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Metabolic response to injury

Question 1: Scenario: A patient sustains a severe burn injury and is admitted to the
hospital. Over the next few days, the patient experiences an increase in body
temperature, heart rate, and oxygen consumption. What is the underlying mechanism
responsible for these metabolic changes? Answer: The metabolic changes observed
in the patient, including increased body temperature, heart rate, and oxygen
consumption, are a result of the systemic inflammatory response triggered by the burn
injury. This response leads to the release of pro-inflammatory cytokines, activation of
the sympathetic nervous system, and increased metabolic demands.

Question 2: Scenario: A patient undergoes a major surgical procedure, such as

abdominal surgery. In the postoperative period, the patient experiences muscle
wasting and weight loss despite adequate nutritional support. What is the term used
to describe this metabolic response to injury? Answer: The term used to describe the
muscle wasting and weight loss observed in the postoperative period is
"postoperative catabolism." This metabolic response is characterized by increased
protein breakdown and energy expenditure, which can contribute to muscle wasting
and negative nitrogen balance.

Question 3: Scenario: A patient is diagnosed with a severe infection, such as sepsis.

Laboratory tests reveal an elevated level of C-reactive protein (CRP). What is the role
of CRP in the metabolic response to infection? Answer: CRP is an acute-phase protein
that is synthesized in the liver in response to inflammation and infection. It plays a
crucial role in the metabolic response to infection by activating the complement
system, enhancing phagocytosis, and promoting the inflammatory cascade.

Question 4: Scenario: A patient is admitted to the emergency department with a

traumatic injury. The patient exhibits increased glycogenolysis, gluconeogenesis, and
lipolysis. What is the purpose of these metabolic changes in response to trauma?
Answer: The increased glycogenolysis, gluconeogenesis, and lipolysis observed in the
patient are part of the metabolic response to trauma aimed at providing a source of
energy for healing and tissue repair. These processes help maintain blood glucose
levels and supply substrates for energy production.

Question 5: Scenario: A patient experiences prolonged fasting due to an extended

period of nil per os (NPO) status. As a result, the patient's body enters a state of energy
conservation and metabolic adaptation. What is the primary fuel source utilized during
this fasting state? Answer: During prolonged fasting, the primary fuel source utilized
by the body is fatty acids derived from adipose tissue. As glucose reserves are

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depleted, the body shifts towards utilizing stored fats through lipolysis and
subsequent beta-oxidation to meet energy demands.

Question 1: Scenario: A patient sustains a severe burn injury involving a large portion
of their body surface area. What metabolic changes occur in response to this injury?
Answer: In response to severe burn injury, the metabolic response includes an
increase in metabolic rate, hypermetabolism, and catabolism. The body releases
stress hormones like cortisol and catecholamines, leading to increased energy
expenditure, protein breakdown, and mobilization of energy stores.

Question 2: Scenario: A patient undergoes major abdominal surgery. What hormonal

changes are expected in the immediate postoperative period? Answer: Following
major abdominal surgery, the body experiences an acute stress response, leading to
an increase in stress hormones such as cortisol, catecholamines, and glucagon.
These hormonal changes contribute to increased blood glucose levels, protein
breakdown, and lipolysis to meet the metabolic demands of healing and recovery.

Question 3: Scenario: A patient with a severe infection is admitted to the hospital. How
does the body's metabolic response differ in the presence of infection? Answer: In the
presence of infection, the body's metabolic response is characterized by an increase
in energy expenditure and the release of pro-inflammatory cytokines. This results in
an elevated metabolic rate, fever, increased protein breakdown, and increased
synthesis of acute-phase reactants such as C-reactive protein.

Question 4: Scenario: A trauma patient is admitted with multiple injuries, including

fractures and soft tissue trauma. How does the body's metabolic response differ in
the setting of trauma? Answer: In the setting of trauma, the body's metabolic response
is marked by an increase in metabolic rate, hypermetabolism, and activation of the
sympathetic nervous system. This leads to increased energy expenditure, catabolism,
and release of stress hormones, which are essential for tissue repair and wound
healing.

Question 5: Scenario: A patient undergoes a major surgical procedure, and the surgical
team utilizes anesthesia and analgesia during the operation. How do these
interventions impact the metabolic response to surgery? Answer: Anesthesia and
analgesia during surgery help to attenuate the metabolic response to surgical stress.
They reduce the release of stress hormones and inflammatory mediators, thereby
minimizing the metabolic and catabolic effects of surgery. This contributes to better
postoperative recovery and reduced risk of complications.

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Shock

Question 1: Scenario: A patient presents to the emergency department with signs of

hypotension, tachycardia, and altered mental status after a severe motor vehicle
accident. What type of shock is most likely affecting the patient? Answer: The
symptoms described are consistent with hypovolemic shock, which occurs due to
significant blood loss, such as in trauma or hemorrhage. Hypovolemic shock is
characterized by decreased circulating blood volume and subsequent inadequate
tissue perfusion.

Question 2: Scenario: A patient with a history of severe heart failure experiences

worsening shortness of breath, hypotension, and cool extremities. What type of shock
is most likely affecting the patient? Answer: The symptoms described are indicative
of cardiogenic shock, which occurs due to the inability of the heart to pump blood
effectively. In heart failure, the heart's pumping function is compromised, leading to
decreased cardiac output and inadequate tissue perfusion.

Question 3: Scenario: A patient with a known severe allergic reaction to peanuts

accidentally consumes peanuts, resulting in sudden-onset difficulty breathing,
swelling, and hypotension. What type of shock is most likely affecting the patient?
Answer: The symptoms described are consistent with anaphylactic shock, which
occurs as a severe allergic reaction. Anaphylactic shock is characterized by
widespread release of inflammatory mediators, leading to vasodilation, increased
capillary permeability, and systemic hypotension.

Question 4: Scenario: A patient presents with a high-grade fever, chills, and signs of
infection. Despite antibiotic therapy, the patient's condition worsens, and they develop
hypotension, altered mental status, and signs of organ dysfunction. What type of
shock is most likely affecting the patient? Answer: The symptoms described are
suggestive of septic shock, which occurs as a severe response to an overwhelming
infection. Septic shock is characterized by a dysregulated inflammatory response,
systemic vasodilation, and impaired tissue perfusion.

Question 5: Scenario: A patient undergoes major abdominal surgery and develops

sudden-onset hypotension, tachycardia, and oliguria in the postoperative period.
Blood tests reveal elevated levels of lactate. What type of shock is most likely
affecting the patient? Answer: The symptoms described are indicative of distributive
or septic shock, which can occur as a complication of surgery. Septic shock results
from systemic infection and is characterized by vasodilation, impaired vascular tone
regulation, and inadequate tissue perfusion.

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Question 1: Scenario: A patient is brought to the emergency department with profuse
bleeding following a motor vehicle accident. The patient appears pale, has rapid and
weak pulses, and is hypotensive. What type of shock is this patient likely experiencing?
Answer: The patient is likely experiencing hypovolemic shock. Hypovolemic shock
occurs due to a significant loss of blood or fluid, leading to decreased circulating
volume and inadequate tissue perfusion.

Question 2: Scenario: A patient with a known severe allergic reaction is brought to the
emergency department with hives, difficulty breathing, and hypotension. What type of
shock is this patient likely experiencing? Answer: The patient is likely experiencing
anaphylactic shock. Anaphylactic shock occurs due to a severe allergic reaction,
leading to the release of inflammatory mediators and causing widespread
vasodilation, increased capillary permeability, and cardiovascular collapse.

Question 3: Scenario: A patient with a history of heart failure presents with fluid
overload, dyspnea, and edema. On examination, the patient has elevated jugular
venous pressure, crackles in the lungs, and peripheral edema. What type of shock is
this patient likely experiencing? Answer: The patient is likely experiencing cardiogenic
shock. Cardiogenic shock occurs due to a severe impairment of cardiac function,
leading to inadequate cardiac output and tissue perfusion. It can result from
conditions such as myocardial infarction, severe heart failure, or arrhythmias.

Question 4: Scenario: A patient develops a severe infection that leads to systemic

inflammation and vasodilation. The patient presents with warm skin, bounding pulses,
and decreased systemic vascular resistance. What type of shock is this patient likely
experiencing? Answer: The patient is likely experiencing septic shock. Septic shock
occurs as a complication of severe infection, leading to a dysregulated immune
response, systemic inflammation, and widespread vasodilation. It is associated with
high mortality rates.

Question 5: Scenario: A patient undergoes surgery for the removal of a large tumor.
After the procedure, the patient develops signs of shock, including hypotension,
tachycardia, and cool extremities. The surgical team suspects an acute adrenal crisis.
What type of shock is this patient likely experiencing? Answer: The patient is likely
experiencing adrenal or adrenal insufficiency crisis, also known as adrenal shock. It
occurs due to the inadequate production of adrenal hormones, particularly cortisol,
leading to vascular collapse and impaired stress response.

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Blood and blood components

Question 1: Scenario: A patient undergoing major abdominal surgery experiences

significant intraoperative bleeding and requires blood transfusion. What are the
indications for blood transfusion in this scenario? Answer: The indications for blood
transfusion in this scenario include hemodynamic instability, symptomatic anemia
(e.g., signs of tissue hypoxia), or a significant drop in hemoglobin levels below a
predetermined threshold (e.g., <7 g/dL) in the presence of ongoing bleeding.

Question 2: Scenario: A patient with a bleeding disorder requires a surgical procedure.

What blood component is typically used to manage bleeding in patients with
coagulation disorders? Answer: Fresh frozen plasma (FFP) is commonly used to
manage bleeding in patients with coagulation disorders. FFP contains clotting factors
and other proteins involved in the coagulation cascade, which can help correct clotting
abnormalities.

Question 3: Scenario: A patient with end-stage renal disease requires regular

hemodialysis. What blood component is typically used to replace the lost red blood
cells during the procedure? Answer: Packed red blood cells (PRBCs) are typically used
during hemodialysis to replace the lost red blood cells. PRBCs are prepared by
removing most of the plasma from whole blood, concentrating the red blood cells.

Question 4: Scenario: A patient with a known blood group O-negative requires an

emergency blood transfusion. What blood type can be safely transfused to this patient
in an emergency situation? Answer: In an emergency situation when the patient's
blood type is unknown, O-negative blood can be safely transfused. O-negative blood
is considered the universal donor as it lacks both A and B antigens and Rh factor,
reducing the risk of immediate transfusion reactions.

Question 5: Scenario: A patient with chronic anemia requires regular blood

transfusions. What blood component can be used to replenish iron stores in these
patients? Answer: Iron sucrose or other iron preparations can be used to replenish iron
stores in patients with chronic anemia who require regular blood transfusions. Iron
supplementation helps prevent or treat iron deficiency anemia, which may develop due
to frequent blood transfusions.

Question 1: Scenario: A patient undergoing a major surgical procedure experiences

significant blood loss and requires transfusion. What are the indications for
transfusing packed red blood cells (PRBCs)? Answer: The indications for transfusing

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PRBCs include symptomatic anemia with hemoglobin levels below a certain threshold
(e.g., <7-8 g/dL) or in patients with active bleeding and hemodynamic instability.

Question 2: Scenario: A patient with a bleeding disorder requires surgical intervention.

What blood component can be administered to help control bleeding in this patient?
Answer: In patients with bleeding disorders, administration of fresh frozen plasma
(FFP) can be considered. FFP contains clotting factors and can help restore
coagulation function.

Question 3: Scenario: A patient with thrombocytopenia due to chemotherapy requires

an elective surgery. What blood component is typically administered in such cases?
Answer: Platelet transfusion is typically administered in patients with
thrombocytopenia to help increase platelet count and prevent bleeding complications.

Question 4: Scenario: A patient with liver failure develops coagulopathy. What blood
component can be administered to correct coagulation abnormalities in this patient?
Answer: In patients with coagulopathy due to liver failure, administration of fresh
frozen plasma (FFP) or specific clotting factor concentrates may be required to
correct the underlying coagulation abnormalities.

Question 5: Scenario: A patient with severe anemia requires immediate blood

transfusion. What blood component is most appropriate for rapid volume expansion
in this situation? Answer: In patients requiring rapid volume expansion, transfusion of
packed red blood cells (PRBCs) is the most appropriate blood component to restore
oxygen-carrying capacity and increase circulating volume.

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Burns

Question 1: Scenario: A patient presents to the emergency department with a

superficial burn on the anterior surface of the forearm after accidentally touching a
hot stove. How would you classify this burn? Answer: This burn is classified as a
superficial or first-degree burn, characterized by redness, pain, and minimal tissue
damage limited to the epidermis.

Question 2: Scenario: A patient sustains a burn injury that affects the entire epidermis
and part of the dermis, resulting in blisters, redness, and moderate pain. How would
you classify this burn? Answer: This burn is classified as a partial-thickness or second-
degree burn, specifically a deep partial-thickness burn, as it involves both the
epidermis and a significant portion of the dermis.

Question 3: Scenario: A patient is brought to the emergency department with

circumferential burns around the chest, impairing respiratory movements. What is the
potential complication associated with this type of burn? Answer: The potential
complication associated with circumferential burns around the chest is the
development of compartment syndrome, which can impede chest expansion and lead
to respiratory compromise.

Question 4: Scenario: A patient experiences a full-thickness or third-degree burn on

the palm of the hand. What are the characteristic features of this type of burn? Answer:
Full-thickness or third-degree burns are characterized by white or charred appearance,
coagulated vessels, and absence of sensation due to the involvement of the entire
epidermis, dermis, and often underlying structures such as nerves and blood vessels.

Question 5: Scenario: A patient sustains a burn injury involving the face, neck, and
hands. Why is this burn considered critical or potentially life-threatening? Answer:
Burns involving the face, neck, and hands are considered critical burns due to the
potential for airway compromise, as well as the functional and aesthetic importance
of these areas. Close monitoring and appropriate management are necessary to
prevent complications and optimize outcomes.

Question 1: Scenario: A 25-year-old patient is brought to the emergency department

with partial-thickness burns on both arms and the anterior chest following a chemical
spill accident. How would you classify the severity of these burns? Answer: Based on
the size and depth of the burns, these would be classified as moderate to severe
partial-thickness burns. The burns involve a significant surface area and require
immediate medical attention.

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Question 2: Scenario: A 5-year-old child sustains full-thickness burns on their face and
hands due to accidental contact with a hot stove. What is the appropriate initial
management for these burns? Answer: The initial management for full-thickness
burns includes ensuring a patent airway, administering appropriate analgesia, and
covering the burns with sterile dressings to minimize the risk of infection. The child
should be referred to a specialized burn unit for further evaluation and management.

Question 3: Scenario: A 40-year-old patient presents with superficial partial-thickness

burns on their lower limbs after a house fire incident. What is the primary goal of initial
burn management in this patient? Answer: The primary goal of initial burn
management in this patient is to relieve pain, prevent infection, and promote wound
healing. The burns should be cleaned gently, and a topical antimicrobial agent or non-
adherent dressing should be applied. Pain management and tetanus prophylaxis
should also be provided as needed.

Question 4: Scenario: A 60-year-old patient suffers from inhalation injury along with
extensive burns on their chest and upper airway following a fire accident. What is the
immediate priority in managing this patient? Answer: The immediate priority in
managing this patient is ensuring a patent airway and providing adequate
oxygenation. A thorough assessment of the airway and respiratory function should be
performed, and if necessary, the patient may require intubation and mechanical
ventilation. Early consultation with a burn specialist is crucial in these cases.

Question 5: Scenario: A 35-year-old patient with deep partial-thickness burns on their

lower limbs is admitted to the burn unit. What is the recommended approach for
wound management in these burns? Answer: In deep partial-thickness burns, the
recommended approach for wound management is typically conservative, with
regular wound care, debridement of non-viable tissue, and the use of appropriate
dressings to facilitate healing. Surgical intervention may be required if there is
evidence of infection, deepening of the burn, or poor wound healing response.

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Wound healing and wound care

Question 1: Scenario: A 55-year-old patient undergoes a surgical procedure and

develops a surgical wound. What are the three phases of wound healing, and how do
they contribute to the overall healing process? Answer: The three phases of wound
healing are the inflammatory phase, proliferative phase, and remodelling phase. The
inflammatory phase involves hemostasis, inflammation, and the recruitment of
immune cells. The proliferative phase involves granulation tissue formation,
angiogenesis, and collagen deposition. The remodelling phase involves collagen
remodelling and wound contraction, leading to scar formation.

Question 2: Scenario: A patient presents with a chronic non-healing wound on the

lower leg. What are the main factors that can impair wound healing in this patient?
Answer: Several factors can impair wound healing, including infection, poor blood
supply, malnutrition, underlying chronic diseases (e.g., diabetes, peripheral vascular
disease), medications (e.g., corticosteroids), and excessive mechanical stress on the
wound. Identifying and addressing these factors is crucial to promote healing in
chronic wounds.

Question 3: Scenario: A patient undergoes a surgical procedure and has sutures or

staples in place to close the wound. When should these sutures or staples be
removed? Answer: The timing of suture or staple removal depends on the location and
type of wound. In general, facial sutures are usually removed within 5-7 days, scalp
sutures within 7-10 days, and sutures/staples on the trunk and extremities within 10-
14 days. However, the decision should be based on the individual patient's healing
progress and the surgeon's assessment.

Question 4: Scenario: A patient has a clean surgical wound that requires dressing.
What are the key principles of wound dressing? Answer: The key principles of wound
dressing include maintaining a moist wound environment, promoting wound
cleanliness, preventing infection, protecting the wound from mechanical trauma, and
facilitating optimal wound healing. Dressings can vary depending on the type of
wound (e.g., dry, exudative) and may include non-adherent dressings, hydrogels,
foams, or antimicrobial dressings, among others.

Question 5: Scenario: A patient with a chronic wound presents with signs of wound
infection, including increased redness, swelling, warmth, and purulent discharge. What
is the appropriate management for an infected wound? Answer: The management of
an infected wound typically involves wound culture to identify the causative organism,
systemic antibiotics to target the specific infection, and wound debridement to

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remove necrotic tissue. In some cases, surgical intervention may be required to
adequately clean and treat the infected wound.

Question 1: Scenario: A 50-year-old patient undergoes an elective surgery and

develops a surgical wound infection. What are the signs and symptoms of a wound
infection? Answer: Signs and symptoms of a wound infection include increased pain,
redness, swelling, warmth, presence of pus or discharge, delayed wound healing, and
systemic symptoms such as fever and malaise.

Question 2: Scenario: A patient sustains a deep laceration on their forearm after a

sharp object accident. What is the recommended approach for wound cleaning and
irrigation? Answer: The recommended approach for wound cleaning and irrigation
involves gentle removal of any debris or foreign bodies, followed by irrigation with a
sterile saline solution or an antiseptic solution to minimize the risk of infection. It is
important to ensure adequate irrigation pressure without causing tissue damage.

Question 3: Scenario: A patient with a chronic non-healing wound on their lower

extremity is being managed in the outpatient setting. What are the key principles of
wound care for this patient? Answer: The key principles of wound care for a chronic
non-healing wound include regular wound cleaning, removal of necrotic tissue or
eschar, appropriate dressings to maintain a moist wound environment, management
of infection if present, and addressing underlying factors such as poor circulation or
metabolic conditions that may hinder wound healing.

Question 4: Scenario: A patient undergoes a surgical procedure that requires the

placement of sutures for wound closure. What factors should be considered in
selecting the appropriate suture material? Answer: Factors to consider in selecting the
appropriate suture material include the location and depth of the wound, tension on
the wound edges, desired tensile strength, potential for infection, and patient factors
such as allergies or tissue reactions. Common suture materials include absorbable
and non-absorbable options.

