Tjandra Mcq

Front 1

Without the use of prophylaxis the risk of deep calf vein
thrombosis in a patient undergoing an anterior resection
for rectal cancer is likely to be at least:
a 10%
b 20%
c 30%
d 50%

Back 1

d

Front 2

Which of the following measures is most likely to reduce
the risk of post operative wound infection with
MRSA?
a 5 days of broad spectrum prophylactic antibiotics
b ensuring the patient showers with chlorhexidine wash
prior to surgery
c a policy of staff handwashing between patients
d screening patients for MRSA carriage prior to surgery

Back 2

c

Front 3

Which of the following constitute the legal standard for
the information that should be passed to a patient to
meet the requirements of ‘informed consent’?
a what a patient in that position would regard as
reasonable
b what a reasoned body of medical opinion holds as
reasonable
c a list of all possible complications contained within a
patient information booklet
d all serious complications that occur in more than 1%
of patients

Back 3

a

Front 4

The best indicator of cardiorespiratory capacity and
reserve for surgery is:
a transthoracic echocardiography
b arterial blood gas analysis
c thallium persantin nuclear imaging of the heart
d functional exercise capacity
e electrographic stress test

Back 4

d

Front 5

The commonest reason for poor outcome after
anaesthesia is:
a inadequate pre-operative assessment and
optimisation
b poor anaesthetic assistance
c blood product unavailability
d poor choice of anaesthetic agents
e inadequate intravenous access

Back 5

a

Front 6

Absolute contraindications to performing neuraxial
(epidural or spinal) local anaesthetic blockade include all
of the following except:
a coagulopathy
b patient refusal
c systemic sepsis
d local infection at insertion site
e pre-existing neurologic deficit

Back 6

e

Front 7

Patients with obstructive sleep apnoea are often
undiagnosed. Clinical features of obstructive sleep
apnoea include all of the following except:
a snoring during sleep
b excessive daytime somnolence
c feelings of choking during sleep
d pulmonary hypertension
e aortic stenosis

Back 7

e

Front 8

Airway assessment should include all of the following
except:
a ability to open mouth
b subluxability of the temporomandibular joint
c thyro-mental distance
d cervical spine mobility and stability
e size of the uvula

Back 8

e

Front 9

A 78-year-old woman develops an arrhythmia 2 days
after a laparotomy for perforated diverticular disease.
The ECG shows a bradycardia of 30 beats/min and
spiked T waves. The only biochemical abnormalities
are a potassium level of 6.3 mmol/L (normal range
3.8–5.2) and a creatinine level of 0.2 mmol/L (normal
range 0.05–0.12). Her monitored vital signs (including
ECG) are normal. What should be your first course of
action?
a give a rapid intravenous infusion of 1 L of 10%
dextrose containing 25 units of soluble insulin
b give an intravenous infusion of 20 mL of calcium
gluconate
c start the patient on haemodialysis
d administer an enema of calcium resonium
e give an intravenous infusion of 30 mmol of sodium
bicarbonate

Back 9

b

Front 10

A 40-year-old man is confused and restless the second
day after upper abdominal surgery and repair of a hiatus
hernia. The most probable cause of his condition is:
a pulmonary embolism
b narcotic overdose
c pulmonary atelectasis
d electrolyte imbalance
e starvation ketosis

Back 10

c

Front 11

You are asked to see a patient in your ward, 7 days
following a left hemicolectomy. The patient has a
discharging wound. The discharge oozes freely between
the sutures and is profuse, watery and blood-stained.
There are no signs of inflammation. What is the most
likely diagnosis:
a dehiscence of the wound
b an anastomotic leak
c discharge from a wound haematoma
d wound infection
e a seroma

Back 11

a

Front 12

You have been asked to see a 68-year-old woman
who has developed abdominal distension 5 days
after a total hip replacement. Her abdomen is
distended but soft. There is no localised tenderness,
and rectal examination is unremarkable. A few
scattered bowel sounds can be heard. The plain
abdominal film shows gas all the way to the
rectum and a dilated caecum and ascending colon. The
radiological diameter of the caecum measures 14 cm.
What will you do as immediate management of this
patient?
a arrange decompression of the caecum by a
caecostomy
b arrange a contrast (gastrografin) enema to exclude
mechanical obstruction
c prepare the patient for laparotomy and right
hemicolectomy
d arrange for decompression by colonoscopy
e insert a rectal flatus tube

Back 12

d

Front 13

A previously fit 55-year-old man has undergone an
emergency right hemicolectomy for a perforated caecal
carcinoma. Two days after the operation you note the
following on his fluid balance sheet – intravenous input
2 L, nasogastric aspirate 2 L, drain losses 700 mL, urine
output 500 mL. Biochemistry shows [Na+] 135 mmol/L,
[K+] 3.0 mmol/L, [Cl−] 100 mmol/L, [HCO−
3 ] 27
mmol/L. Which of the fluid balance regimens below
would you order for the next 24-hour period?
a 2 L N saline + 3 L dextrose 5% + 50 meq KCl
b 2 L N saline + 1 L dextrose 5% + 50 meq KCl
c 1 L N saline + 3 L dextrose 5% + 100 meq KCl
d 3 L N saline + 2 L dextrose 5% + 100 meq KCl
e 1 L N saline + 1 L dextrose 5% + 100 meq KCl

Back 13

d

Front 14

Universal precautions:
a protect operating theatre staff from electric shocks
b prevent polluted air from entering the operating
theatre
c impose a physical barrier between patients and carers
d are only to be used when operating on patients
e protect only against bacterial pathogens

Back 14

c

Front 15

Endoscopic surgery:
a has a very limited role in general surgical practice
b is inherently unsafe because the surgeon cannot touch
the structures being operated on
c is associated with greater post-operative pain and
immobility
d enables cholecystectomy to be performed as day case
surgery in some patients
e can only be used for part of an operation

Back 15

d

Front 16

Sutures:
a should be left in the skin for a minimum of 2 weeks
b often need to be removed with local anaesthetic
c must be tied tightly so that arterial inflow into tissues is
not possible
d made of catgut lose tensile strength within 3 weeks
e of all types must eventually be removed

Back 16

d

Front 17

Surgical drains:
a are removed when they are no longer necessary
b should always be removed the day after surgery
c are removed under general anaesthesia
d are not necessary with modern surgical techniques
e are required after the majority of general surgery
procedures

Back 17

a

Front 18

Nutritional markers include the following except:
a skin fold thickness
b mid-arm muscle circumference
c total leucocyte count
d serum albumin
e skin recall antigens

Back 18

c

Front 19

The requirement for intravenous nutrition per day is:
a 20 kcal/kg body weight
b 30 kcal/kg body weight
c 40 kcal/kg body weight
d 50 kcal/kg body weight
e 60 kcal/kg body weight

Back 19

d

Front 20

Marasmus is characterised by the following
characteristics except:
a inadequate intake of an otherwise balanced diet
b cachexia in the adult
c fluid retention
d decreased metabolic rate
e easy correction with standard nutrition

Back 20

c

Front 21

Treatment of critically ill patients in an intensive care unit:
a increases the cost of care but does not improve the
prognosis
b is associated with a 50% survival rate overall
c is associated with a 15% death rate overall
d is required for 25% of all hospital patients at some
point in their illness
e is not indicated for any patient over 80 years of age

Back 21

c

Front 22

Infection in critical illness is:
a almost always followed by dysfunction in multiple
organ systems
b only able to be diagnosed in the presence of septic
shock
c rarely associated with septic shock
d rarely caused by common bacteria
e often found in the lungs or abdomen

Back 22

e

Front 23

The systemic inflammatory response syndrome:
a consists of at least two from a list of four categories of
physiological and haematological abnormality
b nearly always implies the presence of invasive bacterial
or fungal infection
c rarely occurs after cardiopulmonary bypass
procedures
d helps in the clinical differential diagnosis between
infection types
e is associated with more than a 50% mortality rate

Back 23

a

Front 24

Intravenous fluid resuscitation of hypotensive,
hypovolaemic critically ill patients should be:
a slow and gentle using only colloids
b rapid and partial using crystalloids only
c slow and complete using colloids only
d rapid and complete using crystalloids or colloids or
both
e composed mostly of a solution of 4% albumin

Back 24

d

Front 25

Commonly applied critical care organ support involves all
except one of the following:
a mechanical ventilation for hypercarbia
b vasopressor infusions for low cardiac output states
c haemodiafiltration for uraemia
d platelet transfusion for thrombocytopaenia
e inotropic infusions for low cardiac output states

Back 25

b

Front 26

The best prophylaxis against infection in dirty wounds is
achieved by:
a avoiding the use of local anaesthesia
b inserting a drain into the wound
c administering a large dose of an appropriate antibiotic
d administering tetanus antitoxin
e removing foreign bodies and devitalised tissues

Back 26

e

Front 27

Opportunistic infections caused by Candida albicans and
fungi are not associated with:
a cancer
b amyloid sclerosis
c diabetes
d the administration of cytotoxic drugs
e the use of immunosuppressant drugs after cardiac
transplantation

Back 27

b

Front 28

Which of the following is not an example of metastatic
infection?
a colo-vesical fistula due to diverticular disease of the
colon
b liver abscess after portal pyaemia
c infection in a prosthetic heart valve
d brain abscess secondary to a furuncle
e staphylococcal osteomyelitis in the absence of trauma

Back 28

a

Front 29

Appendisectomy wounds are classified as being:
a clean
b clean-contaminated
c contaminated
d contaminated-dirty
e dirty

Back 29

b

Front 30

The concept of Universal Precautions is based on:
a the ‘barrier nursing’ of all patients with a nosocomial
virus infection
b the resheathing of all used needles
c the need to regard all patients as being potentially
infectious
d the importance of taking a detailed social history from
every patient
e the routine screening of patients for blood-borne
viruses

Back 30

c

Front 31

Immunosuppression:
a is only required for organ transplants where the donor
and recipient are unrelated
b has the side effects of increased risk of infection and
malignancy
c aims to knockout bone marrow and stem cells
d should be doubled if two organs are transplanted (e.g.
kidney and pancreas)

Back 31

b

Front 32

Organ donation:
a between husband and wife is doomed to failure
b from deceased donors exceeds current demand for
organs from deceased donors
c requires that brain stem death criteria are fulfilled
d in Australia is amongst the highest in the developed
nations

Back 32

c

Front 33

Kidney transplantation:
a has a 5-year kidney survival rate of approximately
75–85%
b requires immunosuppression for transplantation
between monozygotic twins
c is one of the least commonly performed organ
transplants
d leads to only poor quality of life in most recipients

Back 33

a

Front 34

Liver transplantation:
a is contra-indicated if jaundice is present
b cannot be performed from live donors
c requires no immunosuppression because of the
antigen filtering system in the liver
d can be life saving in cases of fulminant hepatic failure

Back 34

d

Front 35

Pancreas transplantation:
a can be undertaken using the whole pancreas or just
the islets of Langerhan
b is used in patients with pancreatic enzyme deficiency
syndromes
c using the whole pancreas has a patient survival rate of
15% at 2 years
d does not allow successful recipients to stop exogenous
insulin

Back 35

a

Front 36

Ionising radiation is particularly effective in treatment
except in:
a Hodgkins disease
b Carcinoma of the breast
c Cancer of the rectum
d Cancer of the uterine cervix
e Cutaneous melanoma

Back 36

e

Front 37

Screening for malignant disease is effective in the
following situations except:
a Where a tumour is detected at a stage where it can be
cured by treatment
b Screening is undertaken on an individual patient
basis
c There is high public acceptance of the
process
d Specificity of screening is high
e Sensitivity of screening is high

