Results for the whole quiz (58 questions)

12/11/2018 Applied Surgical Physiology Questions

https://vle.rcseng.ac.uk/mod/quiz/review.php?attempt=94265#q8 1/18

Started on Tuesday, 11 December 2018, 6:48 AM

State Finished

Completed on Tuesday, 11 December 2018, 6:55 AM

Time taken 6 mins 24 secs

Marks 6.00/58.00

Grade 10.34 out of 100.00

For CBM, the grade above is shown relative to the maximum for all correct at C=1.

Results for the whole quiz (58 questions)

Sameh Awad Ibrahim Ahmed Mohamed

Dashboard / My courses / MRCS Success: MRCS Part A online revision tool / Applied Surgical Physiology / Applied Surgical Physiology Questions

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Average CBMmark

0.10

Accuracy 10.3%

CBM bonus 0.0%

Accuracy +Bonus

10.3%

Results for just the 8 answered questionsAverage CBM

mark0.75

Accuracy 75.0%

CBM bonus -2.5%

Accuracy +Bonus

72.5%

Break-down by certaintyC=3 No responses

C=2 No responses

C=1 Responses: 8. Accuracy: 75%. (Optimal range 0% to 67%). You were a bit under-confident using this certainty level.



Question 1Correct

CBM mark 1.00 Weight 1.00

A 40-year-old man presents with clinical and endocrinological features of acromegaly. A microadenoma of the pituitary gland isidentified. Which one of the following is the most compelling reason for treating this tumour?

Select one:

Avoidance of cardiovascular complications

Avoidance of colonic cancer

Avoidance of diabetes

Avoidance of optic pathway compression

Avoidance of radiological progression

Certainty : C=1 (Unsure: <67%) C=2 (Mid: >67%) C=3 (Quite sure: >80%)

Cardiovascular complications have most effect on survival and are best avoided by early treatment.

All other conditions can occur but have less effect upon survival and are therefore less compelling. Radiological progression wouldinitiate additional treatment. Optic pathway compression will not occur with a micro adenoma unless significant growth occurs.

The correct answer is:Avoidance of cardiovascular complications

You did not select a certainty. Assuming: C=1 (Unsure: <67%).



Question 2Correct


A 54-year-old man with osteoarthritis of the left knee presents at your pre-operative clinic. He also suffers with mild portalhypertension, fibrotic pulmonary disease and chronic kidney disease. He is taking captopril (an ACE inhibitor), 50 mg TDS forhypertension. On examination, his blood pressure is 160/120 mmHg. Why has the captopril not lowered his blood pressure?

Select one:

It acts in the kidney to inhibit release of renin from the juxta-glomerular apparatus

It acts in the liver to inhibit conversion of angiotensin I to angiotensin II

It acts in the liver to inhibit conversion of angiotensinogen to angiotensin I

It acts in the lungs to inhibit conversion of angiotensin I to angiotensin II

It acts in the lungs to inhibit conversion of angiotensinogen to angiotensin I


ACE is found in the lung, its acts on angiotensin 1, converting it to angiotensin II.

The correct answer is:It acts in the lungs to inhibit conversion of angiotensin I to angiotensin II




Question 3Correct


A newborn male infant is admitted to the neonatal unit for monitoring as the antenatal scans have shown bilateralhydroureteronephrosis and a thick walled bladder. Which one of the following must be included in the immediate management of thispatient?

Select one:

Antibiotic therapy alone

Commencement of intravenous fluids calculated at 120 mls/kg/day

Placement of a central line to allow blood pressure monitoring

Placement of a nasogastric tube and commencement of trophic feeds

Placement of a urinary catheter, followed by strict fluid balance monitoring


The antenatal finding of bilateral hydroureteronephrosis and a thick walled bladder in a male foetus indicates the strong possibility ofposterior urethral valves. The most important immediate post natal management is the placement of a urinary catheter to relieve thebladder outlet obstruction, followed by careful fluid balance. A diuresis may be seen after relief of the obstruction.

Antibiotic therapy alone - antibiotics would be appropriate treatment for a patient with vesico-ureteric reflux. The scans would beexpected to show bilateral hydroureteronephrosis but would not typically show a thick walled bladder

Commencement of intravenous fluids calculated at 120 mls/kg/day - this fluid rate is too high for a newborn infant



Placement of a central line to allow blood pressure monitoring - there is no indication for invasive blood pressure monitoring in thesynopsis given. Non invasive blood pressure monitoring should be adequate in this scenario

Placement of a nasogastric tube and commencement of trophic feeds - the infants with PUV can usually well and can feed orally aslong as the volumes are carefully monitored

Placement of a urinary catheter, followed by strict fluid balance monitoring - correct

The correct answer is:Placement of a urinary catheter, followed by strict fluid balance monitoring




Question 4Incorrect


A 47-year-old man presents with confusion and a history of chronic pain and coughing. He is normovolaemic but biochemistry revealsplasma Na 130 mMol/L and plasma osmolarity is 255 mOsm/l. A chest radiograph indicates a pulmonary mass. A tentative diagnosisof inappropriate ADH secretion is made. How is ADH released in a healthy individual?

Select one:

Released from the anterior pituitary gland and increases sodium resorption at the proximal convoluted tubule of the kidney

Released from the anterior pituitary gland and increases water resorption from the collecting ducts of the kidney

Released from the hypothalamus and increases water resorption at the proximal convoluted tubule of the kidney

Released from the posterior pituitary gland and increases sodium resorption at the proximal convoluted tubule of the kidney

Released from the posterior pituitary gland and increases water resorption from the collecting ducts of the kidney


ADH is released from the posterior pituitary gland and acts to increased water resorption at the collecting ducts.

The correct answer is:Released from the posterior pituitary gland and increases water resorption from the collecting ducts of the kidney




Question 5Correct


A 1-year-old girl presents with shortness of breath. Her parents have also noticed that her eyes no longer look symmetrical. The rightpupil 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


The clinical features point to a right sided Horner syndrome, secondary to a right apical tumour compressing the sympathetic chain.In this age group the most likely cause is neuroblastoma.

