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AID TO MULTIPLE CHOICE
QUESTIONS IN SURGERY

DR. MMAJ KUMARA


DR. RW SENEVIRATNE
DR. JPM KUMARASINGHE
DR. RP ABEYWICKRAMA
DR. UI HAPUAARACHCHI
DR. MB SAMARAWICKRAMA
AID TO MULTIPLE CHOICE
QUESTIONS IN SURGERY
AID TO MULTIPLE CHOICE
QUESTIONS IN SURGERY

© First Edition 2016

ISBN 978-955-4851-07-8

Published by
Bhathiya Publications
AID TO MULTIPLE CHOICE
QUESTIONS IN SURGERY

Edited by
RW Seneviratne

MMAJ Kumara
MBBS(Peradeniya) MS(Colombo) FRCS(England)
Senior lecturer in Surgery, Faculty of Medicine, University of Ruhuna.

RW Seneviratne
MBBS(Ruhuna) FRCS(England) MSc(Birmingham) MS(Colombo)
Senior lecturer in Surgery ,Faculty of Medicine, University of Ruhuna.

JPM Kumarasinghe
MBBS(Ruhuna) MS(Colombo)
Senior lecturer in Surgery, Faculty of Medicine, University of Ruhuna.

RP Abeywickrama
MBBS(Colombo) MS(Colombo) MRCS(Edinburgh)
Senior lecturer in Surgery, Faculty of Medicine, University of Ruhuna.

UI Hapuaarachchi
MBBS(Ruhuna) MD(Colombo) FRCA(UK) FCARCSI(Ireland)
Senior lecturer in Anaesthesia, Faculty of Medicine, University of Ruhuna.

MB Samarawickrama
MBBS(Ruhuna) Ms(Colombo)
Senior lecturer in Anatomy, Faculty of Medicine, University of Ruhuna.
FOREWORD

It is a great pleasure and a privilege to write a foreword to this book written by a


group of senior academics coming from a diverse academic background. Surgery
always goes hand in hand with anatomy and anaesthesia and this group of
academics is an ideal combination to write a book aiming medical
undergraduates.

Many believe that MCQs assess the factual knowledge and the same fact is
considered to be one of the major limitations of MCQs. However, MCQs can be
made in such a way that they assess higher order thinking which goes beyond
memorizing and recalling facts and data. They can be based on real life scenarios
and made to asses higher learning taxonomies. For this to happen, the creator of
MCQ has to have a wide knowledge on the subject, analytical mind and also be a
critical thinker. Despite all limitations MCQs are popular and widely used in
undergraduate evaluations.

Authors of this book appear to have considered all these aspects in compiling this
book. They have made MCQs and SEQs covering all major areas of general
surgery applicable to medical undergraduates. Writing a book of MCQ and SEQ is
not an easy task. It requires dedication and commitment.

Finally, I take this opportunity to congratulate authors of this book for the
splendid work and hope that medical undergraduates will find this book useful
and informative.

Professor Sarath Lekamwasam


MD, FRCP, PhD (Erasmus, Rotterdam), FCCP,FRACP(Hon)
Hon FCP(SA), FCPSP (Hon)
Dean, Professor of Medicine,
Faculty of Medicine,
University of Ruhuna.
11th Oct 2016 .

i
INTRODUCTION

Multiple choice questions are an important component of surgical assessments.


Although it assess recall of factual knowledge primarily, careful construction can
stretch the objectives towards assessing higher levels of Bloom's Taxonomy such
as Comprehension and application. This higher levels are best tested by single
best response questions and extended matching questions. Multiple choice
questions are by far the most economical in identifying examinee's knowledge
across width and depth of the subject area tested. In essence, this highlights the
importance of using many different formats of questioning which are
complimentary in assessments rather than sticking to one or two types of
format.

Many books are around which contain multiple choice questions in the field of
surgery and related specialties. However, ones by Sri Lankan authors with special
emphasis on knowledge required for local settings are few. This book is designed
for the benefit of local undergraduates, postgraduates as well as practicing
doctors including general practitioners. It will test presentation, investigations
and management of surgical conditions prevalent in Sri Lankan clinical practice.
Authors expect this book will

(a) aid clinical practitioners in revision and updating of their knowledge.


(b) serve as a guide to medical students commencing theirsurgical
appointments.
(c) encourage to expand readers knowledge on areas covered.
(d) assists in speedy revision immediately before surgical examinations.

Dr. RW SENEVIRATNE
Dr. MMAJ KUMARA
Dr. JPM KUMARASINGHE
Dr. RP ABEYWICKRAMA
Dr. UI HAPUAARACHCHI
Dr. MB SAMARAWICKRAMA

ii
ON MAKING AND MARKING MULTIPLE CHOICE QUESTIONS

Constructing good MCQs which require knowledge and experience is the


responsibility of the examiner. On answering MCQs a candidate must look to
develop an insight to frame of mind of the examiner which existed when setting
the question. In this chapter we discuss overall issues regarding construction of
MCQs giving some examples.

An examiner may design an MCQ to test candidate's ability to recall a list.


Examples include aetiology of breast cancer and clinical features of
thyrotoxicosis. Alternatively, he wants to check the key knowledge on a
particular disease. In a run-through MCQ regarding varicose veins, five responses
sometimes come from aetiology, clinical features, investigations, treatment and
complications. It can also be designed to check a higher function such as
selection or analysis. Suitable options for differential diagnoses for a given
presentation or suitable management options for a specific disease condition are
examples.

Five responses usually follow; 2 easy, 1 intermediate, 1 difficult and 1 for the
master, template. First three, check competence whilst last two are
discriminatory responses. Responses are made right or wrong by an examiner,
although by convention there should be more rights than wrongs in the overall
paper. Words like 'always' and 'never' are excluded from terminology respecting
vagaries in clinical conditions. Similarly loose terms such as 'can be', 'may be' and
'more common' are best avoided.

Fine variations, specially when it comes to percentages, should not be tested.


However, the accepted gap for testing is less when the percentages lie at lower
levels than higher levels. For an example incorrect leak rate following anterior
resection of 1% and correct answer of 4% are acceptable for testing. Accepted
prevalence of gas under the diaphragm in an erect chest x-ray of 85% should not
be pitted against an incorrect answer of 89% as variations can exist among
different studies. By convention a clear gap should be given when testing for
percentages. It is important to emphasize here that although exact percentages
iii
are rarely required student must have an approximate knowledge of some
features being most common, common or rare.

The examiner's objectives of setting up an MCQ can span a wide range. Checking
knowledge on facts of figures is common. 'Middle third of the esophagus is
normally lined by stratified squamous epithelium' is such a design.
Understanding of principles of anatomy can be achieved by a response like
'Ethmoidal sinusitis has a higher chance of producing cavernous sinus
thrombosis than frontal sinusitis. A physiological principal such as 'An
unconscious patient always need airway protection' and pathological principal
such as 'Lobar pneumonia usually heals with moderate cavitation of lungs', latter
an incorrect response are amenable to assessment. Management concepts can
be assessed in a statement such as 'Two attacks of quinsy is an indication for
tonsillectomy'. Checking common sense and commonality is evident in response
'Gonococcal infection is a common cause for anterior urethral strictures'.
Student's exposure to ward work can be assessed with responses such as 'Acute
appendicitis is a recognized cause of epigastric pain. One's updated knowledge
can also be assessed and familiarity with important rules and laws such as
Goodsall's law and ulnar paradox are tested easily. Candidate's awareness of
unique features such as 'Mellon seed bodies' and 'Owl's eye appearance' are
popular among some examiners.

Considering specific terms used in responses, MAJORITY or COMMON implies


over 50%. A CHARACTERISTIC feature is present almost certainly and
PATHOGNOMONIC feature is specific to that disease. The words CLASSIC and
TYPICAL are similar to characteristic and pathognomonic but prone to
misinterpretations and not suitable for scientific writing. RECOGNIZED feature is
known to occur and ASSOCIATIONS can be any. RARE is unusual but known to
occur.

Candidate should read the question carefully first time while underlining key
words. Dangerous Deja-Vu feeling can engulf the candidate reading the question
second or third time, persuading him to mark wrong responses as being correct.
As negative marking is a feature in MCQ examinations, many good candidates
leave examination hall early after the initial round of answering.

Finally, candidate will have to mark the answer right or wrong. In this he has to
have a guess at examiner's mind. Following are some of the principles examiners
follow when they are constructing a response.

iv
CORRECT ANSWER may be

- Directly correct e.g. acute pancreatitis is caused by hypercalcaemia


- Indirectly correct. E.g. Clinical features of gastric carcinoma include
discoloration of the skin- Onus is on the candidate to cerebrate that visceral
malignancies of which gastric carcinoma is an example can produce dark
discoloration of axilla which is a component of the skin.

INCORRECT ANSWER can be constructed in many ways to stretch the mental


faculties of the candidate

- Opposite or reverse of correct response e.g. Diarrhoea is a feature of


hypothyroidism
- Parallel but nevertheless wrong answer e.g.5% dextrose is the fluid of
choice for resuscitation in hypovolemic shock
- Feature of a close differential diagnosis e.g. In an 18 years old with
swollen testis, presence of fever suggests torsion-The candidate must
be aware that fever is a feature of close differential diagnosis,
epididimo-orchitis.
- Relevant nonetheless incorrect investigation or treatment e.g OGD is
the gold standard to diagnose GORD
- Check that candidate is a safe doctor e.g. Cephalosporin can be safely
used in penicillin allergy- an incorrect statement.

Some candidates often with superficial knowledge and cavalier attitude tend to
answer many questions beyond their capabilities and land in the failed group.
Some other candidates whose logical thinking run too deep may also think that
examiners are out to trap them. This 'seeing crocodiles in the washing basin'
mind frame, leads to 'paralysis by over analysis' which prevent them from
answering even relatively straightforward questions. Candidate's right level of
attitude should fall in the middle ground between these two extremes.

Dr. RW SENEVIRATNE
Dr. MMAJ KUMARA
Dr. JPM KUMARASINGHE
Dr. RP ABEYWICKRAMA
Dr. UI HAPUAARACHCHI
Dr. MB SAMARAWICKRAMA

v
AKNOWLEDGEMENTS

• Professor Sarath Lekamwasam MD FRCP PhD (Erasmus, Rotterdam), FCCP,


FRACP(Hon) Hon FCP(SA), FCPSP (Hon) Dean, Professor of Medicine, Faculty
of Medicine, University of Ruhuna.
• Dr. D.H.G.M.W.Gunawardana - Demonstrator in Surgery, Faculty of
Medicine, University of Ruhuna
• Dr. N.D.Masakorala - Demonstrator in Surgery, Faculty of Medicine,
University of Ruhuna
• Dr. B.M.Gunaratne - Demonstrator in Surgery, Faculty of Medicine,
University of Ruhuna
• Dr. A.V.H.Amali - Demonstrator in Surgery, Faculty of Medicine, University
of Ruhuna
• Dr. A.M.K.C.Atthanayake - Demonstrator in Surgery, Faculty of Medicine,
University of Ruhuna
• Dr. M.T.D.Silva- Demonstrator in Anatomy, Faculty of Medicine, University
of Ruhuna
• Dr. U.K.S. Ishara - Demonstrator in Surgery, Faculty of Medicine, University
of Ruhuna
• Mr. Sajeewa Wijeweera - Bhathiya publications.

vi
INDEX

1. PRINCIPLES OF SURGERY - DR.MMAJ KUMARA 01-08


2. CLINICAL ANATOMY- DR.MB SAMARAWICKRAMA 09-14
3. ANAESTHESIA- DR.UI HAPUAARACHCHI 15-22
4. CRITICAL CARE - DR.UI HAPPUARACHCHI 23-28
5. TRAUMA AND BURNS - DR.RW SENEVIRATNE 29-36
-6. ORTHOPAEDIC (TRAUMA) - DR.RW SENEVIRATNE 37-44
7. ORTHOPAEDIC (NON TRAUMA)- DR.RW SENEVIRATNE 45-50
8. UPPER GASTROINTESTINAL SURGERY- DR.MMAJ KUMARA 51-56
9. HEPATOBILIARY, PANCREAS AND SPLEEN- DR.MMAJ KUMARA 57-64
10. LOWER GASTROINTESTINAL AND ANORECTAL SURGERY-
DR. JPM KUMARASINGHE 65-70
11. GENITOURINARY- DR.MMAJ KUMARA 71-76
12. HEAD AND NECK- DR.RP ABEYWICKRAMA 77-88
13. BREAST- DR. RP ABEYWICKRAMA 89-98
14. ENDOCRINE- DR.RW SENEVIRATNE 99-106
15. NEUROSURGERY- DR. JPM KUMARASINGHE 107-112
16. CARDIOTHORACIC SURGERY- DR.MMAJ KUMARA 113-120
17. VASCULAR SURGERY - DR. MMAJ KUMARA 121-126
18. PAEDIATRIC SURGERY- DR.RW SENEVIRATNE 127-132
19. SKIN AND SUPERFICIAL LUMPS- DR.MB SAMARAWICKRAMA 133-140
20. MISCELLANEOUS- DR.RW SENEVIRATNE 141-150

vii
viii
1. PRINCIPLES OF SURGERY
DR.MMAJ KUMARA

1.1 Which of the following are true regarding fluid and electrolyte balance?

A) Nasogastric aspirate should be replaced volume to volume with 0.9% saline.


B) 100 mmol of potassium are given iv to cover daily requirements.
C) Long standing fluid deficits should be replaced urgently.
D) Insensible losses are best replaced with Hartman's solution.
E) Total daily intravenous fluid requirement for an adult is approximately 1500
ml.

1.2 Regarding electro cauterization in surgery

A) Bipolar diathermy causes vaporization of water.


B) Unipolar diathermy uses less energy than bipolar.
C) Cardiac arrhythmia is a recognized complication of unipolar diathermy.
D) It is unsafe to use unipolar diathermy during circumcision.
E) Capacitance coupling causes bowel injury in laparoscopic surgery.

1.3 Which of the following are true regarding metabolic response to trauma?

A) It is of similar magnitude regardless of the severity of injury.


B) Plasma levels of insulin is reduced.
C) Pyrexia in the first twenty-four hours is mainly due to infection.
D) In major blunt trauma urinary nitrogen loss is increased.
E) Beta-blockers and statins improve long term survival after major surgery.

1
Answers to question 1.1

A) TRUE-This is the best method to replace fluid and chloride ( Cl- ) lost.
B) FALSE- The requirement is 1mmol/kg/day
C) FALSE-Replacement should be done gradually.
D) FALSE-This is replaced by 5% dextrose.
E) FALSE-It is approximately 2.5 liters per day

Answers to question 1.2

A) TRUE- The possible effects of applying electrical current to tissue are


fulguration, desiccation/ coagulation, or vaporization/ablation.
B) FALSE- Bipolar with limited lateral heat dissipation is safer near nerves.
C) TRUE- It is used well away from pacemaker and only when necessary.
D) TRUE-Unipolar diathremy is not used on appendages such as finger, nose
and ears.
E) TRUE- Electrosurgery is one of the most commonly used energy systems in
laparoscopic surgery. Two major categories of potential complications
related to electrosurgery in laparoscopy are mechanical trauma and
electrothermal injury. The latter can result from unrecognized energy
transfer in the operative field or, less commonly, to unnoticed stray current
outside the laparoscopic field of view. This stray current can result from
insulation failure, direct coupling, or capacitance coupling.

Answers to question 1.3

A) FALSE-Magnitude is related to severity as well as other factors including


genetic makeup.
B) TRUE-All anti insulin hormones such as corticosteroids, adrenalin and GH
are increased.
C) FALSE- This is due to tissue injury.
D) TRUE- This occurs in catabolic phase.
E) TRUE-These are known to modulate metabolic response.

2
1.4 Regarding shock,

A) In Neurogenic shock heart rate fails to rise in line with the drop in blood
pressure.
B) Elderly patients with hypertension, are sometimes in shock with blood
pressure in normal range.
C) Central venous catheters are suitable for rapid fluid resuscitation.
D) Patients in profound hypovolemic shock do not respond adequately to
inotropic therapy.
E) In a patient with normal vital signs after resuscitation persistent lactic
acidosis and low mixed venous oxygen saturation indicate reduced tissue
perfusion.

1.5 The burst abdomen

A) usually occurs on the 5th post-operative day.


B) characteristically proceeded by serosanguinous discharge.
C) recurs rarely.
D) is fatal in approximately 80%.
E) common in jaundiced patients.

1.6 Following infections and most likely causative organisms are correctly
matched

A) Cellulitis – Staphylococcus aureus.


B) Perianal abscess- Streptococcus pyogenic.
C) Acute Tonsillitis- Streptococus pyogenic.
D) Acute appendicitis- Anaerobes.
E) Wound with greenish pus- Escherishia coli.

3
Answers to question 1.4

A) TRUE- This is due to an unopposed vagal action on heart.


B) TRUE- This is a pitfall in the management.
C) FALSE-They are long with a narrow diameter and do not encourage rapid
flow according to Poissels law.
D) TRUE- Fluid replacement is necessary.
E) TRUE- These indicate that although patient's blood pressure is normal
tissue hypoperfusion and hypoxia still persists.

Answers to question 1.5

A) FALSE-Usually occurs at 6-8th post operative day.


B) TRUE-This blood stained pinkish discharge is characteristic.
C) TRUE-Repair is strong.
D) FALSE-Mortality from this condition is usually 30% or less.
E) TRUE- This common in conditions such as liver failure, renal failure and
chronic infections such as TB.

Answers to question 1.6

A) FALSE- Steptococus pyogenis predominate.


B) FALSE- Coliforms and Staphylococus are more common.
C) FALSE- Viruses account for approximately 70%.
D) TRUE -Metronodazole alone is sufficient as antibiotic cover.
E) FALSE- Psudomonas is the culprit.

4
1.7 Which of the following are true regarding tourniquets?

A) Tourniquets are mandatory before amputating an ischemic limb.


B) They Limit hand surgery in a bloodless field to 20 minutes.
C) Exsanguination by spiral tourniquet is preferred before exploring for glass
foreign bodies.
D) It Is applied over forearm to decompress carpal tunnel.
E) Narrow tourniquets are safer and effective.

1.8 Which of the following are true regarding abdominal incisions?

A) Midline incisions are quick to make than transverse incisions.


B) Midline incisions heal better than transverse incisions.
C) Paramedian incisions have less chances of incisional hernia than midline.
D) Pfannenstiel incision gives an excellent cosmetic scar.
E) Upper abdominal incisions have lesser incidence of incisional hernia than
lower ones.

1.9 Regarding properties of imaging

A) Radiation dose of Chest X-ray is more that of a Mammogram.


B) Increase in wave length of Ultrasound facilitates visualization of deep
structures.
C) Approaching waves in US increase in frequency due to Doppler effect.
D) Inability to obtain three dimensional images is a limitation with CT scan.
E) MRI scans are contraindicated in pregnanacy.

5
Answers to question 1.7

A) FALSE- They can damage already fragile vasculature and therefore


contraindicated.
B) FALSE- Torniquets are deflated and reinflated every 20-30 mins.
C) FALSE- Glass foreign bodies can be pressured about causing injuries to vital
structures.
D) FALSE- It can't compress the space between two bones.
E) FALSE- They can produce higher injurious pressure over a narrow area.

Answers to question 1.8

A) TRUE- Incision is through a mostly bloodless and thin line.


B) FALSE- Transverse incisions have more muscle and blood vessels at edges.
C) TRUE- Although cumbersome and time consuming these were preferred
before suture material with longer absorption times came in to use in order
to avoid incisional hernia.
D) TRUE- They are hardly visible after few weeks.
E) TRUE-This is probably due to lesser play of gravity. Even adhesions are less
with upper abdominal incisions.

Answers to question 1.9

A) FALSE - It is 0.4 milisieverts and that of a chest X-ray is 0.1 milisieverts.


B) TRUE - However resolution become less.
C) TRUE - Difference of increasing frequency of in-coming and decreasing
frequency of going-away is converted to colour difference with diagnostic
benefits.
D) False – Three dimentional (3D) images can be reconstructed.
E) False - Magnetic radiation is not harmful to fetus. Gadolinium based
contrast is not used.

6
1.10 A supine X-ray of abdomen will be recommended in diagnosis of

A) perforated viscera.
B) Pancreatitis.
C) Cholelithiasis.
D) region of bowel obstruction.
E) imperforate anus.

1.11 Radiotherapy

A) can cure sqamous cell carcinoma.


B) Is used to treat bone secondaries.
C) is administered locally.
D) Is fractional to avoid nausea and vomiting.
E) cause dermal telangiectasia.

1.12 Regarding ultrasound

A) Piezoelectric crystals transduce magnetic energy and sound energy to


each other.
B) Gain knob helps to obtain the right depth.
C) Fatty tissue allows clear visualization of structures beyond.
D) Kissing IVC is a sign of increased preload.
E) A lines are seen in pulmonary oedema.

7
Answers to question 1.10

A) FALSE- Air under diaphragm is seen in erect chest x ray.


B) TRUE - Sentinel loop and calcification of pancreas is suggestive.
C) TRUE - Only 10% Gallstones are radiopaque.
D) TRUE - This is the advantage of supine film over erect film as latter with
multiple fluid levels will only confirm intestinal obstruction.
E) FALSE - Head down position with metal maker at the anal pit is helpful.

Answers to question 1.11

A) TRUE -Examples include those affecting tounge and upper aerodigestive


tract.
B) TRUE -This offers symptomatic pain relief.
C) TRUE -Brachytheraphy is increasingly practiced in management of varity of
tumours.
D) FALSE -This reduces damage to surrounding tissue.
E) TRUE -This and hard thickened pigmented skin with damaged appendages
are effects.

Answers to question 1.12

A) FALSE - Transfer is between electrical energy and sound energy .


B) FALSE - Focus, gain and depth knobs are separate and balance between
them is most important in acuring right image.
C) FALSE - Fluid is ultrasonographers friend and Fat, Air and Bone(FAB) is the
enemy.
D) FALSE - This sign,indicating collapsing IVC with each cardiac cycle is a
manifestation of volume depletion.
E) FALSE - This reverberating equidistant lines which are reflexions of plura is
a feature of a normal lung Ultrasound.

8
2.CLINICAL ANATOMY
DR.MB SAMARAWICKRAMA

2.1 Neurological structures that are at risk during surgical removal of a


submandibular gland include

A) lingual nerve.
B) chorda tympani nerve.
C) otic ganglion.
D) glossopharyngeal nerve.
E) marginal mandibular branch of facial nerve.

2.2 Which of the following are true or false regarding the periorbital
haematoma?
A) It is associated with conjunctivalhemorrage and subconjunctival
hemorrage.
B) It results from injury to emissary veins.
C) It indicates direct injury to periorbital region.
D) The bleeding is deep to the aponeurosis of the scalp.
E) Numbness of upper face……..is associated.

2.3 Which of the following conditions in the anterior triangle of the neck are due
to developmental abnormality?

A) Thyroglossal cyst.
B) Branchial cyst .
C) Pharyngeal pouch.
D) Branchial sinus.
E) Thyroglossal fistula.

9
Answers to question 2.1

A) TRUE - Lingual nerve is directly related to the deep part of the gland, thus it
is at risk of damage during this surgery.
B) FALSE -The chorda tympani joines with the lingual nerve at the infra
temporal fossa.
C) FALSE -The otic ganglion is a small parasympathetic ganglion located
immediately below the foramen ovale in the infratemporal fossa and on the
medial surface of the mandibular nerve. It is not related to the
submandibular gland.
D) FALSE - It is not related to the submandibular gland.
E) TRUE -Although marginal mandibular nerve is not directly related to the
gland, it can be damaged during the incision for the surgery as it descends
below the mandible before ascending back near angle of the mandible.

