SMLE Surgery 4 — Questions and Answers
Question 1: A 60-year-old male presents with a pulsatile, expansile abdominal mass. CT angiography shows an infrarenal abdominal aortic aneurysm measuring 6.5 cm. What is the recommended management?
- Annual surveillance with ultrasound
- Blood pressure control and observation
- Elective surgical repair (open or EVAR) (Correct answer)
- Emergency surgery only if symptomatic
Correct answer: Elective surgical repair (open or EVAR)
An abdominal aortic aneurysm ≥5.5 cm carries a significant annual rupture risk and is an indication for elective repair, either open surgical repair or endovascular aneurysm repair (EVAR), depending on anatomy and patient fitness.
Question 2: A patient with a history of peptic ulcer disease presents with massive haematemesis. After initial resuscitation, what is the most appropriate definitive investigation?
- Barium swallow
- CT angiography
- Upper GI endoscopy (OGD) (Correct answer)
- Mesenteric angiography
Correct answer: Upper GI endoscopy (OGD)
Upper GI endoscopy (oesophagogastroduodenoscopy) is both diagnostic and therapeutic for upper GI bleeding. It allows identification of the bleeding source and endoscopic haemostasis using clips, thermal coagulation, or injection therapy.
Question 3: A 40-year-old male presents with intermittent claudication in the left calf after walking 200 metres. Ankle-brachial index (ABI) is 0.6. What is the initial management?
- Immediate surgical bypass
- Smoking cessation, supervised exercise, and antiplatelet therapy (Correct answer)
- Endovascular stenting
- Amputation planning
Correct answer: Smoking cessation, supervised exercise, and antiplatelet therapy
For intermittent claudication (Fontaine stage II), initial management includes risk factor modification (smoking cessation is paramount), supervised exercise programmes, and antiplatelet therapy. Revascularisation is reserved for lifestyle-limiting symptoms despite conservative measures.
Question 4: A child swallows a coin. X-ray shows the coin in the oesophagus at the level of the cricopharyngeus. The child is drooling but not in respiratory distress. What is the management?
- Observation for 24 hours and repeat X-ray
- Endoscopic removal within 24 hours (Correct answer)
- Barium swallow
- Heimlich manoeuvre
Correct answer: Endoscopic removal within 24 hours
An oesophageal foreign body with symptoms (drooling indicates inability to handle secretions) requires endoscopic removal within 24 hours to prevent complications such as perforation, mucosal necrosis, or airway compromise.
Question 5: A 50-year-old female presents with a solitary thyroid nodule. Thyroid function tests are normal. Ultrasound shows microcalcifications and irregular margins. What is the next step?
- Thyroid scintigraphy
- Fine needle aspiration cytology (FNAC) (Correct answer)
- Immediate thyroidectomy
- Trial of levothyroxine suppression
Correct answer: Fine needle aspiration cytology (FNAC)
Ultrasound features of microcalcifications and irregular margins are suspicious for thyroid malignancy (TI-RADS 4-5). Fine needle aspiration cytology is the next step to obtain a tissue diagnosis and guide further management.
Question 6: A trauma patient arrives with paradoxical chest wall movement on the right side. Oxygen saturation is 88% on room air. What is the diagnosis and initial management?
- Tension pneumothorax — needle decompression
- Flail chest — intubation and mechanical ventilation if needed (Correct answer)
- Haemothorax — chest tube insertion
- Rib fracture — analgesia only
Correct answer: Flail chest — intubation and mechanical ventilation if needed
Paradoxical chest wall movement indicates flail chest (≥3 consecutive ribs fractured in ≥2 places). Management focuses on adequate analgesia, oxygen supplementation, and mechanical ventilation if respiratory failure develops. The underlying pulmonary contusion often determines the clinical course.
SMLE Surgery 4
A 60-year-old male presents with a pulsatile, expansile abdominal mass.
CT angiography shows an infrarenal abdominal aortic aneurysm measuring 6.5 cm.
What is the recommended management?