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A 19 year old female is admitted with suspected meningitis. The House Officer is due to perform a lumbar puncture. What is the most likely structure first encountered when the needle is inserted?
A. Ligamentum flavum
B. Denticulate ligament
C. Dural sheath
D. Pia Mater
E. Supraspinous ligament
Theme from September 2012 exam
A 34 year old male is being examined in the pre-operative assessment clinic. A murmur is identified in the 5th intercostal space just next to the left side of the sternum. From where is it most likely to have originated?
A. Mitral valve
B. Aortic valve
C. Pulmonary valve
D. Right ventricular aneurysm
E. Tricuspid valve
Theme from September 2012 Exam
What is the correct embryological origin of the stapes?
A. First pharyngeal arch
B. Second pharyngeal arch
C. Third pharyngeal arch
D. Fourth pharyngeal arch
E. Fifth pharyngeal arch
Embryological origin stapes = 2ndpharyngeal arch
Theme from April 2012 Exam
Which muscle initiates abduction of the shoulder?
A. Infraspinatus
B. Latissimus dorsi
C. Supraspinatus
D. Deltoid
E. Teres major
Theme from September 2012 exam
What is the most important structure involved in supporting the uterus?
A. Round ligament
B. Broad ligament
C. Uterosacral ligaments
D. Cardinal ligaments
E. Central perineal tendon
Theme from September 2012 Exam
78 year old man is due to undergo an endarterectomy of the internal carotid artery. Which of the following nervous structures are most at risk during the dissection?
A. Recurrent laryngeal nerve
B. Sympathetic chain
C. Hypoglossal nerve
D. Phrenic nerve
E. Lingual nerve
Nerves at risk during a carotid endarterectomy:
• Hypoglossal nerve• Greater auricular nerve• Superior laryngeal nerve
Theme from May 2011 exam Theme from January 2013 Exam
Which of the following structures is not transmitted by the jugular foramen?
A. Hypoglossal nerve
B. Accessory nerve
C. Internal jugular vein
D. Inferior petrosal sinus
E. Vagus nerve
Contents of the jugular foramen:
Anterior: inferior petrosal sinus Intermediate: glossopharyngeal, vagus, and accessory nerves Posterior: sigmoid sinus (becoming the internal jugular vein) and some meningeal branches from the occipital and ascending pharyngeal arteries
Theme from 2009 exam
With regards to the jugular vein, which of the following statements is untrue?
A. It lies within the carotid sheath
B. It is the continuation of the sigmoid sinus
C. The terminal part of the thoracic duct crosses anterior to it to insertinto the right subclavian vein
D. The hypoglossal nerve is closely related to it as it passes near the atlas
E. The vagus nerve is closely related to it within the carotid sheath
Theme from April 2013 Exam
A 28 year old man requires a urethral catheter to be inserted prior to undergoing a splenectomy. Where is the first site of resistance to be encountered on inserting the catheter?
A. Bulbar urethra
B. Membranous urethra
C. Internal sphincter
D. Prostatic urethra
E. Bladder neck
Theme from 2011 exam
Theme from January 2012 Exam
A 23 year old man undergoes an orchidectomy. The right testicular vein is ligated; into which structure does it drain?
A. Right renal vein
B. Inferior vena cava
C. Common iliac vein
D. Internal iliac vein
E. External iliac vein
Theme from April 2012 Exam
A 24 year old man falls and sustains a fracture through his scaphoid bone. From which of the following areas does the scaphoid derive the majority of its blood supply?
A. From its proximal medial border
B. From its proximal lateral border
C. From its proximal posterior surface
D. From the proximal end
E. From the distal end
Theme from April 2012 Exam
Which of the following forms the medial wall of the femoral canal?
A. Pectineal ligament
B. Adductor longus
C. Sartorius
D. Lacunar ligament
E. Inguinal ligament
Theme from September 2011 Exam
Theme from September 2012 Exam
A 67 year old man is undergoing a transurethral resection of a bladder tumour using diathermy. Suddenly during the procedure the patients leg begins to twitch. Stimulation of which of the following nerves is the most likely cause?
A. Femoral
B. Pudendal
C. Sciatic
D. Obturator
E. Gluteal
Theme from January 2011 Exam Theme from January 2013 Exam
A 5 year old boy is playing with some small ball bearings. Unfortunately he inhales one.To which of the following lung regions is the ball most likely to settle?
A. Right lower lobe
B. Left main bronchus
C. Right upper lobe
D. Left lower lobe
E. None of the above
Theme from September 2011 Exam Theme from January 2013 Exam
An 18 year old man is cutting some plants when a small piece of vegetable matter enters his eye. His eye becomes watery. Which of the following is responsible for relaying parasympathetic neuronal signals to the lacrimal apparatus?
A. Pterygopalatine ganglion
B. Otic ganglion
C. Submandibular ganglion
D. Ciliary ganglion
E. None of the above
Theme from January 2013 Exam
A 43 year old lady is undergoing a total thyroidectomy for an extremely large goitre. The surgeons decide thataccess may be improved by division of the infra hyoid strap muscles. At which of the following sites should they be divided?
A. In their upper half
B. In their lower half
C. In the middle
D. At their origin from the hyoid
E. At the point of their insertion
Theme from 2009 Exam
A 22 year old women has recently undergone a surgical excision of the submandibular gland. She presents to the follow up clinic with a complaint of tongue weakness on the ipsilateral side to her surgery. Which nerve has been damaged?
A. Hypoglossal nerve
B. Lingual nerve
C. Inferior alveolar nerve
D. Facial nerve
E. Lesser petrosal nerve
Three cranial nerves may be injured during submandibular gland excision.
• Marginal mandibular branch of the facial nerve
• Lingual nerve
• Hypoglossal nerve
Theme from April 2012 Exam
You decide to take an arterial blood gas from the femoral artery. Where should the needle be inserted to gain the sample?
A. Mid point of the inguinal ligament
B. Mid inguinal point
C. 2cm inferomedially to the pubic tubercle
D. 2cm superomedially to the pubic tubercle
E. 3cm inferolaterally to the deep inguinal ring
Theme from September 2012 Exam
A 67 year old man undergoes a carotid endarterectomy and seems to recover well following surgery. When he is reviewed on the ward post operatively he complains that his voice is hoarse. What is the most likely cause?
A. Damage to the accessory nerve
B. Damage to the cervical plexus
C. Damage to the glossopharyngeal nerve
D. Damage to the hypoglossal nerve
E. Damage to the vagus
Theme from April 2013 Exam
A 25 year old man has an inguinal hernia, which of the following structures must be divided (at open surgery)to gain access to the inguinal canal?
A. Transversalis fascia
B. External oblique aponeurosis
C. Conjoint tendon
D. Rectus abdominis
E. Inferior epigastric artery Theme from January 2013 Exam
A 34 year old man is shot in the postero- inferior aspect of his thigh. Which of the following lies at the most lateral aspect of the popliteal fossa?
A. Popliteal artery
B. Popliteal vein
C. Common peroneal nerve
D. Tibial nerve
E. Small saphenous vein Theme from April 2012 Exam
A 67 year old man has an abdominal aortic aneurysm which displaces the left renal vein. Which branch of the aorta is most likely to affected at this level?
A. Inferior mesenteric artery
B. Superior mesenteric artery
C. Coeliac axis
D. Testicular artery
E. None of the above
Theme from April 2013 Exam
A 12 year old boy undergoes surgery for recurrent mastoid infections. Post operatively he complains of an altered taste sensation. Which of the following nerves has been injured?
A. Glossopharyngeal
B. Greater petrosal
C. Olfactory
D. Trigeminal
E. Chorda tympani
Theme from April 2012 Exam
What is the anatomical level of the transpyloric plane?
A. T11
B. T12
C. L1
D. L4
E. T10
Theme from September 2012 Exam Theme from January 2013 Exam
A 35 year old man falls and sustains a fracture to the middle third of his clavicle. Which vessel is at greatest riskof injury?
A. Subclavian vein
B. Subclavian artery
C. External carotid artery
D. Internal carotid artery
E. Vertebral artery Theme from April 2013 Exam
A 33 year old man sustains an injury to his forearm and wrist. When examined in clinic he is unable to adduct his thumb. What is the most likely underlying nerve lesion?
A. Radial nerve
B. Superficial branch of the ulnar nerve
C. Median nerve
D. Posterior interosseous nerve
E. Deep branch of the ulnar nerve
Theme from April 2013 Exam
A 63 year old man who smokes heavily presents with dyspepsia. He is tested and found to be positive for helicobacter pylori infection. One evening he has an episode of haematemesis and collapses. What is the most likely vessel to be responsible?
A. Portal vein
B. Short gastric arteries
C. Superior mesenteric artery
D. Gastroduodenal artery
E. None of the above
Theme from January 2012 exam
A 22 year old man is stabbed in the chest at the level of the junction between the sternum and manubrium. Which structure is at greatest risk?
A. Left atrium
B. Oesophagus
C. Thyroid gland
D. Inferior vena cava
E. Aortic arch
Theme from 2009 Exam
Which of the following nerves passes through the greater and lesser sciatic foramina?
A. Pudendal nerve
B. Sciatic nerve
C. Superior gluteal nerve
D. Inferior gluteal nerve
E. Posterior cutaneous nerve of the thigh
Structures passing through the lesser and greater sciatic foramina (medial to lateral): PIN
• Pudendal nerve
• Internal pudendal artery
• Nerve to obturator internus
Theme from 2010 Exam Theme from January 2013 Exam
A 73 year old lady is admitted with brisk rectal bleeding. Despite attempts at resuscitation the bleeding proceeds to cause haemodynamic compromise. An upper GI endoscopy is normal.A mesenteric angiogram is performed and a contrast blush is seen in the region of the sigmoid colon. The radiologist decides to embolise the vessel supplying this area. At what spinal level does it leave the aorta?
A. L2
B. L1
C. L4
D. L3
E. T10
Theme from 2009 Exam
In which space is a lumbar puncture performed?
A. Subdural space
B. Epidural space
C. Subarachnoid space
D. Extradural space
E. Intraventricular space
Theme from January 2013 exam
A 21 year old man is stabbed in the antecubital fossa. A decision is made to surgically explore the wound. At operation the surgeon dissects down onto the brachial artery. A nerve is identified medially, which nerve is it likely to be?
A. Radial
B. Recurrent branch of median
C. Anterior interosseous
D. Ulnar
E. Median
Theme from September 2012 Exam
A 65 year old man with long standing atrial fibrillation develops an embolus to the lower leg. The decision is made to perform an embolectomy, utilising a trans popliteal approach. After incising the deep fascia, which of the following structures will the surgeons encounter first on exploring the central region of the popliteal fossa?
A. Popliteal vein
B. Common peroneal nerve
C. Popliteal artery
D. Tibial nerve
E. None of the above
Theme from 2009 Exam
Theme from January 2013 Exam
A man sustains a laceration between the base of the little finger and wrist. Several weeks after the injury there is loss of thumb adduction power. Which nerve is most likely to have been injured?
A. Superficial ulnar nerve
B. Deep ulnar nerve
C. Median nerve
D. Radial nerve
E. Recurrent branch of median nerve
Theme from 2009 Exam
What is the course of the median nerve relative to the brachial artery in the upper arm?
A. Medial to anterior to lateral
B. Lateral to posterior to medial
C. Medial to posterior to lateral
D. Medial to anterior to medial
E. Lateral to anterior to medial
Relations of median nerve to the
brachial artery:
Lateral -> Anterior -> Medial
Theme from 2009 and 2012 Exams
A 43 year old man is due to undergo an excision of the sub mandibular gland. Which of the following incisions is the most appropriate for this procedure?
