Surgery

Question 1

A 17-year-old boy presented with high grade fever,
nausea, vomiting of ingested matter and flank pain
of three days duration. His temperature is 38.5°C,
and pulse rate is 100/min. However, other physical
examination findings are not remarkable. Laboratory
result is notable for leukocytosis and pyuria. What is
the most likely diagnosis of the boy?
• a. Acute cystitis
• b. Nephrolithiasis
C. Acute prostatitis
• d. Acute pylenophritis

Answer 1

D

Clinical features of lower UTI [19][20]
Irritative lower urinary tract symptoms (LUTS)
Increased urinary frequency
Urinary urgency
Dysuria
Hematuria
Suprapubic tenderness
Clinical features of upper UTI (pyelonephritis) [21]
Symptoms of lower UTI
Fever
Flank pain
Costovertebral angle tenderness
Fatigue/malaise
Nausea and vomiting
See “Clinical features” in “Pyelonephritis.

The most likely diagnosis is:

d. Acute pyelonephritis

Explanation:
1. Clinical Presentation:
• High-grade fever, nausea, vomiting, and flank pain are characteristic of acute pyelonephritis, an infection of the kidney.
• The flank pain suggests involvement of the upper urinary tract.
2. Laboratory Findings:
• Leukocytosis indicates a systemic inflammatory response.
• Pyuria (white blood cells in the urine) points to a urinary tract infection, which supports the diagnosis.
3. Exclusion of Other Options:
• a. Acute cystitis: Typically presents with dysuria, frequency, urgency, and suprapubic pain, but without fever or systemic symptoms like nausea and vomiting.
• b. Nephrolithiasis: Usually causes severe, colicky flank pain, sometimes with hematuria, but fever and pyuria are uncommon unless there is a concurrent infection.
• c. Acute prostatitis: Uncommon in a 17-year-old. Symptoms typically include perineal pain, urinary retention, and systemic symptoms.

Conclusion:

The combination of systemic symptoms (fever, nausea) and localized findings (flank pain, pyuria) strongly supports acute pyelonephritis.

Question 2

A 24-year-old male patient came to an emergency
OPD after he was injured at his back by an unknown
offender three hours back. He had minimal bleeding
from the stab site. On physical examination, he had
2 x 3cm deep laceration to his back, and the fascia
and peritoneum were intact. What is the most
appropriate management for the patient?
• a. Debridement, washing and primary closure
• b. Admit him, IV antibiotics and primary
c l o s u r e
• c. Wound care and delayed primary closure
• d. Wound care daily and let it close by itself

Answer 2

A , ( primary closure for wounds in recent, clean wound ,low risk of infection)

Primary wound closure
Definition: closure of recent wounds by approximation of the wound edges, allowing for healing by primary intention
Indications
Recent, clean wounds that have a low risk of infection
Procedure: See “Wound closure techniques.”
Antibiotics [14]
Minor, uncontaminated injuries: Antibiotic prophylaxis is not routinely required.
Wounds at high risk of infection: Consider antibiotic prophylaxis.
Wound healing
Occurs by primary intention
Wound healing occurs with minimal inflammation and minimal to no granulation tissue formation.
Organ-specific tissue forms at the site of healing
Minimal (hairline) scar formation

Secondary wound closure
Definition: leaving a wound to heal by secondary intention (i.e., without approximating the wound edges)
Indications
Infected wounds, e.g., surgical site infection [15]
Wounds at high risk of infection, e.g., wounds with implanted foreign bodies [6]
Bite wounds that do not meet the criteria for primary closure (see “Bite wounds” for details)
Wounds older than the time frame within which primary closure can be safely performed.
Large wounds with irregular edges that cannot be approximated without tension
Goal: debridement to remove devitalized tissue; removal of contaminants and foreign bodies that may disrupt healing. [6]
Procedure [6]
Administer local, regional, or general anesthesia.
Clean via pressured irrigation using warm, isotonic saline. [6][16]
Perform surgical (sharp) debridement: removal of devitalized tissue and debris to allow for wound healing
Ensure drainage (e.g., silicone/rubber drains, strip of gauze) of deep wounds.
Apply moist dressing.
Immobilize the affected extremity, if necessary.
Further treatment
Wounds at high risk of infection: Consider antibiotic prophylaxis.
Infected wounds: Administer antibiotics (see “Empiric antibiotic therapy for skin and soft tissue infections”).
Regular dressing changes
Reevaluation for delayed primary closure (if needed) after ∼ 3 days
Consider negative pressure wound therapy (NPWT) as an adjunct to stimulate the healing process for large wounds. [14][17]
Wound healing
Occurs by secondary intention
Usually accompanied with pronounced inflammation
Takes longer than wounds that have been repaired with primary closure
Requires the formation of granulation tissue
The wound bed is replaced with increased proliferation of fibroblasts.
Pronounced scar formation
Open wound drainage system
Tertiary wound closure (delayed primary closure)
Definition: surgical closure of a wound after healing by secondary intention has already begun; also known as healing by tertiary intention
Indications
Clean wounds with healthy edges in patients presenting after the time frame within which primary closure can be safely performed.
Contaminated wounds left to heal by secondary intention and with no signs of infection after 3–5 days [6]
Procedure
Clean the wound and debride any areas of devitalized tissue.
Close the wound using an appropriate wound closure technique (e.g., simple interrupted sutures).
Wound healing
Occurs by tertiary intention
Results in a larger scar than with primary or secondary closure due to an interruption in normal wound healing

Question 3

A 22-year-old male patient presented with
progressive mid-abdominal discomfort followed by
anorexia, nausea and vomiting of 24 hours duration.
The pain later shifted to the right iliac fossa. He had
right lower quadrant abdominal tenderness and
WBC count of 12000/mm3 with left shift (NR; 3.54-
9.06 × 103/mm3). What is the ultrasound finding
that supports the most likely diagnosis?
• a. Presence of fluid in general peritoneum
• b. Length of appendix greater than 15mm
c. Presence of air in general peritoneum
• d. Diameter of appendix greater 6mm

Answer 3

Ultrasound findings — The most accurate ultrasound finding for acute appendicitis is an appendiceal diameter of >6 mm

The ultrasound finding that supports the most likely diagnosis is:

d. Diameter of appendix greater than 6mm

Explanation:
1. Clinical Presentation:
• The patient’s symptoms, including mid-abdominal pain shifting to the right iliac fossa, anorexia, nausea, vomiting, and right lower quadrant tenderness, are classic for acute appendicitis.
• Leukocytosis with a left shift (increased neutrophils) supports an inflammatory or infectious process.
2. Ultrasound Findings in Appendicitis:
• The most reliable ultrasound finding for appendicitis is an appendiceal diameter greater than 6mm. This suggests inflammation or swelling of the appendix.
• Other findings can include:
• Non-compressible appendix.
• Increased echogenicity of surrounding fat (suggesting inflammation).
• Presence of periappendiceal fluid or an appendicolith (calcified deposit).
3. Exclusion of Other Options:
• a. Presence of fluid in the general peritoneum: This may indicate perforation with generalized peritonitis, which is a complication of appendicitis, but it is not the most common initial finding.
• b. Length of appendix greater than 15mm: The length of the appendix is not a diagnostic criterion for appendicitis.
• c. Presence of air in the general peritoneum: This suggests perforation and is a late finding, not typically seen in uncomplicated appendicitis.

Conclusion:

The diameter of the appendix greater than 6mm is the most specific and early ultrasound finding supporting the diagnosis of acute appendicitis.

Question 4

A 28-year-old male patient came to a health center
after noticing skin discoloration on his back for
unknown duration. Five hypo-pigmented skin lesions
with loss of sensation on the lesion and enlarged
ulnar nerves were found during examination. What is
the most likely diagnosis?
• a. Leprosy
• b. Ulnar nerve neuropathy
• c. Tinea corporis
• d. Pityriasis alba

Answer 4

The most likely diagnosis is:

a. Leprosy

Explanation:
1. Key Clinical Features:
• Hypopigmented skin lesions with loss of sensation: This is a hallmark sign of leprosy, caused by Mycobacterium leprae. The bacteria attack peripheral nerves, leading to sensory loss in affected areas.
• Enlarged ulnar nerves: Thickened peripheral nerves are a classic finding in leprosy, especially in the ulnar, radial, or peroneal nerves.
2. Exclusion of Other Options:
• b. Ulnar nerve neuropathy: While ulnar nerve neuropathy can cause localized symptoms, it does not present with hypopigmented skin lesions or sensory loss over multiple skin patches.
• c. Tinea corporis: This fungal infection causes well-demarcated, scaly, annular lesions but does not cause loss of sensation or nerve enlargement.
• d. Pityriasis alba: This is a benign skin condition causing hypopigmented patches, commonly in children, but it does not involve nerve thickening or sensory loss.
3. Diagnosis Confirmation:
• A skin smear or skin biopsy can confirm the presence of Mycobacterium leprae.
• Testing for loss of fine touch, pain, and temperature sensation in the lesions further supports the diagnosis.

