SURGERY POSSIBLE QUESTIONS | CLINICAL MEDICINE |

 

1. A 25 years old male has a right side scrotal swelling which is associated with vomiting and abdominal distension what is the probable diagnosis?

1. Reducible inguinal hernia

2. Irreducible inguinal hernia

3. Obstructed inguinal hernia

4. Strangulated inguinal hernia

5. Non of above

2. A 6 years old boy sustained a burn injury with hot water, on examination has blisters on the thigh. What is the degree of tissue injury?

1. First degree

2. Second degree

3. Third degree

4. Fourth degree

5. Full thickness burn

3. A 30 years old female resents at OPD following a motor traffic accident. On examination her hip is flexed, internally rotated and adducted, what is the most likely diagnosis?

1. Fracture of femur

2. Open book fracture of pelvis

3. Posterior dislocation of the hip

4. Anterior dislocation of the hip

5. Central dislocation of the hip

4. What are the most common causative agent of osteomylitis

1. Streptococci species

2. Salmonella species

3. Mycobacterium tuberculosis

4. Staphylococcus aureus

5. E. coli

5. A 30 years old male present at the hospital with high grade fever, on examination he is unconscious BP 60/40mmhg, pulse rate of 136bpm. What is the most likely diagnosis?

1. Hemorrhagic shock

2. Cardiogenic shock

3. Neurogenic shock

4. Septic shock

5. Anaphylactic shock

6. A punched out edge is a characteristic of which type of ulcer;

1. Non specific ulcer

2. Malignant ulcer

3. Tuberculosis 

4. Rodent ulcer

5. Syphilitic 

7. A one year old boy presents with retracted painful swelling on the foreskin. On examination the glans penis is visible and edematous. What is the most likely diagnosis;

1. Penile contracture

2. Acute urethritis

3. Paraphimosis

4. Meatal ulcer

8. A 2 years old child brought at mvumi DDH with history of falling down from a tree. He sustained left tibia fracture. You have decided to refer him for x ray examination. What method of immobilization is best for this child before referral

1. Complete P.O.P cast

2. GALLOW’S traction

3. Internal fixation 

4. External fixation

5. Splint 

9. The following are clinical features of peptic ulcer disease;

1. Burning epigastric discomfort

2. Diffuse abdominal rigidity

3. Vomiting blood 

4. Rebound tenderness

5. Pain which is aggravated by taking food and radiates to the back

10. About wound repair;

1. Wound is observed for seven days in delayed primary closure

2. Secondary closure is performed when the infection is under control

3. Primary wound closure should be done in all wounds

4. Is highly indicated in soft tissue injuries

5. Is not indicated in animal bite

SECTION B: MULTIPLE TRUE/FALSE QUESTIONS                             10 marks

Instructions:

• This section consist of (4) questions with (5) options each

• Write the word TRUE for correct statement and word FALSE for a wrong statement 

• Half (1/2) a mark will be awarded for each correct response

1. Concerning osteomylytis;

1. TRUE      presents with limited use of limb

2. FALSE      Chronic osteomylytis always presents with fever and pain

3. FALSE      in chronic osteomylytis x-ray usually is not diagnostic

4. TRUE      defferential diagnosis could be acute septic arthritis

5. TRUE      chronic osteomylytis may present with no sighns

2. The following statement are true about management of shoulder and elbow dislocation;

1. TRUE            patient can be referred for x –ray examination

2. TRUE            give IV sedation and pain killer before reduction

3. FALSE          open reduction is the method of choice in emergency

4. TRUE            use Kocher’s method in reduction of shoulder dislocation

5. FALSE          Hippocrates is the method used to reposition elbow dislocation

3. Scrotal swelling which you can go above the swelling during examination include;

1. TRUE       Hydrocele

2. FALSE     inguinal hernia

3. FALSE     Enlarged inguinal lymph node

4. TRUE       varicocele

5. TRUE       testicular tumor

4. Considering urine retention;

1. FALSE      Chronic retention is usually painful

2. FALSE      Acute retention is rare and painless

3. TRUE        If caused by Paraphimosis the management is circumcision

4. TRUE        Suprapubic puncture is for temporary relief

5. TRUE        Is managed by urethral catheterization

SECTION C: MATCHING QUESTIONS                                                   10 marks

Instructions:

• This section consist of (2) questions of matching with (5) options each.

