PLAB 1 Surgery and Emergencies — Questions and Answers
Question 1: A 25-year-old man presents to A&E with sudden-onset right iliac fossa pain. On examination, he has rebound tenderness and guarding. His temperature is 38.2°C. Blood tests show WCC 15 x10^9/L and CRP 85 mg/L. What is the most likely diagnosis?
- Mesenteric adenitis
- Acute appendicitis (Correct answer)
- Right ureteric colic
- Crohn's disease flare
Correct answer: Acute appendicitis
Right iliac fossa pain with rebound tenderness, guarding, fever, and raised inflammatory markers is classic for acute appendicitis. This requires urgent surgical assessment and likely appendicectomy. The Alvarado score can aid clinical assessment.
Question 2: A 70-year-old woman presents with sudden-onset severe abdominal pain, bloody diarrhoea, and abdominal distension. She has a history of atrial fibrillation. What is the most likely diagnosis?
- Diverticulitis
- Acute mesenteric ischaemia (Correct answer)
- Gastroenteritis
- Sigmoid volvulus
Correct answer: Acute mesenteric ischaemia
Sudden severe abdominal pain with bloody stools in a patient with AF strongly suggests acute mesenteric ischaemia due to arterial embolism. AF is a major risk factor. This is a surgical emergency with high mortality if not treated promptly with CT angiography and possible surgical or interventional management.
Question 3: According to ATLS principles, what is the correct sequence of the primary survey?
- Breathing, Airway, Circulation, Disability, Exposure
- Airway with cervical spine protection, Breathing, Circulation, Disability, Exposure (ABCDE) (Correct answer)
- Circulation, Airway, Breathing, Disability, Exposure
- Exposure, Disability, Circulation, Breathing, Airway
Correct answer: Airway with cervical spine protection, Breathing, Circulation, Disability, Exposure (ABCDE)
The ATLS primary survey follows the ABCDE approach: Airway (with cervical spine protection), Breathing, Circulation (with haemorrhage control), Disability (neurological status), and Exposure (fully expose the patient while preventing hypothermia).
Question 4: A 45-year-old woman presents with a 6-hour history of severe colicky right upper quadrant pain radiating to the right shoulder tip, nausea, and vomiting. She is febrile at 38.5°C. Murphy's sign is positive. What is the most likely diagnosis?
- Biliary colic
- Acute cholecystitis (Correct answer)
- Acute pancreatitis
- Hepatitis
Correct answer: Acute cholecystitis
RUQ pain with fever and a positive Murphy's sign (inspiratory arrest on palpation of the RUQ) is diagnostic of acute cholecystitis. Biliary colic alone does not cause fever or Murphy's sign. Management includes IV antibiotics and cholecystectomy (ideally within 72 hours per NICE guidelines).
Question 5: A patient arrives in A&E after a road traffic collision. They are hypotensive (BP 80/50), tachycardic (HR 130), with a distended abdomen. What class of haemorrhagic shock does this represent according to ATLS?
- Class I (up to 15% blood loss)
- Class II (15-30% blood loss)
- Class III (30-40% blood loss) (Correct answer)
- Class IV (>40% blood loss)
Correct answer: Class III (30-40% blood loss)
Class III haemorrhagic shock (30-40% blood loss) presents with tachycardia >120, hypotension, tachypnoea, altered mental status, and decreased urine output. Class IV would show more profound hypotension and altered consciousness. Immediate fluid resuscitation and blood products are needed.
Question 6: A 60-year-old man with a history of heavy alcohol use presents with severe epigastric pain radiating to the back, vomiting, and a serum amylase of 1,200 U/L (normal <100). What is the most appropriate initial management?
- Emergency laparotomy
- IV fluids, nil by mouth, analgesia, and monitoring using the Glasgow-Imrie score (Correct answer)
- Oral antibiotics and discharge
- ERCP within 2 hours
Correct answer: IV fluids, nil by mouth, analgesia, and monitoring using the Glasgow-Imrie score
Acute pancreatitis management follows conservative principles: aggressive IV fluid resuscitation, nil by mouth, effective analgesia (avoiding morphine if possible), and severity scoring (Glasgow-Imrie or APACHE II). ERCP is indicated only for gallstone pancreatitis with cholangitis or persistent biliary obstruction.
PLAB 1 Surgery and Emergencies
A 25-year-old man presents to A&E with sudden-onset right iliac fossa pain.
On examination, he has rebound tenderness and guarding.
His temperature is 38.2°C.
Blood tests show WCC 15 x10^9/L and CRP 85 mg/L.
What is the most likely diagnosis?