2013

Question 1

1. What structure do you see in this CXR?
2. What is the complication on this CXR?

Answer 1

1. Central venous catheter
2. Pneumothorax

Question 2

1. What is the name of this endoscopic finding?
2. Mention 2 treatment options for this condition:
3. Explain the pathophysiology of this condition.

Answer 2

1. Esophageal varices
2. • Pharmacologic therapy: vasopressin infusion, beta blockers.
   • Endoscopy (banding, sclerotherapy)
3. Bleeding from formation of oesophageal varices from backup of portal pressure via the coronary vein to the submucosal oesophageal venous plexuses secondary to portal hypertension from liver cirrhosis. (Surgical Recall p.271)

Question 3

1. What is the most likely diagnosis of this lesion?
2. What is the next step?
3. Mention 4 risk factors other than age and gender.

Answer 3

1. Bladder Cancer
2. Biopsy
3. Smoking / Industrial carcinogens / Schistosomiasis / Cyclophosphamide

Question 4

1. What is the name of the device?
2. What is the age range for using this
3. What would you do if not Pavlik?

Answer 4

1. Pavlik Harness
2. Up to six months of age
3. Spica cast

Question 5

1. What is the name of the device?
2. Mention the indications for using this device?
3. What are the possible complications?

Answer 5

1. External fixator
2. • Severe open fracture (IIIB)
   • Fractures with severe contamination
   • Infected non-unions
   • Initial stabilization of soft tissue and bony disruption in polytrauma patient
   • Pelvic fractures
   • Unstable knee, elbow, and ankle dislocation
3. • Pin track infection/breakage
   • Re-fracture
   • Delayed union
   • Soft tissue damage

Question 6

ortho: If severe pain what do you do (I think they meant compartment syndrome)?

Answer 6

• Remove any tight bandage or cast
• Fasciotomy

Question 7

This is a 63-year-old woman with a 3- week history of a breast mass that is not responding to antibiotics.

1. List two abnormal findings.
2. List two investigations that you would order to help establish the diagnosis.
3. What is the most likely diagnosis?

Answer 7

1. • Ulceration and necrosis/destruction of the nipple-areola complex * Skin erythema and dimpling (Peau d’oragne)
2. • Mammography
   • Skin punch biopsy
3. Inflammatory breast carcinoma

Question 8

A 30-year-old male presented with scrotal swelling and history of infertility.
1. Describe the physical finding.
2. What is the operation done for treatment of this condition?

Answer 8

1. Bag of worms
2. Varicocelectomy

Question 9

A 24-year-old patient presented with painless scrotal swelling.
1. What is the diagnosis?
2. Mention two causes.

Answer 9

1. Hydrocele
2. • Patent processus vaginalis
   • Testicular tumor
   • Infection
   • Trauma

Question 10

The previous patient has undergone surgery. The figure shows an intra-operative picture.
1. What is the lining at the tip of the arrow?
2. Mention the two most common complications of this operation.

Answer 10

1. Tunica Vaginalis
2. Hematoma / Infection

Question 11

A 53-year-old man presented to the ER with severe colicky abdominal pain, nausea, and vomiting.
1. List two abnormal findings on the X-ray.
2. What is the diagnosis?
3. Mention two causes of this condition.
4. How would you manage this patient in the ER?

Answer 11

1. • Dilated bowel loops with prominent plica circularis (valvulae conniventes)
   • Multiple air fluid levels
   • Paucity of colorectal gas
2. Small bowel obstruction
3. • Post-surgical adhesions
   • Incarcerated hernia
4. • NPO
   • IV fluid and electrolyte resuscitation
   • NGT insertion for gastric decompression
   • Foley’s catheter insertion to monitor urine output (fluid status)

Question 12

This patient presented with swelling of her left leg after surgery.
1. List the two most probable differential diagnoses.
2. What is the initial investigation that should be done in this case?

Answer 12

1. Deep vein thrombosis / Cellulitis
2. Compression Ultrasonography

Question 13

This view was obtained during a laparoscopic cholecystectomy.
Name the structure A
Name the structure B

Answer 13

A) Cystic duct
B) Cystic artery

Question 14

A 15-year-old girl presented to the casualty with right iliac fossa pain. The figure shows an intraoperative picture of an organ removed during surgery.

