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    Fawzia Sheet Explain Paper2

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    JohnWall

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    © All Rights Reserved
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    of 70
    Fawzya Sheet “2” ay 1) CV aero Telco (ater a) Paper 2: 1.426 years old man motorcyclist loses 1 L of blood secondary to an open fracture of the femur sustained in RTA. Which of the following is the most likely earliest compensatory response in hypovolemia in this patient? Blood . Baroreceptors induced venoconstriction Loss ). Capillary fluid shifts Cc —y a b. c. Decreased atrial natriuretic peptide anaes ‘Niered Blood (AMP) secretion d. Renal fluid retention { | e. Renin Angiotensin system activation Baroreceptor (Chemoreceptor & Carsige Stmulaton Systemic ‘row 8 Volume Redistribution 2. Histology of a discrete palpable lump in the breast of a 34-year-oldwoman has shown apocrine metaplasia, epithelial overgrowth and papillary projections. What is the most likely pathological process? Benign breast cyst Carcinoma of the breast Fibroadenoma Phylioids tumor Plasma mastiditis 3. A35 -year-old woman presents with recurrent peptic ulceration. She is ona proton pump inhibitor previously received Helicobacter pylori eradication therapy three months ago. Which of the following is likely to be raised on venous blood testing? ‘a. Cholecystokinin Gastrin gaegp b. ZOLLINGER-ELLISON SYNDROME ai Panerai (Gastrinoma) e. Secretin © Peptic ulcer disease (often severe) in 95% * Gastrichypersecretion ‘+ Elevated serum gastrin «Single one is malignant ‘+ Multiple isbenign (MEN 1) + GASTRIN LEVEL IS MORETHAN 500 pg/ml © CT Scan, somatostatin scan + Portal vein blood sample MRCSalah Courses (een eae ee 4.3 Year old male boy presented with his mother for rectal blood loss, his mother describes it as aright red blood in the toilet pan. He has no pain on defecation with negative family history. What is the most likely cause? ‘Adenomatous polyp Juvenile polyp Metastatic polyp Multiple polyposis coli peutz jegher syndrome paoep 5. A32-years old man presents with a painful torticollis there is no past medical history and his ‘only complaint is that he has been feeling rather tired over the last 4 nights. On examination, he has large rubbery mass in the lateral aspect of his neck as well as a few smaller masses along his internal jugular vein. You correctly assume that the muscular neck spasm and the large mass are connected. The most likely cause of his torticollis is due to pressure on? a. Ansa cervicalis b. Cervical plexus branch ©. Cranial accessory nerve . Spinal accessory nerve e. Vagus nerve 6. Athin menopausal 52-vear-frid woman is diagnosed with breast cancer. Her menarche was at the age of 14y. She had her first child at age40 years. During lactation, she developed breast abscess that necessitated surgical intervention. She has no family history of breast cancer. Which of the following is the most significant risk factor for this patient? a. Age at first full term pregnancy b. Familial predisposition ©. History of breast abscess d. Interval between in menarche and menopause e. Physical stature Riskfctor Relatverist High rat group ae 10 Ehery Repradctne mafic ‘Ageat menarche 3 “Menurche before age 1 AAgest menopaine 2 “Menopause afer age ‘Ageat int prepaney 3 Naltipaouror ft hl ety 40s te factors Dic ls High intake of saturated ft Boos weight (pestmesopausal) 2 ody mass inder> 35, Aesbol i Excercise Hoe 7 Onl contnceptives 14 Caren wse 0 3 Abeormal expsur air ivory 2 Broa cancer in frst deere reative when youn MRCSalah Courses 7. A30-year-old woman is sent to the outpatient clinic with weight loss of 5 kg over the Last 6 months, She also complains of anxiety, panic attacks and palpations. On Examination. There is a swelling in the anterior neck which moves on swallowing Which of the following is most likely pathology underlying this presentation? a. Graves disease b. Hasliimoto’s thyroiditis . Metastasis to the thyroid d. Papillary carcinoma e. Undifferentiated carcinoma 8. A69-yeac-oJd man has been admitted to the high dependency unit following an anterior resection under general anesthesia. He was given 2 mg of intrathecal morphine. On examination, he looks pale and drowsy. Arterial blood gasses results are: PH pCo2 p02 [Base Excess | Glucose | Lactate Finding 7.28 BAKkPA | 10.2kPa 2.4 21 mmol/L_| 4.0 mmol Normal | 7.35-7.45 | 47-60 | 119-133 | -2to+2 4-7 0.5-2.2 Which 0 fthe following is the most likely diagnosis? Arterial Blood Gases parw came i a. Diabetic ketoacidosis b. Metabolic acidosis ¢, Metabolic alkalosis d. Respiratory acidosis ©. Respiratory Alkalosis R Respiratory pul tar Atalose O Opposite Put Pees f acitocie M Metabolic Pa Twos naioic E Equal 1 wees | Ae Uncempensated : Cor oF WCos normal Partially Compensated: Nothing is normal Compensated : PH is normal (7.4 beseline/neutral) 9. A32 year-old woman has a pigmented lesion excised from her left calf. The histopathological diagnosis is melanoma in situ, which is completely excised with a- 1m margin. What is the next most appropriate management? a. Education about skin self-examination and discharge from follow up, b. Elective inguinal lymph node dissection ¢. Re excision with 2. cm margin d. Removal of any other pigmented lesions + Suggested surgical margins: e. Sentinel lymph node biopsy (2ccording to brestow thickness) stu as1em + Bresow thkknest 4 mm: > 3.cm MRCSalah Courses 10. A 60-year-old man with a past history of angina undergoes an uncomplicated operation, for an inguinal hernia. Postoperatively he is found to be hypotensive, tachycardic and has a raised jugular venous pressure. What is the most likely Underlying cause of his hypotension? a. Reduced afterload b. Reduced parasympathetic tone Deceased cardiac c. Reduced preload contract, d. Reduced stroke volume e. Reduced sympathetic tone ‘Decreased stoke volume and ‘cardiac output Puimonary | =ex="|| Decreased ‘congestion tissue perfusion || coronary artery perfusion 14. A 4-years old boy presents to the Emergency Department with a two-day history of fever, difficulty walking and is unable to weight bear on the right leg. He has been on oral Amoxycillin 250 mg three times a day for a chest infection over the last five days. He is irritable with a temperature of 39.4°C. He does not allow examination and keeps his right hip flexed and adducted. Blood tests are, (WBC) 18.3 (CRP) 146, haemoglobin 11.3 g/dL. Whatis the most likely diagnosis? a. Acute avascular necrosis of hip b. Dislocation of hip c. Perthes disease d. Septic arthritis €. Slipped upper femoral epiphysis 12. A 34-year-oid man is admitted to-the Emergency Department with a head injury. On examination his Glasgow coma scale is 9. ACT scan of the brain demonstrates an extra dural hemorrhage. Which of the following arteries is the most likely source of this? a. Anterior cerebral cooseare b. Middle cerebral . Middle meningeal 4. Posterior cerebral e. Superficial temporal MRCSalah Courses 13. A 65-year-old man has a history of transientischemic attacks. He is due to undergo carotid ‘endarterectomy. Which one of the following is true of the internal carotid artery? a. Begins at the level of the sixth cervical vertebra b. Divides into the anterior, middle and posterior cerebral arteries ¢. Gives off the ophthalmic artery . Is accompanied within the skull by preganglionic sympathetic nerves . Passes through the foramen ovale 14. A 25-year-old male athlete is in training. At rest, how many liters of blood per minute does his heart pump out? a 09 b. 2to3 c. 5to6 d. 8to10 e. 15to20 1. Cardiac output — the volume of blood pumped from each ventricle per minute: co = SV x HR cardiac output = stroke volume X heart rate (mUiminute) —__(mlbeat) (beats/min) a. Average heart rate = 70 bpm b. Average stroke volume = 70-80 m/beat c. Average cardiac output = 5,500 mi/minute MRCSalah Courses 15. A 26-year-oJd man presents to the Emergency Department after sustaining a glass cut to his arm. On examination there is a 10 em longitudinal laceration on the anterior aspect of his upper