PROGRAM PEMANTAPAN AKADEMIK TAHUN 3

SURGERI

Theory Paper
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One BEST answer (OBA) Extended Matching Item / Question (EMI / EMQ) Key Featured Question (KFQ)

OSCE
y y y y y y

Picture (ulcers; x-ray pneumothrox, pleural effusion, etc..; instrument; etc) History taking (abdominal pain? Jaundice? Lumps and bumps? Hernia?) Physical examination (breast, hernia, varicose vein, lumps and bumps, etc) Informed consent (barium enema, surgery, colonoscopy, etc ..) Procedure (urinary catheter, branula, etc) Instrument (central venous catheter; sengstaken blackmore; ryles tube; etc..)

OBA
1. The most important finding in the diagnosis of appendicitis is A. Vomiting B. Fever C. Diarrhea D. Right lower quadrant tenderness E. Referred rebound tenderness (Rovsings sign) Answer :

OBA
2. Which of the following polyps of the colon and rectum is most likely to contain a malignancy? A. Villous adenoma B. Juvenile polyp C. Tubular adenoma D. Inflammatory polyp E. Hyperplastic polyp Answer :

OBA
3. A 65 year old man presented with epigastric pain and vomiting. He has generalized board-like rigidity over his abdomen. He has a history of severe OA of his knees and on regular analgesia. What is the most suitable investigation? A. erect chest x-ray B. erect abdominal x-ray C. supine abdominal x-ray D. USS abdomen E. CT abdomen Answer :

OBA
4. All the following are associated with an increased risk of breast cancer except : A. Dietary consumption of fat B. History of breast cancer in first degree maternal relatives C. Age over 35 D. Early first pregnancy E. infertility Answer :

OBA
5. 42 year old female presents with fatigue, weight gain, hirsuitism and acne. Physical examination reveals an elevated blood pressure, slender arms and legs with multiple bruises and a puffy face. What is the most likely diagnosis? A. phaeochromocytoma B. Cushings syndrome C. Conns syndrome D. Addisons disease E. Hypothyroidism

OBA
8. 71 year old woman presented with pneumaturia. A CT scan is consistent with colovesicle fistula. What do you think is the MOST common cause? A. TB B. iatrogenic C. diverticular disease D. IBD E. Bladder malignancy Answer :

OBA
9. All of the following are physical signs of tension pneumothorax except A. Tracheal shift B. Decreased breath sound C. tachycardia D. hypertension E. Distended neck vein Answer :

OBA
10. A 40 year old Chinese man presented with a 2 month history of painless intermittent fresh PR bleed not mixed with stools and denies any alteration in bowel habit. The most likely diagnosis at this stage is A. colonic angiodysplasia B. anal fissure C. Haemorrhoids D. colorectal ca E. IBD Answer :

OBA
11. A 4 weeks old baby presented with projectile vomiting. The vomitus contained milk taken by the baby. What is the most likely diagnosis? A. duodenal atresia B. jejunal atresia C. congenital hyperthrophic pyloric stenosis D. annular pancreas E. volvulus neonatorum Answer :

OBA
12. A 50 year old diabetic lady presented with high spiking fever, anorexia and malaise accompanied by RUQ pain. Examination revealed tender enlarged liver and USS of liver showed multiloculated cystic mass. What is the most likely diagnosis? A. polycystic liver disease B. amoebic liver disease C. pyogenic liver abscess D. Hepatoma E. hemangioma of the liver Answer :

EMI THEME : FLUIDS

A. B. C. D. E. F. G. Dextrose saline Gelofundin Packed RBC D50% FFP D5% Platelet concentrate H. Harttman Solution
Replacement for excessive loss from ileostomy [Harttman] why? Find out yourself Hypovolemic shock secondary to traumatic splenic injury [packed RBC] Correction of prolonged INR in bleeding esophageal varices [FFP] Maintenance pre-op IV fluidfor fasting patient [Dextrose saline]

