Sugery

A patient with a nonobstructing carcinoma of the sigmoid colon is being prepared for elective resec- tion. To minimize the risk of post- operative infectious complications, your planning should include

A. A single preoperative parenteral dose of antibiotic effective against aerobes and anaerobes

B. Avoidance of oral antibiotics to pre- vent emergence of Clostridium difficile

C. Postoperative administration for 2–4 days of parenteral antibiotics effective against aerobes and anaer- obes

D. Postoperative administration for 5–7 days of parenteral antibiotics effective against aerobes and anaer obes

E. Operative time less than 5 h

A 78-year-old man with a history of coronary artery disease and an asymptomatic reducible inguinal hernia requests an elective hernia repair. You explain to him that valid reasons for delaying the proposed surgery include

Following celiotomy, normal bowel motility can ordinarily be presumed to have returned

A. In the stomach in 4 h, the small bowel in 24 h, and the colon after the first oral intake

B. In the stomach in 24 h, the small bowel in 4 h, and the colon in 3 days

C. In the stomach in 3 days, the small bowel in 3 days, and the colon in 3 days

D. In the stomach in 24 h, the small bowel in 24 h, and the colon in 24 h

E. In the stomach in 4 h, the small bowel immediately, and the colon in 24 h

Which of the following surgical interventions is least likely to provide acceptable prolongation of life for patients with AIDS?

A. Splenectomy for AIDS-related idio- pathic thrombocytopenic purpura

B. Colonic resection for perforation secondary to cytomegalovirus infection

C. Cholecystectomy for acalculous cholecystitis

D. Tracheostomy for ventilator- dependent patients with respira tory failure

E. Gastric resection for a bleeding gastric lymphoma or Kaposi’s sarcoma

A cirrhotic patient with abnor- mal coagulation studies due to hepatic synthetic dysfunction requires an urgent cholecystec- tomy. A transfusion of fresh frozen plasma is planned to minimize the risk of bleeding due to surgery. The optimal timing of this transfusion would be

On postoperative day 3, an otherwise healthy 55-year-old man recovering from a partial hepatec- tomy is noted to have scant serosanguineous drainage from his abdominal incision. His skin sta- ples are removed, revealing a 1.0- cm dehiscence of the upper midline abdominal fascia. Which of the following actions is most appropriate? Pre- and Post-operative Care

A. Removing all suture material and packing the wound with moist ster- ile gauze

B. Starting intravenous antibiotics

C. Placing an abdominal (Scultetus) binder

D. Prompt resuturing of the fascia in the operating room

E. Bed rest

Five days after a sigmoid colec- tomy for cancer, a patient’s skin sta- ples are removed and a large gush of serosanguineous fluid emerges. Examination of the wound reveals an extensive fascial dehiscence. The most appropriate management is

A. Wide opening of the wound to assure adequate drainage

B. Smear and culture of the fluid and appropriate antibiotics after the smear is reviewed

C. Careful reapproximation of the wound edges with tape

D. Immediate return to the operating room

E. Application of a Scultetus binder

Signs and symptoms of hemo- lytic transfusion reactions include

The surgeon should be particu- larly concerned about which coagu- lation function in patients receiving anti-inflammatory or analgesic med- ications?

The substrate depleted earliest in the postoperative period is

Diagnostic abdominal laparo- scopy is contraindicated in which of the following patients?

A. A patient with rebound tenderness following a tangential gunshot wound to the abdomen

B. A stable patient with a stab wound to the lower chest wall

C. A patient with a mass in the head of the pancreas

D. A young female with pelvic pain and fever

E. An elderly patient in the intensive care unit suspected of having intestinal ischemia

A 23-year-old woman under- goes total thyroidectomy for carcinoma of the thyroid gland. On the second postoperative day, she begins to complain of tingling sen- sation in her hands. She appears quite anxious and later complains of muscle cramps. Initial therapy should consist of

A. 10 mL of 10% magnesium sulfate intravenously

B. Oral vitamin D

C. 100 μg of oral Synthroid

D. Continuous infusion of calcium Gluconate

E. Oral calcium gluconate

The enteric fluid with an elec- trolyte (Na+, K+, C1−) content simi- lar to that of Ringer’s lactate is

The two solutions most commonly used to maintain fluid and electrolyte balance in the postoper ative management of patients are 5% dextrose in 0.9% sodium chloride and lactated Ringer’s solution. A correct statement regarding 5% dextrose in 0.9% saline is which of the following?

A. It contains the same concentration of sodium ions as does plasma

B. It can be given in large quantities without seriously affecting acid- base balance

C. It is isosmotic with plasma d. It has a pH of 7.4

D. It may cause a dilutional

The two solutions most commonly used to maintain fluid and electrolyte balance in the postoper ative management of patients are 5% dextrose in 0.9% sodium chloride and lactated Ringer’s solution. Correct statements regarding lactated Ringer’s solution include which of the following?

A. It contains a higher concentration of sodium ions than does plasma

B. It is most appropriate for replacement of nasogastric tube losses

C. It is isosmotic with plasma

D. It has a pH of less than 7.0

E. It may induce a significant metabolic acidosis

Signs and symptoms associated with early sepsis include

The most common physiologic cause of hypoxemia is

A. Hypoventilation

B. Incomplete alveolar oxygen diffusion

C. Ventilation-perfusion inequality

D. Pulmonary shunt flow

E. Elevated erythrocyte 2,3-diphos- phoglycerate level (2,3-DPT)

Generally accepted indications for mechanical ventilatory support include

A. PaO2 of less than 70 kPa and PaCO2 of greater than 50 kPa while breathing room air

B. Alveolar-arterial oxygen tension difference of 150 kPa while breathing 100% O2

C. Vital capacity of 40–60 mL/kg

D. Respiratory rate greater than 35 breaths/min

E. A dead space:tidal volume ratio (VD/VT) less than 0.6

In a hemolytic reaction caused by an incompatible blood transfusion, the treatment that is most likely to be helpful is

A. Promoting a diuresis with 250 ml of 50% mannitol

B. Treating anuria with fluid and potassium replacement

C. Acidifying the urine to prevent hemoglobin precipitation in the renal tubules

D. Removing foreign bodies, such as Foley catheters, which may cause hemorrhagic complications

E. Stopping the transfusion immediately

Which of the following inhalation anesthetics accumulates in air-filled cavities during general anesthesia?

Dopamine is a frequently used drug in critically ill patients because

A. At high doses it increases splanchnic flow

B. At high doses it increases coronary flow

C. At low doses it decreases heart rate

D. At low doses it lowers peripheral resistance

E. It inhibits catecholamine release

Compensatory mechanisms during acute hemorrhage include

A. Decreased cerebral and coronary blood flow

B. Decreased myocardial contractility

C. Renal and splanchnic vasodilation

D. Increased respiratory rate

E. Decreased renal sodium resorption

An 18-year-old woman develops urticaria and wheezing after an injection of penicillin. Her blood pressure is 120/60 mm Hg, heart rate is 155 beats/min, and respiratory rate is 30 breaths/min. Immediate therapy should include

During blood transfusion, clotting of transfused blood is associated with

A. ABO incompatibility

B. Minor blood group incompatibility

C. Rh incompatibility

D. Transfusion through Ringer’s lactate

E. Transfusion through 5% dextrose and water

Among patients who require nutritional resuscitation in an intensive care unit, the best evidence that nutritional support is adequate is

The accidental aspiration of gastric contents into the tracheobronchial tree should be initially treated by

In performing a tracheostomy, authorities agree that

A. The strap muscles should be divided

B. The thyroid isthmus should be preserved

C. The trachea should be entered at the second or third cartilaginous ring

D. Only horizontal incisions should be usedv

E. Formal tracheostomy is preferable to cricothyroidotomy as an emergency procedure

Central venous pressure (CVP) may be decreased by

Wasting of the intrinsic muscles of the hand can be expected to follow injury of the

With regard to wound healing, which one of the following statements is correct?

A. Collagen content reaches a maximum at approximately 1 wk after injury

B. Monocytes are essential for normal wound healing

C. Fibroblasts appear in the wound within 24–36 h after the injury

D. The function of the monocyte in wound healing is limited to phagocytosis of bacteria and debris

E. Early in wound healing, type I collagen is predominant

While you are on duty in the emergency room, a 12-year-old boy arrives with pain and inflammation over the ball of his left foot and red streaks extending up the inner aspect of his leg. He remembers removing a wood splinter from the sole of his foot on the previous day. The most likely infecting organism is

The true statement regarding tendon injuries in the hand is

A. Flexor digitorum superficially inserts on the distal phalanx

B. Flexor digitorum profundus inserts on the middle phalanx

C. The tendons of flexor digitorum superficialis arise from a common muscle belly

D. The best results for repair of a flexor tendon are obtained with injuries in the fibroosseous tunnel (zone 2)

E. The process of healing a tendon injury involves formation of a tenoma

Which one of the following cases is considered a clean contaminated wound?

A. Open cholecystectomy for cholelithiasis

B. Herniorrhaphy with mesh repair

C. Lumpectomy with axillary node dissection

D. Appendectomy with walled-off abscess

E. Gunshot wound to the abdomen with injuries to the small bowel and sigmoid colon

A 25-year-old man is brought to the emergency room after sustaining burns during a fire in his apartment. He has blistering and erythema of his face, left upper extremity, and chest with frank charring of his right upper extremity. He is agitated, hypotensive, and tachycardiac. Which one of the following statements concerning this patient’s initial wound management is correct?

A. Topical antibiotics should not be used, as they will encourage growth of resistant organisms

B. Early excision of facial and hand burns is especially important

C. Escharotomy should only be per- formed if neurologic impairment is imminent

D. Excision of areas of third-degree or of deep second-degree burns usually takes place 3–7 days after injury

E. Split-thickness skin grafts over the eschar of third-degree burns should be performed immediately in order to prevent fluid loss

A. High-dose penicillin should be administered prophylactically

B. Tetanus prophylaxis is not necessary if the patient has been immunized in the previous 3 years

C. This burn can be estimated at 60% total body surface area using the “rule of nines”

D. The most sensitive indicator of adequacy of fluid resuscitation is heart rate

E. This patient should undergo immediate intubation for airway protection and oxygen administration

Which of the following statements regarding carpal tunnel syndrome is correct?

A. It is rarely secondary to trauma

B. It may be associated with pregnancy

C. It most often causes dysesthesia during waking hours

D. It is often associated with vascular compromise

E. Surgical treatment involves release of the extensor retinaculum

Management of leukoplakia of the oral cavity includes

A. Excisional biopsy of all lesions

B. Application of topical antibiotics

C. Low-dose radiation therapy

D. Ascertaining that dentures fit properly

E. Application of topical chemotherapeutic agents

A teenage boy falls from his bicycle and is run over by a truck. On arrival in the emergency room, he is awake and alert and appears frightened but in no distress. The chest radiograph suggests an air- fluid level in the left lower lung field and the nasogastric tube seems to coil upward into the left chest. The next best step in management is

A. Placement of a left chest tube

B. Immediate thoracotomy

C. Immediate celiotomy

D. Esophagogastroscopy

E. Removal and replacement of the nasogastric tube; diagnostic peritoneal lavage

Which of the following conditions is most likely to follow a compression type abdominal injury?

A 65-year-old man who smokes cigarettes and has chronic obstructive pulmonary disease falls and fractures the 7th, 8th, and 9th ribs in the left anterolateral chest. Chest x-ray is otherwise normal. Appropriate treatment might include

A. Strapping the chest with adhesive tape

B. Immobilization with sandbags

C. Tube thoracostomy

D. Peritoneal lavage

E. Surgical fixation of the fractured ribs

A 27-year-old man sustains a single gunshot wound to the left thigh. In the emergency room he is noted to have a large hematoma of his medial thigh. He complains of paresthesias in his foot. On examination there are weak pulses palpable distal to the injury and the patient is unable to move his foot. The appropriate initial management of this patient would be

A. Angiography

B. Immediate exploration and repair

C. Fasciotomy of anterior compartment

D. Observation for resolution of spasm

E. Local wound exploration

A 25-year-old woman arrives in the emergency room following an automobile accident. She is acutely dyspneic with a respiratory rate of 60 breaths/min. Breath sounds are markedly diminished on the right side. The first step in managing the patient should be to

A. Take a chest x-ray

B. Draw arterial blood for blood gas determination

C. Decompress the right pleural space

D. Perform pericardiocentesis

E. Administer intravenous fluids

A 25-year-old woman arrives in the emergency room following an automobile accident. She is acutely dyspneic with a respiratory rate of 60 breaths/min. Breath sounds are markedly diminished on the right side. A chest x-ray of this woman before therapy would probably reveal

A. Air in the right pleural space

B. Shifting of the mediastinum toward the right

C. Shifting of the trachea toward the right

D. Dilation of the intrathoracic vena cava

E. Hyperinflation of the left lung

Among the physiologic responses to acute injury is

A. Increased secretion of insulin

B. Increased secretion of thyroxine

C. Decreased secretion of vasopressin (ADH)

D. Decreased secretion of glucagon

E. Decreased secretion of aldosterone

In a stable patient, the management of a complete transection of the common bile duct distal to the insertion of the cystic duct would be optimally performed with a

A. Choledochoduodenostomy

B. Loop choledochojejunostomy

C. Primary end-to-end anastomosis of the transected bile duct

D. Roux-en-Y choledochojejunostomy

E. Bridging of the injury with a T tube

No operative management of penetrating neck injuries has been advocated as an alternative to mandatory exploration in asymptomatic patients. Which of the following findings would constitute a relative, rather than an absolute, indication for formal neck exploration?