Back 37

b

Front 38

The following statements in relation to simultaneous
regional lymph node dissection at the time of primary
tumour excision are true except:
a Allows more accurate tumour staging
b Allows provision of appropriate prognosis to the
patient
c Can be undertaken with little morbidity
d Allows appropriate adjuvant treatment to be
undertaken
e May confer a survival advantage

Back 38

c

Front 39

In gastro-oesophageal reflux, the following statements
are true except
a alcohol consumption and smoking are important
aggravating factors
b is often associated with disordered oesophageal
motility
c a hiatus hernia is invariably present
d barretts oesophagus may develop
e iron deficiency anaemia may occur as a result of
chronic blood loss

Back 39

c

Front 40

The following statements on the management of
gastro-oesophageal reflux are correct except
a 24-hour oesophageal manometry and pH monitoring
is mandatory in the presence of oesophagitis
demonstrated endoscopically
b a proton pump inhibitor is an effective treatment
c laryngeal spill-over is an indication for surgery
d the most appropriate operation is a laparoscopic
fundoplication
e dysphagia may complicate anti-reflux surgery

Back 40

a

Front 41

For patients suffering from oesophageal cancer, which
of the following symptoms indicates the WORST
prognosis?
a hoarseness of voice
b weight loss of more than 10% of usual body weight
c dysphagia to solid and semi-solid food
d regurgitation of swallowed food
e odynophagia

Back 41

a

Front 42

A 75-year-old man complains of progressive dysphagia
for 2 months. He has loss of 10 lb in weight and can only
tolerate a liquid diet. Oesophageal cancer is suspected.
Which of the following investigations is MOST likely to
detect evidence of distant metastases from his cancer?
a upper endoscopy
b endoscopic ultrasonography
c positron emission tomography
d ultrasound +/− fine needle aspiration of neck
e CT scan

Back 42

c

Front 43

Out of the following, the MOST LIKELY risk factor for
the development of a squamous cell cancer of the
oesophagus is:
a smoking
b alcohol intake
c obesity
d history of cancer of the larynx
e achalasia

Back 43

d

Front 44

The most common benign tumour of the oesophagus is:
a adenosquamous carcinoma
b fibrovascular polyp
c leiomyoma
d haemangioma
e neurofibroma

Back 44

c

Front 45

The diagnosis of chylous leak after oesophagectomy is
NOT helped by:
a analysis of chylomicrons in the chest tube output
b lymphangiogram
c milk challenge
d gastrografin contrast swallow
e test for triglyceride in chest tube output

Back 45

d

Front 46

With a perforation of a duodenal ulcer which occurred 6
h ago, which of the following features is LEAST likely to
be present?
a generalised abdominal tenderness and guarding
b the bowel sounds are hyperactive
c percussion over the liver may demonstrate resonance
d the respiration is shallow and the abdominal muscles
are held rigid
e plain radiograph shows free gas under the diaphragm

Back 46

b

Front 47

Which of the following factors is MOST likely to be
associated with a significant risk of rebleeding from a
duodenal ulcer?
a no further bleeding within 72 hours of the initial
bleed
b a clean based ulcer seen on endoscopy
c age less than 50 years
d a visible vessel with adherent clot seen on endoscopy
e the patient is female

Back 47

d

Front 48

The treatment of choice for a perforated duodenal ulcer
in a 56-year-old man with a strong history of ulcer
disease and signs of peritonitis after 12 hours is
a conservative management with nasogastric suction
and intravenous fluids
b vagotomy and pyloroplasty
c omental patch repair and peritoneal lavage
d highly selective vagotomy
e partial gastrectomy

Back 48

c

Front 49

Following a gastric resection for a stage III gastric cancer
the patient asks whether any further therapy will
improve their prognosis. Which of the following
statements is true?
a chemotherapy is of no use in this setting
b chemoradiotherapy may improve outcome
c radiotherapy may improve outcome
d adjuvant chemotherapy is standard treatment

Back 49

b

Front 50

A 67 year old man is found to have a submucosal 5 cm
tumour in the body of his stomach. The treating
physician considers that this may be a gastrointestinal
stromal tumour. Which one of the following statements
is correct?
a this tumour has a propensity to spread to lymph nodes
b this tumour is benign and unlikely to metastasize
c it is difficult to predict how this tumour will behave
d the tumour is very aggressive and survival is normally
limited

Back 50

c

Front 51

Following gastric resection a patient is told that they
have a T2 N1 (stage II) cancer of the stomach. They ask
about 5-year survival, how many patients from 100 with
such a tumour would be alive at 5 years?
a 10
b 30
c 60
d 90

Back 51

c

Front 52

Endoscopic ultrasound is used in the staging of gastric
cancer. Which of the following statements is true?
a when good quality CT scan is available, EUS adds little
to staging accuracy
b CT scan is better than EUS in assessing N stage
c the availability of EUS removes the need for staging
laparoscopy
d EUS is better than CT in assessing T stage

Back 52

d

Front 53

An 80-year-old woman presents with biliary pain and
stones are seen in the gall bladder on ultrasound. The
probability of the pain being due to a stone in the
common bile duct is approximately:
a 5%
b 10%
c 20%
d 30%
e 50%

Back 53

d

Front 54

A 73-year-old man presents with cholangitis. He has had
no previous abdominal operation. The definitive
treatment should be:
a cholecystectomy and choledocholithotomy
b ERCP and sphincterotomy with stone extraction
c antibiotic therapy followed by laparoscopic
cholecystectomy
d choledocholithotomy
e ERCP, sphincterotomy with stone extraction and later
consideration of cholecystectomy

Back 54

e

Front 55

Which of the following is the appropriate investigation in
a patient presenting with a recent episode of right upper
quadrant pain and a normal physical examination?
a abdominal CT scan
b ERCP
c plain X-ray of the abdomen
d upper abdominal ultrasound
e cholescintigraphy

Back 55

d

Front 56

The following investigation should always be performed
when investigating obstructive jaundice:
a liver ultrasound
b ERCP
c CT scan
d MRCP
e PTC

Back 56

a

Front 57

Bile duct injury during laparoscopic cholecystectomy is
more common:
a in the presence of cholecystitis
b when the surgeon is inexperienced
c if the biliary anatomy is unusual
d when the operation is complicated by haemorrhage
e all of the above

Back 57

e

Front 58

Cholangiocarcinoma is most commonly found:
a in the periphery of the liver
b in the gall bladder
c at the biliary confluence
d in the distal bile duct
e in the duodenum

Back 58

c

Front 59

Primary sclerosing cholangitis is not associated with:
a inflammatory bowel disease
b carcinoma of the bile duct
c gallstones
d multifocal biliary strictures
e hepatocellular carcinoma

Back 59

e

Front 60

Primary hepato-cellular carcinoma may be caused by all
of the following except:
a alcohol
b haemochromatosis
c hepatitis B virus
d steroids
e gallstones

Back 60

d

Front 61

Liver metastases may be treated by all of the following
except:
a arterial embolisation
b cryotherapy
c laparoscopic resection
d open lobectomy
e regional chemotherapy

Back 61

d

Front 62

Regarding pyogenic liver abscesses, which one of the
following is true?
a commonest source for sepsis is the small bowel
b a single organism is usually causal
c obstructive jaundice is a common symptom of
pyogenic abscess
d drainage of the abscess and appropriate antibiotic
therapy are the mainstay of management
e open surgical drainage of the abscess is an essential
part of present treatment

Back 62

d

Front 63

Regarding amoebic liver absesses, which one of the
following is false?
a it is an uncommon disease in Australia and is endemic
in South and Southeast Asia
b intestinal amoebiasis, which leads to liver abscess, is
transmitted by the faeco-oral route
c amoebic serology is usually positive in these patients
d mainstay of treatment is antimicrobial therapy
e amoebic liver abscess must never be drained by
percutaneous technique

Back 63

e

Front 64

Regarding hydatid disease, which one of the following is
incorrect?
a the human is an end host, which breaks the
development cycle of the parasite
b initial infection occurs through the alimentary tract and
is asymptomatic
c the natural history of a hydatid cyst in the human is
one of slow progressive growth
d rupture of a hydatid cyst is a common event
e most symptoms are related to pressure effects on the
liver and surrounding organs

Back 64

d

Front 65

Which one of the following statements regarding the
management of hydatid cysts is false?
a extremely small cysts may be managed conservatively
provided they are followed up to monitor growth
b medical management is successful in the majority of
cases
c medical therapy is usually used to supplement surgical
intervention
d the most common surgical technique is that of
evacuation of the content and de-roofing of the cyst
and the placement of an omental patch in the cavity
e prevention of spillage of the contents into the
peritoneal cavity is of critical importance

Back 65

b

Front 66

The following are true of liver infestations:
a the liver fluke Fasciola hepatica is acquired from sheep
and cattle and infests the biliary tree
b the flat worm Clonorchis sinensis is usually ingested
by eating raw fish
c Clonorchis sinensis infestation leads to recurrent
cholangitis and a high incidence of
cholangiocarcinoma
d biliary ascariasis is caused by the migration of the
common intestinal roundworm into the biliary
tree
e all of the above

Back 66

e

Front 67

The following are causes of pancreatitis:
a gallstones
b alcohol
c mumps
d ampulla of Vater tumours
e all of the above

Back 67

e

Front 68

The pancreas is protected from autodigestion by:
a only secreting enzymes following stimulation by a meal
b secreting enzymes in an inactivated form
c secreting activated enzymes into the pancreatic duct
d packaging the activated enzymes in zymogen
granules
e all of the above

Back 68

b

Front 69

Severity of acute pancreatitis is determined by:
a concentration of serum amylase
b amount of urinary amylase secreted over 24 hours
c clinical scoring systems (Ranson/Imrie)
d amount of peripancreatic fluid collection as
determined by CT scan
e all of the above

Back 69

c

Front 70

The only feature regarding antibiotic use in acute
pancreatitis which is not of importance is:
a antibiotic uptake by pancreatic necrotic tissue
b therapeutic level in serum
c effective against Staphylococcus aureus
d broad-spectrum cover, including anaerobes
e none of the above

Back 70

c

Front 71

Patients who suffer from chronic pancreatitis are totally
cured of their disease by:
a surgical removal of the pancreas
b endoscopic drainage of the pancreatic duct via a stent
c total abstinence from alcohol
d all of the above
e none of the above

Back 71

e

Front 72

Which of the following is an incorrect statement about
pancreatic carcinoma:
a most pancreatic cancers are incurable
b palliation can be achieved with a biliary stent
c palliation can be achieved by surgical bypass of the
tumour
d ampullary cancer has a worse prognosis than
carcinoma of the body of the pancreas
e survival rate of 5% at 5 years from diagnosis can be
expected

Back 72

e

Front 73

Which of the following investigations has little value in
determining the curability of pancreatic carcinoma:
a Ultrasound
b ERCP
c CT scanning
d Serum markers
e Pancreatic biopsy

Back 73

c

Front 74

Regarding the portal circulation in the normal healthy
adult, which one of the following is true?
a normal portal venous pressure is between 20 and 30
mm Hg
b the portal vein is formed by the confluence of the
superior mesenteric vein and the splenic vein behind
the neck of the pancreas
c splenic vein thrombosis does not cause localised portal
hypertension
d portal venous flow provides approximately 30–40% of
total liver blood flow
e the portal venous system contains unidirectional valves
at specific points

Back 74

b

Front 75

Which one of following physical signs is not usually
found in a patient with portal hypertension?
a caput medusae
b hepatomegaly
c ascites
d splenomegaly
e lower limb varicose veins

Back 75

e

Front 76

Regarding patients suffering from portal hypertension,
which one of the following is true?
a hepatocyte destruction caused by cirrhosis account for
the majority of the causes of portal hypertension
b the main diseases leading to cirrhosis in the Australian
population are alcoholic liver disease and chronic viral
hepatitis
c encephalopathy is the most common cause of death in
patients with portal hypertension
d peritonitis complicating ascites in these patients is
usually due to perforated duodenal ulcer
e the commonest source of bleeding varices are the
haemorrhoidal veins