Conclusion:

The combination of hypopigmented, anesthetic skin lesions and enlarged ulnar nerves strongly suggests leprosy.

Question 5

A 29-year-old G-Il, P-I mother, who is a known
Graves’s disease patient on treatment, presented to
the regular OPD at her 36thweeks of gestation with
complaints of palpitation, nervousness, sweating,
and diarrhea of one day duration. On physical
examination, she is anxious and confused, her blood
pressure is 150/90 mmHg, pulse rate is 130/min,
respirations are 28/min, temperature is 38.3°C and
there is systolic ejection murmur at the apex. CBC
results were; hematocrit level of 39percent, WBC
count of 18 x103/mm3, and platelet count of
260x103 /mm3. What is the most likely diagnosis of
this patient?
• a. Myxedema coma
• b. Thyroid storm
c. Eclampsia
• d. Adrenal crisis

Answer 5

The most likely diagnosis is:

b. Thyroid storm

Explanation:
1. Key Features Supporting Thyroid Storm:
• History of Graves’ disease: This is a known hyperthyroid condition, and the patient is likely at risk for complications, especially during pregnancy.
• Acute onset symptoms: Palpitation, nervousness, sweating, diarrhea, and confusion are classic symptoms of a hypermetabolic state.
• Vital signs:
• High fever (38.3°C), tachycardia (130/min), hypertension (150/90 mmHg), and tachypnea (28/min) are hallmark signs of thyroid storm.
• Physical findings: Anxiety and confusion are common in thyroid storm, indicating CNS involvement.
• Normal CBC: Leukocytosis (WBC 18,000/mm³) and elevated hematocrit can occur due to the stress response.
2. Exclusion of Other Options:
• a. Myxedema coma: This is associated with severe hypothyroidism and presents with hypothermia, bradycardia, hypotension, and altered mental status, opposite of this patient’s presentation.
• c. Eclampsia: Typically presents with seizures and other symptoms like severe hypertension, proteinuria, and hyperreflexia, which are not described here.
• d. Adrenal crisis: Adrenal insufficiency presents with hypotension, fatigue, abdominal pain, and electrolyte imbalances, which are not consistent with this patient’s findings.
3. Thyroid Storm and Pregnancy:
• Pregnancy is a hypermetabolic state and increases the risk of thyroid storm in patients with poorly controlled Graves’ disease.
• Precipitating factors like infection, labor, or non-compliance with medication can trigger a thyroid storm.

Conclusion:

This patient’s acute hypermetabolic symptoms and history of Graves’ disease strongly suggest thyroid storm, a life-threatening emergency requiring immediate treatment with beta-blockers, antithyroid drugs, and supportive care.

Question 6

A 35-year-old female patient came to a hospital with
anterior neck swelling of five years duration. Since
the last three month, she has started to experience
palpitation and has a history of hot intolerance with
no history of bone pain, cough or yellowish
discoloration of the eye. On examination, her pulse
rate is 110/min, blood pressure is 120/70mmHg,
and there is lid lag and lid retraction. On thyroid
examination, there is diffusely enlarged thyroid
measuring of 4*3cm,the lower border is reachable.
She is investigated with thyroid function test and the
results show that TSH is 0.3micro unit/mL(Normal;
0.5-5 micro unit/mL), Total T4 is 180
nmol/L(Normal; 55-150 nmol/L), Total T3 is 5
nmol/L(Normal; 1.5-3.5 nmol/L). What is the most
likely diagnosis of the patient?
• a. Toxic multinodular goiter
• b. Toxic Adenoma
• c. Graves’ disease
• d. Follicular neoplas

Answer 6

The most likely diagnosis is:

c. Graves’ disease

Explanation:
1. Clinical Presentation:
• Anterior neck swelling of 5 years: Suggestive of a thyroid pathology.
• Symptoms of hyperthyroidism: Palpitations, heat intolerance, and a rapid pulse (110/min) are indicative of excess thyroid hormone.
• Lid lag and lid retraction: These are signs of thyroid-associated ophthalmopathy, a hallmark of Graves’ disease.
2. Thyroid Examination:
• Diffuse thyroid enlargement: This is a classic finding in Graves’ disease.
• The lower border of the thyroid being reachable suggests no significant retrosternal extension.
3. Thyroid Function Test Results:
• TSH is suppressed (0.3 µU/mL): Indicates hyperthyroidism.
• Elevated T3 (5 nmol/L) and T4 (180 nmol/L): Confirms hyperthyroidism.
• T3 being disproportionately elevated compared to T4 is a pattern commonly seen in Graves’ disease.
4. Exclusion of Other Options:
• a. Toxic multinodular goiter: Typically presents in older patients with a nodular, non-diffuse thyroid gland on examination or imaging.
• b. Toxic adenoma: Causes focal hyperfunctioning nodule(s), not diffuse thyroid enlargement, and no ophthalmopathy.
• d. Follicular neoplasm: Usually presents as a solitary thyroid nodule and does not cause hyperthyroidism or ophthalmopathy.

Conclusion:

The combination of diffuse goiter, hyperthyroidism, and signs of thyroid ophthalmopathy strongly supports the diagnosis of Graves’ disease.

Question 7

A 34-year-old male patient sustained stick injury to
his arm. He had pain and is unable to use his
extremity. On evaluation, his vital signs are in the
normal range. There is visible deformity and crepitus
over the left arm. Distal pulses are intact and there is
wrist drop. What is the most likely explanation for
this case?
• a. Humeral shaft fracture plus radial nerve
injury
• b. Humeral shaft fracture plus radial and ulnar
nerve injury
0 c. Humeral shaft fracture plus median nerve
injury
• d. Humeral shaft fracture plus ulnar nerve
injury

Answer 7

The most likely explanation is:

a. Humeral shaft fracture plus radial nerve injury

Explanation:
1. Key Findings:
• Visible deformity and crepitus: Strongly suggest a humeral shaft fracture.
• Wrist drop: This is a classic sign of radial nerve injury, as the radial nerve innervates the extensor muscles of the wrist and fingers. When injured, the patient cannot extend the wrist.
• Intact distal pulses: Indicates that major vascular structures (like the brachial artery) are not compromised.
2. Radial Nerve and Humeral Shaft Fractures:
• The radial nerve runs in the radial groove of the humerus and is susceptible to injury in humeral shaft fractures.
• Radial nerve palsy often presents with wrist drop and weakness in finger extension but does not affect sensation in the palm, as the palmar branch is supplied by other nerves.
3. Exclusion of Other Options:
• b. Humeral shaft fracture plus radial and ulnar nerve injury: Injury to both nerves would result in additional symptoms, such as sensory loss in the ulnar nerve distribution (e.g., medial hand and fingers) and claw hand deformity, which are not reported here.
• c. Humeral shaft fracture plus median nerve injury: Median nerve injury typically presents with weakness in wrist flexion, thumb opposition, or sensory loss in the lateral palm and fingers, not wrist drop.
• d. Humeral shaft fracture plus ulnar nerve injury: Ulnar nerve injury presents with sensory deficits in the medial hand and motor weakness leading to a claw hand deformity, not wrist drop.

Conclusion:

The combination of humeral shaft fracture and wrist drop strongly suggests radial nerve injury, making option a the correct answer.

