A 47-year-old man presents to the surgical outpatient clinic with a 3-month history of severe pain in the anal canal that occurs suddenly, often at night. He has noticed some painless fresh bleeding per rectum occasionally but there’s no change in bowel habits, no loss of appetite and no loss of weight. On examination, there are Grade I (first degree) haemorrhoids that are not friable. Routine flexible sigmoidoscopy is normal. Which of the following would be the ideal initial management of this condition?

A 76-year-old woman who’s 3 days post-op in the surgical ward following an anterior resection is noted to have an acute shortness of breath and fall in oxygen saturation levels. Her respiratory rate is 16/min. Her ABG reveals an arterial PaO2 of 7.8 kPa (58 mm Hg) and a PaCO2 of 5.7 kPa (42 mmHg). She is on regular morphine for pain relief. Which amongst the following conditions is an unlikely cause for her clinical picture?

A 67-year-old man is seen in the preoperative assessment clinic for bilateral hernia repair. His BMI is 33 and his BP is 146/94. He states that he feels breathless after activity and has noticed easy fatigability. He is noted to have swollen legs and ankles, and manifesting some clinical evidence of congestive heart failure. Which of the following is the best measure of left ventricular contractility?

A 73-year-old man is planned to have a laparoscopic sigmoid colectomy for an adenocarcinoma. His past medical history includes Type 2 DM, mild hypertension and osteoarthritis in both knees. His hospital stay and discharge is being discussed during the pre-operative assessment. Which of the following in not a key element of the Enhanced Recovery after Surgery (ERAS) protocol?

A 69-year-old man is 2 days post elective right hemicolectomy for an adenocarcinoma in his ascending colon. His operation is uneventful and he’s recovering in the surgical ward. He weighs 62 kgs and his BMI is 21.4. He is managing sips of fluid but not any feed so far; his urine output is 28mls/hr and he is not vomiting. His blood results are as follows: Na 143, K 3.9, Phos 0.9, Mg 0.78, Ca 2.59 and urinary sodium 53. Which would be the most ideal maintenance fluid for this patient at this stage?

A 30-year-old woman presents with a perforated duodenal ulcer on a background of longstanding proton pump inhibitor use. She has been having abdominal pain, diarrhoea, indigestion, bloating and unintentional weight loss in the last few months. Her father has had pancreatic and parathyroid surgeries. She is found to be hypercalcaemic with elevated parathyroid hormone levels. What is the most likely diagnosis in this patient?

A 60-year-old man is admitted to the Surgical Assessment Unit with a 2-day history of abdominal pain and vomiting. Haematological investigations show a potassium of 2.5 mmol/l. Which of the following would not be a feature of hypokalaemia on his ECG?

A 14-year-old boy is brought to the A&E with a painful elbow following a fall off a swing. The elbow seems deformed and an X-ray confirms a Gartland Type III supracondylar fracture of his left humerus. You are assessing the neurovascular status of the distal limb and the hand. What would be the position of the hand that would make you suspect an anterior interosseous nerve injury?

A 31-year-old man presents to the A&E with pain and mild swelling in his right distal wrist following a fall from his pushbike on his outstretched hand. On examination, he has very localised tenderness in the region of his anatomical snuff box. A plain X-ray with scaphoid views does not reveal a fracture. What would be the most appropriate management at this stage?

A 34-year-old man injuries his left ring finger when we has playing five-a-side football. The tip of the finger wouldn’t flex but he was able to continue with the game. On examination, his distal phalanx is flexed at the DIP joint and he is unable to extend it. However, passive extension of the distal phalanx is possible and pain free. An X-ray reveals no fracture. What is the most likely diagnosis?

A 31-year-old motorcyclist is involved in a high speed RTA and sustains an injury to his neck. On arrival to the A&E department, he is assessed and stabilised as per the ATLS principles. During secondary survey, he is noted to have 5/5 power on elbow flexion, normal brachioradialis reflex and normal sensation over the lateral aspect of the arm and forearm bilaterally. The power is 0/5 in the wrist and fingers, triceps reflex is lost and there is no sensation in the limb apart from the areas mentioned above. The perianal sensation is intact. Where is the most likely vertebral level and type of lesion?

A 34-year-old man presents with a history of ingestion of sulfuric acid. A careful flexible endoscopy is performed to assess the injury. What else should the initial endoscopy aim to achieve?

A 68-year-old woman presents with a history of dysphagia, a low retrosternal ‘sticking’ sensation and an occasional sensation of choking. A video barium swallow shows an appearance of a ‘bird-beak’ oesophagus. What is the most likely diagnosis in this patient? 

A 52-year-old man with a BMI of 31 presents with a 8-week history of heartburn, acid reflux, halitosis, bloating and belching. Endoscopic examination reveals a gastro-oesophageal reflux disease. Which of the following is not useful in maintaining the lower gastrooesophageal sphincter?

