THEME: THORACIC TRAUMA

A Aortic disruption

B Cardiac tamponade

C Diaphragmatic rupture

D Flail chest

E Haemothorax

F Massive haemothorax

G Myocardial contusion

H Oesophageal rupture

I Open pneumothorax

J Pulmonary contusion

K Simple pneumothorax

L Tension pneumothorax

M Tracheobronchial disruption

N Traumatic asphyxia

The following patients have all had thoracic injuries. Please select the most appropriate diagnosis from the above list. The items may be used once, more than once, or not at all.

 

Scenario 1

A 26-year-old soldier is hit by shrapnel, resulting in a large defect to the left side of his chest. He is brought to Casualty, the paramedics having securely occluded the defect on all sides with a sterile dressing. On examination he is severely dyspnoeic, tachycardic and hypotensive. His trachea is displaced to the right. Percussion reveals the left side of the chest to be hyper-resonant, with decreased air entry on auscultation.

 

Scenario 2

A 50-year-old builder presents to The Emergency Department having been hit by falling scaffolding. He did not initially attend The Emergency Department; however, over the past few hours he has become increasingly dyspnoeic. On examination he has a respiratory rate of 30 breaths/min and a SaO2 of 89%. He has equal air entry bilaterally and normal percussion. Chest X-ray reveals fractures of ribs 2 to 6 on the left side.

 

THEME: CHEST TRAUMA MANAGEMENT

A Arteriography

B Bilateral thoracostomy

C Computed tomography of thorax

D Emergency thoracotomy

E Immediate needle decompression

F Insertion of chest drain

G Intravenous access fluid resuscitation

H Intubation and ventilation

I Pericardiocentesis

J Resuscitation (emergency room) thoracotomy

K Transoesophageal echocardiography

 

Scenario 3

A 27-year-old man is brought to The Emergency Department following a stab wound to the left side of the chest. On examination his respiratory rate is 24 breaths/min, pulse rate is 115/min, and blood pressure is 90/50 mmHg. There is a dull percussion note and decreased air entry on the affected side.

 

Scenario 4

An 18-year-old woman is brought to The Emergency Department after being hit by a car travelling at approximately 50 miles/h. She has a suspected fractured pelvis and a Glasgow Coma Score of 13/15. On arrival, she has a respiratory rate of 36 breaths/min; pulse rate of 120/min and blood pressure is 90/60 mmHg. Examination reveals engorged neck veins, and a hyper-resonant percussion note on the left side of the chest. The background noise in the department renders auscultation of either breath or heart sounds difficult to assess.

 

Scenario 5

A 65-year-old man is the driver in a high-speed road traffic accident. He is brought to The Emergency Department complaining of severe chest pain and difficulty breathing. Examination reveals a shallow respiratory rate of 34 breaths/min and a Sa02 of 92% on 60% oxygen. He has contusions to both sides of the chest and there is reduced air entry bilaterally. Palpation of the chest wall reveals crepitus and asymmetrical movement of the right chest wall.

 

THEME: INFECTION

A Gram-positive haemolytic cocci

B Facultative anaerobic Gram-negative bacilli

C Aerobic Gram-negative rods

D Gram-positive rods

E Gram-negative cocci

F Immunofluorescent spirochaete

 

Select the bacterial organism that most closely matches the clinical situation described below. Each option may be used once, more than once or not at all.

 

Scenario 6

Bloody diarrhoea following prolonged treatment with antibiotics

 

Scenario 7

A perineal wound infection following abdominoperineal resection

 

Scenario 8

A pathogen that causes colonisation of humidifiers and ventilators and opened sterile solutions

 

THEME: UPPER-LIMB NERVE INJURIES

A Posterior interosseous nerve

B Upper cord of the brachial plexus

C Musculocutaneous nerve

D Lower cord of the brachial plexus

E Anterior interosseous nerve

F Radial nerve

G Median nerve

H Suprascapular nerve

I Ulnar nerve

J Long thoracic nerve

 

For each of the case descriptions below, select from the above list the most likely upper-limb nerve injury. Each option may be used once, more than once, or not at all.