arm. He has symptoms suggestive of ulnar nerve injury. On exploring the upper partof the arm we would expect the ulnar nerve to be: anterior then medial to the brachial artery ‘medial then anterior to the brachial artery ‘medial to the brachial artery posterior then medial to the brachial artery posterior to the brachial artery paogp 16. A 55-year-old man presents with acute back pain following a severe road traffic accident. Neurological examination reveals lack of sensation of the umbilicus and below. What is the spinal level of the neurological deficit likely to be? a. T8 b. 19 re > Nerves in the anterior san abdominal wall: Sensory dermatomes -7-u © 7 Isxiphoid region (tip) * T10 is umbilical region © L1is inguinal fold region Innervate muscles — = intercostal nn, 17- TAL * subcostal nerve, T12 © lumbar nn., L1-L4 MRCSalah Courses 17. A- 65-year-oid man complains of being thirsty and getting up in the middle of the night to get to the toilet. His weight is 95.5 kg. height 1.65 in and blood pressure 16794 mmHg. An oral glucose tolerance test was performed and produced the following results: Fasting plasma glucose 5.9mmol Two hours plasma glucose 14.3 mmol The most likely diagnosis: a b. c a. e. Diabetes insipidus Diabetes mellitus Impaired fasting Glycemia impaired glucose tolerance Normoglycemia Fasting glucose (mmol/l) ‘Normal <61 and Impaired fasting 26.1and<7.0 and slycaemia Impaired glucose <70 ond tolerance Diabetes mellitus 278 and/or 2-hour glucose (mmol/)) <78 <78 278 and<11.1 21a ‘Source: (WHO, 2006). Alow sugar diet prior to the OGTT may lead to a more normal result than that obtained on a normal dit. Either a high 2-hour of a raise fasting glucose may indicate diabetes Diabetes: In view of the implications of a diagnosis of diabetes upon a volunteers lifest 18. in a 9-year-old child with cellulitis of the hand, which chronological sequence of immunoglobulin production is correct? peese IgD precedes IgE production IgG precedes IgA production IgG precedes IgE production IgM precedes IgA production IgM precedes IgG production pot ome MRCSalah Courses 19. A 60-yearnold man presents to the-Emergency Department with epistaxis. The source Of the bleeding is identified as Little's area and resolves with direct cautery. Which vessel is most likely responsible for the bleeding? Anterior ethmoidal artery stein Infraorbital artery ehrad — Middle meningeal artery = artery ‘Sphenopalatine artery Li Sphenopalatine ‘Supratrochlear artery Use ave = Plexs) Superor label artery Greater palatine artery. 20. A 75-year-old man presents with esophageal reflux. Endoscopy confirms the Presence of a hiatus hernia. The esophagus passes through the diaphragm at which level? paosp ua Structures passing through Tio diaphragmatic apertures georp ne SS Caval Esophagi ‘Aortic Lateral view trom lett 21. A 78-year-ojd woman with emphysema receiving 28% oxygen by mask has the Following blood gas results: PH pCo2 po2 Bicarbonate | Base Excess Finding 7.28 8 kPa 6.2 kPa 36 mmol/L +5 Normal 7.35-7.45, 4.7-6.0 11.9-43.3 22-26 -2 to +2 Which of the following is the most likely interpretation? Mixed respiratory and metabolic Acidosis Partially compensated metabolic acidosis Partially compensated respiratory acidosis Uncompensated metabolic acidosis Uncompensated respiratory acidosis eaomp MRCSalah Courses 22, A 26-year-old manis having a stereotactic frame fitted to his skull prior to radiosurgery on a cerebral arteriovenous malformation. Four pins secure the frame tightly through the scalp to the outer table of the skull, two anteriorly, two posteriorly. On insertion of one of the-posterior pins, arterial haemorrhage is encountered. Which artery is most likely to have been punctured? ‘The ascending pharyngeal artery Tempend tay 1. The middie meningeal artery The occipital artery oe |. The posterior cerebral artery - The posterior communicating artery = 23. A 26-year-old man presents with a two-month history of unilateral testicular swelling. An ultrasound scan shows a heterogeneous mass within the testis with surrounding fluid. His blood test shows an elevated alpha fetoprotein level Which of the following is the most likely diagnosis? a 1 Classification of testicular tumors a, Lymphoma aE eee b. Orchitis es — ‘age 35 to 45 year cc. Seminoma feratoma (32%) aye 20 f0 35 years @. Teratoma * Combined seminoma and teratoma (4% ) . Tuberculosis + Interstitial tumors (5%) Lymphoma (7% ) * Other tumors (55%) 24. A 2 day old baby presents with increasing respiratory distress. He was born at term By normal vaginal delivery. On examination he has cyanosis of the lower limbs and marked respiratory in drawing of the chest His femoral pulses nt bilaterally and he has been anuric for the last 2 hours. Pulse rate is 140 beats/minute, regular, and his blood pressure is 60/30 mmhg in both upper limbs. What is the most likely diagnosis? Hypoplastic left heart syndrome ia Pe ication oft Hypoplastc leftheart s Celeria-Paton classification of interrupted aor arch Pulmonary atresia and ventricular septal >. wy defect Transposition of the great arteries Tricuspid atresia Interrupted aortic arch Noma pe eee oa + Defined as complete separation of ascending and descending aorta s = * Celoria and Patton classification(1959) —Type A-interruption distal to SCA that i ipsilateral to 2" carotid artery — Type B-interruption b/w 2" carotid and ipsilateral subdavian —Type C-interruption b/w carotids Te eT eee ed 25. A 50-years old woman presents with a history of right upper quadrant pain and jaundice. She reports that her urine was dark in colour and that her stools are offensive and difficult to flush. Which of the following explains the dark urine? a. Increase in conjugated bilirubinuria b. Increase in unconjugated bilirubinuria ¢. increase in urea excretion d. Increase in urinary urobilinogen e. Reduced enterohepatic bile salt circulation DIFFERENTIAL DIAGNOSIS OF JAUNDICE ro ory Jaundics mir ‘Increased Normal Normal Increased Normal Increased very high Nil Nil Present Ni Present Present Urine bilinogens Increased Present Nil Fecal increased Decreased Absent urobilinogen 26. An 80-year-old woman, who has suffered a fall, is found lying on the floor, where, she has- been for over 12 hours. Initial assessment shows that she has a core temperature of 28°C. What would the expected early physiological response to her body temperature be? Increased fat metabolism Increased constriction of peripheral blood vessels Increased hypothalamic set-point Increased metabolic rate. Increased thyroid activity paose Physiologic Effects of 19] MRCSalah Courses 27. A-12-year-old boy presents to the Emergency Department two hours after helping his father cut the grass. He complains of rhinorrhoea, itchy eyes, sneezing and a a blocked nose. He is apyrexial with a haemoglobin of 12.2 g/dL and white blood cell count of 6.8 * 109/L with a raised eosinophil count. Chest X-ray is; clear. Which immunoglobulin is most likely to cause this reaction? (ACID >EGGT) a. IgA Table 5 b WD Classification of hypersensitivity reactions ie ie according to Gell and Coombs e. IgM “Type Alternative name Associated dieases Mediators 1 immediate "Aopy ‘ee typerserstivry ——Anapylas stim 1 Artbody mediated Autoimmune Gor Iypersemtinty hemolytic anemia and complement Condpasure’s disease [ytroblatons ei immune complex. Serum scknom gC mediated ‘Athy Reaction and complement Fyporenctivty Lupus nephise WV Delayed ‘rarsplant ejection Teel, ypersenstivty Contact dermatite macrophages, ‘brea Ihave 28. A 45-year-old man presented with backache and leg pain due to -prolapsed lumbar + intervertebral’ disc. The pain, which is aggravated by coughing and sneezing; radiates to the dorsum of the foot On examination there is weakness, of the dorsiflexion of the foot. Which nerve root is most likely to be involved? a. T12 b. 3 ©. 