FBMV 4751 Enter candidate number I I

Second Examination for the Degree of Bachelor of Medicine

Year 3

-~

MEDICINE and SURGERY

TRINITY TERM 2006

Monday, 26 June, 9.30 a.m. - 12.30 p.m.

This examination paper comprises ten Medicine questions and ten Surgery questions.
You are required to answer ALL the questions.
Enter your candidate number in the space provided above and at the top o f EVERY odd-numbered
page-
This paper is short answer format. Spaces have been left for you to write your answers. Where the
number o f responses is specified (e.g. ‘name five.. .’), the correct number of spaces has been left for
your answers. D o not exceed the requested number of answers.
This booklet has 44 numbered pages; several pages have been left intentionally blank and these blank
pages are clearly indicated. Do not write on the blank pages.
Separate from this booklet is one figure; this is referred to in question 1.
A table o f normal values is provided on page 2 o f this booklet.
Remember it is your own personal responsibility to ensure that you:

write legibly, in permanent dark ink -pencil is not acceptable;

indicate (by crossing out) anything which is not to be read as part of your answer;
hand in all material.

Do not turn over until told that you may do so.

‘ 1
Second Examination for the Degree o f Becbelor of Medicine, 26 June 2006

Normal Values

Haematology
Haemoglobin (H’b) (male) ............................. 13.5- 17.6 g/dl
(female) .......................... 11.5-16.0 g/dl
White cell count (WBC)................................. 4.0-1 1.0 x109/L
Platelets ........................................................... 150-400 x109L
Mean Cell Volume (MCV)............................. 78- 100 fl
Erythrocyte Sedimentation Rate (ESR)
(male) 17-50 yr .......... 1-10 mm
> 50 yr ............ 1-14 mm
(female) 1 7-50 yr .......... 1 - 12 mm
> 50 yr ............ 1-20 mm
C-reactive protein (CRP) ................................ Cl0 m g 5

Biochemistry Blood
Albumin .......................................................... 35-50 g/L
Alanine - amino transferase (ALT) ................ 5-35 I U 5
Aspartate - amino transferase (AST) ............. 5-42 IUL
Alkaline phosphatase ...................................... 80-250 IU/L
Amylase .......................................................... 25-1 80 Somogyi Unitsldl
Bicarbonate ..................................................... 24-30 mmoVL
Bilirubin .......................................................... 3-1 7 pmol/L
Calcium ........................................................... 2.12-2.62 mmol/L
Gamma-glutamyl transpeptidase (GGT) ........ 15-40 I U L
Creatinine ........................................................ 70- 150 pmol/L
Glucose (fasting) ............................................. 3.0-5.5 mmol/L
Lactate dehydrogenase (LDH) ........................ 1 10-250 I U 5
Parathyroid hormone (PTT) ............................. 1.3-7.6 pmoVL
Phosphate ........................................................ 0.8-1.45 mmol/L
Potassium ........................................................ 3.5-5.0 mmovL
Prostate specific antigen (PSA) ...................... < 4 pg/L
Sodium ............................................................ 135-145 mmol/L
Total Protein ................................................... 60-80 g/L
Urate (male) .................................................... 2 10-480 pmoyL
Urate (female) ................................................. 150-390 pmoK
Urea ................................................................ 2.5-6.7 mmoVL
Arterial Blood Gases
Pa CO2 ............................................................ 4.7-6.0 W a
Pa O2 ............................................................... 12.0-14.5 kPa
pH ................................................................... 7 -38-7.44
Base excess ..................................................... 2mmom
3
FBMV 415 1
2
Second Examination for tbe Degree of Bachelor of Medicine, 26 June 2006 Enter candidate number
Question 1 (Medicine)

A 72 year old woman, who has returned from a vacation abroad, is seen in the emergency department
with a two hour history o f palpitations and extertional dyspnoea. She has a cough and is a cigarette
smoker. She has a tachycardia and BP o f 110/70.

An ECG has been performed and is shown in Figure 1 (see separate sheet).

(A) What rhythm does the ECG show? (1 mark)

..............................................................................................................................................
(B) Give three common causes, other than ischaemic or hypertensive heart disease that may
cause this abnormal cardiac rhythm. (3 marks)
1. ..........................................................................................................................................

