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Clinical Officers Council Pre-Internship study materials
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Clinical Officers Council Pre-Internship practice questions

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Question 1Internal Medicine

A 28-year-old man is newly diagnosed with sputum-positive pulmonary tuberculosis and has normal liver and kidney function. Using the abbreviations H = isoniazid, R = rifampicin, Z = pyrazinamide and E = ethambutol, which regimen is standard for a new adult case?

  1. 9 months of HRE with pyridoxine throughout
  2. 6 months of HRZE throughout
  3. 2 months of HRZE, then 4 months of HR Correct answer.
  4. 2 months of HR, then 4 months of ZE

Explanation

New adult pulmonary tuberculosis is treated with a two-month intensive phase of four drugs (HRZE) followed by a four-month continuation phase of two drugs (HR). The pyrazinamide and ethambutol are stopped once the intensive phase ends. Extending four-drug therapy or dropping rifampicin from the continuation phase increases relapse and resistance.

Question 2Internal Medicine

A 24-year-old woman with type 1 diabetes on insulin is alert but sweating and confused. Capillary glucose is 2.6 mmol/L and she can swallow safely. What is the most appropriate immediate treatment?

  1. Intravenous 50% dextrose 50 mL bolus
  2. Intramuscular glucagon 1 mg
  3. Subcutaneous rapid-acting insulin 4 units
  4. Oral glucose 15–20 g Correct answer.

Explanation

A conscious patient who can swallow should be given fast-acting oral carbohydrate, which corrects hypoglycaemia quickly and avoids unnecessary injections. Recheck glucose after 10–15 minutes and repeat if still low, then give a longer-acting carbohydrate. Parenteral therapy is reserved for patients who cannot take anything by mouth or who are unconscious.

Question 3Internal Medicine

A 6-year-old child in a malaria-endemic area has fever and a positive rapid diagnostic test for falciparum malaria, with no danger signs and no vomiting. Which is the recommended first-line treatment?

  1. Single-dose oral sulfadoxine-pyrimethamine
  2. Oral quinine three times daily for 7 days
  3. Oral chloroquine once daily for 3 days
  4. Artemether-lumefantrine Correct answer.

Explanation

Uncomplicated falciparum malaria is treated with an artemisinin-based combination therapy, of which artemether-lumefantrine is the standard first-line agent in most African programmes. It is given as six doses over three days with a fatty meal to improve absorption. Chloroquine resistance is widespread and sulfadoxine-pyrimethamine is no longer adequate as monotherapy.

Question 4Internal Medicine

A 30-year-old woman has microcytic hypochromic anaemia. Which test best confirms that iron deficiency is the cause?

  1. Reticulocyte count
  2. Serum ferritin level Correct answer.
  3. Serum vitamin B12 level
  4. Peripheral blood film showing target cells

Explanation

A low serum ferritin reflects depleted iron stores and is the most specific single test for iron deficiency, especially when anaemia is already present. A normal or high ferritin does not exclude deficiency in inflammation, but a low value is diagnostic. Vitamin B12 and reticulocyte counts assess other mechanisms of anaemia.

Question 5Internal Medicine

Which inhaled drug is prescribed as the reliever for a patient with chronic asthma?

  1. Oral prednisolone once daily
  2. Montelukast at night
  3. Salbutamol as needed Correct answer.
  4. Beclomethasone twice daily

Explanation

Relievers are short-acting bronchodilators such as salbutamol, used for rapid symptom relief of bronchoconstriction. Inhaled corticosteroids and leukotriene antagonists are controllers that reduce airway inflammation but do not relieve acute symptoms. Frequent reliever use signals inadequate control and a need to step up controller therapy.

Question 6Internal Medicine

A 55-year-old man of African ancestry has newly diagnosed hypertension and no other comorbidity. Which is the most appropriate first-line antihypertensive?

  1. Ramipril
  2. Bisoprolol
  3. Methyldopa
  4. Amlodipine Correct answer.

Explanation

Hypertension in people of African ancestry is typically low-renin, so calcium channel blockers such as amlodipine or thiazide-like diuretics are more effective first-line than drugs acting on the renin-angiotensin system. ACE inhibitors are used first-line in younger patients and in those with diabetes or proteinuric renal disease. Beta-blockers and methyldopa are not preferred initial agents for uncomplicated hypertension.