1. What is the pathophysiology of this condition?
2. Mention four differential diagnoses.

Answer 14

1. Obstruction of the appendiceal lumen (most likely by lymphoid hyperplasia, fecalith, … etc.) with resultant increase in intraluminal pressure, infection, and inflammation of the appendiceal surface (initially visceral followed by parietal peritoneum involvement).
2. • Meckel’s diverticulitis
   • Crohn’s disease
   • Mesenteric lymphadenitis
   • Cecal volvulus
   • Gynecologic differentials e.g. tubo-ovarian abscess / pelvic inflammatory disease / ovarian cyst / Mittelschmerz
   • Testicular torsion in male patients

Question 15

1. Name the device shown in the figure.
2. Mention two operations in which
   it is commonly used.

Answer 15

1. Negative pressure (closed suction) drainage device
2. • Thyroidectomy
   • Abdominoplasty
   • Gastric sleeve/gastrectomy

Question 16

1. Name the device shown in the figure.
2. What is it used for?

Answer 16

1. Incentive spirometer
2. To prevent post-operative pulmonary complications e.g. atelectasis and pneumonia that could result from splinting

Question 17

1. What is the operation shown in the figure?
2. Mention two specific complications to this operation other than bleeding and infection.

Answer 17

1. Lichtenstein open (tension-free) mesh hernia repair
2. • Recurrence
   • Numbness/chronic pain in the areas innervated by ilioinguinal, iliohypogastric, or genital branch of genitofemoral nerves
   • Injury to vas deferens leading to impaired fertility
   • Ischemic orchitis/testicular atrophy (rare)

Question 18

This plain KUB was obtained from a 50-year- old man who presented with left loin pain and fever.
1. What is the diagnosis?

Answer 18

Struvite/staghorn stone [obstructive uropathy] complicated by pyelonephritis

Question 19

This figure shows a testicular mass that was excised from a 30-year-old patient.
1. What is the most likely diagnosis?

2. What is the treatment?

Answer 19

1. Testicular Seminoma
2. Radical inguinal orchiectomy ± adjuvant chemotherapy and radiotherapy if stage II/III

Question 20

This figure shows the kidney of a 30-year-old man.
1. What is the complete name of this disorder?

2. What is the mode of inheritance?

Answer 20

1. Adult Polycystic Kidney Disease
2. Autosomal dominant

Question 21

A 50-year-old patient presented with left flank pain. A CT scan was performed.
1. Describe the lesion shown in the figure.

2. Mention two methods of management if the patient has solitary kidney.

Answer 21

1. Well-defined round heterogeneous hypodense lesion with rim enhancement located in the upper lobe of the left kidney.
2. • Surgical excision (partial nephrectomy)
   • Radiofrequency ablation
     *This is most likely a malignant complex renal cyst (renal cell carcinoma)

Question 22

A 63-year-old man presented with neck swelling.

1. Mention two differential diagnoses.
2. Mention two investigations to help establish the diagnosis.

Answer 22

1. • Parotitis
     * Polymorphic Adenoma/Adenoid Cystic Carcinoma
     * Cervical lymphadenopathy
2. • Ultrasound/CT scan
   • Fine needle aspiration cytology (FNAC)
     Which structure is at risk of injury during
     operation?
3. Facial nerve

Question 23

A patient with a previous history of knee arthroplasty (prosthesis) presented with painful knee swelling.
1. Mention four initial investigations.

2. What is the gold standard diagnostic test?
3. Mention two ways to manage this patient

Answer 23

1. • Complete blood count
     * Inflammatory markers (ESR, CRP)
     * Two sets of blood cultures
     * X-ray of the affected joint
2. Knee joint synovial fluid aspiration and analysis
3. • IV antibiotics
   • Emergent open or arthroscopic joint arthrotomy for decompression, debridement, and irrigation.
   • Removal of the prosthetic device

Question 24

1. What is the diagnosis? [2 marks]
2. What is the initial management?
3. What is the appropriate time for definitive management?

Answer 24

1. Trimalleolar ankle fracture (fracture of medial, lateral, and posterior malleoli) with skin blister.
2. • Closed reduction and stabilization with ankle-foot splint
   • Delayed external fixation until soft tissue swelling and skin condition resolve
   • Pain control and monitoring for possible compartment syndrome
3. • When the skin condition subsides (usually after 1-2 weeks)

Question 25

A 4-year-old girl presented with painless limping.
1. List four abnormal findings on the X-ray
2. What are the treatment options for this patient?
3. Which gait she will likely present with?

Answer 25

1. • Small left femoral head
     * Shallow/dysplastic left acetabulum
     * Left femoral head located in the upper outer quadrant
     * Broken Shenton line
2. Open reduction and pelvic osteotomy
3. Trendelenburg gait

Question 26

The figure shows post-trauma pelvic X-ray in a 35-year-old patient.
1. What was the direction of force in this injury according to Young & Burgess classification?
2. What is the diagnosis?