• Match the items in column B with those in A by writing  a letter of correct response in the space provided

• Each correct response is awarded (1) mark; Each item from B is used only once

1. Match the following

COLUMN A (type of wound edges)	COLUMN B ( Example of an Wound/Ulcer)
1.     D               Slopping edges	A.   Squamous cell carcinoma
2.      F                Punched out edges	B.   Edge of a wound
3.      G               Raised edges	C.    Healing wound
4.      E               Undermine edges	D.    Healing ulcer
5.      A               Rolled out edges	E.     Tuberculous ulcer
	F.      Trophic ulcer
	G.     Basal cell carcinoma
	H.      Spreading ulcer

2. Match the following 

COLUMN A (Urinary Symptoms)	COLUMN B (symptom explanation)
1.     C            Hesitancy	A.   abnormal projection of urine
2.     D            Intermittency	B.   sensation of incomplete bladder emptying.
3.     G           Urgency	C.   delay in initiation of urination
4.     E           Nocturia	D.   interruption of urine stream
5.     H          Dysiuria	E.   urinating more than 2 times at night
	F.    need to urinate frequently during the day.
	G.   unsurpassable desire to urinate
	H.   painful urination

SECTION D: SHORT ANSWERS QUESTIONS                                            40 marks

Instruction

• This section consist of (8) question

• Write your answer on the space provided

• Dirt word is not allowed

1. A 20 years female brought at mvumi DDH with right iliac fossa pain associated with fever and vomiting, the pain started around the umbilicus and latter localized on the right ileac, laboratory investigation revealed leucocytosis.

1. What is the most likely diagnosis (1mark)

Acute appendicitis

2. List four deferential diagnosis (4points 1mark each)

• Acute cholecytitis 

• Perforated peptic ulcers

• Meckel’s diverticulitis

• Pelvic inflammatory diseases (Salpingitis) 

• Ectopic pregnancy 

• Twisted ovarian cyst 

• Ruptured ovarian follicles

• Right ureteric colic/ stones

• Right sided acute pyelonephritis 

• Right sided testicular torsion

2. A 30 years male who has history of untreated epigastric pain of burning in nature, now present with history of severe generalized abdominal pain which is associated with high grade fever. On examination he has rebound tenderness and muscle guarding.

1. What is the appropriate diagnosis (2mark)

• Peritonitis secondary to perforated peptic ulcer

2. What are the possible complication if the above patient is operated (3points 1mark each)

Septicaemia

Wound sepsis

Hypovolaemic shock with electrolytes imbalance

Anaemia

Iterstinal obstruction

3. List down causes of paralytic ileus (5points 1mark each)

1. Postoperative

2. Hypokalaemia

3. Uremia

4. Diabetic coma or ketoacidosis 

5. Hypothyroidism

6. Spinal cord injury

7. Hirschsprung’s disease

8. Peritonitis

9. Pharmacological

4. A 26 years old male is involved in the a motor vehicle accident. He complains of pain and inability to use his right shoulder. Clinically, he has lost shoulder contour. His radial pulse is well felt and there is no open wound or any other injuries.

1. What is the most likely diagnosis?                      (2mark)       

Shoulder dislocation 

2. What is the confirmatory investigation                             (1mark)

x-ray of right shoulder

3. List down two methods/maneuvers that can be used to manage this patient (2mark)

1. Hippocrates methods

Kochers method

5. Write down features of benign prostate hypertrophy on digital rectal examination (5points 1mark each)

1. Firm,                                        

2.    Symmetrical,                                  

3.    Not nodulated ,                                  

4.   Median sulcus present,                       

5.   Free rectal mucosa.  

6. List down five cardinal signs of inflammation (5points 1mark each)

1. Heat 

2.  Redness 

3.  Pain 

4.  Swelling 

5.  Loss of function 

7. A 41 years old man presents with gradual onset of painless swelling in the scrotum over the past four years progressively increasing in size. On examination scrotal swelling is soft, can go above it and trans-illumination test positive.

