SAMSONPLAB ACADEMY

Bow Business Centre

Bow Road 153-159

E3 2SE, London

Telephone: +44(0)2089800039

Mobile:+447940433068

Email: info@samsonplab.co.uk

SURGERY LECTURE NOTES 2016

OVERVIEW OF TOPICS
I. Pre-operative Considerations
11. Post-operative Complications
Ill. Neck Lumps
IV. Breast
V. Mesenteric lschaemia
VI. Limb lschaemia
VI I. Per Rectal Bleed
VIII.Inflammatory Bowel Disease
IX. Varicose Veins
X. Lumps in the Groin
XI. Hernias
XI I. Leg Uleers
XI II.Deep Venous Thrombosis
 XIV. Upper Gastrointestinal Bleeding
XV.Acute Abdomen
XVI. Procedures And Relevant Anatomy In Surgery

I. PRE-OPERATIVE CONSIDERATIONS
PRE-OPERATIVE ASSESSMENT
These are investigations that are done before patient goes to theatre.

All patients who are fit and well must have at least full blood count
done before they go to theatre. This is standard procedure.

INVESTIGATIONS

1. Full blood count: even fit and well patients m_t1st have at least
FBC done
This is to check for Haemoglobin levels

There are 2 types of operations:

A. Elective or planned operation
B. Emergency operation

Normal haemoglobin levels:

• >11.3g/dl in w~men(- 1ro1
• >13.5g/dl in men (- di)

For emergency operations:

• Even if Hb is low, always proceed with emergency operations.
• If Hb <8 g/ dl then transfuse and stabilise first before proceeding.
For elective operations:
• On ly proceed if Hb > 10 g/ dl.
• If Hb < 10 g/ dl then defe the operation and investigate first.
• If Hb <8 g/ dl you must also transfuse.

N.B: f.ib <8g/dl = do blood transfusion

1. ECG if you suspect atrial fibrillation or if irregular pulse (atrial

fibrillation) or history of atrial fibrillation.

1. Echocardiogram: do it if there are signs of valvular qisease or left

( (V\ cJr ·rrHJ r )
ventricular failure

1. Refer for specialist opinion if severe problem e.-g. recurrent

angina attacks (just doing an ECG is not enough)
\ I
, r.. _ =- _ 5. S \"Al'Y'O / L
-\O~J\ '"'--=., - 3 . _,
1. Blood Glucose in diabetes

1. Blood pressure monitoring if nypertensive

1. Respiratory function test if respiratory problem e.g. asthma (do

PEFR) or COPD e:.f1(c,t,,...<?,\t Y

1. All Afro-Caribbean do sickle cell test (sickle cell disease is

common in Afro-Caribbean race) l-t;;. e\ec\, oe'0crre.~i:,

1. IV drug abuser or homosexual: do an HIV test (always take

consent before doing it)
 1. Chest X-Ray: do it if Gardiorespiratory function or age >65

1. Clotting Screen: if with history of easy bleeding after minor

procedures like dental extraction.
b~~ow e pi ·\,ia ,. \::oaj~:\ ? r·ernt c-i.·\,an

PRE-OPERATIVE BOWEL PREPARATION

1. Oesophago-duodensoscopy, ERCP, closure (reversal)
ileostomy: do not require any bowel preparation.
E£C () . f r:t.1'0 1c. (l ,a \ nc.f<
C. \\t \10\ ( ' ' ' ,- C 'e I i
1. Colonscopy, rectoplexy, right or left hemicolectomy,'
pancolectomy, sigmoidectomy, anterior resecti9ri,
abdominoperineal resection, Hartman's reversal - all require
full bowel preparation.
a. Give 1 sachet of Picolax a day bef,er-e surgery at 08:00 and
14:00. Picolax = sodium picosulphate. You can also use
magnesium citrate.
b. Patient can eat low residue foods whilst taking bowel
preparation (\ow fi"oc,)

1. Haemorrhoidectomy, examination under general anaesthesia,

. c ~ flexible sigmoidosco})y, proctoscopy, anal fissure - all require
C)
,;'$-- M sphate enema on the day of surgery
\)~€,,

PRE-OPERAlilVE MEDICATION
1. Aspirin can continue until operation
 (,. s)
Z. Target pre-operative INR for patients on Warfarin is INR <'z.5.
Warfarin must be stopped 5 days before the operation and be -..J{"l.'i"\.
cro~ ·IC> '2. Jo1 01 C1 , ';i
given heparin pre-operatively _L ""' H ~~ ;;- ~~(')' ·
3. In diabetic patients start insulin on the morning of surgery (sliding
f\l\e:\ . r -r,'\ ·, I'\ ~A op ;)-1 'r-l < tefO' c
sea le ) · \ '1"
pu+ i l":5<.) ""
4. Prophylactic Antibiotics against infective Endocarditis should not
be given routinely to people undergoing a dental or surgical
procedure. Instead they should be advised to maintain good oral
hygiene, and told how to recognise signs of infective endocarditis
and advised when to s,eek expe.r t help advice.
7) 19 !'\~ o+ {;:' f \ (" l'C rd, ·\ iJ ., b re{e t

ANTIBIOTIC PROPHLAXIS IN SURGERY (sho_~!~-~~- g~y~!'l a induction

or upto 30mins before surgery) \':-\~\:fe\_
':>, 'TI'\/,~ Pi ~- eel'\
Type of Surgery: Gastric/oesophageal surgery eY'1~\~
l
-b w-,.,·c i I"\

G$J1ef>
. gram -ve bac1"ll1," gra11,
Common Pa th ogens: Ent enc +ve cocCl.
Antibiotic of choice: Single dose ~l}!amicin IV .OR c_
~furoxime C)
IV OR co-amoxiclav IV

Type of Surgery: Colorectal surgery

Common Pathogens: Enteric gram ~ve bacilli, enterococci, anaerobes
Antibiotic of choice: Single dose gentamicin IV + metrcinidazole IV/
PROR
®
cefi.lrox1me IV + metronidazole IV OR
co-am0xiclav IV alone

Type of Surgery: Appendicectomy

Common Pathogens: Enteric gram -ve bacilli, enterococci, anaerobes
Antibiotic of choice: Single dose gentamicin IV + metronidazole IV/
PR OR
 t"efUroxime IV+ metronida;z9le IV,,OR
co-amoxiclav IV alone

Type of Surgery: Biliary surgery (open)

Common Pathogens: Enteric gram -ve bacilli, enterococci, clostridia
Antibiotic of choice: Single dosei~efuroxime IV + metronidazole IV/
PROR
gentamicin IV + metronidazole IV /PR or co-amoxiclav IV
alone

Type of Surgery: ERCP

Common Pathogens: Enteric gram -ve bacilli , enterococci-, clostridia
Antibiotic of choice: Single dose g~ntam1cQ IV OR
ciprofloxacin IV/ PO

Type of Surgery: Vascular surgery

Common Pathogens: S. aureus, S. epidermidis, anaerobes in diabetes,
gangrene, or undergoing amputation
Antibiotic of choice: Single dose cefuroxime
IV OR flucloxa~i_~li11JIV +~ent~_mJc_~n)IV. Add
~~--
etronidazole)for suspected anaerob- e -rnfect1on
··~--- ··- - ,,

Type of Surgery: Lower limb amputation/major trauma

Antibiotic of choice: Co-amoxiclav alone OR (for penicillin allergy)

-
,./cefuroxime IV +metronidazole 400-500 mg tds~
--

TYPE OF OPERATIONS l
A. Day case surgery (patient is not admitted)
 B. Inpatient operation

All patients can have a day case surgery except in the"-following

situation:

1. Mentally retarded or learning disal5ility (may not be able to

recognize the complications)
2. Those who live alone
3. Infection at the site of an operation
4. People with severe heart diseases

II. POST-OPERATIVE COMPLICATIONS

A. General complications
B. Specific complications
C. Wound problems

GENERAL COMPLICATIONS

1. Fever (pyrexia)l causes could be:

a. Pneumonia: (cough, fever, shortness of breath) Usually 48 hours

onwards. Investigation: CXR, roe antibiotics (amoxicillin)
,__
IOLJC'I ~
ho.
h ~ \Q~l__ ,. . ;_("\ C''{""I
) Q.
.
'V...
co :o\, cb·\;Cf' ~~ v ..<;:\J,t,_\oY..0
a. Urinary Tract Infection: commonly due to catheterization. Causes
0i\\
~ confusion in elderly, dysuria, frequency, Investigation: MSU, Rx:
antibiotics (t imethoprim )
 a. Atelectasis: Lum! collapse, common in people who{smoke) Chest
\:,...J ')lcde JI I '1
pain an mild fever. Usually within first 48 hours after an
operation which is close to the lungs especially

-splenectom
- Investigation: CXR to rule out pneumonia,
Rx: ph'ysiotherapy

(j) $ - -~
a:·would infection: Usually after 5 days post op. Presents with
discharge from the wound, redness and tenderness around the
Mc,$
wound, Investigation: WOL!f'l~L~wab, Investigation: Microscopy,
culture and sensitivity. Rx: Antibiotics

a. lntraabdominal abscess - (5-_ubphr~_

Oic abs~ess or subhepatic
abscess) Usually after 5 days post op. Presents wit li swingi ng
l fever. Investigation: ~I~~~~~~~n, USS abdom·en. Rx: Incision
and drainage

a. Anastomotic leak: usually after bowel resection. Any

physiological change after bowel resection is always anastomotic
leak until proven otherwise. Does not immediately occur after the
operation. Develops after patient has started eating and drinking,
usually on day 3-7 post op. b \cef~ ccr\ 1v·9 cw-d Jr 1r\ 1f i''eJ
lnvestigaUon: C abdo en. Rx: Antibiotics broad spectrum IV
immediately (cefuroxime + metronidazole), Laparotom

2. lntraabdominal Bleed - usually few hours after surgery

Management: Laparotomy .. ~ C""IC)VIC-C\I cl1C1
- "'\~-\-{'C\~\O

3. Confusion
 1(ln}ection - .UTI .& P.~g!.Jm9ni~ (especially in elderly) Usually after 5
days post op.

1. Medication e.g opiate usually used during an operation.

4. Hypoxia

1. Alcohol withdrawal = delirium tremens. Usually develops 10-72

hrs after last alcohol intake, usually there is high MCV. Symptoms:
agitated, aggressive, confused, sl~-~{~~, (t:emors,fvis_lJa[ J (~ <vec-;-\._)
1

1 ('I\ .\\,,{'
'OC
{hallucinatioris1 usually insects crawling in blanket. . \
~ ' . ., ~ ~ ·"" J) ( ,(-~:-,,)
ft- c-·, 0 io c:\ ( . '- -- l _( ~Qn/C\ ., i ·- c {-
.\ \ .._ {1f'¥ (C° I f
1. Shortness of breath or dyspnea

a. Pulmonary embolism = chest _pain, haemoptysis, 5 days onwards

after an operation

a. Pulmonary oedema = post operative pulmonary oedema almost

always due to fluid overload -\-;,, _,u(oJ) t,\ ,dt ·

a. Pneumonia

a. Pneumothorax due to ventilation pressure especially if there was

a small pneumothorax. Therefore if a patient has a ~~-l!
Rn~_
umoth_orax a·cne~ drain_must b~. inserted] ,. '·\ I \ :i D }\( \ (_) ·\ ('l

~/)( ~1e<Y
a. Myocardial infarction = chest pain radiating to the left arm.

1 . Hypotension
 a. Post operative hypotension almost always is due to bleeding so
give ·r.,r;r venous fJui'ct .

a. Medical conditions like Myocardial infarction, pulmonary

embolism, sepsis

8. Oliguria
Post operative oliguria is almost always due to inadequate fluid
replacement so give fluids.

9. Anuria
Post operative anuria almost always is aue to blocked catheter ,
so heck Gatheter

10. Post operative hyponatraemia

,..,,- a
oul
1. -~_IADH, especially after brain surgery ,v)
' i,Q( 'o ,c
- 'i -
2. Over bydratio_n, especially with fcoHoids t,.
C:) I 1\D~\ - ::...,,0, o w. c'4 , ' '°'fVt~ \ O ~ - c,r ·1 ~ (' 0\ CJ
f\ \ U< -r\ r:. t-\ O rf\on <2,
1

11. Deep venous thromboembolism ~-. ~, 1 ( , c·

" " ., w, l

Symptoms: unilateral cal swelling, pitting oedema, calf pain

In post operative patients we do not use D-dimer as an investigation.
The investigation of choice is always compression ultrasound scan.
e,-H:J A - rf . en J6 r,>\-ci r-

SPECIFIC POST OPERATIVE COMPLICATIONS

1. Mastectomy
Common complication is lymphoedema (arm becomes swollen)
Management; physiotherapy and arm exercise.
 1. Th roidectomy

a. Recurrent Laryngeal Nerve Palsy, pres,ents with hoarseness of

I
voice, usually resolves after s~i;;~tf~~- ') ct'.":i{ot C\

Management: Jteassurance

a. Tracheal obstruction by haematoma usually presents with acute

csnoYtn·
. - -
ess of breath and -----
- -
strid_g/ immediately after the operation,
commonly when the patient is still\~n lhe ·recovery room.,
Management: release the stitches on bedside

a. Hypocalcaemia usually due to hypoparathyiroidism which causes

(~ypocalcaemia:

Patients presents with tetani,{:Cfr~_~kyg~t_~~~-sc"~ and, -fouseag~'~J

sign (carpopedal spasm), muscle irritability
Checkvostek sign = on tapping on the angle on the jaw there is
twitching of the muscles of the face.
Trouseau's sign = on occluding the brachial artery with an inflated
BP cuff the wrist and fingers flex and draw together (carpopedal
spasm)

4. POST TURP (Transu rethral resection of the prostate) SYNDROME

 <1 ~. " The irrigation fluid used to visualise and distend the urethra and
bladder gains intravascular access through the venous circulation
. ("J ("

0w \ O- causing diluti onal hyponatremia.

°'(> Management: Fluid restriction

5. APPENDICECTOMY
Common complication is abdominal C?tJ?elyic ab_
s~~~s_especially if it's
perforated or gangrene appendicitis. There is usually ~wingjngJ
\ feve~~ Investigation: CT scan abdomen, or abdominal
ultrasound scan. Management: I cision nd dramage.

6. SPLENECTOMY
Spleen takes part in immune system so splenectomy causes low
immune function and patients have recurrent infections.
Prophylaxis vaccination is required against the following infections:
i. Pneumaccocal
ii. Meningococcal
iii. Haemophilus influenza
Patients also require long term antibiotics prophylaxis.

7. ABDOMINAL SURGERY
a) Paralytic ileus usually presents with abdominal distention,
constipatio , vomitin nd reduced 6owel soung~ Occurs ~
..I. ~ pfOt-1'\ C\Q C'\ ~- --- - -- - - ------------- -

:e-Oafter the operation. No abdomi ~a pain

0 Investigation: lflain-a!:>.domina_l~ (dilated bowel loops)
Mgt: Nasal gastric tube and Intravenous fluid.
 a. Obstruction secondary totadbe~iQns..~ffhis will occur after _week~,
r:DQnths or years. Cardinal symptoms: /abdominal pai~, vomiting,
1
constipation, abdominal distension~ i ncreased bo~~L_sounds

1. ERCP
a. Acute pancreatitis - abdominal pain
b. Cholangitis

C. WOUND PROBLEMS
Wound swelling, bleeding or discharge needs inspection/exploration of
the wound.

1. Laparotomy wound dehiscence

Dehiscence of laparotomy wound is spontaneoas opening of deep
suture layers with or without superficial layer
Clinical features:
1. ~eros_anguinou~ discharge from wound
2. Usually 7-10 days post op
Treatment: Resuture wound

1. Wound bleeding
Usually bleeding is minor and settles spontaneously.
Clinical features:
1. Wound~oozing
2. Wound_h~m_ijtQHlc~ omRa! pation
Treatment: If rn.ino_r b_leeding, try gentle pressure for 5 minutes.
If ongoing large amount of bleeding, patient may need to go to
theatre
 1. Superficial wound Infection and Abscess1r
Clinical features:
1. Wound pain
2. Pyrexia
3. Pus like discharge
Treatment: Inspection/exploration of ~ ';.~nd~
0
wqb
If temperature >37.5, take blood cultures, CRP, FBC, UB:E.
If abscess¢ wound di{l_i_oage, take ~Jor microscopy, culture
and sensitivity

Ill. NECK LUMPS

Neck lumps are located either in the anterior triangle,
posterior triangle or midline l):) ir:i \·
1·.~.-.
.....,..__. .. -
-· . ,

Anterior triangle lumps

1. Branchial cyst
2. Carotid body tumour
3. Parotid tumour

Midline lumps
1. Thyroglossal cyst
2. Thyroid lump
3. Dermoid cyst

Posterior triangle lumps

1. Cervical
---·--- .. -rib
~ -
 2. Cy.sttc.hyg_rnm_a_
3.Pharyngeal pouch
4. Subclavian aneurysm

1. BRANCHIAL CYST
Lump containing cholesterol cyrystals located in the anterior triangle.
Usually\f>efore age of 30 years. It emerges under the anterior border
of the sternocleidomastoid muscle where the upper 1/3 meets the
lower 2/3. J J _\ '
Investigation: USS, FNAC
Treatment: Surgical removal

2. Carotid body tumour aka~Chemodec~ ~

Located in anterior triangle. It m9_yes side to side but not up and '° o\'
down. . . -, ' · t>
<
It may be pulsatile but usually does IIJ_
Qt cause bruit. It is located just
anterior to the upper 1/3 of sternocleid9matoid muscle.
(\0~
\ ,O\ ·:-.· \-.J-'J.,
.___<', ' ("

Investigation: QQPP.l~r_US$, arteriography

----·- --·-· -. '

Treatment: Surgical extirpation.

