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Question 1 of 104
1. Question
A 39 year old man has a painful palpable mass for the past 6 weeks near his anus. The pain is described as throbbing and worse when sitting down. On examination, the lump is warm, erythematous, and tender. He has a history of diabetes mellitus type 2. What is the SINGLE most likely diagnosis?
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Question 2 of 104
2. Question
A 65 year old woman has been losing weight and feels lethargic. Three years ago, she had a right hemicolectomy for cancer of the ascending colon. She looks pale on examination but there were no abdominal findings. What is the SINGLE most appropriate investigation?
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Question 3 of 104
3. Question
A 60 year old woman has lower abdominal discomfort and mild abdominal distention. On pelvic examination, a nontender, sold irregular right adnexal mass is felt. Her pap smear done a year ago was normal. What is the SINGLE most appropriate tumour marker to request for?
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Question 4 of 104
4. Question
A 60 year old man was admitted the day before his planned elective surgery in the morning to remove his gallbladder. He was advised that the surgery will take around 2 to 3 hours and he should skip breakfast the morning of the surgery. He suffers from Type 1 diabetes mellitus. He was given a reduced dose of his once-daily Tresiba (degludec) insulin the day before the surgery. He also takes Novorapid (aspart) insulin with his meals three times a day. Which of the following is the SINGLE most appropriate management for him on the day of the surgery?
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Question 5 of 104
5. Question
A 31 year old woman has an injury to the right external branch of superior laryngeal nerve during a thyroid surgery. What is the SINGLE most likely symptom in this patient?
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Question 6 of 104
6. Question
A 32 year old man has undergone an open appendectomy earlier today. In theatre, a gangrenous appendix was found. What is the SINGLE most appropriate pain relief to administer post operatively?
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Question 7 of 104
7. Question
A 63 year old woman with a history of ovarian cancer with bony metastases is admitted after having a fall. A plain X-ray of the right thigh reveals a mid-shaft femur fracture. The fracture was managed by closed reduction and percutaneous stabilisation. On the third day of her admission she complaints of worsening colicky abdominal pain. She vomited four times in the last day and still feels nauseous. Her abdomen appears to be distended and is markedly tender. Bowel sounds are not appreciated upon auscultation. What is the SINGLE most appropriate immediate management to relieve this patient’s pain?
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Question 8 of 104
8. Question
A 28 year old pregnant woman with polyhydramnios comes for an ultrasound scan at 31 weeks. On ultrasound scan of the fetus, there was no gastric bubble seen. What is the SINGLE most likely diagnosis?
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Question 9 of 104
9. Question
A 44 year old female presents with right upper quadrant pain radiating to the right shoulder. On examination, her sclera appear yellow. Her BP is 120/85 mmHg; respiratory rate 15/min; Heart rate 85 bpm; Temperature 37.3°C; WBC 9 x 109/L. She has no relevant past medical history and is not on any medications. What is the SINGLE most appropriate investigation?
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Question 10 of 104
10. Question
A 32 year old man was involved in a road traffic accident and was operated for abdominal trauma where a splenectomy was performed. On the second day post-op, his abdomen becomes gradually distended and tender and he complains of epigastric fullness. He feels nauseous and vomited twice in the morning. His blood pressure has now dropped to 70/40 mmHg and he has a pulse rate of 140 beats/minute. A nasogastric tube was inserted and the patient was almost immediately relieved. What is the SINGLE most likely diagnosis?
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Question 11 of 104
11. Question
An 8 year old child has oral burns is found not to be breathing well. Intubation has failed. His oxygen saturations are low. What SINGLE anatomical structure is likely to be pierced to help this child recover?
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Question 12 of 104
12. Question
A 62 year old man presents to the Emergency Department with acute onset of severe, persistent abdominal pain. The pain started two hours ago. On examination, his abdomen is distended and has generalised tenderness. There is no bowel sounds on auscultation. He has a heart rate of 110 beats/minute and a blood pressure of 100/60 mmHg. A venous blood gas was performed which shows a lactate of 6.4. An ECG taken shows evidence of atrial fibrillation. Analgesia, intravenous fluids and broad spectrum antibiotics were started. What is the SINGLE most likely diagnosis?
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Question 13 of 104
13. Question
A 50 year old man underwent a proctocolectomy two weeks ago. He is now complaining of fever, malaise and abdominal pain. The patient suffers from type 2 diabetes mellitus and Crohn’s disease. His pulse rate is 114 beats/minute, blood pressure is 135/85 mmHg and temperature is 39.5°C. What is the most likely cause for his symptoms?
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Question 14 of 104
14. Question
A 44 year old caucasian woman is seen in the surgical outpatient clinic. She complains of intermittent epigastric pain and right upper quadrant pain that radiates to her back over the past 9 months. The pain is associated with nausea and can last several hours before going away. The pain usually starts 2 to 3 hours after eating. It is especially worse when eating fatty food. On examination, there is mild tenderness in the epigastric region. She is not jaundiced. There is no organomegaly or lymphadenopathy. She has a BMI of 35. She has a pulse rate of 85 beats/minute, blood pressure of 130/80 mmHg and her temperature is 37°C. Her blood tests are as follows:
Bilirubin 14 μmol/l (1-14μmol/l)
Alkaline phosphatase 104 IU/I (4-105 IU/
Aspartate transaminase 30 IU/1 (1-31 IU/
Albumin 42 g/L (35-50 g/L)
What is the most appropriate investigation?
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Question 15 of 104
15. Question
A 58 year old man presents with altered bowel habits and painless bleeding per rectum. A full blood count shows the following:
Haemoglobin 82 g/L
White cell count 10.2 x 10^9/L
Neutrophils 4.1 x 10^9/L
Platelets 350 x 10^9/L
A sigmoidoscopy was performed subsequently which showed an ulcer. What is the SINGLE most likely diagnosis?