Back 76

b

Front 77

Considering the management of patients with portal
hypertension, which one of the following statements is
true?
a upper gastrointestinal endoscopy should not be
performed unless there is evidence of variceal bleeding
b liver biopsy is rarely required as a part of the diagnostic
process in determining the underlying disease
c intravenous infusion of drugs such as octreotide and
terlipressin which reduce splanchnic blood flow play an
important role in the prevention of early re-bleed of
oesophageal varices
d the mainstay of management of bleeding oesophageal
varices is the insertion of a Sengstaken–Blakemore
tube
e surgical porto-caval shunts remain the definitive
management of bleeding varices

Back 77

c

Front 78

Which of the following does not play an important role
in the prevention of the first variceal bleed in patients
with portal hypertension?
a surveillance upper gastrointestinal endoscopy
b prophylactic banding of visible varices
c the use of β-blockers
d prophylactic sclerotherapy
e surgical porta-systemic shunt

Back 78

e

Front 79

A 52-year-old man develops symptoms of small bowel
obstruction over a 24-h period. Which of the following
MOST SUGGESTS development of bowel strangulation?
a profuse vomiting
b constant abdominal pain associated with abdominal
guarding
c tachycardia
d high nasogastric aspirate
e hypokalaemic alkalosis

Back 79

b

Front 80

In acute proximal small bowel obstruction:
a the symptoms are prolonged with abdominal
distension prior to vomiting
b there is a tendency towards dehydration, with
hyponatraemia and hypokalaemic, hypochloraemic
metabolic alkalosis
c the vomitus is usually faeculent
d a common cause is gallstone ileus
e decompression with nasogastric tube is not often
required

Back 80

b

Front 81

Spontaneous cholecystoenteric fistula:
a occurs more frequently in young patients
b can be diagnosed by plain abdominal X-rays
c most frequently occurs between the gall bladder and
ileum
d frequently causes obstructive jaundice
e is the most common cause of small bowel obstruction
in females

Back 81

b

Front 82

Common causes of small bowel obstruction do NOT
include:
a post-surgical adhesions
b inguinal hernia
c incisional hernia
d small bowel tumour
e faecal impaction

Back 82

e

Front 83

Investigations in a patient with acute small bowel
obstruction would NOT include:
a supine and erect abdominal radiographs
b blood urea and electrolyte estimation
c gastrografin small bowel follow-through
d technetium-labelled iminodiacetic acid (HIDA) scan
e computed tomography of the abdomen

Back 83

d

Front 84

The following are common causes of large bowel
obstruction except:
a intra-abdominal adhesions
b sigmoid volvulus
c carcinoma of the colon
d diverticular disease
e carcinoma of the rectum

Back 84

a

Front 85

Large bowel obstruction requires urgent treatment
because:
a fluid and electrolyte imbalance is often life threatening
b intracolonic bacterial overgrowth leads to septicaemia
c there is a significant risk of colonic perforation
d small bowel obstruction with ischaemia will eventually
occur

Back 85

c

Front 86

Sigmoid volvulus:
a is common in the under 50 years age group
b is uncommon in Africans
c may lead to ischaemia and perforation of the colon
d is rarely treated successfully by sigmoidoscopic
decompression
e is best treated surgically by subtotal colectomy

Back 86

c

Front 87

Colonic pseudo-obstruction:
a is common in the elderly and debilitated
b should initially be treated by colonoscopic
decompression
c should be treated with sympathetomimetic agents
d is not associated with a risk of caecal perforation
e is liable to require surgical treatment

Back 87

a

Front 88

Complete left-sided large bowel obstruction:
a should be treated by self-expandable metallic stents
b will mostly require treatment by a three-staged
surgical procedure
c is commonly caused by a Crohn’s disease stricture
d should be treated by Hartman’s procedure

Back 88

b

Front 89

Three days after elective repair of an abdominal aortic
aneurysm, a 70-year-old man developed left iliac fossa
pain, abdominal distension, bloody diarrhoea and a fever
of 38◦C. The most helpful investigation would be:
a mesenteric angiography
b limited flexible sigmoidoscopy and biopsy
c gastroscopy
d barium small bowel follow-through
e abdominal ultrasound

Back 89

b

Front 90

Three days after a myocardial infarction with cardiogenic
shock, a 75-year-old man develops abdominal pain and
distension. The abdomen is slightly tender with reduced
bowel sounds. A plain abdominal X-ray shows distended
small bowel without fluid levels. Blood tests reveal a
metabolic acidosis. The most likely diagnosis is:
a perforated peptic ulcer
b mesenteric ischaemia
c pseudo-obstruction of the colon
d acute pancreatitis
e diverticulitis

Back 90

b

Front 91

Following massive small bowel resection for mesenteric
venous thrombosis, the following may develop EXCEPT:
a dehydration
b malnutrition
c lactose intolerance
d fat malabsorption
e adaptation of the colon to absorb vitamin B12

Back 91

e

Front 92

Right iliac fossa pain and nausea in a 62-year-old woman
may be due to the following EXCEPT:
a acute appendicitis
b caecal cancer
c urinary tract infection
d mittelschmerz pain
e sigmoid diverticulitis

Back 92

d

Front 93

The INCORRECT statement on sepsis associated with
appendicectomy for acute appendicitis is:
a may present with a pelvic abscess
b may present as a wound infection
c is reduced by prophylactic peri-operative antibiotics
d is increased by laparoscopic rather than open
appendicectomy
e is most often associated with anaerobic bacteria

Back 93

d

Front 94

The incorrect statement on Meckel’s diverticulum:
a may cause small bowel obstruction due to
intussusception
b may simulate acute cholecystitis
c may present with meal-related central abdominal
pain
d may present with melaena and a normal upper
gastrointestinal endoscopy
e may be diagnosed with a sodium technetium-99 m
scan in some cases

Back 94

b

Front 95

Adenocarcinoma of the small bowel is most commonly
associated with:
a familial adenomatous polyposis
b tuberculosis of the small bowel
c lymphoma
d prolonged use of cytotoxic chemotherapy for breast
cancer
e ulcerative colitis

Back 95

a

Front 96

Carcinoid tumour of the appendix is associated with the
following features EXCEPT:
a most are asymptomatic
b tumours less than 2 cm in size require no further
therapy other than appendicectomy
c it is always malignant
d carcinoid syndrome arises when hepatic metastases
have occurred
e synchronous carcinoid tumour in the distal ileum may
be present

Back 96

c

Front 97

The following are appropriate managements for familial
adenomatous polyposis EXCEPT:
a restorative proctocolectomy and ileoanal pouch
anastomosis
b regular surveillance with flexible sigmoidoscopy
c enrolment in a familial adenomatous polyposis registry
d identification of presymptomatic carrier by molecular
genetic testing
e prophylactic histamine H2 receptor antagonist, as
duodenal cancer is a common cause of death

Back 97

e

Front 98

The INCORRECT statement on FAP:
a inheritance is in autosomal dominant fashion
b the condition accounts for 10% of all colorectal
cancers
c most affected individuals develop polyps by the age of
10 years
d desmoid tumour is an association
e all affected patients will develop colorectal carcinomas
with time

Back 98

b

Front 99

The HNPCC syndrome:
a is inherited in an autosomal dominant pattern
b tends to affect younger patients
c has a predilection for cancer in the proximal colon
d is often associated with metachronous colorectal
cancers
e is linked to hereditary adenomatous polyposis

Back 99

e

Front 100

Hamartomatous polyposis includes:
a Peutz–Jeghers syndrome
b familial adenomatous polyposis
c HNPCC syndrome
d tubulovillous adenoma
e haemangioma

Back 100

a

Front 101

The oncologic outcome of rectal cancer is:
a improved by precise pre-operative staging, including
endorectal ultrasound
b better if the surgery is performed by a surgeon who
has large case volume of rectal cancer
c improved by multimodality therapy for high-risk cancer
d improved by pre-operative chemotherapy alone, if
pre-operative endorectal ultrasound indicates that it is
a T3 cancer
e equivalent whether laparoscopic or conventional open
resection is performed.

Back 101

d

Front 102

A 72-year-old woman presents with left iliac fossa pain,
fever and abdominal distension. Abdominal X-ray reveals
two dilated loops of small bowel. The most likely
diagnosis is:
a left ureteric calculus
b tubo-ovarian abscess
c irritable bowel syndrome
d acute diverticulitis
e sigmoid volvulus

Back 102

d

Front 103

Diverticular disease of the colon is associated with:
a thickening of the longitudinal but not circular muscle
of the colon
b narrowing of the lumen from mucosal hyperplasia
c increased intraluminal pressure within the colon
d high-fibre and high-fat diet
e a high incidence of anastomotic breakdown in elective
surgery

Back 103

c

Front 104

Surgical management of perforated diverticular disease
with faecal peritonitis includes:
a pre-operative mechanical bowel preparation
b Hartmann’s procedure and sigmoid end colostomy
c pre-operative barium enema to define the anatomy
d anterior resection and primary colorectal anastomosis
whenever possible
e use of peri-operative antibiotics optimally with
penicillin and gentamycin

Back 104

b

Front 105

The complications of sigmoid diverticular disease include
the following EXCEPT:
a sigmoid inflammatory phlegmon
b colonic bleeding
c purulent peritonitis
d colovaginal fistula
e colon cancer

Back 105

e

Front 106

Extra-intestinal manifestations of ulcerative colitis include
the following EXCEPT:
a pyoderma gangrenosum
b iritis
c sacroileitis
d sclerosing cholangitis
e eczema

Back 106

e

Front 107

The following features may occur in both ulcerative
colitis and Crohn’s disease EXCEPT:
a proctitis
b erythema nodosum
c toxic megacolon
d non-caseating granuloma
e response to mesalazine

Back 107

d

Front 108

Which of the following statements about Crohn’s disease
is correct?
a adenocarcinoma of the small bowel is a recognised
complication of Crohn’s disease
b when operative resection is required, the sites of
anastomosis should be completely normal
c strictureplasty is associated with a much higher surgical
morbidity than resection
d perianal Crohn’s disease is more commonly associated
with Crohn’s jejunitis than colitis
e haemorrhoidectomy should be performed as early as
necessary because severe symptoms are likely

Back 108

a

Front 109

Ulcerative colitis:
a is a mucosal disease that affects both the large and
small bowel
b in contrast to Crohn’s disease, does not have an
increased risk of colorectal cancer
c surveillance for colon cancer is mandatory, starting at
diagnosis
d toxic megacolon may be the initial manifestation
e salphasalazine is most effective for acute colitis

Back 109

d

Front 110

Indications for restorative proctocolectomy in ulcerative
colitis include:
a toxic megacolon
b a 2-cm villous adenoma in the hepatic flexure of the
colon
c ulcerative proctitis
d severe sacroileitis
e low-grade dysplasia on rectal biopsy

Back 110

b

Front 111

Pathological findings in Crohn’s disease of the small
bowel include:
a enlarged blood vessels, creeping along the sides of
bowel wall towards the mesenteric border
b caseating granulomas occurring in the bowel wall and
mesenteric lymph nodes
c continuous rather than segmental involvement of the
small bowel
d inflammation confined to the mucosa and submucosa
of the bowel
e a cobblestone appearance of the bowel arising
from fissuring of the mucosa and submucosal
oedema

Back 111

e

Front 112

Radiation enteritis:
a is related to techniques of delivery of radiation therapy
b may present acutely with perforation and peritonitis
c may present late with recurrent small bowel
obstruction
d is associated with a high operative morbidity
e may benefit from a high-fibre diet

