PLAB 1 Surgery and Emergencies 2 — Questions and Answers
Question 1: A 35-year-old man sustains a stab wound to the left chest at the 5th intercostal space, midclavicular line. He is hypotensive with muffled heart sounds and distended neck veins. What is the most likely diagnosis?
- Tension pneumothorax
- Cardiac tamponade (Correct answer)
- Massive haemothorax
- Aortic dissection
Correct answer: Cardiac tamponade
Beck's triad — hypotension, muffled heart sounds, and distended neck veins (raised JVP) — is classic for cardiac tamponade. Penetrating trauma at this location can injure the heart. Emergency management includes pericardiocentesis or emergency thoracotomy.
Question 2: A 75-year-old man presents with absolute constipation (no flatus or faeces for 3 days), colicky abdominal pain, and vomiting. Abdominal X-ray shows dilated large bowel with a 'coffee bean' sign. What is the most likely diagnosis?
- Small bowel obstruction
- Sigmoid volvulus (Correct answer)
- Caecal carcinoma
- Paralytic ileus
Correct answer: Sigmoid volvulus
The 'coffee bean' sign on abdominal X-ray is pathognomonic for sigmoid volvulus — a twisting of the sigmoid colon on its mesentery. It is more common in elderly, institutionalised, or psychiatric patients. Initial management is sigmoidoscopic decompression with a flatus tube.
Question 3: A 50-year-old woman presents with a painless, progressively enlarging lump in her right breast. On examination, there is skin tethering and peau d'orange. What is the most appropriate next step?
- Reassure and review in 3 months
- Urgent 2-week wait referral for triple assessment (clinical examination, imaging, and tissue sampling) (Correct answer)
- Prescribe antibiotics for mastitis
- Arrange a routine ultrasound in 6 weeks
Correct answer: Urgent 2-week wait referral for triple assessment (clinical examination, imaging, and tissue sampling)
A painless breast lump with skin tethering and peau d'orange is highly suspicious for breast cancer. NICE guidelines mandate urgent 2-week wait referral for triple assessment: clinical examination, imaging (mammography/ultrasound), and tissue sampling (core biopsy).
Question 4: A 20-year-old male cyclist is brought to A&E after being hit by a car. He has a GCS of 8. According to ATLS, what is the most important immediate airway intervention?
- Insert a nasopharyngeal airway
- Perform endotracheal intubation with in-line cervical spine stabilisation (Correct answer)
- Apply a simple face mask with high-flow oxygen
- Position the patient in recovery position and observe
Correct answer: Perform endotracheal intubation with in-line cervical spine stabilisation
A GCS of 8 or below indicates the patient cannot protect their own airway. ATLS guidelines recommend definitive airway management with endotracheal intubation, maintaining in-line cervical spine stabilisation until injury is excluded. A GCS ≤8 is a key threshold for intubation.
Question 5: A 55-year-old man presents with a pulsatile, expansile abdominal mass. He is haemodynamically stable. An ultrasound shows a 5.8 cm infrarenal abdominal aortic aneurysm. What is the recommended management?
- Conservative management with annual ultrasound surveillance
- Urgent referral to vascular surgery for consideration of elective repair (Correct answer)
- Emergency open surgical repair
- Prescribe aspirin and discharge
Correct answer: Urgent referral to vascular surgery for consideration of elective repair
NICE guidelines recommend referral for consideration of elective repair for AAA ≥5.5 cm due to the significant risk of rupture. Aneurysms 3.0-4.4 cm are monitored annually, and 4.5-5.4 cm are monitored 3-monthly. At 5.8 cm, the benefit of elective repair outweighs surgical risk.
Question 6: A patient in A&E develops a tension pneumothorax. They are in extremis with tracheal deviation, absent breath sounds on the affected side, and hypotension. What is the immediate management?
- Request an urgent chest X-ray before any intervention
- Immediate needle decompression in the 2nd intercostal space, midclavicular line, followed by chest drain insertion (Correct answer)
- Insert a chest drain in the 5th intercostal space as the first intervention
- Administer IV fluids and wait for a senior review
Correct answer: Immediate needle decompression in the 2nd intercostal space, midclavicular line, followed by chest drain insertion
Tension pneumothorax is a clinical diagnosis — do not delay treatment for imaging. Immediate needle decompression (14-16G cannula, 2nd intercostal space, midclavicular line) converts it to a simple pneumothorax. A formal chest drain (5th intercostal space, mid-axillary line) is then inserted.
PLAB 1 Surgery and Emergencies 2
A 35-year-old man sustains a stab wound to the left chest at the 5th intercostal space, midclavicular line.
He is hypotensive with muffled heart sounds and distended neck veins.
What is the most likely diagnosis?