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Question 16 of 104
16. Question
A 55 year old man has a history of weight loss and tenesmus. He is diagnosed with rectal carcinoma. Which SINGLE risk factor is NOT associated with rectal carcinoma?
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Question 17 of 104
17. Question
A 48 year old man complains of rectal bleeding and loss of weight. He has been having bouts of diarrhoea followed by weeks of constipation over the past few months which he has never experienced before. He has a palpable mass in the left iliac fossa. What is the SINGLE most likely diagnosis?
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Question 18 of 104
18. Question
A 56 year old man presents for a surgical consultation. He has an inguinal hernia that has persisted for the past 6 months, and he would like to undergo surgery for the same. The consultant decided that the patient may undergo an elective herniorrhaphy as a day case procedure, and having counselled the patient about the procedure, directed the patient for a pre-anaesthetic check. On evaluation, the patient reports that he had a myocardial infarction 6 weeks ago and underwent stenting for the same. Additionally, he developed a pulmonary embolism 2 years ago, which required hospitalisation and was diagnosed with diabetes mellitus around the same time. On assessment, his heart rate was 96 beats per minute, and blood pressure was 170/90 mmHg. His laboratory reports are available.
HbA1c 68 mmol/mol (<48)
Haemoglobin 128 g/L (130-180)
Which of the following is an absolute contraindication to surgery?
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Question 19 of 104
19. Question
A 28 year old woman who is 8 weeks pregnant has central abdominal pain for the last 36 hours. The pain is now colicky. She reports no vaginal bleeding. She has vomited once and has had an episode of loose stools earlier in the day. She has a temperature of 37.9°C. On examination, she looks ill, and has rebound tenderness in the right iliac fossa. Her urinalysis is negative. Her blood results show
Haemoglobin 130 g/L
White cell count 14.2 x 10^9/L
CRP 130 mg/L
What is the SINGLE most likely diagnosis?
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Question 20 of 104
20. Question
A 44 year old woman had a total abdominal hysterectomy and bilateral salpingo- oophorectomy 5 days ago. She now has increasing abdominal discomfort and is now bloating. She was encouraged to stay well hydrated but she is still unable to pass gas. No bowel sounds are heard. What is the SINGLE most appropriate next step?
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Question 21 of 104
21. Question
A 53 year old man has become increasingly short of breath in the 3 hours since returning to the ward after a thyroidectomy. He has a temperature of 37.5°C, heart rate of 110 beats/minute, blood pressure of 90/60 mmHg, respiratory rate of 35 breaths/minute and SaO2 of 89% on air. There are harsh inspiratory upper airway sounds and reduced air entry bilaterally. What is the SINGLE most appropriate course of action?
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Question 22 of 104
22. Question
A 55 year old man has unexplained weight loss and abdominal pain over the past year. His medical history includes ulcerative colitis. A recent blood test shows the following:
Haemoglobin 95 g/L (130-180)
White cell count 10 x 10^9/L (4-11)
Neutrophils 3.1 x 10^9L (2-7.5)
Platelets 250 x 10^9/L (150-400)
Ferritin 15 ng/ml (20-300)
A colonoscopy was performed and an ulcerated lesion in the sigmoid colon was seen and biopsied. What is the SINGLE most likely diagnosis?
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Question 23 of 104
23. Question
A 34 year old man with a history of Crohn’s disease has throbbing pain and a bloody discharge coming out via a punctum near his anus. The pain is worse when he tries to sit down. On examination, a fistula is seen passing superficially beneath the submucosa layer and does not cross the sphincter muscles. What is the SINGLE most appropriate management?
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Question 24 of 104
24. Question
An 66 year old woman is found to be anaemic. As part of her exam, she had a barium enema which reveals a mass lesion in the right side of the large intestine. What is the SINGLE most likely diagnosis?
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Question 25 of 104
25. Question
A 70 year old man is scheduled to undergo an elective transurethral resection of the prostate. During the pre-anaesthetic assessment, he is found to have a mass at his right groin. The small swelling originates above and medial to the pubic tubercle. The lump is reducible and there a cough impulse is present. There is no tenderness of his right groin. He does not have abdominal pain or discomfort. He has no trouble opening his bowels. He says he has noticed this lump over the past year. What is the SINGLE most appropriate action?
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Question 26 of 104
26. Question
A 44 year old man has just had a hemi-colectomy for colorectal cancer. He is now past- op and has been put on 100% facemask oxygen. An arterial-blood gas analysis reveals
pH is 7.54
PaO2 = 28.8kPa
PaCO2 = 3.8kPa
He is breathless and dyspneic. What is the SINGLE best management for this patient?
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Question 27 of 104
27. Question
A 45 year old man is scheduled to have an elective anterior resection of the rectum. What is the SINGLE most appropriate antibiotic prophylaxis regimen?
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Question 28 of 104
28. Question
A 35 year old diabetic man on insulin is booked in for an elective hernia operation. What is the SINGLE most appropriate management plan for his diabetes on the day of the surgery?
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Question 29 of 104
29. Question
A 15 year old girl is about to be discharged from the hospital after an uncomplicated appendicectomy 24 hours ago. She is experiencing mild pain at the surgical site. She is currently in the surgical ward. She has a temperature of 37.3°C, heart rate of 80 beats/minute, blood pressure of 100/70 mmHg, respiratory rate of 20 breaths/minute and an oxygen saturation of 99%. There are no signs of abdominal rigidity. What is the SINGLE most appropriate management?