A 61-year-old man presents with heart burn and acid reflux. An endoscopy reveals Barrett’s oesophagus 3.6 cm from the GOJ. Biopsies of the segment reveal columnar epithelium with goblet cells and Paneth cells. The crypts show slight architectural irregularity and budding. The lamina propria shows a mild lymphoplasmacytic infiltrate. There’s no evidence of dysplasia. What is the most appropriate management plan for this patient?

A 73-year-old woman is reviewed in the pre-op clinic prior to a planned right total hip replacement. She is known to have underlying cardiac problems and has a single chamber pacemaker in her right atrium for chronic AF. What ECG change would you expect in her?

A 49-year-old man is brought to the Accident and Emergency unit with severe upper abdominal pain and breathlessness after he was punched and kicked several times in his chest and abdomen following an altercation with rival football supporters in a car park outside the stadium. On examination, he is noted to have severe bruising over his left antero-lateral chest wall.  His blood pressure is 108/74 mmHg, his pulse rate is 104/min and his respiratory rate is 20/min. There is decreased airentry in the left lung base and it is dull to percuss. Bowel sounds are heard in his chest. An erect chest X-ray shows reveals multiple rib fractures on the left side and an elevated left hemi-diaphragm.

A 78-year-old man presents with herniation over his anterior abdominal wall. The hernia is reducible and he does not have systemic symptoms. Which amongst the following statements regarding anterior abdominal wall hernias is incorrect?

A 43-year-old man is diagnosed with early stage seminoma of the testis. Which amongst the following is the most reliable and sensitive tumour marker to evaluate its progress?

A 56-year-old woman is admitted with acute pancreatitis. At admission, her LFTs were within normal limits. An ultrasound scan confirms the presence of a calculus gall bladder. The intra- and extra-hepatic ducts are within normal limits. What would be the next most appropriate step in the management of this patient?

A 3-year-old child presents with acute abdomen and intestinal obstruction. A laparotomy identifies a Meckel’s diverticulum. What amongst the following statements regarding Meckel’s diverticulum is incorrect?

An 76-year-old man undergoes emergency repair of a ruptured supra-renal abdominal aortic aneurysm. The superior mesenteric artery was atherosclerotic and the flow appeared sluggish at the end of the procedure. Two days post-op, he is suspected to have developed ischaemia of the bowel and visceral organs. Which parts of the bowel are most likely to be affected?

A 66-year-old man who consumes alcohol in excessive amounts presents with jaundice, portal hypertension and haematemesis. Which amongst the following statements regarding porto-systemic anastomosis is incorrect?

A 4-day-old baby is brought to the paediatric A&E by his mother. She reports that the baby has not passed stool since birth. He is currently breastfeeding, although poorly. She has noticed his abdomen to be swollen. There is no associated vomiting. All other examination findings are unremarkable. AXR shows distended loops of bowel. A barium enema shows a narrowed distal colon with a proximal dilation. The barium contrast was retained for over 24 hours after the procedure. What is the most likely diagnosis?

A 67-year-old male presents with a 3-month history of bleeding per rectum, change in bowel habits and tenesmus. Endoscopic and radiological investigations reveal a 2.5 cm sized tumour in midrectum reaching the adventitia but with no extramural vascular or lymphatic invasion. It is 4.5 cm from the internal anal sphincter and away from the dentate line. There’s no distant metastasis and it is staged as a T2N0M0 lesion. What will be the most appropriate management for this patient?

A 60-year-old female with Crohn’s disease undergoes colonoscopy during which multiple polyps were identified in the colon along with a large growth in the ascending colon that’s partially occluding the lumen. She undergoes a total colectomy and ileo-rectal anastomosis. Histopathology reveals a moderately differentiated adenocarcinoma infiltrating the pericolic fat. Seven out of 19 lymph nodes are infiltrated by the neoplasm. There is no evidence of distant metastases. What would be the next best treatment for her?

A 24-year-old male with a family history of familial adenomatous polyposis has been on surveillance since his teenage years. He is noted to multiple polyps on colonoscopy and requires a definitive surgical management to prevent malignant transformation. He is a semi-professional swimmer and therefor not keen on having a stoma. What would be the best treatment option in this instance?

A 10-week-old male child is brought to the paediatric surgery outpatient clinic with history of clear fluid discharge from the umbilicus. The parents state that they have noticed this ever since the umbilical cord separated. Which of the following is the most likely embryological aetiology?

A 83-year-old man is diagnosed with prostate cancer and is considered to be suitable for active surveillance. Which amongst the following statements is accurate in the first year of active surveillance?

A 9-year-old boy presents with a non-retractile foreskin. He does not currently have any urinary symptoms. On examination the foreskin is thickened, white and stiff. Which one of the following is the most appropriate next step?