Following blunt abdominal trauma, a 12-year-old girl develops upper abdominal pain, nausea, and vomiting. An upper gastrointestinal series reveals a total obstruction of the duodenum with a “coiled spring” appearance in the second and third portions. Appropriate management is

A. Gastrojejunostomy

B. Nasogastric suction and observation

C. Duodenal resection

D. TPN to increase the size of the retroperitoneal fat pad

E. Duodenojejunostomy

Following traumatic peripheral nerve transection, regrowth usually occurs at which of the following rates?

A 28-year-old man is brought to the emergency room for a severe head injury after a fall. Initially lethargic, he becomes comatose and does not move his right side. His left pupil is dilated and responds only sluggishly. The most common initial manifestation of increasing intra-cranial pressure in the victim of head trauma is

A. Change in level of consciousness

B. Ipsilateral (side of hemorrhage) pupillary dilation

C. Contralateral pupillary dilation

D. Hemiparesis

E. Hypertension

A 28-year-old man is brought to the emergency room for a severe head injury after a fall. Initially lethargic, he becomes comatose and does not move his right side. His left pupil is dilated and responds only sluggishly. Initial emergency reduction of intracranial pressure is most rapidly accomplished by

A 31-year-old man is brought to the emergency room following an automobile accident in which his chest struck the steering wheel. Examination reveals stable vital signs, but the patient exhibits multiple palpable rib fractures and paradoxical movement of the right side of the chest. Chest x-ray shows no evidence of pneumothorax or hemothorax, but a large pulmonary contusion is developing. Proper treatment would consist of which of the following?

A. Tracheostomy, mechanical ventilation, and positive end-expiratory pressure

B. Stabilization of the chest wall with sandbags

C. Stabilization with towel clips

D. Immediate operative stabilization

E. No treatment unless signs of respiratory distress develop

A 30-year-old man is stabbed in the arm. There is no evidence of vascular injury, but he cannot flex his three radial digits. He has injured the

Following a 2-h fire-fighting episode, a 36-year-old fireman begins complaining of a throbbing headache, nausea, dizziness, and visual disturbances. He is taken to the emergency room where his carboxyhemoglobin (COHb) level is found to be 31%. Appropriate treatment would be to

A. Begin an immediate exchange transfusion

B. Transfer the patient to a hyperbaric oxygen chamber

C. Begin bicarbonate infusion and give 250mg acetazolamide (Diamox) intravenously

D. Administer 100% oxygen by mask

E. Perform flexible bronchoscopy with further therapy determined byfindings

An elderly pedestrian collides with a bicycle-riding pizza delivery man and suffers a unilateral fracture of his pelvis through the obturator foramen. You would manage this injury by

A. External pelvic fixation

B. Angiographic visualization of the obturator artery with surgical exploration if the artery is injured or constricted

C. Direct surgical approach with internal fixation of the ischia ramus

D. Short-term bed rest with gradual ambulation as pain allows after 3 days

E. Hip spica

Regarding high-voltage electrical burns to an extremity

A. Injuries are generally more superficial than those of thermal burns

B. Intravenous fluid replacement is based on the percentage of body surface area burned

C. Antibiotic prophylaxis is not required

D. Evaluation for fracture of the other extremities and visceral injury is indicated

E. Cardiac conduction abnormalities are unlikely

Which of the following fractures or dislocations of the extremities induced by blunt trauma is associated with significant vascular injuries?

A patient is brought to the emergency room after a motor vehicle accident. He is unconscious and has a deep scalp laceration and one dilated pupil. His heart rate is 120 beats/min, blood pressure is 80/40 mm Hg, and respiratory rate is 35 breaths/min. Despite rapid administration of 2 L normal saline, the patient’s vital signs do not change significantly. The injury likely to explain this patient’s hypotension is

When operating to repair civilian colon injuries

A. A colostomy should be performed for colonic injury in the presence of gross fecal contamination

B. The presence of shock on admission or more than two associated intraabdominal injuries is an absolute contraindication to primary colonic repair

C. Distal sigmoidal injuries should not be repaired primarily

D. Right-sided colonic wounds should not be repaired primarily

E. Administration of intravenous antibiotics with aerobic and anaerobic coverage has not been shown to decrease the incidence of wound infections after repair of colonic injuries

If injury to a major artery in an extremity is suspected, surgical exploration should be carried out regardless of the presence of palpa- ble pulses distal to the injury. The rationale is that the presence of pal- pable distal pulses does not reliably exclude

A. Significant arterial injury

B. Significant injury to adjacent motor nerve trunks

C. Significant injury to adjacent long bones

D. Significant injury to adjacent veins

E. Subsequent development of a compartment syndrome and the need for fasciotomy

Animal and clinical studies have shown that administration of lactated Ringer’s solution to patients with hypovolemic shock may

A. Increase serum lactate concentration

B. Impair liver function

C. Improve hemodynamics by alleviating the deficit in the interstitial fluid compartment

D. Increase metabolic acidosis

E. Increase the need for blood transfusion

An 18-year-old high school football player is kicked in the left flank. Three hours later he develops hematuria. His vital signs are stable. The diagnostic tests performed reveal extravasation of contrast into the renal parenchyma. Treatment should consist of

A. Resumption of normal daily activity excluding sports

B. Exploration and suture of the laceration

C. Exploration and wedge resection of the left kidney

D. Nephrostomy

E. Antibiotics and serial monitoring of blood count and vital signs

An 18-year-old high school football player is kicked in the left flank. Three hours later he develops hematuria. His vital signs are stable. Initial diagnostic tests in the emergency room should include which of the following?

True statements concerning penetrating pancreatic trauma include

A. Most injuries do not involve adjacent organs

B. Management of a ductal injury to the left of the mesenteric vessels is Rouxen-Y pancreaticojejunostomy

C. Management of a ductal injury in the head of the pancreas is pancreaticoduodenectomy

D. Small peripancreatic hematomas need not be explored to search for pancreatic injury

E. The major cause of death is exsanguination from associated vascular injuries

Rapid fluid resuscitation of the hypovolemic patient after abdominal trauma is significantly enhanced by which of the following?

A. Placement of long 18-gauge subclavian vein catheters

B. Placement of percutaneous femoral vein catheters

C. Bilateral saphenous vein cutdowns

D. Placement of short, largebore percutaneous peripheral intravenous catheters

E. Infusion of cold whole blood

Which of the following situa- tions would be an indication for performance of a thoracotomy in the emergency room?

A. Massive hemothorax following blunt trauma to the chest

B. Blunt trauma to multiple organ systems with obtainable vital signs in the field but none on arrival in the emergency room

C. Rapidly deteriorating patient with cardiac tamponade from penetrating thoracic trauma

D. Penetrating thoracic trauma and no signs of life in the field

E. Penetrating abdominal trauma and no signs of life in the field

A 26-year-old man sustains a gunshot wound to the left thigh. Exploration reveals that a 5-cm portion of superficial femoral artery is destroyed. Appropriate management includes

A. Debridement and end-to-end anas- tomosis

B. Debridement and repair with an interposition prosthetic graft

C. Debridement and repair with an interposition arterial graft

D. Debridement and repair with an interposition vein graft

E. Ligation and observation

Laryngeal obstruction. Select the proper intervention for each of the immediately life-threatening injuries of the chest listed below:

Open pneumothorax. Select the proper intervention for each of the immediately life-threatening injuries of the chest listed below:

Flail chest. Select the proper intervention for each of the immediately life-threatening injuries of the chest listed below:

Tension pneumothorax. Select the proper intervention for each of the immediately life-threatening injuries of the chest listed below:

Pericardial tamponade. Select the proper intervention for each of the immediately life-threatening injuries of the chest listed below:

For which of the following malignancies does histologic grade best correlate with prognosis?

The mass appears to be fixed to the underlying muscle, but the overly- ing skin is movable. The next most appropriate step in management is

A 50-year-old man is incidentally discovered to have non- Hodgkin’s lymphoma confined to the submucosa of the stomach during sophagogastroduodenoscopy for dyspepsia. Which of the following statements is true regarding his condition?

A. Surgery alone cannot be considered adequate treatment

B. Combined chemotherapy and radiation therapy, without prior resecton, are not effective

C. Combined chemotherapy and radiation therapy, without prior resection, result in a high risk of severe hemorrhage and perforation

D. Outcome (freedom from progression and overall survival) is related to the histological grade of the tumor

E. The stomach is the most common site for non-Hodgkin’s lymphoma of the gastrointestinal tract

Which of the following statements regarding malignant parotid tumors is correct?

A. Acinar carcinoma is a highly aggressive malignant tumor of the parotid gland

B. Squamous carcinoma of the parotid gland exhibits only moderately malignant behavior

C. Regional node dissection for occult metastases is not indicated for malignant parotid tumors because of their low incidence and the morbidity of lymphadenectomy

D. Facial nerve preservation should be attempted when the surgical margins of resection are free of tumor

E. Total parotidectomy (superficial and deep portions of the gland) is indicated for malignant tumors

Which of the following statements regarding testicular cancer is true?

A. Lymph node dissection after radical orchiectomy is useful for staging but does not increase survival

B. Seminomas and choriocarcinomas are best treated with orchiectomy and retroperitoneal lymph node dissection

C. Seminomas are extremely resistant to radiotherapy

D. Orchiectomy for a testicular mass is approached via the scrotum

E. Cryptorchidism is associated with an increased risk of testicular cancer

Regarding the risk of breast cancer, which of the following statements is true?

A. Breast cancer occurs more com- monly among women of the lower social classes

B. A history of breast cancer in a first- degree family relative is associated with a fourfold increase in risk

C. Women with a first birth after age 30 years have approximately twice the risk of those with a first birth before age 18

D. Cigarette smoking increases the risk of breast cancer

E. Hair dyes have been shown to increase the risk of breast cancer

Human immunodeficiency virus (HIV) has been isolated from many body fluids. Which of the following is a major source of transmission?

Which of the following statements regarding adrenal cortical insufficiency is true?

A. Treatment with exogenous steroids is usually ineffective

B. It is commonly seen as a consequence of metastasis of distant cancers, such as lung or breast, to the adrenal glands

C. Chronic adrenal insufficiency (Addison’s disease) in the preoperative patient should be recognizable by a constellation of findings, including hyperglycemia, hypernatremia, and hypokalemia

D. Death from untreated chronic adrenal insufficiency may occur within hours of surgery

E. The most common underlying cause today is infection with resis- tant tuberculosis

A 35-year-old woman under- goes her first screening mammogram. Which of the following mammographic findings would require a breast biopsy?

A. Breast calcifications larger than 2 mm in diameter

B. Five or more clustered breast microcalcifications per square centimeter

C. A density that effaces with compression

D. Saucer-shaped microcalcifications

E. Multiple round well-circumscribed breast densities

The diagnosis of primary hy- perparathyroidism is most strongly suggested by

A. Serum acid phosphatase above 120 IU/L

B. Serum alkaline phosphatase above 120 IU/L

C. Serum calcium above 11 mg/dL

D. Urinary calcium below 100 mg/day

E. Parathyroid hormone levels below 5 pmol/L

Somatostatin contributes to which of the following processes?

A. Inhibition of adrenocortical cells

B. Inhibition of pancreatic α cells

C. Stimulation of antral gastrin cells

D. Stimulation of secretin-producing cells in the duodenum

E. Stimulation of GI motility

Which of the following statements concerning Cushing syndrome secondary to adrenal adenoma is true?

A. Adrenal adenomas cause 40–60% of all cases of Cushing syndrome

B. Biochemical and x-ray procedures are generally unsuccessful in lateralizing the tumors preoperatively

C. Exploration of both adrenal glands is indicated

D. For uncomplicated tumors, an open transperitoneal surgical approach is usually employed

E. Postoperative corticoid therapy is required to prevent hypoadrenalism

A 40-year-old woman is found to have a 1- to 2-cm, slightly tender cystic mass in her breast; she has no perceptible axillary adenopa- thy. What course would you follow?

A. Reassurance and reexamination in the immediate postmenstrual period

B. Immediate excisional biopsy

C. Aspiration of the mass with cytologic analysis

D. Fluoroscopically guided needle localization biopsy

E. Mammography and reevaluation of options with new information

The course of papillary carci- noma of the thyroid is best described by which of the following statements?

A. Metastases are rare; local growth is rapid; erosion into the trachea and large blood vessels is frequent

B. Local invasion and metastases almost never occur, which makes the term carcinoma misleading

C. Bony metastases are frequent and produce an osteolytic pattern par- ticularly in vertebrae

D. Metastases frequently occur to cervical lymph nodes; distant metas- tases and local invasion are rare

E. Rapid, widespread metastatic involvement of the liver, lungs, and bone marrow results in a 5-year survival rate of approximately 10%

As an incidental finding dur- ing an upper abdominal CT scan, a 3-cm mass in the adrenal gland is noted. The appropriate next step in analysis and management of this finding would be

A woman sustains an injury to her chest after striking the steer- ing wheel of her automobile during a collision. Which of the following statements concerning fat necrosis of the breast is true?