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Question 30 of 104
30. Question
A 61 year old man is brought to Accident & Emergency by paramedics. His wife called the ambulance after her husband started complaining of colicky abdominal pain. He has been vomiting several times today. The patient gives a six-day history without the passage of stool or flatus. He has a history of an abdominal surgery following a gunshot wound 2 years ago. Examination reveals an ill-looking individual who lies absolutely still and reluctant to move. An abdominal examination reveals a generalised tender and distended abdomen. Percussion reveals a tympanic sound. Auscultation reveals hyperactive and high-pitched bowel sounds. An upright abdominal X-ray demonstrates the distended loops of bowel with multiple fluid levels visible. Pain relief and intravenous fluids have been started in the department. What is the SINGLE most appropriate next course of action for this patient?
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Question 31 of 104
31. Question
A 35 year old woman attends the hospital with worsening abdominal pain. She underwent an uncomplicated laparoscopic cholecystectomy 10 days ago as a day case. Her pain is localised at the right upper quadrant. She has a BMI of 21 kg/m2. She has had no other abdominal surgeries before the cholecystectomy. She has a temperature of 39.1°C, a heart rate of 110 beats/minute, respiratory rate of 22 breaths/minute and a blood pressure of 150/95 mmHg. She is guarding at the right upper quadrant. Blood results show:
Haemoglobin 141 g/L (130-180)
White cell count 21 x 109/L (4-11)
Platelets 350 x 109/L (150-400)
Sadium 142 mmol/L (135-145)
Potassium 3.9 mmol/L (3.5-5)
Urea 6 mmol/L (2.0-7)
Creatinine 88 μmol/L (70-150)
eGFR >90 mL/min
CRP 238 mg/L (<10)
Bilirubin 10 μmol/L (3-17)
Serum alanine transferase (ALT) 32 U/L (5-35)
Serum alkaline phosphatase (ALP) 110 U/L (30-150)
Amylase 120 U/L (0-140)
What is the SINGLE most appropriate investigation?
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Question 32 of 104
32. Question
A 45 year old man underwent a hemicolectomy 2 days ago for Crohn’s disease. He develops sudden shortness of breath and chest discomfort. He has been given continuous parenteral morphine for pain relief. His respiratory rate is 30 breaths/minute, heart rate is 120 beats/minute, blood pressure is 110/80 mmHg and oxygen saturation is 87%. What is the most appropriate management?
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Question 33 of 104
33. Question
A 55 year old man with cirrhosis of the liver complains of tiredness and right upper quadrant pain over the last few months. He has lost 8 kg in the last 2 months. The liver is palpable on abdominal examination. What is the SINGLE most appropriate investigation?
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Question 34 of 104
34. Question
A 58 year old lady with a medical history of type 1 diabetes mellitus has a tender lump near the anal opening which has been increasing in size for the last 3 weeks. She complains of constipation and throbbing pain when she sits down. She has a temperature of 38.1°C. The mass is seen to be swollen, erythematous and tender at the edge of the anus. What is the SINGLE most appropriate management?
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Question 35 of 104
35. Question
A 35 year old construction worker is diagnosed with indirect inguinal hernia. Which statement below best describes indirect inguinal hernias?
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Question 36 of 104
36. Question
A 40 year old man presents to the urgent care centre with passing blood per rectum. He passed blood rectally 2 weeks ago and again today. Both episodes occurred while he was straining in the toilet. He managed to defecate first which was followed by splashes of blood into the toilet bowl. On examining the picture taken by the patient, there is evidence of bright red blood splashed around the sides of the toilet bowl. He does not have any abdominal or rectal pain. His observations are within normal limits. A digital rectal examination reveals an empty rectum with no blood on the glove. What is the SINGLE most appropriate diagnosis?
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Question 37 of 104
37. Question
A 60 year old man is readmitted into the hospital following severe abdominal pain and the passage of bloody stools. He describes the pain as cramp-like with a gradual onset. He had a myocardial infarction 2 days ago which was treated with thrombolysis. His regular medications include taking azathioprine for Crohn’s disease. He has a temperature of 37.5°C and a heart rate of 90 beats/minute. What is the most likely reason for his abdominal pain and bloody stools?
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Question 38 of 104
38. Question
A 40 year old manual worker presents with a swelling in the groin. He says he noticed the appearance earlier today and it is accompanied by pain. On examination, a mass is found to be just above and lateral to the pubic tubercle. On examination, the mass is reducible and impulse on coughing is seen. What is the SINGLE most likely diagnosis?
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Question 39 of 104
39. Question
A 40 year old female underwent a laparotomy one week ago. On day 6 post-operatively. you are asked to review her by the nurse in charge. The patient complains that she has not been able to open her bowels since the operation and that she has vomited twice since yesterday. Her past medical history includes hypertension, diagnosed two years ago, for which she takes ramipril. She has a twenty pack year smoking history. She does not drink alcohol at all. On examination, the patient appears to be anxious and uncomfortable. She is also noted to be overweight. She has a distended abdomen and no bowel sounds can be auscultated. There is no tenderness on palpation, apart from some mild discomfort around the laparotomy site. A plain X-Ray of her abdomen revealed gas distributed throughout the small and large gut. Minor fluid levels were seen on an erect abdominal X-Ray. Her vitals are as follows:
Blood pressure 130/82 mmHg
Heart rate 90 beats/min
What is the SINGLE next best step to manage this patient?
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Question 40 of 104
40. Question
A 64 year old man has just had major abdominal surgery. He is not a known smoker and takes no chronic medications. His post-operative pain is being effectively controlled with epidural analgesia. Ten hours post-operatively, he was noticed to have only passed 30 ml of urine in his catheter bag. The patient is otherwise alert, oriented and well. His blood pressure is 100/60 mmHg and his pulse rate is 90 beats/minute. What is the SINGLE most appropriate initial step for this patient?
