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 62-year-old man has a 12-hour history of sudden severe epigastric pain that is now generalised. His abdomen is rigid, and an erect chest radiograph shows free air under the diaphragm. He is alert and talking, with blood pressure 88/55 mm Hg, heart rate 124 beats/min and oxygen saturation 96% on room air. Theatre is being prepared for laparotomy. What is the most appropriate immediate action?

A 67-year-old man with atrial fibrillation develops sudden severe pain, pallor, and coldness of the right leg over 4 hours. The femoral pulse is strong, but popliteal and pedal pulses are absent. Sensation is reduced over the foot, calf muscles are soft, and power is preserved. What is the most appropriate investigation to plan revascularization?

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 45-year-old man has had bilateral groin swellings and dragging pain for six months. Examination shows small bilateral reducible inguinoscrotal swellings with positive cough impulses and a soft, non-tender abdomen. His body mass index is 30 kg/m2. He has had no previous abdominal or groin surgery and no cardiorespiratory disease. Which of the following is the most appropriate definitive management?

A 32-year-old woman attends clinic asking about breast cancer screening. She has no breast lump or nipple discharge, and her breast examination is normal. Her mother was diagnosed with breast cancer at 45 years of age, and the patient recently had genetic testing that showed a pathogenic BRCA1 mutation. She takes a combined oral contraceptive pill. Which screening plan is most appropriate?

A 38-year-old woman had excision of a 2 cm left breast lump that imaging and core biopsy showed to be a fibroadenoma. Final histopathology confirms the fibroadenoma, with a single incidental focus of classic lobular carcinoma in situ close to the margin. There is no invasive carcinoma, ductal carcinoma in situ or atypia elsewhere. Her bilateral mammogram is normal. What is the most appropriate management?

A 30-year-old man presents with 8 hours of right upper quadrant pain after a year of recurrent milder attacks. Temperature is 37.9 °C and heart rate 110 beats/min. He is jaundiced with right hypochondrial tenderness. White cells are 16 × 10⁹/L, direct bilirubin 15 µmol/L, alkaline phosphatase 400 IU/L and amylase 115 IU/L. Ultrasound shows an 11 mm common bile duct with intrahepatic dilatation. Which diagnosis is most likely?

A 45-year-old woman has 18 months of dysphagia to liquids and solids, retrosternal pain on swallowing and regurgitation of undigested food. Barium swallow shows a dilated esophagus tapering to a smooth beak at the cardia. Upper endoscopy shows no mucosal lesion or mass. Which of the following investigations has the highest diagnostic value?

A 44-year-old woman with mild right upper quadrant discomfort undergoes contrast-enhanced magnetic resonance imaging of the liver. A 3 cm lesion in the right lobe shows peripheral nodular discontinuous enhancement in the arterial phase with progressive centripetal filling on delayed images, remaining isointense to blood pool. Which is the most likely diagnosis?

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 52-year-old man develops perioral numbness and carpopedal spasm 24 hours after total thyroidectomy for a euthyroid multinodular goitre. Chvostek and Trousseau signs are positive. Albumin-corrected calcium is 1.78 mmol/L and phosphate is raised; his preoperative calcium was normal. He takes no regular medication and has no history of malabsorption or alcohol use. Which test best establishes the cause of his hypocalcaemia?

A 28-year-old woman presents with a painless left neck swelling. At age 12 she received external beam radiotherapy to the neck for Hodgkin lymphoma. Ultrasound shows a 4 by 3 cm solid nodule confined to the left thyroid lobe, a normal-appearing right lobe and no abnormal cervical lymph nodes. Fine needle aspiration confirms papillary thyroid carcinoma. Which of the following is the most appropriate surgical management?

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 70-year-old woman, para 7, presents with 2 days of abdominal distension, absolute constipation, and vomiting. Temperature is 37.2 °C and heart rate 94 beats/min. There is a tender, irreducible swelling in the right groin lying above and medial to the pubic tubercle, with no overlying skin changes. Abdominal radiography shows multiple small-bowel air-fluid levels. What is the most likely diagnosis?

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 20-year-old woman reports two years of difficulty swallowing that is worse for liquids than for solids, with occasional regurgitation of undigested food and nocturnal cough. Her weight is stable and physical examination is normal. Chest radiograph shows no mediastinal mass. Which of the following is the most appropriate initial investigation?

