SURGERY |CMT LEVEL FIVE SEMESTER TWO| POSSIBLE QUESTIONS

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2. 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.                       5 marks

1. What is the most likely diagnosis 

……………………………………………………………………

2. List four deferential diagnosis 

1. …………………………………………………………………

2. …………………………………………………………………

3. …………………………………………………………………

4. ………………………………………………………………

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

………………………………………………………………………… 

2. What are the possible complication if the above patient is 

1. ……………………………………………………………

2. ………………………………………………………

3. ……………………………………………………………

3. List down five (5) causes of paralytic ileus                 

1. …………………………………………………………………

2. …………………………………………………………………

3. …………………………………………………………………

4. …………………………………………………………………

5. …………………………………………………………………

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. 5 marks

1. What is the most likely diagnosis?                           

……………………………………………………………………

2. What is the confirmatory investigation                             

……………………………………………………………………

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

1. ………………………………………………………………………

2. ……………………………………………………………………….

5. Write down five (5) features of benign prostate hypertrophy on digital rectal examination                                                                                                   

1. ………………………………………………………………………                                      

2.    ………………………………………………………………                                 

3. ……………………………………………………………………………

4. ……………………………………………………………………………

5. …………………………………………………………………………

6. List down five cardinal signs of inflammation                

1. ………………………………………………………………………

2. ………………………………………………………………………

3. ………………………………………………………………………

4. ………………………………………………………………………

5. ………………………………………………………………………

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                                                    

………………………………………………………………………….

2. Give reasons why aspiration is not recommended in the treatment of this patient   

1. …………………………………………………………….

2. …………………………………………………………….

3. …………………………………………………………….

4. …………………………………………………………….

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. How will you manage? 

1. …………………………………………………………………………

2. …………………………………………………………………………

3.  ………………………………………………………………………

   

GUIDED ESSAY QUESTIONS                   

Instructions:

• This section consists of Two (2) questions which are supposed to be answered in a narrative way

• Bulleting and numbering is NOT ALLOWED

• Write your answers on the blank pages of this question paper. 

• Each question should start on a new page

9. 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.           15 marks

• What is the accurate diagnosis

• Discus pre referral management (Investigation and treatment) 

10. 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.

Discuss management of this patient.                                                                15 marks

1. Classify Open Fracture according to Gustilo and Anderson Classification    (5Marks)

Answer:

TYPE    CLINICAL FINDINGS

1    -    Wound less than 1cm, minimal tissue injury, simple fracture pattern, mild        degree of contamination

2    -    Wound between 1cm-10cm, moderate tissue inury, simple fracture pattern, moderate degree of contamination

3A    -    Wound more than 10cm, extensive tissue injury, segmental fracture, severe degree of contamination, adequate tissue coverage. 

3B with periosteal stripping and inadequate tissue coverage

3C    -    ‘’’’’’’’’’’’’’’’’’’’’’’’’’ with NeuroVascular injury.

2. Outline the five (5) stages of fracture healing  (5Marks)

• Stage of haematoma

• Stage of granulation tissue

• Stage of callus

• Stage of remodelling (formerly called consolidation)

• Stage of modelling (formerly called remodelling)

3. List 7 parameters in the International Prostate Scoring System 

Answer;

Any five points (5marks) 1mark each

1. Incomplete emptying

2. Frequency

3. Intermittency

4. Urgency

5. Weak stream

6. Straining

7. Nocturia

4. A 43-year-old man attends the surgical outpatient clinic complaining of intermittent bleeding per rectum for the past 2 months. The blood is always bright red, separate from the stool and drips into the pan. He also complains of itching around the anus. There is no other past medical history of note.

1. The Correct Diagnosis is ……HAEMORROIDS (0.5 mark)……… with………PRURITUS ANI

2. How do you classify the condition                                        (4marks)

• first-degree haemorrhoids: remain in the rectum

• second-degree haemorrhoids: prolapse through the anus on defecation but reduce spontaneously

• third-degree haemorrhoids: prolapse but require manual reduction

• fourth-degree haemorrhoids: prolapse and cannot be reduced

5. Advanced trauma life support is based on management of acute trauma cases. Primary survey is the first key step in assessment of patients presenting with trauma. List five components in Primary Survey of ATLS            (5 Marks)

Answer.