Question 5: Scenario: A patient with a large open abdominal wound is being managed
with negative pressure wound therapy (NPWT). How does NPWT promote wound
healing? Answer: NPWT promotes wound healing by creating a controlled negative
pressure environment that helps remove excess fluid and edema, enhances blood
flow to the wound bed, stimulates granulation tissue formation, and promotes wound
contraction. It also helps to reduce bacterial colonization and support wound closure.

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Surgical infections

Question 1: Scenario: A 60-year-old patient develops a surgical site infection following an

abdominal surgery. What are the common pathogens associated with surgical site
infections, and how are they typically managed? Answer: Common pathogens associated
with surgical site infections include Staphylococcus aureus, including methicillin-
resistant Staphylococcus aureus (MRSA), and Gram-negative bacteria such as
Escherichia coli. Management typically involves appropriate antibiotic therapy based on
culture and sensitivity results, wound debridement if necessary, and ensuring adequate
wound care and infection control measures.

Question 2: Scenario: A patient with a history of multiple abdominal surgeries is

scheduled for an elective procedure. What are the strategies to prevent surgical site
infections in high-risk patients? Answer: Strategies to prevent surgical site infections in
high-risk patients include preoperative screening and decolonization of potential
pathogenic organisms, appropriate antimicrobial prophylaxis, meticulous sterile
technique during surgery, proper wound care, and postoperative surveillance for signs of
infection.

Question 3: Scenario: A patient presents with signs of a surgical wound infection,

including erythema, warmth, and purulent discharge. What is the recommended approach
for diagnosing a surgical site infection? Answer: The recommended approach for
diagnosing a surgical site infection includes a thorough clinical assessment of the
wound, analysis of wound swabs or tissue cultures if indicated, and consideration of
other supporting laboratory investigations such as complete blood count and
inflammatory markers.

Question 4: Scenario: A patient develops a deep-seated surgical site infection with

involvement of surrounding structures. What is the management approach for this
patient? Answer: Management of a deep-seated surgical site infection may involve
surgical intervention such as drainage of abscesses, debridement of infected tissues, and
possibly removal of any implanted devices or foreign bodies. Appropriate antibiotic
therapy should be initiated based on culture and sensitivity results.

Question 5: Scenario: A patient is scheduled for a clean-contaminated surgery. What are

the recommended measures to reduce the risk of surgical site infections in this setting?
Answer: Recommended measures to reduce the risk of surgical site infections in clean-

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contaminated surgeries include proper preoperative preparation, administration of
appropriate antimicrobial prophylaxis, maintaining strict sterile technique during the
procedure, and implementing infection control practices such as proper hand hygiene
and environmental cleanliness.

Question 1: Scenario: A patient undergoes an appendectomy and subsequently develops

a surgical site infection. What are the common causative organisms for surgical site
infections? Answer: Common causative organisms for surgical site infections include
Staphylococcus aureus, including methicillin-resistant Staphylococcus aureus (MRSA),
and gram-negative bacteria such as Escherichia coli, Klebsiella pneumoniae, and
Pseudomonas aeruginosa.

Question 2: Scenario: A patient with a known penicillin allergy requires surgical

prophylaxis. What alternative antibiotics can be used in this patient? Answer: In patients
with a penicillin allergy, alternative antibiotics for surgical prophylaxis may include
cephalosporins (e.g., cefazolin or cefuroxime) or clindamycin, depending on the severity
of the allergy. It is important to consult with an infectious disease specialist or follow
institutional guidelines for appropriate antibiotic selection.

Question 3: Scenario: A patient develops a surgical site infection postoperatively, and

wound cultures reveal the presence of methicillin-resistant Staphylococcus aureus
(MRSA). What is the recommended treatment for this infection? Answer: The
recommended treatment for surgical site infections caused by MRSA includes
appropriate antibiotic therapy, often with agents such as vancomycin or linezolid.
Surgical debridement and drainage of the infected wound may also be necessary.

Question 4: Scenario: A patient with a deep surgical wound infection is not responding to
antibiotic therapy. What additional interventions may be considered in the management
of this infection? Answer: In cases of deep surgical wound infections that are not
responding to antibiotic therapy alone, additional interventions may include surgical
debridement of necrotic tissue, drainage of abscesses, or placement of wound vacuums
or negative pressure wound therapy (NPWT) to promote wound healing.

Question 5: Scenario: A patient develops a postoperative intra-abdominal abscess. What

are the common symptoms associated with this condition? Answer: Common symptoms
associated with postoperative intra-abdominal abscess include fever, localized
abdominal pain, abdominal distension, tenderness, and sometimes signs of systemic
infection such as elevated white blood cell count and sepsis.

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Surgical Audit and Research
Question 1: Scenario: A surgical department in a hospital wants to assess the outcomes
of a specific surgical procedure. What is the purpose of conducting a surgical audit?
Answer: The purpose of conducting a surgical audit is to evaluate and improve the quality
of surgical care provided by assessing surgical outcomes, identifying areas for
improvement, and implementing changes to optimize patient outcomes and safety.

Question 2: Scenario: A surgeon wants to conduct research to evaluate the efficacy of a

new surgical technique. What are the key steps involved in designing a research study in
surgery? Answer: The key steps involved in designing a research study in surgery include
formulating a research question, designing a study protocol, obtaining necessary ethical
approvals, collecting and analyzing data, and interpreting the findings. It is essential to
follow ethical guidelines and adhere to scientific principles during the research process.

Question 3: Scenario: A surgical department wants to evaluate the impact of a new

surgical intervention on patient outcomes. What are the commonly used outcome
measures in surgical research? Answer: Commonly used outcome measures in surgical
research include perioperative complications, mortality rates, length of hospital stay,
functional outcomes, quality of life assessments, and patient satisfaction measures.
These outcome measures help assess the effectiveness and safety of surgical
interventions.

Question 4: Scenario: A surgical audit reveals a high rate of surgical site infections in a
particular surgical unit. What steps should be taken to address this issue? Answer: Steps
to address a high rate of surgical site infections may include identifying contributing
factors, implementing evidence-based infection prevention strategies, improving surgical
techniques, optimizing perioperative antibiotic prophylaxis, educating healthcare
providers, and monitoring infection rates to assess the impact of interventions.

Question 5: Scenario: A surgical team wants to disseminate their research findings in a

scientific conference. What are the important elements of presenting surgical research
in a conference? Answer: When presenting surgical research in a conference, important
elements include a clear and concise introduction, methods used, results obtained, and a
discussion of the implications and limitations of the study. Visual aids such as charts,
graphs, and images can enhance the presentation. It is also essential to engage in
discussions and address questions from the audience.

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Question 1: Scenario: A hospital wants to evaluate the outcomes of laparoscopic
cholecystectomy procedures performed over the past year. What parameters should be
considered in a surgical audit for laparoscopic cholecystectomy? Answer: In a surgical
audit for laparoscopic cholecystectomy, parameters to consider may include
perioperative complications, conversion rate to open cholecystectomy, length of hospital
stay, postoperative pain scores, bile duct injury rates, and patient satisfaction with the
procedure.

Question 2: Scenario: A surgeon is interested in studying the long-term outcomes of a

new surgical technique for hernia repair. What are the steps involved in conducting a
research study in surgical practice? Answer: The steps involved in conducting a research
study in surgical practice include formulating a research question, designing a study
protocol, obtaining ethical approval, collecting and analyzing data, interpreting the results,
and disseminating the findings through publication or presentation.

Question 3: Scenario: A surgical department wants to assess the compliance of its

surgeons with best practice guidelines for antibiotic prophylaxis in elective surgeries.
How can a surgical audit be conducted to evaluate this aspect? Answer: In a surgical
audit for antibiotic prophylaxis compliance, the medical records of patients who
underwent elective surgeries can be reviewed to assess whether appropriate antibiotics
were administered preoperatively, intraoperatively, and postoperatively according to
established guidelines. The audit can also evaluate the timing and duration of antibiotic
therapy.

Question 4: Scenario: A surgeon is planning a retrospective study to assess the risk

factors associated with postoperative wound infections. What data sources can be used
to collect relevant information for the study? Answer: Data sources that can be used to
collect relevant information for a study on postoperative wound infections include patient
medical records, surgical registries, infection control databases, and electronic health
records. These sources can provide information on patient demographics, surgical
details, preoperative risk factors, and postoperative outcomes.

Question 5: Scenario: A surgical department aims to evaluate the impact of a new surgical
pathway on the length of hospital stay for patients undergoing colorectal surgeries. What
statistical analysis can be used to compare the data before and after the implementation
of the new pathway? Answer: To compare the data before and after the implementation
of a new surgical pathway, statistical analysis such as paired t-tests or Wilcoxon signed-
rank tests can be used to assess the significance of differences in the length of hospital

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stay. Other statistical methods such as regression analysis or chi-square tests may also
be employed depending on the specific research objectives.

15
Ethics

Question 1: Scenario: A surgeon is facing a dilemma in obtaining informed consent from

a patient who requires emergency surgery but is unable to provide consent due to their
critical condition. What should the surgeon do in this situation? Answer: In emergency
situations where obtaining informed consent is not possible, the principle of implied
consent and the concept of acting in the best interest of the patient come into play. The
surgeon should make every effort to communicate with the patient's family or next of kin,
provide them with all necessary information about the procedure, risks, and potential
outcomes, and obtain their consent as a surrogate decision-maker.

Question 2: Scenario: A surgeon is asked to perform a surgical procedure that goes

against their personal beliefs or values. How should the surgeon handle this situation?
Answer: Surgeons have the right to exercise conscientious objection, meaning they can
refuse to perform procedures that go against their personal beliefs or values. However, it
is essential for the surgeon to communicate their objection respectfully and promptly to
the patient, providing appropriate information about alternative options and ensuring that
the patient's care is not compromised by arranging for alternative care providers.

Question 3: Scenario: A surgeon suspects that a colleague is involved in unethical

practices, such as performing unnecessary surgeries for financial gain. What should the
surgeon do in this situation? Answer: It is the ethical responsibility of the surgeon to
report suspicions of unethical practices to the appropriate authorities or governing
bodies, such as the hospital administration or medical regulatory board. Whistleblowing
should be done in a responsible manner, ensuring patient confidentiality and following
the established reporting protocols to address concerns about professional conduct.

Question 4: Scenario: A surgeon is facing challenges in balancing the need for patient
care with limited healthcare resources, such as a shortage of beds or surgical equipment.
How should the surgeon make decisions in such resource-constrained situations?
Answer: In resource-constrained situations, surgeons should adhere to the principles of
distributive justice and fairness. Decisions should be based on objective criteria such as
urgency, severity of illness, potential for successful outcome, and equitable distribution
of resources among patients. Ethical frameworks such as triage systems can be used to
guide decision-making in resource allocation.

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Question 5: Scenario: A surgeon is asked to participate in a clinical research study
involving human subjects. What ethical considerations should the surgeon keep in mind
before agreeing to participate? Answer: Before participating in a clinical research study,
the surgeon should ensure that the study has obtained ethical approval from the
appropriate research ethics committee. Informed consent should be obtained from the
participants, ensuring they are adequately informed about the study, its purpose, potential
risks and benefits, and their rights. The surgeon should prioritize patient safety, privacy,
and confidentiality throughout the study.

Question 1: Scenario: A patient presents to the emergency department with a life-

threatening condition requiring immediate surgical intervention. The patient's family is
not available to provide consent, and there is no advanced directive or legal
representative appointed. What should the surgeon do in this situation? Answer: In
emergency situations where obtaining informed consent is not possible, the surgeon has
a duty to act in the best interest of the patient and provide necessary treatment to
preserve life. This is based on the principle of implied consent in emergency situations.
However, it is essential to document the rationale for the intervention and consult with
the hospital's ethics committee if available.

Question 2: Scenario: A surgeon discovers an unexpected finding during a surgical

procedure that was not initially planned. The finding is unrelated to the primary surgical
indication but requires immediate attention. What ethical principles should guide the
surgeon's decision-making in this situation? Answer: The ethical principles that should
guide the surgeon's decision-making include beneficence (acting in the patient's best
interest), autonomy (respecting the patient's right to make decisions about their own
health), and informed consent. The surgeon should communicate with the patient or their
legal representative, explain the situation, and obtain consent for the additional procedure
if possible.

Question 3: Scenario: A surgeon is approached by a pharmaceutical company offering a

significant financial incentive to promote a particular surgical product. What ethical
considerations should the surgeon take into account when deciding whether to accept
the offer? Answer: The surgeon should consider ethical principles such as integrity,
conflict of interest, and patient well-being. Accepting financial incentives from a
pharmaceutical company may create a conflict of interest that can compromise the
surgeon's judgment and independence. The surgeon should prioritize patient welfare,
maintain professional integrity, and adhere to institutional guidelines regarding industry
interactions.

17
Question 4: Scenario: A surgeon is asked to perform a surgical procedure on a minor
without the consent of the parents or legal guardian. What are the ethical considerations
in this situation? Answer: Performing a surgical procedure on a minor without parental or
legal guardian consent raises ethical concerns related to autonomy, beneficence, and
consent. It is important to involve the parents or legal guardian in the decision-making
process, explain the risks and benefits of the procedure, and obtain their informed
consent. In exceptional cases where immediate intervention is required to save the
minor's life, the principle of implied consent in emergencies may apply.

Question 5: Scenario: A surgeon has completed a successful surgical procedure and is

approached by a journalist for an interview. The journalist requests detailed patient
information for a news article. What ethical principles should the surgeon consider in
responding to the journalist's request? Answer: The surgeon should uphold patient
confidentiality and privacy, respecting the principles of confidentiality and non-
maleficence. Patient information should not be disclosed without proper consent or
unless required by law. The surgeon can provide general information about the surgical
procedure and its outcomes while maintaining patient anonymity and confidentiality.

18
Investigation of the surgical patient

Question 1: Scenario: A patient presents with symptoms suggestive of acute

appendicitis. What are the key investigations that should be performed to confirm the
diagnosis? Answer: Key investigations to confirm the diagnosis of acute appendicitis
include a complete blood count (CBC) to assess for leukocytosis, C-reactive protein (CRP)
level to indicate inflammation, and an abdominal ultrasound or computed tomography
(CT) scan to visualize the inflamed appendix and assess for complications.

Question 2: Scenario: A patient with suspected peptic ulcer disease is being evaluated.
What are the appropriate investigations to assess for the presence of Helicobacter pylori
infection? Answer: The appropriate investigations to assess for the presence of
Helicobacter pylori infection in peptic ulcer disease include a urea breath test, stool
antigen test, or serological testing for H. pylori-specific antibodies. Upper gastrointestinal
endoscopy with biopsy for histopathological examination can also be performed.

Question 3: Scenario: A patient presents with clinical features of acute cholecystitis. What
investigations are necessary to confirm the diagnosis and assess for complications?
Answer: Investigations necessary to confirm the diagnosis of acute cholecystitis and
assess for complications include a complete blood count (CBC) to check for leukocytosis
and inflammation, liver function tests (LFTs) to evaluate liver enzymes and bilirubin
levels, and an abdominal ultrasound to visualize the gallbladder and assess for
gallstones, gallbladder wall thickening, or complications such as pericholecystic fluid or
gallbladder distension.

Question 4: Scenario: A patient with suspected colorectal cancer requires staging

investigations. What investigations are commonly performed for the staging of colorectal
cancer? Answer: Common investigations performed for the staging of colorectal cancer
include imaging studies such as computed tomography (CT) scan of the abdomen and
pelvis, magnetic resonance imaging (MRI) of the pelvis, chest X-ray or chest CT scan, and
colonoscopy or flexible sigmoidoscopy with biopsy to confirm the diagnosis and assess
the extent of tumor involvement.

Question 5: Scenario: A patient presents with symptoms of lower urinary tract

obstruction. What investigations should be carried out to evaluate the condition? Answer:
Investigations to evaluate lower urinary tract obstruction may include a urinary flow rate
assessment, measurement of post-void residual urine volume, renal function tests (e.g.,

19
serum creatinine), and imaging studies such as ultrasound or urodynamic studies to
assess bladder function and determine the underlying cause of the obstruction.

Question 1: Scenario: A patient presents with right upper quadrant abdominal pain,
jaundice, and elevated liver enzymes. What are the appropriate investigations to
determine the cause of these symptoms? Answer: The appropriate investigations for this
patient may include liver function tests (LFTs) to assess liver enzymes, bilirubin levels,
and coagulation profile. Imaging studies such as ultrasound or computed tomography
(CT) scan can help evaluate the biliary system, liver, and surrounding structures.
Additional tests, such as viral hepatitis serology or autoimmune markers, may be ordered
based on clinical suspicion.

Question 2: Scenario: A patient presents with rectal bleeding and iron-deficiency anemia.
What investigations would you consider to evaluate the cause of the bleeding? Answer:
In this patient, investigations to evaluate the cause of rectal bleeding may include a
colonoscopy or sigmoidoscopy to visualize the rectum and colon, identify any bleeding
sources, and obtain biopsies if necessary. Blood tests, including a complete blood count
(CBC) and fecal occult blood test (FOBT), may also be ordered to assess the extent of
anemia and identify any hidden blood in the stool.

Question 3: Scenario: A patient with recurrent episodes of cholangitis and biliary colic is
suspected to have choledocholithiasis. What investigations can confirm this diagnosis?
Answer: Investigations to confirm the diagnosis of choledocholithiasis may include an
abdominal ultrasound to visualize the biliary tree and identify any stones. Additionally,
magnetic resonance cholangiopancreatography (MRCP) or endoscopic retrograde
cholangiopancreatography (ERCP) may be performed to assess the biliary anatomy and
remove any stones present in the common bile duct.

Question 4: Scenario: A patient presents with acute appendicitis. What investigations are
typically performed to aid in the diagnosis? Answer: In cases of suspected acute
appendicitis, investigations may include a complete blood count (CBC) to assess for an
elevated white blood cell count, C-reactive protein (CRP) levels, and imaging studies such
as ultrasound or computed tomography (CT) scan of the abdomen. These investigations
can help visualize the appendix and surrounding structures, evaluate for signs of
inflammation, and guide the decision for surgical intervention.

Question 5: Scenario: A patient with lower gastrointestinal bleeding is suspected to have

diverticulosis. What investigations can help confirm the diagnosis and assess the extent
of the condition? Answer: Investigations to confirm the diagnosis of diverticulosis and

20
assess its extent may include colonoscopy, which allows direct visualization of the colon
and identification of diverticula. Other investigations such as a barium enema or CT
colonography may also be considered to evaluate the colon and identify any
complications such as diverticulitis or diverticular bleeding.

21
Pre, intra and post-operative management.

Question 1: Scenario: A patient is scheduled for an elective laparoscopic

cholecystectomy. What are the essential pre-operative management steps for this
patient? Answer: The essential pre-operative management steps for a patient undergoing
laparoscopic cholecystectomy include obtaining informed consent, assessing the
patient's fitness for surgery through a pre-operative evaluation, ensuring appropriate
fasting, and discontinuing medications that may interfere with the surgery or anesthesia.
Pre-operative investigations such as blood tests, electrocardiogram (ECG), and imaging
studies may be performed based on the patient's medical history and surgical indication.