Answers to question 2.2

A) TRUE – Periorbital hematoma due to direct injury causes conjunctival


hemorrage while due to indirect injury or a fracture can cause
subconjunctival hemorrage.
B) TRUE - SCALP is formed by skin, Connective tissue, the aponeurosis, loose
areolar connective tissue and pericranium.Emissary veins connect vessels
in connective tissue with intra cranial vessels. Damage to them can cause
blood to track down below the aponeurosis.
C) TRUE –This is a common cause.
D) TRUE - Bleeding under the aponeurosis of the scalp track down anteriorly
around the eyes and it is known as periorbital haematoma, black eye or
raccoon eyes an another serious cause.
E) TRUE – This is due to damage to infraorbital nerve as a result of fracture
involving inferior orbital plate.

Answers to question 2.3

A) TRUE - Persistence of the thyroglossal duct results in thyroglosal cyst.


B) TRUE -Similarly remnants of 2nd to 4th pharyngeal clefts appear in the
anterior triangle of the neck at the anterior margin of the
sternocleidomastoid muscle as a cystic swelling which is known as branchial
cyst.
C) FALSE - Pharyngeal pouch is acquired condition where the pharyngeal
mucosa bulges out through the inferior constrictor muscle.
D) FALSE -Branchial cyst may open to the exterior and known as brancheal
sinus.
10
E) FALSE - Thyroglossal fistula results from infection and rupture of
thyroglossal cyst and it is never a congenital.
2.4 The nerves at risk of damaging during level two axillary clearance include?

A) Long thoracic nerve.


B) Lateral pectoral nerve.
C) Medial pectoral nerve.
D) Thoracodorsal nerve.
E) Axillary nerve.

2.5 Which of the following conditions leads to avascular necrosis of a bone?

A) Fracture scaphoid at its waist.


B) Dislocation of hip joint.
C) Pulp space infection of fingers.
D) Fracture of the calcaneus.
E) Per trochanteric fracture of the femur.

2.6 Effects of dysfunction of the recurrent branch of the median nerve in carpal
tunnel syndrome include?

A) Impaired flexion of the interphalangeal joint of the thumb.


B) Wasting of the thenar muscles.
C) Impaired sensation over the thenar eminance.
D) Median claw hand.
E) Positive Froment's sing.

11
Answers to question 2.4

A) TRUE - Level 2 clearance is removal of lymph nodes lateral and posterior to


the pectoralis minor and long thoracic nerve which run in the medial wall of
axilla is at risk. The intercosto-brachial nerve run through the central group
of the axilary nodes and this nerve is at higher risk of damage during this
procedure.
B) FALSE – This enters the deep surface of the pectoralis major muscle from
superio-medial direction .
C) FALSE - It enters the deep surface of the pectoralis minor muscle superio-
medial direction.
D) TRUE - The thoracodosal nerve run in the posterior wall of the axilla and is
also at risk of injuring during axillary clearance.
E) FALSE - The nerve lies at first behind the axillary artery, and in front of the
subscapularis, and passes downward to the lower border of that muscle.

Answers to question 2.5

A) FALSE - Avascular necrosis (AVN) or aseptic necrosis of a bone result when


its blood supply is cut off due to some reason. The proximal pole of the
scaphoid get necrosed when it is fractured at the waist as blood supply to
proximal fragment causes through distal part.
B) TRUE - Dislocated hip, if not reduced urgently, will lead to AVN of the head
due to tamponade effect on the head of the femur.
C) TRUE - Neglected pulp space infection leads to thrombosis of the terminal
branches of the digital artery resulting AVN of the terminal phalanx.
D) FALSE - The bones that are at risk of avascular necrosis include the scaphoid,
head of the femur, talus and the distal phalanxes.
E) FALSE - Intracapsular fracture of neck of the femur leads to AVN of the
femoral head.

Answers to question 2.6

A) FALSE - Flexion at the interphhalangeal joint of the thumb is done by the


flexor policis longus muscle which is supplied by the anterior interosseous
nerve.
B) TRUE - Thenar muscles are supplied by recurrent branch of median nerve.
C) FALSE - The recurrent branch has no sensory supply.
D) FALSE - The median claw is due to the paralysis of the lateral two lumbricals
which are supplied by digital nerves.

12
E) FALSE -Froment's sign indicates paralysis of the adductor plolicis muscle
which is supplied by the deep branch of the ulnar nerve.
2.7 A man was taken to the surgical casualty following a stab injury to the
abdomen. The knife was penetrating the rectus abdominis muscle about 5cm
above the symphysis pubis. Through which anatomical layers the knife could
have passed?

A) Membranous layer of superficial fascia.


B) Deep fascia.
C) Anterior layer of the rectus sheath.
D) Posterior layer of the rectus sheath.
E) Parietal peritoneum.

2.8 Branches of which arteries should be ligated before right hemicolectomy?

A) Iliocolic.
B) Right colic.
C) Middle colic.
D) Superior rectal.
E) Left colic.

2.9 Which of the following instances will injure the parital pleura?

A) Stab injury to the root of the neck.


B) Loin incision bellow the 12th rib for nephrectomy.
C) Drainage of an abscess in the right lobe of the liver.
D) Transhiatal oesophagectomy.
E) Rupture of a pulmonary bullae.

13
Answers to question 2.7

A) TRUE – This is the deeper layer of subcutaneous tissue


B) FALSE - There is no deep fascia in any part of the abdomen
C) TRUE - This is formed by the union of the external oblique aponeurosies
D) FALSE- This is a level below the arcuate line where only the anterior layer of
the rectus sheath exists.
E) TRUE - This reflects above the superior surface of bladder.Bladder can get
injured or well distended at the time of injury.

Answers to question 2.8

A) TRUE - Iliocolic supply appendix, ceacum and part of ascending colon.


B) TRUE - Right colic supplies ascending colon.
C) TRUE - Transverse colon is supplied mainly by the middle colic artery and its
right branches require ligation.
D) FALSE - This is a branch of inferior mesenteric artery supplying rectum.
E) FALSE - Branches of the inferior mesenteric artery supply the distal 1/3rd of
the transverse colon and they are only affected in extended right
hemicolectomy.

Answers to question 2.9

A) TRUE - The parietal pleura extend in to the root of the neck as the cervical
pleura thus it can be damage in a stab to the neck.
B) TRUE - Similarly the pleura extend below the 12th rib where it is vulnerable
during nephrectomy through the loin incision.
C) TRUE - Diaphragmatic pleura can be injured during the aspiration of a liver
abscess.
D) TRUE - During transhiatal oesophagectomy mediastinal pleura (part of the
parietal pleura) is damaged.
E) FALSE -Parietal pleura is not affected.

14
3. ANAESTHESIA
DR. UI HAPPUAARACHCHI

3.1 A 40 year old patient with hypertension well controlled on medication is


undergoing PUH repair. The investigation/ s required for preoperative
assessment should include,

A) 12 lead ECG.
B) Serum urea & electrolytes.
C) Prothrombin time.
D) 2D echo.
E) Fasting blood sugar.

3.2 Which of the following is/ are true/false about preparing a patient for major
elective surgery?

A) Dual antiplatelet therapy should be continued during surgery in a patient


diagnosed with ischaemic heart disease one year ago.
B) Heparin infusion should be continued until 4 hours after surgery.
C) Transfusion trigger is 12mg/dl.
D) Bipolar diathermy could be safely used in a patient with implanted
pacemaker.
E) Surgery should be postponed for at least 2 weeks in a patient having upper
respiratory tract infection.

3.3 Which of the following is / are true regarding induction of anaesthesia?

A) An intravenous agent is mandatory.


B) Di-isopropyl phenol can be continued throughout surgery.
C) Barbiturates produces myocardial depression.
D) Isoflurane could be used as an induction agent.
E) Etomidate will cause minimal cardiovascular disturbances compared to
barbiturates.
15
Answers to question 3.1

A) TRUE - This is required as patient is hypertensive.


B) TRUE - Medication for hypertension can alter electrolyte composition.
C) FALSE - There are no specific indications for this test.
D) FALSE - This is requested only if the patient is symptomatic and any cardiac
abnormalities are found on the examination.
E) FALSE - In absence of suggestive clinical history urine for reducing substance
is sufficient.

Answers to question 3.2

A) FALSE - Clopidrogel can be withheld and aspirin continued.


B) FALSE - This should be stopped 4 hours before surgery and restarted as soon
as possible after the procedure.
C) FALSE - This is considered at 8-10mg/dl.
D) TRUE - Diathermy could be safely used more than 15 cm away from the
pacemaker and it should be limited to short bursts.
E) TRUE - Surgery should be postponed for 4-6 weeks to avoid risk of
bronchospasm.

Answers to question 3.3

A) FALSE -Inhalational induction is sometimes performed although it is more


uncomfortable to the patient.
B) TRUE - TIVA (total intravenous anaesthesia) is increasing in popular.
C) TRUE - A drop in blood pressure can have detrimental results in trauma.
D) FALSE - It has a pungent odour and therefore not suitable for inhalational
induction.
E) TRUE - Etomidate causes less myocardial depression and peripheral
vascular resistance, thus contractility of the heart and the blood pressure
remain largely unchanged.

16
3.4 Which of the following is/are true regarding maintenance of airway?

A) Nasopharyngeal tube is measured from tip of the nose to angle of mandible.


B) Oropharyngeal airway is contraindicated in a patient with suspected basal
skull fracture.
C) Oropharyngeal airway is measured from incisor teeth to angle of mandible.
D) Laryngeal mask airway is for experienced practitioners than endotracheal
tube insertion.
E) Size of the endotracheal tube for an 8 year old child is approximately 6 mm.

3.5 Which of the following is/are true or false regarding postoperative nausea
and vomiting (PONV)?

A) Fasting for more than 12 hours would reduce the risk.


B) Propofol has antiemetic effect.
C) History of motion sickness is not associated with increased risk.
D) Laparoscopic surgery will have a reduced risk compared to open surgery.
E) Steroids could be used in resistant vomiting.

3.6 Which of the following procedures can be done as day surgery?

A) Laparoscopy and dye test.


B) Knee arthoscopy.
C) PUH repair.
D) LSV stripping + high ligation.
E) Tonsillectomy.

17
Answers to question 3.4

A) FALSE - Nasopharyngeal tube is measured from tip of nose to tragus.


B) FALSE - oropharyngeal airway could be safely used but nasopharyngeal
airway is contraindicated.
C) TRUE - incisor teeth to the angle of mandible is the measurement.
D) FALSE – Laryngeal mass airway can be used by medics with lesser
experience.
E) TRUE - Formula used is (age/4) + 4 in mm.

Answers to question 3.5

A) FALSE- Prolonged fasting will increase the risk of PONV.


B) TRUE - Compared to other induction agents propofol has antiemetic effects.
C) TRUE - These patients are at high risk of developing PONV.
D) FALSE- Peritoneal insufflation will increase the risk.
E) TRUE - Dexamethasone has a place in resistant vomiting.

Answers to question 3.6

A) TRUE- Patient could be discharged after 6 hours provided if there are no


anaesthetic or surgical concerns.
B) TRUE- Patient could be discharged after 6 hours provided no anaesthetic or
surgical concerns.
C) TRUE - Laparoscopic repairs can be sent home the same day.
D) TRUE - With laser this is even more feasible.
E) TRUE - This is a common day case procedure.

18
3.7 Which of the following are true/false regarding development of stridor
6hours after total thyroidectomy.

A) Perioperative fluid overload.


B) Tracheomalacia.
C) Haemorrhage.
D) Laryngeal oedema is due to intubation.
E) Bilateral recurrent laryngeal nerve palsy.

3.8 Management of chronic pain.

A) Severe neuropathic pain is treated with opioids.


B) Steroid injection is effective in pain due to prolapsed lumbar disk.
C) Lambar sympathectomy is done for improving peripheral blood floor has a
secondary advantage in relieving rest pain.
D) Monotherapy will have better results than multimodal approach.
E) Anticonvulsants could be used in the treatment of chronic pain.

3.9 Which of the following is / are true regarding local anaesthesia?

A) Spinal anaesthesia will have a higher risk of causing systemic bupivacaine


toxicity than epidural anaesthesia.
B) Cardiac arrest is a side effect of bupivacaine.
C) Nerve stimulation is more beneficial than ultrasound in installing nerve
block.
D) Lignocaine is used in topical anaesthesia.
E) Brachial plexus block is used as a sole anaesthetic technique in upper limb
surgery.

19
Answers to question 3.7

A) FALSE- This would produce dyspnoea but not stridor.


B) FALSE- This becomes apparent immediately after the surgery.
C) TRUE- This is a strong possibility and requires an immediate evacuation of
clots.
D) TRUE- This may require re-intubation and ventilation.
E) FALSE- This would appear immediately.

Answers to question 3.8

A) FALSE - It poorly responds to opioids, MAO inhibitors and anticonvulsants


are much more effective.
B) TRUE - It relieves inflammation of the nerve roots.
C) FALSE - It is done primarily to relieve rest pain in advanced PVD.
D) FALSE - Multimodality treatment is more effective in chronic pain.
E) TRUE - Carbamezapine ,Gabapentine and Sodium valproate could be used
in the multimodal approach.

Answers to question 3.9

A) FALSE – The risk is minimal because spinal anaesthesia uses very small
amounts of bupivacaine compared to epidural.
B) TRUE - This happens in overdose.
C) FALSE - Ultrasound visualizes nerve and other structures.
D) TRUE - 4% solution is used during awake fibre optic intubation.
E) TRUE - This has replaced cumbersome and risky Biers Block in experienced
hands.

20
3.10 Regarding regional anaesthesia.

A) Safe dose of bupivacaine is 3 mg/kg.


B) Adding adrenalin to lignocaine increases safety.
C) Bupivacaine is safe in intravenous regional anaesthesia (IVRA).
D) Circumoral numbness is an early symptom of lignocaine toxicity.
E) Post dural puncture headache is an immediate complication of spinal
anaesthesia.

3.11 Which of the following causes will lead to desaturation (< 94%) in post
anaesthesia care unit (recovery area)?

A) Pulmonary aspiration.
B) Prolong use of nitrous oxide intraoperatively.
C) Shivering.
D) Pulmonary oedema.
E) Airway obstruction.

3.12 Post-operative agitation in the post anaesthesia care unit could be due to

A) use of ketamine.
B) urinary bladder distension.
C) TURP syndrome.
D) hypothyroidism.
E) awareness during anaesthesia.

21
Answers to question 3.10

A) FASLE - safe dose is 2 mg/kg.


B) TRUE - adrenaline will cause local vasoconstriction there by reducing the
systemic absorption of lignocaine increasing its safety.
C) FALSE - bupivacaine is unsafe but lignocaine is safer.
D) TRUE - symptoms and signs involving cranial nerves will manifest early due
to their shorter lengths.
E) FALSE –it usually appears in 24-48 hours.

Answers to question 3.11

A) TRUE - Pulmonary aspiration will lead to cerebral hypoxia.


B) TRUE - Nitrous oxide can cause post-operative diffusion hypoxia.
C) TRUE – This will increase oxygen demand leading to hypoxia and also cause
pulse oxymeter to err in reading.
D) TRUE - Pulmonary oedema leads to cerebral hypoxia.
E) TRUE - Airway obstruction due to any cause will lead to cerebral hypoxia.

Answers to question 3.12

A) TRUE - Patients anaesthetised using ketamine should be recovered in a


calm and quiet environment to prevent this.
B) TRUE- This has to be excluded initially.
C) TRUE - Hyponatraemia due to excessive absorption of irrigation fluid will
lead to cerebral oedema.
D) FALSE- This will lead to delayed post-operative recovery.
E) TRUE - Patient will present with post-operative agitation and restlessness if
he had experienced intraoperative awareness.

22
4. CRITICAL CARE
DR.UI HAPPUAARACHCHI

4.1 Which of the following clinical features are suggestive of critically ill patient?

A) Patient saying 'I feel I am going to die'.


B) Ward sister saying this patient does not look right.
C) Temperature of 38.50C.
D) Respiratory rate of 24.
E) Confusion.

4.2 Guidelines for admission into ICU.

A) Require invasive monitoring.


B) Need for inotropes.
C) Need for assisted ventilation.
D) Need for 1:1 monitoring.
E) Need for peritoneal dialysis.

4.3 Which of the following are true regarding fluid and blood products?

A) Daily Na+ loss in urine is less in elderly.


B) Gelofusine is recognised to increase blood transfusion in post-operative
patients.
C) 20% mannitol is isotonic.
D) 1 unit of blood increases Hemoglobin by 2g/dl in a 70 kg adult.
E) Platelets have a half-life of 5 days at a temperature of 40C.

23
Answers to question 4.1.

A) TRUE- fear of dying is a feature of MI, hypovolaemic shock, respiratory


failure.
B) TRUE- experienced staff has their sixth sense probably due to complex
judgement process beyond available scientific evidence.
C) FALSE- Hyperpyrexia, a sign of critically ill is above.
D) FALSE- Respiratory rate should be markedly high.
E) TRUE- Agitation and drowsiness are also significant signs.

Answers to question 4.2

A) TRUE- Some patients can be managed at HDU but central lines and intra-
arterial lines may require ICU care.
B) FALSE- They do not need inotropes.
C) FALSE- Ventilation like CPAP can be managed at HDU.
D) TRUE - This is a requirement for ICU.
E) FALSE- This can be done in an HDU. Failure of two or more organs need ICU
care.

Answers to question 4.3

A) FALSE-This is more in elderly, as their concentration ability is diminishing.


After 33 years of age, all organs drop their function by 1% per year
approximately.
B) TRUE - Dextran are also known to cause coagulopathy.
C) FALSE- 5% solution is isotonic.
D) FALSE- It increases by 1g/dl.
E) FALSE- They are stored at 220C.

24
4.4 Which of the following are true regarding vital organs?

A) Tachycardia reveals cardiac ischaemia due to associated adrenaline surge.


B) PaCO2 above 3.5 kPa indicate hypercapnoea.
C) Hypokalaemia leads to tall T waves.
D) Creatinine level of 110umol/l in a 30y man is diagnosis of renal failure.
E) Adequately filled CVP is above 18 mmHg.

4.5. Disseminated intravascular coagulation.

A) is a drug reaction.
B) bleeding occur from minor abrasions.
C) sudden fall in platelet count below 150 × 109/l is suggestive.
D) APTT is increased and inr is decreased.
E) heparin is contraindicated.

4.6 Regarding deep vein thrombosis/ pulmonary embolism.

A) Without prophylaxis 30% of over 40 years of age undergoing major surgery


develop pulmonary embolism.
B) Varicose vein surgery is a risk factor for DVT.
C) Ventilation/ perfusion (V/Q) lung scan is favoured for diagnosing PE.
D) Surgical thrombo-embolectomy is reserved for massive PE.
E) S1Q3T3 pattern on ECG is pathognomonic for PE.

25
Answers to question 4.4

A) FALSE- It is due to reduced time available for diastolic filling.


B) FALSE- PaCO2 above 6.5 Kpa qualifies for this.
C) FALSE- Hyperkalaemia causes Tall T waves, no P waves and wide QRS
complexes.
D) FALSE- Levels are over 102umol/l for females and over 126umol/l for males.
E) FALSE- Adequately filled CVP is 14-16. Above 18 is overfilled.

Answers to question 4.5.

A) TRUE- Other common causes include sepsis, transfusion reaction and


transplant rejection.
B) TRUE- It is more obvious in larger wound sand venous lines.
C) FALSE- Widely used level is below 100 ×109/L.
D) FALSE- Both values are increased.
E) FALSE- It is indicated in those with evidence of thrombosis.

Answers to question 4.6.

A) FALSE- In this age group, 30% develop DVT and approximately 1% develop
pulmonary embolism.
B) TRUE- Many underestimates this risk.
C) FALSE- Computer tomograghy is now favoured over others.
D) FALSE- It is also used for bilateral Ilio-femoral thrombosis.
E) FALSE- This right ventricular strain pattern can occur in other conditions and
may not be present in PE.

26
4.7 Hypercalcaemia is reduced by

A) intravenous fluids.
B) calcitonin.
C) bisphosphonates.
D) hydrochlorothiazide.
E) steroids.

4.8 Maturity onset diabetes

A) is inherited as autosomal dominant.


B) many present after 40 years.
C) patients usually do not develop ketosis.
D) requires insulin at the time of diagnosis.
E) is associated with deafness.

4.9 Which of the following are true regarding sepsis /systemic inflammatory
response syndrome (SIRS)/ multi organ dysfunction syndrome (MODS) and acute
lung injury (ALI)?

A) Pulse rate more than 120/min is a feature in SIRS.


B) In sepsis localization of focus is mandatory to management.
C) MOF can be managed without organ support initially.
D) Bilateral infilterates on a chest x ray help to differentiate ARDS from milder
form of ALI.
E) ARDS has PaO2/FiO2 ratio 300.

27
Answers to question 4.7.

A) TRUE- Rehydration is an important aspect of management, which if


vigorous lowers the serum level of calcium significantly.
B) TRUE- This reduces serum calcium by inhibiting osteoclastic bone
resorption.
C) TRUE- These are effective in malignancies by inhibiting the osteoclastic
bone resorption and are given intravenously.
D) FALSE- Thiazide diuretics elevate serum calcium level but frusemide reduce.
E) TRUE- These are particularly effective in sarcoidosis and myeloma when
given in high doses.

Answers to question 4.8.

A) FALSE- Five types have been identified where defects in insulin synthesis or
secretion occurs.
B) FALSE- Many of these patients presents in the mid- twenties.
C) TRUE - Ketosis is unusual in this type of diabetes.
D) FALSE- Insulin requirements are low and are not required initially as the
most common type shows marked sensitivity to small doses of
sulphonylureas.
E) FALSE- Diabetes is associated with deafness in the recessively inherited
Wolfram syndrome and in the condition of maternally inherited diabetes
and deafness.

Answers to question 4.9.

A) FALSE- Over 90/min is sufficient.


B) FALSE- Focus can be translocation of gut bacteria in significant number.
C) FALSE-By definition organ support is required
D) FALSE- it is a common feature for ALI and ARDS.
E) FALSE-Ratio is under 200 in ARDS and less than 300 in ALI which is the major
conspicuous difference.

28
5. TRAUMA AND BURNS
DR.RW SENEVIRATNE

5.1 A 36-year-old man is admitted one hour after having kicked in the abdomen.
He is conscious, communicates and has moderate abdominal pain. Abdomen is
distended. On monitoring Pulse rate is 110bpm and BP is 120/100 Hgmm.

A) Airway and Breathing examination can be skipped as patient is conscious.


B) Patient is in class 1 shock.
C) Bolus of 500 ml normal saline is immediately indicated.
D) Hemodynamic status deteriorating after 30min of good response to initial
bolus and subsequently become stabilized after 2nd bolus is known as type
II response.
E) Liver is the most likely organ to be injured.

5.2 A partial thickness burn

A) heals without grafting.


B) deteriorates into full thickness skin loss.
C) rarely causes severe physiological derangement to the patient.
D) require blood transfusion.
E) is diagnosed clinically

5.3 A 30 Year old man, a motorcyclist is admitted to emergency department


following a road traffic accident. He is diagnosed as suffering from complete
transection of the spinal cord at the level of the sixth cervical vertebra. He has no
other significant injuries. Expected clinical signs include

A) Diaphragmatic Breathing
B) Elevated systolic Blood Pressure
C) persistent penile erection
D) Flaccid Paralysis of lower limbs
E) Anal sphincter spasm

29
Answers to question 5.1

A) FALSE - ATLS protocol should be followed.


B) FALSE - He is in class II shock with PR 100-120 /min range , normal SBP ,
elevated DBP and reduced Pulse pressure.
C) FALSE - Bolus in an adult is 1000ml or 20ml/kg. In a child it is 10ml/kg.
D) TRUE – Second fluid bolus was required to pay fluid debt from other
compartment; volume shift from intracellular to extracellular space in the
initial part of shock to compensate.
E) FALSE - Spleen is the most likely organ to be injured in blunt trauma. Liver is
most likely organ to be injured during penetrating trauma and overall
trauma.

Answers to question 5.2

A) TRUE - Scarring can be minimal.