3. Parotid tumour
Located in the anterior triangle at the upper posterior region at the
angle of the jaw.
Usually patient age >40 years
Investigation: USS, mumps test will be negativ
Treatment: Surgical
1J\·,"'Q \u N\f
\ I \
4. Thyroglossal cyst (f'/\1 d ·.v\1 '. ,j ,v1. d rv;, p
- Transillimunating midline lump which ~v~s 9_r:}_ tongue prot._us10n,
but pof
•· · ·· ···
on s wallowing)
. __,,.,. SC> op
Investigation: USS
Treatment: surgical removal

5. Thyroid lump
- Midline lump which[movefon_swalloY-?!ng) but not on tongue
protrusion
Investigation:
1. All patients with thyroid nodules must have TSH measurement.
If low, then measure T4 and T3.
2. USS recommended in patients with atypical solitary nodules
and multiple goiter
a. If it is a CYST then treatment is surgical'removal
b. If it's SOLID then FNAC (Fine needle aspiration cytology).
FNAC is recommended in all patie·nts with solitary
nodules.

IT"HYROID CANCER
Risk factors:
• Pre-existing goiter (boc(o)
• Radiation of neck in childhood

Types including Frequency & Clinical Features

• Papillary (60%) - solitary thyroid nodule
.,
• Follicular (25%) - Slow-growing thyroid mass, symptoms are
usually from distant metastases \Y\O\ pr 1\\/'0., '/)
• Anaplastic (10%) - rapidly growing thyroid mass causing tracheal
and oesophageal compression
 • Medullary (5%) - Thyroid lump, may have MEN II A (medullary
thyroid carcinoma, pheochromocytoma, hyperparathyroidism) or
MEN ii B (medullary thyroid carcinoma, phaeochromocytoma,
multiple mucosal neuromas, Marfanoid habitus) syndrome

Management:
• Papillary
Surgery: total thyroidectomy B: removal of involved lymph
nodes
Adjunctive tx: L-thyroxine to suppress TSH (it stimulates
papillary tumour growth)
Prognosis: Excellent

• Eollicu lar
Surgery: thyroid lobectomy or total thyroidectomy if
metastasis are present
Adjunctive tx: radioactive iodine for distant metastases and
L-thyroxine for replacement therapy to suppress TSH
• Anaplastic
Surgery: \C?rlJi ·paJliaf1Ve to relieve pressure symptoms
No radiotherapy/chemotherapy
Prognosis: Very poor

• Medullary
~)cc:ly_d eJ)haepchrom_o tyoma before treating
Surgery: total thyroidectomy B: excision of regional lymph
nodes

6. Dermoid cyst
 ,J\:
O
\P~
Midline lump that does
... not move on swallowing or tongue protrusion .
If patient is ~ssthan_JO ~ea_rs:1 the dermoid cyst is likely.
Investigation: USS
Treatment: Surgical removal
'10:) ., £-,e-,o~ ~EC.-~ LO fY\P:>
7. Cervical rib =Thoracic outlet syndrome
Located in the posterior triangle.
It is an extension of C-7
It can cause compression of upper arm vein or nerves therefore it can
,'.)it ,<:>r 'r <1
cause tingling and numbness or swelling of the arm. Symptoms depend
on the compressed structure.
Investigation: Cervical spine X-ray
Treatment: Surgkal removal

1. Cystic hygroma
Located on the posterior triangle. These are massively distended
lymphatic vessels. that can cause compression of airway. They present
at birth and transilluminate brightly.
Investigation: USS
Management: Surgical removal

( J ,J Q c \ ,c\ .i\ C') c er\ F er· )

1
1. Pharyngeal pouch
Located in the posterior triangle. It is a diverticulum of the esophagus
which comes out between the inferior pharyngeal constrictor muscles.
(', <,
,t!>...., Symptoms: regurgitation of undigested food particles, halitosis, ,
o oc!O
~ c..c. o t swelling in the neck, b<ci ging in the neck after drinking,dysphagia
tO C

Investigation: If it presents as a mass in the neck then investigation

is USS
 If it presents as a dysphagia then investigation is barium ,mear\-·\
:;;iwn o~

Treatment: surgical

1. Subclavian artery aneurysm

It is a pulsatile mass located n the posterior triangle at the base of
sternocleidomastoid muscle
Investigation: Doppler USS
Treatment: Surgical repair of the aneurysm

IV. BREAST

Symptoms of the breast;

1. Pain
2. Lump
3. Breast cancer
4. Nipple or skin changes
5. Discharge

1. PAIN

Pain in the breast is called mastalgia

Mastalgia can either be cyclical or non cyclical

Cyclical mastalgia - pain occurs every month before periods.

 Mx: reassure patient.

Non Cyclical mastalgia - needs to be investigated just like a lump n

the breast.

1. LUMP IN THE BREAST

All patients with breast lump must undergo triple assessments.

First assessment: Clinical examination of the breast including axillary

lymph nodes.

Second assessment: Imaging

If a woman is < 35 years then perform USS scan only
If she is 35 or above, do mammography first and then USS

Third assessmen.!= Cytology. In either case you have done an

ultrasound scan which will show whether the lump is cyst or solid.

If it's a cyst perform FNAC. Further management depends on the type

of fluid aspirated:
i. if clear fluid just aspirate and reassure the patient.
ii. If blood stained, aspirate send to lab for cytology
iii. If clear fluid but residual mass perform core biopsy.
iv) If the lump is solid perform core biopsy.

EXAMINATION
 'le not attached to underlying structure, (firm in
~c:onsistenc~, smooth surface = it's likely to be fibroadenoma,
especially in a young patient.

If non-mobile lump, hard in consistency, attached to underlying

structure, irregular surface = it's likely carGinoma.

If there are lumps~in ,the axilla it means carcinoma because that is a

sign of metastasis.

If there are no palpable masses the investigation of choice

is stereotactic biopsy. ...,.___J

tumpiness of the breast especially in the upper outer quadrant but no

01')1_..1 - ~ \ ~
dominant mass = Benign Breast Change. Women usually in 30's
presenting with multiple cysts which may be associated with pain or
green brownish discharge from the nipple.
Also called BENIGN BREAST DISEASE, FIBROADENOSIS, FIBROCYSTIC
CHANGE, FIBROCYSTIC BREAST DISEASE,
Management: Triple assessment

Family history=if patient has got no symptoms but just present

because she has got family history of breast cancer then do genetic
testing and counseling.

1. BREAST CANCER
ALL BREAST- LUMPS REQUIRE TRIPl!E ASSESSMENT.

Risk factors
 • Strong family history of breast cancer (genetic factors - BRCA 2
gene)
• Early menarche and late menopause
• Nulliparity

Clinkal Features
• Palpable, hard, irregular, fixed breast lump, usually painless
h t'- c't ::,
• Nipple retraction and skin dimpling
• Nipple eczema in Paget's disease
• Peau d'orange (cutaneous oedema secondary to lymphatic
obstruction)
• Palpable axillary nodes

Investigations: Triple assessment

Treatment: Early breast cancer treatment is aimed at local control

with wide local excision, lymph node treatment and prevention of
systemic relapse.
Treatment of late breast cancer is usually palliative and mostly
medical

1. SKIN CHANGES

1. If nipple skin changes and areola area e.g eGzernatQus changes or

inflammatory changes then it's likely to be Paget's disease,
especially if unilateral. -Q."
Investigation: open biopsy or punch biopsy.,,. 'P
dq· ~,, d µ\

ca c e 'ctop:,'(
\
C')":'n".\orc~ \ . -[) Qx "'t'd . .,')( - s.,JCC:lC I'\

b lO~!; 1
 1. If nipple retraction or peu de orange or ulcer then breast
cancer is the diagnosis.

1. If there is an ulcer on the breast do biopsy of the ulcer. Ulcer

means cancer.

5. DISCHARGE FROM THE NIPPLE

1. ~lood stained discharge can be caused by :
a. Pcilget's disease
b. puct papilloma, esp. if discharge is from the duct, usually
p,ifig~~ QUgj
Investigation: Ductography/ ductogram
a. Breast cancer

1.rCTear]discharge is caused by (mtra uctlPaRill~ll}a (discharge from

the duct).
Investigation: Ductography/ductogram

1~Ora.~_g~i) ellow creamy) green dischar e is caused by duct~~L~1

discharge from, multiple ~uc:ts-. J
Investigation: Ductogram
,· '
ck'.( \n \ ~r:\ r,, 'j 1,:-;
1. Purulent discharge is caused by breast abscess, common in breast
feeding mother. The causative organism is staphylococcus
aureus. Rx: flu cloxacillin.

1. Milk_y discharge is caused by(galact orrhoe '· Causes include

,prolactin-oin~, side effect of(:anti-psychotic medications, and
physiologic in lactating mothers. \"<.:~00~:(;,Jo\
MESENTERIC ISCHAEMIA

Acute Mesenteric lschaemia ..ilV l\

Symptoms:
• Sudden onset of ~ever~abdominal Rain, with~ft abdo}ij~ij is
soft, ~o ~inc:iings on ~xamination of the abdomen.
• Also per rectal bleed
• '5evere hypovolaemia
Risk factors: AF, Ml (mural thrombus), aortic aneurysm, valvular heart
1 . \ / \ - ,. .· . \(' \ -,
disease '(\iv<' ,, ( ("' MJIJ '' ,::· ·,:_,· u • _.,

Cause: Emboli
Investigation: Arteriography.
Management: Intravenous fluids, heparin, gentamicin and
I ~V ,f)\\
metronidazole.

Chronic Mesenteric lschaemia ? \

~ to\ or 'l
\
\0 .(
\
:;1 d {' (i~
\
eo, '(j

Symptoms: Post prandial pain i.e p.ain after eating. Patients lose
weight due to fear of pain after eating. b\Y"~ d· ,\/ 1
, J \ r~~ t -
Risk factors: HTN, DM, high cholesterol ·
Cause: Artherosclerosis
Investigation: Arteriograp·hy
Treatment: reduce the risk of artherosclerosis.

LIMB ISCHAEMIA

Acute limb ischaemia

 Symptoms: 6 P's ~. ainful, paralysis, g le, p~rishing' cold,
J:larasth_esiae, QUlseless r0 ,.. f, <D\i()V<:~ ~~· reu\
Risk factors: AF, Ml (IT!ural thrombus), aortic aneurysm, valvular heart
disease
Cause: Emboli . . .\ ·,"JC,
\Q.t.\(\\ ·,
,,.,-0-·\
Investigation: Doppler USS or arteriography.
Management: Immediate referral to vascula r; surgeon for 1' P,
embolectomy, unfractionated heparin IV
( O. Cf - I . ~ i l"de ,t :.· 'I\O n-,o \

Chronic Limb lschaemia (Peripheral vascular disease)

Symptoms: intermittent claudication
Risk factors: HTN, DM, high cholesterol
Cause: artherosclerosis
Investigation: i) Ankle Brachial Pressure Index (if <0.5 = critical limb
ischemia) ii) Doppler USS iii) arteriography
Treatment:
• Reduce the risk of artherosclerosis. E.g reduce cholesterol and
hypertension
• Also bypass graft if severe symptoms
0
Exercise to improve symptoms of claudication.
Differential diagnosis
Thromboangiitis obliterans (Burger's disease) =usually in young men
around 40 years with strong smoking history.

PER RECTAL BLEED

Causes
1. Haemorrhoids (aka Piles)
 2. Anal fissure
3. Acute mesenteric ischaemia
4. Colonic cancer
5. Rectal cancer
6. Diverticulitis
7. Angiodysplasia
8. Inflammatory bowel disease
9. Trauma
10. Bleeding diathesis

1. HAEMORRHOIDS (AKA PILES)

• History of constipation
• Also common in liver cirrhosis
• Fresh blood per rectal which ~p_!~sh~s i~_tl.e toi etpan
• No pain
• Itching is usually present

STAGES OF HAEMORRHOIDS
• 1st degree - Remains in the rectum
• 2nd degree - Prolapses during defaecation but reduces
spontaneously
• 3rd degree - Prolapses during defecation but requires digital
reduction
• 4th degree - Remains persistently prolapsed, cannot be reduced

Management:
1. Conservative management:
o First line treatment of choice
 o Lifestyle modifications: high fibre diet, topical
anaesthetics, behaviour modifications incl. weight loss,
no reading while in the toilet
2. Non-surgical management:
o Rubber band ligation - good choice for first and second
degree haemorrhoids
o Injection sclerotherapy - an alternative treatment for
first and second degree haemorrhoids
3. Surgical Haemmorrhoidectomy
o Used if minor procedures not effective and in external
haemorroids (3 rd degree haemorroids)
NB. Painful peri-anal haematoma must be treated with incision and
drainage

2. ANAL FISSURE
• Tear on the anus
• History of constipation
• Intense pain in the anus
• Fresh blood per rectal
• Per rectal examination may be impossible due to severe pain
Treatment:
1. First try conservative treatment i.e. laxatives, tfluid intake,
topical lubricants.
2. Topical glyceryl trinitrate (GTN) ointment is the first line
treatment of chronic anal fissure.
3. Topical diltiazem
4. Botulin toxin used if failed response to GTN

3. DIVERTICULITIS
 • Inflammation of diverticulum ~utpocketing of weak area of
intestinal wall)
• Presents with fever and left iliac fossa pain relieved by defecation
• Usually patients are 60 years and above
• Profuse bleeding per rectal but there is no rectal pain

Investigation:
• In the acute phase, CT scan is investigation of choice.
Do not do colonoscopy during acute phase as it can cause
perforation.
• Colonoscopy is best for diverticular disease, can be used in
diverticular bleeding both for diagnosis and treatment.

Management: 1\ntibiotics are 1st choice for acute diverticulitis (co-

amoxiclav or ciprofloxacin and metronidazole)

4. COLONIC CANCER
• Usually elderly patient
• Symptoms of malignancy i.e weight loss, anorexia, fatique,
anaemia.
• Left colonic cancer usually presents with per rectal blood mixed}
\ with stool J
• Right colonic cancer usually presents with anaemia
• Change in bowel habits i .e alternating diarrhea and constipation
Investigation·: Colonoscopy and biopsy

5. RECTAL CARCINOMA
• Elderly patient
 • Symptoms of malignancy i.e. weight loss, anaemia, anorexia,
fatigue, tiredness.
• Fresh per rectal bleed
• (Tenesmus«iwhich is a feeling of incomplete evacuation. ..,
l',..,0c c)..J
• [U ce , in the rectUlll\means(t-9.IJ_<;:et'J roe-_,~.;,
Investigation: Sigmoidoscopy (for lesions in rectum up to sigmoid
colon) and biopsy

6. ANGIODYSPLASIA
• Congenital arterio-venous malformation
\;,00
• Presents in elderly patient with unexplained spontanenous
bleeding per rectum with no other possible cause of bleeding

Investigation: colonoscopy or barium enema which may show no

abnormality. Capsule endoscopy may also be used. ·

7. PERI-ANAL HAEMATOMA
• This is a thrombosed haemorrhoids .
• There is severe pain
• It is locate at the c111a
• It is purple blue lump.