2. ..........................................................................................................................................
3. .......................... i ...............................................................................................................
(C) Which plasma electrolyte abnormality, i f present, should be corrected? (1 mark)

..............................................................................................................................................
(D) Give the 3 drugs that you would consider prescribing to control the tachycardia, and for
each drug give an important side effect, other than rashes or gastro-intestinal
disturbances? (6 marks)

Drug Side eflect

1............................................. ...................................................................................
2. ............................................ ...................................................................................
3 ............................................. ...................................................................................
(E) Give one non-pharmacological treatment that is used to treat this cardiac rhythm
abnormality. (1 mark)

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

~~

For examiner’s use only:

Circle one Clear Fail Borderline Fail Clear Pass High Pass Total Marks= /I2

FBMV 4751 [turn over)

3
Second Examination for the Degree of Bachelor of Medicine, 26 June 2006 Enter candidate number 1 1
Question 2 (Medicine)

A 19 year old girl is admitted with a 12 hour history o f increasing shortness o f breath and wheezing,
due to an acute exacerbation o f her asthma. She normally takes salbutamol and beclomethasone
inhalers, but is not aware o f her best Peak Expiration Flow Rate (PEFR). On examination she has a
respiratory rate o f 25 breathdmin, pulse 120/minand a BP 110/60. Her initial arterial blood gases on
air show a pH 7.5, p@ 9 kPa, pCO2 3.9kPa, HCOs= 20 mmolL.

Give the precise term that best describes her acid base status (1 mark)

..............................................................................................................................................
A chest X-ray has been performed. Give two important respiratory conditions that you
would look for to explain her breathlessness. (2 marks)
1............................................................................................................................................

2. ...........................................................................................................................................

Give two clinical findings and two findings on arterial blood gases that would be
indications for ventilation in an acute asthmatic attack. (4 marks)

Clinical finding 1 ..................................................................................................................

Clinical finding 2. .................................................................................................................

Arterial blood gases 1. ..........................................................................................................

Arterial blood gases 2. ..........................................................................................................

She recovers and is ready to go home five days later. Name three important management
points that you would check with her prior to discharge? (3 marks)
1 ............................................................................................................................................
2. ...........................................................................................................................................
3. ...........................................................................................................................................

Name two different classes of drugs that are known to commonly exacerbate asthma.
(2 marks)
1 ............................................................................................................................................

2. ...........................................................................................................................................

For examiner’s use only:

Circle one Clear Fail Borderline Fail Clear Pass High Pass Total Marks= I12
FBMV 4751 [turn over]
4
b o n d Examination for tbe Degree of Bachelor of Medicine, 26 June 2006 Enter candidate number
Question 3 (Medicine)

You are a F l doctor in General Practice and asked to see a 73 year old woman who was diagnosed
with Parkinson’s disease 12 months ago. Her daughter, who is a nurse, is apprehensive about the
diagnosis and would like confirmation.

(A) Give four physical signs you might elicit in this patient, that would help to confirm the
diagnosis of Parkinson’s disease. (4 marks)
1............................................................................................................................................

2. ...........................................................................................................................................
3............................................................................................................................................

4. ...........................................................................................................................................

(B) Give three causes for Parkinsonism’other than Parkinson’s disease. (3 marks)

1............................................................................................................................................

2. ...........................................................................................................................................

3. ...........................................................................................................................................

(C) It is decided to prescribe a course of levadopa therapy. Give two important common
side effects that the patient and daughter should be warned about. (2 marks)

1 ............................................................................................................................................

2. ...........................................................................................................................................

@) Outline three points of practical guidance that you would give to help with her activities
o f daily living. (3 marks)

1. ...........................................................................................................................................

2. ...........................................................................................................................................

3. ...........................................................................................................................................