Question 2: Scenario: During an intra-operative procedure, the surgeon encounters

unexpected bleeding. What steps should be taken to manage this intra-operative
complication? Answer: In the event of unexpected bleeding during surgery, the surgeon
should take immediate steps to control the bleeding. This may include applying direct
pressure, using hemostatic agents or cautery, ligating or suturing blood vessels, and
considering the need for blood transfusion. The surgical team should communicate
effectively, remain calm, and work together to achieve hemostasis while ensuring the
patient's safety.

Question 3: Scenario: A patient has undergone a major abdominal surgery and is now in
the post-operative period. What are the key aspects of post-operative management for
this patient? Answer: Key aspects of post-operative management include monitoring vital
signs, assessing pain levels, ensuring adequate pain relief, monitoring fluid and
electrolyte balance, promoting early mobilization, and preventing complications such as
deep vein thrombosis (DVT) and pneumonia. Post-operative care also involves wound
care, administering medications as prescribed (including antibiotics and prophylactic
anticoagulants), and providing appropriate nutritional support.

Question 4: Scenario: A patient has undergone a thyroidectomy and is now in the recovery
room. What specific post-operative considerations are important for this patient?
Answer: Specific post-operative considerations for a patient who has undergone a
thyroidectomy include monitoring for signs of hypocalcemia due to potential damage to
the parathyroid glands during surgery. Calcium levels should be monitored, and calcium
supplementation may be necessary. Additionally, close monitoring of airway function,
wound healing, and early detection of complications such as hematoma or recurrent
laryngeal nerve injury are crucial in the post-operative period.

22
Question 5: Scenario: A patient with a history of peptic ulcer disease has been scheduled
for an elective laparoscopic fundoplication. What pre-operative measures should be
taken to minimize the risk of aspiration during surgery? Answer: To minimize the risk of
aspiration during surgery, pre-operative measures should include adequate fasting to
ensure an empty stomach. The patient should be instructed to fast for a specific period
before surgery, usually six to eight hours for solid foods and two hours for clear liquids.
Pre-operative administration of medications such as antacids or proton pump inhibitors
may also be considered to reduce gastric acidity and minimize the risk of aspiration.

Question 1: Scenario: A patient is scheduled for elective appendectomy. What are the
important pre-operative considerations and management steps for this patient? Answer:
Pre-operative considerations for the patient scheduled for elective appendectomy include
obtaining informed consent, assessing the patient's medical history and comorbidities,
performing relevant investigations (e.g., complete blood count, coagulation profile),
ensuring adequate fasting, and providing pre-operative instructions. Intraoperatively,
appropriate anesthesia should be administered, and surgical asepsis should be
maintained. Post-operatively, pain management, monitoring for complications (e.g.,
infection, bleeding), and early ambulation are crucial.

Question 2: Scenario: A patient with a diagnosed liver tumor is scheduled for

hepatectomy. What are the key aspects of intra-operative management for this patient?
Answer: Intra-operative management for a patient undergoing hepatectomy includes
ensuring proper positioning, administering appropriate anesthesia, and closely
monitoring vital signs. Hemodynamic stability should be maintained, and meticulous
surgical technique should be employed to minimize blood loss and ensure adequate
hemostasis. Careful handling of the liver and adherence to aseptic techniques are
essential. Intraoperative imaging techniques, such as intraoperative ultrasound, may be
used to guide the procedure.

Question 3: Scenario: A patient has undergone a laparoscopic cholecystectomy for

symptomatic gallstones. What are the important post-operative management steps for
this patient? Answer: Post-operative management after a laparoscopic cholecystectomy
includes monitoring vital signs, pain management, assessing for complications (e.g.,
infection, bleeding), and ensuring early ambulation. The patient should be encouraged to
resume oral intake and receive appropriate post-operative instructions. Discharge
planning and patient education regarding wound care, activity restrictions, and signs of
potential complications are crucial aspects of post-operative management.

23
Question 4: Scenario: A patient is undergoing emergency exploratory laparotomy for a
suspected abdominal injury. What are the key aspects of intra-operative management in
this emergency situation? Answer: Intra-operative management in emergency exploratory
laparotomy involves rapid assessment and stabilization of the patient's vital signs,
administration of appropriate anesthesia, and prompt identification and control of any
life-threatening bleeding or injuries encountered. Close communication and coordination
between the surgical team, anesthesiologist, and nursing staff are essential to optimize
patient outcomes in this time-sensitive situation.

Question 5: Scenario: A patient is scheduled for a breast lumpectomy under local

anesthesia. What are the important pre, intra, and post-operative management
considerations for this patient? Answer: Pre-operative considerations for a patient
undergoing a breast lumpectomy under local anesthesia include obtaining informed
consent, ensuring proper patient positioning, and providing appropriate pre-operative
instructions (e.g., fasting guidelines). Intra-operatively, sterile techniques should be
followed, and local anesthesia should be administered with meticulous attention to
patient comfort. Post-operatively, wound care, pain management, and monitoring for
signs of infection or hematoma are essential, along with patient education regarding self-
care and follow-up appointments.

24
 Anaesthesia and pain management

Question 1: Scenario: A patient is scheduled for an open cholecystectomy. What type of

anesthesia is commonly used for this procedure, and what are the important
considerations in perioperative pain management? Answer: General anesthesia is
commonly used for an open cholecystectomy. Perioperative pain management
considerations include pre-operative administration of analgesics, intra-operative
administration of appropriate analgesics and anesthetic agents, and post-operative pain
control through the use of multimodal analgesia techniques. Non-opioid analgesics, such
as NSAIDs or acetaminophen, may be used alongside opioids to minimize opioid
consumption and reduce side effects.

Question 2: Scenario: A patient is undergoing a minor skin excision procedure in the

outpatient clinic. What type of anesthesia is typically used for such procedures, and what
are the advantages? Answer: Local anesthesia with or without the use of topical
anesthetics is commonly used for minor skin excision procedures in the outpatient
setting. Advantages of local anesthesia include avoidance of systemic side effects
associated with general anesthesia, improved patient comfort, and the ability to perform
the procedure on an outpatient basis without the need for hospitalization.

Question 3: Scenario: A patient with multiple fractures due to a motor vehicle accident
requires surgical fixation. What type of anesthesia is typically used in orthopedic
surgeries, and how is post-operative pain managed? Answer: Regional anesthesia, such
as spinal or epidural anesthesia, is commonly used in orthopedic surgeries. Regional
anesthesia provides effective pain control during and after the procedure and reduces
the need for systemic opioids. Post-operative pain management may involve a
combination of oral or intravenous analgesics, regional analgesia techniques (e.g.,
epidural analgesia), and non-pharmacological measures such as physical therapy and
patient-controlled analgesia (PCA).

Question 4: Scenario: A patient is scheduled for a laparoscopic appendectomy. What type

of anesthesia is typically used for this procedure, and how is post-operative pain
managed? Answer: General anesthesia with endotracheal intubation is commonly used
for laparoscopic appendectomy. Post-operative pain management may involve a
combination of analgesic medications, including opioids, non-opioid analgesics, and
local anesthetic techniques such as infiltration or intraperitoneal local anesthesia. The

25
use of minimally invasive techniques in laparoscopy often leads to reduced post-
operative pain compared to open surgeries.

Question 5: Scenario: A patient is undergoing a major abdominal surgery that is expected

to be associated with significant post-operative pain. What are the considerations for
post-operative pain management in this case? Answer: In cases of major abdominal
surgery with expected significant post-operative pain, a multimodal approach to pain
management is commonly employed. This includes a combination of analgesic
medications such as opioids, non-opioid analgesics, and regional anesthesia techniques
(e.g., epidural analgesia or transversus abdominis plane block) to provide effective pain
control. Non-pharmacological measures such as early ambulation, deep breathing
exercises, and patient education on pain management techniques may also be
incorporated.

Question 1: Scenario: A patient is scheduled for open hernia repair surgery. What are the
different types of anesthesia that can be used for this procedure, and what are their
advantages and disadvantages? Answer: The different types of anesthesia that can be
used for open hernia repair surgery include general anesthesia, regional anesthesia (such
as spinal or epidural anesthesia), and local anesthesia. General anesthesia provides
complete unconsciousness and muscle relaxation, allowing for optimal surgical
conditions. Regional anesthesia provides anesthesia to a specific region of the body
while the patient remains conscious. Local anesthesia numbs a small area and is typically
used for minor procedures. The choice of anesthesia depends on the patient's overall
health, surgical requirements, and the surgeon's preference.

Question 2: Scenario: A patient is scheduled for a laparoscopic cholecystectomy. What

are the advantages of using pneumoperitoneum during this procedure, and how is pain
managed post-operatively? Answer: Pneumoperitoneum, the insufflation of carbon
dioxide into the abdominal cavity during laparoscopic cholecystectomy, provides a clear
operating field, allowing for improved visualization and surgical precision. Post-
operatively, pain is managed through a multimodal approach, which may include the
administration of intravenous or oral analgesics, local anesthetic infiltration at port sites,
and non-pharmacological methods such as deep breathing exercises. Early ambulation
and appropriate use of analgesics help minimize post-operative pain.

Question 3: Scenario: A patient is scheduled for a major abdominal surgery. What are the
considerations for anesthesia in patients with comorbidities such as diabetes or
hypertension? Answer: Patients with comorbidities require careful pre-operative
evaluation and optimization of their medical conditions. In patients with diabetes, blood

26
glucose levels should be well-controlled before surgery, and insulin or oral hypoglycemic
medications may need adjustment perioperatively. In patients with hypertension, blood
pressure should be adequately managed, and antihypertensive medications may need to
be continued or modified. Anesthesiologists closely monitor vital signs, maintain
hemodynamic stability, and ensure appropriate pain management throughout the
perioperative period.

Question 4: Scenario: A patient is scheduled for a breast reconstruction surgery following

mastectomy. What are the different techniques for post-operative pain management in
this procedure? Answer: Post-operative pain management in breast reconstruction
surgery can include a combination of analgesic medications such as opioids,
nonsteroidal anti-inflammatory drugs (NSAIDs), and local anesthetic techniques such as
regional nerve blocks or the use of long-acting local anesthetics. Non-pharmacological
methods such as cold packs, relaxation techniques, and patient education regarding pain
expectations and management are also important components of pain management.

Question 5: Scenario: A patient is scheduled for an emergency appendectomy. What are

the considerations for anesthesia in this urgent surgical procedure? Answer: In
emergency appendectomy, prompt action is necessary. Anesthesia is typically induced
using intravenous medications, and endotracheal intubation is performed for airway
management. Careful monitoring of vital signs, maintenance of hemodynamic stability,
and effective post-operative pain management are crucial. In this scenario, the
anesthesiologist must work efficiently to ensure patient safety while rapidly preparing the
patient for surgery.

27
Nutrition and fluid therapy
Question 1: Scenario: A patient has undergone major abdominal surgery and is in the
post-operative period. What are the important considerations for providing nutritional
support in this patient? Answer: In the post-operative period, providing adequate
nutritional support is essential for wound healing and recovery. Considerations include
assessing the patient's nutritional status, monitoring intake and output, and evaluating
any specific dietary restrictions or requirements. Initially, oral intake may be limited, and
intravenous fluids may be administered. As the patient progresses, a gradual transition
to oral intake is made, incorporating a balanced diet with appropriate calories, protein,
vitamins, and minerals to promote healing and prevent complications.

Question 2: Scenario: A patient with a gastrointestinal malignancy is undergoing

chemotherapy and radiation therapy. What are the nutritional challenges faced by this
patient, and how can they be addressed? Answer: Patients undergoing chemotherapy and
radiation therapy for gastrointestinal malignancies often experience side effects such as
nausea, vomiting, and difficulty swallowing, leading to decreased appetite and weight
loss. Nutritional challenges include maintaining adequate calorie and protein intake
despite these difficulties. Strategies to address these challenges may include small,
frequent meals, the use of anti-emetic medications, modifications to the texture and
consistency of food, and the involvement of a registered dietitian for personalized
nutritional counseling and supplementation if necessary.

Question 3: Scenario: A patient with severe sepsis is admitted to the surgical intensive
care unit (ICU). What are the goals and considerations for fluid therapy in this patient?
Answer: In a patient with severe sepsis, fluid therapy aims to restore intravascular
volume, maintain tissue perfusion, and correct any electrolyte imbalances. Fluid
resuscitation is typically initiated with crystalloids such as normal saline or balanced
solutions. The response to fluid therapy is closely monitored, and adjustments are made
based on the patient's hemodynamic parameters. Careful attention is given to avoid fluid
overload or pulmonary edema. In some cases, vasopressor medications may be
necessary to support blood pressure and perfusion.

Question 4: Scenario: A patient with a pancreatic injury has undergone surgery and is in
the recovery phase. What are the considerations for enteral nutrition in this patient?
Answer: Enteral nutrition refers to the delivery of nutrients via the gastrointestinal tract.
In a patient with a pancreatic injury, considerations for enteral nutrition include assessing
the function of the gastrointestinal tract, evaluating any anatomic or functional
limitations, and determining the appropriate timing and route of enteral feeding. In some

28
cases, a nasojejunal or gastrojejunal feeding tube may be placed to bypass the
duodenum and ensure optimal nutrient absorption while allowing the pancreas time to
heal.

Question 5: Scenario: A patient with a chronic wound is being managed in the outpatient
setting. What are the nutritional factors that influence wound healing, and how can they
be addressed? Answer: Nutritional factors that influence wound healing include adequate
calorie and protein intake, as well as the intake of specific vitamins and minerals such as
vitamin C, vitamin A, zinc, and iron. In the outpatient setting, a comprehensive nutritional
assessment is performed to identify any deficiencies or malnutrition. Dietary
modifications and supplementation may be recommended to address these deficiencies
and promote optimal wound healing. Additionally, addressing any underlying conditions
such as diabetes or vascular insufficiency is crucial for successful wound healing.

Question 1: Scenario: A patient with severe abdominal trauma is admitted to the

emergency department. What are the key considerations for fluid resuscitation in this
patient? Answer: In a patient with severe abdominal trauma, early fluid resuscitation is
crucial. The initial fluid resuscitation should focus on restoring circulating volume and
maintaining tissue perfusion. Crystalloid solutions such as lactated Ringer's solution or
normal saline are commonly used. The amount and rate of fluid administration depend
on the patient's hemodynamic status, ongoing bleeding, and response to initial
resuscitation. Close monitoring of vital signs, urine output, and laboratory parameters is
essential to guide further fluid therapy.

Question 2: Scenario: A patient with bowel obstruction is scheduled for surgery. What are
the considerations for pre-operative nutritional support in this patient? Answer: Pre-
operative nutritional support is important in patients with bowel obstruction to optimize
their nutritional status and reduce the risk of complications. In some cases, enteral
nutrition may be initiated using a nasogastric or nasoenteric tube to provide adequate
calories, protein, and fluids. However, in cases of complete bowel obstruction, parenteral
nutrition may be required. Close collaboration between the surgical team, nutritionist, and
other healthcare professionals is essential to determine the most appropriate nutritional
support strategy for each patient.

Question 3: Scenario: A patient has undergone major abdominal surgery. What are the
key aspects of post-operative nutrition and fluid therapy for this patient? Answer: Post-
operative nutrition and fluid therapy aim to promote healing, support the patient's
metabolic needs, and prevent complications. Early oral intake is encouraged as tolerated,
starting with clear fluids and gradually advancing to a regular diet. In some cases, enteral

29
nutrition via a feeding tube may be necessary. Fluid therapy is tailored to maintain
hydration, electrolyte balance, and appropriate intravascular volume. Regular monitoring
of nutritional status, fluid balance, and laboratory parameters is important to guide
adjustments in therapy.

Question 4: Scenario: A patient with a severe burn injury is admitted to the burn unit. What
are the specific considerations for nutritional support in burn patients? Answer: Burn
patients have increased nutritional requirements due to the metabolic stress associated
with the injury. Adequate protein intake is crucial for wound healing and prevention of
muscle wasting. Caloric requirements are often increased to meet the heightened
metabolic demands. Enteral nutrition via a feeding tube is typically preferred, but in cases
of extensive burns or gastrointestinal dysfunction, parenteral nutrition may be necessary.
Regular assessment of nutritional status, wound healing, and response to therapy is
essential.

Question 5: Scenario: A patient with gastrointestinal malignancy is undergoing

chemotherapy. What are the nutritional considerations during chemotherapy treatment?
Answer: Chemotherapy can have various gastrointestinal side effects, such as nausea,
vomiting, and decreased appetite. Maintaining adequate nutrition during chemotherapy
is important to support the patient's immune function and prevent malnutrition.
Strategies to manage chemotherapy-induced nausea and vomiting, such as antiemetic
medications and dietary modifications, may be employed. In some cases, nutritional
supplements or oral nutritional support may be recommended to ensure the patient
receives adequate calories and nutrients during treatment.

30
Transplantation

Question 1: Scenario: A patient with end-stage renal disease is scheduled for a kidney
transplant. What are the key considerations in the evaluation and selection of a potential
kidney donor? Answer: In the evaluation and selection of a potential kidney donor, several
factors need to be considered. These include ABO blood type compatibility, HLA
matching, donor-recipient age and size compatibility, absence of donor-specific
antibodies, absence of transmissible infections, absence of significant medical
comorbidities in the donor, and thorough assessment of the donor's renal function and
anatomy. The goal is to ensure the best possible match and minimize the risk of graft
rejection or complications.

Question 2: Scenario: A patient has received a liver transplant. What are the key aspects
of post-operative care and immunosuppression in liver transplantation? Answer: Post-
operative care in liver transplantation involves close monitoring of liver function, fluid
balance, wound healing, and management of potential complications such as rejection
or infection. Immunosuppressive medications are essential to prevent graft rejection.
These medications may include calcineurin inhibitors, corticosteroids, and
antimetabolites. Close monitoring of drug levels, regular follow-up, and collaboration with
the transplant team are crucial to optimize graft function and minimize complications.

Question 3: Scenario: A patient is awaiting a heart transplant. What are the considerations
in the allocation and matching of donor hearts? Answer: The allocation and matching of
donor hearts for transplantation are guided by specific criteria, including blood type
compatibility, body size compatibility, urgency of the recipient's condition, and the
availability of suitable donor organs. The transplant center follows established protocols
and organ allocation policies to ensure fair distribution and maximize the chances of a
successful transplant. The goal is to match the donor and recipient as closely as possible
to minimize the risk of rejection and maximize graft survival.

Question 4: Scenario: A patient is considering a corneal transplant for vision restoration.

What are the different types of corneal transplants and their indications? Answer: The
different types of corneal transplants include penetrating keratoplasty (full-thickness
transplant), lamellar keratoplasty (partial-thickness transplant), and endothelial
keratoplasty. Penetrating keratoplasty is indicated for conditions such as corneal scars,
keratoconus, or corneal dystrophies. Lamellar keratoplasty and endothelial keratoplasty

31
are more selective procedures used for specific conditions affecting the anterior or
posterior layers of the cornea, respectively.

Question 5: Scenario: A patient with end-stage liver disease is scheduled for a liver
transplant. What are the key aspects of organ preservation and transportation in liver
transplantation? Answer: Organ preservation and transportation are crucial in liver
transplantation to ensure the viability of the graft. The liver is typically preserved in a cold
storage solution to minimize metabolic activity and preserve organ function. During
transportation, the organ is carefully packed and transported in a temperature-controlled
environment. Time is of the essence, and the organ is transplanted into the recipient as
soon as possible to optimize graft function and patient outcomes.

