Surgery MCQs:

1. 60 year old, Peri anal swelling, diabetic, increase temp, swollen butt, tender and creps 
A. Debride 
B. Incision and drain 
C. Percut drain 
D. Serial aspiration 

2. Female, creps up to knee. Blood glucose 30. Swollen R foot. What would you give her 
A. FFP 
B. Normal saline 
C. 5% dextrose 
D. Calcium bicarbonate 

3. margins for a 0.75 melanoma 

1cm margins as it is a stage one

4. Symptom most indicative of cancer oesophagus 

Progressive dysphagia

5. Female with micro calcifications on mammogram 

A. FNA 
B. Core biopsy 
C. Mammogram 
D. Ultra sound 

6. Treatment of spinal anaesthesia induced hypotension and tachy with nausea 

IV fluids and vasopressors (phenylephrine, norepinephrine, adrenaline and vasopressin

7. Neuro endocrine tumour 

A. Palpable on abdo exam 
B. Most common at rectum 
C. Size and classification predicts prognosis 
D. Resection not indicated in Mets 

8. Management of infra renal Aneurysm 3.5cm

A. Endo vascular 
B. Open surgery 
C. 6 monthly US 
D. CT 

9. 52 male 2 month blood tinged mucus stool, no constipation, no weight loss, no abdo pain, father had a
surgery for piles 
A. Anal carcinoma 
B. Haemorrhoids 
C. Villious adenoma 
D. Proctitis 

10. Mva, multiple bruising.. which electrolyte disturbance 

A. Hyper calcium 
B. Lactic acidosis 
C. Increase K 
D. Decrease sodium 

11. Overweight man 3 day hx of lower abd pain. Temp 37.6 . Intermittent constipation 
A. Acute cholecys
B. Bladder infxn 
C. Acute diverticulitis 
D. Feacal impaction 

12. 1 day old. Bile stained vomitus 

A. Pyloric stenosis 
B. Duodenal atresia (double bubble)
C. Intestinal malrotation 
D. Jej atresia 

13. 21 year old from Zim. One day vomiting of blood and clots and dark stool. Pale and distended abdomen
and shifting dullness. WCC 13.2 HB 6.4 MCV 64.5 platelet 74 . LFT normal 
A. Gastric ulcer 
B. Gastric varices
C. Duodenal ulcer 
D. Oesophageal varices 

14. Alcoholic vomiting blood . BP 80/60 . Pulse 110. Distended abdo veins and PR blood 
A. B blocker 
B. Endoscope treatment 
C. PPI 
D. Laparotomy

15. Anaemic, increase BP, HB 10 ferritin 10 

A. Faecal occult blood 
B. Cea 
C. Upper and lower scope 
D. CT abdomen 

16. Claudication 200m. Smoker and hypertensive. No pulses below femoral. ABI 0.7 cholesterol 6.5 
A. Angioplasty and exercise 
B. Angio and stent 
C. Anti lipid and exercise and stop smoking 
D. Exercise and lifestyle 

17. 56 male. LOW and bloating and cramps. Daily alcohol. Offensive stool and fail to flush. Glucose 9 (high)
A. Increase lipids 
B. Acute pancreatitis 
C. Chronic pancreatitis 
D. Pancreases adenoma 

18. Acute pancreatitis. Respiratory distress and oedema. 10ml urine 4 hours 
Management
Oxygen via face mask, fluids (most probably ringers)

19. 4 year old drank bleach 

A. Vomiting encouragement 
B. Give water 
C. Endoscope 
D. NGT 

20. 82 year old, rib fractures 6.7.8 .. no flail chest or heamo/pneumo

A. Analgesia and physio (3 or more fractured ribs you don’t discharge)
B. Oral analgesia and discharge 
C. Discharge after intercostal block 
D. Abo and discharge 

21. 3 day post appendix. Temp 38.3 . Suprapubic tenderness and diarrhoea 
A. Leaking stump
B. Abscess 
C. Bladder infection (diarrhoea and fever are common and self-limiting, suprapubic pain)
D. Supp peritonitis 

22. Femur fracture on traction. No pulse 

A. Elevate leg 
B. Surgical exploration 
C. Doppler 
D. Angiogram 

23. Hyper parathyroidism pathology 

A. Adenoma
B. Carcinoma 
Can’t remember the other two options 

24. Arrhythmias and anaesthetic - Halothane

25. 3 week old vomiting, investigations showed contrast didn't go past a certain point and vomiting contrast.
Treatment 
A. Contrast enema 
B. Trail PPI 
C. Emergency lap 

26. Parotid cysts- bilateral - 

A. Eliza 
B. Gene 
C. FNA 

27. cause of widened mediastinum in a trauma patient 

Aortic rupture

28. Pregnant lady with graves. Management

Propylthiouracil (PTU) or surgery

29. Risk factor for gastric ca that showed signet ring cells on histo
Shows diffuse type of adenocarcinoma therefor familial

30. Surgical management of a thyroglossal cyst 

Sistrunk procedure

31. Mobile mass on femoral triangle. Overlying skin normal 

A. Synovial sarcoma 
B. Rhabdosarcoma 
C. Angiosarcoma 
D. Lipoma 

32. Cancer staging for breast 

33. During thyroidectomy. Patients BP and HR increase. What drug would you use next?
Lugol’s iodine
Propylthiouracil
Beta blocker

35. How many hours after a cup of coffee with milk can one have elective sequence 
6 hours
36. Baby, MVA. Chest X-ray shows lung opacification but costeophrenic angles are clear 
A. Pneumonia 
B. Lung contusion 
C. Pleural effusion 

37. Most significant risk cancer for a 74 year old whose niece has cancer 
A. Age 
B. Oral contraceptive 
C. Family history 

38. Old lady burned in shack fire. Difficulty breathing. What to do?
Need for definitive airway (intubation):
Singing of facial hair
Facial burns
Oropharyngeal oedema
Hoarseness of voice
Coughing of soot
Oxygen and intubation

39. Struggling to intubate 

A. Insert LMA 
B. Release cricoid pressure 
C. BMV 

40. How to treat ulcer and varicose veins 

Varicose vein stripping

Staging of an inflammatory breast cancer T4d

The volatile anaesthetic that causes arrhythmias halothane

What imaging you would use for a teenage boy with a lumbar mass MRI

Man with a bilateral parotid cysts  FNA

Guy had trauma with a haemothorax presents 12 days later still with a significant haemothorax-- X-ray, ICD,
bloods

HOP mass 2,5cm—local resection and chemo

Cholangitis—antibiotics with ERCP (stenting and T-tube)

6cm breast mass with ulceration and axillary lymph nodes—stage 3, neoadjuvant chemo and radiation, then
do mastectomy

post total thyroidectomy—T3, TSH, T4

CT scan of an emphysematous pyelonephritis in a diabetic patient 

Management  for a patient presenting with CTLI with tissue loss—angiogram, revascularize, ± amputation