 

Scenario 9

A 25-year-old motorcyclist is brought to the Accident and Emergency Department following a road traffic accident (RTA). He complains of pain in the root of his neck. On examination, his right arm is adducted, internally rotated and extended at the elbow. He has loss of sensation along the outer aspects of the arm and the forearm.

 

Scenario 10

A 65-year-old man is brought to the Accident and Emergency Department with a wrist drop and sensory loss over a small patch at the base of the thumb. X-rays shows a mid-humerus fracture.

 

Scenario 11

A 30-year-old man presents to the Accident and Emergency Department with a deep laceration to his right wrist after he was involved in a fight in his local pub. On examination, he is unable to pinch and has loss of sensation over his little and ring fingers.

 

THEME: CHEST PAIN

A     Acute aortic rupture

B     Unstable angina

C     Rupture of the oesophagus

D     Pneumothorax

E     Pulmonary embolus

F     Mallory-Weiss syndrome

 

Scenario 12

A man with pain in the central chest radiating to the back that started an hour ago. Widened mediastinum was noticed on his chest X-ray and his blood pressure was 180/110 mmHg in the right arm and 110/70 mmHg in the left arm.

 

Scenario 13

A young man with chest pain that started Sunday morning, he has been vomiting the night before. On examination subcutaneous crepitations were found over the chest and shoulder.

 

THEME: CONSENT FOR SURGERY

A Advance refusal

B Battery

C Best interests (treatment in) under common law

D Consent for medical research

E Implied consent (assent)

F Informed consent

G Negligence

H Parental consent

I Treatment under the Mental Health Act

J Ward of court

 

The following descriptions all refer to issues concerning informed consent for surgery. Please select the most appropriate term from the above list. The items may be used once, more than once, or not at all.

 

Scenario 14

A 33-year-old glamour model with severe endometriosis underwent an abdominal hysterectomy/adhesiolysis for chronic pelvic pain. At the time of laparotomy, the uterus was found to be densely adherent to the rectum. The surgeon proceeded with the operation, resulting in a rectal perforation requiring repair and formation of a colostomy. Legal action is taken by the patient against the gynaecologist.

 

Scenario 15

A 63-year-old man underwent a laparoscopic cholecystectomy for symptomatic gallstone disease having previously had surgery for a perforated duodenal ulcer many years previously. Following a difficult procedure requiring laparoscopic adhesiolysis, the patient developed signs of an acute abdomen on the second post-operative day requiring laparotomy and small bowel resection for two perforations which had led to peritonitis. He had a stormy postoperative course on the Intensive Care Unit and eventually was left with a troublesome enterocutaneous fistula requiring further surgery. It is alleged subsequently that during consent, no mention was made of the risk of inadvertent injury to other structures such as bowel.

 

Scenario 16

A 40-year-old woman attends the colorectal outpatient clinic with rectal bleeding. Following history-taking and abdominal examination, the attending coloproctologist performed a rectal examination and proctosigmoidoscopy, the latter of which proved uncomfortable for the patient. The surgeon is surprised to find himself some time later responding to a complaint that the patient said she had not consented to the examination.

 

Scenario 17

A 23-year-old student suffering from a bipolar disorder attempts suicide by jumping in front of a train. He suffers bilateral pneumothoraces and a flail chest. On the ward, he attempts to remove his chest drains and essential oxygen therapy. He is currently under a section 2.

 

THEME: TRAUMA PROCEDURES IN THE RESUSCITATION ROOM

A Pericardiocentesis

B Tube chest drainage

C Needle thoracocentesis

D Emergency thoracotomy

E Venous cutdown

F Cricothyroidotomy

G Diagnostic peritoneal lavage

H Intraosseous infusion

I Central line placement

J Passage of a nasogastric tube

K Endotracheal intubation

 

Match the most appropriate procedure from the list above to each clinical situation described below. Each option may be used once only, more than once or not at all.