A. A transversely orientated incision 4cm below the mandible
B. A transversely orientated incision immediately inferior to the mandible
C. A vertical incision 3 cm anterior to the angle of the mandible and extending inferiorly
D. A transversely orientated incision 2cm above the mandible
E. A transversely orientated incision 12cm below the mandible
Theme from 2009 Exam
A 5 year old boy presents with recurrent headaches. As part of his assessment he undergoes an MRI scan of his brain. This demonstrates enlargement of the lateral and third ventricles. Where is the most likely site of obstruction?
A. Foramen of Luschka
B. Foramen of Magendie
C. Foramen of Munro
D. Aqueduct of Sylvius
E. None of the above
Theme based on September 2011 Exam
Theme based on April 2012 Exam
Theme from September 2012 Exam
Where does the spinal cord terminate in neonates?
A. L1
B. L2
C. L3
D. L4
E. L5
Theme from 2009 Exam
Theme from January 2013 Exam
A 73 year old lady is admitted with acute mesenteric ischaemia. A CT angiogram is performed and a stenotic lesion is noted at the origin of the superior mesenteric artery. At which of the following levels does this branch from the aorta?
A. L1
B. L2
C. L3
D. L4
E. L5
Theme from January 2012 Exam
Following an oesophagogastrectomy the surgeons will anastomose the oesophageal remnant to the stomach, which of the following is not part of the layers that comprise the oesophageal wall?
A. Serosa
B. Adventitia
C. Muscularis propria
D. Submucosa
E. Mucosa
The oesophageal wall lacks the serosa layer
Theme from April 2010 exam
Where is the 'safe triangle' for chest drain insertion located?
A. 4th intercostal space, mid axillary line
B. 5th intercostal space, mid axillary line
C. 4th intercostal space, mid scapular line
D. 5th intercostal space, mid scapular line
E. 4th intercostal space, mid clavicular line
'Safe Triangle' for chest drain insertion:
5th intercostal space, mid axillary line
Theme from April 2012 exam
Your consultant decides to perform an open inguinal hernia repair under local anaesthesia. Which of the following dermatomal levels will require blockade?
A. T10
B. T12
C. T11
D. S1
E. S2
Theme from April 2012 Exam
Which of the following does not pass through the superior orbital fissure?
A. Inferior opthalmic vein
B. Abducens nerve
C. Opthalmic artery
D. Trochlear nerve
E. Superior opthalmic vein
Mnemonic for the nerves
passing through the
supraorbital fissure:
Live Frankly To See Absolutely No Insult
Lacrimal
Frontal
Trochlear
Superior Division of
Oculomotor
Abducens
Nasociliary
Inferior Division of
Oculomotor nerve
Theme from January 2012 Exam
A patient is found to have an ischaemic left colon. Which artery arising from the aorta at around the level of L3 is most likely to account for this situation?
A. Superior mesenteric artery
B. Inferior mesenteric artery
C. Superior rectal artery
D. Ileocolic artery
E. Middle colic artery
Theme from January 2013 Exam
At which level does the aorta perforate the diaphragm?
A. T10
B. T9
C. T8
D. T11
E. T12
Memory aid:
T8 (8 letters) = vena cava
T10 (10 letters) = oesophagus
T12 (12 letters) = aortic hiatus
Theme from April 2012 exam
A 24 year old lady is stabbed in the buttock. Following the injury the wound is sutured in the emergency department. Eight weeks later she attends the clinic, as she walks into the clinic room she has a waddling gait and difficulty with thigh abduction. On examination she has buttock muscle wasting. Which nerve has been injured?
A. Superior gluteal nerve
B. Obturator nerve
C. Sciatic nerve
D. Femoral nerve
E. Inferior gluteal nerve
Theme from April 2012 Exam
At which level is the hilum of the left kidney located?
A. L1
B. L2
C. T12
D. T11
E. L3
Remember L1 ('left one') is the level of the hilum of the left kidney
Theme from April 2012 exam
A 73 year old lady presents with symptoms of faecal incontinence. On examination she has weak anal sphincter muscles. What are the main nerve root values of the nerves supplying the external anal sphincter?
A. S2,3
B. L5, S1
C. S4,5
D. S5
E. S2,3,4
Theme from September 2011 Exam
A 72 year old man has a fall. He is found to have a fractured neck of femur and goes on to have a left hip hemiarthroplasty. Two months post operatively he is found to have an odd gait. When standing on his left leg his pelvis dips on the right side. There is no foot drop. What is the cause?
A. Sciatic nerve damage
B. L5 radiculopathy
C. Inferior gluteal nerve damage
D. Previous poliomyelitis
E. Superior gluteal nerve damage Theme from 2010 Exam
A 28 year old lady requires an episiotomy for a ventouse vaginal delivery. Which of the nerves listed below will usually be anaesthetised to allow the episiotomy?
A. Femoral
B. Ilioinguinal
C. Pudendal
D. Genitofemoral
E. Sacral plexus Theme from April 2013 Exam
A 48 year old lady is undergoing an axillary node clearance for breast cancer. Which of the structures listed below are most likely to be encountered during the axillary dissection?
A. Cords of the brachial plexus
B. Thoracodorsal trunk
C. Internal mammary artery
D. Thoracoacromial artery
E. None of the above
Beware of damaging the thoracodorsal trunk if a latissimus dorsi flap reconstruction is planned. Theme from 2009 Exam
A 53 year old lady is recovering following a difficult mastectomy and axillary nodal clearance for carcinoma of the breast. She complains of shoulder pain and on examination has obvious winging of the scapula. Loss of innervation to which of the following is the most likely underlying cause?
A. Latissimus dorsi
B. Serratus anterior
C. Pectoralis minor
D. Pectoralis major
E. Rhomboids
Theme from April 2012 Exam
A 56 year old lady is referred to the colorectal clinic with symptoms of pruritus ani. On examination a polypoidal mass is identified inferior to the dentate line. A biopsy confirms squamous cell carcinoma. To which of the following lymph node groups will the lesion potentially metastasise?
A. Internal iliac
B. External iliac
C. Mesorectal
D. Inguinal
E. None of the above
Theme from September 2011 Exam
Theme from April 2012 Exam
A 20 year old man is hit with a hammer on the right side of the head. He dies on arrival in the emergency department. Which of these features is most likely to be found at post mortem?
A. Hydrocephalus
B. Supra tentorial herniation
C. Laceration of the middle meningeal artery
D. Sub dural haematoma
E. Posterior fossa haematoma
Theme based on 2011 exam
Which of the following ligaments contains the artery supplying the head of femur in children?
A. Transverse ligament
B. Ligamentum teres
C. Iliofemoral ligament
D. Ischiofemoral ligament
E. Pubofemoral ligament
Theme from 2010 Exam
A 63 year old man is undergoing a coronary artery bypass procedure. During the median sternotomy which structure would routinely require division?
A. Parietal pleura
B. Interclavicular ligament
C. Internal mammary artery
D. Brachiocephalic vein
E. Left vagus nerve
Theme from January 2011 Exam
A man undergoes a high anterior resection for carcinoma of the upper rectum. Which of the following vessels will require ligation?
A. Superior mesenteric artery
B. Inferior mesenteric artery
C. Coeliac axis
D. Perineal artery
E. Middle colic artery
Theme from April 2013
What are the boundaries of the 'safe triangle' for chest drain insertion?
A. Bounded by trapezius, latissimus dorsi, and laterally by the vertebralborder of the scapula
B. Bounded by latissimus dorsi, pectoralis major, line superior to the nipple and apex at the axilla
C. Bounded by latissimus dorsi, serratus anterior, line superior to thenipple and apex at the axilla
D. Bounded by trapezius, deltoid, rhomboid major and teres minor
E. Bounded by trapezius, deltoid and latissimus dorsi
Theme from April 2012 Exam
A 60 year old female attends the preoperative hernia clinic. She reports some visual difficulty. On examination she is noted to have a homonymous hemianopia. Where is the lesion most likely to be?
A. Frontal lobe
B. Pituitary gland
C. Parietal lobe
D. Optic chiasm
E. Optic tract
Lesions before optic chiasm:
Monocular vision loss = Optic nerve lesion
Bitemporal hemianopia = Optic chiasm lesion
Lesions after the optic chiasm:
Homonymous hemianopia = Optic tract lesion
Upper quadranopia = Temporal lobe lesion
Lower quadranopia = Parietal lobe lesion
Theme from April 2012 exam
A 23 year old climber falls and fractures his humerus. The surgeons decide upon a posterior approach to the middle third of the bone. Which of the following nerves is at greatest risk in this approach?
A. Ulnar
B. Antebrachial
C. Musculocutaneous
D. Radial
E. Intercostobrachial
Theme from April 2012 Exam
Following a carotid endarterectomy a man notices that he has a weakness of his tongue. Damage to which of the following nerves is the most likely explanation for this process?
A. Hypoglossal
B. Accessory
C. Ansa cervicalis
D. Vagus
E. Cervical plexus Theme from April 2013
At which of the following levels does the inferior vena cava exit the abdominal cavity?
A. T6
B. T7
C. T10
D. T8
E. T12 Theme from April 2012 Exam
Which of the following structures lies deepest in the popliteal fossa?
A. Popliteal artery
B. Popliteal vein
C. Tibial nerve
D. Common peroneal nerve
E. Popliteal lymph nodes
Theme from January 2012 exam
What is the nerve root value of the external urethral sphincter?
A. S4
B. S1, S2, S3
C. S2, S3, S4
D. L3, L4, L5
E. L5, S1, S2
Theme from April 2012 Exam
A patient presents to the clinic following a surgical procedure. She complains that she is unable to shrug her shoulder. What is the most likely underlying nerve injury?
A. Accessory nerve
B. Cervical plexus
C. Ansa cervicalis
D. Long thoracic nerve
E. Axillary nerve
Theme from April 2013 Exam
A 32 year old man is undergoing a splenectomy. Division of which of the following will be necessary during the procedure?
A. Left crus of diaphragm
B. Short gastric vessels
C. Gerotas fascia
D. Splenic flexure of colon
E. Marginal artery
Theme from 2011 Exam
A patient has a chest drain insertion. There is fresh blood at the chest drain insertion area. Which vessel has been damaged?
A. Pericardiophrenic artery
B. Intercostal vein
C. Right ventricle
D. Vagus artery
E. Intercostal artery
Theme from 2009 Exam
Two teenagers are playing with an airgun when one accidentally shoots his friend in the abdomen. He is brought to the emergency department. On examination there is a bullet entry point immediately to the right of the rectus sheath at the level of the 1st lumbar vertebra. Which of the following structures is most likely to be injured by the bullet?
A. Head of pancreas
B. Right ureter
C. Right adrenal gland
D. Fundus of the gallbladder
E. Gastric antrum
Theme from September 2011 Exam
Which of the following nerves is not contained within the posterior triangle of the neck?
A. Accessory nerve
B. Phrenic nerve
C. Greater auricular nerve
D. Ansa cervicalis
E. Lesser occiptal nerve
Theme from September 2012 Exam
A 42 year old lady is reviewed in the outpatient clinic following a routine surgical procedure. She complains of diminished sensation at the lateral aspect of her foot. Which of the following nerves is likely to be affected?
