peritoneal cavity, as the view is ‘red out.’ The abdomen is distended with free blood in the peritoneal cavity. Which one is the complication of this laparoscopy?

A patient is found to have a Power ratio of more than one. What is the most likely diagnosis of this patient?

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/L, K 3.7 mmol/L, urea 8.9 mmol/L and creatinine 98 µmol/L. The nutrition for this patient is?

A 48-year-old man falls 2 meters from scaffolding onto a flat paved surface. He presents with significant right facial ecchymosis and oedema, loss of vision in his right eye, ptosis and ophthalmoplegia. CT scanning shows a comminuted fracture of the lateral orbital wall and sphenoid bone. What is the most likely diagnosis of this patient?

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?

A 68-year-old Caucasian man presents with a 3-week history of a swelling at the angle of the right jaw. He denies pain or any other symptoms of note. On further enquiry, he has felt lethargic for the past few months but denies weight loss. On physical examination, he has a 4 cm × 3 cm firm irregular swelling arising from the right parotid gland. He has an asymmetrical smile and is unable to purse his lips to whistle. The most likely diagnosis is?

A 29-year-old patient presents with a short history of right upper quadrant pain. She is jaundiced with dark urine and pale stool. She has a fever of 38.9 °C. Abdominal examination gives no suggestion of a palpable gallbladder. The diagnosis is?

A 36-year-old carpenter is diagnosed with a seminoma. To which lymph nodes do a seminoma most commonly spread first?

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 × 1.5 cm. What is the most appropriate course of management?

A 40-year-old woman presents complaining that her right eye hurts and that she cannot tolerate the bright light in the room. She is protecting her right eye with her hand. There is no history of trauma or foreign body. Visual acuity is reduced in the right eye. Examination reveals redness at the junction between the cornea and sclera of the right eye. The right pupil appears small. Slit lamp examination reveals a collection of cells in the anterior chamber of the eye. What is the most likely cause of this woman's symptoms?

A patient is admitted following a house fire. He has extensive partial and full thickness burns over his arms, upper torso and neck. You note black carbon deposits around his nostrils and oropharynx. Which of the following is the immediate priority?

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?

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 mmHg, pulse rate is 105 beats/min and respiratory rate is 23 breaths/min. Oxygen saturation is 98% on room air. Arterial blood gases reveal respiratory alkalosis and a normal PO2. The next stage of management is?

A 56-year-old man is admitted with pyrexia and an acutely painful knee. On examination, the patient is holding the joint rigidly still and is extremely reluctant to let you manipulate the joint. The knee is obviously effused and erythematous. Joint aspirate is strongly positive for white cells (75000/mm3) with polymorphs accounting for 90% of these. Blood tests show a raised urate level. The diagnosis is?

A terrorist bomb blast has injured a large number of people in a market three days before your team arrives on site. Your patient had several cuts on her leg and torso. One on the thigh was deep and 5 cm long. It was sutured by the local first-aid team some five hours after the blast. It is now red or purple in colour and is oozing fluid. It smells (surprisingly the smell is sweet but a little sickly). When you palpate the swelling around the wound, there is a feeling of crackling in the tissue. What is the best diagnosis of this patient?

A 36-year-old man presents with a red and hot lump over the posterior part of the elbow. He is systemically well, apyrexial, has a flexion arc of 100 degrees and radiographs are unremarkable. What is the most likely diagnosis?

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 × 109/L. He is complaining of chest pain and breathlessness and his abdomen is noticeably more distended than in the initial postoperative period with significant 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?

A 54-year-old woman who is undergoing chemotherapy for breast carcinoma underwent an emergency appendectomy for acute perforated appendicitis 4 days ago. She complains of severe pain in the wound, which shows erythema, oedema, skin blistering and crepitus. What is the diagnosis of this patient?

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/L, K 2.2 mmol/L, urea 6 mmol/L, creatinine 50 µmol/L and glucose 6.7 mmol/L. The nutrition for this patient is?

A previously well 35-year-old woman presents with sudden onset severe headache and loss of vision. Her acuity is 6/24 bilaterally on assessment in the emergency department. What is the most likely diagnosis of this patient?

