Cases for Surgical Finals SAQs, EMQs and MCQs - 1st
Edition
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Acknowledgement
I dedicate this book to my wife; without her love, support and understanding
this book would not have been possible.
v
Preface
This book aims to be a complete guide to passing your surgical finals. It is
the only book containing SAQs, EMQs and MCQs, covering all surgical spe-
cialties. With over 140 SAQs, 65 EMQs and 130 MCQs with explanatory
answers we hope that this text enables thorough preparation for exams, and
improves your problem-solving skills through its variety of questions.
Please note that this is intended as a revision book, and we would refer you
to other textbooks for continued learning.
We hope you find this a useful tool for your revision, and wish you the best
of luck in your career.
Mr P Stather and Dr H Cheshire
September 2011
vi
About the Editors
Philip Stather graduated from Leicester Medical School in 2007. He is cur-
rently working as a core surgical trainee in the East Midlands South Deanery.
Helen Cheshire graduated from Leicester Medical School in 2007. She is
currently working as a GP registrar in the East Midlands South Deanery.
vii
Contributors
Dr Saba Ahmed MBChB BSc
FY1 Kettering General Hospital
Dr Scott Castell MBChB
FY1 Kettering General Hospital
Dr Laura Dalton MBChB
FY1 Kettering General Hospital
Dr Nicholas Eastley MBChB
Core Surgical Trainee 1, Kettering General Hospital
Dr Wai Kien Ng MBChB
FY1 Kettering General Hospital
Dr Gita S Patel MBChB
FY2 Kettering General Hospital
Mr Alexander Rawlinson BSc MBChB MRCS(Ed)
Core Surgical Trainee 1, Northampton General Hospital
Dr Georgina Riddiough MBChB (Hons)
FY1 Northampton General Hospital
Dr Shafiq Arif Shahban BSc MBChB
FY1 Kettering General Hospital
Dr Pandora Spillman-Henham MBBS BSc (Hons)
FY1 Kettering General Hospital
Mr Philip Stather MBChB MRCS
Core Surgical Trainee 2, Northampton General Hospital
viii
Abbreviations
AAA abdominal aortic aneurysm
ABPI ankle brachial pressure index
ACTH adrenocorticotrophic hormone
AF atrial fibrillation
AFP alphafetoprotein
AIDS acquired immunodeficiency syndrome
AP antero posterior
APTT activated partial thromboplastin time
ASA American Society of Anesthesiology
AST aspartate transaminase
ATLS acute trauma life support
BMI body mass index
BPH benign prostatic hypertension
BPPV benign paroxysmal positional vertigo
BRCA breast cancer
Ca calcium
CABG coronary artery bypass graft
CBD common bile duct
CLO campylobacter-like organism test for H. pylori
CMV cytomegalovirus
CNS central nervous system
CPAP continuous positive airway pressure
CRP C-reactive protease
CSF cerebrospinal fluid
CTS carpal tunnel syndrome
DDH developmental dysplasia of the hips
DVT deep vein thrombosis
EBV Epstein Barr virus
ERCP endoscopic retrograde cholangiopancreatography
ESR erythrocyte sedimentation rate
FAST focused assessment sonography in trauma
ix
Cases for Surgical Finals
FBC full blood count
FESS functional endoscopic sinus surgery
FNAC fine needle aspiration cytology
FSH follicle stimulating hormone
GA general anaesthetic
GCS Glasgow Coma Score
GI gastrointestinal
GIT gastrointestinal tract
GORD gastroesophageal reflux disease
GTN glycerine tri-nitrate
HCC hepatocellular carcinoma
HIV human immunodeficiency virus
ICP intracranial pressure
IHD ischaemic heart disease
IV intravenous
IVDU intravenous drug user
JVP jugular venous pressure
KUB kidneys, ureters, bladder
LA local anaesthetic
LDH lactate dehydrogenase
LFT liver function test
LH luteinising hormone
LHRH luteinising hormone releasing hormone
LIF left iliac fossa
LRTI lower respiratory tract infection
LMWH low molecular weight heparin
LUQ left upper quandrant
MCP metacarpophalangeal joint
MCV mean corpuscular volume
MDT multidisciplinary team
MI myocardial infarction
MRI magnetic resonance imaging
MSU mid-stream urine
NBM nil by mouth
NG nasogastric
NO nitrous oxide
NSAIDs non-steroidal anti-inflammatory drugs
OGD oesophagogastroduodenoscopy
OM osteomyelitis
OSA obstructive sleep apnoea
PA postero anterior
PDA patent ductus arteriosus
PE pulmonary embolism
x
Abbreviations
PET positron emission tomography
PIP proximal interphalangeal joint
PPI proton pump inhibitor
PR per rectum
PTH parathyroid hormone
PVD peripheral vascular disease
RIF right iliac fossa
RR respiratory rate
RTA road traffic accident
RTC road traffic collision
RUQ right upper quandrant
SAH subarachnoid haemorrhage
SLE systemic lupus erythematosis
SOL space occupying lesion
STI sexually transmitted infection
TB tuberculosis
TMJ temperomandibular joint
TNM tumour, node, metastasis
TRUS transrectal ultrasound
TSH thyroid stimulating hormone
TURP transurethral resection of prostate
U+E urea and electolytes
URTI upper respiratory tract infection
USS ultrasound scan
UTI urinary tract infection
VSD ventriculoseptal defect
VTE venous thromboembolism
xi
Chapter 1
Generalsurgery
Scott Castell
saQs
1 A 22-year-old girl comes to see you in the GP surgery. She complains of
a month-long history of worsening tremor, palpitations and swelling in
the midline of her neck.
