2011

Question 1

A 36 year old man presents with pain on defecation and bleeding.
1. What is the diagnosis?
2. Mention two treatment options for this condition

Answer 1

1. Anal fissure
2. Conservative: stool softeners, sitz baths and bulking agents
   Medical: topical nitroglycerin or nifedipine Surgical: lateral internal sphincterotomy

Question 2

A 58 year old female presents with this breast lesion.
1. Name two findings
2. What is the diagnosis?
3. How could the diagnosis be confirmed?

Answer 2

1. Peau d’orange
   Skin necrosis and ulceration
2. Inflammatory breast cancer
3. By skin punch biopsy: reveals invasion of dermal lymphatics by malignant cells

Question 3

A 43 year old male presents with hematemsis. Upper endoscopy was performed and is shown below.
1. What is the diagnosis?
2. Mention four options that can be used in the management of this patient

Answer 3

1. Bleeding peptic ulcer
2. • Intravenous PPI infusion
   • Therapeutic endoscopy using clips
   • Therapeutic endoscopy using thermal coagulation with or without epinephrine injection
   • Suture ligation of the bleeding ulcer

Question 4

The nurse notices this finding in a 48 year old patient in the surgical ward.
1. What is the diagnosis?
2. Mention two treatment options

Answer 4

1. IV site infection (superficial thrombophlebitis)
2. Stop the infusion and remove the cannula Elevate the affected limb
   Administer analgesics

Question 5

Name the finding in A

Name the finding in B

Answer 5

A. Hypertrophic scar
B. Keloid scar

Question 6

This finding was noticed in a 64 year old lady which has been admitted to the ward long time ago.
1. Name the finding
2. How should this lesion be treated?

Answer 6

1. Pressure (bed) sore (ulcer)
2. • Minimize pressure by repositioning the patient
   • Wound debridement, irrigation and dressing
   • Topical antibiotics
   • Surgical reconstruction of the ulcer

Question 7

1. Name this device
2. What is it used for?

Answer 7

1. Incentive spirometer
2. To prevent postoperative pulmonary
   complications including atelectasis and pneumonia

Question 8

1. Name this device
2. What is it used for?

Answer 8

1. Intermittent pneumatic compression
   device
   To prevent or reduce the risk of
   lymphedema and deep vein thrombosis

Question 9

A 37 year old female presents with left leg pain after her surgery.
1. Name two differential diagnoses
2. How would this condition be investigated?

Answer 9

1. Deep vein thrombosis / Cellulitis
2. Compression US / D-dimers / Coagulation profile

Question 10

This view was attained during a cholecystectomy.
1. Name the structure pointed at by the red arrow
2. Name the structure pointed at by the
blue arrow

Answer 10

1. Cystic artery
2. Cystic duct

Question 11

A 52 year old man presents to the casualty with severe abdominal pain, diffuse tenderness, tachycardia and fever. At the operating theatre, the surgeon found the bowel as shown below.
1. What is the underlying pathophysiology?
2. Mention two causes that can lead to this
complicatIon

Answer 11

1. The bowel suffered a vascular compromise
   (strangulation) with subsequent gangrenous necrosis
2. • Small bowel obstruction due to incarcerated hernia or postoperative adhesions
   • Thromboembolic phenomena leading to mesenteric ischemia as in atrial fibrillation

Question 12

1. What is the diagnosis?
2. How could this lesion be treated?

Answer 12

1. Sebaceous (pilar or epidermoid) cyst
2. • Surgical excision
   • If it gets infected, incision and drainage are performed

Question 13

A 61 year old female developed this complication after a modified radical mastectomy to treat her breast cancer.
1. What is the diagnosis?
2. What is the pathophysiology underlying this complication?

Answer 13

1. Arm lymphedema
2. Lymph node dissection leads to disruption of the lymphatic system and hence, decreased lymphatic drainage of the upper arm resulting in accumulation of lymph

Question 14

1. A 32 year old female who presents as a case of ruptured ectopic pregnancy was found to have a HR of 117 beats/min, a BP of 93/69 mmHg and a Hb of 6.5 mg/dL.
2. A elderly male who was taken back to the ward after undergoing a cholecystectomy.
3. A patient was found dehydrated in the ward. His stoma had a high output.
4. A male patient who underwent an abdominal surgery the day before didn’t have any bowel motions so far. On examination, bowel sounds were absent, and abdomen was tympanic on
   percussion.

