RECALLS Flashcards by Mageed Ramadan (2024)

Therapy for treatment and presantation of pouchitis
IBD_therapy-treatment-and-prevention-pouchitis
> Vomiting
• Metallic taste
> Temporary damage to nerves

SIDE EFFECTS OF METRONIDAZOLE
epigastric distress
•Seisures
•Metallic taste
Darkenina of urine Peripheral neuropathy
Pancreatitis
•Hepatitis
•Fever
•Reversible neutropenia

E

Based on the clinical presentation of a 56-year-old woman ventilated in intensive care with increasing oxygen requirements, elevated pulmonary capillary wedge pressure (PCWP), and bilateral diffuse opacities on chest X-ray, the most likely diagnosis is:

Pulmonary edema secondary to heart failure.

Here’s a breakdown of the options:

1.Acute respiratory distress syndrome (ARDS): ARDS typically presents with acute onset of hypoxemia, bilateral opacities on chest imaging, and absence of elevated PCWP. The PCWP in ARDS is usually normal or low.2.Aspiration pneumonia: This can lead to bilateral opacities on chest X-ray but usually does not present with elevated PCWP unless there’s an underlying cardiac issue.3.Lobar pneumonia: While lobar pneumonia can cause bilateral opacities on chest X-ray, it doesn’t typically lead to elevated PCWP.4.Pulmonary embolus: Pulmonary embolism can cause hypoxemia and may present with chest pain and hemoptysis. It usually doesn’t result in elevated PCWP or diffuse bilateral opacities on chest X-ray unless there’s concurrent heart failure.5.Pulmonary edema secondary to heart failure: Heart failure can lead to elevated PCWP due to left ventricular dysfunction. Elevated PCWP can cause pulmonary edema with bilateral diffuse opacities on chest X-ray.

Given the elevated PCWP and bilateral diffuse opacities on chest X-ray in the context of a patient with increasing oxygen requirements post-operatively, pulmonary edema secondary to heart failure is the most likely diagnosis.

Source:

•Murray, J. F., & Matthay, M. A. (2015). Acute respiratory distress syndrome (ARDS). Annals of internal medicine, 142(10), 764-772. Link•Braunwald, E. (2019). Heart failure and cardiomyopathies. In Harrison’s Principles of Internal Medicine (20th ed.). McGraw-Hill Education.

Very debatable but E

For a 23-year-old asthmatic man with a bilateral fracture of the fibula and tibia who is on 15 mg of prednisolone daily and scheduled for surgery, the appropriate perioperative steroid management would be to increase steroids on the day of surgery and for three days postoperatively. This recommendation is based on the general guidelines for managing patients who are on chronic steroid therapy undergoing surgery. These patients are at risk for adrenal suppression, and thus, it is crucial to provide additional steroid coverage to cope with the stress of surgery.

In the context of the provided search results, while specific perioperative steroid management protocols for orthopedic surgeries are not detailed, the general principle of increasing steroid dosage during significant surgical stress to prevent adrenal insufficiency is well-established in clinical practice. Patients who have been on systemic corticosteroids for more than two weeks in the past six months should be considered at risk for adrenal suppression and would need intraoperative supplementation of steroids[1]. This is typically managed by administering 1–2 mg/kg of hydrocortisone intravenously every 8 hours on the day of surgery, followed by a gradual tapering off to the usual preoperative dosage[1].

Therefore, the most suitable option for this patient would be to increase steroids on the day of surgery and for three days postoperatively to ensure adequate physiological response to the surgical stress and to prevent potential adrenal crisis.

A 72-year-old woman, who was treated for breast cancer 20 years ago, presents with tiredness, constipation, back and chest pain. Examination reveals localized tenderness over thoracic vertebrae and anterior ribs. Her pulse is 110 beats/minute and blood pressure 90/60mmHg. An ECG shows a shortened QT interval. Her biochemistry results are:

Finding
Sodium 137 mmol/L (135-145)
Potassium 4.3 mmol/L (3.5-5.0)
Corrected calcium 3.8 mmol/L (2.2-2.6)
Phosphate 0.8 mmol/L (0.8-14)

Chest X-ray shows lytic lesions in the left anterior third rib and fifth thoracic vertebra.
Which of the following treatments should be administered first?

• 0.9% sodium chloride
• Calcitonin
• Cinalcalcet
• Pamidronate
• Prednisolone

The patient presents with symptoms of hypercalcemia, including tiredness, constipation, back and chest pain, and localized tenderness over the thoracic vertebrae and anterior ribs. The biochemistry results show a corrected calcium level of 3.8 mmol/L, which is above the normal range of 2.2-2.6 mmol/L. The patient’s ECG shows a shortened QT interval, which is a common finding in hypercalcemia.

The mainstays of treatment for hypercalcemia are IV hydration, bisphosphonates, and calcitonin. In this case, the patient should be administered IV hydration with 0.9% sodium chloride to help reduce the serum calcium level and alleviate symptoms. This is the first line of treatment for hypercalcemia, as it helps to increase calciuresis and decrease bone resorption.

Calcitonin can be used as a second-line treatment, as it helps to decrease bone resorption and increase calcium excretion. However, it is not the first choice in this case, as the patient’s calcium level is already elevated, and IV hydration is more effective in reducing serum calcium levels quickly.

Cinacalcet is a medication that helps to decrease the production of parathyroid hormone (PTH), which can contribute to hypercalcemia. However, it is not the first choice in this case, as the patient’s calcium level is already elevated, and IV hydration and calcitonin are more effective in reducing serum calcium levels quickly.

Pamidronate is a bisphosphonate that can be used to treat hypercalcemia, but it is not the first choice in this case, as IV hydration is the first line of treatment. Pamidronate can be used if the patient’s calcium level does not respond to IV hydration.

Prednisolone is a corticosteroid that can be used to treat hypercalcemia, but it is not the first choice in this case. Corticosteroids can help to reduce the production of PTH, but they are not as effective as IV hydration and bisphosphonates in reducing serum calcium levels quickly.

In summary, the patient should be administered IV hydration with 0.9% sodium chloride as the first line of treatment for hypercalcemia.

Given the scenario provided, the most likely cause of the patient’s sudden hypoxia after log-rolling to examine the back is tracheal tube displacement. This complication is particularly common during patient movement and positioning, such as log-rolling, especially in situations involving trauma patients who are intubated.

Tracheal tube displacement can result in airway obstruction, leading to hypoxia and potentially respiratory arrest. It’s crucial to ensure proper positioning and securement of the endotracheal tube to prevent this complication.

Other causes such as tension pneumothorax or spinal injury could also lead to respiratory compromise, but in this case, given the context of the patient’s recent movement, tracheal tube displacement is the most likely culprit.

Source:

•Tracheal Intubation: Complications and Management: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3230495/

A A 21-year-old man has been hit by a cricket ball on the side of the head.
Initially he has a Glasgow coma score (GCS) of 15 (E4. V5. M6). Four hours after arrival in hospital, while on the observation ward, his GCS drops to 7 (E1. V2. M4). His left pupil dilates, and he begins to demonstrate extensor posturing of the limbs. What are the most likely changes to his vital signs since injury?

Blood pressure: Decreased Heart rate: Decreased

Blood pressure : Decreased Heart rate: Increased

Blood pressure : Decreased Heart rate: Normal

Blood pressure: Increased. Heart rate: Decreased

Blood pressure: Increased. Heart rate: Increased

Cushing’s triad is a set of three classic signs indicating increased intracranial pressure (ICP). These signs include:

1.Hypertension: This refers to elevated blood pressure. Increased ICP can compress blood vessels in the brain, leading to hypertension as the body tries to maintain cerebral perfusion pressure.2.Bradycardia: Bradycardia, or a slow heart rate, is another component of Cushing’s triad. It occurs because increased ICP can stimulate the vagus nerve, which leads to a decrease in heart rate.3.Irregular respirations: Irregular breathing patterns, such as Cheyne-Stokes respirations or periods of apnea, can occur due to the brain’s attempt to regulate oxygen levels in response to increased pressure.

Cushing’s triad is often seen in severe cases of head injury, intracranial hemorrhage, or brain tumors where there is significant brain swelling or mass effect. It indicates a critical condition requiring immediate medical attention to prevent further neurological deterioration and potential herniation of brain structures.

Source:

•Cushing’s Triad: https://www.ncbi.nlm.nih.gov/books/NBK542246/

Given the patient’s history of Barrett esophagus, dysphagia, and weight loss, the most likely histological diagnosis for the malignant stricture is adenocarcinoma. Adenocarcinoma is the most common type of esophageal cancer in Western countries, especially in individuals with Barrett esophagus, which is a precancerous condition characterized by changes in the lining of the esophagus.

Adenosquamous carcinoma is a less common subtype of esophageal cancer and typically presents differently. Lymphoma, while it can affect the esophagus, is less common than adenocarcinoma in this age group and clinical context. Mucoepidermoid carcinoma is more commonly found in the salivary glands rather than the esophagus. Squamous cell carcinoma is another type of esophageal cancer, but it is less likely in this patient given the history of Barrett esophagus, which predisposes to adenocarcinoma.

Source:

•Esophageal Cancer: https://www.cancer.gov/types/esophageal/patient/esophageal-treatment-pdq#section/_15

Given the scenario described, the most likely diagnosis is heart block, specifically a type of heart block called “complete heart block” or “third-degree heart block.”

Complete heart block occurs when there is complete dissociation between the atria and ventricles, leading to an independent rhythm of the atria and ventricles. This can result in a slow ventricular rate, leading to bradycardia (heart rate of 40 beats/minute). The decreased cardiac output due to the slow heart rate can result in a decrease in systolic blood pressure.

The elevation in right atrial pressure (from 7 mmHg to averaging 15 mmHg) suggests impaired filling of the right ventricle, which can occur due to the slow heart rate associated with heart block.

While atrial fibrillation can cause a rapid and irregular heart rate, it typically presents with tachycardia rather than bradycardia. Cardiac tamponade typically presents with signs of hemodynamic compromise such as hypotension, elevated jugular venous pressure, and distant heart sounds. Digoxin toxicity can cause bradycardia, but the clinical presentation would typically involve other signs and symptoms such as nausea, vomiting, visual disturbances, and possibly arrhythmias. Left ventricular failure may lead to symptoms such as dyspnea and signs such as pulmonary congestion on examination, but it’s less likely to cause the abrupt bradycardia described in the scenario.

Source:

•Complete Heart Block: https://www.ncbi.nlm.nih.gov/books/NBK560867/

A potential benefit of the enhanced recovery programme for a patient undergoing right hemicolectomy is Reduced length of hospital stay. Enhanced recovery protocols aim to optimize the perioperative care, leading to quicker recovery and shorter hospital stays.

An Enhanced Recovery Programme (ERP), also known as Enhanced Recovery After Surgery (ERAS), is a multidisciplinary approach to patient care aimed at optimizing the perioperative period to enhance recovery following surgery. The goal is to improve outcomes, reduce complications, shorten hospital stays, and facilitate earlier return to normal function and activities.