B) TRUE - This can happen with infection.
C) FALSE - Does not depend much on depth but on the burn surface area,
leading to fluid and electrolyte loss.
D) FALSE- This may be required in large full thickness burns.
E) TRUE - Intact sensation is a guide.

Answers to question 5.3

A) TRUE- Phrenic nerve is intact (C3, 4, 5).


B) FALSE- Neurogenic shock cause loss of sympathetic tone and
vasodilatation.
C) TRUE- This is a definite sign of complete cord transection.
D) TRUE- This is due to spinal shock immediately after injury before the
spasticity sets in.
E) FALSE- Lax anal sphincter tone is to be expected.

30
5.4 In a patient with blunt trauma to the chest which of the following findings are
likely to indicate the need for thoracotomy?

A) Flail Chest involving 4 rib segments.


B) Muffled Heart Sounds on auscultation.
C) Abdominal Distension with diminished oxygen saturation.
D) Initial Chest Drain output of 1500 ml.
E) Chest Drain output of 100 ml for 4 consecutive hours.

5.5 A 18 year old woman present to Emergency Department with 30% scalds
involving Face, upper limbs and front of the trunk. She was brought in 3 hours
after injury. Her weight is 60kg.Which of the following statements are correct on
the management of her condition.

A) Intramuscular Pethidine is a suitable painkiller.


B) 900 milliliters of fluid should be added to her maintenance requirements
over next 4 hours according to Muirs and Barclays Formula.
C) Facial wounds are best managed without dressings.
D) Involved Hands are splinted in position of function after dressings are
applied.
E) Urinary Cathetre is mandatory.

5.6 A 30 year old driver of a car is brought in to hospital after a lorry hitting him
on his side of the vehicle.

A) Neck is immobilized immediately.


B) Left Pneumothorax is expected.
C) Pulse of 90 BPM with systolic blood pressure of 120 Hg mm excludes
hemorrhagic shock.
D) Neurological statue is assessed with Glasgow coma scale in primary survey.
E) Fracture Femur is splinted after completion of log roll.

31
Answers to question 5.4

A) FALSE-This is amenable to strapping, intercostal nerve block and


ventilation
B) TRUE- This indicate cardiac tamponade which warrants pericardiocentesis
followed by thoracotomy
C) FALSE-This suggest hemoperitoneum, reduced perfusion with
diaphragmatic splinting. This requires laparotomy.
D) TRUE- This is a clear indication in ATLS protocol.
E) FALSE- 200ml/hr for 4 consecutive hours or 100ml/hr for 10 hours are
indications for thoracotomy.

Answers to question 5.5

A) FALSE -Intramuscular drug absorption is unpredictable and may lead to


respiratory depression with restoration of the volume in this case.
B) TRUE -Muir and Barclay formula(=0.5%×Body surface area(BSA) × weight)=
one fluid pack given in time intervals of 4/4/4/6/6/and 12 hrs over a period
of 36 hours.
C) TRUE - Betadine dabs are preferred.
D) FALSE- Silver sulphurdiazine is applied and early mobilization is encouraged
under the causes of sterilized bags. Dressings are not encouraged as they
are restrictive
E) TRUE –BSA involving>15% need iv fluid therapy. For accurate
measurement of visceral perfusion, hourly UOP in burn injury is mandatory.

Answers to question 5.6

A) TRUE - ATLS has to be adhered at every stage. Airway and C-spine is the first
step.
B) FALSE - Right pneumothorax is expected.
C) FALSE - In class 1 shock upto 750ml blood can be lost while above
parameters are maintained.
D) TRUE - GCS and AVPU scale can both be undertaken.
E) FALSE - Splinting of fracture femur comes under Circulation component of
the primary survey

32
5.7 Regarding a patient with Major trauma

A) CD insertion for tension pneumothorax must follow CXR review.


B) 50% of chest injuries need thoracotomy .
C) Bradycardia, hypotension and muffled heart sounds are characteristic of
cardiac temponade.
D) Insertion of a urinary catheter is a must.
E) FAST scan is a component of 2ry survey .

5.8 Regarding blunt trauma to the abdomen

A) Seat belt impression implies severe intra abdominal injury.


B) Diagnostic peritoneal lavage is more sensitive to contamination than FAST.
C) Pouch of douglas is the most common area to detect intra-peritoneal
bleeding during FAST scanning.
D) Absence of haematuria excludes renal injury.
E) Liver laceration usually require laparotomy following blunt trauma.

5.9 Which of the following are true regarding injuries to the thoracic viscera?

A) They occur in children without associated bony injuries.


B) Distended neck veins are always due to cardiac temponade.
C) Chest X-ray (AP View) is helpful in diagnosing major vascular injury.
D) hemithorax can contain 2L of blood.
E) Oesophagial injuries present late.

33
Answers to question 5.7

A) FALSE- This is a clinical diagnosis.


B) FALSE- Approximately 15% require thoracotomy.
C) FALSE- Tachycardia is the expected finding. Beck's triad in cardiac
tamponade include distended neck. veins. Hypotension and muffled heart
sounds.
D) TRUE- Urine output is a measure of organ perfusion.
E) FALSE -This is an adjunct to primary survey.

Answers to question 5.8

A) TRUE- Bowel rupture can be expected.


B) TRUE- FAST does not distinguish between blood and bowel contents, a
drawback.
C) FALSE- Hepato- renal pouch in the most likely place to collect blood.
D) FALSE- Pedicle disruptions may not produce hematuria.
E) FALSE- Most of the liver lacerations are managed conservatively.

Answers to question 5.9

A) TRUE- Bones in young children are pliable.


B) FALSE- This may also be due to tension pneumothorax.
C) TRUE- Acute injuries may manifest as widened upper mediastinum.
D) TRUE- This has been found in studies.
E) TRUE- Occupational injuries may take 8-24 hours to clinically manifest.

34
5.10 Which of the following are true regarding blunt trauma to the abdomen?

A) Right dome of the diaphragm is more prone to injury.


B) Renal pedicle injuries are more common in children than adult following
blunt trauma.
C) Small bowel injuries should never be managed conservatively.
D) Rectal injuries are best managed with simple primary repair.
E) Intra-abdominal bladder tears can be managed with urinary catheter for 2
weeks.

5.11 Following feature/s, is/are invariably present in a patient with shock

A) Tachycardia.
B) Hypotension.
C) Tissue hypoxia.
D) Hypothermia.
E) Diminished level of consciousness.

5.12 In a mass casualty situation

A) A critically Injured in a less accessible location can be ignored initially.


B) Triage should be done by junior most doctor allowing seniors to attend
serious casualties.
C) Airway injury should be attended at the same time by triage doctor
D) Lungs are the first organ to injure in a bomb blast.
E ) Eviscerated bowel should be gently put back to abdomen

35
Answers to question 5.10

A) FALSE- This is protected and snugly supported by liver.


B) TRUE- In children padding layer of perinephric fat is deficient.
C) TRUE-They need repair,as enzymatic action is erosive.
D) FALSE-They always need protective colostomy after repair.
E) FALSE- They need to be opened and operative repair is needed.
Extraperitoneal bladder injuries can be managed conservatively with
urinary catheter for 2 weeks.

Answers to question 5.11

A) FALSE- Cardiogenic and neurogenic shock cause bradycardia.


B) FALSE- Early hemorrhagic shock is normotensive.
C) TRUE- This is the common finding.
D) FALSE- Septic shock cause warm peripheries.
E) FALSE- During early part of the shock cerebral blood flow is maintained at
the expense of peripheral perfusion.

Answers to question 5.12

A) TRUE-This is expectant category. It allows resources to be directed towards


greater good.
B) FALSE- This important decision making has to be done by the most senior
doctor.
C) FALSE- Triage doctor should not attend to any injuries until he finishes
triage.
D) FALSE-Ear drums ,lungs and intestines is the order of injury.
E) FALSE- This should be kept out, wrapped in wet gauze.

36
6. ORTHOPAEDIC (TRAUMA)
DR.RW SENEVIRATNE

6.1 Rearding management of orthopaedic injuries of upper limb

A) Spiral fractures of metacarpal bones heal later than transverse fractures


B) Proximal ulnar fracture with dislocation of head of the radius is termed
Galliazi fracture
C) Transverse Fracture of the midshaft of ulna is called night stick injury
D) Supracondylar fracture of humerus always leads to malunion.
E) Fracture neck of humerus is usually managed with internal fixation.

6.2 Which of the following sports injuries usually require open or arthroscopic
surgical repair?

A) Rotator cuff tear in a 25 year old


B) Anterior dislocation of shoulder in an 18 year old
C) Achilles Tendon rupture in a 45 year old
D) Rupture of planter plate in first metatarsophalangeal joint.
E) Flexor tendon pully injury in the hand of a 50 year old

6.3 An 80 years old woman is admitted with a fracture involving neck of the
femur sustained one week ago. She has dysuria and a small decubitus ulcer over
right buttock. She is suffering from Chronic obstructive pulmonary disease
(COPD).Which of the following are true regarding the situation?

A) Osteoarthritis is often the underlying cause


B) Total hip replacement is indicated considering the age irrespective of
fracture anatomy.
C) General anesthesia is preferred.
D) Urinary tract infections should not delay surgery
E) Surgery must wait till pressure sore heals.
37
Answers to question 6.1

A) FALSE - Spiral fractures heal early due to higher contact area between
fracture surfaces.
B) FALSE - This is a description of Montagia fracture.
C) TRUE - A Patient who raise hand to protect the face when assaulted by
another with a stick in the night suffer from this injury which is the classic
description of the mechanism.
D) TRUE - This is a rule although good reduction ensure that disability is
minimal.
E) FALSE - This is usually reduced and managed with the aid of a sling and
gravity.

Answers to question 6.2

A) TRUE - This needs repair in young patients.


B) FALSE – Only recurrent dislocation mandates surgery.
C) FALSE- This can be treated conservatively.
D) FALSE- Terf toe is managed conservatively.
E) TRUE - If not repaired patient will be troubled by bow string effect.

Answers to question 6.3

A) FALSE - Osteophorosis is the underline cause .


B) FALSE - Minimal fixation with screws and plates are done if fracture
anatomy permits.
C) FALSE - Spinal anaesthesia is the standred.
D) FALSE - UTI induced bacteraemia can lead to infection of metal work
E) TRUE - All Sources of active infection need to be removed prior to surgery.

38
6.4 Which of the following fracture-nerve injury associations are common?

A) Neck of the humerus - radial nerve.


B) Neck of the femur - sciatic nerve
C) Severe 4th lumber vertibaral fracture - spinal cord.
D) Supracondylar fracture of humerus - ulnar nerve.
E) Shaft of fibula - common peronial nerve.

6.5 Colles fracture

A) often has an intraarticular extension.


B) does not occur in young age.
C) can be reduced under haematoma block.
D) causes carple tunnel syndrome
E) causes reflex sympathetic dystrophy.

6.6 Fall on the outstretched hand can commonly cause

A) Fracture of the shaft of ulna.


B) Fracture of scaphoid
C) Colles fracture.
D) Sternocalvicular joint subluxation.
E) Fracture of the head of the radius

39
Answers to question 6.4

A) FALSE - Axillary nerve can be injured while radial nerve injury is common in
shaft fractures
B) FALSE - Posterior dislocation of hip is typically associated with this injury.
C) FALSE- Spinal cord ends at lower border of L1 and cauda equina can get
injured with this fracture.
D) TRUE - This injury can occur immediately or later(Tardieu ulnar nerve
palsy).
E) FALSE - Common peronial nerve is related to neck of fibula.

Answers to question 6.5

A) FALSE - Fractures of radius if occur within 2.5 cm of distal articular surface


of radius are called colles if distal fragment is dorsally angulated and smiths
if ventrally angulated. Intra-articular fractures are called dorsal Bartons or
ventral bartons depend on their disposition.
B) FALSE - It can occure at any age although more common in elderly
osteophorotic females.
C) TRUE - Older people can undergo this treatment as less than ideal reduction
is acceptable which can be followed by same day discharge.
D) TRUE - Imperfections in reduction and Fracture healing can lead to narrow
carpal tunnel.
E) TRUE - Injury and Immobilization contributes and sympathetic over activity
suggested but exact mechanism is unkown.

Answers to question 6.6

A) FALSE - This night stick injury is a result of direct blow.


B) TRUE – This is seen in young adults.
C) TRUE - This is common of elderly osteoporotic females.
D) FALSE – Acromio clavicular joint sublaxation is not uncommon.
E) TRUE- This is seen in teens.

40
6.7 Posterior dislocation of the hip joint is

A) most common if the hip is in a neutral position at the time of impact.


B) associated with a fracture of the acetabular rim.
C) associated with injuries of the sciatic nerve.
D) associated with necrosis of head of femur.
E) Initially managed with traction.

6.8 Supracondylar fracture of the humerus

A) is commonly seen in old age.


B) leads to the complication of ischaemic muscle contracture.
C) can lead to disappearance of brachial pulse on reduction.
D) heals in malunion in 30%.
E) is associated with median nerve injury.

6.9 Regarding management of orthopaedic injuries

A) Fracture scaphoid require immobilization even if the X ray at two weeks


does not reveal a fracture.
B) Spiral fracture of MC heals later than transverse fracture.
C) Intertrochanteric fractures always lead to early osteoarthritis.
D) Complete Lower limb fractures always lead to loss of height.
E) Loss of bone over 10 cm gap in tibia makes amputation necessary.

41
Answers to question 6.7

A) FALSE- It occurs in adducted hips.


B) TRUE- Posterior lip fracture is not uncommon.
C) TRUE- This risk is high and disabling.
D) TRUE- The risk is less common compared to central dislocation.
E) TRUE- This realigns the area and reduce pressure on sciatic nerve.

Answers to question 6.8

A) FALSE- This is seen in teens.


B) TRUE- Volkmans is the name.
C) TRUE- If this happens reduction should be reversed until pulse appears
which is followed by immobilization in a new position.
D) TRUE- They almost always heal on malunion
E) TRUE- This is less common compared to other nerve injuries.

Answers to question 6.9

A) TRUE- Bone scan confirmation is ideal.


B) FALSE- It heals early due to higher contact area.
C) TRUE- This is a rule.more than 1mm in separation or a step in an
intraarticular fracture require open reduction and internal fixation (ORIF).
D) TRUE- This is a rule.
E) FALSE- This can be bridged with bone prosthesis or with bone migration.

42
6.10 Which of the following are true regarding ankle and foot

A) Neck of the fibula should be carefully examined for a second fracture in


patients who have fracture lateral malleolus.
B) Internal fixation of fracture of a closed fracture involving medial malleolus is
best done immediately following injury.
C) Out of the metatarsal injuries fracture or dislocation of the first metatarsal
is the most serious.
D) Calcaneal fractures are usually fixed internally.
E) Complete rupture of Achilles tendon sometimes managed conservatively.

6.11 Regarding management of fractures

A) Smith's fracture is usually managed with a dorsal pop slab.


B) U slab is the preferred management option for fracture of the neck of
humerus.
C) Most of the anterior wedge fracture of lumbar vertebrae are managed
conservatively.
D) Intracapsular fracture neck of femur necessitate hemiarthroplasty of the
hip ot total hip replacement(THR).
E) Open fracture of the tibia is best managed with external fixation.

6.12 Which of the following pathological conditions of the upper limb come
under repetitive strain injury?

A) De quervain's tenosynovitis.
B) Skier's thumb.
C) Guyon's canal syndrome.
D) Lateral epicondilitis.
E) Frozen shoulder.

43
Answers to question 6.10

A) FALSE - Fractured medial malloleus is associated with fracture neck of the


femur.
B) TRUE - Development of odema will delay the fixation considerably.
C) FALSE- 2nd Metatarsal bears the weight of the dome
D) FALSE-Conservative Management is always preferred due to the risk of
osteomyelitis with ORIF.
E) TRUE- This option is offered to older people

Answers to question 6.11

A) FALSE- Volar slab is applied but ORIF with buttress plate is often required.
B) FALSE- This is managed with collar and cuff.
C) TRUE- This ……provided no neurological signs are provided two of the three
spinal column should be intact.
D) TRUE- This severs the blood supply to the neck.
E) TRUE- This would take a long time to heal.

Answers to question 6.12

A) TRUE - This is seen in housewives.


B) FALSE -This injury is due to acute rupture of ulnar collateral ligament of first
metacarpophalangial joint.
C) TRUE -This occur in occupations which use hammers frequently.
D) TRUE -This is also called cricket elbow.
E) FALSE -This is a result of prolonged immobilization.

44
7. ORTHOPAEDIC (NON TRAUMA)
DR.RW SENEVIRATNE

7.1 Which of the following statements are correct regarding Acute


Osteomyelitis?

A) Usually caused by Group B streptococcus.


B) Non traumatic Oeteomayalitis is more common in infants than older
children.
C) Diagnosed by X ray during first week.
D) Caused by Psuedomonas in patients with Sickle cell anemia.
E) Patient is likely to suffer recurrent acute attacks throughout his life.

7.2 Regarding cervical spondylosis

A) It is common in Professional divers.


B) Weakness of Lower limbs is a feature.
C) Wasting of interossious muscles of the hand suggest C5/6 disk lesion.
D) Require MRI scan for diagnosis.
E) Physiotherapy is indicated.

7.3 Osteoclastoma (giant cell tumor of bone)

A) characteristically occurs in the shaft of a long bone.


B) It usually occurs before fusion of the epiphyseal plate.
C) reveals subperiosteral new bone which overlies the tumour on x ray.
D) is rarely malignant.
E) characteristically presents as a pathological fracture.

45
Answers to question 7.1

A. FALSE- Staphylococcous aurius is the most common pathogen.


B. TRUE- Their immune system is not fully mature and bones have rich blood
flow.
C. FALSE - X-rays are not useful until 10-14 days.US scan and bone scan helps to
diagnose early.
D. FALSE - Salmonella is the famous culprit in this group of patients.
E. FALSE- This is a sequel of chronic osteomyelitis. Acute osteomyelitis can be
cured with early aggressive management with antibiotics.

Answers to question 7.2

A) FALSE - It is common in jobs prone to regular vibratory movements such as


military and driving.
B) TRUE - This indicate canal compression and require surgical
decompression.
C) FALSE – It suggest C7/T1 leison.
D) FALSE - Clinical features and X-ray are usually sufficient.
E) TRUE - Sypmtoms are periodic and excerbations usually respond to
conservative measures.

Answers to question 7.3

A) FALSE - They usually originate from the epiphysis of long bones.


B) FALSE –Osteoclastoma has a predilection for the epiphyseal/metaphyseal
region of long bones.
C) TRUE - This is a feature of osteoclastoma and known as 'Soap Bubble'
appearance. They are distinguishable from other bony tumors in that graft
cell tissues usually have a non-sclerotic and sharply defined border
D) TRUE - Malignancy in giant cell tumor is uncommon and occurs in
approximately 2% of all cases
E) FALSE -Many present with pain and decreased range of movement. Some
patients may be asymptomatic until they develop a pathologic fracture at
the site of the tumor.

46
7.4 Regarding Knee

A) Prepatellar bursitis is known as clergimens Knee.


B) Infrapateller bursitis is associated with effusion of the knee joint.
C) Haemarthrosis indicate significant trauma.
D) All Loose bodies should be removed.
E) Osteoartheritis commonly affect medial compartment than lateral

7.5 Patients with symptomatic osteoartritsis involving knees are recommended

A) Jogging excercises.
B) Glucosamine and Chondroitin sulphate.
C) Quadriceps strengthening excercises.
D) Intra articular corticosteroids.
E) Knee replacement

7.6 Regarding orthopaedic conditions affecting children

A) Transverse fracture in tibia of common in toddlers


B) Haemophilia is a risk factor for septic arthritis
C) Transient synovitis is associated with recent viral infection
D) Perthes disease usually affects both hips
E) Idiopathic juvenile arthritis is termed oligoarthritis when 3 or less joints are
involved

47
Answers to question 7.4

A) FALSE - It is called housemaids knee.


B) TRUE - This is a sympathetic effusion resulting from inflammation.It is
important to differentiate this entity from septic arthritis
C) FALSE -This can happen with minimal trauma due to rupture of an
osteophyte
D) TRUE - Locking is disabling and damage articular surfaces
E) FALSE - Lateral compartment is exposed to more force due to slight valgus
angulation of knee,

Answers to question 7.5

A) FALSE - They should be low impact and aerobic such as cycling and
swimming
B) FALSE - Benefits are marginal
C) TRUE - This is of moderate benefit.
D) TRUE - This offers short term pain relief
E) TRUE – This is recommended In appropriate selected patients when other
options are not effective.

Answers to question 7.6

A) FALSE - Spiral fracture of tibia following low energy falls is common in


children under 3y hence called 'toddler fracture'
B) TRUE - Staph aureus, streptococcus and gram negative bacteria are
commonly seen
C) TRUE - Nevertheless exact causation is yet to be elucidated
D) FALSE - 80% are unilateral
E) FALSE - When 5 or less joints are involved it is termed oligoarthritis

48
7.7 Regarding amputation of lower limb

A) Saving maximum limb length is the primary objective


B) Below knee amputees consume 20% more energy on movement than
normal individuals
C) Below knee amputation is covered by two equal flaps
D) Syme's amputation offers better mobility than below knee amputation
E) Equinous contracture is common following trans metatarsal amputation

7.8 'Red flag' sign for patients with back pain include

A) Saddle anaesthesia
B) Associated urinary tract infections
C) Use of steroid
D) Age more than 70
E) Right leg straight leg raising test more than 300

7.9 Lumber disk herniation

A) Affect 10-15% population during lifetime.


B) Family history is a risk factor.
C) L4/L5 or L5/S1 disks are involved in over 75% of the time
D) Bilateral sciatica require emergency orthopaedic referral
E) 70% will settle in 3 months with conservative management.

49
Answers to question 7.7

A) FALSE - While this is the primary objective in upper limb amputation,lower


limb should be amputated at a level suitable to fit the locally available
prosthesis
B) TRUE -Above knee amputation use 70% extra energy.this added demand
has an adverse impact on life expectancy
C) FALSE -Posterior flap with a better muscle bulk and blood supply is longer
D) FALSE -Prostheses fitted to below knee stump allow easy movement.
E) TRUE - Gastrocnemius and soleus lenghthening is done to prevent this
complication.

Answers to question 7.8

A) TRUE - This suggest cauda equine lesion


B) TRUE – This is an accompaniment of malignancy, infection, spinal cord
damage
C) TRUE - In sport fractures collapse of vertebrae can occur
D) TRUE - Osteoporotic fractures are common even after minor stresses
E) FALSE --This doesn't lead to permanent disability

Answers to question 7.9

A) FALSE-Figure is 2-4%
B) TRUE- Common Tissue disorders are implicated.
C) FALSE- Finger is over 90%
D) TRUE-This implys the possibility of a central disk and spincter damage
E) TRUE - Others may need steroid injections or microdiscectomy.

50
8. UPPER GASTROINTESTINAL SURGERY
DR.MMAJ KUMARA

8.1 Which of the following is/are true regarding esophageal lesions

A) Squamous carcinoma of the oesophagus is increasing in incidence globally


compared to adeno carcinoma.
B) Abnormal left supraclavicular artery can cause dysphagia.
C) Achalasia cardia causes dysphagia for solids more than liquids.
D) Interval banding is the most beneficial treatment for esophageal varices.
E) Longstanding gastro-oesophageal reflux disease (GORD) is a cause for
dysphagia

8.2 Which of the following findings favour palliative approach for carcinoma of
oesophagus?

A) Carcinoma oesophagus extending to lesser curve


B) Hard enlarged left supraclavicular lymph node
C) Mid oesophgeal tumour detected on bronchoscopy
D) Positive peritoneal washings
E) Enlarged mediastinal lymph nodes

8.3 Which of the following statements is/are true regarding gastro oesophageal
reflux disease (GORD)?

A) Upper gastrointestinal endoscopy can accurately diagnose the condition in


all symptomatic patients.
B) It is a risk factor for mucosal metaplasia of the lower oesophagus.
C) Laparoscopic cardiomyotomy is a treatment option for symptomatic
patients not controlled by medication.
D) Weight reduction and lifestyle modification plays an important role in the
management.
E) Proton pump inhibitors (PPI) fail to achieve symptom control in a majority of

51
patients

Answers to question 8.1

A) FALSE- Adeno carcinoma is increasing due to GORD leading to Barret's


esophagus.
B) FALSE- When due to abnormal subclavian artery. It is known as dysphagia
lusoria.
C) FALSE- Opposite is the true. Solids weigh more and can negotiate increased
pressure of lower esophageal sphincter more easily.
D) TRUE- This has the highest benefit. Propranolol treatment is beneficial to a
lesser degree.
E) TRUE- These patients can develop strictures leading to dysphagia. It can
also lead to Barret's metaplasia and malignant obstruction.

