Surgery Program Pemantapan Akademik Upload

8/3/2019 Surgery Program Pemantapan Akademik Upload

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PROGRAM

PEMANTAPANAKADEMIK

TAHUN 3SURGERI


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Theory Papery One BEST answer (OBA)

y Extended Matching Item / Question (EMI / EMQ)

y Key Featured Question (KFQ)

OSCEy Picture (ulcers; x-ray pneumothrox, pleural effusion, etc..;

instrument; etc)

y History taking (abdominal pain? Jaundice? Lumps andbumps? Hernia?)

y Physical examination (breast, hernia, varicose vein, lumpsand bumps, etc)

y Informed consent (barium enema, surgery, colonoscopy, etc..)

y Procedure (urinary catheter, branula, etc)

y Instrument (central venous catheter; sengstakenblackmore; ryles tube; etc..)


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OBA1. The most important finding in the diagnosis

ofappendicitis is

A. Vomiting

B. FeverC. Diarrhea

D. Right lower quadrant tenderness

E. Referred rebound tenderness (Rovsings

sign)

Answer :


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OBA2. Which of the following polyps of the colon

and rectum is most likely to contain a

malignancy?

A. Villous adenomaB. Juvenile polyp

C. Tubular adenoma

D. Inflammatory polyp

E. Hyperplastic polyp

Answer :


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OBA3. 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 onregular 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 :


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OBA4. 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 degreematernal relatives

C. Age over 35

D. Early first pregnancy

E. infertility

Answer :


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OBA5. 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


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OBA8. 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. IBDE. Bladder malignancy

Answer :


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OBA9. All of the following are physical signs of

tension pneumothorax except

A. Tracheal shift

B. Decreased breath soundC. tachycardia

D. hypertension

E. Distended neck vein

Answer :


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OBA10. A40 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 :


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OBA11. A4 weeks old baby presented with

projectile vomiting. The vomitus containedmilk taken by the baby. What is the most likelydiagnosis?

A. duodenal atresia

B. jejunal atresia

C. congenital hyperthrophic pyloricstenosis

D. annular pancreasE. volvulus neonatorum

Answer :


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OBA12. A50 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 :


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EMI

THEME : FLUIDS

A. Dextrose saline

B. Gelofundin

C. Packed RBC

D. D50%

E. FFP

F. D5%

G. Platelet

concentrate

H. Harttman

Solution

Replacement for excessive lossfrom ileostomy [Harttman] why? Find out yourself

Hypovolemic shock secondaryto traumatic splenic injury[packed RBC]

Correction of prolonged INR inbleeding esophageal varices

[FFP]

Maintenance pre-op IV fluidforfasting patient [Dextrosesaline]


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EMI

THEME : ANEMIA

A. Peptic

ulcer

disease

B. Hemorrhoi

ds

C. Stomach

ca

D. Esophagea

l ca

E. Diverticul

ar disease

F. Right

colon ca

60 yo man with dyspepsia, LOW, LOA

[stomach ca]

60 yo man with RIF pain and LOW. O/E, right

iliac mass felt. [right colon ca]

35 yo women with fresh PR bleed for 3 months.She also complained of constipation for many

years. She noticed the bleeding was painless and

comes after passing hard stool. [hemorrhoid]

A 65 yo man with difficulty in swallowing for

last 3 months. He use to smoke for the last 40years. [esophageal 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]


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EMI

THEME : VASCULAR IX (GOLD STANDARD)

A. Hand helddoppler

B. MRA

C. Duplex u/s

D. Venogram

E. DSA

F. CT scan

G. Air

plethysmography

H. Exercise tredmilltest

Deep veinthrombosis[venogram]

Critical limbischemia [DSA]

5.5cm abdominalaortic aneurysm[CT scan]


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MCQ1. A 60 year old gentleman presented in casualty

with history of left-sided abdominal pain andfaecaluria. The patient had intermittent feverabout 1 week prior to this and was treated with

Paracetamol by a general practitioner. He alsoclaimed no previous illness. Clinicalexamination revealed temperature of37.7 withtenderness over the left iliac fossa. His urinewas contaminated by faeces.

