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e-UKCG practice questions

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Question 1Clinical knowledge: medicine and surgery

A 24-year-old man presents with sudden onset of severe right iliac fossa pain that began around the umbilicus and migrated. He has anorexia and low-grade fever. Which single finding on examination is most suggestive of acute appendicitis?

  1. CVA tenderness on the right
  2. Epigastric tenderness relieved by antacids
  3. Pain on passive extension of the hip
  4. Rebound tenderness at McBurney's point Correct answer.

Explanation

Localised rebound tenderness over McBurney's point reflects peritoneal irritation from an inflamed appendix and is the classic examination finding. Migratory pain from the periumbilical region to the right iliac fossa supports the same diagnosis.

Question 2Clinical knowledge: medicine and surgery

A 68-year-old woman has a painful, swollen left calf after a long-haul flight. Which investigation is the first-line objective test to confirm a suspected deep vein thrombosis?

  1. Magnetic resonance venography
  2. Contrast venography
  3. D-dimer assay
  4. Compression duplex ultrasonography of the leg Correct answer.

Explanation

Compression duplex ultrasound is the first-line imaging test for suspected DVT, with high sensitivity and specificity for proximal thrombosis. D-dimer is useful mainly to exclude DVT in low-probability patients but is non-specific.

Question 3Clinical knowledge: medicine and surgery

A 55-year-old man has a 6-month history of progressive dysphagia, initially to solids and now to liquids, with weight loss. Which diagnosis must be excluded first?

  1. Achalasia
  2. Gastro-oesophageal reflux disease
  3. Oesophageal carcinoma Correct answer.
  4. Globus hystericus

Explanation

Progressive dysphagia with weight loss in an older adult is a red flag for oesophageal malignancy and requires urgent endoscopy. The progression from solids to liquids is typical of a mechanical obstruction from a stricture or tumour.

Question 4Clinical knowledge: medicine and surgery

A 72-year-old woman falls and cannot bear weight on her right hip. The leg is shortened and externally rotated. Which diagnosis is most likely?

  1. Pubic ramus fracture
  2. Acetabular labral tear
  3. Fractured neck of femur Correct answer.
  4. Posterior hip dislocation

Explanation

A shortened, externally rotated leg after a fall in an elderly patient is the classic presentation of a fractured neck of femur. Posterior dislocation instead presents with a shortened, internally rotated and adducted leg.

Question 5Clinical knowledge: medicine and surgery

A 30-year-old man has sudden severe testicular pain with nausea and a high-riding testis. Which is the most appropriate immediate action?

  1. Prescribe antibiotics for epididymo-orchitis
  2. Await scrotal ultrasound before any intervention
  3. Reassure and arrange outpatient review
  4. Urgent urological/surgical exploration Correct answer.

Explanation

Testicular torsion is a surgical emergency; the testis can be salvaged if detorsion occurs within about 6 hours. Ultrasound must not delay exploration when the clinical picture is convincing.

Question 6Clinical knowledge: medicine and surgery

A 45-year-old woman has right upper quadrant colicky pain after fatty meals, and ultrasound shows gallstones. Which complication is suggested by a persistently palpable mass in the right upper quadrant with fever?

  1. Empyema of the gallbladder Correct answer.
  2. Mirizzi syndrome
  3. Biliary colic
  4. Acute pancreatitis

Explanation

A palpable, tender gallbladder with fever (Murphy's sign) suggests acute cholecystitis or empyema of the gallbladder. Empyema represents infected bile within an obstructed gallbladder.

Question 7Clinical knowledge: medicine and surgery

A 62-year-old man has painless visible haematuria. Which diagnosis should be prioritised in the investigation pathway?

  1. Renal calculus
  2. Urinary tract infection
  3. Urothelial (bladder) carcinoma Correct answer.
  4. Benign prostatic hyperplasia

Explanation

Painless visible haematuria in an older adult is a red flag for urothelial malignancy and warrants urgent urological referral and cystoscopy. Painful haematuria is more typical of infection or stones.

