MCQ and EMQ topics

1. In the UK, Colorectal Cancer Screening Pilot the prevalence of adenomas and/or carcinomas in patients undergoing colonoscopy was
a. 10-20%
b. 20-30%
c. 30-40%
d. 40-50%
e. 50-60%

2. A 14 year old boy presents with osteitis fibrosa cystitica (von Recklinghausen’s disease)
Which of the following is the most likely diagnosis?
a. parathyroid adenoma
b. parathyroid carcinoma
c. thyroid adenoma
d. thyroid carcinoma
e. tuberculosis

3. In respect of a patient in an acute NHS hospital, final responsibility for clinical governance in the hospital resides with which one of the following?
a. Clinical director
b. Consultant in charge of the patient
c. Most senior doctor treating the patient
d. Trust’s chief executive
e. Trusts medical director

4. A 60 year old man presents with severe right hypochondrial pain after two weeks holiday in the Dominican Republic. He has had a bout of sickness and diarrhoea with pyrexia. He has been treated with antibiotics for his diarrhea but on his return to the UK he continues with nausea and was seen by his GP who suspects that he may have a continued gastrointestinal infection. An ultrasound of the gall bladder shows a distended gall bladder with no stones. What would be the most likely diagnosis?
a. Acute duodenal ulcer
b. Clostridium difficile infection
c. Helicobacter infection
d. Pancreatitis
e. Salmonella Cholecystitis

7. An 8 year old boy is having an incision in the right iliac fossa for possible appendicits. The appendix is found to be normal.
What is the most likely cause of the patient’s right iliac fossa tenderness?
a. Congenital band adhesion
b. Enlarged mesenteric lymph nodes
c. Gastro-enteritis
d. Meckel’s diverticulum
e. Terminal ileitis

8. A 50 year old woman presents with progressive swelling in the left foot and lower leg over four months duration. She has thread veins.
a. What would be the most appropriate investigation?
b. duplex scan
c. lymphoscintogram
d. MRA
e. USS
f. Venogram

9. A 35 year old alcoholic presents with a massive haematemesis and sequelae of liver disease. Which of the following would be the first interventional treatment according to the British Society of Gastroenterologists guidelines?
a. Gastroscopy and banding
b. Gastroscopy and injection of glue
c. Gastroscopy and injection of sclerosant
d. Sengstaken tube
e. Transaction of the oesophagus

10. The most appropriate surgical treatment for an anastomotic leak following an anterior resection is usually which of the following?
a. Drainage only
b. Drainage plus proximal stoma
c. Primary repair
d. Proximal stoma only
e. Resection of anastomosis plus end-colostomy

11. A 32 year old male was skiing and hit a tree and suffered trauma on the left side of his chest. He managed to ski down and drive to the nearest hospital. On arrival he was noted to be pale and sweaty. On examination his pulse rate was 110 and blood pressure 120/90 mmHg. He had bruising over the area of his 9th, 10th and 11th ribs. He was slightly breathless at rest. His haemoglobin was found to be 9g/dl and an initial ultrasound scan confirmed a large haematoma associated with the spleen. A subsequent CT scan confirmed this finding with no free abdominal fluid.
What would be the most appropriate surgical management?
a. Observation on the ward
b. Packing with surgical gauze and abdominal packs
c. Preservation by wrapping the spleen in supportive bag
d. Splenectomy
e. Splenectomy and implantation of a portion of the spleen in the omentum

12. Which of the following is most likely to be present in an inflammatory aneurysm?
a. CRP < 12 mg/dl
b. ESR < 35 mm/hour
c. Fever
d. Intestinal obstruction
e. Ureteric obstruction

13. A 57 year old female is lethargic with a 2 month history of pain in the lower abdomen. She is pale and there is a palpable mass in the right lower abdomen
Which is the most likely diagnosis?
a. Appendix abscess
b. Appendix mass
c. Caecal tumour
d. Ovarian cyst
e. Pancreatic tumour

14. Which of the following statements is true of the stomach?
a. The left gastric artery is a branch of the hepatic artery
b. The left gastro-epiploic artery is a branch from the splenic artery
c. The right gastric artery is a branch of the coeliac axis
d. The right gastro-epiploic artery is a branch of the hepatic artery
e. The short gastric arteries are branches of the phrenic arteries