Question 8

A 35-year-old female patient presents with colicky
right upper quadrant abdominal pain of three
months duration. Her pain worsens when she eats
fatty meal. Since four days ago, she has persistent
right upper quadrant pain, vomiting of ingested
matter and fever. On physical examination, her blood
pressure is 100/60mmHg, pulse rate is 112/min,
temperature is 38.7 degree centigrade and she has
tenderness during inspiration on right upper
quadrant abdomen. On investigation WBC count was
12,000/mm3, and abdominal ultrasound shows gall
bladder wall of 3.5mm thick and hyperechoic lesion
with posterior shadow within it. What is the best
initial management for this patient?
• a. Maintenance fluid, keep NPO and start sips
when she tolerate
• b. Maintenance fluid, IV antibiotics, and urgent
cholecystectomy
• c. Maintenance fluid, PO antibiotics and
analgesics for seven days
• d. Maintenance fluid, IV antibiotics, analgesics
and bowel rest

Answer 8

The best initial management is:

b. Maintenance fluid, IV antibiotics, and urgent cholecystectomy

Explanation:
1. Clinical Presentation:
• The patient has a history of colicky right upper quadrant (RUQ) pain exacerbated by fatty meals, consistent with biliary colic due to gallstones.
• Persistent RUQ pain, fever, vomiting, and tenderness during inspiration (Murphy’s sign) suggest acute cholecystitis.
• Ultrasound findings of gallbladder wall thickening (3.5mm) and a hyperechoic lesion with posterior shadow (gallstone) confirm the diagnosis.
2. Best Management for Acute Cholecystitis:
• IV antibiotics: To treat infection caused by biliary stasis and inflammation.
• Urgent cholecystectomy: This is the definitive treatment and should ideally be performed within 24-72 hours of symptom onset to prevent complications like perforation or gangrene.
• Maintenance fluids: To address dehydration from vomiting.
• NPO (nothing by mouth): To reduce gastrointestinal stimulation until surgery.
3. Exclusion of Other Options:
• a. Maintenance fluid, keep NPO, and start sips when she tolerates: This approach neglects the need for antibiotics and definitive surgical intervention.
• c. Maintenance fluid, PO antibiotics, and analgesics for seven days: Oral antibiotics are not sufficient for acute cholecystitis, and delaying surgery increases the risk of complications.
• d. Maintenance fluid, IV antibiotics, analgesics, and bowel rest: While partially correct, this does not address the need for urgent cholecystectomy, which is the definitive treatment.

Conclusion:

The optimal initial management for this patient with acute cholecystitis is IV antibiotics, maintenance fluids, and urgent cholecystectomy to resolve the infection and prevent further complications.

Question 9

A 36-year-old woman who was operated for
longstanding goiter presented to a surgical referral
clinic with paresthesias of the distal extremities,
numbness, painful muscle spasms, and seizures in
the 3rd postoperative day. What is the most likely
electrolyte abnormality in this case?
• a. Hypokalemia
• b. Hypocalcemia
• c. Hyponatremia
• d. Hypomagnesemia

Answer 9

The most likely electrolyte abnormality is:

b. Hypocalcemia

Explanation:
1. Post-Thyroidectomy Complication:
• Hypocalcemia is a common complication after thyroid surgery, particularly if the parathyroid glands (which regulate calcium levels) are inadvertently damaged or removed, or their blood supply is compromised.
2. Clinical Features of Hypocalcemia:
• Paresthesias (tingling, numbness) in the distal extremities.
• Painful muscle spasms (tetany), often in the hands and feet.
• Seizures.
• Trousseau’s sign: Carpal spasm induced by inflating a blood pressure cuff.
• Chvostek’s sign: Facial muscle twitching elicited by tapping the facial nerve.
3. Exclusion of Other Options:
• a. Hypokalemia: May cause muscle weakness, cramps, or arrhythmias but not paresthesias or tetany.
• c. Hyponatremia: Can cause confusion, seizures, and lethargy, but does not cause tetany or paresthesias.
• d. Hypomagnesemia: May cause neuromuscular irritability similar to hypocalcemia but is less common after thyroidectomy.
4. Underlying Mechanism:
• The parathyroid glands produce parathyroid hormone (PTH), which regulates calcium homeostasis. Post-surgical hypoparathyroidism leads to decreased serum calcium levels.

Conclusion:

The patient’s symptoms are classic for hypocalcemia, likely due to transient or permanent hypoparathyroidism following thyroid surgery.

Question 10

P Flag question
A 40-year-old female patient came to an OPD with
the complaint of amenorrhea of three months
duration. She also had frequent abortion for which
she visited many private clinics and did not get cure.
She also complained hot intolerance and significant
weight loss. Her pulse rate is 120/min. On
examination, she has lid lag and exophthalmia,
diffused anterior neck swelling which moves with
respiration, and thickened skin over the dorsum of
the foot and pre-tibial region. What is the most likely
explanation for these findings?
O a. Hashimotos thyroiditis
• b. Secondary thyrotoxicosis
• c. Subacute thyroiditis
• d. Graves’ disease

Answer 10

The most likely explanation is:

d. Graves’ disease

Explanation:
1. Key Clinical Features:
• Amenorrhea: Can occur in hyperthyroidism due to hormonal imbalances.
• Hot intolerance and weight loss: Classic symptoms of hyperthyroidism.
• Pulse rate of 120/min: Indicates tachycardia, commonly associated with hyperthyroidism.
• Lid lag and exophthalmia: Hallmark signs of Graves’ disease, caused by thyroid-associated ophthalmopathy.
• Diffuse anterior neck swelling: Suggests a diffuse goiter, typical in Graves’ disease.
• Thickened skin (pretibial myxedema): A specific sign of Graves’ disease due to dermopathy.
2. Exclusion of Other Options:
• a. Hashimoto’s thyroiditis: Typically causes hypothyroidism, not hyperthyroidism. It is associated with fatigue, cold intolerance, and weight gain.
• b. Secondary thyrotoxicosis: Results from excessive TSH production (e.g., TSH-secreting pituitary adenoma) but does not usually involve ophthalmopathy or dermopathy.
• c. Subacute thyroiditis: Causes transient hyperthyroidism due to inflammation but is often painful, and it does not cause exophthalmia or pretibial myxedema.
3. Pathophysiology of Graves’ Disease:
• An autoimmune condition in which TSH receptor antibodies stimulate the thyroid gland, leading to hyperthyroidism.
• The associated ophthalmopathy and dermopathy are due to autoimmune inflammation in the orbit and skin.

Conclusion:

The combination of hyperthyroid symptoms, exophthalmia, diffuse goiter, and pretibial myxedema strongly suggests Graves’ disease.

Question 11

A 48-year-old female patient was admitted to a
medical ICU with the diagnosis of NYHA Class-IV
Stage-C CHF secondary to chronic rheumatic
valvular heart disease. The physicians and nurses in
the ICU were unable to secure IV line. Where is the
most appropriate site for IV access in the patient?
a. Saphenous vein cut down
• b. Intraouseus route
• c. Scalp vein
• d. Jugular vein cut down

Answer 11

The most appropriate site for IV access in this patient is:

a. Saphenous vein cut down

Explanation:
1. Clinical Context:
• The patient has New York Heart Association (NYHA) Class IV congestive heart failure (CHF) secondary to chronic rheumatic valvular heart disease.
• In critically ill patients where peripheral IV access cannot be secured, alternative methods for vascular access must be considered.
2. Saphenous Vein Cut Down:
• This technique involves surgically exposing the greater saphenous vein at the ankle or knee for direct venous cannulation.
• It is reliable in critically ill patients when peripheral veins are not accessible due to shock or edema.
• It is commonly used in emergency situations, particularly in patients where central venous catheterization may not be feasible immediately.
3. Exclusion of Other Options:
• b. Intraosseous route: Used mainly in pediatric patients or adults during extreme emergencies (e.g., cardiac arrest). While effective for temporary access, it is not ideal for a stable patient in this scenario.
• c. Scalp vein: Typically used in neonates or infants, not adult patients.
• d. Jugular vein cut down: Although feasible, it is less commonly performed compared to saphenous vein cut down and carries a higher risk of complications, such as infection or air embolism.

Conclusion:

For a critically ill adult patient with CHF in whom peripheral IV access is not achievable, the saphenous vein cut down is the most appropriate and practical choice for securing IV access.

Question 12

A 54-year-old man came to a hospital with a
compliant of vomiting of coffee ground matter of
five hours duration. He has long standing epigastric
pain, easy fatigability and dark tarry stool. At
presentation, his blood pressure is 85/60mmHg and
pulse rate is 120/min. His abdominal examination
did not reveal remarkable finding. His laboratory
findings show WBC count of 4.3X103/mm3, platelet
count of 178x103 and hemoglobin level of 7g/dl.
What is the most appropriate initial management for
the patient?
• a. Resuscitate and prepare for emergency
laparatomy
• b. Secure IV line and send for upper GI
endoscopy immediately
• c. Resuscitate with double IV line and prepare
cross matched blood
• d. Put him on maintenance fluid and do NG
tube lavage
Previous page

Answer 12

The most appropriate initial management for this patient is:

c. Resuscitate with double IV line and prepare cross-matched blood.

Explanation:

This patient presents with features of upper gastrointestinal (GI) bleeding, as evidenced by:
• Coffee-ground vomiting (indicates blood altered by gastric acid),
• Melena (dark tarry stools, a sign of digested blood in the GI tract),
• Hemodynamic instability (low blood pressure of 85/60 mmHg and a pulse rate of 120 bpm suggest hypovolemic shock),
• Severe anemia (hemoglobin of 7 g/dL).