A community acquired pneumonia - although a pneumonia can present with shortness of breath, the Horner syndrome is not inkeeping

A congenital diaphragmatic hernia - although late presenting congenital diaphragmatic hernia can present with shortness of breath,the Horner syndrome is not in keeping



A congenital pulmonary airway malformations - although late presenting congenital pulmonary airway malformation can present withshortness of breath (usually because of infection in the CPAM), the Horner syndrome is not in keeping

Lymphoma - lymphoma causes lymph node enlargement. The chest X-ray may typically show a mediastinal mass

Neuroblastoma - correct

The correct answer is:Neuroblastoma




Question 6Correct


A 34-year-old man, with a medical history of significant alcohol consumption, developed acute pancreatitis three days ago. Hiscondition deteriorated and he was transferred to ITU. Today he has bilateral pulmonary infiltrates on a chest radiograph and hispulmonary artery wedge pressure is 12 mmHg. He is being ventilated with an Fi02 of 0.45. Which one of the following other criteriamust be present for a diagnosis of Acute Respiratory Distress Syndrome (ARDS) to be made?

Select one:

Core temperature higher than 39.5oC

Heart rate greater than 125 bpm

Pa02, less than 9kPa

Systolic blood pressure, less than 90 mmHg

White cell count greater than 16,500 per uL


Pa02, less than 9kPa is the correct answer, many of the other answers relate to the diagnosis of SIRS as opposed to ARDS.

The correct answer is:Pa02, less than 9kPa




Question 7Incorrect


A 34-year-old man, with a medical history of significant alcohol consumption, developed acute pancreatitis three days ago. Hiscondition has deteriorated and he was transferred to ITU yesterday. Today he is ventilated with an Fi02 of 0.45. His Pa02 is 8 kPaand chest radiographs demonstrate bilateral diffuse infiltration. Which other clinical criterion must be present for a diagnosis of AcuteRespiratory Distress Syndrome (ARDS) to be made?

Select one:

Central Venous Pressure =12 mmHg

Heart rate = 136 bpm

Pulmonary Artery Wedge Pressure = 15 mmHg

Systolic Blood Pressure = 90 mmHg

Temperature = 36.3oC


C indicates non-cardiogenic pulmonary oedema.

Other answers may be criteria for SIRS.

Central venous pressure is not relevant to a diagnosis of SIRS or ARDS.



The correct answer is:Pulmonary Artery Wedge Pressure = 15 mmHg




Question 8Not answered

Weight 1.00

A 46-year-old man with severe asthma and type 2 diabetes is admitted for elective repair of left inguinal hernia. He weighs 92 kg andposes a number of anaesthetic risks. You are discussing anaesthetic options with the anaesthetist and hope to perform the procedureunder local block and hope to optimise his COPD. Which one of the following statements is true given his severe COPD?

Select one:

FEV1:FVC ratio is likely to be increased

FEV1:FVC ratio is likely to be normal

FEV1 is likely to normalise with a beta-2 agonist

FEV1 is unlikely to change with a beta-2 agonist

FVC would be expected to be significantly below normal values


FVC is commonly normal in asthma. However there is often a reduced FEV1 and reduced FEV1:FVC ratio. FEV1 returns towardsnormal with bronchodilator (beta-2 agonist) treatment.



The correct answer is:FEV1 is likely to normalise with a beta-2 agonist



Question 9Correct


You are looking after a 15-year-old patient with 35% burn injury by burn surface area. You are discussing nutritional requirementswith the nursing team. Which of the following should you ensure in this patient?

Select one:

A low protein intake to minimise 3rd space losses

Maintain body weight to within 25% of pre-burn weight

Permissive hyperglycaemia ensues to increase calorie availability for healing

Receive enteral feeding within 72 hours of burn injury

Receive vitamin supplementation


Burns patients should receive high protein intake via enteral feeding ideally within 18 hours of injury.

Hyperglycaemia should be avoided.

Weight should ideally be maintained to within 10% of pre-injury weight.

Vitamin supplementation, though not the primary objective of nutritional management is very important for burn healing and the onlycorrect response above.

The correct answer is:Receive vitamin supplementation







Weight 1.00

A patient with a traumatic brain injury is managed on the intensive care unit. The intracranial pressure is 25 mmHg. Blood pressure is140/80. Which one of the following is the cerebral perfusion pressure?

Select one:

55 mmHg

75 mmHg

85 mmHg

100 mmHg

195 mmHg


CPP is calculated in normal clinical practice in management of traumatic brain injury patients. Tests candidates knowledge of theequation CPP = Mean BP - ICP

Candidate needs to calculate Mean BP = Diastolic BP (80) + 1/3 x Sys (140) - Dis (80) = 100

CPP = 100 - 25 = 75

The correct answer is:75 mmHg




https://vle.rcseng.ac.uk/mod/quiz/review.php?attempt=94265&page=1# 1/15










Weight 1.00

You are called to see a 63-year-old woman who weighs 80 kg. Eight hours earlier, she returned from the operating theatre where anuneventful right hemicolectomy was performed for cancer. She is in shock, her blood pressure is 105/75 mmHg, HR 125 bpm and she has produced 20 ml of urine in the last two hours. Youadminister 500 ml of 0.9% saline solution IV over a period of 10 minutes. Which one of the following effects will take place afteradministering saline solution?

Select one:

Have a positive chronotropic effect

Have a positive inotropic effect

Increase peripheral vascular resistance

Reduce glomerular filtration rate

Reduce secretion of atrial natriuretic peptide (ANP)


From Frank-Starling's Law, the force of contraction (inotropy) will increase.

ANP secretion is likely to increase in response to increased atrial stretch.