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 47-year-old woman, three weeks after laparoscopic sleeve gastrectomy, has generalised peritonitis, temperature 38.9 °C, heart rate 125 beats/min, and blood pressure 90/55 mm Hg. Contrast-enhanced CT shows extravasation of oral contrast at the proximal staple line with a large left subphrenic collection. Which of the following is the most appropriate management?

A 37-year-old man presents after several episodes of forceful vomiting followed by two episodes of small volume hematemesis. Blood pressure is 112/63 mm Hg, heart rate 89 beats/min, respiratory rate 21 breaths/min, oxygen saturation 96% on room air. Hemoglobin is 135 g/L and white cell count 7.8 × 10⁹/L. Bleeding has not recurred. Which of the following is the most appropriate management plan?

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 31-year-old man undergoes emergency laparotomy after 12 hours of severe epigastric pain, a rigid abdomen and free subdiaphragmatic air. At operation there is a 5 mm perforation on the anterior wall of the first part of the duodenum with generalized peritoneal soiling. He is hemodynamically stable. Which of the following is the most appropriate operative management?

A 32-year-old man falls onto his outstretched right hand while playing football. His elbow is swollen and held flexed, with a prominent olecranon posteriorly. The skin is intact, radial pulse is palpable, and hand sensation and finger movement are normal. Radiographs show a posterior elbow dislocation with a displaced radial head fracture. What is the most appropriate initial management?

A 24-year-old man is brought in 4 hours after a motorcycle crash with a closed fracture of the left tibial shaft. He has severe leg pain out of proportion to the injury despite opioids, a tense swollen calf, and marked pain on passive stretch of the toes. Dorsalis pedis pulse is palpable. Which investigation most directly confirms the suspected diagnosis?

A 32-year-old woman has two months of left breast discomfort with spontaneous blood stained discharge from a single duct. She is not pregnant and takes no medication. Examination of both breasts and axillae shows no palpable mass, no skin change, and no lymphadenopathy. Which of the following is the most appropriate initial breast investigation?

A 38-year-old man has four hours of sudden severe abdominal pain after months of frequent NSAID use for joint pain. He is able to stand. Temperature is 37.8 °C and white cell count 13 × 10⁹/L. The abdomen shows generalized tenderness, board-like guarding and absent bowel sounds. Which of the following is the most appropriate initial imaging?

A 90-year-old woman is two days after emergency laparotomy for small bowel obstruction and is receiving morphine for wound pain. She has shallow breathing with reduced bilateral chest movement and reduced air entry at both bases. She is alert, speaks full sentences and is not using accessory muscles. Respiratory rate is 24 breaths/min and oxygen saturation is 89% on 2 L/min nasal oxygen. What is the most appropriate next step?

A 62-year-old woman is scheduled for elective right hemicolectomy for a non-obstructing caecal adenocarcinoma. She has lost 10% of her body weight over 4 months because of poor appetite. She eats and drinks without vomiting or difficulty swallowing, but the dietitian finds her protein and energy intake well below her estimated needs. Serum albumin is 32 g/L. What is the most appropriate next step?

A 68-year-old woman is on postoperative day 7 after dynamic hip screw fixation of a right intertrochanteric fracture. Her temperature is 38.1 °C. The incision is dry and clean, the chest is clear and oxygen saturation is 97% on room air. Her urinary catheter was removed on day 2 and urinalysis is normal. The left calf is 3 cm larger than the right. Which investigation is most appropriate next?

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 60-year-old woman reports six months of dull abdominal aching with 8 kg weight loss. Examination reveals a firm, non-tender 20 cm by 20 cm intra-abdominal mass. CT shows a lobulated fat containing soft tissue mass arising from the retroperitoneum with multiple hypodense liver lesions and no lymphadenopathy. Which of the following is the most likely diagnosis?

A 60-year-old man underwent laparoscopic inguinal hernia repair five days ago and now notices groin swelling. The swelling is fluctuant and mildly tender, with no erythema, warmth, bruising, or cough impulse. Temperature is 37.2 °C, heart rate 80 beats/min, blood pressure 135/80 mm Hg. Which of the following is the most likely diagnosis?