Initial Management Priorities:
1. Resuscitation:
• Establish two large-bore IV lines for fluid resuscitation (e.g., isotonic crystalloids like normal saline or Ringer’s lactate) to stabilize the patient.
• Transfuse cross-matched blood as soon as available to address the anemia and ongoing blood loss.
2. Stabilization before definitive diagnosis:
• Once the patient is hemodynamically stable, an upper GI endoscopy can be performed to identify and potentially treat the source of bleeding.
• Emergency laparotomy is generally reserved for cases where endoscopy fails or the patient continues to deteriorate despite stabilization.
3. Avoid delaying resuscitation:
• Immediate endoscopy (option b) or nasogastric tube lavage (option d) without initial stabilization is inappropriate in a hemodynamically unstable patient.

Rationale for the Incorrect Options:
• a. Resuscitate and prepare for emergency laparotomy: Surgery is not the first-line management unless endoscopic interventions fail or the patient has signs of perforation or uncontrolled bleeding.
• b. Secure IV line and send for upper GI endoscopy immediately: Endoscopy should be deferred until the patient is hemodynamically stable.
• d. Put him on maintenance fluid and do NG tube lavage: Maintenance fluid alone is insufficient, and NG lavage is not an initial life-saving measure.

Question 13

A 55-year-old male patient presented to an
emergency OPD with abdominal pain, distension,
vomiting and failure to pass feces and flatus of three
days duration. He had swelling on the left inguinal
region for the last five years, which failed to reduce
since four days. His physical examination results
show a blood pressure of of 100/60 mmHg, pulse
rate of 112/min, temperature of 38.1 degree
centigrade, abdomen is distended, and
hypertympanic with decreased bowel sound, and
there is a 12 cm x 15 cm non-reducible tender m a s s
on the left inguinal region. What is the most likely
diagnosis?
• a. Strangulated inguinal hernia
• b. Obstructed inguinal hernia
c. Sliding inguinal hernia
• d. Incarcerated inguinal hernia

Answer 13

The most likely diagnosis is:

a. Strangulated inguinal hernia.

Explanation:

The patient presents with symptoms and signs of intestinal obstruction (abdominal pain, distension, vomiting, and inability to pass feces or flatus) along with a long-standing left inguinal hernia that has become non-reducible, tender, and associated with systemic signs of infection (fever and tachycardia).

Key Differentiating Features:
1. Non-reducible and tender mass:
• Suggests that the hernia is incarcerated (contents are trapped) and possibly strangulated (compromised blood supply).
2. Systemic signs (fever, tachycardia):
• Indicate potential ischemia or necrosis of the herniated bowel contents due to strangulation.
3. Hypertympanic abdomen with decreased bowel sounds:
• Classic for intestinal obstruction caused by a hernia.

Why it is strangulated and not the other options:
• a. Strangulated inguinal hernia:
• The tenderness, systemic signs (fever, tachycardia), and inability to reduce the hernia strongly indicate strangulation, meaning the blood supply to the herniated bowel is compromised.
• This is a surgical emergency.
• b. Obstructed inguinal hernia:
• An obstructed hernia refers to bowel trapped within the hernia, causing obstruction but without vascular compromise. The systemic signs (fever, tachycardia) suggest that the hernia is more severe and likely strangulated.
• c. Sliding inguinal hernia:
• This occurs when part of the hernia sac wall includes an organ (e.g., bladder or colon), but it is not relevant in this presentation, which clearly indicates complications.
• d. Incarcerated inguinal hernia:
• An incarcerated hernia refers to a hernia that is non-reducible but without vascular compromise or systemic signs. The patient’s systemic features (fever, tachycardia) and tenderness point toward strangulation instead.

Conclusion:

The clinical presentation strongly suggests a strangulated inguinal hernia, requiring urgent surgical intervention to prevent bowel necrosis and life-threatening complications.

Irreducibility:  When the contents of the sac cannot be completely emptied from the sac because of: o Adhesion formed between the contents and the sac or between the contents themselves; o Growth of the omentum within the sac; o Narrowing of the neck of the sac because of fibrosis, e.g., following continuous pressure of truss; o Retention of faeces in the large intestine occupying the sac.  In a simple irreducible hernia, though the contents cannot be reduced, the blood supply remains intact, and there are no symptoms of intestinal obstruction 2. Obstruction:  Irreducibility+ obstruction of the lumen of the contained bowel leading to intestinal obstruction. The features are: o The hernia is irreducible but painless. o
Cough impulse may be present. o Features of
intestinal obstruction are present. o Can precipitate strangulation if not treated early. P

Hernia is one of the commonest causes of intestinal obstruction. So, hernial sites should always be examined in a patient presenting with intestinal obstruction. 3. Strangulation:  Irreducibility + features of intestinal obstruction + arrest of blood supply to the contained intestine leading to gangrene.  The features are: o The hernia is irreducible and painful. o The sac is tense and tender. o Cough impulse absent. o Features of intestinal obstruction present - pain abdomen, vomiting, abdominal distension, rebound tenderness.  Strangulation is more likely to happen in a hernia with a narrow neck.  Most strangulated herniae are therefore either inguinal or femoral, because these herniae have narrow necks.  Often, the sac contains the greater omentum which may become gangrenous due to arrest of blood supply showing the features of strangulation but without the features of intestinal obstruction.  Strangulation without obstruction also noted in Richter’s hernia.

Reduction-en-masse:  Sometimes, during forceful manual reduction of irreducible hernia, the contents together with the covering sac gets pushed forcibly back into the abdominal cavity; the bowel within the sac may be strangulated by the neck of the sac.  Thus, the symptoms of obstruction or strangulation may not be relieved 5. Incarceration:  Incarcerated hernia is a variety of irreducible hernia where the content of the sac is large gut containing faeces.  The large gut is fixed in the sac because of its size or adhesions.  Here, the hernia can be indented like putty with the fingertip pressure because of the scybalous content of the gut.

Question 14

A 58-year-old man with abdominal distension and
pain of two weeks duration visited a hospital. He
also has blood mixed stool, tenesmus and weight
loss. He was treated for intestinal parasitosis
multiple times. On physical examination, his vital
signs were within the normal range, abdomen was
distended and hyper-tympanic, and bowel sounds
were hyperactive. His hematocrite level was
32percent. Plain abdominal X-ray showed distended
large bowel and barium enema showed apple core
appearance. What is the most likely diagnosis of the
patient?
• a. Colorectal Cancer
• b. Transverse Colon Volvulus
• c. Sigmoid Volvulus
• d. Cecal Volvulus

Answer 14

The most likely diagnosis is:

a. Colorectal Cancer

Explanation:

This patient presents with features suggestive of a large bowel obstruction and symptoms indicative of an underlying colorectal cancer, supported by the imaging findings.

Key Features Supporting Colorectal Cancer:
1. Blood-mixed stool and tenesmus: These are hallmark signs of colorectal cancer, especially if the tumor involves the rectum or sigmoid colon.
2. Weight loss and chronic symptoms: Unintentional weight loss and a two-week duration of symptoms are classic for malignancy.
3. Hematocrit of 32%: Suggests chronic blood loss, likely from a bleeding tumor in the colon.
4. Apple core appearance on barium enema: This is a pathognomonic finding for colorectal cancer. It results from a constricting lesion causing a narrow, irregular lumen.

Why not the other options:
• b. Transverse Colon Volvulus:
• Rare and typically presents with acute abdominal pain and obstruction symptoms. The apple core lesion would not be present.
• c. Sigmoid Volvulus:
• Commonly associated with a history of chronic constipation and elderly patients. It presents with an “omega” sign or “coffee bean” sign on imaging rather than an apple core appearance.
• d. Cecal Volvulus:
• Typically presents with acute obstruction, with imaging showing a markedly distended cecum in the upper left quadrant. The apple core appearance is inconsistent with volvulus.

Conclusion:

The apple core appearance on imaging combined with chronic symptoms, blood in the stool, and weight loss strongly point to colorectal cancer as the most likely diagnosis.

Question 15

A 60-year-old male patient needs to undergo urgent
surgical intervention for small bowel obstruction. He
was on aspirin for the last three years. What is the
best component of blood that should be prepared in
this patient care?
• a. Packed RBC
• b. Cryoprecipitate
• c. Whole blood
• d. Platelet

Answer 15

The best component of blood to prepare for this patient is:

d. Platelet

Explanation:

This patient has been taking aspirin for the last three years. Aspirin irreversibly inhibits platelet function by inhibiting the cyclooxygenase (COX-1) enzyme, which reduces thromboxane A2 production, impairing platelet aggregation. During surgery, this can increase the risk of bleeding, even if platelet counts are normal.