1. Airway maintenance with cervical spine protection

2. Breathing and ventilation

3. Circulation with bleeding control

4. Disability/Neurologic assessment

5. Exposure and environmental control

6. Mr Shio was brought to you with history of fall from a Mango tree at a height

of six meters. On examination you find he is confused and opens eyes to painful

stimuli. When you apply nail bed pressure to the left index finger he extends at

the left elbow. He also has abrasions on his left shoulder and a 3cm x 2cm x1 cm

scalp laceration on his left temporal area.                                                  (5marks)

A. What is the Glasgow coma score of this patient                                   (2marks)

ANS: score is 8/15

B. Mention one investigation for this patient                                             (1mark)

ANS: skull X- Ray, Brain CT-Scan.

C. Mention four symptoms of raised  Intracranial Pressure        (2marks @ 0.5 mark)

ANS: 

1. Severe Headache

2. Vomiting

3. Blurred vision

4. Loss of Consciousness

7.   a. Name any four Classification of   Hernia                                        (2 Marks @ 0.5marks)

Answer;

1. Reducible

2. Irreducible

3. Obstructed or Incacerated

4. Strangulated

5. Inflamed

b. Mention three mechanisms preventing healthy people from occurrence of Hernia 

(3 Marks)

Answer;

1. Obliquity of Inguinal Canal

2. Bulb – valve mechanism

3. Shutter mechanism

1. Read the X ray below and answer the questions that follow

1. Identify the findings in the X ray

AIR FLUID LEVELS                                                                                   (0.5 marks)

2. What is the possible diagnosis of the X ray Above

INTESTINAL OBSTRUCTION                                                               (0.5 marks)

3. How do you manage the condition above ( 4 points)                                (4 marks)

Decompression of the Bowels by NGT

IV fluids

Iv antibiotics

Analgesics

1. Mr Mkalimoto , 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 are, treatment and immediately complications.                                    (15 Marks)

Answer

 Diagnosis –  2 degree Thermal Burn                                    (1 Mark)

Percentege                                                      (2 Mark)

Anterior trunk is 18%

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

   Total area burnt = 36%

Treatment                                      (8 Marks @ 1mark)

• Stop the Burning process 

• Fluid Resuscitation Principles

 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 (avoid NSAIDs)

• Iv antibiotics

• Manage stress ulcers with Ranitidine or Cimetidine

• Apply Topical Agents ( Silverex or Burnox )

What are the criteria for admission of burn patient     (any four points 4 Mark)

• Electrical burns

• Chemical burns 

• >15% TSBA in adults

• >10% TSBA in children 

• Body site affected face,hands, perineum, genitalia 

• Inhalational burns

• Pre-existing illness – renal diseases,

• Circumferential burns

• Patient at the extremes of age

15. Tilalila, a 23-year-old man is brought into the emergency department by ambulance after coming off his motorcycle. He was travelling at approximately 45 mph and hit a stationary car. A trauma call is made and you are the orthopaedic member of the trauma team. There is no other history available and he is in significant pain.

               Examination

        The patient’s pulse is 100/min, blood pressure is 142/88 mmHg and his oxygen saturations are 97 per cent on room air. His Glasgow Coma Score has remained at 15 out of 15. He is strapped onto a spinal board. The trauma team has completed the initial assessment of the patient. The primary survey has been completed and there is no significant chest, abdominal or pelvic injury.

Local Examination the left leg, there is an obvious deformity. His shin is angulated at 45°. There is a 3 cm-diameter wound, which has bone protruding through it. The pedal pulses are palpable. The distal sensation is intact.

1. What is the Diagnosis of the patient?                                                (2 marks)  

OPEN COMPOUND FRACTURE OF LEFT TIBIA AND FIBULA, GUSTILO AND ANDERSON GRADE 2   

2. What is the pattern of this fracture?                                                   (1 marks)

• SEGMENTAL FRACTURE PATTERN

3. Describe other X rays needed to be conducted in this patient.           (3 marks)

• Chest X Ray

• Pelvic X Ray

• Spine X ray

4. How will you manage the patient at the EMERGENCY PHASE of fracture management?                                                                                       (5 marks)   

• IV fluids

• IV antibiotics

• Surgical Debridement

• Analgesics

• Immobilization with Back slab and a window   

5.   What are the 4c’s in checking for viability of muscles during debridement                                  (4marks)

• Colour

• Contractility

• Consistency

• Capillary bleeding