A 70 year-old man presents with vomiting and severe abdominal pain.

His abdominal X-ray is shown

Question:
List 4 X-ray features that would help to distinguish small bowel obstruction from large bowel obstruction: (4)
Your Answer:
Correct Answer:
Any 4 of:

The following features favour a diagnosis of small bowel obstruction:

Question:
What is the commonest underlying cause of small bowel obstruction? (1)
Your Answer:

Correct Answer:
Adhesions (50-70%)

Question:
Name 2 other causes of small bowel obstruction: (2)
Your Answer:

Correct Answer:
Any 2 of:
Herniae
Malignancy
Volvulus
Inflammatory bowel disease
Ischaemic strictures
Gallstones

Question:
List 6 steps in this patient's management in the Emergency Department: (3)
Your Answer:

Correct Answer:
Any 6 of: ( mark each)
Insert IV cannula
Take bloods U&Es, glucose, amylase, FBC, LFTs, clotting, G&S
Commence IV fluids
IV analgesia e.g. morphine 5-10 mg
IV anti-emetic e.g. cyclizine 50 mg
Place nil by mouth
Insert nasogastric tube
Refer to on-call surgeons
Request erect chest X-ray

A 52 year-old man presents to the ED with sudden onset severe upper abdominal pain. The pain is
constant and he is complaining of nausea but has not vomited. There is no history of haematesis or
malaena. His past medical history includes a previously treated duodenal ulcer. The only medication that
he takes is 40mg of omeprazole daily. His observations are as follows: Temperature 37.5C, HR 110, BP
97/56, RR 22, SaO2 98% on air. On examination he is maximally tender to the right of the midline in

epigastric area. His abdominal X-ray is shown below:

Question:
Which sign is visible on the X-ray and what does it signify? (2)
Your Answer:
Correct Answer:
Rigler's sign (double luminal wall sign) air visible on both sides of the intestine.
This signifies a perforated intra-abdominal viscus (likely to be a perforated peptic ulcer)
Image sourced from Wikipedia(link is external)
CC BY-SA 3.0(link is external)

Question:
List 3 indications for an abdominal X-ray in the ED: (3)
Your Answer:

Correct Answer:
Any 3 of:
Suspected bowel obstruction
Suspected bowel perforation
Suspected ingested or inserted foreign body
Suspected renal calculi
Suspected acute colitis (to look for megacolon or 'lead pipe' colon)

Question:
List 6 steps in this patient's management in the ED: (3)
Your Answer:

Correct Answer:
Any 6 of: ( mark each)
Insert IV cannula
Take bloods U&Es, glucose, amylase, FBC, LFTs, clotting, G&S
Commence IV fluids e.g. 1-2 L 0.9% saline
IV analgesia e.g. morphine 5-10 mg
IV anti-emetic e.g. cyclizine 50 mg
Place nil by mouth
Refer to on-call surgeons
Request erect chest X-ray

Question:
List 4 risk factors for the most likely diagnosis in this case: (2)
Your Answer:

Correct Answer:
Risk factors for peptic ulcer disease include: ( mark each)
[Link]

Drugs e.g. corticosteroids / NSAIDs / spironoloactone

You perform an ultrasound scan to assess the aorta of an elderly patient with abdominal pain. Please
refer to the scan below:

Question:
What are the four structures labelled A-D in the scan above? (4)
Your Answer:
Correct Answer:
A Aorta
B Origin of the celiac axis
C Splenic vein
D Superior mesenteric artery

Question:
List 3 features of the inferior vena cava that would enable you to be able to distinguish it from the aorta on
ultrasound scanning. (3)
Your Answer:

Correct Answer:
Any 3 of:
The IVC is right sided whilst the aorta is left sided
The IVC is thin walled whilst the aorta is thick walled
The IVC is compressible whilst the aorta will not compress
The IVC has a transmitted pulse (double bounce) whilst the aorta is pulsatile
The IVC is almond shaped whilst the aorta is round in shape
The IVC varies in shape whilst the aorta has a constant shape

Question:
What is the definition of an AAA on ultrasound scan in the acute setting? (1)
Your Answer:
Correct Answer:
In the acute setting an AAA is defined as a transverse aortic diameter greater than 3 cm.