Question 1: Scenario: A patient with end-stage renal disease is scheduled for a kidney
transplant. What are the important considerations for organ selection and matching in
this patient? Answer: Organ selection and matching in kidney transplantation are crucial
to ensure a successful outcome. Factors such as blood type compatibility, human
leukocyte antigen (HLA) matching, and crossmatching results are considered. Blood type
compatibility is essential to prevent immune reactions. HLA matching aims to minimize
the risk of rejection by matching the recipient's HLA antigens with the donor's antigens.
Crossmatching tests are performed to assess compatibility between the recipient's
antibodies and the donor's lymphocytes. These considerations help to maximize graft
survival and minimize the risk of rejection.

Question 2: Scenario: A patient with end-stage liver disease is scheduled for a liver
transplant. What are the criteria for selecting a suitable liver donor? Answer: Suitable liver
donors are carefully selected to ensure the best possible outcomes for both the donor
and recipient. Donor selection criteria include compatibility in terms of blood type, body
size, and liver function. Donors undergo thorough medical and psychological evaluations
to assess their overall health and suitability for donation. Liver grafts may come from
deceased donors (cadaveric donor) or living donors. In the case of living donors, the
evaluation process ensures that the donor can safely donate a portion of their liver
without compromising their own health.

Question 3: Scenario: A patient has received a heart transplant. What are the challenges
and considerations in managing immunosuppression post-transplantation? Answer:
After a heart transplant, lifelong immunosuppressive therapy is required to prevent
rejection of the transplanted heart. The main challenges include balancing the need for
effective immunosuppression to prevent rejection while minimizing the risk of infections
and medication side effects. Close monitoring of immunosuppressive drug levels, routine

32
follow-up visits, and surveillance for complications are necessary. The patient's immune
function, medication adherence, and potential drug interactions must be carefully
managed to optimize graft function and patient outcomes.

Question 4: Scenario: A patient is scheduled for a bone marrow transplant for the
treatment of hematological malignancy. What are the types of bone marrow
transplantation and their indications? Answer: There are two main types of bone marrow
transplantation: autologous and allogeneic. Autologous bone marrow transplantation
involves using the patient's own bone marrow or stem cells. It is typically used in cases
where the patient's own cells are healthy but high-dose chemotherapy or radiation is
needed. Allogeneic bone marrow transplantation involves using bone marrow or stem
cells from a matched donor. It is used when the patient's own cells are diseased or when
there is a need for immune system replacement. Indications for bone marrow
transplantation include hematological malignancies, certain genetic disorders, and
certain non-malignant conditions such as severe aplastic anemia.

Question 5: Scenario: A patient is being evaluated for a pancreas transplant due to end-
stage pancreatic disease. What are the factors considered in the assessment for
pancreas transplantation? Answer: The assessment for pancreas transplantation
involves careful evaluation of the patient's overall health and suitability for surgery.
Factors considered include the severity of pancreatic disease, absence of significant co-
existing medical conditions that may affect transplantation outcomes, and potential
benefits versus risks of the procedure. The patient's psychological readiness, social
support, and willingness to comply with post-transplant care are also important
considerations. Additionally, the availability of suitable donor organs and the patient's
position on the transplant waiting list are taken into account.

33
Basic Surgical Skills

Question 1: Scenario: You are assisting in a surgical procedure and the surgeon asks you
to demonstrate proper hand scrubbing technique. How would you perform a thorough
hand scrub? Answer: To perform a thorough hand scrub, follow these steps:

1. Wet your hands and apply an appropriate amount of surgical scrub solution.
2. Rub your hands together, including the palms, back of hands, fingers, and under
the nails, for at least 2 minutes, ensuring all surfaces are covered.
3. Pay attention to areas like the fingertips and interdigital spaces.
4. Rinse your hands thoroughly, keeping them elevated to prevent contamination
from running water.
5. Dry your hands with a sterile towel or disposable paper towel, starting from the
fingertips and moving toward the wrists.
6. Use a sterile technique to gown and glove before entering the sterile field.

Question 2: Scenario: You are tasked with preparing a surgical instrument for sterilization.
What are the steps involved in instrument sterilization? Answer: The steps involved in
instrument sterilization include:

1. Pre-cleaning: Remove visible debris from the instrument using a brush and
enzymatic detergent.
2. Packaging: Place the cleaned instrument in a sterilization wrap or pouch, ensuring
it is properly folded and sealed.
3. Sterilization: Choose the appropriate sterilization method based on the instrument
type and facility guidelines, such as autoclaving or ethylene oxide sterilization.
4. Monitoring: Monitor the sterilization process using biological and chemical
indicators to ensure effectiveness.
5. Storage: Store the sterilized instruments in a clean and dry environment, protected
from contamination until they are ready for use.

Question 3: Scenario: You are assisting in a surgical procedure and the surgeon asks you
to demonstrate proper instrument handling technique. How would you handle surgical
instruments safely and efficiently? Answer: When handling surgical instruments,
remember these key points:

34
 1. Hold instruments using the appropriate grasp, ensuring a firm grip without
excessive force.
2. Pass instruments with care, using a neutral zone or transfer tray to avoid
accidental injury.
3. Open and close instruments smoothly and gently, avoiding sudden movements
that may cause tissue trauma.
4. Keep instruments organized on the sterile field, ensuring they are readily
accessible when needed.
5. Maintain the sterility of instruments by avoiding contact with non-sterile surfaces
or items.
6. After use, handle contaminated instruments appropriately for decontamination
and cleaning.

Question 4: Scenario: You are assisting in a wound closure procedure. What are the
important steps in wound closure technique? Answer: The important steps in wound
closure technique include:

1. Hemostasis: Control bleeding by ligating or cauterizing bleeding vessels as

necessary.
2. Irrigation: Thoroughly irrigate the wound with a sterile saline solution to remove
debris and reduce the risk of infection.
3. Layered closure: Close deep layers of the wound, such as muscle and fascia, using
absorbable sutures or staples.
4. Subcutaneous closure: Close the subcutaneous tissue using absorbable sutures
to promote wound healing and minimize dead space.
5. Skin closure: Close the skin using non-absorbable sutures, staples, or adhesive
strips, depending on the wound characteristics and surgeon preference.
6. Dressing: Apply an appropriate sterile dressing to protect the wound and promote
healing.

Question 5: Scenario: You are preparing to suture a simple laceration. What are the
important principles of suturing technique? Answer: The important principles of suturing
technique include:

1. Aseptic technique: Ensure proper hand hygiene and use sterile instruments,
gloves, and sutures to minimize the risk of infection.

35
Question 1: Scenario: You are assisting in a surgical procedure where a skin incision
needs to be made. What are the key steps to ensure a proper surgical incision? Answer:
When making a surgical incision, key steps to ensure a proper incision include:

1. Adequate exposure: Ensure proper visualization of the surgical site to identify

important structures and landmarks.
2. Appropriate skin marking: Mark the incision site using a surgical marker or sterile
ruler, ensuring the appropriate length and direction.
3. Correct tissue handling: Hold the scalpel firmly and at the correct angle,
maintaining control and precision during the incision.
4. Controlled depth: Apply gentle and consistent pressure while making the incision,
taking care to avoid excessive deep or shallow cuts.
5. Hemostasis: Control bleeding using techniques such as electrocautery or ligature
as needed.
6. Proper wound closure: Close the incision using appropriate suturing techniques or
wound closure materials.

Question 2: Scenario: You are participating in a suturing workshop. What are the
principles of proper suturing technique? Answer: The principles of proper suturing
technique include:

1. Adequate exposure: Ensure proper visualization of the wound or tissue being

sutured.
2. Proper needle placement: Insert the needle at the appropriate depth and angle to
ensure secure and precise tissue approximation.
3. Correct needle and suture selection: Choose the appropriate needle type (e.g.,
cutting, taper) and suture material (e.g., absorbable, non-absorbable) based on the
specific needs of the wound.
4. Proper tension: Apply tension to the suture line to achieve proper wound
approximation without excessive tightness or laxity.
5. Secure knot tying: Use appropriate knot tying techniques to ensure secure and
reliable closure.
6. Hemostasis: Control bleeding during suturing by using hemostatic techniques as
needed.

Question 3: Scenario: You are assisting in a laparoscopic procedure. What are the
important considerations for trocar placement? Answer: Important considerations for
trocar placement in laparoscopic procedures include:

36
 1. Anatomical landmarks: Identify key anatomical structures to avoid injury and
ensure optimal trocar placement.
2. Number and location of trocars: Determine the number and location of trocars
based on the surgical procedure, ensuring adequate access and optimal
instrument triangulation.
3. Safe entry techniques: Use safe entry techniques, such as the open or closed
technique, to minimize the risk of injury during trocar insertion.
4. Trocar fixation: Ensure secure fixation of trocars to prevent accidental
dislodgment during the procedure.
5. Gas insufflation: Properly establish and maintain pneumoperitoneum using
appropriate gas pressure and flow rates.

Question 4: Scenario: You are participating in a basic surgical skills workshop, and one of
the stations involves knot tying. What are the key steps for proper knot tying? Answer:
Key steps for proper knot tying include:

1. Proper hand positioning: Hold the needle holder or surgical forceps and suture with
the appropriate grip and hand positioning.
2. Correct knot formation: Practice the proper technique for forming a square knot or
surgeon's knot, ensuring that the loops are securely tied and tightened.
3. Tension control: Apply appropriate tension to the suture strands while tying the
knot, avoiding excessive tightness or slackness.
4. Reliable knot security: Ensure that the knot is secure by performing appropriate
locking maneuvers or additional throws as needed.
5. Neat and flat knot profile: Aim for a neat and flat knot profile without excessive
bulk or tissue distortion.

37
Biohazard disposal

Question 1: Scenario: You are assisting in a surgical procedure that involves the use of
contaminated sharps, such as needles and scalpel blades. How should you dispose of
these biohazardous materials? Answer: Contaminated sharps should be disposed of in
puncture-resistant containers specifically designed for sharps disposal. These
containers should be clearly labeled as biohazardous waste, and they should be securely
sealed to prevent accidental exposure. It is important to follow institutional guidelines
and local regulations regarding the disposal of biohazardous materials.

Question 2: Scenario: After a surgical procedure, you have a tray of used surgical
instruments and disposable materials that are potentially contaminated. How should you
handle the disposal of these biohazardous materials? Answer: Biohazardous materials,
such as used surgical instruments and disposable materials, should be collected in
designated biohazard bags or containers. These bags or containers should be securely
sealed and labeled with biohazard symbols. They should be disposed of in accordance
with institutional guidelines and local regulations for biohazardous waste disposal.

Question 3: Scenario: You are assisting in the removal of infected wound dressings from
a patient's wound. How should you dispose of the contaminated dressings? Answer:
Contaminated wound dressings should be handled with appropriate personal protective
equipment (PPE) to prevent direct contact with potentially infectious materials. They
should be disposed of in biohazard bags or containers designated for contaminated
dressings. These bags or containers should be securely sealed and labeled as
biohazardous waste for proper disposal.

Question 4: Scenario: You are assisting in the removal of a drainage tube from a patient
who had a surgical procedure. How should you dispose of the used drainage tube?
Answer: Used drainage tubes should be carefully removed from the patient, taking
precautions to avoid contact with any drainage fluid. They should be placed in a biohazard
bag or container designated for medical waste disposal. The bag or container should be
securely sealed and labeled as biohazardous waste before proper disposal.

Question 5: Scenario: You are in the operating room and have finished a procedure that
involved the use of gloves, gowns, and other disposable personal protective equipment.
How should you dispose of these items? Answer: Used gloves, gowns, and other
disposable personal protective equipment should be removed and disposed of

38
immediately after the procedure. They should be placed in designated biohazard bags or
containers. It is important to follow proper hand hygiene practices before and after
removing the gloves. The biohazard bags or containers should be securely sealed and
labeled for biohazardous waste disposal.

39
Minimally invasive General Surgery

omy is a minimally invasive approach to remove the kidney in cases of renal cancer. The
advantages of laparoscopic nephrectomy include smaller incisions, reduced blood loss,
shorter hospital stay, faster recovery, and improved cosmetic outcome compared to open
nephrectomy. Laparoscopic nephrectomy has been shown to be equally effective as open
nephrectomy in terms of cancer control and long-term survival.

Question 5: Scenario: A patient requires surgical treatment for morbid obesity. What are
the advantages of laparoscopic bariatric surgery in this patient? Answer: Laparoscopic
bariatric surgery, such as laparoscopic gastric bypass or laparoscopic sleeve
gastrectomy, is a minimally invasive approach for weight loss in patients with morbid
obesity. The advantages of laparoscopic bariatric surgery include smaller incisions,
reduced post-operative pain, shorter hospital stay, faster recovery, and improved
cosmetic outcome. Laparoscopic bariatric surgery has been shown to achieve significant
and sustainable weight loss, improve obesity-related comorbidities, and enhance overall
quality of life.

Question 1: Scenario: You are participating in a laparoscopic cholecystectomy procedure.

What are the advantages of minimally invasive surgery compared to open surgery for this
procedure? Answer: The advantages of minimally invasive surgery (laparoscopic
cholecystectomy) over open surgery include:

1. Smaller incisions: Minimally invasive surgery involves smaller incisions, resulting

in less postoperative pain, reduced scarring, and faster recovery.
2. Reduced blood loss: Minimally invasive techniques result in less blood loss during
the procedure, reducing the need for blood transfusions.
3. Shorter hospital stay: Patients undergoing minimally invasive surgery typically
have a shorter hospital stay compared to open surgery.
4. Faster recovery: Minimally invasive surgery allows for faster recovery and earlier
return to normal activities.
5. Lower risk of complications: The risk of complications, such as wound infection
and hernia formation, is lower with minimally invasive surgery.

Question 2: Scenario: You are assisting in a laparoscopic appendectomy procedure. What

are the key steps involved in performing a laparoscopic appendectomy? Answer: Key
steps in performing a laparoscopic appendectomy include:

40
 1. Patient positioning: Position the patient in the supine position with legs apart to
allow access to the abdomen.
2. Trocar placement: Insert trocars into the abdomen to create ports for the
laparoscopic instruments.
3. Visualization: Insert a laparoscope through one of the trocars to visualize the
abdominal cavity.
4. Exploration and identification: Explore the abdomen to identify the appendix and
confirm the diagnosis of appendicitis.
5. Dissection and removal: Use laparoscopic instruments to dissect the appendix,
ligate the blood vessels, and remove the appendix.
6. Closure: Close the appendiceal stump using a stapler or sutures.
7. Hemostasis and irrigation: Ensure hemostasis and irrigate the abdominal cavity to
remove any debris or infection.
8. Trocar removal and wound closure: Remove the trocars, close the small incisions
with sutures or adhesive strips, and cover with sterile dressings.

Question 3: Scenario: You are observing a laparoscopic hernia repair surgery. What are
the advantages of laparoscopic hernia repair compared to open hernia repair? Answer:
The advantages of laparoscopic hernia repair over open hernia repair include:

1. Less postoperative pain: Laparoscopic hernia repair involves smaller incisions,

resulting in less postoperative pain compared to open surgery.
2. Reduced risk of wound infection: With laparoscopic surgery, there is a reduced risk
of wound infection due to smaller incisions and reduced tissue trauma.
3. Shorter recovery time: Patients undergoing laparoscopic hernia repair typically
have a shorter recovery time and can resume normal activities sooner.
4. Reduced risk of hernia recurrence: Laparoscopic hernia repair is associated with a
lower risk of hernia recurrence compared to open repair.
5. Improved cosmetic outcome: The smaller incisions used in laparoscopic surgery
result in improved cosmetic outcomes, with less visible scarring.

41
Trauma
Question 1: Scenario: A patient arrives at the emergency department with a penetrating
injury to the chest. What is the immediate management of this patient? Answer: The
immediate management of a patient with a penetrating injury to the chest includes:

1. Ensure an open airway: Assess and secure the patient's airway to ensure proper
oxygenation and ventilation.
2. Control external bleeding: Apply direct pressure to any external bleeding sites to
control bleeding.
3. Stabilize any impaled objects: If there is an impaled object, stabilize it in place and
do not attempt to remove it.
4. Administer supplemental oxygen: Provide supplemental oxygen to maintain
adequate oxygenation.
5. Establish intravenous access: Establish large-bore intravenous access for fluid
resuscitation and administration of medications.
6. Perform focused assessment: Perform a rapid focused assessment of the chest,
including auscultation, palpation, and assessment for signs of tension
pneumothorax or cardiac tamponade.
7. Obtain imaging studies: Obtain a chest X-ray or focused ultrasound to assess for
internal injuries.
8. Consult the appropriate surgical specialty: Contact the thoracic surgery team or
trauma surgeon for further management and consideration of operative
intervention if indicated.

Question 2: Scenario: A patient is brought to the emergency department after a motor

vehicle accident with suspected pelvic fractures. What is the initial management of this
patient? Answer: The initial management of a patient with suspected pelvic fractures
includes:

1. Ensure patient stabilization: Ensure the patient is in a stable condition with an open
airway, adequate breathing, and circulation.
2. Perform a primary survey: Perform a primary survey following the ABCDE approach
(Airway, Breathing, Circulation, Disability, and Exposure).
3. Control external bleeding: Apply direct pressure to any external bleeding sites and
consider pelvic binder application to stabilize the pelvis and control bleeding.
4. Obtain imaging studies: Obtain pelvic X-rays, CT scan, or focused assessment with
sonography for trauma (FAST) to evaluate for pelvic fractures and associated
injuries.

42
 5. Administer analgesia: Administer appropriate analgesia to manage pain.
6. Consult the appropriate surgical specialty: Consult the orthopedic surgery or
trauma surgery team for further management, including potential surgical
stabilization of the pelvic fractures if indicated.

Question 3: Scenario: A patient presents to the emergency department with a gunshot

wound to the abdomen. What is the initial management of this patient? Answer: The initial
management of a patient with a gunshot wound to the abdomen includes:

1. Ensure patient stabilization: Ensure the patient is in a stable condition with an open
airway, adequate breathing, and circulation.
2. Control external bleeding: Apply direct pressure to any external bleeding sites.
3. Cover the wound: Cover the wound with a sterile dressing to minimize
contamination.
4. Obtain intravenous access: Establish large-bore intravenous access for fluid
resuscitation and administration of medications.
5. Administer supplemental oxygen: Provide supplemental oxygen to maintain
adequate oxygenation.
6. Perform focused assessment: Perform a focused abdominal examination to
evaluate for signs of peritonitis or intra-abdominal injury.
7. Obtain imaging studies: Obtain a CT scan of the abdomen and pelvis to assess for
internal injuries and identify the trajectory of the gunshot wound.
8. Consult the appropriate surgical specialty: Contact the trauma surgery team or
general surgery team for further management, including potential exploratory
laparotomy if indicated.

Question 1: Scenario: A patient presents to the emergency department with a penetrating

injury to the abdomen. What are the immediate steps in the management of abdominal
trauma? Answer: Immediate steps in the management of abdominal trauma include:

1. Primary survey: Assess the patient's airway, breathing, circulation, disability

(neurological status), and exposure (undressing the patient to assess for
additional injuries).
2. Control external bleeding: Apply direct pressure to any visible bleeding wounds.
3. Assess for signs of shock: Monitor the patient's blood pressure, heart rate, and
respiratory rate to identify signs of hypovolemic shock.
4. Stabilize the patient: Administer supplemental oxygen and establish intravenous
access for fluid resuscitation.

43
 5. Perform focused abdominal examination: Assess for signs of peritonitis,
distension, tenderness, or evisceration.
6. Order appropriate investigations: Consider imaging studies such as FAST
(Focused Assessment with Sonography in Trauma) or CT scan to further evaluate
intra-abdominal injuries.
7. Consult the surgical team: Promptly involve the surgical team for definitive
management, which may include exploratory laparotomy or other interventions
based on the findings.