EMI THEME : ANEMIA

60 yo man with dyspepsia, LOW, LOA [stomach ca] 60 yo man with RIF pain and LOW. O/E, right B. Hemorrhoi iliac mass felt. [right colon ca] ds 35 yo women with fresh PR bleed for 3 months. C. Stomach She also complained of constipation for many ca years. She noticed the bleeding was painless and D. Esophagea comes after passing hard stool. [hemorrhoid] l ca E. Diverticul A 65 yo man with difficulty in swallowing for ar disease last 3 months. He use to smoke for the last 40 F. Right years. [esophageal ca] colon ca 40 yo man with epigastric pain and LOA for few weeks. He is admit to be heavy smoker for ten years. PR showed tarry stool. [peptic ulcer]
A. Peptic ulcer disease

EMI THEME : VASCULAR IX (GOLD STANDARD)

A. Hand held doppler B. MRA C. Duplex u/s D. Venogram E. DSA F. CT scan G. Air plethysmography H. Exercise tredmill test

Deep vein thrombosis [venogram] Critical limb ischemia [DSA] 5.5cm abdominal aortic aneurysm [CT scan]

MCQ
1. A 60 year old gentleman presented in casualty with history of left-sided abdominal pain and faecaluria. The patient had intermittent fever about 1 week prior to this and was treated with Paracetamol by a general practitioner. He also claimed no previous illness. Clinical examination revealed temperature of 37.7 with tenderness over the left iliac fossa. His urine was contaminated by faeces.
A. B. C. D. What is your provisional diagnosis? State 2 pathology that could cause this. What investigation can be done to confirm your diagnosis? What is the treatment for this condition?

ANSWER
What is your provisional diagnosis? Colovesical fistula / rectovesical fistula State 2 pathology that could cause this. Colon diverticulitis; Colon ca What investigation can be done to confirm your diagnosis? Barium enema / CT Scan / Endoscopy What is the treatment for this condition? Antibiotic for infection (probably UTI) Surgery to repair fistula

MCQ
2. A 25 year old man was admitted with history of pain in the right side of the lower abdomen for 4 days. He was well prior to the onset of pain. The pain initially started around the umbilicus and migrated later to the right side. He vomited a few times on the first day. He had reduced appetite. He had opened his bowel on the day of admission. On examination, he was febrile 38C and toxic. The abdomen was not distended. A slightly tender mass of 4x4 cm was felt in the right iliac fossa. Liver and spleen were not palpable. Per rectal examination was normal. Bowel sound were normal.
A. B. C. D. What is your provisional diagnosis? Mention one blood investigation you would do to support the diagnosis. What radiological investigation you would request to assist in the diagnosis? Indicate the treatment you would advice?

ANSWER
What is your provisional diagnosis? Appendicular abscess Mention one blood investigation you would do to support the diagnosis. Total White Blood Cells and differential counts What radiological investigation you would request to assist in the diagnosis? Ultrasound abdomen / CT abdomen Indicate the treatment you would advice? Appendicectomy and drainage of abscess

MCQ
3. A 74 year old retired army officer who is also a diabetic and hypertensive attending a routine medical follow up. During physical examination, an expansile and pulsatile non tender midline abdominal mass is found.
A. B. C. D. E. What is the most likely diagnosis? How do you confirm your diagnosis? Name one major complication of the condition. What are the clinical features of the above complication? Can you name 2 genetic syndromes associated with the above disease?

ANSWER
What is the most likely diagnosis? AAA How do you confirm your diagnosis? Ultrasound scan Name one major complication of the condition. AAA rupture or leak What are the clinical features of the above complication? Severe abdominal pain; Hypovolemic shock; Tender pulsatile abdominal mass Name 2 genetic syndromes associated with the above disease? Marfans Syndrome; Ehler Danlos Syndrome

MCQ
4. A 21 year old man involved in MVA. He was brought to casualty with complaining of left hypochondrium pain, left sided chest wall pain associated with SOB. He was conscious and alert. He is pale. BP 90/50, PR 110, RR 20, sat 95% under room air, GCS 15/15. Respiratory examination revealed reduced expansion and air entry on the left side. The abdomen is mildly distended and there was bruising and tenderness on the left hypochondrium. ? A. What is your initial management when the patient was brought in to the casualty? B. Based on the above parameter, what is the condition of his hemodynamic status? C. State one initial radiological investigation. D. What is the most likely injury that this patient may have sustained?