The correct answer is:Have a positive inotropic effect






Weight 1.00

A 52-year-old insulin-dependant diabetic patient presents following a trivial injury to the mid-foot whilst gardening. 24 hours later hisfoot is very warm and swollen. He has been bearing weight normally. Inflammatory markers are normal. His HbA1c is 80. On examination, the foot is warm to touch, with a temperature difference of 2.5oC. He has a dense peripheral neuropathy. There is noevidence of an infective collection. Radiographs were normal apart from some calcification of the dorsal pedis artery. His pulses werepalpable. Which one of the following is the next most appropriate course of action?

Select one:

Admit for intravenous antibiotics for cellulitis, keeping the patient as mobile as he is able

Advise incision and drainage of a possible diabetic abcess

Apply a total contact plaster cast, non-weight bearing

Discharge home with advice to rest and elevate the limb and seek advice if the symptoms do not improve. Crutches if required

Issue the patient with crutches and review the patient in the ED trauma clinic 2 weeks thereafter


In diabetic patients with peripheral neuropathy, a warm swollen foot may be indicative of a Charcot process. Pulses are often normal.This is not an infective process, though this should be part of your differential.

The patient requires immobilisation in a total contact cast. Failure to protect and immobilise the limb may result in gross architecturaldeformity of the foot.



Review at the joint diabetic foot clinic, where the patient will be seen by a diabetologist, a vascular surgeon and an orthopaedicsurgeon is mandated.

The correct answer is:Apply a total contact plaster cast, non-weight bearing




Weight 1.00

A 20-year-old man, fit and healthy, weighs 70 kg. Sitting at rest, his cardiac output is 5 L/min. Which one of the following is thedistribution of cardiac output, by percentage, to different areas at rest?

Select one:

Coronary 4-5%, Cerebral 10-12%, Renal 10-12%






Distribution of cardiac output varies significantly depending on for example whether the subject is at rest or exercising. Duringexercise coronary blood flow increases, as does blood flow to the limbs, at the expense of other organ systems.

The correct answer is:Coronary 4-5%, Cerebral 10-12%, Renal 20-22%




Weight 1.00

A 44-year-old woman presents with Cushingoid features. Which one of the following tests results is the most reliable at distinguishingCushing's disease from Cushing's syndrome?

Select one:

Elevated BP on 24h monitoring

Elevated levels of CRF (corticotrophin releasing factor)

Elevated levels of HbA1C

Failure to suppress ACTH

No diurnal variation in cortisol level


Cushing's disease is pituitary driven. CRF is normally released by hypothalamus. Other features are non-specific co sequences ofraised cortisol levels.

The correct answer is:Failure to suppress ACTH




Weight 1.00

A 60-year-old man with acromegaly undergoes a trans-sphenoidal procedure to resect a pituitary adenoma. 48 hours post-operativelyhe develops severe thirst, and passes volumes of urine exceeding 5 litres/24h. His sodium level is 166 mmol/l. Which one of thefollowing is the most appropriate treatment to commence?

Select one:

1.8% saline administration

Demeclocycline

Desmopressin

Furosemide

High dose dexamethasone


There are 2 types of diabetes insipidus: cranial diabetes insipidus (CDI) and nephrogenic diabetes insipidus (NDI)CDI is caused by alack of ADH, which means that the kidneys cannot retain water, resulting in extreme thirst.

NDI is a condition in which the kidneys do not respond to normal levels of ADH.The primary symptoms of NDI are polyuria andpolydipsia.

In this case, surgery to remove the tumour has caused a dramatic acute reduction in ADH.

The correct answer is:Desmopressin




Weight 1.00

A 60-year-old man with acromegaly undergoes a trans-sphenoidal procedure to resect a pituitary adenoma. 48 hours post-operativelyhe develops severe thirst, and passes volumes of urine exceeding 5 litres/24h. His sodium level is 166 mmol/l. What is the most likelyexplanation for these symptoms?

Select one:

Cerebral salt wasting syndrome

Diabetes insipidus

Hypoadrenalism

Overload of intravenous fluids in the peri-operative period

Syndrome of inappropriate antidiuretic hormone secretion


Loss of vasopressin is the cause. Desmopressin is the pharmacological structural analogue. All other distractors are involved insodium homeostasis. Demeclocycline is used in treatment of SIADH - not in DI

The correct answer is:Diabetes insipidus




Weight 1.00

A 25-year-old man sustains an anterior skull base fracture. He had a CSF leak for 36 hours after the injury and was admitted forobservation. Four days after injury he reports thirst and a frequent need to pass urine. On examination, the following is found: Blood pressure: 110/70. Pulse rate: 90 bpm. Oxygen saturation 100%. He appears well hydrated. Glasgow Coma Score is 15/15 and he has no neurological deficits, the CSF leak appears to have ceased. Which one of the following is the most likely explanation for his symptoms?

Select one:

Cerebral salt wasting

Dehydration

Diabetes insipidus

Occult CSF leak

Syndrome of inappropriate ADH (SIADH)




DI is characterised by large urine output and thirst. It is most common after anterior skull base fracture as in this scenario. CSW canoccur in neurosurgical conditions but is associated with dehydration. SIADH causes water retention rather than loss. CSF leak in itselfdoes not result in thirst and frequency. Dehydration would not be associated with a "well hydrated" appearance.

The correct answer is:Diabetes insipidus




Weight 1.00

A 56-year-old woman presents with a history of bilateral chronic knee pain. She is easily tired, has obvious fat deposition between hershoulders and has numerous stretch marks in her abdominal skin. A low dose (1 mg oral) overnight dexamethasone suppression testdemonstrates a raised plasma cortisol (150 nmol/L). Which of the following is an indication of normal levels of ACTH?

Select one:

Maximal release from the anterior pituitary gland at noon each day

Maximal release from the anterior pituitary gland in late evening and early morning

Maximal release from the posterior pituitary gland at noon each day

Maximal release from the posterior pituitary gland in late evening and early morning

No evidence of diurnal variation in its release


ACTH is released from the anterior pituitary gland with a recognised diurnal variation.