For examiner’s use only:

Circle one Clear Fail Borderline Fail Clear Pass High Pass Total Marks= /I2
FBMV 4751 [turn over]
5
Second Examination for the Degree of Bachelor of Medicine, 26 June 2006 Enter candidate number
Question 4 (Medicine)

A 56 year old man is seen in clinic with a 12 month history o f epigastric pain radiating through to the
back, diarrhoea, with stools that are pale and float, and weight loss. He is a diabetic on insulin, who
had abdominal surgery over a decade ago. He also gives a history o f drinking eight pints of beer
(3.5% alcohol) and four shorts (25mls) o f whisky a day for the last ten years.
(A). Estimate the amount (in units per week) by which his alcohol intake exceeds the
recommended maximum per week? (1 mark)

..............................................................................................................................................
(B) What is the most likely diagnosis and state a reliable investigation that you would
arrange to confirm this? (2 marks)
Diagnosis. ............................................................................................................................
Investigation. .......................................................................................................................
(C) Four days later he is admitted, sweating, tremulous, ataxic with visual hallucinations and
confusion. What is the most likely diagnosis and in addition to fluid, give the two
specific drugs you would prescribe to treat him? (3 marks)
Diagnosis. ............................................................................................................................
Drug 1. .................................................................................................................................
Drug 2. .................................................................................................................................

@) State three other causes o f steatorrhoea and weight loss and give a specific test that
would establish the diagnosis for each. (6 marks)
Cause Investigation

1............................................. ...................................................................................
2. ............................................ ...................................................................................
3............................................. ...................................................................................

For examiner’s use only:

Circle one Clear Fail Borderline Fail Clear Pass High Pass Total Marks= 112

FBMV 4751 [turn over]

6
Second Examination for the Degree of Bachelor of Medicine, 26 June 2006 Enter candidate number
Question 5 (Medicine)

A 23 year old woman who is an I.V. drug user and lives in a hostel presents with a history of weight
loss,cough and generally feeling unwell. The only prescribed medication she is taking is the oral
contraceptive pill. You are suspicious that she may have tuberculosis.

Apart from history, examination and chest X-ray, what 2 other initial tests would you do
to diagnose TB? (2 marks)

1...........................................................................................................................................
2. ..........................................................................................................................................
What other infection would you offer testing for? (1mark)
..............................................................................................................................................
The diagnosis of pulmonary tuberculosis is confirmed. It is decided to treat her with
quadruple therapy. List the anti-microbial agents that are used in this regimen. (4 marks)
1...........................................................................................................................................

2. ..........................................................................................................................................
3. ..........................................................................................................................................
4. ..........................................................................................................................................
What important drug interaction would you wam her specifically about and what advice
would you give to her? (2 marks)

Drug interaction. ..................................................................................................................

Advice. .................................................................................................................................

She fails to respond to the anti-tuberculoustreatment. What is the most likely cause?
(1 mark)
..............................................................................................................................................
What two public health measures would you undertake? (2 marks)
1. ..........................................................................................................................................

2. ..........................................................................................................................................

For examiner’s use only:

Circle one Clear Fail Borderline Fail Clear Pass High Pass Total Marks= f12
F B W 4751 [turn over]
7
Second Examination for the Degm of Bacbelor of Medicine, 26 June 2006 Enter candidate number
Question 6 (Medicine)

One year ago, a 78 year old lady presented with a Dukes' B carcinoma of the colon which was
treated with surgery and chemotherapy. She now presents with abdominal pain which i s caused by
extensive hepatic metastases.

(A) Your consultant tells you to manage her pain using the WHO analgesic ladder. Give
examples o f the drugs, other than non-steroidal anti-inflammatory drugs (NSAIDS), that
you would use for each level o f pain (mild, moderate and severe), according to the WHO
analgesic ladder (3 marks)

Mild. .....................................................................................................................................
Moderate. ..................... :........................................................................................................

Severe. ..................................................................................................................................

(B) Your team decides to prescribe morphine for this lady, noting that she has no respiratory,
cardiac or renal problems. Give three common side-effects o f morphine that you should
be concerned about in this lady. (3 marks)

1............................................................................................................................................

2. ...........................................................................................................................................

3. ...........................................................................................................................................

(C) Give three classes of anti-emetics you might consider using for patients with cancer and
give and example o f each (6 marks)
Class Example

1.............................................. ...................................................................................
2. ............................................. ...................................................................................
3 .............................................. ...................................................................................