Question:
What is approximate 10-year risk of rupture for an AAA smaller than 5 cm in diameter? (1)
Your Answer:
Correct Answer:
3%

Question:
What is approximate 5-year risk of rupture for an AAA that is greater than 5 cm in diameter? (1)
Your Answer:
Correct Answer:
25%

A 25 year-old man presents to the Emergency Department with a history of sudden pain in his penis that
occurred during sexual intercourse. A photo of his penis is shown below:

Question:
What is the diagnosis and which anatomical structure has been injured? (2)
Your Answer:
Correct Answer:
Penile fracture
The corpus cavernosum
Image sourced from Wikipedia(link is external)
Courtesy of Sevgi Ozcan and Ersin Akpinar CC BY-SA 3.0(link is external)

Question:
Which investigation should be performed to exclude a co-existent urethral injury? (1)
Your Answer:
Correct Answer:
Retrograde urethrogram

Question:
List 5 potential long-term complications of this condition: (5)
Your Answer:

Correct Answer:
Any 5 of:
Penile deviation
Painful intercourse
Erectile dysfunction
Priapism
Arteriovenous fistula
Urethrocavernous fistula
Urethral structure

Question:
Outline 2 management options: (2)
Your Answer:

Correct Answer:
Penile fracture can be managed:
Conservatively (ice-packs, foley catherisation and anti-inflammatories)
Operatively (surgical evacuation of haematoma and repair)

A 76 year-old man presents with a sudden inability to pass urine. He is complaining of lower abdominal
pain and distension. He has recently been diagnosed as having benign prostatic hypertrophy (BPH) by
his GP and has been referred to the Urology outpatient clinic. On examination he has a palpable mass
arising from pelvis that is dull to percussion. You determine he is in urinary retention and decide to pass
a urinary catheter.

Question:
Which important examination should be performed prior to catheterisation and what would it specifically assess?
(2)
Your Answer:
Correct Answer:
Digital rectal examination.
When performing this examination you should assess the size and texture of the prostate, anal tone and the
presence or absence of constipation.

Question:
Name two important investigations that should be performed in the ED for this patient: (2)
Your Answer:
Correct Answer:

Urinalysis
Urea and electrolytes / renal function

Question:
Following catherisation the patient has a post void residual of 1.2 L. He continues to pass a further 1.5 L of urine
over the next 2 hours. Which important complication has occurred and how would you manage the patient?(3)
Your Answer:
Correct Answer:
He has developed a post-obstructive diuresis
The patient will require referral to the on-call Urology team for admission and careful fluid replacement and
monitoring of electrolyte levels.

Question:
List 3 other potential complications of urinary retention: (3)
Your Answer:

Correct Answer:
Any 3 of:
Haematuria
Renal failure
Hydronephrosis
Bladder stones
Detrusor muscle hypertrophy or atrophy
Bladder diverticula

75 year-old man presents with sudden onset back pain and collapse. You suspect that he has an
abdominal aortic aneurysm (AAA) and perform a bedside ultrasound scan, which is shown below:

Question:
Outline 4 features that would enable you to distinguish the aorta from the inferior vena cava on ultrasound
assessment? (4)
Your Answer:

Correct Answer:
The aorta has the following features:
Left sided
Thick walled
Non-compressible
Pulsatile
Round in shape
Constant in shape

Question:
At what vertebral level does the celiac axis arise from the abdominal aorta? (1)
Your Answer:
Correct Answer:
T12

Question:
At what size is elective repair of AAA advocated? (1)
Your Answer:
Correct Answer:
> 5.5 cm

Question:
List 4 risk factors for the development of an AAA: (4)
Your Answer:

Correct Answer:
Any 4 of
Male gender
Smoking
Hypertension
Family history
Age over 65
Ischaemic heart disease
Peripheral vascular disease

A 52-year-old woman presents sweaty and distressed complaining of abdominal pain and nausea. On
examination he has marked abdominal tenderness that is maximal in the epigastric area. She has IV
access and oxygen in place. Her observations are: HR 109, BP 102/53, SaO2 97% on 5L oxygen,
Temperature 37.4C. Her venous blood are shown below:

Venous bloods:
Hb: 12.2 g/dL
WCC 15.8 x 109/L
Urea: 11.2 mmol/L
Creatinine: 114 micromol/L
Calcium: 2.10 mml/L
AST: 216 IU/L
ALP: 448 IU/L
Bilirubin: 23 micromol/L
Amylase: 897 U/L

Question:
You make a diagnosis of acute pancreatitis, what is the most likely cause in this lady? (1)
Your Answer:
Correct Answer:
Gallstones

Question:
How quickly does the amylase rise in acute pancreatitis? (1)
Your Answer:
Correct Answer:
Within 6-12 hours of onset of the attack.