Treatment: Incision and drainage of hematoma

8. INTUSSUSCEPTION
• This condition is common in children.
• The typical age is 5-12 months
• Intermittent abdominal pain
• Child crying while pulling the legs towards the abdominal
 • Per rectal fresh bleed, currant jelly like stools
• There is sausage shaped mass in the abdomen
• Shock

Investigation: Air enema/barium enema

Management: Pneumatic reduction which is the air enema.
(1()('\' ') .\ .--¾',r'!tf \

INFLAMMATORY BOWEL DISEASE

1. Ulcerative colitis
2. Chrohn's disease

ULCERATIVE COLITIS
• Usually young patient (20-30 years) with chron'fc history o(_?_
~o~~~
\~i~rrhea'
• Fever
• Usually does not go beyond ileo.,cecal valve
• Granular inflammation of mucosa
• Extra intestinal manifestation e,g arthrit~s, conjuctivivtis,
{pyoderina·gang·renosum~~ulc:-er1j On the leg
--~~---·- · --~ -- . - -- ~

CROHN'S DISEASE
• Young patient between 20-30 years
• Chronic diarrhoea ( f\6..1., b \ ~c:..··:td,1·)
• -/ + blood per rectal

• Can affect any part of the GI tract from the mouth to the anus
• Transmural granulomatous inflammation of the intestinal mucosa
 • Extra intestinal manifestations can be conjunctivitis, pyodema
gangrenosum, arthritis mouth ulcers

NB: Typical signs of crohns disease are: fistula in ano, peri-anal

(".I C \ n C' n, c)(,,-0 ·:;
abscess, skin tags, skip lesion pattern, {granuloma formation~
cobblestone appearance on colonoscopy, rose thorn appearance,
colonic stricture. These signs suggest Crohn's disease whether there is
per rectal. blee9 or not. . .
· ii. ,-,,-;, ,-_ f '<'"\ c< \t\ll: \ Qve\

VARICOSE VEINS

Signs: Eczematous changes, oedema, pigmentation, tortuous veins

Pathophysiology:
• There are l.Jyp~s of yeins in the lower limb: -~Y.P~rficial veins and
~eepveins.
• The superficial vein drains into deep veins.
• The superficial veins and deep veins are connected by _Qe_
~f9.r~tjog
veins.
• The perforating veins !:lave valves which allow blood flow only in
one direction i .e from superficial to deep veins.

• If the perforating veins become incompetent they begin to allow

flow in opposite direction. i.e from deep into superficial.

Superficial veins
1. Long saphenous vein runs on the medial aspect of the leg all the
away up to the sapheno-femoral junction.
~i'.f j
 2. Short saphenous vein runs on the lateral aspect of the leg into
the sapheno-popliteal vein at the posterior aspect of the leg.
'.'~p _)

Deep veins
1. Popliteal vein
2. Femoral vein

Management
1. ~ifestyle ~odifications (avoid prolonged standing and elevate
legs)
2. Minimally invasive therapie_s:
a. Radiofrequency abl~tion - uses radio frequency energy to
seal the lumen of the long saphenous vein
b. Endovenous laser therapy - uses high-intensity laser
c. Foam sclerotherapy - seals the vein using foam
3. Surgery:
a. Phlebectomy - removal of vein in parts
b. Stripping - removal of the entire vein
c. Sclerotherapy - seals the vein using sclerosing agent
4. Compression stockings if interventional therapy not
c appropriate. Always exclude peripheral arterial disease before
prescribing.

LUMPS IN TH

1. E IDIDYMAL CYSTS =also called spermatoc~

• Usually located on the upper pole of the estes.
 l
,r, ,,... (, I
",: ..]( l\ I
!.
t'~ t. \ ) I I
·. ~• I
\'c'" \J·/01'--· I

• It is above and !?.e~!n_d the teste~, palpable separat~ from the

testes.
• It f_lvct!:,Jates and tran_~jlly.minates
Investigation: USS
Management: Surgical removal if symptomatic otherwise leave it

2. HYDROCOELE This is accumulat ion of fluid within the tunica

mucosa.
• Whole scrotum is enlarged, it can be of very big size e.g 10cm.
• No mass palpable in the testes rather the testes are enlarged as a
whole
• Testes are not palpable
• It fluctuates and transilluminates

Investigation: USS

Management: Aspiration. If asymptoma!ic then reassure.

3. TESTICULAR TUMOUR
• Long standing history of a mass in the testes.
• Mass is f![r!l in consistency , ?_tta_
ch~9 to tlnle te-g_~~-
• If age between 19...::10. its(teratoma
• If age between 30-49 its~e~""'!noma CJe)(\ rrtl

Investigation: Initial investigation i USS and blood tests for markers

Definitive: biopsy by doing orchidectomy.

4. TESTICULAR TORSION
 • Sudden onset of severe testicular pain is always testicular
. _ _ _ . . . - · -• • - _- I > , _,_

torsion until proven otherwise.

• Common in young patients especially adolescents
( n . \f\'jC.O• . . 0 \;-.\~;O '·/ ,-, .1 .\ 11··,UM ( \
• May have vom1trng as well ·
• Pain may start while _rid_
ing a bicycle or playing football or any
other sports but there usually n9._hJstory of trauma

Investigation and Treatment: E~pJ~ra!ory surgery.

\
5. HERNIA ,.. , 1
,

\\I (" ·, ''· ' ,.1 ' ' : .., , \i ·, ,. t/c~\\

• The mass is usually above and medial to pubic tubercle
• -/ + cough impulse
• On examination you cannot get above the mass.

6. VARICOCEL This is due to dilated

-- - .
veins of the scrotum
• Feels like a b~_g_{~qnTI~ ;
: f'
\ '
, , .. , ' '
,, ' \
·, · ; ,. "
I ,, •' '
l .
"'

• Bluish in cololllr
• Disappears when patient lies flat
• Can be itchy and have an aching pain.

Investigation: ~~S
Management: If asymptomatic then reassure
If symptomatic then perform surgery.

7. EPIDIDYMQ-ORGP-ilTIS
• Fever, dysuria, frequency of micturition.
• Swelling and redness on the testes
Investigation: ....---
MSU
Management: antibiotics
INGUINAL HERNIAS
CLASSIFICATION . /,. .. ./ ' '
'I

1. Reducible hernia
o Contents can be replaced completely into the peritoneal
cavity
o Presentation: Painless lump that disappears on lying flat and
with cough impulse
2. Irreducible hernia
o Due to adhesions if itcS contents to the inner wall of the sac
o Presentation: Painless lump, no cough impulse and the lump
is not reducible on examination
3. Strangulated hernia
o Contents of the hernia are constricted by the neck of the
sac to such an extent that their circulation is cut off.
o Unless relieved, gangrene is inevitable and perforation will
eventually occur
o Presentation: Often with ajgns of intestinal obstruction i.e
vomiting, constipation and distended abdomen plus the
lump is tender, not reducible hernia and _ bowel sounds are
increased..
' .

TYPES:
INGUINAL HERNIA
Enters the internal inguinal ring, transverses the inguinal canal. If
large enough it emerges through the external ring and descends into
the scrotum. The hernia can be controlled by pressure with one
finger over the internal inguinal ring.
 -
1 DIRECT INGUINAL HERNIA
(

Pushes
.- ---
through the posterior
- ' -
wall of the inguinal canal media to the
internal ring. It is i:1ot controlled by digital pressure over the internal
ring.

t:Treatment
1. In children ~!~~w 1 Z~~-~.~s__<>.L~ you do herniotomy
2. If presentation is below 1 year, wait until 1 year to do
herniotomy.
3. In adults you do herniorrhaphy or also called hernia repair.
4. If it is REDUCIBl.!E 0R IRREDUCIBLE ·liERNIA then you do elective
(planned) hernia repair
5. If it is STRANGULATED HERNIA then you do immediate hernia
reair.

1. FEMORAL HERNIA:
Mor~ common in wo111en and it com~qD~Y ~trangµJ~tes.
Treatment: Because of high risk of strangulation, all must be
treated ~urgically as soon as possible.

ANATOMY
• The inguinal canal i~_~-cm long.
• It passes downward and rr!~.o.iallrJrpm de~p to superficial from
the internal to the external ring.
• It lies parallel to and immediately abov~ the inguinal ligament.
• The int~rnal_ri_ng feprese~fth~\~~int at which the(_sl~~~matic cor
pushes
.....
, --~
through the transversalis fascia. The internal ring lies
. '

above and lateral to p~pjc_tl:Jben;;le and it is 1-2 cm above the

femoral pulse.
 J J
Jr J

• The ~xternal inguinal ring is a defect in the\~~t~E.~-~Lg,eEque

1,.aponeurosfs1 and lies immediate above and medial to pubic
tubercle
• The inguinal canal contains the spe_rlllatic cqrd and the .Hip-
inguinal nerve. ~ ( ,,, .

\
' '" ' r
' (
,.,
LEG ULCERS -·- Q :,<. i ('( < ,r~,I '
,·1 L,i I· Ir,. ( ( '
( ) /\ IL
I f"; J. { f f .
\o '
r"\\.
~. tr"
1\ ,, ,"·1.r ,1( ',
'; ,,r,

I '.·, ( .... l (.A"' \ '· :,. ·1 ) '· ( JJ \ ~~;

' II (.JI l ( \ l
1. DIABETIC ULCERS (,(I) I ( \ ' .r, i,,
I
• P9t(ll~ss ulcer on the base of heal or base of the metatarsal
• History of diabetes or history of polyuria, thirst and weight loss
Investigation: Blood glucose c\ tv'GI .@\"" )

1. VENOUS ULCER
• Ulcer on the medial malleoli
• On examination there are varicose veins
• History of standing for long time due to venous stasis, e.g. people
who work as waiters or guards.

( I( \i \ ,
1. PYODERMA GAl'-.I_GRENOSUM t '\c ·1< .,, ,· ,t
("(" \ \ \ i::..
• History of inflammatory bowel disease
Investigation: Biopsy for pyoderma gangrenosum

1. MELANOMA
-·
\.......

• Usually middle aged or elderly patients with an ulcer over the

<?,:W' ~, ·-
shin or any other exposed area.
• The ulcer is pigmented, increasing in size with irregular margins
and changing in shape.
 Investigation: biopsy for melanoma

1. ARTERIA_LJ)LCER
• History of ir:,_termittent claudication
• Painful ulcer

0
Signs ":ff~'"o
• Ca f tenderness
• Calf warm to touch
• Swelling of the calf
• Mild fever
• Pitting oedema

WELL' S SCORE
• ~c_tive cancer (treatment within last 6 months or palliative): +1
point
• C,~lf_~Yfelli~~ ? 3 flTI compared to asymptomatic calf (measured 10
cm below tibial tuberosity): +1 point
• Swollen !J~i~a~~T~_l__~uperficial veins (non-varicose, in symptomatic
leg): +1 point
• Unilateral p_itting _~Q_filD 9 (in symptomatic leg): +1 point
• P,r~yious ~ocumented DVT: +1 point
• Swe~ling of entire leg: +1 point
 • Localized tenderness along the deep venous system: +1 point
• Paralysis, paresis, or recent cast immobilization of lower
extremities: +1 point
• Recently bedridden ~ 3 days, or major surgery requiring regional
or general anesthetic in the past 12 weeks: +1 point
• Alternative diagnosis at least as likely: -2 points[4]

1.-PQrJ~~s than zero points is lQ'f'LQfQbqbility .DD

2.1-2 points is irtterrnediate pr9bability
3 ..~ 9..r_more points is high pro_ba_giljty

Management of Deep venous thrombosis

1. IF ,.LOW
. __
,,.,
PROBABmlTY
. -·
, .. ·-
- -
do D-diffi~l as initial inves_
-
t igation
a. If D-dimer -ve it means DVT has been rale,e out.
b. If D-dime_
r. +ve then start treatment with _bgparin and
_i_~v~st_igate with compression US. If confii rimed _l?VT then
add warfarin and continue both warfarin and heparin
until l~R is 2. When INR is 2 stop h~parifl and continu~ _ h -, <1\C
1
· M · · I b 2 3 ..,s • t"'; rv\ t\ '!I - vi ' c·,·\
warf ann. a1nta1n NR -etween - • ·; · '(\ O ~~~ -
1
•
' i.'1 '\ \ -~ ( t),>
1
( {'C'l..H I ('{\ ' ·\ y L:'(H

1. IF ~~TERMEDIATE OR HIGl-:I_e_R.O6ABJ.LITY, DO NOT PERFORM D-

DIMER. SJ"ART liRE~TM.ENT with _low molecular weight heparir:1
,then lnvestig_c1!~ with compression ultrasound scan
a. If +ve then add warfarin and continue both warfarin and
heparin until INR is 2 then stop heparin and continue
warfarin maintaining INR 2-3.

L_BPPER GASTROINTESTINAL BLEEDING

CAUSES:
1. Peptic uleer disease
2. Mallory weiss tear
3. Oesophageal carcinoma
4. Gastric carcinoma
5. Gastric erosions due to medications ( NSAIDs, Aspirin, steroid,
biphophanates)
6. Curling ulcers
7.0esophagealvarices
8. Renal failure

Symptoms: the two main symptoms of upper GI bleeding are -

_ha~i:r,atem~si.s and melena(black stool)

1 . PEPTIC ULCER:
-There are 2 peptic ulcers we need to know: gastric and duodenal
ulcers.

Gastric Uleers
-stomach ulcers
-epigastric pain ~orse with meal_s
-relieved with aRti-acids
-history of indigestion
-patient may lo_os_e weight du~J g_f~s.LQf eatin,g.

Duodenal
-~· -~ -
U-leer
- ..

.,~pigastric p~in relieved with f~od ,~_

n_d _
anti-aciq~
-worse at night due to fasting
 -also called hungry ulcers.

2. '.GASTRIC CARCINOMA 1
'
• Elderly patient
• Symptoms of malignancy i.e weight loss, anorexia, tiredness,
fatique.
• Early satiety
• Epigastric pain or discomfort which may radiate to the back.
• Metastasis to the spraclavicular lymp nodes called virchow's
nodes.
• Common in Japanese.

Investigation: Ciasti:-o.~GP.PY and biopsy

Management: Surgery _
i f no metastasis

3. MALLORY WEISS TEAR

• Usually young patient after binge drinking
• Patient needs not to be a alcoholic. Alcoholics usually suffer from
oesophagealvarices 0
·

• Usually they vomit smaU amount of blood aftef1?et~h(ic~g.

• Usually haemodynamically stable

Investigation: monitor vital signs and FBC_

---- - - --- - ~- - ·-···-·- ·
Management: Check full blood count 24 hrs after

4. OESOPHAGEAL CARCINOMA
• Old
..-
age of the patient -,o
• Dysphagi_a fo qsolid iriitiallY\ then liquids.
• Weight loss, anaemia, anorexia, fatique
 • 0 dynophagia

Investigation: 0~5-ophago-gastroscopy and biopsy

Management:
• If there is !1.Q_rll_~~~~tas~s then treatment is resection of the
oesophagus
• If there is metastasis treat with rradiotherapy.

5. lOESOPHAGEAL VARICES I
• Usually in ~lcohol_
i~-~~or patients with lqrig ~ta.nding liver dis~ase
e.g primary bilary cirrhosis or chronic
- ·- - - viral
·- --· .
~
hepatitis
,~ '

• Massive bleeding
• Patient is Jn ~hqc~
• Repeated haematemesis 'c CJ -\c;.) 1a 'J
• On examination there can be stigmata of liver disease( spider
r . \)·\-c\ r, 0' c\CA'->'{'l
naev1)
• Patient may smell of alcohol

Primary Management of Oesophageal Varices:

PY (OGD) is recommended in all
1. (?~s~phago-duodenso~CQ_
patients when diagnosis of cirrhosis is made.
2. If patient has liver cirrhosis but no oesophageal varices the ne
needs 0~0 -~v-~r:y 3 ye~rs.
3. Cirrhotic patients with smil!LY:~!t~es need repeat 0GD ~y_ery
1_:_i j~ar._s. Use beta blockers for prophylaxis of bleeding. Use
both beta blockers or endoscopic variceal ligation.
4. Nitr~te.s
... .... .
__\ __
may be used together with beta blockers.
-
 5. Sclerotherapy has no role in the primary prophylaxis of
varcieal bleeding.