Question 2: Scenario: A patient is brought to the emergency department with an open

fracture of the tibia. What are the immediate steps in the management of an open
fracture? Answer: Immediate steps in the management of an open fracture include:

1. Assess the patient's ABCs: Ensure the patient's airway, breathing, and circulation
are stable.
2. Control bleeding: Apply direct pressure to any active bleeding sites.
3. Stabilize the fracture: Immobilize the injured limb using splints or a traction device
to prevent further movement.
4. Cleanse the wound: Thoroughly irrigate the wound with sterile saline or antiseptic
solution to reduce the risk of infection.
5. Cover the wound: Apply a sterile dressing to the open wound to protect it from
further contamination.
6. Administer tetanus prophylaxis: Check the patient's tetanus vaccination status
and administer tetanus toxoid or tetanus immunoglobulin as needed.
7. Order imaging studies: X-rays or other imaging modalities should be performed to
assess the extent of the fracture and associated injuries.
8. Consult the orthopedic team: Involve the orthopedic team for further management,
which may include surgical intervention, wound debridement, and fracture fixation.

Question 3: Scenario: A patient arrives at the emergency department with a head injury
following a motor vehicle accident. What are the immediate steps in the management of
head trauma? Answer: Immediate steps in the management of head trauma include:

1. Ensure a patent airway: Assess and maintain the patient's airway, ensuring proper
oxygenation and ventilation.
2. Stabilize the cervical spine: Immobilize the cervical spine to prevent further injury
during assessment and management.
3. Assess level of consciousness: Evaluate the patient's Glasgow Coma Scale (GCS)
score to assess the severity of the head injury.

44
4. Perform neurological examination: Assess pupillary response, motor function, and
signs of focal neurological deficits.
5. Order appropriate imaging studies: CT scan of the head is usually indicated to
evaluate for any intracranial injuries.
6. Control intracranial pressure (ICP): Maintain adequate cerebral perfusion pressure
and control ICP by elevating the head of the bed, administering osmotic diuretics
(e.g., mannitol), and managing ventilation.
7. Consult the neurosurgical team: Involve the neurosurgical team for further
management, which may

45
Skin and subcutaneous tissue

Question 1: Scenario: A newborn baby is brought to you with a cleft lip and palate. How
would you approach the management of this developmental anomaly? Answer: The
management of cleft lip and palate involves a multidisciplinary approach and includes
the following steps:

1. Counseling and support: Provide counseling and emotional support to the parents
regarding the condition and the treatment options available.
2. Feeding and nutrition: Ensure proper feeding techniques, including specialized
bottles and nipples or alternative feeding methods, to ensure adequate nutrition
for the baby.
3. Surgical repair: Plan surgical repair of the cleft lip and palate, typically performed
in stages as the child grows. The timing of surgery will depend on the individual
case and the preference of the surgical team.
4. Speech therapy: Coordinate with a speech-language pathologist to address any
speech and language difficulties that may arise due to the cleft palate.
5. Dental care: Monitor dental development and coordinate with a pediatric dentist
or orthodontist to address any dental issues associated with the cleft.
6. Long-term follow-up: Schedule regular follow-up visits to monitor the child's
growth, development, and address any additional needs that may arise.

Question 2: Scenario: A teenage patient presents with a retrognathic mandible

(underdeveloped lower jaw). How would you approach the management of this
developmental anomaly? Answer: The management of retrognathic mandible
(underdeveloped lower jaw) may involve the following steps:

1. Orthodontic evaluation: Refer the patient to an orthodontist for a comprehensive

evaluation of the dentofacial structures, including the position of the jaws and
teeth.
2. Orthognathic surgery: Consider orthognathic surgery, which involves repositioning
the jaws to improve their alignment and function. This may include advancement
of the mandible through procedures such as sagittal split ramus osteotomy or
distraction osteogenesis.
3. Multidisciplinary consultation: Involve a team of oral and maxillofacial surgeons,
orthodontists, and speech-language pathologists to develop a treatment plan that

46
 addresses the functional and aesthetic concerns associated with the retrognathic
mandible.
4. Pre-surgical orthodontic treatment: Initiate pre-surgical orthodontic treatment to
align the teeth and create a stable occlusion in preparation for the surgical
procedure.
5. Post-surgical orthodontic treatment: Coordinate post-surgical orthodontic
treatment to fine-tune the occlusion and achieve optimal facial aesthetics and
function.
6. Long-term follow-up: Schedule regular follow-up visits to monitor the patient's
post-operative progress and address any potential complications or orthodontic
adjustments that may be required.

Question 3: Scenario: A child is brought to you with ankyloglossia (tongue tie), which is
affecting their ability to breastfeed. How would you manage this developmental anomaly?
Answer: The management of ankyloglossia (tongue tie) may involve the following steps:

1. Assessment: Evaluate the severity of the ankyloglossia, including the range of

motion of the tongue and its impact on breastfeeding and speech development.
2. Lactation support: Collaborate with a lactation consultant to provide support and
guidance for breastfeeding techniques that can accommodate the ankyloglossia.
3. Frenotomy: Consider a frenotomy procedure, which involves releasing the tongue
tie by dividing the restrictive tissue (frenulum) to improve tongue mobility. This
procedure can typically be done using local anaesthesia in a clinical setting.

Question 1: Scenario: A newborn baby is brought to the clinic with a cleft lip and palate.
What is the developmental anomaly associated with this condition, and how would you
manage it? Answer: The developmental anomaly associated with a cleft lip and palate is
called orofacial clefting. Management typically involves a multidisciplinary approach:

1. Surgical repair: Surgical correction of cleft lip is typically performed between 3 to

6 months of age, followed by cleft palate repair around 9 to 12 months of age.
2. Feeding support: Provide guidance and support for feeding the infant, as they may
face challenges due to the cleft palate.
3. Dental care: Monitor dental development and provide appropriate dental care,
including orthodontic treatment, as the child grows.
4. Speech therapy: Early intervention with speech therapy helps address speech and
language difficulties associated with cleft palate.

47
 5. Psychological support: Offer psychological support to the child and their family to
address the emotional and social challenges associated with the condition.

Question 2: Scenario: A 6-year-old child presents with a prominent chin and lower jaw.
What is the developmental anomaly associated with this condition, and how would you
manage it? Answer: The developmental anomaly associated with a prominent chin and
lower jaw is called mandibular prognathism or mandibular excess. Management options
depend on the severity of the condition and may include:

1. Orthodontic treatment: Orthodontic appliances and braces can help correct the
alignment of the teeth and jaw.
2. Orthognathic surgery: In severe cases, corrective jaw surgery may be
recommended to reposition the lower jaw and achieve a more balanced facial
profile.
3. Dental care: Regular dental check-ups and monitoring of dental development are
important for long-term oral health.
4. Psychological support: Provide psychological support to address any self-esteem
or social interaction concerns associated with the condition.

Question 3: Scenario: A 10-year-old child is diagnosed with a condition where the upper
jaw is narrower than normal, resulting in crowded teeth. What is the developmental
anomaly associated with this condition, and how would you manage it? Answer: The
developmental anomaly associated with a narrow upper jaw and crowded teeth is called
maxillary hypoplasia or maxillary deficiency. Management options may include:

1. Orthodontic treatment: Orthodontic appliances, such as palatal expanders, can be

used to gradually widen the upper jaw and create space for proper tooth alignment.
2. Orthognathic surgery: In severe cases, corrective jaw surgery may be
recommended to reposition the upper jaw and improve facial harmony.
3. Dental care: Regular dental check-ups and appropriate dental interventions, such
as extractions or restorations, may be necessary to address crowded or
misaligned teeth.
4. Psychological support: Offer psychological support to address any self-esteem or
social interaction concerns associated with dental and facial aesthetics.

48
Developmental anomalies of the face, mouth and
jaws

Question 1: Scenario: A newborn baby is brought to the clinic with a cleft lip and palate.
What is the developmental anomaly associated with this condition, and how would you
manage it? Answer: The developmental anomaly associated with a cleft lip and palate is
orofacial clefting. Management typically involves a multidisciplinary approach:

1. Surgical repair: Surgical correction of cleft lip is typically performed between 3 to

6 months of age, followed by cleft palate repair around 9 to 12 months of age.
2. Feeding support: Provide guidance and support for feeding the infant, as they may
face challenges due to the cleft palate.
3. Dental care: Monitor dental development and provide appropriate dental care,
including orthodontic treatment, as the child grows.
4. Speech therapy: Early intervention with speech therapy helps address speech and
language difficulties associated with cleft palate.
5. Psychological support: Offer psychological support to the child and their family to
address the emotional and social challenges associated with the condition.

Question 2: Scenario: A 10-year-old child presents with a condition where the upper jaw
is narrower than normal, resulting in crowded teeth. What is the developmental anomaly
associated with this condition, and how would you manage it? Answer: The
developmental anomaly associated with a narrow upper jaw and crowded teeth is
maxillary hypoplasia or maxillary deficiency. Management options may include:

1. Orthodontic treatment: Orthodontic appliances, such as palatal expanders, can be

used to gradually widen the upper jaw and create space for proper tooth alignment.
2. Orthognathic surgery: In severe cases, corrective jaw surgery may be
recommended to reposition the upper jaw and improve facial harmony.
3. Dental care: Regular dental check-ups and appropriate dental interventions, such
as extractions or restorations, may be necessary to address crowded or
misaligned teeth.
4. Psychological support: Offer psychological support to address any self-esteem or
social interaction concerns associated with dental and facial aesthetics.

Question 3: Scenario: A 16-year-old adolescent presents with a small lower jaw and facial
asymmetry. What is the developmental anomaly associated with this condition, and how

49
would you manage it? Answer: The developmental anomaly associated with a small lower
jaw and facial asymmetry is mandibular hypoplasia or mandibular deficiency.
Management options may include:

1. Orthodontic treatment: Orthodontic appliances, such as braces or aligners, can

help align the teeth and improve bite alignment.
2. Orthognathic surgery: In moderate to severe cases, corrective jaw surgery may be
recommended to reposition the lower jaw and achieve facial symmetry.
3. Dental care: Regular dental check-ups and appropriate dental interventions, such
as extractions or restorations, may be necessary to address dental alignment.
4. Psychological support: Offer psychological support to address any self-esteem or
social interaction concerns associated with facial aesthetics and jaw
development.

Question 1: Scenario: A newborn baby is brought to the clinic with a cleft lip and palate.
What is the developmental anomaly associated with this condition, and how would you
manage it? Answer: The developmental anomaly associated with a cleft lip and palate is
called orofacial clefting. Management typically involves a multidisciplinary approach:

1. Surgical repair: Surgical correction of cleft lip is typically performed between 3 to

6 months of age, followed by cleft palate repair around 9 to 12 months of age.
2. Feeding support: Provide guidance and support for feeding the infant, as they may
face challenges due to the cleft palate.
3. Dental care: Monitor dental development and provide appropriate dental care,
including orthodontic treatment, as the child grows.
4. Speech therapy: Early intervention with speech therapy helps address speech and
language difficulties associated with cleft palate.
5. Psychological support: Offer psychological support to the child and their family to
address the emotional and social challenges associated with the condition.

Question 2: Scenario: A 10-year-old child presents with a condition where the upper jaw
is narrower than normal, resulting in crowded teeth. What is the developmental anomaly
associated with this condition, and how would you manage it? Answer: The
developmental anomaly associated with a narrow upper jaw and crowded teeth is called
maxillary hypoplasia or maxillary deficiency. Management options may include:

50
 1. Orthodontic treatment: Orthodontic appliances, such as palatal expanders, can be
used to gradually widen the upper jaw and create space for proper tooth alignment.
2. Orthognathic surgery: In severe cases, corrective jaw surgery may be
recommended to reposition the upper jaw and improve facial harmony.
3. Dental care: Regular dental check-ups and appropriate dental interventions, such
as extractions or restorations, may be necessary to address crowded or
misaligned teeth.
4. Psychological support: Offer psychological support to address any self-esteem or
social interaction concerns associated with dental and facial aesthetics.

Question 3: Scenario: A 16-year-old adolescent presents with a small lower jaw and facial
asymmetry. What is the developmental anomaly associated with this condition, and how
would you manage it? Answer: The developmental anomaly associated with a small lower
jaw and facial asymmetry is called mandibular hypoplasia or mandibular deficiency.
Management options may include:

1. Orthodontic treatment: Orthodontic appliances, such as braces or aligners, can

help align the teeth and improve bite alignment.
2. Orthognathic surgery: In moderate to severe cases, corrective jaw surgery may be
recommended to reposition the lower jaw and achieve facial symmetry.
3. Dental care: Regular dental check-ups and appropriate dental interventions, such
as extractions or restorations, may be necessary to address dental alignment and
occlusion.
4. Psychological support: Offer psychological support to address any self-esteem or
social interaction concerns associated with facial aesthetics and jaw alignment.

Question 4: Scenario: A 3-year-old child presents with a protruding lower jaw and
malocclusion. What is the developmental anomaly associated with this condition, and
how would you manage it? Answer: The developmental anomaly associated with a
protruding lower jaw and malocclusion is called mandibular prognathism or mandibular
excess. Management options depend on the severity of the condition and may include:

1. Orthodontic treatment: Orthodontic appliances and braces can help correct the
alignment of the teeth and jaw.

51
Oropharyngeal cancer

Question 1: Scenario: A 55-year-old male patient presents with a persistent sore throat,
difficulty swallowing, and a non-healing ulcer in the back of the mouth. What are the
possible causes and management options for this patient? Answer: The possible cause
of the patient's symptoms is oropharyngeal cancer. Management options may include:

1. Diagnostic workup: Perform a thorough examination, including a complete history,

physical examination, and imaging studies (such as CT scan or MRI) to evaluate
the extent of the tumor and detect any lymph node involvement.
2. Biopsy: Obtain a tissue sample from the ulcer for histopathological analysis to
confirm the diagnosis of oropharyngeal cancer.
3. Staging: Determine the stage of the cancer based on the TNM (tumor, node,
metastasis) system to guide further treatment decisions.
4. Multidisciplinary approach: Involve a multidisciplinary team, including surgical
oncologists, radiation oncologists, and medical oncologists, to develop a
comprehensive treatment plan.
5. Treatment options: Treatment options may include surgery (such as transoral
robotic surgery or radical neck dissection), radiation therapy, chemotherapy, or a
combination of these modalities.
6. Rehabilitation: Provide post-treatment rehabilitation, including speech therapy and
swallowing exercises, to help restore normal function and improve quality of life.
7. Regular follow-up: Schedule regular follow-up visits to monitor the patient's
response to treatment, assess for any recurrence, and provide ongoing supportive
care.

Question 2: Scenario: A 45-year-old female patient presents with a painless lump in the
neck and hoarseness. What are the possible causes and diagnostic steps to evaluate this
patient? Answer: The possible cause of the patient's symptoms is metastatic spread of
oropharyngeal cancer to the cervical lymph nodes. Diagnostic steps may include:

1. History and physical examination: Obtain a detailed history and perform a

thorough examination, including a neck examination to evaluate the presence of
lymphadenopathy.
2. Imaging studies: Perform imaging studies, such as CT scan or MRI, to assess the
primary tumor site and determine the extent of lymph node involvement.

52
 3. Fine-needle aspiration (FNA) biopsy: Perform an FNA biopsy of the neck lymph
node to obtain a tissue sample for histopathological analysis and confirm the
presence of metastatic disease.
4. Staging: Determine the stage of the cancer based on the TNM system to guide
further treatment decisions.
5. Multidisciplinary approach: Involve a multidisciplinary team, including surgical
oncologists, radiation oncologists, and medical oncologists, to develop an
appropriate treatment plan.
6. Treatment options: Treatment options may include surgery (such as neck
dissection or primary tumor resection), radiation therapy, chemotherapy, or a
combination of these modalities.
7. Regular follow-up: Schedule regular follow-up visits to monitor the patient's
response to treatment, assess for any recurrence, and provide ongoing supportive
care.

Question 3: Scenario: A 60-year-old male patient with a history of tobacco and alcohol
use presents with a persistent ulcer on the tongue and difficulty speaking. What are the
possible causes and management options for this patient? Answer: The possible cause
of the patient's symptoms is squamous cell carcinoma of the tongue. Management
options may include:

1. Diagnostic workup: Perform a thorough examination, including a complete history,

physical examination, and imaging studies (such as CT scan or MRI) to evaluate
the extent of the tumor and detect any lymph node involvement.

Question 1: Scenario: A 60-year-old patient presents with persistent throat pain and
difficulty swallowing. Upon examination, a mass is identified in the oropharynx. What is
the likely diagnosis, and how would you manage this patient? Answer: The likely diagnosis
is oropharyngeal cancer. Management options may include:

1. Biopsy: Perform a biopsy of the oropharyngeal mass to confirm the diagnosis and
determine the histological subtype.
2. Staging workup: Conduct imaging studies (such as CT scan, MRI) and other
investigations to determine the extent of the disease (e.g., lymph node
involvement, distant metastasis).
3. Multidisciplinary approach: Involve a multidisciplinary team including surgeons,
radiation oncologists, medical oncologists, and speech therapists to develop a
comprehensive treatment plan.

53
 4. Treatment modalities: Treatment options for oropharyngeal cancer may include
surgery, radiation therapy, chemotherapy, or a combination of these, depending on
the stage and characteristics of the tumor.
5. Rehabilitation: Address post-treatment functional deficits through speech therapy,
swallowing exercises, and supportive care to enhance quality of life.

Question 2: Scenario: A 45-year-old patient presents with a painless lump in the neck.
Further evaluation reveals a primary tumor in the tonsil. What is the likely diagnosis, and
what would be the appropriate treatment approach? Answer: The likely diagnosis is
tonsillar cancer. The appropriate treatment approach may include:

1. Biopsy and staging: Perform a biopsy of the tonsillar mass to determine the
histological type and stage of the tumor.
2. Imaging studies: Conduct imaging studies (such as CT scan, MRI, PET-CT) to
assess the extent of the tumor, including lymph node involvement and distant
metastasis.
3. Multidisciplinary management: Involve a multidisciplinary team including
surgeons, radiation oncologists, medical oncologists, and speech therapists to
develop an individualized treatment plan.
4. Treatment options: Treatment for tonsillar cancer may involve surgery (such as
transoral robotic surgery or radical tonsillectomy), radiation therapy,
chemotherapy, or a combination of these, depending on the stage and
characteristics of the tumor.
5. Rehabilitation: Provide supportive care, including speech therapy and swallowing
exercises, to address functional deficits following treatment.

Question 3: Scenario: A 55-year-old patient presents with hoarseness, persistent sore

throat, and enlarged cervical lymph nodes. Examination reveals a mass in the larynx.
What is the likely diagnosis, and how would you approach the management of this
patient? Answer: The likely diagnosis is laryngeal cancer. The management approach
may include:

1. Biopsy and staging: Perform a biopsy of the laryngeal mass to confirm the
diagnosis and determine the histological subtype. Staging workup, including
imaging studies, will help assess the extent of the disease.
2. Multidisciplinary consultation: Involve a multidisciplinary team, including
surgeons, radiation oncologists, medical oncologists, and speech therapists, to
develop a comprehensive treatment plan.