1. What is the provisional diagnosis                                                    (1 mark)

Hydrocele 

2. Give reasons why aspiration is not recommended in the treatment of this patient   (4 mark)

1. Recurrence is about 100%

2. Infection can be introduced

3. Hemorrhage can occur

4. Puncture of testis may occur

8. A 24-year-old female was admitted to the hospital after a motor vehicle accident. She sustained a right humerus fracture, multiple rib fractures and a contusion over her right lower leg. The next morning, she was complaining of severe pain in her right lower leg. Her temperature was 37.2°C, heart rate was 96/min, respiratory rate was 18/min, and blood pressure was 140/82 mmHg. Physical examination reveals a tense swelling around the right calf region. The pain is worsened on palpation and passive movements of the foot. Neurological examination reveals motor weakness and hypoesthesia of the distal right leg.

1. What is the most likely diagnosis? 2 mark 

• Acute compartment syndrome

2. How will you manage? (3mark @ 1mark)

• Elevate the limb

• Iv fluids

•  Observe carefully for improvement

• If no improvement refer for immediate surgical decompression (fasciotomy)

1. A 45 years old male presents to you with history of abdominal pain, distension and constipation for 5 days, these features are associated with vomiting but no history of fever. However he has a history of abdominal surgery 3 years ago.

1. What is the accurate diagnosis

• Intestinal obstruction secondary to adhesion 2mark

2. Discus pre referral management (Investigation and treatment) each point 2 mark

• Correction of fluid and electrolyte imbalance iv fluids

• Nasogastric decompression

• Nil per oral

• Prophylactic antibiotics

• Hb level& blood grouping

• Cathetelization 

2. A 78 years old male presented to your health center complaining frequent waking up at night for urination, weak stream and sense of incomplete bladder emptying after urination for the past six month. He also complains of burning sensation during urination for the past one week and hypogastric region is distended and tender to palpation.

Discus management of this patient.

Provitional diagnosis (3mark)

• Acute urine retenstion secondary to BPH                                 (1mark)

• UTI                                                                                            (1mark)

Due to distended tender abdomen and burning sensation   (1mark)

Pyhysical findings                             (2mark)

• Differential diagnosis                          4 mark

• Urethral stricture

• Carcinoma of the prostate

• Bladder stone

• Phimosis and para phimosis

• Spinal card disase

• Investigation                                 2 mark

• Urinalysis

• RFT

• PSA

• Treatment                            4mark

• Urethral cathetalization

• SPC if cathealization per uethraal fails

• Ciprofloxacine

• Reter patient for surgical intervesion

1. A 34 year old man presented to the health center with complains of swelling of the groin for 1 year, abdominal distension and vomiting for 1 day. This swelling was on and off for the past one year but didn’t disappear for the past 2 days. On examination: dry mucous membrane with mild palmar pallor. Local examination: inguino-scrotal swelling which cant get above it with tenderness on palpation. Per abdomen: distended abdomen,hyper-tympanic with exaggerated bowel sound. Describe the management of this patient and complications which may occur due to this condition/15 

Dx obstructed inguinal hernia/2

Reason (4points @1 mark)

• Abd pain

• Vomiting

• Exag bowel sound

• Inguinal scrotatal swelling which cant get above it

Investigations 

• Hb level/1

• Blood grouping/1

• Rbg/1

Rx (6points@1mark each)s

• Iv line with iv fluids

• Urethral catheterization

• Iv broad spectrum antibiotics

• NGT for decompression

• Nil per oral

• refer

2.  A 25 years old boy is brought to hospital complaining of sudden onset of abdominal pain followed by progressive abdominal distension and inability to pass stool and flatus for 2 days, vomiting and fever for 1 day. The vomitus has offensive smell.

Describe the management of this patient./15 marks

Dx intestinal obstruction/2

Reason

• Abd pain/1

• Abd distension/1

• Inability to pass stool/1

• Voimiting/1

Ddx intestinal perforation/1

Investigations:

• FBP/1

• Blood group and cross match/1

Rx:

• NGT /1

• Iv fluids/1

• Antibitics/1

• Urinary catheter/1

• Surgical operation/1

• Conclusion/1

3. A40- years lady presents at Songea regional hospital with complains of sudden onset of abdominal pain which started at the umbilicus two day ago and currently shifted to the right iliac fosa. The pain was associated with nausea and vomiting. On examination: temperature is 38.7C, PR = 86 beats/minute, BP = 110/74 mmHg and rebound tenderness at the right iliac fossa. 