The correct answer is:Maximal release from the anterior pituitary gland in late evening and early morning




Weight 1.00

A 22-year-old man is involved in a RTC and undergoes intra-medullary nailing for a grossly contaminated open tibial fracture. He iscommenced on IV broad spectrum antibiotics due to the wound contamination. 48 hours post-operatively he develops a widespreadpetechial rash, neurological dysfunction and respiratory insufficiency. Which one of the following is the most ely diagnosis?

Select one:

Fat embolism syndrome

Penicillin allergy

Post-operative pneumonia

Streptococcal septicaemia

Venous thromboembolism


FES can occur 1 to 3 days after trauma with an incidence of 1-20% (depending on diagnostic criteria). Increasing risks are associatedwith younger age, closed fracture (not exclusively), intra-medullary nailing for fracture. Classic symptoms include tachycardia, feverand respiratory insufficiency. The pathognominc petechial rash in FES affects conjunctiva, oral mucosa and neck. The CXR can showbilateral, diffuse, non-specific shadowing, but most commonly is normal despite clinical and laboratory evidence of hypoxaemia.

The correct answer is:Venous thromboembolism




Weight 1.00

A 25-year-old woman had her first baby four years ago and she breast fed for 18 months. Two years after weaning her infant, shebegan to notice spontaneous discharge of milky fluid from both nipples. The discharge is considerable and often profuse but it is notblood stained. The discharge is persisting and causing the patient significant embarrassment. Elevated levels of which of thefollowing hormones is likely to be the cause of the patient's symptoms?

Select one:

Oestrogen

Oxytocin

Progesterone

Prolactin

Testosterone


The clinical history at this age and with the triad of bile vomiting, abdominal distension and failure to pass meconium points to a likelydiagnosis of Hirschsprung's disease. The diagnostic test is therefore a suction rectal biopsy to look for an absence of ganglion cells.The normally sited anus rules out an anorectal anomaly.

Suction rectal biopsy - correct



Upper gastrointestinal contrast study - the presence of bile vomiting may lead the candidate to consider malrotation and volvulus buttypically children with malrotation have passed meconium. If this is felt to be ambiguous then an alternative answer option would beplain abdominal x-ray - this would lead you to upper or lower GI obstruction but not to the underlying cause without furtherinvestigation

Blood cultures - sepsis is a possible cause but less likely

Lower gastrointestinal contrast study - lower GI contrast can be used to investigate lower GI obstruction but will not prove a diagnosisof Hirschsprung's disease

Ultrasound scan - USS is unlikely to be contributory here

The correct answer is:Prolactin












Weight 1.00

A 45-year-old man is diagnosed with a peptic ulcer. He is prescribed ranitidine. Which one of the following is the mechanism of actionfor ranitidine?

Select one:

Block H+-K+ ATPase

Lower intracellular levels of cyclicAMP

Inhibit release of gastrin

Inhibit release of acetylcholine

Increase the numbers of cholinergic receptors


Ranitidine acts to block the H2 receptor, and thereby reduces the level of the intracellular secondary messenger cyclic AMP.

The correct answer is:Lower intracellular levels of cyclicAMP




Weight 1.00

You examine a 35-year-old patient with hearing loss in the left ear. Weber's Test lateralises to the right ear. Rinnes's test shows airconduction to be better than bone conduction (AC>BC) in the left ear. Which one of the following is most likely to account for the lossof hearing?

Select one:

CP angle tumour

Excessive ear wax

Middle ear infection

Otoscerosis

Traumatic injury to the ossicular chain


The pattern of hearing tests is consistent with sensorineural hearing loss. All the incorrect options are examples of conductive hearingloss. A CP angle tumour - eg vestibular schwannoma, causes sensorineural hearing loss.

The correct answer is:CP angle tumour




Weight 1.00

A 23-year-old soldier is admitted to the Emergency Department with a closed fracture of the distal tibia. He has been involved in atraining exercise in mid-June, and has drunk only 500 ml of water in the last 16 hours. He is collapsed, confused, anuric and hisplasma Na is 155 mmol/L. Which of the following will this cause?

Select one:

ADH to be produced in, and released from, the anterior pituitary gland

ADH to be produced in, and released from, the posterior pituitary gland

ADH to be produced in, and released from, the hypothalamus

ADH to be produced in the hypothalamus and released from the anterior pituitary gland

ADH to be produced in the hypothalamus and released from the posterior pituitary gland


An understanding of diuresis pathways is essential when treating shocked patients. It is also important to know that ADH is releasedfrom the posterior pituitary but is actually synthesized in the hypothalamus.

The correct answer is:ADH to be produced in the hypothalamus and released from the posterior pituitary gland




Weight 1.00

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

Select one:

ACE inhibitor

Alpha blocker

Aquaporin

Beta Blocker

Calcium channel blocker




Scan shows SAH. This is communicating rather than obstructive: all ventricles are seen on the scan (lateral, 3rd and 4th) and aredilated. This excludes A, B and D. NPH is a form of communicating hydrocephalus but the presence of the SAH and the raisedpressure appearance on the scan (no atrophy) excludes this diagnosis.

The correct answer is:Calcium channel blocker




Weight 1.00

A 19-year-old man has suffered severe brain injury following a vehicular accident. A tentative diagnosis of brain stem death has beenmade. This is confirmed by the apnoea test, in which PaCO2 rises to 8 kPa following withdrawal of ventilatory support. Rise ofPaCO2 may occur pathologically; which of the following would cause a normal physiological elevation of PaCO2 in an uninjuredindividual?

Select one:

Elevation of plasma pH

Hypoventilation

Increased affinity of haemoglobin for oxygen

Reduction of urinary pH

Vasconstriction of cerebral arteries


Compensation for the respiratory acidosis will be excretion of H+ ions in the urine

Ventilation will be stimulated, CO2 causes vasodilation in the cerebral circulation, and Hb affinity for Oxygen falls (shift to right).