54
3. Treatment options: Treatment for laryngeal cancer may involve surgery (such as
partial or total laryngectomy), radiation therapy, chemotherapy, or a combination
of these, depending on the stage and characteristics of the tumor. Preservation of
laryngeal function and voice rehabilitation may be prioritized whenever possible.
4. Rehabilitation: Provide post-treatment speech therapy and voice rehabilitation to
improve functional outcomes and quality of life.

55
Disorders of salivary glands

Question 1: Scenario: A 35-year-old patient presents with a painless swelling in the right
parotid region. The swelling increases when eating and subsides at rest. What is the likely
diagnosis, and how would you manage this patient? Answer: The likely diagnosis is a
parotid salivary gland duct stone or sialolithiasis. Management options may include:

1. Conservative measures: Encourage the patient to massage the affected area,

apply warm compresses, and drink plenty of fluids to help dislodge the stone.
2. Salivary gland massage: Gentle massage of the salivary gland may help stimulate
salivary flow and dislodge the stone.
3. Medications: Prescribe sialagogues (agents that increase saliva production) or
antibiotics if infection is present.
4. Minimally invasive procedures: If the stone does not pass spontaneously, consider
interventional procedures such as sialendoscopy or extracorporeal shock wave
lithotripsy (ESWL) to fragment or remove the stone.
5. Surgical intervention: If conservative measures and minimally invasive procedures
fail, surgical removal of the stone or the affected salivary gland may be necessary.

Question 2: Scenario: A 40-year-old patient presents with recurrent episodes of painful

swelling in the submandibular region after meals. The swelling subsides spontaneously.
What is the likely diagnosis, and how would you manage this patient? Answer: The likely
diagnosis is a submandibular salivary gland duct stone or sialolithiasis. Management
options may include:

1. Conservative measures: Encourage the patient to increase fluid intake, apply warm
compresses, and practice good oral hygiene.
2. Sialogogues: Prescribe sialagogues, such as sour candies or lemon juice, to
stimulate saliva flow and help dislodge the stone.
3. Medications: Antibiotics may be prescribed if there is evidence of infection.
4. Minimally invasive procedures: If the stone does not pass spontaneously, consider
interventional procedures such as sialendoscopy or ESWL to fragment or remove
the stone.
5. Surgical intervention: If conservative measures and minimally invasive procedures
fail, surgical removal of the stone or the affected salivary gland may be necessary.

56
Question 3: Scenario: A 50-year-old patient presents with a painless, slowly enlarging
mass in the submandibular region. It has been present for several months. What is the
likely diagnosis, and how would you manage this patient? Answer: The likely diagnosis is
a submandibular salivary gland tumor. Management options may include:

1. Imaging studies: Perform imaging studies, such as ultrasound or MRI, to evaluate

the size, location, and characteristics of the tumor.
2. Fine-needle aspiration cytology (FNAC): Perform FNAC to obtain a tissue sample
for histopathological examination and to confirm the nature of the tumor (benign
or malignant).
3. Surgical excision: Complete surgical excision is the mainstay of treatment for
submandibular salivary gland tumors. The extent of surgery depends on the size,
location, and nature of the tumor.
4. Histopathological examination: Send the excised specimen for histopathological
examination to determine the tumor type and grade, which will guide further
management and prognosis.
5. Adjuvant therapy: Depending on the histopathological findings, adjuvant therapy,
such as radiotherapy or chemotherapy, may be considered.

Question 1: Scenario: A 40-year-old patient presents with swelling and pain in the right
parotid gland. The swelling increases during meals. What is the likely diagnosis, and how
would you manage this patient? Answer: The likely diagnosis is acute parotitis.
Management options may include:

1. Antibiotic therapy: Prescribe appropriate antibiotics to treat the underlying

infection causing parotitis.
2. Analgesics and warm compress: Recommend analgesics for pain relief and the
application of warm compresses to the affected area to alleviate symptoms.
3. Hydration and sialagogues: Encourage adequate hydration and the use of
sialagogues (e.g., lemon drops) to promote salivary flow and prevent duct
obstruction.
4. Salivary gland massage: Advise gentle massage of the affected gland to help
promote drainage and relieve symptoms.
5. Education: Provide instructions on oral hygiene, including regular tooth brushing
and rinsing, to maintain oral health and prevent recurrent episodes.

Question 2: Scenario: A 60-year-old patient presents with a painless, gradually enlarging

mass in the submandibular region. The mass is firm and mobile. What is the likely
diagnosis, and how would you manage this patient? Answer: The likely diagnosis is a

57
submandibular gland tumor, such as a pleomorphic adenoma or Warthin tumor.
Management options may include:

1. Imaging studies: Conduct imaging studies (such as ultrasound or MRI) to assess

the characteristics and extent of the tumor.
2. Fine-needle aspiration (FNA) or biopsy: Perform FNA or biopsy to obtain a tissue
sample for histopathological examination and confirm the diagnosis.
3. Surgical excision: Surgical excision of the tumor is the mainstay of treatment for
submandibular gland tumors. The extent of surgery will depend on the nature and
size of the tumor.
4. Postoperative follow-up: Regular postoperative follow-up is essential to monitor
for recurrence or complications and to ensure optimal recovery.

Question 3: Scenario: A 25-year-old patient presents with recurrent episodes of painful

swelling in the sublingual region, especially during meals. The patient also reports dry
mouth. What is the likely diagnosis, and how would you manage this patient? Answer:
The likely diagnosis is sublingual gland sialolithiasis (salivary gland stone). Management
options may include:

1. Conservative management: Encourage hydration, warm compresses, sialagogues

(e.g., lemon drops), and gland massage to promote salivary flow and dislodge the
stone.
2. Pain management: Prescribe analgesics to alleviate pain during acute episodes.
3. Salivary gland duct dilation or stone removal: In cases where conservative
measures fail, the stone can be manually removed or the duct can be dilated to
facilitate the passage of the stone.
4. Referral for surgical intervention: If conservative and minimally invasive measures
are ineffective, referral to a specialist for salivary gland surgery, such as
sialendoscopy or salivary gland excision, may be necessary.

58
Endocrine General Surgery: Thyroid and parathyroid

Question 1: Scenario: A 35-year-old patient presents with a palpable lump in the neck and
is diagnosed with a thyroid nodule. What steps would you take to evaluate and manage
this patient? Answer: When evaluating and managing a patient with a thyroid nodule, the
following steps are typically taken:

1. Thorough history and physical examination: Assess the patient's symptoms, risk
factors, and perform a detailed examination of the neck and thyroid gland.
2. Imaging studies: Perform a neck ultrasound to evaluate the size, characteristics,
and vascularity of the nodule. Additional imaging, such as CT or MRI, may be
required in certain cases.
3. Fine-needle aspiration (FNA) biopsy: Obtain a tissue sample from the nodule using
FNA biopsy for cytological examination to determine if it is benign or suspicious
for malignancy.
4. Thyroid function tests: Evaluate thyroid hormone levels to assess the function of
the thyroid gland.
5. Management based on FNA results: Depending on the FNA results, the
management options may include observation, thyroid hormone suppression
therapy, repeat FNA, or surgical removal of the nodule or the entire thyroid gland.

Question 2: Scenario: A 50-year-old patient presents with symptoms of hyperthyroidism,

including weight loss, palpitations, and tremors. On examination, an enlarged thyroid
gland with a bruit is noted. What is the likely diagnosis, and how would you manage this
patient? Answer: The likely diagnosis is Graves' disease, an autoimmune disorder causing
hyperthyroidism. Management options may include:

1. Antithyroid medication: Initiate treatment with antithyroid medications, such as

methimazole or propylthiouracil, to control the hyperthyroidism.
2. Beta-blockers: Prescribe beta-blockers, such as propranolol, to manage the
symptoms of palpitations, tremors, and anxiety.
3. Radioactive iodine therapy: Consider radioactive iodine therapy to achieve long-
term control of hyperthyroidism, especially if antithyroid medications fail or are not
suitable for the patient.
4. Thyroidectomy: If antithyroid medications and radioactive iodine therapy are
contraindicated or declined by the patient, surgical removal of the thyroid gland
(thyroidectomy) may be considered as a treatment option.

59
 5. Regular follow-up: Monitor the patient's thyroid function, symptoms, and adjust the
treatment accordingly to maintain thyroid hormone levels within the desired range.

Question 3: Scenario: A 40-year-old patient presents with symptoms of hypothyroidism,

including fatigue, weight gain, and cold intolerance. On examination, a firm, painless
thyroid nodule is palpated. What is the likely diagnosis, and how would you manage this
patient? Answer: The likely diagnosis is Hashimoto's thyroiditis, an autoimmune disorder
causing chronic inflammation of the thyroid gland leading to hypothyroidism.
Management options may include:

1. Thyroid hormone replacement therapy: Initiate treatment with levothyroxine to

restore thyroid hormone levels and alleviate symptoms of hypothyroidism.
2. Surveillance of the thyroid nodule: Monitor the thyroid nodule with periodic clinical
examination and imaging (ultrasound) to assess for any significant changes in
size, characteristics, or suspicious features.
3. Fine-needle aspiration (FNA) biopsy: Perform FNA biopsy of the nodule to evaluate
for malignancy or suspicious features.

Question 1: Scenario: A 40-year-old patient presents with a painless swelling in the front
of the neck. On examination, you find a palpable, non-tender, solitary nodule in the thyroid
gland. What is the likely diagnosis, and how would you manage this patient? Answer: The
likely diagnosis is a solitary thyroid nodule. Management options may include:

1. Evaluation: Perform thyroid function tests (TFTs), including TSH and free T4 levels,
to assess thyroid function.
2. Imaging studies: Conduct an ultrasound of the thyroid gland to evaluate the
characteristics of the nodule and assess for any suspicious features.
3. Fine-needle aspiration (FNA) biopsy: Perform FNA to obtain a tissue sample for
histopathological examination and to rule out malignancy.
4. Observation or surgery: Depending on the results of the FNA biopsy and the size
of the nodule, the patient may be managed with observation or surgical
intervention, such as a thyroid lobectomy or total thyroidectomy.

Question 2: Scenario: A 55-year-old patient presents with symptoms of hyperthyroidism,

including weight loss, palpitations, and heat intolerance. Physical examination reveals a
diffusely enlarged thyroid gland and signs of thyrotoxicosis. What is the likely diagnosis,
and how would you manage this patient? Answer: The likely diagnosis is Graves' disease,
an autoimmune condition causing hyperthyroidism. Management options may include:

60
 1. Thyroid function tests: Measure TSH, free T4, and possibly T3 levels to confirm the
diagnosis of hyperthyroidism.
2. Radioactive iodine therapy: Offer radioactive iodine therapy as a first-line
treatment option for definitive control of hyperthyroidism. It destroys the
overactive thyroid tissue.
3. Antithyroid drugs: Prescribe antithyroid medications, such as propylthiouracil or
methimazole, to achieve temporary control of hyperthyroidism before definitive
treatment or in certain cases when radioactive iodine is contraindicated.
4. Beta-blockers: Administer beta-blockers, such as propranolol, to alleviate
symptoms such as palpitations, tremors, and heat intolerance.
5. Follow-up: Schedule regular follow-up visits to monitor thyroid function and adjust
medication dosages as needed.

Question 3: Scenario: A 65-year-old patient presents with a painless, slowly enlarging

neck mass. On examination, you find a firm, non-tender, solitary nodule in the thyroid
gland. What is the likely diagnosis, and how would you manage this patient? Answer: The
likely diagnosis is a thyroid carcinoma, such as papillary thyroid carcinoma or follicular
thyroid carcinoma. Management options may include:

1. Evaluation: Conduct a thorough evaluation, including thyroid function tests, neck

ultrasound, and FNA biopsy, to determine the type and extent of the thyroid
carcinoma.
2. Surgical intervention: Surgical removal of the affected thyroid lobe (thyroid
lobectomy) or total thyroidectomy, along with removal of any involved lymph
nodes, may be indicated depending on the tumor characteristics and staging.
3. Postoperative follow-up: Schedule regular postoperative follow-up visits to
monitor for recurrence or metastasis, assess thyroid hormone replacement
therapy requirements, and manage any potential complications.

61
Adrenal glands

Question 1: Scenario: A 45-year-old patient presents with symptoms of uncontrolled

hypertension, severe headaches, and palpitations. On examination, you find a palpable
mass in the abdomen. What is the likely diagnosis, and how would you manage this
patient? Answer: The likely diagnosis is a functioning adrenal gland tumor, such as a
pheochromocytoma. Management options may include:

1. Blood pressure control: Initiate alpha-blockers, such as phenoxybenzamine, to

control blood pressure before surgical intervention.
2. Surgical removal: Proceed with surgical removal of the tumor, preferably by an
experienced surgeon in an appropriate center, following adequate preoperative
preparation.
3. Perioperative management: Administer alpha-blockers and, if necessary, beta-
blockers before surgery to prevent hypertensive crisis during tumor manipulation.
4. Postoperative follow-up: Schedule regular follow-up visits to monitor blood
pressure control, assess for tumor recurrence, and manage any potential
complications.

Question 2: Scenario: A 30-year-old patient presents with symptoms of weight gain,

fatigue, and muscle weakness. On examination, you find a small, firm mass in the adrenal
gland. What is the likely diagnosis, and how would you manage this patient? Answer: The
likely diagnosis is an adrenal incidentaloma. Management options may include:

1. Evaluation: Conduct hormonal evaluation, including measurement of cortisol,

aldosterone, and catecholamine levels, to determine the functionality of the
adrenal mass.
2. Imaging studies: Perform imaging studies, such as CT or MRI, to assess the
characteristics and size of the adrenal incidentaloma.
3. Hormonal control: If the adrenal mass is functional and causing hormonal excess
(e.g., Cushing's syndrome or primary aldosteronism), initiate appropriate medical
management or surgical intervention based on the specific hormone involved.
4. Observation: If the adrenal incidentaloma is non-functional and not causing any
hormonal abnormalities, consider observation with regular imaging studies to
monitor for any changes in size or characteristics.

62
Question 3: Scenario: A 40-year-old patient presents with symptoms of excessive hair
growth, irregular menstrual cycles, and weight gain. On examination, you find multiple
small nodules in both adrenal glands. What is the likely diagnosis, and how would you
manage this patient? Answer: The likely diagnosis is bilateral adrenal hyperplasia or
adrenal adenomas causing adrenal gland dysfunction. Management options may include:

1. Hormonal evaluation: Perform hormonal evaluation, including measurement of

cortisol, aldosterone, and sex hormone levels, to determine the specific hormonal
abnormalities and their effects on the patient's symptoms.
2. Medical management: Initiate appropriate medical management, such as
mineralocorticoid receptor antagonists (e.g., spironolactone) or glucocorticoid
receptor antagonists (e.g., mifepristone), based on the specific hormone involved
and the patient's clinical presentation.
3. Surgical intervention: In cases of unilateral adrenal adenoma causing hormone
excess or suspicion of malignancy, consider surgical removal of the affected
adrenal gland.
4. Long-term follow-up: Schedule regular follow-up visits to monitor hormonal
control, assess for tumor recurrence or progression, and manage any potential
complications.

Question 1: Scenario: A 45-year-old patient presents with uncontrolled hypertension and

a CT scan reveals a 3 cm mass in the adrenal gland. What is the likely diagnosis, and how
would you manage this patient? Answer: The likely diagnosis is an adrenal incidentaloma,
which refers to an adrenal mass discovered incidentally during imaging for unrelated
reasons. Management options may include:

1. Hormonal evaluation: Measure plasma and urinary levels of metanephrines,

aldosterone, cortisol, and other relevant hormones to assess for hormone
hypersecretion.
2. Imaging studies: Conduct further imaging studies, such as an MRI or CT with
contrast, to characterize the mass and determine the likelihood of malignancy.
3. Surgical intervention: Consider surgical removal of the adrenal mass
(adrenalectomy) if it is large, suspicious for malignancy, causing hormonal excess,
or causing significant patient anxiety.
4. Follow-up: Schedule regular follow-up visits to monitor the patient's blood
pressure, hormonal levels, and potential recurrence or development of new adrenal
lesions.

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Question 2: Scenario: A 30-year-old patient presents with weight loss, fatigue, and low
blood pressure. Lab investigations reveal low cortisol levels. What is the likely diagnosis,
and how would you manage this patient? Answer: The likely diagnosis is adrenal
insufficiency (Addison's disease). Management options may include:

1. Hormone replacement therapy: Administer glucocorticoids (such as

hydrocortisone) and mineralocorticoids (such as fludrocortisone) to replace the
deficient hormones.
2. Individualized dosing: Adjust the hormone replacement therapy dosages
according to the patient's symptoms, physical stressors, and physiological needs.
3. Patient education: Educate the patient on the importance of adherence to
medication, recognizing signs of adrenal crisis, and appropriate stress
management.
4. Regular follow-up: Schedule regular follow-up visits to monitor the patient's
symptoms, hormone levels, and adjust medication dosages as needed.

Question 3: Scenario: A 50-year-old patient presents with hypertension, palpitations, and

headaches. Lab investigations reveal elevated levels of plasma metanephrines. What is
the likely diagnosis, and how would you manage this patient? Answer: The likely diagnosis
is pheochromocytoma, a tumor of the adrenal medulla. Management options may
include:

1. Preoperative alpha-blockade: Initiate alpha-blockers (such as phenoxybenzamine)

to control blood pressure and prevent hypertensive crises before surgical
intervention.
2. Beta-blockers: Administer beta-blockers (such as propranolol) to manage
tachycardia and palpitations caused by excess catecholamines.
3. Surgical intervention: Schedule surgical removal of the adrenal tumor
(adrenalectomy) once blood pressure is adequately controlled.
4. Postoperative follow-up: Regularly monitor blood pressure and assess for any
recurrence or development of new tumors.

Question 4: Scenario: A 25-year-old patient presents with features of excessive hair

growth, acne, and menstrual irregularities. Lab investigations reveal elevated levels of
serum androgen hormones. What is the likely diagnosis, and how would you manage this
patient? Answer: The likely diagnosis is adrenal hyperplasia or adrenal androgen excess.
Management options may include:

64
1. Hormonal therapy: Administer anti-androgen medications (such as
spironolactone) or oral contraceptive pills containing estrogen and progesterone
to manage symptoms of androgen excess.
2. Regular monitoring: Schedule regular follow-up visits to assess the patient's
symptoms, hormone levels, and adjust medication dosages

65
Pancreas

Question 1: Scenario: A 50-year-old patient presents with severe upper abdominal pain
radiating to the back, along with nausea and vomiting. Lab investigations show elevated
serum amylase and lipase levels. Imaging reveals evidence of pancreatic inflammation.
What is the likely diagnosis, and how would you manage this patient? Answer: The likely
diagnosis is acute pancreatitis. Management options may include:

1. Supportive care: Provide supportive measures such as intravenous fluids, pain

control, and antiemetic medications to manage symptoms and maintain
hydration.
2. NPO status and bowel rest: Advise the patient to maintain nothing by mouth (NPO)
status to allow the pancreas to rest and recover.
3. Monitoring and investigations: Regularly monitor vital signs, laboratory
parameters, and imaging studies to assess the severity and complications of
pancreatitis.
4. Nutritional support: Initiate enteral feeding through a nasojejunal tube or
parenteral nutrition if oral intake is not feasible for an extended period.
5. Identification and management of etiological factors: Determine and manage any
underlying causes of pancreatitis, such as gallstones, alcohol use, or medication-
induced pancreatitis.
6. Consultation and referral: Consider consulting a gastroenterologist or pancreatic
specialist for further evaluation and management, especially in severe or
complicated cases.