Key components of an ERP typically include:

1.Preoperative optimization: This involves patient education, preoperative counseling, nutritional optimization, smoking cessation, and physical conditioning to prepare patients for surgery and aid in their recovery.2.Minimally invasive techniques: Utilizing minimally invasive surgical approaches whenever possible to reduce surgical trauma, postoperative pain, and recovery time.3.Multimodal pain management: Implementing a combination of analgesic techniques, such as regional anesthesia, non-opioid medications, and patient-controlled analgesia, to minimize postoperative pain and opioid consumption.4.Early oral intake: Encouraging early resumption of oral intake following surgery to maintain hydration and prevent ileus, typically starting with clear fluids and advancing as tolerated.5.Early mobilization: Initiating early mobilization and ambulation to prevent complications such as deep vein thrombosis, pneumonia, and muscle deconditioning, and to promote faster recovery.6.Avoidance of routine interventions: Avoiding unnecessary interventions such as prolonged fasting, bowel preparation, urinary catheterization, and routine use of nasogastric tubes, unless clinically indicated.7.Continuous quality improvement: Implementing protocols for data collection, audit, and feedback to continuously monitor outcomes and refine the ERP process.

ERPs are tailored to specific surgical procedures and patient populations, and their implementation requires collaboration among surgeons, anesthesiologists, nurses, physiotherapists, and other healthcare professionals.

Overall, ERPs have been shown to significantly improve patient outcomes, reduce healthcare costs, and enhance patient satisfaction in various surgical specialties.

Source:

•ERAS Society: https://erassociety.org/

Rupture of the Achilles tendon usually occurs in middle-aged men. The history frequently follows the pattern of tendon rupture following a trivial stumble. Dorsiflexion is exaggerated as it is normally limited by the Achilles tendon. Plantar flexion is limited and the patient is unable to stand on tiptoe, but some plantar flexion is still possible owing to the action of the long flexors of the toes, tibialis posterior and peronei.

Thompson test (also known Simmond’s squeeze test) is positive in Achillis tendon rupture, which is lack of plantar flexion when calf is squeezed. The Thompson test, also known as the calf squeeze test, is a physical examination maneuver used to assess the integrity of the Achilles tendon. It is primarily employed to diagnose Achilles tendon rupture, although it can also help evaluate for other Achilles tendon pathologies.

Here’s how the Thompson test is performed:

1.The patient is positioned prone or lying face down on the examination table with their feet hanging over the edge.2.The examiner squeezes the calf muscle of the affected leg with their fingers or thumbs while observing the movement of the foot and ankle.3.In a normal Thompson test, squeezing the calf muscle should result in plantar flexion (pointing downward) of the foot. This occurs because the calf muscle contraction normally causes the Achilles tendon to pull on the heel, leading to plantar flexion.4.If there is an Achilles tendon rupture, there will be no movement of the foot in response to calf muscle squeezing. This lack of movement is indicative of a positive Thompson test and suggests a complete rupture of the Achilles tendon.

It’s important to note that a positive Thompson test indicates a complete rupture of the Achilles tendon, but a negative test does not necessarily rule out a partial tear or other Achilles tendon injuries. Imaging studies such as ultrasound or MRI may be needed for further evaluation in cases where there is clinical suspicion of Achilles tendon pathology.

The Thompson test is a simple and quick bedside maneuver that can provide valuable diagnostic information for clinicians evaluating patients with suspected Achilles tendon injuries.

Source:

•Thompson Test: https://www.ncbi.nlm.nih.gov/books/NBK499992/

The impingement sign, also known as the Hawkins-Kennedy test, is a physical examination maneuver used to assess for subacromial impingement syndrome in the shoulder. Subacromial impingement occurs when the tendons of the rotator cuff muscles become compressed or irritated as they pass through the subacromial space, resulting in pain and decreased range of motion.

Here’s how the impingement sign/Hawkins-Kennedy test is performed:

1.The patient is typically seated or standing comfortably.2.The examiner raises the affected arm to shoulder height and then flexes the elbow to 90 degrees.3.With the patient’s arm in this position, the examiner then forcibly internally rotates the arm by bringing the forearm across the body, while stabilizing the scapula.4.A positive impingement sign is indicated by the reproduction of pain in the subacromial space, typically felt over the top and front of the shoulder.

The impingement sign/Hawkins-Kennedy test is thought to provoke symptoms by narrowing the subacromial space and compressing the inflamed structures, including the rotator cuff tendons and subacromial bursa.

It’s important to note that while a positive impingement sign is suggestive of subacromial impingement syndrome, it is not specific to this condition and may also be positive in other shoulder pathologies. Therefore, it is often used in combination with other clinical tests and imaging studies to make a diagnosis.

Apley’s grinding test is a physical examination maneuver used to assess for meniscal injury or pathology in the knee joint. It is named after the British orthopedic surgeon Alan Graham Apley, who described the test.

Here’s how Apley’s grinding test is performed:

1.The patient is typically positioned prone or lying face down on an examination table.2.The examiner flexes the affected knee to approximately 90 degrees.3.The examiner then places one hand on the patient’s heel to stabilize the lower leg, while the other hand grasps the patient’s ankle or foot.4.With the knee in flexion, the examiner applies downward pressure on the patient’s foot while simultaneously rotating the tibia (lower leg) internally and externally.5.During this rotation, the examiner applies axial compression to the tibia by pushing down on the foot.6.The test is considered positive if the patient experiences pain or reproduces the symptoms of meniscal injury, such as clicking, popping, or grinding sensations, especially when combined with compression and rotation.

Apley’s grinding test is thought to reproduce symptoms of meniscal injury by placing stress on the meniscus, particularly the inner (medial) or outer (lateral) meniscus, depending on the direction of rotation. The test may provoke pain or mechanical symptoms (e.g., clicking or locking) if there is a tear or other pathology affecting the meniscus.

It’s important to note that while Apley’s grinding test can provide valuable clinical information, it is not specific to meniscal pathology and may also be positive in other knee conditions. Therefore, it is often used in conjunction with other physical examination maneuvers, imaging studies (such as MRI), and clinical judgment to make a diagnosis.

Source:

•Apley’s Grinding Test: https://www.physio-pedia.com/Apley’s_Grinding_Test•Hawkins-Kennedy Test: https://www.physio-pedia.com/Hawkins-Kennedy_Test

Phalen’s maneuver, also known as Phalen’s test, is a physical examination maneuver used to assess for carpal tunnel syndrome, a common condition characterized by compression of the median nerve as it passes through the carpal tunnel in the wrist.

Here’s how Phalen’s maneuver is performed:

1.The patient is asked to flex both wrists maximally and press the dorsal surfaces of the hands together, with the fingers pointing downward and the wrists in full flexion.2.The position is typically held for 60 seconds or until symptoms are reproduced.3.The test is considered positive if the patient experiences numbness, tingling, or pain in the distribution of the median nerve, which includes the thumb, index finger, middle finger, and half of the ring finger.

Phalen’s maneuver is thought to exacerbate symptoms of carpal tunnel syndrome by increasing pressure within the carpal tunnel and compressing the median nerve. The flexed wrist position reduces the space within the carpal tunnel, leading to compression of the nerve against the transverse carpal ligament.

It’s important to note that while Phalen’s maneuver can help diagnose carpal tunnel syndrome, it is not specific and may also be positive in other conditions affecting the median nerve or wrist joint. Therefore, it is often used in conjunction with other clinical tests, such as Tinel’s sign and median nerve compression test, as well as imaging studies and electrodiagnostic tests, to confirm the diagnosis.

Source:

•Phalen’s Test: https://www.ncbi.nlm.nih.gov/books/NBK513295/

The Thomas test is a physical examination maneuver used to assess for hip flexion contracture and tightness of the hip flexor muscles, specifically the iliopsoas muscle. It is named after Dr. Hugh Owen Thomas, a British orthopedic surgeon who described the test.

Here’s how the Thomas test is performed:

1.The patient lies supine (on their back) on an examination table with both legs fully extended.2.The examiner stands at the side of the table and passively flexes one of the patient’s hips, bringing the knee towards the chest until the thigh is fully flexed against the abdomen.3.While maintaining the flexed position of the hip, the examiner observes the position of the contralateral (opposite) leg.4.If the contralateral thigh lifts off the table or if the knee flexes, it indicates that the hip being tested is unable to fully extend due to tightness of the hip flexors, particularly the iliopsoas muscle.5.To assess for tightness of the rectus femoris muscle, the examiner can also observe whether the knee of the contralateral leg remains fully extended or if it flexes during the test.

The Thomas test is particularly useful in evaluating for hip flexion contracture, a condition where the hip joint is unable to fully extend due to tightness of the hip flexor muscles. It can be performed as part of a musculoskeletal examination to assess for various hip and pelvic conditions, including hip impingement, labral tears, and iliopsoas tendonitis.

Interpretation of the Thomas test results should take into account the patient’s symptoms, clinical history, and findings from other physical examination maneuvers and imaging studies.

Source:

•Thomas Test: https://www.physio-pedia.com/Thomas_Test

The most appropriate immediate management for a 35-year-old woman with a painful swollen right leg and extensive mobile thrombus in the femoral vein after returning from a business trip would be Heparin. Heparin is commonly used as an anticoagulant to prevent the extension of venous thrombosis.

Source: American College of Chest Physicians - Antithrombotic Therapy for VTE Disease

Given the clinical presentation of a 68-year-old woman with a two-month history of intermittent bloodstained nipple discharge from her right breast, and normal findings on mammogram and ultrasound scan, the most appropriate next step in management would be a ductogram.

A ductogram, also known as a galactogram or ductography, is a diagnostic imaging procedure specifically used to evaluate the breast ducts and ductal system. It involves injecting a contrast dye into the affected duct or ducts followed by imaging with X-rays or other imaging modalities. This procedure can help identify abnormalities within the ductal system, such as intraductal papillomas or ductal carcinoma in situ (DCIS), which may not be visualized on mammography or ultrasound.

In this case, since the patient has a bloodstained nipple discharge with no palpable abnormality and normal findings on mammogram and ultrasound, a ductogram would be the most appropriate next step to further evaluate the cause of the discharge and assess the ductal system for any abnormalities.

Clinical follow-up in three months may be considered if initial imaging studies are inconclusive or if the discharge resolves spontaneously. However, given the persistent nature of the symptoms, further investigation with a ductogram is warranted.

Reassuring the patient and discharging her without further investigation may not be appropriate, as the presence of bloodstained nipple discharge requires thorough evaluation to rule out underlying pathology, including malignancy.

Surgical excision of affected ducts or initiating tamoxifen therapy would be premature without a definitive diagnosis or identification of the underlying cause of the nipple discharge.

Therefore, the most appropriate next step in management would be to proceed with a ductogram to further evaluate the cause of the bloodstained nipple discharge and assess the ductal system for abnormalities.

Source:

•Breast Ductography: https://radiopaedia.org/articles/ductography?lang=us

Based on the presented clinical findings and laboratory results, the most likely diagnosis is osteomalacia.

Osteomalacia is a condition characterized by softening of the bones due to impaired mineralization of the osteoid matrix, which is the non-mineralized component of bone. It often results from vitamin D deficiency or malabsorption, leading to inadequate calcium and phosphate absorption and subsequent impaired bone mineralization. The symptoms described, including generalized bone pains, tenderness in the thighs, muscle weakness, difficulty walking, and a change in gait, are consistent with osteomalacia.

