Surgery

Question 2

Medications that slow fracture healing.

Answer 2

Non-steroidal anti-inflammatory drugs (NSAIDS) are linked to slow bone healing.

Other drugs that slow the rate of healing include steroids, immunosuppressive agents and anti neoplastic drugs.

Question 3

Anastrozole is an aromatase inhibitor used for the treatment of oestrogen receptor-positive breast cancer in postmenopausal women,

Answer 3

Aromatase inhibitors reduce peripheral oestrogen synthesis, which accounts for the majority of oestrogen production in postmenopausal women. Patients taking these medications are at an increased risk of osteoporosis.

Question 4

Breast cysts should be aspirated as there is a small risk of breast cancer, especially in younger women.

Question 5

Anterior resection is the most commonly performed operation for rectal tumours, except in lower rectal tumours

Question 6

A Hartmann’s procedure is a resection of the rectosigmoid colon and closure of the anorectal stump with an end colostomy being formed. This is not used for upper rectal tumours.

Answer 6

An abdomino-perineal excision of rectumis a type of resection performed for tumours of the anal verge.

Question 7

Non-ischaemic priapism occurs due to

Answer 7

large volume arterial inflow to the penis from trauma or congenital malformation. An important first step is to confirm if the priapism is cavernosal blood gas analysis which will indicate if it is ischaemic or non-ischaemic.

Question 8

Vomiting associated with pyloric stenosis is

Answer 8

non-bilious and is typically projectile. Its peak age of onset is age 4-8 weeks. Weight loss and dehydration are very common at presentation. On examination, there may be visible peristalsis and a palpable olive-sized pyloric mass, best felt during a feed. Lack of ability to pass stool and a distended abdomen are not usually features of this condition

Question 9

All patients with peripheral arterial disease should take

Answer 9

clopidogrel and atorvastatin

Question 10

All patients with peripheral arterial disease should take

Answer 10

clopidogrel and atorvastatin

Question 11

The most common type of penile cancer is

Answer 11

squamous cell carcinoma, not adenocarcinoma.

Question 12

Sodium valproate induced pancreatitis is more common in young adults and tends to occur within the first few months of treatment

Question 13

Hypertension and bradycardia,

Answer 13

which represents the classic Cushing’s triad (hypertension, bradycardia, and irregular breathing) seen in raised intracranial pressure (ICP).

Question 14

Caecal, ascending or proximal transverse colon cancer →

Answer 14

right hemicolectomy

Question 15

Venous duplex ultrasound is the investigation of choice for varicose veins/chronic venous disease - it will show retrograde venous flow

Question 16

Adjuvant hormonal therapy for ER +ve breast cancer: anastrozole in post-menopausal women

Aromatase inhibitors (e.g. anastrozole) may cause osteoporosis

Answer 16

Tamoxifen is an oestrogen receptor antagonist that is routinely used as an adjuvant therapy in ER-positive breast cancer in pre-menopausal women.

Tamoxifen’s pro-oestrogenic effects on the liver increase clotting factors, leading to a hypercoagulable state. This risk is greater in women who are immobilised, undergoing surgery or have other VTE risk factors.

Question 17

Total parenteral nutrition should be administered via a central vein as it is strongly phlebitic

Answer 17

A subclavian line is the correct answer because the tip of the line is in the right atrium/superior vena cava. This is regarded as a central line through which total parenteral nutrition (TPN) can be administered, minimising the risk of phlebitis.

Question 18

Excessive infusions of any intravenous fluid carry the risk of development of tissue oedema and potentially cardiac failure. Excessive administration of sodium chloride is a recognised cause of

Answer 18

Hyperchloraemic acidosis and therefore Hartmans solution may be preferred where large volumes of fluid are to be administered.

Question 19

In a patient with hypercalciuria and renal stones, calcium excretion and stone formation can be decreased by the use of thiazide diuretics

Answer 19

Cholestyramine reduces urinary oxalate secretion and can decrease oxalate stones, not calcium stones.

Oral bicarbonate can increase the alkalization of the urine and decrease uric acid stones rather than calcium stones.

Pyridoxine may reduce oxalate stones rather than calcium stones by reducing urinary oxalate secretion.

Question 20

A loop ileostomy can be used to defunction the colon to protect an anastomosis

Answer 20

Small bowel heals very well and reversal of an ileostomy is relatively easy and carries less risk.

Question 21

Faecal elastase is a useful test of exocrine function in chronic pancreatits

Question 22

A small subset of the population has an autosomal dominant mutation, leading to a lack of the specific acetylcholinesterase in the plasma which acts to break down suxamethonium(muscle relaxant ), terminating its muscle relaxant effect. Therefore, the effects of suxamethonium are prolonged and the patient needs to be mechanically ventilated and observed in ITU until the effects of suxamethonium wear off.