5 = ; - J e. S2 Sinavoct | “nator” Screening |squet and rise | weet waiting | Watning on per Bessie, | wonarenanee | Somtasert MRCSalah Courses lew) UT 29. A 75-year-old woman, who has a carcinoma of the upper rectum, undergoes anterior resection. The arterial blood supply of the upper rectum arises from which of the following? a. Coeliac artery al Vet b. Iliocolic artery cana ce ¢. Inferior mesenteric artery Lutcoke 4. Internal iliac artery oo e. Superior mesenteric artery or, Lutcoke Srey eee Spc! Sigrid clon Uperhaltot 30. A 65-year-old man is undergoing an abdominal aortogram, A stenosis is demonstrated in a lateral aortic branch, arising at the level of the body of the second lumbar vertebra. The stenosed vessel is most likely to be the: a. coeliac artery b. inferior mesenteric artery ¢. left renal artery d. second left lumbar artery . superior mesenteric artery MRCSalah Courses 31. A 40-year-old man is admitted to the surgical day case unit for repair of his left inguinal hernia. On examination he is noted to have diffuse skin tanning, spotty pigmentation of the elbows, nipples and buttocks, and pigmentation of the scar from a previous right inguinal hernia repair. Three hours after the operation be becomes severely hypotensive. ‘Whats the most likely cause? Addison's disease a. ACTH deficiency b. Adrenal insufficiency ;. Growth hormone deficiency d. Potassium deficiency @. Thyroxine deficiency 32. A 19-year-old woman presents to the Emergency .Department profoundly hypovolemic having fallen from a horse. A postero-anterior (PA) chest radiograph shows a fracture to the medial third of the left clavicle. Which of the following vessels was-most likely damaged? Brachiocephalic trunk Left axillary artery Left common carotid artery Left subclavian artery Left vertebral artery gaocp 33. 65 years old man presented with an inguino-scrotal swelling in the right groin which is non tender. A cough impulses is elicited. At operation, an indirect inguinal hernia is repaired. The cremasteric muscle is derived from which of the following: a. External oblique aponeurosis ‘yer of scrotum b. Internal oblique muscle wee ¢. Rectus abdaminis muscle external spermatic fascia . Rectus sheath Sromaste toca e Internal spormatc fascia Trsusversalis fascia : Coverings of spermatic cord (Spermatic fascia) concentric layers of fascia derived fram ayers of anterior sooomninal wat ‘ exomal spermatic fascia - derived from EO {cremate facia - ered fom 10 *intonal spermatic asc derived from fascia Fansversalis atched io margins of deep Inguinal fing MRCSalah Courses Part A — illu: 34. A 70-y ear-old woman is in the recovery area and receives 28% oxygen by mask. Blood gas shows: PH pOo2 poz Finding a 10 kPa 12 kPa Normal 7.35-7.45, 4.76.0 11.9-13.3 Reduced sensitivity of which receptors is most likely to be responsible for this blood gasses Picture? (Respiratory acidosis) a. Adrenergic receptors b. Baroreceptors Ch c. Central chemoreceptors d. Jreceptors e. Lung stretch-receptors tors sisal oie, eas }—) (cues mecees) (eter “RERASH tena HEA, ean 1 00 messune © 35. A 28-year-old man presents with pain in his left scrotum. A diagnosis of Varicocele is made. Which vessel is involved? a. Femoral vein b. Inferior epigastric vein c. Long saphenous vein d. Internal pudendal vein e. Testicular vein MRCSalah Courses 36. A 60-year-old man, who is a heavy smoker, presents with a 10-day history of frank painless haematuria. His prostate is slightly enlarged on rectal examination. His haemoglobin is 11.3 gidL. creatinine 84 pmol/L and prostate specific antigen (PSA.) is 3,1 mg/dL. What is the most likely pathological process? a. Benign prostatic hyperplasia b. Prostate cancer oy Bladder Cancer c. Renal cell carcinoma d. Transitional cell carcinoma of bladder (Most: common: transional coll carcinoma, papillomatous + Risk factors: smoking, dyes used in rubber & cable industry, phenacetin- containing analgesics, women tx with Cytoxin for cervical cancer + Chronic stones->risk for squamous cell bladder cancer e. Urinary tract infection 37-. A 34-year-old woman presents with an irregular mass in the right breast which is clinically, radiologically and histologically malignant. Her mother died of breast cancer at the age of 58 and her grandmother died of ovarian-cancer at the age of 55. Which gene is most likely to be involved in the development of this woman tumor? a. BRCA1 b. oe c. 4. = e. PTEN (oo apts Breast cancer aM cases wih eS ‘own eee FIGURE 8-2. Percentage of breast cancer cases with a genetic mutation. Table3.1. Relative risk (RR) for breast cancer Low (<2 RR) Moderate (2-4 RR) High risk 4 RR) ‘Age al menarche< 12 ‘Age at first birth> 30 BRCAI/BRCA2 mutation Age at menopaase>55 Mather or sister with breast cancer Age> 70 Nulliparity Previous breast cancer Obesity Radiation exposure Hormone replacement therapy eT eee ed 38. 65-year-old man presents with a non-tender swelling in the right hemi-scrotum. At operation, the hydrocele sac is opened and 400 ml of fluid is drained. Which anatomical structure surrounds the fluid? a. Dartos muscle b. Patent processus vaginalis Anomalies of Tunica vaginalis c. Testicular capsule d. Tunica albugin e. Tunica vaginalis c = 39. A 24 years old man is brought to the Emergency Department following a road traffic accident. He has obvious airway compromise due to mouth! facial haemorrhage which requires a surgical airway. The surface landmarks used to localize the optimal site for a tracheostomy incision are midway between the suprasternal notch and which of the following? a. Cricoid b. Hyoid Tracheostomy c. Mastoid . Laryngeal prominence The transverse mi aS . Thyroid: incision is made rr ra ete seen 40. A 60-year-old man has -an anterior resection for a high rectal carcinoma. The histopathology report indicates the lesion is Dukes’ stage 8. What is the approximate average five years survival rate for patients with these lesions? a. 10% b. 20% ©. 35% d. 70% Prognosis (5-yr survival) 2. 90% + Stage | (Dukes A): 95% + Stage I! (Oukes By2): 70-80% + Stage Ill (Dukes C7): 40% + Stago IV (Dukes D): 5% MRCSalah Courses 41. A 20-years man presents to the Emergency Department after accidentally tripping over and lacerating his hand on a glass bottle. On examination there is a 2. cm laceration on the hypothenar eminence with loss of flexion in the distal interphalangeal joint of the little finger. What is the most likely tendon to be injured? a. Flexor digiti minimi brevis b. Flexor digitorum profundus on . Flexor digitorum superficialis oa d. Fourth palmar interosseous \ e. Lumbirical an o,f ovr i ( 42 A 75-year-old man, who smokes heavily, underwent coronary artery bypass grafting six months ago. A left internal-mammary artery graft was used. He now complains of angina on pegging his laundry on the washing line to dry. Which of the following lesions best explains his symptoms? a. Micro-emboli from the left common carotid artery b. Micro-emboli from the left internal carotid artery . Stenosis of the subclavian artery at the level of the costo-cervical trunk . Stenosis of the subclavian artery distal to the insertion of scalenus anterior e. Stenosis of the subclavian artery proximal to the first branch MRCSalah Courses 43. A 50-year-old alcoholic man presents-to the Emergency Department and is found to be unable to extend his wrist, thumb and fingers of his right hand. He is also found to have weak extension of the right elbow joint and loss of sensation on the dorsum of the first web space . Which nerve is most likely to have been injured? Median nerve ‘Musculocutaneous nerve Posterior interosseous nerve Radial nerve Ulnar nerve psege 44. A55 year-old man presents with acute back pain following a severe road traffic accident. Neurological examination reveals lack of dorsiflexion of the left ankle joint. Which of the following spinal cord, segments are most likely to be injured? 