2017

Question 1

A 60 year old female who is a smoker for the past 20 years presented to you with a history of intermittent abdominal pain and rectal bleeding, leukocytosis, and fever.
1. List two differential diagnosis
2. What is the imaging modality shown in the picture and what are the findings
3. List 4 complications that can result if this condition is not treated

Answer 1

1. diverticulitis/diverticulosis, ibd
2. barium enema– diffuse diverticula in colonic wall
3. hemorrhage, perforation, sepsis, fistula, obstruction

Question 2

57 year-old male presented with diffuse abdominal pain,
constipation, and weight loss.
1. Name the study shown in the image? What is shown?
2. What is the most likely diagnosis?
3. Mention 4 lab blood tests you would order?
4. Mention 2 non lab blood tests you would order?
5. What is the treatment of this condition?

Answer 2

1. Barium enema; Apple core sign
2. Colon cancer of the proximal transverse colon
3. CBC, LFT, RFT, tumor markers (CEA)
4. a. Colonoscopy, tissue biopsy
   b. CT abdomen and chest
5. Extended right hemicolectomy

Question 3

A patient with history of renal stone underwent a
surgical procedure:
1. What is the name of this device? What is the procedure?
2. Mention 2 complications of this procedure?

Answer 3

1. Nephrostomy tube; PCNL
2. Infection / Sepsis / Injury to adjacent organ

Question 4

Name the following lymph node groups:
1:
2:
3:
5:

Answer 4

1 : paracaval
2: precaval
3: interaortacaval
5: paraortic

Question 5

70 year old gentleman with painless gross hematuria
1. What is Diagnostic modality and describe what do you see?

2. What is the diagnosis?
3. Mention 2 treatment options.

Answer 5

1. CT urography with a hyperdense irregular mass protruding into the bladder lumen
2. Bladder cancer
3. a. TURBT with intravesical chemotherapy
   b. radical cystectomy with urinary diversion

Question 6

1. What is the diagnosis?
2. Which nerve is at risk?
3. What is the management?

Answer 6

1. Anterior shoulder dislocation
2. Axillary nerve
3. Closed reduction + sling

Question 7

14-month-old female presented to you
1. What is the diagnosis?
2. Describe 3 x-ray findings.
3. What is the management?

Answer 7

1. Developmental dysplasia of the hip
2. Broken Shelton line, femoral head in outer quadrant, small femoral head, shallow acetabulum
3. Closed reduction, check with hiparthrogram, spica cast

Question 8

You are asked to explain the situation to the physician over the phone.
*note: They gave us an x-ray in both AP and lateral views, and the picture provided here is different from the one given to us in the exam, so the answers don’t match exactly but you get the point..
1. Describe the x-ray (3 points).

2. What is the management?

Answer 8

1. Segmental fracture of tibia, oblique fracture of fibula with shortening, anterior translation of both tibia and fibula
2. Open reduction internal fixation

Question 9

45 yr old female, with past history of hysterectomy, presented with 2 days history of nausea, vomiting, and abdominal pain.

1. What is the investigation used?
2. What is the finding?
3. Mention 2 causes of the finding
4. Mention 2 initial management
5. If the conservative treatment fails, what will be done next?

Answer 9

1. CT with contrast
2. Small bowel obstruction
3. Adhesions/hernia
4. NPO, NGT, Foley’s, IV Fluids
5. Treatment of underlying cause so adhesiolysis for adhesions, hernia repair for hernia

Question 10

1. Name the elements used to make a cast?
2. Mention the order in which they are used to make a full cast?

Answer 10

1. A: cotton padding
   B: Plaster of paris bandage roll
   C: fabric stockinette/ tubular bandage
   D: Elastic bandage
2. C, A, B, D

Question 11

1. What’s the name of the device shown in the picture?
2. Give 4 indications to use it ?

Answer 11

1. External skeletal fixator
2. a. Severely contaminated fracture
   b. Pelvic fractures
   c. Infected fractures
   d. Initial management in polytrauma patient