Answer 14

1. Packed red blood cells
2. Ringer’s lactate
3. 0.9% sodium chloride [high stomal output is likely to result in dehydration, and sodium and magnesium depletion. Intravenous normal saline should be given to reduce stomal output and correct the dehydration.]
4. 5% dextrose in normal saline and KCL [The scenario describes a case of paralytic ileus, commonly occurring postoperatively likley due to hypokalemia; KCL should be administered.]

Question 15

A 43 year old woman presents a history of right Flank pain.
1. What is the finding detected on imaging?
2. What is the imaging modality used?
3. Name two causes of the finding in this
woman
4. Name the available treatment options for this patient’s condition
5. If the same patient presents with fever, hypotension and nausea and vomiting,
name two treatment options would be used in this case

Answer 15

1. A right upper ureteic stone lateral to the transverse process of L3 vertebra with mild hydronephrosis
2. Plain coronal reconstruction CT scan
3. • Hyperparathyroidism
   • Hypercalciuria
   • Inflammatory bowel disease (Crohn’s)
   • Hyperuricemia
4. • External shockwave lithotripsy
   • Ureteroscopy and stone extraction
   • Uretreoscopy and stone fragmentation with laser
   • Open ureterolithotomy
5. • Insertion of a double J stent
   • Percutaneous nephrostomy

Question 16

A 63 year old male presents with history of abdominal pain and hematuria.
1. What is the finding detected in this patient’s CT?
2. What is the likely diagnosis?
3. Mention three risk factors for this condition
4. What further investigations would be ordered for this patient?
5. Name two systemic manifestaions of this disease
6. Mention two treatment options available for this patient

Answer 16

1. A large right renal mass with heterogenous enhancement
2. Renal cell carcinoma
3. • Smoking
   • Cadmium exposure
   • Leather industry
   • Von Hippel-Lindau syndrome
4. • Urinalysis for hematuria
   • Renal ultrasound
   • CBC, ESR, LFTs for paraneoplastic syndromes
   • Metastatic workup: CT scan of chest, abdomen, and pelvis; liver ultrasound & LFTs; bone scan
5. • Anemia, polycythemia, raised ESR
   • Hyperclacemia
   • Hypertension
   • Stauffer’s syndrome (hepatic cell dysfunction)
   • Peripheral edema
6. • Radical nephrectomy
   • Targeted therapy: anti-VEGF, anti-tyrosine kinase, anti-IL2

Question 17

A 25 year old male was brought to the casualty after having a motorcycle accident. He had an open tibial fracture, and vascular injury was found and repaired thereafter.
1. According to the Gustillo-Anderson
classification for open fractures, where does this fracture stand?
2. What is the most important step in the
management of this fracture in the ER?

Answer 17

1. Grade IIIC
2. Administration of intravenous antibiotics for 72 hours

Question 18

A 4 year old child is brought by his parents with a complaint of painless limping. Shown is his pelvic x-ray.
1. Mention two findings in this x-ray
2. What is the diagnosis?
3. How can this condition be treated in
this child?

Answer 18

1. Broken right shenton line
   Right femoral head is is in the upper outer quadrant
   Acetabular dysplasia
2. Developmental dysplasia of the hip
3. Open reduction with pelvic osteotomy

Question 19

A 26 year old man who is a known case of ankylosing spondylitis fell off a ladder. He immediately experienced severe back pain. Shown is imaging of his back.
1. Which imaging modality is this?
2. What the diagnosis?
3. What is the feared complication?

Answer 19

1. CT scan
2. T3-T4 vertebral dislocation
3. Spinal cord injury (complete cord transection)

Question 20

A 65 year old man has fallen on his shoulder. Shown is his shoulder x-ray.
1. What is the diagnosis?
2. What test is likely to be positive on physical examination?
3. What nerve is at risk of being injured?

Answer 20

1. Anterior shoulder dislocation
2. Apprehension test
3. Axillary nerve

Question 21

A 71 year old lady complains of knee pain that increases with activity and is relieved by rest. Her knee x-ray is shown.
1. What is the diagnosis?
2. Name three x-ray findings
3. What is the optimal treatment option at this age?

Answer 21

1. Right knee osteoarthritis
2. Asymmetrical joint space narrowing Osteophytes
   Subchondral sclerosis
3. Total knee replacement

Question 22

1. What nerve is injured in A?
2. What nerve is injured in B?

Answer 22

1. Ulnar nerve
2. Radial nerve

Question 23

Following a car accident, a 34 year old man was hospitalized immediately. He was found to have a tibial fracture which was fixated with an intramedullary nail. Few ours after the surgery, he develops severe pain out of proportion in his leg.
1. What is the diagnosis?
2. What is the treatment of this condition?

