B14 end of semester 9

PLASTIC SURGERY

1/ a 40-year old man is burned while sleeping at home. His right upper and lower extremity and
the anterior aspect of the upper chest have extensive 2 nd degree burn.

The extent of the burn is calculated as

a) 10%
b) 20%
c) 30%
d) 40% *
e) 50%

2/ a 60-year old woman has a 4 cm diameter lesion on her right shin. It has been growing for the
last year. It has a central area of crusting, under which is a deep ulcer. Around the periphery there
is an indurated margin. The picture is of which of the following?

a) benign mole
b) malignant melanoma
c) squamous cell carcinoma *
d) basal cell carcinoma
e) Marjolin,s ulcer

3/ a 50-year-old man presents with problems with right index finger. He said that it gets stuck when
he bends his finger, and he has to manually straighten it. He has no history of trauma to the area.
The most possible diagnosis is

A/ de Quervain,s tenovaginitis

B/ Dupuytren,s contracture

C/ Mallet finger

D/ tendon sheath infection

E/ trigger finger *
Lower GI

1/ A 60 year – old man presents extremely unwell with left – sided abdominal pain, fever and
shock. At emergency laparotomy he is found to have a large tumour of the sigmoid colon, which
has perforated causing faecal contamination. What is the most appropriate operation?

a. Left hemicolectomy and primary anastomosis.

b. Sigmoid colectomy.
c. Hartman’s procedure. *
d. Anterior resection.
e. Ab dominoperineal resection.

2/ Diverticulosis of the colon commonly occurs in:

A. Sigmoid colon*
B. Caecum
C. Transverse colon
D. Rectum
E. Ascending colon

3/ A left sided colonic cancer frequently presents with

a. Occult blood in the stool.

b. Anemia.

c. Morning diarrhea.

d. Intestinal obstruction.*

e. Feculent vomitus.

4/ a 25 – year-old man has recurrent fistula in ano. He also complains of weight loss, recurrent
attacks of diarrhea with blood mixed in the stool and tenesmus. Proctoscopy revealed a healthy
normal rectum. What is the most likely diagnosis?

a) Crohn’s disease *
b) Ulcerative colitis
c) Amoebic colitis
d) Ischemic colitis
e) Colitis associated with AIDS
NEUROSURGERY

1/ Raised intracranial pressure can be treated with all of the following EXCEPT:

a) Elevation of the head of the bed

b) Drainage of cerebrospinal fluid through a ventriculostomy
c) Hypoventilation *
d) Intravenous mannitol
e) Intravenous urea

2/ The level of consciousness for a head injury patient is BEST evaluated by:

a) Glasgow coma scale *

b) Response to pain
c) CT scan
d) Pupillary response
e) Visual stimulated potentials

3/ in the management of a 55-year old woman struck by a car, mannitol is given to do which of
the following?

a) Increase CSF formation.

b) Increase the respiratory rate.
c) Increase the pulse rate.
d) Replace fluid loss.
e) Lower raised intracranial pressure (ICP) *

OTHERS

1/ Murphy’s sign is positive in:

a. Acute appendicitis
b. Acute cholecystitis*
c. Perforated duodenal ulcer
d. Acute pancreatitis
e. Acute gastritis

2/ Fluid thrill is a sign that is elicited by:

a) Listening to the abdomen in different positions

b) Listening to the chest in different positions
c) Percussion the chest in case of pleural effusion
d) Percussion of the abdomen from midline towards the flanks
e) Tapping the abdomen by one hand and feeling by the other *
EMQs

Theme: diagnosis of billiary tract disease

A/ acute cholecystitis

B/ ascending cholangitis

C/ chalangiocarcinoma

D/ choledocolithiasis

E/ chronic cholecystitis

F/ billiary colic

G/ gallbladder perforation

H/ primary sclerosing cholangitis

For each of the following scenarios, select the most likely diagnosis. Each option may be used once,
more than once or not at all.

1/ a 60-year-old woman presents with worsening jaundice and weight loss. An abdominal ultrasound
shows dilatation of the common bile duct. Magnetic resonance cholangiopancreatogram confirms an
irregular stenosing lesion in the common bile duct. (C)

2/ a 50-year-old woman with known gallstones presents with 12-month history of indigestion attacks
and flatulence. Symptoms occur after meals and last for one hour. On examination, she is obese, not
anaemic or jaundiced. Her abdomen is soft and non-tender. (E)

3/ a 38-year-old woman presents with a 48-hour history of right upper quadrant pain, nausea and
vomiting. On examination, she is clinically jaundiced and her temperature is 38.5 C*. An abdominal
ultrasound shows multiple stones in the gallbladder and a common bile duct diameter of 9mm.
(A)
Theme: management of head injury

A/ admit for neurological observation

B/ CT head scan

C/ send home with written advice

D/ intubation and ventilation

E/ refer to neurosurgery

For each of the following patients presenting with head injury, select the most appropriate
management. Each option may be used once, more than once or not at all.