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Question 41 of 104
41. Question
A 62 year old woman presents to the Emergency Department with per rectal bleeding that started yesterday but has been ongoing. She reports this as dark red blood. On taking a full history, she states that she has painful defecation. In the last 2 months, she has noticed a change in bowel habit. Her blood tests show.
Haemoglobin 91 g/L
White cell count 8.9 x 10^9/L
Neutrophils 3.1 x 10^9/L
Platelets 310 x 10^9/L
What is the SINGLE most likely diagnosis?
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Question 42 of 104
42. Question
A 24 year old man presents to the GP with a swelling in the left scrotal area which has progressively become more obvious over the past few months. The swelling causes mild discomfort. He is able to notice the swelling when he is standing up, but the swelling disappears when he is lying flat. While examining him in the standing position, a swelling can be palpated at the left scrotal region. The superior surface of the swelling cannot be palpated. What is the most likely diagnosis?
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Question 43 of 104
43. Question
A 72 year old man presents with intermittent difficulty in swallowing with regurgitation of stale food materials. Lately, he has been having a chronic nocturnal cough. What is the SINGLE most likely diagnosis?
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Question 44 of 104
44. Question
You are asked to review a 70 year old man had a right hemicolectomy for caecal carcinoma 4 days ago as he has abdominal distension and recurrent vomiting. He has not opened his bowels since the surgery. On auscultation, there are no bowel sounds present and the abdomen looks distended. He has a temperature of 37.3°C and a heart rate of 90 beats/minute. A plain X-ray of the abdomen shows dilated small bowels. A full blood count was done of which results show.
White cell count 9 x 10^9/L
Haemoglobin 120g/L
What is the SINGLE most appropriate next management?
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Question 45 of 104
45. Question
2 hours after an appendectomy, a 33 year old man complains of feeling unwell, having abdominal pain. He has a pulse of 128 beats/minute, a blood pressure of 88/55 mmHg and a respiratory rate of 32 breaths/minute. What is the SINGLE most likely reason for his observations?
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Question 46 of 104
46. Question
A 59 year old man presents to the Emergency Department with abdominal pain which started 18 hours ago. The pain had gradual onset which initially started at the left abdomen associated with nausea. His medical history includes heart failure, diabetes and hypertension. On examination, his abdomen has generalised tenderness. A digital rectal examination shows blood per rectum. He has a heart rate of 80 beats/minute, blood pressure of 150/80 mmHg and a temperature of 37.9°C. What is the SINGLE most likely diagnosis?
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Question 47 of 104
47. Question
A 55 year old man has been admitted for an elective herniorrhaphy. He has a history of asthma which he takes salbutamol and inhaled corticosteroids. He was admitted twice to ICU for asthma exacerbations 10 and 12 months ago. His medical history includes a myocardial infarction 2 months ago. His BMI is 31 kg/m2. He has a deep vein thrombosis 2 years ago. He has a blood pressure of 155/95 mmHg. Which among the following is the SINGLE most likely reason to postpone his surgery?
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Question 48 of 104
48. Question
A 27 year old woman attends her GP surgery on Remembrance Day for a routine check- up. She is now nine months post-splenectomy. All her pre-splenectomy vaccines were given appropriately. Which vaccine is still required for this patient?
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Question 49 of 104
49. Question
A 60 year old man has difficulty in swallowing. He has regurgitation of undigested food and bad breath. He has been coughing a lot lately. He has lost some weight during the last couple of months and is concerned about oesophageal cancer. What is the SINGLE most appropriate initial investigation?
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Question 50 of 104
50. Question
A 63 year old female patient presents to Accident & Emergency (A&E) with the complaint of profuse rectal bleeding. She describes having had the urge to defecate but passing a large volume of bright red blood instead. The patient also complains of a 2-day history of left lower abdominal pain which is exacerbated by eating. She last opened her bowels a day ago with loose stools. She feels nauseous but has not vomited. The patient describes her diet as consisting of mainly canned meat products. An abdominal examination reveals localised tenderness in the left lower quadrant with normal bowel sounds. However, there is no guarding or rebound tenderness. A rectal examination shows presence of blood on the examiners glove. The patient’s observations are as follows:
Blood pressure 87/56 mmHg
Heart rate 102 beats/minute Temperature 38.1°C
Oxygen saturation 99% on room air
Respiratory rate 20 breaths/minute
What is the SINGLE most appropriate management for this patient?
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Question 51 of 104
51. Question
A 52 year old man has hoarseness of voice following a thyroid surgery a week ago. There has been no signs of improvement. What is the SINGLE most likely anatomical structure(s) involved?
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Question 52 of 104
52. Question
A 25 year old woman with longstanding constipation has severe anorectal pain an defecation. She notices streaks of blood that covers her stool. Rectal examination is impossible to perform as she is in such great pain. She recalls that the symptoms started followed a particular episode of sharp intense pain on defaecation. What is the SINGLE most likely diagnosis?
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Question 53 of 104
53. Question
A 31 year old previous healthy gym instructor was involved in a road traffic accident. He sustained an intra-capsular fracture of his femur requiring an operation. A hemi- arthroplasty is performed and he is admitted to the orthopaedic ward. What is the most likely complication he can suffer from?
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Question 54 of 104
54. Question
What anatomical structure is pierced during a midline port insertion during a laparoscopic cholecystectomy?
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Question 55 of 104
55. Question
A 27 year old woman presents to Accident & Emergency with the complaint of right upper quadrant pain. She has no other complaints and is experiencing no ather symptoms. Her past medical history is significant for gallstone disease as confirmed on ultrasound. Her last episode of biliary colic was three years ago, for which she received analgesia. Each episode of pain that she has presented with in the past has been managed successfully with morphine and has resolved completely after treatment with analgesia. Her medical notes show that the last ultrasound that she had shows an increased common bile duct diameter. What is the SINGLE most appropriate initial investigation for this patient?