Answers to question 8.2

A) FALSE - Adeno carcinoma of oesophagus commonly involves gastric cardia


and may therefore extend into fundus or down the lesser curve. Some
degree of gastric excision is essential to achieve adequate local clearance.
Curative attempt is possible with a construction of a new lesser curve.
B) TRUE - This is “trossier s sign”. Cutaneous metastasis or involved enlarged
supraclavicular lymph nodes indicate disseminated disease.
C) TRUE - Many middle and upper third oesophageal carcinoma are
sufficiently advanced at the time of diagnosis that the trachea or broncus
are involved.
D) TRUE - This indicates peritoneal spread.
E) FALSE -These indicate local invasion and resectable with en block of
oesophagectomy.

Answers to question 8.3

A) FALSE -Endoscopy may be required and 24 hour pH recording is the gold


standard for diagnosis of GORD
B) TRUE - Barret's oesophagus is a squamous metaplastic change in the lining
of mucosa of the oesophagus.
C) FALSE -Laparoscopic Nissens fundoplication is indicated.
D) TRUE -Simple measures include weight reduction , cessation of smoking and
reduced consumption of alcohol, tea,coffee etc. Avoidance of large meals
late at night and modest degree of head up tilt of the bed are also
beneficial.

52
E) FALSE -PPI s are the most effective drug treatment for GORD.

8.4 Regarding gastro oesophageal reflux disease (GORD)

A) It is aggravated with rolling hiatus hernia


B) It can mimic angina
C) Endoscopy is the gold standard in diagnosis.
D) PPI reduse symptoms in over 50%
E) Nissens fundoplication relieves gas bloat

8.5 Which of the following are true of risk factors for development of carcinoma
of the stomach?

A) Presence of a gastrointestinal stromal tumour (GIST)


B) Helicobacter pylori infection
C) Betel chewing
D) Pernicious anaemia
E) Cigarette smoking

8.6 Which of the following are true regarding Carcinoma of stomach

A) It is associated with Blood Group O.


B) Succession splash is a feature.
C) Loss of weight is a late feature.
D) Symptoms respond to H2 receptor antagonists.
E) They are sited mainly in the pre-pyloric area.

53
Answers to question 8.4

A) FALSE –It is aggravated by sliding hernia.


B) TRUE -This is a pitfall in the diagnosis of Myocardial infarction.
C) FALSE -24 hours pH measurement is the gold standard for diagnosis
D) TRUE -90% respond to PPI
E) FALSE – Gas bloat along with dysphagia are complications of Nissen s
fundoplication

Answers to question 8.5

A) FALSE - Leiomyoma of GI tract are colectively known as GIST. They may arise
from any part of GI tract but 50% are found in the stomach. Mucosa
overlying the tumour is normal and a supportive biopsy may miss the
diagnosis.
B) TRUE- This is a recognised risk factor. There is a high incidence of gastric
carcinoma in populations with high prevalence of H.Pylori. H. Pylori
infection is associated with gastritis, gastric atrophy and intestinal
metaplasia.
C) FALSE – Betel chewing is associated with oral and esophageal malignancies.
D) TRUE - Patients with pernicious anaemia and gastric atrophy are at an
increased risk.
E) TRUE -Other risk factors include high salt intake,low fibre intake and
positive family history.

Answers to question 8.6

A) FALSE - Associations include 5 As. Anemia,asthenia,blood group


A, Anorexia and Acoholhydria .
B) TRUE - This is due to delayed emptying , a result of gastric outlet obstruction
and occurs in distal obstructing tumors.
C) FALSE – Loss of appetite and resulting Loss of weight are early features.
D) TRUE - This can delay the diagnosis and thus worsen prognosis. Those over
45years present with symptoms of peptic ulcers require UGIE before
medical treatment.
E) FALSE - Pylorus and antrum account for only 7% and 13% respectively .
Carcinomas of gastro oesophageal junction , cardia and body together
account for approximately 60%.
54
8.7 Gastric ulcers

A) are most common along grater curve.


B) are visualized by Barium meal in 90% instances.
C) Approximately 25% require surgery.
D) are mainly managed by HSV and drainage procedure when surgery is
indicated.
E) if perforated will be revealed by an erect chest X ray as gas under
diaphragm in over 95% cases

8.8 Reagarding gastric outlet obstruction (GOO)

A) Pancreatic pseudocyst is a cause.


B) Hypochloraemic alkalosis is more common in those due to peptic ulcer
aetiology.
C) Aciduria is an early feature.
D) It responds to aggressive medical therapy
E) Surgery is frequently required

8.9 Bleeding duodenal ulcers

A) can present with bright red passages of blood through rectum.


B) Cause torrential bleeding.
C) are effectively managed by embolization of the feeder.
D) may require emergency Whipple operation
E) are caused by Helicobactor pylori.

55
Answers to question 8.7

A) FALSE -Chronic gastric ulcers are much more common on the lesser curve
especially at incisura angularis.
B) FALSE- It does not provide this high degree of accuracy
C) FALSE –Surgery is occasionally required for complicated ulcers. Vast
majority of uncomplicated ulcers are treated medically.
D TRUE – Surgery is rarely required.
E) FALSE -An erect plain chest radiograph will reveal free gas under the
diaphragm in an excess of 50% of the cases.

Answers to question 8.8

A) TRUE –This can cause extra mural obstruction.


B) FALSE-This is more common with other aietiological factors.
C) FALSE -This is a late feature
D) TRUE-This is indicated in non malignant causes
E) TRUE- Pyloric exclusion and gastrojejunostomy is the operation required
mostly.

Answers to question 8.9

A) FALSE – This is possible with severe bleeding.


B) TRUE – This occurs If posterior ulcer erodes into gastroduodenal artery or in
the event of aortodeodenal fistular.
C) TRUE -This is an option before surgery is special in trial.
D) FALSE - Whipples is a major complex procedure which is not attempted in
an emergency situation.
E) TRUE - H.pylori and NSAIDS are the most important aetiological factors.

56
9. HEPATOBILIARY, PANCREAS AND SPLEEN
DR.MMAJ KUMARA

9.1 A patient with obstructive jaundice due to a stone in the common bile duct
had a failed ERCP.He became febrile and collapses 48 hour later. Which of the
following is/are correct regarding immediate management?

A) Oxygen via face mask.


B) Intravenous Fluids.
C) Intravenous Cloxacillin.
D) Intramuscular Vitamin K.
E) Emergency Cholecystectomy

9.2 In patients with Acute Cholecystitis

A) Gall stones are always present.


B) Diagnosis is confirmed by a CT scan.
C) Pericholecystic abscess is the most common complication.
D) Presence of Jaundice invariably implies a stone in CBD.
E) Emergency cholecystectomy is contraindicated.

9.3 Regarding patients with pancreatic cancer

A) Cancer arising from tail of the gland is usually curable with distal
pancreatectomy.
B) Maturity onset diabetes is not uncommon.
C) They often present with palpable Gall Bladder.
D) Peri ampullary cancers have better prognosis.
E) They can be treated palliatively with Whipples (Pancreatico-duodenectomy
and gastrointestinal bypass) procedure.

57
Answers to question 9.1

A) TRUE- Picture is that of Ascending Cholangitis leading to septic shock.


B) TRUE- Shock requires an IV line and fluids.
C) FALSE- Antibiotic should give a wide coverage to include mainly gram
negatives and anaerobes. Cloxacillin is inappropriate.
D) FALSE- Vitamin K should be given intravenously to avoid intramuscular
haematoma in jaundiced patients with coagulation problems. Treating
Physician has to consider dangerous triad of Infection, Coagulopathy and
Hepato-renal syndrome in patients with obstructive jaundice.
E) False- Cholecystectomy may not help in this acute sepsis. Admission to
intensive care unit and stabilization should be followed by emergency
drainage of obstructed biliary tree. As ERCP has failed, Ultrasound guided
drainage via Percutaneous Transhepatic cholangiography (PTC) is the next
option. Open/Laparoscopic drainage with relief of obstruction with or
without T Tube along with Cholecystectomy is the last resort in this
emergency.

Answers to question 9.2

A) FALSE- They are not present in about 5%.Acalculus cholecystitis is common


in diabetics and in immunosuppressed.
B) FALSE- Ultrasound is usually employed and sufficient.
C) TRUE - Other complications of acute cholecystitis include empyema of
gallbladder, mucocele and localized peritonitis if ruptured.
D) FALSE- Gall stones in cystic duct can produce obstruction of hepatic duct via
pressure on the adjacent wall or oedema. This is called Mirrizzi's syndrome.
E) FALSE- Hot cholecystectomy is practised in some centres.

Answers to question 9.3

A) FALSE - Logic may persuade this to be correct on the grounds of easy


resectability as the tumour is away from vital structures such as duodenum
and bile duct. In clinical practice these tumours present very late and
therefore inoperable.
B) TRUE- Loss of endocrine and exocrine function occurs.
C) TRUE- Knowledge regarding Curuvoiseres Law is tested.
D) TRUE- Early detection due to obstructive jaundice as well as favourable
histopathology allow better prognosis.
E) FALSE- Whipples is a major complex procedure and attempted only with

58
curative intent.

9.4 Pancreatic pseudo cyst

A) usually resolves spontaneously.


B) usually presents with vomiting.
C) may present with obstructive jaundice.
D) If persists more than 6 months require surgery.
E) can be treated endoscopically.

9.5 A patient is diagnosed with acute pancreatitis. What are the investigations
that would help in assessing the severity of the condition?

A) Arterial blood gas analysis


B) C-reactive protein
C) Serum amylase level
D) Serum lipase level
E) Total polymorph nuclear leukocyte count

9.6 Bile duct stones

A) are found in more than 50% patients with gallbladder stones


B) cause symptomatic bile duct obstruction sooner or later
C) are best managed by 'wait and see' approach if the patient is asymptomatic
D) are associated with palpable gall bladder
E) are best treated by endoscopic surgery than open surgery

59
Answers to question 9.4

A) TRUE - most pseudocysts resolve spontaneously.


B) FALSE - They usually present as a mass following acute pancreatitis.
C) TRUE -Cysts at head of pancreas can present with obstructive jaundice.
D) FALSE -If persist more than six weeks or reach more than six centimetres in
size surgery is warranted.
E) TRUE -Cyst can be drained via posterior wall of stomach using an upper
gastrointestinal endoscope.

Answers to question 9.5

A) TRUE – This contributes to severity scoring (Glasgow).


B) TRUE -This Has an independent prognostic value. A level of >210mg/ml in
the first four days or >120mg/ml at the end of the first week indicates
severe attack.
C) FALSE - A level elevated at 3 times the laboratory normal is regarded as
diagnostic. The level is highest during the first 24 hours and then reduces
rapidly. It is not related to severity of the attack.
D) FALSE - A level of more than twice the laboratory normal upper limit is
diagnostic; level is not related to the severity of attack. Sensitivity and
specificity is >90%.
E) TRUE - This contributes to the severity scoring (Glasgow)

Answers to question 9.6

A) FALSE - In young patients (<50 years), less than 5% of patients with


symptomatic gallstones have choledocholithiasis. This increases to 20% in
over 70 year olds.
B) TRUE - most symptomatic patients present with painful obstructive
jaundice.
C) FALSE - Bile duct stones should be removed if found during a diagnostic ERC,
PTC or at an operation.
D) FALSE - in obstruction of the common bile duct due to a stone, distension of
the gallbladder seldom occurs as the organ is already shrivelled.
E) TRUE - Endoscopic papillotomy with a sphincterotomy is the preferred first
technique.

60
9.7 Regarding asymptomatic gall bladder stones

A) They are the most common indication to seek medical advice by patients
with gallbladder stones.
B) Majority will present with symptoms during the next two years
C) Cholesterol stones are more common than brown pigment stones
D) All such patients with diabetes must be treated with early
cholecystectomy
E) They need to be treated with cholecystectomy due to the risk of
development of cancer

9.8 Regarding pancreatic neuro endocrine tumours (PNET)

A) Functional Tumours present earlier than Non-functional tumours


B) They can manifest as unexplained chronic diarrhoea.
C) Potential for malignancy is higher in Glucagonomas than Insulinomas.
D) They are associated with Multiple Endocrine Neoplasia Type II (MEN II)
E) They can present with large gastric ulcers resistant to PPI.

9.9 Which of the following are true regarding surgery of spleen?

A) Need for splenectomy is often encountered in ITP.


B) Perforation of gastric antrum is a possible complication
C) High risk of DVT is due to post op immobility
D) Risk of OPSI(Overwhelming post splenectomy sepsis) is extremely rare 3
months after splenectomy
E) Auto transplantation may maintain splenic function following splenectomy
for trauma.

61
Answers to question 9.7
A) TRUE - they are diagnosed incidentary when uss abdomen is performed for
other reasons.
B) FALSE - about 1-2% of asymptomatic patients will develop symptoms per
year requiring surgery.
C) TRUE - Most are composed of altering layers of cholesterol crystals and
musin. Less frequent are the black pigment stones associated with chronic
haemolytic disorders and brown pigment stones associated with
bactobillia.
D) TRUE - Diabetics have a high risk of perforation during an attack of acute
cholecystitis
E) FALSE - Asymptomatic gallstones do not usually require treatment on this
basis. However many are offered elective laparoscopic cholecystectomy as
the ease of surgery outweights the risks of complications.

Answers to question 9.8


A) TRUE - Non-functioning tumours may be found incidentally. Functioning
tumours presents with symptoms due to excess production of specific
hormones, eg: hypoglycaemia with insulinoma.
B) TRUE - WDHA( watery diarrhoea, hypokalaemia and achlorhydria) and
VIPomas present in this way
C) TRUE - malignancy potentials of pancreatic tumours- Gastrinoma- 60-
90%, Glucagonoma-50-80%, Insulinoma <10%
D) FALSE - 15- 30% of patients with pancreatic endocrine tumour have MEN
I.3 Ps- Hyperparathyroidism (PTH), Gastrinoma(pancrease), Prolactinoma
(pituitary).
E) FALSE – gastrin producing lesion of zollinger ellison syndrome leads to
multiple small gastric ulcers

Answers to question 9.9


A) TRUE - Splenectomy is done in refractory thrombocytopenia.
B) FALSE - This fistula may result from damage to the greater curvature of the
stomach during ligation of the short gastric vessels.it can be caused by
direct injury of delayed necrosis
C) FALSE -it is due to increased platelet count postoperatively which increases
the blood viscosity.
D) FALSE -This risk is greatest within the first 2-3 years after splenectomy. So
antibiotic prophylaxis with penicillin is recommended at least for this
period.
E) TRUE-Multiple human and animal studies have established that splenic
autotransplantation is a relatively safe and easily performed procedure that
results in the return of some haematologic and immunologic parameters to

62
baseline levels.

9.10 Regarding primary carcinoma of liver (Hepatoma)

A) Haemochromatosis is a cause
B) Incidental detection of right hypochondrial mass is the most common
mode of presentation
C) It is not seen in children
D) Treatment is palliative
E) Radiotherapy has no place in treatment of primary cancer

9.11. Regarding the colorectal liver metastasis

A) About 15% of patients with colo-rectal cancers have synchronous liver


metastasis at the time of diagnosis.
B) Is associated with raised alfa-feto protein levels
C) Portal vein embolization is a curative treatment option in tumours confined
to one lobe
D) In resectable cases patient would tolerate 60% of resection of liver
E) Thee metastasis in a single lobe may benefit from curative surgery

9.12 Which of the following are true regarding imaging of the biliary system?

A) Computed tomogram with oral contrast is used to evaluate liver lesions.


B) Magnetic resonant cholangiogram cannot be done in patients with metal
implants.
C) Ultrasound scan is a good investigation to visualize gallbladder.
D) 25% of the gallstones are seen in the X-ray abdomen.
E) Endoscopic retrograde cholangiogram is the first investigation in suspected
bile duct stones.

63
Answers to question 9.10

A) TRUE-Others include hepatitis B & C ,alcohol and alpha 1 antitrypsin


deficiency.
B) FALSE-Most common presentation is the sudden deterioration of liver
function tests in a known patients with chronic liver disease.
C) FALSE-Those with congenital liver disease can develop hepatocellular
carcinoma in childhood .
D) FALSE- Combined chemotherapy, surgical resection and liver
transplantation are curative in selected minority.
E) FALSE- Radiotherapy using Yttrium 90 show a significant response.

Answers to question 9.11

A) FALSE - Around 1/3 of patients will have liver metastases at the time of
diagnosis and 50% will develop liver metastases at some point in life
accounting for majority of deaths
B) FALSE - Alfa fetoprotein level is elevated in hepatocellular CA. Increased
levels with metastases are rare.
C) FALSE - Portal vein embolization is complementary and not curative when
used alone. When combined with surgical resection it improves outcome.
This redirects portal blood to segments that will remain after surgery, thus
increasing their size.
D) TRUE - Liver surgeons are increasingly aggressive in treatment and the only
absolute limitation on what can be resected is in terms of leaving enough
functional liver behind.
E) TRUE -Single or several well localized liver metastases can now be resected
with relatively low mortality and morbidity. Use of Argon laser and
harmonic scalpel has immensely facilitated liver resection.

Answers to question 9.12

A) FALSE – intravenous contrast which is excreted via biliary tree is used.


B) TRUE - Metal implants are a contraindication for MRI. This magnetizes and
move metals with possible disastrous consequences.
C) TRUE – This visualizes gallbladder, gallstones , and duct dilatation as well as
pericholecystic abscess.
D) FALSE - Only 10% are visualized in AXR, whereas 90% of urinary calculi are
visualized.
E) FALSE-First line is USS which will reveal duct dilatation and other valuable

64
information

10. LOWER GASTROINTESTINAL AND ANORECTAL SURGERY


DR. JPM KUMARASINGHE

10.1 Regarding familial adenomatous polyposis (FAP)

A) It is inherited in an X-linked dominant manner.


B) Polyps appear during adolescence.
C) It is more common in descending colon.
D) It is associated with Osteomas.
E) Abdomino-perineal resection is the treatment of choice.

10.2 Causes of painful fresh bleeding per-rectum include,

A) Thrombosed external haemorrhoids


B) Polyp in the lower rectum
C) Angiodysplasia
D) Anal fissure
E) Peri-anal abscess

10.3 The causes of a newborn not passing meconium within 48 hours of birth
include

A) Ileal atresia.
B) Infantile pyloric stenosis.
C) Hirschsprung disease.
D) Hypothyroidism.
E) Necrotizing entero-colitis.

65
Answers to question 10.1

A) FALSE - Inheritance is mainly autosomal dominant. Recessive varieties


exist.
B) TRUE – They bleed in 30s and succumb to carcinoma by 40s
C) TRUE - However some patients have exclusively right sided polyps which
necessitates colonoscopy over flexible sigmoidoscopy for diagnosis
D) TRUE - Epidermal cysts complete the triad of Gardner's syndrome
E) FALSE - Anal canal and sometimes rectum are spared

Answers to question 10.2

A) FALSE- Acutely painful lump is the presentation


B) FALSE- Pain is not a feature
C) FALSE- Bleeding can be torrential. Pain is not a feature
D) TRUE- Toothpaste sign on stools is present
E) FALSE- This causes pain without bleeding.

Answers to question 10.3

A) TRUE- Obstruction to flow is complete.


B) FALSE- Obstruction is incomplete and faeces can be produced below this
level. Presentation is typically after 3 weeks of life.
C) TRUE- This slows large bowel.
D) TRUE- This slows large bowel.
E) FALSE- Diarrhoea is the feature seen

66
10.4 A 30 year old man presented with passing of loose stools mixed with blood
and mucous for 6 months. Features in favour of Crohn's disease over Ulcerative
colitis include,

A) Anal tags
B) Episodes of intestinal obstruction
C) Visual disturbances
D) Polyarthralgia
E) Resistant UTI

10.5 A 40 year old man presented with painful and tender perianal lump at 4 o
clock and fever for 2 days. He complains of two similar episodes over last one
year. Perianal fistula associated abscess, is suspected.

A) I & D can be done under local anaesthesia if patient is in severe pain


B) Culture and sensitivity of pus is most likely to reveal Staph aureus
C) EUA is likely to reveal an internal opening of a fistula at 4 o'clock
D) Fistula tract is expected to heal spontaneously
E) Endoscopy is a treatment option.

10.6 Constipation is

A) defined as decreased frequency in passing stool


B) uncommon in children under 10 years
C) usually due to colorectal carcinoma in elderly
D) a feature of multiple endocrine neoplasia (MEN) syndrome.
E) a common symptom of Parkinsons disease.

67
Answers to question 10.4

A) TRUE- Perianal sepsis and tags is Common in Crohn's


B) TRUE- This is possible due to ileal strictures. It can be multiple giving rise to
“string of lakes” appearance on Barium meal and follow through.
C) FALSE- Iritis is a feature in both.
D) FALSE- It is a feature common to both
E) TRUE- This suggests colovesicle fistula. Internal fistulation is a feature of
Crohn's

Answers to question 10.5

A) FALSE- This is not recommended as EUA is required along with good


drainage.
B) FALSE- History suggest fistula as a root cause and coliforms are expected
C) FALSE- Internal opening is expected at 6 O' clock according to Goodsalls law
D) FALSE- This is extremely unlikely to occur. patient is more likely to need
surgery in the future.
E) TRUE- Fistular tract can be explored with fistuloscopy and obliterated
with laser.

Answers to question 10.6

A) FALSE- Even a passage of one single hard stool is considered as constipation.


B) FALSE-They suffer often due to irregular intake of food and fibre.
C) FALSE- Although colorectal cancer induced constipation is common in
elderly dehydration, low fibre intake, lack of physical activity, medication
and hypothyroidism account for the vast majority.
D) TRUE- Hypoparathyroidism induced hypercalcaemia is common in MEN1
syndrome
E) FALSE- Constipation can be due to side effects of anti-parkinsonism drugs.

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10.7 Regarding anal fissures

A) The majority are located in the posterior midline.


B) They are rare in childhood.
C) Per rectal examination should be performed after topical anaesthesia
D) Inflamed indurated margins are characteristic of acute fissures.
E) Topical diltiazem is curative

10.8. Regarding perianal fistula

A) Majority are associated with infection of anal glands.


B) Tract with external opening at 2 O, clock usually has the internal opening at
2 O'clock .
C) CT scan is considered the gold standard in delineating anatomy.
D) Loose seton wire is widely used than the tight seton.
E) Use of Fistular plug has a significant risk of incontinence.

10.9 Regarding Diverticulitis

A) Pain is typically felt in the left iliac fossa.


B) Conservative management with IV fluids and antibiotics are successful in
settling most attacks.
C) Colonoscopy is useful in the diagnosis.
D) Perforation is a common cause for gas under diaphragm on chest x-ray.
E) Rabbit pellet' stool is a feature.

69
Answers to question 10.7

A) TRUE- Muscles are less supported in this area.


B) FALSE- It is not uncommon in children with constipation.
C) FALSE- Perianal examination is contraindicated as it can cause vasovagal
cardiac arrest in addition to severe pain.
D) FALSE-There are features of chronic fissures along with internal polyps and
External skin tag giving characteristic “Red Indian canoe” appearance to the
lesion
E) TRUE- However, many complain of severe headache. Majority will need
Internal Anal Sphincterotomy

Answers to question 10.8

A) TRUE -Approximately 85% are associated with anal gland infections.