A. Most patients report a history of trauma

B. The lesion is usually nontender and diffuse

C. It predisposes patients to the development of breast cancer

D. It is difficult to distinguish from breast cancer

E. Excision exacerbates the process

The most likely diagnosis in a patient with hypertension, hypo kalemia, and a 7-cm suprarenal mass is

True statements regarding Paget’s disease of the breast include that it

A. Usually precedes development of Paget’s disease of bone

B. Presents with nipple-areolar ecze- matous changes

C. Does not involve axillary lymph nodes because it is a manifestation of intraductal carcinoma only

D. Accounts for 10–15% of all newly diagnosed breast cancers

E. Is adequately treated with wide excision when it presents as a mass

A 40-year-old man who has a long history of peptic ulcer disease that has not responded to medical therapy is admitted to the hospital. His serum gastrin levels are markedly elevated; at celiotomy, a small, firm mass is palpated in the tail of the pancreas. Correct statements concerning this patient’s condition include which of the following?

A. Histamine or a protein meal will markedly increase basal acid secretion

B. Secretin administration will suppress acid secretion

C. The pancreatic mass will probably be benign

D. Distal pancreatectomy is the treatment of choice

E. H2 receptor antagonists have not been beneficial in the treatment of this condition

Of the common complications of thyroidectomy, the one that may be avoided through prophy- laxis is

A. Injury to the recurrent laryngeal nerve

B. Injury to the superior laryngeal nerve

C. Symptomatic hypocalcemia

D. Thyroid storm

E. Postoperative hemorrhage and wound hematoma

Following correction of the patient’s hypercalcemia with hydration and gentle diuresis with furosemide, the most likely therapeutic approach would be

A. Administration of maintenance doses of steroids

B. Radiation treatment for bony metastases

C. Neck exploration and resection of three out of four parathyroid glands

D. Neck exploration and resection of a parathyroid adenoma

E. Avoidance of sunlight, vitamin D, and calcium-containing dairy prod- ucts

99. A 36-year-old woman, 20 wk pregnant, presents with a 1.5-cm right thyroid mass. Fine-needle aspiration is consistent with a pap- illary neoplasm. The mass is “cold” by scan and solid by ultrasound. Which method of treatment would be contraindicated?

A. Right thyroid lobectomy

B. Subtotal thyroidectomy

C. Total thyroidectomy

D. Total thyroidectomy with lymph node dissection

E. 131I radioactive ablation of the thyroid gland

True statements about discharge from the nipple include

A. Intermittent thin or milky dis- charge can be physiologic

B. Expressible nipple discharge is an indication for open biopsy

C. Bloody discharge is indicative of an underlying malignancy

D. Galactorrhea is indicative of an underlying malignancy

E. Pathologic discharge is usually bi- lateral

True statements regarding Cushing’s disease and Cushing syndrome include which of the following?

A. Adrenocortical hyperplasia is the most common cause of Cushing’s disease

B. Overproduction of ACTH is pathognomonic of Cushing syndrome

C. Clinical manifestations of Cushing’s disease and Cushing syndrome are identical

D. Cushing syndrome is caused only by neoplasms of either the pituitary or adrenal glands

E. Cushing’s disease is incurable

A 34-year-old woman has recurrent fainting spells induced by fasting. Her serum insulin levels during these episodes are markedly elevated. Correct statements regarding this patient’s condition include which of the following?

A. The underlying lesion is probably an α-cell tumor of the pancreas

B. The underlying lesion is usually multifocal

C. These lesions are usually malignant

D. Serum calcium levels may be elevated

E. She should be screened for a coexistent pheochromocytoma

The incidence of breast cancer

A. Increases with increasing age

B. Has declined since the 1940s

C. Is related to dietary fat intake

D. Is related to coffee intake

E. Is related to vitamin C intake

Tumor not palpable, clinically positive lymph nodes fixed to one another, no evidence of metastases. For the clinical description select the appropriate stage of breast cancer.

Tumor 5.0 cm; clinically positive, movable ipsilateral lymph nodes; no evidence of metastases. For the clinical description select the appropriate stage of breast cancer.

Tumor 2.1 cm, clinically negative lymph nodes, no evidence of metastases For the clinical description select the appropriate stage of breast cancer.

Tumor not palpable but breast diffusely enlarged and erythematous, clinically positive supraclavicular nodes, and evidence of metastases. For the clinical description select the appropriate stage of breast cancer.

Tumor 0.5 cm, clinically negative lymph nodes, pathological rib fracture. For the clinical description select the appropriate stage of breast cancer.

A 43-year-old man presents with signs and symptoms of peri- tonitis in the right lower quadrant. The clinical impression and sup- portive data suggest acute appen- dicitis. At exploration, however, a tumor is found; frozen section sug- gests carcinoid features. For the tumor described, choose the most appropriate surgical procedure. A 2.5-cm tumor at the base of the appendix.

Omeprazole has been added to the H2 antagonists as a therapeu- tic approach to the management of acute gastric and duodenal ulcers. It acts by

A. Blocking breakdown of mucosal- damaging metabolites of NSAIDs

B. Providing a direct cytoprotective effect

C. Buffering gastric acids

D. Inhibiting parietal cell hydrogen- potassium-ATPase

E. Inhibiting gastrin release and pari- etal cell acid production

Evidence that a splenectomy might benefit a patient with immune (idiopathic) thrombocy- topenic purpura (ITP) includes

A. A significant enlargement of the spleen

B. A high reticulocyte count

C. Megakaryocytic elements in the bone marrow

D. An increase in the platelet count on cortisone therapy

E. Patient age of less than 5 years

Which of the following state- ments concerning imperforate anus is true?

A. Imperforate anus affects males more frequently than females

B. In 90% of males, but only 50% of females, the rectum ends below the level of the levator ani complex

C. The rectum usually ends in a blind pouch

D. The chance for eventual continence is greater when the rectum has descended to below the levator ani muscles

E. Immediate definitive repair of the anatomic defect is required to max- imize the chance of eventual conti- nence

A patient with a history of familial polyposis undergoes a diagnostic polypectomy. Which of the following types of polyps is most likely to be found?

What is the most common serious complication of an end colostomy?

Which of the following state- ments regarding pancreatic carci- noma is true?

A. The majority of cases present with jaundice alone

B. CT scan, angiography, and laparoscopy have been unsuccessful in predicting resectability

C. If a patient is jaundiced, the resectability rate is less than 5%

D. 99% of patients with pancreatic cancer have metastatic disease at the time of diagnosis

E. The 5-year survival rate after a Whipple procedure (pancreatico- duodenectomy) performed for cure is 30–40%

A. Simple closure with omental patch

B. Truncal vagotomy and pyloroplasty

C. Antrectomy and truncal vagotomy

D. Highly selective vagotomy

E. Hemigastrectomy

A 45-year-old woman is explored for a perforated duodenal ulcer 6 h after onset of symptoms. She has a history of chronic peptic ulcer disease treated medically with minimal symptoms. Six weeks after surgery, the patient returns complaining of postprandial weakness, sweating, light-headedness, crampy abdomi- nal pain, and diarrhea. The best management would be

A. Antispasmodic medications (e.g., Lomotil)

B. Dietary advice and counseling that symptoms will probably abate within 3 month of surgery

C. Dietary advice and counseling that symptoms will probably not abate but are not dangerous

D. Workup for neuroendocrine tumor (e.g., carcinoid)

E. Preparation for revision to Roux- en-Y gastrojejunostomy

A 55-year-old man complains of chronic intermittent epigastric pain, and gastroscopy demonstrates a 2-cm ulcer of the distal lesser curvature. Endoscopic biopsy yields no malignant tissue. After a 6-wk trial of H2 blockade and antacid therapy, the ulcer is unchange

A. Proper therapy at this point is

B. Repeat trial of medical therapy b. Local excision of the ulcer

C. Billroth I partial gastrectomy

D. Billroth I partial gastrectomy with vagotomy

E. Vagotomy and pyloroplasty

A 60-year-old male alcoholic is admitted to the hospital with hematemesis. His blood pressure is 100/60 mm Hg, the physical examination reveals splenomegaly and ascites, and the initial hematocrit is 25%. Nasogastric suction yields 300 mL of fresh blood. After initial resuscitation, this man should undergo

During an operation for car- cinoma of the hepatic flexure of the colon, an unexpected discontinuous 3-cm metastasis is discovered in the edge of the right lobe of the liver. The surgeon should

A. Terminate the operation, screen the patient for evidence of other metas- tases, and plan further therapy after the reevaluation

B. Perform a right hemicolectomy and a right hepatic lobectomy

C. Perform a right hemicolectomy and a wedge resection of the metastasis

D. Perform a cecostomy and schedule reoperation after a course of systemic chemotherapy

E. Perform local resection of the primary colon cancer and plan radiation therapy for the lesion on the liver

A 42-year-old man with no history of use of nonsteroidal anti- inflammatory drugs (NSAIDs) pre- sents with recurrent gastritis. Infection with Helicobacter pylori is suspected. Which of the following statements is true?

A. Morphologically, the bacteria is a gram-positive, tennis-racket-shaped organism

B. Diagnosis can be made by serologic testing or urea breath tests

C. Diagnosis is most routinely achieved via culturing endoscopic scrapings

D. The most effective way to treat and prevent recurrence of this patient’s gastritis is through the use of single drug therapy aimed at eradicating H.pylori

E. The organism is easily eradicated

Which of the following her- nias follows the path of the spermatic cord within the cremaster muscle?

A 70-year-old woman has nausea, vomiting, abdominal dis- tention, and episodic, crampy mida- bdominal pain. She has no history of previous surgery but has a long history of cholelithiasis for which she has refused surgery. Her abdom- inal radiograph reveals a spherical density in the right lower quadrant. Correct treatment should consist of

Which of the following state- ments concerning Hirschsprung’s disease is true?

A. It is initially treated by colostomy

B. It is best diagnosed in the newborn period by barium enema

C. It is characterized by the absence of ganglion cells in the transverse colon

D. It is associated with a high inci- dence of genitourinary tract anomalies

E. It is the congenital disease that most commonly leads to subsequent fecal incontinence

Spontaneous closure of which of the following congenital abnormalities of the abdominal wall generally occurs by the age of 4?

Laparoscopic cholecystec- tomy is indicated for symptomatic gallstones in which of the following conditions?

Infants with anorectal anom- alies tend to have other congenital anomalies. Associated abnormali- ties include which of the following?

A 48-year-old woman devel- ops pain of the right lower quad- rant while playing tennis. The pain progresses and the patient presents to the emergency room later that day with a low-grade fever, a white blood count of 13,000, and com- plaints of anorexia and nausea as well as persistent, sharp pain of the right lower quadrant. On examina- tion she is tender in the right lower quadrant with muscular spasm and there is a suggestion of a mass effect. An ultrasound is ordered and shows an apparent mass in the abdominal wall. Which of the fol- lowing is the most likely diagnosis?

In determining the proper treatment for a sliding hiatal her- nia, the most useful step would be

A. Barium swallow with cinefluoroscopy during Valsalva maneuver

B. Flexible endoscopy

C. 24-h monitoring of esophageal pH

D. Measuring the size of the hernia

E. Assessing the patient’s smoking and drinking history

Which of the following state- ments regarding the etiology of obstructive jaundice is true?

A. A markedly elevated SGOT and SGPT are usually associated with obstructive jaundice

B. When extrahepatic biliary obstruction is suspected, the first test should be endoscopic ultrasonog- raphy (EUS)

C. A Klatskin tumor will result in extrahepatic ductal dilation only

D. A liver-spleen scan will add signifi- cantly to the diagnostic workup for obstructive jaundice

E. Carcinoma of the head of the pan- creas can cause deep epigastric or back pain in as many as 80% of patients

A previously healthy 9-year- old child comes to the emergency room because of fulminant upper gastrointestinal bleeding. The hemorrhage is most likely to be the result of

Operative planning and pre- operative counseling for a patient with a rectal carcinoma can be best provided if the patient is staged before surgery by

Which statement regarding absorption by the small intestine is true?

A. All but the fat in milk is digested and absorbed in humans by the end of the duodenum

B. Complete absorption of carbohydrates in a normal meal occurs in the ileum

C. In short gut syndrome, much of the dietary carbohydrate appears in the stool

D. Aldosterone markedly decreases sodium transport across the gut mucosa

E. Enzymes of the brush border of the small intestine can digest and absorb less than 5% of an average protein meal in the absence of the pancreas

Local stimuli that inhibit the release of gastrin from the gastric mucosa include which of the fol- lowing?

For a symptomatic partial duodenal obstruction secondary to an annular pancreas, the operative treatment of choice is

Which of the following statements concerning carcinoma of the esophagus is true?