You are called to review a 4-day old baby born in the post-natal ward born at 36-weeks gestation. The neonatologists have noticed an area of inflamed erythema between the genitalia and the anus. There is evidence of localised inflammation and the nurse states that the stools are very loose with greenish-brown colour. The baby is feeding normally. What is the most likely diagnosis?

A 78-year-old woman trips in the toilet and lands on her left hip. She normally mobilises with a zimmer frame. Her PMH includes hypertension, type II DM, angina and 2xMI. On examination, she has a shortened and externally rotated left leg. The X-ray shows a partially displaced fracture of her left femoral head. What would be the most appropriate management for this patient?

A 39-year-old man presents to the A&E with a painful right knee 48 hours after he injured it whilst playing squash. He also sustained a deep laceration over the antero-medial aspect of the knee during the incident. He is now unable to weight bear in his right leg. On examination, his right knee is swollen (effusion) and erythematous. There is tenderness along the medial joint line and all active movements are restricted. His temperature is 38.40C, HR is 98 beats/min, BP 122/78 and RR 18/min. What is the most likely diagnosis?

A 21-year-old professional squash player presents to the Accident and Emergency unit with severe, stabbing pain just above his right knee joint. He states that the pain was of sudden onset and happened when he took a sharp stride during a match. On examination, he walks with a limp and is unable to extend the leg. There is a swelling over the supra-patellar region and is identified to have a low-lying patella. Knee jerk is absent.

A 63-year-old man underwent a L3/4 lumbar microdiscectomy 2 weeks ago. He returns with worsening severe low back pain and poor range of spinal movements. Power, sensation and reflexes in his lower limbs seem intact. He has normal anal tone and perianal sensation. The wound looks healthy and there’s no collection. Temperature is 38.4oC, WCC in 15.8 and CRP is 193. What’s the most likely diagnosis?

A 60-year-old man is attends A&E with a 4 day history of rapidly worsening bowel incontinence, severe lower back pain, impotence. On examination, his lower limbs have normal muscle tone, normal patellar reflex and loss of ankle reflex bilaterally. Babinski sign is positive. PR examination reveals loss of anal tone and loss of sensation in the perineal region. What is the most likely diagnosis?

A 24-year-old man sustains a stab injury to the right side of his spine. He is diagnosed with Brown-Sequard Syndrome. Which amongst the following is not a feature of this syndrome?

An 66-year-old man is referred by the GP to the ENT clinic with a 2/52 history of worsening painless right-sided sight loss, a right-sided headache and a tender scalp when he combs her hair. She also reports of night sweats, fever and occasional visual disturbance. Laboratory tests reveal an elevated CRP and ESR. What is the initial management of this patient?

A 63-year-old retired engineer is admitted to the vascular ward for an elective left carotid endarterectomy for 80% stenosis. When you are doing a preoperative assessment, you note that he has a right homonymous hemianopia. He does not have any other visual symptoms but he complains of recent weakness in his right arm and right side of face. What is the most likely cause for this finding?

A 6-week-old baby is brought in with bulging fontanel, a rapid increase in head circumference, seizures, vomiting, excessive sleepiness and poor feeding. She is diagnosed with hydrocephalus. Which amongst the following statements regarding hydrocephalus is incorrect?

A 23-year-old previously fit and healthy woman presents with a six-week history of a lump over the left side of her neck. She has noticed sweating at night and increased temperature in the evenings, and believes she has lost about a stone in weight in the last two-to-three months. On examination, she has a 2cm-sized inflamed, swollen, soft and fluctuant lump in the supraclavicular region. What would be the most likely diagnosis of this patient?

You are consenting a 68-year-old man for a carotid endarterectomy. He asks you the common complications and the nerves that are most likely to be affected?

A new-born is diagnosed with cleft lip and palate. Which one amongst the following statements is incorrect regarding cleft lip and palate in the UK?

A 47-year-old woman presents with a 6-8 month history of fatigue, gradual weight gain and cold intolerance. On examining the thyroid gland, it is non tender, firm and rubbery. Patient’s skin is dry and there is a loss of the outer third of her eyebrows. Her blood results are as follows:

A 62-year-old woman who is a smoker with long history of hypertension is referred to the GP to the emergency surgical admissions unit with a sudden history of weakness of left arm and leg. On examination, she has loss of vibration and position sense on the left and when asked to protrude her tongue, it moves to the right. There is no other focal neurology. What is the most likely diagnosis?

A 56-year-old lady presents with a 3-month history of painful lump in the right side of her neck associated with mild hoarseness of voice, dysphonia and circumoral paraesthesia. On examination, she is noted to have a hard, woody swelling in her left thyroid lobe. USS of the neck reveals a hypo-echoic and hypo-vascular mass with diffuse fibrosis extending into adjacent soft tissues. T3/T4 levels are low, TSH is raised, negative for antibodies and elevated plasma levels of IgG4. What is the most likely diagnosis in this patient?