Management of Active Oesophageal Bleeding:

1. Take care of the_~ B..C'~ of the patient
2. Get IV- lines
~ .
and send bloods including Group and Save
3. Cross match 6 units of blood
4. Emergency endoscopy (OGD)
a. Treatment of choice is band ligationJ
b. Sclerotherapy should be used if ligation is technically
difficult.
5.'Short term ( < 1 week) antibiotic prophylaxis should be
prescribed e.g. ciprofloxacin, in any pateitn with cirrhosis anq
·GI bleeding.
6. Somatostatin or its analogue must be prescribed e.g. octreotide
7. If bleeding does not stop with above measures, the balloon
Sengstaken tube tamponade
8. If all fails consider Transjugular lntrahepatic Porto-systemic
Shunt (TIPS)

Prevention of Secondary Bleeding (Rebleeding)

1. Use of band liga!jon (or sclerotherapy) plus l?~t~ ..bJo_tk~c~.
2. Band ligatiQD is the first method.
3. Sclerotherapy should only be used if band ligation is technically
difficult
4. TIPS is more effective than endoscopic procedures but does not
increase survival

6. GASTRIC EROSIONS
 6
• Common in patient who are long term use of non ~teroidal ani-
nflammaor drugs e.g ibuprofen, naproxen,aspirin, a
• Also steroid especially if patient is allergy to NSAIDs then is more
likey to have been using steroid since he/she can not use NSAIDs.
• Also biphosphanate. E.g alendionic acid.
• There can be history of back or joint pain or rheumatoid arthritis
or osteoarthritis which indicate that patient has been taking
NSAIDs
\ \ \ '\

7. CURLING ULCERS
These is usually after burns. 1,;

Treatment: ifreat with proton pump inhibitors (~Pl) if ulcers are

severe

8. CHRONIC RENAL FAILURE

Can also cause ulcers due to reduced excretion of gastrin
- - . . - --- - --. ... · · · - - · ----~ · ·· --~h-•h•

MANAGEMENT OF UPPER GI BLEEDING

1. FBC to check foij Hb

2. If you suspect patient of having oesophageal varices then
needs urgent upper GI endoscope
3. Usually all patient with upper GI bleeding will need UGI
endoscope except in cases of Mallory Weiss tear where there
small amount of bleed.
4, Banding and sclerotherapy may be performed during
endoscopy.
 ACUTE ABDOMEN

RIGHT UPPER QUADRANT

1. ACUTE CHOLECYSTITIS
Inflammation of the gall bladder usually with pre-existing g~llstones.

Signs 8: Symptoms:
• Fever
• Pain in t~e right quadrant radiating to the right s~apuJ?.l worse
. hf f d ·- \ ,_ ., .; '
w1 t atty oo s. : ·, ·\ , ,1· \ -' ·
. . . ' ,- ·ii ;' _:,
• Nausea and vomiting
• MurJ:}hy's sign is positive

Investigation:
1.Jl~.S.. is the investigation of clJ.,oice (look for gallstones)
2. f.ARCP (Magnetic resonance cholangiopancreatography) is
indicated if no evidel)_C~ _of gallstones found despite classical
biliarY p~tr:i~
3. ERCP should not be used as a routine investigation but in those
(0°1: patief.ltS who are likely to require intervention.
\ '
? )

Management:
1. Symptomatic gallstones are most effectively treated with
laparoscopi c cho lecystectomy.
/~
J 3cM )
 2. Asymptomatic gallstones should be managed conservatively
unless in the following situations when laparascopic
cholecystectomy is recommended
a. Big stones in the gall bladder >-. vv-...
b. Small stones in the gall bladder but in very young patients
c. High risk of complications like in a diabetic patient

1.'CHOLANGIITIS - This is inflammation of the common bile duct.

Signs & Symptoms:

Charcot's triad of cholangitis: rig_hL~E~~_r quadrant Ra!n, fever and
j_~undjce
Reynold's
·-··-"' ··- ·- - . -~-
._ - . ....,
p~nt~g
. -..
of ascending cholangitis: Charcot's triad + shock
and altered mental status

Investigation: USS
Management: ceft1roxime and metronidazole.

1. BILIARY COLIC - Usually presents with intermittent pain in the

right upper quadrant due to pain caused by the stones in the
0
gallbladder. co

Signs & Symptoms

• Pain in the RUQ
• Radiating to the right shoulder
! ' o-<~\
• Jaundice
., but there is no feveriJ YJ''

Investigation:
 1) USS
2) ERCP-if obstructive jaundice and worsening LFT or if there is
a stone in the common bile duct.

Management: Conservative treatment is first line treatment for

small stones.

1. PYELONEPHRITIS
Signs & Symptoms
• Loin pajr, -I hC'i'v vi I, J'i I c· .
• Fever ('

• Dysuria and frequency

• Rigor§ and yomiting
Investigation: MSU
Manageme..ot: Antibiotics: cefuroxime or cefotaxime

1. LOWER LOBE PNEUMONIA

Signs & Symptoms:
• Fever
• C9l:Jg~h proJurl ~ ,Jc
• Shortness of breath
• Sputum
- -,- -

• Chest pain
Investigation: CXR
Management: Antibiotics

-\.~(\ \
1. RENAL COLIC \i\\(:VN'\ .

Signs & Symptoms

 • Intermittent loin pain
• Haematuria
Investigation: JVU c. r \.-:: tJr\~
Management: rehydration or stone removal.

1. AMOEBIC HEPATIC ABSCESS

• History of travel to tropic~l area~ and giarrhea
• Right upper quadrant pain and jaundice
Investigations: US~, Stool antigen
Treatment: Metronidazole +/- Incision and Drainage

1. ACUTE VIRAL HEPATITIS A (HAV)

• History of tr~vel e.g ts>. lridi_a
• Upper quadrant pain
• Jaundice
• Diarrhoea
,......
Investigation: Hepatitis serology
.. . .,.,.,,
Management: lnterfer9n
, ·

LEFT UPPER QUADRANT

1. SPLENIC RUPTURE
• Usually is due to ~r~y_ma. I 'L

• On examination there are bruise_

s__on_tbe abdomen
Investigation: USS abdomen
Management: Laparotomy.
 1. PYELONEPHRITIS=same as in RUQ.
2. RENAL STONE=same as in RUQ
3. LOWER LOBE PNEUMONIA=same as in RUQ

EPIGASTRIC PAIN

1. PERFORATED PEPTIC ULCER

• Pain and tenderness in the epigastrium or upper abdomen
• May be history of indigestion or use of NSAIDs or history of
rheumatoid arthritis or back pain because people with these
conditions usually use NSAIDs.

Investigation: Erect CXR=to see~ as under the diaphragm

(pneu moperitoneu m)
Management: LaparotomY,

1. ACUTE PANCREATITIS
• Epigastric or upper abdominal pain which radiates to the back
• Profuse vomiting
• Abdominal pain may quickly become generalized
e \Reduced bowel sounds c::,h, CI,'. ) ,_,\i-, '~' ,\ .· ' ''., \ \, \

• Patient is in shock i.e low BP and tachycardia.

Investigations:
1. Investigation of choice is serum amylase to confirm diagnosis.

2. pla~_ma lipase can also be used and is more sensitive than

amylase
 3. -~SS to l_~ok for gallstones

4. ~T..abdomen is the gold standard if diagnosis is not clear after

checking amylase and lipase

Treatment:
1. .IV fluids and NGT if vomiting

2, Prophylactic antibiotics

3. Gallstone-related pancreatitis needs urgent ERCP and

laparoscopic cholecystectomy should be performed within 2
weeks.

1. MYOCARDIAL INFARCTION
··7- • Epigastric pain ) ~)('hr · ·• ,

• Elderly patient
• Nausea
• Sweating in the palms
• History of ischaemic heart disease.
Investigation: ECG &Cardiac enzymes. · \1

~ GHT ILIAC FOSSA

1. APPENDICITIS
• Central abdominal pain which then moves to right iliac fossa
• Vomiting, fever, ~~orexia
• On examination there rebound and guarding
• THIS IS A CLINICAL DIAGNOSIS
Investigation: FBC
Management: Appendicectomy
' I

1. SALPINGITIS OThis is Pelvic Inflammatory Disease

~

• It is due to sexually transmitted infection, commonly Chlamydia

• Per vaginal disharge
Investigation: Endocervical swab
-
Management: Antibiotics.

1. TUBO-OVARIAN ABSCESS OComplication of pelvic inflammatory

disease
• Usually there is swinging fever
• On examination there is a mass in the in the iliac fossa.
Investigation: . USS "_.., .
0
Management: Incision and drainage.

1. URETERIC COLIC Due to stones in the ureiter.

• Right or left iliac fossa pain which radiates to the groin.
• Haematuria
et ) r,"
\ ~If "" f' .,0v1
Investigation: IVU in.\ 1c-·,.,._,c,r.r )u:... u(C)9<C1 ~ I
Management: Rehydration or depending on the size of the stone
may use lithotripsy or open surgery.

LEFT ILIAC FOSSA

1. DIVERTICULITIS See Diverticulitis under section of PER RECTAL

BLEED.

1. URETERIC COLIC - same as in RIF

2. SALPINGITIS_- same as in RIF_
3. TUBO-OVARI AN ABSCESS - same as in RIF
CENTRAL ABDOMEN

1. INTESiflNAL OBNSTRUCTION
The four cardinal signs of intestinal obstruction
o Vomiting
o Abdominal pain
o Distended abdomen
o Absolute constipation
Investigation: Plain abdominal X-ray=dilated bowel loops
Management: Surgery

1. ABDOMINAL AORTIC ANEURYSM=

• Usually middle aged or elderly patient
• Pulsatile mass in the abdomen
• Absent femoral pulses bilaterally
• Patient is in shock i .e low BP and tachycardia
• Abdominal pain which radiates to the back
Investigation: CT abdomen
Management: Laparotomy.

3) ACUTE MESENTERIC ISCHAEMIA

• Sudden onset of abdominal pain, with no signs of peritonism i.e
no rigidity or guarding.
• There is per rectal bleed
• History of IHD or AF or valvular heart disease
• Cause is an emboli
Investigation: Arteriography
Management: Heparin and antibiotics.
SUPRAPUBIC AREA

1. UTI - urinary tract infection.

• Dysuria
• Frequency of micturition
• Fever
Investigation: MSU
Management: J\ntibiotics, usually Tri! methoprim

1 BLADDER STONES-
• Pain on urination
• Haematuria
• Usually suprapubic pain
Investigation: A.:. and Mo::-:i\ or~ofr ,c-i C
C KUB x-ray is the ~Jtigl investigation
~ _ IY,U is the most appropriat~ investigation
1
Management: Rehydration or storne removal.

XVI. PROCEDURES AND RELEVANT ANATOMY

IN SURGERY

1. _Neeale Cr.icothyroidotomy - Cricothyroid membrane will be the

last structure pierced before reaching the desired anatomical
space, the trachea.
 I

1. ~~est. -drain th to ~th intercostal space at the mid axillary line

- 4__
~ -·. ~· --
- , . ..

through the "safe triangle". Pierce the intercostal muscles. The

structure likely to be damaged is the intercostal nerve.

1. ~_
umbar pu,ncture - Inserted between-~~ & L4, landmarks is the
plane between the iliac crests. Pierces the dura mater before
reaching CSF
 SAMSONPLAB ACADEMY LIMITED
Email: info@samsonplab.co.uk
Tel: 07940433068
Address: Bow house Business Centre
153--159 Bow Road
London
E3 2SE
SURGERY SINGLE BEST ANSWER 6

1. A 14:year old boy presents with a two-ho .r. h ~ , of s~ye.r~J_eft

~ige.d testicular pain. He has n9--yrinary s~mp Qms and is otherwise
fit and well. On examination the _right tes -€'S'i ~ ormal but the left
_hemi-scrotum is swollen and ac;w ~ -ender. What is the
appropriate initial investigatio!1? ~ i 1 "'>I ·l v
A. Mid-stream urine \, '

/.\s:i Ultrasound scan of the test 1

C. CT scan of testes
D. Urethral swab
/® Exploratory surge

~
2. A frail ~ ye . old man returns to the clinic a day after having
had a rigt']t_- 1de hydrocele aspirated. He complains of pain in the
scroturm, , jc he has noted to be ~woUen. On examination, there
is ,...~e. a~r swelling in the right side of the scrotum. What is the
. o ?\gpropriate initial investigation? ~:h:· (nrf\rii-·, ·.c'"'.ll sc {O~un"
\
j '\
""'")' ,. (,... . ·\ :n1 ,
'- \" I

B. CT scan testes
(J:'5 Ultrasound scan
D. Mid-stream urine
E. Cystoscopy

1
 3. An BO-year old man complains of testicular pain tbree days post-
Qp~ratively. On examination his temperature is .38C. He has an -in-
dwelling urinary catheter and both testes are tender. What is the
most appropriate initial investigation?
A. Mid-stream urine C /\ U 7 \ -b
B. Urethral swab co-\ \c\ - J":1.·
_.C. Exploratory surgery ) i n:,, f
1
\co--\
1 1
-/( D':1 Urine culture from catheter specimen'P-r-cc-
E. No investigation required

4. A ~0-year old woman presents with nipple dis · arge ~ om the

left side, which she states has been blood stai0 d There is a
giscbarge from sifigle..,duct! on the left nipple; icti tests positive
for blood. Clinical examination and l)lam a ·'hy showed no
1. -

abnormalities. What is the most appropri9, e e~t investigation?

)(..1,~;."V")',.
A. Ultrasound scan
B. mammography
C. swab the discharge
D. Fine needle aspiration
( ~) Ductography

5. A ?_9-year ol 1 G an compl i ? rtJ,at her right nipple has

•

changed becnmimi
X '1,
.ec:fden
m- q d with sca
1

1
-
y skin
_,
i The left nipple is
normal bu e r',ght a Ola and nipple shows an area of redness
with seal~ s· ~in e uption. There is no nipple discharge and there are
no lum~s h t is the most appropriate next investigation?
~ r"i f \ \

'i

B':' Mammography
~ - Open biopsy o{
D. Fine needle biopsy
E. Core biopsy !.. \0

2
 6. A 30-year old woma_n comes to the clinic because she is
concerned about breast cancer. She has (ho s_ymptom""s) of breast
disease and clinical examination is normal. She has a positive
family history for breast cancer, her sister developed breast cancer
at 32 and her mother at 45 years of age. What is the most
appropriate next investigation?

A. Ultrasound scan
B. Mammography
../ ( C. Genetic testing and counselling
D. Fine needle biopsy
E. Open biopsy

7. A~~ year old woman has found a Rai_o_l ss ~ rn her righJ

c00-lla. She has no other symptoms. There s j, p in the upper
outer quadrant of the right breast and a smo , th 1cm lump, which
is mobile in the right axilla. What is th st appropriate next
investigation?
J· A Mammography
---L ( B Ultrasound scan ~
G
C. Fine needle biopsy }, r

D. Core biopsy ~
E. Lymph nodes V
..._

8. A 70-yea ~ man comes to the clinic complaining of a lu_mp

in the,,..-!eft ) east. There is a 4c.lJ1 hard, ir_!~gular tump which is
fixed t0 e skin and chest wall. Amammogram u~trasound scan
andi fin " needle cytology have yi~~ed equivdc l r~~ llt ,Cbut there
is a suspicion that it is malignant. What is the most appropriate
ne-~ investigation?
A. Mammography
B. Ultrasound scan
C. Fine needle biopsy
v D Core biopsy

3
 E. Open biopsy

9. A 14-yeqr old boy is (Dau~eated \and in f!!iJd__pa~ri. 12 h9urs after

an appendectomy. What is the most effective· appropriate
analgesia?
A. Paracetamol oral (. .f'('Jd'f, •· , .,,, \
B. Codeine sulphate and tramadol orally
C. Morphine oral
D. Subcutaneous morphine
,_/~_E~)Diclofenac rectal

10. A 72-year old man is undergoing asses of a cb{npo~nd

fracture of the tibia and fibula. Wh most effective
appropriate analgesia? y>(?t("\(\(°'

A. Oral ibuprofen
B. Paracetamol oral
C. Int ramuscular diamorphine

E. Non steroid anti-inflammatory drug.

12. A 25-year old ast hmat" man has undergone an excision of a

sebaceous cyst on the scalp within the last 24 hours. What is the
most appropriate effective analgesia?
4
 A. Morphine orally
B. Intramuscular pethidine
C. Ibuprofen (i,r , , 1

D. Morphine bolus
-/ E Oral paracetamol

13. A 25-year old man, who has been drinking heavily a a~ )

evening party, presents to the A&E departmen~ ,'th vomiting , ·. t
started one hour ago. He has repeated e.tcning and s a! o
vomited a small amount of fresh _blood. What is t fi ,'ost
appropriate next management step?
A. Intravenous fluid replacement
B. Measurement of the vital signs

14. A 38-year old woman ith known primary biliary cirrhosis

vomited a small quantity o a . blood the previous day. Her pulse
and blood pressure ar nor~l, and she is not__ana.e.r:n.i~. She is not
taking any medj~a, ·or-1. What is the most appropriate next
management step.

j5 A 40-year old woman with cbronic; _c1ctiYe.. hepatitis and known

esophageal vadces is resuscitated in the A&E department
following a massive he.matemesis. Shortly after admission, she
suffers a fyrt_hg_[J~rge _hematemesjs. What is the most appropriate
next investigation?
A. Full blood count
-/(ID Urgent endoscopy
5
 C. Coagulation screen
D. Ultrasound scan of the abdomen

E. Ct scan of the abdomen

16. A 45-year old man with( ~ ngstanding ~C?_wer ba':_~' pain present;
to the A&E department afte fiavmg vomifed a S!Jlall quantit , f
altered blood. He is nqt shocked. He gives a six month his, , rY
indigestion. What is the most appropriate next management t:e. ? '

A. Gastro-oesophagoduodenoscopy
:s:1 Drug history

C. Urgent endoscopy

D. Coagulation screen
E. Faecal occult blood

17. A 70-year old man presents , 1tl-l ~kg wetght loss over the
1

course of 3 months. He is 1pat . and --irea. Shortly before admission

· he had a large hematemesis 15 i~ not shocked. He gives a three
month history of indigestio · i th occasional vomiting. What is the
most appropriate nex ·1 ves Jgatio_n? \<, 0
- - {:.o) . ,.~,vC.
,rd,.
( ('''

1:-8. A 35-year old premenopausal woman presents with a history of

severe pain in the right breast which radiates to the axilla. The
· ain is intermittent and gets worse five days prior to the onset of
menstruation. She has tenderness in the outer aspect of the right
breast. There is no palpable abnormality. What is the most likely
diagnosis? ci2 €. t-1' 0': • ~\r.
,
0· Benign breast disease (Fibroadenosis)
-f '~(OcyJ1 ,e, chonge
-(10 10('(,J\ C b1eo.s\ cJ1~€0.s-€,
6
 B. Breast cancer
C. Fibroadenoma
D. Paget's disease
E. Duct ectasia

19. A 40-year old woman has noticed a l_ump in her left breast fo
the last four months. There is a hard, ill-defined lump measu n ·
3cm present in the lower outer aspect of her left breast, with s, , e
redness of the overlaying skin. There are palpable lymph no6e i

y
the axilla and the left supraclavicular fossa. What is the most lll<ely
diagnosis?