Question 7Internal Medicine

A 40-year-old man has a duodenal ulcer with a positive stool antigen test for Helicobacter pylori. Which regimen is appropriate eradication therapy?

  1. Amoxicillin alone for 7 days
  2. PPI + amoxicillin + clarithromycin for 14 days Correct answer.
  3. Metronidazole plus a PPI for 5 days
  4. A proton pump inhibitor twice daily alone for 4 weeks

Explanation

Eradication requires acid suppression combined with at least two antibiotics, typically a proton pump inhibitor plus amoxicillin and clarithromycin for 14 days. This triple therapy achieves high cure rates and promotes ulcer healing while reducing recurrence. Single agents or short two-drug courses lead to treatment failure and resistance.

Question 8Internal Medicine

Which cerebrospinal fluid pattern is typical of acute bacterial meningitis?

  1. Eosinophil predominance with normal glucose
  2. Lymphocyte predominance with normal glucose and protein
  3. Normal cell count with a mildly raised protein
  4. Neutrophil predominance, low glucose, high protein Correct answer.

Explanation

Bacterial meningitis produces a purulent CSF picture dominated by neutrophils, with a low glucose ratio to serum and a markedly raised protein. Viral meningitis more often shows a lymphocytic picture with normal glucose. These findings guide immediate empirical antibiotics, which should not be delayed for lumbar puncture in an unstable patient.

Question 9Internal Medicine

A 58-year-old man has central chest pain and ST elevation in leads V2 to V4. Which single drug given early most reduces mortality?

  1. Supplemental oxygen for all patients
  2. Aspirin 300 mg chewed Correct answer.
  3. Prophylactic intravenous lignocaine
  4. Subcutaneous morphine

Explanation

Chewed aspirin produces rapid platelet inhibition and reduces mortality in acute myocardial infarction, so it should be given as early as possible. Morphine relieves pain but does not alter mortality, and oxygen is only indicated when saturation is low. Prophylactic lignocaine is not recommended because of pro-arrhythmic harm.

Question 10Internal Medicine

A 70-year-old man with atrial fibrillation also has hypertension and diabetes and has had no previous stroke or bleeding. What is the most appropriate therapy to reduce his stroke risk?

  1. No antithrombotic therapy
  2. Aspirin 75 mg daily
  3. Clopidogrel 75 mg daily
  4. Apixaban Correct answer.

Explanation

His CHA2DS2-VASc score is high enough to warrant therapeutic anticoagulation, and a direct oral anticoagulant such as apixaban is preferred to warfarin for convenience and safety. Antiplatelet drugs do not provide adequate stroke prevention in atrial fibrillation. Bleeding risk should be assessed but rarely outweighs the benefit here.

Question 11Internal Medicine

A 22-year-old with type 1 diabetes has glucose 28 mmol/L, blood ketones 5 mmol/L, pH 7.10 and blood pressure 95/60 mmHg. What is the first step in management?

  1. Oral rehydration solution
  2. Intravenous 0.9% sodium chloride Correct answer.
  3. Intravenous sodium bicarbonate
  4. An intravenous bolus of soluble insulin

Explanation

These features define diabetic ketoacidosis, and the immediate priority is volume resuscitation with isotonic saline before insulin is started. Insulin can then be infused with potassium replacement once the potassium is known to be adequate. Bicarbonate is reserved for extreme acidaemia because routine use worsens outcomes.

Question 12Internal Medicine

A 65-year-old smoker with COPD remains breathless despite using salbutamol as needed. Which is the most appropriate addition to maintenance therapy?

  1. Tiotropium Correct answer.
  2. Inhaled beclomethasone alone
  3. Regular inhaled salbutamol alone
  4. Long-term oral prednisolone

Explanation

Long-acting bronchodilators, including long-acting muscarinic antagonists such as tiotropium, improve symptoms and reduce exacerbations in COPD and are preferred over regular short-acting agents. Inhaled corticosteroids are added only in selected patients with frequent exacerbations. Long-term oral steroids cause harm and are avoided.

Question 13Internal Medicine

Which feature is part of the CURB-65 score used to assess the severity of community-acquired pneumonia?

  1. Temperature above 38 °C
  2. White cell count above 15 × 10⁹/L
  3. Heart rate above 100 beats per minute
  4. Confusion Correct answer.