1/ a 40-year-old man fell down the stairs and hit his head. His son said that he lost consciousness for
a minute. The patient does not have amnesia and his Glasgow coma score is 15. (C)

2/ a 60-year-old man fell at home. He appears well, but it was apparent that he has been drinking.
He has a large laceration to his head and skull X-ray shows a hairline fracture on the left side.
(A)

3/ a 20-year-old woman is involved in a road traffic accident. She is unresponsive, makes no

response to painful stimuli. She has a swelling over the left temporal region.
(D)

PROBLEMS

TRAUMA

A driver of a motor vehicle involved in a head-on collision with another vehicle, was transferred to
accident and emergency department. He was fully conscious and communicative but becoming
increasingly breathless, with central cyanosis. On examination, he has bruising over his right upper
chest, trachea is shifted to the left, hyper-resonant right chest with diminished breath sounds.

1/ The most probable diagnosis would be

a) Right hemothorax
b) Tension pneumothorax *
c) Right pulmonary contusion
d) Myocardial contusion
e) Ruptured thoracic aorta
2/ The ER doctor performed the required initial steps and asked for one urgent blood investigation
to be done

a) Random blood sugar

b) Haemoglobin and haematocrit value
c) Serum amylase level
d) Arterial blood gases *
e) Blood grouping

3/ He was sent then for radiological assessment to confirm the diagnosis which should be

a) Ultrasound of the chest

b) CT scan of the chest
c) MRI of the chest
d) Postero-anterior and lateral chest X-ray *
e) Ventilation – perfusion scan of the chest

4/ Following confirmation of the diagnosis an urgent action was decided which should be

a) Urgent insertion of a chest tube.*

b) Urgent right thoracotomy
c) Urgent start of mechanical ventilation
d) Urgent pericardiocentesis
e) Urgent blood transfusion

BREAST

A worried 45-year-old woman attending the breast clinic, gives a three-week history of a blood-
stained discharge from her right nipple. On examination, there is no thickening or eczema of the
nipple and no palpable lesion in the underlying area. Other breast is free.

1/ The examining doctor mentioned that he likes to carry another examination which is relevant to
the case

a) Measure the body temperature

b) Examine the heart
c) Examine the axillae *
d) Gynaecological examination
e) Chest X-ray
2/ After he finished with examination he ordered a radiological investigation to help him in the
diagnosis

a) US of the breast
b) Mammography *
c) CT breast
d) MRI breast
e) Radioactive scan of the breast

3/ To finalize his diagnosis another investigation was required

a) FNA
b) Incision biopsy
c) Cytology test of the nipple discharge *
d) Culture and sensitivity of the nipple discharge
e) Wire – guided biopsy

PRE-OPERATIVE ASSESSMENT

A 60-year-old man is assessed for an emergency laparotomy for peritonitis due to colonic
diverticular perforation. He passes 45 ml of urine over the last two hours, his blood count and serum
biochemistry are

Hb : 9.8 g/l WBC: 21000 cells/cmm

Na: 145mmol/l K: 5.6 mmol/l

HCO3: 30 mmol/l urea: 60 mmol/l

The above results shows that he has

a) Respiratory alkalosis
b) Respiratory acidosis
c) Metabolic alkalosis
d) Metabolic acidosis*
e) Hyperkalemic alkalosis

He was found to have renal malfunction, his doctor decided to improve it using many tools including

a) Intravenous antibiotics*
b) Peritoneal dialysis
c) Concentrated saline solution 3%
d) Fresh frozen plasma
e) Mannitol infusion
Following optimizing his condition, he was operated upon with

a) Sigmoid colectomy with end to end anastomosis

b) Closure of the perforation
c) Total colectomy with ileo-rectal anastomosis
d) Hartmann,s procedure*
e) Peritoneal wash and drainage

1/ The above shown picture is

a) Oral cholecystogram
b) Ba. Swallow
c) Ba.enema
d) ERCP*
e) Intravenous urography (IVU)
2/ There is evidence of the pathology as

a) Stones in the gallbladder

b) Stones in the common bile duct*
c) Renal stones
d) Achalasia of the oesophagus
e) Diverticular disease of the colon

3/ One of the complications of this procedure could be

a) Aspiration pneumonia
b) Perforation of the bowel
c) Acute pancreatitis *
d) Renal failure
e) Anaphylactic shock

1/ The above lesion followed a thorn prick injury, it bleeds easily to touch, mildly tender. This could
be

a) Squamus cell carcinoma

b) Malignant melanoma
c) Inclusion cyst
d) Foreign body granuloma*
e) Cavernous haemangioma
2/ This should be treated with

a) Local antibiotic ointment

b) Daily dressing
c) Diathermy excision*
d) Finger amputation
e) radiotherapy

1/ The above picture is which of the following

a) ultrasound of the thyroid gland

b) ultrasound of the parotid gland
c) radioactive scan of the thyroid gland*
d) radioactive scan of the heart
e) MRI of the uterus
2/ It shows clearly the pathology

a) Stone in the parotid gland

b) Cold nodule of the thyroid gland*
c) Hot nodule of the thyroid gland
d) Ventricular septum defect of the heart (VSD)
e) Molar pregnancy

The above neonate has this lesion in his low back, he was born with it

1/ This most probably is

a) Cavernous haemangioma
b) Lymphangioma
c) Birth injury to the back
d) Infected placental remnant
e) Meningocele*

2/ This should be treated with

a) Daily dressing
b) Antibiotic ointment
c) Surgical repair*
d) Radiotherapy
e) Diathermy