~- Fibroadenoma A,
,,--(.~) Breast cancer
C. Duct papi lloma
D. Paget's disease
E. Fibroadenoma

20. A 45-year old worn -. s~ nts with a 1s.tocy of frecurre t )

_bscessej.) in the right brea ver the (1.ast three yea.[S} The last
time this occurred as . ix eeks ago. There is a small area of
swelling and indu atio t the junction of the areola and skin of
the right breast w r~pus has recently disc~arged. No masses are
felt in the br~ast. ~hat is the most likely diagnosis?
/,r.A) Mamm ~ , uc ~ stula i, c1c:i1\i(· i

21 . A f _3~year old woman who was recently started on oral

contracepti_ve __pill presents with a wbiie _c:lischarge from both
nipples. What is the most likely diagnosis?
A. Fibroadenoma

7
 B. Breast cancer
C. Duct papilloma
D. Cyclical mastalgia
~ ( E. Galactorrhoea

22. A 54-year old woman presents wit_ h r, 6-week history of nip,[91le

discharge. There is a thick, creamy, fo l d elling discharge w>. --
sever_~_
l _ducts in the right b-reast. There are no palpab e lM p,h'
nodes. What is the most likely diagnosis?
A. Duct papilloma " 0 ~ ' \ ,;( \c., :i ·., ·/'

1,_B) Duct ectasia

C. lntraductal papilloma - 1),-'c-1·,.r \,J1 1./ ti
D. Periductal mastitis
E. Fibroadenoma

23. A 5O-year old woman has l:lAd rg0ne an anterior resection for
carcinoma of the rectum. _Q n the eventh post--operative day she
has\Jow rade pyrexi.a. (37.5£ aAcl is complaining of in in the left
(£_a[ • She has P.itting oedem,_-a 0f the eft ankle. What is the most
appropriate immediat e l westigation? . . t ··\
0
A. Arterial blood g .s
B. Ventilation perf io scan
v'\_ C) Doppler ul. ~asound scan of the legs
D. CT sca:i o the chest

A 24-year old man underwent an Appendectomy six days ago

for a perforated appendix. He appeared to be making a good
,. recovery but developed an [ ntermittent pyrexia (up to 39C) for
which there is no obvious cause. What is the most appropriate
immedi~{e. ~vestigation? o\J~c<2 '))
..;' @ Ultrasound scan of the abdomen -

8
 B. irscan abdomen ~:_
'
C. Wound swab
D. Per rectal examination
E. Mid-stream urine

25. A 69-year old man has undergone emergency repair of e

ruptured abdominal aortic aneurysm. He was noted to be seve elM
hypotensive pre-operatively and during surgery. Following sur · e
his blood pressure was satisfactory. It was noted that t er · i _no
urine draining from his catheter. What is the mos~ pp.~ g fate
immediate management? V
A. Intravenous fluid bolus

~~
B. Blood transfusion
C Check urine catheter
D. CT scan abdomen

~
E. Ultrasound scan abdomen

26. A 60-year old woman has nd rgone a left hemi-colectomy for

carcinoma of the splenic fl . , r:e. On the fourth post-operative day
she develops chest pai radt ting to the left arm. What is the most
appropriate immediate · estigation? 1\.c s

Si, A 25-year old woman presents with a four month _history of a

lefmp in the upper outer quadrant of the right breast. It does not
change in relation to her menstrual cycle and there is a 2cm mobile
well defined lump in the upper outer quadrant. She says she has a
phobia of needles. What is the most appropriate initial
investigation?
"'© Ultrasound scan
B. Fine needle biopsy
9
 C. Mammography
D. Ductogram
E. Core biopsy

28. A ~~_-year old woman complains because of t~flderness and

lLJrnpiness in the lower l?teral quadrant of her breast. She has had
this for 12 months and has noted that its worse premenstrual.
There is c:1iffuse nodularity and tenderness in the lower lateral
aspect of the left breast. What is the most appropriate initi
investigation?
A. Mammography
. B') Ultrasound scan
C. CT scan
D. Testing for breast cancer
E. Stereotactic biopsy

30. A 5 · -year old woman undergoes a mammogram which shows an

are o mic;:ro~calcification in the left breast. The radiologist is
c0r,icerned that it might be malignant. There are no palpable
aonormalities in either breast. What is the most appropriate initial
investigation? · - · ·· ··· ·

A. Ultrasound scan
B -Fine needle biopsy
C. Core biopsy

10
-/i D Stereotactic fine needle biopsy
E. Triple assessment (clinical examination, imaging and cytology)

31. A 55-year old woman presents with a two month history of a

l~.m.J>~ in her ri_gtitpr~ast. On examination there is a firm, irregular A(>-;
l!Jrnp in the upper outer quadrant of the right breast. In additio : V
there are small p~lpab.le mobile nodes in the right axilla. There ~ e
no supraclavicular nodes palpable. What is the most lf el ~
diagnosis?
A. Fibroadenoma
B. Cyclical mastalgia
J(9. Carcinoma
D. Nipple eczema
E. Paget's disease

33. A ear old woman presents to clinic having noticed a .bloqd

lM'eS discharge from her left nipple, together with dry skin over
ttie left areola. On examination there was blood stained discharge
3/'i h dry skin. There were no palpable lumps in the breast. What is
the most likely diagnoses?
A. Breast cancer
-1~ Paget's disease
C. Fibroadenoma

11
 D. Cyclical mastalgia
E. Cyst

34. A 25-year old woman, six weeks following the b_i_rt_b_of her_first
child, complains of increasing p?,in and swelling in the rfght -breast.
On examination, the right breast is noted to be ~ed and warm t©.
touch. In the inner aspect there is a localized, tender swelU
What is the most likely diagnosis?
A. Breast carcinoma
,/ B. Breast abscess
C. Periductal mastitis
D. Nipple eczema
E. Non-cyclical mastalgia

~- A 71-year old man with a previous history of pain in his calves

o , walking is brought to the Accident and Emergency department
after having collapsed in the _S.!Iegj:. He is complaining of
)
~bdominal pain radiating to his back. What is the most appropriate
investigation? ·
A. Ultrasound scan abdomen

12
 B. Arteriography
, . C. CT scan abdomen
. Urgent laparotomy
E. Erect chest X--ray

37. A12.:year old woman who is f, we~ks pregnant presents to the

Accident and Emergency department with sudden onset of left '-ll'§
fpssa p<iin. She is pale and has a pulse rate of 110Lminute wi a
plood pressure of 105/.65mmHg. On examination fie e ·s
~ende~nes~ i~ her left iliac fossa . .What is the mosty app g ·ate
mvest1gat10n. ,,c\...o·, c_..
A. Ultrasound scan abdomen '· ·-r A,
v'@ Laparoscopy ....._ ~
C. CT scan abdomen ~~ r
D. Erect chest X--ray ,V
E. Pregnancy test

38. A ~year old wpman prel :st a 1:2,:.bour history of severe

epigastric pain associated · several episodes of vomiting. She
drinks O_"Q_ ..u.njts.~ . of alcohol) er week. There is teoqerne~s with
~ardin in the epig ,t ·om. Plain radiography shows flO evidence
of free gas. What i the ~ ost appropriate investigatioQ? .
r\\f t l 1'~ \ ·{ \ :.:,
A. CT scan ab · ome
B. Ultrasourr sGao>abdomen

,9. A 45-year old man is admitted with a history of 24 hours of

colicky central, abdomin-al ·pafri) and fbile -~tairied vomiting , His only
past medical history is an Appendectomy when he was 12. On
examination his abdomen is distended but there is _no tenderne~s.
Bowel sounds are increased. What is the most useful
- -·-···
investigation?
.... . .,_._ ..,
..,.. -,.

13
 A. Erect chest X--ray
B. CT scan abdomen
C. Ultrasound scan abdomen
D. Serum amylase
E. Plain abdominal X-ray v

40. A 15-month old baby has been locked in a car in direct sun ,ig , t
for three hours. ·· When brought into the A&E department 1 h is
distressed and on arrival, his vital signs are normal. W at · he
most appropriate management?
__,, Water by mouth
B. Gastrostomy
C. Intravenous normal saline 0. 9%
D. Intravenous dextrose 5%
E. No immediate action required

41. A 28-year old woman who js a , insulin dependent diabetic has

returned from holiday in Greece fi th diarrhoea and vomiting for
the last 48 hours. Her bloo p es_sl'.Jre and temperature are normal.
There are 1+ Ketones in hey ut;,i ne and blood glucose of 1Bmmol/l.
What is the most appr, · ~riate,.,immediate management?
./(AJ Intravenous flui . sali,e 0. 9%
B. Intravenous flui a~fne 9%
C. lntravenou dex r,0se 5%
D. Oral relil 1ratt0· solution (sodium 60mmol/l)
1

E. Oral r.etj. d ation solution (sodium 90mmol/l)

~- 1 A 20-year old man has ~~tei:,~i-~~ pa~tial thickness burns over

otn arms and front of the chest after lighting a barbecue. The
accident happened an hour ago. What is the most appropriate
~ imm~qiate management?
A. Intravenous fluid saline 9%
v> B. Intravenous fluid saline 0. 9%
C. Intravenous dextrose

14
 D. refer to burns unit
E. Anaesthetise and intubate

~
JI'.\·(_)
43. A 90-yeqr old man had a dense, l.eft-sided stroke last wee~ and
is still unable to swallow properly. He has been on intravenous (IV)
fluids since admission. What is the most appropriate management?
A. Gastroscopy
B. Nasal gastric tube
./ ( CJ Gastrostomy
D. Intravenous fluids saline 0. 9 %
E. Water by mouth

44. A 50-year old man is c;9r1cerr.,~d beca s Re as a strong family

history of prostate cancer. Digital r.ec · l examination of his
prostate is normal. What is the most .a.: pr~ i ate investigation?
A. Transrectal ultrasound scan and i' ~s
B. Transrectal ultrasound scan ~ ·
_,.. ( C~ Prostate specific antigen V
D. CT scan

,Jt T<t.ar.1. rectal ultrasound scan of the prostate

B r ansrectal ultrasound scan and biopsy
e. Cystoscopy
D. Nuclear medicine bone scan
E.CT scan

15
 46. A 70 year old man with known P-rostate ___c~ncer presents with
recent onset of low_~r_ -~~~k and right hip pain. What is the most
appropriate investigation? ·
A. MRI scan of the spine
J 'B. Nuclear medicine bone scan
C. Transrectal ultrasound scan of the prostate
D. CT scan of the pelvis
E. Skeletal survey

)
47. An ~0-y~ar old
1
man with a 10 year history of rostate cancer
presents with a recent onset of _d . syrj a, bilatl< rat loin .pain and
pyrexia. What is the most appropriate investig U · ?,,
A. Ultrasound scan of the kidneys .. <__ ~
B. Cystoscopy
C. MRI scan
/, D Mid-stream urine
E. Intravenous urogram

48. A 65-year old I<), resents with a fracture of the left humeral
shaft. X-ray .,: ow~ areas of ~ f~..9sclerosis in the humerus. What is
the most a p op, ·tte investigation?
A Ra .io~ jcat skeletal survey
B. NuG e . r 5one scan of the bone
~ I sean of the hip
D. ~ RI scan of the pelvis
L . Serum calcium levels
>

49. A 75-year old woman is in hospital being treated for persistent

p11e_umQrria with a pr_qtgnged course of antibiotics. The fever recurs
and she develops b_lo9dy di~rrhoea accompanied by mucus. What is
the most likely diagnosis?

16
 A. Campylobacter infection
B. E.coli
v( C. Pseudomembranous colitis
D. Rectal carcinoma
E. Viral gastroenteritis

50. An 80-year old woman complains of qrigb_t red rectal bl e ·ng...

The blood is on the _surface of the _stool and also C'splash · s ·,i:, Ke
tOitet1 She has a longstanding history of constipation with JS age
of hard faeces. What is the most likely diagnosis?
A. Anal fissure
v([) Haemorrhoids
C. Rectal carcinoma
D. Ulcerative colitis
E. Angiodysplasia

51. A 78-year old man " sents with a four __ month history of
increasing freq uency ,'f efe ation. The stools are becoming looser
and now contain bloot!I ., d mucus. He also complains of Qrgency
when passing stoo d a sensation of Jncomplete ~yg_<:uatio_n. What
is the most likely d1 nosis?
A. Coloni a cin/m a
v',C]) Ree2 t ar. inoma

IDJ iverticulitis
. Crohn's disease

52. A 24-year old woman returns from an .overseas holiday dLJring

which she developed fever and _diarrhoea. One week after
returning to the UK, she notes fresh blood mixed with the stools.
What is the most likely diagnosis?
17
 A. Inflammatory bowel disease
B. Rectal carcinoma
C. Irritable bowel syndrome
] ~J\nc ~->
D. Diverticulitis
.A E Campylobacter infection
-1\ ,,
1
{~ r,;1: ~o,, /

\.___ 'iJ\ Cl '· I ~ .0 1 ' C.

'f:: co\i - b f\O b\ocdly ~\co\:,
53. A 23:year old omc!!1 presents with c~<;J~rrent\ blood aiarr ea I

over a six-month period. Further questioning reveals two m···. e at

similar epjsodes two years ago. What is the most likely diag · os·~?
A. Crohn's disease (no

./ B Ulcerative colitis
C. Irritable bowel syndrome
D. Gastroenteritis
E. haemorrhoids

54. A 49-year old sheet et J worker presents with an

·nt ermit ten , uncomfortab~· e · ing in the lef.t. _groin . What is the
most appropriate managem t ?

55. A ~-year old woman has ~~v~g~_ ji<;hemtc. _h~art d_i~e,\_~e

following a myocardial infarction five years ago. She presents with
,., increasing discomfort from a hysterectomy 1,Q_y_e.g_r_s__previou.s.ly. It
reduces with pressure. What is the most appropriate management?
A. Elective hernia repair

18
.!(~) Abdominal support
C. TRUSS
D. Observation
E. Give analgesia and review in 2 weeks.

-./ A Immediate herniorrhaphy

B. Elective herniorrhaphy
C. Herniotomy
D. Abdominal support
E. TRUS

57. A five ~y~ar _oldJhas been faun 0 l:i ve a reduc;Jble__swelling in

the [ig_h1._gfoin . Both testes a e n i mally placed in the scrotum.
What is the most appropriate mana~ement?
A. Hernia repair
B. Reassure
C Herniotomy
D. TRUS

5,ij. A 7-year old man with rnci ooro.a of the .Qronchus develops
s:t1p!3rior vena cava obstruction following radiotherapy. What is the
m@t appropriate immediate( management?
Ho(f'l€f ::i :,~!\dfon1e

B. Stenting
C. Bypass
D. Radiotherapy
E. No immediate treatment indicated

19
 59. A 49-year old man with .rn~ta~t~!j~ carcinoma has intractable
t-f-niccoughs. What is the most appropriate management?
. t -~')
A. Dexamethasone tablets /
" B. Haloperidol injection
C. Hyoscine injection
D. Cyclizine injection
E. Quinine sulphate

60. A 49-year old woman has fungating malodorou breas·/ cancer.

The ~_dOL:lf. is qj_~!~~ssing to her relatives. - ~a~ is the most
appropriate management?
J A0Metronidazole gel
B. Bisphosphonate intravenously
C. Haloperidol injection
D. Prednisolone suppositories
E. Local oestrogen

~t 14
Adying 57-ye ri olcJ man with bronchial carcinoma is una~l~ to
cough up bronchial eeretions. The noise is distressing to his carers.
What is the mm t ap ropriate management?

[': Cyclizine injection

62. A 78-year old man is suffering from b_lpody rectal discharge

following radiotherapy for carcinoma of the prostate. What is the
most appropriate management?

20
 A. Dexamethasone orally
B. Rectal diazepam
C. Diclofenac rectal
v'(D. Prednisolone suppositories
E. Loperamide capsules

63.