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Question 56 of 104
56. Question
A 14 year old boy was brought to the hospital by his parents because of a painful swelling located in his neck. Physical examination revealed that the swelling is located in the midline of his neck below the hyoid bone just in front of the trachea. It was also established that the mass is a palpable non-tender mobile fluid filled lump that moves upwards on swallowing and on protrusion of the tongue. It was measured to be about 1.5 cm in diameter. After a thorough history and physical examination had been performed, the patient was suspected to have a thyroglossal cyst. What is the SINGLE most appropriate investigation to perform?
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Question 57 of 104
57. Question
A 72 year old man is seen in the GP clinic for his annual medication review. He takes amlodipine and metformin. His recent blood results show the following:
Haemoglobin 89 g/L (130-180)
Mean cell volume (MCV) 70 fL (76-96)
Ferritin 10 ng/ml (20-300)
He denies any blood in his stool. He has no family history of colorectal cancer. He was referred by the GP for suspected colorectal cancer. If this patient did indeed have colorectal cancer, where would the tumour likely be?
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Question 58 of 104
58. Question
A 60 year old woman has been having occasional stools with blood for the past 6 months. She denies abdominal pain. She opens her bowels regularly daily. She weighed 55 kg 6 months ago. She now weighs 52 kg. She continues to have a good appetite. The results of her stool microscopy and culture are normal. Her abdominal and rectal examinations in the clinic are unremarkable. What is the SINGLE most appropriate action?
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Question 59 of 104
59. Question
A 34 year old man has a “dragging sensation” felt at his scrotum with a palpable mass at his left scrotum. The mass is reducible. He has a history of an appendicectomy 5 years aga. An increase in swelling of the mass is palpable when he coughs. What is the likely diagnosis?
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Question 60 of 104
60. Question
A 41 year old woman attends the Emergency Department with a painful right groin that started two days ago. She noticed a lump coming out of her groin. She has vomited several times in the morning and feels bloated. She has not been able to open her bowels for the past day but has managed to pass flatus. On examination, there is abdominal distension and an irreducible mass below the inguinal ligament on the right groin. There is a cough impulse present. What is the SINGLE most likely diagnosis?
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Question 61 of 104
61. Question
A 57 year old man complains of symptoms of vomiting, tiredness, and palpitations. He has lost 8 kg in the last 3 months. On examination, hepatomegaly and ascites is noted. He has a palpable left supraclavicular mass. Records show that he is blood group A. What is the SINGLE most likely diagnosis given the symptoms and risk factors?
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Question 62 of 104
62. Question
A 67 year old male is brought to Accident & Emergency by paramedics. His wife called the ambulance after her husband started complaining of colicky abdominal pain. The patient gives a five-day history without the passage of stool or flatus. Examination reveals an ill-looking elderly male who lies absolutely still and reluctant to move. An abdominal examination reveals a tender and distended abdomen. Auscultation reveals hyperactive and high-pitched bowel sounds. A digital rectum exam reveals an empty rectum. An upright abdominal X-ray demonstrates the presence of multiple air-fluid levels. Pain relief and intravenous fluids were started in the department. What is the SINGLE most appropriate next course of action for this patient?
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Question 63 of 104
63. Question
A 24 year old woman attends Accident and Emergency complaining of abdominal pain, nausea and vomiting for the past 24 hours. The pain is constant and started yesterday in the right lower quadrant of her abdomen. The pain became worse during the night and she woke up to severe pain in the right lower quadrant. She vomited once but had been feeling nauseous throughout the day yesterday. On observation, she is of a slim build and is in obvious discomfort. She is pyrexial with a fever of 37.9°C and a heart rate of 98 beats/minute. Her blood pressure is 120/80 mmHg. On examination, there is pain on palpation of her right iliac fossa. Blood analysis revealed a white cell count of 14 x 109/L and a CRP of 50. Her pregnancy test is negative. She is given analgesia, IV fluids, antibiotics, antiemetics and is kept nil by mouth. What is the SINGLE most appropriate next step in management?
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Question 64 of 104
64. Question
A 72 year old man has been vomiting continuously over the past 4 days. He has vomited every single meal. He has been admitted to the hospital. He is on the surgical list for a total gastrectomy for non-metastatic gastric carcinoma that will be performed in a few days. He is malnourished and pale. He was 70 kg a month ago, but he now weighs 50 kg. On examination, there is a palpable mass at the epigastrium. His blood tests show the following:
Haemoglobin 90 g/L (130-180)
White cell count 12 x 10^9/L (4-11)
Platelets 350 x 10^9/L (150-400)
Sodium 132 mmol/L (135-145)
Potassium 3.3 mmol/L (3.5-5)
Urea 12 mmol/L (2.0-7)
Creatinine 151 μmol/L (70-150)
eGFR 60 mL/min (>90)
Which is the most appropriate method to provide preoperative nutrition?
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Question 65 of 104
65. Question
A 35 year old woman presents to the GP surgery with complaints of passing blood per rectum. She complains of a 3 month history of bright red blood not mixed with stools on wiping using toilet paper. Occasionally, she sees blood splashed in the toilet pan when trying to defecate. She finds it difficult to pass stools and often has to strain to empty her bowels. She does not have any rectal pain with the bleeding. On examination, her perineum is normal. There is no mass felt while doing a digital rectal examination and the rectum is empty. The gloved finger is not stained with blood. What is the most appropriate investigation to refer to?
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Question 66 of 104
66. Question
A 75 year old man attends the surgical outpatient clinic with the feeling of incomplete defecation with alternating diarrhoea and constipation over the past 5 months. His motions have been looser with mucous over the past few weeks and there is passage of blood clots mixed within the stool. On examination, his abdomen is soft and non-tender with no palpable masses. A digital rectal examination revealed no mass. What is the SINGLE most likely diagnosis?