Back 112

e

Front 113

The following treatments are appropriate for a
high-output enterocutaneous fistula EXCEPT:
a a high-fibre diet
b total parenteral nutrition
c intravenous fluid and electrolyte replacement
d sandostatin
e skin care by an enterostomal therapist

Back 113

a

Front 114

An enterocutaneous fistula that occurs 5 days after a
small bowel resection for Crohn’s disease may be
associated with the following EXCEPT:
a anastomotic breakdown
b persistent intestinal obstruction distal to the fistula
c the presence of an inadequately drained abscess
adjacent to the anastomosis
d traumatic enterotomy during adhesion lysis, which has
been overlooked
e recurrent Crohn’s disease

Back 114

e

Front 115

Surgery for complete rectal prolapse includes the
following EXCEPT:
a abdominal rectopexy
b sigmoid colectomy and rectopexy
c Hartmann’s procedure
d perineal proctosigmoidectomy
e D´elorme’s procedure (mucosal sleeve resection)

Back 115

c

Front 116

Full-thickness rectal prolapse is characterised by:
a faecal incontinence in approximately half the patients
b a rare association with uterine prolapse
c a peak incidence in elderly males
d a high incidence of psychotic disorders
e characteristic abnormalities on anorectal manometry

Back 116

a

Front 117

Complications of ileostomy include the following
EXCEPT:
a ileostomy prolapse
b skin irritation around stoma site
c ileostomy retraction
d food bolus obstruction
e peptic ulcer

Back 117

e

Front 118

Which of the following is INCORRECT concerning stoma
management?
a pre-operative stoma siting and counselling are
important
b further measurements for new stoma appliances are
performed approximately 4 weeks after surgery
c dietary restrictions are necessary
d sexual activities are to be avoided because of the
stoma
e the enterostomal therapist is an integral member of
the management team

Back 118

d

Front 119

The preferred treatment of an ischiorectal abscess is:
a a prolonged course of antibiotics to abort the infection
b incision and drainage under general anaesthesia
c needle aspiration under local anaesthesia
d warm salt baths
e fistulotomy

Back 119

b

Front 120

The aetiology of anal fistula includes:
a anal gland infection
b ulcerative colitis
c ischaemic colitis
d anal syphilis
e levator syndrome

Back 120

a

Front 121

Painful perianal conditions include:
a Bowen’s disease
b second-degree haemorrhoids
c perianal haematoma
d anal warts
e ulcerative colitis

Back 121

c

Front 122

Complications of haemorrhoidectomy include the
following EXCEPT:
a severe anal pain
b urinary retention
c anal stricture
d pyelonephritis
e rectal bleeding

Back 122

d

Front 123

Anal fissure is characterised by the following EXCEPT:
a severe anal pain during and immediately after
defecation
b bleeding on defecation
c a sentinel anal skin tag
d a relapsing history
e a patulous anus

Back 123

e

Front 124

A 48-year-old woman presents with thick greenish nipple
discharge from both breasts. There is no palpable breast
lump, although both nipples are slightly retracted. The
patient does not take any medication. Mammogram and
ultrasound do not show any evidence of cancer. The
most likely diagnosis is:
a galactorrhoea
b duct papilloma
c mammary duct ectasia
d fibroadenoma
e lobular carcinoma in situ

Back 124

c

Front 125

A 42-year-old woman presents with a 2-cm breast lump,
detected 2 weeks ago. The lump is discrete but soft.
There is no past history of breast disease. The initial
management includes:
a repeat clinical examination in 4 weeks’ time to detect
any changes
b bilateral mammogram with or without breast
ultrasound
c fine needle aspiration cytology of the lump as breast
imaging is unnecessary in this age group
d excision biopsy
e unilateral mammogram and ultrasound of the breast
with the lump

Back 125

b

Front 126

Mammography screening programmes:
a reduce mortality of breast cancer, especially in women
aged between 40 and 50 years
b detect smaller cancers with a lower incidence of
axillary nodal metastases than in the unscreened
population
c show a higher incidence of lobular but not ductal
carcinoma in situ
d include quality assurance targets of attendance
rates higher than 50% and recall rates lower
than 50%
e involve radiologists as the primary personnel
responsible for diagnosis and management

Back 126

b

Front 127

A 39-year-old woman has a 5-cm, grade III breast
cancer. Twelve of 16 lymph nodes contain metastases.
The oestrogen receptor is negative, although the
progesterone receptor is positive. There is no evidence of
systemic metastases on chest X-ray and bone scan.
Following a total mastectomy and axillary clearance, the
MOST likely follow-up management would be:
a regular review, with reservation of chemotherapy for
recurrent disease
b adjuvant tamoxifen
c adjuvant chemotherapy
d adjuvant radiotherapy
e oophorectomy

Back 127

c

Front 128

Correct statement concerning ductal carcinoma in situ
(DCIS):
a it is associated with microcalcification on
mammography
b DCIS is less commonly found in women undergoing
routine mammographic screening
c comedo subtype is rarely multicentric
d there is a high risk for lymph node metastasis with the
papillary subtype
e the risk for progression to invasive cancer is smaller
than with lobular carcinoma in situ

Back 128

a

Front 129

Thyroid follicular cells arise primarily from:
a the laryngeal cartilage
b the second bronchial arch
c the oesophagus
d the base of the tongue
e the neural crest

Back 129

d

Front 130

FNAC can reliably diagnose all types of thyroid cancer
except:
a follicular thyroid cancer
b papillary thyroid cancer
c anaplastic thyroid cancer
d medullary thyroid cancer
e metastases from renal cell cancer

Back 130

a

Front 131

The type of thyroid cancer with the worst prognosis
(5-year survival <1%) is:
a papillary thyroid cancer
b follicular thyroid cancer
c anaplastic thyroid cancer
d medullary thyroid cancer
e thyroid lymphoma

Back 131

c

Front 132

Thyroiditis presenting following a viral infection with an
exquisitely tender, enlarged, firm thyroid gland, and
with systemic symptoms of headache and malaise is
generally due to:
a Hashimoto’s thyroiditis
b de Quervain’s (subacute) thyroiditis
c Reidels thyroiditis
d acute bacterial thyroiditis
e non-specific thyroiditis

Back 132

b

Front 133

Damage to one recurrent laryngeal nerve during
thyroidectomy generally leads to:
a the need for a tracheostomy
b an inability to sing high notes
c inability to project the voice to the back of a hall
d a falsetto voice
e a hoarse voice

Back 133

e

Front 134

The parathyroid glands arise from:
a the third and fourth branchial pouches
b the base of the tongue
c the first branchial pouch
d the thyroid parenchyma
e a tracheal diverticulum

Back 134

a

Front 135

Parathyroid hormone (PTH) has a half-life of:
a 7 seconds
b 5 minutes
c 1 hour
d 2 days
e 5 weeks

Back 135

b

Front 136

Primary hyperparathyroidism is due, in 90% of cases,
to:
a metastatic cancer
b parathyroid cancer
c parathyroid hyperplasia
d multiple parathyroid tumours
e a single parathyroid adenoma

Back 136

e

Front 137

The diagnosis of primary hyperparathyroidism is usually
confirmed by the following biochemical results:
a raised serum calcium, suppressed PTH
b raised serum calcium, raised or normal PTH
c normal serum calcium, raised PTH
d normal serum calcium, suppressed PTH
e low serum calcium, raised or normal PTH

Back 137

b

Front 138

The most common cause of hypoparathyroidism is:
a congenital absence of the parathyroids
b autoimmune parathyroid failure
c parathyroid cancer
d surgical removal of the parathyroids at total
thyroidectomy
e acute bacterial infection

Back 138

d

Front 139

Adrenal masses occur in:
a <1% of the population
b 3–7% of the population
c 10–20% of the population
d 40–50% of the population
e >66% of the population

Back 139

b

Front 140

Conn’s syndrome is due to a tumour of the adrenal
cortex secreting excess:
a cortisol
b adrenaline
c noradrenaline
d aldosterone
e sex steroids

Back 140

d

Front 141

Paragangliomas arise from:
a the adrenal cortex
b the adrenal medulla
c the carotid bifurcation
d the foregut
e parasympathetic tissue arising from the neural crest

Back 141

e

Front 142

The initial test used to diagnose Cushing’s syndrome is
measurement of:
a serum cortisol and 24-hour urinary free cortisol
levels
b serum ACTH
c serum cortisol after a dexamethasone test
d plasma renin/aldosterone ratio
e serum catecholamines

Back 142

a

Front 143

Adrenal “incidentalomas” should be removed when they
are:
a >25 cm
b >10–15 cm
c >3–5 cm
d >1 cm
e any size at all

Back 143

c

Front 144

The most common form of functioning tumour of the
pancreatic islet cells is:
a gastrinoma
b insulinoma
c somatostatinoma
d vipoma
e glucagonoma

Back 144

b

Front 145

The Zollinger–Ellison syndrome can be controlled by
administration of:
a omeprazole
b folic acid
c methotrexate
d atenolol
e atorvastatin

Back 145

a

Front 146

The islets of Langerhans contain all these types of cells
except:
a alpha cells
b beta cells
c gamma cells
d delta cells
e enterochromaffin cells

Back 146

d

Front 147

The Snellen visual acuity in a patient is noted to be 6/60
in the right eye and 6/18 in the left eye. Which of the
following statements is correct?
a the Snellen acuity in the right eye is better than the left
eye
b the denominator expresses the distance acuity in the
tested eye
c the numerator expresses the near vision in the tested
eye
d Snellen acuity compares a tested eye to a normally
seeing eye

Back 147

d

Front 148

Which of the following is most likely to be found in a
patient with an orbital blow-out fracture?
a proptosis
b horizontal diplopia
c anosmia
d upper gum anaesthesia

Back 148

b

Front 149

The preferred treatment for an intra-ocular infection is:
a intravenous steroids
b intensive antibiotic drops
c intensive antibiotic drops combined with intravenous
antibiotics
d intravenous antibiotics

Back 149

b

Front 150

Which modality of treatment is most useful for
nasopharyngeal carcinoma?
a chemotherapy
b radiotherapy
c surgery
d immunotherapy
e hormonal therapy

Back 150

b

Front 151

Which of the following statement concerning
nasopharyngeal carcinoma is INCORRECT ?
a keratinising SCC is most common in developed
countries
b examination of the nasopharynx is usually positive
c in 90% of patients, cervical nodes were involved
d there are known aetiological factors
e the tumour tends to infiltrate widely

Back 151

b

Front 152

Which of the following statement concerning parotid
gland tumours is INCORRECT ?
a a cystic lesion in the lower pole is likely to be benign
b a long-standing tumour that enlarges and becomes
painful suggests malignancy
c bilateral tumours in elderly men are usually benign
d facial nerve palsy suggests malignant disease
e needle aspiration cytology of parotid tumours is
contraindicated

Back 152

e

Front 153

The commonest tumour of the head and neck area is:
a pleomorphic tumour of the parotid gland
b squamous cell carcinoma of the larynx
c squamous cell carcinoma of the skin
d basal cell carcinoma of the skin
e carcinoma of the thyroid gland

Back 153

d

Front 154

The most common paediatric soft tissue sarcoma in the
head and neck area is:
a angiosarcoma
b malignant fibrous histiocytoma
c dermatofibrosarcoma protuberans
d rhabdomyosarcoma
e chondrosarcoma

Back 154

d

Front 155

The highest propensity for lymph node metastasis occurs
in squamous cell carcinoma of the:
a ear
b scalp
c upper lip
d nose
e lower lip

Back 155

c

Front 156

The commonest type of hernia is:
a inguinal
b femoral
c epigastric
d incisional
e umbilical