A. Alcohol has been implicated as a precipitating factor

B. Squamous carcinoma is the most common type at the cardioesophageal junction

C. It has a higher incidence in males

D. It occurs more commonly in patients with corrosive esophagitis

E. Surgical excision is the only effective treatment

A 30-year-old man with a duodenal ulcer is being considered for surgery because of intractable pain and a previous bleeding epi- sode. Serum gastrin levels are found to be over 1000 pg/mL (normal 40–150) on three separate determi- nations. The patient should be told that the operation of choice is

The most common clinical presentation of idiopathic retroperitoneal fibrosis is

In planning the management of a 2.8-cm epidermoid carcinoma of the anus, the first therapeutic approach should be

A. Abdominoperineal resection

B. Wide local resection with bilateral inguinal node dissection

C. Local radiation therapy

D. Systemic chemotherapy

E. Combined radiation therapy and chemotherapy

Indications for operation in Crohn’s disease include which of the following?

Which of the following organisms is most closely associ- ated with gastric and duodenal ulcer disease?

Which statement regarding adenocarcinoma of the pancreas is true?

A. It occurs most frequently in the body of the gland

B. It carries a 1–2% 5-year survival rate

C. It is nonresectable if it presents as painless jaundice

D. It can usually be resected if it pre- sents in the body or tail of the pan- creas and does not involve the common bile duct

E. It is associated with diabetes insipidus

Correct statements concerning intussusception in infants include which of the following?

A. Recurrence rates following treatment are high

B. It is frequently preceded by a gastrointestinal viral illness

C. A 1- to 2-wk period of parenteral alimentation should precede surgical reduction when surgery is required

D. Hydrostatic reduction without surgery rarely provides successful treatment

E. The most common type occurs at the junction of the descending colon and sigmoid colon

A 32-year-old woman pre- sents to the hospital with a 24-h history of abdominal pain of the right lower quadrant. She under- goes an uncomplicated appendec- tomy for acute appendicitis and is discharged home on the fourth postoperative day. The pathologist notes the presence of a carcinoid tumor (1.2 cm) in the tip of the appendix. Which of the following statements is true?

A. The patient should be advised to undergo ileocolectomy

B. The most common location of carcinoids is in the appendix

C. The carcinoid syndrome occurs in more than half the patients with carcinoid tumors

D. The tumor is an apudoma

E. Carcinoid syndrome is seen only when the tumor is drained by the portal venous system

Which of the following statements regarding direct inguinal hernias is true?

A. They are the most common inguinal hernias in women

B. They protrude medially to the inferior epigastric vessels

C. They should be opened and ligated at the internal ring

D. They commonly protrude into the scrotal sac in men

E. They incarcerate more commonly than indirect hernias

Which of the following state- ments regarding stress ulceration is true?

A. It is true ulceration, extending into and through the muscularis mu- cosa

B. It classically involves the antrum

C. Increased secretion of gastric acid has been shown to play a causative role

D. It frequently involves multiple sites

E. It is seen following shock or sepsis, but for some unknown reason does not occur following major surgery, trauma, or burns

Which statement concerning cholangitis is correct?

A. The most common infecting organ- ism is Staphylococcus aureus

B. The diagnosis is suggested by the Charcot triad

C. The disease occurs primarily in young, immunocompromised patients

D. Cholecystostomy is the procedure of choice in affected patients

E. Surgery is indicated once the diag- nosis of cholangitis is made

An 88-year-old man with a history of end-stage renal failure, severe coronary artery disease, and brain metastases from lung cancer presents with acute cholecystitis. His family wants “everything done.” The best management option in this patient would be

A. Tube cholecystostomy

B. Open cholecystectomy

C. Laparoscopic cholecystectomy

D. Intravenous antibiotics followed by elective cholecystectomy

E. Lithotripsy followed by long-term bile acid therapy

Dieulafoy’s lesion of the stomach is characterized by

A. A large mucosal defect with underlying, friable vascular plexus

B. Frequent rebleeding after endoscopic treatment

C. Massive bleeding that requires subtotal gastrectomy

D. Location in the proximal stomach

E. Acid-peptic changes of the gastric mucosa

During an appendectomy for acute appendicitis, a 4-cm mass is found in the midportion of the appendix. Frozen section reveals this lesion to be a carcinoid tumor. Which of the following statements is true?

A. No further surgery is indicated

B. A right hemicolectomy should be performed

C. There is about a 50% chance that this patient will develop the carcinoid syndrome

D. Carcinoid tumors arise from islet cells

E. Carcinoid syndrome can occur only in the presence of liver metastases

Correct statements regarding rectal carcinoid tumors include

A. Endoscopic resection is sufficient for tumors smaller than 2 cm

B. Patients frequently present with the carcinoid syndrome

C. They are rapidly growing tumors

D. Local recurrence is rare with complete resection of the primary lesion

E. They can develop the carcinoid syndrome even in the absence of liver metastases

Indications for surgical removal of polypoid lesions of the gallbladder include

A. Size greater than 0.5 cm

B. Presence of clinical symptoms

C. Patient age of over 25 years

D. Presence of multiple small lesions

E. Absence of shadowing on ultrasound

A patient who has a total pancreatectomy might be expected to develop which of the following complications?

A 28-year-old previously healthy woman arrives in the emer- gency room complaining of 24 h of anorexia and nausea and lower abdominal pain that is more intense in the right lower quadrant than elsewhere. On examination she has peritoneal signs of the right lower quadrant and a rectal tem- perature of 38.38°C (101.8°F). At exploration through incision of the right lower quadrant, she is found to have a small, contained perfora- tion of a cecal diverticulum. Which of the following statements regard- ing this situation is true?

A. Cecal diverticula are acquired disorders

B. Cecal diverticula are usually multiple

C. Cecal diverticula are mucosal herniations through the muscularis propria

D. Diverticulectomy, closure of the cecal defect, and appendectomy may be indicated

E. An ileocolectomy is indicated even with well-localized inflammation

True statements regarding cavernous hemangiomata of the liver in adults include

A. The majority become symptomatic

B. They may undergo malignant transformation

C. They enlarge under hormonal stimulation

D. They should be resected to avoid spontaneous rupture and life threatening hemorrhage

E. A liver/spleen radionucleotide scan is the most sensitive and specific way to make the diagnosis

A 72-year-old patient with an intractable type I ulcer along the incisura with a significant amount of scarring along the entire length of the lesser curvature (SELECT 1 PROCEDURE). Select the appropriate surgical procedure for the patient.

A 46-year-old patient with gastric outlet obstruction sec- ondary to ulcer disease and severe inflammation around the pylorus and first and second portions of the duodenum (SELECT 1 PROCEDURE). Select the appropriate surgical procedure for the patient.

A 90-year-old patient with a bleeding duodenal ulcer (SELECT 1 PROCEDURE) Select the appropriate surgical procedure for the patient.

A 36-year-old patient with a type III (pyloric) ulcer that is refractory to medical treatment (SELECT 1 PROCEDURE). Select the appropriate surgical procedure for the patient.

The most common congenital diaphragmatic hernia in infants (SELECT 1 ABNORMALITY) Match each description with the correct abnormality.

The hernia most likely to cause acute respiratory distress in infants (SELECT 1 ABNORMALITY) Match each description with the correct abnormality.

Among the cardiovascular anomalies of newborns, the one most likely to present with cyanosis is

The superior vena cava syndrome is most frequently seen in association with

A. Histoplasmosis (sclerosing mediastinitis)

B. Substernal thyroid

C. Thoracic aortic aneurysm

D. Constrictive pericarditis

E. Bronchogenic carcinoma

During endoscopic biopsy of a distal esophageal cancer, perfora- tion of the esophagus is suspected when the patient complains of significant new substernal pain. An immediate chest film reveals air in the mediastinum. You would recommend

A. Placement of a nasogastric tube to the level of perforation, antibiotics, close observation

B. Spit fistula (cervical pharyngostomy), gastrostomy

C. Left thoracotomy, pleural patch oversewing of perforation, drainage of mediastinum

D. Esophagogastrectomy via celiotomy and right thoracotomy

E. Transhiatal esophagogastrectomy with cervical esophagogastrostomy

A 3-year-old child with congenital cyanosis is most probably suffering from

A correct statement concerning bronchial carcinoid tumors is that

A. They frequently metastasize

B. They most commonly arise in peripheral terminal bronchioles

C. They rarely produce the carcinoid syndrome

D. They are radiosensitive

E. Five-year survival is less than 50%

Initial management of a patient who has a flaccid neurogenic bladder may include which of the following measures?

A. Surgical bladder augmentation

B. Self-catheterization

C. Supravesical urinary diversion

D. Limiting fluid intake to less than 300 mL/day

E. Transurethral resection of the bladder neck

Which of the following state- ments regarding hypospadias is correct?

A. It is often associated with chordee (ventral curvature of the penis)

B. It is associated with undescended testes in more than 50% of cases

C. It is a rare fusion defect of the posterior male urethra

D. It occurs sporadically, without evidence of familial inheritance

E. The most common location is penoscrotal

The recommended treatment for stage A (superficial and submucosal) transitional cell carcinoma of the bladder is

A 36-year-old man presents to the emergency room with renal colic. A radiograph reveals a 1.5- cm stone. Which of the following statements regarding this disorder is correct?

A. Conservative treatment including hydration and analgesics will not result in a satisfactory outcome

B. Serial kidney, ureter, bladder (KUB) radiographs should be used to follow this patient

C. The urinalysis will nearly always reveal microhematuria

D. When the acute event is correctly treated, this disease seldom recurs

E. Elevated BUN and creatinine are expected

Optimal management of bi- lateral undescended testicles in an infant is

A. Immediate surgical placement into the scrotum

B. Chorionic gonadotropin therapy for 1 mo; operative placement into the scrotum before age 1 if descent has not occurred

C. Observation until the child is 2 years old because delayed descent is common

D. Observation until age 5; if no descent by then, plastic surgical scrotal prostheses before the child enters school

E. No therapy; reassurance of the parent that full masculinization and normal spermatogenesis are likely even if the testicle does not fully descend

Seminoma is accurately de scribed by which of the following statements?

A. It is the most common type of tes- ticular cancer

B. Metastases to liver and bone are fre- quently found

C. It does not respond to radiation

D. The 5-year survival rate approaches 50%

E. Common presentation is that of a painful lump that transilluminates

A 10-year-old boy presents to the emergency room with testicular pain of 5 h duration. The pain was of acute onset and woke the patient from sleep. On physical examination, he is noted to have a high- riding, indurated, and markedly tender left testis. Pain is not diminished by elevation. Urinalysis is unremarkable. Which of the fol- lowing statements regarding the patient’s diagnosis and treatment is true?

A. There is a strong likelihood that this patient’s father or brother has had or will have a similar event

B. Operation should be delayed until a technetium scan clarifies the diag nosis

C. The majority of testicles that have undergone torsion can be salvaged if surgery is performed within 24 h

D. If torsion is found, both testes should undergo orchiopexy

E. The differential diagnosis includes spermatocele

Genitourinary tuberculosis in a male patient is suggested by which of the following findings?

Which of the following state- ments regarding carcinoma of the prostate is true?

A. It has a higher incidence among American blacks than other American ethnic groups

B. A single microscopic focus of prostate cancer discovered on transurethral resection of the prostate (TURP) is an indication for radical prostatectomy

C. It arises initially in the gland’s central portion

D. It commonly produces osteoclastic bony metastases

E. Screening for prostate-specific antigen, although easily done, offers no advantage over simple rectal examination in the detection of the disease

Which of the following state- ments regarding benign prostatic hyperplasia (BPH) is true?

A. The fibrostromal proliferation of BPH occurs mainly in the outer portion of the gland

B. Assuming a voided volume greater than 100 mL, a peak urine flow rate of 30 mL/s or less is good evidence of outflow obstruction

C. Suprapubic prostatectomy for BPH involves enucleation of the entire prostate and eliminates the risk of future prostate cancer

D. Indications for surgery include acute urinary retention and recur- rent urinary tract infections (UTIs)

E. BPH is a risk factor for the development of prostatic cancer

During the course of an oper- ation on an unstable, critically ill patient, the left ureter is lacerated through 50% of its circumference. If the patient’s condition is felt to be too serious to allow time for defini- tive repair, alternative methods of management include

A. Ligation of the injured ureter and ipsilateral nephrostomy

B. Ipsilateral nephrectomy

C. Placement of a catheter from the distal ureter through an abdominal wall stab wound

D. Placement of a suction drain adjacent to the injury without further manipulation that might convert the partial laceration into a complete disruption

E. Bringing the proximal ureter up to the skin as a ureterostomy

A pedestrian is hit by a speeding car. Radiologic studies obtained in the emergency room, including a retrograde urethro- gram, are consistent with a pelvic fracture with a rupture of the urethra superior to the urogenital diaphragm. Management should consist of

A. Immediate percutaneous nephrostomy

B. Immediate placement of a Foley catheter through the urethra into the bladder to align and stent the injured portions

C. Immediate reconstruction of the ruptured urethra after initial stabilization of the patient

D. Immediate exploration of the pelvis for control of hemorrhage from pelvic fracture and drainage of the pelvic hematoma

E. Immediate placement of a suprapubic cystostomy

Meniscal tears usually result from which of the following circumstances?