Explanation

CURB-65 stands for Confusion, Urea above 7 mmol/L, Respiratory rate 30 or more, Blood pressure below 90 systolic or 60 diastolic, and age 65 or above. Each item scores one point and guides the decision between home, ward and intensive care management. Fever, tachycardia and leucocytosis are prognostic markers but are not part of the score.

Question 14Internal Medicine

A man with cirrhotic ascites undergoes diagnostic paracentesis. What ascitic polymorphonuclear cell count establishes the diagnosis of spontaneous bacterial peritonitis?

  1. ≥50 cells/mm³
  2. ≥1500 cells/mm³
  3. ≥5000 cells/mm³
  4. ≥250 cells/mm³ Correct answer.

Explanation

An ascitic neutrophil count of 250 cells/mm³ or more defines spontaneous bacterial peritonitis, even if culture is negative. Treatment with a third-generation cephalosporin should start promptly once the count is known. Higher thresholds apply to secondary peritonitis, which usually has multiple organisms and a much greater cell count.

Question 15Internal Medicine

A 45-year-old man has severe epigastric pain radiating to the back with vomiting. Which result best confirms acute pancreatitis?

  1. Total serum amylase twice the upper limit of normal
  2. Plain abdominal X-ray showing ileus
  3. C-reactive protein of 40 mg/L
  4. Lipase three times the upper limit of normal Correct answer.

Explanation

A serum lipase greater than three times the upper limit of normal is more sensitive and specific than amylase for acute pancreatitis and remains raised longer. Together with characteristic pain, it is sufficient for diagnosis without imaging. Amylase can be raised in other abdominal emergencies and in renal failure.

Question 16Internal Medicine

A patient with chronic kidney disease has a potassium of 7.2 mmol/L and widened QRS complexes on the ECG. Which treatment should be given first?

  1. Insulin with 50% dextrose
  2. Oral sodium polystyrene sulfonate
  3. IV 10% calcium gluconate Correct answer.
  4. Nebulised salbutamol

Explanation

Widened QRS complexes indicate hyperkalaemic cardiac toxicity, and intravenous calcium stabilises the myocardium within minutes without lowering the potassium. Insulin-dextrose and salbutamol then shift potassium into cells while removal from the body is arranged. Calcium is repeated if ECG changes persist.

Question 17Internal Medicine

A 65-year-old man with small cell lung cancer has serum sodium 122 mmol/L, low serum osmolality, urine osmolality 550 mOsm/kg, urine sodium 60 mmol/L and no oedema. What is the most likely diagnosis?

  1. SIADH Correct answer.
  2. Primary polydipsia
  3. Cranial diabetes insipidus
  4. Diuretic-induced hyponatraemia

Explanation

Euvolaemic hypotonic hyponatraemia with inappropriately concentrated urine and high urine sodium is the hallmark of the syndrome of inappropriate antidiuretic hormone secretion, commonly caused by small cell lung cancer. Management is fluid restriction and treatment of the underlying tumour. Hyponatraemia from diuretics usually accompanies volume depletion.

Question 18Internal Medicine

A patient with HIV has a CD4 count of 150 cells/µL. Which prophylactic drug is indicated?

  1. Azithromycin
  2. Cotrimoxazole Correct answer.
  3. Acyclovir
  4. Fluconazole

Explanation

Cotrimoxazole prophylaxis is started when the CD4 count falls below 200 cells/µL to prevent Pneumocystis jirovecii pneumonia and toxoplasmosis. It is continued until immune recovery on antiretroviral therapy is sustained. Other agents have narrower indications based on specific opportunistic risks.

Question 19Internal Medicine

A 35-year-old woman has symmetrical small-joint synovitis and a positive rheumatoid factor. Which drug should be started as first-line disease-modifying therapy?

  1. Allopurinol
  2. Long-term oral prednisolone
  3. Methotrexate Correct answer.
  4. Colchicine

Explanation

Methotrexate is the anchor disease-modifying drug in rheumatoid arthritis and should be started early to prevent joint erosion. Folic acid is co-prescribed to reduce mucocutaneous and haematological toxicity. Steroids give symptomatic relief but do not replace disease-modifying therapy.