For examiner's use only:

Circle one Clear Fail Borderline Fail Clear Pass Kigh Pass Total Marks= 112

FBMV 4751 [turn over]

8
Second Examination for the Degree ofBachelor of Medicine. 26 June 2006 Enter candidate number
Question 7 (Medicine)

A 37 year old physically fit executive, who has returned from a walking holiday in the Himalayas,
presents with a disabling, painful, swollen left knee, such that he is unable to walk. There is no
locking or giving way to suggest a mechanical cause. H e feels unwell and his temperature is 37.8’C.
Give the three most likely diagnoses. (3 marks)
1............................................................................................................................................

2. ...........................................................................................................................................
3. ...........................................................................................................................................

Give three additional clinical features that you would look for in this patient. (3 marks)

1. ...........................................................................................................................................

2. ...........................................................................................................................................
3. ...........................................................................................................................................

You decide to aspirate the joint State three investigations that you would request on the
aspirate. (3 marks)

1............................................................................................................................................

2. ...........................................................................................................................................

3. ...........................................................................................................................................

Give three blood tests, other than Hb,FBC, C W ,ESR and U&E that you would request
and for each state the disease you are seeking. (3 marks)
Blood test Condition
1. ............................................. ...................................................................................
2 .............................................. ...................................................................................
3 .............................................. ...................................................................................

For examiner’s use only:

Circle one Clear Fail Borderline Fail Clear Pass High Pass Total Marks= /12
FBMV 4751 [turn over]
9
Second Examination for the Degree of Bachelor o f Medicine, 26 June 2006 Enter candidate number I I
Question 8 (Medicine)

Whilst visiting her son in hospital, a previously well 59 year old woman, on no medication, over a
matter ofminutes becomes unable to move her right arm, her right leg and is unable to speak. Within
ten minutes the ward staff have taken her to the emergency department.

(A) Give three possible mechanisms for this acute stroke. (3 marks)
1. ..........................................................................................................................................

2. ..........................................................................................................................................
3. ..........................................................................................................................................
(B) Give the likely part o f the brain involved and its arterial territory. (1mark)

..............................................................................................................................................
Thirty minutes later a CT brain scan is essentially normal.
(C) What immediate treatment could be considered to reduce the extent o f disability or
death? (1 mark)

..............................................................................................................................................
(D) What four investigations would help guide secondary prevention measures? (4 marks)
1 ...........................................................................................................................................

2. ..........................................................................................................................................
3. ...........................................................................................................................................
4. ......... ................................................................................................................................
~

During the subsequent week in hospital she slowly improves and is nomotensive.

(E) What three drugs would you prescribe that have been shown to reduce her risk o f fbrther
stroke? (3 marks)

1. ..........................................................................................................................................

2. ..........................................................................................................................................
3. ..........................................................................................................................................

For examiner’s use only:

Circle one Clear Fail Borderline Fail Clear Pass High Pass Total Marks= f12
FBMV 475 1 [turn over]
10
Second Examination for the Dcgrcc of Bachelor of Medicine, 26 June 2006 Enter candidate number
Question 9 (Medicine)

Whilst examining a 35 year old man for an insurance medical you discover his BP to be 150/100,
together with bilateral abdominal masses. YOUarrange an ultrasound which shows polycystic
kidneys.

(A) Give four other renal presentations o f this disease. (4 marks)

1. ..........................................................................................................................................

2. ..........................................................................................................................................
3. ..........................................................................................................................................
4. ..........................................................................................................................................
State three extra-renal manifestations o f this condition? (3 marks)

1...........................................................................................................................................

2. ..........................................................................................................................................
3. ..........................................................................................................................................
A blood test reveals a creatinine o f SOOpmoyL, calcium o f 1.98mmoVL, phosphate o f
22mmoVL and albumin of 43g/L. What medications should be started to improve his
calcium and phosphate metabolism? (2 marks)

1. ..........................................................................................................................................
2. ..........................................................................................................................................
@) You start him on an angiotensin-converting enzyme (ACE) inhibitor. State three
important side-effects, other than rashes and gastro-intestinal disturbances, that you
would warn him about. (3 marks)
1...........................................................................................................................................