Volkmann’s ischemic contracture is associated with

A. Intertrochanteric femoral fracture

B. Supracondylar fracture of the humerus

C. Posterior dislocation of the knee

D. Traumatic shoulder separation

E. Colles “silver fork” fracture

In an uncomplicated disloca- tion of the glenohumeral joint, the humeral head usually dislocates primarily in which of the following directions?

The most severe epiphyseal growth disturbance is likely to result from which of the following types of fracture?

A. Fracture dislocation of a joint adja- cent to an epiphysis

B. Fracture through the articular carti- lage extending into the epiphysis

C. Transverse fracture of the bone shaft on the metaphyseal side of the epiphysis

D. Separation of the epiphysis at the diaphyseal side of the growth plate

E. Crushing injury compressing the growth plate

Which of the following frac- tures is most commonly seen in healthy bones subjected to violent falls?

In a failed suicide gesture, a depressed student severs her radial nerve at the wrist. The expected disability is

A. Loss of ability to extend the wrist

B. Loss of ability to flex the wrist

C. Wasting of the intrinsic muscles of the hand

D. Sensory loss over the thenar pad and the thumb web

E. Palmar insensitivity

Which of the following statements regarding compartment syndromes following orthopedic injuries is true?

A. The first sign is usually loss of pulse in the extremity

B. Passive flexion of the extremity proximal to the involved compart- ment will aggravate the pain

C. Surgical decompression (fasciectomy) is necessary only as a last resort

D. These syndromes are most commonly associated with supracondy- lar fractures of the humerus and tibial shaft

E. The syndrome is often painless

In contrast to closed reduc- tion, open reduction of a fracture

A. Produces a shorter healing time

B. Decreases trauma to the fracture site

C. Produces a higher incidence of nonunion

D. Reduces the risk of infection

E. Requires longer periods of immobilization

Epileptiform convulsion may be a cause. (SELECT 1 INJURY) For description above, select the type of fracture or dislocation with which it is most likely to be associated.

Avascular necrosis is not uncommon. (SELECT 1 INJURY) For description above, select the type of fracture or dislocation with which it is most likely to be associated.

The radial head is dislocated and the proximal third of the ulna is fractured. (SELECT 1 INJURY) For description above, select the type of fracture or dislocation with which it is most likely to be associated.

Tenderness in the anatomist’s snuffbox may be observed. (SELECT 1 INJURY) For description above, select the type of fracture or dislocation with which it is most likely to be associated.

Association with hyperparathyroidism (SELECT 1 DISEASE). For description above, select the type of bone disease with which it is most likely to be associated.

A defect in the mineralization of adult bone secondary to abnormalities in vitamin D metabolism (SELECT 1 DISEASE). For description above, select the type of bone disease with which it is most likely to be associated.

Genetically determined disorder in the structure or processing of type I collagen (SELECT 1 DISEASE). For description above, select the type of bone disease with which it is most likely to be associated.

Synonym for Paget’s disease (SELECT 1 DISEASE). For description above, select the type of bone disease with which it is most likely to be associated.

Which of the following state- ments regarding glioblastoma mul- tiforme is true?

A. It is a neuronal cell tumor

B. It arises from the malignant degeneration of an astrocytoma

C. With aggressive treatment, most patients can live up to 10 years with this disease

D. It is the most common childhood intracranial neoplasm

E. With combined surgery, chemotherapy, and radiation therapy, cure rates now approach 50%

Which of the following statements regarding skull fractures is true?

A. Depressed fractures are those in which the patient’s level of consciousness is diminished or absent

B. Compound fractures are those in which the skull is fractured and the underlying brain is lacerated

C. Any bone fragment displaced more than 1 cm inwardly should be elevated surgically

D. Drainage of cerebrospinal fluid via the ear or nose requires prompt surgical treatment

E. Most skull fractures require surgical treatment

An acute increase in intracra- nial pressure is characterized by which of the following clinical find- ings?

Which of the following state ments about schwannomas is true?

A. They represent central nerve tumors

B. Treatment is via excision

C. They arise most frequently in motor nerves

D. They often degenerate to malignancy

E. The most common presentation is a painful mass

Which of the following statements about craniopharyngiomas is true?

A. The tumors are uniformly solid

B. The tumors are usually malignantq

C. Children with these tumors often develop signs and symptoms of acromegaly

D. The tumors may cause compression of the optic tracts and visual symptoms

E. The primary mode of treatment is radiation therapy

Which of the following statements regarding cerebral contu- sions is true?

A. They occur most frequently in the occipital lobes

B. They may occur opposite the point of skull impact

C. They are rarely accompanied by parenchymal bleeding

D. They may occur spontaneously in patients receiving anticoagulants

E. Anticonvulsants have no role in the early management of this disorder

True statements regarding meningiomas include that they

A. Are malignant in 50% of cases

B. Occur predominantly in men

C. Are treated primarily by surgical excision

D. Are cured, when properly treated, in nearly 95% of cases

E. Arise from the dura

While watching a golf tournament, a 37-year-old man is struck on the side of the head by a golf ball. He is conscious and talkative after the injury, but several days later he is noted to be increas- ingly lethargic, somewhat con- fused, and unable to move his right side. (SELECT 1 DIAGNOSIS). For description above, select the type of vascular event with which it is most likely to be associated.

A 42-year-old woman complains of the sudden onset of a severe headache, stiff neck, and photophobia. She loses consciousness. She is later noted to have a dilated pupil. (SELECT 1 DIAGNOSIS). For description above, select the type of vascular event with which it is most likely to be associated.

A25 year-old known substance abuser is brought to the ED with a suspected overdose. Which of the following is not considered a universal antidote?

Which of the following is not a classic sign of a basal skull fracture?

A19 year-old female with a traumatic head injury is brought to the ED by EMS. She is hemodynamically stable but requires assisted ventilation through an endotracheal tube. She does not open her eyes to painful stimuli and maintains an abnormal extension posture. Which of the following is incorrect?

A. her GCS is 3

B. a GCS of 8 is an indication for intubation

C. Isolated head injuries can cause shock

D. She should be ventilated to a pCO2 of 30-35 mm Hg

E. All are incorrect

The following statements regarding epistaxis are false EXCEPT:

A. Epistaxis rarely occurs in children

B. It commonly results from rupture of posterior placed nasal vessels

C. It may be treated by ligation of the ipsilateral internal carotid artery

D. Epistaxis may be treated by cautery of Little’s area with silver nitrate

E. It is not a common cause of emergency admission to ENT wards

A52 year-old dentist comes to your office complaining of severe bilateral buttock cramps and thigh fatigue during a tennis match and recent onset of impotence The most likely diagnosis is:

A. Lumbosacral disc problem

B. Multiple sclerosis

C. Leriche syndrome

D metastatic carcinoma of the spine

Patients with an organic cause for impotence are often characterized by all of the following EXCEPT:

Which of the following is not a sign or symptom of carpal tunnel syndrome :

A. Loss of sensation to the proximal palm

B. positive Phalen test

C. positive Tinel sign

D. Pain involving the thumb, index, long, and part of the ring digits

E. Delayed transit time on nerve conduction study

In which of the following are systemic antibiotics not indicated :

A. Animal bite to hand

B. Laceration over metacarpal-phalangeal joint sustained after punching someone in a fight

C. positive Finkelstein test

D. Burn wound to 75% of the dorsal aspect of the hand

E. Acute suppurative tenosynovitis

Prolonged vomiting is associated with what electrolyte abnormality?

A. Hypochloremic hypokalemic metabolic acidosis

B. Hypochloremic hypokalemic metabolic alkalosis

C. Hyperchloremic metabolic acidosis

D. hyperkalemia

E. None of the above

Indications for immediate operative intervention rather than conservative management for arterial insufficiency include all the following EXCEPT:

Surgical indications for diverticulitis include all of the following EXCEPT:

All of the following radiologic abdominal plain film findings are consistent with mechanical bowel obstruction except:

A. a "step ladder" pattern

B. Dilated small bowel loops

C. air-fluid levels at uniform height in same bowel loop

D. Absence of gas in large bowel

E. Rows of small gas accumulations in valvulae conniventes (i.e."string of pearls")

After a weekend of heavy drinking, a 28 year-old male presents with abdominal pain radiating to the back. What is the investigative and prognostic modality of choice for the suspected diagnosis?

An 18 year-old motorcyclist presents in the emergency department following an accident. He has a compound tibia and fibula fracture of the right leg and on examination the right leg has no pulses. Your immediate treatment should be:

Which of the following is the most serious complication of a dis placed supracondylar fracture of the humerus?

A compartment syndrome of the forearm

B. Failure to heal

C. Healing in a non-anatomical position

D. Injury to the median nerve

E. Significantly limited range of elbow motion

Which of the following is not a complication of untreated otitis media?

With respect to control of micturition, all of the following are true EXCEPT:

A. Damage to the cerebral cortex results in hyperactivity of the detrusor

B. The basal ganglia inhibits bladder overactivity

C. The cerebellum coordinates emptying of the bladder

D. Damage to the cerebellum results in hypotonicity of the detrusor

E. Injury above the brainstem results in hyperactive bladder only

Which of the following drugs will not promote urine retention?

A patient with a subarachnoid hemorrhage (SAH) caused by a right anterior communicating artery aneurysm undergoes successful surgery 2 days after the hemorrhage. Three days later, right arm weakness develops. The most likely diagnosis is:

Complications of tonsillectomy include all of the following EXCEPT:

Features characteristic of acute tonsilitis include all of the following EXCEPT:

A 6 month-old baby has had mild inspiratory stridor for the last 2 months. The most likely cause of this is:

A 48 year-old male is brought to the ED with CPR being administered. The ECG shows electrical activity present but you cannot palpate a carotid pulse. Which of the following is not on the differential for pulseless electrical activity?

A 37 year-old male arrives at the Emergency Department unconscious. He is warm and sweaty. His heart rate is 52 bpm, his BPis 90/60. His pupils are constricted, his eyes are teary, and he is drooling. You assume he is suffering from a toxidrome. What antidote will you give him?

A 83 year-old man has fallen while walking down stairs. He is brought to the emergency department with a 3-part intertrochanteric hip fracture. Which of the following procedures would you choose to perform?

A 45 year-old man with a history of polycystic kidney disease presents with painless gross hematuria. You order:

A. No investigation is required since the hematuria is most likely due to the rupture of renal cyst(s)

B. No investigation at this time. Investigate if gross hematuria persists

C. U/S

D. U/S, urine C&S, cystosco

A 75 year-old man with a history of nocturia has not micturated for the last 10 hours, and is complaining of severe lower abdominal pain. The most likely cause is:

A43 year-old woman is brought to the Emergency Department after being burned in a house fire. You estimate first degree burns to 20% of her body, second degree burns to 11% of her body, and third degree burns to 9% of her body. She weighs 60 kg and is 120 cm tall. What IV therapy would you begin immediately?

A. Normal saline at 200 cc/hr for 24 hours

B. Normal saline at 400 cc/hr for 24 hours

C. Normal saline at 150 cc/hr for 8 hours, then 75 cc/hr for the next 16 hours

D. Normal saline at 300 cc/hr for 8 hours, then 150 cc/hr for the next 16 hours

E.normal saline at 600 cc/hr for 8 hours, then 300 cc/hr for the next 16 hours

Risk factors for hepatocellular carcinoma include all of the following EXCEPT:

A16 year-old female fell while roller-blading on her outstretched right hand. At a nearby emergency department X rays confirmed the diagnosis of a closed Colles fracture. The proper reduction technique for this wrist fracture is which of the following:

A. Slight extension, full pronation, and full ulnar deviation

B. Slight flexion, full supination, and full radial deviation

C.slight extension, full supination, and full ulnar deviation

D. Slight flexion, full pronation, and full ulnar deviation

E. Slight extension, full pronation, and full radial deviation

Which of the following is least likely to cause avascular necrosis:

Which of the following is true regarding mandibular fractures?

A. They are predominantly unilateral

B. Compound fractures are rarely intraoral

C. They may manifest with numbness in the V2 facial nerve distribution

D. Malocclussion of teeth is a common sign

E. They seldom result in trismus

With respect to painful scrotal swelling, all of the following are true EXCEPT:

A. Torsion of testicular appendages will usually subside without surgical intervention

B. nausea/vomiting is very common in epididymitis

C. Ultrasound is helpful in determining the cause of hematocele

D. Torsion most commonly occurs in young males

E. Orchitis may result in testicular atrophy

Which is following statement about PSA is true?

A. Every man past the age of 50 should have an annual PSA test as a primary screen for prostate cancer

B. PSA is best used to follow disease progression or recurrence post-operatively

C. PSA is a useless test

D. Increased complex PSA to total PSA ratio favors BPH over prostate cancer

E. All of the above

A 40 year-old women presents to the ER with fever, no nausea or vomiting, and left flank pain radiating to the groin. Body CT reveals 8 mm stone in the left proximal ureter. You should:

A. Send her home because renal stone is benign disease

B. Send her home with oral analgesics and ask her to come back if the pain does not resolve in the next 24 hours

C. admit, close monitoring, hydration and analgesics

D. admit, hydration, analgesics and IV antibiotics. (e.g. Amp and Gent), and consider stenting if the symptom persists

Nasopharyngeal carcinoma:

A. Is most common in people from Cambodia

B. Presents early with nasal pain

C. Is treated by wide surgical excision

D. Is monitored by measurement of Epstein-Barr virus antibodies

E. Is curable in 90% of patients

Factors which contribute to the development of squamous cell cancers of the head and neck include all of the following EXCEPT:

Which of the following statements about aspiration of a peanut into the tracheobronchial tree is FALSE?