Question 8Clinical knowledge: medicine and surgery

A 28-year-old woman has a firm, smooth, mobile breast lump that is non-tender. Which diagnosis is most likely?

  1. Fat necrosis
  2. Breast abscess
  3. Fibroadenoma Correct answer.
  4. Invasive ductal carcinoma

Explanation

A smooth, well-defined, mobile and non-tender lump in a young woman is characteristic of a fibroadenoma. Malignancy is more typically hard, irregular and fixed.

Question 9Clinical knowledge: medicine and surgery

A 58-year-old man has a pulsatile, expansile abdominal mass. Which finding on examination best distinguishes an abdominal aortic aneurysm from a transmitted aortic pulsation?

  1. Absent femoral pulses
  2. A palpable expansile mass with a widened aortic diameter Correct answer.
  3. A bruit heard over the epigastrium
  4. Tenderness on deep palpation

Explanation

The key sign of an AAA is an expansile mass with a widened aortic diameter on palpation, distinguishing it from a normal aorta transmitted through the abdominal wall. Bruits and tenderness are non-specific.

Question 10Clinical knowledge: medicine and surgery

A 70-year-old man has a painful, cold, pulseless leg with mottling and reduced sensation. Which is the most urgent management priority?

  1. Oral anticoagulation and outpatient review
  2. Elevation and compression bandaging
  3. Graduated compression stockings
  4. Immediate vascular assessment for revascularisation Correct answer.

Explanation

Acute limb ischaemia threatens limb viability and requires urgent vascular assessment for revascularisation. The six Ps (pain, pallor, pulselessness, paraesthesia, paralysis, perishing cold) indicate a surgical emergency.

Question 11Clinical knowledge: medicine and surgery

A 40-year-old woman has a 3 cm thyroid nodule with no compressive symptoms and normal thyroid function. Which is the most appropriate next step in assessment?

  1. Radioiodine scanning
  2. Total thyroidectomy
  3. Ultrasound-guided fine needle aspiration Correct answer.
  4. Thyroxine suppression therapy

Explanation

Ultrasound-guided fine needle aspiration is the key test to assess a thyroid nodule for malignancy, guided by ultrasound features. Function tests and imaging help but cytology determines further management.

Question 12Clinical knowledge: medicine and surgery

A 65-year-old man has painless jaundice and a palpable gallbladder (Courvoisier's law). Which diagnosis is most likely?

  1. Viral hepatitis
  2. Pancreatic head carcinoma Correct answer.
  3. Gallstone impaction in the cystic duct
  4. Acute cholecystitis

Explanation

Courvoisier's law states that a palpable, non-tender gallbladder with painless jaundice is unlikely to be due to stones and suggests malignant obstruction, typically pancreatic head carcinoma. Chronic stone disease fibroses the gallbladder, preventing distension.

Question 13Clinical knowledge: medicine and surgery

A 22-year-old man has a penetrating abdominal wound with evisceration of bowel. Which is the most appropriate immediate management?

  1. Irrigation and primary closure in the emergency department
  2. CT scan before any intervention
  3. Resuscitation and urgent laparotomy Correct answer.
  4. Discharge with wound care advice

Explanation

Evisceration after penetrating abdominal trauma mandates resuscitation and urgent laparotomy. Delay for imaging increases the risk of peritonitis and sepsis from unrecognised visceral injury.

Question 14Clinical knowledge: medicine and surgery

A 50-year-old woman has a 2 cm superficial burn on the forearm with blistering and severe pain. Which is the most appropriate initial management?

  1. Cool running water, analgesia, and non-adherent dressing Correct answer.
  2. Rupture all blisters and apply antibiotic ointment
  3. Apply ice directly to the burn
  4. Apply butter or oil to the burn

Explanation

Cool running water for 20 minutes, analgesia and a non-adherent dressing are standard first aid for a superficial partial-thickness burn. Ice and traditional remedies can worsen tissue damage or infection.