 

Scenario 18

A patient with a systolic blood pressure of 60 mmHg following stab wound to chest, distended neck veins, reasonable bilateral air entry, central trachea.

 

Scenario 19

A patient with a systolic blood pressure of 60 mmHg following blunt chest trauma, distended neck veins, no air entry on the right side, tracheal deviation to the left.

 

THEME: SHOCK

A Cardiogenic shock

B Septic shock

C Neurogenic shock

D Hypovolaemic shock <15% volume loss

E Hypovolaemic shock 15–30% volume loss

F Hypovolaemic shock >40% volume loss

 

Scenario 20

A motorcyclist was admitted to the emergency department having been thrown a distance of 30 feet. He was wearing a helmet and had recovered consciousness at the scene. He remained confused. Pulse 40 bpm, respiratory rate 30/min, blood pressure (BP) 75/60 mmHg, on catheterization there was no urine output. Lateral cervical spine X-rays were suggestive of a fracture of C6.

 

Scenario 21

A 25-year-old marathon runner was involved in a road traffic accident while out training. She was admitted to the emergency department with a pulse of 100 bpm, BP 75/60 mmHg, respiratory rate 30/min. Her abdomen was generally tender, peritoneal lavage was positive. There was no urine output.

 

THEME: HEAD INJURY (TYPES)

A Basal skull fracture

B Depressed skull fracture

C Diffuse axonal injury

D Extradural haematoma

E Intracerebral haemorrhage

F Intraventricular haemorrhage

G Le Fort I fracture

H Le Fort II fracture

I Le Fort III fracture

J Linear vault fracture

K Subarachnoid haemorrhage

L Subdural haematoma

 

The following patients have all sustained head injuries. Please select the most appropriate clinical description from the above list. The items may be used once, more than once, or not at all.

 

Scenario 22

A 26-year-old man is assaulted with a baseball bat. On examination, he has multiple lacerations and bruises on his face. There is blood in the left external auditory meatus and bilateral black eyes with a left subconjunctival haematoma. Glasgow Coma Scale (GCS) is 15.

 

Scenario 23

A 31-year-old falls from a height sustaining multiple injuries, including blunt injury to the head. She is deeply unconscious on arrival at The Emergency Department (GCS 3) with normal pupils. A CT scan demonstrates no focal abnormality but there is poor grey–white differentiation and loss of sulcal pattern with effacement of both lateral ventricles. The neurosurgeons place a monitoring bolt which demonstrates an intracranial pressure of 50 mmHg.

 

Scenario 24

A 29-year-old woman with a history of epilepsy has a witnessed fit and fall with a blunt injury to the left side of her head with laceration. She recovers rapidly from the fit to a GCS of 15 by the time of her arrival in The Emergency Department and is awaiting a skull X-ray when she starts to become drowsy and confused. She is moved to the resuscitation area where her GCS declines rapidly to 7, requiring intubation.

 

THEME: SURGICAL INCISIONS

A Gable

B Gridiron (or skin crease modification)

C Kocher

D Lanz

E Lateral thoracotomy

F Left paramedian

G Long midline

H Lower midline

I Median sternotomy

J Right paramedian

K Rutherford–Morrison

L Thoracoabdominal

M Transverse ‘unilateral’ Pfannenstiel

N Upper midline

 

The following are descriptions of patients requiring surgery. Please select the most appropriate incision for the required operation from the list. The items may be used once, more than once, or not at all.

 

Scenario 25

A 72-year-old woman presents to The Emergency Department with a 1-day history of a painful lump in the left groin and vomiting. On examination she has a hard, tender, irreducible mass just below the inguinal ligament.

 

Scenario 26

A 38-year-old woman has been taking regular diclofenac for relief of chronic backache. She is referred to The Emergency Department with sudden onset of upper abdominal pain. On examination she is pyrexial and tachycardic, abdominal examination reveals severe epigastric tenderness. There is a pneumoperitoneum evident on an erect chest X-ray.