Answer 26

1. Antero-posterior force
2. Open book fracture

Question 27

A 25-year-old male was involved in a road traffic accident. He has sustained a pelvic fracture.
1. Mention six initial steps in the management.

Answer 27

• Conduct ATLS protocol to check for other serious
  injuries and identify the source of bleeding.
• Resuscitate with fluids and blood as needed.
• Initiate prophylactic IV antibiotics for 72 hours and tetanus booster.
• Apply a pelvic wrap if unstable pelvic fracture.
• Perform DPL or FAST to look for hemoperitoneum
  if bleeding is not controlled.
• If positiveperform a laparotomy
• If negative but he is still hemodynamically unstableperform angio-embolization
• Apply external fixator until definitive management

Question 28

This is an ERCP film of a 35-year-old patient.

1. List two abnormal findings.
2. List two symptoms this patient might present with.
3. List three potential complications specific for this procedure.

Answer 28

1. • Dilation of the common bile duct
     * Multiple filling defects within the common bile duct, most likely stones
2. • Right upper quadrant pain
   • Dark urine, pale stools, scleral icterus [jaundice]
3. • Pancreatitis
   • Infection [ascending cholangitis]
   • Bleeding
   • Perforation

Question 29

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

Answer 29

1. Incentive Spirometry
2. To prevent post op respiratory complications e.g. atelectasis

Question 30

What is this tool?

Answer 30

Clip/Staple remover

Question 31

1. What’s this device called?
2. Mention two surgeries where its commonly used?

Answer 31

1. Closed suction drainage device
2. ◦ Thyroidectomy
   ◦ Abdominoplasty
   ◦ Ruptured appendix

Question 32

1. What is this instrument?
2. When do we use it?
3. Mention a complication?

Answer 32

1. Sengastaken-Blackmore tube
2. In cases of variceal bleeding not responding to endoscopic therapy
3. Mucosal ulceration and necrosis, Esophageal perforation.

Question 33

A 40 year old male didn’t feel the ulcer until he smelled it.
1. What’s the diagnosis?
2. What your management plan?

Answer 33

1. Neuropathic ulcer (didn’t feel it is key also the location of the ulcer aids in diagnosis)
2. -

Question 34

This is an 80 year old female who is immobile in bed after suffering a stroke.
1. What’s your diagnosis?
2. What’s your management plan?

Answer 34

1. Pressure ulcer
2. ◦ * treat underlying medical issues including nutrition
   ◦ * continue with preventative measures (pressure relief, assess for pressure points e.g. wheelchairs, manage continence issues, divert contaminants e.g. urine and feces)
   ◦ * wound debridement, moisture retentive or antimicrobial dressing, regular reassessment
   ◦ * systemic antibiotics for infections
   ◦ * assess for possible reconstruction

Question 35

1. What’s the diagnosis?
2. What’s the most likely etiology?
3. How would you manage

Answer 35

1. Carbuncle
2. Staphylococcus aureus
3. ◦ Incise and drain large lesions to relieve pressure and pain
   ◦ If afebrile: hot wet packs, topical antibiotic
   ◦ If febrile/cellulitis: culture blood and aspirate pustules (Gram stain and C&S) Cloxacillin for 1-2 wk

Question 36

1. What’s the most likely diagnosis.
2. What’s the treatment.

Answer 36

1. Sebaceous cyst
2. Excision

Question 37

A 20 year old female complaining of a mass in her anterior neck
1. Give two differentials.
2. Mention two investigations you would like to do to get the diagnosis.

Answer 37

1. Thyroglossal duct cyst
   Lipoma
2. Ultrasound
   Fine needle aspiration

Question 38

A 37 year old male went for surgery, he had epigastric pain. This was noticed in the surgery.
1. What is the diagnosis?
2. What is a classic finding on physical exam?
3. What other procedure should be done during the surgery?

Answer 38

1. Perforated duodenal ulcer
2. Rigidity
3. Abdominal irrigation omental patch

Question 39

A 40 year old male with epigastric pain.
1. What’s the diagnosis
2. How would you treat

Answer 39

1. Perforated “duodenal” ulcer (duodenal because it’s the most common cause it is hard to say duodenal based on imaging alone; im not sure if they want you to specify gastric or duodenal
2. ◦ Aggressive fluid resuscitation, IV antibiotics, exploratory laparotomy
   ◦ Duodenal ulcer perforation treatment graham patch
   ◦ If gastric ulcer perforation patching if patient unstable. If stable partial gastrectomy/wedge resection and must take multiple biopsies if gastric ulcer perforation to exclude malignancy

Question 40

his lady has an anal condition.
1. What’s the diagnosis?
2. Mention one way of treating it.