Back 156

a

Front 157

The most serious and urgent complication of a hernia is:
a pressure on the spermatic cord
b irreducibility
c obstruction
d strangulation
e neuralgia

Back 157

d

Front 158

Indirect inguinal hernias:
a can hardly ever be distinguished from direct inguinal
hernias by clinical examination
b rarely occur in children
c can be treated by herniotomy, herniorraphy and
hernioplasty
d should not be treated laparoscopically
e arise beneath the inguinal ligament

Back 158

c

Front 159

Femoral hernias:
a may occasionally appear above the inguinal ligament
in young children
b should always be repaired surgically
c can be treated with a surgical truss
d are caused by a defect in the cribriform fascia
e may compress the femoral artery

Back 159

b

Front 160

A 70-year-old man presents with a 1-cm painless nodule
on the side of his nose. This has been present for
3 weeks. The centre of the lesion appears to contain a
plug of hard skin. What is the most likely diagnosis?
a squamous cell carcinoma
b basal cell carcinoma
c keratoacanthoma
d Merkel cell carcinoma
e seborrhoiec keratosis

Back 160

c

Front 161

A 45-year-old motor mechanic presents with a nodule on
the tip of his finger. This has been present for 12 months
and it bothers him now when he presses on that finger.
He seems to remember injuring that finger at work
several years earlier. On examination there is a 0.5-cm
nodule and the overlying skin is intact. What is the most
likely diagnosis?
a dermoid cyst
b epidermoid cyst
c pyogenic granuloma
d dermatofibroma
e cylindroma

Back 161

b

Front 162

The parents of a 4-week-old boy are concerned about a
lump above the infant’s right eye. It has been present
since birth and has not changed in size. The skin over the
1-cm lump is intact and the lump appears to be attached
to the underlying tissues. What is the most likely
diagnosis?
a dermoid cyst
b epidermoid cyst
c cystic hygroma
d branchial cyst
e osteoma

Back 162

a

Front 163

A 75-year-old man has what appears to be a 1-cm basal
cell carcinoma on the side of his nose immediately below
his left eye. What would be the most appropriate
treatment?
a radiotherapy
b application of 5-fluorouracil cream
c injection of vinblastine
d excision and split-skin graft
e excision and full-thickness graft

Back 163

e

Front 164

A 17-year-old girl presents with a painless swelling on
the anterior aspect of her right leg. This has been present
for about 6 months and does not bother her much,
except that it itches occasionally. The lump is pink and
firm, and the overlying skin is intact. What is the most
likely diagnosis?
a basal cell carcinoma
b epidermoid cyst
c Bowen’s disease
d dermatofibroma
e malignant melanoma

Back 164

d

Front 165

Soft tissue sarcomas are commonest in:
a the abdomen and retroperitoneum
b the head and neck
c the lower limb
d the upper limb
e the thorax

Back 165

c

Front 166

The commonest site of metastasis for soft tissue
sarcomas is:
a regional lymph nodes
b liver
c bone
d lungs
e brain

Back 166

d

Front 167

Which of the following is an indication for removal of a
lipoma?
a a 3-cm lipoma in the tibialis anterior
b a 3-cm lipoma in the subcutaneous fat of the anterior
abdominal wall
c a 3-cm lipoma in the subcutaneous fat of the
buttock
d a lipoma of many years standing which has not
changed in size
e a lipoma on CT scanning of homogeneous
density

Back 167

a

Front 168

Desmoid tumours:
a are increasingly commoner in woman as they
age
b occur in the root of the mesentry in association
with the FAP syndrome
c cause death by metastasis
d tend not to recur locally
e metastasise to regional lymph nodes

Back 168

b

Front 169

Cellulitis:
a is occasionally caused by Gram-negative coliforms
b often occurs spontaneously without any apparent
cause or organism
c is treated with rest, immobilisation and high-dose
penicillin
d frequently requires surgical drainage
e is often complicated by suppuration and skin necrosis

Back 169

c

Front 170

Fournier’s gangrene:
a is a form of pyomyositis
b occurs mainly in debilitated patients and can be
life-threatening
c is usually due to stapylococcal infection
d can be treated by hyperbaric oxygen alone
e is seldom managed surgically

Back 170

b

Front 171

Hidradenitis suppurativa:
a is a complication of cystic fibrosis
b rarely occurs in the axillae or groin
c may be associated with pilonidal sinus
d chronic cases are improved by excisonal surgery
e antibiotics have no role in management

Back 171

d

Front 172

Clostridial infections:
a are common in domestic gardeners
b can usually be treated expectantly
c are nearly always confined to HIV-positive patients
d advanced infections resolve with hyperbaric therapy
alone
e require urgent surgical debridement

Back 172

e

Front 173

Which of the following does not predispose to ischaemic
necrosis and wound breakdown?
a excessive tension
b foreign body
c application of vacuum
d haematoma
e irradiation

Back 173

c

Front 174

Lesions such as naevi, birthmarks and skin cancers can
be:
a removed with elliptical excision
b excised perpendicular to Langer’s lines
c excised across the line of least tension or maximum
laxity
d excised using incisions that transgress cavities or
flexion creases
e closed with a z-plasty following all excisions

Back 174

a

Front 175

Sutures should:
a be placed horizontally to the wound through the
tissues to approximately the full depth of the wound
b be the least number to maintain closure
c be of the greatest calibre to maintain closure
d remain once cross hatching has occurred
e sutures should be left in for longer periods in young
patients compared to the elderly patients

Back 175

b

Front 176

A graft shaved at a dermal level, which includes elements
of the epidermis and dermis:
a is a full-thickness graft
b is used where large areas of skin are required
c is sensate immediately after transfer
d is limited by the donor defect to be closed
e requires 1 week before blood flow is established in it

Back 176

b

Front 177

The following are critical determinants of patient
outcome following injury, EXCEPT:
a time from injury to definitive care
b presence of a well-organised regional system of
trauma care
c protocols and guidelines when clinical experience is
limited
d early mobilisation of teams led by doctors to most
scenes of injury
e thrombosis prophylaxis

Back 177

d

Front 178

Hypovolaemic shock can result from any of the
following, EXCEPT:
a pulmonary laceration
b extradural haemorrhage
c pelvic fracture
d femur fracture
e laceration to scalp

Back 178

b

Front 179

A restrained 32-year-old male involved in a head-on
motor vehicle collision presents with chest pain and the
following vital signs on arrival in the emergency
department: Heart rate – 120/minute; Blood pressure –
86/50; GCS score – 10; and O2 saturations of 92%.
Which of the following takes first priority?
a urgent CT scan of the head to rule out an extradural
haemorrhage with midline shift
b rapid resuscitation with 2 large-bore intravenous
cannulae and warmed fluids
c ECG and an echocardiogram to eliminate cardiac
contusion as the cause of his hypotension
d obtaining an urgent cross match
e elimination of tension pneumothorax as a cause of his
symptoms/signs:

Back 179

e

Front 180

Which of the following is NOT considered an immediate
threat to life?
a fracture of T6 with a complete spinal cord transection
b splenic injury with ongoing bleeding
c open pneumothorax
d rapidly rising intra-cranial pressures
e aspiration

Back 180

a

Front 181

The volume of fluid replacement required in the first
24 hours in a 70-kg adult with 30% burns is
approximately:
a 2,500 mL
b 4,000 mL
c 7,500 mL
d 10 500 mL
e 12 500 mL

Back 181

c

Front 182

Fluid replacement in a 70-kg adult with 30% burns
should maintain a urine flow of:
a 35 mL/hour
b 70 mL/hour
c 105 mL/hour
d 140 mL/hour
e 175 mL/hour

Back 182

b

Front 183

Mesh split skin grafts are used in burns because:
a they release haematomas
b they cause less pain
c they produce a better cosmetic result
d the donor site heals more quickly
e all of the above

Back 183

a

Front 184

Which of the following bacteria occur commonly in burn
wound infections?
a Klebsiella spp.
b Clostridium difficile
c Bacteroides fragilis
d Staphylococcus epidermidis
e Pseudomonas pyocyanea

Back 184

e

Front 185

Radiologic evidence of an acute fracture includes:
a loss of continuity in cortical bone
b osteoporosis
c sclerosis of bone
d reduced adjacent soft tissue markings
e gas in the surrounding muscle

Back 185

a

Front 186

In assessing the severity of an acute fracture, one must
always:
a examine for subcutaneous emphysema
b examine for evidence of gangrene
c examine the status of the neurovascular system of the
fractured part
d examine for a temperature and arrhythmia
e examine for evidence of a fat embolism

Back 186

c

Front 187

The cardinal feature of a compartment syndrome are:
a pain
b hyperthermia
c rubor
d punctate ecchymosis
e limb hyperactivity

Back 187

a

Front 188

When a plaster cast is applied for a fractured wrist, care
must be taken to instruct the patient on symptoms of:
a pulmonary embolism
b fat embolism
c air embolism
d compartment syndrome
e Choong–Baker syndrome

Back 188

d

Front 189

Dislocation may be missed in the following circumstance:
a posterior dislocation of the hip
b posterior dislocation of the shoulder
c posterior dislocation of the elbow
d posterior dislocation of the sternoclavicular joint
e posterior dislocation of the knee

Back 189

b

Front 190

Degenerative arthritis is a common condition
characterised by:
a joint pain, stiffness, contracture and deformity
b recurrent haemarthroses, joint swelling and a charcot
joint
c high temperature, exquisite joint pain and
constitutional symptoms
d flitting arthralgia, skin rash and sore throat
e single joint swelling, conjunctivitis and urethritis

Back 190

a

Front 191

The radiologic features of degenerative arthritis include:
a syndesmophytes, bamboo spine
b joint narrowing, subchondral sclerosis, osteophyte
formation, cyst formation
c joint debris, density, derangement and destruction
d osteoporosis, valgus knee, marked joint synovitis

Back 191

b

Front 192

Crystal arthropathy may be seen in the following
condition:
a hyperurecaemia
b chondrodysplasia
c haemachromatosis
d Osgood–Schlatters disease
e osteochondritis dissecans

Back 192

a

Front 193

Septic arthritis is associated with the following features:
a exquisite pain with attempted joint motion
b minimal constitutional symptoms
c low incidence in children
d low incidence in the elderly
e never associated with trauma

Back 193

a

Front 194

Septic arthritis should be managed urgently with:
a amputation
b arthrodesis
c arthrocentesis
d arthrocutaneous fistula
e arthroplasty

Back 194

c

Front 195

In the treatment of head injury, the following is true:
a steroids are regularly used
b patients with a Glasgow Coma Scale score less than 8
are usually intubated and ventilated
c antibiotics are routinely used
d pyrexia is nearly always due to severe infection
e severe fluid restriction is necessary

Back 195

b

Front 196

The best investigation for patients with severe head
injury is:
a CT Scan
b skull X-ray
c EEG
d ultrasound
e MRI

Back 196

a

Front 197

Traumatic intracerebral haematomas following blunt
trauma:
a can usually be diagnosed by skull X-ray
b are usually associated with severe brain injury
c always need to be drained
d should be treated with fluid restriction
e are always associated with a skull fracture

Back 197

b

Front 198

An acute subdural haematoma:
a shows a characteristic hyperdense extra-cerebral mass
b is often associated with only a minor head injury
c virtually never need surgical excision
d can always be managed with diuretic therapy
e usually causes an ipsilateral hemiparesis

Back 198

a

Front 199

The following is true:
a meningiomas are the most common adult brain
tumours
b brain tumours are rare in children
c high-grade cerebral gliomas are invariably fatal
d metastatic cancer in the brain is uncommon
e oligodendroglioma is the most common type of
glioma

Back 199

c

Front 200

Cerebral gliomas in adults:
a do not infiltrate through the brain
b are best managed with chemotherapy
c rarely cause raised intracranial pressure
d are best visualised by MRI
e most frequently occurs in the cerebellum