1, L2&L3 12,13 &L4 L4,L5 &S1 Nerve root La ‘$1, S2&S3 $3, 84885 paoge Der eel etd 45. A 21 -year-old man is admitted to the Emergency Department with a stab injury to his right chest. Pulse rate is 110 beats/minute and blood pressure is 85/40 mmHg Chest X-ray shows a large right haemothorax and a very small right apical pneumothorax. Which is the first substance secreted in the process leading to increased renal reabsorption of sodium in response to the above injury? Angiotensin | Angiotensin it Angiotensinogen Antidiuretic hormone Renin paese Renin-Angiotensin-Aldosterone System Bees ANGIOTENSIN I feresent ae moet MAN Arrexent Ctere PROKMIAL, Tse Cant feed passin eto Ao! 46. A 21-year-old man has been stabbed in the back of the knee, dividing the popliteal artery, and is undergoing repair via a posterior approach. Which of the following structures is most likely to be encountered first, when dissecting deep from the skin incision? Popliteal artery Popliteus muscle Popliteal vein Tibial nerve Soleus muscle eae rp MRCSalah Courses 47. A 78-year-old woman presents with urinary urgency and incontinence. The external urethral sphincter is innervated by which of the following nerve roots? a 13,485 b. L4, 5&5) c. L5,81&2 d. S1,2&3 e. $2384 Autonomic Control of Micturition ~Contaction fhe intemat oo Sretvalspnnctr an iaxaton 2 ‘tthe detrnar muse slows the badder land prevents emetying * Visceral non-pain ~ Stretch receptors in Blader wall, (csp tions) aetect“llness™ + Parasympathetic ~ Gontaction fhe datas ‘roel sphincter + Somatic Motor (voluntary) ~ Pudoadal neve aintans onic ‘ontnction of externa urethra! Spnirter wl wauntary ‘nites 48. A 40-.year-Qld woman presents with a parotid tumour. A biopsy reveals perineural invasion. Which is the most likely pathology? a. Acinic cell .carcinoma b. Adenocarcinoma ¢. Adenoid cystic carcinoma 4. Lymphoma e. Pleomorphic salivary adenoma 1 Mucoepidermoid cacinems ‘+ Common neoplasm in both adults and children + The most common cancer in parotid andmino salivary sands *+ Two grades: Low grade & High grace + tow grade veryslow growing on-metastasiing ‘eneraly behave ikea benign tumor** + Hh erode aearessve growth and invasion widespread metastasis and death ietastasizeto cervicallymph nodes spread haematogenously tothe lung, ler, bone. MRCSalah Courses ‘BENIGN MALIGNANT -Plomorphi adeno -Aucoepidermoica > wantin tumour - Aden cyte ca nua col sdenema *Maorant poomerpic -Myoenihetoma serena ~Canaleuar adenoma -Basaicl ce Duet papi >Savary duc ea 2. Adenoid cystic carcinoma + Most common malignancy of the submandibular gland + Second most common salvary gland cancer overall + Very slow growing over years + Commonrecurrence ‘+ Metastasis viathe blood stream + Three histologic types- tubular, eribiform, soll + Solié type has worse prognosis + Characteristic perineural invasion . ral spread isan adverse prognostic sign ‘causes recurence and astart metastass + Follow-up of 15 to 20 years is required as late recurrences occur. Pe 49. A 19-year-old man was assaulted and sustained injuries to the right side of his head. After two weeks he notices dial his right eye is dry and it could not produce tears. from which ganglion is post synaptic fibers arise to supply lacrimal gland? a. Geniculate ganglion b. Inferior ganglion of the vagus nerve c. Otic ganglion d. Pterygopalatine ganglion e. Superior cervical ganglion Parasympathetic ganglion of Head and Neck Oro-Otic Coanist =Citiany 50. A 36-year-old man undergoes a right inguinal hernia repair under general Anaesthetic as a day patient. He has a nerve block after the procedure. On recovery he has weakness of the right leg. Which nerve has been affected? a. Femoralnerve b. Genitofemoral nerve . Ilioinguinal nerve d. Lateral cutaneous nerve e. Sciatic nerve MRCSalah Courses 51. A man suffers a brachial plexus injury. On examination, he has a Horner's syndrome in association with upper limb paralysis. Which nerve roots does the Homer's syndrome suggest involvement of? a. C2 &C3roots b. C4&C5roots c. C6 &C7roots d. C8&T1 roots e. T2&T3 roots + the sympathetic outflow to the upper limb is ‘from the 2° to the Sth theracie ganglia, + Stellate ganglion ‘composite ganglion formed by fusion of the Inferior cervical ganglion anc the frst thoracic angion + fact carefuly preserved to prevent a Horner's syndrome. 52. A 60-year-old woman with breast carcinoma complains of difficulty chewing her. . food and is found to have numbness of the lower lip on one side. CT scanning shows a small metastatic lesion affecting the bony skull base on the same side as the lip numbness. Which foramen is the most likely to involve? a. Foramen caecum b. Foramen magnum c. Foramen ovale d. Foramen rotundum ‘Cetntornfoxarina . Foramen spinosum ‘CN tact n) pte canal "en ipa) Suprior oon esr ‘GNI (caaorotorn) NIV recta). {GN Vy (opiate) NVI aoaucentn) — V1 = Opthanic oe Gear orvie|fssme) |. "GxvC maaan ay Foren oe V2= mayillary ‘ON Vg (manabular 0.) (Fecaman Retvndvm) | Merenseuaterestin Masdibelar “end FRO iz ‘GNX (apna accousoryn) ypoplossl canal 'EN'xH yeodassaln) fereey 53. Which one of the following muscles is an extensor of the hip? Adductor longus Gracilis Niopsoas Pectineus Semitendinosus eaoce Summary: Muscle Actions at the Hip Joint Abduction: Elesion: Lateral Rotation: 1. Tliopsoas 1. Adduetor magnus (hamstring) 2 Sadduetors 2. Gluteus maximus Tensor fiscialatae 3,_Peetineus 3. Sartorius 4. Sartorius 4. Sartorius 4. 2 Obturators 5. Rectus femoris 5. 2Gemellars 6. Gracilis 6. Quadratus femoris 7. Piriformis prime moversin bold Mei 1 Adductorlongus 1 2 Adductor brevis 2. Adductor magnus ham.) 3 Adductor magnus 3. Biceps femoris (long bead) 3. Adducter brevis 4. Peetineus 4. Semimembranosus 1. Tensor fascia latae 5. Semitendinosus 94. In order to expose the right axillary artery, a transverse skin incision is typically made below the clavicle from a point just lateral- to the sternal end of the clavicle to the deltopectoral groove. Which of the following structures would be encountered in the dissection down to the vessel? Lateral thoracic artery Phrenic nerve ‘Suprascapular artery Thoracic duct Thoraco-acromial artery sapere Thorac) Deold ‘coma ranch Pectoral arch ‘aya MRCSalah Courses 55. A 55-year-bld man presents to the-Emergency Department after collapsing. On examination his pulse is 124 beats/minute, blood pressure is 60/30 mmHg, respiratory rate is 34 breathsiminute and his peripheries are warm. Whatis the most likely diagnosis, for this patient? a. Cardiac failure : b. Haomormage Comparison of different types of shock c. Hypovolemia d. Pulmonary embolus ie aa Pere Pn Popad Hypowolemic attired pice Increased SVR ool pole, melst kin Uso decreased Cardiogenic ‘Hypotension, tachycardia Decreased CO bs ‘Weak thready pulse Increased SVR ‘Cool pal, most skin UO<'0 nity (races, tacnypnea = tension, BRADYCARDIA DereexedCO Neurogenic yan ony SKN Venous arterial vasodilation ost sympathetictone i tension tchyenrsia Decreased CO Amphiiacic name eernsed 2 Prurts, utara Restessresn, decreased LOC Septic Hypotension, Tachyearda Decreased £0, Fullbounding pulse tachyones Decreased SVR Pi, warm, Rushed skin Decreased UO, fever 56. In the posterolateral approach to a posterior malleolar fracture, an incision is made between the calcaneal (Achilles) tendon and the distal-.fibula. Which of the following structures is at risk? Deep peroneal (fibular) nerve Saphenous nerve Superficial peroneal (fibular) nerve Sural nerve Tibial nerve gaese Superfcial peroneal ( _Extersor dgitorum revs (28) Peroneus tertus ‘url nerve Peroneal longus tendon Peroneal — brevis tendon MRCSalah Courses 57. A 25-year-old woman undergoes an elective right thoracoscopic procedure for treatment of right palmar hyperhidrosis. Diathermy is applied to a neural structure lying anterior to the neck of the right first rib. What is the most likely complication to occur as a result of this procedure? a. Bradycardia b. Hoarseness ¢. Homer's syndrome d. Raised right hemi diaphragm e. Reduced right biceps tendon reflex Oividos + the sympathetic outflow to the upper limb is nowes from the 2" tothe Sth thoracic ganglia, * Stellate ganglion ‘composite ganglion formed by fusion of the inferior cervical ganglion and the first thoracic teanglion + fact carefully preserved to prevent a Horner's syndrome. 