 

THEME: MANAGEMENT OPTIONS IN A PATIENT WITH HEAD INJURY

A Admit for neuro-observations

B Craniotomy

C Computed tomography (CT) scan

D Discharge

E Discharge and head injury instructions

F Elective burr hole

G Emergency burr hole

H Emergency laparotomy

I Endotracheal intubation

J Intracranial pressure monitoring

K Mannitol

L Mannitol and transfer to Neurosurgical Unit

M Skull X-ray

 

Scenario 27

A 70-year-old woman attends The Emergency Department having fallen at home. She is unclear of the events surrounding the fall, and as she lives alone, no collateral history is available. She has vomited three times since arrival in the department. Her Glasgow Coma Scale (GCS) is currently 15. All other observations are normal. There is no evidence of focal neurological deficit.

 

Scenario 28

A 38-year-old gentleman has been involved in a road traffic accident and brought to The Emergency Department as a ‘trauma call’. The ambulance staff inform you that he was a pedestrian hit by a car travelling at approximately 40 mph. He has sustained a significant head injury but the paramedic crew report that he was alert at the scene and that his pupils were equal and reactive. Having completed the primary survey, your examination reveals a GCS of 8, and a fixed dilated left pupil. There is no evidence of hemiparesis. No other significant injuries are apparent, and the patient is stable, and has a pulse rate of 50/min and a blood pressure of 160/80 mmHg. You request an urgent CT scan, but are informed that this will not be possible in your unit as the scanner is undergoing repair.

 

THEME: LAPAROSCOPIC COMPLICATIONS

A Abdominal wall emphysema

B Bleeding

C Carbon dioxide embolus

D Lower limb venous thromboembolism

E Omental emphysema

F Pneumomediastinum

G Pneumothorax

H Port site hernia

I Reduced venous return

J Respiratory compromise

K Visceral injury: obstruction

L Visceral injury: perforation

 

The above are all descriptions of complications that may arise as a result of laparoscopic surgery. For each clinical scenario please select the most appropriate answer from the above list. The items may be used once, more than once, or not at all.

 

Scenario 29

A 45-year-old obese man is undergoing a laparoscopic cholecystectomy. The abdomen has been rapidly insufflated with carbon dioxide. The anaesthetist alerts you to a sudden and rapid drop in blood pressure with a concomitant tachycardia. There is no evidence of intra-abdominal bleeding on inspection with the scope.

 

Scenario 30

A 51-year-old woman undergoes a difficult laparoscopic cholecystectomy. In the ensuing 48 h she develops jaundice. Liver function tests are: AP 250 mmol/litre, bilirubin 147 mmol/litre. An urgent endoscopic cholangiogram does not delineate the intrahepatic biliary tree.

 

THEME: PERIPHERAL NERVE INJURY

A Femoral nerve

B Common peroneal nerve

C Deep peroneal nerve

D Superficial peroneal nerve

E Sural nerve

F Tibial nerve

G Saphenous nerve

 

Pick the most appropriate option from the above list. Each option may be used once only, more than once or not at all.

 

Scenario 31

A 28-year-old man sustains a varus injury to his left knee while skiing. He notes loss of sensation over front and anterior half of the leg and dorsum of the foot.

 

Scenario 32

A 32-year-old motorcyclist is involved in a road traffic accident and sustains a severe laceration 6 cm above the ankle on the lateral aspect of his leg. He is unable to evert his foot and has noted some numbness over the dorsum of foot and medial four toes.

 

THEME: MULTIPLE TRAUMA

A Cardiac tamponade

B Flail chest

C Haemothorax

D Tension pneumothorax

E Aortic rupture

F Ruptured spleen

 

For each patient described below, select the most likely single diagnosis from the list of options above. Each option may be used once, more than once or not at all.