2. ..........................................................................................................................................
3. ..........................................................................................................................................

For examiner’s use only:

Circle one Clear Fail Borderline Fail Clear Pass High Pass Total Marks= I12

FBMV 415 1 [turn over]

11
Second Examination for the Degree of Bachelor o f Medicine, 26 June 2006 Enter candidate number
Question 10 (Medicine)

A 54 year old man is brought to the emergency department by ambulance having been found
unconscious by his neighbours. His ‘BM’ is off the top o f the scale, he has 1+ketonuria and his
U+Es show: Na = 166 mmol/L, K = 5.4 mmoVL, Urea = 22.3 mrnoVL, Creatinine = 256 pnol/L,,
glucose = 48.1 mmol/L.
What is the calculated serum osmolality? (1mark)
..............................................................................................................................................
Give the precise diagnostic term for this condition. (1 mark)

..............................................................................................................................................
List the six most important points o f your initial management. (6 marks)

1 . ...........................................................................................................................................
2. ...........................................................................................................................................

3. ...........................................................................................................................................

4. ...........................................................................................................................................

5 . ...........................................................................................................................................

...........................................................................................................................................
List four complications you will be monitoring for. (4 marks)

1. ...........................................................................................................................................

2. ...........................................................................................................................................

3. ...........................................................................................................................................

4. ...........................................................................................................................................

For examiner’s use only:

Circle one Clear Fail BorderIine Fail Clear Pass High Pass Total Marks= I12
FBMV 4751 [turn over]
12
Second Examination for the Degree of Bachelor of Medicine, 26 June 2006 Enter candidate number
Question 11 (Surgery)

A 42 year old woman is referred to the endocrine surgical clinic with a 2cm thyroid nodule on the
right side. She is biochemically euthyroid.
(A) What is the most likely diagnosis? (1 mark)

..............................................................................................................................................
(B) What test should be performed in clinic to confirm the diagnosis? (1 mark)
..............................................................................................................................................
(C) Name three important factors either in the patient's history or on physical examination
that would lead you to suspect clinically that the nodule may be malignant. (3 marks)

1............................................................................................................................................

2. ...........................................................................................................................................

3. ...........................................................................................................................................

@) Name three pathological varieties of thyroid tumours. (3 marks)

z ............................................................................................................................................
2. ...........................................................................................................................................

3. ...........................................................................................................................................

(E) The patient proceeds to total thyroidectomy. Name three specific early complications
that may arise as a consequence of this procedure. (3 marks)

I. ...........................................................................................................................................
2. ...........................................................................................................................................

3. ...........................................................................................................................................

(F) What tumour marker specific to the thyroid gland may be used to monitor the patient
following surgery for thyroid cancer? (1 mark)
..............................................................................................................................................

For examiner's use only:

Circle one Clear Fail Borderline Fail Clear Pass High Pass Total Marks= 112
[turn over]
13
Second Examination for tbc Degree ofBachelor of Medicine, 26 June 2006 Entcr candidate number
Question 12 (Surgery)

A 74 year old man who is a retired bus driver presents with a six month history o f weight loss. He
says he had been eating normally until a week before, when he started to feel sick and bloated. He
has become very constipated over the last few weeks and he appears very thin, pale and short of
breath at rest. Rectal examination and rigid sigmoidoscopy shows a stenosing carcinoma at the
rectosigmoid junction.

What type of carcinoma are biopsies likely to show? (1 mark)

..............................................................................................................................................
Abdominal examination suggests ascites. What are two common bedside clinical tests
(clinical signs) for ascites? (2 marks)

1............................................................................................................................................

2. ...........................................................................................................................................

Name two important staging investigations. (2 marks)

1. ...........................................................................................................................................

2. ...........................................................................................................................................

Name three likely causes o f his shortness o f breath. (3 marks)

1............................................................................................................................................

2. ...........................................................................................................................................

3. ........................................................................................... ;...............................................
Name two therapeutic options which may alleviate the ascites. (2 marks)

1. ...........................................................................................................................................