A. Sural
B. Superficial peroneal
C. Deep peroneal
D. Medial plantar
E. Lateral plantar
Theme from April 2012 Exam
A sprinter attends A&E with severe leg pain. He had forgotten to warm up and ran a 100m sprint race. Towards the end of the race he experienced pain in the posterior aspect of his thigh. The pain worsens, localising to the lateral aspect of the knee. The sprinter is unable to flex the knee. What structure has been injured?
A. Anterior cruciate ligament
B. Posterior cruciate ligament
C. Semimembranosus tendon
D. Semiteninosus tendon
E. Biceps femoris tendon
Theme from 2009 Exam
Which nerve supplies the interossei of the fourth finger?
A. Radial
B. Median
C. Superficial ulnar
D. Deep ulnar
E. Posterior interosseous
Mnemonic:
PAD and DAB
Palmer interossei ADduct
Dorsal interossei ABuct
Theme from April 2013 Exam
A 45 year man presents with hand weakness. He is given a piece of paper to hold between his thumb and index finger. When the paper is pulled, the patient has difficulty maintaining a grip. Grip pressure is maintained by flexing the thumb at the interphalangeal joint. What is the most likely nerve lesion?
A. Posterior interosseous nerve
B. Deep branch of ulnar nerve
C. Anterior interosseous nerve
D. Superficial branch of the ulnar nerve
E. Radial nerve
Theme from January 2012 exam
Which of the following cranial foramina pairings are incorrect?
A. The foramen lacerum and internal carotid artery.
B. Foramen ovale and mandibular nerve.
C. Optic canal and ophthalmic artery.
D. Optic canal and ophthalmic nerve.
E. Foramen rotundum and maxillary nerve.
Question derived from 2010 and 2011 exams
A man has an incision sited than runs 8cm from the deltopectoral groove to the midline. Which of the following is not at risk of injury?
A. Cephalic vein
B. Shoulder joint capsule
C. Axillary artery
D. Pectoralis major
E. Trunk of the brachial plexus
Theme from April 2012 Exam
A surgeon is due to perform a laparotomy for perforated duodenal ulcer. An upper midline incision is to be performed. Which of the following structures is the incision most likely to divide?
A. Rectus abdominis muscle
B. External oblique muscle
C. Linea alba
D. Internal oblique muscle
E. None of the above
Theme from September 2011 Exam
A 23 year old man is injured during a game of rugby. He suffers a fracture of the distal third of his clavicle, it is a compound fracture and there is evidence of arterial haemorrhage. Which of the following vessels is most likely to be encountered first during subsequent surgical exploration?
A. Posterior circumflex humeral artery
B. Axillary artery
C. Thoracoacromial artery
D. Sub scapular artery
E. Lateral thoracic artery Similar theme in September 2011 Exam
What is the most useful test to clinically distinguish between an upper and lower motor neurone lesion of the facial nerve?
A. Blow cheeks out
B. Loss of chin reflex
C. Close eye
D. Raise eyebrow
E. Open mouth against resistance
Upper motor neurone lesions of the facial nerve- Paralysis of the lower half of face.
Lower motor neurone lesion- Paralysis of the entire ipsilateral face.
Theme from April 2012 Exam
A 23 year old man is involved in a fight, during the dispute he sustains a laceration to the posterior aspect of his right arm, approximately 2cm proximal to the olecranon process. On assessment in the emergency department he is unable to extend his elbow joint. Which of the following tendons is most likely to have been cut?
A. Triceps
B. Pronator teres
C. Brachioradialis
D. Brachialis
E. Biceps Theme from 2009 Exam
During the course of a radical gastrectomy the surgeons detach the omentum and ligate the right gastro-epiploic artery. From which vessel does it originate?
A. Superior mesenteric artery
B. Inferior mesenteric artery
C. Coeliac axis
D. Common hepatic artery
E. Gastroduodenal artery
Theme from January 2013 Exam
A 43 year old man is reviewed in the clinic following a cardiac operation. A chest x-ray is performed and a circular radio-opaque structure is noted medial to the 4th interspace on the left. Which of the following procedures is the patient most likely to have undergone?
A. Aortic valve replacement with metallic valve
B. Tricuspid valve replacement with metallic valve
C. Tricuspid valve replacement with porcine valve
D. Pulmonary valve replacement with porcine valve
E. Mitral valve replacement with metallic valve
Theme from April 2012 Exam
A 63 year old lady is diagnosed as having an endometrial carcinoma arising from the uterine body. To which nodal region will the tumour initially metastasise?
A. Para aortic nodes
B. Iliac lymph nodes
C. Inguinal nodes
D. Pre sacral nodes
E. Mesorectal lymph nodes
Theme from 2011 exam
A 23 year old lady is undergoing a trendelenberg procedure for varicose veins. During the dissection of the saphenofemoral junction, which of the structures listed below is most liable to injury?
A. Superficial circumflex iliac artery
B. Superficial circumflex iliac vein
C. Femoral artery
D. Femoral nerve
E. Deep external pudendal artery
Theme from September 2011 exam
Which of the following nerves is responsible for the motor innervation of the sternocleidomastoid muscle?
A. Ansa cervicalis
B. Accessory nerve
C. Hypoglossal nerve
D. Facial nerve
E. Vagus nerve
Theme from January 2013 Exam
A 42 year old lady has had an axillary node clearance for breast malignancy. Post operatively she reports weakness of the shoulder. She is unable to push herself forwards from a wall with the right arm and the scapula is pushed out medially from the chest wall. What is the most likely nerve injury?
A. C5, C6
B. C8, T1
C. Axillary nerve
D. Long thoracic nerve
E. Spinal accessory nerve
Theme from January 2012 and 2009 Exam
A 36 year old male is admitted for elective surgery for a lymph node biopsy in the supraclavicular region. Post operatively the patient has difficulty shrugging his left shoulder. What nerve has been damaged?
A. Phrenic nerve
B. Axillary nerve
C. C5, C6 lesion
D. C8, T1 lesion
E. Accessory nerve
Theme from September 2011 Exam
A 17 year old male presents to the clinic. He complains of difficulty using his left hand. It has been a persistent problem since he sustained a distal humerus fracture as a child. On examination there is diminished sensation overlying the hypothenar eminence and medial one and half fingers. What is the most likely nerve lesion?
A. Anterior interosseous nerve
B. Posterior interosseous nerve
C. Ulnar nerve
D. Median nerve
E. Radial nerve
Theme from April 2012 Exam
A 56 year old man is undergoing a pancreatectomy for carcinoma. During resection of the gland which of the following structures will the surgeon not encounter posterior to the pancreas itself?
A. Left crus of the diaphragm
B. Superior mesenteric vein
C. Common bile duct
D. Portal vein
E. Gastroduodenal artery
Theme from 2010 Exam
Which of the following bones is related to the cuboid at its distal articular surface?
A. All metatarsals
B. 5th metatarsal
C. Calcaneum
D. Medial cuneiform
E. 3rd metatarsal
Theme from April 2012 Exam
A 34 year old lady presents with symptoms of faecal incontinence. Ten years previously she gave birth to a child by normal vaginal delivery. Injury to which of the following nerves is most likely to account for this process?
A. Genitofemoral
B. Ilioinguinal
C. Pudendal
D. Hypogastric autonomic nerve
E. Obturator
Theme from April 2012 Exam
A 56 year old man undergoes an abdomino-perineal excision of the rectum. He is assessed in the outpatient clinic post operatively. His wounds are well healed. However, he complains of impotence. Which of the following best explains this problem?
A. Sciatic nerve injury
B. Damage to the internal iliac artery
C. Damage to the hypogastric nerve plexus
D. Damage to the vas
E. Damage to the genitofemoral nerve
Theme from 2012 Exam
A woman develops winging of the scapula following a Patey mastectomy. What is the most likely cause?
A. Division of pectoralis minor to access level 3 axillary nodes
B. Damage to the brachial plexus during axillary dissection
C. Damage to the long thoracic nerve during axillary dissection
D. Division of the thoracodorsal trunk during axillary dissection
E. Damage to the thoracodorsal trunk during axillary dissection
Theme from January 2012 exam
Which nerve directly innervates the sinoatrial node?
A. Superior cardiac nerve
B. Right vagus nerve
C. Left vagus nerve
D. Inferior cardiac nerve
E. None of the above
Theme from September 2011 Exam Theme from September 2012 Exam
A 30 year old man presents with back pain and the surgeon tests the ankle reflex. Which of the following nerve roots are tested in this manoeuvre?
A. S3 and S4
B. L4 and L5
C. L3 and L4
D. S1 and S2
E. S4 only
Theme from April 2012 Exam
An 18 year old male presents to casualty with a depressed skull fracture. This is managed surgically.Over the next few days he complains of double vision on walking down stairs and reading. On examination the left eye cannot look downwards and medially. Which of the nerves listed below is most likely to be responsible?
A. Facial
B. Oculomotor
C. Abducens
D. Trochlear
E. Trigeminal nerve
Theme from September 2012 Exam
A 16 year old boy is hit by a car and sustains a blow to the right side of his head. He is initially conscious but on arrival in the emergency department is comatose. On examination his right pupil is fixed and dilated. The neurosurgeons plan immediate surgery. What type of initial approach should be made?
A. Left parieto-temporal craniotomy
B. Right parieto-temporal craniotomy
C. Posterior fossa craniotomy
D. Left parieto-temporal burr holes
E. None of the above
Theme from April 2012 Exam
A 56 year old man is having a long venous line inserted via the femoral vein into the right atrium for CVP measurements. The catheter is advanced through the IVC. At which of the following levels does this vessel enter the thorax?
A. L2
B. T10
C. L1
D. T8
E. T6
Theme from 2010 Exam
A 23 year old man falls and injures his hand. There are concerns that he may have a scaphoid fracture as there is tenderness in his anatomical snuffbox on clinical examination. Which of the following forms the posterior border of this structure?
A. Basilic vein
B. Radial artery
C. Extensor pollicis brevis
D. Abductor pollicis longus
E. Extensor pollicis longus
Theme from 2009 Exam Theme from September 2012 Exam
The integrity of which muscle is assessed by the Trendelenberg test?
A. Sartorius
B. Quadratus femoris
C. Semimembranosus
D. Gluteus medius
E. Piriformis
Theme from 2011 Exam
Which of the following regions of the male urethra is entirely surrounded by Bucks fascia?
A. Preprostatic part
B. Prostatic part
C. Membranous part
D. Spongiose part
E. None of the above
Theme from 2010 Exam
A 73 year old man has a large abdominal aortic aneurysm. During a laparotomy for planned surgical repair the surgeons find the aneurysm is far more proximally located and lies near the origin of the SMA. During the dissection a vessel lying transversely across the aorta is injured. What is this vessel most likely to be?
A. Left renal vein
B. Right renal vein
C. Inferior mesenteric artery
D. Ileocolic artery
E. Middle colic artery
Theme from April 2012 Exam
A 56 year old machinist has his arm entrapped in a steel grinder and is brought to the emergency department. On examination, he is unable to extend his metacarpophalangeal joints and abduct his shoulder. He has weakness of his elbow and wrist. What has been injured?
A. Ulnar nerve
B. Axillary nerve
C. Medial cord of brachial plexus
D. Lateral cord of brachial plexus
E. Posterior cord of brachial plexus
The posterior cord gives rise to:
• Radial nerve ((innervates the triceps, brachioradialis, wrist extensors, and finger extensors)
• Axillary nerve (innervates deltoid and teres minor)
• Upper subscapular nerve (innervates subscapularis)
• Lower subscapular nerve (innervates teres major and subscapularis)
• Thoracodorsal nerve (innervates latissimus dorsi)
Theme from September 2012 exam
A 60 year old female is undergoing a Whipples procedure for adenocarcinoma of the pancreas. As the surgeons begin to mobilise the pancreatic head they identify a large vessel passing inferiorly over the anterior aspect of the pancreatic head. What is it likely to be?
