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Clinical Question Bank: Surgery

n33b

FIRST!!!
Please read the rules before posting. Enjoy!

Surgery


General Surgery

A finding of bilirubinuria (conjugated bilirubin) in the absence of urobilinogen in urinalysis would indicate which of the following conditions?
a) Increased rate of haemolysis
b) Choledocholithiasis
c) Hepatocellular injury (e.g. hepatitis)
d) Transitional cell carcinoma of the bladder
e) Both (a) and (c) are correct

The correct answer is b) Choledocholithiasis. For there to be no urobilinogen in the urine would mean that no bilirubin is being converted to urobilinogen in the gut, i.e. there must be an obstruction along the biliary tree. With choledocholithiasis (obstruction of the common bile duct with a gallstone), none of the bilirubin reaches the gut and so all of it goes back into the blood as conjugated bilirubin, which is then excreted by the kidneys. In all other options, bilirubin is not stopped from reaching the gut (although maybe slowed in (c)), so there would still be some reabsorption of converted bilirubin in the form of urobilinogen and its subsequent renal clearance.

- authored by Matt
Which of the following does describes the boundaries of the femoral triangle?
a. inguinal ligament, ilacus, adductor magnus
b.gracilis, inguinal ligament, ilacus
c. sartorius, gracilis, obturator internus
d. sartorius, adductor magnus, inguinal ligament
e. saphenous ligament, inguinal ligament, adductor magnus

Best remembered by the SAIL mnemonic (superior, medial and lateral boundaries in that order): sartorius, adductor magnus, inguinal ligament. Answer is d.

Which of the following describes the anatomical separation of the foregut, midgut, and hindgut?
a. ligatment treitz, distal 1/3 transverse colon
b. ligament treitz, splenic flexure
c. ligament treitz, hepatic flexure
d. ampulla vater, splenic flexure
e. ampulla vater, distal 1/3 transverse colon

Answer is e. Ligament treitz separates upper and lower GI tract.

Vascular
Which of the following is the most important risk factor for peripheral vascular disease?

a. smoking
b. diabetes
c. hypertension
d. obesity
e. hyperlipidaemia

Answer is a. Diabetes is also an important one but by far a is the most important.

A 74 year old lady is required to have a contrast scan of her lower limbs for treatment of peripheral vascular disease. Of the following factors all associated with contrast-induced nephropathy which is the most significant?

a. pre-existing renal impairment
b. dehydration
c. NSAID medications
d. congestive heart failure
e. type 2 diabetes mellitus

Answers is a... but the others are all important too.
 
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frootloop

Doctor
Moderator
Otolaryngology

1) Which of the following is NOT true of acoustic neuroma (vestibular schwannoma)?
a) Unilateral sensorineural hearing loss (SNHL) in an adult should always be investigated to exclude this condition
b) It causes progressive hearing loss and imbalance
c) Typically, acoustic neuromas are slow-growing
d) Audiography and MRI are helpful diagnostic tools
e) This condition only occurs in individuals with familial neurofibromatosis type 2
f) If it encroaches on CN VII, it can cause corneal anaesthesia
Answer: E. NF2 is a rare cause of vestibular schwannoma, where it may be bilateral

2) Which of the following pieces of information is most helpful to you to clinically differentiate between presbyacsis and a tumour as the reason for a 65-year-old woman’s hearing loss?
a) She describes her hearing loss as ‘gradual’, and has only begun to notice it over the past few months
b) Otoscopy is normal
c) Audiography reveals that her hearing loss is mostly in the higher frequencies
d) The hearing loss is confined to the right ear
e) She has a blood pressure of 153/102
Answer: D. Tumours are usually bilateral, presbyacusis isn’t. Otherwise, both are gradual enough that ‘over the last few months’ doesn’t help you separate them, and neither are likely to change what the canal or the T.M. look like. Presbyacusis is primarily a high-frequency loss, but so are ~2/3rds of vestibular schwannoma’s.

3) Answer true or false for each of the following:
a) The most common bacterial causes of acute otitis media are Strep pneumoniae, H influenzae and M caterrhalis
b) The definitive treatment for cholesteatoma is surgical
c) Dental pain may refer to the ear via the glossopharyngeal nerve
d) In otitis media with effusion (OME), the primary purpose of tympanostomy tubes (grommets) is to release said effusions from the middle ear
a) True (In NZ, at least. I presume it's similar over the ditch)

b) True. Cholesteatomas (ironically containing no cholesterol or lipids of any kind) can damage the ossicles, CNVII, the cochlea and the semicircular canals, aaand they can erode into the middle cranial fossa causing meningitis, extradural abcesses, and so on. It's best to get rid of them.

c) False. Otalgia can be referred dental pain, but via CN V, not IX. Oropharynx pain can refer to the ear via glossopharyngeal, though.

d) False. I got grilled for this one, because it sounded logical that a disease with the word 'effusion' in the name would be treated by getting rid of the effusions. But in OME, the major benefit of grommets is that they allow pressure equalisation between the middle ear and the outside. Children have flat, short Eustachian tubes with a narrow isthmus, so they block off easily - especially if the middle ear is all inflamed after the kid has had acute otitis media. So they can end up with 'stagnant' air in the middle ear, and that gets reabsorbed - causing a negative pressure. So fluid gets sucked out of the tissue to equalise the pressure. Releasing that fluid is therefore only part of the picture.

4) Which of the following statements about salivary gland pathology is NOT true?
a) Parotid tumours are usually benign (~80%) and superficial to the facial nerve plan (~90%)
b) Sjorgren's Syndrome affects the lacrimal glands, but spares the salivary glands
c) Frey's Syndrome (swelling, redness in check during salivation) may be caused by damage to the auriculotemporal nerve during parotidectomy
d) Sublingual gland dysfunction may reduce the normal mucinous protection for dentition
Answer: B. Sjorgren's Syndrome is an autoimmune disease affecting exocrine glands - including the salivary glands
 

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