A 29-year-woman attends the endocrine clinic with a 4-month history of a fairly enlarging lump in the right side of her neck. There’s no significant PMH and she is not on regular medications. On examination, there’s a palpable nodule in the right lobe of the thyroid gland. T3, T4 and TSH levels are within normal range. She is referred to have an US scan. Which amongst the following features would you not expect to find if the lump were to be malignant?

A 35-year-old woman sustains an iatrogenic injury to a mesenteric vessel during laparoscopy for suspected appendicitis. There is 1.7 L of blood in the suction. Her HR is 124/min, BP is 98/76 mmHg and RR is 30/min. Her CR is 4 secs and her peripheries are cold. She is responsive to fluids at this stage. What type of shock does she have?

A 29-year-woman attends the ENT clinic with a 4-6-week history of a gradually enlarging lump in the right side of her neck. There’s no significant PMH and she is not on regular medications. On examination, there’s a palpable nodule in the right lobe of the thyroid gland. T3, T4 and TSH levels are within normal range. US confirms a semi-cystic, 1-cm unencapsulated nodule. Which of the following is the most appropriate next step in evaluation?

A 26-year-old sales assistant undergoes appendicectomy for a grossly inflamed appendix. Histology reports the presence of a 2.8 cm sized carcinoid tumour at the base of the appendix that involves the mesoappendix and periappendiceal fat. Relevant investigations have been carried out and it does not reveal any distant disease. She does not manifest any other signs or symptoms. What is the most appropriate management in this patient?

A 56-year-old woman presents with a 4/12 h/o a firm mass her left thyroid gland. USS reveals this to be a 4.2 cm sized mass with microcalcification and irregular borders. A couple of enlarged lymph nodes are seen in the peri-tracheal region. She undergoes a core biopsy that shows Orphan-Annie nuclei and psammoma bodies. What would be the most appropriate management for her?

A 33-year-old man is brought to the A&E following a high-speed RTA. He has been intubated by the paramedics. On examination, his GCS is 7, BP is 78/48, HR is 140 and RR is 28. Primary survey reveals evidence of a pneumothorax and a tensely distended abdomen with copious free intraperitoneal fluid on FAST scan. What should be most appropriate treatment at this stage?

A 54-year-old primary school teacher has suffered from Grave’s disease for nearly 15 years and now is increasingly troubled by worsening eye signs. She has been on carbimazole but recently required hospitalisation for neutropenia. She is keen to get the condition treated again. Her TFTs are consistent with toxicity and her AST to ALT ratio is 2:1 with an elevated GGT. What would be the most appropriate treatment option?

A 24-year-old motorcyclist is brought to the A&E following a high speed RTA. On examination, he has fractures to his skull and face. His eyes open to voice, he is mumbling incoherent words and localises to pain. What is his GCS?

An 82-year-old Jehovah’s witness is brought into A&E with a bleeding duodenal ulcer. He is hypotensive and tachycardic, sweaty and pale and is becoming agitated but oriented. His Hb is 6.2. He has a written advanced directive refusing all blood transfusion and the paramedics have handed over that he reported he would not want blood under any circumstance. He is now saying he will accept whatever is needed to save his life. What is the most appropriate intervention at this stage?

A 56-year-old woman presents with weakness and fatigability, anorexia, nausea, vomiting, abdominal pain and myalgias. On examination, she is noted to have orthostatic hypotension. Her blood biochemistry reveals hyponatremia, hyperkalaemia and hypercalcemia. She is suspected to have adrenal insufficiency. Which amongst the following will be the most appropriate screening investigation to diagnose and distinguish the condition?

A 24-year-old man presents with palpitations, hypertension, headache and heavy sweating. Initial investigations reveals excessive amounts of free metanephrins in both urine and plasma. Which amongst the following would be the most definitive diagnostic investigation in this patient?

A 27-year-old female in the surgical ward who is 2 days post-debridement of an abdominal wall abscess, develops fever, abdominal or flank pain, vomiting and severe headache. She also appears confused and disoriented. Her BP is 92/66, blood glucose is low and her electrolytes reveal hyponatremia and hyperkalaemia. Abdominal examination reveals rigidity and rebound tenderness. She is also noted to have a petechial rash in her trunk and larger purpura and ecchymoses in her lower limbs. What is the most likely diagnosis?

A fit 63-year-old is referred to the endocrine surgery clinic with a homogenous 9mm non-functioning right adrenal mass that was identified incidentally on CT scan of his abdomen that was performed following an RTA. What is most appropriate management of this mass?