Why platelet preparation is critical:
1. Aspirin’s impact on platelets:
• Aspirin-induced platelet dysfunction cannot be reversed until new platelets are produced (which takes 7–10 days).
• Transfusion of functional platelets may be necessary if excessive bleeding is anticipated or occurs during surgery.
2. Urgent surgical intervention:
• Given the need for immediate surgery, there is no time to discontinue aspirin or wait for the body to regenerate functional platelets.

Why not the other options:
• a. Packed RBC:
• Packed RBCs are used for anemia or significant blood loss. There is no indication that the patient is anemic or has already lost blood.
• b. Cryoprecipitate:
• Cryoprecipitate is rich in fibrinogen, factor VIII, von Willebrand factor, and factor XIII. It is used for specific coagulation disorders, such as DIC or hypofibrinogenemia, not for platelet dysfunction.
• c. Whole blood:
• Whole blood is rarely used in modern practice and is typically reserved for massive trauma cases or where both volume and oxygen-carrying capacity are needed.

Conclusion:

Platelet transfusion is the most appropriate preparation in this patient with aspirin-induced platelet dysfunction to minimize the risk of bleeding during surgery.

Question 16

A 75-year-old female patient came to a surgical OPD
with complaints of difficulty of swallowing for three
months. She also had hoarseness of voice. On
evaluation, she was chronically sick looking. She had
left supraclavicular LAP. What is the most
appropriate initial diagnosis for this patient?
• a. Achalasia
• b. Lyphoma
• c. Esophageal cancer
• d. Tuberculos LAP

Answer 16

The most appropriate initial diagnosis is:

c. Esophageal cancer

Explanation:

This patient presents with progressive dysphagia (difficulty swallowing) and hoarseness of voice, which are classic symptoms of esophageal cancer. Additionally, the presence of left supraclavicular lymphadenopathy (Virchow’s node) and her chronically ill appearance further support the suspicion of malignancy.

Key Features Supporting Esophageal Cancer:
1. Progressive dysphagia:
• Initially for solids and later for liquids, which is typical in esophageal cancer due to tumor growth causing obstruction.
2. Hoarseness of voice:
• Indicates possible involvement or compression of the recurrent laryngeal nerve by the tumor or metastatic lymph nodes.
3. Left supraclavicular lymphadenopathy:
• Known as Virchow’s node, strongly suggests metastatic spread of a gastrointestinal malignancy, commonly esophageal or gastric cancer.

Why not the other options:
• a. Achalasia:
• Achalasia can cause dysphagia, but it is not associated with systemic signs like lymphadenopathy or hoarseness of voice. Barium swallow in achalasia typically shows a “bird-beak” appearance, which is diagnostic.
• b. Lymphoma:
• Lymphoma can cause lymphadenopathy and constitutional symptoms, but it does not commonly present with dysphagia and hoarseness of voice.
• d. Tuberculous LAP:
• Tuberculous lymphadenitis typically presents as painless lymphadenopathy, often without associated dysphagia or hoarseness. Constitutional symptoms like fever and night sweats would also be expected.

Conclusion:

The combination of progressive dysphagia, hoarseness of voice, and Virchow’s node is most consistent with esophageal cancer as the initial diagnosis. Further evaluation, including endoscopy and biopsy, is warranted to confirm the diagnosis.

Question 17

A patient who had been diagnosed with pulmonary
tuberculosis came to an emergency room with a
complaint of difficulty of breathing and chest pain.
He is tachypenic and has signs of fluid collection on
the right side which was tapped and found to be
grossly purulent. His physician decided to insert
chest tube. Where is the safest site of chest tube
insertion on this patient?
• a. Fifth Intercostal space anterior to the mid-
axillary line
• b. Fifth Intercostal space anterior to the
anterior -axillary line
• c. Second Intercostal space below and lateral
to the pectoralis major muscle
• d. Seventh Intercostal space below the level of
the nipple

Answer 17

The safest site for chest tube insertion in this patient is:

a. Fifth intercostal space anterior to the mid-axillary line.

Explanation:

The patient has signs of empyema (grossly purulent fluid) and requires chest tube drainage. Proper placement of the chest tube is essential to ensure safety and effectiveness.

Key Details for Safe Chest Tube Placement:
1. Fifth Intercostal Space, Mid-Axillary Line:
• This is the standard and safest site for chest tube insertion.
• The mid-axillary line avoids major muscles, blood vessels, and nerves.
• It provides easy access for draining pleural fluid, air, or pus.
2. Why Fifth Intercostal Space?:
• It ensures the tube is placed in the pleural cavity without risk of damaging abdominal organs (e.g., liver or spleen).

Why Not the Other Options?
• b. Fifth intercostal space anterior to the anterior-axillary line:
• Although this is close, it increases the risk of injuring the pectoralis major muscle.
• c. Second intercostal space below and lateral to the pectoralis major muscle:
• The second intercostal space is the preferred site for needle decompression in tension pneumothorax, not for chest tube insertion.
• d. Seventh intercostal space below the level of the nipple:
• This site is too low and increases the risk of injuring abdominal organs, especially the liver on the right side.

Conclusion:

The fifth intercostal space at the mid-axillary line is the standard and safest site for chest tube insertion in cases of empyema, pleural effusion, or pneumothorax.

Question 18

An 18 year old male sustained flame burn injury with an estimated body surface area of 30%. The patient’s weight is 50kg. Your senior has advised you to give him a ringer’s lactate IV after calculating the fluid requirement for the first 24 hours using parkland’s formula. How much fluid does the patient require for first 24 hours?
Select one:
a. 5 liters
b. 8 liter
c. 6 liter
d. 3 liter

Answer 18

C parklands formula 4 L/kg/% body surface area 1/2 given over the first 8 hrs and the second half over 16 hrs

Question 19

A 60 year old male patient is taken to OR for complete small bowel obstruction after he presented with bilious vomiting of 4 days duration. Intra-operatively, he had a viable distended bowel and de-rotation was done. Postoperatively, he still had abdominal distension with bilious vomiting and has hypoactive bowel sounds. The most likely cause of ileus is?
Select one:
a. Hypomagnesemia
b. Hypocalcemia
c. Hypokalemia
d. Hyponatremia

Answer 19

The most likely cause of postoperative ileus in this patient is:

c. Hypokalemia

Explanation:

Postoperative ileus, particularly following abdominal surgery, is commonly caused by electrolyte imbalances, among which hypokalemia is the most frequent contributor.

Why Hypokalemia is the Likely Cause:
1. Potassium’s Role in Gastrointestinal Motility:
• Potassium is essential for maintaining smooth muscle function and the action potentials required for peristalsis. Hypokalemia disrupts these processes, leading to reduced bowel activity and ileus.
2. Common Postoperative Factors Leading to Hypokalemia:
• Loss of potassium from vomiting (as seen in this patient with prolonged bilious vomiting).
• Increased renal potassium excretion due to stress or medications (e.g., diuretics, IV fluids without potassium supplementation).
• Poor oral intake during the perioperative period.
3. Clinical Features:
• Abdominal distension, bilious vomiting, and hypoactive bowel sounds are classic for ileus, often exacerbated by hypokalemia.

Why Not the Other Options:
• a. Hypomagnesemia:
• Hypomagnesemia can cause ileus but is less common. It usually occurs alongside hypokalemia and is not the primary cause here.
• b. Hypocalcemia:
• Hypocalcemia primarily causes neuromuscular excitability (e.g., tetany) rather than ileus. It is not a common cause of postoperative ileus.
• d. Hyponatremia:
• Hyponatremia affects the central nervous system more than the gastrointestinal system and is not directly associated with postoperative ileus.

Conclusion:

The most likely cause of ileus in this patient is hypokalemia, making it essential to check and correct serum potassium levels postoperatively.