Question 15Clinical knowledge: medicine and surgery

A 35-year-old man has a deep laceration over the palm from a knife. Which structure is most at risk and should be formally assessed?

  1. Brachial plexus
  2. Median nerve only
  3. Radial artery only
  4. Flexor tendons and digital nerves Correct answer.

Explanation

Palmar lacerations risk injury to flexor tendons and digital nerves, which require formal assessment of tendon function and sensation. Vascular injury is possible but tendon and nerve injuries are the key functional concern.

Question 16Clinical knowledge: medicine and surgery

A 60-year-old man has a swelling in the groin that is above and medial to the pubic tubercle and expands on coughing. Which diagnosis is most likely?

  1. Psoas abscess
  2. Saphena varix
  3. Femoral hernia
  4. Inguinal hernia Correct answer.

Explanation

An inguinal hernia lies above and medial to the pubic tubercle, while a femoral hernia lies below and lateral. An expansile cough impulse supports a hernia.

Question 17Clinical knowledge: medicine and surgery

A 45-year-old woman has a solitary thyroid nodule and undergoes fine needle aspiration reported as Thy3 (indeterminate). Which is the most appropriate next step?

  1. Observation with no further action
  2. Diagnostic hemithyroidectomy Correct answer.
  3. Radioiodine ablation
  4. Repeat FNA in 5 years

Explanation

An indeterminate (Thy3) cytology result carries a significant malignancy risk and usually warrants diagnostic hemithyroidectomy for histology. Repeat cytology or observation risks missing a carcinoma.

Question 18Clinical knowledge: medicine and surgery

A 55-year-old man has a large, non-tender, fluctuant swelling in the scrotum that transilluminates. Which diagnosis is most likely?

  1. Hydrocele Correct answer.
  2. Testicular tumour
  3. Varicocele
  4. Inguinal hernia

Explanation

A hydrocele is a fluid collection in the tunica vaginalis that transilluminates and is typically non-tender. An inguinal hernia may contain bowel and does not transilluminate.

Question 19Clinical knowledge: medicine and surgery

A 70-year-old woman has a 4 cm ulcerated lesion on her lower lip with rolled edges. Which histological type is most likely?

  1. Kaposi sarcoma
  2. Basal cell carcinoma
  3. Squamous cell carcinoma Correct answer.
  4. Melanoma

Explanation

Squamous cell carcinoma commonly arises on sun-exposed sites such as the lower lip and may ulcerate. Basal cell carcinoma is more typical on the face but the lower lip is a classic site for SCC.

Question 20Clinical knowledge: medicine and surgery

A 30-year-old man has a stab wound to the left chest with hypotension and distended neck veins. Which is the most likely diagnosis?

  1. Flail chest
  2. Haemothorax
  3. Tension pneumothorax
  4. Cardiac tamponade Correct answer.

Explanation

Hypotension with distended neck veins after penetrating chest trauma suggests cardiac tamponade, where blood in the pericardium impairs filling. Tension pneumothorax also causes shock but with absent breath sounds and tracheal deviation.

Question 21Clinical knowledge: medicine and surgery

A 62-year-old man has a 5 cm abdominal aortic aneurysm with a serum creatinine of 180 micromol/L and severe chronic obstructive pulmonary disease. Which factor most influences the decision for elective repair?

  1. The presence of an epigastric bruit
  2. The exact aneurysm diameter alone
  3. Overall operative risk versus risk of rupture Correct answer.
  4. The patient's blood group

Explanation

The decision for elective AAA repair balances rupture risk against operative risk from comorbidity. Aneurysm size is a major factor but significant comorbidity may favour conservative management or endovascular repair.