Back 200

d

Front 201

Brain tumours in children:
a most commonly occur in the posterior fossa
b can be cured with surgery
c never metastasise
d invariably have an excellent prognosis
e most frequently present with epilepsy

Back 201

a

Front 202

Cerebral aneurysms:
a usually occur on the peripheral intracranial
vessels
b can be definitively diagnosed by a CT scan
c are the most common cause of subarachnoid
haemorrhage in adults
d are virtually always multiple
e usually present with focal seizures

Back 202

c

Front 203

Subarachnoid haemorrhage:
a is most commonly due to ruptured arterial venous
malformation in adults
b usually presents as an epileptic seizure as the initial
symptom
c must be evacuated as an emergency
d is characterised by the onset of a sudden severe
headache
e is frequently due to haemorrhage from a tumour

Back 203

d

Front 204

In considering pituitary tumours, the following is true:
a the tumour is always confined to the sellar
b adults frequently present with growth retardation
c prolactin-secreting tumours are best treated with
surgery
d ACTH-secreting tumours cause Cushing’s disease
e posterior pituitary function is almost always absent in
patients presenting with large tumours

Back 204

d

Front 205

Carpal tunnel syndrome:
a most frequently occurs in men
b is due to the compression of the ulnar nerve at the
wrist
c usually causes severe weakness in the hand
d is especially associated with pregnancy and lactation
e causes decreased sensation on the dorsum of the
hand

Back 205

d

Front 206

In considering spinal cord compression, the following is
true:
a the most common cause is an intramedullary spinal
cord tumour
b the management of compression by a malignant
metastatic tumour is best undertaken utilizing
chemotherapy
c the usual treatment for spinal cord compression due
to malignant tumours is urgent surgery or
radiotherapy
d spinal pain is a late feature of spinal cord compression
e metastatic tumours are rarely a cause of spinal cord
compression

Back 206

c

Front 207

In considering nerve injuries, the following is true:
a a neurapraxia almost never recovers
b neurotmesis is a mild form of injury, likely to be
transient
c an Erb’s palsy is due to damage of the upper trunk of
the brachial plexus
d Horner’s syndrome in association with a brachial
plexus injury is indicative of an excellent prognosis
e injury to the radial nerve in the upper arm causes
weakness of finger flexion

Back 207

c

Front 208

Considering peripheral nerve entrapments, the following
is true:
a the ulnar nerve is frequently trapped at the elbow in
front of the medial epicondyle
b carpal tunnel syndrome is due to entrapment of the
radial nerve at the wrist
c meralgia paraesthetica is due to entrapment of the
lateral cutaneous nerve of the thigh
d the principal symptom of meralgia paraesthetica is
weakness of the leg
e the early features of ulnar nerve entrapment at the
elbow is numbness involving the thumb and index
finger

Back 208

c

Front 209

Which of the following is true about a pulsatile mass in
the abdomen?
a it must be an aortic aneurysm
b an ultrasound would be the best initial investigation
c no imaging is needed if the mass is not tender
d immediate surgery is indicated
e immediate angiography is indicated

Back 209

b

Front 210

Which of the following suggest that acute arterial
ischaemia is due to embolus in a 70-year-old woman?
a she is in atrial fibrillation
b her symptoms developed slowly over a month
c she has had long-standing intermittent claudication
d she smokes
e she is an insulin-dependent diabetic

Back 210

a

Front 211

Which of the following is true about arterial trauma?
a all arterial injury is associated with pulsatile bleeding
b the commonest cause in Australia is penetrating
injury
c the distal pulses will be absent
d there is no relationship to major joint dislocations
e bleeding is more likely with partial than with complete
arterial transection

Back 211

e

Front 212

Which of the following is true about the diabetic foot
complications?
a the neuropathy is only sensory
b there is no relation to ongoing smoking
c the metatarsal phalangeal joints do not dislocate
d the prognosis is worse with arterial disease and
ongoing smoking
e there is no place for surgical management

Back 212

d

Front 213

Which of the following is not true about the anatomy of
extracranial arterial disease?
a the left subclavian artery arises directly from the aortic
arch
b the vertebral artery is a branch of the subclavian
carotid artery
c the vertebral arteries form the basilar artery
d there is no communication between the anterior and
posterior cerebral circulations
e there is a low-resistance flow pattern in the internal
carotid artery

Back 213

d

Front 214

An 80-year-old woman presents with transient right
hemiparesis, lasting 15 minutes and resolving completely.
She is otherwise healthy and independent. Her carotid
duplex scan shows >80% stenosis of her left internal
carotid artery. Despite aspirin therapy, she has a
further episode. Which of the following statements is
true?
a she is best managed on warfarin therapy
b left carotid endarterectomy is indicated
c carotid stenting is a preferred option to surgery
d she is facing a cumulative 5% stroke within the next
3 years
e lowering her blood cholesterol level will reduce her
immediate risk of stroke

Back 214

b

Front 215

Which of the following is true about the pathology of
extracranial arterial disease?
a atherosclerosis is the commonest cause of internal
carotid stenosis
b recurrent stenosis occurs in >50% of patients after
carotid endarterectomy
c carotid body tumours arise from the vertebral
arteries
d fibromuscular disease is commonest in young men
e Takayasu’s disease is commonly known as ‘pulsing
disease’

Back 215

a

Front 216

Which if the following is true about carotid
endarterectomy?
a it is associated with a high (>5%) risk of
peri-operative stroke
b closure with a patch decreases the risk of recurrent
stenosis
c there is a plane between the atheromatous plaque and
the intima
d it is the procedure of choice for fibromuscular disease
e it precludes the use of a carotid stent for recurrent
stenosis

Back 216

b

Front 217

A 65-year-old man presents with angina, and a left neck
bruit is heard. Which of the following statements is
correct?
a the first priority is investigation of the bruit
b the bruit may be arising from the aortic valve
c a carotid angiogram in indicated
d there is no relationship between angina and a carotid
bruit
e the left internal carotid artery must be occluded

Back 217

b

Front 218

With regards to varicose veins, which of the following is
incorrect?
a varicose veins are dilated, tortuous and visible when
the patient is standing
b valvular incompetence is an integral component of the
pathogenesis of varicose veins
c the principal superficial venous systems of the lower
limbs are the long and the short saphenous systems
d the principal route of venous drainage from the lower
limb is via the superficial venous system
e the principal driver of venous drainage from the legs in
the erect position is the calf pump

Back 218

d

Front 219

Which of the following is incorrect? Patients with
varicose veins may present to their doctor because of:
a calf pain after walking 200 m that is relieved by resting
for 5 minutes
b a superficial ulcer on the ankle
c aching discomfort in the calf after prolonged
standing
d superficial thrombophlebitis
e spontaneous bleeding from a varix

Back 219

a

Front 220

Which ONE of the following is correct?
a venography is an accurate method for investigating
varicose veins
b duplex scanning has little to add to the pre-operative
investigation of varicose veins
c the most frequent cause of recurrent varicose veins is
neovascularisation
d due to frequent, serious late complications, all patients
with varicose veins should be advised to have surgery
e patients with varicose veins and who have
haemosiderin deposits and liposclerosis at the ankle
should be treated

Back 220

e

Front 221

Which of the following is NOT true in the management
of patients with varicose veins?
a below-knee-length elastic stockings may be definitive
treatment in the patient in whom surgery is
contraindicated because of co-morbidities
b injection with a sclerosing agent followed by elastic
compression for 4–6 weeks can be beneficial
c using a below-knee elastic stocking may help decide if
calf symptoms are due to varices
d surgical trials have demonstrated that it is not
necessary to remove the long saphenous vein in the
thigh
e endoscopic techniques to divide incompetent
perforating veins have been developed

Back 221

d

Front 222

Primary lymphoedema:
a should be differentiated from oedema due to varicose
veins with a duplex scan
b should be investigated with lymphoscintography
before deciding on treatment
c is more common in women
d usually responds to nocturnal elevation and elastic
compression during the day
e the response to therapy is monitored by serial
measurement of limb circumference

Back 222

b

Front 223

Which of the following is not correct with respect to
upper tract urinary calculi?
a approximately 80% of upper tract stones pass
spontaneously
b calcium oxalate is the commonest component of these
stones
c diuresis at the time of an episode of ureteric colic
facilitates spontaneous passage of the stone
d urate calculi may be dissolved with alkalinisation of
urine
e infection stones are most commonly associated with
Proteus species of bacteria, which contain urease

Back 223

c

Front 224

Which of the following is correct with respect to prostate
cancer?
a compared with men under the age of 65 years,
prostate cancer in the elderly is very rarely an
aggressive cancer
b most patients diagnosed with prostate cancer present
with lower urinary tract symptoms
c 80% of men presenting with an elevated serum
prostate specific antigen (PSA) have prostate cancer
d approximately 95% of prostate cancer patients have a
durable response (>36 months) to androgen
suppression therapy
e the obturator, internal iliac and presacral lymph
nodes are commonly involved in prostate cancer
metastases

Back 224

e

Front 225

Which of the following is correct?
a ‘obstructive symptoms’ of hesitancy, a reduced flow
and terminal dribbling indicate bladder outflow obstruction (BOO) in more than 90% of men 50 years
and over
b benign prostatic hyperplasia (BPH) is predominantly a
stromal hyperplasia
c a residual of more than 100 mL on three consecutive
occasions is diagnostic of BOO
d the size of the prostate on digital rectal examination
(DRE) is a reliable indicator of the presence or absence
of BOO
e all men with chronic urinary retention benefit
clinically from transurethral resection of the
prostate

Back 225

b

Front 226

Which of the following is not correct?
a a mid-stream specimen of urine (m/s/u) submitted for
microscopy, culture and sensitivities (m/c/s) remains
the standard approach for diagnosing a urinary tract
infection
b vesico-ureteric reflux of infected urine in infancy
causes reflux nephropathy
c patients with reflux nephropathy are at risk for
developing chronic pyelonephritis, hypertension and
renal failure
d E. coli is the bacterium responsible for most urinary
tract infections
e first-line management of a 20-year-old woman
with her first episode of lower urinary tract symptoms
of acute onset involves obtaining an m/s/u for
m/c/s and prescribing a 10-day course of one of
the new quinolone drugs (ciprafloxacin or norfloxacin)

Back 226

e

Front 227

Your recommendation for a 45-year-old man with a
history of suspected haematuria 2 weeks earlier, who is
currently asymptomatic, is:
a an m/s/u submitted for m/c/s, voided urinary
cytology and ultrasound examination of both upper
and lower tracts
b an m/s/u submitted for m/c/s, voided urinary
cytology, intravenous urography and
cystourethroscopy
c reassurance with advice to return if and when the
bleeding recurs for investigation at that time
d an m/s/u submitted for m/c/s and voided urinary
cytology
e an m/s/u submitted for m/c/s, voided urinary
cytology and CT scan of the urinary tract

Back 227

b

Front 228

Penile cancer has the following characteristics except:
a almost exclusively found in the uncircumcised male
b commonly associated with the human papilloma virus
c usually a squamous cell carcinoma
d commonly involves the inguinal lymph nodes
e is most commonly treated with radiotherapy

Back 228

e

Front 229

Which of the following features is true of testicular
cancer?
a is most common in elderly men
b arises most commonly from germ cells
c commonly metastasises to the inguinal nodes
d is insensitive to radiation therapy
e has a 75% cure rate

Back 229

b

Front 230

The coronary artery bypass graft conduit with the
highest patency after 5 and 10 years is:
a left internal thoracic artery
b right internal thoracic artery
c left radial artery
d right radial artery
e left or right long saphenous vein