Answer 23

1. Compartment syndrome
2. Immediate fasciotomy of the involved compartment

Question 24

A 58 year old male presents to the casualty with severe colicky abdominal pain, nausea and vomitimg, and constipation of three days duration.
1. Describe two findings in this abdominal x-ray
2. What is the diagnosis?
3. Mention briefly how you would manage this patient in the emergency room

Answer 24

1. Multiple air fluid levels
   Dilated bowel loops with prominent pilcae circularis
2. Small bowel obstruction
3. NPO, fluid and electrolyte resuscitation, NG tube inseration and foley’s catheter insertion

Question 25

Few hours later, the same patient started to suffer from a more severe pain that is becoming continuous in nature. He was taken immediately to the operation theatre for an exploratory laparotomy.
What is the pathophysiology underlying this finding?

Answer 25

The obstructed bowel suffered a vascular compromise (strangulated) and underwent gangrenous necrosis

Question 26

A 43 year old male presents with the condition shown.
1. What is the diagnosis?
2. What is the the underlying pathophysiology?
3. What is the optimal treatment option?

Answer 26

1. Carbuncle
2. A skin and subcutaneous tissue infection involving multiple hair follicles with abscess formation
3. Saucerization of the carbuncle (excision of the whole infected and dead tissue leaving a large clean cavity)

Question 27

While doing an appendectomy, the surgeon encountered the shown finding in the ileum.
1. What is the abnormal structure shown?
2. What is the embrylogical origin of this structure?
3. Mention three complications of this abnormality

Answer 27

1. Meckel’s diverticulum
2. The vitelline duct (omphalomesenteric duct)
3. • Meckel’s diverticulitis
   • Small bowel obstruction
   • Lower GI bleeding
   • Intussusception

Question 28

1. What is the likely diagnosis?
2. Upon stabilizing the patient, what would be your next step?

Answer 28

1. Perforated duodenal ulcer
2. Ulcer pilcation and the use of omental (graham) patch

Question 29

A 71 year old male presents to the OPD with lower urinary tract symptoms and a diagnosis of BPH was established.
1. Mention four voiding symptoms this patient might have
2. Name two work up tests to be conducted for such patient other than CBC and RFT

Answer 29

1. Hesitancy
   Intermittency
   Weak stream
   Straining to urinate
   Sense of incomplete emptying
   Urinary retention
2. Serum PSA level
   Urinalysis
   Uroflowmetry

Question 30

A 23 year old male had a road traffic accident, fractured his lower limb and sustained the injury shown
1. According to the Gustillo-Anderson classification for open fractures, where does this fracture stand?
2. What is the shown device?
3. How would this wound be covered?

Answer 30

1. Grade IIIb
2. External fixator
3. By placement of a skin graft

Question 31

A 20 year old teenager fell on his shoulder while in a football match and sustained the injury shown.
1. What is the injury shown?
2. How can this injury be managed?

Answer 31

1. Mid-clavicular fracture
2. By Analgesia, checking the neurovascular status of the upper limb and immobilization by an arm sling for 4 to 6 weeks

Question 32

1. What is the abnormality shown?
2. Name one permanent complication of such lesion

Answer 32

1. Fracture of the left femoral neck
2. Avascular necrosis of the femoral head

Question 33

1. What is the name of this test?
2. What does it test for?

Answer 33

1. Gerber lift-off test
2. Internal rotation of the shoulder joint
   (subscapularis msucle tear)

Question 34

A 45 year old man has a history of neck pain that radiates to his left arm associated with a tingling sensation. He acutely presents with bilateral lower limb weakness and urinary incontinence.
1. What complication did this patient develop?
2. Identify the structures labeled A and B

Answer 34

1. Cervical myelopathy
2. A: spinal cord
   B: T1 vertebral body

Question 35

1. Is this lesion benign or malignant?
2. Provide two evidences that support your judgement

Answer 35

1. Benign
2. Well-defined lesion
   No periosteal reaction

Question 36

A 3 year old child is noticed by his parents to have painless limping. Shown is his pelvis x-ray.
1. What is the diagnosis?
2. How can this condition be managed in
this child?

Answer 36

1. Developmental dysplasia of the hip
2. Open reduction with pelvic osteotomy