Management of a patient complaining of biliary colic and found to have gall stones—ERCP and the lap
cholecystectomy 

Indication for a thyroidectomy in a patient with long standing goitre—tracheomalacia risk

Management of an elderly lady with varicose veins and a non-healing venous ulcer—varicose vein stripping

Indication for surgery for a grave’s disease patient who came in complaining of red bulging eyes—cannot radio
ablate if orbitopathy

Greatest risk factor for breast cancer in a 74 year old woman with previous contraceptive use /hysterectomy
with hormone replacement and I think smoker—age, female, HRT, smoker

Best modality to confirm diagnosis of a dvt—duplex doppler US

Management of a Breast lesion shown to have micro calcifications—core biopsy

Signs suspicious of malignancy in a thyroid u/s—hypoechogenic, central vascularization, microcalcification,

halo, irregular borders, invasion, elastography

Imaging for a neck mass that moves with swallowing—US

Managing a Tirads 5 thyroid mass—FNA

Biopsy of choice of what looked like a SCC—for anal the wedge biopsy, skin its punch biopsy

Management of elderly lady involved in shack fire and now can’t breathe well—oxygen and intubate

Management of MVA victim with positive FAST scan after being stabilized—exploratory laparotomy

Organ injured in a 7 year old girl who fell from her bike and hit side wall—liver or spleen depending on side

How soon patient can have RSI after having full cup of coffee with milk—as soon as you want, it’s an RSI, if
elective then 6 hours

Child with flu like symptoms abdo pain who later presents with worsening pain and blood in stool—viral
gastroenteritis

Commonest type of hernia in middle aged females—inguinal

Mobile mass with intact overlying skin on femoral triangle—lipoma

Paediatric Lumbar tumours—most commonly glial tumours

A neonate came in after vomiting, investigations showed contrast didn't go past a certain point, what is the
next investigation you'd do—enema

CT scan of what looked like emphysematous pyelonephritis

Treating zollinger elisson—resection and PPI

Parotid cysts- bilateral - diabetes mellitus, endocrinopathy (hypothyroidism), starvation, medications

(thiourea, diuretics), alcohol abuse and heavy metals

Common cause of widened mediastinum in a normotensive patient—thoracic aortic aneurysm or hilar

lymphadenopathy

Indications for goitre removal—compression, cosmetic, pregnant, orbitopathy, failed radioablation, failed
medical management, other thyroid problem or allergy to iodine

Most important risk factor for breast ca—female, age

1. A 42 year old woman underwent lumpectomy and axillary dissection for a 2cm, moderately differentiated,
ER-negative infiltrating ductal carcinoma. Pathologic examination revealed adequate margins, and 1 of 19
lymph nodes was found to be positive for carcinoma. Which of the following treatment plans is most
appropriate? (a) Radiation alone (b) Single-drug chemotherapy and radiation therapy (c) Multidrug
chemotherapy and radiation therapy (d) Multidrug chemotherapy, radiation therapy, and tamoxifen Answer:
[c]

2. In which patient should MRI be used as an adjunct to mammography for breast cancer screening purposes?
(a) A 27 year old woman in whose mother breast cancer was diagnosed at age 52 (b) A 52 year old woman with
dense breasts (c) A 72 year old woman with a history of DCIS (d) A 31 year old woman whose sister carries the
BRCA mutation Answer: [d]

3. Laparoscopic cholecystectomy is most strongly containdicated in which of the following situations? (a)
Previous upper abdominal surgery (b) Known common bile duct stones (c) Chronic obstructive pulmonary
disease (d) Gallbladder cancer Answer: [d]

4. Which of the following is an unfavourable prognostic factor in patients with acute alcoholic pancreatitis? (a)
Initial white blood cell count higher than 16,000/mm3 (b) Elevated serum triglycerides during the initial 48
hours (c) Serum amylase level higher than 1200 iU/L on admission (d) Serum lipase level more than three times
normal Answer: [a]

20. A jaundiced, otherwise healthy patient is noted to have a 3cm mass in the head of the pancreas on CT.
EUS-guided fine-needle aspiration shows cancer. The mass abuts the portal vein, but there is no clear evidence
of vessel involvement or metastatic disease. Which of the following is the most appropriate next step? (a)
MRCP (b) Direct angiography (c) Operative exploration and potential resection (d) Endoscopic placement of a
biliary stent Answer: [c]

1. How to evaluate for vascular injury after a long bone leg fracture
 Assessment:
o Part of the secondary survey:
o Hard signs of vascular injury:
a. Massive external bleeding, absent or diminished pulses, expanding
or pulsatile haematoma, palpable thrill or pulsation, signs of distal
ischaemia (pain, pallor, paraesthesia, paralysis, perishingly cold)
b. These warrant immediate exploration
i. On-table angiogram is performed
 ii. Ischaemic time of muscle is 6 hours (from injury)
o Soft signs:
a. Proximity injury, small, non-pulsatile haematoma, neurological
deficit, history of arterial bleeding
b. Presence of peripheral pulses does not exclude injury
i. Present in 10% of injuries requiring repair
c. These require differential pressure indices (Doppler of systolic BP)
distal to injury
i. Differential index >10% mandates angiogram and predicts
need for surgical repair in 90%
ii. If index <10%: observe for 4 hours and re-evaluate by
differential pressures

2. Which scenario would most likely accompany vascular compromise?

A. Knee dislocation
 (Posterior) Carries a 65% risk of popliteal artery injury
 Other high risk regions:
o Distal femur fracture (displaced)
o Anterior shoulder dislocation
o Supracondylar fracture of the humerus
B. Neck of femur fracture

3. Appendicitis successfully managed conservatively, when should the patient come back?
A. If pain returns
B. 6 weeks for follow-up
C. Wait and do an elective appendectomy

4. Inflammatory breast ca staging

 All inflammatory cancers start as a Stage III (T4d NX M0)
o IIIB: cancer has spread to tissues near the breast, ie the chest wall or skin, including
ribs and muscles in the chest. There may be spread to lymph nodes within the
breast (internal mammary) or in the axilla. No metastatic spread (T4d, N0-2, M0)
o IIIC: cancer has spread to 10 or more axillary nodes, internal mammary nodes
and/or infraclavicular nodes. There is no metastatic spread (T4d N3, M0)
 If there is distant spread, it is a stage IV (T4d, any N, M1)

5. Patient from rural Mpumalanga and RVD reactive, now presents with varices and a palpable spleen.
Liver isn’t palpable, there is no ascites, no jaundice. Likely diagnosis
A. HIV cholangiopathy
B. Schistosomiasis
C. Hepatitis B
D. Hepatitis C

6. What lung pathology do mine workers get?

A. Pneumoconiosis
a. Coal-workers (inhalation of coal dust particles)
B. Silicosis
a. Metal mining, stone quarrying, sandblasting, pottery/ceramic manufacturers