Question 22Clinical knowledge: medicine and surgery

A 25-year-old man has a stab wound to the abdomen with haemodynamic instability and peritonitis. Which is the most appropriate management?

  1. Observation with serial examination
  2. CT abdomen with contrast
  3. Immediate laparotomy Correct answer.
  4. Diagnostic peritoneal lavage

Explanation

Haemodynamic instability with peritonitis after penetrating abdominal trauma is an indication for immediate laparotomy. Imaging and observation are reserved for stable patients without peritonitis.

Question 23Clinical knowledge: medicine and surgery

A 48-year-old woman has a 3 cm firm breast lump with skin dimpling and nipple retraction. Which feature most strongly suggests malignancy?

  1. Skin dimpling and nipple retraction Correct answer.
  2. Smooth, mobile consistency
  3. Bilateral symmetry
  4. Cyclical tenderness

Explanation

Skin dimpling and nipple retraction indicate tethering of the skin and duct to an underlying malignancy. Smooth, mobile lumps and cyclical tenderness are more typical of benign disease.

Question 24Clinical knowledge: medicine and surgery

A 66-year-old man has intermittent claudication with a reduced ankle-brachial pressure index. Which finding best supports significant peripheral arterial disease?

  1. ABPI of 1.2 with normal pulses
  2. A bruit over the femoral artery only
  3. Bilateral pitting oedema
  4. ABPI of 0.6 with a reduced walking distance Correct answer.

Explanation

An ABPI below 0.9 indicates significant peripheral arterial disease and correlates with claudication. An ABPI of 1.2 may suggest calcified, non-compressible vessels rather than normal perfusion.

Question 25Clinical knowledge: medicine and surgery

A 38-year-old man has a 2 cm well-differentiated thyroid cancer with no lymph node involvement. Which is the most appropriate surgical approach?

  1. Hemithyroidectomy alone with no follow-up
  2. Radioiodine ablation without surgery
  3. Observation only
  4. Total thyroidectomy with consideration of radioiodine Correct answer.

Explanation

Differentiated thyroid carcinoma is typically managed with total thyroidectomy, allowing radioiodine ablation and thyroglobulin surveillance. Hemithyroidectomy may be considered for low-risk disease but follow-up is essential.

Question 26Clinical knowledge: medicine and surgery

A 24-year-old man presents with a 6-hour history of central abdominal pain that has migrated to the right iliac fossa. He has anorexia, nausea and a temperature of 37.9°C. Examination shows tenderness and guarding at McBurney's point. Which is the most likely diagnosis?

  1. Ureteric colic
  2. Acute cholecystitis
  3. Acute appendicitis Correct answer.
  4. Acute diverticulitis

Explanation

Migratory pain from the periumbilical region to the right iliac fossa reflects early visceral then parietal peritoneal irritation from an inflamed appendix. Localised guarding at McBurney's point with low-grade fever and anorexia is the classic picture. Diverticulitis affects the left side and ureteric colic produces loin-to-groin pain without guarding.

Question 27Clinical knowledge: medicine and surgery

A 72-year-old woman has a 3-day history of a painful, red, swollen left leg. The calf is warm and tender with pitting oedema. Which investigation is the most appropriate first-line to confirm the diagnosis?

  1. Magnetic resonance venography
  2. Contrast venography
  3. Duplex ultrasound of the leg veins Correct answer.
  4. Serum D-dimer assay

Explanation

Compression duplex ultrasound is the investigation of choice for suspected deep vein thrombosis, being non-invasive and highly sensitive for proximal thrombus. D-dimer is useful only to exclude DVT in low-probability cases and is often raised in this older patient with an inflammatory leg. Contrast and MR venography are reserved for equivocal cases.

Question 28Clinical knowledge: medicine and surgery

A 68-year-old man has a 2 cm squamous cell carcinoma excised from the dorsum of his hand. Which risk factor is most strongly associated with this tumour type?