B) TRUE -Goodsalls Law is generally true.
C) FALSE -Endoscopic Ultrasound and MRI are preferred.
D) TRUE -This is less painful and constitute the initial phase of many
operations attempted
E) FALSE -This is a sphincter saving technique.

Answers to question 10.9

A) TRUE- This is due to inflammation of parietal peritoneum.


B) TRUE- Even small abscess under 2cm are settled this way.
C) FALSE- This is not recommended in the acute setting as it can perforate
inflamed and weak bowel wall.
D) TRUE- It is a common cause for gas under diaphragm along with perforated
gall bladder, stomach, appendix and malignancy involving large bowel.
E) TRUE- This is common.

70
11. GENITOURINARY
DR.MMAJ KUMARA

11.1 Undescended testis increases the risk for,

A) Infertility.
B) Epididymo-orchitis
C) Susceptibility to trauma.
D) Torsion.
E) Malignancy.

11.2 Ureteric stones

A) are sometimes asymptomatic.


B) cause pain free windows between episodes of ureteric colic.
C) are almost always accompanied by hematuria.
D) are mostly radio opaque
E) sometimes necessitate urgent intervention.

11.3 Which of the following statements are correct regarding the management
of a ten year old boy who presents with an acutely painful scrotum?

A) Initial antibiotic therapy and analgesia should be considered if pain has


been there for less than two hours.
B) A normal Duplex scan of the scrotum reliably excludes the necessity for
surgery.
C) Patient should be fasting for solids for six hours prior to surgery, if needed.
D) Surgery is unlikely to salvage the affected testis if the presentation is after
12 hours.
E) If found to be due to torsion of the testis, contra lateral testis should be
fixed.

71
Answers to question 11.1

A) TRUE – They should be fixed in the scrotum with in the first year of life for
best outcome
B) FALSE – There is no added risk.
C) TRUE – Testis in a more superficial location with less mobility is more
susceptible to trauma.
D) TRUE – When it is inside the abdomen testis can move freely and get torted
easily
E) TRUE – Orchidopexy may not diminish the risk but accessibility improve the
prospects of early diagnosis

Answers to question 11.2

A) TRUE – Many remain asymptomatic and smaller ones can pass through
without symptoms.
B) TRUE
C) TRUE – Usually, small amount of hematuria is common and sometimes it is
the only symptom.
D) TRUE –Around 90% stones are radio opaque.
E) TRUE – Obstructed urinary system if infected, need to have urgent
decompression to prevent sepsis.

Answers to question 11.3

A) False – Urgent exploration without any delay is required.


B) False- Only exploration is reliable.
C) False – Exploration of testis should be done within six hours from the
beginning of pain even without fasting.
D) True – After six hours ischemic necrosis of testis can develop.
E) True –The other testis should also be fixed because anatomical
predisposition is likely to be bilateral.

72
11.4 Which of the following are true regarding a 65 year- old man presenting with
frank haematuria?

A) Presence of pain excludes the possibility of malignancy.


B) Initial haematuria is likely to be of prostatic origin.
C) An elevated PSA during acute symptoms confirms the diagnosis of prostate
cancer.
D) Presence of thread like clots suggests bleeding from the upper urinary
tract.
E) A normal CT urogram excludes bladder carcinoma.

11.5 Which of the following are true regarding the upper urinary tract trauma?

A) Absence of frank haematuria excludes renal injury.


B) Unexplained hypotension is a presenting feature.
C) Majority need surgical exploration.
D) Polycystic kidneys are less likely to get injured.
E) Angioembolization is a treatment option.

11.6 Which of the following are true regarding carcinoma of the prostate?

A) Most of the prostatic cancers present with obstructive symptoms.


B) Erectile dysfunction is a recognized presentation.
C) Trans rectal ultrasound and biopsy is the gold standard in confirming the
diagnosis.
D) PSA level over 10 nanograms/ml confirms metastatic disease.
E) Radical prostatectomy is of value in locally advanced disease.

73
Answers to question 11.4

A) False – Obstruction of the ureters by the malignancy, blood clots or stones


can cause pain associated with haematuria.
B) True – Urethral and prostatic diseases causes initial haematuria .
C) False – PSA can be increased following any damage to prostate by acute
conditions such as UTI, epididymo-orchitis or even following per rectal
examination.
D) True – These occur following damage to the kidneys and ureters.
E) False – Cystoscopy is more accurate.

Answers to question 11.5

A) False – Upper urinary tract trauma can cause bleeding in to the abdomen
without producing haematuria if ureter is avulsed.
B) True – large amount of retroperitoneal haemorrhage can cause sudden
hypovolaemic shock.
C) False – Most of the cases are managed conservatively.
D) False – They make bigger targets for forces.
E) True – Bleeding can be terminated by embolizing the damaged arteries.

Answers to question 11.6

A) False – Obstructive symptoms usually can appear later.


B) True – Damaged to the roots of the sacral plexus by metastases can cause
erectile dysfunction.
C) True – This can locate and biopsy even impalpable lesions.
D) False – PSA level more than 10 nanograms/ml is suggestive of prostatic
malignancy and more than 20 nanograms/ml is likely to have metastatic
disease.
E) False – This is only suitable for localized disease when life expectancy is
more than 10 years.

74
11.7 Which of the following are true regarding Urethral strictures?

A) Instrumentation is the most common cause for anterior strictures.


B) Water can' perineum is a complication.
C) Falling astride injury leads to strictures of the prostatic urethra.
D) Repeated dilatation is an accepted management option in experienced
hands.
E) In Optical urethrotomy , the incision is made at 6'O clock position

11.8 Which of the following are correct regarding scrotal lumps?

A) Varicoceles almost always lead to infertility.


B) Testicular tumours are associated with large hydroceles.
C) Torsion of testis does not present after 18 years.
D) Sebaceous cysts are more common in scrotum than in rest of the body.
E) Hydroceles are always transilluminant.

11.9 Which of the following are true regarding varicoceles?

A) It is more common on the right side.


B) It is the most common correctable cause of male infertility.
C) Failure to disappear in supine position is a sinister feature.
D) Ultrasound scan is required before surgery.
E) Minimally invasive techniques are among the treatment options.

75
Answers to question 11.7

A) FALSE- Post stricture dilatation lead to para-urethral sepsis with multiple


discharging sinuses.
B) TRUE- Discharging sinuses can also occur in crohn's disease.
C) FALSE – Anterior urethra is usually damaged following falling astride injury.
D) TRUE – Repeated dilatation by graded dilators is a management option for
urethral strictures.
E) FALSE- Incisions are made at 12 O' clock on the strictures.

Answers to question 11.8

A) False-Only a small fraction present with infertility.


B) False -They are associated with lax small hydroceles.
C) False- However, they are common in younger ages.
D) True-This is the favorite site for sebaceous cysts. Only larger and
symptomatic ones are removed.
E) False-Chronic ones specially as a result of filariasis are opaque.

Answers to question 11.9

A) FALSE-It is more common on the left side.


B) TRUE-However most patients with varicoceles are fertile.
C) TRUE- This suggest proximal obstruction to veins possibly due to
malignancy.
D) TRUE- It will confirm diagnosis and grade I varicoceles are only visible on
ultrasound. It also helps to identify intra-abdominal malignancy as a cause
of varicocele.
E) TRUE-Laparoscopic treatment is popular.

76
12. HEAD AND NECK
DR.RP ABEYWICKRAMA

12.1. Regarding infections of the middle ear

A) Hemophilus influenza is the most common cause for acute otitis media.
B) Chronic otitis media leads to conductive hearing loss.
C) Tonsillectomy is an option for the treatment of chronic otitis media.
D) Myringoplasty alone has a very high success rate in resolution of chronic
otitis media.
E) Grommets insertion is a treatment option for cholestetoma.

12.2. Which of the Following statements are true regarding salivary glands?

A) Calculi are most common in the parotid gland.


B) 80% of the minor salivary gland tumours are malignant.
C) Patients with viral parotitis present with more swelling, pain and systemic
symptoms than bacterial parotitis.
D) Chronic liver disease is a recognized cause of parotid swelling.
E) Adenolymphoma is the most common benign tumour of the salivary glands.

12.3 Which of the following statements are true regarding conditions affecting
head and neck ?

A) Tonsillar hypertrophy may lead to stridor in extreme cases.


B) Patterson-Kelly syndrome is associated with dysphagia .
C) Pharyngeal pouch usually presents as a swelling on right side of the neck.
D) Tonsillectomy is essential following drainage of a Quincy's abscess.
E) Maxillary sinusitis cannot be diagnosed on plain X-ray.

77
Answers to question 12.1.

A) TRUE- It is responsible 90% of acute otitis media.


B) TRUE - This can occur in toddlers and may also cause sleeping disturbances.
C) TRUE - Patients may also require myringoplasty and even ossiculoplasty .
D) FALSE -Adenoidectomy may also be required.
E) FALSE - Gromet tubes are for chronic secretory otitis media while
cholesteotoma require surgical removal

Answers to question 12.2.

A) FALSE- Calculi are most common in submandibular gland due to


concentrated secretions and dependent position.
B) TRUE-They also tend to invade and metastasize early.
C) FALSE-Viral parotitis has more swelling but pain and systemic symptoms are
more common with Bacterial parotits.
D) TRUE-Exact mechanism is not known but fatty deposition due to deranged
liver metabolism and increased amylase production as a compensatory
mechanism is implicated.
E) FALSE - Pleomorphic Adenoma has this honour.

Answers to question 12.3.

A) FALSE- Stridor is the name for expiratory noise resulting from obstruction at
larynx and trachea while the noise from obstruction above the larynx is
called stertor and that at bronchi and bronchioles is called rhonchi.
B) TRUE –Post-cricoids web leading to dysphagia along with associated Iron
deficiency is given the name of Siderophenic Dysphagia. This is a
premalignant condition.
C) FALSE - Pouch usually present at left side of the neck.
D) FALSE - Tonsillectomy is indicated following development of two attacks of
Quincy.
E) FALSE - Haziness or a fluid level is seen.

78
12.4. Which of the following statements are correct regarding fractures of the
maxilla?

A) Infraorbital nerve damage is expected.


B) Diplopia occur usually due to associated direct eye trauma .
C) Fractures are clearly visible on X ray.
D) Patient is advised to keep nose clear by blowing out any blood and
secretions.
E) They require referral to maxillo-facial surgeons

12.5. Cervical spondylosis

A) is more common with professional heavy vehicle drivers.


B) responds usually to conservative measures.
C) leads to dizziness.
D) causes wasting of inteossious muscle in the hands is due to C5/6 disk
prolapse.
E) rarely require surgical decompression as canal has more free space unlike
the lumber area.

12.6. Which of the following presentations match the given diagnosis?

A) Loss of hearing for feminine voices - Presbycusis


B) Facial nerve palsy with hearing loss and vertigo – Bell's palsy
C) Fluctuating hearing loss and tinnitus – Mennier's disease
D) Progressive conductive hearing loss - Otosclerosis
E) Positional vertigo after head injury - Vesitibular neuronitis

79
Answers to question 12.4.

A) TRUE - This is detected by absent or diminished sensation over prominence


of cheek and numbness of upper teeth.
B) FALSE - Diplopia is usually due to extra ocular muscles being trapped in the
fracture involving the of floor of the orbit.
C) FALSE - Fractures are difficult to visualize on X-ray. Indirect evidence is
offered by fluid level in the maxillary sinus.
D) FALSE - Patient should be specifically advised against this as air will move in
to fracture haematomas, leading to serious infections.
E) TRUE - Interpretation of X-rays and management of these injuries are for
specialists.

Answers to question 12.5.

A) TRUE – It is common in all professions where jerky movements of the body


are frequent.
B) TRUE - Symptoms tend to have exacerbations and remissions.
C) TRUE - However, other serious conditions for dizziness need to be excluded
first.
D) FALSE – Interossiuos muscles are supplied by T1 root.
E) FALSE - Unremitting pain, progressive motor weakness and compression of
cord require surgical decompression. Cord almost fills the cervical canal.

Answers to question 12.6.

A) TRUE - Loss comes initially for high pitched voices in Presbyacusis.


B) FALSE - Ramsey hunt syndrome is the diagnosis. Bell's palsy only produces
lower motor neuron type 7th nerve lesion.
C) TRUE - Vertigo complete the triad.
D) TRUE - Symptoms appear in early adult life and family history is present in
approximately 50%.
E) FALSE - Correct answer is benign positional vertigo.

80
12.7. Which of the following are true regarding the nose and sinusitis?

A) Septal haematoma demands urgent surgery.


B) Unilateral polyps are more likely to have serious pathology than bilateral
ones.
C) All septal deformities require correction.
D) Epistaxis from anterior vessels are more severe than posterior bleeds.
E) Maxillary sinusitis is associated with ear pain.

12.8. Regarding branchial cysts and fistulae

A) They originate from the 2nd branchial cleft .


B) Cyst contains fluid with cholesterol crystals.
C) 1st branchial cleft fistula extends to external auditory canal.
D) Branchial cyst is superficial to sternocleidomastoid muscle.
E) Recurrences are common following interventions.

12.9. Which of the following are true regarding the oral carcinoma?

A) Approximately 25% are adenocarcinomata.


B) Dysarthria is a feature.
C) Lichen planus is a premalignant condition.
D) Surgery and radiotherapy give comparable outcomes.
E) Five year survival is approximately 85%.

81
Answers to question 12.7.

A) TRUE-Else abscess, intracranial infection and later nasal deformity may


occur.
B) TRUE -In children, it may be an meningocele and in adults a carcinoma.
C) FALSE -Asymptomatic and cosmetically acceptable ones do not require
intervention.
D) FALSE - Posterior bleeding is heavy and difficult to control.
E) TRUE - Both are caused by carious teeth in upper jaw. It is due to referred
pain

Answers to question 12.8.

A) TRUE - Failure to completely obliterate 2nd branchial cleft is the cause.


B) TRUE - It also contains cellular debris.
C) TRUE - 2nd branchial cleft fistula pass through the carotid bifurcation to
tonsillar pillars.
D) FALSE - It is deep to sternocleidomastoid muscle.
E) TRUE- Complete excision is difficult due to closely related structures such as
internal jugular vein and carotid vessels.

Answers to question 12.9.

A) FALSE – Approximately 90% are squamous carcinomata.


B) TRUE - This is especially true for posterior malignancy
C) TRUE - Leukoplakia and erythroplakia are more common premalignant
lesions
D) TRUE -If one fails the other is deployed.
E) FALSE - It is around 63% .

82
12.10. Cataract

A) Is more common in diabetics.


B) can be congenital.
C) causes uveitis.
D) causes sudden loss of vision.
E) can be treated medically.

12.11. Causes of acute red eye include

A) Conjunctivitis.
B) Glucoma.
C) Episcleritis.
D) Uveitis.
E) Chalzion .

12.12. Which of the following are helpful in differentiating acute angle closure
glaucoma from chronic open angle glaucoma?

A) Pain
B) Shape of visual field loss
C) Hypermetropia
D) Cupping of optic disk
E) Moderately dilated unreactive pupil

83
Answers to question 12.10

A) TRUE- Increased formation of sorbitol is implicated.


B) TRUE- This presents in childhood and usually bilateral.
C) FALSE- Uveitis can cause cataract and it is also a complication of surgery for
cataract.
D) FALSE- It leads to gradual loss of vision.
E) FALSE- Surgery is the only option.

Answers to question 12.11

A) TRUE- This causes scleral and palpebral congestion and redness but spares
circumcorneal area.
B) TRUE- Acute glaucoma is a cause.
C) FALSE- This is a benign, self-limiting and a localized condition. Up to 1/3 can
be associated with systemic conditions such as rheumatoid arthritis and
systemic lupus erythematous.
D) TRUE- This can be associated with many systemic inflammatory conditions.
E) FALSE- This condition, known as “Stye”, does not usually produce changes
in conjunctiva.

Answers to question 12.12

A) TRUE- Acute angle closure glaucoma presents with pain, red eye, visual
impairment and sometimes with nausea and vomiting.
B) TRUE- Arcute area of loss (scotoma) is seen in Primary open angle
glaucoma.
C) TRUE- Close angle glaucoma is common in small hypermetropic eyeballs.
D) FALSE- This is common to glaucoma of both types.
E) TRUE-This important feature also helps to differentiate acute angle
glaucoma from other conditions of Acute Red Eye.

84
12.13. Regarding the examination of pupillary responses

A) Direct light response requires cerebral function.


B) Unilateral dilated fixed pupil is always a sinister sign.
C) Pinpoint pupils in an unconscious patient confirms overdose of opioids.
D) An absent papillary reflexes in an eye always represent a disease in the
ipsilateral optic nerve.
E) The pupillary response is not altered by corneal laceration.

12.14. Which of the following management options are correct regarding eye
diseases?

A) Floaters and flashes are usually due to tiredness and are initially managed
with 'Wait and see' approach.
B) Loss of red reflex in an eye is normal up to five years of age.
C) Dendritic ulcers are treated by tropical steroids.
D) Glass intraocular foreign bodies are visible on X-ray.
E) Obstruction of central retinal artery leads to sudden ocular pain and loss of
vision.

12.15. Which of the following statements are true regarding ophthalmological


emergencies?

A) Dendritic ulcers are best treated by acyclovir eye drops.


B) Circumcorneal redness is a characteristic of viral conjunctivitis.
C) Open angle Glaucoma usually presents with severe pain and vomiting.
D) Episcleritis does not require an urgent referral to an ophthalmologist.
E) In retinal detachment, straight lines in the environment appear curved.

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Answers to question 12.13.

A) FALSE- Light reflexes are mediated at brain stem level.


B) FALSE- Traumatic mydriasis or previous cataract surgery can lead to dilated
fixed pupil.
C) FALSE- This could also be due to brain stem haemorrhage.
D) FALSE- Fault may be with sensory (retinal or optic nerve) or motor
(parasympathetic palsy or muscle damage from trauma). If consensual
response is seen in the other eye, sensory path should be intact and the
damage to ipsilateral motor pathway is the cause.
E) FALSE- Pupil will plug the laceration and lead to abnormal shape and non-
reactivity.

Answers to question 12.14

A) FALSE- This may herald retinal detachment although typical “curtain falling
down” may follow later. Urgent referral to ophthalmologist is needed.
B) FALSE- Retinoblastoma should be strongly suspected.
C) FALSE- This can cause blindness and is absolutely contraindicated.
D) TRUE - Glass is visible on x ray specially in eyes-up and eyes-down views.
E) FALSE- Obstruction of retinal artery or vein leads to sudden painless loss of
vision.

Answers to question 12.15.

A) TRUE - Dendritic ulcers are due to Herpes simplex virus. Acyclovir is a key
option.
B) FALSE- Circumcorneal redness is seen in more serious conditions such as
acute angle closure glaucoma and anterior uveitis.
C) FALSE- This Presents with silent gradual visual loss and is termed “thief of
sight”.
D) TRUE - This inflammation of the conjunctiva in the episclera, is often seen as
an inflammatory nodule. Visual acuity is normal. This is usually self-limiting,
1/3 may be associate with polyarthritis nodusa, systemic lupus
erythematous or rheumatoid arthritis.
E) TRUE – The retinal detachment can present with 4”f”s-floaters, flashes,
field loss and fall in acuity.
86
12.16. A 30 year old man develops unilateral exophthalmos three days after a
head injury. A bruit is heard over an eye. Which of the following features favour
carotico-cavernous fistula as a cause?

A) Bruit over eye ball.


B) Papilledema.
C) Infected laceration over nose.
D) Conjunctival oedema.
E) Pulsation over eyeball.

12.17. Which of the following diseases are among the aetiological factors for
preventable blindness?

A) Congenital rubella syndrome


B) Cataract
C) Glaucoma
D) Trachoma
E) Macular degeneration

12.18. Which of the following are true regarding cataract?

A) Cataract is found in 75% of those over 65 years of age.


B) Red reflex is absent in cataract
C) Cataract can be hereditary
D) Dystrophia myotonica is a cause
E) Ocular biometry is mandatory before surgery

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Answers to question 12.16.

A) TRUE- This condition may follow carotid pseudo aneurysm rupture with
reflux of blood into the cavernous sinus. Increased flow manifests as a bruit.
B) TRUE- Increased retrobulbar pressure leads to papilloedema.
C) FALSE- This may lead to cavernous sinus thrombosis with a similar picture
but without bruit.
D) TRUE- Conjunctival oedema is due to venous congestion.
E) TRUE- Transmitted arterial pulsations give way to this sign.

Answers to question 12.17.

A) TRUE- Can be prevented by maternal immunization.


B) TRUE- Surgery can avert blindness.
C) TRUE- This can be prevented by halting disease progression after early
recognition and timely treatment.
D) TRUE- The organism mainly spread via flies and can be prevented by good
sanitation and regular washing of hands.
E) FALSE-This is age related and has a hereditary predisposition.

Answers to question 12.18.

A) TRUE- It also occurs in 20 % of 45-65 year olds.


B) FALSE- With immature cataract, the red reflex can be present.
C) TRUE- Anterior and posterior polar cataracts are commonly inherited.
D) TRUE- Others include diabetes mellitus, steroid use and high myopia.
E) TRUE- This is a measurement of the curvature of the cornea and length of
the eye which enables prediction of the suitable intraocular lens implant for
the patient.

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13. THE BREAST
DR. RP ABEYWICKRAMA

13.1. Regarding carcinoma of the breast

A) It is safely excluded, if the patient is under 25 years of age.


B) Risk is increased by miscarriages.
C) Impalpable lesions detected by mammography require a MRI scan.
D) Involvement of ipsilateral supraclavicular node pushes stage to N3.
E) Carcinoma affecting male breast carries favorable prognosis.

13.2. Complications of mastectomy include

A) Paraesthesia along outer aspect of arm


B) Sarcoma
C) Recurrent cellulitis
D) Frozen shoulder
E) Hypertrophy of lattisimus dorsi muscle

13.3 Mammographic features favoring a malignant lesion of the breast include


presence of

A) microcalcifications
B) tissue asymmetry
C) cystic lesions
D) A spiculate mass
E) Increased nodularity of the breast

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Answers to question 13.1.

A) FALSE - Cancers are known to occur in this age group especially in those with
genetic susceptibility harbouring BRCA 1 & BRCA 2 genes.
B) TRUE - Miscarriages increase exposure of women to oestrogen, the
dominant hormone in early pregnancy without allowing exposure to
balancing effects of progesterone in late pregnancy.
C) FALSE - Wire guided localization and excision is not preferred throughout.
D) FALSE - This is M1
E) FALSE - Male breast cancer spread early due to minimal intervening breast
tissue.

Answers to question 13.2.

A) FALSE - Parasthesia will involve inner aspects of arm if intercostobrachial


nerve is damaged.
B) TRUE - Lymphangiosarcoma can occur usually after 10 or more years in an
lymphadematous arm due to damage to lymphatics during axillary
dissection.
C) TRUE - This is common in any lymphoedematous limb.
D) TRUE - This follows poor mobilization of upper limb after axillary dissection.
E) FALSE - Atrophy can occur if thoracodorsal nerve is damaged.

Answers to question 13.3

A) TRUE - Approximately 95% of all DCIS are diagnosed because of


mammographically detected micro calcifications.
B) TRUE - Asymmetry is due to local invasion and involvement of fibrous
septae inside the breast
C) FALSE - Unlike cancerous tumors, which are solid, cysts are fluid-filled
masses in the breast. Cysts are very common and are rarely associated with
cancer. A follow-up ultrasound is the best way to differentiate a cyst from a
cancer, because sound waves pass right through a liquid-filled cyst.
D) TRUE - Benign masses are often round or oval with circumscribed margins.
Malignant lesions tend to have irregular, indistinct, or spiculated margins.
E) FALSE - Most nodules are lesions such as cysts, fibroadenomas, or small
lymph nodes.

