Free SMLE Surgery questions

A 34-year-old woman has had 8 months of progressive dysphagia to both solids and liquids and regurgitation of undigested food at night. Barium swallow shows bird-beak narrowing at the gastro-oesophageal junction, and high-resolution manometry confirms absent peristalsis with failure of lower oesophageal sphincter relaxation. Upper endoscopy excludes malignancy. She is fit for any intervention. Which of the following is the most effective definitive treatment?

A 64-year-old man has a cold, painful left leg. The limb is pale and pulseless with reduced foot power. Angiography shows superficial femoral artery occlusion, and catheter-directed thrombolysis restores a dorsalis pedis pulse. He is kept on bed rest with the leg immobilized for 4 days, and thromboprophylaxis is withheld because of oozing at the femoral puncture site. Which complication is he at greatest risk of during this admission?

A 36-year-old woman has had a left neck swelling for three years. Examination shows a firm left thyroid mass with no palpable cervical lymph nodes. TSH is 1.8 mIU/L. Ultrasound shows a 3.8 by 3.4 cm mixed solid and cystic nodule occupying most of the left lobe. Fine needle aspiration is reported as Bethesda IV, follicular neoplasm. Which of the following is the most appropriate management?

A 30-year-old man is rescued from a closed space house fire and brought to the emergency department. He has superficial partial thickness burns of both arms covering 12% of body surface area and is alert. The team is deciding whether he has an inhalation injury requiring early intubation. Which of the following findings would most strongly confirm significant inhalation injury?

A 15-year-old girl is five days after laparotomy for perforated appendicitis and now needs mechanical ventilation. Her abdomen is distended, tense, and tender. After a contrast-enhanced computed tomography she bleeds from her mouth, endotracheal tube, and venepuncture sites. Blood pressure is 90/50 mm Hg, heart rate 121 beats/min, temperature 35.6 °C. Which of the following is the most likely diagnosis?

A 25-year-old man is brought in after a head-on motor vehicle collision. He is unresponsive with a Glasgow Coma Scale score of 8. His neck veins are distended, breath sounds are absent on the right, and percussion there is hyperresonant. Blood pressure is 78/44 mm Hg. Which of the following is the most urgent initial intervention?

A 50-year-old man with hypertension and type 2 diabetes reports two months of intermittent perianal discharge. Two months ago he had a painful perianal swelling that burst spontaneously, after which the pain settled but seepage of pus onto his underwear continued. Examination shows a small posterior perianal opening exuding pus. Temperature is 36.6 °C. Which of the following is the most likely diagnosis?

A 55-year-old woman presents with colicky abdominal pain, distension and bilious vomiting. She has had known gallstones for 10 years. She is dehydrated with a distended abdomen and hyperactive bowel sounds. Heart rate is 120 beats/min, hemoglobin 100 g/L and white cells 18.6 × 10⁹/L. Computed tomography shows dilated small bowel loops with a transition point and air within the biliary tree. Which diagnosis is most likely?

A 37-year-old woman, para 5, has had Graves disease for five years. It is controlled on carbimazole, but two attempts at stopping the drug caused biochemical relapse. Examination shows severe bilateral exophthalmos with lid retraction and diplopia. Ultrasound shows a normal sized, homogeneously hypervascular thyroid. Which of the following findings most strongly indicates thyroidectomy rather than radioactive iodine?

A 45-year-old sheep farmer has a two-month history of right upper quadrant pain, vomiting and low-grade fever of 37.6 °C. He is tender in the right upper quadrant. Computed tomography shows a 6 cm hepatic cyst with a partially calcified wall and internal daughter cysts. Serology for Echinococcus granulosus is positive. Which is the most appropriate treatment?

A 27-year-old woman with a body mass index of 38 kg/m² has had right iliac fossa pain, nausea and anorexia for six days. Temperature is 37.9 °C, heart rate 96 beats/min, white cell count 13 × 10⁹/L, and a urine pregnancy test is negative. She has right iliac fossa tenderness without a palpable mass. Which of the following is the most appropriate next investigation?

A 70-year-old multiparous woman presents with abdominal distension and bilious vomiting for one day. The abdomen is distended and tympanic. There is a rounded, tender, irreducible swelling in the right groin lying below and lateral to the pubic tubercle. Abdominal radiography shows dilated small bowel loops with multiple air fluid levels. Which of the following is the most likely diagnosis?

A 29-year-old woman underwent right hemithyroidectomy for a symptomatic 4 cm colloid nodule. Final histopathology shows the benign colloid nodule plus an incidental 8 mm well differentiated papillary carcinoma, unifocal, with clear margins, no extrathyroidal extension and no lymphovascular invasion. Neck ultrasound after surgery shows a normal left lobe and no abnormal nodes. Which of the following is the most appropriate management?

A 26-year-old woman at 20 weeks gestation reports three episodes of right upper quadrant pain with nausea over two weeks, each settling within four hours. She is afebrile, the abdomen is soft and non-tender, and ultrasound shows gallstones with a normal wall and no duct dilatation. Which is the most appropriate management?

A 44-year-old man has a two month anterior neck swelling. A hard 1.5 cm lump in the left lobe moves with swallowing, and no cervical lymph nodes are palpable. Ultrasound shows a mildly enlarged thyroid with a 1.5 cm solid left lobe nodule and a normal right lobe. Fine needle aspiration confirms medullary thyroid carcinoma. Which of the following is the most appropriate procedure?

A 35-year-old man with a right tension pneumothorax and an open right femoral fracture was treated at a rural clinic with a chest tube and limb splinting, then transferred by ambulance. Thirty minutes into transfer his oxygen saturation falls from 97% to 82%, heart rate rises to 130 beats/min and respiratory rate to 34 breaths/min. Which of the following is the most appropriate immediate action?

A 35-year-old man is three days after total thyroidectomy for multinodular goiter and reports perioral tingling and hand cramps. Serum calcium remains 1.72 mmol/L despite 48 hours of oral calcium carbonate, calcitriol, and repeated intravenous calcium gluconate infusions. He has taken a proton pump inhibitor for two years and has had poor oral intake. Which of the following is the most appropriate next step in management?

A 28-year-old man has had two years of sharp anal pain with defecation and occasional fresh bleeding. Examination shows a chronic posterior midline fissure with a sentinel skin tag and visible internal sphincter fibres. Six months of topical diltiazem, stool softeners and sitz baths have failed. Which of the following is the most appropriate surgical management?

A 58-year-old woman has a four-month history of an enlarging right breast lump with blood stained nipple discharge. Examination shows a 4 cm central hard mass with ill-defined edges, nipple inversion, and enlarged axillary nodes. Mammography shows a subareolar irregular density with microcalcification and thickening of the overlying skin. Which of the following is the most appropriate next step in management?