A. The peanut is more likely to be in the left lower lobe bronchus.

B. Expiratory wheeze is the most likely finding on physical exam

C. The peanut should be removed with the patient under general anesthesia through an open bronchoscope with forceps designed to grasp peanuts

D. A chest x-ray may show atelectasis distal to the blocked bronchus

E. Pneumonia may be a complication

A60 year-old man presents to your office with back and leg pain and trouble urinating. On examination, he has decreased sensation over the buttocks, normal motor power and absent ankle jerks bilaterally. How should this patient be managed:

A. Plain films of the lumbar spine

B. CT myelogram of the lumbar spine

C. Bedrest for 2 weeks with early mobilization

D. Emergency discectomy

E. NSAIDs and physiotherapy

A72 year-old man on physical examination is found to have expressive dysphasia and mild right arm weakness. The most probable location of his lesion is:

Initial management of any patient with coma of undetermined cause includes all except:

A16 year-old girl is brought to hospital by her frantic parents after a bee sting. Vitals sings are BP 70/40, RR 30 and laboured, HR 140, T 37.5. Which of the following would not be an option in her management?

A 24 year-old woman arrives at the Emergency Department unconscious. Her BP is 90/60, her heart rate is 60 bpm, she is breathing at 8 breaths per minute and her O2 sat is 86%. Her eyes remain closed even after pain stimulation and the only sounds she makes are incomprehensible. Her elbows and wrists are flexed with her feet extended. This patient’s GCS score is:

Which physical exam finding below is usually not associated with increasing intracranial pressure?

A. Deteriorating level of consciousness

B. Increasing heart rate and increasing blood pressure

C. yawning, hiccuping, vomiting

D. seizures

E. Unilateral sixth cranial nerve palsy

Which of the following is false regarding post-operative wound infections?

A. S. Aureus is the most common cause

B. Usually present with fever post of day 3-4

C. Increased likelihood in diabetics

D. Mainly treated with antibiotics

E. Risk increases with length of surgery

Which of the following signs and symptoms warrant surgical intervention for patients with small bowel obstruction?

A. Abdominal tenderness

B. air-fluid levels on abdominal x-ray

C. Worsening abdominal pain

D. Feculent vomitus

E. Air in the colon and rectum on abdominal x-ray

A59 year-old woman presents to her family physician with a 3 cm palpable, well circumscribed, non-tender breast mass. She first noticed it several months ago and believes it has increased in size since then. Her mother and maternal aunt were diagnosed with breast cancer in their early 50’s. She has no other health complaints. A subsequent mammogram shows no abnormalities. Which of the following is the next most appropriate step in management?

Which of the following is false regarding pancreatic pseudocysts?

A. It is caused by duct leakage

B. Clinically suspected if persisting pain > 2 weeks following

diagnosis of acute pancreatitis

C. Majority are treated surgically

D. Surgical intervention is typically delayed to allow pseudocyst to mature

E. Lacks true epithelium

An overweight, 45 year-old man presents with left lower quadrant tenderness and a one week history of abdominal pain, loose non-bloody stools and worsening fever. Laboratory investigation yields leukocytosis with neutrophilia and left shift. What is the diagnostic modality of choice?

A19 year-old woman is brought to the emergency room following involvement in a motor vehicle accident. On examination, she has a GCS of 10 and swelling over the occipital protuberance. The most appropriate imaging study is:

Which of the following radiographic features is most consistent with osteoarthritis of the knee?

A. Marginal erosions

B. juxta-articular osteopenia (demineralization)

C. Loss of articular cartilage with narrowing of the radiologic joint space

D. osteonecrosis (avascular necrosis) of the medial femoral condyle

E. Syndesmophyte formation

Which of the following statements is incorrect with respect to wound healing?

A. Epithelialization can occur within 24 hours following primary closure of a wound

B. Maximum wound strength is often achieved after 2 years

C. Wounds continue to gain strength after collagen synthesis has reached an equilibrium

D. Wound contracture is mediated by myofibroblasts

E. The incidence of wound infection increases with healing by secondary intention

Which of the following is not a cause of sensor-neural hearing loss:

Which of the following is not true of Meniere’s disease?

A. Characterized by quadrad of vertigo, hearing loss, tinnitus and aural fullness

B. Vertigo burns out with time

C. Can be treated with diuretics

D. It is the result of an abnormal buildup of potassium

E. The vertigo lasts for seconds

A neurosurgeon complains of a 3 week history of awakening at night with right-hand discomfort that resolves after several minutes. On examination, he has mild weakness of thumb abduction and diminished pain sensibility on the palmar aspect of the thumb and index finger. The most likely diagnosis is:

A. Carpal tunnel syndrome

B. Cervical radiculopathy

C. Reflex sympathetic dystrophy

D. tendonitis

E. Left middle cerebral artery ischemic attacks

A73 year-old woman presents with a 6 month history of deteriorating gait and low back discomfort, exacerbated by walking. Examination is unremarkable except for hypoactive muscle stretch reflexes in the legs. X-rays of the lumbosacral area shows the expected degenerative changes associated with a woman of her age. The most likely diagnosis is:

Which of the following findings is inconsistent with cardiac tamponade?

Which of the following is NOT a cause of major lower gastrointestinal hemorrhage?

A. diverticulitis

B. angiodysplasia

C. Aortoenteric fistula

D. None of the above

All of the following have been associated with posterior shoulder dislocation EXCEPT:

Management of an open fracture should always include each of the following EXCEPT:

A. Assessment of neurovascular status

B. Reduction and fixation of fracture

C. Irrigation and debridement of wound

D. Application of sterile dressing

E. Application of topical antibiotic

Which of the following is an absolute indication for a tonsillectomy?

Which of the following statements regarding the Glasgow coma scale is true?

A. It serves as a scale to assess the long-term sequelae of head trauma

B. A high score correlates with a high mortality

C. It includes measurement of intracranial pressure

D. It includes measurement of pupillary reflexes

E. It includes measurement of verbal response

Controlled hyperventilation (induced hypocapnia) is frequently recommended following head trauma. The therapeutic consequences of this therapy include

A. Reduction of endogenous catecholamines

B. Reduction of intracellular potassium levels

C. Increase in cerebrovascular resistance

D. Induction of compensatory metabolic alkalosis

E. Requirement of monitoring the intracranial pressure

Which of the following statements regarding skull fractures is true?

A. Depressed fractures are those in which the patient’s level of consciousness is diminished or absent

B. Compound fractures are those in which the skull is fractured and the underlying brain is lacerated

C. Any bone fragment displaced more than 1 cm inwardly should be elevated surgically

D. Drainage of cerebrospinal fluid via the ear or nose requires prompt surgical treatment

E. Most skull fractures require surgical treatment

An 18-year-old man is admitted to the emergency room following a motorcycle accident. He is alert and fully oriented, but witnesses to the accident report an interval of unresponsiveness following the injury. Skull films disclose a fracture of the left temporal bone. Following x-ray, the patient suddenly loses consciousness and dilation of the left pupil is noted. This patient should be considered to have

An acute increase in intracranial pressure is characterized by which of the following clinical findings?

Which of the following statements regarding cerebral contusions is true?

A. They occur most frequently in the occipital lobes

B. They may occur opposite the point of skull impact

C. They are rarely accompanied by parenchymal bleeding

D. They may occur spontaneously in patients receiving anticoagulants

E. Anticonvulsants have no role in the early management of this disorder

While watching a golf tournament, a 37-year-old man is struck on the side of the head by a golf ball. He is conscious and talkative after the injury, but several days later he is noted to be increasingly lethargic, somewhat con- fused, and unable to move his right side. For description above, select the type of vascular event with which it is most likely to be associated.

Total joint replacement is a frequently performed operation. Which of the following is correct with regard to a joint replacement?

A. It is indicated in cases of septic arthritis

B. It loosens quickly if "held in place" by methyl methacrylate cement

C. It is contraindicated in patients with poor dentition

D. It is contraindicated below the age of 60 years

E. It produces "wear particles" which may result in granulomatous disease

A 62 year old woman has multiple small bowel fistulae following a complicated course of peritonitis. What is the most likely abnormality that will be found on her arterial blood gas (ABG) and biochemistry analysis?

A. Respiratory alkalosis

B. Metabolic acidosis with increased anion gap

C. Respiratory acidosis with bicarbonate retention

D. Metabolic acidosis with normal anion gap

E. Metabolic alkalosis with decreased anion gap

A 19 year old man, presents to the Emergency Department with a supra-condylar fracture of the distal humerus. Later that evening, after surgical fixation he is noted to have a wrist drop with a patch of numbness on the dorso-radial aspect of the wrist. What is this most likely to be due to?

A 72 year old man suddenly develops pain, and weakness of his right shoulder. On examination, he has trouble initiating abduction at the shoulder but with the arm at 90 degrees abduction strength is near normal. Rupture of which of the following tendon is most likely to produce this deficit?

A 25 year old man who sustains a clean, fairly superficial, 3cm long laceration to his left forearm on a piece of broken glass. Which one of the following statements about management is true?

A. Prophylactic antibiotics are required

B. Thorough cleansing with saline is the decontamination method of choice

C. Immediate tetanus prophylaxis is required as this is a tetanus-prone wound

D. X-ray is required even if the whole length and depth of the wound can be visualised

E. The wound should be closed in layers

A 72 year old retired office worker, has a chest X-ray prior to elective surgery. This shows a solitary 5cm nodule. Which of the following does NOT suggest a diagnosis of lung cancer as the cause of pulmonary nodule?

A 72 year old man has a fracture of the neck of his left femur after a fall. Six days later after internal fixation, his left leg and thigh are swollen. His temperature is 37.5ºC and is otherwise asymptomatic. What is the next step in management?

A. Continue observation

B. Arrange a plain X-ray of his left lower limb

C. Arrange a venous duplex ultrasound of his left lower limb

D. Perform a blood culture and start empirical antibiotics

E. Perform hip surgery immediately

A 17 year old student who fell off his skateboard 2 days ago. He presents to the Emergency Department with pain over the base of his thumb and tenderness over the region of the anatomical snuffbox. There is also a small amount of swelling over the same region with no other deformity. What is the most likely diagnosis?

A 28 year old man is involved in a head-on vehicle collision. He had allegedly been drinking at a pub with friends and left after a dispute. He was initially trapped in the car with the major impact on his right thigh. He is brought into the Emergency Department conscious, but pale with a pulse of 135bpm and blood pressure of 90/60mmHg. He has deformity of his mid thigh with visible bone protruding from a wound. Which of the following is the correct terminology to describe his fracture?

A 28 year old man, is involved in a head-on vehicle collision. He had allegedly been drinking at a pub with friends and left after a dispute. He was initially trapped in the car with the major impact on his right thigh. He is brought into the Emergency Department conscious, but pale with a pulse of 135bpm and blood pressure of 90/60mmHg. He has deformity of his mid thigh with visible bone protruding from ananterior wound. Which of the following is the most likely early complication?

Soft tissue healing is an ordered process. Which of the following is NOT a stage in this type of wound healing?

Which of the following is true regarding surgical therapy for colorectal cancer?

A. Adjuvant therapy is indicated for all patients with colorectal cancer

B. The goal of adjuvant therapy is to improve the chances of cure

C. Adjuvant radiotherapy is indicated for patients with colon cancer

D. Adjuvant chemotherapy for colon cancer should continue for at least 12 months

E. Adjuvant chemotherapy is unsuitable for patients over 65 years of age

A 7 year old child who weighs 25 kilograms is fasting for a series of investigations and a possible operative procedure. Assuming normal hydration initially, what would be an appropriate intra-venous maintenance fluid volume?

What is the most useful guide to the likely post-operative opioid requirements of a patient undergoing a laparotomy?

A. The weight of the patient

B. The estimated lean body mass of the patient

C. The gender of the patient

D. The age of the patient

E. The magnitude of the surgery

A 55 year old woman, presents to the Emergency Department with a 24 hour history of right upper quadrant pain, passing dark coloured urine and a fever of 38.7ºC. Abdominal ultrasound shows multiple gallstones in the gallbladder and a dilated common bile duct of 1.5 cm. What is the most likely diagnosis?

Which of the following is true regarding the management of burns?

A. All patients require prophylactic antibiotics

B. Superficial (or first degree) burns have minor blisters only and should not require pain relief

C. Full thickness (or third degree) burns are very painful and require pain relief

D. Adults should receive 3 litres of normal saline within the first 12 hours to replace fluid lost via burnt skin

E. First aid involves placing the burnt area under cold running tap water for 20 minutes

You are called to see a 65 year old man on the surgical ward. He underwent a hemicolectomy for carcinoma of the colon 5 days ago, and has had increasing abdominal pain over the past 24 hours. He is able to talk to you but looks unwell. His heart rate is 130/minute, his blood pressure is 90/60 mmHg, his temperature is 38.5ºC, and his respiratory rate is 32/minute. His peripheral oxygen saturation is 96 percent while receiving oxygen via a simple face mask. What should your initial response be?