A. Dexamethasone
B. Nystatin suspension
./( ·c) Bisphosphonates intravenously
D. Haloperidol injection
E. Allopurinol

64. A lO-year old man presen ,t"wit ~· painful swelling of the right-
sided scrotal contents two we s fter an episode of unprotected
sexual intercourse. What is· e most appropriate investigation?
A. Culture for mid-stea 1 , rine
B. Syphilis serologM
C. Ultrasound scan of t he testes

6 ·- :A:-'5_0-year old man presents with a five day history of painful

~ e, ling of the right-sided scrotal contents. He gives a history of
)ecent urinary frequency and dysuria. He denies any recent sexual
contact. What is the most appropriate investigation?
A. Urethral swab
B. Ultrasound scan of the scrotum
·, '( C.)Mid-stream urine for culture and sensitivity

21
 D. Intravenous urogram
E. Immediate surgical exploration

I
66. A 10-year old man presents with a painless _swelling in the in
the left side of the scrotum which has been present for [bree)
[years, What is the most appropriate investigation?
A. Mid-stream urine
B. Gram stain urethral smear
/. C. ultrasound scan of the scrotum
D. CT scan of the scrotum
E. Syphilis serology

67. A tO-year old man presents with ~~ in . ,JsweJling of the right

testicle which has been present fo tw.o o What is the most
appropriate investigation?
A. CT scan scrotum
-.I' B; Ultrasound scan scrotum
C. Chlamydia screen
D. Transrectal ultr

68. A ~ ar old man presents with a history of severe dgbt:SJded

scr tal pain and swelling of a few hours duration associated with
~/0mitio . What is the most appropriate investigation?
A. l::Jltrasound of the scrotum
B. CT scan of the scrotum 0 .,J

J@1mmediate surgical exploration

D. Culture of mid-stream urine
E. Syphilis

22
 69. A 43-year old woman with bone pqin, t\A/o previous episodes of
_!p.9-cicreatitisl and fhype_rcalcaemi presents with a right sided
~yreteric __~torie) What is the most likely diagnosis?

A. Bladder diverticulum
B. Dehydration
C. Renal tubular acidosis
D. Recurrent urinary tract infection
,, · ( E Primary hyperparathyroidism

70. A 70-year old man with a previous hist r:y

_
u reter presents with left renal colic. He 1'11 s · "lory of
intermittent swelling and pain in his r'1gl1t: kn~e. What is the most
likely diagnosis?
A. Myeloma
,/~13) Gout
C. Septic arthritis
D. Rheumatoid arthritis
E. Renal failure ~

g[~ an with a one year history of weighf lossJ

proteinu~ia, naemia and \bone paiij presents with left ureteric
colic. ,.A-rler. . r1throcyte sedimentation rate (ESR) is(f1()) mm in the
firs ,.tq ~ What is the most likely aetiology? c)e.? 0 _ tO

C. Tumour lysis syndrome

D. Primary hyperparathyroidism
E. High calcium intake

23
 72. A 50-year old man has had recurrent episodes of acute and
very painful arthritis, he presents with renal colic shown to be due
to ureteric calculi. What is the most appropriate investigation?
( A 24 hour urinary urate
B. Urinary urate
C. 24 serum urate
D. Intravenous urogram /

E. Plain x--ray

73. A 40-year old woman presents with renal colic, ·ma ing eveals
~
multiple small stones. Serum biochemical investigat10ns looking for
a primary cause are all normal. What is th .( mostv- appropriate
investigation?
A. Intravenous urogram
B. Serum urate
C. 24 hour urinary urate
D. Serum calcium
E. Dietary history

74. A 40-year ol ·\"'tilia;,;::---c,:....._

w..._,it.--h_ a history of severe rvascular diseE1 e
develops severe ~ ga1ns What is the most appropriate
investigation?-
.A

,Y
,, 75. A 40-year old woman who was previously treated for breas
c_an r, was unwell until six months ago. She has been complaining
of abdn._ ioal Rai n and in reased thirst and passing large amounts
9 _ urine. More recently ~~-~___ ha~ become confused. There are !J_.O

24
 neurological signs. But she appears to be clinically dehydrated.
·rundoscopy is normal. What is the most likely diagnosis?
A. Cerebral metastasis C'~'\CVro\r J i( cJ "':; 'y rv,e \cnv~.~\
1
B Hypercalcaemia
C. Liver metastasis
D. Dehydration
E. Lymphedema

7~. A 30-year old woman, who has previously been trea ~ for
\breast cance·n presents with a two month history of ·ncn s'flg back
eain, W~gJ<ne~s in h~L l~gs and giffi_~_ulty in pas_sin ine. She has a
~pa.~tic J2t9-dq~r and we~~ness of all leg muscle Wlic;t is the most
likely diagnosis?
A. Faecal impaction .boc~ pc-1, n
,/ B Spinal cord compression ·(.t,('(' '( r E'.:i:'.> 11, \ :5
·rl1.q ,q 1 -, ~ ~;:,,n_9 )r , (
C. Bone metastasis .:Jrci:_;\ i C \c '4dp 1
D. Metastasis to the bladder
E. Pathological fracture

as treated for breast call~er five years

ago by a l_~g- mast- -·e o , and radigth~n~py. She complains of
stiffnes~ and swelli g of her fir1gru and heayj!)~S~_Qf .IJe.r l_~ft _aE!:D·
The left ar "ls mar, swollen than the right with limitation of
moveme~ i , a joints. What is the most likely diagnosis?
A. Ver10~ 01D truction
./t B ym9hedema
C4 Art:>erial obstruction

E. Local metastasis

78. A 50-year old woman, who was treated five years ago for
breast cancer, attends the -Accident and Emergency department
having had/a a , she complains of Rfil[l_i o e rightJ1ip. She cannot
25
 bear the weight and has significant limitation of right hip
movements. What is the most likely diagnosis?
v(A) Pathological fracture
B. Hypocalcaemia
C. Non accidental injury
D. Spinal cord compression
E. Lymphoedema

79. A 50: year old woman has had a ri ht mastec om t ree iears
ago for breast cancer. For the past six weeks srne as" had
(headaches) and more recently, has been noted t0' hav - ecome
incontinent. There are no ocal neurological .sig.ds. Fundoscopy
reveals ap1 edema What is the most likely dia osis?.,,
- - - e
A. Hypocalcaemia q
../ B Cerebral metastasis
C. Local recurrence of the disease
D. Spinal cord compression
E. Optic nerve compression

80. A 60-year old n ith severe cervical ~Rondy_litis has a

~iffi_c;:_l:11t -~pper gasti:-oi , e inal endoscopy performed. That evening
I

s_ubcutaneous emp !,SE], · a is noted in his neck. A ~t,est x-ray shows

no abnormali}Y.- Wh;.t is the most appropriate initial management?

81. A 30-year old woman underwent a subtotal th roidectomy for a

retrost ernal goitre, Two hours after the procedure she becomes
b_reathless and cyanosed. On examination of the chest there is no
. . mov·e ment oo1b_e__righL sJd.e, percussion note is h ~per-resonant and

26
 th~ a2ex ~~at is pispl<l,c;:gd to the left. What is the most appropriate
initial management?
1 (!,. Insertion of the chest drain
B. Surgery
C. Chest X-ray
D. Laryngoscope
E. CT scan chest

82. A _3__5-year old woman underwent a tot~l thYrc:>id.ecton:,yy or a

f9llicular carcinoma of the thyroid. On the eve . ing a ~er the
operation she notices \peri9r~L para~~thesja and th - staff observe
\ neurorr,yscular Jrrit~bility1 What is the most appr 1 f;)riate inftial
management?
A. CT scan of the head
B. Administer bisphosphonates
' I

/r C.)Administer calcium ( V
1

D. Dexamethasone
E. Oral prednisolone ~G
83. A 40-year oman has a c;tif(if_ult thyroidectQ.JTIY for
recurrent thy otoxi ~psis. In the recovery room she develops _strJdor.
What is the , o. a~propriate initial management? -
A. Call t ~ a ·pesthetist to intubate

84. A 70-year old man is admitted to the AftE department with a

history of ~_l;J_dge_n, onset of (?ain for 24 hours and now has s~vere
constant abdominal pain. On examination he is J}ale, sweating and
.,, , - ~

restl~s~. His pulse rate is 1_?9, beats/min; blood pressure is -60

27
 systolic mmHg. His abdomen is distended, tender and has a
pulsatile mass present. What is the most likely diagnosis?
A. Faecal impaction
w ( _B~. Abdominal aortic aneurysm
C. Intestinal obstruction
D. Mesenteric ischemia
E. Strangulated hernia

85. A 1Q_-year old woman comes to the Accident and Erner ~ncy
department w(t ~ an
inflam~c:I j[l:dex finge_r ~fte_r a PUA tur_ . ound
from a rosg _e'f_
~oq1 . She rece1ves an m3ect10n .~f a _1 tetanus
immunoglobulin and is commenced on oral pen.it.Hin. hilst the
wound is being dressed, she complains of thi t , per -oral itching
and she has a skin rash. She then collapses. ,,~ ~- )S" the most likely
diagnosis? :Y
A(>-
A. Spinal shock
B. Pulmonary embolism
"\v
/ @ Anaphylaxis lip ~s,\r- 1\\i \
D. Adrenal insufficiency
E. Staphylococcal sepsis

86. A 37-year old fN. , ~ n presents to the accident and emergency

department f -elin~ .u nwell. Following her last period, she has had
an Qffeos·~e · g1nal di_sc:harge. She routinely uses tampqn~.
Examinan' on re eals al or, weating. Pulse rate is {!)T O- beats /µ
minute; b,[c.io ,,,,. pressure is(§O/iQ} mmHg. There is lower abdominal
tende11 e s and vaginal examination reveals an Q.ffen~jve __gischarge.
Hat is the most likely diagnosis?
eningococcal septicaemia
8. Staphylococcal septicaemia
C. Anaphylaxis
D. Pelvic inflammatory disease
E. Anaphylaxis

28
 87. A qfvertif~l_
ul'll protruding between the lower most horizontal
fibres and the higher oblique fibres of the inferior constrictor
muscle. What is the most likely anatomical feature?
A. Branchial cyst
B. Carotid body tumour
/@ Pharyngeal pouch
D. Subclavian aneurysm
E. Cystic hygroma

,:'(B. Carotid body tumour

C. Cystic hygroma
D. Lyphadenopathy

89. A stru : u e i ~ he midline between the thyroid gland and the

hyoid bo e. hat is the most likely anatomical feature?

90. An expansile p_yJ.s.ating mass in the base of the p~ terior

triangle for the neck. What is the most likely anatomical feature?

29
 A. Cervical rib
B. Branchial cyst
C. Cystic hygroma
· ( D. Subclavian aneurysm
E. Thyroglossal cyst

91. A hard fixed linear mass attached to the $_event~ cePl.tcc!l

vertebra, causing fullness at the CQO_~ of the neck. What is t e rrnost
likely anatomical feature?
J:, "'A Cervical rib
B. Branchial cyst
C. Lymphadenopathy
D. Cystic hygroma
E. Pharyngeal pouch

92. A 30-year old man r - ents with p_rie_L_epjs_ode.s of severe

f~hoot ing paJrisJ in t ~ rec y m. Rectal exa-mination and flexible
sigmoidoscopy a~e bo-t , rmal.i What is the most likely diagnosis?

, 3. A 32-year old man presents with abdominal _~ , blQ_ ody

rjja rrho a and rectal _pain. Rectal examination reveals oedematous
~kin tags andcanatfistala Rectal biopsy shows ranulomat a Patient
has oraj_yJc_ers. What is the most likely diagnosis?
A. Rectal carcinoma
B. Ulcerative colitis

30
 C Crohn's disease
D. Gastroenteritis
E. Diverticulitis

94. A 22-year old woman with fhronics_gnstipation presents wit

~ev~_r~ a_norectal pain on ..defecation. Rectal examination p_rov" s
irnposs~ble because of pain and spasm. What is the most l1 ely
diagnosis?
A. Haemorrhoids
./ B Anal fissure
C. Rectal prolapse
D. Foreign body
E. Angiodysplasia

A §J-year old man presents with a th ee da histoty of

a ore.ctal pain aggravated by defecation. Rectal examination
reveals a purple_ coloured, tender lump at the g.QgLverge. Flexible
sigmoidoscopy shows normal rectal mucosa and b.ard. faec::~s. What
is the most likely diagnosis?
A. Haemorrhoids
B. Anal fissure
-./,, C Peri-anal haematoma

31
 D. rectal prolapse
E. Proctal fugax

97. A 35-year old man attends the Accident and Emergency

department having just passeq _a stone in his urine. He has just
returned from working outdoors in Egypt and admits to a poor flui
intake. He plans to stay in the UK. What is the most li~l~
prognosis?
A. Recurrent renal stones
B. Dehyd ration
C. Progressive renal failure
D. Pyelonephritis
,,,ft No further problems

99. ~ 75-year old woman undergoes open removal of arr taghorn

ca!aulus from a kidney. She is discharged on long term prophylactic
a tibiotics. Her renal function is normal. What is the most likely
prognosis?
~ - No further problems
B. Progressive renal failure
C. Progressive hydronephrosis
D. Recurrent urinary tract infection

32
 E. Operative stone removal

100. A 35-year old man with renal colic attends the accident and
emergency department. An IVU shows a mid-uretic stone. A week
later he returns in severe pain having still not passed the stone.
What is the most likely prognosis?
/ A. Recurrent renal colic
. Recurrent infection
C. No further problems
D. Urinary obstruction
E. Operative stone removal

A. (-reactive protein [' .

B. D-dimer V
../i . Doppler ultrasound scan~

D. Venogram ~ )., ,
E. Thrombophilia V
__

~
102. A 60-fea o~fl man has just been rescued from a hq_use fire.
H f s fa:c1 ,t an chest burns and i askin . about his family. There
is soc{' ira Ile pharynx and he has sutg{c[_ gasal hairs. What is the
mo · . RP~opriate immediate management?
~ Rit-ir.avenous fluids
B. efer to burns unit
,-----~,_. Anaesthetize and intubate
D. Oral fluid resuscitation
E. Reassure and discharge home with advice

103. A 1?-year old man f~ll asleep while S_l:JQ~~tb.tog two days ago.
He has diffuse skin redness with sparing of areas protected by

33
 clothing. He is otherwise well. What is the most appropriate
immediate management?

-AA. discharge home with advice

B. Intravenous fluid resuscitation
C. wound irrigation
D. Ice packs
E. Oral fluids

104. A two ~~r (?ld___ boy spills a recently prepared cup of /. over
his shoulder and the front his chest covering an are of less than 3%
of the total surface area. He is crying and unc 6p'e.rsative. What is
the most appropriate immediate management?
'- C ') '
> ,_) (. ,1\
A. Oral fluids
...l{"'B Analgesia with opiates
C. Ice packs
D. Wound irrigation
E. Burns dressing

tY"\ L \ \c;u t '('{\0 1

,, n ""J I (\ ;) '\ h1 S
105. A 28-year old j d I s. ri l worker sustains a 10% sqlld with hot
water to his trunk ana Legs . He has been given analgesic~ on site.
What is the most a , (Dr@priate immediate management? L ,t
A. Pain reli f1 ·it h piate . . .,,,, \
1
..l'(_B Specia 1s,t ref rral to burns unit e\ r__· "

C. lnt.i;aN-enous fluids with normal saline

106. A 45-year old ~Jectrician sustains a contact electrical injury to

the fingers of his dominant hand. There are (fu(l f hicknes~ burns to
( the pulps of his fingers and movement is painful. He has been given
appropriate analgesics. What is the most appropriate i,:nmeq_i_~_te
r,-:tan.~_gernent? ,i°
-~)

34
 A. intravenous fluids
\
.. 1 Referral to burns unit
C. Pain relief with opiates
D. wound dressing
E. intubate

107. A 17-year old girl presents with a 12 hour history of l w.e

abdominal pain with urJnary frequency. She is R~le a <?.I
temperature of 37.BC. She has (!"ebound tendefr'r1es~~ in the ngh
foss a. What is the most likely diagnosis?
0

A. Ectopic pregnancy
B. Diverticulitis
C. Ureteric stones
'-"'@ Appendicitis
E. UTI

108. A 40-year old woman re, ts wit h a six hour history of

s~yere _u.pp.er gbdomi_
nal p~1i and vomit ing. She is stttingJorward
and restless. She is shocke ith diffuse abdominal tenderness.
What is the most like~

1,0 . A 28-year old woman , who smoke~J}~ci!_'_ily and !~kes _g_n,ta~iE_s

regularly for mdigestio presents with a sudden onset of severe
abdominal pain. She is lying very still and is shocked. She has a
diffuse abdominal rigidity. She had a normal menstrual period two
weeks ago. What is the most likely diagnosis?
A. Appendicitis
B. Acute pancreatitis
35
 C. Ectopic Pregnancy
D. UTI
../ E. Peptic ulcer perforation

110. A Z2-year old woman presents with a sud.d.~n onset of ~_evere

abdom,inal pain. She complains of (:lizziness when she sits up. Her:
last menstrual period was eigbt..we_eks -~p. On examination of tm
abdomen she has rebound tenderness and guarding. What is t lie
most likely diagnosis?
A. Appendicitis
.,{BJ Ectopic pregnancy
C. Renal calculi
D. UTI
E. Tuba-ovarian abscess

111. A 32-year old woman prese t s j;J seyere right sided

abdominal pain of three hours duratio e is rolling around. She
ha·s no abdominal signs. The pai ram,a.t s to the groin. What is the
most likely diagnosis? \, ' --
.I( JS... ureteric calculi
B. Pyelonephritis
C. UTI

112. ~ 2 ear old man vyith a previous history of angina,

myp c:ar,df~l infarction and intermittent~claudication presents with
s aden onset of severe pain in his left foot during rest. He smokes
3Q. _garett es a day. What is the most likely cause?