7. Oesophageal ca with hoarseness. Mass is located to the mid-thoracic region. What is the mass
compressing?
A. Right recurrent laryngeal nerve
B. Left recurrent laryngeal nerve
 The left recurrent laryngeal nerve is more susceptible to compression by a tumour than
the right (due to its anatomical location)
 i. The right recurrent laryngeal nerve is more likely injured in thyroid and
parathyroid surgery due to its anatomic location
 Course:
i. Recurrent laryngeal nerves branch off the vagus nerves
1. Left branches at aortic arch
 Passes inferior to the arch of the aorta, immediately lateral to
ligamentum arteriosum and ascends to the larynx in the
groove between the trachea and oesophagus
2. Right at right subclavian artery
 Hooks around the right subclavian artery and ascends
between the trachea and oesophagus
 Runs postero-inferiorly through the superior mediastinum on
the right side of the trachea. It then passes posterior to right
brachiocephalic vein, SVC and the root of the right lung where
it divides into its branches

8. Grade the severity of pancreatitis

 Atlanta classification
Mild Moderate Severe
No organ failure Transient organ failure Persistent organ failure (>48h), single or
(resolves within 48 hours) multiple organ failure
No local or systemic Local complications or Local complications: peripancreatic fluid
complications exacerbation of co-morbid collections, pancreatic and peripancreatic
disease necrosis, pseudocyst and walled-off
necrosis
Usually resolves within the
first week
Mortality is rare Mortality: 36-50%

9. Fall from height with bilateral calcaneous fractures. What imaging would you order?
 CT spine
 20% patients suffer injuries to spine, pelvis
o Should x-ray knees, spine and pelvis

10. 80-year-old in an MVA with intraventricular and subdural bleeds. What do you do next?
 Neuroprotective ventilation
 ATLS Guidelines:
o Urgent CT scan
o Must rapidly achieve cardiopulmonary stabilisation
 Perform early endotracheal intubation in comatose patients
 Ventilate with 100% oxygen until blood gas measurements
are obtained and then adjust appropriately
o Maintain SATS >98%
 Attain euvolaemia ASAP and try to maintain SBP >/= 110mmHg for
patients older than 70
 Reverse any anticoagulants and try to avoid analgesia and anaesthetics
as far as reasonably possible (delays the recognition of progression of
lesion)
 Try to use short-acting, easily reversible agents at lowest dose
needed
 Reserve hyperventilation to those with acute neurological
deterioration or signs of herniation
 Should not undergo prolonged hyperventilation with PCO2
<25mmHg
o Can cause cerebral ischaemia
  Acts by reducing PCO2 and inducing cerebral vasoconstriction
o Use in moderation and for as little time as possible:
keep PaCO2 at 35mmHg
 Performed until emergent craniotomy can be performed
 Can use mannitol to decrease ICP (normally used after
hyperventilation)

11. Picture of a reducible umbilical hernia in a 3-4-year-old with no other complications. What do you do?
A. Review in one year
 Delay until age 4-5 to allow for potential spontaneous closure, unless significant
symptoms are present
B. Surgery

12. Picture of a baby with scrotal swelling, no GI symptoms, a low-grade fever and tenderness to
palpation. Likely diagnosis?
A. Scrotal abscess
B. Infected sebaceous cyst
 This is a possibility, but appears less likely (limited information given)
C. Incarcerated femoral hernia
 Femoral hernias (and especially incarcerated femoral hernias) are very uncommon in the
paediatric population. They would also be more likely to present with a crampy
abdominal pain

13. Immediate management of post-subclavian CVP pneumothorax

A. Intubate
B. Oxygen
C. Needle thoracotomy

14. Diabetic foot – what antibiotics to use

 Superficial ulcer: Oral Antibiotics aimed at S Aureus and Strep
 Deep ulcer: IV aimed at Gram + and – organisms, including anaerobes
 EML guidelines recommend first-line therapy of: Amoxicillin/Clavulanic Acid
A. Erythromycin (second line)
B. Azithromycin (not included in guidelines)
C. Clarithromycin (second line - used if pregnant)

15. Management of a peri-anal abscess

 Primarily surgical, including careful examination under anaesthesia and adequate drainage
of the pus. Deroofing the abscess is essential, and specimens should be sent for histology and
bacteriological assessment.
 Antibiotics are prescribed only if underlying cellulitis is present or there is susceptibility to
infection (e.g. diabetes).
o parenteral antibiotics (broad-spectrum cephalosporins and metronidazole) should
be administered
 Anatomical considerations: inappropriate incision of sphincter muscle → result in
incontinence
 Suggested post-op management:
o Analgesics, stool bulking agents and stool softeners

16. How do you manage a thyroid storm during a thyroidectomy?

 EML - Hospital level guidelines & Medbear notes:
o IV fluids
o Carbimazole (antithyroid drug) (30mg, PO, 6 hourly)
o Lugol’s iodine [block the release of thyroid hormone] 10 drops (oral)
o Atenolol [control signs and symptoms] (50mg, PO, daily) / Propranolol (60-80mg,
PO, 4-6 hourly)
 o If life-threatening: Hydrocortisone (100mg, IVI, 8 hourly)

17. How do you manage a venous ulcer?

A. Compression dressings
B. Compression stockings
 Medbear:
i. 4 layer compression stockings
ii. Analgesia
iii. Antibiotics if infected
iv. Warn patient to avoid trauma to leg
v. Encourage rest and elevation of leg
vi. Once healed: compression stockings for life

94. Mr Nkosi is a newly diagnosed T2DM, with random plasma glucose of 12mmol/L, no end-organ
damage and he has a good effort tolerance. His ASA physical state class is:
A) 1
B) 2
C) 3
D) 4
E) 5
ASA classification:

18. 60 year old, peri-anal swelling, diabetes, fever, swollen buttock (tender and creps) – perianal abscess
A. Debride
B. Incision and drain
C. Percutaneous drain
D. Serial aspiration
19. Female patient with creps to the knee. Blood glucose is 30. Swollen right foot. What would you give
her. - ?cellulits/diabetic foot
A. FFP – not indicated
B. Normal saline - ?But really not too sure
C. 5% dextrose – not indicated
D. Calcium bicarb
20. Margins for 0.75 melanoma – 1cm margin
 Melanoma in Situ: 5-10 mm margins
 invasive melanoma (pT1) ≤ 1.0 mm thick: 1 cm margins
 invasive melanoma (pT2) 1.01-2.00 mm thick: 1-2 cm margins
 invasive melanoma (pT3) 2.01-4.00 mm thick: 1-2 cm margins
 invasive melanoma (pT4) > 4.0 mm thick: 2 cm margins
21. Symptom most indicative of oesophageal ca
Progressive dysphagia liquid to solid.
22. Female with microcalcifications on mammogram
A. FNA
B. Core biopsy – microcalcifications and spiculations likely IDC
C. Mammogram
D. Ultrasound
23. Treatment of spinal anaesthesia-induced hypotension and tachycardia with nausea.
Same as 97 at end. Just worried about the tachycardia.
24. Neuroendocrine tumour
A. Palpable on abdominal examination
B. Most common at the rectum
C. Size and classification predicts prognosis
D. Resection not indicated when there are metastases – Has benefit
25. Management of infer-renal aneurysm (3.5mm) supposed to be cm
Indications for surgery
Symptomatic
>5,5cm
Growing more than 1cm/year (5mm/6months)
A. Endovascular – EVAR only done for infrarenal AAA. Recommended when possible. [SA Vasc
society guidelines)
B. Open surgery – for juxt/suprarenal disease
C. 6-monthly ultrasound – 2 yearly
D. CT
26. 52-year-old male with 2-month hx of blood-tinged mucous stool, no constipation, no LOW, no
abdominal pain. Father had surgery for piles
A. Anal ca – would expect constipation and LOW
B. Haemorrhoids – quite a weird one though
C. Villous adenoma
D. Proctitis - painful
27. MVA, multiple bruises. What electrolyte disturbance would occur
Crush syndrome/traumatic rhabdomyolysis. As muscles die, they absorb water, calcium and
sodium and release myoglobin, phosphate and potassium. Biggest issues - Hypotension,
renal failure, acidosis, hyperkalemia and hypocalcemia.
A. Hypercalcaemia (hypocalcaemia)
B. Lactic acidosis
C. Increased potassium -
D. Hyponatraemia (not sure why this doesn’t happen, maybe cos absorbing water as well)
28. Overweight man with 3-day hx of lower abdominal pain. Temperature is 37.6°C. He has intermittent
constipation
A. Acute cholecystitis
B. Bladder infection
C. Acute diverticulitis due to low grade fever, other symptoms don’t fit others
D. Faecal impaction
29. One-day-old with bile-stained vomitus
A. Pyloric stenosis – would not be bile stained
B. Duodenal atresia - bile stained NB and first day
C. Intestinal malrotation – predisposes to volvulus in first year, also bile stained
D. Jejunal atresia – much less common than duodenal
30. 21-year-old from Zimbabwe. One-day hx of vomiting blood and clots with dark coloured stool. Pale
and distended abdomen with shifting dullness. WCC 13.2, Hb 6.4, MCV 64.5, Plt 74, LFT is normal
 Cirrhosis can have normal LFTs.
A. Gastric ulcer – very rare to produce ascites
B. Gastric varices – not sure if clots point to one more. ? less likely as acidity wouldn’t allow blood to
clot but esophageal can clot before reaching there.
C. Duodenal ulcer – very rare to produce ascites
D. Oesophageal varices – more common than gastric
31. Alcoholic comes in vomiting blood- BP 80/60, pulse 110. Distended abdominal veins and PR blood.
A. B-blocker – only for secondary prevention after
B. Endoscopic treatment - signs of portal hypertension, likely variceal
C. PPI - also should be given as supportive
D. Laparotomy
32. Anaemic, increased BP, Hb 10 and ferritin 10
A. Faecal occult blood
B. CEA
C. Upper and lower scope – need to find source
D. CT abdomen
33. Claudication of 200m. Smoker and hypertensive. No pulses below the femoral. ABI 0.7 and cholesterol
6.5
A. Angioplasty and exercise
B. Angio and stent
C. Anti-lipid, exercise and stop smoking
D. Exercise and lifestyle

D – Displacement is to stop vena caval compression and imp

78) Which of the following will save the most lives?

a) Improved control over drunk driving
b) Improved ambulance services
c) Improved emergency rooms
d) More intensive care beds
e) More dedicated theatres

Factors driving the epidemic of trauma in SA: Urbanisation (increased crime and violence), Substance abuse,
GBV, Demilitarisation, Globalisation. The other factors above affect service delivery.

79) Trauma can be called a systemic disease. Which of the following is true of the severely injured patient
immediately after resuscitation with large volumes of cold crystalloid fluids, prolonged surgery and massive
blood transfusion?
a) Tendency to hypercoaguability
b) Coagulopathy
c) Pyrexia
d) Hypertension
e) Bradycardia
In response to trauma, the body increases production of coagulation factors as well as increases fibrinolysis.
However in severe trauma, this process leads to a depletion of coagulation factors, exacerbated by acidosis,
hypothermia, dilutional effects of fluids and banked blood. In this state, expect to find increased Fibrin
Degradation Products, raised Prothrombin index and a decreased Plt count.
After about 7 days, a hypercoaguable state ensues, which when exacerbated by immobility can lead to DVTs.

80) A 25 year old male suffered a gunshot wound to the face. His systolic BP is 90, GCS 7/15 and RR 8
breaths/min. What is the first priority?
a) Oxygen saturation monitoring
b) Tracheotomy
c) Jaw Thrust
d) Orotracheal intubation
e) Cricothyroidotomy

The patient’s airway is threatened (GCS < 9; facial trauma). Therefore, a definitive airway must be established.
Other predisposing conditions are: SBP < 70 mmHg, unstable # maxilla, bilateral # mandible, inhalational burns
and tracheal or laryngeal injury.

81) A 30 year old female driver was involved in a head-on collision. The steering wheel of her vehicle was bent,
the front windscreen was smashed and she had to be extricated from the vehicle. She is irritable, anxious and
disorientated. GCS is 14/15, BP 105/70 HR 120 bpm. She states that she only suffered minor injuries and wants
to go home. What is the appropriate level of triage for this patient?
a) Priority 1
b) Priority 2
c) Priority 3
d) Priority 4
e) She does not require triage as there is nothing wrong with her

Based on the Triage by Mechanism, extrication is a P1. Other P1 indications is: PVA, ejection from vehicle,
rollover, death of another passenger, significant deformation of vehicle or axle shift, High speed.

82) Which of the following will kill first?

a) Cardiac tamponade
b) Subdural haematoma
c) Hypothermia (core temperature 33 deg C)
d) Obstructed airway
e) Tension pneumothorax

Airway is the first priority as an obstructed airway can be fatal in 3 to 5 minutes

83) A 54 year old male alcoholic arrives in the emergency room after a road traffic accident. He cannot
remember the incident. His vital signs are as follows: GCS 14/15. BP 120/80, RR 18 breaths/min. He has a
sluggish reacting dilated right pupil. His friends confirm that they binged on alcohol. The most appropriate
intervention is:
a) Intravenous mixture of dextrose water, MgSO4, Vit B Co, and Vit C (Jet Fuel)
b) Observation for 6 hours and discharge
c) CT Scan of the brain
d) Discharge to the care of his friends
e) Counselling on the dangers of alcohol abuse

Indications for CT Scan in head injuries: Loss of Consciousness, amnesia, depressed LOC, severe headache,
localising signs, GCS < 14, localising signs, persistent and severe headache. Additionally in this patient, factors
increasing the need for CT include his age.