Back 230

a

Front 231

Regarding the results of coronary artery bypass
grafting:
a an operative mortality of over 10% is common
b patients with poor left ventricular function have a
higher operative mortality
c older patients have less post-operative morbidity
d diabetes has no influence on post-operative morbidity
e the use of an internal mammary artery improves
survival but does not provide long-term freedom from
angina

Back 231

b

Front 232

Regarding cardiac valve prosthesis:
a mechanical valves require no long-term
anticoagulation
b tissue valves are highly durable
c mechanical valves have lower bleeding and
thromboembolic rates
d tissue valves are generally preferred in the mitral
position
e structural failure is extremely rare in mechanical
valves

Back 232

e

Front 233

Complications of cardiac valve replacement surgery
include:
a anticoagulant (warfarin) related haemorrhage
b cerebral thromboembolism
c prosthetic valve endocarditis
d structural deterioration of tissue valves after 10 to
15 years
e all of the above

Back 233

e

Front 234

Which of the following clinical signs is NOT present in a
patient with a tension pneumothorax?
a tachypnoea
b hypotension
c elevated jugular venous pressure
d tracheal deviation towards the side of the
pneumothorax
e hyper-resonant percussion note on the side of the
pneumothorax

Back 234

d

Front 235

Immediate insertion of a chest tube may be lifesaving in
which condition?
a carcinoma of the lung
b pulmonary embolism
c tension pneumothorax
d pleural effusion
e lung abscess

Back 235

c

Front 236

The pathological type of carcinoma of the lung with the
worst prognosis is:
a small-cell carcinoma
b large-cell carcinoma
c adenocarcinoma
d squamous cell carcinoma
e adenosquamous cell carcinoma

Back 236

a

Front 237

The greatest chance of long-term survival in a patient
with a localised carcinoma of the lung is provided
by:
a chemotherapy
b radiotherapy
c combined chemotherapy and radiotherapy
d surgical excision
e immunotherapy

Back 237

d

Front 238

The most common cause of constipation is:
a slow-transit constipation
b inadequate dietary fibre and fluids
c obstruction from colorectal cancer
d hypothyroidism
e rectocele

Back 238

b

Front 239

A 31-year-old lady lawyer has chronic constipation not
responding to laxatives. She has 80% of transit markers
retained in the ascending colon 5 days after ingestion.
Thyroid function tests, defecating proctogram and anorectal physiologic tests were otherwise normal. The
most appropriate management is:
a use a combination of laxatives, enemas and rectal
washout
b right hemicolectomy
c total colectomy and ileorectal anastomosis
d electro-colonic stimulation
e aerobic dancing (high-impact type)

Back 239

c

Front 240

A 24-year-old female secretary has constipation for
3 weeks after starting a new job. There are no other
abdominal symptoms and no family history of colorectal
cancer. The most appropriate management is:
a try taking enough dietary fibre and fluids
b colonoscopy and anorectal physiology tests
c anorectal biofeedback therapy
d teach self digital extraction of faeces from rectum
e repeat thyroid function tests at least 3 times

Back 240

a

Front 241

A 43-year-old mother of two children complains of
difficulty in initiating rectal evacuation. She feels there is
a lump in the perineum which requires vaginal reduction
prior to effective evacuation. The most appropriate
management is:
a teach good hygienic practices
b avoid excessive sexual relationships
c transit marker studies
d defecating proctogram
e anorectal biofeedback

Back 241

d

Front 242

After a previous hysterectomy, a 55-year-old mother of 3
children complains of constipation. Defecating
proctogram showed lack of relaxation of the puborectalis
paradoxus at defecation. The most appropriate
management is:
a yoga taught by genuine Indian guru
b regular use of St. Mark’s anal dilator prior to defecation
c anorectal biofeedback therapy
d mandatory use of squatting posture at defecation
e avoid laxatives but teach rectal washout instead

Back 242

c

Front 243

Which of the following is CORRECT with faecal
incontinence?
a none of the treatments for faecal incontinence is
satisfactory
b faecal incontinence should only be managed by a
specialist
c sphincteroplasty is performed only if there is an intact
sphincter
d specialised testing with endoanal ultrasond and
anorectal physiology could be helpful in managing
severe faecal incontinence
e specialised treatment such as sacral nerve stimulation
is not available in Australia

Back 243

d

Front 244

Faecal incontinence:
a is more common in men than in women
b is more common than urinary incontinence
c is often improved by pelvic floor exercises
d is usually managed by surgery
e is usually due to complications of anorectal surgery

Back 244

c

Front 245

Most patients presenting with massive rectal bleeding:
a will bleed to death unless they have surgery
b usually were found to have colon cancer
c usually were found to have rectal cancer
d should have a capsule endoscopy performed
immediately
e should have a proctosigmoidoscopy performed before
a colonoscopy

Back 245

e

Front 246

Patients with massive rectal bleeding:
a should never have surgery until the precise site and
cause of rectal bleeding is identified
b should have a nasogastric tube inserted before any
other investigation to exclude an upper
gastrointestinal source of bleeding
c should proceed directly to a mesenteric angiogram
d should be appropriately resuscitated
e should have radionuclide scan performed immediately,
regardless of the amount of bleeding

Back 246

d

Front 247

The INCORRECT statement regarding passage of black,
tarry stools is:
a it is usually an indication of bleeding from the upper
gastrointestinal tract
b it can be mimicked by the ingestion of iron medication
c it is commonly a symptom of a cancer of the colon
d It can be present without other symptoms
e it is often but not universally associated with
haematemesis

Back 247

c

Front 248

The causes of haematemesis and melaena include the
following EXCEPT:
a oesophageal varices
b gastric ulceration
c epistaxis with swallowed blood
d beetroot ingestion
e gastritis
f Mallory–Weiss tear

Back 248

d

Front 249

The following statements apply to the patient who has
suffered a GI bleed EXCEPT:
a be pale and sweaty
b be faint and have a bradycardia
c be faint and have a tachycardia
d require urgent resuscitation with normal saline initially
e appear quite well with normal supine blood pressure

Back 249

b

Front 250

Which of the following is the INCORRECT statement on
the diagnosis of the cause of the bleeding episode?
a is the most urgent requirement in patient management
b may be suspected from a history of NSAID (non
steroidal inflammatory drug) intake
c can made by early endoscopy of upper GI tract
d can often be combined with treatment at the initial
endoscopy
e surgical intervention is required for ongoing blood
loss

Back 250

a

Front 251

INCORRECT statement on haematemesis and melaena:
a is a serious condition with a high mortality and
morbidity rate?
b now occurs in an older age group of patients.
c has been eliminated with the advent of Cox2 inhibitor
anti-inflammatory drugs.
d when associated with oesophageal varices may require
repeated interventions for control.
e is best managed in a dedicated specialist treatment
unit.

Back 251

c

Front 252

Which of the following conditions may not be a cause of
obstructive jaundice?
a choledochal cyst
b ulcerative colitis
c hydatid disease
d scleroderma
e chronic pancreatitis

Back 252

b

Front 253

Drugs which may cause hepatotoxic drug reactions do
not include:
a paracetamol
b vitamin A
c nitrofurantoin
d flucloxacillin
e oestrogen

Back 253

b

Front 254

Which of the following clinical features is found in a
patient presenting with acute abdominal pain who has
generalised peritonitis?
a slow pulse rate
b extreme restlessness and writhing around in agony
c motionless with pain, worse with movement
d normal bowel sounds
e deep palpation of most abdominal organs is possible

Back 254

c

Front 255

Acute epigastric pain is unusual in which of the following
conditions?
a acute pancreatitis
b acute cholecystitis
c perforated peptic ulcer
d acute diverticulitis
e ruptured abdominal aortic aneurysm

Back 255

d

Front 256

Immediate laparotomy would not be recommended in a
patient diagnosed as having which of the following
conditions?
a mesenteric infarction
b perforated peptic ulcer with generalised peritonitis
c acute pancreatitis
d acute cholecystitis
e ruptured abdominal aortic aneurysm

Back 256

c

Front 257

Which of the following parameters is the most practical
for monitoring the progression of the underlying
pathological process responsible for acute abdominal
pain in a patient being initially managed
non-operatively?
a erythrocyte sedimentation rate (ESR)
b C-reactive protein (CRP)
c white cell count
d white cell scan
e serum phosphate

Back 257

c

Front 258

Pelvic abscess that occurred 5 days after an anterior
resection of rectum:
a is usually due to anastomotic leak
b usually requires surgery and a Hartmann’s procedure
c will usually settle with intravenous antibiotics
d is best detected by MRI
e is best detected by endorectal ultrasound

Back 258

a

Front 259

Common causes of post-surgical pelvic abscess include:
a cholecystectomy
b appendicectomy
c laparoscopic but not conventional open anterior
resection
d rectovaginal fistula
e use of powdered surgical gloves

Back 259

b

Front 260

In portal hypertension:
a there is increased portal blood volume
b there is a decrease in portal blood pressure
c there is increased splanchnic vasoconstriction
d there is hypoproteinaemia due to increased renal
protein losses
e there is reduced splanchnic lymphatic flow

Back 260

a

Front 261

The following conditions are typically associated with
ascites:
a filiariasis
b Gilbert’s disease
c abdominal tuberculosis
d large uterine fibroids
e ectopic pregnancy

Back 261

c

Front 262

In patients with ascites:
a bacterial peritonitis can be prevented by prophylactic
antibiotics
b leveen shunts may alleviate ascites associated with
portal hypertension
c pancreatitis may develop
d may be relieved by spironolactone
e paracentesis gives long periods of relief, often lasting
several months

Back 262

d

Front 263

In jaundiced patients with ascites:
a there is a low risk for hepatorenal syndrome because
of splanchnic vasodilatation
b coagulation profiles are usually normal
c the systemic blood volume is increased
d the renal blood flow is increased
e there is a poor prognosis when operating for
malignant disease

Back 263

e

Front 264

The following cancers are commonly associated with the
development of ascites:
a lymphoma
b endometrial
c GIST tumours
d mucus-secreting villous adenoma
e ovarian

Back 264

e

Front 265

The most common cause of enlargement of the
jugulodigastric lymph node in a child 9 years of
age is:
a Hodgkin’s disease
b glandular fever
c tonsillitis
d non-Hodgkin’s lymphoma
e metastatic Wilm’s tumour

Back 265

c

Front 266

Metastatic involvement of the posterior triangle nodes in
the neck is most likely to be due to:
a nasopharyngeal carcinoma
b basal cell carcinoma of the shoulder region
c laryngeal carcinoma
d squamous cell carcinoma of the posterior scalp
e carcinoma of the oesophagus

Back 266

d

Front 267

The symptoms of dysphagia include the following
EXCEPT:
a very common and thus can be ignored in most cases
b may be associated with reflux symptoms
c may be associated with significant pain
d can present acutely with total obstruction of the
oesophagus
e may be associated with diminished pharyngeal
propulsion

Back 267

a

Front 268

The causes of dysphagia may be the following EXCEPT:
a classified as pharyngo-oesophageal and oesophageal
b pharyngo-oesophageal causes are often neurological
in origin, e.g. CVA
c associated with altered motility of the oesophagus
d achalasia is a disease primarily of the oesophageal
musculature and is coexistent with gastro-oesophageal
reflux
e be associated with an adenocarcinoma of the mucosal
lining

Back 268

d

Front 269

The cause of dysphagia can often be identified by the
following EXCEPT:
a upper GI endoscopy
b barium swallow examination
c upper abdominal ultrasound examination
d CT examination of the chest
e oesophageal manometry

Back 269

c

Front 270

Patients with dysphagia may complain of the following
EXCEPT:
a regurgitation of fluid and food when recumbent at
night
b difficulty with swallowing fluids more than solid food
c difficulty with swallowing solid food more than liquids
d may have significant weight loss
e may have no weight loss
f their partner may complain of snoring