The correct answer is:Reduction of urinary pH




Weight 1.00

A 28-year-old man suffers a crush injury to his right leg as a result of an accident on a construction site. After being freed, his bloodpressure is 110/80 mmHg and his plasma potassium is 6.7 mmol/L. Which one of the following will this cause?

Select one:

Absence of T waves on an ECG

Release of ADH

Release of aldosterone

Release of insulin

Raised plasma osmolarity


Hyperkalaemia is a potent stimulus for aldosterone release. It does not have an effect on insulin release (although insulin will cause areduction in plasma K).

The correct answer is:Release of aldosterone




Weight 1.00

A 63-year-old man undergoes a total thyroidectomy for the treatment of an anaplastic thyroid carcinoma. On recovery from surgery,he describes tingling in the peri-oral region and demonstrates tetany. A diagnosis of acute hypocalcaemia is made. The clinical signsare due to which of the following options?

Select one:

A reduction in plasma levels of 1,25 Dihydroxycholecalciferol

Increased neuronal permeability to Na

Inhibition of release of acetycholine as the neuromuscular junction

Reduced availability of Ca in the sarcoplasmic reticulum

Reduced neuronal permeability to Na


A reduction in level of ionised Ca in plasma increases the neuronal permeability to Na, hence enhancing action potentials in bothmotor and sensory nerves.

C and D would both contribute to flaccidity or paralysis.

The correct answer is:Increased neuronal permeability to Na




Weight 1.00

A 29-year-old man who lives as a 'rough sleeper' on city streets, is admitted to the Emergency Department at 11.00 pm on a Februarynight. He has a wound to the left maxillary region. He is unconscious, his blood pressure is 90/75 mHg and his core temperature is33.9oC. This will cause which of the following?

Select one:

Increased secretion of insulin

Metabolic acidosis

Metabolic alkalosis

Reduced affinity of haemoglobin for oxygen

Reduction in both PT (Prothrombin Time) and PTT (Partial Thromboplastin Time)


Hypothermia causes tissues to revert to anaerobic metabolism.

Hypothermia will increase Hb affinity for oxygen, and will increase PT and PTT, contributing to a coagulopathy.

The correct answer is:Metabolic acidosis




Weight 1.00

You review a patient on the High Dependancy Unit two days following a low anterior resection for ischaemic colitis. The patient is inmild renal failure, has a low Hb requiring transfusion, but is otherwise stable. He is mildly hypothyroid and diet controlled type IIdiabetic. Which of the following is to be expected after this kind of operation and will help you manage the post-operative period inthis patient?

Select one:

A decrease in ACTH, ADH and TSH

A decrease in systemic insulin release and glycogenolysis

A decrease in TSH and systemic insulin release

An increase in nor-adrenaline, gluconeogenesis and TSH

An increase in systemic insulin release, T3 and T4


The systemic response to surgery involves many organ systems:

Renal: increase renin-angiotensin system

Pituitary: increase ACTH, ADH & GH; decrease TSH

Thyroid: decrease T3 & T4

Hepatic: increase gluconeogenesis & glycogenolysis



Pancreatic: increase glucagon and decrease insulin

The correct answer is:A decrease in TSH and systemic insulin release




Weight 1.00

A 45-year-old woman presents with weight loss, polydipsia, polyuria, and glycosuria of two months duration. Her blood glucose is 12mmol/L, two hours after eating. Which of the following will happen after administration of insulin by injection?

Select one:

Decrease plasma potassium levels

Increase plasma potassium levels

Inhibit glycogen synthesis

Inhibit uptake of amino acids into all cells in the body

Stimulate uptake of glucose into all cells in the body


Insulin decreases plasma potassium levels.

Insulin promotes glycogen synthesis and increases amino acid uptake into cells.

Insulin does stimulates uptake of glucose into cells, but not ALL cells; it has no effect on neural cells hence answer E is incorrect.

The correct answer is:Decrease plasma potassium levels














Weight 1.00

A 35-year-old man, previously well, develops an infected jejuno-cutaneous fistula following surgical repair of a stab wound to thejejunum. He is treated with a temporary jejunostomy, which drains a considerable amount of fluid. The volume and derivation of fluidhe is losing via the jejunostomy is best described as which one of the following?

Select one:

1.25L: Pancreatic, 250 ml, Intestinal 500 ml, Gastric 500ml

1.5L: Pancreatic 250 ml, Intestinal 250 ml, Gastric 1L

3L: Pancreatic 500 ml, Intestinal 2 L, Gastric 500 ml

3L: Pancreatic 1 L, Intestinal 1 L, Gastric 500 ml

4L: Pancreatic 1 L, Intestinal 2 L, Gastric 1 L


It its important to appreciate the relative volumes of fluids produced at various locations in the GI tract.

This will help a surgeon plan what volume of fluids need replacing dependant on the site of surgical intervention or diversion e.g.ileostomy versus colostomy.

Equally, a knowledge of what electrolytes may be lost or gained at various locations is key.

The correct answer is:4L: Pancreatic 1 L, Intestinal 2 L, Gastric 1 L




Weight 1.00

A 64-year-old woman presents with tingling in the 1st, 2nd, 3rd and lateral border of the 4th digits and the volar surface of the hand.The symptoms cause her to awake at night and are exacerbated by using a computer keyboard. Which one of the followinginvestigations is most likely to confirm the diagnosis?

Select one:

MRI brain

MRI cervical spine

MRI wrist

Nerve conduction studies

Somatosensory evoked potentials


Imaging investigations such as an MRI scan are useful for identifying structural abnormalities. However, CTS is best investigated bynerve conduction studies, which will identify a slower nerve conduction rate, due to nerve compression, which is diagnostic.