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13.4. A 30-year-old woman, who is currently breast-feeding her first born child,
develops an erythematous and tender area on the upper outer quadrant of one
of her breasts. She is also febrile and overlying skin has an area of black
discoloration. Which of the following statements are true concerning her
diagnosis and management?

A) The most common organism which would be expected in a culture is


Staphylococcus aureus.
B) Open surgical drainage is indicated.
C) Breastfeeding should be discontinued.
D) If ultrasound scan shows multiple loculi, aspiration is preferred over incision
and drainage.
E) In the event of residual swelling persisting after drainage, a biopsy is
indicated.

13.5. Which of the following are true regarding a 32- year-old woman with four
children presenting with five centimeter lump in the upper outer quadrant of her
left breast?

A) Breast cancer is excluded clinically if the family history is not suggestive.


B) Absence of history of trauma excludes fat necrosis.
C) Mammogram is sometimes indicated.
D) Immediate excision biopsy of the lump is offered as a one stage solution.
E) She can be offered reassessment later if cytological diagnosis of
fibroadenoma is made.

13.6. Regarding carcinoma of the breast,

A) It usually presents with breast pain.


B) Three centimeter tumour with peau- de- orange sign is classified as a T2
lesion.
C) In a patient diagnosed with a breast cancer, a palpable ipsilateral lymph
node pushes the final staging to N1.
D) Aspirate of breast cysts should be sent for cytology.
E) Involvement of the axillary lymph nodes is an indication for neoadjuvant
therapy.
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Answers to question 13.4.

A) TRUE - The causative agent is typically Staphylococcus aureus which enters


the breast tissue through a milk duct or crack in the nipple.
B) TRUE – This approach is required due to overlying skin necrosis on the
abscess.
C) FALSE- The aim of treatment is to cure the abscess quickly and effectively,
ensuring maximum benefit to the mother with minimal interruption of
breast feeding
D) FALSE - Breakdown of loculi need finger dissection.
E) TRUE - Breast carcinoma, specially its notorious inflammatory variety is
known to occur during pregnancy and lactation.

Answers to question 13.5.

A) FALSE - Breast cancer can occur at this age even without family history.
B) FALSE - Only about 50% with fat necrosis gives a history of trauma.
C) TRUE - If the lady has pendulous breast with lax tissue after multiple
pregnancies and lactation, mammogram can be informative.
D) FALSE - Imaging and cytology is necessary to confirm malignancy and assess
size and multi-centricity including the status of contralateral breast before
making of the treatment plan.
E) FALSE - Lumps of 5 cm or more need excision as risk of malignancy is higher.

Answers to question 13.6.

A) FALSE - Majority present as a painless lump.


B) FALSE – Paeu-de- orange sign indicates skin involvement pushing the stage
to T 4b.
C) FALSE - Up to 1/3 palpable nodes do not contain cancer in this scenario
while 1/3 with palpably normal axilla has nodes containing cancer.
D) FALSE - If fluid is clear and mass disappears no cytology is necessary.
Recurrence requires reaspiration and cytology.
E) FALSE - T2N1 or below is classified as early breast cancer and neoadjuvant

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therapy can be obviated.

13.7. Bad prognostic features of breast carcinoma include

A) Tubular carcinoma.
B) Absence of vascular invasion.
C) HER 2 receptor positivity.
D) Oestrogen receptor positivity.
E) Triple negative tumour.

13.8. Which of the following are true regarding treatment of a breast carcinoma?

A) Radical mastectomy has a survival advantage over simple mastectomy.


B) Wire localization is a useful diagnostic as well as a therapeutic option.
C) All patients undergoing breast conserving surgery (BCS) will require
radiotherapy.
D) There is no significant difference in overall survival for a given stage when
BCS with radiotherapy is compared with mastectomy.
E) Isolated bony metastasis is cured by radiotherapy.

13.9. Determination of Nottingham Grade of Breast Carcinoma depends on

A) Nuclear pleomorphism.
B) Vascular invasion.
C) Mitotic activity.
D) Degree of glandular-duct differentiation.
E) Lymphocytic infiltration.

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Answers to question 13.7.

A) FALSE - Rare histological variants usually carrying a better prognosis,


include tubular, colloid, mucinous and medullary carcinomas.
Inflammatory carcinoma has the highest aggressive behavior.
B) FALSE - Absence of vascular invasion suggests absence of metastasis.
C) TRUE - HER2/neu over expression was associated with a more aggressive
tumor phenotype and a worse prognosis but patients with HER2/neu can be
treated with monoclonal antibodies.
D) FALSE - Presence of oestrogen and progesterone receptors is a prognostic
factor because they can be treated with adjuvant hormonal therapy.
E) TRUE - Breast cancer tested negative for estrogen receptors (ER-),
progesterone receptors (PR-) and HER2 (HER2-) is termed triple-negative. A
triple-negative breast cancer does not respond to hormonal therapy or
agents that target HER2 receptors, such as Herceptin.

Answers to question 13.8.

A) FALSE - Hence radical mastectomy is rarely done.


B) TRUE - The surgeon uses the wire implanted preoperatively to locate the
abnormality and remove it totally with surrounding tissues in the operating
room. This specimen is x-rayed to determine completion of resection.
C) TRUE - Resection margins should be clear and remaining breast will require
radiotherapy.
D) TRUE - This has made BCS popular as a treatment strategy.
E) FALSE- Radiotherapy is only a palliative measure and used to reduce the
pain and size.

Answers to question 13.9.

A) TRUE - It depends on the variation of the appearance of the nuclei.


B) FALSE -This predicts the chance of distal metastasis but not an independent
prognostic and behavioral factor in breast cancer.
C) TRUE - Number of mitosis per high power field is measured.
D) TRUE - Percentage of glandular and ductal tissue shows the differentiation
of tumor.
E) FALSE - This predict the chance of lymph node metastasis but not an
independent prognostic factor in breast cancer.

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13.10. A 50 year old man presents with bilateral gynaecomastia of recent onset.
His prolactin level was elevated. Possibilities include

A) Pitiutary microadenoma.
B) Pitiutary macroadenoma.
C) Rathke's cleft cyst.
D) Chronic liver disease.
E) Aspirin therapy.

13.11. Which of the following are indicated for local radiotherapy after
mastectomy?

A) Node positive lesion.


B) Presence of liver metastases.
C) A large tumour.
D) An upper outer quadrant tumour.
E) Breast conservation surgery.

13.12. Regarding adjuvant therapy for breast cancer

A) External beam radiotherapy is exclusively used.


B) Tamoxifen is valuable in premenopausal women.
C) Absence of estrogen receptors and progesterone receptors is a
contraindication for hormonal therapy.
D) Aromatase inhibitors cause osteoporosis.
E) Cyclophosphamide, Methotrexate and 5- fluorouracil (CMF) regimen
provides adequate chemotherapy.

95
Answers to question 13.10.

A) TRUE - Prolactinoma is the most common pituitary tumor. If the size is less
than 1cm it is considered as microadenoma which can secrete prolactin.
B) TRUE - Macroadenomas are more than 1cm tumours and they also can
secrete prolactin.
C) FALSE - This can cause pituitary insufficiency via pressure necrosis of the
pituitary gland.
D) TRUE - Failure to metabolize oestrogen causes gynaecomastia in males.
E) FALSE - Gynaecomastia has no such aetiology.

Answers to question 13.11.

A) TRUE - This reduces chance of local recurrence.


B) TRUE - Distal metastasis is an indication.
C) TRUE - Tumours usually over 5 cm require radiotherapy.
D) FALSE - Medial half tumours require radiation to include internal mammary
nodes.
E) TRUE - This is an indication in most of the centres.

Answers to question 13.12.

A) FALSE - Brachytheraphy is an option.


B) TRUE - Aromatase inhibitors are preferred in postmenopausal females.
C) TRUE - This is the current recommendation.
D) TRUE - Dexa scans are performed in some centers before and during the
treatment.
E) FALSE - Drugs from groups such as taxanes or anthracyclines are combined.

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13.13. Regarding benign disease of breast.

A) Repeated aspiration is preferred over incision and drainage for breast


abscess.
B) Periductal mastitis has an association with high alcohol intake.
C) Bromocriptine is useful in cyclical mastalgia.
D) Giant fibroadenomata occur in older women.
E) Bilateral clear nipple discharges are considered as benign.

13.14. Regarding breast reconstruction following mastectomy

A) It is offrerd to women younger than 45 years.


B) Latissimus dorsi flap is suitable for those who had large breasts.
C) Transversus abdominis muscle (TRAM) flap is preferred to reconstruct the
breast of a 30 year old unmarried woman.
D) Silicon prosthesis will give a better cosmetic effect than flaps in breast
reconstruction.
E) Silicon prosthesis is preferred over tissue flaps.

13.15. Which of the following are true regarding the management of a breast
lump?

A) C4 cytology in an FNAC requires a repeat FNAC.


B) A 50 year old woman with C2 cytology needs reassurance only.
C) Tamoxifen is the best drug for hormonal treatment of breast carcinoma in
elderly.
D) Skin dimpling is pathognomonic of breast carcinoma.
E) Risk of relapse is more common in type 2 breast cysts.

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Answers to question 13.13.

A) FALSE - Incision and drainage prevent the formation of mammary fistulae.


B) FALSE - Smoking has an association with periductal mastitis.
C) TRUE - Evening primrose oil and danasol are alternatives to bromocriptine.
D) FALSE - Large fibroadenomas typically occur in teenage girls.
E) TRUE - Most of those present with bilateral symptoms and signs have
benign disease.

Answers to question 13.14.

A) FALSE - There is no age limitation to the offer.


B) FALSE - Latissimus dorsi flap gives less bulk than Transverse Rectus
Abdominis muscle (TRAM) flap.
C) FALSE - Due to replacement of the abdominal defect with the mesh
expansion of abdomen during pregnancy will encounter difficulties.
D) TRUE - Implantation of silicon prosthesis can be done during or after.
E) FALSE - Flaps are preferred over silicone implants due to less potential
complications.

Answers to question 13.15.

A) TRUE – C4 cytology in woman with clinically and mammographically


suspicious abnormalitiesis is an indication for repeat FNAC or core biopsy to
obtain a definitive diagnosis of breast carcinoma prior to treatment.
B) FALSE- C2 cytology from a discrete lump in a woman over 35 years is offered
further examination in 3-6 months or removal even it is clinically and
radiolagically benign.
C) FALSE- Elderly patients who are oestrogen receptors positive benefit more
from aromatase inhibitors.
D) FALSE- This may also be due to fat necrosis, trauma, previous treatment or
involution.
E) FALSE- Of the two types of breast cysts, (type1-high potassium /sodium
ratio and type 2-low potassium /sodium ratio) risk of relapse is more
common in type 1. Multiple cysts at presentation also increase the risk of
relapse.

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14. ENDOCRINE
DR. RW SENEVIRATNE

14.1. Regarding thyrotoxicosis

A) The incidence of cardiac failure is higher in Graves disease than secondary


thyrotoxicosis.
B) Weakness of distal muscles is a prominent feature.
C) Exophthalmos can be unilateral.
D) Anti-thyroid drugs are used with intention to enable cure.
E) Beta blockers should be stopped a week before thyroidectomy.

14.2. Clinical features of primary hyperparathyroidism include

A) Diarrhoea
B) Depression
C) Trousseau's sign
D) Pathological fractures
E) Renal failure

14.3. A 30- year- old woman presents with a small palpable nodule in the left lobe
of the thyroid gland which was noticed two weeks ago. She had no previous
history of thyroid disease. Which of the following are true regarding her
management?

A) Ultrasound scan of thyroid gland is indicated.


B) Normal T4 level excludes defects in hormonal production.
C) Left thyroid lobectomy and isthmectomy are indicated if the FNAC reveals a
papillary carcinoma.
D) All enlarged suspected lymph nodes should be removed at the time of
thyroid surgery.
E) Anaplastic thyroid carcinoma is a strong probability.

99
Answers to question 14.1.

A) FALSE - Cardiac failure is more common in secondary thyrotoxicosis due to


effects of age and comorbidity.
B) FALSE- Thyrotoxicosis is an aetiological factor for proximal myopathy.
C) TRUE - Exopthalmos is immunological in origin and it is usually bilateral.
D) TRUE - It is curable in approximately 50%. Six months to two years of
treatment may be required.
E) FALSE - Beta blockers should continue usually for one week after
thyroidectomy, as the half-life of thyroxin is approximately 7 days

Answers to question 14.2


.
A) FALSE - Constipation is associated with hypercalcemia.
B) TRUE - Range of psychological disturbances occur including depression
and manic state.
C) FALSE - This is a feature hypocalcaemia following hypoparathyroidism
D) TRUE - Osteitis fibrosa cystica (Von Recklinghausen's disease) is a known
feature of primary hyperparathyroidism
E) TRUE - Hypercalcemia can lead to renal failure via urolithiasis.”Bones,
stones, moan and groans” is a useful pneumonic to remember regarding
effects of hyperparathyroidism

Answers to question 14.3.

A) TRUE - This will show size and consistency of nodule. It will also
differentiate prominent nodule of multinodular goiter from a true solitary
nodule.
B) FALSE - T3 and TSH may be abnormal even with a normal T4 level.
C) TRUE - This is an accepted treatment for those under 40 years of age with
papillary cytology specially if the size is under one centimeter while those
over 40 undergo total thyroidectomy.
D) FALSE - The “berry picking” method is not recommended and appropriate
block dissection is indicated with lymph node metastasis.
E) FALSE - This usually occur in advanced age.

100
14.4. Which of the following are true regarding medullary carcinoma of the
thyroid gland?

A) Diarrhoea is a presenting feature.


B) Familial variety is due to autosomal recessive gene.
C) It is associated with Multiple Endocrine Neoplasia Type 1(MEN I)
D) It is associated with increased Carcino- Embryonic Antigen levels
E) Deposition of amyloid is a feature.

14.5. Phaeochromocytoma

A) has a familial predisposition.


B) is bilateral in 5% of the affected.
C) presents with episodic hypertension.
D) leads to orthostatic hypotension.
E) is a recognized cause of hypoglycemic attacks.

14.6. Regarding Pancreatic Endocrine Tumours

A) Approximately 5% are associated with MEN syndrome


B) Symptomatic hypoglycaemia after exercise with plasma glucose of <2.8
mmol/l is highly suspicious of an insulinoma.
C) Gastrinomata usually present with gastric ulceration.
D) Nonfunctioning pancreatic endocrine tumours (NF-PETs) have a worse
prognosis than PETS.
E) MRI Scan is the gold standard for diagnosis.

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Answers to question 14.4.

A) TRUE - This is thought to be caused by 5-hydroxy tryptamine or


prostaglandins secreted by medullary carcinomas.
B) FALSE - It is due to Autosomal dominant gene giving offsprings a 50% risk.
Those at risk should be identified and must have prophylactic
thyroidectomy early in the life.
C) FALSE - It is associated with both A and B types of MEN II syndrome.
D) TRUE - This is a more reliable tumour marker than calcitonin in medullary
thyroid cancers.
E) TRUE – This is a well-known feature with medullary cancers appearing as
having acellular eosinophilic material in the cytoplasm.

Answers to question 14.5.

A) TRUE - This has an association with MEN II, von Hippal -Lindau and NF-1
syndromes and genetic testing is useful in prediction.
B) FALSE - It is 10% bilateral, 10% inherited, 10% extra-adrenal, 10%
malignant and 10 % occur in children giving rise to the eponym“10%
Tumour”.
C) TRUE - Haedache and palpitations are other common associated features
in pheochromocytomas.
D) TRUE – Orthostatic hypotension can occur in between hypertensive
attacks.
E) FALSE - It produces hyperglycemic episodes in about 40% due to high
epinephrine and norepinephrine.

Answers to question 14.6.

A) FALSE – About 15% tumours are associated with MEN syndrome.


B) TRUE - These two along with relief of symptoms by injection of glucose
constitute Whipples triad.
C) FALSE – It commonly presents with the symptoms of peptic ulcer disease.
D) TRUE - About 70%of NF-PET s are malignant.
E) FALSE - Endoscopic Ultrasound is the gold standard to detect Pancreatic
Endocrine Tumours.

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14.7. Regarding nonsurgical treatment of thyrotoxicosis

A) Lugol's iodine is useful for failed treatment with antithyroid drugs.


B) Antithyroid drugs are preferred in children.
C) Radioiodine is the treatment of choice for thyrocardiacs.
D) Betablockers reduce Iodine uptake by thyroid gland.
E) Propylthiouracil (PTU)is teratogenic.

14.8. Regarding primary hyperaldesteronism (PHA/Conn's syndrome)

A) It typically affects women between 50-70 years.


B) Low serum potassium level is a reliable diagnostic feature.
C) Majority are due to adrenal adenomata.
D) Thiazide diuretics form first line of therapy.
E) Surgery is reserved for adenomata and carcinomata.

14.9.Regarding thyroid malignancies

A) FNAC is diagnostic in papillary carcinoma.


B) Hurthle cell tumors have a better prognosis than papillary.
C) Calcitonin level serves as a valuable tumour marker in the follow up of
medullary carcinoma after total thyroidectomy and lymph node dissection.
D) Lymphoma is a close differential diagnosis for anaplastic thyroid carcinoma.
E) Approximately 20% of lymphomata arise in the background of thyroiditis.

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Answers to question 14.7.

A) FALSE – They are only used for a short period prior to surgery in order to
reduce vascularity.
B) TRUE - Until late teen years they are recommended antithyroid drugs.
C) TRUE –Significant number of them are unfit for surgery due to age and
comorbidities.
D) FALSE - They only control somatic clinical features of thyroid hormone.
E) FALSE -PTU is used during pregnancy.

Answers to question 14.8.

A) FALSE - Females between 30-50 years are the main category affected.
B) FALSE - Normokalemic PHA can occur.
C) FALSE - Majority are due to adrenal hyperplasia.
D) FALSE - Potassium sparing diuretics are used.
E) FALSE - Limited resections are done for hyperplasia

Answers to question 14.9.

A) TRUE - However it is unable to differentiate follicular carcinoma from


adenoma.
B) FALSE - This variety of follicular carcinoma has a higher risk of being
malignant.
C) TRUE
D) TRUE - Better differentiation techniques developed recently has led to
decreased reporting of anaplastic carcinoma.
E) FALSE - Majority arise in the background of thyroiditis.

104
14.10. Regarding surgery for thyroid disease.

A) Serum calcium should be estimated pre operatively.


B) Majority of the thyroidectomies will need ligation of middle thyroid veins.
C) Incidence of non-recurrent laryngeal nerve is approximately 1 in 1000.
D) Nerve stimulators have significantly reduced the incidence of injury to
recurrent laryngeal nerve.
E) Post-operative hypocalcaemia can become clinically apparent two weeks
after surgery.

14.11. In primary hyperparathyroidism

A) There are enlarged parathyroid glands with hypersecretion of


parathormone (PTH).
B) Diagnosis is arrived usually by detecting incidentally elevated serum
calcium levels.
C) Deteriorating renal function is an indication for parathyroidectomy.
D) Diuretics aggravate hypercalcaemia.
E) Bisphosphonate therapy has a place in severe hypercalcemia.

14.12. Which of the following are true regarding adrenal diseases

A) Conn's syndrome is suspected in a patient with hypertension and low


potassium level.
B) Conn's syndrome is sometimes treated with spironolactone.
C) In Cushing's disease, patients are at an increased risk of hospital acquired
infection.
D) Prophylactic anticoagulation is essential before adrenalectomy.
E) After unilateral adrenalectomy, cortisol should be given postoperatively.

105
Answers to question 14.10.

A) TRUE - Low calcium may accompany thyroid or parathyroid disease,


nutritional deficiencies and Varity of other conditions. Special precautions
are required perioperatively to avoid symptomatic hypocalcaemia.
B) FALSE - Venous anatomy is variable and middle thyroid vein is absent in
significant number of patients. Ligation is required in about 30%.
C) FALSE - Incidence is approximately 1%.
D) FALSE - No studies have proven this up to date.
E) TRUE - Although typically present between 2nd and 5th post-operative day
symptoms can appear even in 2-3 weeks.

Answers to question 14.11.

A) TRUE - Primary hyperparathyroidism is usually a sporadic disease with


hypercalcemia and increased PTH level due to enlargement of one or more
glands and hypersecretion of PTH.
B) TRUE - Classical symptoms of bone disease, renal calculi, pancreatitis and
psychiatric disturbances are rare and many patients are asymptomatic.
C) TRUE- Urinary tract calculi, reduced bone density, high serum calcium, over
50 years of age and symptomatic hypercalcaemia are among other
indications.
D) TRUE - Lithium can also increase calcium level.
E) TRUE- It is a calcium reducing agent.

Answers to question 14.12.

A) TRUE - primary hyperaldosteronism is defined as hypertension as a result of


hypersecretion of aldosterone.
B) TRUE -Antihypertensives and diuretic therapy causing hypokalemia and
influencing renin angiotensin aldosterone system has to be discontinued.
C) TRUE - Risk of thromboembolic and myocardial complications are also
increased.
D) TRUE – Thromboembolism is a risk during post-operative period.
E) TRUE –Objective is the suppression of contralateral gland.

106
15. NEUROSURGERY
DR.JPM KUMARASINGHE

15.1. Cerebral aneurysms

A) are present at birth.


B) usually occur where arteries bifurcate.
C) are multiple in approximately 50% of the affected.
D) surgery is mandatory.
E) usually present with cranial nerve palsy.

15.2. During the first 48 hours following a head injury the causes of a rising
intracranial pressure include

A) Intracerebral haemorrhage.
B) Cerebral oedema.
C) CSF rhinorrhoea.
D) Meningitis.
E) Excessive hyperventilation.

15.3. In head injuries the signs of an expanding intracranial lesion include.

A) Deteriorating level of consciousness.


B) Rising pulse rate.
C) Falling blood pressure.
D) Small pupils.
E) 6th Nerve palsy

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Answers to question 15.1.

A) FALSE - Acquired ones are associated with life style factors such as;
hypertension, obesity and smoking congenital ones develop later in life.
B) TRUE - Berry aneurysms are commonly found in those sites.
C) FALSE - Majority are single.
D) FALSE - Interventional radiology with coil insertion is effective.
E) FALSE - Usually present with severe headache and loss of consciousness as a
consequence of a rupture.

Answers to question 15.2.

A) TRUE - Time to compensate by auto regulation is not available.


B) TRUE - This is a result of direct injury and ishcheamia.
C) FALSE - This is due to fracture of cribriform plate.
D) FALSE – Increased intracranial pressure caused by meningitis is a late
presentation if occurs.
E) TRUE - Excessive CO2 washout causes vasoconstriction leading to
ischaemia following increase in cerebral odema and raising of intra cranial
pressure.

Answers to question 15.3.

A) TRUE - This can be due to cerebral damage as well as brainstem herniation.


B) FALSE - Cushing reflex causes pulse rate to reduce.
C) FALSE - The blood pressure rises.
D) FALSE - Fixed dilated pupils are a feature.
E) TRUE - 6th nerve is one of the first structures to get affected by the increase
of intracranial pressure and is a false localizing sign.
.

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15.4. After section of a peripheral nerve

A) The axon grows distally at approximately 1mm per day.


B) The growing end of the nerve can be localised by percussion.
C) Primary nerve suturing should be undertaken as soon as possible.
D) Prognosis after repair is best if the nerve cut is of mixed type.
E) Distal muscles are best managed with splinting to prevent contractures.

15.5. Which of the following lesions are true regarding ring enhancing lesions on
CT scan of brains ?

A) Thick and nodular appearance favours neoplasm.


B) There is an extensive oedema around cerebral abscess.
C) In neurocysticercosis calcified lesions are present.
D) An incomplete ring is seen in tuberculoma.
E) Increased perfusion of contrast favours a malignancy.

15.6. Regarding brain tumours

A) Gliomas are always malignant.