Question 20Internal Medicine

A 60-year-old man has exertional dyspnoea, a raised jugular venous pressure and bibasal crepitations. Which investigation best confirms the diagnosis of heart failure?

  1. Resting 12-lead ECG
  2. Echocardiography Correct answer.
  3. Chest radiograph
  4. Serum troponin

Explanation

Echocardiography confirms the diagnosis by demonstrating impaired systolic or diastolic function, valve disease or chamber enlargement. It also guides therapy by measuring ejection fraction. The chest radiograph and ECG support the clinical picture but cannot confirm ventricular dysfunction.

Question 21Internal Medicine

A pleural aspirate has a protein of 42 g/L while the serum protein is 65 g/L; the fluid LDH is within the normal serum range. How should this pleural fluid be classified?

  1. A transudate, because the fluid LDH is normal
  2. Exudate, because the protein ratio exceeds 0.5 Correct answer.
  3. An exudate, because the fluid protein exceeds 30 g/L
  4. A transudate, because the fluid protein is below 60 g/L

Explanation

Light's criteria classify fluid as exudative if the pleural-to-serum protein ratio exceeds 0.5, the pleural-to-serum LDH ratio exceeds 0.6, or the fluid LDH exceeds two-thirds of the upper limit of normal serum LDH. The ratio here is 0.65, so the fluid is an exudate requiring further investigation such as cytology and culture. Absolute protein values alone are unreliable.

Question 22Internal Medicine

An arterial blood gas in a breathless patient shows sodium 140 mmol/L, chloride 100 mmol/L and bicarbonate 10 mmol/L. What is the anion gap?

  1. 40 mmol/L
  2. 30 mmol/L Correct answer.
  3. 20 mmol/L
  4. 10 mmol/L

Explanation

The anion gap is calculated as sodium minus the sum of chloride and bicarbonate, giving 140 − 110 = 30 mmol/L. The normal range is roughly 8–12 mmol/L, so this represents a high anion gap metabolic acidosis such as ketoacidosis, lactic acidosis or poisoning. The gap helps narrow the differential and guide further tests.

Question 23Internal Medicine

A patient with acute severe asthma remains wheezy and tachycardic after repeated nebulised salbutamol with ipratropium, systemic corticosteroids and oxygen. Which additional treatment is indicated?

  1. Intravenous broad-spectrum antibiotics
  2. Intravenous magnesium sulphate Correct answer.
  3. Intravenous furosemide
  4. Oral montelukast

Explanation

Intravenous magnesium sulphate is the next adjunct in severe asthma that has not responded to inhaled bronchodilators and steroids, because it relaxes bronchial smooth muscle. It is given as a single slow infusion with monitoring for hypotension. Failure to improve should prompt consideration of intensive care and ventilatory support.

Question 24Internal Medicine

Which treatment approach is correct in thyroid storm?

  1. PTU and propranolol, with iodine an hour later Correct answer.
  2. Intravenous levothyroxine with a beta-blocker
  3. Radioactive iodine as the emergency treatment
  4. Lugol's iodine given before the first thionamide dose

Explanation

Thyroid storm is treated with a thionamide such as propylthiouracil to block hormone synthesis, a beta-blocker for sympathetic symptoms, and iodine to block release. Iodine must be given at least an hour after the thionamide, otherwise it acts as substrate for further hormone production. Supportive care with fluids, cooling and treatment of precipitants is essential.

Question 25Internal Medicine

A man with persistent vomiting has a creatinine of 200 µmol/L, a urine sodium of 12 mmol/L and a fractional excretion of sodium of 0.4%. What is the most likely cause of his kidney injury?

  1. Acute interstitial nephritis from NSAIDs
  2. Acute tubular necrosis
  3. Obstructive uropathy
  4. Pre-renal acute kidney injury Correct answer.

Explanation

Vomiting causes volume depletion, and the intact tubules avidly reabsorb sodium and water, producing a low urine sodium and a fractional excretion below 1%. This pattern indicates a pre-renal cause that should respond to fluid replacement. Intrinsic renal injury typically gives a fractional excretion above 2%.

Question 26Internal Medicine

A 34-year-old woman has fatigue and pallor. Her full blood count shows a microcytic, hypochromic anaemia. Which laboratory result is most characteristic of iron deficiency?