58 / A 33-year-old man presents to the orthopedic outpatient clinic with a six-month history of low back pain radiating to the lateral aspect of the left upper thigh. Micturition and defecation are normal and there is no history of previous Injury. On examination, left lateral flexion of the spine is limited but a full range of hip movements are observed, although it is painful. Sensation is altered over the front of the knee. Left knee reflex is reduced. Which spinal nerve- is most likely to have been compressed? au Pe b. L2 a ULL co 13 aut Sas es tr eet e 59. A 2S-year old motorcyclist is admitted following a road traffic accident, having sustained- bilateral femoral fractures and a ruptured spleen. Three days postoperatively lie is noted to be confused, hypoxemic and difficult to ventilate. His observations show a blood pressure, of 120/80.mmHg, regular pulse of 88 beats/minute and he is apyrexial. A chest X-ray shows bilateral diffuse lung infiltrates. What is the most likely underlying diagnosis? a. Adult respiratory distress syndrome b. Atelectasis . Bronchopneumonia d. Pulmonary oedema e. Pulmonary thrombo-emboilism MRCSalah Courses 60. On-an ultrasound scan of the popliteal fossa when investigating-a swelling, which of the following structures is closest to the capsule of the knee joint? Great (long) saphenous vein a b. Popliteal artery one ©. Popliteal vein eran 4d. Small (short) saphenous vein e. Tibial nerve tore 61. A 25 years old man sustains a twisting injury while playing football. He develops immediate swelling of the knee and he can not continue the game. Six months later, he Is still not able to play football. His knee feels unsteady and tends to give way. On examination, he has a full range of knee motion. There is a positive anterior draw test and a small effusion. What is the most likely structure damaged? Anterior cruciate ligament Lateral collateral ligament ‘Medial collateral ligament - Oblique popliteal ligament Posterior cruciate ligament TESTS FOR TEARSIN CRUCIATE LIGAMENTS. A gaogp a. = Se 62. A 62-year-old man required a partial gastrectomy for a large benign ulcer in his gastric. antrum. When he is reviewed in clinic, six months later he complains of palpitations, weakness ind sweating along with a cramp-like abdominal pain which occurs within an hour of eating n meal. Usually, he has to lie down for 30-40 minutes until the symptoms subside. What is the most likely cause of his symptom pattern? a. Chronic gastroparesis b. Dumping syndrome "p ©. Delayed gastric ph gt ngyeg emptying d. Reflux gastritis Iyperomel ——eageoprate at caps e. Recurrent ulceration Rao aoa hrrpecn vequearaton ‘iaynptons Irs ease areas woken + oe ve tetris aston MRCSalah Courses 63. in septic shock, noradrenaline is used to increase the systemic vascular resistance This action is a result of the stimulation of which of the following ? a. at b. a2 ©. Bt d. p2 eof Epinephrine Dopamine Dobutmine Prenveshrine Niropmside ao wephine CO1-1 s 50 $20 B19 4 HR, 1 notrooy 82> vasodiatzion. a > vasoconsicion > SVR at > vasoconstriction > 5VR 8137 HR tinotroy MicB2 efects (1 duress natures renal vastaation, (Woprovenbenetin preventing tor morality) B14 HR, notrooy a eets vasoconstriction > 4 V8 81 > 1 HR, Pinotropy ‘Mid 2. ol sntagonit “> vasdton > PAR. SVR Proxphodestense Inhibitor (POE hide": Myocardl: FAM > ‘eontrality + Musotropy Vasculature: FAM > vanodiation > V SUR/PVN 1 > vaceconeticion > VR NO activates guanaly-ylase(in vas smooth mus) I oS eee ‘nia ‘myocardial demas Isduemicinjury dueto pateroad ‘amine ‘myocardial 0, demand Anythia Hypotension ypotersion ‘Arhythnia ‘ated ‘yanidetosiciy Sco > sasoaition| Tyramismath 64. A 56-year-old man presents with acute epigastric pain and vomiting. On examination he has guarding in the upper abdomen His test results are: Value Normal ‘Serum amylase ‘900 IU/L <100) ‘Serum ALT. 64 1U/L <50 Alkaline Phosphatase 93 1UIl 20-120 ‘Albumin 38 gi ‘35.50 ‘Gamma GT 500 IU/L <60 Bilirubin 45 umol/L. 0-20 Triglyceride 2.9 mmol a7 Which of the following is the most likely etiology of this condition? a. Alcohol b. Choledocholithiasis c. Hypertriglyceridemia d. Hypocalcaemia e. Mump * Biliary pancreatitis * Amylase Usually > 1000 u » AST, ALT Acute elevation ‘with rapid resolution » Alkaline phosphatase and bilirubin Increased * Ultrasound Gallstones, dilated common bile duct, * CT scan Gallstones, dilated common bile duct, fereey * Alcoholic pancreatitis * S. amyiaseUsually <500 iu ASTALT Minimal elevation that does not fluctuate » ALP Not usually elevated USG shows Changes of chronic pancreatitis » Pancreatic calcif cation, dilated pancreatic duct with stones 65. A 47-year-old woman with end stage renal failure requires an elective cholecystectomy for symptomatic gallstone disease. Her hemoglobin preoperatively is 7.2 g/dl. What is the major cause of her anaemia? Si Caley deficiency WHAT CAUSES ANEMIA b. E ropoietin deficiency Etat ieee te IN CHRONIC KIDNEY DISEASE? d. Iron deficiency e. Vitamin B12 deficiency Relative Erythropoietin (EPO) deficiency B ron dotcorey O Blood loss G Shortened red cot te span G2 Vitamin deficiencies The “uremic milieu” /Bone marrow suppression © ntermaion O Hyperparathyroidism 66. A 60-year-old man undergoes cystectomy a bladder carcinoma. During surgery, the ureters are identified. On which region of the bladder do the ureters pierce the bladder wall? Anterior surface ‘Apex Lateral surfaces Neck Posterior surface (base) eaoce 67. A 65 year-old man had a colonic resection for carcinoma 12 hours ago. He is now passing concentrated urine ata rate of 0.5 mi/kg/hr. Which endocrine response is most likely to have caused this? Decreased aldosterone release Decreased insulin release Decreased thyroxine release Increased adreno-coriticotrophic hormone (ACTH) rele’ Increased Vasopressin release (ADH) papge MRCSalah Courses 68. A 28-year-old man presents with an ischiorectal abscess. Where is ths abscess cavity likely to be sited? a. Above the levator ani Z b. Between external and internal anal sphincter a . Lateral to the obturator internus |. Medial to the internal anal-sphincter . Medial to the pudendal canal 69. A 36-year-pld man falls on his outstretched right hand.-Examination reveals « tenderness in the anatomical snuffbox. Which one of the following tendons form a boundary of the anatomical snuff box? Abductor pollicus brevis . Extensor carpi radialis brevis Extensor cairpi radialis longus Extensor indicis Extensor poliicis longus eaece 70. A 58-year-old- woman complains of cramps and tingling in her legs and arms 48 hours following a sub total thyroidectomy. Her vital signs, are stable. Investigations reveals anormal white-cell count and normal haemoglobin. The NA is 132 mmol/L K+3.2 mmol/L and Ca 1.60 mmol/L. Serum albumin is normal .The next appropriate step is intravenous infusion of? a. Calcium chloride i: b. Magnesium sulphate Hypocalceria: c. Potassium chloride d. Sodium bicarbonate e. Sodium chloride ‘© Correct underlying cause ‘© check albumin © cheorie ‘Check vtamin0, PTH PO calcium supplements, tami Dif needed ‘© Acute symptomatic = 100-300mg elemental 1V calcium = Calcium gluconate 2-3 grams (9% elemental) = Calcium chloride 1 gram (27% elemental) = Then 05-2mg/kg/hr, reduce dose later MRCSalah Courses 71. A.40-year-old woman presents with fecal incontinence and anatomically intact internal and external anal sphincters. Which structure is most likely to have been damaged? a. First sacral nerve-root b. Obturator nerve: c. Pelvic splanchnic nerves e. Pudendal nerve 72. Abdominal free fluid will collect in the lowest part of the peritoneal cavity. At operation with the patient supine, in which of the following will the fluid collect first? a, Hepatorenal pouch b. Left subphrenic space c. Lesser sac . Right paracolic gutter e. Right subphrenic space 73. A 45-year-old homeless man presents with a cough and weight loss over three months. On examination his BMI (Body Mass Index) is 19 and he has reduced breath sounds in the right upper zone. His chest X-ray shows a cavitaing lesion in the right upper lobe. He undergoes a bronchoscopy and a brornchial biopsy. The biopsy shows featureless necrosis surrounded by epithelioid macophages and giant cells. Which of the following is the most likely diagnosis? a. Actinomycosis b. Bronchiectasis c. Sarcoidosis d. Squamous @. Tuberculosis Il carcinoma MRCSalah Courses 74. A healthy 36 years old man is being assessed with a view to being a life related kidney donor. Which are of following investigations is most accurate for measuring the GFR? Creatinine clearance . Glucose Clarence Inulin Clarence : at the Teicd |. PAH i a Urea clearance nee ete PAH can be used to measure t ents the ki re 75. A 34-year-old pregnant woman develops a swollen leg. Her mother and maternal aunt also had a similar problem during their pregnancies. Which of the following tests is likely to be positive? a. Antiendomysial antibodies Antiphospholipid Syndrome Cri b. Antimitochondrial antibodies Sydney revision of Sapporo criteria 2006 ¢. Antinulear antibodies d. Antiphospholipid antibodies ICAL CATER 1A cHITERA e. Antithyroglobulin antibodies 1. Vascular . 