The correct answer is:Nerve conduction studies




Weight 1.00

A 19-year-old is admitted with a penetrating knife injury. His injuries are consistent with a severed left half of his thoracic spinal cordat 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


T8 level approx 5 cm above umbilicus. Dorsal column loss causes ipsilateral loss below level of injury - light touch, consciousproprioception, 2 point discrimination, vibration. Pain (pinprick) and temperature loss are contralateral and start a couple of levelsbelow the injury. They are spinothalamic modalities NOT dorsal column. Bladder control may be lost but it is not a dorsal columnfunction.

The correct answer is:Loss of light touch sensation on the left with an upper level 5 cm above the umbilicus




Weight 1.00

A 60-year-old woman presents with left sided weakness and headaches that have developed and progressed over two weeks. Thereis no history of seizures. On examination her GCS is 15/15, there is mild weakness of the left upper and lower limbs (grade 4/5). Thefollowing pre and post contrast CT scans were performed. Which of the following drugs is most appropriate to prescribe to helpcontrol her symptoms?

Select one:

Codeine

Dexamethasone

Hypertonic saline



Levetiracetam (Keppra)

Mannitol


The patient has symptoms of raised ICP and focal neurological deficit. Codeine might improve HA. Keppra reduces risk of fits.Hypertonic and mannitol both reduce ICP and may improve HA and perhaps neurology. However, dexamethasone is much moreappropriately prescribed to have a more sustained effect upon the oedema with a good prospect of improving HA and focal deficit.

The correct answer is:Dexamethasone




Weight 1.00

You see a 34 year old female in the Emergency Department following a road traffic collision. The ambulance crew reported aGlasgow Coma Score (GCS) of 9 at the scene with pupils that were equally reactive to light. You record her GCS as 5 and note thatshe now has a fixed dilated pupil on the left. She is intubated and ventilated. Vitals signs are as follows: Pulse: 67 bpm. Blood pressure: 150/94. Oxygen saturations: 100%. A CT scan is performed. You arrange to transfer her 25 kilometres to the nearest neurosurgical unit. Which one of the followingmeasures is most appropriate during transfer?



Select one:

Administer barbiturates

Administer hypertonic saline

Administer inotropes



Hyperventilate to a PaCO2 of 3.3 kPa

Perform an emergency burr hole


Osmotic diuretics reduce ICP. Hypertonic saline is the most commonly used nowadays ahead of mannitol. Hyperventilation to thisdegree is not desirable because such a low CO2 reduces cerebral blood flow. Inotripes are not required given the BP. Barbituratesand emergency burr hole are not appropriate during such a short transfer

The correct answer is:Administer hypertonic saline




Weight 1.00

A 6-week-old boy presents with a two day history of projectile vomiting, as a consequence of pyloric obstruction. His arterial pH is7.53. To which of the following will this lead to?

Select one:

Hyperventilation

Hypoventilation

Raised levels of plasma ionized Calcium

Reduced affinity of haemoglobin for oxygen

Reduced urinary pH


The metabolic alkalosis will contribute to a compensatory hypoventilation.

Ionized calcium will fall (hence may have signs of hypocalcaemia).

Oxygen disassociation curve will shift to the left.

The correct answer is:Hypoventilation




Weight 1.00

A 20-year-old woman presents with progressive weakness and fatigue. She reports ptosis, finds many day-to-day tasks tiring and hasdifficulty climbing stairs. A diagnosis of myasthenia gravis is confirmed. The disruption of neuromuscular function is the result of whichone of the following?

Select one:

Demyelination of pre-synaptic nerve fibres

Failure of acetylcholine production

Failure of re-uptake of choline at the synapse

Increased levels of acetylcholinesterase at the synapse

Reduction in the number of post-synaptic cholinergic receptors


The condition is the result of a reduction of the number of cholinergic receptors, often the result of auto-antibodies.

Treatment involves raising levels of Ach, by selective blockade of acetylcholinesterase, there is no evidence that the levels of enzymeare altered in the untreated patient.

The correct answer is:Reduction in the number of post-synaptic cholinergic receptors




Weight 1.00

A 32-year-old man attends the Emergency Department with a superficial knife wound to his left arm, the result of an accident whilstdecorating. There are no apparent neurological, muscular or vascular defects. You will close the wound under local anaesthesia, byregional infiltration of lignocaine (2%, with adrenaline). Which of the following actions will produce local anaesthesia to the surgicalfield?

Select one:

Blocking neuronal membrane Na channels

Inhibiting pre-synaptic release of Acetylcholline

Inhibiting production of soluble inflammatory mediators at the wound

Opening neuronal membrane Na channels

Stimulating neuronal membrane Na/K ATPase


Lignocaine blocks Na channels, so preventing the conduction of an action potential.

It may also block Na/K ATPase, but does not block this pathway.

The correct answer is:Blocking neuronal membrane Na channels




Weight 1.00

A 35-year-old man presents with hypotension (BP 100/75 mmHg), reduced cardiac output and a heart rate of 54 bpm. An ECGexamination allows a diagnosis of sinus bradycardia to be made and 500 mcg of atropine is administered intravenously. Which one ofthe following are non-cardiac effects of this drug?

Select one:

Miosis, hyposalivation and reduced gastric pH

Miosis, hypersalivation and reduced gastric pH

Mydriasis, hypersalivation and increased gastric pH

Mydriasis, hyposalivation and increased gastric pH

Mydriasis, hyposalivation and reduced gastric pH


The parasympatholytic actions of atropine will cause mydriasis, (pupil dilatation), hyposalivation (reduced salivary secretions) andreduced gastric acid production, hence gastric pH will rise.

The correct answer is:Mydriasis, hyposalivation and increased gastric pH




Weight 1.00

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'shistory and presentation?

Select one:

Acetabular fracture

Anterior posterior compression fracture (open book)

Fractured neck of femur

Lateral compression fracture

Vertical sheer fracture


The mechanism of injury here is anterior- posterior compression from the petrol tank of the motor bike that would get forced up intothe pelvis with a head on collision. These fractures are associated with haemodynamic instability. As the injury involves the pelvisopening up at the front clinically the legs can assume an externally rotated position. A lateral compression and acetabular fracture isassociated with impact from one side. The mechanism for a vertical sheer fracture is normally a fall from height, although it is oftenassociated with haemodynamic instability.