  1. Chronic cumulative ultraviolet radiation exposure Correct answer.
  2. High dietary fibre intake
  3. Recurrent herpes simplex infection
  4. Chronic gastro-oesophageal reflux

Explanation

Squamous cell carcinoma of sun-exposed skin is strongly associated with cumulative ultraviolet exposure, which causes DNA damage in keratinocytes. It commonly arises on the head, neck and dorsum of the hands in older patients. Reflux, dietary fibre and herpes infection are not recognised risk factors.

Question 29Clinical knowledge: medicine and surgery

A 55-year-old man is admitted with haematemesis and melaena. He is tachycardic at 110 beats per minute with a blood pressure of 100/65 mmHg. Two large-bore cannulae are sited. Which is the most appropriate initial fluid resuscitation?

  1. Rapid intravenous crystalloid bolus with blood cross-match Correct answer.
  2. Subcutaneous fluid administration
  3. Oral rehydration solution
  4. Intravenous colloid given as a slow infusion

Explanation

In acute upper gastrointestinal haemorrhage with haemodynamic compromise, prompt restoration of circulating volume with intravenous crystalloid while cross-matched blood is arranged is the immediate priority. Two large-bore cannulae permit rapid flow. Oral, subcutaneous and slow colloid routes are inadequate in shock.

Question 30Clinical knowledge: medicine and surgery

A 30-year-old woman presents with sudden severe right-sided flank pain radiating to the groin, with visible haematuria. She is afebrile. Which is the most likely diagnosis?

  1. Ureteric calculus Correct answer.
  2. Renal cell carcinoma
  3. Acute urinary retention
  4. Acute pyelonephritis

Explanation

Sudden severe colicky loin-to-groin pain with haematuria in an afebrile young adult is typical of a ureteric stone. The pain is caused by obstruction and ureteric spasm. Pyelonephritis causes fever and loin tenderness, while renal cancer is usually painless and retention causes a distended bladder.

Question 31Clinical knowledge: medicine and surgery

A 60-year-old man is found to have a blood pressure of 185/105 mmHg on repeated measurement. Which term best describes this finding?

  1. Stage 2 hypertension Correct answer.
  2. White coat hypertension
  3. Hypertensive emergency
  4. Normal blood pressure

Explanation

Repeated clinic readings of 185/105 mmHg exceed the threshold for stage 2 hypertension, which requires sustained elevation confirmed by ambulatory or home monitoring. White coat hypertension refers to elevated clinic but normal ambulatory readings. Hypertensive emergency requires acute target-organ damage.

Question 32Clinical knowledge: medicine and surgery

A 45-year-old man has a 1 cm laceration to the forearm that is clean and 4 hours old, with intact distal neurovascular function. Which is the most appropriate management?

  1. Wound irrigation, primary closure and tetanus status check Correct answer.
  2. Antibiotics alone without closure
  3. Immediate skin grafting
  4. Delayed closure after 7 days

Explanation

A clean, recent, uncomplicated laceration with intact distal function is managed by thorough irrigation, careful wound edge apposition and tetanus prophylaxis assessment. Primary closure is appropriate within the golden period for clean wounds. Grafting, delayed closure and antibiotics alone are unnecessary here.

Question 33Clinical knowledge: medicine and surgery

A 65-year-old woman has a firm, non-tender mass in the left lobe of the thyroid and a history of hoarseness. Which clinical feature most raises concern for malignancy?

  1. Mild tenderness on palpation
  2. New vocal cord palsy causing hoarseness Correct answer.
  3. A family history of goitre
  4. A smooth mobile nodule

Explanation

New hoarseness from recurrent laryngeal nerve palsy suggests tumour invasion beyond the thyroid capsule and is a red flag for malignancy. Smooth mobility and mild tenderness are more typical of benign disease. A family history of simple goitre does not itself indicate cancer.

