EWMERGENCY+TRAUMA-EMQ-32

1.THEME: HEAD INJURY

A Open skull fracture

B Subarachnoid haemorrhage

C Subaponeurotic scalp haematoma

D Basal skull fracture

E Subdural haematoma

F Concussion

G Extradural haematoma

H Diffuse axonal injury

For each of the case descriptions below, select the most appropriate diagnosis from the list above.

Scenario 1

A 25-year-old motorcyclist is brought to the Accident and Emergency Department after being involved in a high speed road
traffic accident (RTA). He is unconscious and is noted to have a periorbital haematoma. On examination, a clear fluid mixed
with blood is seen coming out of his nostrils.

Basal skull fracture Correct answer

Fractures of the skull vault may be linear, comminuted or depressed. Bruising over the mastoid process (retroauricular bruising
– Battle sign) (late sign) and periorbital haematoma (Raccoon eyes) are classical signs of basal skull fractures. Middle fossa
fractures present with rhinorrhoea/otorrhoea (blood mixed with CSF that does not clot), haemotympanum, ossicular disruption
and VIIth and/or VIIIth cranial nerve palsies.

Scenario 2

A 39-year-old man walks into the Accident and Emergency Department after being assaulted with a baseball bat. He had a
momentary loss of consciousness but feels fine at present. Whilst in the Accident and Emergency Department he gradually
becomes confused and later unconscious with a Glasgow Coma Scale (GCS) score of 8. His right pupil appears dilated.

Extradural haematoma Correct answer

Acute extradural haematoma should be suspected after a head injury where the patient has a fluctuating level of
consciousness (though not always). The patient may briefly lose consciousness but soon recover (lucid interval). It is
associated with trauma and is usually seen in the young. Extradural bleeds are commonly due to direct trauma to the temporal
or parietal bones causing injury to the middle meningeal artery or vein. With increasing bleed (haematoma), lateralising signs
develop, including an ipsilateral dilated pupil and a contralateral hemiparesis. This may eventually lead to bilateral fixed pupils
and a coma that culminates in respiratory arrest.

Scenario 3

A 56-year-old man presents to the trauma clinic with a fluctuant swelling under his scalp and bilateral swollen eyelids. He fell
off a 5-feet-high step-ladder 5 days ago. On examination, the swelling extends from the frontal to the occipital region. He is well
otherwise and his GCS score is 15.

Subaponeurotic scalp haematoma Correct answer

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In contrast to a localised scalp haematoma, a subaponeurotic haematoma is diffuse, arising in the space between the galea
and the pericranium. It usually occurs a few days after a head injury. It presents as a large, diffuse and fluctuant swelling
underneath the scalp, extending from the frontal region to the occiput. It may be associated with swollen eyelids. This
haematoma does not need aspiration as it gradually resolves over a number of weeks.

Scenario 4

An 84-year-old man with dementia is brought to the Accident and Emergency Department with a left-sided hemiparesis. The
carer from the patient’s nursing home believes that he might have hit his head against the bathtub 10 days ago. Since then, he
has complained of recurrent episodes of headaches and has been noticed to have ‘variation’ in his consciousness level. He
takes warfarin on prescription for atrial fibrillation.

Subdural haematoma Correct answer

Most subdural haematomas are secondary to trauma, sometimes trivial, where the patient (or carer) does not recall the
incident. Spontaneous subdural haematomas can occur in elderly patients with cerebral atrophy due to shearing of the
subdural veins (venous plexus); alcoholics, epileptics and patients on anticoagulants are more susceptible. About 20% of
subdural haematomas are bilateral. In chronic subdural haematoma, the patient may not become symptomatic for many days
or even weeks after the injury. If the haematoma continues to enlarge, the patient presents with a headache, a fluctuating level
of consciousness (not usually seen in acute subdural haematoma), failing intellect and hemiparesis.

2.

Theme: Correction of haemostatic defects

A Cryoprecipitate

B Prothrombin complex concentrate

C Protamine sulphate

D Intravenous vitamin K

E Platelets

F Platelets, fresh frozen plasma and cryoprecipitate

For each of the scenarios below select the most appropriate treatment from the list of options above. Each option may be used
once only, more than once or not at all.

In patients who are over-anticoagulated with warfarin, treatment depends on the INR, the presence or absence of spontaneous
bleeding and the urgency of the required correction. Patients with INR >5.0 or who show bleeding should be reversed, usually
with vitamin K although additional fresh frozen plasma may be required in severe bleeds, urgent situations of very high INRs.
Cryoprecipitate contains only fibrinogen and factor VIII and will not reverse warfarin.

Scenario 2 is clearly disseminated intrvascular coagulation (DIC) secondary to sepsis, and despite to comparatively mild
haematological abnormalities and the lack of bleeding, aggressive treatment with plasma and platelets is required. In this case
cryoprecipitate should be added to help support the fibrinogen which is dramatically reduced.

FFP (compared to prothrombin complex concentrate) only has a partial effect and is not the optimal treatment and should
never be used for the reversal of warfarin anticoagulation in the presence of severe bleeding. FFP contains insufficient
concentration of vitamin K factors to reverse the bleeding deficiency.

Scenario 1

A 68-year-old man on long term warfarin therapy for atrial fibrillation is admitted to the ward 48 h prior to elective TURP. He
complains of minor gingival bleeding only and has an INR of 7.5.

Intravenous vitamin K Correct answer

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Intravenous vitamin K

Scenario 2

A 32-year-old woman is admitted with acute cholecystitis. Despite antibiotic treatment, her condition deteriorates and she
becomes hypotensive, oliguric and hypoxic. There is no bleeding but investigations show platelets 21 x 109/l, prothrombin time
21 s (control 16 s), activated partial thromboplastin time 69s (control 36 s), fibrinogen 0.2 g/dl (normal range 2–4 g/dl).

Platelets, fresh frozen plasma and cryoprecipitate Correct answer

Platelets, fresh frozen plasma and cryoprecipitate

Scenario 3

A 43-year-old woman on warfarin for a prosthetic mitral valve has increasing confusion following a fall. There is radiographic
evidence of an acute subdural haematoma that requires urgent surgical drainage. Her INR is 4.5.

Prothrombin complex concentrate Correct answer

Prothrombin complex concentrate

3.

Theme: Lung segments

A Apical

B Superior lingular

C Lateral basal (left)

D Medial (right)

E Medial (left)

F Inferior lingular

Pick the most appropriate option from the above list. Each option may be used once only, more than once or not at
all.

Scenario 1

A three-year-old child has inhaled a foreign body – where is it most likely to be embedded?

Medial (right) Correct answer

Medial (right)

Inhaled foreign objects that enter the bronchial tree most frequently lodge in the medial right lung segment as the
right main bronchus is wider and more vertical.

Scenario 2

A 67-year-old has tuberculosis – which lobe is most likely to be affected?

Apical Correct answer

Apical

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Scenario 3

A 27-year-old has pneumonia – which lobe is most likely to be affected?

Lateral basal (left) Correct answer

Lateral basal (left)

Pneumonia tends to affect the basal segments as the lungs are not so well ventilated.

Scenario 4

20-year-old footballer is kicked in the mouth and inhaled a tooth. Where is this likely to impact?

Medial (right) Correct answer

Medial (right)

Inhaled foreign objects that enter the bronchial tree most frequently lodge in the medial right lung segment as the
right main bronchus is wider and more vertical.

4.

Theme: Types of shock

A Anaphylactic

B Cardiogenic

C Class 1 haemorrhagic

D Class 2 haemorrhagic

E Class 3 haemorrhagic

F Class 4 haemorrhagic

G Endocrine-related

H Iatrogenic

I Neurogenic

J Non-haemorrhagic hypovolaemic

K Septic

L Spinal

The following are descriptions of shock. Please select the most appropriate diagnosis from the above list. The items
may be used once, more than once, or not at all.

Scenario 1

A 32-year-old man is stabbed in the left side of the chest. Initial assessment reveals engorged neck veins, respiratory rate 30
breaths/min, pulse rate 120/min and blood pressure 80/40 mmHg despite attempts at fluid resuscitation; on auscultation heart
sounds are muffled. His urine output has not been assessed.

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Cardiogenic Correct answer

B – Cardiogenic

This patient has Beck’s classic triad of tachycardia, muffled heart sounds and engorged neck veins with hypotension resistant
to fluid therapy suggesting cardiac tamponade. Cardiac tamponade, a well-recognised cause of cardiogenic shock, results in
impairment of cardiac function and effective failure of the heart to maintain the circulation by ‘pump failure’. It has a 90%
mortality, prompt pericardiocentesis providing the only relief.

Scenario 2

A 72-year-old man presents with sudden onset of severe central abdominal pain radiating to the back. On examination, he is
very anxious, with respiratory rate 33 breaths/min, pulse rate 120/min and blood pressure 90/40 mmHg. He has passed 15 ml
of urine since he was catheterised 1 h ago. Both femoral pulses are only faintly palpable.

Class 3 haemorrhagic Correct answer

E – Class 3 haemorrhagic

This patient most likely has a leaking abdominal aortic aneurysm associated with a 30–40% blood volume loss (approximately
2000 ml in a 70-kg adult). Patients with this volume of blood loss almost always present with the classic signs of inadequate
peripheral perfusion, marked tachycardia and tachypnoea, significant changes in mental status, and a measurable fall in
systolic pressure. Management includes urgent fluid resuscitation, blood transfusion and emergency surgical repair.

Scenario 3

A 61-year-old man becomes acutely confused day 3 postabdominal aortic aneurysm repair. Examination reveals temperature
38°C, respiratory rate 36 breaths/min, pulse rate 140/min and blood pressure 90/40 mmHg despite attempts at fluid
resuscitation. He has passed a negligible volume of urine since he was catheterised 1 h ago. Ironically his peripheries are
warm to the touch.

Septic Correct answer

K – Septic

This patient has developed septic shock. Circulating endotoxins, commonly from Gram-negative organisms, produce
vasodilatation – producing a widened pulse pressure and warm peripheries – and impair energy utilisation at a cellular level.
Tissue hypoxia can occur even with normal or high oxygen delivery rates because of increased tissue oxygen demands and
direct impairment of cellular oxygen uptake. In addition, the endotoxin causes capillary wall hyperpermeability, worsened by the
stimulation of proteolytic enzymes, leading to poorly controlled fluid transfer from the intravascular to the interstitial space,
effectively resulting in hypovolaemia. The situation is aggravated by the negatively inotropic effect of bacterial endotoxin on the
myocardium.

5.