15. A 75 year old female presents with a tender incarcerated paraumbilical hernia and small bowel obstruction. Clinical examination reveals an aortic systolic murmur. An echocardiogram shows severe aortic stenosis with an ejection fraction of 27%.
What should the next step be?
a. Conservative management
b. Perform a repair under local anaesthetic
c. Repair should proceed under general anaesthetic
d. She should undergo emergency aortic valve replacement prior to hernia repair
e. The patient should be anticoagulated prior to theatre

16. Multiple endocrine neoplasia Type 1 syndrome (MEN1; Werner’s syndrome) is:
a. An autosomal recessive inherited disorder
b. Associated with hyperparathyroidism
c. Associated more commonly with solitary pancreatic tumours
d. Associated with tumours arising from the posterior pituitary gland
e. Oesophageal peptic ulceration

17. Nine year old boy post-trauma with low BP and requiring a blood transfusion – father is a Jehovah’s Witness and refuses a transfusion. Range of options for treatment from leaving child to die to making him a Ward of Court to going ahead regardless.

18. Recently NICE-approved renal transplant medication – need to pick name from list.

19. 6.7cm infra-renal AAA on US in a 56 year old man high blood pressure. What is the next investigation to determine if he is suitable for endovascular reconstruction?

20. 82 year old man with AAA suitable to endovascular reconstruction with COPD and angina. Which intervention is best for him?

21. Patient with a GIST with 2 mitoses per high powered field – which is the best treatment for a pelvic recurrence?

22. 32 year old pregnant woman with a splenic aneurysm who is haemodynamically stable – what do you do? Options range from operate to do nothing to stent to coil and stent.

23. Which patients do not need any pre-operative vascular investigations?
a. Primary long saphenous varicose veins
b. Primary short saphenous varicose veins
c. Redo surgery for long saphenous varicose veins
d. Redo surgery for short saphenous varicose veins
e. Chronic venous insufficiency

24. 56 year old man, fit and well, T1, N0 oesophageal tumour at 35 cm on imaging, medical endoscopist splits tumour trying to dilate it – what do you do? Options range from drain and antibiotics to immediate definitive surgery to stent to no treatment at all.

25. Pancreatic cancer outcomes

26. Composition of Hartmann’s solution in detail

27. Composition of gastric juice in detail

28. Partition of body water between different compartments

29. Testicular US indicating a haematoma – needs exploration – which approach do you use?

30. 18 year old woman with a positive urine dipstick for beta-HcG and LMP 9 weeks ago – presents with RIF pain, normal BP, pr 90 bpm, temperature 38 degrees – what is the diagnosis?

31. Right hemicolectomy with involved ureter over 8cm – what do you do? Options range from leaving tumour behind to re-anastomosing ureter after resection to taking out the whole kidney and ureter on the right.

EMQs

BREAST SURGERY

Options
A. Localising biopsy and axillary clearance
B. Localising biopsy excision and axillary sampling
C. Lumpectomy alone
D. Mastectomy alone
E. Mastectomy and axillary clearance
F. Mastectomy and axillary sample
G. Quandrantectomy
H. Wide local excision and axillary clearance
I. Wide local excision and axillary sample

For each of the following questions, choose the single most appropriate option from the list of options above. Each option may be used once, more than once or not at all.

1. A 42 year old woman has been found in the asymptomatic clinic with an impalpable 0.5cm area of microcalcification in the right breast upper outer quadrant. Stereo core biopsy has shown a grade one tubular cancer.
2. A 56 year old woman has a 4 cm central cancer of the left breast. Core biopsy has revealed a grade three cancer.
3. A 58 year old woman has extensive microcalcification of the left breast. Core biopsy of three areas of the left breast has shown medium grade ductal carcinoma in situ (DCIS)

PAIN RELIEF

Options
A. Elective ventilation for 24 hours
B. Epidural analgesia
C. Intramuscular narcotic analgesia
D. Narcotic by patient controlled analgesia
E. Non steroidal anti-inflammatory drug/paracetamol
F. Oral narcotic analgesia
G. Sedation with diazepam
H. Spinal analgesia
I. Wound infiltration with bupivacaine
J. Wound infiltration with lignocaine

For each of the scenarios below, which is the most appropriate form of post-operative pain relief from the list of options above. Each option may be used once, more than once or not at all.