A. Superior mesenteric artery
B. Coeliac axis
C. Inferior mesenteric artery
D. Aorta
E. Left gastric artery
Theme from January 2012 Exam
Which of the following structures does not lie posterior to the right kidney?
A. Psoas major
B. Transversus abdominis
C. Quadratus lumborum
D. Medial artcuate ligament
E. 10th rib
Theme from April 2012 Exam
Which of the following muscles is not within the posterior compartment of the lower leg?
A. Peroneus brevis
B. Flexor digitalis longus
C. Soleus
D. Popliteus
E. Flexor hallucis longus
Theme from 2007 Exam
A 20 year old man undergoes an open appendicectomy performed via a lanz incision. This surgeon places the incision on a level of the anterior superior iliac spine in an attempt to improve cosmesis.During the procedure the appendix is found to be retrocaecal and the incision is extended laterally.Which of the following nerves is at greatest risk of injury?
A. Genitofemoral
B. Ilioinguinal
C. Obturator
D. Lateral femoral cutaneous
E. Femoral
Theme from April 2012 Exam
A 32 year old man is stabbed in the neck and the inferior trunk of his brachial plexus is injured.Which of the modalities listed below is least likely to be affected?
A. Initiating abduction of the shoulder
B. Abduction of the fingers
C. Flexion of the little finger
D. Sensation on the palmar aspect of the little finger
E. Gripping a screwdriver
Inferior trunk of brachial plexus.
• C8 and T1 roots
• Contributes to ulnar nerve and part of median nerve
Theme from September 2012 Exam
A 23 year old man presents with delayed diagnosis of appendicitis. The appendix is retrocaecal and has perforated causing a psoas abscess. Into which structure does the psoas major muscle insert?
A. Greater trochanter of the femur
B. Linea aspera of the femur
C. Lesser trochanter of the femur
D. Iliac crest
E. None of the above
Theme based on 2011 exam
A 63 year old man is due to undergo a splenectomy. Which splenic structure lies most posteriorly?
A. Gastrosplenic ligament
B. Splenic vein
C. Splenic artery
D. Splenic notch
E. Lienorenal ligament
Theme from 2011 Exam
A 62 year old man presents with arm weakness. On examination he has a weakness of elbow extension and loss of sensation on the dorsal aspect of the first digit. What is the site of the most likely underlying defect?
A. Axillary nerve
B. Median nerve
C. Ulnar nerve
D. Radial nerve
E. Musculocutaneous nerve
Theme from April 2012 Exam
Theme: Nerve injury
A. Median nerve
B. Ulnar nerve
C. Radial nerve
D. Anterior interosseous nerve
E. Posterior interosseous nerve
F. Axillary nerve
G. Musculocutaneous nerve
Please select the nerve at risk of injury in each scenario. Each option may be used once, more than once or not at all.
44. A 43 year old typist presents with pain at the dorsal aspect of the upper part of her forearm. She also complains of weakness when extending her fingers. On examination triceps and supinator are both functioning normally. There is weakness of most of the extensor muscles. However, there is no sensory deficit.
The correct answer is Posterior interosseous nerve
The radial nerve may become entrapped in the "arcade of Frohse" which is a superficial part of the supinator muscle which overlies the posterior interosseous nerve. This nerve is entirely muscular and articular in its distribution. It passes postero-inferiorly and gives branches to extensor carpi radialis brevis and supinator. It enters supinator and curves around the lateral and posterior surfaces of the radius. On emerging from the supinator the posterior interosseous nerve lies between the superficial extensor muscles and the lowermost fibres of supinator. It then gives branches to the extensors.
45. A 28 year teacher reports difficulty with writing. There is no sensory loss. She is known to have an aberrant Gantzer muscle.
The correct answer is Anterior interosseous nerve
Anterior interosseous lesions occur due to fracture, or rarely due to compression. The Gantzer muscle is an aberrant accessory of the flexor pollicis longus and is a risk factor for anterior interosseous nerve compression. Remember loss of pincer grip and normal sensation indicates an interosseous nerve lesion.
46. A 35 year tennis player attends reporting tingling down his arm. He says that his 'funny bone' was hit very hard by a tennis ball. There is weakness of abduction and adduction of his extended fingers.
The correct answer is Ulnar nerve
Theme from September 2012 exam
The ulnar nerve arises from the medial cord of the brachial plexus (C8, T1 and contribution from C7). The nerve descends between the axillary artery and vein, posterior to the cutaneous nerve of the forearm and then lies anterior to triceps on the medial side of the brachial artery. In the distal half of the arm it passes through the medial intermuscular septum, and continues between this structure and the medialhead of triceps to enter the forearm between the medial epicondyle of the humerus and the olecranon. It may be injured at this site in this scenario
In relation to the middle cranial fossa, which of the following statements relating to the foramina are incorrect?
A. The foramen rotundum transmits the maxillary nerve
B. The foramen lacerum transmits the internal carotid artery
C. The foramen spinosum lies posterolateral to the foramen ovale
D. The foramen ovale transmits the middle meningeal artery
E. The foramen rotundum lies anteromedial to the foramen ovale
Theme addressed in 2010 and 2011 exam
During an operation for varicose veins the surgeons are mobilising the long saphenous vein. Near its point of entry to the femoral vein an artery is injured and bleeding is encountered. From where is the bleeding most likely to originate?
A. Femoral artery
B. Profunda femoris artery
C. Superficial circumflex iliac artery
D. Superficial epigastric artery
E. Deep external pudendal artery
Theme from 2011 Exam
What is embryological origin of the pulmonary artery?
A. First pharyngeal arch
B. Second pharyngeal arch
C. Fourth pharyngeal arch
D. Fifth pharyngeal arch
E. Sixth pharyngeal arch
Theme from September 2011 Exam
Theme from September 2012 Exam
A 53 year old lady presents with pain and discomfort in her hand. She works as a typist and notices that the pain is worst when she is working. She also suffers symptoms at night. Her little finger is less affected by the pain. Which of the nerves listed below is most likely to be affected?
A. Radial
B. Median
C. Ulnar
D. Anterior interosseous nerve
E. Posterior interosseous nerve
Motor supply: LOAF
L ateral 2 lumbricals
O pponens pollicis
A bductor pollicisbrevis
F lexor pollicis brevis
Theme from April 2012 Exam
Which of the following muscles lies medial to the long thoracic nerve?
A. Serratus anterior
B. Latissimus dorsi
C. Pectoralis major
D. Pectoralis minor
E. None of the above
Theme from 2009 Exam
A 25 year old man is being catheterised, prior to a surgical procedure. As the catheter enters the prostatic urethra which of the following changes will occur?
A. Resistance will increase significantly
B. Resistance will increase slightly
C. It will lie horizontally
D. Resistance will decrease
E. It will deviate laterally
Theme from September 2011 Exam
Which of the following nerves is the primary source of innervation to the anterior scrotal skin?
A. Genital branch of the genitofemoral nerve
B. Pudendal nerve
C. Ilioinguinal nerve
D. Femoral branch of the genitofemoral nerve
E. Obturator nerve
Theme from April 2012 Exam
A 38 year old man presents to the clinic with shoulder weakness. On examination he has an inability to initiate shoulder abduction. Which of the nerves listed below is least likely to be functioning normally?
A. Suprascapular nerve
B. Medial pectoral nerve
C. Axillary nerve
D. Median nerve
E. Radial nerve
Theme from April 2012 Exam
A 72 year old lady with osteoporosis falls and sustains an intracapsular femoral neck fracture. The fracture is completely displaced. Which of the following vessels is the main contributor to the arterial supply of the femoral head?
A. Deep external pudendal artery
B. Superficial femoral artery
C. External iliac artery
D. Circumflex femoral arteries
E. Superficial external pudendal artery
Theme from 2010 Exam
A 21 year old man is hit with a hammer and sustains a depressed skull fracture at the vertex. Which of the following sinuses is at risk in this injury?
A. Superior sagittal sinus
B. Inferior petrosal sinus
C. Transverse sinus
D. Inferior sagittal sinus
E. Straight sinus
Theme in September 2011 Exam
A 19 year old man is playing rugby when he suddenly notices a severe pain at the posterolateral aspect of his right thigh. Which of the following muscle groups is most likely to have been injured?
A. Semimembranosus
B. Semitendinosus
C. Long head of biceps femoris
D. Gastrocnemius
E. Soleus
Theme from April 2012 Exam
A 23 year old is stabbed in the groin and develops hypovolaemic shock. What is the most likely finding on analysis of his urine?
A. Decreased specific gravity
B. Increased specific gravity
C. Increased urinary glucose
D. Increased urinary protein
E. Increased red blood cells in the urine
Theme from April 2013 Exam
A 45 year old male is diagnosed with carcinoma of the head of the pancreas. He reports that his stool sticks to the commode and will not flush away. Loss of which of the following enzymes is most likely to be responsible for this problem?
A. Lipase
B. Amylase
C. Trypsin
D. Elastase
E. None of the above
Theme from April 2012 Exam
A 34 year old man receives morphine following an appendicectomy. He develops constipation as a result. Which of the following best accounts for this process?
A. Stimulation of DOPA receptors
B. Inhibition of DOPA receptors
C. Stimulation of μ receptors
D. Stimulation of serotonin release
E. Inhibition of serotonin release
4 Types of opioid receptor:
• δ (located in CNS)- Accounts for analgesic and antidepressant effects
• k (mainly CNS)- analgesic and dissociative effects
• μ (central and peripheral) - causes analgesia, miosis, decreased gut motility
• Nociceptin receptor (CNS)- Affect of appetite and tolerance to μ agonists.
Theme from April 2013 Exam
A 56 year old male presents to the acute surgical take with severe abdominal pain. He is normally fit and well. He has no malignancy. The biochemistry laboratory contacts the ward urgently, his corrected calcium result is 3.6 mmol/l. What is the medication of choice to treat this abnormality?
A. IV Pamidronate
B. Oral Alendronate
C. Dexamethasone
D. Calcitonin
E. IV Zoledronate
Theme from January 2012 exam
An over enthusiastic medical student decides to ask you questions about ECGs. Rather than admitting your dwindling knowledge on this topic, you bravely attempt to answer her questions! One question is what segment of the ECG represents ventricular repolarization?
A. QRS complex
B. Q-T interval
C. P wave
D. T wave
E. S-T segment
Theme from January 2012 exam
A 28 year old man is shot in the abdomen and haemorrhages. Which of the following substances will produce vasoconstriction in response to this process?
A. Renin
B. Angiotensin I
C. Angiotensin II
D. Aldosterone
E. None of the above
Similar theme to September 2011 Exam
A 43 year old lady is recovering on the intensive care unit following a Whipples procedure. She has a central venous line in situ. Which of the following will lead to the "y" descent on the waveform trace?
A. Ventricular contraction
B. Emptying of the right atrium
C. Emptying of the right ventricle
D. Opening of the pulmonary valve
E. Cardiac tamponade
JVP
3 Upward deflections and 2 downward
deflections
Upward deflections
• a wave = atrial contraction
• c wave = ventricular contraction
• v wave = atrial venous filling
Downward deflections
• x wave = atrium relaxes and tricuspid
valve moves down
• y wave = ventricular filling
Theme from January 2012
A 25 year old man is undergoing respiratory spirometry. He takes a maximal inspiration and maximally exhales. Which of the following measurements will best illustrate this process?