B Embolism secondary to mural thrombus

C. Embolism secondary to valvular heart disease
D. Diabetes
E. Trauma

36
 113. A ?8-year old woman with (atrial fibrHlatiori) presents with a
cold, painful left_ arm. What is the ·most likely cause?
( A~ Embolism secondary to mural thrombus
( B. Embolism secondary to valvular heart disease
C. Polycythaemia rubra vera
D. Raynaud's disease
E. Burger's disease

"'
114. A 30-year old man is admitted with a spiral fract r<t of the
right tibia. A long leg plaster is applied. Fou , ours later he
complains of severe pain in the calf and is unab IZ to ove his toes.
What is the most likely cause?

/
A. Acute thrombosis
._. B Compartment syndrome
C. Trauma
D. Deep venous thrombosis
E. Cellulitis

ho smokes [4c cigarettesj a day presents

an
with a three day ·sto of p~in in the second and third to~s of his
teft foot. The toes r · ischemio His lower limbs are palpable. His
blood sugar is rnnal. What is the most likely cause?

../

116. A_50-year-- old man develops an infection around the nail of his
. - - -,

right hallux following fhiropody. Despite local treatment the toe

~b
\J,O,j
C. ~ b,OJ1(\

37
 becomes gangrenous. He has no history of claudication and his
pulses are nor£11al. What is the most likely cause?
. /(A.
,,.,.-~
Diabetes
B. Peripheral vascular disease
0
C. Raynaud's disease t·).- \('('''·
\~: •.,- C )...;
,•j
\ . .,

/:
D. Polyarteritis I~-

E. Blood dyscrasias
. . \ ~,. Ac~ , ····.-,'1 / I
,t 1\, 1~-'. j\~ C, ~ • . . ~ u"'l
.,,. ""' ~. ''·· /. -

117. An 80-year old man with metast~ t~:'·carcjJloma .tlecomes

confused with abdominal distension and \faecal i comtinence. He is
o·n ~ -!!~oes_opia. es\ What is the most appropria· e m ~ nagement?
A. Prescribe laxatives \
,/I B Administer an enema
C. High fibre diet
D. Increase fluid intake I • t. '.? l :
E. Reduce opiate analgesia

118. A 55-year old oma wi th known S(?Jfl~J_rn~.tastases from

breast cancer becomes . u eated and confused. Serum creatini oe
is 120 mmo/l; blood_ . 1 cose is 5.4 vrnmol/l; serum calciu 3.2
mmolll. She is re , ·ng intravenous (IV) fluids. What is the most
appropriate r.Ff nagement? -
\
C)' '- l C<Y:i'('

-\(. \:,~.\,\t"t'.J <' (:,. I'

pn~ . pt (.~'('d I()\
/-·\\; {-\\ c. <.. 5 . S
'3 ::\ <1 ~ '(y\ '(Y'Q \ / L..

119. A 45-year old man·· is dying of acquired immunodeficiency

syndrome (AIQ?). He i in considerable pain, q_espit~ ~QfQbj_Q_e
_pbate, slow releas 20 g daily, A_m itriptyline 100mg at night and
~~pr~xen 500mg twic a day. What .is the most appropriate
management?
-38
 A. Patient controlled analgesia
/i B Increase opiate analgesia ( u9 -(o CcD \'Y\9,)
C. Prescribe corticosteroid
D. Palliative radiotherapy
E. Nutritional supplements

120. A 65-year old man with p,_rostate canc~r has extensive p ~Yi

t;::a:e:~:~:e:~c. What is the most appropriate manv nJ, -

spread of the disease with P-~io not adequately control~ M .~t

B. Palliative chemotherapy
JlC Palliative radiotherapy
D. Set a syringe drive
E. Increase opiate analgesia

121. An 82-year old man i,t h bronchi al carcinoma and known

cerebral m~tastases ev. lops' weakness of his right arm but is in no
pain. What is the mos~ ~p,ropriate management?
A. Increase opiate

122. A ]_5-year old sin_glELman, who · o in a top floor flat

and y'{orks as a _crane driver, presents '1'ith a hree month history of
interml t1:enrswen1 og in the rig_bt"groio. He is a ~_mQker, is fit and
well and is O.Qt taking any medicatigos. Examination reveals a l~rge
inguinal hernia extending to the scrotum. What is the most
appropriate management? - /· d' .-~-\\
\ \ (\ \(('\ /

39
 ,, ,'""
,,

A. Mesh repair as a day case

/ B Mesh repair as an inpatient (l1v 0.2) 0
\ane)
C. Herniotomy
D. Reassure
E. mesh repair and orchiectomy

123. An 85-year old man presents with a large, tender (irrequ · le) ~
right jo.gl)inaL.berni.? extending into his scrotum. He has n hts
hernia repaired on previous occasions and had a l m , c . ciiaU
\ir.!f.arctio.rn two years ago but at present is fit and well. h t is the
most appropriate management?
'--

j (M c'rnesh repair as inpatient

B. Mesh repair and an out patient
C. urgent herniotomy
D. TRUSS
E. Abdominal support

124. A 40-year old bank managEir presents at a routine medical

with a jgbt inguinal herni 1$fe states that this hernia has been
irr~reasing in size and 0ecasi0nally can be tender. He is lmarrieq/and
isffr and .weU-with ne ~edical __ bj~!o_ry_Qf _11q_t~. What is the most
appropriate mana@ , . e t?
A. Herniorrha~by as ·n patient
../

125. A\ fx_yecirl old boy is noted on a medical examination at school

to have an in ~jp_aj_ h~rnja. This is notJrotJbling bim. What is the
0

most appropriate management?

A. herniorrhaphy

40
 \
( \ '
u 'f 001 ,:, )

D. TRUSS
E. Abdominal support

126. A tQ-year old boy is admitted for a right ioguJriaChernioto- ~

His blood pressure is normal but his piJJse is irregu!.a.tJ What i tne
most appropriate next management step?
A. Chest X--ray
B. Full blood count
C. Urea and electrolytes
,.,.:- ( D. ECG
. A,
~
E. Echocardiogram

127. An eight _y_ear old _girl with (extii!asi~ ellE is admitted for
_abdC>minc!J surgery.. She has had s·, nifti;9 t f~eezi.n~ _ _for !h.~ past
1

year and she has sllght [centra~ a 0sli,7 on \fnoderate exerf10n} Her
chest x-ray is normal. W at i the most appropriate next
investigation? ~

/ A Respiratory functio test \., '

B. Chest X--ray
C. Abdominal X-ra
D. Electrocar ,iogra

1 @~ . J 12-year old_ boy is a~mit!ed for removal o_f a t~sticular

swe.t t ng. On abdommal exammat10n he has an lep1gc!stnL mc!~S"')
<;tJe t and abdominal X-rays are unremarkable. What is the most
a ' propriate next investigation?
A. Abdominal X--ray
Ji B CT scan abdomen
C. Clotting screen
D. Skeletal survey
41
 E. Chest X--ray

129. A 70-year old woman with a gangrenou~_ fifth toe on her left ~
foot has a history of polyJJfi? and l9:c~~ pf w.~_
0
iabJ. What is the most .r-
appropriate next investigation?
A. Blood pressure monitoring
J ® Serum blood glucose
C. Angiography
D. Doppler ultrasound scan of the leg
E. Urea and electrolytes

130. A ?,Q-year old woman is admitt fo an gpen. ~~,l ectiye

ctlg_lec~stect9r_ny. Her haemoglobi· (~" , chest x- ray and
electrocardiogram (ECG) are norma but she has a ~tstory _of
p_l~eding after a dental extractio bat is the most appropriate
next investigation?
A. Full blood count
B. Liver function test
./ ~) Clotting screen

13 . A 2-year old man is admitted for a tot~Lbip replacement, a

ull t:laematological work up is normal. He l}as __recemtly n9tic~d
wo sening _chest_pain __on___e>te..rUon. What is the most appropriate
i,ext management step?
A. Echocardiogram
B. Coronary angiogram
C. MRI of the heart
~ Electrocardiogram
E. Full blood count
42
 132. Chest X-ray shows (ais.ed right diaphragm with ?_mall pleural
effusion above. What is the most likely complication of
cholecystectomy?
A. Acute renal failure
-../ B Sub-phrenic abscess
C. Small bowel obstruction
D. Inferior vena cava thrombosis
E. Pulmonary embolism

133. Ultrasound scan shows intra-ab 6- in ! \free f lYidJ with

(Raralytic ileus What is the single l" ely complication of
~bql~{:~c.tomy?
A. Stone in common bile duct
B.
C. Acute pancreatitis
/D
E. Small bowel 1 r, ction
134. Liver . G io \ests show raised alkc1_lifl_e ,p,hosphatase, raised
qilirubin ~ o ma albumin and normal hepatocellular ~_r,!zymes.
What is ttie ust likely complication of cholecystectomy?
~\ h~;f'A~ IC,

Acute pancreatitis
Stone in the common bile duct
E. Acute renal failure
135. Ultra,,~ound scan shows dilated common bile duct with no free
intra-abdominal fluid or bowel distension. What is the most likely
complication of cholecystectomy?
43
. ./' A Stone in common bile duct
B. Myocardial infraction
C. Biliary peritonitis
D. Acute renal failure
E. Acute pancreatitis
136. Chest X-ray shows signs of left ventricular dilatation and a ;
electrocardiograph (ECG) shows Q waves with ST elevation. h tis
the most likely complication of cholecystectomy? "
A. Stone in common bile duct
B. Sub-phrenic abscess
C. Acute renal failure
D. Small bowel obstruction
/ (E) Myocardial infraction
137. A 23-year-old man who has beeJil r.e eiving c clospori lJ for the
treatment of his rheumatoid rthrlis presents with o.dynoph!3-gia
and mild qy~ hagia. Oesopha eal ndoscopy reveals multiple small
white plaques on the bas~ground of an abnormally reddened
mucosa. What is the most a ~ ropriate management?
A. Endoscopic dit talt:ion
. ,/1 B.
C.

IV acyclovir (High dose)

31-year-old woman with AIDS presents .wi h odynophagia
Oe.sophageal endoscopy reveals multiple iWat ovl
ulcers in the
l wer oes9phagus. The mu~9$a _contains.. m.u ltiple ve_sicles. What is
, the most appropriate management?
../@ IV acyclovir (low dose)
B. Surgical resection
C. Endoscopic insertion of Atkinson tube

44
 D. Heller's myotomy
E. Triple therapy
139. A i_9-year obese man presents with dysphagia. Barium swallow
demonstrates a smooth rat-tail appearance. He has complained of
heartburn for the last 6 months. What is the most appropriate
management? 1 •
(1i(' \ n.JI

A. Surgical repair
B. Sclerotherapy
"'~ ( 0 Oesophageal dilatation
D. Surgical resection
E. IV ganciclovir

140. A 62-year-old man presents w.ith Y.S· hagia. He says ~t'~ been
P!~gressive, having started wi h · ~a difficulty for swallowing
~.9_ljds, but now also involved qui ~ He looks wasted. What is the
most appropriate management.
./ Ii.. Radiotherapy ~
B. Triple therapy
C.
D.
E. ~~ii:'.o ,, · nazole systemically administered
'
14 . P. ~0,.year-old man presents with maJaise and back pain, which
~n
r-,'as , _e present for three months. He is found to have sjgJJ!{i~ant
· ~ einuria. What is most likely underlying risk factor?
A. Dehydration
v@ Multiple myeloma
C. Pregnancy
D. Varicose veins
E. Hormone replacement therapy (HRT)
45
 142. A 30year woman presents with a three mo11th history of
a~enorrhoea. What is the most likely underlying risk factor?

•I A. Pregnancy
B. Inherited clotting abnormality
C. Multiple myeloma
D. Polycythaemia rubra vera
E. Dehydration
143. A 60-year-old man with a lethork a ppearance prese
p!eurjtic chest pain. He has palpable sple_
nomegaly. ~W.ha
most likely underlying risk factor?
A. Multiple myeloma
-/ B Polycythaemia rubra vera
C. Malignancy
D. Clotting disorder
E. Dehydration

144. A 70-year-old man ~r sents with t>a.f~ _pgin and jaundice. What
is the most likely : ~ e,rlying risk factor? __
c _ _ _, . .

A.

Varicose veins
Dehydration
145. A 25-year-old woman with a family history of deep vein
thrombosis presents with sudden onset of chest ain and shortness
of breath .she was prescribed the combined oral contraceptive pill
six months ago and has not missed any tablets. She has developed
calf swelling and tenderness. What is the most likely diagnosis?
@ Pulmonary embolism
46
 B. Clotting disorder
C. Pregnancy
D. Hormone replacement therapy (HRT)

A.
B. Venography
.,(c) Arteriography
D. Electrocardiography (ECG)
E. Coagulation profile
147. A 34-year-old man complains of pain i , calves on walking.
The pa-fr1 is absent at rest. Wbr. t ts he most derin11ive
investigation?

(9
B.

D. . ion (V / Q) scan
E.

148. A ., s- ear-old man complains of intermittent pain i~___his toe on

-~
a$
l~i1r.ig. He says that in addition it looks 'white'. What is the most
itive investigation?
A. Digital subtraction angiography
B. Femoral duplex scan
/© Ankle-branchial index measurement
D. Ventilation perfusion (V / Q) scan

47
 E. Femoral arteriography
149. A 46-year old woman is brought to the accident and
emergenci department· breathless and complaining of chest pain.
She has a two-month hlSfory -of leg pain. What is the most
definitive investigation? ·
J A Ventilation perfusion (V /Q) scan
B. Femoral duplex scan
C. Electrocardiography (ECG)
D. Femoral arteriography
E. Venography
150. A ~Q-year old married woman presents t
Emergency department with a sudden
abdominal pain. Her last menstrual perio
has pain radiating to the left shoulder.
diagnosis?
A. Acute gastroenteritis
B. Acute pancreatitis G
C. Appendicitis
D. Biliary colic
Ectopic pr goar1cy
151. A 15-ye r.~ ol~ irl presents with a 21~~ou,r history of central
abdomin l ~n, followed by pain in the right iliac fossa which is
worse on co~g-hing. She has (~v~r and rebound tenderness in the
right i ·1 -c ossa. What is the most likely diagnosis?

Appendicitis
Perforated peptic ulcer
D. Renal colic
E. Salpingitis

48
 152. A 30-year old woman has severe f.colic and upper abdominal
pain radiating to her right scapula and is vomiting. What is the
most likely diagnosis?
~ J\J Cholecystitis
B. Strangulated hernia
C. Pancreatitis
D. Ulcerative colitis
E. Urinary tract infection (UTI)
153. A 12-year old girl has central abdominal pain and i, vo iting.
On ~xamination t her abdomen is found to be 0ist~ nae with no
. ~bound tenderness) and a tender lump in h~er r:igAt roin. What is
the most likely diagnosis?
-- Strangulated hernia A(>-:
B. Perforated peptic ulcer ,V
C. Biliary colic
D.
E.
Appendicitis
Acute gastritis
G~

Appendicitis
Urinary tract infection (UTI)
155. A 31-year-old woman presents with acute, severe abdominal
pain. Her blood pressure is 1,,00/60 mmHg and no abdominal signs
a~e found. Haemoglobin level is ~17 g/d nd the plasma amylase is
only mildly raised. What is the most likely diagnosis?
,J
Acute mesenteric ischemia
49
·' r '
 B. Appendicitis
C. Biliary colic
D. Acute pancreatitis
E. Perforated peptic ulcer
156. A 49-year-old man with a 10-year history of h_ypert~nsio1,1
presents-at casualty with severe ret rosternal pain radiating to .-Ai\ >"'
left arm for 30 minutes. What is the most appropriate pain reli fl
A. Paracetamol
~ Diamorphine
C. Transcutaneous electrical nerve stimulatje.
D. NSAID
E. Carbamazepine
157. A _ 5.2-year-old man with seve e l , t d in pajJ presents at
casualty. A ~.rine dipstick reveals a 120s1 iw.e result. What is the most
appropriate pain relief?
A. Dexamethasone
B. Diamorphine
Diclofenac
D.
E.
carcinoma and known
headache. What is the most

Dexamethasone
NSAID
C. Paracetamol
D. Diamorphine
E. Nifedipine

50
 159. A _53-year old man develops a J1,1dden pain_ful firsJ right
m_etatarso-phalangeal joint. What is the most ~ppropriate pain
·relief? . ( -c,o l -

A. Carbamazepine
~ B Non steroid anti-inflammatory drug
C. Nifedipine
D. Diamorphine
E. Paracetamol ~,
160. A 35-year old woman comes to the clinic for scre~ni n~ f her
breas~s. What is the most appropriate investigatio~?--'\
A. Open biopsy _ 0
B. Fine needle aspiration cytology A['~ T
C. Ultrasound ,V
D. Reassurance
./·'@ Mammography
161. A 35-year old woman . resemd with a mass in the right upper
q~agrant of her right breast
7
ound, SJl]qoth mass is found in the
axilla. What is the mo app~priate investigation?
A.
B.
C.