The correct answer is:Anterior posterior compression fracture (open book)














Weight 1.00

A 58-year-old woman presents with a sudden onset of severe headache, associated with nausea and vomiting. On examination herGlasgow Coma Scale is 13/15. A CT scan is performed. Which one of the following is the most likely cause of the ventriculardilatation?

Select one:

Anterior communicating artery aneurysm compressing foramina of Monro

Aqueduct stenosis

Haemorrhagic obstruction of arachnoid granulations

Intraventricular haemorrhage obstructing CSF flow

Normal pressure hydrocephalus




This may test simple factual knowledge. Knowledge of membrane receptors in blood vessels and the effect of calcium on vasculartone may help. The distractors mostly have effects upon blood vessels. The disruption of Na+ homeostasis commonly seen in SAHaccounts for use of Aquaporin.

The correct answer is:Haemorrhagic obstruction of arachnoid granulations




Weight 1.00

You examine a 35-year-old patient with hearing loss in the left ear. Weber's Test lateralises to the right ear. Rinnes's test shows airconduction to be better than bone conduction (AC>BC) in the left ear. Which one of the following is most likely to account for the lossof hearing?

Select one:

CP angle tumour

Excessive ear wax

Middle ear infection

Otoscerosis

Traumatic injury to the ossicular chain


The correct answer is:CP angle tumour




Weight 1.00

A 50-year-old patient is diagnosed with pheochromocytoma. Which one of the following is the most likely associated finding?

Select one:

Headache

Palpitations

Persistent hypertension

Sweating

Transient recurrent hypertension


Most pheochromocytomas are incidental findings. The classic triad of headache, sweating and palpitations are in fact rare. Thecommonest presenting finding is transient hypertension, which settles between episodes.

The correct answer is:Transient recurrent hypertension




Weight 1.00

You are discussing a complicated patient preoperatively with the anaesthetist, during theatre list brief. The patient is about to undergoan elective laparoscopic cholecystectomy, a requirement of which is to establish a pneumoperitoneum using carbon dioxide. He haspreviously suffered a myocardial infarction though a recent echocardiogram shows normal cardiac function. The anaesthetist advises about the effects of the imminent surgery on the patients cardiorespiratory parameters. Which of thefollowing will cause a CO2 pneumopertineum in this patient?

Select one:

Decreased peripheral vascular resistance

Decreased stroke volume

Increased cardiac output

No increased risk of pulmonary embolus

Respiratory alkalosis


The CO2 pneumoperitoneum necessary to perform laparoscopic surgery, increases intra-peritoneal pressure.

This results in a decreased stroke volume, resulting in a decrease in cardiac output by 30%, an increase in peripheral vascularresistance of approximately 40% and and increased risk of a venous thrombus formation.



The absorption of CO2 all contributes to an overall respiratory acidosis.

The correct answer is:Decreased stroke volume




Weight 1.00

You are called to the ward to see a 26-year-old woman who underwent a lumbar discectomy a few hours ago. On examination thepatient has retracted eyelids. Her eyes are upturned and in a fixed position. Her teeth are tightly clenched and her neck is extended.She appears to hear what you say but is unable to relax her contracted muscles. Since surgery she has received morphine for painrelief and metoclopramide for the prophylactic prevention of nausea. Which one of the following is the most likely explanation for hersymptoms?

Select one:

Complex partial seizure

Generalised tonic clonic seizure

Oculogyric crisis

Simple partial seizure

Somatoform conversion disorder


Metoclopramide is approved for use to prevent post-operative nausea. Oculogyric crisis is an idiosyncratic reaction that the juniordoctor may have to recognise and manage. It is most common in young women shortly after starting treatment (see BNF). Ditractorsare plausible alternatives but description is typical of oculogyric crisis.

The correct answer is:Oculogyric crisis




Weight 1.00

You are called to theatre recovery to see a 4-year-old child who had a tonsillectomy earlier. She has been spitting out fresh blood forthe past 30 minutes, which the recovery nurse has collected. 250 ml of blood is in the bowl and the nurse tells you the child weighs32 kg. Assuming that there is minimal saliva in the bowl, and that the child has not swallowed any blood, approximately whatpercentage of her total blood volume has she lost?

Select one:

0.05

0.1

0.15

0.2

0.25


The total blood volume (TBV) of a child is 75-80 ml/kg, so for this child TBV is approximately 2400-2560 ml.

The correct answer is:0.1




Weight 1.00

In a 60-year-old man presents to the outpatient clinic with irritative lower urinary tract symptoms. Which of the following does not raiseprostate specific antigen?

Select one:

Acute bacterial prostatitis

Benign prostatic hypertrophy

Digital rectal examination

Increased age

Urinary tract infection


Digital rectal examination (DRE) does not cause a raised PSA.

Raised PSA must not be attributed to DRE. If the PSA is raised it is due to another cause. A,B, D & E are all causes for raised PSA.

The correct answer is:Digital rectal examination




Weight 1.00

A 60-year-old man smokes 20 cigarettes a day and has done so for 25 years. He presents with shortness of breath, and a respiratoryrate of 28 breaths per minute. His tidal volume is 400 ml and FEV1 is 60% of normal for his age. An arterial blood sample reveals: pH 7.47. PaO2 8kPa. PaCO2 4kPa. Saturation 90%. Hb concentration 14g/dL. The hyperventilation is due to which one of the following?

Select one:

Acidosis, detected by peripheral chemoreceptors

Hypocapnia, detected by central chemoreceptors

Hypocapnia, detected by peripheral chemoreceptors

Hypoxaemia, detected by central chemorecptors

Hypoxaemia, detected by peripheral chemoreceptors




Hypoxaemia is detected by peripheral chemoreceptors (aortic and carotid bodies).