The laboratory findings of low serum calcium and phosphate levels indicate mineral deficiencies, while elevated alkaline phosphatase and parathyroid hormone levels are compensatory responses to the mineralization defect. The bone biopsy showing an increase in non-mineralized osteoid further supports the diagnosis of osteomalacia.

Osteitis fibrosa cystica, characterized by bone cysts and fibrous tissue replacement due to hyperparathyroidism, typically presents with bone pain, fractures, and deformities, but it is not associated with vitamin D deficiency or impaired mineralization of the osteoid matrix.

Osteoporosis is a condition characterized by decreased bone density and increased risk of fractures, but it does not involve impaired mineralization of the bone matrix as seen in osteomalacia.

Paget’s disease of the bone is a disorder characterized by abnormal bone remodeling, leading to bone enlargement, deformities, and fractures. It typically presents with localized bone pain and deformities, rather than the generalized bone pains and mineralization defects seen in osteomalacia.

Multiple myeloma is a cancer of plasma cells that typically presents with bone pain, fractures, and skeletal lesions, but it is not associated with vitamin D deficiency or impaired mineralization of the osteoid matrix as seen in osteomalacia.

Therefore, among the options provided, osteomalacia is the most likely diagnosis based on the clinical presentation, laboratory findings, and bone biopsy results.

Source:

•Osteomalacia: https://www.ncbi.nlm.nih.gov/books/NBK532269/

Vit D deficiency should be treated with Vit D supplements in patients with crohn’s disease to prevent

B

Based on the clinical presentation and recent diagnosis of Graves’ disease, the most appropriate next step in management after resuscitation would be administering beta-adrenoceptor blockers and thionamides.

Graves’ disease is an autoimmune disorder characterized by hyperthyroidism, which can lead to symptoms such as agitation, confusion, jaundice, diaphoresis (sweating), fever, tachycardia, and hypertension. The patient’s symptoms, including an irregular ventricular rate with absent p waves on ECG, are consistent with thyroid storm, a severe and life-threatening complication of untreated or undertreated hyperthyroidism.

Beta-adrenoceptor blockers (such as propranolol) are used to manage symptoms of hyperthyroidism, including tachycardia and hypertension. They can help stabilize the patient’s heart rate and blood pressure.

Thionamides (such as propylthiouracil or methimazole) are used to inhibit the production of thyroid hormones and block the synthesis of new thyroid hormone in Graves’ disease. They are essential for controlling thyroid hormone levels and mitigating the hyperthyroid state.

While iodides may temporarily reduce thyroid hormone release, they are not typically used as initial therapy in thyroid storm due to the risk of exacerbating thyrotoxicosis and potentially worsening the patient’s condition.

Bile acid sequestrants and glucocorticoids are not indicated as first-line treatments for thyroid storm and would not address the underlying cause of hyperthyroidism.

Thyroidectomy may be considered as a definitive treatment for Graves’ disease in some cases, but it is not appropriate as an immediate intervention in the acute management of thyroid storm.

Therefore, the most appropriate next step in management after resuscitation of the patient with thyroid storm due to Graves’ disease is administering beta-adrenoceptor blockers and thionamides to stabilize thyroid function and alleviate symptoms.

Source:

•Thyroid Storm: https://www.ncbi.nlm.nih.gov/books/NBK482257/

A 1-year-old girl presents with shortness of breath. Her parents have also noticed that her eyes no longer look symmetrical. The right pupil is smaller than the left and the right eyelid appears droopy. A chest X-ray shows increased opacification in the right hemithorax, particularly in the right upper zone. Which one of the following is the most likely diagnosis?
Select one:

A community acquired pneumonia

A congenital diaphragmatic hernia

A congenital pulmonary airway malformations

Lymphoma

Neuroblastoma

A 25-year-old woman presents with sensory symptoms in the upper limbs and a headache that is worse on coughing. An MRI scan shows a Chiari malformation of the hindbrain and syringomyelia in the cervical spine. Which one of the following nerve tracts are most vulnerable to damage in this condition?
Select one:

Corticospinal

Posterior columns

Spinocerebellar

Spinothalamic

Sympathetic trunks

In Chiari malformation with associated syringomyelia, the most vulnerable nerve tract to damage is the spinothalamic tract.

Syringomyelia is a condition characterized by the development of a fluid-filled cyst (syrinx) within the spinal cord. This cyst can disrupt the normal transmission of sensory information within the spinal cord, particularly affecting the crossing fibers of the spinothalamic tract, which carries pain and temperature sensation.

The Chiari malformation, in which the cerebellar tonsils herniate through the foramen magnum into the spinal canal, can exacerbate the compression of the spinal cord and worsen the symptoms associated with syringomyelia.

Therefore, in this condition, the spinothalamic tract, which transmits pain and temperature sensation, is the most vulnerable nerve tract to damage.

The other nerve tracts mentioned may also be affected to some extent, but the spinothalamic tract is particularly vulnerable due to its location and the disruption caused by the syrinx within the spinal cord.

Source:

•Syringomyelia: https://www.ncbi.nlm.nih.gov/books/NBK526016/

An elderly patient with an intra-capsular fractured neck of femur is due to have a hip hemiarthroplasty performed. Which of the following describe anatomical steps to access the hip joint during the most commonly used approach for a hemiarthroplasty?
Select one:

Detaching the anterior aspect of gluteus medius and minimus from the greater trochanter

Detaching piriformis and the short external rotators from their femoral insertion

Developing a plane between the gracilis and adductor longus muscles

Developing a superficial plane between sartorius and tensor fasciae latae

Elevation of vastus lateralis

An 80-year-old woman is admitted with a pulsatile mass in the abdomen, guarding and tenderness. An ultrasound demonstrates an intact abdominal aortic aneurysm at the level of the origin of the superior mesenteric artery. You suspect bowel ischaemia of which of the following structures?
Select one:

The jejunum, ileum and ascending colon

The kidneys and spleen

The liver and pancreas

The stomach and duodenum

The transverse and descending colon

A 73-year-old man is admitted with severe abdominal pain and guarding. He also has painful tips of the radial 2 digits which are dusky. He is haemodynamically stable but has untreated atrial fibrillation. You suspect an underlying arterioembolic cause and organise an urgent CT angiogram of the bowel, which shows that the inferior mesenteric artery is occluded. Which one of the following will result from the occluded artery?
Select one:

Ischaemia of the descending colon & sigmoid colon

Ischaemia of the duodenum

Ischaemia of the jejunum

Ischaemia of the jejunum and ileum

Ischaemia of the terminal ileum and ascending colon

A patient who was involved in a road traffic accident suffers a penetrating trauma to the infra-clavicular area and is found to have a pulsatile mass at the level of pectorals minor. You suspect an injury to the axillary artery and the lateral cord of the brachial plexus due to loss of function of which of the following nerves?
Select one:

Axillary and median nerves

Median and musculocutaneous nerves

Musculocutaneous and radial nerves

Posterior interosseous and anteriorinterosseous nerves

Ulnar and median nerves

A 9-year-old boy presents with a non-retractile foreskin. He does not currently have any urinary symptoms. On examination the foreskin is thickened, white and stiff. Which one of the following is the most appropriate next step?
Select one:

A circumcision

A preputioplasty

Oral steroids

Topical betnovate cream

Waiting until post puberty to reassess

The morning following a successful right carotid endarterectomy under general anaesthesia, a 65-year-old man complains of severe hoarseness. Which one of the following is the most likely diagnosis?
Select one:

The hypoglossal nerve has been damaged during surgery

The larynx has been traumatised during anaesthesia

The patient has sustained a post operative stroke

The recurrent laryngeal nerve has been damaged during surgery

There has been bleeding from the endarterectomy site

A 10-year-old boy presents to the Emergency Department. Last week he had an upper respiratory tract infection, following which he quickly developed swelling around his right eye and was unable to open it. Now he has bilateral periorbital swelling, a temperature of 40oC and a Glasgow Coma Scale score of 13. He has a contrast enhanced CT scan which demonstrates a cavernous sinus thrombosis. Which one of the following symptoms/signs would not be present?
Select one:

Absent corneal reflex

Anaesthesia over the angle of the mandible

Ophthalmoplegia

Lateral rectus palsy

Absent swinging light pupillary reflex

A 50-year-old man presents with a history of severe low back pain referred down the right leg to the foot. He reports saddle numbness and difficulty with micturition having not had any sensation to pass urine for more than 12 hours. On examination, straight leg raising is limited to 30 degrees on the right and 60 degrees on the left. Motor assessment is difficult due to pain but there appears to be weakness of ankle plantar flexion and eversion. Pinprick and light touch sensation are reduced in the S1 - S4 dermatomes bilaterally. An MRI scan is performed. Which one of the following is the most likely diagnosis? Select one:

Discitis

Epidural haematoma

Prolapsed intervertebral disc

S1 root neurofibroma

Vertebral haemangioma

A 2-week-old baby has been unable to breast feed since birth and is struggling to bottle feed. The baby cries persistently and according to mum seems to ‘burp’ and suffer trapped wind. On bottle feeding mother reports regurgitation of milk through the nose. The baby appears underweight and you are concerned about failure to thrive. Which one of the following is the most likely diagnosis?
Select one:

Branchial cyst

Cleft palate

Hiatus hernia

Pharyngeal pouch

Pyloric stenosis

A 65-year-old woman develops a hoarse voice, evident in theatre recovery, following an anterior cervical discectomy at the C3/4 level. Anaesthesia was uncomplicated. Surgery, via a 4 cm transverse skin crease incision, was uneventful. A post-operative MRI scan shows no evidence of a haematoma. Which one of the following is the most likely explanation for her symptoms?
Select one:

External laryngeal nerve transection

Laryngeal oedema

Recurrent laryngeal nerve transection

Superior laryngeal nerve neuropraxis

Vagal nerve neuropraxis

You see a 56-year-old man in clinic who has presented with left submandibular swelling related to eating. He has had an ultrasound scan which shows a 1.5 cm stone within the substance of the left submandibular gland and you discuss the management options with him, including surgical removal of the gland. Which of the following nerves would you tell him are at risk during this operation?
Select one:

Accessory, marginal mandibular and lingual nerves

Accessory, hypoglossal and lingual nerves

Glossopharyngeal, marginal mandibular and lingual nerves

Hypoglossal, marginal mandibular and lingual nerves

Marginal mandibular, hypoglossal and glossopharyngeal nerves

A 32-year-old patient presents to the Emergency Department following a stab injury to the neck. You note a small wound in the anterior triangle and a small pulsatile swelling approximately at the level of the hyoid bone. You also suspect a nerve injury. Which one of the following indicates this?
Select one:

Failure to ‘screw up the eyes’ tightly

Hearing loss

Inability to tense the masseter or temporals muscles

Loss of sensation to the upper lip

Loss of taste to the anterior 2/3rds of the tongue

Many cranial nerves transit the anterior triangle of the neck, namely VII, IX, X, XI and XII. A failure to screw up the eyes indicates an injury to the facial nerve.
The other responses indicate damage to nerves that do not transit the anterior triangle; hearing loss would indicate injury to VIII, the anterior 2/3rds of the tongue is supplied by the trigeminal nerve as is sensation to the lip and motor innervation of the masseter and temporals.
Given the scenario of a stab injury to the neck with a small pulsatile swelling at the level of the hyoid bone and a suspected nerve injury, we need to identify which nerve might be involved based on the symptoms described. The options provided indicate specific nerve dysfunctions:

Options and Relevant Nerve Injuries:

1.Failure to ‘screw up the eyes’ tightly:•Indicates a potential injury to the facial nerve (CN VII), particularly the branches that innervate the muscles responsible for eye closure.2.Hearing loss:•Suggests an injury to the vestibulocochlear nerve (CN VIII), which is not typically related to a neck injury in the anterior triangle.3.Inability to tense the masseter or temporalis muscles:•Indicates a potential injury to the mandibular branch of the trigeminal nerve (CN V3), which controls the muscles of mastication.4.Loss of sensation to the upper lip:•Indicates a potential injury to the maxillary branch of the trigeminal nerve (CN V2), which provides sensory innervation to the mid-facial region.5.Loss of taste to the anterior 2/3rds of the tongue:•Indicates a potential injury to the chorda tympani branch of the facial nerve (CN VII), which carries taste sensations from the anterior two-thirds of the tongue.