Question:
List 4 of the Glasgow criteria for predicting the severity of acute pancreatitis within 48 hours of admission: (4)
Your Answer:

Correct Answer:
Any 4 of:
Age in years > 55
PaO2 < 7.9 kPa
White cell count > 15x109/L
Calcium < 2 mmol/L
Urea > 16 mmol/L
Blood glucose > 10 mmol/L
Serum LDH > 600 IU/L
Albumin < 32 g/L

Question:
List 4 early complications seen with acute pancreatitis: (2)
Your Answer:

Correct Answer:
Any 4 of: ( mark each)
Acute renal failure
Disseminated intravascular coagulation
Hypocalcaemia
Acute respiratory distress syndrome
Multi-organ failure
Pancreatic necrosis
Peritonitis

Question:
List 4 other causes of a markedly elevated amylase level: (2)
Your Answer:

Correct Answer:
Any 4 of: ( mark each)
Renal failure
Ectopic pregnancy
Diabetic ketoacidosis
Perforated duodenal ulcer
Mesenteric ischaemia / infarction
Pancreatitic carcinoma
Burns
Mumps

A 32 year-old man presents with severe right-sided loin pain and vomiting. His Intravenous urogram (IVU)
is shown below:

Question:
Describe the above IVU. (2)
Your Answer:
Correct Answer:
Small radio-opaque calculus in right distal ureter
Right sided hydro-ureter
Right sided hydronephrosis

Question:
Outline 4 points in his immediate management? (2)
Your Answer:

Correct Answer:
Any 4 of: ( mark each)
Take bloods (renal function, full blood count and CRP)
IV fluids e.g. 1 L 0.9% Saline
Analgesia e.g. PR Diclofenac and IV Morphine
Anti-emetic e.g. 10 mg IV Metoclopramide
Refer to on call Urologists for admission

Question:
What complications could result following the giving of contrast media for an IVU? (2)
Your Answer:
Correct Answer:
Anaphylaxis
Contrast induced nephropathy / Acute deterioration in renal function

Question:
List 4 contraindications to performing an IVU. (2)
Your Answer:

Correct Answer:
Any 4 of: ( mark each)
Significant renal impairment (creatinine > 150 mol/L)
Previous reaction to contrast media or iodine
History of severe atopy or asthma
Pregnancy (1st trimester)
Metformin administration
Multiple myeloma
Cardiac failure (risk of arrhythmias)

Question:
List 4 indications for admission of the above patient. (2)
Your Answer:

Correct Answer:
Any 4 of: ( mark each)
Inadequate pain control
Signs of urinary sepsis / infected obstructed system
Significantly deranged renal function
Obstruction of the kidney / ureter (Hydronephrosis)
Stone > 5 mm in size

Bilateral stones

A 23 year-old man presents with a 3-day history of abdominal pain and intermittent vomiting. Initially the
pain was vague and central in nature. It has now moved to the right lower quadrant. On examination he is
tender in the right iliac fossa and there is a fullness, which you suspect is a mass, palpable in the right
iliac fossa.

Question:
What is the anatomical explanation for his early vague central abdominal pain? (2)
Your Answer:
Correct Answer:
This is an example of visceral pain. Visceral pain is caused by compression in or around an organ or by
stretching of the abdominal cavity. It is classically vague and is usually localised by the patient to the embryonic
site of the organ affected, which may be different to the actual site of the organ.

Question:
What is the embryonic derivation of the appendix? (1)
Your Answer:
Correct Answer:
The midgut

Question:
Outline 4 management points for this patient in the Emergency Department: (2)
Your Answer:

Correct Answer:
Any 4 of: ( mark each)
Take bloods FBC, U&Es, CRP
Urinalysis
IV analgesia e.g. morphine 5-10 mg
IV anti-emetic e.g. cyclizine 50 mg
IV fluids e.g 0.9% saline 1 L
Place nil by mouth
Refer to Surgeons

Question:
List 6 causes of a right iliac fossa mass other than an appendix mass: (3)
Your Answer:
Correct Answer:
Any 6 of: ( mark each)

Caecal carinoma
Crohn's disease
Pelvic kidney
Ovarian mass
Ileocaecal TB
Enlarged gall bladder
Iliac lymphadenitis
Psoas abscess
Retroperitoneal tumour
Actinomycosis
Common iliac artery aneurysm
Spigelian hernia

Question:
You suspect a perforated appendix. Which antibiotics would you give? (please include doses) (2)
Your Answer:
Correct Answer:
Cefuroxime 1.5 g IV
Metronidazole 500 mg IV

A 25 year-old woman presents with a 3-day history of abdominal pain and intermittent vomiting. The pain
and tenderness is maximal in the right iliac fossa. She is pyrexial with a temperature of 38.2C.

