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IMM TOACS (17 Aug 2006)







Static a lady with recurrent vomiting for one week known case of duodenal ulcer taking irregular
treatment for the last three days. She has become severly dehydrated with pulse 110/min, and BP of
100/70 mmHg. Succussion splash is positive. The serum electrolyte levels are: sodium -132 mmol/l,
potassium -2.9 mmol/l, chloride-92 mmol/l, HCO3-32 mmol/l
1- What is the most likely abnormality
2- What are the electrolyte abnormalities in this patient?
3- How will you resuscitate this case?
4- What parenteral fluids will you give?
Static A 60 years old lady with a lesion on right side of tongue for one year, the lesion has gradually
increased in size of neck two months ago. There is history of anorexia and weight loss for six months.
Picture: a picture of weak elderly lady with an ulcer on right lateral border of middle third of tongue
with unhealthy granulation tissue in the base. A globular swelling 5x4 cm in right submandibular region
with normal overlying skin
1- What is most likely diagnosis?
2- Which test will confirm the diagnosis?
3- How will you manage the neck lesion in this patient?
Interactive Examiner along with observer asking about the emergency procedures done independently
and assisted during the training
1- The operative steps of closed and open suprapubic cystostomy
2- Steps and principles of operating upon an appendicular abscess
3- Steps of emergency splenectomy

Static A young lady met with a road traffic accident . she was brought to emergency room with severe
shortness of breath. After initial resuscitation and stabilization, x-ray chest was taken which is shown on
x-ray viewer.
Chest x-ray: left pneumothorax with a chest tube in pleural cavity. A small air fluid level in left pleural
cavity. Trachea shifted to right side along with the mediastinum
1- What are the radiological findings?
2- What complications this patient might suffer?
3- What is the indication of thoracostomy in this patient?
4- When will you remove the chest tube?
Interactive Two examiners asking about the elective procedures done during training
1- Steps of lichensteins mesh repair
2- Why plastic surgeons donot use Pyodine in cleaning operative field?
3- What do plastic surgeons wear on hands ? (some unheard thing, I never came across before)
Interactive A young man fell from a roof with head injury with pulse 120/min and BP 90/60 mmHg.
There is a bruise in right lower chest cage and right hypochondrium. The abdomen is distended and rigid.
You take the patient to operation theatre and make a midline incision. There is a gush of blood and
extrusion of clots from peritoneal cavity. Examiner asked:
1- What will you do next?
2- You find a deep laceration in right love of liver. Hwo will you manage it?
3- How can you ascertain the types of blood (arterial or venous) extravasting from the liver
laceration with the help of Pringles maneuver?
4- What will you do if you cannot control bleeding by suturing the laceration?









Counseling An elderly lady with a rectal carcinoma 4 cm from anal verge. The patient asks:
1- What is my disease
2- Will I die from the disease
3- How will you manage it
4- What are the risks in operation
5- Will I survive after the operation
6- Can the disease be treated without an operation
7- I was told about my intestine coming out of abdomen, what does it mean?
8- Will my clothes be soiled with colostomy?
9- Will I be able to offer my prayers?
10- What could be the postoperative complications?
Static An ERCP
1- What is the name of investigation
2- What are the radiological findings in the investigation
3- What could be the best method of managing this condition
4- What are the complications of this investigation
Interactive-surgical skills perform a tru-cut biopsy of a 5x4 cm breast swelling about 1 cm deep to skin
infront of an examiner.(simulatd on an apple fixed on the card board). The tru-cut biopsy needle was
faulty. Sliding the sheath over the obturator while inside the swelling to take the biopsy was rather
Static A young boy fell from a height revealing following in the x-ray. X-ray (lateral views only) of
tibia and fibula: shows comminuted spiral fracture of lower third of Tibia and spiral fracture of lower
third of Fibula with an intact ankle mortice.
1- What are the radiological findings?
2- What complication this child may face?
3- How will you manage this case?
4- What could be the late complications?
Static an 18 years old laborer presented with a painful right sided inguino-scrotal swellings of 18 hours
duration. Picture: right inguino-scrotal area of the patient shown with large swelling involving the whole
of the right side of scrotum extending up to the superficial inguinal ring. The overlying skin appeared
tense and erythematous
1- List the three most likely diagnoses
2- Which incison will you make for this condition
3- What could be the post-operative complications in this patient?
Interactive Take the history from a female patient , 45 years with a breast lump 4x4 cm, retraction of left
nipple with bloody discharge, an examiner was just observing the history taking
Static a middle aged lady presenting right side loin pain which used to radiate to the back for three
months, following investigations was done.
IVU FILM: it was showing double reter on right side joining at the level of LV4, there was dilatation of
right pelvicalyceal system and dilatation of double ureter, clubbing of calyces on the right side and an
obstruction in right common ureter at the level of sacrum
1- What are radiological findings
2- What further tests would you like to do
3- How will you manage the case
4- What are the newer treatment modalities for this condition
Interactive-surgical skills while doing an abdominal surgery, your assistant accidentally breached the
small bowel with scalpel casuing a transverse laceration of small bowel. Instruction: you are asked to
repair the bowel. There are two assistants ( and assistants) at your command to provide you the
instruments you ask and do what you ask them t do. (donot forget to apply the non-crushing intestinal
clamps before startin the bowel repair)
Static a 20 years old female presenting with off and on vomiting and constipation for three months, for
last three days, she is having severe vomiting with abdominal distension and absolute constipation , there
is a history of anorexia and weight loss. Plain x-ray abdomen (erect): Multiple air fluid levels, more so

in central abdomen.
1- How will you resuscitate the patient?
2- What important pre-operative steps will you take?
3- What findings will you encounter during laprotomy?
4- What post-operative steps will you take?