a Give three possible causes of a lump in the midline of
the neck. (3 marks)
b Through history and examination, how would you
determine the cause of the lump? Give four factors in
the history and four in the examination. (4 marks)
c You ascertain the lump is most likely thyroid in origin.
Name two different types of thyroid lump. (2 marks)
d Give three ways you would further investigate the
thyroid lump. (3 marks)
e Not all thyroid lumps require surgery. Give two
indications for surgical removal of the thyroid. (2 marks)
f Why is hoarseness of the voice a complication of thyroid
surgery? (1 mark)
2 A 57-year-old lady presents to her GP with a 2-week history of vague
abdominal discomfort and back pain. Her past medical history includes a
fractured wrist 2 weeks previously. She comes in with her husband who
comments that she has been ‘acting strange’ lately.
a Routine blood tests show that her serum calcium level is
3.0 mmol/L. Give three other symptoms you should ask
about. (2 marks)
b You admit her to hospital, what four other
investigations would you request? (4 marks)
c Results show that she has primary hyperparathyroidism.
What three blood results could you expect? (3 marks)
d What is the commonest cause of primary
hyperparathyroidism? (1 mark)
e It is decided that surgical management of this lady is
appropriate. What three complications may arise from
surgery? (3 marks)
1
Cases for Surgical Finals
3 A 46-year-old man presents to A&E after recently being discharged
following an explorative laparoscopy. He complains his scar is not
healing. Examination reveals a swollen, erythematous area around one of
his laparoscopy wounds.
a Name four signs associated with any inflammatory
response. (4 marks)
b You diagnose the lump as a post-surgical cutaneous
abscess. Give three ways in which you would further
investigate this. (3 marks)
c What is the definitive curative treatment for cutaneous
abscesses? (1 mark)
d Name three risk factors for forming an abscess. (3 marks)
e Name three complications of abscess formation. (3 marks)
4 A 30-year-old gentleman presents to A&E after injuring his finger. He
works on a construction site and says that he caught his finger in a drill.
Examination reveals an open wound at the tip of his left middle finger
that will require cleaning and suturing.
a Give three methods you may use to control the pain for
the patient to facilitate cleaning and suturing. (3 marks)
b Explain the mechanism of action for local anaesthetic
(LA) agents. (3 marks)
c What other agent would you normally administer along
with LA, but is contraindicated in this case, and why is it
contraindicated? (2 marks)
d Name three types of LA agent. (3 marks)
e When the LA agent is administered, the skin of the
finger becomes warm and dry – what is the explanation
for this? (2 marks)
f What are the benefits of administering local anaesthesia
over general anaesthesia? (4 marks)
5 Frank is a 65-year-old man who has severe osteoarthritis. He requires a
hip replacement under general anaesthetic (GA).
a Explain the triad of general anaesthesia. (3 marks)
b What are the three phases of general anaesthesia? (3 marks)
c Induction of anaesthesia can be either IV or inhalation.