Question 23

Indications for thoracotomy in haemothorax include >1.5L blood initially or losses of >200ml per hour for >2 hours

Question 24

According to SIGN guidelines, patients with clinical signs of superficial thrombophlebitis affecting the proximal long saphenous vein should have an ultrasound scan to exclude concurrent deep vein thrombosis (DVT

Question 25

Surgery / diabetes: once-daily insulin dose should generally be reduced by 20% on the day before and the day of surgery

Question 26

Multiparametric MRI has replaced TRUS biopsy as the first-line investigation in suspected prostate cancer

Question 27

Local anesthetic toxicity can be treated with

Answer 27

IV 20% lipid emulsion

Question 28

Propofol is an antiemetic and is therefore particularly useful for patients with a high risk of post-operative vomiting

Question 29

In England, abdominal aortic aneurysm screening (AAA) is offered to men during the year they turn 65. AAA screening: 4.5-5.4cm is a medium aneurysm and requires 3-monthly ultrasound assessment

Question 30

Usually, an ileostomy is on the right iliac fossa whilst a colostomy is on the left iliac fossa

Question 31

In the emergency setting where the bowel has perforated, the risk of colon-colon anastomosis is much greater. This is because it may lead to an anastomotic leak, resulting in the release of the bowel contents into the intraabdominal space. Therefore, an end colostomy is often safer and can be reversed at a later date.

Question 33

Following a subarachnoid haemorrhage, most intracranial aneurysms are now treated with a coil by an interventional neuroradiologist

Question 34

Breast abscess in lactational women:

Answer 34

Staphylococcus aureus is the most common cause

Question 35

OPHTHALMOLOGY

Question 36

Diabetes is now the most common cause of Argyll-Robertson pupil in the UK because neurosyphilis is now rarely seen Highly specific to neurosyphilis

Question 37

Subconjunctival haemorrhage could be an early and clinically important tool in detecting warfarin over anticoagulation Hence, the INR level should be checked in this patient prior to carrying out any other intervention

Question 38

Wet age-related macular degeneration is characterised by choroidal neovascularisation Dry age-related macular degeneration is characterised by drusen, here described as small accumulations of extracellular material between Bruch's membrane and the retinal pigment epithelium of the eye, making this the correct option.

Question 39

Latanoprost is a prostaglandin analogue which works by increasing the outflow of aqueous humour from the eye, thereby reducing intraocular pressure. It is recommended as first-line treatment for POAG(primary open angle glaucoma) in the NICE guidelines.

Answer 39

Timolol is a non-selective beta-blocker which reduces the production of aqueous humour, thus lowering intraocular pressure. Dorzolamide is a carbonic anhydrase inhibitor which also decreases aqueous humour production. It may be used as adjunctive therapy in patients with POAG who are not adequately controlled on monotherapy, Brimonidine is an alpha-2 adrenergic agonist that both decreases production of aqueous humour and increases uveoscleral outflow.

Question 40

Corneal abrasion: topical antibiotics should be given to prevent secondary bacterial infection Chloramphenicol

Question 41

Keratoconjunctivitis sicca, also known as dry eye syndrome, affects approximately 15-25% of rheumatoid arthritis (RA) patients

Question 42

Patients with orbital cellulitis require admission to hospital for IV antibiotics due to the risk of cavernous sinus thrombosis and intracranial spread

Question 43

Following ocular trauma, an assessment should be made for orbital compartment syndrome as this may require immediate decompression prior to imaging etc

Answer 43

immediate canthotomy

Question 44

Photophobia in the affected eye and fluorescein staining demonstrates a small, feathery area of abnormal uptake.

Answer 44

Herpes simplex keratitis immediate referral to an ophthalmologist topical aciclovir

Question 45

Holmes-Adie pupil is 'Bilateral in 80% of cases May be associated with absent ankle/knee reflexes' Slowly reactive to accommodation but very poorly (if at all) to light'

Question 46

Adenoviral conjunctivitis is highly contagious. It is also the most common type of viral conjunctivitis.

Question 47

Hypertensive Retinopathy The disease severity is classified based on the Keith-Wagener classification, which has four categories numbered I-IV.

Answer 47

The presence of papilloedema is pathognomonic for a category IV Keith-Wagener hypertensive retinopathy, making this the correct option.

Question 48

I Arteriolar narrowing and tortuosity Increased light reflex - silver wiring II Arteriovenous nipping III Cotton-wool exudates Flame and blot haemorrhages These may collect around the fovea resulting in a 'macular star' IV Papilloedema

Question 49

Topical fusidic acid eye drops should be used to treat bacterial conjunctivitis in pregnant women.

Question 50

Central retinal artery occlusion.

Answer 50

Fundoscopy typically reveals a pale retina with a cherry-red spot at the fovea due to obstruction of blood flow in the central retinal artery.

Question 51

An extremely painful and deep red injected eye in a patient with a systemic connective tissue disease such as systemic lupus erythematosus (SLE) should raise suspicion of

Answer 51

scleritis.

Question 52

Optic neuritis typically presents with subacute visual loss developing over hours to days, rather than a sudden onset

Question 53

One of the most common causes of chorioretinitis is cytomegalovirus, which in itself affects up to 40% of patients with AIDS. It is essential an HIV test is performed in such patients.

Question 54

Scleritis is painful, episcleritis is not painful