 

Scenario 33

A 57-year-old man is brought into the emergency department following a road traffic accident. He is conscious with an adequate airway. The Glasgow Coma Score (GCS) is 15. He is tachypnoeic (30 rpm). His pulse is 150 bpm and reduced in volume. The distal pulses are present. His blood pressure (BP) is 85/45 mm Hg. The chest X-ray shows multiple rib fractures on the left side (ribs 7, 8 and 9) and a small pneumothorax. A left chest drain is inserted and bubbles in the waterseal bottle. Pelvic X-ray is normal. Analysis of the diagnostic peritoneal lavage fluid reveals a white cell count (WCC) of 1000/mm3 and an amylase of 400 units. He remains hypotensive (BP 90/55 mm Hg) despite 2 l of fluid resuscitation.

 

Scenario 34

A 30-year-old man is brought into the emergency department following a road traffic accident. He is conscious. He has tachypnoea (46rpm), tachycardia (135 bpm) and distended neck veins. His systemic BP is 90/45 mmHg. His heart sounds are greatly diminished. A chest X-ray shows three fractured ribs (ribs 5, 6 and 7) on the left side and a small pneumothorax. A left chest drain drains air and no blood, the BP is 95/50 mmHg after 2 l of crystalloid infusion. The electrocardiogram (ECG) shows reduced voltage in QRS complexes.

 

THEME: KNEE INJURIES

A Medial meniscus

B Lateral meniscus

C Medial collateral ligament

D Lateral collateral ligament

E Patella fracture

F Anterior cruciate ligament

G Posterior cruciate Ligament

 

Scenario 35

A young footballer injures his right knee in a tackle and develops swelling of the knee a few days later. He presents to casualty with an area of tenderness 2–3 cm above the joint line on medial aspect. He has increased valgus deformity on examination.

 

Scenario 36

A 60-year-old develops a painful left knee following a fall. On examination in the orthopaedic clinic a few days later, swelling on the left knee is seen. Flexion views of both knees show that the left tibia plateau lies more anteriorly than on the right.

 

Scenario 37

A patient involved in a road traffic accident hits his knee on the dashboard, producing an immediate haemarthrosis. X-ray shows no bony injury, but he later experiences difficulty walking down stairs.

 

THEME: PERIPHERAL NERVE INJURY

A     Distal ulnar nerve injury

B     Lower brachial plexus injury

C     Median nerve compression

D     Mixed peripheral nerve injury

E     Proximal radial nerve injury

F     Proximal ulnar nerve injury

G    Upper brachial plexus injury

 

For each of the clinical scenarios listed below, select the most likely type of nerve injury. Each option may be used once, more than once, or not at all.

 

Scenario 38

On examination you notice a patient has clawing of their right hand. There is hyperextension of the metacarpophalangeal joints and mild flexion at the interphalangeal joints of the ring and little finger. There is some loss of muscle bulk in the medial border of the forearm and flattening of the hypothenar eminence. They are unable to adduct and abduct the fingers, and flexion of the wrist results in abduction. There is altered sensation in the little finger and ulnar border of the hand. There is normal sensation in the arm.

 

Scenario 39

A 40-year-old woman is seen in outpatients complaining of progressively worsening numbness in her right index finger and thumb. She has also noticed she has become clumsier with her right hand. At night she gets tingling in the same digits; dangling her arm out of the bed seems to improve the symptoms.

 

THEME: TREATMENT OPTIONS FOR RENAL/URETERIC CALCULI

A Percutaneous nephrolithotomy

B Conservative management

C Insertion of a ureteric stent

D Extracorporeal shock-wave lithotripsy

E Nephrectomy

 

Scenario 40

A 32-year-old man has a 24-hour history of right ureteric colic. He is apyrexial and pain controlled with simple analgesia, and imaging reveals a 3-mm distal right ureteric calculus with no hydronephrosis.

 

Scenario 41

A 72-year-old woman has a history of recurrent urinary tract infections (UTIs). Imaging demonstrates a large staghorn calculus in her right kidney with a normal-looking left kidney. A renogram demonstrates 35% function on the right side.

