Contents ix

107 Electrolytes 226

108 Lung function 227
Answers 228

SECTION 10: EMQ REVISION BOXES 246

Abdominal pain 248
Weight loss 249
Hepatobiliary surgery 250
Chronic liver disease 251
Paediatric surgery 252
Surgical radiology 253
Inflammatory bowel disease 254
Skin lesions 255
Thyroid malignancy 256
Thyroid disease 257
Urology investigations 258
Renal calculi 259
Lump in the groin 260
Dizziness/vertigo 261
Sore throat 262
Dysphagia 263
Neck lumps 264
The paediatric hip 265
Upper limb nerve injury 266
Lower limb nerve injury 267
Reflexes and motor nerve roots 268
Upper limb orthopaedic conditions 269
Lower limb orthopaedic conditions 270
Red eye 271
Retinal signs 272
Pupils 273
Ocular movements 274
Visual field defects 275
Hypertensive retinopathy 276
Diabetic retinopathy 277
Neurosurgery/head injury 278
Arterial blood gases 279
Classical EMQ descriptions of blood gases 280
Skin cover in plastic surgery 281

Index 283
Contributors
Mr Obiekezie Agu MS FRCS(Gen)
Consultant Vascular Surgeon, University College Hospital, London, UK
Miss Sarvi Banisadr BSc(Hons) MBBS MRCS
Specialist Registrar General Surgery, Royal Marsden Hospital, London, UK
Mr Andrew Bath BMedSci BMBS FRCS(ORL)
Consultant ENT Surgeon, Norfolk and Norwich University Hospital, UK
Dr Brigitta Brandner FRCA MD
Consultant Anaesthetist, University College Hospital, London, UK
Mr Raymond Brown MA MBChir FRCS FRCOphth
Consultant Ophthalmologist, University Hospital of North Staffordshire, UK
Mr Fares Haddad BSc MCh(Orth) FRCS(Orth)
Consultant Orthopaedic Surgeon and Honorary Senior Lecturer, University
College London Hospitals, UK
Mr Naveed Jallali BSc MBChB(Hons) MRCS
Specialist Registrar, Plastic and Reconstructive Surgery, Royal Free Hospital,
London, UK
Mr Rohan Nauth-Misir BSc FRCS(Urol)
Consultant Urologist and Clinical Director Urology, University College Hospital,
London, UK
Miss Reshma Syed MBBS MRCS(Ophth)
Specialist Registrar Ophthalmology, University Hospital of North
Staffordshire, UK
Mr Zishan Syed BA
Medical Student, University of Cambridge, Cambridge, UK
Mr Peter Tassone MBChB MRCS
Specialist Registrar, ENT surgery, Norfolk and Norwich University Hospital, UK
Preface
EMQs and Data Interpretation Questions in Surgery has two main roles. First, we
aim to provide a bank of questions for examination practice, as familiarity
breeds confidence. The EMQ revision boxes in EMQs in Clinical Medicine
(Hodder Arnold: 2004) have been popular and so we have included a separate
revision boxes section for easy reference.
Second, we wanted to provide an informative text with detailed explanations,
taking advantage of the collective knowledge from our colleagues in the surgical
specialties.
We sincerely hope that this book helps you in the build-up to your examination
and wish you all the best in your medical career!
Irfan Syed and Mohammed Keshtgar
Acknowledgements
This book would not have been possible without the excellent work in reviewing,
writing and editing questions by our colleagues.
Many thanks also to Jane, Sara, Amy and the Hodder Arnold team for their
efforts in bringing this project to fruition.
SECTION 1: EMQS IN
GENERAL SURGERY
1 Abdominal pain (i)
2 Abdominal pain (ii)
3 Small bowel obstruction
4 Abdominal masses
5 Anorectal conditions
6 Management of colorectal cancer
7 Management of inflammatory bowel disease
8 Investigation of gastrointestinal bleeding
9 Paediatric surgery
10 Splenomegaly
11 Ulcers
12 Abnormal abdominal x-rays
13 Complications of gallstones
14 Breast conditions
15 Treatment of breast cancer
16 Skin lesions
17 Presentation with a lump
18 Pathology terminology
19 Thyroid conditions (i)
20 Thyroid conditions (ii)
21 Feeding the surgical patient
22 The shocked surgical patient
23 Chest trauma
24 Glasgow Coma Scale
25 Complications of blood transfusion
26 Head injury
1 EMQs in general surgery

QUESTIONS

1 Abdominal pain (i)

A large bowel obstruction H aortic dissection

B acute pancreatitis I diverticulosis
C perforated viscus J duodenal ulcer
D appendicitis K renal colic
E small bowel obstruction L colorectal carcinoma
F acute cholecystitis M mesenteric adenitis
G ulcerative colitis

For each clinical scenario below give the most likely cause for the clinical
findings. Each option may be used only once.

1 A 45-year-old man with a history of gallstones presents in A&E with severe

epigastric pain radiating to the back and vomiting.

2 A 28-year-old man presents with sharp left loin and left upper quadrant pain
radiating to the groin. He is not jaundiced.

3 A 44-year-old woman presents with continuous right upper quadrant pain, vomit-
ing and fever. There is marked right upper quadrant tenderness when palpating on
inspiration.