1, anti-Cardiolipin IgG / IgM 2. Pregnancy Morbidity: a) death of normal fetus a ae 2. anti-beta-2 glycoprotein I ) premature birth at < 34 (era) wks dueto preeclampsia 3. Lupus anticoagulant 23 consecutive abortions (LAC) at Paras 3 pate ot == ache gehen era eft penn "l Seen — ry, “wave “ovendon” 4 — a flv ro constrict qpalerrns memcemenyeeos ot = += Cose vision and bright light ci “eT + Pupls diate (Sympathetic) 4 % ? Sevan oo it sete our ns 110. A 32-year-oid mountain biker presents to the outpatient clinic. He fell awkwardly, with excessive lateral flexion of his neck to the left side. He describes some paresthesia over his right shoulder and lateral arm. Which appears to have been improving over the past hour? What is the most likely injury suggested by this history? Axonotmesis of the C5n. root Axonotmesis of the T1 n. root Neuropraxia of the C5n. root Neuropraxia of the T1 n. root Neurotmesis of the C5n. foot eaoee MRCSalah Courses 111. A 62-year-old woman presents with a firm irregular mass in the upper outer quadrant of the right breast This appears malignant on mammography, and fine needle aspiration cytology is reported as C5 which is the first lymph nodes to which the tumour is most likely to metastasize? a. Initial node. b. Primary node - ¢. Secondary node d. Sentinel node e. Virchow’s nodes 112. A 50-year-old woman presents with a history of faecal incontinence over the past, few years. She had a prolonged and difficult first stage of labour 20 years previously. Physical examination reveals a relatively lax anal sphincter. Which nerve is likely to have been damaged in labour? Autonomic! nerves to the rectum . Genitofemoral nerve Lumbosacral trunk Obturator nerve . Pudendal nerve a b. ©. d. 113. A 26-year-old man presents to the Emergency Department with extensive bleeding from rm, after sustaining a glass injury.-On examination- there is n 7 cm transverse laceration ire anterior aspect of his elbow. On exploring the cubital fossa, you would expect the brachial artery to be? a. anterior to the median nerve Contents of cubital fossa b. lateral to the biceps tendon. . lateral to the median nerve ; Brachial . medial to the median nerve actery ©. superficial to the bicipital aponeurosis MRCSalah Courses 114, A 53-year-old man complains of ‘crushing’ chest pain at rest He has chronic hypertension and is a heavy smoker. His pulse rate is 138 beats/minute and blood pressure 140/90 mmHg. What is the principal cause underlying his reduced coronary artery blood flow? a. Decreased cardiac muscle wall tension b. Decreased coronary oxygen extraction ©. Decreased diastolic interval d. Decreased systolic interval e. Decreased vagal tone Falasonsho beaten hart ate (Herd ling and cardiac ott C0} 115. A 58-year-old woman, a known patient with thoracic right-sided meningioma, presents with features suggestive of a Brown-Sequard syndrome. The clinical findings will include which of the following? a. Left sided weakness, left sided proprioception and vibration loss, right sided loss of pin prick sensation b. Right sided weakness, right sided proprioception and vibration loss, left sided loss of pin prick sensation c. Right sided weakness. right sided proprioception and vibration loss, right sided loss of pin prick sensation d. Right sided weakness, left sided proprioception and vibration loss, right sided loss of pin prick sensation e. left sided weakness, right sided proprioception and vibration loss, left sided loss of pin prick sensation. Incomplete =| Spinal Cord Syndromes Sepwsora res ad Anterior Cord Syndrome antral Cord Syndrome Brown-Séquard Syndrome @ ® ®& + Bilotoralioss of moter, pain + Sensory and motor defict + Ipsilateral cas of motor, fané temperature sensation + Usper extremites affected vibration. proprioception below level of injury more than lower entremiies + Contralateral loss of pain + Intact vibration and + Hyperextension injury ‘and temperature pronocepton| * Classiealy im older patients + Penetrating Fauma or + Hyperienon iniury or who have undertying lateral compression disruption of antencr spinal conical disease artery MRCSalah Courses 116. 70-year-old woman presents with a fractured left humerus. X-rays show an osteolytic lesion at the site of the fracture. Histological examination of a sample taken at the time of internal fixation shows a metastatic carcinoma. Where is the most likely primary site? a. Breast b. Colon c. Endometrium d. Ovary e. Stomach Bone Metastases Origin: most common sites of origin (primary) are lung, breast prostate and kidney” ting 00 Prostate 50-70 ‘Symptoms: pain (esp at night) possible Hdokins 70 fracture or nerve compression may "Y, s cause elevated calcium level or lead to Melanoma 40 Bader as 117. A 74-year-old man presents with a pulsatile swelling in his abdomen. The principal abnormality within the wall of arterial aneurysms is loss of? a. adventitial collagen pL ecventital destin +" Detectable sorte wal patho Is not aways . intimal collage 5 @. intimal elastin Present in dissection. tomedaldaein + The most frequent histologically detectable lesion is medial degeneration (cystic medial degeneration). = Characterized by elastic tissue fragmentation and separation of elastic and fibro muscular elements of tunica media by small cleft like spaces. = These are not truly "cysts". 118, A 24-year-old woman presents with a swelling in the thyroid gland. She also has enlarged lymph nodes in the left anterior triangle of the neck. Which of the following is the most likely diagnosis? ane @. Anaplastic carcinoma Carcinoma of Thyroid § ia coe oeeronn Type (%) age spread Prognosis d. Medullary carcinoma Paptiery 80-70 young acuts Lymphatic. to Excelent e. Papillary carcinoma anes bales Folleuler 20.25 Youngmdde Blaod ream, Good wth 1O-50(%45) omocialy to rasio-osne bone therapy ‘Anaplastic 10-15 Elderly ‘Aggressive Very poor local extension 540 Unuay ler, Loca Variable More btfamiialymphate, casas car lead steam fama casas MRCSalah Courses 119. A 20-year old man with a severe head injury is being ventilated using positive pressure. Which of the following is a physiological consequence of this? a. Decreased extra fluid volume b. Decreased cardiac preload ¢. Increase in intrathoracic blood volume d. Increased cardiac preload e. Increased cardiac stroke volume + Decreased preload + Pestivelvedr pressure 1 na volume > comoression of he heat by te inated unos ‘She ivarara pressure fe hear anes ees eg." RAP) > venous olum docases 2 prelod's educrd > stoke vane decreases > carsec ouput ar blood pressure may ‘ops canbe mnumeod wa Tad whch Reps restore acoguat venous ftum an eld “+ Patients who are very senstve to changein prdoad conditions (eg. presence of ypevolema tamponade, PE severe ar rapping) a partulryBrve fo hypoterson when + Reduced afterload + Ling expansion ineases extramural pressure jwhich helps pump blood outo the thorax) ‘and thereby reduces LV atercad + When the carsiac parlance m may dearmned by changes n aftr than preload Condens (eg. hypervoleme pater wih systnic heart falure), PPV may be associated with ‘an improved svoke volume. PPV is very hotuln patents wih caronenic pulmonary ‘Sema, sit helps reduce prebad (ung congestion) and aftorbad. As aresul stoke ‘lume tends to incase 120. A 70-year-old man presents with a one-week history of epigastric pain and profuse vomiting The most likely consequence i ff, Complications of vomiting a. hypochloremic acidosis Totaia b. hypokalaeinic alkalosis Seana . raised serum chloride d. raised urine sodium e. reduced renin