84) Which of the following conditions is an immediate threat to life to be excluded during the Primary Survey?
 a) Blunt cardiac injury
b) Stable fracture pelvis
c) Haemothorax of 350ml
d) Compound fractured tibia and fibula
e) Flail chest and pulmonary contusion

Threats to life: Airway (Maxillofaical trauma, Neck injuries, Penetrating injuries to thoracic inlet,
shock/cerebral hypoxia, coma/GCS < 8, Hypothermia; in addition, with signs indicating a threatened airway
e.g. air hunger, gurgling, stridor etc…) Breathing (Tension Pneumothorax, Massive Haemothorax (>2L), Sucking
chest wound, Flail chest and pulmonary contusion), Circulation (Chest, Abdomen, Pelvis, Limbs (long bones and
soft tissues), external).

85) A 30 year old male presents with massive facial trauma. He is gurgling, oxygen saturation is 89%, BP
130/90, HR 120 bpm. Surgical cricothyroidotomy is:
a) Not an option, since his airway is not threatened
b) Not an option because of the risk of local trauma to the trachea and larynx
c) An option, if at least 4 attempts at oro-tracheal intubation failed
d) Not an option, since tracheotomy is far safer
e) Preferably performed after needle cricothyroidotomy

Only 2 attempts at intubation is permitted, following which rescue/surgical airway interventions must be
considered. An airway is indicated in this patient due to massive facial trauma.

86) Which of the following will most likely lead to a threatened airway?
a) Bilateral fractured ramus of the mandible
b) Lefort type 1 fracture maxilla
c) Lefort type 2 fracture of the maxilla
d) Extensive fracture base of skill
e) Fractured cervical spine

87) A 20 year old female suffered a gunshot of the abdomen. The entrance wound is in the epigastrium, and
the exit wound is left paraspinal. She has consumed alcohol in large amounts. Her vital signs are normal. After
initial assessment, the appropriate treatment is:
a) Admit and observe for abdominal signs
b) Perform a sonar examination to assess for organ damage and the need for laparotomy
c) Laparotomy
d) Diagnostic peritoneal lavage
e) Contrasted CT-scan of the abdomen to assess for visceral injury

This patient is haemodynamically stable and it may be assumed that she is not peritonitic – therefore we can
perform further investigations – FAST is a quick modality to assess for fluid in the abdomen, which if present
may then lead to a laparotomy being necessary (particularly if the patient subsequently becomes unstable).
DPL is becoming obsolete with the use of FAST. Contrasted CT scan can be performed after a FAST and if
everything is normal, the patient can then be admitted and observed for abdominal signs and deterioration.

88) It is a Sunday night in a busy emergency room. Is this 21 year old professional athlete shocked or not:
- Systolic BP 95 mmHg
- HR 110/min
- Calling for his lawyer because the service is slow
- Lacerated scalp covered with a compression bandage – soaked with blood
- RR 32 breaths/min
a) Yes
b) No

Given the compression bandage soaked with blood (a scalp laceration can bleed excessively), and the mild
tachycardia and irritability, this patient’s symptoms fall within Class 1 shock.
89) Which of the following is true of injured small children
a) They decompensate early after blood loss
b) Cardiac output is increased primarily by increased myocardial contractility
c) The larynx is situated deep into the oropharynx
d) The trachea is short compared to an adult
e) They are prone to rub fractures

??

90) Which is correct for central cord syndrome?

a) Rugby injury is the commonest cause of central cord syndrome
b) Central cord syndrome is associated with movement in the lower limbs, with paralysis of the upper
limbs
c) Central cord syndrome is associated with movement in the upper limbs, with paralysis of the lower
limbs
d) Central cord syndrome is associated with the opposite side and loss of sensation on the same side

91) Mr Smith has a strong family history of malignant hyperthermia. He has no past anaesthetic history. He is
now coming for wisdom teeth extractions. The most appropriate anaesthetic management would be:
a) GA with sevoflurane and NO suxamethonium
b) Total Intravenous Anaesthesia (TIVA) with avoidance of suxamethonium and all volatile
inhalational agents
c) GA with the use of suxamethonium but no inhalational agents
d) GA with the use of volatile agents but avoidance of thiopentone
e) GA with desflurane but avoidance of suxamethonium

Malignant Hyperthermia is caused by a dysfunction in the ryanodine receptor which, in susceptible patients
triggered by Suxamethonium and all volatile inhalational anaesthetic agents, results in uncontrolled release of
calcium from the sarcoplasmic reticulum. Subsequent to this, the patient presents with: Early – tachycardia,
tachypnoea (and increased minute ventilation with increased End Tidal CO2 and increased FiO2 to EtO2
hiatus), masseter spasm and early exhaustion of soda lime. Additional signs, include ventricular ectopics and
peaked T Waves. Later signs include cyanosis, palpable pyrexia, generalised rigidity, prolonged bleeding and
dark urine (rhabdomyolysis).
Management: Call for help, stop all inhalational anaesthetics and scoline and hyperventilate with 100% O2,
Give dantrolene 2.5 to 3 mg/kg IV with repeat doses of 1 mg/kg every 5 mins to a max of 10 mg/kg. Actively
cool the patient, Treat acidosis, hyperkalaemia, myoglobinaemia and coagulopathy.

92) A 23 year old MVA victim presents for emergency surgery with an HR of 53 bpm, a BP of 210/130, a left
sided hemiparesis and progressive neurological deterioration. The most appropriate management would be to:
a) Use of Sodium Nitroprusside to lower his diastolic BP to below 110 mmHg before proceeding with
induction
b) Administer atropine to treat the bradycardia before inducing anaesthesia
c) Delay surgery in order to radiologically rule out an associated cervical spine fracture
d) Proceed immediately with a general anaesthetic utilising rapid sequence induction technique utilising
Manual Inline Axial Stabilisation
e) Intra-operatively reduce PaCO2 to below 24 mmHg as soon as possible by means of hyperventilation

??

93) A 50 year old patient presents to theatre for appendicectomy. He has chronic renal failure, complicated by
hypertension and hyperkalaemia
a) Patient should receive a rapid sequence induction/intubation
b) Suxamethonium should be used to facilitate intubation in this patient
c) Patient should be given a pre-load of 1 litre of Ringer’s Lactate
 d) Atracurium would be the ideal muscle relaxant in this patient
e) Intravenous lignocaine would be the most effective way to blunt intubation response in this case

There are no indications for an RSI (unless the patient is uraemic in the setting of his chronic renal failure).
Suxamethonium is contraindicated (in all cases of hyperkalaemia, or any state that predisposes to hyper
kalaemia).