Question:
List 4 possible causes for her presentation: (2)
Your Answer:

Correct Answer:
Any 4 of: ( mark each)
Appendicitis
Ectopic pregnancy
Urinary tract infection
Torsion of ovarian cyst
Pelvic inflammatory disease
Caecal diverticulitis
Gastroenteritis

Question:
List 4 non-imaging investigations you would perform for this lady: (2)
Your Answer:

Correct Answer:
Any 4 of: ( mark each)
Urinaylsis

Beta HCG
Full blood count (raised white cell count)
CRP
High vaginal swabs

Question:
What is a 'positive Rovsing's sign' and what does it indicate? (2)
Your Answer:
Correct Answer:
Rovsing's sign is pain felt in the right iliac fossa on pressing on the left iliac fossa. It is a sign of acute
appendicitis.

Question:
Describe the precise anatomical location of McBurney's point. What does it represent? (2)
Your Answer:
Correct Answer:
McBurney's point is a point over the right side of the abdomen that is 1/3 of the distance from the anterior superior
iliac spine to the navel. This point represents the most common location of the base of appendix at its point of
attachment to the caecum.

Question:
Which two bacterial groups should be covered in the case of a perforated appendix? (2)
Your Answer:
Correct Answer:
Gram negative rods
Facultative anaerobes

A 75-year-old man presents with a fever, severe genital pain and discharging painful ulcerated area on his
scrotum. On examination his scrotum is erythematous and subcutaneous crepitus can be elicited.

Question:
What is the most likely diagnosis? (1)
Your Answer:
Correct Answer:
Fourniers gangrene

Question:
List 4 co-morbid risk factors associated with this diagnosis. (4)
Your Answer:

Correct Answer:
Any 4 of:
Diabetes mellitus
Malignancy
Liver cirrhosis
Vascular disease
Intravenous drug use
Alcoholism
Chronic corticosteroid steroid therapy
Chemotherapy
Morbid obesity
HIV
Immunosuppression

Question:
List 4 important investigations in this case. (2)
Your Answer:

Correct Answer:
Any 4 of: ( mark each)
Routine bloods FBC, U&Es, CRP, LFTs
Blood cultures
Wound swab / cultures
Tissue biopsy
CT scan of area

Question:
Outline 6 treatment points for this patient. (3)
Your Answer:

Correct Answer:
Any 6 of: ( mark each)
Oxygen
IV fluids e.g. 1-2 L 0.9% saline
IV analgesia e.g. morphine 5-10mg plus paracetamol 1g
IV antibiotics e.g. Ceftriaxone 2g plus Clindamycin 600mg
Urinary catheter and hourly urine output monitoring
Hyperbaric oxygen therapy (HBOT)
Refer to Urology team for surgical debridement
Refer to ITU for post-operative / supportive care

A 75-year-old woman presents to the minors area of your ED with a right sided, painful groin swelling.
You suspect that it is an inguinal hernia.

Question:
List 4 differential diagnoses, other than an inguinal hernia: (2)
Your Answer:

Correct Answer:
Any 4 of: ( mark each)
Femoral hernia
Lipoma
Lymphadenopathy
Groin abscess
Saphena varix
Vascular aneurysm or pseudoaneurysm

Question:
Describe 4 important examination points that would enable you to distinguish an indirect from a direct inguinal
hernia: (2)
Your Answer:

Correct Answer:
Indirect inguinal hernias are: (Any 4 of:)
Elliptical in shape (compared with direct hernias that are round)
Less likely to be easily reducible
Less likely to reduce spontaneously on reclining
Slow to appear on standing (compared with direct hernias that appear immediately)
Reduced superiorly then supero-laterally (compared with direct hernias that reduce superiorly then
posteriorly)
Controlled by pressure over the deep inguinal ring
More prone to strangulation (because of narrow neck of deep inguinal ring)

Question:
Describe the contents of the inguinal canal in this case: (2)
Your Answer:

Correct Answer:
In a woman the inguinal canal contains:
Round ligament
Ilioinguinal nerve

Question:
Describe the surface markings of the superficial and deep inguinal rings: (2)
Your Answer:

Correct Answer:
The superficial inguinal ring lies 1 cm above and lateral to the pubic tubercle.
The deep inguinal ring lies at the midpoint of the inguinal ligament (half-way between the anterior superior iliac
spine and the pubic tubercle).