Theme: Drugs used in critical care

A Adenosine

B Adrenaline

C Amiodarone

D Amrinone

E Atropine

F Digoxin

G Dobutamine

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H Dopamine

I Dopexamine

J Lignocaine

K Nitroglycerin

L Noradrenaline

The following are descriptions of drugs used in the management of the critically ill patient. Please select the most appropriate
drug from the list. The items may be used once, more than once, or not at all.

Scenario 1

A predominant β1-agonist, used to improve cardiac output in patients with myocardial failure, provided intravascular volume is
satisfactory.

Dobutamine Correct answer

G – Dobutamine

Dobutamine stimulates both β1- and β2-receptors. Stimulation of β1-receptors produces a good cardiac inotropic and
chronotropic response, leading to improved cardiac output, and stimulation of β2-receptors produces a degree of vasodilatation,
especially in skeletal muscle (‘inodilatation’). Dobutamine can be used in combination with noradrenaline if sepsis and
hypotension are a problem. Studies have demonstrated that dobutamine is more effective than dopamine (dosage-dependent
roles, for example at low doses it is a D1A-agonist, at intermediate doses β1-adrenoreceptor effects appear, and at high doses
a1-effects predominate) when improvements in oxygen delivery [D(O2)] and uptake [V(O2)] are considered.

Scenario 2

A phosphodiesterase III inhibitor; acting as both a positive inotrope and a peripheral vasodilator; it is effective in cardiogenic
shock.

Amrinone Correct answer

D – Amrinone

Amrinone (and enoximone) are phosphodiesterase III inhibitors that increase intracellular cyclic AMP. They improve
hypotension, principally caused by cardiogenic shock, by their dual action of increasing cardiac output and
decreasing systemic vascular resistance (‘inodilatation’). The addition of dobutamine is considered to be synergistic.

Scenario 3

A predominant a1-agonist; the first line in patients with septic shock.

Noradrenaline Correct answer

L – Noradrenaline

Noradrenaline stimulates a1-adrenoreceptors with minor β1- and β2-effects. It is employed conventionally when increased
systemic vascular resistance (to increase the blood pressure by increasing left ventricular after-load) is required to maintain the
mean arterial pressure after fluid replacement and dobutamine infusion have proved inadequate. This is commonly the case in
septic shock where inflammatory mediator activation causes systemic vasodilatation.

6.

Theme: Priorities in immediate trauma care

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A Airway management

B Anteroposterior chest X-ray

C Anteroposterior pelvis X-ray

D Chest drain

E Chest X-ray

F Cross-match and blood transfusion

G Intravenous access and fluid resuscitation

H Lateral cervical spine X-ray

I Pericardiocentesis

J Pneumatic anti-shock garment

K Rewarming

L Urgent neurological opinion

The following scenarios describe road traffic accidents where the patient has been brought in by ambulance with cervical spine
immobilisation and 100% oxygen administered by mask. However, no other active management has been instigated. From the
list above please select the most appropriate resuscitation measure with the highest priority. A measure may be chosen once,
more than once, or not at all.

Scenario 1

An 18-year-old motorcyclist is brought in after being thrown off his bike. He is confused and there is evidence of blood and
vomit around his mouth. Vital signs: blood pressure 130/65 mmHg, pulse rate 110/min, respiratory rate 28 breaths/min.

Airway management Correct answer

A – Airway management

Regardless of the presentation of the patient, the management of this man follows the Advanced Trauma Life Support (ATLS)
criteria of Airways, Breathing and Circulation. It appears that he has sustained oro-facial trauma, and possibly aspirated. He
needs oropharyngeal suction and insertion of an appropriate airway. Once his breathing has been managed, intravenous
access must be gained to begin fluid resuscitation. He demonstrates signs of Class II haemorrhagic shock (15–30% blood
loss).

Scenario 2

A 35-year-old woman is brought to casualty after being pinned in her car following collision with a lamp post. After extrication it
is apparent that she had not been wearing a seatbelt. On examination, after appropriate airway management, she
demonstrates central cyanosis, distended neck veins but equal air entry with marked bruising over her anterior chest wall. Vital
signs: blood pressure 80/40 mmHg, pulse rate 140/min, respiratory rate 50 breaths/min.

Pericardiocentesis Correct answer

I – Pericardiocentesis

This lady has signs of cardiac tamponade, although a differential diagnosis would have included tension pneumothorax had
she demonstrated unequal air entry. Cardiac tamponade results in the classic Beck’s triad of raised jugular venous pressure,
muffled heart sounds and hypotension. There would also be a resultant pulsus paradoxus or a large fall in systolic pressure
and blood volume on inspiration. Her hypotension is secondary to a low cardiac output because of ineffectual myocardial

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contraction. Immediate pericardiocentesis is necessary, which involves insertion of a broad-bore needle, attached to a three-
way syringe, into a point 1–2 cm inferior to the left of the xiphochondral junction. The needle should be advanced slowly, while
aspirating, towards the tip of the left scapula, while carefully observing the electrocardiogram trace for evidence of a
‘current of injury’, eg extreme ST-T waves or widened QRS complexes. This alerts the operator to the fact that the
needle has been inserted into the myocardium.

Scenario 3

A 20-year-old man is brought in after being found under the wheel of a car. He is drowsy, aggressive but keeps complaining of
abdominal and left leg pain. Vital signs: blood pressure 80/40 mmHg, pulse rate 150/min, respiratory rate 38 breaths/min.

Intravenous access and fluid resuscitation Correct answer

G – Intravenous access and fluid resuscitation

This man has clear signs of Class IV haemorrhagic shock. This is seen following blood loss of more than 2 litres (>
40%) and results in drowsiness and, occasionally, aggression. Class IV haemorrhagic shock is classified as a pulse
rate > 140/min, decreased blood pressure and pulse pressure, and a respiratory rate > 35 breaths/min. The likely
source of bleeding is from within the abdomen and a possible long-bone fracture of his lower limb, both of which will
also require attention. However, he requires management according to the A,B,C principles of ATLS, with specific
management of his circulation. In the initial stages, in casualty, this involves crystalloid fluid replacement followed
promptly by blood therapy.

7.

Theme: Management decisions in trauma care

A Abdominal X-ray

B Angiogram

C Chest drain

D Computed tomography scan

E Diagnostic peritoneal lavage

F Emergency laparotomy

G Emergency thoracotomy

H Focused Assessment Sonographically of Trauma (FAST) scan

I Fracture management

J Local wound exploration

K Resuscitation thoracotomy

L Transfer to specialist unit

M Ultrasound

In the following scenarios, each patient has undergone a primary survey, and now requires a management decision. From the
list above, choose the most appropriate answer. Each item may be used once, more than once, or not at all.

Scenario 1

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A 38-year-old cyclist has been brought in to casualty after being knocked off his bicycle by a lorry. He was extricated from
under one of the wheels, which was lying across his abdomen. He has bruising to this area and is complaining of considerable
abdominal pain. He is conscious and maintaining a blood pressure of 120/70 mmHg, pulse rate 110/min and respiratory rate 20
breaths/min. A FAST scan is negative.

Computed tomography scan Correct answer

D – Computed tomography (CT) scan

The CT scanner is also known as the ‘doughnut of death’ to many trauma surgeons, highlighting the need for a stable patient,
an appropriate accompanying team and adequate resuscitation facilities in the imaging unit. Often this is not the case, making
management decisions difficult. If in doubt about your facilities, then it would be prudent to consider other options, including
proceeding to theatre. If the patient demonstrates any signs of compromise prior to transfer then delay doing so until
resuscitation has been completed. This gentleman appears to have signs of intraabdominal trauma but is currently stable.
Despite its drawbacks, CT imaging is excellent for assessing the extent of organ damage, retroperitoneal injury and pelvic
organ injury and in therefore assisting decisionmaking regarding operative intervention. It has an accuracy of 92–98% but can
miss small diaphragmatic and bowel injuries.

Scenario 2

A 55-year-old gentleman has been brought in after falling 7 m off his ladder while painting the outside of his house. His fall was
broken by his ladder, and he was unconscious for 3 min before being found by his wife. He has a large occipital scalp
laceration that is bleeding profusely but there is no underlying skull fracture. He has, however, fractured his left ninth and tenth
ribs posteriorly but has no clinical or radiographical evidence of a pneumothorax. He now has a Glasgow Coma Score of 14
with blood pressure 60/40 mmHg, pulse rate 140/min and respiratory rate 36 breaths/min. Despite aggressive fluid
resuscitation, his vital signs remain the same. He has a tender left hypochondrium.

Emergency laparotomy Correct answer

F – Emergency laparotomy

Despite the evidence of a significant head injury, this gentleman’s immediate threat to life is hypovolaemia from an ongoing
intra-abdominal bleed. This is likely to originate from his spleen, and is not improving despite resuscitation. The ‘tap’ must be
turned off and he needs to undergo an emergency laparotomy. A FAST scan would confirm free fluid (and would routinely be
performed in units with a radiologist in the trauma team); however, it would not influence management. The patient should not
have a CT scan until after laparotomy.

Increased availability of imaging techniques (CT and FAST scans) has led to a decline in the use of diagnostic peritoneal
lavage. However, its application continues to be described in the ATLS guidelines for both haemodynamically stable and
unstable patients. The Editor’s view is that it has a role in the haemodynamically unstable with a negative FAST scan where
doubt exists regarding laparotomy but where a CT scan is contraindicated.

Scenario 3

A 24-year-old motorcyclist is brought in after a head-on collision with a car. He was conscious on arrival but complained of pain
in his chest, back and left ankle. Examination reveals a blood pressure of 100/70 mmHg, pulse rate 90/min and a respiratory
rate 28 breaths/min. His ankle is deformed and painful to move. There is evidence of tracheal shift and the left hemithorax is
not moving. A chest X-ray demonstrates haemopneumothorax and chest drain insertion results in immediate drainage of 1600
ml blood. Despite initial clinical improvement, the drain continues to collect fresh blood at a rate of several hundred ml per 10
min.

Emergency thoracotomy Correct answer

G – Emergency thoracotomy

This man was suffering from a massive haemothorax (with a bit of pneumothorax). The chest drain resolves the respiratory
embarrassment but fails to help the haemorrhage, which is on-going. Thoracotomy is indicated if a surgeon, qualified by
training and experience, is present in the following scenarios:

• >1500 ml blood drains immediately

• >200 ml/h blood drains for > 2–4 h

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 • persistent transfusions
• penetrating anterior trauma medial to the nipple, or posteriorly, medial to the scapula.