• Describe the management of this patient based on the diagnosis, differential diagnoses, investigations and treatment.

Answer

Diagnosis: Appendicitis 

Reasons: -Abdominal pain which started at the umbilicus and shifted to the right iliac fossa 

                      -Rebound tenderness at the iliac fossa 

      Definition : appendicitis is a condition characterized by inflammation of the vermiform    appendix.

The differential diagnosis : (any 3@ 1 marks)

• Regional enteritis 

• Ureteric colic

• Perforated peptic ulcer

• Pancreatitis

• Cholecystitis

• Tersion/rupture of ovarian cyst,

• Renal colic

• Diverticulitis

• PID

• Ectopic pregnancy

• UTI

• Lymphadenitis

Investigation  (any 4@1 Mark)

• Ultrasonography (diagnosis and ruling out ectopic, adenitis…)

• Full blood picture – Leukocytes

• Urine for pregnancy test 

• Urine for WCB

• Blood grouping and cross match 

Treatment

General measure (any 4@ 1 Mark)

• Establish IV access and give fluid for hydration preferably Ringers lactate

• IV antibiotics ( Ampicillian or Ceftriaxone plus metronidazone )

• Administer parenteral antibiotics 

• Keep the patient nil per Oral

• Catheterize the patient

Specific treatment ( 1 Mark )

• Appendectomy is the curative treatment.

Postoperative management ( 1 Mark )

• IV fluid Ringer lactate /Normal saline

• Continue with antibiotics 

• Monitoring ( temperature, PR, RR, BP, urine output…)

4. A 10-year-old girl weighing 24kgs was brought at Iringa regional hospital 2 hours after sustaining the burn injury to the anterior chest, abdomen and the anterior aspect of the right lower limb by hot water. Local examination revealed a pink skin with tender multiple blisters.

Describe the management of this patient.

Answer

Diagnosis: is 2nd degree burn with 27% BSA

Body surface area burn;

• Anterior chest=9%

• Abdomen=9%

• Lower Limb=9%

• Total = 27%

Investigation ( describe any 4 @ 1 Mark )

• Full blood picture

• Serum electrolyte

• Blood grouping and cross matching

• Liver function test

• Renal function 

• Arterial blood gas

Fluid management

For the first 24 hours

• Formular: parkland ( 4mls/kg x BSA )

• = 4 x 24 x 27

• = 2592mls ~ 2600mls

• 1300mls will be infused for 8hours and 1300mls will be infused for the rest 16 hours to make a total of 24 hours.

• Use Ringers lactate

The next day: Maintenance fluid:

• Formula: 100mls/kg for the first 10kgs and 50mls/kg for next 10kg and 20mls/kg for the rest kgs.

• = ( 1000 + 500 + 80 )

• = 1580mls for 24 hours

• Use dextrose saline 5% dextrose

Other supportive management

• Give analegesia which is opioid ( IM Pethidine 25mg 6hourly for 2days )

• Catheterize the patient to monitor urine output.

• Wound management ( @0.5 Mark )

• Irrigation of the wound with Normal saline.

• Wound dressing

• Tetanus toxoid 0.5mls stat

• Monitor vitals (Temperature Pulse rate, respiratory rate, urine output and blood pressure)

5. A 45- year woman present at a dispensary with complaints of constipation for 5 days, vomiting and abdominal pain for 2 years. On examination: distended abdomen with decreased movement with respiration generalized tenderness, hyper-tympanic with diminished bowel sounds. Describe the management of this patient and its related complications.

Answer.

Diagnosis 

Intestinal obstruction

Reasons 

Constipation, vomiting, abdominal distension generalized tenderness, hyper-tympanic and diminished bowel sound.