A. Functional residual capacity
B. Vital capacity
C. Inspiratory capacity
D. Maximum voluntary ventilation
E. Tidal volume
Theme from April 2012 Exam
What is the typical stroke volume in a resting 70 Kg man?
A. 10ml
B. 150ml
C. 125ml
D. 45ml
E. 70ml
Theme from April 2012 Exam
A 25 year old man undergoes an appendicetomy for appendicitis. The appendix is submitted for histopathological evaluation. Which of the following is most likely to be identified microscopically?
A. Macrophages
B. Neutrophils
C. Fibroblasts
D. Lymphocytes
E. Stem cells
Theme from April 2013 Exam
A 73 year old man has an arterial line in situ. On studying the trace the incisura can be seen. What is the physiological event which accounts for this process?
A. Atrial repolarisation
B. Mitral valve closure
C. Ventricular repolarisation
D. Elastic recoil of the aorta
E. Tricuspid valve closure
Theme from 2010 Exam
It is the temporary rise in aortic pressure occurring as a result of elastic recoil
A 22 year old man suffers a blunt head injury. He is drowsy and has a GCS of 7 on admission. Which of the following is the major determinant of cerebral blood flow in this situation?
A. Systemic blood pressure
B. Mean arterial pressure
C. Intra cranial pressure
D. Hypoxaemia
E. Acidosis
Theme from 2009 Exam
Hypoxaemia and acidosis may both affect cerebral blood flow. However, in the traumatic situation increases in intracranial pressure are far more likely to occur especially when GCS is low. This will adversely affect cerebral blood flow.
A 43 year old man has recurrent episodes of dyspepsia and treatment is commenced with oral antacids. Which of the hormones listed below is released in response to increased serum gastrin levels and decreases intra gastric pH?
A. Cholecystokinin
B. Histamine
C. Somatostatin
D. Insulin
E. Vasoactive intestinal peptide
Theme from January 2013 Exam
Which of the following cell types is least likely to be found in a wound 1 week following injury?
A. Macrophages
B. Fibroblasts
C. Myofibroblasts
D. Endothelial cells
E. Neutrophils
Theme from April 2012 Exam
Which of the following best accounts for the action of PTH in increasing serum calcium levels?
A. Activation of vitamin D to increase absorption of calcium from the
small intestine.
B. Direct stimulation of osteoclasts to absorb bone with release of
calcium.
C. Stimulation of phosphate absorption at the distal convoluted tubule of
the kidney.
D. Decreased porosity of the vessels at Bowmans capsule to calcium.
E. Vasospasm of the afferent renal arteriole thereby reducing GFR and
calcium urinary loss.
Theme from April 2012 Exam
PTH increases the activity of 1-α-hydroxylase enzyme, which converts 25-
hydroxycholecalciferol to 1,25-dihydroxycholecalciferol, the active form of vitamin D.
Osteoclasts do not have a PTH receptor and effects are mediated via osteoblasts.
What is the most likely cause for this patients deterioration?
A. Acute respiratory alkalosis secondary to hyperventilation
B. Over administration of oxygen in a COPD patient
C. Metabolic acidosis secondary to severe pancreatitis
D. Metabolic alkalosis secondary to hypokalaemia
E. Acute respiratory acidosis secondary to pneumonia
Theme from April 2012 exam
A 43 year old man has a nasogastric tube inserted. The nurse takes a small aspirate of the fluid from the stomach and tests the pH of the aspirate. What is the normal intragastric pH?
A. 0.5
B. 2
C. 4
D. 5
E. 6
•
Theme from January 2012 Exam
Theme: Critical care
A. Hypovolaemia
B. Normal
C. Cardiogenic shock
D. Septic shock
For each of the scenarios outlined in the tables below, please select the most likely diagnosis from the list. Each option may be used once, more than once or not at all.
51. A 45 year old man is admitted to the intensive care unit following a laparotomy. He has a central line, pulmonary artery catheter and arterial lines inserted. The following results are obtained:
Pulmonary artery occlusion pressure Cardiac output Systemic vascular resistance
Low Low High
Hypovolaemia
Theme from April 2012 Exam
Cardiac output is lowered in hypovolaemia due to decreased preload.
52. A 75 year old man is admitted to the intensive care unit following a laparotomy. He has a central line, pulmonary artery catheter and arterial lines inserted. The following results are obtained:
Pulmonary artery occlusion pressure Cardiac output Systemic vascular resistance
High Low High
Cardiogenic shock
In cardiogenic shock pulmonary pressures are often high. This is the basis for the use of
venodilators in the treatment of pulmonary oedema.
53. A 22 year old lady is admitted to the intensive care unit following a laparotomy. She has a central line, pulmonary artery catheter and arterial lines inserted. The following results are obtained:
Pulmonary artery occlusion pressure Cardiac output Systemic vascular resistance
Low High Low
Septic shock
Decreased SVR is a major feature of sepsis. A hyperdynamic circulation is often present. This is the reason for the use of vasoconstrictors.
A 22 year old lady receives intravenous morphine for acute abdominal pain. Which of the following best accounts for its analgesic properties?
A. Binding to δ opioid receptors in the brainstem
B. Binding to δ opioid receptors at peripheral nerve sites
C. Binding to β opioid receptors within the CNS
D. Binding to α opioid receptors within the CNS
E. Binding to μ opioid receptors within the CNS
4 Types of opioid receptor:
• δ (located in CNS)- Accounts for analgesic and antidepressant effects
• k (mainly CNS)- analgesic and dissociative effects
• μ (central and peripheral) - causes analgesia, miosis, decreased gut motility
• Nociceptin receptor (CNS)- Affect of appetite and tolerance to μ agonists.
Theme from April 2012 Exam
Which of the following areas is predominantly concerned with thermoregulation?
A. Hypothalamus
B. Anterior pituitary
C. Cerebellum
D. Brain stem
E. Temporal lobe Theme from 2012 Exam
A 19 year old man is attacked outside a club and beaten with a baseball bat. He sustains a blow to the right side of his head. He is brought to the emergency department and a policy of observation is adopted. His glasgow coma score deteriorates and he becomes comatose. Which of the following haemodynamic parameters is most likely to be present?
A. Hypertension and bradycardia
B. Hypotension and tachycardia
C. Hypotension and bradycardia
D. Hypertension and tachycardia
E. Normotension and bradycardia
Theme from April 2013 Exam
Which substance can be used to achieve the most accurate measurement of the glomerular filtration rate?
A. Glucose
B. Protein
C. Inulin
D. Creatinine
E. Para-amino hippuric acid Theme from January 2013 exam
Creatinine declines with age due to decline in renal function and muscle mass. Glucose, protein (aminoacids) and PAH are reabsorbed by the kidney.
A 17 year old lady with long standing anorexia nervosa is due to undergo excision of a lipoma. Which of the following nutritional deficiencies is most likely to be implicated in poor collagen formation as the wound heals?
A. Deficiency of copper
B. Deficiency of iron
C. Deficiency of ascorbic acid
D. Deficiency of phosphate
E. None of the above
Theme from January 2011
A 45 year old man is undergoing a small bowel resection. The anaesthetist decides to administer an intravenous fluid which is electrolyte rich. Which of the following most closely matches this requirement?
A. Dextrose / Saline
B. Pentastarch
C. Gelofusine
D. Hartmans
E. 5% Dextrose with added potassium 20mmol/ L
Theme from April 2012 Exam
A 16 year old girl develops pyelonephritis and is admitted in a state of septic shock. Which of the following is not typically seen in this condition?
A. Increased cardiac output
B. Increased systemic vascular resistance
C. Oliguria may occur
D. Systemic cytokine release
E. Tachycardia
Cardiogenic Shock:
e.g. MI, valve abnormality
increased SVR (vasoconstriction in response to low BP)
increased HR (sympathetic response)
decreased cardiac output
decreased blood pressure
Hypovolaemic shock:
blood volume depletion
e.g. haemorrhage, vomiting, diarrhoea, dehydration, third-space losses during major operations
increased SVR
increased HR
decreased cardiac output
decreased blood pressure
Septic shock:
occurs when the peripheral vascular dilatation causes a fall in SVR
similar response may occur in anaphylactic shock, neurogenic shock
reduced SVR
increased HR
normal/increased cardiac output
decreased blood pressure
Theme from January 2012 Exam
The SVR is reduced in sepsis and for this reason a vasoconstricting inotrope such as
noradrenaline may be used if hypotension and oliguria remain a concern despite administration of adequate amounts of intravenous fluids.
Which receptor does noradrenaline mainly bind to?
A. α 1 receptors
B. α 2 receptors
C. β 1 receptors
D. β 2 receptors
E. G receptors
•
Theme from 2009 Exam
A 12 year old child is admitted with a 12 hour history of colicky right upper quadrant pain. On examination the child is afebrile and is jaundiced. The abdomen is soft and non tender at the time of examination. What is the most likely cause?
A. Infectious hepatitis
B. Acute cholecystitis
C. Cholangitis
D. Hereditary spherocytosis
E. Gilberts syndrome
Theme from September 2012 Exam
A 40 year old man presents with obstructive jaundice. Twenty years previously he underwent a right hemicolectomy for a mucinous right sided colonic carcinoma. He was subsequently diagnosed as having Lynch syndrome. What is the most likely cause of his jaundice?
A. Hepatocellular carcinoma
B. Liver metastasis from colonic cancer
C. Pancreatic carcinoma
D. Duodenal carcinoma
E. Gastric carcinoma
Theme from April 2013
Theme: Breast disease
A. Tuberculosis
B. Actinomycosis
C. Duct ectasia
D. Fibroadenoma
E. Fat necrosis
F. Intraductal papilloma
G. Breast abscess
H. Breast cancer
What is the most likely diagnosis for each scenario given? Each diagnosis may be used once, more than once or not at all.
6. A 32 year old woman presents with a tender breast lump. She has a 2 month old child.Clinically there is a tender, fluctuant mass of the breast.
Breast abscess
Theme from January 2013 Exam
Theme from September 2011 Exam
This lady is likely to be breast feeding and is at risk of mastitis. This may lead to an abscess if notNtreated. Staphylococcus aureus is usually the causative organism.
7. A 53 year old lady presents with a creamy nipple discharge. On examination she has discharge originating from multiple ducts and associated nipple inversion.
Duct ectasia
Duct ectasia is common during the period of breast involution that occurs during the menopausal period. As the ducts shorten they may contain insipiated material. The discharge will often discharge from several ducts.
8. A 52 year old lady presents with an episode of nipple discharge. It is usually clear in nature. On examination the discharge is seen to originate from a single duct and although it appears clear, when the discharge is tested with a labstix it is shown to contain blood. Imaging and examination shows no obvious mass lesion.
Intraductal papilloma
Intraductal papilloma usually cause single duct discharge. The fluid is often clear, although it may be blood stained. If the fluid is tested with a labstix (little point in routine practice) then it will usually contain small amounts of blood. A microdocechtomy may be performed.
A 2 day old baby is noted to have voiding difficulties and on closer inspection is noted to have hypospadias. Which of the following abnormalities is most commonly associated with the condition?