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Question 67 of 104
67. Question
You are working as a Foundation Year (FY2) doctor in the surgical department. A 65 year old man is in the ward following resection of an adenocarcinoma in his descending colon. During the operation, the surgeon also opted to do a left hemicolectomy. On the tenth postoperative day, he suddenly developed left abdominal pain. By the time he had alerted the nurse to his pain, three hours had already lapsed. The pain is severe and dull in nature and worsens when he moves or turns to his sides. There is no associated nausea or vomiting. His past medical history is significant for a background of chronic obstructive pulmonary disease (COPD) of which part of his medications include oral steroids. He also has a thirty pack-year smoking history. Upon physical examination, the patient appears to be anxious and lethargic. Abdominal examination reveals an area of tenderness at his left lower quadrant but no rigidity or guarding is present. Bowel sounds are sluggish. His vitals are as follows:
Temperature 37.8°C
Blood pressure 130/82 mmHg
Heart rate 100 beats/minute
What is the SINGLE most likely cause of his pain?
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Question 68 of 104
68. Question
During a routine colonoscopy for colorectal cancer screening, a 64 year old man was found to have grade 3 haemorrhoids. On questioning after the procedure, he says that the haemorrhoids do not cause any pain or rectal bleeding. What is the SINGLE most likely management?
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Question 69 of 104
69. Question
A 50 year old man is seen in the pre-assessment clinic for an elective herniorrhaphy in a week. He has been having pain around the hernia and abdominal discomfort. He is able to open his bowels without problems. His medical history includes a myocardial infarction 2 months ago. He takes dabigatran for prophylaxis of recurrent deep-vein thrombosis which his last DVT was 3 years ago. His recent blood test show.
Haemoglobin 120 g/L (130-180)
Which SINGLE best criteria would lead to his elective procedure being postponed?
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Question 70 of 104
70. Question
A 60 year old man presents with a lump in the left supraclavicular region. He complains of reduced appetite and he has lost 7 kg in the last two months. What is the SINGLE most probable diagnosis?
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Question 71 of 104
71. Question
A 32 year old man is about to undergo an elective inguinal hernia surgery. His blood tests show:
Haemoglobin 82 g/L
Mean cell volume 70 fL
White cell count 5 x 10^9/L
Platelets 180 x 10^9/L
What is the SINGLE most appropriate next action?
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Question 72 of 104
72. Question
A 49 year old woman with a background of complicated Crohn’s disease has been having vaginal discharge of faecal material and vaginal passage of flatus. She also has significant weight loss and is malnourished. A fistula is suspected between the bowels and the vagina. What is the most likely structure involved in the formation of the fistula with the vagina?
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Question 73 of 104
73. Question
A 57 year old male presents with sudden onset of severe abdominal pain, nausea and vomiting. The pain initially started as left lower quadrant pain but is now generalized. He has a temperature of 38.9° C and a pulse of 135 beats/minute. On examination, his abdomen has generalized guarding and rigidity. He has no past medical or surgical history of note and he is not taking any regular medications. What is the SINGLE most likely diagnosis?
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Question 74 of 104
74. Question
A 60 year old man has right upper quadrant discomfort. He has lost 10 kg in the last 4 months. On examination, a palpable liver with nodularities was found. Three years ago, he had a right hemicolectomy for a colorectal cancer. What is the SINGLE most appropriate tumour marker to investigate?
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Question 75 of 104
75. Question
A 46 year old woman presents to her local GP with the primary complaint of yellowing of her eyes and skin. She says that her son, who works in the United States, noticed it first when he visited home last week and she is now seeking medical advice upon his insistence. On further questioning, the patient reveals that she has also been suffering from constant back pain for the past few months. She thinks that her back pain is from an old university hockey injury that she sustained when she was a young woman. She admits that the back pain keeps her up at night. She also admits that she has noticed a drastic 10 kilogram weight loss in the past five weeks but thinks that is due to her not having much of an appetite anymore. The patient smokes 12 cigarettes a day and has smoked for the past eighteen years. She admits to drinking alcohol more than average on a weekly basis. She has worked for over twenty years in the NHS as a nurse but is now on sabbatical. She reports no complaints in her private or professional life. Upan physical examination, the patient appears cachectic. There is marked yellowing of her sclera and her skin. There are numerous scratch marks on her torso and limbs. When questioned about them, the patient admits to feeling itchy constantly. Abdominal examination reveals a palpable mass just beneath the liver. Blood tests were done and the results are as follows:
Bilirubin 28 μmol/L (3-17)
Alanine transferase (ALT) 76 U/L (5-35) Aspartate transaminase (AST) 73 U/L (5-35)
Alkaline phosphatase (ALP) 329 U/L (30-150)
Gamma glutamyl transferase (GT) 346u/L (8-60)
A random capillary blood glucose test shows her blood glucose level to be 18 mmol/L.
What is the SINGLE most likely diagnosis for this patient?
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Question 76 of 104
76. Question
A 14 year old boy is seen in the Emergency Department after a blunt abdominal injury from falling off his bicycle. He has bruises on his left abdomen. On examination, his abdomen is very tender. He has a heart rate of 90 beats/minute, a blood pressure of 100/70 mmHg, respiratory rate of 22 breaths/minute and oxygen saturation of 98%. An emergency CT with contrast of his abdomen and pelvis was requested which report shows a grade 2 splenic injury with subcapsular splenic haematoma with no evidence of active contrast extravasation. What is the SINGLE most appropriate action?