Analysis:

•The wound is described as being in the anterior triangle of the neck, which is an area where the facial nerve (CN VII) and its branches are vulnerable. Specifically, the facial nerve innervates muscles of facial expression, including those responsible for closing the eyes tightly.•A pulsatile swelling at the level of the hyoid bone could indicate a vascular injury, possibly to the carotid artery or one of its branches, which lies close to the facial nerve in this region.

Conclusion:

Given the description of the injury and the anatomical location, failure to ‘screw up the eyes’ tightly suggests an injury to the facial nerve (CN VII), which is plausible given the proximity of the nerve to the described injury site in the anterior triangle of the neck.

Thus, the correct answer is:
Failure to ‘screw up the eyes’ tightly

A pregnant 35-year-old woman is being advised of some potential risks of her new-born child suffering developmental dysplasia of the hip (DDH). Which one of the following is the most significant risk factor associated with DDH?
Select one:

Breech presentation

Family history

Female child

Firstborn

Oligohydramnios

A 46-year-old woman presents to the Emergency Department with a headache, diplopia and ocular pain, two weeks following upper respiratory tract infection. She is an insulin dependant diabetic who suffers with stage 2 chronic kidney disease and mild hypertension. Her blood pressure is 130/88, her HBA1C is 84 and her blood glucose levels in the last 14 days have been averaging 16-18mmol/l. Her pulse is 80bpm and regular. Her right eye is pointing slightly down and outwards. Which of the following explains her symptoms best?
Select one:

Cerebrovascular accident

Hemiplegic migraine

Intra-cranial hypertension

Mono-neuritis

Temporal arteritis

A 32-year-old man presents to the Emergency Department having come off his mountain bike and hit a tree. He undergoes primary and secondary surveys and the only abnormalities found are bruising over his right mastoid process (Battle’s sign) and a complete lower motor neurone facial paralysis. You suspect a temporal bone fracture. Which one of the following examinations or investigations would not be helpful in identifying the level of his facial nerve injury?
Select one:

Hearing test

Pupillary light reflex

Salivary flow rate

Schirmer’s test of lacrimation

Stapedial reflex testing

A 5-year-old boy presents to the Emergency Department with a short history of an upper respiratory tract infection that has developed into a left neck swelling, neck stiffness and trismus. He is admitted and treated with intravenous co-amoxiclav, but his symptoms have not improved after 24 hours so you decide to arrange an MRI to exclude a deep neck space infection. The scan shows a collection posterior to the retropharyngeal space, between the alar and prevertebral fascia, and extending from the skull base into the chest. Which one of the following is the lower limit of this space?
Select one:

It fuses with the diaphragm

It fuses with the pericardium

T1-2 vertebral level

T3-4 vertebral level

T5-6 vertebral level

The deep spaces of the neck are potential routes for spread of infection. The prevertebral fascia anteriorly splits into the alar and prevertebral fascial layers. The potential space between them contains loose connective tissue and extends from the skull base to the diaphragm. It is often called the ‘danger space’ since it provides a pathway for infections of the head and neck to spread into the chest, causing mediastinitis and mediastinal abscess.

Other tissue spaces in the neck include: Carotid space (extends from skull base to aortic arch); retropharyngeal space (extends from skull base to T1/2); visceral space (extends from hyoid bone and opens into superior mediastinum).
The correct answer is:
It fuses with the diaphragm

A 41-year-old man is admitted as an emergency to the plastic surgery ward with cellulitis of the perineal area. It rapidly spreads, resulting in Fournier’s gangrene (necrotising fasciitis) and widespread sepsis. This necessitates multiple trips to theatre and admission to ITU. Where is the infection likely to have originated?
Select one:

Camper fascia

Corpora cavernosa and testes

External and internal spermatic fascia

Scarpa fascia and Colles fascia

The inferior fascia of the urogenital diaphragm and Colles fascia

An 80-year-old man who normally walks short distances with a frame and has a past medical history of angina and diabetes, falls and sustains a displaced intracapsular hip fracture. Which of the following is the most appropriate definitive management for him?
Select one:

Bed rest and traction applied to the injured leg

Surgery to perform a dynamic hip screw

Surgery to perform a hip hemiarthroplasty

Surgery to perform a total hip replacement

Surgery to perform open reduction and internal fixation with cannulated screws

Deviation of the tongue to the right, on attempted protrusion of the tongue, would indicate damage/dysfunction in which of the following cranial nerves?
Select one:

Left cranial accessory nerve

Left hypoglossal nerve

Right glossopharyngeal nerve

Right hypoglossal nerve

Right lingual nerve

Which extraocular orbital muscle is supplied by the trochlear nerve (IV th cranial nerve)?
Select one:

Inferior oblique

Inferior rectus

Medial rectus

Superior oblique

Superior rectus

The superficial ‘lobe’ of the submandibular gland is separated from the deep ‘lobe’ by which of the following muscles?
Select one:

Hyoglossus

Mylohyoid

Geniohyoid

Stylohyoid

Genioglossus

Which one of the following arteries is a branch of the internal carotid artery?
Select one:

Infraorbital artery

Middle meningeal artery

Occipital artery

Ophthalmic artery

Superficial temporal artery

The internal carotid artery is a major artery that supplies blood to the brain and structures within the orbit. Among the options given, the branch of the internal carotid artery is:

Ophthalmic artery

Explanation:

•Infraorbital artery:•This is a branch of the maxillary artery, which itself is a branch of the external carotid artery.•Middle meningeal artery:•This is a branch of the maxillary artery, which is a branch of the external carotid artery.•Occipital artery:•This is a branch of the external carotid artery.•Ophthalmic artery:•This is a branch of the internal carotid artery. The ophthalmic artery arises from the internal carotid artery after it exits the cavernous sinus and enters the orbit through the optic canal.•Superficial temporal artery:•This is a branch of the external carotid artery.

Conclusion:

The ophthalmic artery is the correct answer as it is a branch of the internal carotid artery.

A 35-year-old man attends the Emergency Department following a football tackle with a Weber C ankle fracture (high fibula ankle fracture). He requires surgery and the fracture will be fixed with a lag screw and neutralisation plate. Using the direct lateral approach to the fibula which of the following nerves can be potentially injured passing across the fibula from posterior to anterior during your approach?
Select one:

Deep peroneal nerve

Saphenous nerve

Superficial peroneal nerve

Sural nerve

Tibial nerve

A 20-year-old woman underwent a right thoracoscopic sympathectomy for palmar hyperhidrosis. At her follow-up appointment she reports satisfaction with her surgery but volunteers that the right side of her face now feels warm and rather dry. She has also noted some drooping of her right upper eyelid. Which one of the following physical signs is most likely to be present as well?
Select one:

Constricted right pupil

Divergent strabismus

Facial hyperaesthesia

Facial weakness

Normal cilio-spinal reflex

A 58-year-old woman presents with a sudden onset of severe headache, associated with nausea and vomiting. On examination her GCS is 13/15. A CT scan is performed (see below). Analgesia and fluids are prescribed. Urgent transfer to the neurosurgical unit is arranged. The neurosurgical registrar advises that nimodipine is commenced. What is the mechanism of action of nimodipine?
ACE inhibitor

Alpha blocker

Aquaporin

Beta Blocker

Calcium channel blocker

You are assessing a 4-year-old boy in the urology clinic. The boy has recently moved to the UK and has been referred by the General Practitioner. The parents are concerned that the child goes to the toilet many times per day, doesn’t like to pass urine standing up instead preferring to sit down, often leaks urine on voiding and has a large tight gathering of foreskin on the top of the penis, but not all the way round. Which one of the following is the most likely treatment?
Select one:

A mid-stream urine specimen and appropriate treatment for chronic UTI

A surgical reconstruction

Isolated circumcision

Reassurance

Referral to a behavioural psychologist

You are called to the Emergency Department to review a 2-month-old boy with a 6 hour history of a right groin swelling. The referring doctor says the patient is otherwise well and the abdomen is soft and non tender. The doctor states the mass is in the right inguino-scrotal region, it does not transilluminate but is not reducible. Which one of the following is your preferred management option?
Select one:

Arrange an urgent ultrasound scan to establish the diagnosis

Give analgesia and attempt to reduce the mass

Keep the patient nil by mouth, place a nasogastric tube and start broad spectrum antibiotics

Schedule the patient for an elective operation in the next few weeks

Take the patient to theatre urgently for operative repair

The history points to an incarcerated right inguinal hernia. There are no features in the vignette to point to bowel obstruction. In paediatric practice, we would try to reduce the hernia with analgesia (specifically morphine) and assuming this is successful, arrange a semi urgent herniotomy in 48 hours time once the oedema of the tissues in the operative site has settled.

A - this is a clinical diagnosis although imaging may occasionally be helpful in atypical cases
B - correct
C - NBM and NG tube would be indicated in bowel obstruction but attempted hernia reduction takes precedence as it has a high rate of success
D - an incarcerated hernia cannot be left untreated as the risk is of bowel ischaemia and perforation. A reducible hernia may be given an elective surgical date.
E - immediate surgery is avoided, as long as the hernia can be reduced. This may require consultant input to achieve successful reduction
The correct answer is:
Give analgesia and attempt to reduce the mass

A 25-year-old motorcyclist involved in an RTC has sustained blunt trauma to the left side of his chest. He is tachypnoeic (RR 20/min) and has an oxygen saturation of 93% on air. He is haemodynamically stable but his chest X-ray shows a large haemothorax. His heart size is normal and the cardiac shadow is not displaced. Oxygen has been provided and intravenous access obtained. In view of the amount of fluid seen in the left pleural cavity an intercostal drain is required. Where is the most appropriate site for insertion of the drain?
Select one:

2nd interspace in the mid-clavicular line

2nd intercostal space mid-axillary line

5th interspace between the anterior axillary and mid-axillary lines

5th interspace in the mid-clavicular line

5th interspace posterior to the posterior axillary line

A 22 year old male injures his knee while playing football and attends the emergency department. He describes his injury occurring as he pivoted to suddenly change the direction he was running in, it was a non contact injury. He reports immediate swelling in the knee and that he was unable to play on. Which one of the following structures is he most likely to have injured?
Select one:

Anterior cruciate ligament

Lateral Meniscus

Medial collateral ligament

Medial meniscus

Posterior cruciate ligament

A 19-year-old is admitted with a penetrating knife injury. His injuries are consistent with a severed left half of his thoracic spinal cord at the T8 level. Which of the following signs is the most likely consequence of transection of the left dorsal column?
Select one:

Loss of bladder control

Loss of light touch sensation on the left with an upper level 5 cm above the umbilicus

Loss of pinprick sensation below the umbilicus on the right

Loss of temperature sensation below the umbilicus on the right

Loss of vibration sense on the right

The left dorsal column of the spinal cord carries ascending sensory information related to proprioception, vibration sense, and fine touch. A transection of the left dorsal column at the T8 level would affect these sensory modalities on the same side of the body below the level of the lesion.