  1. Low serum ferritin Correct answer.
  2. Raised mean corpuscular volume
  3. High transferrin saturation
  4. High serum ferritin

Explanation

Serum ferritin reflects body iron stores, so a low value is the most sensitive single marker of iron deficiency and is usually accompanied by low transferrin saturation and microcytosis. Ferritin is an acute-phase reactant, so a normal value in inflammation does not fully exclude deficiency.

Question 27Internal Medicine

A 60-year-old man is diagnosed with community-acquired pneumonia. Which organism is the most frequent cause?

  1. Streptococcus pneumoniae Correct answer.
  2. Mycoplasma pneumoniae
  3. Haemophilus influenzae
  4. Staphylococcus aureus

Explanation

Streptococcus pneumoniae remains the single commonest causative organism of community-acquired pneumonia across adult age groups. Atypical organisms such as Mycoplasma are seen but are less frequent overall.

Question 28Internal Medicine

A 45-year-old woman reports weight gain, cold intolerance and constipation. Her pulse is 54 beats per minute, and examination shows dry skin and delayed ankle reflexes. Serum TSH is 28 mU/L and free T4 is low. Which diagnosis best fits these findings?

  1. Subclinical hypothyroidism
  2. Euthyroid sick syndrome
  3. Secondary hypothyroidism
  4. Primary hypothyroidism Correct answer.

Explanation

A low free T4 with a markedly raised TSH localises the problem to the thyroid gland itself, which defines primary hypothyroidism. In secondary hypothyroidism the TSH would be low or inappropriately normal because pituitary drive is lost.

Question 29Internal Medicine

A 68-year-old woman with type 2 diabetes has been taking metformin for several years. Her latest eGFR is 25 mL/min/1.73 m². What is the most appropriate action regarding her metformin?

  1. Continue metformin and recheck renal function in three months
  2. Double the metformin dose to improve control
  3. Continue metformin at the current dose
  4. Stop metformin Correct answer.

Explanation

Metformin should be stopped when the eGFR falls below 30 mL/min/1.73 m² because reduced renal clearance predisposes to accumulation and lactic acidosis. Alternative glucose-lowering agents are then chosen according to renal function.

Question 30Internal Medicine

A 45-year-old woman describes a sudden severe headache that reached maximum intensity within seconds. Her neurological examination is normal and a non-contrast CT scan performed 4 hours after onset is normal. What is the most appropriate next step?

  1. Start empirical intravenous antibiotics
  2. Perform a lumbar puncture for xanthochromia Correct answer.
  3. Reassure her and discharge with simple analgesia
  4. Repeat the CT scan in 24 hours

Explanation

A normal CT early after a thunderclap headache does not exclude subarachnoid haemorrhage, so lumbar puncture is performed at least 12 hours after symptom onset to look for xanthochromia from red cell breakdown. Missing the diagnosis risks a catastrophic rebleed.

Question 31Surgery

During the primary survey of a seriously injured patient, which step follows immediately after the airway has been secured with cervical spine protection?

  1. Breathing and ventilation assessment Correct answer.
  2. Circulation with haemorrhage control
  3. Disability and neurological status
  4. Exposure with temperature control

Explanation

The primary survey follows a fixed sequence: catastrophic haemorrhage control, airway with cervical spine protection, breathing, circulation, disability and exposure. Once the airway is secured, breathing is assessed by inspecting the chest, auscultating and checking oxygenation.

Question 32Surgery

Which finding is the earliest cardiovascular sign of hypovolaemic shock in a previously healthy young adult?

  1. Absent pulses at the wrist and ankle
  2. Bradycardia with widened pulse pressure
  3. Systolic pressure below 90 mmHg
  4. Tachycardia with narrow pulse pressure Correct answer.

Explanation

Baroreceptor-driven tachycardia and peripheral vasoconstriction maintain systolic pressure early in haemorrhage, so the pulse pressure narrows before hypotension appears. A fall in systolic pressure is a late and unreliable sign in young adults.

Question 33Surgery

A 45-year-old man develops sudden severe epigastric pain, and an erect chest radiograph shows free gas under both hemidiaphragms. Which diagnosis is most likely?

  1. Perforated peptic ulcer Correct answer.
  2. Acute cholecystitis
  3. Small bowel obstruction
  4. Acute pancreatitis

Explanation

Free subdiaphragmatic gas in a patient with sudden severe epigastric pain indicates a perforated hollow viscus, most often a peptic ulcer. The erect chest film is the standard initial investigation for this finding.