B) Oligodendroma is the most common benign tumour.
C) Secondary tumours are usually due to gastrointestinal primaries.
D) Lung is the most common site of secondary spread.
E) Pituitary tumours are mostly benign.

109
Answers to question 15.4.

A) TRUE - Human axon growth rate can reach 1 mm/day in small nerves and
slightly higher in large nerves.
B) TRUE - This stimulates an electric impulse.
C) TRUE - Early end to end suturing or nerve grafting interposition under
magnification is the best option.
D) FALSE –Repair of pure motor or sensory nerves have better results than
mixed nerves.
E) TRUE - They should be frequently exercised using physiotherapy and
electrical stimulation to prevent wasting.

Answers to question 15.5.

A) TRUE - This is due to crab like extensions of neoplasm to surrounding


structures.
B) TRUE - The inflammatory reaction elicited around abscess causes this
oedema.
C) TRUE - This is seen in end stage quiescent cysts.
D) FALSE - This is seen in demyelinating lesions.
E) TRUE - This is due to increased blood supply to malignant foci.

Answers to question 15.6.

A) FALSE - Benign gliomas are seen in childhood.


B) FALSE - Meningiomas is the most common.
C) FALSE - After Breast and lung, multiple myeloma, melanoma as well as head
and neck tumours predominate. Gastrointestinal tumours rarely
metastasize to brain.
D) FALSE - Primary tumours are not known to spread outside the brain.
E) TRUE - 90% are benign.

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15.7. Regarding the management of brain tumours

A) Acoustic neuromas are treated by radiotherapy.


B) Hormone replacement is usually required for pituitary macroadenomas.
C) Transphenoidal route is preferred for pituitary tumour excision.
D) Surgery has no place in the management of malignant gliomas.
E) Benign tumours have an approximately 60% five year survival if operated.

15.8. A 25-year old man presents with weakness in the upper limbs, spastic
paralysis of lower limbs and priapism 12 hours after a fall. He has a pulse rate of
84/min and BP of 75/50mmHg. Which of the following statements are true?

A) Patient has an incomplete spinal injury.


B) Patient is in spinal shock.
C) Urinary catheter is mandatory.
D) Inotropes are indicated.
E) Methyl prednisolone is continued up to maximum of 24 hours.

15.9. Benign extramedullary tumour arising from left 11th thoracic nerve root

A) causes burning pain around left groin crease.


B) shows no recognizable abnormalities on a plain x-ray.
C) is associated with hypertension.
D) has tuberculosis as a differential diagnosis.
E) usually has features of myelopathy on presentation.

111
Answers to question 15.7.

A) FALSE - They are meningiomas and are resistant to Radiotherapy.


B) TRUE - They are nonsecretive and diminish pituitary hormonal output by
compression necrosis.
C) TRUE - This access is direct and has minimum risk of damaging cerebral
tissue.
D) FALSE - Debulking is useful to relieve symptoms and prolongs life.
E) FALSE - They are slow growing with defined margins and 5 year survival is in
the region of 90%.

Answers to question 15.8.

A) FALSE - Priapism is an unmistakable sign of complete spinal injury.


B) FALSE - In spinal shock lower limbs will show flaccid paralysis.
C) TRUE - This will assess volume status and also reduce requirement for
patient management.
D) TRUE - Patient is hypotensive and in neurogenic shock. Maintainance of
cerebral circulation desires higher pressure.
E) FALSE - Patients who present 3-8 hours later after spinal injury steroids are
given until 48 hours have elapsed.

Answers to question 15.9.

A) FALSE - Burning pain should be above this level according to


demonstration.
B) FALSE - It will show erosive changes.
C) TRUE - These are usually neurofibromas which are associated with
pheochromacytomas.
D) TRUE - This can produce slow compression symptoms.
E) FALSE - It will present early with lesser symptoms and myelopathy is a late
feature.

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16. CARDIOTHORACIC SURGERY
DR. MMAJ KUMARA

16.1. Mechanical heart valves

A) require anticoagulation for life.


B) are liable to infection.
C) last 10 years.
D) obstructive to blood flow than normal valves.
E) when fails it is gradual.

16.2. Regarding coronary artery bypass graft (CABG)

A) Poor ventricular function associated with multi vessel disease is an


indication.
B) The 10year patency rate for long saphenous vein grafts is reported to be 50-
60%.
C) Poor cardiac output state in the first few hours after surgery is expected.
D) Deep wound infection following CABG has a mortality rate of 40%.
E) Cerebro vascular accident is a recognized complication.

16.3. which of the following are true?

A) In Tetrology of Fallot ,Chest X Ray reveals boot shaped heart.


B) Once Eisenmenger's syndrome is developed closure of the shunt should be
done immediately.
C) Dilated neck veins, tachycardia, muffled heart sounds are known as Beck's
triade.
D) Classical “3” sign of aortic knuckle is seen in transposition of great vessels.
E) Spontaneous closure of patent ductus arteriosus (PDA) is to be expected
until 5years of age.

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Answers to question 16.1

A) TRUE- Mechanical valves are thrombogenic and therefor the patient


requires systemic anticoagulation usually with warfarin. Consequal
restriction of activities is a major drawback
B) TRUE- The risk of prosthetic valve endocarditis is lifelong and incidence is
higher with mechanical & lowest with homograft and auto graft values.
They are catastrophic with a mortality of approximately 50%.
C) FALSE- They are extremely durable and can last a life time. Biological valves
have a life time of approximately 10 years.
D) TRUE- All surgical valves are more obstructive than natural valves of the
patient. These valves lack an inner lining mucosa which reduce mechanical
impedance.
E) FALSE- Structural failure in mechanical valves is uncommon.in biological
valves failure rate can reach 60% after 15 years and decrease in function is
gradual and give enough time for surgeons to intervine. Mechanical valves
fail quickly allowing little time to save the patient.

Answers to question 16.2

A) TRUE- Indications to CABG include more than 50% stenosis of Left main
stem, >50% stenosis of proximal left anterior interventricular artery,
narrowing of 2 out of 3 main coronary arteries disease (triple vessel disease)
B) TRUE- However recent studies suggested that the early use of lipid lowering
agents &antiplatelet agents can improve vein grafts long term potency.
C) TRUE- This is in response to an ischeamia/reperfusion type injury.often
inotropic agents are required at this time to support the heart and
circulation.
D) TRUE- This results in sternal dehiscence and mediastinitis. Treatment is
debridement and/or rewiring of the sternum. Infection are more common
in diabetics and in obese.
E) TRUE- This is due to embolism originate from a thrombus in aortic arch or
heart chambers with hypoperfusion leading to watershed infarction.

Answers to question 16.3

A) TRUE- Complications of Tetrology of fallot include ventricular septal


defect, over riding aorta, pulmonary stenosis and right ventricular
hypertrophy.
B) FALSE- Closure of the shunt is contraindicated if right to left shunt serves to
decompress the pulmonary circulation.
C) FALSE- Hypotension is a feature, not tachycardia.
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D) FALSE- This is a feature of co-arctation of the aorta.
E) FALSE- After 6 month spontaneous closure is rare.
16.4 A dissecting aneurysm of the aorta.

A) follows cardiac catheterization.


B) cause extensive medistinal destruction when it ruptures.
C) is associated with severe back pain.
D) is associated with high arched palate.
E) may present with acute renal failure.

16.5. Regarding cardiac valve surgery

A) Mitral valve repair is preferred over implants.


B) Paravalvular leak is the most common septic complication following
artificial valve insertion.
C) Patient with calcified acending aorta (Porcelein aorta) benefit from
transcatheter implantation of valve.
D) Mortality associated with elective aneurism repair is approximately 10%.
E) Mortality following Prosthetic Valvular endocardistis is 15% with aggressive
antibiotic therapy.

16.6. Regarding CABG

A) Pre-operative CT angiogram is an alternative for those who are unable or


unwilling to undergo catheter angiogram.
B) 70% reduction of a vessel diameter on angiography indicates severe
stenosis.
C) Cardiac pump is nessasary for coronary artery bypass.
D) Angina symptoms are relieved by 90% after a sucsessful bypass.
E) Perioperative mortality associated with CABG is 5-7%.

115
Answers to question 16.4.

A) TRUE-While hypertension, connective tissue disorders, vasculitis and many


other conditions are implicated in the aetiology, trauma both external blunt
as well as iotrogenic are important causes. Cardiac catheterization and
open cardiac surgery are common iotragenic causes.
B) FALSE-The aneurism dissect between two layes of tunica media.
C) TRUE-Pain usually affect lower chest .
D) TRUE-This is a Marfans association.
E) TRUE-This occur if dissection extending caudally involve both ostea of renal
arteries.

Answers to question 16.5

A) TRUE-Repair of this valve is always preferred whenever possible.


B) FALSE-Valve thrombosis is most common with annual incidence of 3-5%.
C) TRUE-Other groups who benift include patients with severe deformities in
the chest.
D) FALSE- This is less than 5%.
E) FALSE - It is in the range of 50%.

Answers to question 16.6

A) FALSE-No angiogram other than catheter angiogram can give a surgeon


the relavent information.
B) FALSE-90% on angiography indicate 70% or more narrowing in cross
sectional area. Severe stenosis is classified as 70-99% narrowing in cross
sectional area and 50-70% narrowing of cross section area is regarded as a
moderate stenosis.
C) FALSE-Off pump bypass is possible with octopus.
D) TRUE-This falls to 80% at 5 years and 60% at 10 years.
E) FALSE- it is 2-3%.

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16.7. During cardiopulmonary bypass procedure ,

A) Heart is arrested in systole.


B) Heart is allowed to beat every 45 minites.
C) Warming cardioplegic solutions are used.
D) Cool solutions are used.
E) Anticoagulants are used.

16.8. Complications of Cardio pulmonary bypass (CPB) include

A) SIRS.
B) Intestinal ischemia.
C) Hepatitis.
D) Fat embolism.
E) Myocardial infarction.

16.9. Regarding congenital heart disease (CHD)

A) They arise during 2-6 weeks of gestation.


B) Acynotic CHD account for 1 out of 3 of all CHDs.
C) Fallot,s Tetralogy is the most common cyanotic CHD.
D) Osteum Secondam defects account for approximately 30% of ASDs.
E) Incidence of Eisenmengers syndrome is decreasing.

117
Answers to question 16.7.

A) FALSE- It is arranged in diastoli using high concentration of pottassium


B) FALSE- This is allowed in every 15-30 minutes.
C) TRUE-They are beneficial when restarting heart.
D) TRUE- They reduce metabolic demands.
E) TRUE- This prevents activation of coagulation casacade when blood is in
contact with artificial surfaces of pump conduits.

Answers to question 16.8.

A) TRUE – This is due to activation of inflammatory marker due to exposure of


blood to artificial surfaces of the machine.
B) TRUE- it is approximately 10% of all congenital heart diseases
C) FALSE – This complication is not recorded.
D) FALSE - Air embolism can occur.
E) TRUE - The strains heart is subjected to during procedure naturally
increases this risk.

Answers to question 16.9.

A) TRUE- They arise within 3-8 weeks


B) FALSE- approximately 2/3 are acyanotic.
C) TRUE
D) FALSE-This accounts for approximately 70% of ASDs.
E) FALSE-This is due to improvements in early detection and surgery.

118
16.10. A 70 year-old heavy smoker with history of COPD present with
spontaneous onset unilateral; pneumothorax. Which of the following facts are
true?

A) Its likely to be a primary pneumothorax.


B) Management is possible without intervension.
C) Aspiration can be sufficient.
D) Some require thoracotomy.
E) Tuberculosis is a possible cause.

16.11.Regarding Carcinoma of Lung

A) Small cell carcinomas account for 80%.


B) Chronic intractable Cough is the most common presenting symptom.
C) Apical region of the left lung is the most common site .
D) Can present with Teteny .
E) Pulmonary lobectomy is the minimal surgical procedure with a curative
intent.

16.12. Which of the following are borders of triangle of safety?

A) Upper border of the seventh rib.


B) Lateral border of pectoralis major.
C) Anterior axillary line.
D) Mid axillary line.
E) Upper border of fifth rib.

119
Answers to question 16.10.

A) FALSE-Primary pneumothorax occur in younger people who are typically


thin , tall and with a positive family history.
B) TRUE-If no shortness of breath and size is less than 1 cm intervention is not
nessasary.
C) TRUE-If no shortness of breath and size is 1-2 cm aspiration is sufficient.
D) TRUE-This may be for purpose of decortication in persistant air leaks or for
curative perposes in conditions such as lung cancer.
E) TRUE-Fragile lung tissue caused by tuberculosis or lung carcinoma can lead
to spontaneous pneumothorax.

Answers to question 16.11.

A) FALSE -They account for 20% and 80% are non small cell carcinomas of
which adenocarcinoma is predominant
B) FALSE - Haemoptysis is the presenting complain in approximately 50%
C) FALSE - Apical region of right lung is most commonly involved. Apical
tumours can involve lower trunk of brachial plexus when it is called
Pancoast,s tumour.
D) TRUE- Lung cancer is associated with series of paraneoplastic syndromes.
E) FALSE- wedge resection or segmentectomy are employed with intended
cure.

Answers to question 16.12.

A) FALSE- Upper border of the fifth rib


B) TRUE- This forms anterior border of the triangle of safety
C) FALSE- Mid axillary line
D) TRUE- This forms posterior border of the safe triangle
E) TRUE- This forms inferior border of the safe triangle.

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17. VASCULAR SURGERY
DR.MMAJ KUMARA

17.1Which of the following features suggest advanced peripheral vascular


disease(PVD)

A) Night pain relieved by dependant position of the foot.


B) Intermittent claudicating at 200 metres.
C) An Ulcer over the medial malleolus.
D) Sexual dysfunction .
E) Ankle Brachial Index of 0.8.

17.2. Regarding Peripheral vascular disease(PVD).

A) It is more common with those who suffer from rheumatoid arthritis.


B) Rest pain can be usually managed conservatively.
C) ABI of 0.6 warrants surgery.
D) Sympathectomy increases arterial flow to deep tissues.
E) Poly tetra fluro ethylene (PTFE) vascular grafts have longest patency.

17.3.Regarding Deep vein thrombosis (DVT)

A) DVT following splencetomy is due to prolonged immobilization .


B) D- dimer has a strong negative predictive value.
C) Risk can be eliminated by pneumatic calf compression.
D) Low molecular weight heparin is used in treatment and prophylaxis.
E) It can cause vericose veins.

121
Answers to question 17.1

A) TRUE – These symptoms constitute Fontain III along with rest pain .Fontain
III and IV are classified as critical ischemia
B) FALSE-This per se does not suggest critical ishcheamia
C) FALSE - This is usually a feature of venous disease while ulcers on Lateral
side of ankle and tips of toes are common with arterial disease.
D) FALSE - This clinical entity, termed Lerich's Syndrome can happen early in
the disease and is due to aorto-illeal involvement.
E) FALSE - Ankle Brachial Index of 0.8 is considerd as early Perpheral vascular
Disease.

Answers to question 17.2.

A) TRUE - This is due to associated vasculitis.other more important risk


factors include diabetes, smoking dyslipidaemia and hypertension.
B) FALSE - This indicate Fontain grade III and advanced PVD demanding
intervention to save the limb.
C) FALSE - Normal is 0.9 and advanced peripheral vascular disease is considerd
as 0.5 or below.However clinical correlation is required in deciding the
treatment.
D) FALSE - It improves blood flow to superficial tissues and facilitate wound
healing
E) FALSE - Vein grafts have that honour.

Answers to question 17.3.

A) FALSE - This is usually due to thrombocytosis


B) TRUE – Positive predictive value is less.
C) FALSE - Risk cannot be eliminated even with mechanical and chemical
prophylaxis but reduced.
D) TRUE - Even unfractioned heparin can be used in both roles but more
cumbersome to administer.
E) TRUE - This is usually due to fibrosis and destruction of perforater valves.
Opposite is not true. Varicose veins are not a risk factor for DVT unless
thrombophlebitis superveins.However deep vein thrombosis is a possible
122
complication of injection therapy or surgery for varicose veins.

17.4. A 70 years old man present with non-healing ulcer over medial side of an
ankle. He has varicose veins affecting ipsilateral leg.

A) Fasting blood sugar is a mandatory.


B) Wound swab for culture and sensitivity is indicated.
C) Biopsy is important to consider .
D) Venogram is the investigation of choice to delineate venous anatomy of the
limb.
E) Surgical treatment of varicose veins must be done prior to attempts on
healing of ulcer.

17.5. A cystic hygroma

A) is a lymphangioma.
B) is assocuiated with Downs syndrome.
C) is usually situated in the posterior mediastinum.
D) usually regress by puberty.
E) can be treated b injection of a sclerosant.

17.6. Acute arterial occlusion of lower limb

A) is characterized by a dusky cyanosis of the limb.


B) should be treated conservatively if the site of the occlusion is above the
inguinal ligament.
C) demands the urgent use of vasodilator drugs.
D) Is usually painless due to the anoxic damage to peripheral nerves.
E) may produce irreversible muscle necrosis after 4 hours.

123
Answers to question 17.4.

A) TRUE - All with chronic ulcers require diabetes to be excluded.


B) TRUE - Once a week culture sensitivity is reccomended in chronic ulcers as
flora can be changed frequently.
C) TRUE - Low threshold for biopsy should exist to exclude possibility of
squamous cell carcinoma. Marjorins ulcer is relatively common in chronic
venous ulcers, osteomyelitis sinuses and in burn scars.
D) FALSE - Duplex Doppler provide required information and make invasive
investigation redundant.
E) FALSE - Ulcer healing with four layer bandaging can predede or succeed
surgery.

Answers to question17.5.

A) TRUE – These are usually found where head and limbs join trunk
B) FALSE - It is often seen in Turners syndrome.
C) FALSE - Most common sites are left posterior triangle and axillas. Impact of
the effects of secondary infection depends on site.
D) FALSE - They do not regress but can expand.
E) TRUE - Surgery is the main option.

Answers to question 17.6.

A) FALSE - Pallor is expected.Cyanosis occurs in acute venous obstruction such


as thrombosis of common femoral vein.Plegmesia cerula dolence and
plegmesia rubra dolence are synonyms for clinical appearance of legs
following arterial and venous obstruction respectively.
B) FALSE - This requires immediate surgical intervension to save the limb.
C) FALSE- This is not of significant benefit.
D) FALSE - This is painful. Remember 5 Ps of acutely ischeamic limb (pain,
pallor, parasthesia, pulseless, perishing cold)
E) FALSE - This will take 6-8 hours and can be delayed by fasciotomy.Hence the
importance of latter before a vascular injury get transferred for repair.

124
17.7. Abdominal aortic aneurysms

A) arise from an atheromatous vessel in approximately 25% of the cases.


B) characteristically produce epigastric pain.
C) are associated with duodenal ulceration.
D) are found incidentally is managed without intervention.
E) can present with gangrene of toes.

17.8. Regarding the management of intermittent claudication.

A) Absolute walking distance is the most important determinant of the


management of intermittent claudication.
B) Absence of femoral pulses suggest inoperability.
C) Arteriography is mandatory .
D) Most patients are managed with surgery.
E) Exercise can obviate the need for surgery.

17.9. In patients with cerebro vascular accident,

A) Recovery is never complete.


B) Hypertension is the most important contributing cause.
C) Most strokes are caused by intracerebral haemorrage.
D) Carotid surgery is mandatory if stenosis is more than 50% .
E) Risk of complications following angioplasty and stenting is less than that
following carotid endarterectomy.

125
Answers to question 17.7.

A) FALSE - Approximately 80% of abdominal aortic aneurisms arise from


atheromatous vessels.
B) FALSE - Back pain is carateristic.
C) TRUE - Fatal aorto-duoedinal fistula can occure although they are more
common at graft site following aneurismal repair.
D) FALSE - If diameter 5.5 cm or above the risk of rupture is higher than the risk
of death from an elective repair.Increasing use of Intravascular shunts
lowers threshold for intervention.
E) TRUE – This is due to embolization from aortic thrombus.

Answers to question 17.8.

A) FALSE - Relative walking distance compared with age and lifestyle is


important.
B) FALSE- Stents and grafts can re-establish distal circulation.
C) FALSE- This is performed only if intervension is considered.
D) FALSE - Most are managed conservatively
E) TRUE - Garded exercise programmes can encourage development of
collateral circulation and can obviate the need for surgery in a propotion of
patients.

Answers to question 17.9.

A) FALSE - Complete recovery is seen following transient ischeamic


attack(TIA).
B) TRUE - Congenital disease, diabeties, smoking, and low flow states are
among other contributing factors.
C) FALSE - Ischemia account for over 80%.This distinction which can be made
on CT-Head facilitate important decision making on thrombolysis.
D) FALSE – If more than 70% it is mandatory and those more than 50% benefit
if they are symptomatic.To treat asymptomatic patients life expectancy
should be at least 5 years..
E) FALSE - The risk of complications such as re-stroke and myocardial
infarction is equal or higher with angioplasty and stenting.

126
18. PAEDIATRIC SURGERY
DR.RW SENEVIRATNE

18.1. Regarding surgery in children under 3 years of age

A) 2hours fasting for breast milk is adequate prior to anaesthesia.


B) Abdominal incisions can be closed with absorbable sutures.
C) Bowel anastomoses can be closed with interrupted single layer extra
mucosal sutures.
D) Transverse incision gives better access to intra-abdominal organs.
E) Cardiorespiratory arrest in children is usually due to cardiac cause.

18.2. Which of the following are true regarding testicular torsion?

A) most common in 1-5 years of age.


B) must be relieved within 6-8hrs to salvage testis.
C) Three point fixation of affected testis is sufficient.
D) if diagnosis is doubtful a colour Doppler scan becomes necessary.
E) torsion of appendix of testis is a differential diagnosis.

18.3 Infantile hypertrophic pyloric stenosis,

A) presents with non-bilious projectile vomiting.


B) is usually seen after 6weeks.
C) has a congenital predisposition.
D) causes Hypochloraemic hypokalaemic alkalosis.
E) require Ramsted's pyloromyotomy for cure.

127
Answers to question 18.1.

A) FALSE- In paediatric population fasting time for solids is 6 hrs, for breast
milk is 4hrs and for clear fluids it is 2hrs.
B) TRUE- Strength provided is adequate and restrictive effect which can occur
when abdominal wall is growing, is avoided.
C) TRUE – Healing is rapid.
D) TRUE- Width of the abdomen is relatively more in children.
E) FALSE- Respiratory causes predominate.

Answers to question 18.2

A) FALSE- Testicular torsion is commonly seen in adolescents and it is rare


after 25 years of age.
B) TRUE- Else ischeamic necrosis with effects on future fertility will take place.
C) FALSE- Other testis also require three point fixation.
D) FALSE- Althogh Doppler ultrasound scan has a place, exploration is the
safest option.This increases the chances of salvage and if negative
permanant damage is incurred.
E) TRUE- Other diffential diagnosis include epididymo orchitis and torsion of
appendix of epididymis.

Answers to question 18.3

A) TRUE - This is characteristic.


B) FALSE- It typically present between 3 to 6 weeks.
C) TRUE- It is commen in first born males.
D) TRUE- If neglected more severe metabolic derangements can occure.
E) TRUE- Only mucosa is left intact.

128
18.4. Intussusception

A) is seen mostly during 3months to 2 years of age.


B) is iliocolic in 80% of children.
C) in the majority has a pathological lead point.
D) classically presents with colicky abdominal pain.
E) most of them end up with operative reduction.

18.5. Biliary atresia

A) leads to vit K dependent coagulopathy.


B) shows small gallbladder on ultrasound scan of abdomen.
C) has intraoperative cholangiogram as the gold standard in diagnosis.
D) may need liver transplantation.
E) requires Kasai portoenterostomy within 8 weeks of age.

18.6. Inguinal hernia in infant males

A) Is more common in premature boys.


B) Is bilateral in 30%.
C) show transillumination.
D) Is best repaired in infancy.
E) can be irreducible.