A. What is your provisional diagnosis?B. State 2 pathology that could cause this.

C. What investigation can be done to confirm yourdiagnosis?

D. What is the treatment for this condition?


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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 yourdiagnosis?

Barium enema / CT Scan / Endoscopy

What is the treatment for this condition?

Antibiotic for infection (probably UTI)

Surgery to repair fistula


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MCQ2. A25 year old man was admitted with history of

pain in the right side of the lower abdomen for 4days. He was well prior to the onset of pain. Thepain initially started around the umbilicus andmigrated later to the right side. He vomited a few

times on the first day. He had reduced appetite. Hehad opened his bowel on the day of admission. Onexamination, he was febrile 38C and toxic. Theabdomen was not distended. A slightly tender massof4x4 cm was felt in the right iliac fossa. Liver andspleen were not palpable. Per rectal examination

was normal. Bowel sound were normal.A. What is your provisional diagnosis?B. Mention one blood investigation you would do to support

the diagnosis.

C. What radiological investigation you would request to assistin the diagnosis?

D. Indicate the treatment you would advice?


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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


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MCQ3. A74 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. What is the most likely diagnosis?

B. How do you confirm your diagnosis?

C. Name one major complication of the condition.

D. What are the clinical features of the above

complication?

E. Can you name 2 genetic syndromes associated with the

above disease?


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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


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4. A21 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. BP90/50, PR 110, RR 20,

sat95%

under room air, GCS15/15. Respiratoryexamination 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?

MCQ


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What is your initial management when the patient wasbrought in to the casualty?

Primary survey ABCDE resuscitation when needed

Based on the above parameter, what is the condition of hishemodynamic status?

Hypovolemic shock

State one initial radiological investigation.

Chest X-Ray

What is the most likely injury that this patient may havesustained?

Splenic injury; mesenteric tear, renal injury; bowel injury;hemothorax, pneumothorax; retroperitoneal injury;


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OSCE1. A30 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, BP110/55, 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)


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Outline your initial clinical assessment of

this patient. (5 marks)

Assess airway

Assess breathingAssess circulation

Assess disability - level of consciousness

Expose patient

List 4 initial blood investigation relevant to

this patient. (2 marks)

FBC; RP; ABG; GXM


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OSCE2. 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.


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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 cannulais in-situ


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OSCE3. Please demonstrate the method of male

catheter bladder.


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ANSWER

1. Introduce and greet

2. Explain to patient and obtain consent

3. Wash hand and wear glove. ASEPTIC TECHNIQUE

4. Clean and drape

5. Squirt local anaesthetic gel into urethra

6. Hold penis upward position

7. Insert catheter gently

8. Check the drainage of urine; press bladder if no

urine drained9. 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


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OSCE4. Chest X-Ray

A. Describe the salient

features. (5 marks)

B. What is thediagnosis. (3 marks)

C. What is the

immediate

treatment?(2marks)


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ANSWER

Describe the salient features.

(5 marks)

Increased radiolucency right hemithorax

Trachea shifted to the leftLoss 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 right2nd

ICS midclavicular line


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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.


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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 ofthis device.

Pneumothorax / bleeding / infection / hemothorax / etc..


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OSCE6. 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.


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ANSWER

1. Introduce yourself

2. Explain the procedure

3. Explain the necessity of the procedure

4. Explain that patient has the right to refuse surgery

5. Offer other possible alternative

6. Patient will be on long term thyroxine and follow up

7. 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!


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PPD

A Jehovah patient who have very low hemoglobinand need blood transfusion. However patientrefuse because it is against his Jehovahs belief.

1. How do you explain to the patient regardingimportance and necessities of blood transfusion?

Patient now undergoing to worseninghypovolemic shock. He really have to be

transfused to save his life.

2. If patient still refuse blood transfusion, what is yournext action? Transfuse or not transfuse? Why?


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TQ.

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