Hypocapnia will not drive hyperventilation

The patient is not acidotic

The correct answer is:Hypoxaemia, detected by peripheral chemoreceptors




Weight 1.00

You see a 34-year-old woman in the Emergency Department following a road traffic collision. The ambulance crew reported aGlasgow 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 afixed dilated pupil on the left. A CT scan is performed. 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


All 5 of the options are shown on this trauma scan. The obvious abnormality is the mass on the left side (using standard radiologyconvention for side). This has the classic lens shape. Although not particularly large it accounts for the dilated pupil on the left andwarrants emergency surgery.

The correct answer is:Extradural haematoma




Weight 1.00

A 17-year-old girl, has sustained an open fracture to her left tibia, having been struck by a moving car. She is confused and oliguric,her blood pressure is 95/75 mmHg. Part of her physiological response to hypovolaemia will be release of renin from the juxta-glomerular apparatus of the kidney. In this clinical situation, where will renin act?

Select one:

On angiotensinogen to produce angiotensin I

On angiotensin I to produce angiotensin II

On the adrenal cortex to stimulate release of aldosterone

On the hypothalamus to stimulate release of ADH

On the renal collecting ducts to stimulate reabsorption of sodium ions


Renin acts directly on angiotensinogen to produce angiotensin 1. Angiotensin 1 has limited biological effects though is converted tothe potent vasoconstrictor angiotensin 2, which will act to maintain normotension especially in hypovolaemia.

The correct answer is:On angiotensinogen to produce angiotensin I














Weight 1.00

An 18-year-old girl, fit and healthy, is involved in a road traffic accident whilst riding her bicycle. She suffers an open fracture of theright tibia and blunt injury to the abdomen. On arrival at hospital her blood pressure is systolic 100 mmHg, diastolic 75 mmHg, heartrate is 130 bpm. Which one of the additional following clinical findings would allow a diagnosis of Systemic Inflammatory ResponseSyndrome?

Select one:

PaCO2 5.1 kPa

Respiratory rate 23 breath per minute

Temperature 36.1oC

Temperature 37.8oC

White cell count, 11,300 per uL


B is the only clinical finding that meets the additional criteria for a diagnosis of SIRS to be made.

The correct answer is:Respiratory rate 23 breath per minute




Weight 1.00

An 18- year-old girl, fit and healthy, is involved in a road traffic accident whilst riding her bicycle. She suffers an open fracture of theleft tibia, and blunt injury to the abdomen. On arrival at hospital, her blood pressure is systolic 95 mmHg, diastolic 75 mmHg, herrespiratory rate is 25 bpm. The presence of which one of the following other clinical criteria listed below would allow a diagnosis ofSystemic Inflammatory Response Syndrome?

Select one:

Heart rate 125 bpm

PaCo2 4.8kPa

Temperature 36.4oC

Temperature 37.8oC

White cell count 5,500 per uL


A is the only criterion which meets the requirements for a diagnosis of SIRS in this patient

The correct answer is:Heart rate 125 bpm




Weight 1.00

A 25-year-old motorcyclist is admitted following a high speed road traffic collision. He is paraplegic with a sensory level at T5. He isnoted 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


Priapism is due to loss of descending inhibition of sacral parasympathetic output. Other distractors are reasonable considerations butall are incorrect.

The correct answer is:Loss of inhibition of the parasympathetic nervi erigentes




Weight 1.00

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

Select one:

Corticospinal

Dorsal columns

Spinocerebellar

Spinothalamic

Vestibulospinal


Herniation of tonsils compresses the craniocervical junction and cases syringomyelia. The spinothalamic tracts cross in region ofcentral canal - these are vulnerable to damage when a syrinx expands. Typically causes tingling, burns on hands in a "suspended" orcape-like distribution.

The correct answer is:Spinothalamic




Weight 1.00

A 36-year-old woman has undergone resection of the terminal ileum due to Crohn's disease. A result of long term effects of thesurgery is a deficiency of which one of the following?

Select one:

Calcium

Glucose

Iron

Vitamin B2

Vitamin K


The terminal ileum is the site of absorption of fat soluble vitamins (ADEK), all other nutrients listed are absorbed more proximally inthe small intestine

The correct answer is:Vitamin K




Weight 1.00

You see a 34-year-old man in the Emergency Department following a road traffic collision. The ambulance crew reported a GlasgowComa 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 fixeddilated 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


The pupil is innervated by autonomic nerve fibres. Parasympathetic fibres cause pupillary constriction, travelling from the Edinger–Westphal nuclei in the midbrain via cranial nerve III to the pupilloconstrictor muscle. Increased intracranial pressure may causecompromise of this pupillary response and is one of the few signs detectable in the unconscious patient.

The correct answer is:Loss of parasympathetic innervation of the pupil




Weight 1.00

A 70 kg fit and well 40-year-old man attends the emergency department with a laceration over his thigh. You plan to examine andwash the wound under local anaesthetic. Which of the following is the correct maximum dose you could give?

Select one:

10.5 ml of 1% lignocaine with adrenaline




21 ml of 1% lignocaine with adrenaline


The maximum dose of lignocaine with adrenaline is 5mg/kg, the maximum dose of lignocaine without adrenaline is 3mg/kg.

1ml of 2% lignocaine contains 20mg/ml

1ml of 1% lignocaine contains 10mg/ml

Therefore the maximum dose of lignocaine (with adrenaline) a 70kg man can have is 350mg (70 x 5). For a 2% solution themaximum dose will be 17.5ml (350/20), and for a 1% solution the maximum dose with be 35ml.




Weight 1.00

The correct answer is:17.5 ml of 2% lignocaine with adrenaline

A 71-year-old woman is referred having attended the opticians. She has a bitemporal hemianopia. An MRI scan shows suprasellarextension 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 nasal retinal fibres decussate in the compressed optic chiasm. Distractors can all cause field defects.

The correct answer is:Compression of decussating nasal retinal fibres



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Results for the whole quiz (58 questions)