A 31-year-old estate agent undergoes a routine appendicectomy. The histology reveals a carcinoid tumour of the appendix. She is recently manifesting some relevant symptoms such as hot flushes, mild breathlessness and chest pain. Which of the following is not an appropriate investigation in the further management of this patient?

A 44-year-old man is intubated and ventilated in the ICU for raised intracranial pressure following a head injury. Which one amongst the following is not a recognised management option to reduce raising intracranial pressure in an adult following a head injury?

You are called to the ward to review a 73-year-old lady who is day one post total hip replacement. The nursing staff are concerned that she is being less responsive in the last hour or so. Her BP is 124/86, Pulse is 76/min and RR is 8/min. You suspect opiate overdose or a CVA. An ABG is performed. Which one of the following results is it most likely to be?

A 54-year-old woman has previously undergone an open cholecystectomy for gallstone disease. She now presents with abdominal pain and obstructive jaundice. She has previously undergone ERCP twice in an attempt to remove a CBD stone. What would be the next most appropriate step in her management?

A 66-year-old man has undergone an AP resection 5 days ago. He complains of shortness of breath and dizziness. On examination, his heart rate is 90/min and RR is 18/min. You do a 12-lead ECG since you are uncertain of the diagnosis. If he were to have a PE, which amongst the following ECG changes would you not expect to find in the ECG?

A 59-year-old woman is about to undergo an elective laparoscopic cholecystectomy. Her BMI is 29.8 and she has a history of hypertension, angina and an MI 3 years ago. She is anxious about having a pneumoperitoneum for the procedure and asks about the complications. Which one of the following is a feature of pneumoperitoneum?

A 67-year-old man is undergoing a right femoro-popliteal bypass for worsening intermittent claudication. You are assisting your consultant to perform anastomosis of the top end. Which suture material would your consultant ask to perform the anastomosis?

A 61-year-old roofer presents to A&E with a swollen knee joint with no history of trauma. On examination, the joint is erythematous, has a gross effusion, is slightly warm to touch, and his range of movements are painful. His temperature is 38.1°C, heart rate is 86/min, and BP is 124/84 mmHg. The blood results are as follows: Hb 14.5 gm/dl; WCC 14.5; Plt – 286; CRP – 127; uric acid level 12.8 mg per 100 ml (510 µmol/l). What would be the most appropriate management of this patient?

A 63-year-old woman presents to the A&E with a 24-hour history of sudden onset of pain and swelling of her right knee. There’s no history of trauma. PMH: OA in both knees. Medications: Ibuprofen. Her temperature is 37.4°C (98.6°F), pulse is 97/min, RR is 19/min, and BP is 129/79 mm Hg. Examination of the right knee reveals warmth, erythema, effusion and significant tenderness with minimal range-of-movement. Examination of synovial fluid from joint aspiration shows that a clear fluid that has positively birefringent rhomboid crystals under polarized light microscopy. Deposition of which of the following substances is the most likely?

A 23-year-old woman is referred by the GP to the surgical outpatient clinic with a four-to-six-month history of postprandial abdominal pain associated with weight loss, nausea and vomiting of partially digested food. She states that the pain is relieved by lying prone or to her left. On examination, her abdomen seems distended with some high pitched bowel sounds. What is themost likely diagnosis?

A 54-year-old woman with Crohn’s disease undergoes incision and drainage of an infected perianal abscess. What would be most appropriate method of wound management in this patient?

A 91-year-old lady who lives in a nursing home is brought to the A&E after she sustained a pre-tibial laceration to her right shin when she knocked her leg against a coffee table. On examination, there’s a 6-cm sized V-shaped laceration with the flap of skin rolled over and surrounding bruising. There’s no underlying haematoma or evidence of bony injury. What would be most appropriate method of wound closure in this patient?

A 72-year-man is undergoing excision of a large basal cell carcinoma from his back and the wound is being considered for closure using a skin graft. Which of the following statements is true regarding skin grafts?

A 56-year-old woman who presented with painless lymph nodes in neck, persistent fatigue, night sweats and severe itching is diagnosed with Hodgkin’s disease. Which one of the following is not considered to be a poor prognostic indicator in Hodgkin’s disease?

A 63-year-man is due to have a split skin grafting to cover his lower leg fasciotomy defect. Which one of the following conditions is not a contraindication for split skin grafting?

An 83-year-old lady presents with a 6-month history of a non-healing ulcer over the medial gaiter area of her right leg. The ulcer has sloping edges, a small amount of slough and eczema of the surrounding skin. A diagnosis of venous ulcer is made. Which of the following is not an appropriate treatment option in this patient?

A 68-year-old lady presents with a 4 year of history of a recalcitrant venous ulcer over the medial aspect of her right leg presents with a recent history of bleeding and enlargement of the ulcerated area. Which amongst the following statements regarding Marjolin’s ulcer is correct?