It should be performed in theatre with full equipment. NB This procedure differs from a resuscitation thoracotomy (ie one
performed in The Emergency Department), which has only two indications:

• penetrating chest injury with witnessed cardiac arrest of < 5 min duration
• uncontrolled life-threatening haemorrhage with tracheo-bronchial bleeding.

8.

Theme: The red eye

A Acute closed-angle glaucoma

B Allergic conjunctivitis

C Anterior uveitis

D Corneal abrasion

E Corneal foreign body

F Corneal ulceration haemorrhage

G Episcleritis

H Hyphaema

I Infective conjunctivitis

J Keratitis

K Scleritis

L Sub-conjunctival

The following patients all present complaining of a red eye. For each, please select the most appropriate diagnosis from the
above list. The items may be used once, more than once, or not at all.

Scenario 1

A 55-year-old woman with rheumatoid arthritis presents to The Emergency Department minors department with a 48-h history
of progressively worsening pain and florid erythema to her right eye. She complains of constant watering but has not noticed
any discharge. On examination she has a localised area of inflammation that is extremely tender to pressure. The injected
vessels are in the deep layer of the eye.

Scleritis Correct answer

K – Scleritis

The sclera and episclera can both become inflamed in autoimmune conditions, particularly rheumatoid arthritis. Unlike
conjunctivitis, inflammation of these layers of the eye produces a localised region of injection. The distinction between
episcleritis and scleritis is related to severity of symptoms and potential complications. Scleritis is characteristically much more
painful than episcleritis, and the signs of inflammation are more extensive. It may ultimately result in ocular perforation. All
patients require opthalmological review, and steroid eye drops will provide symptomatic relief and hasten recovery.

Scenario 2

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A 60-year-old man attends The Emergency Department in the late evening. He describes the onset of sudden excruciating pain
in his left eye associated with an episode of vomiting and ‘haziness’ of vision. He tells you that this has occurred twice in the
past, and was relieved by going to sleep. On closer examination you note that his eye is inflamed and tender. The cornea is
cloudy, and the pupil is semi-dilated and fixed in response to light.

Acute closed-angle glaucoma Correct answer

A – Acute closed-angle glaucoma

This scenario depicts a typical presentation of acute closed-angle glaucoma. This includes the rapid onset of pain,
characteristically in the evening, when the pupil becomes semi-dilated (light intensity decreases). Prior episodes that have
been relieved by sleep, when the pupil constricts, are also distinctive in this disease. In acute closed-angle glaucoma
apposition of the lens to the back of the iris prevents the flow of aqueous from the posterior chamber to the anterior chamber.
Accumulation of aqueous behind the iris pushes it forwards on to the trabecular meshwork, preventing normal drainage of
aqueous from the eye. This causes an acute rise in intraocular pressure, requiring emergency intervention to preserve sight.
Acetazolamide given intravenously and pilocarpine eye drops should be rapidly administered until definitive surgical/laser
decompression can be achieved.

Scenario 3

A 35-year-old golfer attends the emergency eye clinic after his golfing partner accidentally caught him in the left orbit with his
club. He complains of double vision and discomfort to his eye, and there is a laceration to his upper eyelid. You notice that his
left eye movements are restricted during your examination, and that he has blood in the anterior chamber of his eye. Palpation
reveals crepitus in the peri-orbital tissues.

Hyphaema Correct answer

H – Hyphaema

Blood in the anterior chamber of the eye is known as a hyphaema. Commonly resulting from blunt trauma to the globe, this
must be treated as an emergency as further bleeding may increase intraocular pressure and compromise sight. Other
important sequelae of blunt ocular trauma are also demonstrated in this case. When the eye itself absorbs impact, transmitted
forces to the orbit can result in a ‘blow-out’ fracture, particularly of the thin orbital floor. Clues to such an occurrence include
diplopia, defective eye movements (related to inferior rectus muscle prolapse through the fracture site), emphysema (fracture
through a sinus) and recession of the eye (enophthalmus).

Scenario 4

A 24-year-old man is seen in the ophthalmology outpatient department after referral by his general practitioner for recurrent
attacks of uncomfortable red eyes. On closer questioning he describes a prodromal history of pain and morning stiffness to his
lower back. On inspection of the affected eye injection is most pronounced around the iris, and his pupil is irregular in outline.

Anterior uveitis Correct answer

C – Anterior uveitis

Inflammation of the iris and ciliary body is known as anterior uveitis. At risk groups for such disorders include those with
seronegative arthropathies, particularly if they are positive for HLA-B27 histocompatability antigen (in this case the young man
has symptoms of ankylosing spondylitis). Other causes include sarcoidosis, and several infections such as herpes zoster
ophthalmicus, syphilis and tuberculosis. It is important to treat the underlying cause and ensure that there is no disease in the
rest of the eye that is giving rise to signs of an anterior uveitis (including more posterior inflammation, a retinal detachment, or
an intraocular tumour).The pupil is irregular because of adhesions of the iris to the lens (posterior synechiae). Topical steroids
help to reduce inflammation.

9.

Theme: Acute loss of vision

A Acute closed-angle glaucoma

B Blunt traumatic loss of vision

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C Endophthalmitis

D Giant cell (temporal) arteritis

E Ischaemic optic neuropathy

F Migraine

G Occipital lobe ischaemia

H Occipital lobe trauma

I Optic nerve trauma

J Optic neuritis

K Orbital cellulitis

L Penetrating traumatic loss of vision

M Raised intracranial pressure

N Retinal artery occlusion

O Retinal detachment

P Vitreous haemorrhage

The following patients all present complaining of acute visual loss. For each, please select the most appropriate diagnosis from
the above list. The items may be used once, more than once, or not at all.

Scenario 1

A 65-year-old man presents to the emergency eye department complaining of a sudden loss of vision in his right eye. On direct
questioning you are able to elicit a history of right-sided scalp tenderness and recent malaise. Fundoscopy reveals
haemorrhages on the disc and disc margin on the right, with cotton wool spots around the disc. His erythrocyte sedimentation
rate is 118.

Giant cell (temporal) arteritis Correct answer

D – Giant cell (temporal) arteritis

This scenario demonstrates the classical presentation of someone afflicted with giant cell arteritis. The patient often notices
scalp tenderness (often on combing the hair on the affected side), with concurrent visual loss and malaise. They may also
report pain on chewing (jaw claudication) and shoulder pain. There is an association with polymyalgia rheumatica. An
erythrocyte sedimentation rate (ESR) greater than 40 is highly suggestive of the disease (and there are very few other
diagnoses with an ESR > 100). Be aware that a temporal artery biopsy may miss the affected section of artery as the disease
can skip regions of vascular endothelium. A strong history should prompt the commencement of oral or intravenous high-dose
steroid therapy (even prior to biopsy and its results). Steroids will not restore visual loss but will prevent loss of sight in the
other eye.

Scenario 2

A 70-year-old woman attends her general practitioner’s surgery with a history of a ‘curtain’ coming down rapidly in her left eye.
She had a prior history of flashing lights and ‘spots’ floating in her vision. She has recently had surgery for a left-sided cataract.

Retinal detachment Correct answer

O – Retinal detachment

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Retinal detachment can occur in <st1:time ">1 : 10, 000 of the normal population. The probability is increased in people who
are short-sighted (myopes); have undergone cataract surgery, as in this specific case, (particularly if this was complicated by
vitreous loss); have suffered from a detached retina in the other eye; or who have been subjected to recent severe eye trauma.
Symptoms of posterior vitreous detachment, including ‘floaters’ (pigment or blood in the vitreous) and flashing lights (retinal
traction), may precede the onset of retinal detachment itself. As the condition progresses, the patient notices the development
of a visual field defect, often likened to a ‘shadow’ or ‘curtain’ coming down. If a superior detachment occurs this field defect
can evolve rapidly. If the macula becomes detached there is a marked fall in visual acuity.

Scenario 3

A 60-year-old woman presents to The Emergency Department with a recurrent history of fleeting loss of vision in her left eye,
often lasting up to 10 min. She tells you that she has just had another episode an hour earlier. On fundoscopy the acutely
affected retina is swollen and white, and the fovea appears very red. You also notice that she has a bruit over her left carotid
artery and the carotid pulse appears slightly diminished.

Retinal artery occlusion Correct answer

N – Retinal artery occlusion

Retinal artery occlusion is usually embolic in nature. The three main forms of emboli are: fibrin-platelet emboli (from diseased
carotids, as in this case); cholesterol emboli (from diseased carotids) and calcific emboli (from diseased heart valves). The
presentation can vary but often the patient complains of sudden painless loss of all or part of the vision. In this scenario the
fleeting loss of vision experienced by the patient is caused by the fibrin–platelet emboli obstructing, and then passing through,
the retinal circulation (amaurosis fugax). Symptoms, therefore, persist for a few minutes then dissipate. Cholesterol and calcific
emboli (which are less pliant) may result in permanent obstruction of the retinal vessel, with no visual recovery. On fundoscopic
examination the acutely affected retina is oedematous (swollen, pale), while the fovea remains red (cherry red spot) as it has
no supply from the retinal circulation. Acute management of the condition is aimed at dilating the arteriole to encourage
passage of the embolus. Results are often disappointing (although better if the patient is seen within 24 h of the onset of
obstruction). Intravenous acetazolamide (reducing intra-ocular pressure), ocular massage (to exert pressure on vessels in an
attempt to dislodge the embolus), anterior chamber paracentesis (to release aqueous and rapidly lower intra-ocular pressure)
and carbon dioxide re-breathing (vasodilatory effects) are therapeutic techniques that can be employed. The patient should be
thoroughly investigated for systemic vascular disease.

10.

Theme: Abdominal trauma

A Laparotomy
B Trial of conservative management
C Computed tomography (CT) scan of abdomen
D Laparoscopy
E Diagnostic peritoneal lavage

For each of the scenarios below select the most appropriate next action. Each option may be used once, more than
once, or not at all.

Scenario 1

A 45-year-old car driver is seen by the surgical team in the Accident and Emergency Department, following a high-speed road-
traffic accident. He was tender in the right upper quadrant and a CT scan has shown a small, isolated tear in the right lobe of
his liver with some free fluid in the peritoneal cavity. A secondary survey reveals no other significant injury. He has a pulse of
80 and a blood pressure (BP) of 140/90.

Trial of conservative management Correct answer

As long as patient 1 remains haemodynamically stable, a liver injury such as this can be managed conservatively. However in
the event of haemodynamic instability he would require a laparotomy. Continued liver bleeding may present as a fall in
haemoglobin and increase in fluid requirements rather than sudden cardiovascular collapse so it is vital that haemoglobin
levels are checked regularly.