34. 60 year old, peri-anal swelling, diabetes, fever, swollen buttock (tender and creps)
E. Debride
F. Incision and drain
G. Percutaneous drain
H. Serial aspiration
35. Female patient with creps to the knee. Blood glucose is 30. Swollen right foot. What would you give
her
E. FFP
F. Normal saline
G. 5% dextrose
H. Calcium bicarb
36. Margins for 0.75 melanoma
37. Symptom most indicative of oesophageal ca
38. Female with microcalcifications on mammogram
E. FNA
F. Core biopsy
G. Mammogram
H. Ultrasound
39. Treatment of spinal anaesthesia-induced hypotension and tachycardia with nausea
40. Neuroendocrine tumour
E. Palpable on abdominal examination
F. Most common at the rectum
G. Size and classification predicts prognosis
H. Resection not indicated when there are metastases
41. Management of infer-renal aneurysm (3.5mm)
E. Endovascular
F. Open surgery
G. 6-monthly ultrasound
H. CT
42. 52-year-old male with 2-month hx of blood-tinged mucous stool, no constipation, no LOW, no
abdominal pain. Father had surgery for piles
E. Anal ca
F. Haemorrhoids
G. Villous adenoma
H. Proctitis
43. MVA, multiple bruises. What electrolyte disturbance would occur
E. Hypercalcaemia
F. Lactic acidosis
G. Increased potassium
H. Hyponatraemia
44. Overweight man with 3-day hx of lower abdominal pain. Temperature is 37.6°C. He has intermittent
constipation
E. Acute cholecystitis
F. Bladder infection
G. Acute diverticulitis
H. Faecal impaction
45. One-day-old with bile-stained vomitus
E. Pyloric stenosis
F. Duodenal atresia
G. Intestinal malrotation
 H. Jejunal atresia
46. 21-year-old from Zimbabwe. One-day hx of vomiting blood and clots with dark coloured stool. Pale
and distended abdomen with shifting dullness. WCC 13.2, Hb 6.4, MCV 64.5, Plt 74, LFT is normal
E. Gastric ulcer
F. Gastric varices
G. Duodenal ulcer
H. Oesophageal varices
47. Alcoholic comes in vomiting blood- BP 80/60, pulse 110. Distended abdominal veins and PR blood.
E. B-blocker
F. Endoscopic treatment
G. PPI
H. Laparotomy
48. Anaemic, increased BP, Hb 10 and ferritin 10
E. Faecal occult blood
F. CEA
G. Upper and lower scope
H. CT abdomen
49. Claudication of 200m. Smoker and hypertensive. No pulses below the femoral. ABI 0.7 and cholesterol
6.5
E. Angioplasty and exercise
F. Angio and stent
G. Anti-lipid, exercise and stop smoking
H. Exercise and lifestyle
50. 56-year-old male. LOW and bloating with cramps. Daily alcohol intake. Offensive stool that doesn’t
flush. Glucose is 9.
A. Increased lipids
B. Acute pancreatitis
C. Chronic pancreatitis
D. Pancreas adenoma
51. Acute pancreatitis with respiratory distress and oedema. 10mL urine in 4 hours. Management
includes fluids and organ support for 7 days

52. 4-year-old drank bleach

A. Encourage vomiting
B. Give water
C. Endoscope
D. NGT
53. 82-year-old with fractures of ribs 6, 7, and 8. There‘s no flail chest or haemo-/pneumothorax
A. Analgesia and physio
B. Oral analgesia and discharge
C. Discharge after intercostal block
D. ABO and dischargre
54. Day 3 post-appendectomy. Temperature 38.3°C. suprapubic tenderness and diarrhoea
A. Leaking stump
B. Abscess
C. Bladder infection
D. Suppurative peritonitis
55. Femur fracture on traction. No pulse
A. Elevate leg
B. Surgical exploration
C. Doppler
D. Angiogram
56. Hyperparathyroidism pathology
A. Adenoma
B. Carcinoma
C. ?
D. ?
57. Arrhythmias and anaesthetic – halothane
58. 3-week-old vomiting. Investigations showed contrast not going past a certain point and vomiting
contrast. Treatment?
A. Constrast enema
B. Trial of PPIs
C. Emergency laparotomy
59. Bilateral parotid cysts
A. ELISA
B. GXP
C. FNA
60. Cause of widened mediastinum in a trauma patient
61. Pregnant patient with Grave‘s disease, management?
62. Risk factor for gastric ca that shows signet ring cells on histo
63. Surgical management of thyroglossal cyst
64. Mobile mass in femoral triangle. Overlying skin is normal
A. Synovial sarcoma
B. Rhabdosarcoma
C. Angiosarcoma
D. Lipoma
65. Cancer staging for breast ca
66. During thyroidectomy, patient‘s HR and BP increase. What drug would you use next?
67. How many hours after a cup of coffee with milk can one have an elective sequence induction?
68. Baby involved in an MVA. CXR shows lung opacification, but costophrenic angles are clear
A. Pneumonia
B. Lung contusion
C. Pleural effusion
69. Most significant risk factor for a 74-year-old whose niece has cancer
A. Age
B. Oral contraceptive
C. Family history
70. Old lady burnt in a shack fire. She has difficulty breathing. What do you do?
71. Struggling to intubate
A. Insert a LMA
B. Release cricoid pressure
C. BMV
72. How do you treat ulcers and varicose veins
73. Hx alludes to HOP ca – 2cm mass with no clinical mets. Management
A. Chemo and surgery
B. Whipples
74. Risk factor for incisional hernia
A. Diabetes
B. Smoking
C. Wound sepsis
D. Age
75. 5-year-old going for a tonsillectomy. Which anaesthetic would you use
A. Sevoflurane
B. Isoflurane
C. Enflurane
D. Desflurane
76. 43-year-old female with a first degree relative with colorectal ca. Patient had a colonscopy at 40-
years-old that showed a polyp that was resected (no cancer). What screening should you use?
A. Faecal occult blood yearly
B. Flexible sigmoidoscopy
C. ?
D. ?
77. 16-year-old male presents after MV, clinically stable. Pancreatic laceration on eFAST. What do you do
next?
 A. Conservative medical management
B. Emergency laparotomy and splenectomy
C. Empiric antibiotic therapy
78. Suspicious for malignancy thyroid nodule. Clinically the patient is euthyroid. What do you do?
79. Compartment syndrome – diagnosis (cannot dorsiflex their ankle) and management (fasciotomy)
80. Rhabdomyolisis management
81. How to evaluate for vascular injury after a long bone leg fracture (hard and soft signs)
82. Which scenario would most likely accompany vascular compromise?
C. Knee dislocation
D. Neck of femur fracture
E. ?
F. ?
83. Appendicitis successfully managed conservatively, when should the patient come back?
D. If pain returns
E. 6 weeks for follow-up
F. Wait and do an elective appendectomy
84. Inflammatory breast ca staging
85. Patient from rural Mpumalanga and RVD reactive, now presents with varices and a palpable spleen.
Liver isn’t palpable, there is no ascites, no jaundice. Likely diagnosis
E. HIV cholangiopathy
F. Schistosomiasis
G. Hepatitis B
H. Hepatitis C
86. What lung pathology do mine workers get?
C. Pneumoconiosis
D. Silicosis
87. Oesophageal ca with hoarseness. Mass is located to the mid-thoracic region. What is the mass
compressing?
C. Right recurrent laryngeal nerve
D. Left recurrent laryngeal nerve
88. Grade the severity of pancreatitis
89. Fall from height with bilateral calcaneous fractures. What imaging would you order?
 CT spine
90. 80-year-old in an MVA with intraventricular and subdural bleeds. What do you do next?
 Neuroprotective ventilation
91. Picture of a reducible umbilical hernia in a 3-4-year-old with no other complications. What do you do?
C. Review in one year
D. Surgery
E. ?
F. ?
92. Picture of a baby with scrotal swelling, no GI symptoms, a low-grade fever and tenderness to
palpation. Likely diagnosis?
D. Scrotal abscess
E. Infected sebaceous cyst
F. Incarcerated femoral hernia
93. Immediate management of post-subclavian CVP pneumothorax
D. Intubate
E. Oxygen
F. Needle thoracotomy
94. Diabetic foot – what antibiotics to use
D. Erythromycin
E. Azithromycin
F. Clarithromycin
95. Management of a peri-anal abscess
96. How do you manage a thyroid storm during a thyroidectomy?
A. IV propannalol
B. IV …
 C. IV …
D. IV …
97. How do you manage a venous ulcer?
C. Compression dressings
D. Compression stockings
E. ?
F. ?
98. Bilateral parotid cysts. Which is the next most appropriate investigation?
A. Core biopsy
B. Incisional biopsy
C. ELISA
99. Post-thyroidectomy investigations
A. 6-hourly calcium
B. ?
C. ?
D. ?
100.identify structure on CT