Question 12

1. Name the instruments A,B,C:
2. Mention one indication fo reach:

Answer 12

1. A: two way latex foley catheter B: underwater seal chest drain C: central venous catheter
2. A: management of urinary retention
   B: pneumothorax
   C: monitoring of the central venous pressure

Question 13

1. Name each instrument?
2. Mention 1 indication for each?

Answer 13

1. A: closed suction drain
   B: Endotracheal tube
2. A: Prevent fluid collection after surgery
   B: secure a definitive airway, such as respiratory failure with facial fractures

Question 14

40 year old man presented with flank pain and hematuria

1. Which diagnostic modality is this?
2. What is the diagnosis?
3. What lab tests would help in the diagnosis?
4. What is the treatment?
5. What are complications of the treatment?

Answer 14

1. CT KUB
2. Renal calculi
3. Urinalysis, electrolytes, basic metabolic panel, uric acid test
4. PCNL
5. Bleeding, infection, adjacent organ injury, retained stone, renal dysfunction

Question 15

Q1 what is the device shown in the first picture? Mention one indication For it.

Q2: What is shown in the second picture? Mention one indication for it.

Answer 15

1. Sengastaken-blakemore tube.
   * Indication: rebleeding due to esophageal or gastric varices that does not respond to endoscopic therapy.
2. Percutaneous gastrostomy tube.
   * Indication: gastric feeding in the case of proximal GI pathology.

Question 16

This was found by the surgeon during laparoscopy
Q1: what is the diagnosis?

Q2: mention two complications if it was left untreated.

Answer 16

1. • Appendicitis.
2. • Rupture and peritonitis.
   • Appendicular mass.
   • Appendicular abscess.

Question 17

Q1: what is the diagnosis?

Q2: mention two possible complications if the condition is left untreated.

Answer 17

1. Diverticulosis.
2. • Massive painless lower GI bleeding.
   • Diverticulitis.
   • Perforation.
   • Large bowel obstruction.

Question 18

A male patient presented with severe abdominal pain, obstipation and Vomiting.
Q1: what is the diagnosis?

Q2: list four initial investigations that will aid in the diagnosis

Q3: what is the treatment?

Answer 18

1. SBO due to incarcerated (possibly strangulated) inguinal hernia.
2. • KUB erect x-rays: bowel dilatation and multiple air-fluid levels.
   • CT scan with contrast
   • US of abdomen
   • Electrolytes, lactic acid, etc..
3. Herniorrhaphy with possible resection of the strangulated bowel segment

Question 19

Female patient with a history resected sigmoid cancer.
Q1: describe the finding.

Q2: What tumor marker may help in the diagnosis?

Q3: what investigations will help in the diagnosis?

Q4: how can you reach a definitive diagnosis?

Answer 19

1. Multiple hypodense well- circumscribed lesions occupying both right and left liver lobes giving cannon-ball appearance suggestive of liver metastasis.
2. CEA (carcinoembryonic antigen).
3. • Colonoscopy/ sigmoidoscopy.
   • CT of abdomen and pelvis to check for metastasis.
   • Chest x-rays for lung metastasis.
   • CBC, LFTs, liver enzymes etc..
4. Colonoscopy with biopsy.

Question 20

Q1: mention three differential diagnoses.

Q2: mention three investigations before the surgery

Q3: What are the indications for surgery?

Q4: after the surgery, the patient developed difficulty breathing with Swollen neck. What is your next step?

Answer 20

1. • Thyroid nodule or malignancy * Thyroglossal duct cyst
     * Branchial cleft cyst
     * Lipoma
2. • CBC, LFTs, RFTs, coagulation profile for any surgical operation.
     * Thyroid function test , US and
     FNA for this case.
3. • Malignancy
     * Airway obstruction
     * Patient’s cosmetic concern
4. Surgical evacuation: open wound by removing sutures, evacuate the hematoma and look for bleeding source and coagulate the vessel , then put a closed suction drain.