Answer 40

1. Anal fistula
2. fistulotomy

Question 41

1. What is this procedure.
2. Mention two complications.

Answer 41

1. Ileostomy
2. Infection, stenosis, parastomal herniation, skin irritation, necrosis

◦ The picture we had was up close similar to this one you have to be able to tell the difference from colostomies using other methods other than location (LLQ vs RLQ)

Question 42

A 27 year old female with watery diarrhea
1. Describe the findings
2. What’s the likely diagnosis

Answer 42

1. Creeping fat, thickened bowel wall
2. Crohn’s disease

◦ Note we had a different pic in the exam but the scenario would make it easy for you to recognize crohns

Question 43

30 year old lactating mother presented as shown
1. What’s the diagnosis?
2. How do you manage?

Answer 43

1. Breast abscess
2. Discontinue nursing, IV antibiotics (nafcillin/oxacillin), I&D usually required
   ◦ Note some resources say continue breastfeeding and I’m not sure what is practiced in Kuwait.

Question 44

A 45 year old female was diagnosed with breast cancer and this procedure was done during surgery
◦ What is this procedure called?

Answer 44

Sentinel lymph node biopsy

Question 45

We seriously had this picture with 4 questions and no scenariobut the good news its straight from Dr. Saad’s lecture on Kidney tumors just memorize it well his questions are from his lecture you just need to study it really well
1. Describe the image
2. What’s your diagnosis
3. How would you investigate. Mention two investigations you would order
4. How would you manage

Answer 45

All answers from Dr. Saad’s lecture

Question 46

A 80 year old female had an MRI
1. Describe the this image
2. What’s your diagnosis
3. How would you treat?
4. Mention two ways to treat if the patient had a single kidney?

Answer 46

1. -
2. Renal cell carcinoma
4. Partial nephrectomy Radiofrequency ablation Cryotherapy
   (from his lecture)

Question 47

◦ This eloop was all about scrotal pathology
◦ We had a scenario which describes testicular torsion then we were asked about differentials. Its better to give differentials that cause “painful” scrotal swelling to be exact
◦ They asked for 4 clinical findings in testicular torsion
◦ The second case was testicular cancer (painless scrotal swelling in a young male for a long time). Questions were about treatment and risk factors (from Dr. Saad’s lecture memorize them)

Question 48

A 10 year old boy fell off his scoter.
1. What’s the fracture called.
2. Describe the fracture.
3. How would you manage.

Answer 48

?

Question 49

◦ What is this test called.
◦ Describe it in detail.
◦ What are structures injured?

Answer 49

-

Question 50

◦ A 20 year old lady fell of a horse.
◦ What’s the diagnosis.
◦ Mention three anatomical structures at risk
◦ How would you manage.

Answer 50

-

Question 51

◦ A 27 year old had a car accident.
◦ What’s the diagnosis
◦ How would his lower limb be positioned

Answer 51

-

Question 52

Describe
◦ Mention two possible primary sources

Answer 52

This is straight from the MSD lecture on bone tumors by dr. Fathy
◦ Here what he said about this picture “two sites give osteosclerotic lesions breast and prostate”
◦ Ortho needs tafreegh and I wish I had known this earlier, you are aware now and I hope you get a better outcome than I did
◦ Best of luck

Question 53

A 42 year old male presents with hematemesis.
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 53

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

Question 54

A patient with a previous history of knee arthroplasty (prosthesis) presented with painful knee swelling
1. Mention four initial investigations
2. What is the gold standard diagnostic test?
3. Mention two ways to manage this patient

Answer 54

1. • Complete blood count
   • Inflammatory markers (ESR, CRP)
   • Two sets of blood cultures
   • X-ray of the affected joint
2. Knee joint synovial fluid aspiration and analysis
3. • IV antibiotics
   • Emergent open or arthroscopic joint arthrotomy for
     decopression, debridement, and irrigation
   • Remove prosthetic device

Question 55

1. Name this device
2. Indications

Answer 55

1. Gastrostomy tube
2. irrigations \Feeding

Question 56

1. What is this instrument?
2. When do we use it?

Answer 56

1. Sengastaken-Blackmore tube
2. In cases of variceal bleeding not responding to endoscopic therapy

Question 57

1. Name this instrument
2. Mention two indications:

Answer 57

1. Nasogastric tube
2. Feeding
   Upper GI bleeding

Question 58

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

Answer 58

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 59

A 61 year old female developed this complication after a surgical procedure
1. What is the finding?
2. What is the pathophysiology of this presentation?