Question 20

A 65 year – old female patient presented with right upper quadrant pain of a year duration associated with progressive yellow discoloration of the eyes. On examination she has a deep icteric sclera and mild right upper quadrant tenderness and palpable gall bladder. Abdominal ultrasound showed dilated biliary tree but no stone. What coagulation profile is mostly affected in this patient?
Select one:
a. INR
b. Bleeding time
c. PTT
d. PTD

Answer 20

D. PT … the because bole is essential for the absorption of vitamin K and extrinsic factors II,vii,IX and Y. Giving vitamin K helps in correcting the bleeding abnormalities

Question 21

A 55 year-old female was treated for UTI three times in the past two years and urine cultures showed Proteus and Klebsiella species. Currently she has right flank pain, but no previous history of nephrolithiasis. A kidney-ureter-bladder (KUB) view with tomography reveals poorly opacified dendritic stone in the renal pelvis and lower pole calyces. What is the composition of the stone in this patient?
Select one:
a. Magnesium ammonium phosphate stones
b. Calcium phosphate stones
c. Uric acid stones
d. Calcium oxalate stones

Answer 21

The correct answer is:

a. Magnesium ammonium phosphate stones

Explanation:

This patient’s recurrent urinary tract infections (UTIs) caused by Proteus and Klebsiella species strongly suggest struvite stones (magnesium ammonium phosphate stones). These stones form in the setting of chronic UTIs caused by urease-producing bacteria.

Key Features Supporting the Diagnosis:
1. Recurrent UTIs:
• Proteus and Klebsiella are urease-producing bacteria that hydrolyze urea into ammonia, raising urinary pH and promoting the precipitation of magnesium ammonium phosphate.
2. Stone Characteristics:
• Struvite stones are classically described as dendritic and often fill the renal pelvis and calyces, forming a staghorn calculus.
3. Radiographic Findings:
• Struvite stones are radiopaque due to their mineral composition, but they may be poorly opacified on imaging.
4. No History of Nephrolithiasis:
• The stone formation is secondary to infection rather than metabolic disorders.

Why Not the Other Options?
• b. Calcium phosphate stones:
• These are associated with hypercalciuria and renal tubular acidosis, not chronic UTIs.
• c. Uric acid stones:
• These are radiolucent (not visible on KUB) and form in acidic urine, not alkaline urine associated with UTIs.
• d. Calcium oxalate stones:
• The most common type of kidney stone, but they are not directly associated with recurrent UTIs or urease-producing bacteria.

Conclusion:

The composition of the stone in this patient is magnesium ammonium phosphate (struvite stones), which form due to recurrent UTIs caused by urease-producing bacteria like Proteus and Klebsiella.

Question 22

A 55 year-old male patient came to your clinic with symptoms of left side pluritic chest pain ,dry cough high grade fever of one week duration. On P/E, T=38.5oc, RR= 28/min, dullness and decreased air entry over left posterior lung field. Laboratory showed exudative type of pleural fluid and gram positive diplo-cocci. He was stated on antiobiotics. What additional measure would you take?
Select one:
a. Observation
b. Intubation
c. Chest tube insertion
d. Add steroid

Answer 22

The correct answer is:

c. Chest tube insertion

Explanation:

This patient presents with symptoms and signs suggestive of parapneumonic effusion or empyema (infection of the pleural space). The findings include:
• Pluritic chest pain, dry cough, and high-grade fever indicating a likely infectious cause.
• Dullness and decreased air entry over the left posterior lung field, which points to a pleural effusion.
• Exudative pleural fluid and the presence of gram-positive diplococci, likely Streptococcus pneumoniae, further support the diagnosis of empyema.

Rationale for Chest Tube Insertion:
• The presence of exudative pleural fluid (often associated with infection) combined with a likely diagnosis of empyema requires drainage of the pleural fluid.
• Chest tube insertion is the standard procedure for draining infected pleural fluid (empyema) and is necessary to reduce the risk of complications such as sepsis, respiratory failure, or fibrothorax (chronic pleural scarring).

Why Not the Other Options?
• a. Observation:
• Observation alone is not sufficient in this case, as there is a clear infection (empyema) that requires intervention for drainage to prevent complications.
• b. Intubation:
• Intubation is not indicated unless there is severe respiratory distress or failure, which is not evident from the provided clinical data.
• d. Add steroid:
• Steroids are not routinely used in the treatment of empyema or parapneumonic effusion, especially in the early stages. Antibiotics and drainage are the mainstays of treatment.

Conclusion:

The appropriate next step in this patient’s management is chest tube insertion to drain the pleural fluid and treat the underlying infection effectively.

Question 23

A 60 year – old male patient was undergoing surgery for benign prostatic hyperplasia and the estimated intra operative blood loss was 1200 ml , but bleeding controlled at the end of the surgery. What is the best post-operative fluid management of this patient?
Select one:
a. Transfuse with two units of plasma + maintenance fluid
b. Transfuse him with two units of whole blood + maintenance fluid
c. Replace the deficit with equal amount (1200ml) of crystalloids+ maintenance
d. Transfuse him with one unit of whole blood and maintenance fluid.

Answer 23

The correct answer is:

c. Replace the deficit with equal amount (1200 ml) of crystalloids + maintenance

Explanation:

Postoperative fluid management is critical, especially in patients who have undergone surgery with significant blood loss. However, the patient has benign prostatic hyperplasia (BPH) surgery, and the blood loss is considered moderate (1200 ml), which is typically managed with crystalloids.

Rationale for Crystalloid Use:
• Crystalloid solutions (like normal saline or Ringer’s lactate) are the preferred choice for volume replacement following blood loss, especially when the patient is stable and does not show signs of ongoing active bleeding or significant hemodynamic instability.
• The 1200 ml blood loss can be replaced with an equal volume of crystalloids to restore intravascular volume and maintain hydration.
• Maintenance fluids are also needed to meet ongoing fluid and electrolyte requirements.

Why Not the Other Options?
• a. Transfuse with two units of plasma + maintenance fluid:
• Plasma transfusion is typically used in cases of coagulopathy or when a patient requires clotting factor replacement. There is no indication of coagulopathy or significant bleeding requiring plasma here.
• b. Transfuse him with two units of whole blood + maintenance fluid:
• Whole blood transfusion is generally reserved for patients with severe blood loss or shock, especially when hemoglobin levels are significantly low. The estimated blood loss of 1200 ml does not usually warrant whole blood transfusion in a stable patient.
• d. Transfuse him with one unit of whole blood and maintenance fluid:
• Whole blood transfusion is not required for moderate blood loss unless there are signs of hemodynamic instability, significant blood loss, or anemia. In this case, crystalloids should be prioritized over blood products.

Conclusion:

The best approach to post-operative fluid management for this patient is to replace the 1200 ml deficit with crystalloids and provide maintenance fluids to meet ongoing needs.

Question 24

A 60 year old female patient underwent right hemi colectomy for colonic mass. On her sixth postoperative day, she developed abdominal pain with vomiting. On physical examination, PR is 120/min and abdominal examination is notable for distension, otherwise she has no pertinent finding. The most likely diagnosis is?
Select one:
a. Anastomotic leak
b. Paralytic ileus
c. Dehydration
d. Wound infection

Answer 24

The correct answer is:

b. Paralytic ileus

Explanation:

Paralytic ileus is a common postoperative complication, particularly following abdominal surgeries like colectomy. It is caused by a temporary loss of intestinal motility and is often seen within the first week after surgery.

Key Features Supporting the Diagnosis:
1. Timeline:
• The patient developed symptoms on postoperative day 6, which aligns with the typical onset of paralytic ileus.
2. Symptoms:
• Abdominal pain, vomiting, and distension are classic features of paralytic ileus.
• Hypoactive or absent bowel sounds (not mentioned but often present) would further support the diagnosis.
3. Vital Signs:
• The elevated pulse rate (PR = 120/min) may indicate dehydration secondary to vomiting or stress from the condition, but no signs of severe infection or systemic inflammation are present.
4. No Pertinent Abdominal Findings:
• The absence of focal tenderness, peritonitis, or wound-related signs reduces the likelihood of anastomotic leak or wound infection.

Why Not the Other Options?
• a. Anastomotic leak:
• Typically presents with systemic signs of sepsis, such as fever, tachycardia, hypotension, and localized peritonitis. The absence of these findings makes this less likely.
• c. Dehydration:
• While dehydration may contribute to tachycardia, it is not the primary diagnosis. Dehydration would not explain the abdominal distension and vomiting.
• d. Wound infection:
• Wound infections usually present with localized redness, warmth, discharge, or systemic signs of infection. These are not noted in this case.

Conclusion:

The most likely diagnosis is paralytic ileus, which is consistent with the patient’s postoperative course and clinical findings. Further management may include supportive care with fluid replacement, bowel rest, and monitoring for resolution.