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Question 77 of 104
77. Question
A 38 year old man underwent a left total nephrectomy a few hours ago for renal cell carcinoma. He now complains of feeling unwell. The wound dressing is heavily soaked with blood and there is blood all over the bedsheets as well. He has a heart rate of 121 beats/minute, blood pressure of 74/40 mmHg and a respiratory rate of 30 breaths/minute. After the administration of 1 litre of 0.9% normal saline, his blood pressure rises to 100/70 mmHg. What is the most appropriate intravenous resuscitation for this patient?
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Question 78 of 104
78. Question
A 61 year old man has just had a pancreaticoduodenectomy. A five hours after his operation, the nurse realises that he has not been passing urine. He has a urinary catheter and his drainage bag shows a total of 80 mls. The records show that during the first hour the drainage bag had 35 ml and the second hour, it had 79 ml and the third hour it had 80 ml. His blood pressure is 130/80 mmHg, heart rate is 70 beats/minute, respiratory rate is 22 breaths/minute and oxygen saturation is 98%. What is the SINGLE most likely reason for his clinical presentation?
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Question 79 of 104
79. Question
A 35 year old woman who is day 1 post caesarean section complains of inability to void. She denies dysuria but complains of fullness. She was given an epidural for analgesia. What is the SINGLE most appropriate investigation?
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Question 80 of 104
80. Question
A 62 year old lady with family history of ovarian carcinoma. A pelvis ultrasound scan reveals a complex mass that is 7 cm by 5 cm in the left adnexa. What is the SINGLE most appropriate tumour marker to request for?
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Question 81 of 104
81. Question
A 25 year old man with confirmed testicular cancer attends your clinic for the results of the histopathology report. A radical orchiectomy was performed one month ago. He is complaining of a painful swelling in the groin. On examination, the swelling appears to be located superior to the inguinal ligament and medial to the pubic tubercle. What is the most likely diagnosis?
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Question 82 of 104
82. Question
A 32 year old woman starts bleeding profusely in theatre during an elective caesarean section. She had a spinal block and was awake throughout the procedure. She is now found to be unconscious on the theatre table. Her blood pressure has dropped to 70/40 mmHg. What is the SINGLE most likely diagnosis?
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Question 83 of 104
83. Question
A 22 year old man attends the Surgical Assessment Unit with worsening cramping abdominal pain. The pain started a week ago and has gradually worsened. He has been having an estimate of 10 diarrhoea episodes a day. On examination, a palpable mass can be felt at the right lower quadrant of his abdomen. His abdomen is tender. He has a temperature of 38.2°C, a respiratory rate of 25 breaths/minute, a heart rate of 89 beats/minute and blood pressure of 120/69 mmHg. His blood results show the following:
Haemoglobin 129 g/L (130-180)
White cell count 26 x 10^9/L (4-11)
Platelets 539 x 10^9/L (150-400)
CRP 282 mg/L (<10)
Serum urea 14 mmol/L (2.0-7)
Serum creatinine 143 μmol/L (70-150) eGFR >90 mL/min
He was started on intravenous antibiotics. His medical history includes Crohn’s disease which was diagnosed 2 years ago. What is the SINGLE most appropriate investigation?
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Question 84 of 104
84. Question
A 30 year old lady has a long history of dysphagia especially when eating solid foods. Her symptoms of dysphagia has been worsening over the past few months. She notices that she regurgitates stale fluid. She also suffers from an on going nocturnal cough that started several months ago. What is the SINGLE most likely diagnosis?
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Question 85 of 104
85. Question
A 61 year old Canadian man registers to the GP surgery in the UK. He has recently moved to the UK and would like to know which cancer screening test is available in the UK for him?
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Question 86 of 104
86. Question
A 65 year old diabetic man has an anterior resection for carcinoma of the rectum. 6 days after surgery he experiences worsening abdominal pain and develops a fever. His heart rate is 101 beats/minute, his temperature is 39°C and his blood pressure is 110/80 mmHg. On examination, there is a generalized abdominal tenderness. What is the SINGLE most appropriate investigation?
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Question 87 of 104
87. Question
A 49 year old lady had a colostomy closure 4 days ago. She now comes with fluctuating small swelling in the stoma. Her temperature is 37.9°C, respiratory rate is 18/min, pulse rate is 80 bpm. What is the SINGLE most appropriate management?
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Question 88 of 104
88. Question
A 33 year old man has undergone an elective open inguinal hernia repair as a day case He has a normal body mass index and is usually fit and healthy. What is the SINGLE most appropriate management for venous thromboembolism prophylaxis?
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Question 89 of 104
89. Question
A 41 year old pregnant woman presents to A&E with right upper quadrant pain that started in the last 12 hours and is gradually worsening. She has dark urine and pale stools for the last 2 days. She is noted to have a yellow sclera on examination. Her blood pressure is 145/95 mmHg. What is the SINGLE most appropriate investigation?
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Question 90 of 104
90. Question
A 42 year old man had an open appendicectomy 3 days ago. He now has increasing abdominal discomfort and complains of bloating. He was encouraged to stay well hydrated but he is still unable to pass gas. There are no bowel sounds heard. He has mild generalised abdominal tenderness on palpation. Blood test have been requested which show the following:
Haemoglobin 138 g/L (130-180)
White cell count 11 x 10^9/L (4-11)
Platelets 320 x 10^9/L (150-400)
Sodium 131 mmol/L (135-145)
Potassium 2.5 mmol/L (3.5-5)
Calcium 2.02 mmol/l (2.1-2.6)
Urea 2 mmol/L (20-7)
Creatinine 72 μmol/L (70-150)
eGFR >90 mL/min
What is the SINGLE most likely cause of his discomfort?
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Question 91 of 104
91. Question
A 65 year old man presents with severe lower left abdominal pain that started 2 days aga. He has been feeling nauseous. He last defecated 3 days ago. A CT scan a few years ago showed evidence of diverticula disease. He has a blood pressure of 120/80 mmHg, a heart rate of 100 beats/minute, a respiratory rate of 21 breaths/minute and a temperature of 39.1°C. On examination, he is tender at the left iliac fossa with guarding. He has active bowel sounds. He is started on intravenous antibiotics and intravenous fluids. What is the SINGLE most likely outcome in a few days?