A 27-year-old man presents with a 3-4 month history of diarrhoea, abdominal pain, extreme tiredness and unintentional weight loss. He has also noted a sore tongue and ulceration in his mouth. His blood investigations are as follows: Hb – 10.9 gm/dl, MCV 108 fl, MCHC raised, WCC – 8.2 gm/dl and Platelet – 132 x 109/L. There’s some evidence of anisocytosis and poikilocytosis. On examination of his abdomen, he is mildly tender in his right iliac fossa. What is the most likely explanation for this haematological picture?

An 83-year-old man presents with a suspicious lesion in his right pinna. Which one of the following statements is correct regarding risk factors for skin cancer?

A 44-year-old lady presents with a deeply pigmented lesion with irregular borders over her upper back. Clinical examination is strongly suspicious of a melanoma. Which amongst the following statements regarding melanoma is correct?

A 67-year-old man, fit and healthy, ASA 1, with no significant PMH is to undergo an elective right open hernia repair. What will be the most appropriate type of anaesthesia?

A 28-year-old woman presents with a suspicious naevus in her right lower leg. There are no palpable groin lymph nodes and there is no hepatomegaly. An excision biopsy of the lesion confirms a 1.8 mm Breslow thick nodular melanoma, which is ulcerated and is in the vertical growth phase. What will be the next most appropriate aspect in her management?

A 71-yr-old man is brought to the A&E by the paramedics following a house fire. He was found unconscious at the scene. On examination, he is noted to have deep partial thickness and full thickness burns to his face, neck, chest and both upper limbs. On initial assessment, his GCS is 12, BP is 104/68, HR is 122/min, RR is 35/min and Saturation is 89% on 100% high flow oxygen. He seems quite agitated. The TBSA burnt is estimated to be about 30%. Which amongst the following is not an appropriate initial treatment consideration in this patient?

Which of the following features would you not expect to find in a patient with superficial partial thickness (superficial dermal) burns?

A 19-year-old man is referred by the GP to the orthopaedic clinic with a 4-6-week history of pain around his left knee. There’s no history of trauma. He complains of constant dull pain in his knee and finds it difficult to weight bear. On examination, a swelling is palpated above the joint line. An X-ray performed confirms a bony mass arising from the metaphysis that is associated with a ‘Sun-burst’ appearance, periosteal lifting with formation of Codman’s triangle and new bone formation in the soft tissues. What is the most likely diagnosis?

A 3-year-old boy is brought to the paediatric outpatient clinic with a 3-4 month history of shortness of breath, difficulty swallowing, loss of appetite and being unsteady on his feet. On examination, he is noted to have multiple, small, blue-coloured lumps on his skin. Biopsy of the lesions reveal Homer Wright rosettes. His urine is positive for vanillylmandelic acid. Which one of the following is the most likely diagnosis?

A 45-yr-old woman is brought to the A&E following a house fire. On examination, she is noted to have mostly deep dermal and full thickness burns to the entire surface of her back, posterior aspect of both lower limbs, and right forearm and hands. What would be her estimated TBSA burnt?

A 63-yr-old man is brought to the A&E following a fire in his garage. He was fixing his car when a loud explosion was heard and he was found unconscious when rescued by the fire service. The garage and the car were in flames. On examination, he is noted to have deep dermal and full thickness burns to his back, both upper limbs, face and neck. The TBSA burnt is estimated to be about 45% and he weight 75 kilograms. In total, how much and what resuscitation fluid should he receive per hour for the first 8 hours?

A 72-year-old man presents to the A&E with critical ischaemia of his left foot. A CT angiogram demonstrates a complete occlusion of the femoro-popliteal segment, with a two-vessel run-off via the anterior and posterior tibial arteries. Which one of the following would be the most appropriate management option?

A 78-year-old man presents with isolated left thigh claudication worse in the lower part of his hamstring. He states that the pain is felt quite deep in the thigh and points to the mid-thigh posteriorly. He has no pain in his gluteal region or lower legs. Where is the most likely level of the occlusion?

Which one of the following is not a feature of Leriche Syndrome?

An 85-year-old male is diagnosed with diffuse aorto-iliac disease extending unilaterally to his left common femoral artery. He has intermittent claudication at 50 yards and occasional rest pain. He has a past history of aorto-enteric fistula and has got a stoma for a previous abdominoperineal resection. He is not very mobile but wishes to have some relief from the symptoms. What will be the most appropriate surgical management in this patient?

You are assessing a 67-year-old lifelong smoker with a BMI of 32.5 in the pre-assessment clinic for an elective hernia repair. An ABG analysis shows his O2 saturation to be 91% and he is suspected to have undiagnosed COPD. Which amongst the following ABG finding is most likely in this patient?