Question 25

A 30 year-old male sustains a displaced intra-capsular femoral neck fracture after a motor vehicle collision. On Examination, the neurovascular structures are intact but the injured limb is shortened and externally rotated. What is the most likely expected complication at two year follow-up?
Select one:
a. Malunion
b. Hip instability
c. Chondrolysis
d. Avascular necrosis

Answer 25

The correct answer is:

d. Avascular necrosis

Explanation:

Displaced intra-capsular femoral neck fractures are highly prone to avascular necrosis (AVN) of the femoral head due to disruption of the blood supply. The femoral neck is largely supplied by the medial femoral circumflex artery, and fractures in this region can impair the vascular flow to the femoral head, leading to ischemia and eventual necrosis.

Key Features Supporting the Diagnosis:
1. High Risk for AVN:
• Displaced intra-capsular fractures have a significant risk (up to 30-50%) of causing AVN due to the disruption of the arterial supply to the femoral head.
2. Delayed Complication:
• AVN typically develops gradually, often becoming evident months to years after the injury. At a 2-year follow-up, this is the most likely complication.
3. Clinical Presentation:
• Patients may present with hip pain, stiffness, and limited range of motion if AVN develops.

Why Not the Other Options?
• a. Malunion:
• Malunion is more common in extra-capsular fractures (intertrochanteric or subtrochanteric) and is less likely in intra-capsular fractures, where complications are dominated by AVN or nonunion.
• b. Hip instability:
• Hip instability is uncommon in this scenario if the fracture is properly treated. Proper fixation or replacement (e.g., total hip arthroplasty or hemiarthroplasty) typically restores stability.
• c. Chondrolysis:
• Chondrolysis (loss of cartilage in the joint) is rare and often associated with intra-articular injuries or conditions like slipped capital femoral epiphysis, not femoral neck fractures.

Conclusion:

The most likely complication at a 2-year follow-up for this patient with a displaced intra-capsular femoral neck fracture is avascular necrosis. Early recognition and appropriate management of the fracture can help reduce the risk.

Question 26

A 40 year old male patient sustained road side accident of two hours duration. He complains of generalized abdominal pain. On physical examination, blood pressure-80/40 mmHg, pulse rate- 120/min and feeble. Guarding and rigidity noted on abdominal examination and has bruising over the bilateral flank. Which one is the most likely cause of hypotension?
Select one:
a. Pelvic injury
b. Liver injury
c. Retroperitoneal injury
d. Splenic injury

Answer 26

C . Grey turners sign shows retroperitoneal bleeding

Question 27

A 40 year old male, relatively well patient came with obstipation of two days duration with associated history of abdominal pain and distension. Upon examination, BP -90/60mmHg, PR- 92/min and has dry buccal mucosa. He has tense but non tender abdomen with bloody stool on examining finger. The possible cause of the above complaint is?
Select one:
a. Ileosigmoid knotting
b. Ulcerative colitis
c. Sigmoid volvulus
d. Intussusceptions

Answer 27

The correct answer is:

c. Sigmoid volvulus

Explanation:

Sigmoid volvulus is the most likely cause of this patient’s presentation, given the history, examination findings, and clinical features.

Key Features Supporting Sigmoid Volvulus:
1. Obstipation, Abdominal Pain, and Distension:
• These are classic symptoms of large bowel obstruction, with sigmoid volvulus being a common cause, especially in adults.
2. Bloody Stool:
• Indicates ischemia or strangulation, which are complications of volvulus due to twisting of the bowel and compromise of the blood supply.
3. Tense but Non-Tender Abdomen:
• Suggests distension from bowel obstruction without peritoneal irritation (no perforation yet).
4. Hypovolemia and Dehydration:
• The dry mucosa and BP of 90/60 mmHg with a PR of 92/min suggest dehydration due to fluid shifts and third-spacing associated with bowel obstruction.

Why Not the Other Options?
• a. Ileosigmoid knotting:
• This is a rare condition causing acute obstruction but is usually associated with sudden onset of severe pain, rapid deterioration, and peritoneal signs due to bowel necrosis, which are not described here.
• b. Ulcerative colitis:
• UC typically presents with diarrhea (often bloody), abdominal cramping, and systemic symptoms like fever. It does not usually cause acute obstruction or severe distension as seen here.
• d. Intussusception:
• While it can cause bloody stools (“red currant jelly stool”), it is more common in children. In adults, intussusception is rare and often caused by a lead point such as a tumor, presenting with intermittent pain rather than continuous distension and obstipation.

Conclusion:

The patient’s presentation is most consistent with sigmoid volvulus, a common cause of large bowel obstruction in adults. Immediate confirmation with imaging (e.g., abdominal X-ray showing the “coffee bean sign”) and appropriate management (endoscopic decompression or surgery) are necessary.

Question 28

A 40 year-old male presents with a one month history of heel pain after starting training for The Great Ethiopian Run. The heel is tender when squeezed but no swelling. A foot radiograph is unremarkable. What is the most likely diagnosis?
Select one:
a. Stress fracture
b. Osteomyelitis
c. Acute fracture
d. Subtalar arthritis

Answer 28

The correct answer is:

a. Stress fracture

Explanation:

A stress fracture is the most likely diagnosis in this scenario given the patient’s history, symptoms, and physical examination findings.

Key Features Supporting Stress Fracture:
1. History of Overuse:
• The patient recently started training for a long-distance run, a common activity associated with repetitive stress on bones, particularly the calcaneus (heel bone).
2. Heel Tenderness:
• Tenderness when the heel is squeezed is a hallmark of a calcaneal stress fracture.
3. Absence of Swelling:
• Swelling may not always be present in early stress fractures.
4. Unremarkable Radiograph:
• Stress fractures often do not appear on initial X-rays. They may become visible weeks later as periosteal reaction or callus formation.

Why Not the Other Options?
• b. Osteomyelitis:
• Osteomyelitis typically presents with systemic symptoms (fever, malaise) and localized signs of infection (swelling, erythema, warmth). These are absent here.
• c. Acute fracture:
• Acute fractures usually follow a specific traumatic event, which the patient does not report. Also, acute fractures are usually visible on radiographs.
• d. Subtalar arthritis:
• Subtalar arthritis typically presents with pain and stiffness in the hindfoot, exacerbated by inversion or eversion. It is unlikely in a young individual with no history of joint disease or trauma.

Conclusion:

The patient’s presentation is consistent with a stress fracture of the calcaneus, commonly seen in runners due to repetitive impact forces. Management includes rest, activity modification, and possibly immobilization, depending on severity. Advanced imaging (e.g., MRI or bone scan) can confirm the diagnosis if needed.

Question 29

A 45 year old female patient came with anterior neck swelling of three years duration. She has recently developed weight loss with easy fatigability and palpitation. Upon examination, she has PR of 110/min and has diffusely enlarged thyroid gland with palm sweating on musculoskeletal system. What physical finding indicates primary thyrotoxicosis?
Select one:
a. Fine tremor
b. Facial flushing
c. Proximal muscle weakness
d. Acropachy

Answer 29

The correct answer is:

d. Acropachy

Explanation:

Thyroid acropachy is a rare but specific physical finding that indicates primary thyrotoxicosis (most commonly associated with Graves’ disease). It presents as digital clubbing, periosteal bone formation, and soft tissue swelling of the hands and feet, and is almost always associated with long-standing, untreated or severe Graves’ disease.

Key Features Supporting Acropachy as a Sign of Primary Thyrotoxicosis:
• It is strongly associated with Graves’ disease, which is the most common cause of primary thyrotoxicosis.
• Other manifestations of Graves’ disease include diffuse goiter, exophthalmos, and pretibial myxedema, but acropachy is a highly specific finding.

Why Not the Other Options?
• a. Fine tremor:
• While fine tremor is a common symptom of thyrotoxicosis, it is not specific to primary thyrotoxicosis and can be seen in secondary causes or other hyperadrenergic states.
• b. Facial flushing:
• Facial flushing is a nonspecific finding and can occur in various conditions, including menopause, fever, or hyperadrenergic states.
• c. Proximal muscle weakness:
• Proximal muscle weakness is common in hyperthyroidism, but it is also nonspecific and may be seen in other myopathic or metabolic conditions.

Conclusion:

Thyroid acropachy (option d) is the most specific physical finding indicating primary thyrotoxicosis, particularly in the setting of Graves’ disease. Further evaluation with thyroid function tests (elevated free T4 and suppressed TSH) and thyroid receptor antibody testing can confirm the diagnosis.