129
Answers to question 18.4.

1. TRUE- Weaning period with ingestion of bacteria inflaming lymphoid tissue


of gastro intestinal tract appears to be an important contributing factor.
2. TRUE
3. FALSE- Pathological lead point is present in 2 – 12 %.
4. TRUE- Vomiting and passage of “red currant jelly” stools among other are
important features.
5. FALSE- Majority benefit from hydrostatic reduction.

Answers to question 18.5.

1. TRUE- Fat malabsorption leads to vit K deficiency, which is required for


clotting factor synthesis.
2. TRUE- Gallbladder undergoes disuse atrophy.
3. TRUE- Dye is injected retrogradely to visualize the biliary tree.
4. TRUE- Strictures following initial resuscitation procedures can leads to liver
failure requiring transplantation.
5. TRUE- Operative success rate is higher if surgery is done within this period.

Answers to question 18.6.

1. TRUE- Incidence is in the region is 1:50 for boys .


2. FALSE- It is bilateral in 15%.
3. TRUE- This is due to fluid in patent processes vaginalis.
4. TRUE- it is required as soon as possible as risk of strangulation is high.
5. TRUE- This usually occurs due to incarcerating constriction at the external
inguinal ring.

130
18.7. Regarding testicular abnormalities in children

A) Testis can be found near umbilicus.


B) Retractile testis occupy base of the scrotum.
C) Undescended testis can be impalpable.
D) Those with bilateral impalpable testis usually become infertile.
E) Orchidoplexy at 2 years for undesended testis improves effects on fertility.

18.8. Which of the following are classical features of non-accidental injuries?

A) Bruises of various ages


B) Fracture of an anterior rib
C) Pulled elbow
D) Fracture radius and ulnar in a toddler
E) Bucket handle metaphysis fracture

18.9. Regarding retinoblastoma in children

A) It is multicentric
B) Many are hereditary
C) White reflex aids diagnosis
D) Retinopathy of prematurity is a differential diagnosis
E) Enucleation of the affected eye is necessary.

131
Answers to question 18.7

1. FALSE- Even ectopic testis which can be found in thigh or perineum does not
reach this area.
2. TRUE- However it can retract proximally anytime.
3. TRUE- It can be situated inside the abdomen.
4. TRUE-This indicate severe histology and functional abnormalities
5. FALSE-Up to 1 year this is achievable

Answers to question 18.8.

A) TRUE- Regular injuries by the attacker is evident


B) FALSE- Fracture of posterior ribs should rouse suspicion
C) FALSE- This is a common injury in children under 5-years
D) TRUE-Any fracture in a child below walking age is suspicious
E) TRUE- This is characteristic of non-accidental injuries

Answers to question 18.9

A) TRUE- Other eye should be closely monitored


B) TRUE- Those with family history needs carefull monitoring
C) TRUE- Normally it should be red reflex
D) FALSE- Radiotherapy, cryotherapy, chemotherapy and laser cure smaller
lesions
E) TRUE- Primary hyperplastic vitreous and intra ocular infections are other
important differential diagnoses.

132
19. SKIN AND SUPERFICIAL LUMPS
DR. MB SAMARAWICKRAMA

19.1. Which of the following are premalignant conditions of the skin?

A) Bowen's disease
B) Solar keratosis
C) Xeroderma pigmentosa
D) keratoacanthoma
E) Dermatofibroma

19.2. Which of the following are true regarding squamous cell carcinoma (SCC)
of skin?

A) It usually spreads via lymphatics when originates from pre-existing chronic


scar
B) Ulcer with punched out edges is a feature
C) Verrucous carcinoma is a form SCC
D) Spread via blood is a common feature
E) Wide local excision is the sole mode of treatment

19.3. Basal cell carcinoma (BCC),

A) occurs at mucocutaneous junctions


B) spread via lymphatics
C) appear as cystic lesions
D) presence of pigmentation is a feature
E) does not occur beyond the region of the face

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Answers to question 19.1.

A) TRUE -Bowen's disease refers to squamous carcinoma in situ and origin


from outer most layer of the skin.
B) TRUE-Solar keratosis also known as actinic keratosis and this results from
exposure to sunlight
C) TRUE -Xeroderma pigmentosa is a condition where there is defective DNA
excision repair mechanism
D) FALSE -keratoacanthoma is a symmetrical cutaneous growth with a central
cater filled with keratin plug
E) FALSE -This is a benign fibrous nodule of skin frequently found on lower
limbs

Answers to question 19.2.

A) FALSE-Chronic scars do not have lymphatics


B) FALSE -Malignant ulcer has raised and everted edges
C) FALSE-Verrucous carcinoma is a different type of carcinoma
D) FALSE -SCC are characterized by local and lymphatic spread
E) FALSE -Wide local excision, radiotherapy and amputation are among the
treatment options.

Answers to question 19.3.

A) TRUE-This can occur anywhere including mucocutaneous junctions


B) FALSE-This is a locally spreading carcinoma
C) TRUE-The different types of BCC are nodular,cystic,and pigmented
D) TRUE-It can mimic melanoma
E) FALSE- The most common site is the face, but they can occur in other
places.

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19.4.Risk facors for the development of a melanoma include

A) Exposure to sunlight
B) Albinism
C) Hairy mole
D) Blue naevus
E) Junctional naevus

19.5. Which of the following changes of a naevus are suggestive of malignant


transformation

A) Induration
B) Bleeding
C) Ulceration
D) Appearance of hair
E) Change in shape

19.6.Which of the following skin conditions are associated with systemic illness?

A) Pyoderma gangrenosum
B) Erythema nodosum
C) Acanthosis nigricans
D) Hidradenitis suppurativa
E) Vitiligo

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Answers to question 19.4.

A) TRUE- Exposure to ultraviolet light is the major causal factor


B) TRUE-Damage from sun exposure is more in the absence of melanocytes
C) FALSE-Occur when melanocytes layer in epidermis
D) FALSE- This is a benign lesion which is 4 times more common in children.It
typically affect extremities and face.large congenital naevus (>20cm) and
xeroderma pigmentosa are rsk factors for melanoma
E) TRUE-deeply pigmented macule/papule that occurs commonly in
childhood or adolescence

Answers to question 19.5.

A) FALSE -This is not a feature of melanoma


B) TRUE -Neoplasm is very vascular and bleed with minimal trauma
C) TRUE-Rapid growth of tumour leads to ischemia of superficial layers with
subsequent ulceration
D) FALSE -Melanoma is typically devoid of hair
E) TRUE -Change in size, shape, colour, inflammation, crusting, itching, halo
around a mole are all features of a transplantation in to a melanoma

Answers to question 19.6.

A) TRUE-This is a condition occurring in leg characterized by skin necrosis and


ulcer. This is associated with leukemia, lymphoma, systemic lupus
erythematous, inflammatory bowel disease ;
B) TRUE-Erythema nodosum is an inflammatory condition occurring usually at
shins and associations include systemic infections, pregnancy,
inflammatory bowel disease,etc;
C) TRUE -Acanthosis is associated with obesity, insulin resistance, diabetes
mellitus, Cushings disease, etc;
D) FALSE –It is a local suppuration of apocrine sweat glands
E) FALSE -Is not associated with systemic illness. It has an autoimmune
aetiology

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19.7. Lumps which are attached to the skin include

A) Sebaceous cyst
B) Congenital dermoid cysts
C) Implantation dermoid cysts
D) Ganglion
E) Nodular neurofibroma

19.8. Which of the following is/are true of a hypertrophic scar?

A) Ocurring is restricted to scars involving chest wall


B) It respond well for steroid injection
C) It is genetically determined
D) Growth continues approximately 6 months
E) It is controlled by wearing pressure garments

19.9. Which of the following are true regarding causes of hernia

A) Laparoscopic port site incisions have a hernia rate of 1%


B) Right inguinal hernia is common after appendicitis.
C) Hernia is more due to increased abdominal pressure than due to weaken
abdominal wall.
D) Hernia risk is negatively related to BMI.
E) Hernia is more common in smokers.

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Answers to question 19.7.

A) TRUE-Sebaceous cyst is attached at the site of punctum


B) FALSE-This is within skin.that is subcutaneous
C) TRUE-Attached to the skin at the site of the initial trauma
D) FALSE-This is a lump arising from tendon synovial sheath
E) FALSE-This is attached to a nerve and is subcutaneous.Lumps attached to
structures like tendons and nerves are mobile in lateral direction.

Answers to question 19.8.

A) FALSE-Hypertrophic scars can occur anywhere in the body


B) TRUE-Streoid is a forward treatment option
C) FALSE-This is not genetically determined
D) TRUE-Keloid scars expand for longer periods
E) TRUE-Is a available treatment option

Answers to question 19.9.

A) TRUE- Incidence in laparoscopic port site incisions is 1-5% and in


laparotomy incisions is 10-50%.
B) TRUE- Appendicectomy inscision leads to denervation of local muscles.
C) FALSE- Hernia rate among Olympic athlete are no more than general
population.
D) TRUE- A recent Swedish report has shown that inguinal hernia is less
common in obese patients
E) TRUE

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19.10. Which of the following are true regarding management of hernia

A) All hernias require surgical repair


B) Laparoscopic pre peritoneal inguinal hernia mesh needs no fixation
C) Polypropylene mesh is impregnated with antibiotics.
D) Mesh shrinkage over a period of time contribute to recurrence.
E) An infected mesh can be managed conservatively with IV antibiotics.

19.11.Following are true regarding inguinal hernia

A) They are more commoner in males.


B) Obstruction of bowel is inevitable if strangulated.
C) Caecum can be included in its contents
D) Inguinal hernia repair can be done under LA
E) Mesh repair reduces the incidence of recurrence to 10%

19.12.Femoral hernia,

A) Is more common in women than inguinal.


B) Lies lateral to femoral vein.
C) Can be felt above the inguinal ligament.
D) Cough impulse which exhibits is beneficial in diagnosis.
E) Rarely recurs.

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Answers to question 19.10.

A) TRUE- Watchful waiting can only be undertaken in asymptomatic inguinal


hernia or paraumbilical hernia in elderly frail patients.
B) TRUE- Friction is sufficient to hold the mesh.
C) FALSE- Its hydrophobic and monofilament microstructure impede bacterial
ingrowth.
D) TRUE- Mesh may not continue to cover defect after a period.
E) FALSE - Need to remove it and IV antibiotics should be given, but mesh
requires removal.

Answers to question 19.11.

A) TRUE
B) FALSE- In Richter's Hernia part of the bowel wall is strangulated but lumen is
patent.
C) TRUE-Caecum can come down and form part of the contents in sliding
hernia IN the right side.
D) TRUE
E) FALSE-Mesh Repair reduces recurrence rate to 1%.

Answers to question 19.12.

A) False- Even in females it is less common than inguinal hernia. Femoral canal
is larger and incidence of femoral hernia is higher in females
B) False- It lies medial to the vein in the femoral canal.
C) True - Inguinal ligament lies above the femoral hernia. But as it increases in
size and the lump is reflected superiorly and becomes difficult to
distinguish from direct inguinal hernia.
D) False- Femoral hernia is usually negative for a cough impulse.
E) True – Mesh plug and suturing obstructs the narrow canal well.

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20. MISCELLANEOUS
DR.RW SENEVIRATNE

20.1.Regarding skin grafting

A) Forearm is a common donor site for split skin grafts


B) Presence of pseudomonas at the graft site culture is an absolute
contraindication for grafting
C) Staphylococous epididimus is known as the graft destroyer.
D) Holes should not be made on the graft except for the purpose of expanding
it to cover wider area
E) Full thickness skin graft is encourage contraction less than split thickness
graft.

20.2. Compared to Full Thickness Grafts, Split Skin Grafts

A) are more cosmetically acceptable.


B) are valuble on face.
C) have high take up rate.
D) can be used over wider area.
E) are more durable.

20.3.Regarding Organ Transplant

A) Glomarulonephritis is acommon indication for renal transplant


B) Pancreatic transplants are usually combined with renal transplant
C) Liver transplants have five year survival rate up to 40-50%.
D) Ischemic cardiomyopathy can be managed with a heart transplant
E) Small bowel transplants have been used for chron s disease with high
success rate
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Answers to question 20.1
.
This is very much a clinical question to check clinical exposure of medical
students

A) False- Cosmetic unacceptability is against it.


B) False - Pseudomonas on serface can be mechanically removed at the time of
procedure.
C) False - Streptococous pyogenes is called the graft destroyer
D) False - Holes are made to prvent it from being lifeted away by underlying
seroma or haematoma
E) True- Full thickness grafts causes less contraction of the wound.

Answers to question 20.2.

A) FALSE- Full Thickness Grafts give better texture and color match to that of
normal skin.
B) FALSE-Full thickness is used.
C) TRUE- The Percentage take is more with split skin grafts.They are usually
taken in 5 days as opposed to 7 days for Full Thickness Skin Grafts.
D) TRUE- The Split Skin Grafts can be harvested from wider area sand their size
can be further expanded by meshing .
E) FALSE - The Split Skin Grafts are very thin and not suitable for areas such as
fingertips.

Answers to question 20.3.

A) TRUE- Diabetes mellitus is another common indication


B) TRUE – Both are usually done for diabetic patients
C) FALSE - Survival rate exeeds 70%
D) TRUE - This is the most common indication for heart transplant
E) FALSE - Results are poor as Graft Versus Host Disease is common as a result
to high lymphoid tissue content

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20.4. Regarding reconstructive techniques

A) Random flaps can be used for adjacent areas only.


B) Maximum Length to breath ratio of an axial flap is 2:1
C) Latismus dorsai flap used for breast reconstruction is a pedicled flap.
D) US scan is valuble in assessment of silican leak.
E) Iliac creast is the preffered sit for bone grafts

20.5 Which of the following statements are correct regarding hand infections?

A) Web space infections are most painful.


B) Onychogryposis is treated with wedge resection.
C) Melon seed bodies are a result of bacterial infection
D) Tenosinovitis of a finger is a surgical emergency.
E) Incision and drainage must be done at the most fluctuant point once
established.

20.6.Which of the following statements are true regarding management of Hand


injuries?

A) Sausage shaped swelling of index finger following prick injury with severe
pain on passive extension need immediate surgery.
B) Fracture of neck of the fifth Metacarpal usually need internal fixation.
C) Surgical repair of digital nerve injury beyond Metacarpo-phalangial joint
are not useful.
D) Flexure tendon injury in no mans land should be repaired urgently by the
casualty surgeon.
E) Klinert traction is valuable after repair of long flexure tendons to fingers.

143
Answers to question 20.4.

A) FALSE- Via delaying technique or cross limb distant sites can be served.
B) False - 6:1 is achived with axial flaps
C) True – Lattisimus dorsi is also used as a free flap in other areas
D) False - MRI scan is used as US scan image is below required resolution.
E) True – This is an easily acsessible and generous site for bone graft.

Answers to question 20.5.

A) FALSE- Most painful are pulp space infections due to rich innervations and
confined space.
B) False - Onychogryposis is treated with Total Ablation of Nail bed.
C) TRUE - Melon seed bodies are calcified bodies in distended palmer bursae
resulting from Tuberculosis ,tubercular ulnar bursitis is common as
compound palmer ganglion.
D) TRUE - This needs incision and irrigation of the flexor sheath under
anesthesia in order to prevent later adhesions.
E) FALSE - In hand Infections should be drained before fluctuation manifest as
fluctuation is late due to tissue tension. Breast abscesses too should be
drained without waiting for fluctuation as fluctuation is difficult to elicit in
the soft organ.

Answers to question 20.6.

This question assess candidates knowledge about management of a common


injury which needs meticulous care in order to avoid serious permanent
disability.

A) TRUE - The diagnosis is Tenosinovits.


B) FALSE - Fracture of neck of 5th metacarpal is usually managed
conservatively with neighbor splinting, elevation and early movements.A
drop in knukle does not produce significant disability.
C) FALSE - Digital nerves are repaired with useful results if the injury is proximal
to proximal interpalangial joint. Must repair nerve include both digital
nerves of the thumb, radial digital nerve of index,ulnar digital nerve of
fourth finger due to functional reasons.
D) FALSE - This repair should be undertaken by plastic surgeon or a hand
surgeon.
144
E) TRUE - This allow extended fingers to flex passively using recoil of elastic
bands on flexor aspect.

20.7. Regarding achieving of a soft tissue cover

A) Thick skin grafts have a better take up rate than thin grafts.
B) Gastrocnemius flap is used frequently in management of compound
fracture of femur.
C) Transverse rectus abdominis flap (TRAM) can be offered at the time of
mastectomy.
D) Radial forearm flap is a pedicled flap.
E) Ilizerov technique is employed widely in tissue expansion.

20.8. Regarding immunosuppressive drugs

A) Cyclosporine interferes with the assembly of messenger RNA and DNA.


B) Azathioprine suppresses T cell production.
C) Steroids have specific suppressive effect on T cell function.
D) One of the principal complications of antibodies is acute toxicity due to
target cell lysis.
E) Immunosuppression will lead to increased incidence of tumours

20.9.Which of the following are true regarding transplantation?

A) Transplantation can be done in a patient with a history of cancer within last


5 years.
B) Chronic viral infections are not a contraindication for transplantation.
C) Major histocompatibility complex (MHC) mismatching should be zero.
D) A 75 year old can be a donor.
E) It will take 5-14 days for acute rejection.

145
Answers to question 20.7.

A) FALSE - In the early part nutrients are taken into grafts by diffusion.
Increasing thickness makes diffusion difficult.
B) FALSE - gastrocnemius is the muscle of choice for reconstruction of soft
tissue defects are upper third of tibia as well as knee joint.
C) TRUE - This is increasingly undertaken at dedicated centres and reduce
patient distress.
D) FALSE – It is a free flap and used in head and neck reconstruction.
E) FALSE – It is a type of external fixator used in orthopaedic surgery to expand
or lengthen bones.

Answers to question 20.8.

A) FALSE - Cyclosporines are fungal derivatives that suppress T cell


production of cytokines.
B) FALSE - Azathioprine Is an anti-proliferative drug which interferes with the
assembly of messenger RNA and DNA.
C) TRUE - They also has an effect on antigen presenting cell function.
D) TRUE - This increases the risk of infection and malignancy.
E) TRUE - Immunosuppression will reduce the ability to provide surveillance
and eradication of malignant cells within the body. Therefore it increases
the risk of tumours particularly in the skin and reticulo endothelial system
(Non Hodgkin's Lymphoma).

Answers to question 20.9.

A) FALSE - It should be declined because the metastatic disease can stay latent
after previous apparently curative surgery.
B) FALSE - It is a general contraindication for transplantation. The risk of
acceleration of disease should be considered carefully.
C) FALSE - Ideal is zero or one but down to three mismatches (out of six MHC
loci )are acceptable.
D) FALSE - Donor age is between 2years and 70 years.
E) TRUE - Rejection is an early immunological complication.

146
20.10. Which of the following are true/false?

A) Donar kidney should be kept at 4 0C in theatre.


B) Muscle cutting incision is used
C) Renal artery is anastomosed end to side to external ileac artery.
D) Renal vein thrombosis is a surgical complication.
E) Renal vein is anastomosed end to side to external iliac artery.

20.11. Regarding liver transplantation,

A) Chronic liver disease is a common indication for liver transplantation.


B) Upper limit of recipient's age is limited to 65 years.
C) Paediatric recipient can be transplanted with segmental grafts from adult
donors.
D) Donor can be of any age.
E) Surgical complications do not include inferior vena caval thrombosis.

20.12. Which of the following are true/false regarding artificial nutritional


support

A) Tube feeding is discontinued for 4-5 hours overnight


B) Gastric fistula persisting for 2 weeks after removal of percutaneous
endoscopic gastrostomy tube will heal spontaneously
C) Fluid overload is recognized with daily weighing of the patient
D) Peripheral parenteral nutrition is appropriate for short term feeding
E) Refeeding syndrome is characterized by hypomagnesaemia

147
Answers to question 20.10.

A) TRUE - This also involves assessment for damage, cleaning off excess fat,
and preparing renal vein and artery for rapid anastomosis
B) FALSE - External iliac vein is approached .
C) TRUE - It can also be anastomosed end to end to internal iliac artery.
D) TRUE - Other complications include bleeding, ureteric leakage and stenosis
and development of lymphocele around kidney.
E) TRUE -Transplanted kidneys are established in iliac fossa for improved
stabilization.

Answers to question 20.11.

A) TRUE- Other indications are cholestatic liver disease, inborn errors of


metabolism, some primary hepatic malignancies, hepatic venous
occlusions such as Budd-chiari syndrome, acute liver failure.
B) FALSE- recipient can be of any age.
C) TRUE- This has helped with the shortage of paediatric donors.
D) FALSE- Age is between 2-65 years.
E) FALSE- Other complications include bleeding, portal vein or hepatic vein
thrombosis, hepatic artery thrombosis, biliary leakage or stenosis ,ununion
can be expected in up to 10% of cases.

Answers to question 20.12.

A) TRUE- This is to allow gastric pH to return to normal. There is evidence that


this reduces incidence of nosocomial pneumonia and aspiration
B) FALSE - This necessitate surgical closure
C) TRUE- If daily weight gain is more than 1 kg /day indicates fluid retention
D) TRUE- It is usually accepted to 2 weeks.
E) TRUE- Severe fluid and electrolyte shifts are noted in malnourished patients
undergoing refeeding. This results in hypo phosphotaemia , hypocalcaemia
and hypomagnesaemia

148
20.13. which of the following are true/false regarding research methodology

A) Temporal relationship between disease occurrence and exposure can be


established in Prevalence studies.
B) Cohort studies are better suited to examine rare exposures.
C) Case control studies are suitable to investigate rare outcomes.
D) Prospective cohort studies are done to investigate natural history of
disease.
E) In evidence based practise level 1 evidence must be supported by
randomized controlled trials.

20.14. Regarding cardio pulmonary resuscitation

A) Unresponsive patient not having normal breathing is assumed to be in


cardiac arrest
B) The only effective treatment for ventricular fibrillation and pulseless
ventricular tachycardia is attempted defibrillation
C) The end point of successful cardio pulmonary resuscitation is return of
spontaneous circulation
D) The cardiac arrest rhythm in hospitalized patients is usually non- shockable
E) Noisy breathing need not always be considered as obstructed airway

20.15 A patient presented to a surgical clinic with radial nerve injury secondary to
fracture head of the radius. His disabilities due to this injury are

A) Innability to extend interphalangeal joints (IPJ)


B) Loss of extension at metacarpophalageal joints (MCPJ)
C) Loss of sensation over the dorsal aspect of 1st web space
D) Loss of wrist extension
E) Impaired supination

149
Answers to question 20.13.

A) FALSE- They examine data on disease and exposure at one particular time
B) TRUE - Subjects are selected by their exposure status allowing research to
collect reserach samples.
C) TRUE - Subjects are selected from the outset by their outcome status
D) TRUE - Long-term observation is done sometime spanning generations
E) TRUE - Level 1 evidence is supported by high quality multicentre or single
centre randomized control trial with adequate power or systematic
reviews.

Answers to question 20.14

A) TRUE - and this is an indication to start CPR


B) TRUE – this underlies the importance of the ease of access to defibrillators
as majority of patients having MI go into VF/pulseless VT
C) FALSE – this is survival to hospital discharge with complete neurological
recovery
D) TRUE – this is usually pulseless electrical activity or asystole
E) FALSE – it is a golden rule in resuscitation to regard noisy breathing as
obstructed breathing

Answers to question 20.15

A) FALSE - Extension at IPJ is carried out by lumbrical which are supplied by


median and ulnar nerves
B) TRUE - Lesion at this level denervates all extensor muscles of the thumb and
fingers. Therefore extension at the MCPJ is lost
C) FALSE - Sensory supply to this area is by the superficial branch of the radial
nerve.
D) FALSE - Wrist extension is not loss because the extensor carpi radialis
muscles are intact
E) FALSE - At this level supitator muscle is already innervated

.............

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