4. A 46 year old man presents following Milligan-Morgan Haemorrhoidectomy
5. A 68 year old woman presents with a history of COPD, following an anterior resection.
6. A 38 year old man following a laparoscopic extra-peritoneal inguinal hernia repair

BLUNT ABDOMINAL INJURY

Options
A. Bladder injury
B. Colonic rupture
C. Major crushing injury to the liver
D. Mesenteric haematoma
E. Pelvic fracture
F. Splenic haematoma
G. Subcapsular liver haematoma
H. Transection of the duodenal-jejunal flexure
I. Transection of the neck of the pancreas

What is the most likely damage resulting from the following injuries? Each option may be used once, more than once or not at all.

7. A 9 year old girl sustains a blunt abdominal injury from the handlebars of her bicycle when it hit a brick wall. She has bruising of the anterior abdominal wall and is tender in the epigastrium. On admission, she is haemodynamically stable, her Hb is 14g/dl, serum amylase is 600 IU/lt and USS of the abdomen shows fluid in the lesser sac. Over the next 24 hours her pain and tenderness increases and she becomes generally unwell

8. A 28 year old driver of a car is admitted after being cut out of his car which was involved in a high-speed, head-on crash. He was wearing a seat-belt. He is fully conscious and has severe abdominal pain. On examination he is haemodynamically stable, has widespread abdominal tenderness and his Hb is 15gm/dl.

9. A 6 year old girl is crushed when a heavy bookshelf falls on top of her. When she is first seen in the A&E department she is anxious and tearful, but does not complain of abdominal pain. On examination, she has a tachycardia of 120 bpm, her BP is 120/50 mmHg, she has mild upper abdominal tenderness. Whilst undergoing an X-ray of the abdomen, she becomes hypotensive.

FINGER PAIN

Options
A. Carpal tunnel
B. Foreign body
C. Gout
D. OA in joint
E. Pathological fracture
F. Peripheral vascular occlusion
G. Raynaud’s syndrome
H. Rest pain
I. Scleroderma
J. Tendinitis
K. Thoracic outlet syndrome
L. Vasculitis

In the following scenarios, which of the above options would be the most appropriate cause. Each option may be used once, more than once or not at all.

10. A 35 year old woman has intermittent shooting pain along the fifth (little) finger. It has been present for two years.
11. A 65 year old woman has intermittent pain in the thenar eminence, particularly when trying to lift anything
12. A 25 year old woman who works as a secretary complains of pain in the index finger worse towards the end of the day

SKIN LESIONS

Options
A. Acral malignant melanoma
B. Dermatofibromata
C. Glomus tumour
D. Junctional naevus
E. Lentigo maligna
F. Lipoma
G. Nodular basal cell carcinoma
H. Nodular malignant melanoma
I. Morphoea melanoma
J. Neurofibromata
K. Psoriasis
L. Sebaceous cyst
M. Squamous cell carcinoma

For each of the scenarios below, choose the most appropriate diagnosis from the options above. Each option may be used once, more than once or not at all.

13. A 78 year old retired gardener has a pigmented lesion on the left cheek with a darker patch in one area.
14. A 56 year old woman comes to the clinic with a painless firm lump on one leg which has been present for several years.
15. A 40 year old Afro-Caribbean has a pigmented lesion under the second toenail

ABDOMINAL MASS

Options
A. Appendix abscess
B. Appendix mass
C. Caecal tumour
D. Carcinoma descending colon
E. Diverticular mass
F. Ectopic pregnancy
G. Fibroid (uterine)
H. Ovarian cyst
I. Pancreatic tumour
J. Rectal carcinoma
K. Renal tumour
L. Sigmoid volvulus
M. Terminal ileal mass

In the following scenarios choose the most appropriate option from the list above. Each option may be used once, more than once or not at all.

16. A 17 year old boy has a five day history of lower abdominal pain, nausea and temperature of 37.8oC. He is tender in the right iliac fossa and a mass is palpable
17. A 28 year old woman has a three day history of RIF pain. She is complaining of shoulder tip pain and is unable to lie flat. There is an indistinct mass in the lower left abdomen. She has a temperature of 37.2oC
18. A 57 year old woman is lethargic with a two month history of pain in the lower abdomen. She is pale and there is a palpable mass in the right lower quadrant.



