Surgical Masterclasses

1. Surgical Masterclasses Mr Stephen McLaughlin Semester 9 2010

2.  1. Right upper quadrant pain, jaundice and fever is a characteristic of what clinical problem? a) Biliary colic   b) Acute cholecystitis   c) Cholangitis   d) Pancreatitis

3. 2.You are asked to see a 38 year old woman, on a surgical ward, 8 hours after a laparoscopic cholecystectomy. The nurses report that she has been in some pain and has complained of shortness of breath. A set of arterial blood gases has been drawn while she was breathing room air and the result is as follows – pH 7.48 (NR 7.35-7.45), pO2 105 (NR 80-90), pCO2 25 (NR 30-40). The most likely explanation for the blood gas result is? a) Pneumonia   b) Hyperventilation   c) Pulmonary embolus   d) Asthma   e) Post operative bleeding

4. 3. 10.1 You are called by Microbiology because the tip of a central venous catheter(CVC) you sent 2 days ago has grown gram positive cocci.The patient concerned had developed a fever 6 days post total colectomy. You had not identified a focus for the fever but the CVC had been removed . Blood cultures have subsequently been negative. The correct interpretation of this result is: a) The patient has staphylococcus bacteraemia   b) The patients central line was colonized by staphylococci   c) Incorrect sterile technique was used when the tip was removed   d) The patient has septicaemia

5. 4. Which of the following are not complications of acute pancreatitis? a) Hypoxia   b) Hyperglycaemia   c) Renal Failure   d) Hypercalcaemia

6. 5. Which hernia is most likely to be complicated by bowel ischaemia? a) inguinal   b) umbilical   c) femoral   d) incisional

7. 6. The standard treatment for an inguinal hernia in a 50 year old man who is minimally symptomatic is which of the following? a) Observation with surgery if it enlarges]   b) Sutured repair   c) Open Mesh repair   d) Laparoscopic mesh repair

8. 7.A 16 year old boy presents with acute severe left testicular pain. On examination the left testes is high in the scrotum and exquisitely tender.  This patient needs; a) Intravenous antibiotics   b) Testicular ultrasound   c) Surgical Exploration of the testes   d) Non steroidal anti inflammatory drugs    

9. 8. You are the night intern in casualty when a 57 year old woman with known metastatic breast cancer presents at 4 am. She complains of increasing thoracic back pain over several days not responding to oral analgesia. She doesn’t complain specifically of weakness or bowel or bladder symptoms but on examination there is a sensory level at approximately T9.What is the investigation that this lady needs urgently?

10. 9. A 55 year old woman presents with a 2 cm lump in her right breast. The lump is in the upper outer quadrant and is firm and mobile. No axillary lymphadenopathy is palpable. The most appropriate management is? a) Mastectomy and axillary clearance   b) Lumpectomy and axillary clearance   c) Fine needle aspiration of the lump   d) CT scan of the chest and abdomen   e) Nuclear bone scan

11. 10. A 35 year old medical receptionist presents having found what she thinks may be a breast lump on self breast examination. On examination she has generalized lumpy breasts with no discrete masses present.  Which of the following is the best test to investigate further? a) mammogram   b) ultrasound   c) mammogram and ultrasound   d) CT scan

12. 11. A 50 year old cleaner presents with a lump in the left breast that is both clinically and radiologically suspicious for cancer.   How should a diagnosis best be reached? a) fine needle aspirate and cytology   b) Percutaneous core biopsy   c) Incisional biopsy   d) Excisional biopsy    

13. 12. The most common site for recurrent breast cancer is? a) bone   b) lung   c) liver   d) brain

14. 13. In assessing the prognosis of early breast cancer what is the most important prognostic factor? a) age   b) size   c) grade of tumour   d) receptor status   e) nodal status

15. 14. A 60 year old retired policeman presents with colicky abdominal pain, vomiting and abdominal distension. He is clinically dehydrated. He has a past history of an appendicectomy, hypertension and cataracts.The most appropriate resuscitation fluid for this man is a) 5% Dextrose   b) 5% dextrose with Potassium chloride   c) Normal saline   d) Normal Saline with potassium chloride   e) Synthetic colloid

16. 15. A 59 year old man has presented to Emergency and is found to have a ruptured abdominal aortic aneurysm. Which of the following is most likely? a) Clinical features of an acute abdomen   b) Absent pulses in one leg   c) A tender pulsatile mass in the abdomen   d) A prominent abdominal bruit

17. 16. Which is the best initial investigation to screen for an abdominal aortic aneurysm in a 60 year old man with a strong family history of that condition ? a) Aortogram   b) Abdominal aortic ultrasound   c) CT Scan of the Abdomen   d) Plain abdominal x-ray   e) Ankle brachial index (ABI)    

18. 17. A 70 year old diabetic man presents with calf claudication due to stenosis in the proximal popliteal artery . Which of the following clinical features is most likely? a) Normal femoral pulse, weak popliteal pulse, a bruit in the lower thigh region.   b) No femoral pulse   c) A large popliteal aneurysm   d) A cool paralysed foot

19. 18. A 72 year old man presents with a 4 month history of pain in the left calf while walking that is relieved by rest. He has no pain at rest and is an ex-smoker with a 30 pack year previous history. He is not diabetic, hypertensive or hypercholesterolaemic. On examination his dorsalis pedis and posterior tibial arteries are impalpable bilaterally. His left popliteal artery is weak and the right present. Femoral arteries are palpable and have no bruits. The most appropriate initial investigation is? a) Lower limb angiogram   b) Lower limb doppler   c) Plain X-ray of the left calf   d) CT of the lumbar spine   e) Lower limb nerve conduction studies    

20. 19. Which of the following would be an indication for urgent surgery in small bowel obstruction? a) Previous small bowel obstructions that have settles slowly with conservative management   b) Elderly patients with cardiac or respiratory disease   c) Severe constant pain unrelieved by narcotics   d) Dehydration on arrival in emergency requiring major fluid resuscitation

21. 20. Which of the following characteristics of PR bleeding mandates full investigation   a) Severe pain on defecation   b) Bright red bleeding   c) Blood mixed with bowel action   d) Blood on toilet paper

22. 21. A 54 year old grocer has adenocarcinoma of the colon resected and the pathology reveals 5 nodes positive for disease.    The next most appropriate management is? a) colonoscopy   b) Adjuvant chemotherapy   c) Radiotherapy   d) Observation with 3 monthly CT scans:

23. 22. A 53 year old man Mr Brown presents to your general practice with a 6 month history of reduced urinary stream, nocturia (3/night) and terminal dribbling. The most appropriate next step is a) Perform a Prostatic specific antigen (PSA) test   b) Perform a digital rectal examination   c) Perform a prostatic ultrasound   d) Perform a radionucleide bone scan   e) Perform a pelvic CT scan

24.  23. (part 2)On examination, you discover Mr. Brown has a palpable bladder. He becomes very uncomfortable as you palpate his lower abdomen.    His most immediate problem is likely to be a) urinary tract infection (UTI)   b) bladder tumour   c) constipation   d) acute urinary retention

25. 24. The immediate management is? a) more UTI specific antibiotics   b) referral to surgeons   c) urinary catheterization   d) laxatives

26. 25. The most common complication following urinary catheter insertion is? a) urinary retention   b) urinary tract infection   c) urethral perforation   d) haematuria