Scenario 2

13
A 19-year-old man is brought into the Accident and Emergency Department after been stabbed in the epigastrium. Despite
adequate fluid resuscitation he remains hypotensive (BP 90/45) and tachycardic (pulse 120). A primary survey suggest he has
no other injuries.

Laparotomy Correct answer

There is some role for laparoscopy in the assessment of penetrating trauma but patient 2 is unstable and requires definitive
management in the form of a laparotomy. A stab wound in this region may have breached the diaphragm and the presence of
an associated intra thoracic injury must be considered in such a patient.

Scenario 3

A 17-year-old motorcyclist is seen in the resuscitation room following a high-speed road-traffic accident. Radiology in the
resuscitation room has shown a haemopneumothorax (for which a chest drain has been inserted) and a fractured right femur.
He was hypotensive on arrival but he has responded to fluid resuscitation. He has some bruising over his lower abdomen but
no peritoneal signs.

Computed tomography (CT) scan of abdomen Correct answer

There is no absolute indication for a laparotomy in patient 3 but the possibility of a significant abdominal injury must be
considered. Diagnostic peritoneal lavage is generally considered to be an obsolete technique. Assuming patient 3 remains
stable he should be investigated by an abdominal computed tomography (CT) scan. This is a sensitive means of evaluating the
peritoneal cavity and retroperitoneum following trauma. Obviously if his condition were to deteriorate he may then require a
laparotomy.

11.

Theme: Chest injury

A Aortic injury

B Flail segment

C Pericardial injury

D Pneumothorax

E Pulmonary contusions

For each of the scenarios below, select the most likely chest injury from the list of options above. Each option may be used
once, more than once, or not at all.

Scenario 1

A young man with a penetrating chest injury is clinically well on admission, and has a normal chest film. However, he
deteriorates while on the ward and has a tachycardia, hypotension and dyspnoea when reviewed. His pulse is weak and JVP is
raised.

Pericardial injury Correct answer

C – Pericardial injury

Scenario 1 is likely to be the result of a cardiac tamponade. Signs indicating this include a weak pulse, raised JVP, hypotension
and tachycardia. The only other condition that may cause similar signs is a tension pneumothorax. However, the patient has a
normal chest film which makes this unlikely.

Scenario 2

A cricketer is hit by a ball in the chest. He initially carries on with the game but then collapses, and is ‘blue-lighted’ to the
Emergency Department. He is dyspnoeic, drowsy and has barely audible breath sounds.

14
Pneumothorax Correct answer

D – Pneumothorax

The patient in scenario 2 is likely to have a pneumothorax as he has absent breath sounds, is dyspnoeic and drowsy
as a result of hypoxia.

12.

Theme: Dyspnoea

A Cardiac tamponade

B Left haemothorax

C Left tension pneumothorax

D Pulmonary embolus

For each of the descriptions listed below, select the most likely diagnosis from the above list. Each option may be
used once, more than once, or not at all.

Scenario 1

A patient has distended neck veins, having been stabbed lateral to the trachea. Examination reveals decreased breath sounds,
hyperresonant lung fields and tracheal deviation.

Left tension pneumothorax Correct answer

C – Left tension pneumothorax

The patient here has signs of a tension pneumothorax. No tracheal deviation is seen in cardiac tamponade.

Scenario 2

A patient presents with ECG changes in lead III, Q wave with inverted T and changes in lead I.

Pulmonary embolus Correct answer

D – Pulmonary embolus

Here, the characteristic ECG changes seen in pulmonary embolus are: S1, Q3, T3.

Scenario 3

A patient has dullness to percussion of the left chest.

Left haemothorax Correct answer

B – Left haemothorax

Dullness to percussion is indicative of fluid in the pleural space, hence the most appropriate answer here is a
haemothorax.

13.

Theme: Chest and thoracic wall injuries

15
A Cardiac tamponade

B Diaphragmatic rupture

C Flail chest

D Fracture of the sternum

E Myocardial contusion

F Perforated oesophagus

G Pulmonary contusion

H Ruptured thoracic aorta

I Tension pneumothorax

J Traumatic haemothorax

For each of the following situations, select the most appropriate cause for the chest condition from the above list.
Each option may be used once, more than once, or not at all.

Scenario 1

A 38-year-old man presents with respiratory distress, tachycardia and distended neck veins following a penetrating injury to the
right side of his chest. The patient’s BP is 100/60 mmHg and respiratory rate is 20/min.

Tension pneumothorax Correct answer

I – Tension pneumothorax

Tension pneumothorax occurs following penetrating injuries to the chest. This is a surgical emergency as it may result in
cardiorespiratory arrest if the tension is not relieved immediately. With each inspiration air is drawn into the pleural space and
has no route to escape (acting as a one-way valve). Patients present with respiratory distress, distended neck veins and
deviation of the trachea to the opposite side. There is a shift of the mediastinum to the contralateral hemithorax. The immediate
management is insertion of a large bore needle (cannula) into the second intercostals space in the mid-clavicular line on the
affected side. Following this an intercostal chest drain must be inserted and connected to an underwater seal.

Scenario 2

A 47-year-old taxi driver involved in a RTA presents with lacerations over his chest and abdomen. On examination, bowel
sounds are heard in the chest. X-ray reveals bowel gas shadows in his left lung fields.

Diaphragmatic rupture Correct answer

B – Diaphragmatic rupture

Diaphragmatic rupture occurs in high-speed blunt abdominal trauma against a closed glottis. Diaphragmatic rupture is more
common on the left as the liver acts as a protective buffer on the right side. Bowel sounds may be heard in the chest. An X-ray
may reveal bowel gas in the lung fields as the colon and stomach may herniate into the thorax. The surgical approach (trans-
thoracic or trans-abdominal) depends on the stage of recognition and the presence of associated injuries. If detected early and
with associated intra-abdominal injuries, a trans-abdominal approach is acceptable.

Scenario 3

A 78-year-old gentleman who is a known alcoholic presents with severe chest pain following an episode of vomiting blood.
Chest X-ray reveals gas in the mediastinum and in the subcutaneous tissues.

16
Perforated oesophagus Correct answer

F – Perforated oesophagus

Spontaneous perforation of the oesophagus (Boerhaave’s syndrome) is a result of severe barotrauma. The pressure in the
oesophagus rapidly increases and the oesophagus perforates (tears) at its weakest point (lower third). The usually history is
that of a patient experiencing severe chest or upper abdominal pain following a heavy meal or a bout of drinking (usually
bingeing). Haematemesis may or may not be present. This condition may be misdiagnosed as a myocardial infarction or
perforated peptic ulcer. Severe upper abdominal rigidity may be seen, even in the absence of peritoneal contamination.

Scenario 4

A 38-year-old motorcyclist is brought to the Emergency Department following a major RTA. On examination, he has a raised
JVP and muffled heart sounds. The patient’s blood pressure is 100/84 mmHg and his pulses fade on inspiration.

Cardiac tamponade Correct answer

A – Cardiac tamponade

Cardiac tamponade occurs following trauma, lung or breast carcinoma, pericarditis and myocardical infarction. The signs
include: raised JVP, falling BP and muffled heart sounds (Beck’s triad). In addition, with inspiration the JVP rises (Kussmaul’s
sign) with a fall in systolic blood pressure of more than 10 mmHg (pulsus paradoxus). Chest X-ray reveals a globular heart; the
left heart border is convex or straight and the right cardiophrenic angle is < 90°.

14.

THEME: Head injury

A Base-of-skull fracture
B Extradural haemorrhage
C Le Fort fracture type I
D Le Fort fracture type II
E Subarachnoid haemorrhage
F Subdural haemorrhage

For each of the following scenarios choose from the above list the most likely diagnosis. Each option may be used once, more
than once, or not at all.

Scenario 1

A 69-year-old man, in sheltered accommodation, tripped over the edge of his coffee table 1 week ago. He didn’t lose
consciousness. The warden says the patient has become increasingly confused over the last 3 weeks. On examination the
patient smells strongly of alcohol and his body is covered with small bruises which seem to be the result of previous falls.

Subdural haemorrhage Correct answer

Subdural bleeds often present a week or more after the initial injury, which may be relatively innocuous. Chronic alcoholics are
at increased risk of having a subdural bleed; they are prone to recurrent falls, may have signs of chronic liver disease (spider
naevi, bruising) and may have abnormal clotting factors that predisposes them to a higher risk of haemorrhage.

Scenario 2

A 23-year-old man presents to the casualty department after being punched in the face a few hours ago. There had been no
loss of consciousness. He complains he cannot hear well out of his left ear. On examination, there appears to be blood behind
the left tympanic membrane.

Base-of-skull fracture Correct answer

A base-of-skull fracture should always be suspected if the patient has any of the following signs: bruising around the eyes
(‘racoon eyes’), haemotympanum, CSF leak from the nose or ears, bruising behind the ear ( Battle’s sign).

17
Scenario 3

A cricketer is hit by the ball on his left temporal region. He lost consciousness for a minute. Despite a small bruise just in front
of his left ear tragus, he decides not to go to hospital because he says he feels fine. After one day, he develops a progressive
headache and begins to vomit.

Extradural haemorrhage Correct answer

This scenario is typical of someone with a possible extradural bleed. It is caused by a fracture of the temporal or parietal bone
causing laceration of the middle meningeal artery. These patients may or may not suffer loss of consciousness at the time of
the initial injury and appear fine (‘lucid interval’). They may deteriorate rapidly after a few hours/days complaining of symptoms
associated with a rise in intracranial pressure (headache, vomiting, decrease in the level of consciousness).

Scenario 4

A 19-year-old is brought to A&E after being repeatedly punched in the face. On examination, his face is grossly swollen and
there is a palpable step in his maxilla. There appears to be an intermittent discharge of clear fluid from his nose.

Le Fort fracture type II Correct answer

Le Fort fractures lie between the frontal bone, base of the skull and mandible. They are classified as Le Fort I, II and III
depending upon the severity of injury. Le Fort I involves only the tooth-bearing portion of the maxilla. Le Fort II involves the
maxilla, nasal bones and medial aspects of the orbits. Le Fort III involves the maxilla, zygoma, nasal bones, ethmoid and the
small bones of the base of the skull. Classically there is a ‘palpable step’ in the maxilla and there may be CSF rhinorrhoea,
diplopia and conjuctival haematoma.

15.