19. Topic – Statistical tests. Choose best test for
a. non-parametric comparison of 2 medians between 2 separate groups (i.e. not repeated measures)
b. examination of the effect for 3 different categorical variables on survival simultaneously
c. comparison of 3 different sets of categorical data (non-parametric test)

20. Endoscopic screening frequencies in different high risk groups:
a. 28 year old man with Peutz-Jeghers syndrome
b. 10 year old adopted boy with 50 polyps on coloscopy
c. 40 year old woman with rectal symptoms and a family history of bowel cancer (grandmother diagnosed at 85 and aunt diagnosed at 60)

21. All of the following patients have urinary retention: identify the causes in the following cases from a long list:
a. 28 year old woman who also has weak legs and had a medical termination of pregnancy abroad 5 weeks ago
b. 7 year old boy with a palpable bladder
c. ?

22. Identify the likely causes of dysphagia in the following patients:
a. 40 year old man with dysphagia to liquids only
b. 60 year old man with gradually progressive dysphagia and speech changes leading to slurring and weight loss
c. 82 year old man with progressive dysphagia and weight loss

23. Breast cancer management
a. 82 year old woman with advanced cancer
b. LCIS
c. Grade 3 invasive ductal cancer and large tumour

24. Trauma – how would you manage a…
a. Delayed pneumoperitoneum
b. ?
c. ?

25. Colorectal surgery – how would you manage
a. Late discharge of faeculant material from the wound of an otherwise very well patient?
b. ?
c. ?

26. Anal problems – what is the likely diagnosis in a patient with:
a. A small lump at the anal verge with an ulcer overlying and some palpable inguinal lymph nodes
b. A woman with a history of painful defaecation after a period of constipation
c. A small skin lesion near the anal verge (nodular, pigmented, bleeds easily)

27. Whole question on leg ulcers in which mini-vignettes need diagnoses

28. Jaundice – what is the underlying problem?
a. Middle-aged woman with a history of breast cancer and jaundice and vomiting is found to have diabetes and a huge dilated stomach on gastroscopy
b. ?
c. ?

29. Testicular swellings:
a. 10 year old with a swollen scrotum
b. 27 year old with a hard nodular mass
c. 43 year old with a mass that transilluminates and is separate from the testis

30. Haematuria – likely causes in the following patients:
a. 7 year old girl with haematuria and suprapubic pain
b. 18 week pregnant woman suprapubic pain and history of recent cough
c. 32 week pregnant woman with right-sided abdominal pain

31. Nuclear medicine – which techniques are used in the following situations?
a. Post cholecystectomy pain with normal MRCP and US
b. Sentinel lymph node biopsy
c. Facial pain and a history of breast cancer.

32. A patient with rest pain often hangs his leg out of the bed to relieve the pain the mechanism that causes improvement is:

33. A Patient with pain in leg at night often walks around the bed to improve symptoms the mechanism behind this is:

a) gravity
b) decreased cardiac output
c) increased cardiac output
d) straightening leg
e) bending leg
f) increased metabolic rate
g) decreased metabolic rate

34. A Tramp presents with gangrenous toes the most likely cause is
a) cold
b) pressure
c) ischaemia
d) trauma

The best initial investigation for the following scenarios
35. 67 yr old man with stable claudication attending clinic for follow up

36. 75 yr old man with claudication attending clinic c/o temporary right leg weakness for less than 24 hrs 2 days ago

37. Man presenting with claudication to the clinic
a) reassure and review in clinic in 3 mths
b) ABPI
c) Carotid Doppler
d) angiogram
e) CT angiography
f) duplex
g) mri

38. 88 yr lady with fix flexion deformity of knee with gangrenous fore foot and immobile best treatment

39. Long superficial femoral occlusion with one vessel run off (peroneal) what is the best treatment option?
a) angioplasty
b) stenting
c) above knee amputation
d) no treatment
e) below knee amputation
f) femoral distal bypass

40. A patient’s parents want to review their medical notes, who do they have to address their initial application to?
a) NHS Trust
b) Consultant in charge of hospital
c) GP
d) PCT
e) chief exec

41. A patient attending for elective AAA repair is found to have MRSA on nasal swab on admission the most appropriate action is
a) carry on with op and no treatment
b) carry on with op and start topical rx
c) cancel operation and treat and await for negative swabs

42. Which is true of cervical rib?
a) occurs in 3% of population
b) is bilateral in 0.2 % of population

43. A patient presents to clinic requiring a lap chole but is a drug addict and you suspect he is HIV +ve do you….
a) refuse to operate and refer to another consultant
b) do the operation
c) double glove and do the operation
d) tell the patient you will not put your staff under such a risk and refuse to operate
e) Operate but insist the patient has a HIV test
f) Operate but request the patient has an HIV test.