A 72-year-old male with Type II diabetes mellitus presents with an infected 2nd toe extending to the base of the proximal phalanx and localised tissue necrosis. An X-ray confirms underlying osteomyelitis. He has had ulcers in this toe for a number of years now and has taken many courses of antibiotics. His mobility is good and he goes for regular morning walks with his wife. What would be the definitive management plan for this patient?

A 14-day-old baby is brought to the paediatric plastic surgery clinic with unilateral cleft lip and palate. The mother is keen to understand the optimum age at which the initial surgeries will be carried out to correct the conditions.

An 86-year-old man has presents to the A&E with a 6-hour history of worsening severe lower back pain. His BP is 112/82, pulse is 78/min, RR is 16/min and O2 sats 99% on air. CT scan reveals a 6.4-cm sized leaking aneurysm that is contained in the retroperitoneal region. It further reveals the aneurysm to be 12 mm inferior to the renal arteries with a straight neck and minimal calcification. The right CIA in fully patent but the left CIA shows a 80% blockage. What would be the most appropriate management in this patient?

A 53-year-old woman presents with a 52 mm sized tumour in her right breast. The hormone status is identified to be ER-ve and HER2+ve. Core biopsy of the axilla shows metastatic cells. The staging CT scans are normal. What is the most appropriate management of this patient?

A 76-year-old man is identified from the screening programme with a 6.2 cm infra-renal abdominal aortic aneurysm. CT reconstruction shows the infra-renal aneurysm neck to be 4mm distal to the renal arteries and to have an angulation of 90 degrees. The iliac arteries are patent and not aneurysmal. What would be the most appropriate management option?

Mr Masters, a 69-year-old gentleman, is an in-patient in the oncology ward with severe dysphagia secondary to advanced oesophageal carcinoma. He has not tolerated oral intake for a week and has lost 6 kilograms in weight within 4 weeks. He is due for palliative chemotherapy. He has normal bowel sounds. He will need nutritional support for a minimum of 6 weeks. Which amongst the following is the most ideal method?

A 43-year-old man presents to the A&E with a history of swelling and stiffness in his right knee about 10 days after 5-a-side football. He has pain when twisting or rotating his knee, difficulty in straightening his knee fully and a feeling of this knee being locked when he tries to move it. He also has a feeling of the knee giving way. OE, there’s swelling around the inside of his knee with joint line tenderness. There’s no joint laxity and abduction stress test is negative. What is the most likely diagnosis in this patient?

A 49-year-old woman, who is a smoker, is referred to the breast clinic with a 10-day history of a gradually enlarging swelling adjacent to her left nipple-areolar complex. She undergoes triple assessment and is diagnosed with periductal mastitis. She is systemically well but states that the pain is worsening in the area. She has not had any treatment so far. What would be the most appropriate treatment at this stage?

A 29-year-old woman 3 weeks postpartum presents to the breast clinic with a red, painful 3 cm lump in her left breast. What would be the most appropriate management in this patient?

A 68-year old lady with small-cell lung cancer is admitted to the thoracic ward with confusion and seizures. Routine bloods reveal serum Na of 119. Further investigations show normal thyroid function tests, 9am coristol >500 nmol/L, serum osmolality 240 mosmol/kg, urine osmolality 800 mosmol/kg and urine Na 75mmol/L. What is the most likely explanation for this clinical picture?

A 65-year-old man presents to the clinic with weakness along the right side of his mouth and lower lip 2-week following excision of a malignant tumour from his right submandibular gland. He has difficulty in closing the mouth and unable to move his lower lip. There’s no sensory loss. Which nerve is most likely to be injured?

A 45-year-old woman presents to her GP with questions regarding screening for breast cancer since she has a few distant family members who have had breast cancer in the past. Regarding breast screening, which of the following statements is incorrect?

A 75-year-old male is in the ICU following an emergency Hartmann’s procedure for an obstructing sigmoid carcinoma. He is currently 8 days post-op. He has high NG aspirates despite slow enteral feeding at 10mls/hour. On examination, he appears very frail and weak. He has hypoproteinemia. His abdomen is mildly distended and generally tender but with no peritonism. His stoma looks healthy but not functional yet. Bowel sounds are absent. What is the best way to manage his nutrition?

You are seeing a 30-year-old BRCA1 carrier in the clinic seeking a prophylactic mastectomy and immediate reconstruction. Which one of the following statements about female carriers of the BRCA1 gene mutation is incorrect?

A 5-year-old boy is brought into the emergency department with a deep lip laceration following a fall while playing in the park. He is accompanied by his 17-year-old neighbour who is his babysitter. The parents are uncontactable at present. He is likely to require a general anaesthetic for wound exploration and closure. What would be best option for managing the situation and treating the child?

