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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

A 47-year-old woman is diagnosed with an unofficial2.5 em Grade 3 invasive ductal carcinoma of the right breast. Following MDT discussion the consultant sees the patient in clinic to convey management options. Which of the following would be the most appropriate management plan for this patient?

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

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

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

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

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

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

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

You see a 50-year-old woman with a history of atrial fibrillation, who presents to the emergency department with a sudden onset of pain in the left forearm. The pain started 3 hours ago, and has been increasing in intensity since. On examination, the left forearm is cold and pale. The left axillary pulse is present, but distal pulses are absent. Movement and sensation are intact in the left hand. There is no history of trauma. What is the most appropriate next step in this patient's management?