1.  12 year old boy has CXR to investigate non-resolution of chest infection, anterior mediastinal mass found.  Most likely cause is:

a. Germ cell tumour

b. Lymphoma

c. Neuroblastoma

d. Mediastinal thyroid

e. Thymoma

2.  Considering IV fluid composition:

a. 5% dextrose has Na+ content of 50mmol/L

b. 5% dextrose has Na+ content of 40mmol/L

c. Hartmanns has Cl- content of 111mmol/L

d. Normal saline has Na+ content of 131mmol/L

3.  50yr old fit and well man has OGD done by gastro, tumour at 37cm unable to pass, therefore dilated.  Sudden onset of chest pain 1 hr later, with free mediastinal gas.  CT demonstrates early tumour with no nodes.  Options:

a. Contact local oesophagogastric unit

b. Transfer to surgical ward for IV antibiotics

c. Transfer to medical ward for IV antibiotics

d. Laparotomy and insertion of transhiatal drains

e. Re-endoscope and insertion of covered stent

4.  In emergency femoral hernia repair, bleeding may be encountered following division of the free edge of the lacunar ligament.  Which vessel:

a. Genito-femoral artery

b. Obturator artery

c. Inferior epigastric artery

d. Femoral artery

5.  Four days after elective colonic resection, 70 yr old man develops tachycardia with drop in blood pressure.  ECG shows atrial fibrillation.  Management:

a. Cardioversion

b. Amiodarone

c. Digoxin

d. Carotid sinus massage (or something like that)

6.  A seventy five yr old man develops a tachycardia and pyrexia 4 days following a right hemicolectomy for cancer. 

a. This is most likely due to a right subphrenic collection

b. Most infective complications involve anaerobic organisms

c. Another 2 but I can’t remember

Other topics that have come up recently

Calcitonin – particularly its physiological effects

GCS – particularly calculating the score from a given scenario

Ext anal sphincter nerves

Nottingham prognostic index – question on calculating it based on tumour parameters given

Scrotal swellings

Endoscopic intervention for upper GI bleed – new SIGN guidelines have been adopted by BSG

FAP/HPNCC genetics

Transplant complications

Rx SVT

Complications of AV fistula (presume transplant related)

Stellate ganglion anatomy

Azygous vein anatomy

Discharging of psychiatric patient

Levels of evidence

Triage

MALTs

Colorectal polyp f/up

Risk factors for oesophageal cancer

Complications post-R hemi

Ix of ?GI bleeds

Rx diffuse oesophageal spasm

Lymphoedema

AAA (EVAR/Open)

Long-term complications/sequelae coeliac disease

Liver abscesses – common causes/organisms

Thoracic outlet obstruction

Prostacyclin infusion (role of)

Limb ulceration – types and therefore, likely origins

Rx anal fissure

Pruritis ani

Presentation of hypercalcaemia

Nuclear imaging – particularly in thyroid and parathyroid surgery

Paeds maintenance fluids – calculating volume

Fluids in gastric outlet obstruction

Rx appendiceal carcinoid – when R hemi/not

MEN I

MEN II

BRCA I

BRCA II

Traumatic pancreatic injury

Splenic artery aneurysm – management

Ix obstructive jaundice

Scrotal swelling after renal transplant

Signs of intracerebral bleed + raised ICP

Assoc of primary sclerosing cholangitis with UC

Type I error

Type II error

Pituitary hormones

Benign skin lesions

Salmonella cholecystitis (a 50yr old man comes back from mexico with upper abdo pain after being unwell with D+V whilst away.  Answer is salmonella cholecystitis, after he had typhoid (salmonella typhi) whilst away!!!!!)

Thyroid surgery – ops/VC injury

Contra-indications to transplant donation

Dieulafoy’s lesion

Management of splenic injury

Management of liver injury

Management of delayed diagnosis of sigmoid perf

Breast surgery – which op when?

Brainstem death

Immunosuppressant drugs – consistently get question about S/Es of calcineurin inhibitors (cyclosporine particularly)

Mx residual disease after surgery for Ca rectum

Mx T3N1 oesophageal Ca

Mx axillary vein damage at axillary clearance

LCIS

Hormone Rx in breast Ca

Mediators of SIRS