A 17-year-old man presents to the Emergency Department with an acutely painful, swollen right testis
and severe abdominal pain. You suspect he is suffering from testicular torsion.

Question:
Give 3 differential diagnoses: (3)
Your Answer:

Correct Answer:
Any 3 of:
Torsion of the hydatid of morgagni
Epididymoorchitis
Orchitis
Trauma
Testicular tumour

Question:
Outline 4 history points that would favour testicular torsion as the diagnosis: (2)
Your Answer:

Correct Answer:
Any 4 of: ( mark each)
Sudden onset
Sever pain
Accompanied by vomiting
Occurred during sleep (half of torsions occur during sleep)
Previous history of torsion to other testis
Previous history of less severe episodes that have resolved in recent past
History of undescended testis

Question:
Outline 4 examination points that would favour testicular torsion as the diagnosis: (2)
Your Answer:

Correct Answer:
Any 2 of: ( mark each)
Testis lies high in scrotum
Testis too tender to touch
Opposite testis lies horizontally (Angell's sign)
Pain not relieved by elevating testis (Negative Prehn's sign)
Absence of cremasteric reflex

Question:
How can the abdominal pain be explained anatomically? (1)
Your Answer:
Correct Answer:
The abdominal pain occurs because the testis retains its embryological nerve supply that is primarily from the
T10 sympathetic pathway.

Question:
Outline your management of this patient: (2)
Your Answer:
Correct Answer:
Give IV analgesia e.g. morphine 5-10 mg
Refer urgently to Surgical / Urological team on-call

A 66 year-old man presents with vomiting and severe abdominal pain. His abdominal X-ray is shown
below:

Question:
List 4 X-ray features that would help to distinguish large bowel obstruction from small bowel obstruction: (4)
Your Answer:

Correct Answer:
The following features favour a diagnosis of large bowel obstruction:
Dilated loops of bowel > 6 cm in size
Loops of bowel peripherally (framing the small bowel)
Small number of loops visible
Incomplete haustral folds
Image sourced from Wikipedia(link is external)
Courtesy of James Heilman CC BY-SA 3.0(link is external)

Question:
What is the commonest underlying cause of large bowel obstruction? (1)
Your Answer:
Correct Answer:
Carcinoma of the bowel (approximately 60%)

Question:
Name 2 other causes of large bowel obstruction: (2)
Your Answer:

Correct Answer:
Any 2 of:
Diverticulitis
Herniae
Inflammatory bowel disease
Adhesions
Volvulus
Constipation / faecal impaction

Question:
List 6 steps in this patient's management in the Emergency Department: (3)
Your Answer:

Correct Answer:
Any 6 of: ( mark each)
Insert IV cannula
Take bloods U&Es, glucose, amylase, FBC, LFTs, clotting, G&S
Commence IV fluids
IV analgesia e.g. morphine 5-10 mg
IV anti-emetic e.g. cyclizine 50 mg
Place nil by mouth
Insert nasogastric tube
Refer to on-call surgeons

Request erect chest X-ray

A 73-year-old man presents with an acutely painful left lower leg. He has a known history of peripheral
vascular disease but the pain has suddenly worsened. You are concerned that he may have critical limb
ischaemia. He has been given supplemental oxygen by the triage nurse and has intravenous access in
situ. A routine set of bloods has been sent to the lab.

Question:
List 6 clinical features that are suggestive of critical limb ischaemia. (3)
Your Answer:

Correct Answer:
Any 6 of: ( mark each)
Pain at rest
Pain relieved by placing limb in dependent position
Absent foot pulses
Absent sensation
Skin of limb cold to the touch
Mottled or pale appearance of skin
Limb paralysis
Severe ulceration or gangrene

Question:
Outline the Fontaine classification used to classify the severity of the ischaemia: (2)
Your Answer:

Correct Answer:
4 stages: ( mark each)
Stage I Asymptomatic
Stage II Intermittent claudication
Stage III Ischaemic rest pain
Stage IV Ulceration and/or gangrene

Question:
Name two bedside tests that could be performed to assess the severity of his limb ischaemia. (2)
Your Answer:
Correct Answer:
Buergers test
Ankle-brachial pressure index (ABPI)

Question:
List the next three things that you would do for this patient. (3)

Your Answer:
Correct Answer:
Administer 5000 units of intravenous heparin
Give analgesia e.g. intravenous morphine
Make an urgent referral to the on-call vascular surgeon