A. Change the mask to a reservoir mask (non-rebreather) to increase the oxygen supply

B. Request a chest X-ray

C. Give one litre of normal saline as quickly as possible intravenously

D. Take some blood for a cross-match

E. Insert a urinary catheter to monitor urine output

Which of the following is the organism most likely to cause endocarditis early after prosthetic valve surgery?

A 71 year old former gardener, presents with acute back pain which has steadily worsened over the past 6 weeks. On examination, you note thoracic kyphosis with no scoliosis. His mid-thoracic spine is tender to palpation and his spinal mobility is limited. You suspect an osteoporotic fracture. Which of the following is the next most appropriate diagnostic test to confirm your suspicion?

A 79 year old man with chronic atrial fibrillation who presents complaining of severe persistent periumbilical pain over the last 12 hours. On examination he looks unwell but is afebrile and has a pulse rate of 96. On abdominal examination he is diffusely tender but has no rebound, no localising signs and bowel sounds are occasionally heard.Which of the following is the most likely diagnosis?

A 64 year old female presents with a two-year history of perianal itching and irritation more noticeable in the past month. Inspection of the perineum shows an area of hyperkeratosis, leucoplakia and an associated large irregular ulcer on the anal verge in the mid-line posteriorly. What should be the next step in her management?

A. Perform a wide local excision

B. Prescribe a steroid cream

C. Patient to apply rectogesic ointment 5 percent (nitroglycerin-base)

D. Perform an internal anal sphincterotomy

E. Perform an incisional biopsy

A 45 year old man is involved in a motor vehicle accident. He presents 2 weeks later with pain involving the right shoulder, scapula and upper limb. What sensory findings would be suggestive of a C6 radiculopathy?

A. Numbness in a patch over the deltoid

B. Parasthesia over the upper trapezius

C. Numbness in the axilla

D. Paraesthesia of the index finger and thumb

E. Numbness of the little and ring fingers

Which of the following is NOT an indication for tracheotomy?

A 25 year old male falls onto his outstretched hand. Upon examination, he is tender in the anatomical snuffbox. Which carpal bone is he most likely to have fractured?

George Ramonez, a 55 year old man, presents to the Emergency Department with haematemesis. He looks unwell and pale. He has a pulse rate of 130/min and blood pressure of 80/50 mmHg. His Glasgow Coma Score is 9. Physical examination shows a jaundiced patient with multiple spider naevi on his chest, gynaecomastia and an enlarged liver. What is the most appropriate initial step in managing this patient?

A. Protect patient’s airway

B. Intravenous fluid resuscitation

C. Red blood cell transfusion

D. Urgent gastroscopy

E. Urgent coeliac artery angiogram

A 25 year old motorcyclist, presents with severe central chest pain to the Emergency Department following a motor vehicle accident. His pulse rate is 130/min and blood pressure is 90/60 mmHg. A chest X-ray shows multiple fractured ribs on the right and a widened superior mediastinum. His abdomen is soft and non-tender with no sign of external injuries. Abdominal Focused Assessment with Sonography for Trauma (FAST) was negative. Which of the following is the most appropriate management of this patient?

A. MRI of the chest and abdomen

B. Diagnostic peritoneal lavage

C. Arch aortogram

D. Exploratory thoracotomy and laparotomy

E. Thoracotomy in the Emergency Department

A 20 year old bystander outside a pub, presents to the Emergency Department with hypotension and stab wounds to the abdomen. Her pulse rate is 140/min and blood pressure is 80/50 mmHg on arrival. She has already had 3L of normal saline intravenous fluid resuscitation. Physical examination shows two 2cm long stab wounds in the epigastric region of the abdomen. Following resuscitation, which of the following is the most appropriate management of this patient?

A. Trauma laparotomy

B. Diagnostic laparoscopy ± laparotomy

C. Diagnostic peritoneal lavage

D. Repeated Focused Assessment with Sonography for Trauma (FAST)

E. Observe and continue resuscitation in the surgical Intensive Care Unit

A 12 year old boy, sustains a penetrating wound of the thigh while trail bike riding. He is taken to the Emergency Department where the wound is debrided. When questioned, his mother is certain that he received the usual childhood immunisations during the first year of life and again before attending school at the age of 5 years.Which of the following is the most appropriate management?

A. Administer one dose of tetanus immune globulin

B. Administer one dose of tetanus toxoid

C. Administer a course of three tetanus toxoid injections

D. Measure his antibody response to tetanus toxoid

E. Administer topical antibiotics

A 56 year old man who asks you, his GP, whether he should undergo prostate cancer testing. Which of the following statements regarding prostate cancer screening is true?

A. Prostate cancer screening in this man is not recommended because he has no family history

B. Surgical treatment of early prostate cancer results in a reduction in mortality

C. The PSA test does not detect the disease in an earlier stage

D. Screening is not recommended because it is much more expensive than breast cancer screening

E. Men at this age are not at risk of developing prostate cancer so do not need screening

How is an "open" fracture defined?

A. There is a full thickness break of the bone

B. Requires surgical (open) reduction

C. Requires antibiotic therapy

D. Requires internal (surgical) fixation

E. Associated with a breach in the overlying skin

Which of the following accelerates the natural process of fracture healing?

A. Multivitamin tablets

B. Drinking milk

C. Application of a plaster of Paris cast

D. Restoring anatomical continuity of the bones

E. Treatment with bisphosphonate medication

Which of the following is NOT a stage in normal soft tissue wound healing?

An 18 year old motorcyclist who is brought to hospital by ambulance following a single-vehicle crash. He has a compound fracture of the right femur and is agitated and disorientated. Which of the following is NOT an immediate priority?

A. Assess air-entry and position of the trachea

B. Check upper airways to ensure patency

C. Urgent full blood count

D. Urgent blood sugar level

E. Establish intravenous access

A 57 year old man who attends your surgery complaining that he has noticed bright blood on the toilet paper several times over the last two months. He has a past history of haemorrhoids, diagnosed in his 30s. On examination his perianal area looks normal and he has a normal rectal examination. Which of the following is the most appropriate next action?

A patient is having an epidural inserted for postoperative analgesia. He is having a laparotomy, with a midline incision from xiphisternum to pubic symphysis. Where would be a suitable vertebral interspace to insert the epidural catheter?

What is the most likely cause of hypotension in a patient with an epidural infusion of local anaesthetic?

What is the most likely cause of upper airway obstruction in an unconscious patient?

Which of the following compounds can be used as a part of a bowel preparation regimen for a patient prior to large intestinal surgery?

A 25 year old male patient is recovering from a laparotomy he underwent earlier in the day. His vital signs show a blood pressure of 120/80 mmHg and a pulse rate of 120 per min. His in-dwelling catheter has drained 100 mls since coming back from the operating theatre ten hours ago. He has a wound drain which has drained 450 mls of blood looking fluid. Which of the following would be the most appropriate course of action?

A. Administer a unit of colloid and send off an urgent cross match and full blood count. Reassess the pulse rate and urine output after the fluid bolus

B. Monitor closely and if the blood pressure drops then give the patient more fluids

C. Administer a unit of O negative blood and send off an urgent cross match and full blood count. Reassess the pulse rate and urine output after the fluid bolus D. Give the patient 20 mg of lasix

E. Monitor the patient closely. If the urine output increases then do nothing

An obese 65 year old female with renal failure has had a laparotomy. On day five post operative she develops copious serous ooze from her midline abdominal wound. She is afebrile. This is likely to be due to which of the following?

Which of the following best describes a compound that can be applied topically to human tissue to inhibit or kill micro-organisms with the aim of reducing the risk of sepsis?

A 78 year old female presents febrile, tachycardic and with abdominal pain. On examination, you note a tender mass in the left iliac fossa. After initial resuscitation and routine blood tests, what would be the most appropriate investigation?

A trauma patient with a suspected cervical spine injury requires intubation. Which of the following statements is true regarding the intubation?

A. Manual in-line stabilisation (MILS) makes the laryngoscopy and intubation easier

B. The hard collar should be left in place

C. Traction should be applied as the collar is removed

D. MILS should prevent any movement of the patient's head

E. A soft collar should be applied after endotracheal intubation

A 15 year old male presents with central periumbilical pain, a low grade temperature and nausea. Over the next couple of hours, the pain shifts to the right iliac fossa. Which of the following is the most likely diagnosis?

What is an important difference between sedation and general anaesthesia?

A. Amnesia

B. Lack of movement in response to painful stimulus

C. Maintenance of spontaneous respiration

D. Ability to interact with one's environment

E. Analgesia

A 58 year old male presents with severe pain and bright red bleeding on defaecation. On examination, there is a tear associated with a small inflammatory skin tag in the posterior midline of the anus. This lesion is typical of which of the following?

A hirsute 20 year old male presents with severe pain in the internatal cleft. He has a low grade temperature and on examination there is a red tender lump in that region. What is the most likely diagnosis?

Graduated compressive stockings are applied to patients recovering from surgery to prevent which of the following?

A patient with a suspected intra-abdominal abscess would have the following pattern to their temperature chart?

A. A constant temperature of about 38°C

B. A constant temperature below 36°C

C. Night fevers rising to 40°C

D. Temperature that varies between normal and 40°C

E. Temperature that alternates between 35°C and 37.5°C

A healthy 36 year old patient is having an elective operation under generalanaesthesia. Eight minutes after endotracheal intubation, the pulse oximeter saturation drops from 98 percent to 88 percent. What is the most likely cause of this?

What is the mechanism of action of local anaesthetics on nerve cells?

A. Blockade of nicotinic acetylcholine receptors

B. Enhancement of Gamma Aminon Butyric Acid-B (GABA-B) receptor activation

C. Blockade of the membrane Na-K-ATPase

D. Blockade of voltage-gated sodium channels

E. Inhibition of release of acetylcholine

What is an advantage of tramadol over morphine?

A. Fewer interactions with antidepressants compared with morphine

B. Less respiratory depression

C. Less likely to cause seizures

D. Less diarrhoea

E. Easily reversed with flumazenil

A 75 year old woman is brought into the Emergency Department by ambulance after a fall at home. She is unable to walk and complains of severe groin pain when she moves her left leg. On examination she is lying in bed with her left leg externally rotated. The left leg is 3 cm shorter than the right leg. She is usually well and takes no medications. What is the most appropriate investigation?

A four year old boy is brought to the Emergency Department. His mother states that he has fallen from the backyard trampoline. He has a swollen and obviously deformed right elbow. The radial pulse is absent and the hand is white. The child says that his hand "feels funny". What is the most likely diagnosis?

A. Dislocated radial head with an ulnar fracture

B. Subluxed radial head

C. Proximal ulnar fracture

D. Supracondylar humeral fracture

E. Fractured medial epicondyle

A. Urgent nerve conduction studies

B. Straighten the arm as far as possible and immobilise in a back slab

C. Place the arm in a sling and arrange orthopaedic review within 24 hours

D. Infiltrate local anaesthetic around the elbow for immediate analgesia

E. Notify the case to the Department of Community Services

A 21 year old man is brought to the Emergency Department. He has been drinking heavily and fell while attempting to avoid arrest. His ankle is very swollen and obviously deformed. Foot pulses are present and the skin is unbroken but tightly stretched over the medial side of the ankle. What is the most likely diagnosis?

A. Partial tear of the medial (deltoid) ligament of the ankle

B. Fracture dislocation of the ankle

C. Fractured neck of talus

D. Navicular fracture

E. Calcaneal crush fracture

A 35 year old woman is brought into the Emergency Department by ambulance after being found lying in the gutter. She is able to speak but is unable to give coherent answers to questions. Her initial vital signs are as follows: heart rate 120 bpm, blood pressure 80/40 mmHg, temperature 38ºC and respiratory rate 28 bpm. What would be your first step on reaching her bedside?

A. Perform a neurological examination

B. Remove her clothing, looking for signs of injury

C. Ask for an urgent 12 lead electrocardiogram (ECG)

D. Auscultate her chest

E. Insert an intravenous cannula

A 22 year old man who was out drinking last night comes into the Emergency Department complaining of a sore right hand. When asked how this might have happened he is evasive. On examination, he is tender over the ulnar aspect of the hand and wrist and has a swollen lip and a bruise around his right eye. What is your provisional diagnosis of his hand injury?

A. A sprained wrist

B. A Bennett's fracture

C. A displaced Colles' fracture

D. A fracture of the medial carpal bones

E. A fracture of the 5th metacarpal bone

A 78 year old woman presents with diffuse abdominal pain, worsening over the past 2 days. She is nauseated and anorexic. She has not defecated in two days. Herbackground is notable for chronic atrial fibrillation and hypertension. On examination, she looks very unwell and has a generally tender abdomen on palpation. What diagnosis do you need to rule out?

A previously well 65 year old woman is brought in by ambulance after a collapse at home. She is unconscious but breathing spontaneously. She does not open her eyes to a painful stimulus but has an abnormal flexion response in her limbs. Her only vocal response is intermittent groans. What is her Glasgow Coma Score?