Question 34Surgery

An elective operation in which the gastrointestinal tract is opened under controlled conditions without unusual contamination is classified as:

  1. Clean-contaminated Correct answer.
  2. Dirty
  3. Infected
  4. Clean

Explanation

Clean-contaminated surgery involves a controlled opening of the gastrointestinal, respiratory or genitourinary tract without unusual contamination. The classification predicts the risk of surgical site infection and guides prophylaxis.

Question 35Surgery

A head-injured patient opens his eyes only to painful stimulus, speaks confused words, and withdraws his limb from pain. What is his Glasgow Coma Scale score?

  1. 10 Correct answer.
  2. 8
  3. 11
  4. 9

Explanation

The score is E2 (eyes to pain) + V4 (confused speech) + M4 (withdraws from pain) = 10. The Glasgow Coma Scale ranges from 3 to 15.

Question 36Surgery

Which intravenous fluid is most appropriate for the initial resuscitation of an adult with hypovolaemia from trauma?

  1. 0.45% sodium chloride
  2. 10% dextrose in water
  3. 5% dextrose in water
  4. 0.9% sodium chloride Correct answer.

Explanation

Isotonic crystalloid, either 0.9% sodium chloride or a balanced salt solution, is first-line for hypovolaemic resuscitation because it remains in the extracellular space and expands plasma volume. Dextrose solutions are metabolised rapidly and do not restore circulating volume.

Question 37Surgery

Peau d'orange appearance of the breast skin is caused by:

  1. Dermal lymphatic obstruction by tumour Correct answer.
  2. Fat necrosis with calcification
  3. Duct ectasia with periductal inflammation
  4. Superficial thrombophlebitis of breast veins

Explanation

Tumour infiltration of dermal lymphatics causes oedema and tethering of the skin, producing the peau d'orange appearance of locally advanced breast carcinoma. It is a sign of advanced disease.

Question 38Surgery

A 55-year-old woman with a previous caesarean section presents with colicky abdominal pain, vomiting and absolute constipation. What is the most likely cause of her small bowel obstruction?

  1. Gallstone ileus
  2. Inguinal hernia
  3. Adhesions Correct answer.
  4. Colorectal carcinoma

Explanation

Adhesions from previous abdominal or pelvic surgery are the commonest cause of small bowel obstruction in adults. Hernias are the second commonest cause.

Question 39Surgery

A 70 kg man has 30% total body surface area partial-thickness burns. Using the Parkland formula, what volume of crystalloid should be given in the first 24 hours from the time of injury?

  1. 6,300 mL
  2. 4,200 mL
  3. 12,600 mL
  4. 8,400 mL Correct answer.

Explanation

The Parkland formula is 4 mL × body weight in kg × percentage burn, giving 4 × 70 × 30 = 8,400 mL over 24 hours. Half is given in the first 8 hours and the remainder over the next 16 hours.

Question 40Surgery

A young man with a stab wound to the chest is hypotensive, with distended neck veins, absent breath sounds and hyperresonance on the right. What is the immediate management?

  1. Needle decompression of the right pleural cavity Correct answer.
  2. Intercostal drain insertion under fluoroscopy
  3. Urgent chest radiograph before treatment
  4. Pericardiocentesis

Explanation

Tension pneumothorax is a clinical diagnosis treated at once by needle decompression in the second intercostal space at the midclavicular line, followed by a chest drain. Delaying treatment for imaging risks cardiac arrest.

Question 41Surgery

Which is the most common cause of acute pancreatitis in adults worldwide?

  1. Alcohol
  2. Hypertriglyceridaemia
  3. Gallstones Correct answer.
  4. Trauma

Explanation

Gallstones account for most cases of acute pancreatitis worldwide, with alcohol second. Identifying the cause matters because it guides prevention of recurrence.

Question 42Surgery

A patient develops perioral tingling and carpopedal spasm 48 hours after total thyroidectomy. Which is the most likely cause?