A. Cryptorchidism
B. Diaphragmatic hernia
C. Ventricular - septal defect
D. Bronchogenic cyst
E. Atrial septal defect
Theme from January 2012 Exam
Hypospadias most commonly occurs as an isolated disorder. Associated urological abnormalities may be seen in up to 40% of infants, of these cryptorchidism is the most frequent (10%).
Theme: Liver lesions
A. Cystadenoma B. Hydatid cyst
C. Amoebic abscess D. Mesenchymal hamartoma
E. Liver cell adenoma F. Cavernous haemangioma
Please select the most likely lesion for the scenario given. Each option may be used once, more than once or not at all.
10. A 38 year old lady presents with right upper quadrant pain and nausea. She is otherwise well and her only medical therapy is the oral contraceptive pill which she has taken for many years with no ill effects. Her liver function tests are normal. An ultrasound examination demonstrates a hyperechoic well defined lesion in the left lobe of the liver which measures 14 cm in diameter.
The correct answer is Cavernous haemangioma
Cavernous haemangioma often presents with vague symptoms and signs. They may grow to considerable size. Liver function tests are usually normal. The lesions are typically well defined and hyperechoic on ultrasound. A causative link between OCP use and haemangiomata has yet to be established, but is possible.
11. A 37 year old lady presents with right upper quadrant pain and nausea. She is otherwise well and her only medical therapy is the oral contraceptive pill which she has taken for many years with no ill effects. Her liver function tests and serum alpha feto protein are normal. An ultrasound examination demonstrates a 4cm non encapsulated lesion in the right lobe of the liver which has a mixed echoity and heterogeneous texture.
The correct answer is Liver cell adenoma
Liver cell adenomas are linked to OCP use and 90% of patients with liver cell adenomas have used the OCP. Liver function tests are often normal. The lesions will typically have a mixed echoity and heterogeneous texture.
12. A 38 year old shepherd presents to the clinic with a 3 month history of malaise and right upper quadrant pain. On examination he is mildly jaundiced. His liver function tests demonstrate a mild elevation in bilirubin and transaminases, his full blood count shows an elevated eosinophil level. An abdominal x-ray is performed by the senior house officer and demonstrates a calcified lesion in the right upper quadrant of the abdomen.
Hydatid cyst
Similar theme in September 2011 Exam
Hyatid disease is more common in those who work with sheep or dogs. Liver function tests maybe abnormal and an eosinophilia is often present. Plain radiographs may reveal a calcified cyst wall
A 5 year old boy presents to the clinic with short stature suggestive of achondroplasia. What is the genetic basis of this condition?
A. X linked defect
B. Y linked defect
C. YY linked defect
D. Autosomal dominant defect
E. Autosomal recessive defect
Theme from April 2013 Exam
A 58 year old man has been suffering from mechanical back pain for several years. One morning he awakes from sleep and feels a sudden onset of pain in his back radiating down his left leg. Which of the following events is most likely to account for his symptoms?
A. Prolapse of inner annulus fibrosus
B. Prolapse of outer annulus fibrosus
C. Prolapse of nucleus pulposus
D. Rupture of the ligamentum flavum
E. None of the above
Theme from 2009 Exam
Theme from September 2012 Exam
A 34 year old man presents to the surgical clinic 8 months following a laparotomy for a ruptured spleen. He complains of a nodule in the centre of his laparotomy wound. This is explored surgically and a stitch granuloma is found and excised. From which of the following cell types do granulomata arise?
A. Polymorpho nucleocytes
B. Plasma cells
C. Reed- Sternberg cells
D. Platelets
E. Macrophages
Granulomas are organised collections of macrophages
Theme from 2011 Exam
A 72 year old man has just undergone an emergency repair for a ruptured abdominal aortic aneurysm. Pre operatively he was taking aspirin, clopidogrel and warfarin. Intra operatively he received 5000 units of unfractionated heparin prior to application of the aortic cross clamp. His blood results on admission to the critical care unit are as follows:
Full blood count Hb 8 g/dl
Platelets 40 * 109/l
WBC 7.1 * 109/l
• His fibrin degradation products are measured and found to be markedly elevated. Which of the following accounts for these results?
A. Anastomotic leak
B. Disseminated intravascular coagulation
C. Heparin induced thrombocytopenia
D. Adverse effect of warfarin
E. Adverse effects of antiplatelet agents
Theme from April 2012 Exam
A 23 year old man presents to the surgical clinic with an inguinal hernia. On examination he has a small direct hernia. However, you also notice that he has pigmented spots around his mouth, on his palms and soles. In his history he underwent a reduction of an intussusception aged 12 years. Which of the following lesions is most likely to be identified if a colonoscopy were performed?
A. Hamartomas
B. Tubulovillous adenoma
C. Colorectal cancer
D. Crohns disease
E. Hyperplastic polyps
Theme from April 2012 Exam
Theme from January 2013 Exam
He is most likely to have Peutz-Jeghers syndrome which is associated with Hamartomas.
A 56 year old surgeon has been successfully operating for many years. Over the past few weeks she has begun to notice that her hands are becoming blistering and weepy. A latex allergy is diagnosed. Which of the following pathological processes accounts for this scenario?
A. Type 1 hypersensitivity reaction
B. Type 2 hypersensitivity reaction
C. Type 4 hypersensitivity reaction
D. Type 3 hypersensitivity reaction
E. None of the above
Hypersensitivity reactions:
ACID
type 1 --Anaphylactic
type 2 --Cytotoxic
type 3 --Immune complex
type 4 --Delayed hypersensitivity
Theme from 2012 Exam
A 43 year old man presents with haemoptysis and is diagnosed as having tuberculosis. Which of the cell types listed below will usually internalise the tubercule bacullis?
A. Fibroblast
B. Neutrophil
C. Erythrocyte
D. Macrophage
E. Eosinophil
Theme from January 2013 Exam
Which of these tumour markers is most helpful in identifying an individual with hepatocellular carcinoma?
A. Serum AFP
B. Serum CA19-9
C. CEA
D. Beta HCG
E. CA125
Theme from September 2011 Exam
Theme: Renal stones
A. Calcium oxalate B. Uric acid
C. Cystine D. Struvite
E. Calcium phosphate
Please select the most likely stone type for each of the following urinary tract stone scenarios. Each option may be used once, more than once or not at all.
34. A 73 year old lady is undergoing chemotherapy for treatment of acute leukaemia. She develops symptoms of renal colic. Her urine tests positive for blood. A KUB x-ray shows no evidence of stones.
Uric acid
Chemotherapy and cell death can increase uric acid levels. In this acute setting the uric acid stones are unlikely to be coated with calcium and will therefore be radiolucent.
35. A 16 year old boy presents with renal colic. His parents both have a similar history of the condition. His urine tests positive for blood. A KUB style x-ray shows a relatively radiodense stone in the region of the mid ureter.
The correct answer is Cystine
Cystine stones are associated with an inherited metabolic disorder.
36. A 43 year old lady with episodes of recurrent urinary tract sepsis presents with a staghorn calculus of the left kidney. Her urinary pH is 7.3. A KUB x-ray shows a faint outline of the calculus.
The correct answer is Struvite
Theme from April 2012 Exam
Chronic infection with urease producing enzymes can produce an alkaline urine with formation of struvite stone.
A pathologist is examining a histological section and identifies Hassall's corpuscles. With what are they most commonly associated?
A. Follicular carcinoma of the thyroid
B. Medulla of the thymus
C. Medulla of the spleen
D. Medulla of the kidney
E. Fundus of the stomach
Theme from 2010 Exam
Theme from January 2013 Exam Theme from April 2013 Exam
A 32 year old man is involved in a house fire and sustains extensive partial thickness burns to his torso and thigh. Two weeks post operatively he develops oedema of both lower legs. The most likely cause of this is:
A. Iliofemoral deep vein thrombosis
B. Venous obstruction due to scarring
C. Hypoalbuminaemia
D. Excessive administration of intravenous fluids
E. None of the above
Theme from 2009 Exam
A 45 year old lady has recently undergone a thyroidectomy for treatment of medullary thyroid cancer. Which of the following tumour markers is used clinically to screen for recurrence?
A. Free T3
B. Thyroglobulin
C. Calcitonin
D. Free T4
E. Thyroid stimulating hormone
Theme from 2011 Exam
A 22 year old man is kicked in the head during a rugby match. He is temporarily concussed, but then regains consciousness. Half an hour later he develops slurred speech, ataxia and loses consciousnesses. On arrival in hospital he is intubated and ventilated. A CT Scan is performed which shows an extradural haematoma. What is the most likely cause?
A. Basilar artery laceration
B. Middle meningeal artery laceration
C. Laceration of the sigmoid sinus
D. Laceration of the anterior cerebral artery
E. Laceration of the middle cerebral artery
Theme based on September 2011 Exam
Theme from April 2013 Exam
A baby is born by normal vaginal delivery at 39 weeks gestation. Initially all appears well and then the clinical staff become concerned because the baby develops recurrent episodes of cyanosis. These are worse during feeding and improve dramatically when the baby cries. The most likely underlying diagnosis is:
A. Choanal atresia
B. Oesophageal reflux
C. Tetralogy of Fallot
D. Oesophageal atresia
E. Congenital diaphragmatic hernia
Theme from 2011 exam
Theme from April 2013 Exam
A 20 year old man is involved in a road traffic accident. Following the incident he is unable to extend his wrist. However, this improves over the following weeks. Which type of injury is he most likely to have sustained?
A. Radial nerve neurotmesis
B. Radial nerve neuropraxia
C. Axillary nerve axonotmesis
D. Ulnar nerve neuropraxia
E. Ulnar nerve axonotmesis
Theme from April 2011 Exam
Transient loss of function makes neuropraxia the most likely injury. The wrist extensors are innervated by the radial nerve making this the most likely site of injury.
Theme: Thyroid neoplasms
A. Follicular carcinoma B. Anaplastic carcinoma
C. Medullary carcinoma D. Papillary carcinoma
E. Lymphoma F. Hashimotos thyroiditis
G. Graves disease
For the following histological descriptions please select the most likely underlying thyroid
neoplasm. Each option may be used once, more than once or not at all.
51. A 22 year old female undergoes a thyroidectomy. The resected specimen shows a non
encapsulated tumour with papillary projections and pale empty nuclei.
Papillary carcinoma
Theme from April 2012
The presence of papillary structures together with the cytoplasmic features described is strongly suggestive of papillary carcinoma. They are seldom encapsulated.
52. A thyroidectomy specimen from a 43 year old lady shows a mass with prominent oxyphil cells and scanty thyroid colloid.
The correct answer is Follicular carcinoma
Hurthle cell tumours are a variant of follicular neoplasms in which oxyphil cells predominate. They have a poorer prognosis than conventional follicular neoplasms
53. A 32 year old lady undergoes a thyroidectomy for a mild goitre. The resected specimen shows an intense lymphocytic infiltrate with acinar destruction and fibrosis.
Hashimotos thyroiditis
Lymphocytic infiltrates and fibrosis are typically seen in Hashimotos thyroiditis. In Lymphoma only dense lymphatic type tissue is usually present.
From which of the following cell types do giant cells most commonly originate?
A. Neutrophils
B. Myofibroblasts
C. Fibroblasts
D. Macrophages
E. Goblet cells
Theme from September 2011 and 2009 Exam
A 43 year old lady with hypertension is suspected of having a phaeochromocytoma. Which of the following investigations is most likely to be beneficial in this situation?