 

Scenario 42

A 40-year-old woman has a 3-day history of left ureteric colic. She is pyrexial and tachycardic with an increased white cell count. Imaging reveals a 9-mm mid-ureteric calculus on the left with severe left-sided hydronephrosis.

 

THEME: RENAL CALCULI

A Percutaneous nephrolithotomy (PCNL)

B Extracorporeal shock wave lithotripsy (ESWL)

C Alkaline diuresis

D Nephrectomy

E Percutaneous nephrostomy

F Expectant therapy

 

For each of the following cases listed below, select the most likely single treatment from the options listed above. Each option can be used once, more than once or not at all.

 

Scenario 43

A 30-year-old pregnant woman (26 weeks) presents with septicaemia and abdominal pain. Investigations reveal an obstructed right kidney due to a 2 cm calculus. She is commenced on intravenous antimicrobials.

 

Scenario 44

A 40-year-old man presents with a left-sided renal colic. Intravenous urogram (IVU) shows a 1 cm calculus in the upper third of his ureter. There is no complete obstruction. His symptoms fail to resolve on conservative management.

 

THEME: THYROID DISEASE

A Medullary thyroid carcinoma (MTC)

B Anaplastic carcinoma

C Follicular carcinoma

D Lymphoma

E Follicular adenoma

F Papillary carcinoma

 

For each patient described below, select the most likely single diagnosis from the list of options above. Each option may be used once, more than once or not at all.

 

Scenario 45

A 13-year-old girl presents to the surgical outpatient department with a neck swelling. Clinical examination shows a 2.8 cm solid lump in the left thyroid lobe, and two enlarged cervical lymph nodes lateral to the thyroid mass. Ultrasonography confirms the solid nature of the thyroid nodule. FNA biopsy of the thyroid nodule reveals malignant cells with vesicular appearance of nuclei. The nodule is cold on radio-isotope scanning.

 

Scenario 46

A 60-year-old man presents to the outpatients with rapidly enlarged thyroid swelling and hoarseness. Clinical examination shows a 2.8 cm solid lump in the left thyroid lobe and two enlarged cervical lymph nodes lateral to the thyroid mass. Ultrasonography confirms the solid nature of the thyroid nodule. FNA biopsy of the thyroid nodule reveals malignant cells with vesicular appearance of nuclei. The nodule is cold on radio-isotope scanning.

 

THEME: INOTROPES
A Noradrenaline
B Adrenaline
C Dopamine
D Dobutamine
E Dopexamine

For each of the clinical scenarios below match the most suitable inotrope. Each option may be used once, more than once, or not at all.

 

Scenario 47

A 79-year-old patient is admitted with abdominal pain and a raised serum lactate of 2.0. She has a blood pressure of 90/60 and a pulse of 95 bpm in A+E. She is resuscitated and taken to theatre, where she undergoes small-bowel resection with end ileostomy and mucous fistula. Post-operatively, she requires inotropic support; the surgeon is concerned about the viability of the remaining bowel.

 

Scenario 48

A 56-year-old man with a history of ischaemic heart disease has a myocardial infarction 2 d post-hemiarthroplasty for a fractured neck of femur. He is clinically shocked, with a blood pressure of 80/45 and a pulse of 50 bpm, he normally takes atenolol. He is transferred to the Coronary Care Unit and started on inotopic support.

 

Scenario 49

A 45-year-old man requires a surgical airway for epiglottitis, this is performed as an emergency in A+E before initial observations are carried out, the airway is successfully placed, and initial observations are formed. The patient is peripherally well perfused (temperature 38.2°C and blood pressure unrecordable with a thready pulse 140 bpm). He requires inotropic support in the Intensive Therapy Unit.

 

Scenario 50

An obese, diabetic, smoking arteriopath suffers a cardiac event after a difficult femoral popliteal bypass graft. He develops congestive cardiac failure and is shocked and peripherally poorly perfused. He is reviewed by the Intensive Therapy Unit team who are confident he is well hydrated and has a low cardiac output and high systemic vascular resistance.