Theme: ASA (American Society of Anesthesiologists) physical status classification

A ASA 1
B ASA 2
C ASA 2E
D ASA 3
E ASA 4

For each of the following case histories, select the most likely answer from the above list. Each option may be used
once, more than once, or not at all.

Scenario 1

A 20-year-old man, with no past medical history, admitted electively for an inguinal hernia repair.

ASA 1 Correct answer

This patient is young and presents with no comorbidity, therefore ASA 1 is the correct answer.

Scenario 2

A 72-year-old woman, with unstable angina, poorly controlled hypertension and COPD, admitted electively for a right radical
nephrectomy.

ASA 4 Correct answer

This woman is an ASA 4 as she has unstable angina, which is viewed as a constant threat to her life. An ASA 3 would
suggest functional limitation only.

Scenario 3

A 50-year-old man, with diet-controlled diabetes, admitted electively for a circumcision.

18
ASA 2 Correct answer

He has mild systemic disease with no other significant past history, therefore is an ASA 2.

Scenario 4

A 42-year-old man, with well-controlled, non-insulin-dependent diabetes, admitted as an emergency with appendicitis.

ASA 2E Correct answer

He is an ASA 2 as although he has diabetes it is well controlled; the E denotes an emergency case.

16.

Theme: Head injuries - Glasgow Coma Scale (GCS)

A GCS 14
B GCS 11
C GCS 15
D GCS 7
E GCS 6

For each of the following case histories, select the most likely answer from the above list. Each option may be used
once, more than once, or not at all.

Scenario 1

A 25-year-old man brought to A&E after being knocked off his mountain bike by a car. His eyes open to pain and he localises
to pain but seems disorientated.

GCS 11 Correct answer

This patient scores 2 for having eyes that open to pain, 5 for localising to pain and 4 for being disorientated.

Scenario 2

A 32-year-old man brought into A&E with a dislocated right shoulder is complaining of and pointing to an area of severe pain in
his right shoulder. He appears orientated and has his eyes open.

GCS 15 Correct answer

With eyes that are open spontaneously (4), being orientated (5) and having an appropriate motor response (6), this patient has
a GCS of 15.

Scenario 3

A 44-year-old man involved in an RTA brought into A&E with decorticate posturing, incoherent mumbling and eyes that open to
a painful stimulus.

GCS 7 Correct answer

A patient whose eyes only open to pain (2), mumbles incoherently (2) and has abnormal flexion (decorticate) (3) has a GCS of
7.

Scenario 4

A 40-year-old man jumped off a bridge. He has been brought into A&E with decerebrate posturing, eyes that open to a painful
stimulus and is making incomprehensible sounds.

19
GCS 6 Correct answer

A patient whose eyes only open to pain (2), mumbles incoherently (2) and has abnormal extension (decerebrate posturing) (2)
has a GCS of 6.

17.

Theme: Interpretation of pupil size

A Oculomotor nerve compression

B Horner's syndrome
C Drugs
D Pontine lesion
E Optic nerve injury
F Metabolic encephalopathy
G None of the above

For each of the operative scenarios listed below, select the most likely cause of the pupillary findings. Each option
may be used once, more than once, or not at all.

Scenario 1

A 75-year-old male smoker is admitted short of breath and complaining of right-sided chest pain. He has a mass in the apex of
his right lung. He is given intravenous morphine for pain relief. On examination you note that he has mild right-sided ptosis and
miosis.

Horner's syndrome Correct answer

Horner’s syndrome is unilateral miosis, partial ptosis and anhydrosis. It is caused by disruption of the cervical
sympathetics, in this case by an apical lung tumour.

Scenario 2

An 18-year-old female is brought in to the emergency department. She has been found collapsed at the back of a nightclub.
There is no evidence of a head injury. She has a reduced Glasgow Coma Scale. Both pupils are constricted and it is difficult to
assess whether they are responsive to light.

Drugs Correct answer

Causes of bilaterally small pupils include drugs (opiates), a destructive lesion of the pons and a metabolic encephalopathy. In
this case the most likely cause is illicit drug use.

Scenario 3

During the secondary survey of a severely head-injured patient, you find mild bilateral dilatation and a sluggish pupillary
response to light.

Oculomotor nerve compression Correct answer

An early sign of temporal lobe herniation is mild pupillary dilatation and a sluggish response to light. This is caused by mild
compression of the oculomotor nerve (cranial nerve III). As herniation worsens there is further dilatation, ptosis and paralysis of
the ocular muscles innervated by CN III.

Scenario 4

A workman is injured in an explosion on a building site. He has shrapnel wounds to his head and chest. His pupils seem to be
equal. However, the right pupil does not react directly to light but does react to light in the opposite eye.

Optic nerve injury Correct answer

20
This patient has sustained a penetrating injury to his right optic nerve. This leads to a pupil that is cross reactive
(Marcus–Gunn pupil) and may be dilated or normal in size.

18.

Theme: Glasgow Coma Scale

A 14
B 13
C 12
D5
E4
F3
G0

For each of the clinical scenarios listed below, select the correct Glasgow Coma Score for the patient. Each option
may be used once, more than once, or not at all.

Scenario 1

A 66-year-old gentleman is brought in by ambulance. He was found collapsed having fallen off a ladder. On arrival the
paramedics are performing cardiopulmonary resuscitation.

3 Correct answer

Eye opening: none – 1, best motor response: none – 1, verbal response: none – 1

Scenario 2

You see a 16-year-old girl in the emergency department. She seems to be sleeping and smells of alcohol. She opens her eyes
when you ask her to and tries to knock your hand away when you rub on her sternum. When she opens her eyes you have a
brief conversation, which doesn’t quite make sense.

12 Correct answer

Eye opening: to speech – 3, best motor response: localises pain – 5, verbal response: confused conversation – 4

Scenario 3

A 30-year-old woman is brought in by ambulance. She was ejected from her car during a road traffic collision. She is tolerating
an oropharygeal airway, is tachyopnoeic, tachycardic and has a systolic blood pressure of 90/30 mmHg. She is not opening her
eyes and abnormally flexes to pain. She was making some sounds when she first came in but is now silent.

5 Correct answer

Eye opening: none – 1, best motor response: abnormal flexion – 3, verbal response: none – 1

Scenario 4

A 28-year-old is brought in from a nightclub. He has fallen from a balcony and sustained a head injury. He has been drinking
and taking illicit drugs. He is being aggressive and tried to punch your house officer but missed. He is now shouting abuse
although it doesn’t seem to make sense.

14 Correct answer

Eye opening: spontaneous – 4, best motor response: obeys commands – 6, verbal response: confused conversation –
4

19.

21
THEME: INJURIES TO THE UPPER ARM AND SHOULDER REGION

A Fracture of the coracoid process

B Anterior dislocation of the shoulder
C Fracture of the greater tuberosity
D Fracture of the acromion process
E Posterior dislocation of the shoulder
F Fracture of the head of humerus
G Fracture of the neck of scapula
H Fracture of the neck of humerus
I Acromioclavicular joint subluxation
J Ruptured coracoacromial ligament

Please select the most appropriate diagnosis from the above list. Each option may be used once, more than once, or
not at all.

Scenario 1

A 39-year-old motorcyclist is brought to the Accident and Emergency Department after being involved in a high-speed road-
traffic accident. He sustained severe trauma to his right upper back when he fell onto the road. There is bruising and
tenderness over this region. He has drooping of the right shoulder with lengthening of the arm. Movement of the shoulder is
severely restricted and the arm is held in adduction.

Fracture of the neck of scapula Correct answer

Scapular neck fractures are usually caused by direct trauma to the upper back, as in a fall from height or by high-speed road-
traffic accidents. It can also result from an anterior or posterior force applied to the shoulder region. Patients present with
bruising and tenderness over the scapular region on the affected side; maximal tenderness is over the lateral humeral head.
There is also drooping of the affected shoulder with apparent lengthening of the arm, particularly with fracture of the neck of the
scapula. Patients with scapular neck fractures resist all shoulder movements and will hold the limb in adduction. Fractures of
the scapula, first or second ribs or the sternum, suggest a magnitude of injury so severe that associated injuries to the head,
neck, spinal cord, lungs and the great vessels should be ruled out. Most scapular neck fractures can be treated conservatively.
Internal fixation is indicated for some articular fractures of the glenoid cavity.

Scenario 2

An 18-year-old man is brought to the Accident and Emergency Department with a painful shoulder, after falling awkwardly
during a rugby tackle. On examination, there is a swelling in the deltopectoral groove with lowering of the anterior axillary fold
and a prominent acromion process. The arm is slightly abducted and externally rotated.

Anterior dislocation of the shoulder Correct answer

Anterior (subcoracoid) dislocation is the commonest type of dislocation of the shoulder. The usual mechanism of injury is a fall
onto the outstretched arm with the arm abducted and externally rotated. It can also result from various sporting injuries,
commonly basketball and rugby. Pain is severe and the patient is unwilling to attempt movements of the shoulder. A swelling
may be noticed in the deltopectoral groove (displaced head) with an undue prominence of the acromion process. The arm is
held in slight abduction and external rotation. There may be flattening and loss of contour of the shoulder just below the
acromion process and lowering of the anterior axillary fold. If the axillary nerve is damaged, patients may present with loss of
sensation over the upper, outer aspect of the arm (regimental badge area).

Scenario 3

An 80-year-old woman presents to the Accident and Emergency Department with extensive bruising and pain over her right
upper/mid arm. She tripped while in toilet and banged her right arm against the edge of the bathtub 2 days ago. She is unable
to move her right shoulder. She suffers from osteoporosis.

Fracture of the neck of humerus Correct answer

Fracture of the neck of the humerus is common in middle-aged and elderly patients. The fracture could result from direct
trauma to the upper arm. In elderly patients, particularly women, the bone is frequently osteoporotic; the possibility of a
pathological fracture secondary to malignancy should also be borne in mind. The patient may present with extensive bruising

22
and pain over the upper- and mid-parts of the arm. Sometimes the presentation is delayed since the patient may be able to use
the arm to some extent without much pain. This is particularly true for impacted fractures. The modern Neer’s classification for
fractures of the proximal end of humerus is based on the involvement of the four parts: a) articular segment of the head, b) the
greater tuberosity, c) the lesser tuberosity and d) the surgical neck. Depending on the number of parts displaced they are
called as two-part, three-part or four-part fractures.

20.

THEME: INJURIES TO THE FOREARM AND HAND

A Pulled elbow
B Fracture of the olecranon process
C Monteggia's fracture
D Fracture of the coronoid process
E Fracture of the radial head
F Smith's fracture
G Colles' fracture
H Scaphoid fracture
I Galeazzi's fracture
J Dislocated elbow

Please select the most appropriate diagnosis from the above list. Each option may be used once, more than once, or
not at all.