Question 2: Scenario: A 55-year-old patient presents with weight loss, new-onset diabetes,
and painless jaundice. Imaging reveals a mass in the head of the pancreas. What is the
likely diagnosis, and how would you manage this patient? Answer: The likely diagnosis is
pancreatic adenocarcinoma. Management options may include:

1. Tissue diagnosis: Obtain a tissue diagnosis through endoscopic ultrasound-

guided fine-needle aspiration (EUS-FNA) or core biopsy to confirm pancreatic
adenocarcinoma.
2. Multidisciplinary approach: Involve a multidisciplinary team, including surgeons,
medical oncologists, radiation oncologists, and gastroenterologists, to develop a
comprehensive treatment plan.

66
 3. Surgical intervention: Evaluate the resectability of the tumor and consider surgical
resection, such as a Whipple procedure (pancreaticoduodenectomy), if
appropriate.
4. Chemotherapy and radiation therapy: Administer neoadjuvant or adjuvant
chemotherapy and radiation therapy to improve outcomes and manage the
disease.
5. Palliative care: If the tumor is unresectable or advanced, focus on providing
symptomatic relief and palliative care to improve quality of life.

Question 3: Scenario: A 30-year-old patient presents with recurrent episodes of severe

hypoglycemia, especially after meals. Lab investigations show elevated levels of serum
insulin and C-peptide. Imaging reveals a pancreatic mass. What is the likely diagnosis,
and how would you manage this patient? Answer: The likely diagnosis is an insulinoma,
a neuroendocrine tumor of the pancreas. Management options may include:

1. Localization: Use imaging techniques, such as a CT scan or endoscopic

ultrasound, to localize the insulinoma within the pancreas.
2. Surgical resection: Plan for surgical resection of the insulinoma to remove the
tumor and alleviate symptoms of hypoglycemia.
3. Preoperative management: Prior to surgery, optimize the patient's glucose control
with dietary modifications, medications, and frequent monitoring of blood glucose
levels.
4. Intraoperative localization: Utilize intraoperative ultrasound or other techniques to
precisely localize the insulinoma during surgery.
5. Postoperative monitoring: Regularly monitor blood glucose levels postoperatively
and provide appropriate education on managing potential complications and long-
term glucose control.

Question 1: Scenario: A 50-year-old patient presents with severe abdominal pain radiating
to the back, nausea, and vomiting. Laboratory investigations show elevated serum
amylase and lipase levels. Imaging reveals inflammation of the pancreas. What is the
likely diagnosis, and how would you manage this patient? Answer: The likely diagnosis is
acute pancreatitis. Management options may include:

1. NPO (nil per os) and fluid resuscitation: Initiate bowel rest by withholding oral
intake and provide intravenous fluids to maintain hydration and correct any
electrolyte imbalances.
2. Pain management: Administer analgesics, such as opioids, to relieve pain.

67
 3. Nutritional support: Initiate enteral or parenteral nutrition as needed to meet the
patient's nutritional requirements.
4. Identification and treatment of underlying causes: Determine the cause of
pancreatitis, such as gallstones or alcohol consumption, and treat accordingly.
5. Monitoring and complications management: Regularly monitor the patient's
clinical status, including pain, laboratory parameters, and signs of complications,
such as infected necrosis or pseudocyst formation.

Question 2: Scenario: A 60-year-old patient presents with obstructive jaundice, weight

loss, and pale stools. Imaging reveals a mass in the head of the pancreas. What is the
likely diagnosis, and how would you manage this patient? Answer: The likely diagnosis is
pancreatic adenocarcinoma (pancreatic cancer). Management options may include:

1. Tissue diagnosis: Perform a biopsy of the pancreatic mass to confirm the

diagnosis.
2. Multidisciplinary approach: Involve a multidisciplinary team, including surgeons,
medical oncologists, radiation oncologists, and palliative care specialists, to
develop an individualized treatment plan.
3. Surgical intervention: Surgical resection, such as a Whipple procedure
(pancreaticoduodenectomy), may be considered if the tumor is resectable and the
patient is fit for surgery.
4. Chemotherapy and/or radiation therapy: Administer systemic chemotherapy or
radiation therapy as part of the treatment plan, either before or after surgery,
depending on the stage and characteristics of the tumor.
5. Supportive care: Provide supportive care, including pain management, nutritional
support, and psychological support, to address the patient's symptoms and
improve quality of life.

Question 3: Scenario: A 35-year-old patient with a history of chronic pancreatitis presents

with recurrent attacks of severe abdominal pain. Imaging reveals multiple fluid-filled
collections in the pancreas. What is the likely diagnosis, and how would you manage this
patient? Answer: The likely diagnosis is chronic pancreatitis with pancreatic pseudocysts.
Management options may include:

1. Pain management: Administer analgesics and pancreatic enzyme replacement

therapy to alleviate pain and aid in digestion.
2. Nutritional support: Provide nutritional counseling, including a low-fat diet and
pancreatic enzyme supplementation, to optimize nutrition and manage
malabsorption.

68
3. Interventional procedures: Interventional radiology-guided percutaneous drainage
or endoscopic drainage may be performed to manage symptomatic pseudocysts.
4. Surgical intervention: Consider surgical intervention, such as cystgastrostomy or
cystjejunostomy, for large or symptomatic pseudocysts that do not respond to
conservative management.
5. Long-term follow-up: Schedule regular follow-up visits to monitor the patient's
symptoms, nutritional status, and pancreatic function, and provide ongoing
support.

69
Breast

Question 1: Scenario: A 45-year-old patient presents with a painless lump in the breast.
On examination, you find a solitary, mobile, non-tender mass. What is the likely diagnosis,
and how would you manage this patient? Answer: The likely diagnosis is a benign breast
lump, such as a fibroadenoma. Management options may include:

1. Imaging studies: Conduct a mammogram or breast ultrasound to further evaluate

the characteristics of the lump and assess its benign nature.
2. Clinical follow-up: If the lump is determined to be a benign lesion based on imaging
and clinical evaluation, the patient may be reassured and advised for regular breast
self-examinations. Clinical follow-up visits may be scheduled to monitor the
stability of the lump.

Question 2: Scenario: A 55-year-old patient presents with a new-onset, painless, fixed

lump in the breast. On examination, you find a non-mobile, hard mass with irregular
borders. What is the likely diagnosis, and how would you manage this patient? Answer:
The likely diagnosis is breast cancer. Management options may include:

1. Imaging studies: Conduct a mammogram and breast ultrasound to evaluate the

extent of the lesion and assess for any associated findings.
2. Tissue diagnosis: Perform a biopsy of the breast mass to confirm the diagnosis
and determine the histological type and grade of the cancer.
3. Staging workup: Conduct further imaging studies, such as a CT scan or PET-CT,
and assess lymph node involvement to determine the stage of the cancer.
4. Multidisciplinary approach: Involve a multidisciplinary team, including surgeons,
medical oncologists, radiation oncologists, and pathologists, to develop an
individualized treatment plan.
5. Treatment options: Treatment for breast cancer may involve surgery (such as
lumpectomy or mastectomy), chemotherapy, radiation therapy, hormonal therapy,
or a combination of these, depending on the stage and characteristics of the
tumor.

Question 3: Scenario: A 35-year-old patient presents with bloody nipple discharge and a
palpable mass in the breast. On examination, you find a subareolar mass with nipple
retraction. What is the likely diagnosis, and how would you manage this patient? Answer:

70
The likely diagnosis is intraductal papilloma or Paget's disease of the breast.
Management options may include:

1. Imaging studies: Conduct a mammogram or breast ultrasound to evaluate the

characteristics of the mass and assess for any associated findings.
2. Ductography or galactography: Consider a specialized imaging study to evaluate
the ductal system and identify the site of the lesion.
3. Tissue diagnosis: Perform a biopsy of the breast mass or nipple to confirm the
diagnosis and determine the extent of involvement.
4. Surgical intervention: Depending on the extent of the disease and the presence of
associated findings, surgical excision of the mass or nipple-areola complex may
be necessary.
5. Postoperative follow-up: Regularly monitor the patient for any signs of recurrence
or progression of the disease and provide appropriate surveillance.

Question 4: Scenario: A 40-year-old patient presents with breast asymmetry and ptosis
(sagging). The patient desires improvement in breast shape and position. What is the
likely diagnosis, and how would you manage this patient? Answer: The likely diagnosis is
breast ptosis (sagging). Management options may include:

1. Evaluation and patient counseling: Assess the degree of breast ptosis and discuss
the available options for breast enhancement and reshaping.
2. Surgical intervention: Depending on the severity of the ptosis, options for surgical
correction may include breast

Question 1: Scenario: A 40-year-old female patient presents with a painless lump in her
breast. On examination, you find a firm, non-tender, mobile mass. What is the likely
diagnosis, and how would you manage this patient? Answer: The likely diagnosis is a
benign breast lump, such as a fibroadenoma. Management options may include:

1. Imaging studies: Conduct imaging studies, such as a mammogram or ultrasound,

to evaluate the characteristics of the lump and determine if further investigation is
required.
2. Fine-needle aspiration (FNA) or core needle biopsy: Perform FNA or core needle
biopsy to obtain a tissue sample for histopathological examination and confirm
the benign nature of the lump.

71
 3. Observation or surgical excision: Depending on the size, characteristics, and
patient preference, the benign breast lump may be managed with observation or
surgical excision.

Question 2: Scenario: A 50-year-old patient presents with a painless lump in her breast.
On examination, you find a firm, non-tender, fixed mass with irregular borders. Imaging
reveals microcalcifications. What is the likely diagnosis, and how would you manage this
patient? Answer: The likely diagnosis is breast cancer. Management options may include:

1. Tissue diagnosis: Perform a core needle biopsy or excisional biopsy to obtain a

tissue sample for histopathological examination and determine the type and stage
of breast cancer.
2. Multidisciplinary approach: Involve a multidisciplinary team, including surgeons,
medical oncologists, radiation oncologists, and pathologists, to develop an
individualized treatment plan.
3. Surgical intervention: Surgical options for breast cancer may include breast-
conserving surgery (lumpectomy) or mastectomy, depending on the tumor
characteristics and patient preference.
4. Adjuvant therapy: Administer adjuvant therapies such as radiation therapy,
chemotherapy, targeted therapy, or hormonal therapy, depending on the subtype
and stage of breast cancer.
5. Regular follow-up: Schedule regular follow-up visits to monitor the patient's
response to treatment, assess for any recurrence, and provide ongoing support.

Question 3: Scenario: A 30-year-old patient presents with nipple discharge. On

examination, you find a palpable mass beneath the areola. Imaging reveals a dilated duct.
What is the likely diagnosis, and how would you manage this patient? Answer: The likely
diagnosis is an intraductal papilloma. Management options may include:

1. Imaging studies: Conduct imaging studies, such as a mammogram or ultrasound,

to evaluate the characteristics and location of the intraductal papilloma.
2. Ductography or galactography: Perform ductography or galactography to visualize
the affected duct and confirm the diagnosis.
3. Surgical excision: Surgical excision of the intraductal papilloma may be performed
if it causes bothersome symptoms, if imaging findings are suspicious, or if
malignancy cannot be ruled out.
4. Regular follow-up: Schedule regular follow-up visits to monitor for any recurrence
or development of new papillomas.

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73
Cardio-thoracic General Surgery- Chest - Heart and
Lungs

Question 1: Scenario: A 55-year-old patient presents with chest pain, shortness of breath,
and palpitations. ECG shows ST-segment elevation in leads V2-V6. What is the likely
diagnosis, and how would you manage this patient? Answer: The likely diagnosis is ST-
segment elevation myocardial infarction (STEMI). Management options may include:

1. Immediate reperfusion therapy: Administer fibrinolytic therapy or perform

percutaneous coronary intervention (PCI) to restore blood flow to the affected
coronary artery.
2. Antiplatelet therapy: Prescribe dual antiplatelet therapy, typically aspirin and
P2Y12 receptor inhibitors (such as clopidogrel), to prevent further clot formation.
3. Beta-blockers, ACE inhibitors, and statins: Initiate beta-blockers, ACE inhibitors or
angiotensin receptor blockers, and statins as part of secondary prevention
measures.
4. Cardiac rehabilitation: Encourage the patient to participate in cardiac rehabilitation
programs for exercise training, risk factor modification, and education on heart-
healthy lifestyle.

Question 2: Scenario: A 65-year-old patient presents with chronic cough, dyspnea, and
recurrent respiratory infections. Imaging reveals multiple lung nodules and enlarged
mediastinal lymph nodes. What is the likely diagnosis, and how would you manage this
patient? Answer: The likely diagnosis is lung cancer with mediastinal lymph node
involvement. Management options may include:

1. Tissue diagnosis: Perform a bronchoscopy with biopsy or image-guided biopsy to

obtain a tissue sample for histopathological examination and determine the type
and stage of lung cancer.
2. Multidisciplinary approach: Involve a multidisciplinary team, including surgeons,
medical oncologists, radiation oncologists, and pulmonologists, to develop an
individualized treatment plan.
3. Surgical intervention: Surgical options for lung cancer may include lobectomy,
pneumonectomy, or wedge resection, depending on the tumor characteristics,
stage, and patient's fitness for surgery.

74
 4. Adjuvant therapy: Administer adjuvant therapies such as chemotherapy, radiation
therapy, targeted therapy, or immunotherapy, depending on the tumor subtype and
stage.
5. Palliative care: Provide palliative care and supportive interventions to address
symptoms, optimize quality of life, and address psychosocial needs.

Question 3: Scenario: A 40-year-old patient presents with sudden-onset pleuritic chest

pain, dyspnea, and hemoptysis. Imaging reveals a filling defect in the pulmonary artery.
What is the likely diagnosis, and how would you manage this patient? Answer: The likely
diagnosis is pulmonary embolism (PE). Management options may include:

1. Anticoagulation therapy: Initiate anticoagulation therapy, such as low molecular

weight heparin or direct oral anticoagulants (DOACs), to prevent further clot
formation and promote clot resolution.
2. Hemodynamic support: Provide hemodynamic support with intravenous fluids,
supplemental oxygen, and, in severe cases, consider thrombolytic therapy.
3. Inferior vena cava (IVC) filter placement: Consider IVC filter placement in patients
with contraindications to anticoagulation or in those with recurrent PE despite
therapeutic anticoagulation.
4. Long-term anticoagulation: Prescribe long-term anticoagulation therapy for an
appropriate duration, depending on the underlying cause and risk factors for PE.

Question 1: Scenario: A 55-year-old patient presents with chest pain, shortness of breath,
and palpitations. ECG shows ST-segment elevation in leads V2-V6. What is the likely
diagnosis, and how would you manage this patient? Answer: The likely diagnosis is ST-
segment elevation myocardial infarction (STEMI). Management options may include:

1. Immediate reperfusion therapy: Administer fibrinolytic therapy or perform

percutaneous coronary intervention (PCI) to restore blood flow to the affected
coronary artery.
2. Antiplatelet therapy: Prescribe dual antiplatelet therapy, typically aspirin and
P2Y12 receptor inhibitors (such as clopidogrel), to prevent further clot formation.
3. Beta-blockers, ACE inhibitors, and statins: Initiate beta-blockers, ACE inhibitors or
angiotensin receptor blockers, and statins as part of secondary prevention
measures.
4. Cardiac rehabilitation: Encourage the patient to participate in cardiac rehabilitation
programs for exercise training, risk factor modification, and education on heart-
healthy lifestyle.

75
Question 2: Scenario: A 65-year-old patient presents with chronic cough, dyspnea, and
recurrent respiratory infections. Imaging reveals multiple lung nodules and enlarged
mediastinal lymph nodes. What is the likely diagnosis, and how would you manage this
patient? Answer: The likely diagnosis is lung cancer with mediastinal lymph node
involvement. Management options may include:

1. Tissue diagnosis: Perform a bronchoscopy with biopsy or image-guided biopsy to

obtain a tissue sample for histopathological examination and determine the type
and stage of lung cancer.
2. Multidisciplinary approach: Involve a multidisciplinary team, including surgeons,
medical oncologists, radiation oncologists, and pulmonologists, to develop an
individualized treatment plan.
3. Surgical intervention: Surgical options for lung cancer may include lobectomy,
pneumonectomy, or wedge resection, depending on the tumor characteristics,
stage, and patient's fitness for surgery.
4. Adjuvant therapy: Administer adjuvant therapies such as chemotherapy, radiation
therapy, targeted therapy, or immunotherapy, depending on the tumor subtype and
stage.
5. Palliative care: Provide palliative care and supportive interventions to address
symptoms, optimize quality of life, and address psychosocial needs.

Question 3: Scenario: A 40-year-old patient presents with sudden-onset pleuritic chest

pain, dyspnea, and hemoptysis. Imaging reveals a filling defect in the pulmonary artery.
What is the likely diagnosis, and how would you manage this patient? Answer: The likely
diagnosis is pulmonary embolism (PE). Management options may include:

1. Anticoagulation therapy: Initiate anticoagulation therapy, such as low molecular

weight heparin or direct oral anticoagulants (DOACs), to prevent further clot
formation and promote clot resolution.
2. Hemodynamic support: Provide hemodynamic support with intravenous fluids,
supplemental oxygen, and, in severe cases, consider thrombolytic therapy.
3. Inferior vena cava (IVC) filter placement: Consider IVC filter placement in patients
with contraindications to anticoagulation or in those with recurrent PE despite
therapeutic anticoagulation.
4. Long-term anticoagulation: Prescribe long-term anticoagulation therapy for an
appropriate duration, depending on the underlying cause and risk factors for PE.

76
Question 1: Scenario: A 65-year-old patient presents with chest pain, shortness of breath,
and fatigue. An ECG shows ST-segment elevation. What is the likely diagnosis, and how
would you manage this patient? Answer: The likely diagnosis is ST-segment elevation
myocardial infarction (STEMI). Management options may include:

1. Urgent reperfusion therapy: Perform emergency coronary angiography to identify

the culprit artery and then administer percutaneous coronary intervention (PCI) or
thrombolytic therapy to restore blood flow to the affected myocardium.
2. Antiplatelet and antithrombotic therapy: Administer aspirin, P2Y12 receptor
inhibitors (such as clopidogrel), and anticoagulants (such as heparin) to prevent
further clot formation.
3. Beta-blockers, ACE inhibitors, and statins: Initiate medications to optimize cardiac
function, reduce myocardial workload, and manage risk factors for future cardiac
events.
4. Cardiac rehabilitation: Enroll the patient in a cardiac rehabilitation program to
improve cardiovascular fitness and lifestyle modifications.
5. Regular follow-up: Schedule regular follow-up visits to monitor the patient's
cardiac function, manage medications, and provide ongoing support.

Question 2: Scenario: A 55-year-old patient presents with chronic cough, recurrent

respiratory infections, and hemoptysis. Imaging reveals a mass in the lung. What is the
likely diagnosis, and how would you manage this patient? Answer: The likely diagnosis is
lung cancer. Management options may include:

1. Tissue diagnosis: Perform a biopsy of the lung mass to confirm the diagnosis and
determine the histological subtype of lung cancer.
2. Staging workup: Conduct imaging studies, such as CT scan or PET-CT, and other
investigations to determine the stage and extent of the disease.
3. Multidisciplinary approach: Involve a multidisciplinary team, including thoracic
surgeons, medical oncologists, radiation oncologists, and pulmonologists, to
develop an individualized treatment plan.
4. Treatment modalities: Treatment options for lung cancer may include surgery,
radiation therapy, chemotherapy, targeted therapy, or immunotherapy, depending
on the stage and characteristics of the tumor.
5. Regular follow-up: Schedule regular follow-up visits to monitor the patient's
response to treatment, assess for any recurrence, and provide ongoing support.