What is your initial management when the patient was brought in to the casualty? Primary survey ABCDE resuscitation when needed Based on the above parameter, what is the condition of his hemodynamic status? Hypovolemic shock State one initial radiological investigation. Chest X-Ray What is the most likely injury that this patient may have sustained? Splenic injury; mesenteric tear, renal injury; bowel injury; hemothorax, pneumothorax; retroperitoneal injury;

OSCE
1. A 30 year old motorcyclist was brought to casualty by ambulance after being involved in a head-collision with a car. On arrival, he was complaining of RUQ abdominal pain. O/E, PR 90, BP 110/55, RR 25. His pupils were equal and reactive to light. There was tenderness in RUG of his abdomen, with voluntary guarding. A. Outline your initial clinical assessment of this patient. (5 marks) B. List 4 initial blood investigation relevant to this patient. (2 marks)

Outline your initial clinical assessment of this patient. (5 marks) Assess airway Assess breathing Assess circulation Assess disability - level of consciousness Expose patient List 4 initial blood investigation relevant to this patient. (2 marks) FBC; RP; ABG; GXM

OSCE
2. A 50 year old man is admitted to the surgical ward with a diagnosis of intestinal obstruction. He is clinically dehydrated and requires intravenous hydration. You are required to demonstrate the insertion of peripheral venous cannula.

ANSWER
1. Introduce and greet 2. Explain to patient and obtain oral consent 3. Select site (where?) 4. Apply tourniquet 5. Clean with alcohol swab 6. Venepuncture made comfirmed by flashback 7. Cannula advanced 2-3 mm into vein 8. Sheath advance into vein and needle withdrawn 9. Tourniquet released 10. Cannula secured with adhesive tape 11. Flush with saline prior to use to ensure cannula is in-situ

OSCE
3. Please demonstrate the method of male catheter bladder.

ANSWER
1. 2. 3. 4. 5. 6. 7. 8. Introduce and greet Explain to patient and obtain consent Wash hand and wear glove. ASEPTIC TECHNIQUE Clean and drape Squirt local anaesthetic gel into urethra Hold penis upward position Insert catheter gently Check the drainage of urine; press bladder if no urine drained 9. Inflate balloon with amount of water (not normal saline!!!) as stated on the catheter 10. Pull back catheter until resistance encountered 11. Connect catheter to urine bag

OSCE
4. Chest X-Ray A. Describe the salient features. (5 marks) B. What is the diagnosis. (3 marks) C. What is the immediate treatment? (2marks)

ANSWER
Describe the salient features. (5 marks) Increased radiolucency right hemithorax Trachea shifted to the left Loss of vascular markings Mediastinal shift collapsed right lung
What is the diagnosis. (3 marks) Right Tension Pneumothorax What is the immediate treatment? (2marks) Needle thoracocentesis at right 2nd ICS midclavicular line

OSCE

5.

Picture A. Identify this device. B. Give 2 indications. C. Give 2 sites for insertion of this device. D. How would you confirm its proper placement? E. Name four complications associated with the use of this device.

ANSWER
Identify this device. Central venous catheter (Length? Lumen?) Give 2 indications. Hydrational status / administer inotropic drug / TPN / etc Give 2 sites for insertion of this device. Short line : Internal Jugular Vein / Subclavian vein Long line : Brachial vein How would you confirm its proper placement? Chest X-Ray Name four complications associated with the use of this device. Pneumothorax / bleeding / infection / hemothorax / etc..

OSCE
6. This 40 year old woman is about to undergo a total thyroidectomy for a thyroid cancer. As a house officer, you are required to obtain an informed consent from this patient.

ANSWER
Introduce yourself Explain the procedure Explain the necessity of the procedure Explain that patient has the right to refuse surgery Offer other possible alternative Patient will be on long term thyroxine and follow up Possible complication Bleeding; Infection; Hypocalcaemia; Recurrent laryngeal nerve injury; tracheal injury 8. Ask patient whether he/she have any questions 9. IF PATIENT REFUSE, DONT FORCE! 1. 2. 3. 4. 5. 6. 7.

PPD
A Jehovah patient who have very low hemoglobin and need blood transfusion. However patient refuse because it is against his Jehovahs belief. 1. How do you explain to the patient regarding importance and necessities of blood transfusion? Patient now undergoing to worsening hypovolemic shock. He really have to be transfused to save his life. 2. If patient still refuse blood transfusion, what is your next action? Transfuse or not transfuse? Why?

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