2 A 36-year ~ d w , man comes with a hard mass in her breast.

~ he skin is tettie're . Ultrasound and mammography were
inconclusive. The patient wants to be satisfied that this is not
malignant. What is the most appropriate management?
A. Reassurance
,/(]\
\.7 Open biopsy
C. Fine needle aspiration cytology
51
 D. Computed tomography (CT)
E. Mammography
163. A 36-year old woman presents with itching of her left nipple.
On examination, no ulceration is seen. But a scaly lesion around
the nipple is observed. What is the most appropriate management?
A. Reassurance
J'® Open biopsy
C. Lymphangiography
D. Magnetic resonance imaging (MRI)
E. Wide excision

A. Wide excision
B. Ultrasound
C.
D. Mammography
./i E) Reassurance
165. A ~0-year ol , ma presents with a painful _filVel~ing of the
right-sided s rot<\l contents two weeks after an episode of
!::!nprotected se ual Jntercourse. What is the most appropriate
investigat ·o ,~
~ lture of mid-stream specimen of urine
Gram-stained urethral smear
Human immunodeficiency virus (HIV) antibody test
D. Immediate surgical exploration of the scrotum
E. Intravenous (IV) urogram
166. A @.!]!}er complains of burns to his (rightarm
from pet rol fire
four hours ago. There is a circumferential mixed partial and ful

52
 l t hickness)burn covering his right arm from his elbow to his
fingers .. What is the mpst appropric1te management?
A. Aspirate blisters
B. Blood carboxyhaemoglobin concentration
C. Neutralizing agent
.J@ Escharotomy
E. Oral fluids
167. A patient has an ex.pansile pulsating mass in he a , of
sternocleidomastoid muscle in the posterior triangle ,
What is the most likely diagnosis? ~ 1,
A. Pharyngeal pouch ~
/(~: ~~~::~a:y:;eurysm ,(""\ ~
D. Lymphadenopathy ~v
E. Cystic hygroma \., '
1

168. A ~ard fixed linear ma ·f tached to the seventh cervical

vertebra, causing fullness a, -he root of the neck. What is the
most likely diagnosis? \.-
A. Submamd.ibu ~ gland enlargement
B. Cat oti~ ~ody tumour
, yr01d enlargement
ymphadenopathy

_,,_
E.) Cervical rib

A 169. An 85-year old woman is admitted with intE?sJ_inal_obstruction.

Her hemoglobin (Hb) is . g/dl, packed cell volume (PVC) 48%
area}~ mm/dl sodium 115 mmol/l, potassium 5 mmol/l. What is
the most 9ppropriate initial management? t.Jo. _ 1 ~·_) . 1 •1'.0
A. Defer operation and investigate
53
 B. Fresh frozen plasma
C. Immediate blood transfusion and defer operation
,/'@Immediate blood transfusion, stabilise and proceed to surgery
E. Pre-operative ERCP
170. A 4-5-year old pre~menopausal woman is admitted for elective
hernia repair. Her Hb !_iLB-1_.J(.dl mean cell haemoglobin (MDH) 22pg
MCH concentration 28 g/dl, mean cell volume (MCV) 70 her wh"te
blood count (WBC) is within normal limits. What/ is the ( ost .,.
1
aQQrQgrJate initi~l .man?gement?

A. Defer operation and investigate

B. Proceed with planned surgery
C. Vitamin K injections
D. Immediate blood transfusion, stabilise, ah~ roceed to surgery
E. Pre-operative ERCP

171. A 65-year old man has , ae , et.emesis. Endoscopy shows a

\duodenal ulcer which was injected)." He has a-furtbe_r:_h9~metemesis
and his blood pressure dro s t • ~00/60 mmHg. His Hb is~ g/dl.
MCH 25 pg, MCH concentra tpn 3 g/ dl, MCV ~5fl. What is the most
appropriate initial ma.ff gement? ,:.

planned surgery

_D. -\1.i~ ~n K injections

· . I mediate blood transfusion, stabilise and proceed to surgery

54
172. A 60-year old woman is admitted for elective cholecystectomy.
Her preoperative electrocardiogram (ECG) shows rapid, irregular
_rhythrn with absent P waves. What is the most appropriate initial
management?
, A: Defer operation and investigate
B. Proceed with planned surgery
C. Vitamin K injection
D. Fresh frozen plasma
E. Immediate blood transfusion and defer operation
173. A -~-~-year old woman is admitted with a two , eek , 1story of
~-~vere upper abdominal pain, pale stoo_ls and dar- rine. An ultra
sound scan showstoilated bile ducts\ What is tH o t appropriate
initial management?
~
i-- A. CT scan abdomen
B. Pre-operative ERCP
C. Ultrasound Scan
D. Abdominal x-ray
E. MRI scan of abdo
174. A 45-year old wol\lila has right-sided abdominal pain radiating
to .the._ __groin and r -a,r.0scopic· haematuriai, she has taken _regulcir
faiclc:>fe1Jgci fo r: over 5 year~ for her period pain. What is the most
likely comgl · a ior.i to develop?
A. No ·r.l f lying cause (idiopathic)

"'D. Renal tubular acidosis

E. Schistosomiasis
175. A 50-year old man has renaj_ __ colic. He has chronic sarcoidosis
with rec_u rrent erythe_ma nodosum and bre~thlessness. What is the
most likely complication?
A. UTI

55
-.A B. Hypercalcaemia
C. Hyperoxaluria
D. Papillary necrosis
E. Renal tubular acidosis
176. A 45-year old man who was previously fit has left renal colic
An IVU shows a 4mm calculus obstructing the left ureter. What: is
the most likely ccimplication? ,
A. Dehydration
B. Hypercalcaemia
./ © Obstruction
D. Hyperuricaemia
E. No underlying cause (idiopathic)
177. A 25-year old white man present s wf h three months history
of ri__ght groi.!1 swelliog. He is otherwise fi and well, takes regular
exercise and has no__pa_st medical H~t:apy. Examination confirms the
presence of a ri.ght ingtJip~l ~ la ¥ What is the most appropriate
pre-operative investigatio ?

,i

178. A v8·~ear old woman presents with a long history of l~~~_rrent

Lfr-:inary, r,fectjons and Jeft renal pain. An intravenous urogram (IVU)
s~o.)'s a _lar_ge ston~ in the _left renal . pelvjs, but _
no obstruction.
What is the most likely complication will he develop?
a Infection
b. Dehydration
c. No underlying cause (idiopathic)
d. Obstruction

56
 e. Papillary necrosis
179. A 45-year old man has just passed a stone in his urine. He
ru_oi Jgng distaoces. regularly. What is the most likely risk factor for
renal stones?
a. Cystinuria
-/'( b. Dehydration
c. Hypercalcaemia
d. Hyperoxaluria
e. Hyperuricaemia
180. A 3-year old African-Caribbean man has ____. . . _
hernias. His haemoglobin is 11 g/ dl. What is th
pre-operative investigation?
,.,/ A, Sickle cell test
B. Echocardiogram
C. Electrocardiogram
D. Full blood count
E. Hepatitis screen
a
181. A man has reducible ~ -~~ow the pubic tubercle and on
occlusion of the eep guinal ring, cough impulse is present.
What is the mo ly diagnosis?

0. pigelian hernia

0 . Lumbar
,JB2. A 35 year old male builder presented with sudden onset of
severe ~bdominal pain. He was _previously fit and well other
than taking 1ouprofen~ for a \Lon _ ter knee injury. On
exam i nation he is i n seve·re pa i n , p u ls e = 1_ LO b pm ,
BP=110/70mmHg and has a rig~~ abdomen. What is the most
fikely diagnosis?
A. Biliary peritonitis

57
 B. lschemic colon
C. Pancreatic necrosis
D. Perforated diverticulum
·-1 (E) Perforated peptic ulcer
183. A woman 5 days post-op f or hH~t eral salphingo-oopherectom~
and abdominal hysterectomy has developed abdominal p,f n
and om1 tin- 1 associated with _abdominal distension and c~Gl '
pass gas. No bowel sounds heard, although well hy~.,.tea='
What is the most appropriate next step? ~ y
./ ( A. X- Ray abdomen d~\ ,·· ,
" f°'' ·,-,. ()
'

B. Exploratory laparoscopy
C. CT Abdomen
D. USG
E. Barium enema
-.- ..,
1
184(tA but~ er ·stabbed accident . is groiD. He bled so much
that the towel was so ked i lood and BP=80/50mmHg,
2
1Rulse=130bpm~ What% of cir u(atory blood did helose?
-- A. < 15% l . ~ · I\ r rn r w,n I <-YS i·:

A. Thromboangitis Obliterans
, .,,, B. Sciatica
C. DVT
/ .
D Atheroscleros1s
E. Embolus I

58
186. A man presents with ~crotal swelling, the swelling is cystic
and is non-tender. It rs Tocated 1n the l UPP?f-PQJij of the
posterior part of the testis. What is the most likely diagnosis?

./; A Epididymal cyst

B. Testicular cancer
C. Hydrocele
D. Teratoma
E. Testicular torsion
187. A 34 year old (African-Caribbean\ man wit
sarcoidosis has presented with ,bilateral kidne
is the most likely cause for this patient st
A. Hypercalcemia
B. Hyperuricemia
C. Diet

188. A man on _V'{arfarin po te¢,. for ti~mi~pl~_ctqmy. As the patient

is about to unde -gc;:> surgery. What option is the best for him?
A. Cantin it h warfarin
B. Conr , ~,. wi th warfarin and add heparin
Ci t o bwarfarin and add aspirin

,..._._.....,
D. Stop warfarin and add heparin
E. Stop warfarin
la'dy, p_ost-.colostomy closure after 4days comes with
f~_uctuating S_._11J.9-JL.s.welling in the ~_toma. What is the most
appropriate management?
A Local exploration
B. Exploratory laparotomy
C. Open laparotomy
D. Reassure

59
190. A 63-year old lady with a ~M1_=32 comes to the ED with
complaints of Rigmentation on her legs. Exam: dilated veins
could be seen on the lateral side of her ankle. Which of t he
following is involved?
,,1 (A. Short saphenous vein
B. Long saphenous vein
C. Deep venous system
D. Popliteal veins
E. Sapheno-femoral junction
191. Which of the following formulas is used for c
for qurn patients? (Joc-¥-\cM,o
A. 4 x weight(lbs) x area of burn= mi off , ids
B. 4 x weight(kgs) x area of bur - B of f (uids
C. 4 X Weight(kgs) X area of .U ~ ml Of fluids
D. 4 x weight(lbs) x area of
E. 4. 5 x weight (kg )~ a ~ a of burn = dl of fluids
192. A 72 year old man. resent~ with .i ntermittent difficulty in
a
swallowing with rre . u,r:g,i:t,ationJ of - ~ food materials.
Sometimes he w . , s u~-at night with a feeling of suffocation.
What is the sing,t m , st likely cause of dysphagia?
A. Ben1i-A sf cture
B. Esoplna eal carcinoma
C. sag ageal spasm
Q P ryngeal pouch

----- . Systemic sclerosis

ear old man with Ciincer of middle 1/3 of the esophagus
p ·esents with g sphagj_g. What is the most appropriate
~ .... ·i-mmediate management?
A. Chemotherapy
B. Radiotherapy
.Ii C Stenting
D. Gastrostomy
E. TPN

60
194. A m a n p res e n ts w i t h a b d o m i n a l pa i n , v om i ti n g ,
pulse=120bp111, BP=90/ 6QmmHg and a rigitj qbdomen. His
che~t is:clear: What is the immediate maneigement? - .
A. Call radiology
B. Admit to medical ward
/ (C. Urgent admission to ITU
D. Recheck the BP
E. Administer parenteral antibiotics
195. A 78 year old gentleman suddenly collapsed. His · R=1 pm, '9
BP=70/40mmHg. Exam: pulsatile mass in abdome . What is
the most likely diagnosis?
1
- ( A Aortic aneurysm

B. Mesenteric cyst
--,

C. Umbilical hernia
D. Mesenteric thrombosis
196. A patient on ipsulin is bo ~ed j• - or a hernia operation. What
is the most appropriate anajement of insulin?
Xi A Give insulin and alrn 1>re-op
B. Stop insuli tor t~e duration of the op

D. Gi e ins ,Jin as usual pre-op

E. N, ne
197. A ~~ r-old male has been operated for .?..!?flominal tra~ina
ay splenec:t<>_r,rJY was done. On the ] rd -J?.Q.S.t::.OP day the
patient developed ?f.Y!e abdominal pain and dtst~IJSiQD in the
!-Jpper abdominal area with !2Y- ?tension. ~n insertion of_ {tylesJ
1et..9bes 2L of cc:>ff~_e ground flu1d was asp1rated. What 1s the
most likely diagnosis? -
./@ Acute gastric dilatation
'f @ Reactionary haemorrhage
C. Subphrenic abscess
D. DVT
61
 E. Left lower lobe atelectasis
198. 2 hours after an ~ppendec:tomy, a patient complains of a J.apid
JjR.and _fever. He says --there is ·also abdornin~l _pain and pain in
the shouloer _are_a. What is happening to this patient?
A, Intra-abdominal bleeding
B. Anastomotic leak
C. Sepsis
D. Intestinal obstruction
199. A 23-year-old woman presents with a _1 _cm _small s
mobile mass in her _l~ft _breast. She is very anxious.
most appropriate investigation?
A. Mammography

"' B. US breast
C. FNAC
D. Mammography and US
200.A 42-year old female who ·s a e e comes with severe upper
abdominal pain and right hou er tip _µ,ain with a temp=37.8C.
1_

She has 5 children. Wh tis 1:Me most likely,.dia.gnosis?

A. ERCP r· ," r·F u··i',\C•Y,\
•('.,. .._ ,,., 1 I 1-- • ..,.~/~.... ~

d man with a ll}_Q"IP in front of his .n~ck which

. mi~d l~ __ _f\ge_
move up while he's swallowing. US shows a mass replacing the
l¥t1obe of thyroid. And spread to the sternocleidomastoid and
at:ljacent muscles. What is the most likely diagnosis?
, , - .1l{!) Thyroid cancer
B. Pharyngeal pouch
(
C. Bronchus cancer
D. Thyroid cyst
E. Larynx cancer
62
202. A Lc1_d_y_ with post iteo-colectomy closure of stoma has a small
4cm swelling around the stoma. What is the most appropriate
management of the swelling?
·/S.. . Local exploration of swelling
B. Exploratory laparotomy
C. Open laparotomy and re-closure
D. Abdominal binder
{l1
E. Truss (,:'_., c-Jf r, ,, ; ,

203. A 70 year old man presents with a \i;?_Lm-c;hed:ou~ ~ eer oei,.ween

his t<?.~~- He is a _ heavy drinker and !_~moken. Exa : (~ r is
yelloVf and the !foot turns red') when dang ,in · off the bed.
What is the most likely diagnosis?
,/' Arterial ischemia ulcer
B. Malignancy
C. Neuropathic ulcer
D. Pressure ulcer

204.A 35-year old ~rrian ~ · s,.ents with mass in the_ grojn. Exam:
mass found just j)elow and ~ateral to the p!,Jl::>,ic tubercle. There is
no
.... cough
. impulse ei 1 is irr~ducible. What is the most likely
,, . {'

diagnosis?
A. Dir ct i gumal hernia
B,. St an~dtated hernia

~ Saphena varix
E. Femoral aneurysm
A 70-year old man presents with a fluctuant swelling of the
scrotum which 1feels like worm~ when he is standing but
regresses when he lies down. What is the most likely
diagnosis?
./t . Varicocele
B. Hematocele

63
C. Testicular cancer
D. Epididymal cyst
E. Saphena varix

64