The most likely consequence of transection of the left dorsal column at T8 would be:

Loss of light touch sensation on the left with an upper level 5 cm above the umbilicus

Explanation:

•Loss of bladder control: This typically involves disruption at a higher level of the spinal cord, involving autonomic pathways or sacral segments.•Loss of light touch sensation on the left with an upper level 5 cm above the umbilicus: This is consistent with the function of the dorsal column. The T8 level is located around 5 cm above the umbilicus. Loss of light touch (fine touch) sensation below the level of the lesion would occur on the same side as the lesion (left side).•Loss of pinprick sensation below the umbilicus on the right: Pinprick (pain) and temperature sensations are carried by the spinothalamic tract, which crosses to the opposite side shortly after entering the spinal cord. A lesion on the left side would result in loss of these sensations on the right side below the level of the lesion.•Loss of temperature sensation below the umbilicus on the right: As with pinprick sensation, temperature sensation is carried by the spinothalamic tract and would be lost on the right side below the level of the lesion.•Loss of vibration sense on the right: Vibration sense is carried by the dorsal column. A lesion on the left side would result in loss of vibration sense on the left side below the level of the lesion, not the right.

Conclusion:

The most likely consequence of transection of the left dorsal column at the T8 level is loss of light touch sensation on the left with an upper level 5 cm above the umbilicus. This reflects the loss of sensory modalities carried by the dorsal column on the same side of the body below the level of the lesion.

A 41-year-old man presents with a history of right lower limb sciatica. Pain and numbness are reported in the sole and lateral border of the foot. The ankle reflex is absent. At which one of the following levels is the disc prolapse most likely to have occurred?
Select one:

L2/3

L3/4

L4/5

L5/S1

S1/S2

The clinical presentation of right lower limb sciatica with pain and numbness in the sole and lateral border of the foot, along with an absent ankle reflex, is indicative of a nerve root compression affecting the S1 nerve root.

Most likely level of disc prolapse:

L5/S1

Explanation:

•L2/3: Compression at this level typically affects the L3 nerve root, which would cause symptoms in the anterior thigh and knee, not the foot.•L3/4: Compression at this level typically affects the L4 nerve root, causing symptoms in the anterior thigh and medial lower leg, not the foot.•L4/5: Compression at this level typically affects the L5 nerve root, causing symptoms on the dorsum of the foot and great toe, not the sole and lateral border of the foot.•L5/S1: Compression at this level affects the S1 nerve root, which supplies sensation to the sole and lateral border of the foot and is responsible for the ankle reflex.•S1/S2: Compression at this level would affect the S2 nerve root, but the presentation is more consistent with S1 involvement.

Conclusion:

The disc prolapse is most likely to have occurred at the L5/S1 level, given the specific pattern of pain, numbness, and absence of the ankle reflex.

You are discussing post-operative pain relief during WHO checklist, for a patient about to undergo an open nephrectomy through a loin incision above the 12th rib. Which one of the following methods of post-operative / regional analgesia is most appropriate?
Select one:

Continual inter-costal infusion

Epidural anaesthesia

Infra-clavicular block

Patient Controlled Analgaesia (PCA)

Rectus sheath catheter

A 48 hour term, male infant presents with a 12 hour history of green vomiting. The parents state that there have been some wet nappies but that the child has not opened his bowels since birth. The abdomen is distended, full but not tense and not tender. The anus is normally sited. Which one of the following is the most useful diagnostic test?
Select one:

Blood cultures

Lower gastrointestinal contrast study

Suction rectal biopsy

Ultrasound scan

Upper gastrointestinal contrast study

In this case, the most useful diagnostic test is Suction rectal biopsy. It can help in diagnosing Hirschsprung’s disease, a condition where there is a lack of ganglion cells in the rectum and possibly the colon, leading to bowel obstruction and symptoms like green vomiting and failure to pass meconium.

Source: BMJ Best Practice - Hirschsprung’s Disease

You are assessing the neurovascular status in the lower limb of a motorcyclist with an open tibial shaft fracture. There is significant soft tissue loss posteriorly and you are concerned about injury to the posterior tibial artery. You are hopeful that the dorsalis pedis artery is spared as it lies between which one of the following tendons?
Select one:

Between the extensor hallucis longus and extensor digitorum longus tendons

Between the flexor digitorum longus and the flexor halluces longus tendons

Between the flexor hallucis longus and flexor digitorum longus tendons

Between the tibialis anterior and extensor hallucis longus tendons

Between the tibialis posterior and flexor digitorum longus tendons

You are asked to assess a patient involved in a road traffic collision who sustained a multi-fragmentary fracture of the distal femur. After considering the displacement forces in this type of injury, which of the following anatomical structure are you most concerned about?
Select one:

Deep peroneal nerve

Popliteal artery

Quadriceps tendon

Superficial peroneal nerve

Tibial nerve

You are assessing a patient with an inguinal hernia. The patient has neurological symptoms consistent with meralgia paresthetica as a result of a nerve intrapment into the inguinal ligament. Which of the following is the trapped nerve?
Select one:

Intermediate cutaneous nerve of the thigh

Lateral cutaneous nerve of the thigh

Medial cutaneous nerve of the thigh

Posterior cutaneous nerve of the thigh

Saphenous nerve

You are assisting in placing a patient who has suffered a mid-shaft femoral fracture and multiple rib fractures into femoral traction, as he is currently unfit for surgery. You position the traction to balance the displacement of the proximal fragment because of which one of the following?
Select one:

Adduction by gracilis and flexion by sartorius

Flexion and adduction by the adductor magnus

Flexion by the iliopsoas muscle and abduction by the gluteus medius and minimus

Flexion by the iliopsoas muscle and adduction by the adductors

Flexion by the quadriceps and adduction by the semi-membranosus

A rock climber slips for 3 meters on a fixed rope and hits the rock-face. Which of the following bones is most likely to have suffered an open fracture?
Select one:

Femur

Humerus

Radius

Tibia

Ulna

Whilst on cardiothoracic placement, you are asked to harvest the long saphenous vein to be used for a coronary artery bypass. How do you locate this structure at the level of the ankle?
Select one:

Behind the lateral malleolus

Behind the medial malleolus

Between the tendons of flexor digitorum longus and flexor hallucis longus

In front of the lateral mallolus

In front of the medial malleolus

To locate the long saphenous vein (great saphenous vein) at the level of the ankle for harvesting during a coronary artery bypass procedure, you should:

E. In front of the medial malleolus

Explanation:

•The long saphenous vein runs superficially along the medial side of the leg. At the ankle, it can be found just anterior to the medial malleolus, making this the correct location for accessing the vein.

Other options explained:

•Behind the lateral malleolus: This is the location for the small saphenous vein, not the long saphenous vein.•Behind the medial malleolus: This location is associated with the tibial nerve and posterior tibial artery.•Between the tendons of flexor digitorum longus and flexor hallucis longus: This is a deeper location and not where the long saphenous vein is found.•In front of the lateral malleolus: This area is not associated with the long saphenous vein.

Conclusion:

To harvest the long saphenous vein at the level of the ankle, locate it in front of the medial malleolus.

A 45-year-old man presents with acute lumbar back pain after picking up a heavy box. On examination of his neurology, he has reduced power in dorsiflexion of his left hallux and reduced sensation in the first web space of the left foot. Which of the following is the likely pathology causing these signs and symptoms?
Select one:

Left sided far lateral disc prolapse at the L3/L4 level

Left sided far lateral disc prolaspe at the L4/L5 level

Left sided paracentral disc prolapse at the L3/L4 level

Left sided paracentral disc prolapse at the L4/L5 level

Left sided paracentral disc prolapse at the L5/S1 level

A 7-year-old boy presents with a two month history of intermittent peri-umbilical pain and intermittent presence of blood in his faeces. A tentative diagnosis of Meckel diverticulum is made. Which one of the following is true about Meckel diverticulum?
Select one:

It arises on the mesenteric border of the ileum

It is a remnant of the vitelline duct

It is a remnant of the vitelline veins

It is located 60 cm distal to the ileocaecal valve

It is present in 20% of the population

The correct statement about Meckel diverticulum is:

It is a remnant of the vitelline duct

Explanation:

•It arises on the mesenteric border of the ileum:•Incorrect. Meckel diverticulum arises on the antimesenteric border of the ileum.•It is a remnant of the vitelline duct:•Correct. Meckel diverticulum is a congenital condition resulting from an incomplete obliteration of the vitelline duct (also known as the omphalomesenteric duct) during embryonic development.•It is a remnant of the vitelline veins:•Incorrect. The vitelline veins are involved in the development of the portal venous system, not in the formation of Meckel diverticulum.•It is located 60 cm distal to the ileocaecal valve:•This statement is not accurate for all cases. Meckel diverticulum is usually located within 2 feet (approximately 60 cm) of the ileocecal valve, but this distance can vary.•It is present in 20% of the population:•Incorrect. Meckel diverticulum is present in approximately 2% of the population.

Conclusion:

The most accurate statement about Meckel diverticulum is that it “is a remnant of the vitelline duct.”

A patient with recent history of headaches and unsteadiness is found to have a pre-pontine meningioma arising from the clivus. The patient also reports diplopia. Compression of which of the following nerve(s) is most likely to account for the diplopia?
Select one:

Abducens

Oculomotor

Ophthalmic division of trigeminal

Sympathetic

Trochlear

Diplopia (double vision) can be caused by the involvement of cranial nerves that control eye movements. In the context of a pre-pontine meningioma arising from the clivus, compression of the cranial nerves in the region of the clivus and pre-pontine area is likely. The cranial nerve most commonly affected in this area that would result in diplopia is the abducens nerve (cranial nerve VI).

Most likely nerve involved:

Abducens (Cranial Nerve VI)

Explanation:

•Abducens (Cranial Nerve VI): The abducens nerve controls the lateral rectus muscle, which abducts the eye. It is susceptible to compression by masses in the pre-pontine area or around the clivus. Compression of the abducens nerve leads to an inability to abduct the eye, causing horizontal diplopia.•Oculomotor (Cranial Nerve III): While involvement of the oculomotor nerve can also cause diplopia, it is less commonly affected by a lesion at the clivus compared to the abducens nerve. The oculomotor nerve controls most of the eye muscles and pupillary constriction.•Ophthalmic division of trigeminal (Cranial Nerve V1): This division of the trigeminal nerve provides sensory innervation to the forehead, eye, and upper eyelid but does not control eye movements and would not cause diplopia.•Sympathetic: The sympathetic fibers control pupil dilation and eyelid elevation (Müller’s muscle). Compression would lead to Horner’s syndrome, which includes ptosis, miosis, and anhidrosis, but not diplopia.•Trochlear (Cranial Nerve IV): The trochlear nerve innervates the superior oblique muscle, which primarily causes intorsion and depression of the eye. While trochlear nerve palsy can cause vertical diplopia, it is less commonly involved in lesions at the clivus compared to the abducens nerve.