Question 34Clinical knowledge: medicine and surgery

A 70-year-old man with atrial fibrillation presents with sudden painless loss of vision in the right eye. The fundus shows a pale retina with a cherry-red spot at the macula. Which is the most likely diagnosis?

  1. Vitreous haemorrhage
  2. Central retinal artery occlusion Correct answer.
  3. Central retinal vein occlusion
  4. Retinal detachment

Explanation

Sudden painless monocular visual loss with a pale, oedematous retina and a cherry-red macular spot is the classic appearance of central retinal artery occlusion. The cherry-red spot represents preserved choroidal perfusion at the fovea. Atrial fibrillation is a common embolic source.

Question 35Clinical knowledge: medicine and surgery

A 58-year-old man has a 4 cm descending colon adenocarcinoma with no evidence of distant metastasis. Staging shows tumour invading through the muscularis propria into the subserosa, with two involved regional nodes. Which is the most appropriate management?

  1. Defunctioning colostomy without resection
  2. Endoscopic mucosal resection alone
  3. Watchful waiting with repeat colonoscopy
  4. Left hemicolectomy with adjuvant chemotherapy Correct answer.

Explanation

A node-positive, locally advanced but non-metastatic colon cancer is treated with oncological resection (hemicolectomy with lymphadenectomy) followed by adjuvant chemotherapy. Stage III disease benefits from adjuvant treatment. Endoscopic resection, stoma alone and observation are inadequate for invasive node-positive disease.

Question 36Clinical knowledge: medicine and surgery

A 35-year-old woman has a 4 cm simple cyst in the right lobe of the liver found incidentally. She is asymptomatic with normal liver function tests. Which is the most appropriate management?

  1. Immediate surgical deroofing
  2. Reassurance and no intervention Correct answer.
  3. Systemic antiparasitic therapy
  4. Percutaneous aspiration and sclerosis

Explanation

An asymptomatic simple hepatic cyst is a benign developmental lesion requiring no treatment; the key step is confirming typical imaging features. Surgical deroofing is reserved for large symptomatic cysts. Aspiration and sclerosis or antiparasitic therapy apply to other cystic lesions such as hydatid disease.

Question 37Clinical knowledge: medicine and surgery

A 50-year-old woman develops a wound infection 5 days after abdominal surgery. The wound is red, indurated and discharging pus. Which is the most appropriate initial step?

  1. Start oral antihistamines
  2. Apply a compressive dressing
  3. Open the wound, drain the pus and send a sample for culture Correct answer.
  4. Apply a topical steroid cream

Explanation

A postoperative wound abscess requires source control: opening the wound to drain pus relieves tension and allows sampling for microbiology to guide antibiotics. Steroids, antihistamines and compression do not address the infected collection. Antibiotics alone are insufficient when pus is present.

Question 38Clinical knowledge: medicine and surgery

A 62-year-old man has a 6 cm infrarenal abdominal aortic aneurysm. Which measurement threshold most strongly indicates the need for elective repair?

  1. Diameter of 4.5 cm
  2. Diameter of 5.5 cm or greater Correct answer.
  3. Diameter of 3.0 cm
  4. Diameter of 4.0 cm

Explanation

Elective repair of an infrarenal abdominal aortic aneurysm is generally offered when the maximum diameter reaches about 5.5 cm, or when it expands rapidly or becomes symptomatic. Below this threshold, rupture risk is lower than operative risk, so surveillance is preferred. Smaller diameters are monitored with ultrasound.

Question 39Clinical knowledge: medicine and surgery

A 28-year-old woman has a 2 cm thyroid nodule and undergoes fine needle aspiration reported as Thy3a (atypia of undetermined significance). Which is the most appropriate next step?

  1. Radioiodine ablation
  2. Repeat ultrasound-guided fine needle aspiration or diagnostic hemithyroidectomy Correct answer.
  3. Immediate total thyroidectomy without further sampling
  4. Observation alone with no follow-up

Explanation

Thy3a cytology carries an indeterminate risk of malignancy, so further assessment with repeat sampling or diagnostic hemithyroidectomy is recommended. Immediate total thyroidectomy over-treats a lesion that may be benign. Radioiodine is used for confirmed differentiated carcinoma, and no follow-up risks missing malignancy.