4 A 26-year-old male with a previous history of abdominal surgery presents with

colicky central abdominal pain rapidly followed by production of copious bile-
stained vomitus.

5 A 50-year-old man with a history of epigastric pain presents with constant severe
generalized abdominal pain. On examination he is distressed and has a rigid
abdomen. Pulse is 110/min, BP 100/60 mmHg.

Answers: see page 28

 Extended matching questions 3

2 Abdominal pain (ii)

A hepatitis H Crohn’s disease

B irritable bowel syndrome I carcinoma of caecum
C umbilical hernia J acute appendicitis
D primary sclerosing cholangitis K gastric ulcer
E perforated duodenal ulcer L hepatocellular carcinoma
F small bowel obstruction M diverticulitis
G ulcerative colitis

For each clinical scenario below give the most likely cause for the clinical
findings. Each option may be used only once.

1 A 21-year-old student presents with a cramping diffuse abdominal pain associated

with alternating constipation and diarrhoea. Colonoscopy and inflammatory
markers are normal.

2 A 9-year-old girl presents with fever, nausea and right iliac fossa pain. She says
that the pain ‘was around my belly button before’.

3 A 35-year-old man presents with weight loss, diarrhoea and abdominal pain. On
examination he has aphthous ulcers in the mouth and a mass is palpable in the
right iliac fossa. Blood tests reveal low serum B12 and folate.

4 A 72-year-old man with a history of constipation presents with increased temper-

ature, diarrhoea and left iliac fossa pain. On examination there is tenderness in the
left iliac fossa.

Answers: see page 29

 4 EMQs in general surgery

3 Small bowel obstruction

A adhesions F intussusception
B strangulated inguinal hernia G intra-abdominal abscess
C small bowel atresia H Meckel’s diverticulum
D Crohn’s disease I midgut volvulus
E irritable bowel syndrome

For each clinical scenario below give the most likely cause for the clinical
findings. Each option may be used only once.

1 A 54-year-old woman presents to A&E with a 48-hour history of colicky abdomi-

nal pain, vomiting and abdominal distension. Basic observations on arrival are:
pulse 120/min, BP 100/75 mmHg, temperature 38°C. Abdominal examination
reveals generalized tenderness, with a firm, tender, 3 ! 4 cm swelling in the right
groin. Bowel sounds are absent.

2 A 13-year-old boy underwent an appendicectomy 7 days ago for a suppurative

appendicitis. Over the past 48 hours he has complained of right iliac fossa pain,
vomiting and abdominal distension. Bowel sounds are absent. Basic observations
on arrival are: pulse 110/min, BP 105/64 mmHg, temperature 37.2°C. His mother is
a nurse and says that he has had spiking temperatures of above 38°C at home.

3 A 76-year-old man with a history of hemicolectomy 3 years ago presents to his GP

with worsening colicky abdominal pain associated with vomiting, and abdominal
distension. Basic observations on arrival are: pulse 98/min, BP 165/75 mmHg,
temperature 37.8°C. On abdominal examination there is a distended abdomen
with no tenderness, rebound or guarding. Bowel sounds are tinkling.

4 A 23-year-old man with a 6-month history of weight loss, anorexia, recurrent

abdominal pain after eating, and diarrhoea presents to A&E. The pain is colicky
associated with vomiting, absolute constipation, and abdominal distension over
the past 3 days. Basic observations on arrival are: pulse 120/min, BP 89/56 mmHg,
temperature 38.2°C. He is tender in the central abdominal region without guarding
or rebound. Blood tests: Hb 10.1 g/dL, WCC 18.0 ! 109/L, CRP 155, Alb 28.

Answers: see page 30

 Extended matching questions 5

4 Abdominal masses

A renal cell carcinoma G diverticulosis

B ovarian carcinoma H hepatocellular carcinoma
C gastric carcinoma I caecal carcinoma
D sigmoid carcinoma J psoas abscess
E fibroids K abdominal aortic aneurysm
F pancreatic pseudocyst L ovarian cyst

For each clinical scenario below give the most likely cause for the clinical
findings. Each option may be used only once.

1 A 65-year-old man collapses in the street. On examination he has an abdominal

mass lying above the umbilicus that is expansile and pulsatile.

2 A 75-year-old man with a 3-month history of dyspepsia presents with weight loss
and abdominal distension. On examination, a 3.5-cm, hard, irregular tender epi-
gastric mass can be felt which moves on respiration. Percussion of the distended
abdomen reveals shifting dullness. The left supraclavicular node is palpable.

3 A 70-year-old woman presents with a mass in the right iliac fossa and severe
microcytic anaemia. On examination the mass is firm, irregular and 4 cm in
diameter. The lower edge is palpable.

4 A 35-year-old woman is worried about an abdominal mass that has grown over
the last 6 months and a similar length history of very heavy menstrual bleeding
with no intermenstrual bleeding. On examination, a knobbly mass can be felt in
the middle lower quadrant that is dull to percussion. The lower edge is not
palpable. She is otherwise well.

5 A 70-year-old alcoholic presents with a tender upper abdominal mass. CT shows a

thick-walled, rounded, fluid-filled mass adjacent to the pancreas.

Answers: see page 31