2. ...........................................................................................................................................

Over the next few weeks his general condition deteriorates, and the rectosigmoid tumour causes
complete obstruction.

(F) Give two appropriate options that can be used to alleviate the obstruction? (2 marks)

1. ...........................................................................................................................................

2. ...........................................................................................................................................

For examiner’s use only:

Circle one Clear Fail Borderline Fail Clear Pass High Pass Total Marks= /12
FBMV 475 I [turn over]
14
Second Examination f o r the Degm ofBachelor of'Medicine, 26 June 2006 Enter candidate number

Question 13 (Surgery)

A 59 year old man presents to the emergency department with acute upper abdominal pain radiating
to the back. He has vomited four times and continues to retch whilst being interviewed. Abdominal
examination reveals generalised peritonitis and there are no bowel sounds. The SHO in the
emergency department has measured the amylase which is 2340 Somogyi Unitddl. She has referred
the patient to you for admission with a diagnosis o f acute pancreatitis.

(A) Name the two most common pre-disposing causes o f acute pancreatitis. (2 marks)
1. ...........................................................................................................................................

2. ...........................................................................................................................................

After taking the history and examining the patient, you agree with the diagnosis and arrange some
investigations to stratify the severity of the attack. The following results are obtained:-

WBC = 19.0 x 109LL; Glucose = 4.0 mmol/L; LDH = 360 IUL; Urea = 9 mmol/L;
, Calcium = 2.0 mmovL; Pa 0 2 = 7.9 H a .

(B) Would you classify the pancreatitis as mild,moderate or severe? (1 mark)

..............................................................................................................................................
(C) List four immediate steps which you would institute in the management o f this patient.
(4 marks)
1............................................................................................................................................

2. ...........................................................................................................................................
3. ...........................................................................................................................................

4. ...........................................................................................................................................

@) The clinical course o f acute pancreatitis is variable. List four life threatening
complications of acute pancreatitis that can OCCLU in the first ten days of the illness.
(4 marks)
1............................................................................................................................................

2. ...........................................................................................................................................

3. ...........................................................................................................................................

4. ...........................................................................................................................................

(E) What is the indication for surgery for fblminant pancreatitis? (1 mark)
..............................................................................................................................................

For examiner's use only:

Circle one Clear Fail Borderline Fail Clear Pass High Pass Total Marks= I12

FBMV 4751 [turn over]

15
Second Examination for the Degree of Bacbelor of Medicine, 7% June 2006 Enter candidate number
Question 14 (Surgery)

A 78 year old man presents with a 4 hour history of left sided abdominal pain radiating through to
the back associated with collapse. On examination BP 90/60 mmHg, pulse 120/min. The abdomen
is difksely tender with a mass palpable in the left side. He is presumed to have a ruptured
abdominal aortic aneurysm (AAA).

(A) List four immediate essential features of management that you would take. (4 marks)
1............................................................................................................................................

2. ...........................................................................................................................................

3. ...........................................................................................................................................

4 ............................................................................................................................................

(B) List four of the differential diagnoses o f ruptured AAA. (4 marks)

1............................................................................................................................................

2. ...........................................................................................................................................

3. ...........................................................................................................................................

4. ...........................................................................................................................................

(C) List three potential complications of unruptured aortic aneurysms. (3 marks)

I ............................................................................................................................................

2. ...........................................................................................................................................

3. ...........................................................................................................................................

@) What is the perioperative mortality for ruptured AAA? (1 mark)

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

For examiner’s use only:

Circle one Clear Fail Borderline Fail Clear Pass High Pass Total Marks= I12
FBMV 4751 [turn over]
16
Second Examination for the Degree of Bscbelor of Medicine, 26 June 2006 Enter candidate number
Question 15 (Surgery)

A 30 year old woman is transferred to the emergency Service unconscious from the scene of a road traffic
accident. The Ambulance Paramedics report that they believe that she has been thrown out of her open
top sports car by acute deceleration. Immediate examination shows extensive facial and cranial skin
abrasions with swelling. There is an obvious open left femoral fracture.
Name the three initial priorities in the management of this patient. (3 marks)
1...........................................................................................................................................