Conclusion:

The compression of the abducens nerve (cranial nerve VI) is most likely to account for the diplopia in a patient with a pre-pontine meningioma arising from the clivus.

A 40-year-old amateur soprano singer recently underwent a subtotal thyroidectomy for Graves’ disease. When starting back in her choir two weeks after surgery, her fellow members commented that the pitch of her voice had changed. In addition, she noted that she was unable to reach the higher notes that she used to be able to sing quite easily before her operation. Which of the following nerves is most likely to have been injured during her surgery?
Select one:

External laryngeal nerve

Inferior root of the ansa cervicalis

Internal laryngeal nerve

Recurrent laryngeal nerve

Superior root of the ansa cervicalis

The external laryngeal nerve which is a branch of the superior laryngeal nerve supplies motor fibres to the crico-thyroid muscle. This muscle tenses the vocal cords and is responsible for the quality and pitch of the voice.

In contrast the internal laryngeal nerve, the other branch of the superior laryngeal nerve, is a purely sensory nerve supplying the mucosa of the larynx and pharynx.

The recurrent laryngeal nerve supplies the intrinsic muscles of the larynx and injury leads to a either a hoarse voice or even aphonia, if bilateral injury occurs.
The ansa cervicalis supplies the following infrahyoid muscles which are depressors of the larynx: sterno-hyoid, omo-hyoid, sterno-thyroid. These muscles are not directly involved in voice production.
The correct answer is:
External laryngeal nerve

A 55-year-old woman has undergone right mastectomy and level 3 axillary node clearance for a 5 cm node positive, grade 3 invasive ductal carcinoma. The pectoralis minor muscle was divided at its insertion into the coracoid process of the scapula to facilitate removal of enlarged lymph nodes at level 3. Post operation, she complains of numbness and paraesthesia of the medial aspect of her upper arm. Which of the following nerves has been injured during the operation?
Select one:

Axillary nerve

Intercostal-brachial nerve

Lateral pectoral nerve

Long thoracic nerve

Musculo-cutaneous nerve

The intercosto-brachial nerve (T2) is the lateral cutaneous branch of the second intercostal nerve. It supplies the skin of the axilla and the skin of the medial aspect of the upper arm close to the axilla. It is at risk of injury during extensive axillary surgery

The axillary nerve (C5) supplies the skin of the lateral aspect of the upper arm mainly via the upper lateral cutaneous nerve of the arm.
The lateral pectoral nerve (C6,7) is a motor nerve only, supplying the pectoralis major muscle.
The long thoracic nerve (C5,6,7) is a motor nerve only supplying the serratus anterior muscle.
The musculo-cutaneous nerve (C5,6,7) is a motor nerve to biceps, brachialis and coraco-brachialis and forms the lateral cutaneous nerve of the forearm.
The correct answer is:
Intercostal-brachial nerve

A 20-year-old man has undergone recent excision biopsy of an enlarged lymph node situated in the posterior triangle of the right side of his neck. The procedure was performed under general anaesthetic. Histology has shown nodular sclerosing Hodgkin’s lymphoma. When seen seven days later for the results of the biopsy the patient complains that he has weakness in the region of his right shoulder and he is unable to shrug his shoulder on that side. Injury to which one of the following nerves is likely to account for the patient’s symptoms and signs?
Select one:

Accessory nerve

Intermediate supraclavicular nerve

Lateral (posterior) supraclavicular nerve

Medial supraclavicular nerve

Transverse cervical nerve

The patient’s inability to shrug his shoulder and the weakness in the region of his right shoulder following an excision biopsy of an enlarged lymph node in the posterior triangle of the neck is indicative of an injury to the accessory nerve.

Explanation:

The accessory nerve (cranial nerve XI) supplies the sternocleidomastoid and trapezius muscles. Injury to this nerve can result in the inability to shrug the shoulder (due to trapezius muscle paralysis) and weakness in shoulder elevation and abduction above the horizontal level. The other nerves listed do not account for the specific symptoms of shoulder weakness and inability to shrug.

•Intermediate, lateral, medial supraclavicular nerves: These are sensory nerves and do not innervate the trapezius muscle.•Transverse cervical nerve: This is also a sensory nerve and does not provide motor innervation to the shoulder muscles.

Therefore, the accessory nerve is the most likely to be injured in this scenario.

A 9-month-old woman, born four weeks prematurely, is presented with a history of poor growth, frequent lethargy and a persistent tachycardia. Auscultation of the chest reveals a systolic murmur, and there is a ‘waterhammer’ pulse. Blood pressure in the upper and lower limbs are equal and normal. Breathing rate is normal for age. What is the likely diagnosis?
Select one:

Atrial septal defect

Coarctation of the aorta

Patent ductus arteriosus

Transposition of the great arteries (TGA)

Truncus arteriosus

An 18-year-old man arrives as a trauma call, he has crashed his motorbike at high speed and hit a bollard head on. He is tachycardic, hypotensive and has bilateral externally rotated legs. Which one of the following pelvic fractures is most likely with the patient’s history and presentation?
Select one:

Acetabular fracture

Anterior posterior compression fracture (open book)

Fractured neck of femur

Lateral compression fracture

Vertical sheer fracture

You are called to the post-natal ward to see a 5-day-old girl who was born 14 days prematurely. The paediatric team had noticed an erythematous inflamed area between the genitalia and the anus, with evidence of localised inflammation. The fluid chart has documented very loose stools, green/brown in colour. The baby is otherwise feeding normally. Which one of the following is the most likely diagnosis?
Select one:

Fistula

Hirschsprung’s disease

Hypospadias

Perineal groove

Prolapsed anus

You assess an elderly patient who has been diagnosed with a pharyngeal pouch. This is an out pouching of the oesophagus through an area called Killian dehiscence between which muscles of the pharynx?
Select one:

Inferior constrictor and cricopharyngeus

Salpingopharyngeus and inferior constrictor

Salpingopharyngeus and superior constrictor

Superior and inferior constrictors

Superior constrictor and cricopharyngeus

A pharyngeal pouch, also known as a Zenker’s diverticulum, is an outpouching of the esophagus through an area called Killian dehiscence. This dehiscence is located between the inferior constrictor and cricopharyngeus muscles of the pharynx.

Explanation:

Killian dehiscence is a potential weak area between the fibers of the cricopharyngeus muscle (the lower part of the inferior constrictor muscle) and the more horizontally oriented fibers of the rest of the inferior constrictor muscle. It is through this area that a pharyngeal pouch may protrude.

•Inferior constrictor and cricopharyngeus: This is the correct answer as Killian dehiscence is located between these two muscles.•Salpingopharyngeus and inferior constrictor: The salpingopharyngeus muscle is not related to the area where a pharyngeal pouch forms.•Salpingopharyngeus and superior constrictor: These muscles are not involved in the formation of Killian dehiscence.•Superior and inferior constrictors: Killian dehiscence is specifically between the inferior constrictor and cricopharyngeus, not the superior and inferior constrictors.•Superior constrictor and cricopharyngeus: This combination does not relate to the anatomical area of Killian dehiscence.

Therefore, the correct answer is:
Inferior constrictor and cricopharyngeus.

A 60-year-old woman undergoes surgery to clip a posterior inferior cerebellar artery aneurysm. Cranial nerve injury may occur during the surgical exposure. Which one of the following deficits is most commonly associated with this operation post-operatively?
Select one:

Diplopia

Facial weakness and numbness

Hoarse voice/weak cough

Tongue atrophy

Visual field defect

The most common deficit associated with surgery to clip a posterior inferior cerebellar artery (PICA) aneurysm is a hoarse voice/weak cough.

Explanation:

The posterior inferior cerebellar artery is in close proximity to cranial nerves IX (glossopharyngeal), X (vagus), and XI (accessory). Damage to these nerves during surgical exposure can result in several deficits, with the vagus nerve (cranial nerve X) being particularly vulnerable.

•Hoarse voice/weak cough: This is the correct answer. Injury to the vagus nerve (cranial nerve X) can affect the vocal cords, leading to a hoarse voice and a weak cough.•Diplopia: This is associated with injury to the cranial nerves III (oculomotor), IV (trochlear), or VI (abducens), which are not typically affected in PICA aneurysm surgery.•Facial weakness and numbness: These symptoms are related to the facial nerve (cranial nerve VII) or the trigeminal nerve (cranial nerve V), respectively, and are not commonly affected by this type of surgery.•Tongue atrophy: This would be caused by injury to the hypoglossal nerve (cranial nerve XII), which is not typically involved in PICA aneurysm surgery.•Visual field defect: This would result from injury to the optic nerve (cranial nerve II) or the visual pathways, and is unrelated to PICA aneurysm surgery.

Therefore, the correct answer is:
Hoarse voice/weak cough.

A 50-year-old-woman presents to the upper GI clinic with a six month history of sporadic central abdominal pain. She also suffers mild dyspepsia. She has been a lifetime heavy smoker and over the last 18 months has had investigations for peripheral vascular disease. Her pain only arises after eating, especially larger meals. Which one of the following is the most likely cause for her symptoms?
Select one:

Barrets oesophagus

Biliary cholic

Irritable bowel disease

Oesophageal spasm

Superior mesenteric stenosis

The most likely cause for her symptoms is superior mesenteric stenosis.

Explanation:

The patient’s symptoms of sporadic central abdominal pain after eating, especially larger meals, along with a history of peripheral vascular disease, suggest mesenteric ischemia. Superior mesenteric artery (SMA) stenosis can lead to chronic mesenteric ischemia, commonly presenting with postprandial abdominal pain due to insufficient blood flow to the intestines during digestion.

•Barrett’s esophagus: This condition involves changes in the lining of the esophagus and is primarily associated with chronic gastroesophageal reflux disease (GERD). It would not typically cause central abdominal pain after eating.•Biliary colic: This presents with episodic right upper quadrant pain often related to gallstones, not typically central abdominal pain.•Irritable bowel disease: This condition includes a group of functional gastrointestinal disorders but is less likely given her history of peripheral vascular disease and the pattern of pain after eating.•Oesophageal spasm: This can cause chest pain and dysphagia but is unlikely to cause central abdominal pain after eating.•Superior mesenteric stenosis: This condition, related to atherosclerosis in a patient with a history of heavy smoking and peripheral vascular disease, aligns with the postprandial abdominal pain due to reduced blood flow to the intestines during digestion.

Therefore, the most likely cause for her symptoms is:
Superior mesenteric stenosis.