A 45 year old man underwent open right inguinal hernia repair with mesh for a large right inguinoscrotal hernia 3 days ago. He presents to the Emergency Department with worsening right testicular pain since the surgery. On physical examination,there is no groin swelling seen but marked swelling and tenderness in his right scrotum. What is the most likely diagnosis?

A 65 year old man, presents with a 2 day history of colicky abdominal pain and vomiting. He has a background history of open anterior resection for rectal cancer 3 years ago. On physical examination, his abdomen is firm and distended. There is a midline laparotomy scar and a 6cm lump in the middle of the scar, which is tender to palpate and not reducible. X-ray of the abdomen shows multiple central bowel loops with air-fluid levels. What is the most appropriate treatment plan?

A. Non-operative management

B. Emergency diagnostic laparoscopy

C. Gastrograffin small bowel series

D. Gastrograffin enema

E. Emergency exploratory laparotomy

A thin, 85 year old woman who presents with a left groin lump. She complains of nausea and vomiting and has a background history of hypertension and varicose veins. Physical examination reveals a 1.5cm firm lump below and lateral to the left pubic tubercle. The lump is not reducible and she does not have a cough impulse.What is the most likely diagnosis?

A 40 year old woman, presents with right upper quadrant pain having been the front seat passenger in a high speed head-on motor vehicle collision. On arrival at the Emergency Department, her heart rate is 100 beats per minute and blood pressure is 110/60 mmHg. She is alert and orientated. Her abdomen is mildly distended and there is mild right upper quadrant tenderness. CT scan of the abdomen and pelvis show moderate size liver laceration with surrounding fluid. What is the most appropriate treatment plan?

A. Admit for close and frequent observation

B. Diagnostic laparoscopy

C. Exploratory laparotomy

D. Diagnostic peritoneal lavage

E. Angiography +/- embolisation

You are called to see a confused patient on the surgical wards, who is currently receiving oxygen via facemask at 4L/min. Which of the following observations would suggest that the patient is critically ill?

A. Body temperature of 39.6ºC

B. Heart rate of 92 bpm

C. Respiratory rate 38/minute

D. Blood pressure 110/50 mmHg

E. Peripheral oxygen saturation of 93 percent

You are asked to review a 73 year old man who had a partial gastrectomy 4 days ago. He has a history of ischaemic heart disease and chronic obstructive airway disease. On examination he has a temperature of 38.3°C, a heart rate of 124/min, blood pressure of 80/40 mmHg, warm peripheries and the jugular venous wave-form is not visible. What is the most likely cause for this scenario?

A 45 year old morbidly obese male presents with a two day history of pain in the left calf and swelling of the ankle. Which of the following is the correct management?

A. Elastic stockings and aspirin with a review in 5 days

B. Bed rest with elevation of the left leg

C. Venous duplex ultrasound scan of the left leg

D. Subcutaneous heparin for 6 days

E. Plain X-ray of the left ankle

Which of the following is NOT a symptom or a sign of acute lower limb ischaemia?

The highest risk for post-operative deep vein thrombosis (DVT) is associated with which of the following types of surgery?

What is the most effective modality for prevention of post-operative deep vein thrombosis (DVT) following laparoscopic anterior resection for sigmoid colon cancer?

A. Venous foot pump (VFP)

B. Intermittent pneumatic compression (IPC)

C. Low molecular weight heparin (LMWH)

D. Aspirin

E. Thigh length graduated compression stocking (GCS)

On discharge from hospital following Total Hip Arthroplasty (THA), patients should receive which of the following for 4 weeks for venous thromboembolism (VTE) prophylaxis?

A 24 year old man admitted to the Emergency Department following a motor vehicle accident. He has a contused chest wall and is in respiratory distress. His left chest is resonant on percussion and no breath sounds can be heard on auscultation. His trachea is deviated to the right. What is the most likely diagnosis?

A 25 year old man who has had a motor bike accident. On arrival at the Emergency Department, his vital signs are heart rate 130/minute, blood pressure 90/60 mmHg, respiratory rate 32/minute, temperature 36ºC and his peripheral oxygen saturation is 97 percent. What should be your initial response?

A. Assess his airway and apply an oxygen mask

B. Insert an IV cannula and take blood for a cross-match

C. Assess his cervical spine and then apply a hard collar

D. Assess his Glasgow Coma Score

E. Request a cervical spine X-ray and chest X-ray

A 25 year old man who has had a motor bike accident. On arrival at the Emergency Department, his vital signs are heart rate is 130/minute, blood pressure of 90/60 mmHg, respiratory rate of 32/minute, temperature is 36°C. His peripheral oxygen saturation is 97 percent on room air. What would be your initial order for IV fluids?

A. Two packs of O negative blood over half an hour

B. A litre of normal saline over 2 hours

C. A litre of 4 percent dextrose and 0.18 percent saline over an hour

D. A litre of normal saline over half an hour

E. A litre of Hartmans solution over 2 hours

A 24 year old woman presents with a 3 day history of lower abdominal pain and swinging fever to 39°C. She underwent laparoscopic appendicectomy for perforated appendicitis 5 days ago. The procedure was uncomplicated and she was discharged following 2 days of hospital admission. On physical examination, her temperature is 38.9°C, pulse rate is 120 beats/minute and blood pressure is 140/70 mmHg. Her abdomen is mildly distended and there is mild right iliac fossa tenderness. The laparoscopic wounds are clean. What is the most likely diagnosis?

A man is brought into the Emergency Department after being assaulted. His Glasgow Coma Score (GCS) is 8 and he has a markedly dilated pupil on the right. Which of the following is the most important priority?

A skin flap refers to soft tissue that is characterised by which of the following?

A. Can be designed in any shape, form and size

B. Incorporates its own vascular supply

C. Cannot be designed in all parts of the body

D. Contains all layers of the skin and muscle

E. Does not leave a donor site behind after harvesting

An acute attack of abdominal colic means that the pain:

A. Has been present for at least 12 hours

B. Is so severe that the patient cannot clearly describe it

C. Is sharp and worse on inspiration

D. Is constant and severe

E. Is of recent onset and rises and falls in intensity

Regarding analgesic doses of ketamine, which of the following statements is correct?

A. It should be given carefully to asthmatics as it may worsen bronchospasm

B. It is likely to cause nausea and vomiting

C. It antagonises the effects of opiates

D. It is unlikely to cause respiratory depression

E. It may worsen neuropathic pain

A 56 year old man is brought into the Emergency Department following a car accident. When you assess his respiratory system you find that he has reduced chest expansion on the right with a midline trachea. The percussion note is dull on the right posteriorly and laterally but resonant on the left. He is very tender in the right axilla. Breath sounds are absent at the right base and generally vesicular with occasional crackles elsewhere. What is the most likely diagnosis based on these findings?

A. Haemothorax on the right

B. Simple pneumothorax on the right

C. Right lower lobe aspiration pneumonitis

D. Acute severe asthma

E. Generalised lung contusions

A 45 year old man who presents to the Emergency Department with pain in the lateral aspect of his wrist after a fall on an outstretched hand. On examination he is tender in his anatomical snuffbox. On X-ray he does not have an obvious fracture. Which fracture are you most concerned about?

A. Fracture of the proximal thumb

B. Fracture of the scaphoid

C. Fracture of the radial styloid

D. Fracture of the base of the second metacarpal bone

E. Fracture of the capitate

A 45 year old man, presents to Emergency Department after being knocked off his bicycle by a car. He is talking and has no recollection of the event. Physical examination is unremarkable except for bilateral periorbital brusing. CT scan of the head shows a small amount of air in the cranial cavity. What is the most likely diagnosis?

Mrs Chubb, a 60 year old woman, presents to the Emergency Department following a motor vehicle accident. On primary survey: her airway is intact; she is breathing spontaneously with a respiratory rate of 20 per minute, pulse rate of 90 beats per minute and blood pressure of 140/90 mmHg; Glasgow Coma Score of 15. The secondary survey is unremarkable except for marked tenderness over the mid sternum on palpation. No haemothorax, pneumothorax or fractures are seen on a chest X-ray with a sternal view. What is the most likely diagnosis?

A 65 year old woman, presents to the Emergency Department following a motor vehicle accident. Following initial assessment, she is found to have a minimally displaced fractured left clavicle. What is the most appropriate management following 5 milligrams of intramuscular morphine injection?

A. Thoracic epidural analgesia with bupivacaine

B. Spinal analgesia with bupivacaine

C. Open interal fixation of clavicle under general anesthesia

D. External fixation of clavicle under local anaesthesia

E. Oral analgesia and rest the arm in a sling

A 22 year old man, presents to the Emergency Department after being tackled in rugby. He complains of left arm pain and is unable to move his left shoulder because of pain. X ray shows a minimally displaced fracture of the mid shaft of the humerus. His left arm is warm with good distal pulses. Sensation in the left upper arm is also normal. What is the most appropriate management of this humeral fracture?

A. Oral analgesia and support the arm in a sling

B. Open reduction and internal fixation under general anaesthesia

C. External fixation under local anaesthesia

D. Upper limb angiogram to exclude dissection of left brachial artery

E. Closed reduction under sedation

A 15 year old girl presents with a 12 hour history of right iiac fossa pain. Which of the following symptoms or signs is usually not associated with a diagnosis of acute appendicitis?

A. Pain starting in the peri-umbilical region and moving to the right iliac fossa.

B. Temperature of 39.5 degrees

C. Localised tenderness in the right iliac fossa

D. Coated tongue with bad breath

E. Pain that strated in the right iliac fossa

A 35 year old woman presents with a 24 hour history of right iliac fossa pain. She is tender with moderate rebound tenderness in the right iliac fossa. Which of the following is the LEAST likely differential diagnosis?

A. Acute appendicitis

B. Right tubo-ovarian abscess

C. Mesenteric adenitis

D. Ruptured ovarian follicle (Mittelschmertz syndrome)

E. Ruptured endometrial cyst of the ovary

A 72 year old woman presents with severe abdominal pain. She has been on the waiting list for a laparoscopic cholecystectomy for gallstone disease. She is afebrile,with a normal pulse and blood pressure and is tender in the epigastrium. Aprovisional diagnosis of acute pancreatitis is made and confirmed with an elevated lipase and amylase level. Which of the following is NOT useful in predicting the severity of acute pancreatitis?

In which of the following is topical anaesthesia with lignocaine NOT effective?

A 23 year old man presents with abdominal pain after a single low velocity gunshot wound to the left chest. The entrance wound is 3 cm inferior and lateral to the left nipple and the exit wound 6 cm below the left scapula. A chest tube is inserted and drains 400 ml of blood initially and 50 ml over the next hour. A chest X-ray reveals an expanded lung and no pleural fluid. His initial blood pressure was 70/20 mmHg with a pulse of 120/min. After 2 litres of saline his blood pressure is 85/55 mmHg and pulse is 110/min. An initial FAST (focused abdominal scan in trauma) scan is negative. Which of the following should be the next step in his management?

A. A computed tomography (CT) scan of chest and abdomen

B. Repeat FAST

C. Continued observation

D. Emergency laparotomy

E. Local wound exploration under local anaesthetic

A 48 year old woman develops sudden onset of right sided abdominal pain while playing tennis. She presents to you with persistent sharp pain in the right lower abdomen with associated nausea. Examination reveals a low grade fever (37.2ºC) and tenderness to the right of the midline below the umbilicus with an impression of a mass in this region. Which of the following is the most likely diagnosis?

A 72 year old man undergoes a right total knee replacement and on the 2nd post operative day is found to have a swollen leg with pain in the calf on movement. Which of the following would be the most likely diagnosis?

A. Normal post operative swelling

B. Acute joint infection

C. Popliteal artery thrombosis

D. Post operative bleed into the joint space

E. Post operative deep vein thrombosis (DVT)

A 24 year old man has fallen from his motorbike. He was paraplegic at the scene with a sensory level at T10. You review him in the Emergency Department. His legs appear warm and well perfused but he is tachycardic (105 bpm) and hypotensive (85/40 mmHg). His haemoglobin level is normal (120 g/L). What is the most correct statement?

A. He has undiagnosed internal bleeding and requires further imaging

B. He has undiagnosed bleeding and should be given whole blood

C. He has spinal shock and needs resuscitation with crystalloid

D. He is a young athlete and this is normal for age

E. He has spinal cord shock which can be reversed with high dose intravenous methylprednisolone

A 50 year old man was moving house when he felt a twinge in his back that was followed by the sudden onset of severe pain in his left leg. It travelled from the buttock into the posterior thigh and calf. The pain has been present for 2 weeks. He has now noticed that his calf muscles are weak on the left side. He is unable to stand on his toes on the left side. A CT scan of the lumbar spine shows a left lateral disc protrusion compromising the S1 nerve root. Which is the most correct statement?

A. Surgical treatment should be offered

B. Intensive physiotherapy for at least 2 months should be offered

C. Epidural steroid injection should be offered

D. Rest and analgesia should be offered

E. An operative decision will depend on the size of the disc on MRI scanning

A 65 year old woman collapsed while standing at the watercooler at work. She was noted to clutch at her head as she fell. She is brought to the Emergency Department and a computed tomography (CT) scan is reported as showing blood in the basal cisterns. What is the most likely diagnosis?

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