Answer 59

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 60

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

Answer 60

1. intermittent pneumatic compression device
2. To prevent or reduce the risk of lymphedema and deep venous thrombosis

Question 61

This finding is in a lactating female
1. What is the diagnosis?
2. How will you manage?

Answer 61

1. Breast abscess
2. • Incision and drainage
   • Give antibiotics

Question 62

1. What is your diagnosis?
2. List 4 complications

Answer 62

1. Gallstones causing biliary colic
2. • acute cholecystitis
   • Choledocholithiasis
   • Biliary pancreatitis
   • Gallstonee ileus

Question 63

1. What is the diagnosis?
2. how would you treat this patient?

Answer 63

1. Perianal abscess
2. Incision and drainage and antibiotics

Question 64

Patient with perianal discharge with no pain
1. Diagnosis?
2. Treatment?

Answer 64

1. Perianal fistula
2. Placing a soft seton permits resolution of surronding inflammation + Fistulotomy

Question 65

Patient presenting with this finding in the natal cleft
1. What is the diagnosis?
2. Treatment:

Answer 65

1. Pilonodal sinus
2. remove the tract with
   the hair that is trapped inside

Question 66

1. What is the diagnosis
2. Mention two complications?

Answer 66

1. Diverticulosis
2. • Diverticulitis
   • Perforation and peritonitis

Question 67

1. Name the signs
2. Mention two causes:

Answer 67

1. image
2. • Hemorrhagic pancreatitis
     * Trauma

Question 68

Patient presented with severe abdominal distention, constipation, and vomiting
1. What is your diagnosis?
2. How will you manage?

Answer 68

1. Bowel obstruction caused by inguinal hernia
2. IV fluids , NPO, Foleys NG Tube
   Hernia repair

Question 69

1. What is this?
2. Why is it used?

Answer 69

1. Mesh for hernia repair
2. As reinforcement of posterior wall after reducing a hernia and decrease the risk or recurrence

Question 70

1. What is the diagnosis
2. What is the management?

Answer 70

1. Intussusception
2. Manual reduction followed by segmental resection and primary anastomosis

Question 71

1. Describe the finding
2. During surgery what else should be done after resection of this testis?

Answer 71

1. Torsion with necrotic testis
2. Orchidopexy of the other testis

Question 72

This is a mass found in a testicle
1. What is the most likely diagnosis?
2. What is the treatment?

Answer 72

1. Testicular cancer (seminoma)
2. Radical orchiectomy +/- adjuvant chemotherapy and radiotherapy

Question 73

1. What is the complete name of this conditon?
2. What is the mode of inheritence?

Answer 73

1. Adult polycystic kidney disease
2. Autosomal dominant

Question 74

This plain KUB was obtained from a 50 years old male presenting with loin pain and fever
1. What is you diagnosis?

Answer 74

1. Struvite stone causing pyelonephritis

Question 75

A 70 yr old male with this uroflowmetry results
1. Mention 4 voiding symptoms this patient has
2. What tests will u order other than CBC, RFT, and urodynamics?
3. Name two drug classes used to relieve the symptoms in this patient (use generic names)
4. Name two surgical options to treat this patient

Answer 75

1. Weak stream
   Intermittency
   Hesitancy
   Straining to void
2. PSA
   Transrectal ultrasound with biopsy Transabdominal ultrasound
3. alpha aderenergic antagonist e.g. alfuzosin
   5 alpha reductase inhibitors e.g. finesteride
4. Transuretheal resection of the prostate Open prostatectomy

Question 76

a 40 year old lady who jumped from the second floor to the ground. She now presented with severe back pain and bilateral leg weakness.
1. What is the finding
2. What investigation u will do
3. What is the mangement

Answer 76

1. Wedge compression fracture in L3
2. CT scan and MRI
3. Urgent sugical decompression of the spinal cord

Question 77

1. What is the diagnosis?
2. What is the immediate management?

Answer 77

1. dislocation of the right glenohumeral joint [shoulder joint] most likely an anterior dislocation
2. Closed reduction and immoblization with a sling

Question 78

1. Name two structures at risk?
2. How will you initially manage this patient?

Answer 78

1. Brachial artery Radial nerve
2. Closed reduction and arm
   sling (not sure)

Question 79

What’s the name of the test being performed
and explain how it is done

Answer 79

Question 80

70 years old patient presented with shoulder
stifness
1. Mention two radiological findings?
2. How will you manage at this stage?

Answer 80

1. • Loss of joint space
     * Subchondral sclerosis * Osteophyte formation
2. Joint replacement (not sure)