A 44-year-old man is having an excision of a suspicious mole on his back. Towards the end of the operation, he informs you that there is another mole on his back, which he is worried about and would like excised as well. You examine this mole and determine that there are no red flag features. However, he is adamant that he would like this mole excised during this operation. How would you proceed with the situation?

A 15-year-old boy is brought to the orthopaedic out-patient clinic with a 6-week history of pain around his right thigh and knee. He states that the pain started following an injury to his right knee sometime ago following a football injury. He states the pain to be of dull ache in the region and but has full range of movements in his knee. He is able to weight bear but walks with a limp. On examination, there is no joint line tenderness but a non-specific swelling is identified in the lower thigh. His temperature is 37.8 degree C, WCC – 12.8, ESR -32. What diagnosis is important to be ruled out?

A 32-year-old man presents with excruciating right loin pain. CT urography shows a standing column of fluid within the right ureter and an opacity at the level of sacro-iliac joint where the ureter crosses the iliac vessels. What is most likely diagnosis?

A 41-year-old woman has undergone a high tie and ligation for varicosity of her long saphenous vein. She develops a DVT 8 days post-op. Which of the following statements regarding the aetiology and epidemiology of venous thromboembolism is incorrect ?

A 65-year-old avid gardener is referred to the surgical outpatient clinic by the GP with a solitary, friable nodular lesion over the dorsum of his left middle finger. He reckons that he injured his finger whilst gardening 5 days ago. On examination, the bluish-black lesion appears nodular, compressible and highly friable. What is the most likely diagnosis in this patient?

A 65-year-old man with previously diagnosed squamous cell cancer of the lung is admitted in the urology ward with a 48-hour of right loin pain. A diagnosis of renal stones is made. Investigations reveal raised serum calcium (3.2mmol/L) and low parathyroid hormone levels (2pg/ml). What is the most likely explanation for this clinical picture?

A 68-year old gentleman is seen in the pre-op assessment clinic for a right total hip replacement. His wife states that over the course of the last year he has become increasingly tired when doing his regular gardening and at times appeared to be having chest pain, although he denies this. In passing, she also states that he collapsed several weeks ago but refused to go to the hospital. ECG recording shows sinus rhythm and left ventricular hypertrophy. No ischaemic changes are seen. What is the most likely diagnosis in this patient?

A 3-year-old boy is referred to orthopaedic clinic by his concerned GP. The child walks into the clinic with a waddling, wide-based gait with tip-toe walking. His mother mentions that he is prone to recurrent falls and is beginning to struggle climbing stairs. When a full history is taken, it transpires he did not begin walking until 18 months. As his mother beckons him to stand up, you notice that the child has a positive Gower’s sign. Xray of the hip is unremarkable. What’s most likely diagnosis in this child?

You are the CST in the Orthopaedic department. A 77-year-old woman sustained a Smith’s fracture of her left wrist following an accidental fall. She has been treated with a plaster cast and is scheduled to be reviewed in the clinic in two weeks. She has had risk assessment for falls, and she is classified as low risk. She is due for discharge and she is happy to go home. She has full mental capacity. Her daughter however has some concerns. She is worried that her mother will fall again and wants referral to be made to an elderly care home. What will be the most appropriate option in this situation?

A 79-year-old man, who is a life-long smoker, presents with a 2-month history of malaise, general weight loss, constipation and polyuria. Biochemistry reveals anaemia and hypercalcemia. Radiological investigations confirm an osteosclerotic bony secondary in his lumbar spine but the primary is not identified. General examination is unremarkable apart from multiple moles over his back and trunk. What is the most likely primary tumour?

A 74-old-year old man presents with intermittent claudication in his left leg after walking about 70-80 yards. He currently has no rest pain in this limb. He has generalised atherosclerotic disease and an angiogram confirms an ostial flush occlusion of the superficial femoral artery extending to the adductor canal. The flow the popliteal artery is normal with good distal run-off. What would be the most appropriate management in this patient?

You are the CST on call in the surgical ward. A 76-year-old woman was brought into hospital two weeks ago with confusion, abdominal pain and weight loss. Further assessment and investigations including colonoscopy revealed a cancerous growth in her ascending colon. This is recorded in the notes. At the time of diagnosis, your consultant communicated the diagnosis to the patient’s daughter. The patient is currently out of her confused state and is deemed mentally capable. Her daughter requests that you keep the diagnosis away from her mother as she thinks her mother will not handle the news well. The patient wishes to speak to you and asks what was found during colonoscopy? Which one of the following actions would be the most appropriate?

A 6-month-old baby girl is brought to the clinic with history of frequent respiratory tract infections, difficulty breathing, tiring when feeding and skipped heartbeats. A subsequent chest X-ray and echocardiography reveals an atrial septal defect. Which amongst the following statements regarding the development of the atrium is correct?