101.56-year-old male. LOW and bloating with cramps. Daily alcohol intake. Offensive stool that doesn’t
flush. Glucose is 9.
E. Increased lipids
F. Acute pancreatitis
G. Chronic pancreatitis
H. Pancreas adenoma
102.Acute pancreatitis with respiratory distress and oedema. 10mL urine in 4 hours. Management
includes fluids and?
Acute and Supportive Management of Acute Pancreatitis
a) Resuscitate as necessary: aggressive IV fluid resus with crystalloids (correct 3 rd space fluid loss,
maintain IV vol., adequate perfusion of pancreatic/extra-pancreatic organs); other ABCs of resus
b) Monitoring of vitals: high-care/ICU if severe, general ward if mild; monitor vitals and urine
output, possibly CVP; electrolyte monitoring incl. calcium; ABGs for oxygenation and acid-base
status
c) NBM (gastric rest) to prevent pancreatic stimulation, and nutritional support: gastric
decompression with NGT if persistent vomiting/significant delayed gastric
emptying/ileus/intestinal obstruction; acid suppression (PPI, etc.)- no effect on disease course,
but protects against stress ulcers, octreotide no benefit; NBM for 2/7 until more stable; start oral
feeding early if only mild pancreatitis; prolonged NBM= poorer recovery due to nutritional
deficiency (therefore think about PEG/PEJ/open jejunostomy, then TPN, if severe pancreatitis)
d) Analgesia: no NSAIDs=worsen pancreatitis and cause renal failure (as already decreased renal
perfusion in acute pancreatitis); opioid analgesia (tramadol) other than morphine, as it increases
tone of sphincter of Oddi- more pancreatic enzyme retention in pancreas, accelerates pancreas
cell destruction)
e) Treat fluid and electrolyte imbalances- incl. hypoglycaemia, hypocalcaemia
f) Antibiotics: prophylactic or therapeutic (no benefit if mild). Prophylactic- severe acute
pancreatitis, prevent super-infection of necrosis as vastly increase mortality: give imipenem
shown to prevent sepsis; therapeutic in cholangitis (co-exist with gallstone acute pancreatitis, or
as a complication); and infection of pancreatic necrosis/pseudocyst; duration of 14 days
g) Support for organ failure- if present, manage in high-care/ICU: PEEP ventilation if
hypoxaemia/resp distress (e.g. ARDS); dialysis and CVP monitoring for AKI/acute renal failure;
fluid resus and inotropes if hypotensive
103.4-year-old drank bleach (chlorine)
E. Encourage vomiting (contraindicated- cause more caustic damage))
F. Give water (contraindicated- safety concerns, lack of efficacy)
G. Endoscope (do for all patients to evaluate level of injury. Do before NGT)
H. NGT (only perform under endoscopic guidance, not blind as risk of perf/further damage)
104.82-year-old with fractures of ribs 6, 7, and 8. There‘s no flail chest or haemo-/pneumothorax
 E. Analgesia and physio
F. Oral analgesia and discharge
G. Discharge after intercostal block
H. ABO and dischargre
105.Day 3 post-appendectomy. Temperature 38.3°C. suprapubic tenderness and diarrhoea
E. Leaking stump
F. Abscess
G. Bladder infection
H. Suppurative peritonitis
106.Femur fracture on traction. No pulse
E. Elevate leg
F. Surgical exploration
G. Doppler
H. Angiogram
107.Hyperparathyroidism pathology
E. Adenoma (most common cause of hypercalcaemia is parathyroid adenoma, therefore first
investigation with raised calcium- check for elevated PTH)
F. Carcinoma
G. ?
H. ?
108.Arrhythmias and anaesthetic
Halothane; enflurane to a lesser extent; succinylcholine; pancuronium
109.3-week-old vomiting (usual age of onset for pyloric stenosis but may be other form of intestinal
obstruction). Investigations showed contrast not going past a certain point and vomiting contrast.
Treatment?
D. Contrast enema
E. Trial of PPIs (not shown to have any benefit)
F. Emergency laparotomy (emergency surgery not necessary, can delay until patient more stable)
110.Bilateral parotid cysts (assoc. with Sjogren’s Syndrome and HIV)
D. ELISA
E. GXP
F. FNA
111.Cause of widened mediastinum in a trauma patient
a) Aortic dissection/injury
b) Cardiac tamponade/pericardial effusion
c) Thoracic vertebral/rib fracture
d) Very rarely, diaphragmatic hernia
112.Pregnant patient with Grave‘s disease, management?
a) Increased risk of prematurity, foetal loss, malformations
b) Severity often falls in pregnancy
c) Transient exacerbations- 1st trimester, postpartum
d) Carbimazole/neomercazole propylthiouracil still often used. Propylthiouracil preferred as crosses
placenta less and less present in breastmilk
e) Partial thyroidectomy often done 2nd trimester- for dysphagia, stridor, large goitre, suspected Ca,
antithyroid drug allergy
f) Labour, delivery, surgery, anaesthesia may precipitate thyroid storm. Monitor and have
emergency equipment and staff on standby
113.Risk factor for gastric ca that shows signet ring cells on histo
a) General Risk factors for gastric ca: H. pylori infection; diet- preserved meats/nitrosamines,
low in fibre, low socioeconomic status leading to poor refrigeration and thus poor
preservation; smoking; family history; blood group A; hereditary familial cancers- FAP, Lynch,
Gardner’s, Peutz-Jeghers and associated Menetrier’s disease; previous gastric cancer;
previous partial gastrectomy- >7 years ago more significant; Barret Oesophagus; chronic
atrophic gastritis incl. pernicious anaemia; previous diagnosis of gastric polyps
b) Specific to signet cell gastric Ca (diffuse/infiltrative type): younger, female patients, in
proximal stomach; N.B. hereditary (familial) diffuse gastric cancer syndrome
114.Surgical management of thyroglossal cyst
 a) Sistrunk procedure: resection of cyst, its tract, and central portion of hyoid bone
115.Mobile mass in femoral triangle. Overlying skin is normal
E. Synovial sarcoma
F. Rhabdosarcoma
G. Angiosarcoma
H. Lipoma
116.Cancer staging for breast ca, clinical