Question 21

Q1: what is the diagnosis?

Q2: mention two treatment options for this condition

Answer 21

1. • Achalasia.
2. • Medical: calcium channel
     blockers.
   • Endoscopic :dilation of LES using
     pneumatic ballon. Injection of
     botulinum toxin.
   • Surgical: Division of the muscle
     at lower end of esophagus.

Question 22

Q1: what is this condition called?

Q2: mention two causes for it.

Answer 22

1. • Gynecomastia.
2. • Drug use (cimetidine, sprinolactone).
   • Cirrhosis.
   • Chronic renal insufficiency.
   • Cushing syndrome.
   • Kleinfilter syndrome.

Question 23

A patient suffered from a road traffic accident, his x-ray is shown below. The patient is hypotensive and is tachycardia.
They conducted FAST and it was negative.
Q1: describe the findings (three points)

Answer 23

• Disrupted shenton line.
• Pubic diastasis.
• Disrupted sacroiliac joint.

Question 24

Q1: What is the device shown?

Q2: Mention 2 other uses of this device (other
than the scenario)?

*there was a question about complications of this injury I think?

Answer 24

1. • External fixator.
2. • Pelvic fractures.
   • Unstable knee, elbow and ankle dislocation.
   • Infected nonunion.
   • Initial stabilization of soft tissue and bony
     disruption in polytrauma patient.

Question 25

Q1: What is the diagnosis?

Q2: What is the nerve at risk?

Q3: What is the management?

Answer 25

1. Anterior shoulder dislocation.
2. Axillary nerve.
3. Closed reduction + sling.

Question 26

14 months old patient came with painless limp.
Q1: what is the diagnosis?
Q2: what can you see in the X-Ray?
Q3: What is the management?

Answer 26

1. Developmental dysplasia of the hip.
2. Disrupted shenton line, acetabular dysplasia, dislocation of the femoral head (its in the upper outer quadrant), small femoral head.
3. Closed reduction, post reduction hip arthrogram, spica cast for 2-3 months.

Question 27

This was an unclear, new x-ray question. The x-ray was similar to this one.
There was a bilateral fracture in tibia and fibula, I think the fibula was spiral or oblique fracture and the tibia was comminuted, I don’t remember.
The question was: you’re in on-call and this patient came to you, how would you describe this x-ray to your consultant on the phone? They wanted 3 points.
-just briefly mention whatever you see on the x-ray.

Question 28

A young man presented with a hard scrotal mass. He underwent Orchidectomy.
Q1: Name two anatomical structures in the picture.

Q2: Where should the surgeon make the incision for this
Procedure?

Q3: What investigations will you order to confirm/stage the diagnosis?

Answer 28

1. -Testis.
   -Spermatic cord.
2. -Inguinal ligament.
3. -Ultrasound of testis.
   -CT scan.
   -Tumor markers: AFP, HCG, LDH.

Question 29

There was a video showing ureteric stone. The steps of removing the stone were shown, its just like the picture.
Q1: What is the procedure?

Q2: Mention three types of this
condition

Answer 29

1. Laser lithotripsy.
2. • Cysteine stone
   • Uric acid stone
   • Calcium oxalate stone

Question 30

There was a video showing urethral stricture.
Q1: What is the diagnosis?

Q2: What are the causes?

Answer 30

1. Urethral stricture.
2. • Recurrent infections.
   • Recurrent/prolonged instrumentations. (foley’s catheter).

Question 31

Q1: Mention 2 findings?

Q2: list two risk factors for this condition

Q3: Name two investigations will aid in staging the disease.

Q4: What 4 things would you do next?