Back 270

f

Front 271

dysphagia can be caused by the following EXCEPT:
a benign strictures in the oesophagus
b squamous carcinoma of the oesophagus
c pharyngeal diverticulum
d oesophageal spasm
e uncomplicated sliding hiatus hernia

Back 271

e

Front 272

A 65-year-old woman has a chronic leg ulcer. Which of
the following is the least likely case?
a squamous cell carcinoma
b giant cell arteritis
c superficial venous valvular incompetence
d deep venous valvular incompetence
e trauma

Back 272

b

Front 273

The most important measure to get a chronic venous
ulcer to heal is:
a apply a dressing
b stop smoking
c apply compression bandaging/stockings
d surgery to excise the ulcer
e counselling

Back 273

c

Front 274

Which of the following is true regarding chronic leg
ulcers?
a they are generally well managed
b 80% are due to superficial venous insufficiency
c a biopsy is best done of the ulcer edge
d basal cell carcinoma is the commonest malignancy in
the leg
e arterial and venous ulcers are easily distinguished

Back 274

c

Front 275

Which of the following is true regarding the calf-muscle
pump?
a it plays no part in venous return to the heart
b it cannot work if the valves are incompetent
c it is the only musculo-venous pump
d it depends on good ankle movement
e it cannot work if arterial disease is present

Back 275

d

Front 276

Bilateral leg swelling with pitting oedema may be caused
by the following EXCEPT:
a reduced lymphatic removal of exudate
b increased capillary permeability
c decreased filtration pressure at the arteriolar end
d reduced oncotic pressure
e excessive fluid intake

Back 276

c

Front 277

A 75-year-old female underwent a right-sided total hip
replacement. On post-operative day 10, she complained
of discomfort and swelling over her right thigh and calf.
She has been ambulating satisfactorily. Which of the
following statements is true?
a bed rest and diuretic therapy should be prescribed
b a CT scan of the lower pelvis and right hip should be
done
c a Doppler study of the lower limb deep venous system
should be performed
d local complications of surgery is the most likely cause
for the swelling
e a plain X-ray of the right hip is most informative

Back 277

c

Front 278

The following statements on acute lymphangitis of the
lower limb are correct EXCEPT:
a improperly managed, it may lead to lymphadenitis
b lymphangiography is the investigation of choice in the
management
c rest and elevation of the affected limb is appropriate
d cellulitis may be the initiating cause
e appropriate antibiotics should include cover for
streptococcal infection

Back 278

b

Front 279

Eight days following a low anterior resection for
carcinoma of the rectum, a 65-year-old man developed
unilateral gross swelling of his right lower limb. Select the
correct statement:
a a diagnosis of deep venous thrombosis can confidently
be made on the basis of clinical signs
b deep venous thrombosis is unlikely as the patient had
received peri-operative prophylactic subcutaneous
heparin
c a past history of superficial thrombophlebitis in this
patient is almost certainly related to deep venous
thrombosis
d the short saphenous vein is usually the site of origin of
deep venous thrombosis
e ilio-femoral thrombosis is likely as it commonly follows
pelvic surgery

Back 279

e

Front 280

A 24-year-old female at 32 weeks’ gestation presents
with loin pain and haematuria. The best initial radiologic
study is:
a IVP
b non-contrast CT scan
c renal ultrasound
d cystourethroscopy
e PET scan

Back 280

c

Front 281

The best evaluation of the lower urinary tract is with:
a bladder ultrasound
b cystourethroscopy
c voiding cystourethrogram
d triple-phase CT scan
e MRI

Back 281

b

Front 282

You are asked to see a 65-year-old man who 3 days
previously underwent a laparotomy for a perforated
duodenal ulcer. He has become confused and is causing
a disturbance in the ward. You see from the notes that
he suffers with chronic obstructive pulmonary disease
and normally drinks three glasses of wine a day. The only
medication he was taking prior to admission was
atenolol. To this stage his post-operative recovery has
been uneventful and he has been given morphine
regularly. Your first action should be to:
a start on an alcohol withdrawal protocol and give
diazepam
b attach a face mask and administer oxygen
c examine his chest and start antibiotics
d increase intravenous fluids and give 1 L isotonic saline
over 4 hours
e substitute pethidine for morphine on the drug chart

Back 282

b

Front 283

You are called to see a 56-year-old man with dyspoea
and pleuritic chest pain. Five days earlier he underwent a
laparotomy and gastric resection. On examination he has
a temperature of 37.5◦C, a tachypnoea of 25, a pulse
rate of 90 and a blood pressure of 130/95 mm Hg. His
heart sounds are normal and there are no added sounds
or murmurs. There is good air entry to both bases and
the percussion note is resonant in all areas. A chest X-ray
and a ventilation-perfusion scan are performed. Which
one of the following combinations of test results
indicates a high probability of a pulmonary embolus in a
particular zone of the lung:
chest X-ray ventilation scan perfusion scan
a normal normal reduced
b normal abnormal normal
c consolidation normal reduced
d consolidation abnormal normal
e normal abnormal reduced

Back 283

a

Front 284

You are asked to see a 65-year-old woman who feels
unwell and faint. Seven days previously she underwent
an elective sigmoid colectomy for carcinoma. The
procedure was uncomplicated and until now, she had
been making an uneventful recovery. On examination
she has a temperature of 39.5◦C, a pulse rate of
100 beats per minute and a blood pressure of 90/60 mm
Hg. Her respiratory rate is 15 breaths per minute. She
has cool clammy peripheries. Her abdomen is tender in
the left iliac fossa, around the wound site. Which of the
following is the most reasonable explanation for her
current problem?
a myocardial infarction
b pneumonia
c secondary haemorrhage
d pulmonary embolus
e septic shock

Back 284

e

Front 285

A 72-year-old diabetic develops a discharge from his
midline abdominal wound 7 days after surgery for
perforated diverticular disease. The most likely cause of
the discharge is:
a a faecal fistula
b wound haematoma
c wound infection
d deep wound dehiscence
e small-bowel fistula

Back 285

c

Front 286

An otherwise fit 57-year-old man spikes a temperature
of 39◦C 5 days after an open appendicectomy for acute
appendicitis. There is a tender, reddened and fluctuant
swelling at the medial end of the wound. What is the
most appropriate initial action to take?
a arrange a CT scan of the abdomen
b arrange an ultrasound scan of the wound and anterior
abdominal wall
c start the patient on oral antibiotics
d open the wound to allow free drainage
e send off blood samples for a white cell count and
culture

Back 286

d

Front 287

The claw hand:
a is sometimes called an intrinsic plus hand
b occurs following a median nerve injury
c results in loss of power grip of the fingers into the
palm
d is more obvious in a proximal, ulnar palsy than a distal
palsy
e includes metacarpophalangeal joint extension of the
involved fingers

Back 287

e

Front 288

From which of the following blood vessels does the
bleeding in a patient with massive haemopytsis usually
occur?
a pulmonary artery
b pulmonary vein
c bronchial artery
d bronchial vein
e thoracic aorta

Back 288

c

Front 289

Which of the following lung conditions is NOT a
common cause of massive haemoptysis?
a carcinoma of the lung
b pulmonary arteriovenous malformation
c tuberculosis
d lung abscess
e aspergillosis

Back 289

a

Front 290

The investigation which will most reliably determine the
site of bleeding in a patient with massive haemoptysis
is:
a chest X-ray
b CT scan of the chest
c radionuclide lung scan
d bronchoscopy
e pulmonary angiogram

Back 290

d

Front 291

Definitive therapy in a patient with massive haemoptysis
may include:
a broad-spectrum antiobiotics
b surgical resection of the bleeding source
c pulmonary arterial embolisation
d radiotherapy
e all of the above

Back 291

e

Front 292

Severe epistaxis in the elderly patient is most likely to be
due to:
a cardiac failure
b hypertension
c nasal tumour
d alcoholism
e Osler’s Disease

Back 292

b

Front 293

An L4–5 disc prolapse is most likely to cause:
a pain from the buttock across the thigh, but not
beyond the knee
b an L4 radiculopathy
c weakness of ankle plantar flexion
d weakness of extensor hallucis longus
e an absent ankle jerk

Back 293

d

Front 294

A cauda equina syndrome:
a is a benign clinical problem
b requires urgent decompression
c has no influence on bladder function
d can only be present if the patient has severe leg pain
e can be managed best with manipulation

Back 294

b

Front 295

Which of the following features is not true of complete
testicular torison?
a most common between puberty and the age of
25 years
b is not associated with tenderness of the cord
c pain is relieved by elevation of the scrotum
d usually shows changes on colour Doppler ultrasound
e requires urgent surgical treatment

Back 295

c

Front 296

Torsion of a testicular appendage:
a occurs most commonly after puberty
b involves the head of the epididymis
c involves the hydatid of Morgagni
d causes severe scrotal pain
e requires urgent surgery

Back 296

c

Front 297

Acute epididymo-orchitis is characterised by the
following features except:
a history of urinary tract infection
b rapid onset of pain
c swollen tender testes
d tenderness of the cord
e pyrexia and leucocytosis

Back 297

b

Front 298

A 30-year-old man presents with 1 week of right sciatica
and has numbness on the dorsum of his right foot and
weak dorsiflexion at the ankle. Which of the following is
true?
a he probably has an L4–L5 disc prolapse, with
compression of the L4 nerve root
b he needs an urgent CT myelogram
c he can be managed initially with rest and analgesics
d he is likely to require surgery
e he should be encouraged to undertake spinal
extension exercises

Back 298

c

Front 299

A 35-year-old woman presents with acute lumbar back
pain, bilateral sciatica, difficulty in voiding and on
examination has weakness in the ankles and feet, absent
ankle reflexes and decreased sensation in the soles of
both feet. Which of the following statements is false?
a she has developed an acute cauda equina compression
b she has developed an acute spinal cord compression
c central disc prolapse at L5–S1 is a likely cause
d urgent magnetic resonance imaging is required
e urgent surgery will be required

Back 299

b

Front 300

A 30-year-old diabetic presents with a severe mid and
lower thoracic pain, radiation of the pain to the
mid-abdomen, and on examination he is tender in the
thoracic spine at the level of T10, has weak lower limbs
and finds it difficult to walk. Which of the following
statements is false?
a CT scan will be helpful as an initial investigation
b he should have an FBE and ESR
c he may have a dissecting aneursym of the aorta
d a needle biopsy is indicated initially
e an MRI is indicated and urgent surgery should be
considered

Back 300

d

Front 301

Post-traumatic confusion commonly occurs due to the
following conditions except:
a cerebral contusion
b intracerebral haematoma
c hypoxia
d hypernatraemia
e venous engorgement

Back 301

d

Front 302

Post-traumatic confusion may require the following
treatments except:
a i.v. sedatives
b i.v. codeine
c i.v. morphine
d physical restraint
e oxygen supplementation

Back 302

b

Front 303

With reference to the actions of the extra-ocular
muscles, which of the following is correct?
a in adduction, the superior oblique elevates the eye.
b in abduction, the inferior rectus depresses the eye.
c in adduction, the inferior oblique muscle intorts the eye.
d in abduction, the inferior oblique muscle intorts the
eye.

Back 303

b

Front 304

The muscle most employed in reading is:
a the medial rectus.
b the lateral rectus.
c the superior oblique.
d the inferior oblique.

Back 304

c

Front 305

When investigating a case of diplopia, a helpful sign is:
a the patient prefers to fixate on a target with the eye
with the paretic muscle.
b the image from the eye with the paretic muscle is
displaced most.
c the paralysis of one extra-ocular muscle has no effect
on the other muscles.
d the patient prefers to fixate on a target with the eye
with healthy muscles.

Back 305

d