Question 3: Scenario: A 45-year-old patient presents with sudden-onset chest pain and
dyspnea. On examination, you find decreased breath sounds on the left side and

77
mediastinal shift. Imaging reveals a complete collapse of the left lung. What is the likely
diagnosis, and how would you manage this patient? Answer: The likely diagnosis is a
tension pneumothorax. Management options may include:

1. Immediate decompression: Perform a needle decompression or insert a chest

tube into the affected side to relieve the tension and restore lung expansion.
2. Oxygen therapy: Administer supplemental oxygen to support oxygenation and
improve the patient's respiratory status.
3. Stabilization and monitoring: Observe the patient closely for any signs of
hemodynamic instability or respiratory distress and provide appropriate
supportive care.
4. Surgical intervention: Consider surgical repair, such as video-assisted
thoracoscopic surgery (VATS) or open thoracotomy, depending on the underlying
cause and recurrence risk factors.
5. Regular follow-up: Schedule regular follow-up visits to monitor lung re-expansion,
assess for any complications, and provide ongoing support.

78
Abdomen

Question 1: Scenario: A 30-year-old patient presents with severe abdominal pain in the
right lower quadrant. On examination, you find tenderness and rebound tenderness in that
area. What is the likely diagnosis, and how would you manage this patient? Answer: The
likely diagnosis is acute appendicitis. Management options may include:

1. Evaluation and investigation: Perform a thorough history and physical

examination. Confirmatory tests, such as complete blood count and abdominal
ultrasound or CT scan, may be done to aid in diagnosis.
2. Appendectomy: Surgical removal of the inflamed appendix (appendectomy) is the
mainstay of treatment.
3. Antibiotic therapy: Administer prophylactic antibiotics before surgery to reduce the
risk of surgical site infections.
4. Postoperative care: Monitor the patient's recovery, provide pain management, and
ensure appropriate wound care.
5. Regular follow-up: Schedule regular follow-up visits to assess the patient's
postoperative recovery, manage any complications, and provide ongoing support.

Question 2: Scenario: A 40-year-old patient presents with recurrent episodes of upper

abdominal pain, bloating, and indigestion. The pain is relieved after eating and worsens
with fasting. What is the likely diagnosis, and how would you manage this patient?
Answer: The likely diagnosis is peptic ulcer disease, specifically a duodenal ulcer.
Management options may include:

1. Confirmation of diagnosis: Conduct an upper gastrointestinal endoscopy to

visualize the ulcer and obtain biopsy samples for histopathological examination.
2. Acid suppression therapy: Prescribe proton pump inhibitors (PPIs) to reduce
gastric acid secretion and promote ulcer healing.
3. Helicobacter pylori eradication: Test for and treat Helicobacter pylori infection, a
common cause of duodenal ulcers, with a combination of antibiotics and PPIs.
4. Lifestyle modifications: Advise the patient to avoid smoking, alcohol consumption,
and nonsteroidal anti-inflammatory drugs (NSAIDs), which can exacerbate ulcer
symptoms.
5. Regular follow-up: Schedule regular follow-up visits to assess the patient's
response to treatment, manage any complications, and provide ongoing support.

79
Question 3: Scenario: A 50-year-old patient presents with painless, jaundice, weight loss,
and a palpable gallbladder. Imaging reveals a dilated common bile duct and a mass in
the head of the pancreas. What is the likely diagnosis, and how would you manage this
patient? Answer: The likely diagnosis is pancreatic cancer with biliary obstruction.
Management options may include:

1. Tissue diagnosis: Perform a biopsy of the pancreatic mass to confirm the

diagnosis and determine the histological subtype of pancreatic cancer.
2. Staging workup: Conduct imaging studies, such as CT scan or MRI, and other
investigations to determine the stage and extent of the disease.
3. Multidisciplinary approach: Involve a multidisciplinary team, including surgeons,
medical oncologists, radiation oncologists, and gastroenterologists, to develop an
individualized treatment plan.
4. Treatment modalities: Treatment options for pancreatic cancer may include
surgery, radiation therapy, chemotherapy, targeted therapy, or immunotherapy,
depending on the stage and characteristics of the tumor.
5. Regular follow-up: Schedule regular follow-up visits to monitor the patient's
response to treatment, assess for any recurrence, and provide ongoing support.

Question 1: Scenario: A 45-year-old patient presents with severe abdominal pain, nausea,
and vomiting. On examination, you find a tender, distended abdomen. Imaging reveals
signs of bowel obstruction. What is the likely diagnosis, and how would you manage this
patient? Answer: The likely diagnosis is bowel obstruction. Management options may
include:

1. NPO (nil per os) and fluid resuscitation: Withhold oral intake and provide
intravenous fluids to maintain hydration and correct electrolyte imbalances.
2. Nasogastric tube insertion: Insert a nasogastric tube to decompress the stomach
and relieve gastric distention.
3. Bowel rest and monitoring: Keep the patient NPO and closely monitor for any signs
of improvement or complications.
4. Surgical intervention: Consider surgical intervention, such as exploratory
laparotomy or laparoscopy, if the obstruction does not resolve or if signs of
strangulation or peritonitis develop.
5. Regular follow-up: Schedule regular follow-up visits to monitor the patient's
progress, assess for any complications, and provide ongoing support.

Question 2: Scenario: A 55-year-old patient presents with recurrent episodes of epigastric

pain, nausea, and vomiting. On examination, you find tenderness in the upper abdomen.

80
Imaging reveals gallstones. What is the likely diagnosis, and how would you manage this
patient? Answer: The likely diagnosis is symptomatic gallstones or cholelithiasis.
Management options may include:

1. Dietary modifications: Advise the patient to avoid fatty and fried foods, as well as
foods that trigger symptoms.
2. Medications: Prescribe medications, such as ursodeoxycholic acid, to dissolve
cholesterol gallstones in select cases.
3. Cholecystectomy: Consider elective cholecystectomy, either laparoscopic or open,
to remove the gallbladder and prevent further symptomatic episodes.
4. Regular follow-up: Schedule regular follow-up visits to monitor the patient's
symptoms, assess for any complications, and provide ongoing support.

Question 3: Scenario: A 50-year-old patient presents with abdominal distention,

constipation, and difficulty passing gas. On examination, you find a tympanic abdomen
and absent bowel sounds. Imaging reveals a dilated colon. What is the likely diagnosis,
and how would you manage this patient? Answer: The likely diagnosis is colonic
obstruction. Management options may include:

1. NPO and fluid resuscitation: Withhold oral intake and provide intravenous fluids to
maintain hydration and correct electrolyte imbalances.
2. Nasogastric tube insertion: Insert a nasogastric tube to decompress the bowel and
relieve distention.
3. Bowel rest and monitoring: Keep the patient NPO and closely monitor for any signs
of improvement or complications.
4. Surgical intervention: Consider surgical intervention, such as exploratory
laparotomy or laparoscopy, to identify and address the cause of the obstruction
(e.g., tumor resection, adhesiolysis).
5. Regular follow-up: Schedule regular follow-up visits to monitor the patient's
progress, assess for any complications, and provide ongoing support.

81
Urinary System

Question 1: Scenario: A 40-year-old patient presents with severe lower abdominal pain,
frequent urination, and hematuria. On examination, you find tenderness in the suprapubic
region. Urine analysis reveals the presence of bacteria and leukocytes. What is the likely
diagnosis, and how would you manage this patient? Answer: The likely diagnosis is acute
bacterial cystitis (urinary tract infection). Management options may include:

1. Antibiotic therapy: Prescribe appropriate antibiotics based on urine culture and

sensitivity results to target the underlying bacterial infection.
2. Analgesics and urinary alkalization: Administer pain medications to alleviate
symptoms and consider urinary alkalization (e.g., with sodium bicarbonate) to
reduce the burning sensation during urination.
3. Hydration: Encourage increased fluid intake to promote urinary flushing and
prevent dehydration.
4. Follow-up and urine culture: Schedule a follow-up visit to assess the patient's
response to treatment and obtain a repeat urine culture to confirm bacterial
clearance.

Question 2: Scenario: A 60-year-old patient presents with lower back pain, lower
abdominal pain, and difficulty passing urine. On examination, you find a palpable,
distended bladder. Imaging reveals an enlarged prostate gland. What is the likely
diagnosis, and how would you manage this patient? Answer: The likely diagnosis is
benign prostatic hyperplasia (BPH) with acute urinary retention. Management options
may include:

1. Urinary catheterization: Insert a urinary catheter to relieve urinary retention and

empty the bladder.
2. Alpha-blockers and 5-alpha reductase inhibitors: Prescribe medications, such as
alpha-blockers (e.g., tamsulosin) and 5-alpha reductase inhibitors (e.g.,
finasteride), to alleviate symptoms and reduce prostate size.
3. Regular follow-up and monitoring: Schedule regular follow-up visits to assess the
patient's response to treatment, monitor prostate size, and evaluate any potential
complications.
4. Surgical intervention: Consider surgical interventions, such as transurethral
resection of the prostate (TURP) or minimally invasive procedures (e.g., laser

82
 ablation, transurethral microwave therapy), for symptomatic BPH that does not
respond to conservative management.

Question 3: Scenario: A 50-year-old patient presents with sudden-onset severe flank pain
radiating to the groin. On examination, you find costovertebral angle tenderness. Imaging
reveals a 5mm stone in the left ureter. What is the likely diagnosis, and how would you
manage this patient? Answer: The likely diagnosis is ureteric colic due to ureteric stone
(renal colic). Management options may include:

1. Pain management: Administer analgesics, such as nonsteroidal anti-inflammatory

drugs (NSAIDs) or opioids, to alleviate severe pain.
2. Hydration: Encourage increased fluid intake to promote urinary flow and facilitate
stone passage.
3. Medical expulsive therapy: Consider prescribing alpha-blockers (e.g., tamsulosin)
to relax the ureter and aid in stone passage.
4. Observation and follow-up: Monitor the patient's symptoms and closely observe
for signs of infection or obstruction. Schedule a follow-up visit to assess stone
passage and provide further intervention if necessary.
5. Interventional procedures: If conservative measures fail or complications arise,
consider interventional procedures such as extracorporeal shockwave lithotripsy
(ESWL) or ureteroscopy with stone removal.

Question 1: Scenario: A 35-year-old patient presents with severe colicky flank pain
radiating to the groin. On examination, you find costovertebral angle tenderness. Imaging
reveals a 4 mm stone in the right ureter. What is the likely diagnosis, and how would you
manage this patient? Answer: The likely diagnosis is ureteral colic due to a renal stone.
Management options may include:

1. Pain management: Administer analgesics, such as nonsteroidal anti-inflammatory

drugs (NSAIDs) or opioids, to relieve pain.
2. Hydration and medical expulsive therapy: Encourage adequate hydration and
consider prescribing alpha-blockers (e.g., tamsulosin) to facilitate stone passage.
3. Observation and follow-up: Monitor the patient's symptoms and imaging to assess
for stone passage or the need for further intervention.
4. Interventional procedures: If the stone does not pass spontaneously or if there are
complications, intervention may be necessary, such as extracorporeal shock wave
lithotripsy (ESWL), ureteroscopy with stone extraction, or percutaneous
nephrolithotomy (PCNL).

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Question 2: Scenario: A 50-year-old patient presents with urinary frequency, urgency, and
a burning sensation during urination. Urinalysis reveals the presence of white blood cells
and bacteria. What is the likely diagnosis, and how would you manage this patient?
Answer: The likely diagnosis is urinary tract infection (UTI). Management options may
include:

1. Antibiotic therapy: Prescribe appropriate antibiotics based on the culture and

sensitivity results to treat the UTI.
2. Fluid intake and urinary hygiene: Encourage increased fluid intake and proper
urinary hygiene practices, such as wiping front to back, to prevent recurrent UTIs.
3. Follow-up: Schedule a follow-up visit to ensure resolution of symptoms and to
assess for any complications or recurrence.

Question 3: Scenario: A 40-year-old patient presents with recurrent episodes of gross

hematuria. Imaging reveals a solid mass in the renal pelvis. What is the likely diagnosis,
and how would you manage this patient? Answer: The likely diagnosis is renal cell
carcinoma. Management options may include:

1. Tissue diagnosis: Perform a biopsy of the renal mass to confirm the diagnosis and
determine the subtype and stage of renal cell carcinoma.
2. Surgical intervention: Consider surgical removal of the affected kidney
(nephrectomy) or partial nephrectomy depending on the tumor size, location, and
staging.
3. Postoperative follow-up: Schedule regular postoperative follow-up visits to
monitor for any recurrence, assess renal function, and provide ongoing support.

Question 4: Scenario: A 55-year-old patient presents with lower urinary tract symptoms
such as frequency, urgency, weak stream, and nocturia. On examination, you find an
enlarged prostate gland. What is the likely diagnosis, and how would you manage this
patient? Answer: The likely diagnosis is benign prostatic hyperplasia (BPH). Management
options may include:

1. Watchful waiting: Monitor the patient's symptoms and provide lifestyle

modifications such as fluid restriction, timed voiding, and avoidance of bladder
irritants.
2. Medications: Prescribe alpha-blockers (e.g., tamsulosin) or 5-alpha-reductase
inhibitors (e.g., finasteride) to relieve symptoms and reduce the progression of
BPH.

84
3. Surgical intervention: If medical management fails or if there are complications,
surgical options such as transurethral resection of the prostate (TURP) or laser
ablation may be considered.

85
Penis, Testis and scrotum

Question 1: Scenario: A 25-year-old patient presents with a painless lump in the scrotum.
On examination, you find a firm, non-tender mass separate from the testis. What is the
likely diagnosis, and how would you manage this patient? Answer: The likely diagnosis is
a scrotal hernia. Management options may include:

1. Clinical evaluation: Assess the size, reducibility, and content of the hernia.
2. Surgical intervention: Consider surgical repair of the hernia, either through open
herniorrhaphy or laparoscopic herniorrhaphy, depending on the patient's age,
comorbidities, and surgeon's preference.
3. Regular follow-up: Schedule regular follow-up visits to monitor the patient's
postoperative recovery and assess for any recurrence or complications.

Question 2: Scenario: A 30-year-old patient presents with a painful, swollen, and tender
scrotum. On examination, you find an enlarged, erythematous, and tender testis. What is
the likely diagnosis, and how would you manage this patient? Answer: The likely diagnosis
is testicular torsion. Management options may include:

1. Urgent surgical intervention: Perform immediate exploration and detorsion of the

twisted testis. Fixation of the contralateral testis may also be considered.
2. Orchidopexy: Perform orchidopexy, or fixation of the testis to the scrotum, to
prevent future episodes of torsion.
3. Regular follow-up: Schedule regular follow-up visits to monitor the patient's
postoperative recovery, assess testicular function, and provide ongoing support.

Question 3: Scenario: A 40-year-old patient presents with erectile dysfunction, difficulty

achieving or maintaining an erection, and reduced libido. What is the likely diagnosis, and
how would you manage this patient? Answer: The likely diagnosis is erectile dysfunction
(ED). Management options may include:

1. Medical therapy: Prescribe phosphodiesterase type 5 (PDE5) inhibitors, such as

sildenafil, tadalafil, or vardenafil, to enhance erectile function.
2. Lifestyle modifications: Encourage the patient to adopt a healthy lifestyle,
including regular exercise, a balanced diet, stress reduction, and smoking
cessation.

86
 3. Psychological counseling: Consider referral to a psychologist or sex therapist to
address any underlying psychological factors contributing to ED.
4. Regular follow-up: Schedule regular follow-up visits to monitor the patient's
response to treatment, adjust medication dosages if necessary, and provide
ongoing support.

Question 4: Scenario: A 35-year-old patient presents with a painful, swollen glans penis
and urethral discharge. On examination, you find erythema and purulent discharge from
the urethral meatus. What is the likely diagnosis, and how would you manage this patient?
Answer: The likely diagnosis is urethritis, most commonly caused by sexually transmitted
infections (STIs) such as gonorrhea or chlamydia. Management options may include:

1. Diagnostic testing: Perform laboratory tests, such as urethral swab or urine

analysis, to identify the causative organism.
2. Antibiotic therapy: Prescribe appropriate antibiotics based on the susceptibility of
the identified pathogen and local guidelines for the management of STIs.
3. Partner notification and treatment: Advise the patient to inform sexual partners
about the diagnosis so they can seek appropriate testing and treatment.

Question 1: Scenario: A 25-year-old patient presents with a painful, swollen scrotum. On

examination, you find an enlarged, tender, and erythematous testicle. What is the likely
diagnosis, and how would you manage this patient? Answer: The likely diagnosis is acute
epididymo-orchitis. Management options may include:

1. Antibiotic therapy: Prescribe antibiotics, such as ciprofloxacin or doxycycline, to

cover both sexually transmitted and urinary tract infection-related organisms.
2. Scrotal support and pain management: Advise the patient to wear supportive
underwear and administer analgesics to alleviate pain and discomfort.
3. Symptom relief measures: Recommend scrotal elevation, cold packs, and bed rest
to reduce inflammation and improve symptoms.
4. Regular follow-up: Schedule regular follow-up visits to monitor the patient's
response to treatment, assess for any complications, and provide ongoing
support.

Question 2: Scenario: A 40-year-old patient presents with a painless lump in the scrotum
that has been present for several months. On examination, you find a non-tender, firm
mass separate from the testicle. What is the likely diagnosis, and how would you manage

87
this patient? Answer: The likely diagnosis is a hydrocele. Management options may
include:

1. Observation: If the hydrocele is small and asymptomatic, it may be managed

conservatively with regular observation.
2. Surgical intervention: If the hydrocele is large, causing discomfort, or affecting the
patient's quality of life, surgical treatment (hydrocelectomy) may be considered.
3. Regular follow-up: Schedule regular follow-up visits to monitor the size of the
hydrocele and assess for any complications.

Question 3: Scenario: A 30-year-old patient presents with a painful erection that has
lasted for several hours. On examination, you find a rigid, painful penis. What is the likely
diagnosis, and how would you manage this patient? Answer: The likely diagnosis is
priapism. Management options may include:

1. Immediate intervention: Perform a penile blood gas analysis to differentiate

between ischemic (low-flow) and non-ischemic (high-flow) priapism.
2. Ischemic priapism: For ischemic priapism, which is an emergency, interventions
may include aspiration of blood from the corpora cavernosa or intracavernosal
injection of sympathomimetic agents, such as phenylephrine.
3. Non-ischemic priapism: Non-ischemic priapism, typically caused by trauma, may
be managed conservatively with observation and pain management.
4. Regular follow-up: Schedule regular follow-up visits to monitor the patient's
condition, assess for any recurrence, and provide ongoing support.

Question 4: Scenario: A 50-year-old patient presents with erectile dysfunction and

decreased libido. On examination, you find decreased testicular size and gynecomastia.
Lab investigations reveal low testosterone levels. What is the likely diagnosis, and how
would you manage this patient? Answer: The likely diagnosis is hypogonadism.
Management options may include:

1. Hormone replacement therapy: Prescribe testosterone replacement therapy to

restore hormone levels and improve symptoms.
2. Regular monitoring: Schedule regular follow-up visits to monitor the patient's
response to hormone replacement therapy, assess for any complications, and
adjust the dosage if needed.
3. Lifestyle modifications: Encourage a healthy lifestyle, including regular exercise, a
balanced diet, and avoidance of smoking and excessive alcohol consumption.

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