Answer 31

1. • Fungating mass in the bladder wall. * Surrounding healthy mucosa.
2. • Smoking.
   • Schistosomiasis.
   • Chronic irritation.
   • Aromatic amines.
     3.
   • CT urography.
   • US.
   • Metastatic workup: CT chest, abdomen and pelvis.
     4.
   • Resect and stage by TURBT.
   • Urine cytology.
   • Metastatic work.
   • CT urogram.
   • Kidney ultrasound for hydronephrosis.

Question 32

1. List two abnormalities you can see?
2. What is your final diagnosis?

Answer 32

2. Subchondral Sclerosis
3. Osteophytes
4. Joint space Narrowing
   Note: In the exam, the doctor asked us to specify exactly at which level was the narrowing, and it was L4-L5 and L5-S1
5. Spine Osteoarthritis

Question 33

What are two findings?

Answer 33

1. Osteophytes
2. Joint space narrowing
   Note: The findings in the exam weren’t really clear, it seemed like a normal knee x-ray.

Question 34

1. What is this Study?
2. What is your diagnosis?
3. Mention 2 investigations you would order other than blood tests?
4. What is the treatment?

Answer 34

1. Barium Enema
2. Colon Cancer (apple core sign)
3. Colonoscopy and biopsy * CT scan
4. Extended Right Hemicolectomy ( because it was at the transverse colon)

Question 35

• This patient was undergoing an appendectomy, and this structure was found:
  1. Identify the structure?
  2. What is the origin of this structure?
  3. Mention two complications of this structure?
  4. What is the usual location of this structure?

Answer 35

1. Meckel’s Diverticulum
2. Vitelline Duct
3. • Small Bowel Obstruction
     * Intussusception
     * Bleeding
     * Meckel’s Diverticulitis
4. 2 feet from the ileocecal valve

Question 36

A female presented with Abdominal pain, obstipation, and vomiting. She has a previous history of hysterectomy.
1. What imaging technique is used?
2. What are the findings?
3. What are some common causes?
4. What is your initial management?

Answer 36

1. CT scan of the abdomen
2. Dilated small bowel loops with air fluid levels and prominent plicae circularis
3. Hernia and Adhesions
4. *Fluid replacement with IV fluids
   * NGT to decompress the bowels
   * Analgesia for pain
   * Anti-emetics

Question 37

Identify and give one indication:

Answer 37

Foley Catheter – Monitor Urine Output

Question 38

Identify and give one indication:

Answer 38

Underwater Seal Chest Drain System— Tension Pneumothorax ( for decompression)

Question 39

1. What is the finding?
2. How would you manage this patient?

Answer 39

1. Hyperlucency and loss of the lung markings of the right lung and mediastinal shift to the left – Tension Pneumothorax
2. Chest decompression with a large bore needle in the 2nd intercostal space midclavicular line, followed by chest tube placement.

Question 40

1. What do you see?
2. What is the pathology?
3. What are the complications of this procedure?

Answer 40

1. (there were many small arrows pointing to the stones in the gallbladder and there were no stones in the CBD)
   Gallbladder stones
2. (not sure) Gallstones/Acute cholecystitis/Biliary Colic
3. Acute pancreatitis
   Esophageal Injury
   Bleeding
   Allergic reaction to contrast

Question 41

1. Mention 3 differentials:
2. Indications for surgery?
3. Tests to do before surgery?
4. What investigation would you order if there was retrosternal extension of the mass?
5. If the patient underwent thyroidectomy, and post-op, she developed a mass and difficulty in breathing, what would you do immediately?
6. Post-OP, the patient couldn’t produce any high pitched sounds, what happened?