release * Electrolyte imbalance- hypokalemia * Hypochloremic metabolic alkalosis + Maiiony-Weiss tear * Boerhaave syndrome: eso. rupture 121. A 22-year-old men arrives in the Emergency Department with sudden breathlessness due to alarge pneumothorax. An immediate chest drain is inserted into the fifth loft intercostal space in the mid-axillary line, There is hemorrhage into the drainage bottle. Which of the following structures is the most likely cause of this acute hemorrhage? a. Intercostal artery. b. Left pericardiophrenic artery ¢. Linguia of the lung . Right ventricle of the heart @. Spleen fereey 122. The right and left pulmonary arteries are derived from which of the following embryological aortic arches? a. Second pharyngeal arch Tenetcartinge | Neve ane b. Third pharyngeal arch Moly . Fourth pharyngeal arch row males | va ys d. Fifth pharyngeal arch = Bxteantid e. Sixth pharyngeal arch ee yd dower _e Derivatives of branchial clefts and = youd pharyngeal pouches Hyldigons Comme cond seu ee x ‘ele - rad rove tino ema — “payntynpane nee ue vi eae eeeceereaee ergo ee lags Sacha ~seerarparanys Conte yt a Recent 123. In the fetal circulation, the majority of blood passing from the inferior vena cava into the right atrium subsequently passes next into which; one of the following? a. Aorta b. Left atrium ©. left ventricle d. pulmonary artery e. Right ventricle ‘The circulatory process: + The blood toes about haf «minute Fron the placenta, bod passes org Hoe" unis ven teh te fea tothe onder uroce "Ta he ony esta hat cari wid Hod, the nferarvencova where ‘Sith the Blood from the lower boy. Fgh strand not fit it (Stucted crac throug the foramen ‘rae into te lect envrcle nd pases ie MRCSalah Courses 124. A 36-year-old butcher injures his left index finger with a knife, suffering a deep laceration on the palmar aspect of the middle phalanx. On examination he is unable to fiex DIP, which tendon is likely to have been injured? a. flexor carpi radialis b. flexor carpi ulnaris ¢. Flexor digitorum profundus . Flexor digitorum superficialis e. Flexor indicis 125. A 39-year-old woman with large, expanding ovarian mass that is removed surgically, requiring a lateral pelvic wall clearance, of lymph nodes. Four days postoperatively she ‘complains of painful spasms in the groin area and remarks that she has an area of numbness ‘on the modial side of her thigh. Tho most likely explanation for these, problems is that during surgery an injury was inflicted on the: a. femoral nerve b. genitofemoral nerve ¢. lumbosacral trunk d. L3 ventral ramus e. Obturator nerve MRCSalah Courses 126. A 70-year-old patient is found to have sodium of 125 mmol/L. on examination. There is no signs of hypovolemia. His plasma osmolarity is 280 mOsmiL_ and his Urine osmolarity is 1000 mOsmiL. "Which of the following is the best explanation of these findings? a. Central diabetes insipidus b. Cerebral salt wasting syndrome . Nephrogenic diabetes insipidus d. Syndrome of inappropriate anti-diuretic hormone (ADK) secretion. e. Water deprivation = Common diagnostic criteria for SIADH Common disgnostc eter for SIADH Giterianccatng hel ot SUUDH Decree eum camel (7S mar) nw xmaaty<109 mms Ercsamia bert or crue youre sat nne oamotaty 100 mOsmg yperteems Urnary sodium excation 40 malt Puyipsiepotara Nomalenl uneton Severe npartodoma porate eoden <136 mnt) 127. A .surgeon is carrying out an elective splenectomy for congenital spherocytosis. Which structure will be divided in order to mobilise the spleen from the posterior abdominal wall? ‘a. Gastrosplenic ligament b. Lesser omentum ¢. Lienoreaal ligament d. phrenicocolic ligament . Short gastric vessels ‘Stomach Gastrosplenic palpable spleen four fingers breadths below the costal margin, is noticed. full blood counts have shown a persistent thrombocytopenia. Bone marrow examination has shown megakaryocytic hyperplasia. ‘What is the most likely cause of the thrombocytopenia? a. Ineffective production in bone marrow b. Platelet destruction in the bone marrow c. Platelet destruction in the liver d. Platelet destruction in the spleen e. Platelet storage in the spleen MRCSalah Courses 129A 7 years old boy presents with recurrent attacks of pneumonia. Culture showed Psudomonas aeruginosa. His mother confirms that he had meconium ileus in the neonatal period. Which of the following is the most likely finding in this boy? Pa ersephase idiot Classical Cystic Fibrosis b. Increased sweat chloride c. increased sweat creatinine = Presentation! d. Increased sweat potassium = Newborn with meconium ius e. Increased sweat urea ~ Infanttoddler with asthma or recurrent pneumonia = Infant with malabsorption / falure to thrive ~ Adolescent with pancreatitis + Diagnosis— sweat chloride test + Newborn screening ~ Immunoreactive trypsinogen ~ Identifies carriers as well as affecteds 130. A 42 years old woman has a Cholicystectomy and develops a self-limiting postoperative ‘wound infection. By what process would bacterial ingestion have been enhanced? a. Apoptosis b. Autophagy ¢. Metaplasia d. Opsonisation @. Phagocytosis 131. After resection of a rectal tumour a patient experiences erectile dysfunction. Which of the following nerves is most likely to have been damaged in surgery? a. Genitofemoral nerve b. Lumbosacral plexus c. Pelvic splanchnic nerves d. Perinea! branch of $4 e. Pudendal nerve Male Reprod. Viscera Innervation ‘Sympathetic 5; shoot) supply: Descending with testicular arteries or via hypogastric plexuses Parasympathetic (, point) supply: From $2.54; traveling via pelvic splanchnic nerves > pelvic plexus [prostaticplexus) > cavernous nerve reach erectile tissue ‘Somaticinnervation (Voluntary Motor to Perineal Muscles/Touch Sensation to Penis/Scrotum): Pudendal N.(S2-S4) fereey 132, A 15-year-old girl has been treated for tuberculosis over the previous 6 months She presents to Her doctor with fatigue, loss of Appetite and weight loss. On examination, her blood pressure is 90/55 mmHg and she has increased pigmentation. What is the next most appropriate investigations Aldosterone level Oral glucose tolerance test Random Cortisol level ACTH stimulation test water deprivation test Addison's disease goaogp Addison's Disease Diagnostic Studies — = Subnormal levelsof cortisol * Levels fail to rise over basal levels with ACTH stimulation test. ‘= Latter indicates primary adrenal disease. «Positiveresponse to ACTH stimulation indicates functioning adrenal gland. 133. A 73-year-old man with a history of irregular bowel movements presents with dysuria, pneumaturia and an Escherichia coli urinary tract Infection. CT scans show a mass involving ‘the sigmoid colon and the bladder. What is the commonest cause of this presentation? a. Adenocarcinoma of the sigmoid colon b. Colonic diverticular disease ©. Crohn's disease d. Transitional cell carcinoma of the bladder e. Ulcerative colitis Hinchey clasueation Description — 7 Coble iifanmationpercale absces orphleymon (confined) 7 Colonic inflammations retroperitoneal cor pelvic abscess (distant) ow Colonic inflammationspurulent peritonitis 7 Colonic inflammationsfecal peritonitis MRCSalah Courses 134. A 30-year-old man is assaulted with a hammer and sustains a depressed fracture at the Vertex, of the skull Profuse venous bleeding is noted at the fracture site. Which vascular structure is most likely to have been perforated? a. Cavernous sinus b. Inferior sagittal sinus c. Sigmoid sinus 4. Superior petrosal sinus e. Superior sagittal sinus 135. A 87-year-old heart transplant recipient is keen-to join the cardiac, rehabilitation program. Which of the following factors is most likely to increase cardiac output in this patient during moderate exercise? Decreased negative intrathoracic pressure Decreased venous tone Decreased ventricular compliance Increased atrial filling Increased intrapericardial pressure eaese 136. An 18-year-old woman foll 9 meters while rock climbing. She had a renal transplant two years ago. She is brought to the Emergency Department for resuscitation and appropriate analgesia given. When correctly prescribed, witch of following analgesic drugs would be most likely to adversely