Which is most common, and what induction agents are
widely used? (4 marks)
d What physiological markers are used for monitoring
during a GA? (4 marks)
e As the muscle relaxant is administered in to Frank, he
appears to shake and his muscles contract. He then
relaxes. This is common during induction. What is
happening? (3 marks)
2
General surgery
f Give three potential complications of general
anaesthesia. (3 marks)
6 Margaret is a 62-year-old lady who is due to have a routine laparoscopic
cholecystectomy. She meets the anaesthetist before the operation, who
performs a full pre-operative assessment.
a List four main aims of the pre-operative assessment. (4 marks)
b Margaret had a myocardial infarction (MI) 4 years
previously, and is known to suffer from mild ischaemic
heart disease (IHD). What four pre-operative
investigations would you consider for her? (4 marks)
c ASA Classification is a scale determined by the
American Society of Anesthesiologists. It describes a
patient’s risk for anaesthetic. Briefly describe the levels
within this classification. (5 marks)
d Assessment of a patient’s airway is an important aspect
of pre-operative assessment. Give three factors that
contribute to a potentially difficult intubation. (3 marks)
e What is the name given to the scoring system for
determining difficult intubation? (1 mark)
7 Ben is a 24-year-old man who comes in for a diagnostic laparoscopy. The
surgeon meets with him prior to the operation to obtain consent.
a Explain the term ‘informed consent’. (2 marks)
b In order to give consent, Ben must be determined to
have capacity. Give four aspects of capacity. (4 marks)
c List two circumstances in which someone else can give
consent on behalf of the patient. (2 marks)
d During the operation, the surgeon decides that he will
have to convert to an open procedure. He performs
a laparotomy. Under what circumstances is this
considered legal? (2 marks)
8 A 32-year-old man presents to A&E after falling off a ladder at work.
He landed on a 100 mm nail sticking out of a plank of wood. The nail is
embedded in the anterior abdominal wall. After stabilisation in A&E, you
are part of the surgical team asked to review the patient.
a Give four aspects of your initial assessment of this patient. (4 marks)
b Examination reveals that the patient has peritonitis and
is shocked. What is the likely cause? (1 mark)
c Give four investigations you would consider. (4 marks)
d What would you expect to see on an erect chest X-ray? (1 mark)
e What would be the surgical procedure of choice for this
patient? (1 mark)
3
Cases for Surgical Finals
9 Joanne is a 45-year-old lady who attends A&E complaining of stomach
pain following a car accident yesterday. History reveals that her car slid
on ice and she hit a lamppost at approximately 20 mph. She thinks she
hit her stomach on the steering wheel, and complains of pain in her left
upper quadrant (LUQ).
a Give three organs at risk in this area. (3 marks)
b Further examination reveals severe tenderness in the
LUQ and also pain in her left shoulder. Explain the
shoulder tip pain. (2 marks)
c Give two normal functions of the spleen. (2 marks)
d What is the likely cause for splenic injury in this case? (1 mark)
e Give four causes of splenomegaly. (4 marks)
f Joanne becomes hypotensive and tachycardic, and the
decision is made to operate. She requires a splenectomy.
Give four aspects of post-operative advice that should be
given to the patient. (4 marks)
10 David is a 15-year-old boy who presents to A&E with vague abdominal
pain, which is now moving to his right side and he is reported by his
mother to be off his food. Examination reveals he is tachycardic and
dehydrated. He looks in obvious discomfort and has pain in his right iliac
fossa (RIF).
a Give the two most likely differential diagnoses. (2 marks)
b You examine David. What is Rovsing’s Sign? (1 mark)
c Give four aspects of your initial management. (4 marks)
d What is the definitive treatment of choice? (1 mark)
e Give three potential complications of acute appendicitis. (3 marks)
eMQs
A Bupivicaine
B Adrenaline
C Brachial plexus block
D Lidocaine
E Procaine
1 Has a short onset of action and is most commonly used in A&E.
2 Has a short duration of action and is used commonly for minor surgical
procedures.
3 Is used in epidural anaesthesia.
4 Will cause temporary paraesthesia of the hand and arm.
5 Causes vasoconstriction and prevents spread around the body.
4
General surgery
A Rovsing’s Sign
B Umbilical pain
C Ectopic pregnancy
D Mesenteric adenitis
E Perforation
6 Initial onset of pain caused by irritation of visceral nerve fibres.
7 A differential diagnosis in a young woman.
8 A shocked patient with guarding and rebound tenderness.
9 Pain in the RIF when the left iliac fossa (LIF) is pressed.
10 Abdominal pain in a child 2 weeks following coryzal symptoms.
A Congestive heart failure
B A patient with mild systemic disease
C Patient refusal with informed consent
D Gastrectomy
E Cholecystectomy
11 Will require a group and save prior to surgery.
12 Is a contraindication to surgery.
13 Signifies ASA Grade II.
14 Will require a cross-match prior to surgery.
15 Is a significant comorbidity in all surgical patients.
A Incision and drainage
B Pilonidal abscess
C Antibiotics
D Empyema
E Perianal abscess
16 Is defined as a collection within a pre-existing cavity.
17 May be a complication of Crohn’s disease.
18 Occurs in the natal cleft.
19 Is the treatment of choice for an abscess.
20 Should be used in cases where surrounding cellulitis is evident.