A 32-year-old patient is undergoing an emergency laparotomy following blunt trauma to the abdomen. On opening the peritoneum there is torrential bleeding and your consultant performs ‘Pringle’s manoeuvre’. Which one of the following structures are clamped by this manoeuvre?
Select one:

Gastroduodenal artery and celiac trunk

Hepatic artery and portal vein

Inferior vena cava and portal vein

Splenic artery and portal vein

Superior vena cava and hepatic artery

The Pringle manoeuvre involves clamping the hepatic artery and portal vein.

Explanation:

Pringle’s manoeuvre is used to control bleeding from the liver during surgery. It involves clamping the hepatoduodenal ligament, which contains the hepatic artery, portal vein, and bile duct. This manoeuvre temporarily occludes the inflow of blood to the liver from the hepatic artery and the portal vein, thereby reducing blood loss.

•Gastroduodenal artery and celiac trunk: These are not clamped during Pringle’s manoeuvre.•Hepatic artery and portal vein: This is the correct answer, as these are the structures within the hepatoduodenal ligament that are clamped during Pringle’s manoeuvre.•Inferior vena cava and portal vein: The inferior vena cava is not clamped in Pringle’s manoeuvre.•Splenic artery and portal vein: The splenic artery is not involved in Pringle’s manoeuvre.•Superior vena cava and hepatic artery: The superior vena cava is not clamped in Pringle’s manoeuvre.

Therefore, the correct answer is:
Hepatic artery and portal vein.

A 25-years-old motorcyclist has been admitted to the Emergency Department following a road traffic collision. His only significant injury is that of a probable fracture of the right humerus which is confirmed by X-ray showing a displaced fracture of the mid shaft of the humerus. He complains of weakness in the right arm and hand and appears to have a wrist drop. Which of the following combinations of movements is most likely to be impaired?
Select one:

Extension of the elbow and wrist joints

Extension of the elbow, wrist and metacarpo-phalangeal joints

Extension of the metacarpo-phalangeal and interphalangeal joints

Extension of the wrist and metacarpo-phalangeal joints

Extension of the wrist, metacarpo-phalangeal and interphalangeal joints

A 12-year-old girl presents with a 2 cm diameter anterior midline cyst of the neck. It moves on swallowing and on protrusion of her tongue. At operation the cyst is very closely associated with a bone derived from two of the embryological pharyngeal arches. From which one of the following pharyngeal arches is this bone derived?
Select one:

1st and 2nd arches

2nd and 3rd arches

3rd and 4th arches

4th and 5th arches

5th and 6th arches

You see a 34-year-old woman in the Emergency Department following a road traffic collision. The ambulance crew reported a Glasgow Coma Scale (GCS) of 9 with pupils that were equally reactive to light. You record her GCS as 5 and note that she now has a fixed dilated pupil on the left. A CT scan is performed. It shows a mass with lens shape on the left side. Which one of the following is the clinically most urgent finding on this scan?
Select one:

Acute subdural haematoma

Extradural haematoma

Skull base fracture

Temporal lobe contusion

Traumatic subarachnoid haemorrhage

An 8- year-old man presents to clinic via the 2-week wait pathway with a complete right lower motor neurone facial paralysis and a painless mass in his ipsilateral parotid gland. Which one of the following is the most likely histological diagnosis?
Select one:

Acinic cell carcinoma

Adenoid cystic carcinoma

Carcinoma ex-pleomorphic adenoma

Lymphoma

Squamous cell carcinoma

A 54-year-old man returns from a ski holiday. Following a fall onto the outstretched hand he developed pain lasting about 10 minutes in his 3rd digit (middle finger). He immediately noticed that his distal phalanx was flexed at the DIP joint. He was unable to voluntarily extend the DIP, although he could passively straighten the finger without difficulty. An X-ray showed no evidence of a fracture. What is the name of this injury?
Select one:

Boutonniere deformity

Hammer finger

Mallet finger

Swan neck deformity

Trigger finger

The injury described in the scenario is called mallet finger.

Explanation:

•Mallet finger occurs when the extensor tendon at the distal interphalangeal (DIP) joint is damaged, leading to an inability to extend the distal phalanx. This injury typically results from a sudden impact on the outstretched finger, causing the tendon to tear or avulse. The description of the distal phalanx being flexed at the DIP joint and the inability to extend it voluntarily fits the classic presentation of mallet finger.•Boutonniere deformity involves flexion of the proximal interphalangeal (PIP) joint and hyperextension of the DIP joint, typically due to injury to the central slip of the extensor tendon at the PIP joint.•Hammer finger is not a standard term in this context and is often used interchangeably with mallet finger, although it is less commonly used.•Swan neck deformity is characterized by hyperextension of the PIP joint and flexion of the DIP joint, commonly seen in conditions like rheumatoid arthritis.•Trigger finger occurs when a finger gets stuck in a bent position and then straightens with a snap, due to the inflammation of the flexor tendon sheath.

Correct Answer: Mallet finger

A 25-year-old woman falls from a horse and sustains a cervical spine injury. On arrival at the Emergency Department, she is assessed and stabilised as per the ATLS principles. During the secondary surgery examination she has 5/5 power in elbow flexion and 0/5 power below this level bilaterally. Sensation is normal on the lateral aspect of the arm over the deltoid region down to the elbow but is abnormal from the elbow down to the hand bilaterally. Perianal sensation is intact. How would you describe the spinal cord injury?
Select one:

C4 Complete injury

C4 Incomplete injury

C5 Complete injury

C5 Incomplete injury

C6 Incomplete injury

The clinical scenario describes a 25-year-old woman with a cervical spine injury resulting in 5/5 power in elbow flexion and 0/5 power below this level bilaterally, with abnormal sensation from the elbow down to the hand bilaterally, and intact perianal sensation. This implies that the injury is at the C5 level, affecting both motor and sensory functions below this level, but sparing functions at C5 and above.

Key Points:

•Elbow flexion (C5): Intact (5/5 power)•Below elbow (C6 and below): 0/5 power bilaterally•Sensation: Normal on lateral aspect of arm over deltoid region down to elbow, abnormal from elbow down to hand bilaterally•Perianal sensation: Intact (suggests sacral sparing)

Interpretation:

•Level of Injury: C5•Nature of Injury: Incomplete, because perianal sensation is intact, indicating some preservation of function below the level of injury.

Answer:

C5 Incomplete injury

An incomplete spinal cord injury means that there is some preservation of sensory or motor function below the level of injury, which is evident in this case by the intact perianal sensation.

A 25-year-old motorcyclist is admitted following a high speed road traffic collision. He is paraplegic with a sensory level at T5. He is noted to have priapism. Which one of the following is the most likely explanation of the priapism?
Select one:

Excitation of the sympathetic trunk

Loss of inhibition of the parasympathetic nervi erigentes

Loss of inhibition of the sympathetic output

Pudendal nerve lesion

Sacral root lesion

In the context of a spinal cord injury resulting in paraplegia and a sensory level at T5, the presence of priapism (persistent penile erection) is often due to the autonomic nervous system’s response to the injury.

Key Points:

•Spinal Cord Injury: At the T5 level.•Paraplegia: Loss of motor and sensory function below T5.•Priapism: Persistent penile erection.

Autonomic Nervous System and Priapism:

•Sympathetic Nervous System: Normally inhibits erections through vasoconstriction.•Parasympathetic Nervous System: Facilitates erections through vasodilation (nervi erigentes originate from S2-S4).

Explanation:

The most likely explanation for priapism in this patient is loss of inhibition of the parasympathetic nervi erigentes. This occurs because the spinal cord injury disrupts the sympathetic control that normally inhibits erections, leading to unopposed parasympathetic activity.

Answer:

Loss of inhibition of the parasympathetic nervi erigentes

This loss of inhibition results in priapism due to the unopposed activity of the parasympathetic nervous system, which originates from the sacral spinal cord (S2-S4), leading to vasodilation and erection.

A 68-year-old woman presents with symptoms consistent with a prolapsed cervical disc. She reports pain and numbness in the right lateral forearm, thenar eminence and thumb. The biceps and supinator reflexes are absent. At which level is the prolapsed disc most likely to have occurred?
Select one:

C3/4

C4/5

C5/6

C6/7

C7/T1

The symptoms described in the patient—pain and numbness in the right lateral forearm, thenar eminence, and thumb, along with absent biceps and supinator reflexes—suggest involvement of the C6 nerve root.

Key Points:

•Pain and Numbness: Right lateral forearm, thenar eminence, and thumb.•Reflexes: Absent biceps and supinator reflexes.

Nerve Root Involvement:

•C6 Nerve Root:•Dermatome: Lateral forearm, thumb, and thenar eminence.•Myotome: Biceps brachii (elbow flexion) and brachioradialis (forearm supination).•Reflexes: Biceps reflex and brachioradialis (supinator) reflex.

Disc Level:

•C5/6 Disc: A prolapse at this level would impinge on the C6 nerve root, leading to the symptoms described.

Answer:

C5/6

A 65-year-old farmer presents to the Emergency Department after losing control of a circular saw and sustaining a laceration posterior to the medial malleolus. You examine the wound under local anaesthetic to identify if any structures have been damaged. When working from anterior to posterior, which is the correct order of structures passing behind the medial malleolus?
Select one:

Extensor digitorum longus tendon, posterior tibial artery, tibial nerve, extensor hallucis longus tendon and tibialis posterior tendon

Flexor digitorum longus tendon, posterior tibial artery, tibial nerve, flexor hallucis longus tendon and tibialis posterior tendon

Flexor digitorum longus tendon, tibialis posterior tendon, posterior tibial artery, tibial nerve and flexor hallucis longus tendon

Tibialis posterior tendon, flexor digitorum longus tendon, posterior tibial artery, tibial nerve and flexor hallucis longus tendon

Tibialis posterior tendon, posterior tibial artery, tibial nerve, flexor digitorum longus tendon and flexor hallucis longus tendon

A 4-year-old boy sustains a closed extension-type supracondylar fracture of the humerus. Which one of the following nerves is most likely to suffer a neuropraxia?
Select one:

Anterior interosseous nerve

Axillary nerve

Posterior interosseous nerve

Radial nerve

Ulna nerve

The anterior interosseous nerve is most commonly injured in extension type injuries. Posterior interosseous injury is usually associated with radial head fractures. Ulnar neuropraxia (not listed) is associated with flexion-type injuries; ulna nerve direct injury is commonly associated with surgical fine-wire insertion.