2. ..........................................................................................................................................
3. ..........................................................................................................................................
Chest, cervical spine and pelvic X-rays are normal. Name two further radiological
examinations that are required in this patient. (2 marks)
1...........................................................................................................................................

2. ..........................................................................................................................................
What are the three components o f the Glasgow coma scale? (3 marks)

1. ..........................................................................................................................................
2. ..........................................................................................................................................
3...........................................................................................................................................

Resuscitation with intravenous fluids is under way and you have completed the primary
and the secondary survey which reveal no other injuries. Give four further measures that
you will take in her immediate management. (4 marks)
1...........................................................................................................................................

2. ..........................................................................................................................................
3. ..........................................................................................................................................
4, ...........................................................................................................................................

For examiner’s use only:

Circle one Clear Fail Borderline Fail Clear Pass High Pass Total Marks= /12

FBMV 4751 [turn over]

17
Second Examination for the Degree of Bachelor of Medicine, 26 June 2006 Enter candidate number
Question 16 (Surgery)

Where is the usual onset o f pain in acute appendicitis? (1 mark)

..............................................................................................................................................
What pathological process is often thought to underlie the initiation o f acute
appendicitis? (1 mark)

..............................................................................................................................................
List two ways in which the initial pain classically changes. (2 marks)

1. ...........................................................................................................................................

2. ...........................................................................................................................................

What is responsible for these changes in symptomatology? (1 mark)

..............................................................................................................................................
List two systemic symptoms, other than nausea and vomiting, associated with acute
appendicitis. (2 marks)

1............................................................................................................................................

2. ...........................................................................................................................................

List four of the major differential diagnoses most pertinent to a 25 year old woman
presenting with symptoms suggestive o f acute appendicitis. (4 marks)

1. ...........................................................................................................................................

2. ...........................................................................................................................................

3. ...........................................................................................................................................

4. ...........................................................................................................................................

What test should initially be performed to exclude the most serious of these conditions?
(1 mark)