Investigation

Haemoglobin level

Blood grouping

Treatment 

• Give IV fluid preferably RL or NS

• Inset indwelling urethral catheter

• Insert NGT  and Nil per oral

• IV broad spectrum antibiotics

• IV Ampicilin 500mg stat

• IV Metronidazole  500mg stat

• IV Gentamicin 80mh stat

• Urgently refer the patient

6. A 32 years old man present to the hospital with complaints of fever and painful thigh for 5 days.  On examination, Temperature is 38.6oC, PR 112 6/min, BP 100/70mmHg.  He has slightly enlarged fluctuant right thigh covered with disquarmed skin, very tender right thigh with reduced movement of both right hip and right knee joint movement.  How will you manage this patient? Answers:

1. Diagnosis                                        (2 Marks)

• Rt thigh abscess

• ddx – Cellulites/fasciitis

2. Investigations:                                    (3 Marks)

• FBP

• Blood grouping and X-match at least 2 units

• Blood for culture and sensitivity

• RBG

• Urinalysis

• PITC

3. Management:                                    (10 Marks)

• Start IV antibiotics: Inj Ampiclox 1gm 8 hrly; I.V Metranidazole 500mg 8hrly X 72 hrs then review and change according to culture result.

• Counsel the patient on the operative procedure and get consent.

• Alert the OT team

• Perform Incision and drainage of the abscess on Rt thigh under general anaesthesia.

• Leave open the incision to allow more drainage of pus.

• Transfuse blood if needed

• Dress the wound daily until the wound has no more pus and is pink with granulation.

• Perform secondary wound suturing after granulation 

• Manage the risk factor found: e.g. if diabetic start on insulin regime if HIV positive refer to CTC on discharge for counseling ART

• 
  

7. A young man unknown is brought to the casualty after being involved in motor vehicle accident. On examination is unconscious with a bleeding laceration on the scalp.  He opens his eyes on painful stimulation, flexes his limb on painful stimuli and gives incomprehensible sounds. Describe his condition and how is he going to be managed.       

8. A 50 years old man with 70 Kgs, was brought to you with history of thermal injury 3 hours ago. On examination you find that the anterior chest, abdomen and both upper limbs are affected with huge blisters and wounds.  He is conscious but in severe pains.  Explain the management of this patient based on estimation of percentage of burnt area, investigation, treatment and immediately complications.                                    (15 Marks)

Answer

 Diagnosis – Burn                                      (1 Mark)

Percentege                                          (2 Mark)

Anterior trunk is 18%

Each upper limb is 9% x 2 = 18%,

   Total area burnt = 36%

Treatment                                          (8 Mark)

 Fluid resuscitation principles

 Insert intravenous cannula (16G or 14G) through unburned skin.

Popular formulas: Modified Brooke (2 ml) and Parkland (4ml)/kg/%BSA).

 In the first 24 hours post burn, 

• Use Parkland formula.

• Give Ringer’s Lactate 4ml x % of BSA x body weight (kg). (if Ringer's Lactate is not available, you can use normal saline)

• 4*36*70 =10080 mls

• ½ of fluid in remaining 5 hours = 5040 in 5 hours

• ½  of fluid in remained in next 16 hours

• Insert a Foley’s catheter to assess urine output. 

• If urine output is inadequate, increase infusion by 200ml next hour.

 In the 2nd 24 hours

• Add 5% dextrose

• Electrolyte and fluid replacement will be guided by urine output

• Cardiac rhythm should be continually monitored for arrhythmia

Give

• Tetanus Prophylaxis

• Analgesics

Immediate complication of burn                            (4 Mark)

• Fluid and Electrolyte imbalance

•  Hypovolaemic shock 

•  Acute Renal Failure-extensive burns 

•  Local wound sepsis-common-septicaemia

•  Paralytic ileus-acute gastric dilatation. 

• Anaemia 

•  Respiratory failure-smoke 

• Curling’s ulcer with gastric erosions 
  

9. Mr Limbu aged 36 years old mal is brought to you with history motorcycle accident and sustained injury on the right thigh. On examination; he is alert, pale, PR=110 beat/minute, BP=90/50mmHg with slow capillary refill. On local examination; swollen, tender and deformed mid third of right thigh. Describe the diagnosis and management of this patient at dispensary and complications of fracture.                                           (15 Marks)                                                                 

Answer 

Diagnosis -  

Fracture of right shaft of femur                                                                      (1.5 Marks) Haemorrhagic shock                                                                     (1.5 Marks)

      

Management                                             (6 Marks)

I.V fluids (RL/NS)

Hb level, blood grouping and cross matching

Immobilization of the Fracture

Urethral catheterization

Analgesics

Refer with blood donor

Complications of fracture    

Shock

Mal union 

Non union

Nerve injury

Injury of blood vessels

Inter position of soft tissue

Injury to the surrounding tissue