A. Dexamethasone suppression test
B. Urinary 5-Hydroxyindoleacetic Acid (5-HIAA)
C. Histamine provocation test
D. Tyramine provocation test
E. Urinary vanillymandelic acid measurements
Theme from September 2011 Exam
Theme from September 2012 Exam
A 46 year old lady presents with symptoms of diarrhoea, weight loss of 10 Kg and a skin rash of erythematous blisters involving the abdomen and buttocks. The blisters have an irregular border and both intact and ruptured vesicles. What is the most likely diagnosis?
A. Colonic adenocarcinoma
B. Pancreatic adenocarcinoma
C. Tropical sprue
D. Glucagonoma
E. Insulinoma
Theme from September 2011 Exam
Theme from September 2012 Exam
Glucagonoma is strongly associated with necrolytic migratory erythema.
A 56 year old man presents with symptoms of neuropathic facial pain and some weakness of the muscles of facial expression on the right side. On examination he has a hard mass approximately 6cm anterior to the right external auditory meatus. What is the most likely diagnosis?
A. Pleomorphic adenoma
B. Adenocarcinoma
C. Mucoepidermoid carcinoma
D. Adenoid cystic carcinoma
E. Lymphoma
Theme from September 2011 Exam
The patient is most likely to have a malignant lesion within the parotid. Of the malignancies listed; adenoid cystic carcinoma has the greatest tendency to perineural invasion.
A 45 year old women with a thyroid carcinoma undergoes a total thyroidectomy. The post operative histology report shows a final diagnosis of medullary type thyroid cancer. Which of the tests below is most likely to be of clinical use in screening for disease recurrence?
A. Serum CA 19-9 Levels
B. Serum thyroglobulin levels
C. Serum PTH levels
D. Serum calcitonin levels
E. Serum TSH levels
Theme from September 2012 Exam
A 56 year old man has undergone a radical nephrectomy. The pathologist bisects the kidney and identifies a pink fleshy tumour in the renal pelvis. What is the most likely disease?
A. Renal cell carcinoma
B. Transitional cell carcinoma
C. Angiomyolipoma
D. Phaeochromocytoma
E. Renal adenoma
Most renal tumours are yellow or brown in colour. TCC's are one of the few tumours to appear pink.
Theme from April 2012
73 year old man presents with haemoptysis and is suspected of suffering from lung cancer. On examination he has an enlarged supraclavicular lymph node. Which of the following features is most likely to be present on histological examination?
A. Increased mitoses
B. Apoptosis
C. Barr Bodies
D. Multinucleate giant cells
E. Granuloma
Theme from 2011 Exam
Increased mitoses are commonly seen in association with malignant transformation of cells. Apoptosis is not a common feature of metastatic cancer. Barr Bodies are formed during X chromosome inactivation in female somatic cells.
Which of the following pathological explanations best describes the initial pathological processes occurring in an abdominal aortic aneurysm in an otherwise well 65 year old, hypertensive male?
A. Loss of elastic fibres from the adventitia
B. Loss of collagen from the adventitia
C. Loss of collagen from the media
D. Loss of elastic fibres from the media
E. Decreased matrix metalloproteinases in the adventitia
Theme from April 2012 Exam Theme from April 2013 Exam
A 28 year old lady has a malignant melanoma removed from her calf. Which of the following pathological criteria carries the greatest prognostic weighting?
A. Vascular invasion
B. Abnormal mitoses
C. Breslow thickness
D. Perineural invasion
E. Lymphocytic infiltrates Theme from April 2012 Exam
A 20 year old girl presents with a thyroid cancer, she is otherwise well with no significant family history. On examination she has a nodule in the left lobe of the thyroid with a small discrete mass separate from the gland itself. Which of the following is the most likely cause?
A. Follicular carcinoma
B. Anaplastic carcinoma
C. Medullary carcinoma
D. Papillary carcinoma
E. B Cell Lymphoma Theme from September 2011 Exam
A 28 year old lady is breast feeding her first child. She presents with discomfort of the right breast. Clinical examination demonstrates erythema and an area that is fluctuant. Aspiration and culture of the fluid is most likely to demonstrate infection with which of the following organisms?
A. Clostridium perfringens
B. Staphylococcus aureus
C. Streptococcus pyogenes
D. Staphylococcus epidermidis
E. Actinomycosis Theme from 2013, 2010 and 2009 Exam
Staphylococcus aureus is the commonest cause. The infants mouth is usually the source as it damages the nipple areolar complex allowing entry of bacteria.
Theme: Tumour markers
A. Invasive ductal carcinoma of the breast B. Prostate cancer
C. Gastric cancer D. Ovarian cancer
E. Colorectal cancer F. Pancreatic adenocarcinoma
G. Seminoma testicular cancer H. Non-seminomatous testicular cancer
I. Hepatocellular carcinoma
For each tumour marker please select the most likely underlying malignancy. Each option may be used once, more than once or not at all.
77. Raised beta-human chorionic gonadotropin with a raised alpha-feto protein level
Non-seminomatous testicular cancer
Theme from April 2012 Exam
A raised alpha-feto protein level excludes a seminoma
78. Elevated CA 19-9
Pancreatic adenocarcinoma
79. Raised alpha-feto protein level in a 54-year-old woman
Hepatocellular carcinoma
Theme from January 2013 exam
A 56 year old man is diagnosed as having a glioma. From which of the following cell types do these tumours usually originate?
A. Astrocytes
B. Oligodendrocytes
C. Ependymal cells
D. Squamous cells
E. Neuroglial cells
Theme from January 2012 Exam
Gliomas originate from glial (otherwise known as neuroglial) cells. These serve a structural function in the CNS. The tumours produced may resemble a number of CNS cell types. Tumours are therefore named according to the cells they resemble rather than the origin. Where this is not possible they are termed gliomas.
مهم جدا
A 63 year old man finds that he has to stop walking after 100 yards due to bilateral calf pain. He finds that bending forwards and walking up hill helps. He is able to ride a bike without any pain. What is the most likely underlying cause?
A. Lumbar canal stenosis
B. Diabetic neuropathy
C. Aorto-iliac occlusion
D. Occlusion of the superficial femoral artery
E. Pelvic rheumatoid arthritis
Theme from April 2012 Exam
Theme from April 2013 Exam
The positional nature of the pain and the fact that improves with walking uphill makes an underlying vascular aetiology far less likely.
A 73 year old lady is admitted for a laparoscopic cholecystectomy. During her pre-operative assessment it is noted that she is receiving furosemide for the treatment of hypertension. Approximately what proportion of the sodium that is filtered at the glomerulus will be subsequently excreted?
A. Up to 25%
B. Upt to 75%
C. Between 3 and 5%
D. 4cm in diameter are malignant
Theme from 2011 Exam
Incidentalomas of the adrenal gland are common and represent the most likely lesion in this scenario.Clearly the other lesions are all possibilities but are unlikely.
Theme: Chest pain
A. Pulmonary embolism B. Acute exacerbation asthma
C. Physiological D. Mitral valve stenosis
E. Aortic dissection F. Mitral regurgitation
G. Bronchopneumonia H. Tuberculosis
I. None of the above
What is the most likely diagnosis for the scenario given? Each option may be used once, more than once or not at all.
47. A 28 year old Indian woman, who is 18 weeks pregnant, presents with increasing shortness of breath, chest pain and coughing clear sputum. She is apyrexial, blood pressure is 140/80 mmHg, heart rate 130 bpm and saturations 94% on 15L oxygen. On examination there is a mid diastolic murmur, there are bibasal crepitations and mild pedal oedema. She suddenly deteriorates and has a respiratory arrest. Her chest x-ray shows a whiteout of both of her lungs.
The correct answer is Mitral valve stenosis
Mitral stenosis is the commonest cause of cardiac abnormality occurring in pregnant women.Mitral stenosis is becoming less common in the UK population, however should be
considered in women from countries were there is a higher incidence of rheumatic heart
disease. Mitral stenosis causes a mid diastolic murmur which may be difficult to auscultate unless the patient is placed into the left lateral position. These patients are at risk of atrialfibrillation (up tp 40%), which can also contribute to rapid decompensation. Physiologicalchanges in pregnancy may cause an otherwise asymptomatic patient to suddenly deteriorate. Balloon valvuloplasty is the treatment of choice.
48. A 28 year old woman, who is 30 weeks pregnant, presents with sudden onset chest pain associated with loss of consciousness. Her blood pressure is 170/90 mmHg, saturations on 15L oxygen 93%, heart rate 120 bpm and she is apyrexial. On examination there is an early diastolic murmur, occasional bibasal creptitations and mild peal oedema. An ECG shows ST elevation in leads II, III and aVF.
Aortic dissection
Aortic dissection is associated with the 3rd trimester of pregnancy, connective tissue disorders (Marfan's, Ehlers- Danlos) and bicuspid valve. Patients may complain of a tearing chest pain or syncope. Clinically they may be hypertensive. The right coronary artery may become involved in the dissection, causing myocardial infarct in up to 2% cases (hence ST elevation in the inferior leads). An aortic regurgitant murmur may be auscultated.
49. A 28 year old woman, who is 18 weeks pregnant, presents with sudden chest pain. Her blood pressure is 150/70 mmHg, saturations are 92% on 15L oxygen and her heart rate is 130 bpm.There are no murmurs and her chest is clear. There is signs of thrombophlebitis in the left leg.
Pulmonary embolism
Chest pain, hypoxia and clear chest on auscultation in pregnancy should lead to a high
suspicion of pulmonary embolism.
Theme question in September 2011 exam
Pregnant women can decompensate rapidly from cardiac compromise.
A 63 year old man has a history of claudication that has been present for many years. He is recently evaluated in the clinic and a duplex scan shows that he has an 85% stenosis of the superficial femoral artery. Two weeks later he presents with a 1 hour history of severe pain in his leg. On examination he has absent pulses in the affected limb and it is much cooler than the contra-lateral limb. Which processbest accounts for this presentation?
A. Thrombosis
B. Embolus
C. Atheroma growth
D. Sub intimal dissection
E. Anaemia
Theme from April 2012 Exam
A 55 year old man undergoes a colonoscopy and a colonic polyp is identified. It has a lobular appearance and is located on a stalk in the sigmoid colon. Which of the processes below best accountsfor this disease?
A. Apoptosis
B. Metaplasia
C. Dysplasia
D. Calcification
E. Degeneration
Theme from April 2012 Exam
Most colonic polyps described above are adenomas. These may have associated dysplasia. The more high grade the dysplasia the greater the level of clinical concern.
Theme: Paediatric ano-rectal disorders
A. Ulcerative colitis B. Juvenile polyps
C. Haemorroids D. Intussceception
E. Rectal cancer F. Anal fissure
G. Arteriovenous malformation
Please select the most likely cause for the condition described. Each option may be used once, more than once or not at all.
79. A 4 year old boy is brought to the clinic. He gives a history of difficult, painful defecation with bright red rectal bleeding.
Anal fissure
Theme from April 2012 Exam
Painful rectal bleeding in this age group is typically due to a fissure. Treatment should include stool softeners and lifestyle advice.
80. A 2 year old has a history of rectal bleeding. The parents notice that post defecation, a cherry red lesion is present at the anal verge.
The correct answer is Juvenile polyps
Theme from September 2012 Exam
These lesions are usually hamartomas and this accounts for the colour of the lesions. Although the lesions are not themselves malignant they serve as a marker of an underlying polyposis disorder.
81. A 12 year old is brought to the colorectal clinic with a history of rectal bleeding, altered bowel habit, weight loss and malaise. Abdominal examination is normal.