Question 40Clinical knowledge: medicine and surgery

A 60-year-old man with intermittent claudication is found to have an ankle-brachial pressure index of 0.6 in the affected leg. Which feature best supports a diagnosis of critical limb ischaemia rather than stable claudication?

  1. Rest pain relieved by dependency and a non-healing ulcer Correct answer.
  2. Absence of hair on the toes
  3. Pain only after walking 200 metres
  4. A palpable popliteal pulse

Explanation

Critical limb ischaemia is defined by rest pain or tissue loss (ulceration or gangrene) with objective evidence of severe arterial insufficiency. Rest pain relieved by hanging the leg down reflects severe distal hypoperfusion. Claudication pain is exertional and relieved by rest, and hair loss alone is non-specific.

Question 41Clinical knowledge: medicine and surgery

A 40-year-old man presents with a painful, swollen, tender testis of sudden onset with no urinary symptoms. He is afebrile. Which diagnosis must be urgently excluded?

  1. Epididymo-orchitis
  2. Hydrocele
  3. Varicocele
  4. Testicular torsion Correct answer.

Explanation

Sudden severe testicular pain in a young man is testicular torsion until proven otherwise, and the testis must be explored urgently to avoid infarction. Epididymo-orchitis usually has fever and urinary symptoms. Hydrocele and varicocele are typically painless swellings.

Question 42Clinical knowledge: medicine and surgery

A 58-year-old woman has a 3 cm ulcerated lesion on the lower eyelid margin with rolled pearly edges and telangiectasia. Which histological type is most likely?

  1. Squamous cell carcinoma
  2. Basal cell carcinoma Correct answer.
  3. Malignant melanoma
  4. Sebaceous adenoma

Explanation

A pearly, rolled-edged ulcerated lesion with visible telangiectasia on sun-exposed skin is characteristic of nodular basal cell carcinoma. It is locally invasive but rarely metastasises. Squamous cell carcinoma is usually keratotic and scaly, and melanoma is pigmented.

Question 43Clinical knowledge: medicine and surgery

A 45-year-old man has a 2 cm firm lump in the left parotid region that has been slowly enlarging for 2 years. Facial nerve function is normal. Which is the most likely diagnosis?

  1. Parotid abscess
  2. Parotid duct calculus
  3. Pleomorphic adenoma Correct answer.
  4. Warthin tumour

Explanation

A slow-growing, painless, firm parotid mass with intact facial nerve function is most often a pleomorphic adenoma, the commonest benign salivary tumour. Warthin tumours are typically cystic and occur in older smokers, mainly in the tail. Abscess and calculi cause acute pain and swelling.

Question 44Clinical knowledge: medicine and surgery

A 32-year-old woman has a 1 cm well-differentiated thyroid papillary carcinoma confined to one lobe with no lymph node involvement. Which is the most appropriate initial surgical management?

  1. Observation with annual ultrasound
  2. Total thyroidectomy with neck dissection
  3. Radioiodine ablation alone
  4. Hemithyroidectomy Correct answer.

Explanation

For a small, unifocal, low-risk papillary thyroid carcinoma confined to one lobe, hemithyroidectomy is an accepted and often preferred option to reduce surgical morbidity. Total thyroidectomy with neck dissection is reserved for larger or node-positive disease. Radioiodine is adjuvant therapy, not primary treatment.

Question 45Clinical knowledge: medicine and surgery

A 65-year-old man has a 5 cm radiolucent stone in the bladder with recurrent urinary tract infections. Which is the most appropriate management?