You are reviewing the blood test results of a 50-year-old man who has been admitted following a crush injury to his right leg. His serum potassium is found to be low at 2.9mmol/L following earlier correction of hyperkalaemia. You request an ECG for this patient. Which one of the following ECG changes is not characteristic of hypokalaemia?

A 55-year-old solicitor presents to the urology outpatients department with a 6-month history of abnormal angulated penis on erection. This has made sexual intercourse particularly difficult and painful and has been affecting his relationship with his wife. After further questioning, a diagnosis of Peyronie’s disease is offered. All of the following statements regarding Peyronie’s disease are true, except?

You are asked to assist in theatre during an emergency appendicectomy. The consultant asks you to locate McBurney's point. From the list below, which answer best describes the location of McBurney's point?

A 36-year-old man presents with irregular swelling in the inguinal region with multiple purulent discharging sinuses involving the anterior abdominal wall and perineum, a swollen knee and a previous history of a swelling in the foot with similar discharging sinuses. What is the diagnosis of this patient?

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?

Which of the following is not encountered when making Kocher’s (right subcostal) incision during an open cholecystectomy?

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?

You are assisting with a primary open right inguinal hernia repair in a 27-year-old male. During the operation, the lead surgeon asks you to define the boundaries of the inguinal canal. Which of the following does not form part of the boundaries of the inguinal canal?

A patient presents having fallen on his head from a height. The atlas is fractured and expanded. What is the most likely diagnosis of this patient?

A 40-year-old patient presents with abdominal pain. He appears unkempt and gives only a vague history. On examination, he is tender over his right iliac fossa where a mass can be felt. The mass is soft and boggy. Compression is possible, which accentuates a similar swelling found below the level of the inguinal ligament. The swelling is not hot or erythematous. On mobilization, the patient complains of severe back pain. The diagnosis is?

A 60-year-old woman has been admitted as an emergency with a 4-day history of severe right upper quadrant pain, vomiting, jaundice and intense pruritus and is very toxic – high temperature with rigors and hyperdynamic circulation. The diagnostic of this patient is?

An 18-year-old student presents with a 6-month history of a painless lump in her right breast. She is currently mid cycle and does not report any cyclical change in the lump. On examination a 3 cm × 2 cm lump is found in the inner lower quadrant of the right breast as well as a 1 cm × 0.5 cm lump in the upper outer quadrant of the same breast. Both are smooth on palpation and have sharp edges. They slip easily between the examining fingers of the physician. The primary problem is likely to be a?

A 65-year-old woman has been admitted through the Accident and Emergency Department (A&E) with abdominal pain, abdominal distension, faeculent vomiting and constipation. She has lost 20 kg in weight in 4 months. Examination reveals a patient with features of acute distal small bowel obstruction and Hb of 8 g/dL. She has never had an operation in the past. What is the diagnosis for this patient?

A 14-year-old boy falls from a swing and sustains a blow to his face. He is knocked out for 1 minute but makes a rapid and full neurological recovery. His upper central incisors are avulsed. What is the most likely diagnosis of this patient?

The patient in Question 6 had a central line inserted and was transferred to the high-dependency 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 cmH2O. You attempt a fluid bolus of 250 mL of colloid, following which her central venous pressure increases and remains at 15 cmH2O. Her urine output over the next hour is 10 mL. Which one of the following statements is the most correct?

Rheumatoid arthritis is a multisystem connective tissue disease. Which of the following is not a pulmonary complication of rheumatoid arthritis?

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 cm 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 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?

A 35-year-old woman underwent an emergency appendicectomy for acute perforated appendicitis. Having had an uneventful appendicectomy and being discharged home after 2 days, she returned to hospital 1 week later feverish with a temperature of 41°C, lower abdominal pain and a tachycardia. She looks ill and toxic. What is the most likely diagnosis of this patient?

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 55-year-old man is about to undergo a diagnostic knee arthroscopy as a day case. He has type 2 diabetes mellitus for which he takes metformin 850 mg/day. The most appropriate perioperative management is?

A patient presents with symptoms suggestive of adhesive capsulitis (frozen shoulder). Which of the following systemic conditions is most commonly associated with this?

A 73-year-old man attends as an outpatient 4 weeks after undergoing a right inguinal hernia repair. He reports good function and the surgical site has healed well. However, he volunteers that since the procedure, he has had a feeling of numbness over the right hemi-scrotum but no such change on the left side. Which one of the following nerves is most likely to be affected?