Ulcerative colitis
The systemic features in the history are strongly suggestive of inflammatory bowel disease
rather than the other causes.
Which of the following processes facilitates phagocytosis?
A. Apoptosis
B. Opsonisation
C. Proteolysis
D. Angiogenesis
E. Necrosis
Theme from 2008 Exam
A 70 year old male presents with painless frank haematuria. Clinical examination is unremarkable. Routine blood tests reveal a haemoglobin of 18g/dl but are otherwise normal. What is the most likely underlying diagnosis?
A. Squamous cell carcinoma of the bladder
B. Adenocarcinoma of the prostate
C. Adenocarcinoma of the kidney
D. Wilms tumour
E. Transitional cell carcinoma of the renal pelvis Theme from April 2012 Exam
Polycythaemia is a recognised feature of renal cell carcinoma. Wilms tumours most commonly occur in children.
A newborn infant is noted to have a unilateral cleft lip only. What is the most likely explanation for this process?
A. Incomplete fusion of the second branchial arch
B. Incomplete fusion of the nasolabial muscle rings
C. Incomplete fusion of the first branchial arch
D. Incomplete fusion of the third branchial arch
E. Incomplete fusion of the secondary palate
Theme from April 2012 Exam
Unilateral isolated cleft lip represents a failure of nasolabial ring fusion. It is not related to branchial arch fusion. Arch disorders have a far more profound phenotype and malformation sequences.
Which of the following tumours are most likely to give rise to para-aortic nodal metastasis early?
A. Ovarian
B. Bladder
C. Rectal
D. Caecal
E. Cervical Theme from 2009 Exam
Ovarian tumours are supplied by the ovarian vessels, these branch directly from the aorta.
The cervix drains to the internal and external iliac nodes.
A splenectomy increases the risk of infection from all the following organisms except?
A. Pneumococcus
B. Klebsiella
C. Haemophilus influenzae
D. Staphylococcus aureus
E. Neisseria meningitidis
Theme from 2010 Exam
Theme: Pharyngitis
A. Infectious mononucleosis B. Acute bacterial tonsillitis C. Quinsy D. Lymphoma
E. Diptheria
Please select the most likely underlying cause for the following patients presenting with pharyngitis. Each option may be used once, more than once or not at all.
4. An 8 year old child presents with enlarged tonsils that meet in the midline and are covered with a white film that bleeds when you attempt to remove it. He is pyrexial but otherwise well.
The correct answer is Acute bacterial tonsillitis
Theme from April 2012 Exam
In acute tonsillitis the tonsils will often meet in the midline and may be covered with a
membrane. Individuals who are systemically well are unlikely to have diptheria.
5. A 10 year old child presents with enlarged tonsils that meet in the midline. Oropharyngeal examination confirms this finding and you also notice peticheal haemorrhages affecting the oropharynx. On systemic examination he is noted to have splenomegaly.
The correct answer is Infectious mononucleosis
A combination of pharyngitis and tonsillitis is often seen in glandular fever. Antibiotics
containing penicillin may produce a rash when given in this situation, leading to a mistaken label of allergy.
6. A 19 year old man has had a sore throat for the past 5 days. Over the past 24 hours he has notices increasing and severe throbbing pain in the region of his right tonsil. He is pyrexial and on examination he is noted to have a swelling of this area.
Quinsy
Unilateral swelling and fever is usually indicative of quinsy. Surgical drainage usually
produces prompt resolution of symptoms.
Theme: Thyroid disorders
A. Sick euthyroid B. Hyperthyroidism
C. Hypothyroidism D. Normal euthyroid
E. Anxiety state F. Factitious hyperthyroidism
For each of the scenarios please match the scenario with the most likely underlying diagnosis. Each answer may be used once, more than once or not at all.
10. A 33 year old man is recovering following a protracted stay on the intensive care unit recovering from an anastomotic leak following a difficult Trans hiatal oesophagectomy. His progress is slow,and the intensive care doctors receive the following thyroid function test results:
TSH 1.0 u/L
Free T4 8
T3 1.0 (1.2-3.1 normal)
Sick euthyroid
Theme from April 2012 Exam
Sick euthyroid syndrome is caused by systemic illness. With this, the patient may have an
apparently low total and free T4 and T3, with a normal or low TSH. Note that the levels are only mildly below normal.
11. A 28 year old female presents to the general practitioner with symptoms of fever and diarrhoea. As part of her diagnostic evaluation the following thyroid function tests are obtained:
TSH < 0.01
Free T4 30
T3 4.0
Hyperthyroidism
The symptoms are suggestive of hyperthyroidism. This is supported by the abnormal blood results; suppressed TSH with an elevated T3 and T4.
12. A 19 year old lady presents with palpitations. The medical officer takes a blood sample for thyroid function tests. The following results are obtained:
TSH > 6.0
Free T4 20
T3 2.0
The correct answer is Hypothyroidism
An elevated TSH with normal T4 indicates partial thyroid failure. This is caused by Hashimotos, drugs (lithium, antithyroids) and dyshormogenesis.
Theme: Cardiac murmurs
A. Pulmonary stenosis B. Mitral regurgitation
C. Tricuspid regurgitation D. Aortic stenosis
E. Mitral stenosis F. Aortic sclerosis
What is the most likely cause of the cardiac murmur in the following patients? Each option may be used once, more than once or not at all.
18. A 35 year old Singaporean female attends a varicose vein pre operative clinic. On auscultation a mid diastolic murmur is noted at the apex. The murmur is enhanced when the patient lies in the left lateral position.
Mitral stenosis
Theme from September 2011 exam
A mid diastolic murmur at the apex is a classical description of a mitral stenosis murmur. The most common cause is rheumatic heart disease. Complications of mitral stenosis include atrial fibrillation, stroke, myocardial infarction and infective endocarditis.
19. A 22 year old intravenous drug user is found to have a femoral abscess. The nursing staff contact the on call doctor as the patient has a temperature of 39oC. He is found to have a pan systolic murmur loudest at the left sternal edge at the 4th intercostal space.
Tricuspid regurgitation
Intravenous drug users are at high risk of right sided cardiac valvular endocarditis. The
character of the murmur fits with a diagnosis of tricuspid valve endocarditis.
20. An 83 year old woman is admitted with a left intertrochanteric neck of femur fracture. On examination the patient is found to have an ejection systolic murmur loudest in the aortic region. There is no radiation of the murmur to the carotid arteries. Her ECG is normal.
The correct answer is Aortic sclerosis
The most likely diagnosis is aortic sclerosis. The main differential diagnosis is of aortic
stenosis, however as there is no radiation of the murmur to the carotids and the ECG is
normal, this is less likely.
A 33 year old man is involved in a road traffic accident. He is initially stable and transferred to the accident and emergency department. On arrival he is catheterised. One minute later he becomes hypotensive, with evidence of angioedema surrounding his penis. What is the most likely explanation for this event?
A. Type V latex hypersensitivity reaction
B. Type IV latex hypersensitivity reaction
C. Type III latex hypersensitivity reaction
D. Type I latex hypersensitivity reaction
E. Type II latex hypersensitivity reaction
Theme from January 2013 exam
Theme from April 2012 Exam
A 52 year old man with dyspepsia is found to have a duodenal ulcer. A CLO test is taken and is positive.Which statement relating to the likely causative organism is false?
A. It is a gram negative organism
B. It lives only on gastric type mucosa
C. It may occupy areas of ectopic gastric metaplasia
D. In patients who are colonised there is commonly evidence of fundal gastritis on
endoscopy
E. It produces a powerful urease that forms the basis of the Clo test
Theme from January 2011 Exam
Helicobacter pylori accounts for >75% cases of duodenal ulceration. It may be diagnosed with either serology, microbiology, histology or CLO testing. Helicobacter pylori rarely produces any typical features on endoscopy. Where infection is suspected the easiest course of action is to take an antral biopsy for Clo testing in the endoscopy suite.
A 13 month old boy is brought to the surgical clinic by his mother because his left testicle is not located in the scrotum. At which of the following sites would the testicle be located if it were an ectopic testis?
A. Canalicular
B. Inguinal
C. External inguinal ring
D. Superficial inguinal pouch
E. High scrotal
Theme from September 2011 Exam
Theme from January 2012 Exam
Ectopic testes are those that come to lie outside the normal range of embryological descent (i.e. in the superficial inguinal pouch). Other sites of ectopic testes include; base of penis, femoral and perineal.
Theme: Causes of chest pain
A. Pulmonary embolism B. Anterior myocardial infarction
C. Inferior myocardial infarction D. Proximal aortic dissection
E. Distal aortic dissection F. Boerhaave Syndrome
G. Mallory weiss tear H. Perforated gastric ulcer
Please select the most likely cause of chest pain for the scenario given. Each option may be used once, more than once or not at all.
67. A 52 year old male presents with tearing central chest pain. On examination he has an aortic regurgitation murmur. An ECG shows ST elevation in leads II, III and aVF.
The correct answer is Proximal aortic dissection
Theme from 2011 Exam
An inferior myocardial infarction and AR murmur should raise suspicions of an ascending aorta dissection rather than an inferior myocardial infarction alone. Also the history is more suggestive of a dissection. Other features may include pericardial effusion, carotid dissection and absent subclavian pulse.
68. A 52 year old male presents with central chest pain and vomiting. He has drunk a bottle ofvodka. On examination there is some mild crepitus in the epigastric region.
The correct answer is Boerhaave Syndrome
The Mackler triad for Boerhaave syndrome: vomiting, thoracic pain, subcutaneous
emphysema. It commonly presents in middle aged men with a background of alcohol abuse.
69. A 52 year old male presents with central chest pain. On examination he has an mitral
regurgitation murmur. An ECG shows ST elevation in leads V1 to V6. There is no ST
elevation in leads II, III and aVF.
Anterior myocardial infarction
The most likely diagnosis is an anterior MI. As there are no ST changes in the inferior leads, aortic dissection is less likely.
An 18 month old boy presents with recurrent urinary tract infections. As part of the diagnostic work-uphe is noted to have abnormal renal function. An ultrasound scan is performed and shows bilateral hydronephrosis. What is the most likely underlying diagnosis?
A. Urethral valves
B. Meatal stenosis
C. Hydronephrosis
D. Pelvico-ureteric junction obstruction
E. Benign prostatic hyperplasia
Theme from April 2012 Exam
A posterior urethral valve is an obstructive, developmental uropathy that usually affects male infants (incidence 1 in 8000). Diagnostic features include bladder wall hypertrophy, hydronephrosis and bladder diverticula.
A 78 year old lady presents with a tender swelling in her right groin. On examination there is a tender swelling that lies lateral to the pubic tubercle. It has a cough impulse. What is the most likely underlying diagnosis?
A. Thrombophlebitis of the great saphenous vein
B. Femoral hernia
C. Thrombophlebitis of saphena varix
D. Inguinal hernia
E. Obturator hernia
Theme from April 2012 Exam
Whilst a thrombophlebitis of a saphena varix may cause a tender swelling at this site, it would not usually be associated with a cough impulse.
A 22 year old man undergoes a splenectomy for an iatrogenic splenic injury. On the second post operative day a full blood count is performed. Which of the following components of the full blood count is the first to be affected ?
A. Erythrocyte count
B. Reticulocyte count
C. Eosinophil count
D. Monocyte count
E. Lymphocyte count
Theme from January 2012 Exam
The granulocyte and platelet count are the first to be affected following splenectomy. Then reticulocytes increase. Although a lymphocytosis and monocytosis are reported, these take several weeks to develop.
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