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

~~~~ ~

For examiner’s use only:

Circle one Clear Fail Borderline Fail Clear Pass High Pass Total Marks= 112
FBMV 4751 [turn over]
18
Second Examination for the Degree of Bachelor of Medicine, 26 June 2006 E n b x candidate number
Question 17 (Surgery)

A 60 year old former blacksmith presents to the ENT clinic with a 20 year history o f progressive
hearing loss.
What are the five cardinal symptoms o f ear disease in addition to deafness? (5 marks)

1. ...........................................................................................................................................

2. ...........................................................................................................................................

3. ...........................................................................................................................................

4. ...........................................................................................................................................
5 ............................................................................................................................................

If this patient’s hearing loss is occupational, which one o f these symptoms is most likely
to accompany the deafhess? (1 mark)
..............................................................................................................................................
When examining the patient with an otoscope, in which three directions would you
gently pull the pinna to afford the best possible view o f the tympanic membrane?
(3 marks)
1............................................................................................................................................

2. .............................................................. ;............................................................................
3. ...........................................................................................................................................

What investigation would you obtain to assess his hearing? (1 mark)

..............................................................................................................................................
What are the two findings of this investigation in a patient with occupational deafness?
(2 marks)
1. ...........................................................................................................................................

2. ...........................................................................................................................................

For examiner’s use only:

Circle one Clear Fail Borderline Fail Clear Pass High Pass Total Marks= I12

FBMV 4751 [turn over]

19
Second Examination for the Degree of Bacbelor of Medicine, 26 June 2006 Enter candidate number[
Question 18 (Surgery)

Mr Jones is a 55 year old man referred with a suspected right inguinal hernia to the surgical clinic by
his GP. Clinically he has a lump in his right groin,thatstarts in the mid inguinal region and descends
into his scrotum.

(A) Detail four steps or physical findings that you could perform to establish that this i s
indeed an inguinal hernia (4 marks)
1............................................................................................................................................

2. ...........................................................................................................................................

3 ............................................................................................................................................

4. ...........................................................................................................................................

Mr Jones is otherwise fit and well and is listed for day surgery repair o f his hernia.
(J3) What is the current preferred surgical method of repairing an inguinal hernia? (1 mark)
..............................................................................................................................................
At operation Mr Jones is identified as having an indirect as opposed to a direct inguinal hernia.

(C) What anatomical structure is used per-operatively to distinguish between the two types
o f hernia? (1 mark)

..............................................................................................................................................
As part o f his anaesthetic h4r Jones is given an ilio-inguinal block for post operative pain relief.

@) What is the anatomical landmark used for this procedure? (1 mark)

..............................................................................................................................................
(E) What local anaesthetic agent is used for this procedure? What strength is used
(percentage) and how long does the local anaesthetic effect last for? (3 marks)
Name.....................................................................................................................................

Strength (!?A)..........................................................................................................................
Effect lastsfor .......................................................................................................................

For examiner’s use only:

Circle one Clear Fail Borderline Fail Clear Pass High Pass Total Marks- 112

FBMV 4751 [turn over]

20
Second Examination for the Degree of Bachelor of Medicine, 26 Jnne 2006 Enter candidate number

Question 18 (Surgery) continued

Unfortunateiy h4.r Jones suffers a complication as a result of the ilio-inguinal block and is unable to
go home as a result o f this.

(F) What is the most common complication o f this procedure causing a delay of discharge?
(1 mark)

..............................................................................................................................................
(G) What is the incidence of this complication in delaying discharge in hernia patients?(1 mark)
..............................................................................................................................................

-~ ~~~ ~~ ~ ~

For examiner’s use only:

Circle one Clear Fail Borderline Fail Clear Pass High Pass Total Marks- f12
FBMV 4751 [turn over]
21
Second Examination for the Degree of Bachelor of Medicine, 26 June 2006 Enter candidste number
Question 19 (Surgery)

A fit 63 year old man with a previous history o f lower urinary tract symptoms presents to the
emergency department with painful urinary retention. On examination, his bladder i s palpable and
his prostate is enlarged but clinically benign. You are called to catheterise him urethraliy, but the
catheter will not pass into the bladder.
What procedure should be done next to achieve bladder drainage? (1 mark)
..............................................................................................................................................
Once a catheter is in the bladder, what two important pieces of information should be
recorded with reference to the drained urine (2 marks)
1............................................................................................................................................

2. ...........................................................................................................................................

List the two likely possible diagnoses (2 marks)

1............................................................................................................................................

2. ...........................................................................................................................................

List two urological procedures that may be necessary. (2 marks)

1............................................................................................................................................

2. ...........................................................................................................................................

List three complications of untreated bladder outflow obstruction. (3 marks)

1............................................................................................................................................

2. ...........................................................................................................................................
3. ...........................................................................................................................................

Name two medical treatments which may prevent acute urinary retention in the presence
o f lower urinary tract symptoms. (2 marks)
1............................................................................................................................................

2. ............................................................................. .............................................................

For examiner’s use only:

Circle one Clear Fail Borderline Fail CIear Pass High Pass Total Marks= /I2

FBMV 4751 [turn over]

22
Second Examination for the Degree of Bachelor of Medicine, 26 June 2006 Enter candidate number
Question 20 (Surgery)

A 60 year old farmer presents with a new pigmented lesion on his cheek. You suspect malignant
melanoma

(A) Name two important differential diagnoses (2 marks)

1............................................................................................................................................

2, ...........................................................................................................................................
What four characteristics might identify this lesion as a melanoma? (4 marks)
1............................................................................................................................................

2. ...........................................................................................................................................
.5 . ...........................................................................................................................................
4. ...........................................................................................................................................

Name four different aetiological factors for the development of malignant melanoma.
(4 marks)
1............................................................................................................................................

2. ...........................................................................................................................................

3 ............................................................................................................................................

4. ...........................................................................................................................................

@I What pathological feature on excised specimen dictates further treatment and prognosis?
(1 mark)

..............................................................................................................................................
Q How might micrometastases be detected? (1 mark)
..............................................................................................................................................

For examiner’s use only:

Circle one Clear Fail Borderline Fail Clear Pass High Pass Total Marks= 112

FBMV 475 1
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