  1. Hypocalcaemia after parathyroid injury Correct answer.
  2. Bilateral recurrent laryngeal nerve palsy
  3. Expanding cervical haematoma
  4. Thyroid storm with fever

Explanation

Transient or permanent hypoparathyroidism after total thyroidectomy lowers serum calcium, producing perioral paraesthesia, carpopedal spasm and a positive Trousseau sign. Serum calcium should be checked and replaced promptly.

Question 43Surgery

A 9-month-old infant has episodic screaming, vomiting and a sausage-shaped abdominal mass, with red currant jelly stools. Which is the most appropriate initial treatment?

  1. Hydrostatic enema reduction Correct answer.
  2. Immediate laparotomy and resection
  3. Nasogastric decompression alone
  4. Intravenous antibiotics alone

Explanation

Idiopathic ileocolic intussusception in a stable infant is first treated by pneumatic or hydrostatic enema reduction, which succeeds in most cases. Operation is reserved for failed reduction, perforation or peritonitis.

Question 44Surgery

A femoral hernia sac lies:

  1. Below and lateral to the pubic tubercle Correct answer.
  2. Through the inguinal canal
  3. Within the scrotum, anterior to the testis
  4. Above and medial to the pubic tubercle

Explanation

The femoral canal lies below and lateral to the pubic tubercle, so a femoral hernia emerges there, whereas an inguinal hernia emerges above and medial to the tubercle. Femoral hernias carry a high risk of strangulation and are repaired early.

Question 45Surgery

A 35-year-old man has severe throbbing perianal pain, fever and a tender fluctuant swelling beside the anus. Which is the definitive treatment?

  1. Oral laxatives and sitz baths
  2. Topical steroid cream
  3. Rubber band ligation
  4. Incision and drainage Correct answer.

Explanation

An acute perianal abscess is treated by prompt incision and drainage under anaesthesia, with antibiotics as an adjunct. Antibiotics or local measures alone will not resolve a pus collection.

Question 46Surgery

A young man struck on the temple is briefly unconscious, recovers, then deteriorates with a fixed dilated pupil. Which is the most likely diagnosis?

  1. Diffuse axonal injury
  2. Extradural haematoma Correct answer.
  3. Subarachnoid haemorrhage
  4. Chronic subdural haematoma

Explanation

A lucid interval followed by deterioration and a fixed dilated pupil is characteristic of an expanding extradural haematoma, usually from a torn middle meningeal artery. Urgent CT and neurosurgical referral are required.

Question 47Surgery

Ten minutes into a blood transfusion, a patient develops fever, loin pain, hypotension and dark urine. What is the first action?

  1. Stop the transfusion immediately Correct answer.
  2. Give antihistamine and continue
  3. Give furosemide and continue transfusion
  4. Slow the rate and give paracetamol

Explanation

These features indicate an acute haemolytic reaction, usually from ABO incompatibility. The transfusion must be stopped at once and circulation supported with crystalloid while the reaction is investigated.

Question 48Surgery

For elective colorectal surgery, prophylactic antibiotics should be given:

  1. On the first postoperative day
  2. Only when the wound appears infected
  3. Within 60 minutes before skin incision Correct answer.
  4. At the time of skin closure

Explanation

Prophylaxis aims to achieve adequate tissue levels at the moment of incision, so a single dose is given within 60 minutes before skin incision, with re-dosing for long procedures or major blood loss.

Question 49Surgery

A patient develops a temperature of 38.2 degrees Celsius on the first postoperative day after laparotomy. Which is the most likely cause?

  1. Wound infection
  2. Atelectasis Correct answer.
  3. Deep vein thrombosis
  4. Anastomotic leak

Explanation

Fever in the first 24 to 48 hours after surgery is most often due to atelectasis from poor lung expansion. Chest physiotherapy, adequate analgesia and early mobilisation are the main measures.

Question 50Surgery

An elderly constipated man has gross abdominal distension, and a plain radiograph shows a coffee-bean shaped loop arising from the pelvis. After successful endoscopic detorsion, what is the most appropriate definitive management?

  1. Immediate Hartmann procedure in the same admission
  2. Repeat endoscopic detorsion when needed
  3. Elective sigmoid colectomy Correct answer.
  4. Long-term laxatives alone

Explanation

Sigmoid volvulus recurs frequently after simple endoscopic detorsion, so elective sigmoid colectomy is advised in fit patients to prevent further episodes. Emergency resection is reserved for gangrene or perforation.