Question 30

A 60-year-old male patient, who is on his third postoperative day for colonic cancer, has developed abdominal pain
and vomiting. The pain is a t the epigastric area and it radiates to the back. Abdominal ultrasound shows thickened
gall bladder wall and peri-cholecystic fluid collection but no gallstone. CBC shows WBC count of 19000celo/mm 3,
What is the most effective management for this patient?
O a. Exploratory laparatomy and colostomy
• b. Fluid resuscitation and V antibiotics
O c, I antibiotics and immediate cholecystectomy
• d. Exploratory laparatomy

Answer 30

The most effective management for this patient is:

b. Fluid resuscitation and IV antibiotics

Explanation:

The patient likely has acalculous cholecystitis, a condition characterized by inflammation of the gallbladder without gallstones. This is common in critically ill or postoperative patients and can lead to severe complications if untreated.
1. Key features suggesting acalculous cholecystitis:
• Postoperative state (common in surgical patients).
• Symptoms of abdominal pain radiating to the back and vomiting.
• Ultrasound findings: thickened gallbladder wall and pericholecystic fluid without gallstones.
• Elevated WBC count (19,000/mm³), indicative of infection or inflammation.
2. Initial management:
• Fluid resuscitation: Correct dehydration and maintain perfusion to organs.
• IV antibiotics: Broad-spectrum antibiotics targeting gram-negative and anaerobic bacteria are crucial to control infection.
3. Definitive management:
• If symptoms persist or complications develop, a percutaneous cholecystostomy (gallbladder drainage) may be needed.
• Immediate cholecystectomy is generally avoided initially in acalculous cholecystitis, especially in unstable or postoperative patients, as it carries high surgical risk.

Why not the other options?
• a. Exploratory laparotomy and colostomy:
• Not indicated unless there are signs of bowel obstruction or perforation, which are not mentioned here.
• c. IV antibiotics and immediate cholecystectomy:
• Immediate surgery is too risky in this postoperative patient and is not the first-line treatment for acalculous cholecystitis.
• d. Exploratory laparotomy:
• Not warranted unless there is suspicion of a surgical emergency, such as perforation or ischemic bowel.

Conclusion:

The most effective initial management is fluid resuscitation and IV antibiotics, followed by close monitoring and further intervention if needed.

Question 31

A 51-year-old male patient came to a regular OPD with complaints of constipation and rectal bleeding He is
chronically sick looking and has pale conjunctiva. On per-rectal examination there is no fissure on hemoithold. What
is the m o s t appropriate diagnostic method in this patient’s care?
D a Abdomino-pelvic US
D o . Colonoscopy
Air-contrast enema
D d . Fecal Occult blood test

Answer 31

The most appropriate diagnostic method in this patient’s care is:

b. Colonoscopy

Explanation:

Given the patient’s symptoms of constipation, rectal bleeding, pale conjunctiva (indicating anemia), and chronic illness, a serious underlying gastrointestinal condition such as colorectal cancer or inflammatory bowel disease should be considered. A colonoscopy is the gold standard for evaluating the colon and rectum in such cases and can help diagnose:
• Colorectal cancer
• Polyps
• Inflammatory bowel disease (e.g., ulcerative colitis, Crohn’s disease)
• Other causes of rectal bleeding

Why not the other options?
• a. Abdomino-pelvic US:
• While useful for diagnosing abdominal or pelvic organ pathologies (e.g., liver, kidneys, bladder), ultrasound is not effective for evaluating the colon or detecting colorectal cancer.
• c. Air-contrast enema:
• This was once used for detecting colon issues but has largely been replaced by colonoscopy due to its superior accuracy and ability to biopsy abnormal tissue.
• d. Fecal Occult Blood Test (FOBT):
• This test can detect hidden blood in the stool, which may indicate a gastrointestinal bleeding source, but it is not a diagnostic test and should not be relied upon solely to establish a definitive diagnosis. It is more of a screening tool.

Conclusion:

Colonoscopy is the most appropriate method for diagnosing the cause of this patient’s symptoms, including rectal bleeding, constipation, and anemia, as it allows for direct visualization of the colon and rectum and potential biopsy if needed.

Question 32

A 32-year-old male patient sustained road traffic accident after a car he was in rolled over many times, He was
immediately brought t o a n emergency room and he was conscious and complaining right side flank pain and reddish
discoloration o f urine. What best investigation modality should be used to identify the cause of hematuria?
t i o n
O a . CT with V contrast
• b. Csytouerethrogram
• c. Abdominopelvie ultrasoung
• d. Plain abdominal X-ray

Answer 32

The best investigation modality to identify the cause of hematuria in this patient is:

a. CT with IV contrast

Explanation:

Given the road traffic accident and the presence of flank pain and hematuria, the patient is at risk for renal or urinary tract injury. A CT scan with intravenous (IV) contrast is the most effective imaging modality to evaluate potential traumatic injuries, including:
• Renal lacerations or contusions
• Urinary tract injuries (bladder, urethra)
• Retroperitoneal hematomas

The IV contrast helps to clearly delineate injuries to the kidneys, ureters, and bladder and can also help identify any associated fractures or other injuries.

Why not the other options?
• b. Cystourethrogram:
• Typically used to evaluate bladder or urethral injuries, especially in cases of suspected trauma to the lower urinary tract. However, it is not as effective for evaluating the kidneys or other organs for injuries resulting from trauma.
• c. Abdominopelvic ultrasound:
• While it is a non-invasive imaging modality, it has limited sensitivity in detecting renal injuries or evaluating the full extent of trauma. It is not as definitive as CT with contrast for traumatic injuries.
• d. Plain abdominal X-ray:
• X-rays are not sufficient to assess soft tissue or organ injuries like those to the kidneys or bladder, and they do not provide detailed information regarding hematuria sources or renal trauma.

Conclusion:

A CT scan with IV contrast is the most appropriate initial investigation for this patient to evaluate potential trauma to the kidneys or urinary tract and identify the cause of hematuria.

Question 33

A 65-year-old male patient came with abdominal pain of three days duration. Associated with this he had abdominal
distention and failure to pass feces and flatus. His pulse rate was 120/min and respiratory rate was 32/min. Plain
abdominal x-ray showed coffee bean appearance, with the convexity of the loop lying in the right upper quadrant.
What is the most likely diagnosis?
a. Large bowel obstruction secondary to decal volvulus
• b. Large bowel obstruction secondary to sigmoid volvulus
@cLarge bowel obstruction secondary to rectal cancer
d Small bowel obstruction secondary to small bowel volvulus
5 5

Answer 33

The most likely diagnosis in this case is:

b. Large bowel obstruction secondary to sigmoid volvulus

1. Clinical Presentation:
   
   • The patient has symptoms of large bowel obstruction, including:
     
     • Abdominal pain.
     • Abdominal distention.
     • Failure to pass feces and flatus (obstipation).
   • The elevated pulse rate (120/min) and respiratory rate (32/min) suggest systemic distress, which can occur in bowel obstruction.
2. Radiological Findings:
   
   • The coffee bean appearance on plain abdominal X-ray is a classic sign of sigmoid volvulus.
   • In sigmoid volvulus, the twisted loop of the sigmoid colon forms a characteristic shape resembling a coffee bean, with the convexity typically pointing toward the right upper quadrant.
3. Sigmoid Volvulus:
   
   • Sigmoid volvulus occurs when the sigmoid colon twists around its mesentery, leading to obstruction and potential ischemia.
   • It is more common in elderly patients and those with chronic constipation or a history of neurological disorders (e.g., Parkinson’s disease).

• a. Large bowel obstruction secondary to cecal volvulus:
  
  • Cecal volvulus typically presents with a coffee bean appearance in the left upper quadrant, not the right upper quadrant.
  • It is less common than sigmoid volvulus.
• c. Large bowel obstruction secondary to rectal cancer:
  
  • Rectal cancer can cause obstruction, but it would not produce the coffee bean sign on X-ray. Instead, it might show a mass or stricture in the rectum.
• d. Small bowel obstruction secondary to small bowel volvulus:
  
  • Small bowel obstruction would present with different radiological findings, such as multiple air-fluid levels and a “string of pearls” appearance. The coffee bean sign is specific to large bowel volvulus.

1. Immediate Stabilization:
   
   • Administer IV fluids and correct electrolyte imbalances.
   • Insert a nasogastric tube to decompress the stomach.
2. Non-Surgical Reduction:
   
   • Perform sigmoidoscopy or colonoscopy to attempt detorsion of the volvulus.
   • Place a rectal tube to relieve the obstruction.
3. Surgical Intervention:
   
   • If non-surgical methods fail or if there are signs of bowel ischemia (e.g., peritonitis, sepsis), surgical resection of the affected segment may be required.

In summary, the patient’s symptoms, clinical findings, and radiological features strongly suggest sigmoid volvulus as the most likely diagnosis. Prompt intervention is essential to prevent complications such as bowel ischemia or perforation.