Scenario 1

A 35-year-old man presents to the Accident and Emergency Department with a painful upper forearm after being involved in a
fight in his local pub. There is pain and tenderness over the elbow region and upper forearm. Plain radiography reveals an
angulated fracture at the junction of the proximal and middle third of the ulna and the head of the radius is dislocated anteriorly.

Monteggia's fracture Correct answer

Monteggia’s fractures, comprising less than 5% of forearm fractures, are primarily associated with falls on an outstretched hand
with forced pronation. The mechanism of injury is that of transmission of force through the hand and forearm with the elbow
partially flexed. It can also result from direct trauma to the forearm. Monteggia’s fracture is characterised by angulation at the
junction of the proximal and middle third of ulna accompanied by anterior dislocation of the radial head. Following injury,
patients may present with elbow pain. Depending on the type of fracture and severity, they may also have elbow swelling,
deformity, crepitus and paraesthesia. Elbow flexion and forearm rotation are limited and painful. Radial head dislocation may
lead to radial nerve injury. The posterior interosseous branch of the radial nerve, which courses around the neck of the radius,
is especially at risk, especially in Bado’s type II injuries.

Scenario 2

A 38-year-old woman presents to the Accident and Emergency Department with a painful right wrist after having fallen on her
outstretched hand. On examination, there is mild swelling over the wrist and the movements are restricted. The pain is maximal
over the distal end of radius in the snuffbox region, which is worsened on longitudinal compression of the thumb.

Scaphoid fracture Correct answer

The scaphoid is the most commonly fractured carpal bone. The mechanism of injury is usually a fall on the outstretched hand
with the wrist extended and radially deviated. This causes extreme dorsiflexion at the wrist and compression to the radial side
of the hand leading to fracture of the scaphoid. The patient usually complains of a deep, dull pain in the radial wrist, which is
worsened by gripping or squeezing. It is also exacerbated by active extension and adduction of the thumb. Tenderness in the
anatomic snuffbox and pain on longitudinal compression of the thumb (scaphoid compression test) are the most accurate signs
of scaphoid fracture, although the former is more commonly performed. There may be mild wrist swelling or bruising and,
possibly, fullness in the anatomic snuffbox, suggesting a wrist effusion. Early accurate diagnosis and management of scaphoid
fractures is vital: a delay can lead to a variety of adverse outcomes including persistent pain, nonunion, delayed union,
decreased grip strength, decreased range of wrist motion and osteoarthritis of the radiocarpal joint. The differential diagnosis
for suspected scaphoid injuries include distal radius fracture, fractures of other metacarpal bones, scapholunate dissociation,
tenosynovitis or strains.

Scenario 3

23
A 55–year-old woman presents to the Accident and Emergency Department with a painful swelling over her left distal forearm
following a road-traffic accident. On examination, there is tenderness, swelling and deformity over this region. Plain
radiography reveals a fracture at the middle and distal thirds of the radius with the fragment of the radius tilted towards the
ulna. There is disruption of the distal radioulnar joint.

Galeazzi's fracture Correct answer

Galeazzi’s fracture is a fracture of the junction of the distal third and middle third of the radius with associated subluxation or
dislocation of the distal radioulnar joint. They usually occur after a fall on the hand with a rotational force superimposed on it
(axial load placed on a hyperpronated forearm). It can also occur following direct blow to the middle/distal forearm as in road-
traffic accidents. Patients present with pain and soft-tissue swelling at the distal third radius fracture site and at the wrist joint.
On examination, there is bruising, swelling and tenderness over the lower end of the forearm. Deformity may be present. Plain
radiography reveals the displaced fracture of the radius and the fragments of the radius are usually tilted medially towards the
ulna. The ulnar head is prominent due to dislocation of the inferior radioulnar joint. Galeazzi’s fractures in adults should be
treated by open reduction and internal fixation. Surgical reduction of both the radius and distal radioulnar joint provides the best
opportunity for healing.

21.

THEME: BRACHIAL PLEXUS INJURIES

A Median nerve
B Axillary nerve
C Ulnar nerve
D Radial nerve
E Musculocutaneous nerve
F Medial pectoral nerve
G Suprascapular nerve
H Long thoracic nerve
I Lateral pectoral nerve
J Nerve to rhomboid

Please select the most appropriate diagnosis from the above list. Each option may be used once, more than once, or
not at all.

Scenario 1

A 55-year-old woman presents to the Accident and Emergency Department with pain over her right upper arm after sustaining
an injury to the region following a fall. On examination, there is bruising and tenderness over the mid-arm region. Neurological
examination reveals sensory loss over the lateral side of the back of the hand and she is unable to extend her wrist.

Radial nerve Correct answer

Radial nerve compression or injury may occur at any point along the anatomical course of the nerve. It may be associated with
fracture of the humerus, especially in the middle third or at the junction of the middle and distal thirds; the radial nerve lies in
the spiral grove in this region. The presentation may be at the time of the injury or secondary to fracture manipulation; delayed
presentation may be seen from a healing callus. The other important site of compression of the radial nerve is in the proximal
forearm in the area of the supinator muscle and involves the posterior interosseous branch. Such injuries cause wrist drop
(paralysis of the extensor muscles of the wrist, finger and thumb) and also paralysis of the brachioradialis and the supinator
muscles. Very proximal lesions may affect the triceps muscle. There is sensory loss over the dorsoradial aspect of the hand
and the dorsal aspect of the radial 3 1/2 digits.

Scenario 2

A 32-year-old man presents to the Orthopaedic Clinic with inability to raise his right arm. He had a deep intramuscular injection
to his deltoid region 2 days ago. On examination, there is a small area of anaesthesia over the insertion of deltoid and loss of
shoulder abduction beyond 10–15°.

Axillary nerve Correct answer

The axillary (circumflex) nerve can be injured or damaged after fracture dislocation of the upper humerus, shoulder dislocation,
pressure from casts or splints, improper use of crutches or deep intramuscular injections. There may be wasting and weakness

24
of the deltoid resulting in the loss of shoulder abduction. The patient is unable to initiate abduction of the shoulder because the
supraspinatus and the deltoid help the early phase of abduction; supraspinatus causes the first 10–15° of abduction followed
by deltoid, which helps in further 90–100° of abduction. There may be a small area of sensory loss over the insertion of deltoid
(upper outer aspect of the deltoid region; also called the ‘regimental badge area’). Relevant investigations in patients with
suspected axillary nerve injuries secondary to intramuscular injection include electromyography, nerve biopsy and magnetic
resonance imaging.

Scenario 3

A 68-year-old woman presents to the Orthopaedic Clinic complaining of a ‘prominent scapula’. She had recently undergone
mastectomy for breast cancer. On examination, the scapula becomes prominent (standing out) over the vertebral border and
the inferior angle when she is asked to push her arms against the wall.

Long thoracic nerve Correct answer

The long thoracic nerve (nerve of Bell), comprising C5, 6, 7 nerve roots, supplies the serratus anterior muscle, which helps to
stabilise the scapula. This nerve may be injured following injuries to the brachial plexus or could be damaged during surgeries
to the chest wall, breast (including mastectomy and breast augmentation) or the axillary region. Other causes include
radiotherapy, trauma, anaesthetic nerve block and transaxillary incision. Paralysis of the serratus anterior muscle causes
winging of the scapula particularly when the patient is asked to push his/her arms against resistance.

22.

THEME: INJURIES TO THE CHEST AND THORACIC CAVITY

A Oesophageal rupture
B Diaphragmatic rupture
C Myocardial contusion
D Fracture of the sternum
E Traumatic haemothorax
F Ruptured thoracic aorta
G Tension pneumothorax
H Cardiac tamponade
I Flail chest
J Hiatus hernia

Please select the most appropriate diagnosis from the above list. Each option may be used once, more than once, or
not at all.

Scenario 1

A 35-year-old man is brought to the Accident and Emergency Department with a penetrating injury to the right side of his chest
sustained during a brawl in his local pub. He is in respiratory distress, has distended neck veins and breath sounds are absent
on the right side of chest. His pulse is 118/min, blood pressure is 96/60 mmHg and his respiratory rate is 22/min.

Tension pneumothorax Correct answer

Tension pneumothorax occurs following penetrating chest injuries. This is a surgical emergency as it may result in cardio-
respiratory arrest if the tension is not relieved immediately. With each inspiration air is drawn into the pleural space and has no
route to escape (acts as a one-way valve). Patients present with chest pain, respiratory distress (air hunger), tachypnoea,
tachycardia, hypotension, distended neck veins and unilateral absence of breath sounds. The chest wall on the affected side is
hyper-resonant on percussion and the trachea may be deviated to the opposite side. The mediastinum may also be shifted to
the contra-lateral hemi-thorax. Immediate management consists of insertion of a large bore needle (cannula) into the second
intercostal space in the mid-clavicular line on the affected side. Definitive management includes an intercostal chest drain and
connecting it to an underwater seal.

Scenario 2

A 47-year-old taxi-driver is brought to the Accident and Emergency Department after being involved in a road-traffic accident.
He has deep lacerations over his left chest and upper abdomen. On examination, bowel sounds are heard in the chest. Plain
radiography after naso-gastric tube insertion reveals the tube to be in the thoracic cavity.

25
Diaphragmatic rupture Correct answer

Diaphragmatic rupture occurs in high-speed blunt abdominal traumas when the patient has got a closed glottis. It is more
commonly diagnosed on the left as the liver obliterates the defect or acts as a protection on the right side. Blunt trauma
produces large radial tears in the diaphragm that lead to herniation of the bowel contents into the thoracic cavity. Bowel sounds
may be heard in the chest. X-ray may reveal bowel gas in the lung fields as the colon and stomach may herniate into the
thorax. Diaphragmatic ruptures may be missed initially if the chest film is misinterpreted as showing an elevated diaphragm,
acute gastric dilatation, subpulmonary haematoma or a loculated pnuemohaemothorax. If a laceration of the diaphragm is
suspected, a gastric tube should be inserted. When the gastric tube appears in the thoracic cavity on the chest film, the need
for special contrast studies is eliminated. Magnetic resonance imaging is accurate in visualising the anatomy of the diaphragm
(and diaphragmatic injuries) and so the investigation of choice. The surgical approach (trans-thoracic or trans-abdominal)
depends on the stage of recognition and the presence of associated injuries. If detected early in a patient with other intra-
abdominal injuries, a transabdominal approach is acceptable.