affect her renal function in this situation? a. Diclofenac ‘ Vesolltr Pes Vcore b. Ditycrocodeine arate Somme . paractamot = fe. Tramadol 4 Normal GFR Reduced GFR MRCSalah Courses 137. A 77-year-old man is admitted with acute urinary retention secondary to benign prostatic hyperplasia. A urinary catheter is inserted and of has free flow of concentrated urine. Which of the following best accounts for the action of the counter current multiplier mechanism that leads to the concentration of urine in the Loop of Henle? Active transport of solute out of thin section ascending limb ¢. Permeability to solute in descending limb d. Permeability to solute in thick ascending limb (222) . Permeability to water of thin section ascending limb ili, THE COUNTERCURRENT Counter Current Multiplier eee oe ee The interstitialfluid of the kidney is gradually concentrated from cortical to medullary part, thus inner medulla is highly concentrated with the presence of urea and through a mechanismof counter current multiplier. *+ This mechanism causes gradual osmotic outflow of water from the filtrate back to kidney as it passes downward in the descending loop of Henle. + Ascending loop of Henle does not allow outflow of ‘water from its filtrate instead actively transport [Actve sat transport out ofthe watermpermeant thick = ees ‘ascending limb establishes an herizontal gradient of about 200, Sodium ionsinto kidney interstitiursto sustain its aremeeSun a0 between tne toute had andthe weauery high concentration. Isr, 138. A 52-year-old man is found to have multiple myeloma. What skull X-ray appearances would be characteristic? ‘What is Active Myeloma? a. Diffuse thickening of the calvarium b. Hair on end* appearance c. Multiple fractures d. Multiple osteolytic lesions . Multiple osteosclerotic lesions 139, A 56-year-old man undergoes resection of his ileum secondary to ischemic bowel. Which of the following effects is most likely to be seen in this patient postoperatively? a. Decreased bile salt synthesis by the liver b. Decreased concentration of bile salts in colonic content? ¢. Decreased mean corpuscular volume d. Decreased reabsorption of vitamin B12 e. Decreased stool frequency fereey 140. A previously healthy 45 years old woman undergoes emergency Splenectomy following traumatic rupture of the spleen. A left subclavian central venous pressure (CVP) line to guide fluid therapy is inserted. At this time she becomes distressed and acutely dyspneic, with a blood pressure of 75/40 mmHg. There are decreased breath sounds on the left. Her temperature is 35.5°C. What is the most likely cause? Acute blood Loss . Anaphylaxis Myocardial infarction |. Sputum retention Tension pneumothorax 441. During the second (proliferative) phase of wound healing the predominant cells in the wound site are fibroblasts. This cell is of mesenchymal origin -and produces the matrix and collagen needed; to strengthen the scar. Cross linkage of collagen requires hydroxy-proline and hydroxy-lysine residues, which requires a specific vitamin to be available in sufficient quantities. Deficiency of which vitamin results in collagen that is unstable? a. Vitamin 82 (riboflaVine) b. Vitamin 86 (pyridoxine) i ¢. Vitamin C (ascorbic acid) Collagen Synthesis 4. Vitamin D (cholecaleifero!) @. Viarune Gooashasshale * Vitamin C also required for hydroxylation of lysine residues + Hydroxylysy! residues permit cross-linking or collagen and other post-translational modifications * Vitamin C may also influence mRNA levels needed for collagen synthesis. 142. A 19- year-old man fell down a flight of stairs. On presentation to the Emergency Department his Glasgow Coma Score (GCS) was 14/15 with no local neurological signs. An hour later he vomited and his GCS deteriorated to 10. He developed a fixed and dilated left pupil. Which of the following is likely to seen on the scan? a. Left-sided acute subdural Lucid interval haematoma b. Left-sided extradural haematoma c. Leftsided midbrain haematoma * An epidural hemorrhage is often characterized by the d. Right-sided acute subdural foci pecans ot een hitenties Ce lant trouma/ a blow te the head fllowe Fe cia eecammeaane = 1) nial confusion, decreased consciousness, ols of = 2) “lucid interval” (20-50%) bie perc of ul corciousness/estored mental status. The datiert seers back to hs/her “normal sl” ~ 3) Change in mental status +/- unstable vial signs (blood prewure, hear rate * the patient becomes confuse, somotet (sleepy), may have fereey 143. A 70-year-old woman weighing 5Q kg undergoes open Cholicystectomy. Postoperative pain relief is administered by intravenous morphine infusion (morphine 4 mg; 5 minute lock out). Twenty-four hours postoperatively she is in an agitated, confused state. Her temperature is 37.1°C-.pulse 90 beats/minute 110/80 mmHg. Her urine output is 35 ml/hour. Arterial blood gases are: PH pGo2 poz Bicarbonate | Base Excess Finding 7.27 10 kPa 9.6 kPa 36 mmol/L. 6 Normal 7.35-7.45 4.74.0 11.9-13.3 22-26 -2to +2 Which of the following is the most likely explanation to account for false findings? a. Hypovolaemia b. Opiate induced hypoventilation . Pain induced hyperventilation d. Pulmonary embolus e. Silent myocardial infarction 144. A 70-year-old woman from a nursing home is brought to’ the Emergency Department with abdominal pain and vomiting. On examination, she is dehydrated and her abdomen is distended. There is a 3 cm x 4 cm swelling in the right groin which is non tender, and there is no cough impulse. At operation, a femoral hernia is found. Which one of the following lies immediately lateral to the hernial neck? |. Femoral artery oe b. Femoral nerve ball cc. Femoral vein Arter: nual igamant 4. Inguinal ligament + Peston Upamertot e. Pectineal ligament Cosper(pcined '» Media Lacunar ligamert (Ginberats 145. A 64-year-old woman is-reviewed in the Emergency Department with an acute right groin swelling, below and lateral to the pubic tubercle. Which of the following forms the medial boundary of the ring through which this hernia is protruding? a. Conjoint tendon b. Inferior epigastric artery ¢. Inguinal ligament d. Lacunar ligament e. Pectineal ligament MRCSalah Courses 146, A. 27-year-old has had pancolitis for the last five years. Which one of these complications is the least likely to develop? a. b. ry a. 147. An 82-year-oid woman had a hemiarthroplasty of the hip six hours agi dependent diabetic and has been on long-term non-steroidal analgesic: Arthritis Cholangitis, iritis Polyarteritis Toxic megacolon Extraintestinal manifestations less than 10 percent at initial presentation 25 percent in their lifetime = “Musculoskeletal (most frequent) * nondestructive peripheral arthrts (arge joints) and ankyiosing spondyits * uveitis and + Selentis, itis, and conjunctive = Skin * erythema nodotum and pyoderma gangrenasim = Hepatobiliary + Primary sclerosing cholangitis (Alp) fay liver. ard autoimmune iner disease + fatigue, pruntus fevers, cls, night sweats, ard right upper quadrant pain = Hematopoietic/coagulation * venous anc arteralthomboomtd iam + Rutimmure hemolyte anemia (AHA) = Pulmonary (rare) * parenchymal ung disease, semstis,thomboombolic disease, anddrug-nduced lung toxcty he is an insulin- In the last three hours she passed, viaher urinary catheter, a total of 20 ml of urine. Her pulse rate is 120 beats/minute and regular, her blood pressure 100/60 mmHg and capillary refill is 3 seconds. Blood urea and electrolyte levels ars ‘Sodium: Potassium Creatinine Urea Finding 435 mmoli_ ‘4.0 mmol/l. 440 umolll. 42.0 mmol Normal. 437-144 3.5-4.9 35-110 3.27.5 je most likely cause of this is: eaesp MRCSalah Courses ‘Acute Tubular necrosis blocked urinary catheter diabetic nephropathy non-steroidal anti-inflammatory drugs (22?) Reduced renal perfusion 148, Witch single respiratory test parameter (FEV1 Forced expiratory volume in one second; FVG-- Forced vital capacity) is the best prediction for morbidity and mortality after surgery? Confronted flow volume loop FEV1<4L FEVAIFVC <70%. . ‘Maximum inspiratory Volume <2 L Reduced residual volume paoos <50%prodied 1.51 <20l0

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