  1. Open cystolithotomy Correct answer.
  2. Extracorporeal shockwave lithotripsy
  3. Percutaneous nephrolithotomy
  4. Conservative management with hydration

Explanation

Large bladder stones (over about 3–4 cm) are best treated by open cystolithotomy, which allows complete removal and assessment of any underlying bladder outflow obstruction. Shockwave lithotripsy is unsuitable for bladder stones of this size, and nephrolithotomy addresses kidney stones.

Question 46Clinical knowledge: medicine and surgery

A 70-year-old man with a history of diverticular disease presents with a rigid, tender left lower quadrant and fever. CT shows a pericolic abscess of 2 cm with no free gas. Which is the most appropriate initial management?

  1. Oral laxatives and discharge
  2. Percutaneous drainage of the abscess
  3. Intravenous antibiotics and observation Correct answer.
  4. Emergency Hartmann's procedure

Explanation

A small (under about 3 cm) pericolic abscess complicating diverticulitis without perforation or generalised peritonitis is managed initially with intravenous antibiotics and close observation. Larger abscesses may require percutaneous drainage. Emergency surgery is reserved for generalised peritonitis or failure to improve.

Question 47Clinical knowledge: medicine and surgery

A 42-year-old woman has a 3 cm firm, irregular breast mass with skin dimpling. Core biopsy shows invasive ductal carcinoma. Which feature most strongly predicts a poor prognosis?

  1. Axillary lymph node involvement Correct answer.
  2. Presence of skin dimpling
  3. Tumour size of 3 cm
  4. Oestrogen receptor positivity

Explanation

Axillary lymph node status is the single strongest prognostic factor in operable breast cancer, reflecting the likelihood of systemic spread. Tumour size and skin tethering matter but carry less weight than nodal involvement. Oestrogen receptor positivity predicts response to endocrine therapy and is a favourable feature.

Question 48Clinical knowledge: medicine and surgery

A 55-year-old woman has a 1.5 cm papillary thyroid carcinoma with a single involved central compartment node. Which is the most appropriate surgical approach?

  1. Hemithyroidectomy alone
  2. Radioiodine ablation without surgery
  3. Total thyroidectomy with central compartment neck dissection Correct answer.
  4. Observation with serial thyroglobulin

Explanation

In papillary thyroid carcinoma with confirmed nodal involvement, total thyroidectomy with central compartment lymph node dissection is recommended to achieve clearance and allow radioiodine therapy and thyroglobulin surveillance. Hemithyroidectomy alone leaves involved nodes and complicates follow-up.

Question 49Clinical knowledge: medicine and surgery

A 60-year-old man with a 6 cm abdominal aortic aneurysm is being assessed for elective repair. He has severe chronic obstructive pulmonary disease and a serum creatinine of 180 micromol/L. Which factor most strongly argues for a less invasive approach?

  1. Male sex
  2. Aneurysm diameter of 6 cm
  3. Significant cardiorespiratory comorbidity Correct answer.
  4. Age over 55 years

Explanation

The decision between open and endovascular repair in an infrarenal aneurysm depends heavily on fitness for major surgery. Severe respiratory disease and renal impairment substantially increase open operative risk, favouring endovascular repair where anatomy permits. Diameter, sex and age influence overall risk but are less decisive.

Question 50Clinical knowledge: medicine and surgery

A 48-year-old woman has a 2 cm superficial partial-thickness burn to the anterior thigh with blistering and severe pain. Which is the most appropriate initial management?

  1. Prophylactic systemic antibiotics
  2. Immediate split-skin grafting
  3. Application of ice directly to the burn
  4. Cool running water, analgesia, non-adherent dressing and tetanus review Correct answer.

Explanation

A small superficial partial-thickness burn is managed by cooling with running water for about 20 minutes, analgesia, a non-adherent dressing and tetanus prophylaxis assessment. Grafting is reserved for deep or full-thickness burns. Direct ice causes further thermal injury and prophylactic antibiotics are not routinely indicated.