30. A 60 year old male patient presents bleeding D1 ulcer that could not be controlled endoscopically. At
laparotomy, the best course of action is?
a) Alcohol injection into bleeding vessel by endoscopy
b) IV octreotide continuous infusion
c) Laser coagulation of the vessel
d) Under-running of the vessel
e) Partial gastrectomy with B2 gastrojejunostomy

31. Which of the followings may be the earliest sign of significant re-bleeding after successful endoscopic
haemostasis of peptic ulcer bleeding?
a) Abdominal pain and distension
b) Coffee ground vomiting
c) Fresh melena
d) Hypotension
e) Tachycardia

32. A gastrointestinal stromal tumour (GIST) arises from which cellular lineage?
a) Epithelial
b) Endodermal
c) Haematolymphoid
d) Mesenchymal
e) Vascular

33. The commonest benign lesion of the liver is:

a) Hepatic adenoma
b) Haemangioma
c) Hepatic cyst
d) Liver abscess
e) Liver granuloma

34. K.I. is a 45 year old man with chronic alcoholic liver disease. He presents with right upper quadrant
abdominal discomfort and jaundice for a week. On examination, he has splenomegaly, ascites and tender
abdomen. Ascites in portal hypertension is associated with:
a) A high ascitic amylase level
b) A difference between serum and ascites albumin levels of greater than 11g/l
c) A decrease in total body sodium
d) Lower serum aldosterone levels
e) The presence of systemic vasoconstriction

35. With reference to the previous vignette: which one of the following drugs would be most useful in treating
ascites of portal hypertension?
a. A beta adrenergic blocker
b. A L-type calcium channel blocker
c. An aldosterone antagonist
d. An angiotensin converting enzyme inhibitor
e. A somatostatin analogue

36. With reference to the vignette: what is the most likely cause of the tender abdomen?
a) Acute suppurative appendicitis
 b) Acute suppurative pyelonephritis
c) Ruptured peptic ulcer disease
d) Acute diverticular disease
e) Spontaneous bacterial peritonitis

37. Congenital megacolon (Hirschsprung’s disease) occurs when:

a) The anus fails to form leaving an incomplete large bowel
b) The autonomic nerves grow upwards into the distal part of the large intestine from the body wall, but
fail to reach the proximal part
c) The autonomic nerves fail to innervate the entire large intestine by growing from proximal to distal
d) The somatic sensory nerves fail to grow all the way down the large intestine so that the lower part
does not have a sensory nerve supply
e) There is intestinal neuronal dystrophy

38. A 40 year old woman was well until 4 weeks ago, when she developed a urinary tract infection and was
treated with appropriate broad spectrum antibiotics. 10 days ago she developed fever, lower abdominal
pain, watery diarrhoea with mucus and some blood. On examination, her abdomen is diffusely tender
particularly in the lower quadrants; and sigmoidoscopy showed a hyperaemic rectal mucosa with plaque-
like lesions. The most likely diagnosis is:
a) Amoebic colitis
b) Acute Crohn’s colitis
c) Acute Shigella colitis
d) Acute ischaemic colitis
e) Acute pseudomembranous colitis

39. A patient presents with a head injury (Glasgow Coma Scale 7/15), distending abdomen and positive
diagnostic peritoneal lavage. Vitals post-resuscitation with 300ml Ringers, and 100ml colloid; BP 85/40,
pulse rate 115/min. What is the most appropriate action?
a) Immediate CT scan of the brain
b) Rapid infusion of colloid to stabilise him for CT scan of the brain
c) Immediate laparotomy
d) Rapid infusion of packed red cells since he is losing blood
e) Rapid transfusion of fresh frozen plasma

40. Hypospadias and epispadias, congenital anomalies related to abnormal sites of urethral opening in the
penis, may lead to:
a) Development of testicular germ cell tumour
b) Development of prostatic hyperplasia
c) Interference with normal erection
d) Predisposition to cancer in penis
e) Predisposition to urinary tract infection

41. A 4 day old girl was operated on for low intestinal obstruction. The clinical picture was a history of bile
stained vomiting with general abdominal distension. Distended loops of intestine could be visualised
through the anterior abdominal wall and visible peristalsis was present. Rectal examination revealed a
blind pouch. Which of the following is the most likely embryological cause?
a) Development of annular pancreas
b) Failure of breakdown of the cloacal membrane
c) Failure of formation of the descending colon
d) Lack of sacral parasympathetic nerves
e) Pyloric stenosis

42. A full term male infant starts vomiting clear fluids 5 weeks after delivery. Over a period of just 24 hours he
lost nearly half a kilo in weight. What is the most likely cause?
a) Duodenal septum
b) Corona virus infection
c) Jejunal obstruction
 d) Pyloric stenosis
e) Small bowel volvulus

43. Lymphoedema of the lower extremity is rarely associated with:

a) Atherosclerosis
b) Groin dissection
c) Congenital hypoplasia of lymphatics
d) Filariasis
e) Recurrent lower limb infections

44. A stasis or gravitational or varicose ulcer of the lower extremity is almost always associated with:
a. Active deep vein thrombophlebitis
b. Chemical dermatitis
c. Incompetent communicating vein(s)
d. Peripheral vascular disease
e. Superficial thrombophlebitis

45. A 30 year old polytrauma patient with multiple fractures developed fat embolism syndrome. In treating
the pulmonary complication of the fat embolism syndrome, the single most effective therapeutic
approach is?
a) Adequate oxygenation
b) Administration of intravenous heparin
c) Blood transfusion
d) Immobilisation of the fracture
e) Intravenous alcohol