Scenario 3

A 28-year-old man is brought to the Accident and Emergency Department with severe chest and epigastric pain. He was
repeatedly punched on his chest and upper abdomen when he was involved in a fight in a nightclub. Plain radiography reveals
gas in the mediastinum, subcutaneous emphysema and a left-sided haemothorax. His pulse is 124/min and blood pressure is
100/70 mmHg.

Oesophageal rupture Correct answer

Oesophageal perforation caused by closed chest injuries or direct trauma to the oesophagus is rare and accounts for about
10% of all oesophageal ruptures. However, if unrecognised, it could be life threatening. The clinical picture could be identical to
that of post-emetic oesophageal rupture (Boerhaave’s syndrome). The perforation secondary to closed chest injuries is usually
in the upper third of the oesophagus while Boerhaave’s syndrome is more common in the lower third. Oesophageal perforation
causes leakage of oesophageal/gastric contents into the mediastinum. The patient presents with epigastric pain or shock out of
proportion to the apparent injury. Presence of mediastinal air in plain radiography and subcutaneous emphysema suggests the
diagnosis, which can be confirmed by contrast studies and/or oesophagoscopy. The resulting mediastinitis and immediate or
delayed rupture into the pleural space could lead to empyema. Oesophageal injury should be considered in any patient who: (i)
has a left pneumothorax or haemothorax without a rib fracture; (ii) has received a severe blow to the lower sternum or
epigastrium and is in pain or shock out of proportion to the apparent injury or; (iii) has particulate matter in the chest tube after
the blood begins to clear. Wide drainage of the pleural space and mediastinum with direct repair of the injury via a thoracotomy
is the most appropriate treatment. The prognosis is good if the repair is performed early (within a few hours of injury).

23.

THEME: LOWER LIMB NERVE INJURIES

A Pudendal nerve
B Tibial nerve
C Lateral cutaneous nerve of thigh
D Saphenous nerve
E Sciatic nerve
F Common peroneal nerve
G Medial plantar nerve
H Femoral nerve
I Sural nerve
J Lateral plantar nerve

Please select the most appropriate nerve injury from the above list. Each option may be used once, more than once,
or not at all.

Scenario 1

A 25-year-old man presents to the Orthopaedic Clinic with a painful right knee and difficulty walking. He was hit over the lateral
side of his knee with a hockey stick 2 days ago. On examination, he is unable to dorsiflex and evert his left foot. He has
reduced sensation over the lateral aspect of his lower leg and the dorsum of this foot and toes. X-ray shows a fracture of the
fibular neck.

Common peroneal nerve Correct answer

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Common peroneal nerve (lateral popliteal nerve; L4–S2) injury is common following fibular neck fractures since the nerve
winds down the neck and is relatively superficial at this point. Isolated fractures of the proximal fibula or fibular shaft are
however uncommon and are usually due to a direct blow producing transverse or comminuted fractures. The fibula can also be
injured by indirect forces, with the proximal fibula most commonly fractured by external rotation forces and the distal fibula by
internal rotation forces. The common peroneal nerve can also be injured following a trauma or injury to the knee, use of tight
plaster casts and pressure to the fibular neck region from positions during deep sleep or coma. Common peroneal nerve gives
motor supply to the dorsiflexor and evertor muscles of the ankle and toes. Its sensory braches supply the anterior and lateral
aspect of the leg and whole of the dorsum of the foot and toes except the lateral aspect of the foot (supplied by the sural
nerve). Injury to this nerve results in foot drop and the patient is unable to dorsiflex and evert the foot. The sensory loss is over
the anterior and lateral aspect of the leg and dorsum of the foot and the toes.

Scenario 2

A 25-year-old man is brought to the Accident and Emergency Department following a deep stab-wound injury to his upper left
thigh. On examination, he has numbness over the anterior thigh and medial aspect of his leg. He is unable to extent his knee
and the knee jerk is diminished.

Femoral nerve Correct answer

Femoral nerve (L2–4) reaches the front of the leg by penetrating the psoas muscle before it exits the pelvis by passing beneath
the medial inguinal ligament to enter the femoral triangle. In the femoral triangle, it lies just lateral to the femoral artery and
vein. It may be injured by direct penetrating wounds, gunshot wounds, traction during surgery, injuries to the femoral triangle,
by massive haematoma within the thigh, psoas abscess, fractured pelvis or by hip dislocation. It innervates the iliopsoas (a hip
flexor) and the quadriceps (a knee extensor). The motor branch to the iliopsoas originates in the pelvis proximal to the inguinal
ligament and injury at or above this level leads to loss of hip flexion. The sensory branch of the femoral nerve, the saphenous
nerve, innervates skin of the medial thigh and the anterior and medial aspects of the calf. Damage to this femoral nerve causes
weakness of the quadriceps muscle and decreased patellar reflex. The patient finds that the knee gives way on walking and
has difficulty climbing stairs. There is numbness over the anterior thigh and medial aspect of the leg.

Scenario 3

A 37-year-old man is brought to the Accident and Emergency Department after a high-speed road-traffic accident. He hit his
flexed knee against the dashboard of his car. On examination, there is loss of sensation over the sole of the foot. He is unable
to flex his toes. Ankle jerk is lost. Plain radiography reveals posterior dislocation of the knee.

Tibial nerve Correct answer

The tibial nerve (S1–S2) may be damaged by posterior dislocation of the knee, posteriorly displaced fractures of the tibia,
sports injuries and severe fractures around the knee joint. It may also be compressed behind the medial malleolus by the
posterior tarsal tunnel. Tibial nerve supplies the flexor compartment giving muscular branches to the deep surface of soleus,
flexor digitorum longus and hallucis longus and tibialis posterior. It divides into medial and lateral plantar branches to supply the
intrinsic muscles of the foot and provides sensation to the plantar surface of the foot. It also provides cutaneous and articular
branches to the medial side of the ankle and foot. Injury to the tibial nerve results in loss of toe flexion and inability to invert the
ankle. Ankle jerk is lost. There is complete sensory loss over the plantar surface of the foot.

24.

Theme: Chest pain

A Oral analgesia
B Oral analgesia and admission
C Chest drain and analgesia

For each of the scenarios below select the most appropriate treatment. Each option may be used once, more than
once, or not at all.

Rib fractures may be extremely painful. The importance of treating rib fractures is in the management of the underlying lung
and the prevention of pulmonary complications such as pneumonia and collapse. Atelectasis will occur if the lung is not aerated
fully, which would occur if there is poor chest expansion due to pain. Young patients can tolerate a rib fracture more easily than
elderly patients. With good physiotherapy and analgesia, these young patients may be managed conservatively at home.
However, elderly patients would not tolerate rib fractures so well and necessitate admission with regular analgesia,
physiotherapy and probably prophylactic antibiotics. In a polytrauma patient, it would be wise to insert a chest drain for both the

27
treatment of the pneumothorax and to prevent the development of a recurrent or tension pneumothorax when the patient is
ventilated.

Scenario 1

Young footballer with fracture of the fourth rib, normal chest X-ray.

Oral analgesia Correct answer

Scenario 2

Elderly man with fracture of the fourth rib and normal chest X-ray.

Oral analgesia and admission Correct answer

Scenario 3

Polytrauma – fracture of the fourth rib and femur, and pneumothorax.

Chest drain and analgesia Correct answer

25.

THEME: TRAUMA MANAGEMENT

A Chest X-ray (CXR) erect

B Plain abdominal X-ray
C X-ray pelvis
D Laparotomy
E Abdominal ultrasound

For each of the patients described below, select the single most appropriate action from the options listed above.
Each option may be used once, more than once, or not at all.

Scenario 1

A young woman presents having fallen off her horse, landing on the left side of the abdomen. There has been no loss of
consciousness or head injury. A fall in blood pressure was noted and was resuscitated with two units of Haemaccel. Hb in A&E
was 9.8 g/dl.

Abdominal ultrasound Correct answer

The patient is now haemodynamically stable and therefore one can investigate her. The best imaging technique from the
choice above is ultrasound, but if given the choice computed tomography (CT) would be better.

Scenario 2

A young man has been stabbed in the mid line, just above the umbilicus. Four to six hours after being admitted to hospital and
observed, he develops signs of peritonitis.

Laparotomy Correct answer

The patient is unstable and an emergency laparotomy is indicated.

26.

28
THEME: CHEST INJURY

A Aortic injury
B Pericardial injury
C Pneumothorax
D Flail segment
E Pulmonary contusions

For each of the patients described below, select the single most likely diagnosis from the options listed above. Each
option may be used once, more than once, or not at all.

Scenario 1

A young man with penetrating chest injury is clinically well on admission and has a normal chest film. However, he deteriorates
on the ward and has a tachycardia, hypotension, and dyspnoea when you are asked to see him. His pulse is weak and his
jugular venous pressure (JVP) is raised, and breath sounds are present.

Pericardial injury Correct answer

The clinical scenario here is likely to be due to pericardial effusion. Signs indicating this include weak pulse, raised
JVP, hypertension and tachycardia. The only other condition which may cause these symptoms is a tension
pneumothorax. However, he has a normal chest film and breath sounds which makes this unlikely.

Scenario 2

A cricketer is hit by a ball in the chest. He initially carries on with the game but then collapses and is rushed to A&E. He is
dyspnoeic, drowsy and has barely audible breath sounds.

Pneumothorax Correct answer

This patient is likely to have a pneumothorax as he has absent breath sounds, is dyspnoeic and drowsy due to hypoxia.

27.

THEME: SHORTNESS OF BREATH

A Tension pneumothorax L
B Cardiac tamponade
C Haemothorax L
D Pulmonary embolus

For each of the patients described below, select the single most likely diagnosis from the options listed above. Each
option may be used once, more than once, or not at all.

Scenario 1

A patient has been stabbed lateral to the trachea and presents with distended neck veins, decreased breath sounds,
hyperresonance to percussion and tracheal deviation.

Tension pneumothorax L Correct answer

This clinical scenario has signs of tension pneumothorax.

Scenario 2

A patient presents with ECG changes in Q-wave III, inverted T and changes in II.

Pulmonary embolus Correct answer

The characteristic ECG changes seen in pulmonary embolus are S-wave I, Q-wave III and T-wave III.

29
Scenario 3

A patient presents with dull to percussion left chest.

Haemothorax L Correct answer

Dullness to percussion is indicative of a haemothorax.

28.

Theme: Radial nerve injury

A Compression at the level of the elbow

B Fracture at the level of the mid-humerus
C Compression at the level of the axilla
D Laceration at the level of the wrist

Describe the level of injury for the following patients. Each option may be used once, more than once, or not at all.