A 22-year-old woman is one week after laparoscopic appendectomy with mild lower abdominal pain and occasional loose stools. She is afebrile, heart rate 78 beats/min, abdomen soft with mild tenderness only near the port site. Computed tomography shows a 2 cm by 2 cm retrocaecal collection. Which of the following is the most appropriate next step in management?

A 25-year-old man returns on the eighth day after open appendectomy for perforated appendicitis with pain and redness around the wound. The incision is discharging pus and is tender, but the abdomen is soft. Temperature is 38 °C, heart rate 110 beats/min, blood pressure 110/70 mm Hg. Which of the following is the most appropriate 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 31-year-old woman at 10 weeks gestation has had four separate attacks of right upper quadrant pain after fatty meals over the past five weeks, each lasting about three hours. She is afebrile, her abdomen is non-tender, and ultrasound shows multiple gallstones without wall thickening. Which is the most appropriate management plan?

A 45-year-old man is brought in after a high-speed car crash in which his chest struck the steering wheel. Blood pressure is 92/60 mm Hg and pulse 118 beats/min. A segment of the right anterolateral chest wall moves inward on inspiration and outward on expiration, with crepitus over several ribs. The trachea is midline and breath sounds are present bilaterally. Which injury explains the abnormal chest wall movement?

A 19-year-old man is brought to the emergency department after a hard tackle to the right chest during a football match. He has right-sided chest pain and mild breathlessness. Blood pressure is 100/70 mm Hg, heart rate 96 beats/min, and oxygen saturation 94% on oxygen. Breath sounds are absent on the right, with crepitus over the chest wall. The trachea is midline. What is the initial step?

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?

A 32-year-old man is brought in after a motorcycle collision. He is unconscious with a Glasgow Coma Scale score of 6 and has a deep thigh laceration that has bled heavily at the scene. His blood pressure is unrecordable, extremities are cold and pale, and haemoglobin is 60 g/L. He takes no regular medications. Which pulse finding is most likely on examination?

A 30-year-old man is brought in after a high-speed motor vehicle collision. Focused ultrasound shows free intraperitoneal fluid. After 1 L of warmed Ringer's lactate, his blood pressure rose briefly from 82/50 to 100/62 mm Hg but has fallen again to 84/52 mm Hg, with pulse 130 beats/min. Haemoglobin is 60 g/L. Which fluid should be given next?

A 42-year-old man is brought to the emergency department after a high-speed car crash with chest pain. His airway is patent, breath sounds are equal bilaterally, and his neck veins are distended. Blood pressure is 88/45 mm Hg, heart rate 110 beats/min, and respiratory rate 30 breaths/min. Which of the following is the most likely diagnosis?

A 35-year-old woman is one day after total thyroidectomy for a large multinodular goiter. While the nurse inflates the blood pressure cuff on her arm, the wrist flexes and the fingers draw together into a painful spasm that persists for two minutes. She also reports tingling around the mouth and in the fingertips. Which of the following is the most appropriate next step in management?

A 63-year-old woman with type 2 diabetes for 20 years finds a 2 cm ulcer over the lateral border of her left foot, beneath the fifth metatarsal head. She had felt no pain. The ulcer has a red granulating base, a callused edge and serous discharge. Dorsalis pedis and posterior tibial pulses are intact. Which type of ulcer is most likely?

A 62-year-old man with diabetes has 3 months of worsening left calf pain after walking a few metres. The pain now worsens when he lies down and eases when he hangs the leg over the bed. For 2 weeks he has had a discharging, non-healing ulcer on the left great toe. The left foot is cool and pale with absent popliteal and tibial pulses. Which investigation is most definitive?

A 71-year-old man who smokes and has hypertension and type 2 diabetes is seen in the vascular clinic. The right popliteal and foot pulses are diminished. There is a healed scar from a previous left popliteal bypass. Which finding would indicate that his right leg is now at risk of limb loss?

A 72-year-old woman, bedbound from severe osteoarthritis, has a deep right heel ulcer and fever of 38.9 °C. The ulcer exposes muscle and contains wet necrotic tissue with foul-smelling discharge, and the surrounding skin is red and warm. Pedal pulses are palpable. White cell count is 22 × 10⁹/L. Intravenous antibiotics have been started after blood cultures. What is the most appropriate next step?