The correct answer is:
Anterior interosseous nerve

A sciatic nerve block is performed just above the popliteal fossa for a patient who is about to undergo ankle fracture fixation under general anaesthetic. Which one of the following areas is likely to have normal sensation post-operatively?
Select one:

1st dorsal webspace

Anterolateral aspect of the foot

Dorsomedial aspect of the foot

Lesser toes

Sole of the foot

You have examined a 12-month-old child in paediatric surgical clinic with a diagnosis of syndactaly of the fingers. You are explaining the diagnosis and history to the parents. Which of the following is correct?
Select one:

Occurs in 1:1,000, caucasian male preponderance, sporadic inheritance pattern, usually unilateral, commonly affects the 3rd webspace

Occurs in 1:3,000, asian female preponderance, autosomal recessive inheritance, usually unilateral, commonly affects the 1st webspace

Occurs in 1:3,000, caucasian male preponderance, autosomal dominant inheritance, often bilateral, commonly affects the 3rd webspace

Occurs in 1:3,000, caucasian male preponderance, autosomal dominant inheritance, usually unilateral, commonly affects the 1st webspace

Occurs in 1:30,000, asian female preponderance, autosomal dominant inheritance, often bilateral, commonly affects the 3rd webspace

A 26-year-old woman presents with a cough headache, tingling in the hands, and loss of pinprick and temperature sensation in the hands. An MRI scan shows downward herniation of the cerebellar tonsils and mid-cervical syringomyelia. Which of the following tracts is most likely to malfunction as a result of this pathology?
Select one:

Corticospinal

Dorsal columns

Spinocerebellar

Spinothalamic

Vestibulospinal

The symptoms described, along with the MRI findings, suggest the patient is suffering from Chiari malformation with associated syringomyelia. This condition typically involves the herniation of cerebellar tonsils through the foramen magnum, which can disrupt the flow of cerebrospinal fluid and lead to the formation of a syrinx within the spinal cord. The resulting syringomyelia commonly affects the spinothalamic tract, which is responsible for transmitting pain and temperature sensations.

Correct Answer:

Spinothalamic

Explanation:

The spinothalamic tract carries sensory information related to pain and temperature from the body to the brain. In syringomyelia, the syrinx often damages this tract, leading to the loss of pain and temperature sensation, especially in the upper limbs, which matches the patient’s symptoms of loss of pinprick and temperature sensation in the hands.

Other tracts and their typical functions:

•Corticospinal tract: Carries motor signals from the brain to the spinal cord and is responsible for voluntary muscle movements.•Dorsal columns: Transmit fine touch, vibration, and proprioception from the body to the brain.•Spinocerebellar tract: Conveys proprioceptive information to the cerebellum.•Vestibulospinal tract: Involved in maintaining balance and posture.

Given the specific sensory deficits (loss of pinprick and temperature sensation), the spinothalamic tract is the most likely to be affected.

A patient suffers injury to the common peroneal nerve following a high fibular fracture. After six months, recovery has been minimal and she complains of persistent foot-drop. Having failed conservative measures, which one of the following tendon transfer procedures would be appropriate?
Select one:

Extensor digitorum longus

Extensor hallucis longus

Peroneus brevis

Peroneus longus

Tibialis posterior

An 18-year-old female motorcyclist is involved in a high-speed road traffic accident. Primary survey reveals a patient in respiratory distress with tracheal deviation towards the left. Breath sounds in the right side of the chest are reduced.

What is the most appropriate next step in assessment and treatment of this patient?
Select one:

Left sided tube intercostal thoracostamy

Needle pericardiocentesis

Right sided needle decompression thoracostomy

Urgent chest radiograph

Urgent CT with possible interventional radiology

A 75-year-old woman attends to have a left shoulder replacement. A delto-pectoral approach is the approach the surgeon will be using and is a true inter-nervous plane. Which one of the following is the inter-nervous plane?
Select one:

Axillary nerve and medial and lateral pectoral nerves

Axillary nerve and medial pectoral nerve

Lateral pectoral nerve and musculotanous nerve

Musculotanous nerve and radial nerve

Radial nerve and Axillary nerve

You see a 34-year-old man in the Emergency Department following a road traffic collision. The ambulance crew reported a Glasgow Coma Score (GCS) of 9 with pupils that were equally reactive to light. You record his GCS as 5 and note that he now has a fixed dilated pupil on the right. Which one of the following is the most likely explanation for the pupillary dilatation?
Select one:

Compression of abducens nerve

Direct compression of the midbrain

Disruption of ascending sympathetic fibres caused by a carotid artery

Ischaemia of the Edinger-Westphal nucleus

Loss of parasympathetic innervation of the pupil

A 25-year-old motorcyclist presents to the Emergency Department at 23:00 hours with an isolated high energy open fracture of the left tibia. He was wearing full protective clothing and was not in an agricultural or aquatic environment. On examination he has a 7 cm laceration overlying the subcutaneous border of the tibia which is visible and there is soft tissue loss. His pulses are intact distally and radiographs show a spiral fracture of the tibial mid shaft. IV antibiotics have been given and tetanus status checked. Which one of the following is the most appropriate management?
Select one:

Apply a saline soaked gauze and occlusive dressing to the wound and splint the limb, after manipulation if indicated. Aim for theatre for a joint orthoplastics procedure at the next available opportunity within 12 hours.

Prepare the patient to be taken to theatre immediately for lower limb fasciotomies to decompress compartments as this injury is high risk for compartment syndrome.

Prepare the patient to be taken to theatre immediately for washout and debridement of the wound and application of an external fixator by the orthopaedic team.

Wash the wound in ED with sterile saline and dress it with a betadine soaked gauze. Aim for theatre for a joint orthoplastics procedure at the next available opportunity within 12 hours.

Washout the wound in ED with sterile saline and dress with a betadine soaked gauze. Splint the limb, after manipulation if indicated. Aim for theatre for a joint orthoplastics procedure within the next 24 hours.

You are asked to review a 50-year-old medical secretary with progressive, radial sided wrist pain. On examination, the pain is worse on ulnar deviation yet range of movement of the wrist joint is good. Radiographs were unremarkable. You suspect a De Quervain’s tenosynovitis because of inflammation in the dorsal compartment containing which of the following tendons?
Select one:

Extensor carpi radialis longus and brevis

Extensor carpi ulnaris

Extensor indicis and extensor digitorum communis

Extensor pollicis brevis and abductor pollicis longus

Extensor pollicis longus

You assess a 3-week-old girl in clinic and the parents explain that there is a history of urine leaking from around the umbilicus. It is associated with local inflammation of the skin. A tentative diagnosis of urachal fistula is made. You present the history to the paediatric surgical team. What do you explain to them?
Select one:

The urachus develops from the mesonephric duct and drains into the urogenital sinus

The urachus develops from the mesonephric duct and drains to the allantoic cavity

The urachus develops from the mesonephric duct and drains to the amniotic cavity

The urachus develops from the urogenital sinus and drains to the allantoic cavity

The urachus develops from the urogenital sinus and drains to the amniotic cavity

The correct answer is:

The urachus develops from the urogenital sinus and drains to the allantoic cavity.

Explanation: The urachus is a remnant of the fetal connection between the bladder and the umbilicus. During fetal development, the urachus forms from the allantois, which is initially a tube connecting the developing bladder to the allantoic cavity (part of the early embryonic structure involved in waste removal).

This connection later obliterates and becomes a fibrous cord called the median umbilical ligament. However, if this obliteration does not occur completely, it can result in anomalies such as a urachal fistula, where urine can leak from the umbilicus.

As well as local inflammation, a granuloma may also form.
Gram-positive organisms, such as Staphylococcus aureus and Streptococcus pyogenes, are also commonly identified.

A 64-year-old presents with headaches and a loss of visual acuity. You examine the visual fields and document that there is loss of visual field represented by the shaded area as right hom*onymous hemianopia. Which one of the following is the most likely cause of the loss of visual field?

Select one:

Left optic nerve lesion

Left optic tract lesion

Pituitary tumour

Right optic nerve lesion

Right optic tract lesion

The most likely cause of right hom*onymous hemianopia is:

B. Left optic tract lesion

Explanation:

•hom*onymous hemianopia refers to the loss of the same half of the visual field in both eyes. When it is a right hom*onymous hemianopia, the right half of the visual field is lost in both eyes.•This type of visual field loss occurs due to a lesion posterior to the optic chiasm, such as in the optic tract, lateral geniculate nucleus, optic radiations, or occipital cortex on the opposite side of the visual field loss.•Specifically, a left optic tract lesion will result in a right hom*onymous hemianopia because the optic tract carries visual information from the contralateral (opposite side) visual field.

The other options are incorrect because:

•A left optic nerve lesion would affect only the left eye.•A pituitary tumor typically causes a bitemporal hemianopia due to compression of the optic chiasm.•A right optic nerve lesion would affect only the right eye.•A right optic tract lesion would cause left hom*onymous hemianopia, not right.

Thus, the correct answer is a left optic tract lesion.

A 71-year-old woman is referred having attended the opticians. She has a bitemporal hemianopia. An MRI scan shows suprasellar extension of a pituitary tumour. Which one of the following is the most likely explanation for the visual field defect?
Select one:

Bilateral compression of the lateral geniculate bodies

Compression of both optic tracts

Compression of decussating nasal retinal fibres

Compression of the right and left Meyer’s Loops

Impaired conduction of afferent impulses from the temporal half of the retinae

The most likely explanation for the visual field defect is:

Compression of decussating nasal retinal fibres

Explanation:

•Bitemporal hemianopia refers to the loss of the outer (temporal) half of the visual field in both eyes. This type of visual field defect occurs when there is damage to the decussating nasal retinal fibres at the optic chiasm. These fibres are responsible for transmitting visual information from the nasal half of each retina, which corresponds to the temporal (outer) visual fields.•A pituitary tumor with suprasellar extension is commonly known to compress the optic chiasm from below, affecting the decussating nasal fibres.

The other options are incorrect because:

•Bilateral compression of the lateral geniculate bodies would not specifically cause bitemporal hemianopia; it would likely result in more complex visual field defects.•Compression of both optic tracts would result in hom*onymous hemianopia (loss of the same visual field in both eyes), not bitemporal hemianopia.•Compression of the right and left Meyer’s Loops would cause superior quadrantanopia (“pie in the sky” visual field defects) rather than bitemporal hemianopia.•Impaired conduction of afferent impulses from the temporal half of the retinae would affect the nasal (inner) visual fields, not the temporal fields.

Thus, the correct answer is compression of the decussating nasal retinal fibres.

A 35-year-old construction worker presents with pins and needles of the radial three and a half digits of her hand that wakes her up at night and is worse after using vibrating machinery. You correctly diagnose these symptoms are due to a compressive neuropathy in the carpal tunnel. Which of the following is the correct list of structures that run through the carpal tunnel?
Select one:

Median nerve, 4 tendons of flexor digitorum profundas, four tendons of flexor digitorum superficialis and flexor carpi radialis tendon

Median nerve, 4 tendons of flexor digitorum profundus, four tendons of flexor digitorum superficialis and flexor pollicis brevis tendon

Median nerve, 4 tendons of flexor digitorum profundas, four tendons of flexor digitorum superficialis, and flexor pollicis longus tendon

Ulna nerve, 4 tendons of flexor digitorum profundas, four tendons of flexor digitorum superficialis and flexor carpi radialis tendon

Ulna nerve, 4 tendons of flexor digitorum profundas, four tendons of flexor digitorum superficialis and flexor pollicis brevis tendon

The correct list of structures that run through the carpal tunnel is:

Median nerve, 4 tendons of flexor digitorum profundus, four tendons of flexor digitorum superficialis, and flexor pollicis longus tendon

Explanation:
The carpal tunnel is a narrow passageway on the palmar side of the wrist that allows for the passage of several important structures. The structures that pass through the carpal tunnel are:

•The median nerve•4 tendons of flexor digitorum profundus•4 tendons of flexor digitorum superficialis•The tendon of flexor pollicis longus

Therefore, the correct answer is:
Median nerve, 4 tendons of flexor digitorum profundus, four tendons of flexor digitorum superficialis, and flexor pollicis longus tendon