A 22-year-old man (O blood group) sustained a splenic injury in a road traffic accident. He is undergoing a transfusion of 4 units prior to surgery. You are asked to review the patient 10 minutes into the transfusion as he has become unwell and agitated. He has pyrexia (39.5°C) with associated tachycardia (120 beats/min) and hypotension (80/50 mmHg). Which of the following is the most likely cause?

During a ward round you are told to list the structures found in the adductor (Hunter's) canal. From the list below, select the statement that best describes the structures found in the adductor (Hunter's) canal?

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?

A 40-year-old van driver has been brought to the accident and emergency (A&E) department with severe shortness of breath. He was involved in a road-traffic accident (RTA) when there was a head-on collision while not wearing a seat belt. There is bruising over his sternum. His neck veins are distended, with a systolic pressure of 80 mmHg and pulse rate of 130/minute. The trachea is in the midline, but breath sounds are difficult to discern because there is a lot of noise in the A&E department. The pulse oximeter shows an oxygen saturation of 92%. What is the most likely diagnosis of this patient?

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?

A 38-year-old painter and decorator presents with gradual onset of pain in both shoulders, left worse than right. This is especially severe when he is trying to paint ceilings. On examination, pain is experienced at between 60 and 100 degrees of abduction. Shoulder radiographs are normal. What is the most likely diagnosis?

An initial primary survey of the chest is intended to quickly identify the following causes of cardiorespiratory compromise, except?

You are asked to assist the lead surgeon with a midline laparotomy in theatre. The patient has small bowel obstruction confirmed 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?

A 45-year-old male who sustained haemorrhagic shock secondary to polytrauma is being fluid resuscitated. A central venous catheter is being inserted. From the list below, choose the answer which correctly describes where the central venous pressure is being measured from?

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 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?

A 24-year-old male falls from a roof while intoxicated. He is admitted GCS E3V4M5, and CT demonstrates a thin layer of high density distributed diffusely over the brain surface. What is the most likely diagnosis of this patient?

A 58-year-old man with insulin dependent diabetes presents with chronic erythema and discharge over an ulcerated area located over the first MTPJ of his left foot. CRP is 60 and ESR is 75. Radiographs reveal a destruction of the head of the first metatarsal. What is the most likely diagnosis?

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?

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?

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?

A patient on warfarin for multiple deep vein thrombosis is about to undergo an emergency laparotomy for a perforated sigmoid colon. Which of the following is the best preoperative strategy?

A patient with longstanding osteoarthritis presents with pain on movement of his shoulder. You perform a full shoulder exam. You note that you can re-create the pain by asking the patient to abduct his shoulder against resistance. You conclude that there is impingement of which one of the following structures?

You perform an arterial blood gas investigation on the patient in Question 20. The results show a pH of 7.31, pO2 11.5, pCO2 4.1 kPa, bicarbonate 24 mmol/L and lactate 6.0. Which of the following is not a cause of lactic acidosis?

In which one of the following scenarios is the complication of lymphedema of the arm more likely to occur after resection of a breast tumour and axillary clearance?

A 48-year-old Caucasian man presents to the emergency department complaining of sudden-onset 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?

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?

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?

A 68-year-old man has been admitted as an emergency with colicky abdominal pain with constipation for 3 days. In between the colics he is left with a dull ache. On abdominal examination he is in some discomfort with tenderness and distension particularly in the peripheral part. Over the past 4 months he has been increasingly constipated having to take large amounts of laxatives to open his bowels. What is the diagnosis for this patient?

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?

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 58-year-old man with a history of chronic liver disease attends with a bilateral fixed flexion deformity of the ring and little fingers, left worse than right. What is the most likely diagnosis?

An 18-year-old driver is involved in a high-energy motor vehicle accident. He sustains facial injuries from the windscreen and a fractured sternum from the steering wheel, and his right knee is painful and swollen. Radiographs are unremarkable. What is the most likely diagnosis?

A 7-year-old child is admitted with a supracondylar fracture. His hand is cold and pulseless; however perfusion is restored following fracture reduction. The integrity of which structure is of major concern?

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?

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?