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Question 92 of 104
92. Question
A 55 year old woman recovering from a surgery for a toxic goiter is found to be cyanosed in the recovery room. Her neck is tense and her blood pressure is 85/45 mmHg. There is blood oozing from the drain. What is the SINGLE most likely diagnosis?
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Question 93 of 104
93. Question
A 34 year old diabetic man has a positive family history for colon cancer. He is a smoker and smokes 8 cigarettes a day. He also consumes in excess of 30 units of alcohol per week. Due to the pressures of his job, he is only able to exercise once a month. Which of the following carries the SINGLE greatest risk for colon cancer?
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Question 94 of 104
94. Question
A 49 year old female presents with right upper quadrant pain radiating to the right shoulder. An ultrasound establishes the diagnosis of gallstones. Her BP is 120/85 mmHg: respiratory rate 15/min; Heart rate 85 bpm; Temperature 37.3°C; WBC 9 x 109/L. What is the SINGLE most appropriate management?
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Question 95 of 104
95. Question
A 65 year old man presented to the Emergency Department complaining of abdominal pain which began 3 days ago and has worsened since. He also complains of feeling unwell in general and developed a fever the previous evening. He reports having undergone surgery and his records confirm that he underwent a lower anterior resection a week ago for rectal cancer. On examination, he appears grossly unwell, has a blood pressure of 100/60 mmHg, pulse rate of 110 beats/minute and a temperature of 38°C. On examination, generalised tenderness and guarding are appreciated. Which of the following is the most appropriate investigation for this patient?
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Question 96 of 104
96. Question
A 38 year woman post cholecystectomy on the surgical ward complains of blurred vision and nausea. Her surgery was completed 6 hours ago. She is conscious but is confused as to her orientation to place. Her BP is 105/70 mmHg, pulse of 96 bpm, temperature is 37.5° C and respiratory rate of 8 breaths/minute. Auscultation reveals bilateral vesicular breathing which is more pronounced on inspiration. What is the most likely cause of her symptoms?
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Question 97 of 104
97. Question
A 39 year old woman has been having tingling and numbness of her thumb, index and middle fingers for a while. She has been treated with local steroids but there was no improvement. She has planned to undergo a surgical procedure. What is the SINGLE most likely structure to be incised?
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Question 98 of 104
98. Question
A 52 year old diabetic man comes with complaints of severe pain in his anus. The pain started a week back and has gradually increased in severity. The pain is throbbing in nature and is particularly worse when he sits down and right before a bowel movement. On examination, there is a tender palpable mass noted in the perianal region with erythematous changes on the overlying skin. He has a pulse rate of 90 beats/minute and a temperature of 37.5°C. What is the SINGLE most appropriate management?
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Question 99 of 104
99. Question
A 63 year old man presents with severe lower abdominal pain that started 2 days ago. He has nausea and vomited once a few hours ago. He suffers with longstanding constipation. He last defecated 2 days ago. He has a blood pressure of 120/80 mmHg, a heart rate of 100 beats/minute, a respiratory rate of 21 breaths/minute and a temperature of 39.3°C. On examination, he is tender at the left iliac fossa with guarding. What is the SINGLE most appropriate action?
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Question 100 of 104
100. Question
A 44 year old woman with a background of complicated Crohn’s disease started having foul-smelling feculent discharge from her vagina. A fistula is suspected between the bowels and the vagina. What is the most likely structure involved in the formation of the fistula with the vagina?
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Question 101 of 104
101. Question
A 55 years old man who used to work as a gym trainer presents to the GP surgery with an annoying lump in his grain for a few months. On examination, a soft tissue mass is found below the inguinal ligament and lateral to the symphysis pubis. There is no impulse while coughing. There is no erythema. There is mild tenderness on palpation. He has a history of an orchiectomy operation several years ago for testicular cancer. What is the most likely diagnosis?
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Question 102 of 104
102. Question
A 49 year old man had a sigmoid colectomy 48 hours ago. He is recovering well and has been apyrexial since the operation. His blood results postoperatively show a CRP of 75 and a white blood cell count of 13 x 10^9/L. He is mobilising well and has started oral fluids and a light diet. He has no further complains besides a mild abdominal discomfort. On examination, he has a soft, non tender abdomen. His surgical wounds are dry. What is the SINGLE most appropriate management?
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Question 103 of 104
103. Question
A 73 year old woman was referred to the surgical assessment unit by her GP. She complains of worsening dull, aching epigastric pain that radiates to her upper lumbar region over the past few months. She has noticed recent dark urine and pale stools over the preceding month. Her stools are difficult to flush. Her appetite is slightly reduced and she has noticed that her clothes are becoming loose. Her past medical history is significant for non-insulin dependent diabetes mellitus which was diagnosed 5 years ago. She enjoys a glass of wine on most days. On examination, her conjunctiva appears yellow. There is mild tenderness in the epigastric region. Her blood tests are as follows:
Haemoglobin 125 g/L (115-160 g/L)
White cell count 13 x 109/L (4-11 x 109/L)
Bilirubin 81 μmol/l (1-14μmol/l)
Alkaline phosphatase 250 IU/I (4-105 IU/)
Aspartate transaminase 101 IU/L (5-35 IU/L)
Albumin 38 g/L (35-50 g/L)
What is the SINGLE most appropriate investigation?
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Question 104 of 104
104. Question
A 72 year old male is due for a lower anterior resection of the colon due to colorectal carcinoma. What is the SINGLE most appropriate prophylactic antibiotic regimen to be given in theatre in his case?
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