In low radial nerve lesions, ie those due to fractures or dislocations at the elbow, the posterior interosseus nerve may be injured
and the patient is unable to extend the fingers; there is also weakness of thumb abduction and extension. In high lesions such
as in fractures of the humerus or due to prolonged tourniquet pressure, there is weakness of the radial extensors of the wrist
and numbness over the anatomical snuff box. In very high lesions, the radial nerve may be compressed in the axilla, eg, crutch
palsy, which leads to paralysis of the triceps and absent triceps reflex.

Scenario 1

A 25-year-old man presenting with weakness of wrist and hand with paralysis of the triceps and absent triceps reflex.

Compression at the level of the axilla Correct answer

Scenario 2

A 19-year-old man presenting with a wrist drop with inability to extend the metacarpophalangeal joints of the hand, together
with altered sensation over the region of the anatomical snuff box. The triceps reflex is present.

Fracture at the level of the mid-humerus Correct answer

Scenario 3

A 30-year-old man presenting with inability to extend the metacarpophalangeal joints of the hand with weakness of thumb
abduction and interphalangeal extension.

Compression at the level of the elbow Correct answer

29.

Theme: Making good use of available imaging resources

A Plain radiographs
B CT pulmonary angiography
C Lung perfusion scan
D Percutaneous (conventional) angiography
E None of the above

For each of the following situations, select the most likely answer from the above list. Each option may be used once,
more than once, or not at all.

Scenario 1

30
A previously well 52-year-old man has become hypotensive, tachycardic and oliguric 2 h after a somewhat ‘tricky’ embolisation
procedure to treat a right hepatic artery aneurysm.

Percutaneous (conventional) angiography Correct answer

This may well be the fastest way of both finding and dealing with the site of blood loss which must be presumed to
have originated from the previous catheterization procedure.

Scenario 2

A 21-year-old man attends a local district general hospital following a road traffic accident. He is responsive but has a widening
of his mediastinum seen on posterior–anterior(PA) chest X-ray. He is currently haemodynamically stable. The nearest
cardiothoracic surgeon is in a tertiary referral centre 1 h away and asks for further investigation.

CT pulmonary angiography Correct answer

In a stable patient, as in this case, the ‘gold standard’ is to perform angiography to look at the great vessels; however, this is
only recommended if the patient is within a cardiothoracic centre with surgeons available. In this case, a CT scan is fast, and
images can often be sent to the cardiothoracic surgeons electronically. If the patient is stable this should not delay transfer
significantly if requested promptly.

Scenario 3

Day 10 post-operative, a 65-year-old lady suffers pleuritic chest pain and collapse whilst at the toilet. She cannot seem to get
her breath, and arterial saturations are measured at 87%. She gradually improves but shows some abnormalities on chest X-
ray. The consultant would like further investigation as to the cause.

CT pulmonary angiography Correct answer

As a general rule ventilation-perfusion scans are very accurate at detecting acute PE, especially in cases where there is
anormal chest X-ray. This is because most false positives arise in patients with underlying chest disease such as chronic
obstructive pulmonary disease (COPD). Thus in patients with an abnormal chest X-ray, most centres currently advocate CT
scanning to avoid such confusion. Small filling defects can be very accurately detected by this method.

Scenario 4

A 23-year-old man becomes acutely dyspnoeic, cyanosed and distressed shortly after having an internal jugular line inserted
for chemotherapy. He is tachycardic with distended neck veins and a deviated trachea.

None of the above Correct answer

The patient has a life threatening tension pneumothorax. This is a clinical diagnosis that has already been made. Feel
free to get a plain radiograph after you have decompressed the patient’s chest and saved his life.

5739

30.

Theme: Abdominal Injury

A Abdominal ultrasound or computed tomography (CT) scans

B Cystourethrography
C Immediate surgery
D Closed observation
E Fluid resuscitation

For each of the scenarios below, choose the most appropriate action from the list shown above. Each option may be
used once, more than once, or not at all.

Scenario 1

31
A 25-year-old man was kicked and punched at his left flank. On arrival at the Accident and Emergency Department, his clinical
observations were GCS 15/15, heart rate (HR) 105/min, blood pressure (BP) 120/70 mmHg, respiratory rate (RR) 20/min and
SpO2 on air was 96%. Primary survey was completed and was uneventful. There was bruising and tenderness over his left
flank. What will be the most appropriate next step of management?

Abdominal ultrasound or computed tomography (CT) scans Correct answer

Abdominal ultrasound or computed tomography (CT) scans

In view of the nature of his injury, it is crucial to rule out splenic and/or renal injury. An abdominal ultrasound or CT
scan will be of great help in establishing this.

Scenario 2

A 38-year-old male driver wearing a seat belt was involved in a road traffic accident. There was no head injury, thoracic injury,
limb injury or obvious external blood loss. He has extensive bruising on his left hypochondriac region of his abdomen. Despite
adequate fluid resuscitation, his observations are anxious, HR 136/min, blood pressure (BP) 70/50 mmHg, RR 22/min and
SpO2 100% on high flow oxygen. What is the most appropriate management?

Immediate surgery Correct answer

Immediate surgery

It is obvious that this man did not respond to fluid resuscitation due to continuous intra-abdominal haemorrhage, in
this case, splenic injury is high on the list (left renal injury involving the vascular pedicle is also likely). Such patient
will need immediate laparotomy.

Scenario 3

A 21-year-old soldier was shot at his abdomen. His clinical observations are: GCS 15/15, HR 120/min, blood pressure (BP)
75/50 mmHg after intravenous fluid resuscitation, RR 24/min, SpO2 98% on high flow oxygen. There was an entry wound of the
bullet at his umbilical region, exit wound at his right flank. What is his next management?

Immediate surgery Correct answer

Immediate surgery

All high-velocity penetrating gun shot wounds (GSW) or low-velocity penetrating (stab) abdominal injury with
hypotension or shock are indications for immediate laparotomy.

Scenario 4

A 5-year-old girl fell and landed onto her abdomen sustaining marked bruising ecchymosis of her epigastric region on her
anterior abdominal wall. She was tender over this region but there were no peritonitic signs. She remains haemodynamically
normal. Her abdominal ultrasound scan is unremarkable. Her blood tests including serum amylase were within the normal
limits. What will be the appropriate management for this girl?

Closed observation Correct answer

Closed observation

This patient’s injury is very likely to be superficial knowing that her general condition remained stable and abdominal
ultrasound scan/blood test were unremarkable. She will benefit from in-patient closed observation and analgesia.

31.

THEME: DIAGNOSIS OF SURGICAL EMERGENCIES

A Acute cholecystitis
B Acute Appendicitis

32
C Ectopic pregnancy
D Perforated peptic ulcer
E Acute pancreatitis

For each of the scenarios below, choose one diagnosis from the list above. Each option may be used once, more than
once, or not at all.

Scenario 1

A 36-year-old woman presented with acute onset of abdominal pain, associated with nausea and vomiting. The pain, which has
been present for the past 2 hours, is colicky, right upper quadrant, localised, and with no aggravating or relieving factors. She
has a BMI of 35.

Acute cholecystitis Correct answer

Acute cholecystis secondary to gallstones is common in women in their forties, with increased BMI, and of reproductive age. In
most cases the gallstones are asymptomatic and remain unnoticed for many years; but when they cause irritation of the gall
bladder, this results in colicky, right hypochondrial pain. Touching the gall bladder area with the thumb while the patient takes a
deep breath will cause the patient to stop her breath because of pain caused by contact between the inflamed gall bladder and
the abdominal wall (Murphy’s sign).

Scenario 2

A 16-year-old boy presented in A&E with acute onset of lower abdominal pain, associated with fever and vomiting. The pain is
colicky around the umbilicus, shifts to the right iliac fossa, and has no aggravating or relieving factors. On examination he has
rebound tenderness.

Acute Appendicitis Correct answer

These are the classic signs of acute appendicitis. It occurs when the appendix is obstructed by a faecolith or foreign body in the
lumen, by a fibrous stricture in its wall from a previous inflammation, or by enlargement of lymphoid follicles in its wall
secondary to a catarrhal inflammation of its mucosa. Occasionally it is associated with a carcinoid tumour. As the appendix of
the infant is wide-mouthed and well drained, and as the lumen of the appendix is almost obliterated in old age, appendicitis at
the two extremes of life is relatively rare.

Scenario 3

A 70-year-old man on analgesics for rheumatoid arthritis presented with acute onset of severe abdominal pain radiating
towards the right shoulder, aggravated by movement and relieved by sitting still. He is also feeling nauseated.

Perforated peptic ulcer Correct answer

Perforated peptic ulcer is common in older patients taking NSAIDs or steroids for systemic diseases. A previous history of
peptic ulceration is obtained in most cases, although patients in agony may forget this. In a delayed case, after 12 hours or
more, the features of generalized peritonitis with paralytic ileus become manifest – there is abdominal distension and effortless
vomiting, and the patient is extremely toxic and in oligaemic shock.

32.

Theme: Wound infections

A Orf virus
B Brucella
C Pseudomonas
D Klebsiella
E Coxsackievirus
F Streptococcus pyogenes

For each of the scenarios below choose the most likely cause of infection. Each option may be used once, more than
once, or not at all.

33
Scenario 1

A women sustains a burn from an oven grill. She works as a nurse in the Urology Unit. Eight days later she noticed green pus
in wound.

Pseudomonas Correct answer

Pseudomonas inhabits human and animal gastrointestinal tract, water and soil. The organism survives in moist environments in
hospital and may also survive in aqueous antiseptic and other fluids. It affects patients with an underlying condition eg. Burns
and malignancy or as a result of therapeutic interventions eg urinary catheterisation.

Scenario 2

A 35-year-old butcher cut himself. Later that night he noticed some red lines radiating from the wound.

Streptococcus pyogenes Correct answer

Streptococcus pyogenes can cause the following

· tonsillitis and pharyngitis

· peritonsillar abscess

· otitis media

· mastoiditis

· wound infections with cellulites and lymphangitis

·erysipelas

necrotising fascitis.

Scenario 3

A 60-year-old gentleman pricked his index finger on a rose bush thorn. A few days later he noticed some redness and swelling
near nail of index finger.

Klebsiella Correct answer

Klebsiella spp inhabit the human intestine. Some strains are saprophytic in soil, water and vegetation. They are responsible for
wound infections, urinary tract infections (UTIs), septicaemia, endocarditis and, rarely, pneumonia.

34