Answer 41

1. • Thyroid nodule
   • Multinodular goiter
   • Lipoma
   • Lymphoma
   • Thyroglossal cyst
     2.
   • Compressive symptoms
   • Thyroid cancer
   • Cosmetic Reasons
     3.
   • Thyroid Function Tests
     *Ultrasound
     4.
   • CT scan? (Not sure)
     5.
     Bedside Evacuation of Hematoma and ligate/coagulate bleeding vessels in the OR.
     6.
   • Injury of the External Branch of the Superior Laryngeal Nerve

Question 42

• A diabetic male didn’t feel the ulcer until he smelled it
  1. What are the abnormal findings?
  2. What is the pathophysiology?
  3. What 2 investigations would help in diagnosis other than blood tests?
  4. How to manage this patient?

Answer 42

1. • In the exam, there was a big toe amputation, and
     the ulcer was a lot bigger in the plantar surface of the foot
     * There was some granulation tissue and necrosis of the ulcer
2. • Because he’s diabetic, he has peripheral neuropathy,
     so he could not feel any ulcers that might develop on the plantar area * Healing is impaired in diabetics.
3. • Doppler ultrasound of lower limb vessels
   • Tissue swab and culture
4. • Serial extensive debridement of the necrotic tissue along with
     broad-spectrum antibiotics and offload pressure from the foot

Question 43

Identify and give 3 indications:

Answer 43

Cystoscope
Indications:
1- Management of Bladder Stone 2-Resection of Bladder tumor 3-Management of Bladder Contracture

Question 44

Q1: What’s the name of the device?
Q2: Mention 3 uses for it.

Answer 44

1. Flexible ureteroscopy
2. 1) Visualization of the ureter
   2) Retraction of ureteric stone
   3) Lithotripsy of renal stone

Question 45

• 45 year old male presents with symptoms of weak urinary stream and you performed this test.
• Q1: What’s the name of the test?
• Q2: Name the labelled components.
  a) Top Y-axis?
  b) Bottom Y-axis?
  c) Bottom X-axis?

Answer 45

1. Uroflowmetry
2. a) Urine volume
   * b) Urine flow rate
   * c) Time
   The pictures were reversed in the exam.

Question 46

1. Mention 3 tests you would order before the surgery other than CBC, RFT, and coagulation profile?
2. How would yould approach this surgically?

Answer 46

1. • LDH
     * B-HCG * AFP
2. Through the Inguinal Ligament

Question 47

1. What complication might the patient develop after the fracture?
2. After the surgery, would you let the patient fully bear weight?

Answer 47

1. • Fat embolism
     * Hemorrhage
2. Yes (not sure; but according to Dr. Ali Jaragh, whats the purpose of surgery if you wouldn’t let the patient walk after?)

Question 48

This patient had a car accident.
1. What is the diagnosis?
2. What is the presentation of the limb affected?
3. Mention 2 complications
4. Which nerve is affected?

Answer 48

1. Posterior Hip Dislocation
2. Hip Flexed, Adducted, and internally rotated
3. Hemorrhage
   Osteoarthritis (late)
4. Sciatic

Question 49

1. What’s the direction of force that caused the injury?
2. Name the abnormalities in the X-ray
3. What is a major complication of this injury?
4. What structures are at risk?
5. What is the treatment modality used for this patient?

Answer 49

1. Anterioposterior
2. • Pubic Diastasis
   • SI joint Disruption
3. Massive Bleeding
4. Urogenital organs
5. External Fixator

Question 50

1. What treatment modality is used for this patient?
2. What is the rationale of using such modality?

Answer 50

1. Skeletal Traction
2. • Maintaining bone alignment
   • Decrease muscle spasms

Question 51

• This patient presents with lower back pain but no bowel/urinary symptoms.
  1. Which level is affected?
  2. What symptoms might the patient present have other than pain?
  3. What is your initial management?
  4. If the patient presented with urinary and fecal incontinence, how would you manage?

Answer 51

1. L4-L5
2. • Bilateral lower limb weakness
   • Numbness and paresthesia
3. • Lifestyle modifications: Weight reduction, Smoking cessation
   • Physiotherapy
   • NSAIDs
4. Emergent Laminotomy and Discectomy (Cauda Equina Syndrome)