BLEEDING PER RECTUM

Answer the following questions (10 Marks)

1) Mention the most common cause of painful bleeding per anum? (1 mark)

2) Mention two cause of painless bleeding per anum? (2 marks)

3) Name the origin of bleeding if stool blood is bright red? (1 mark)

4) Name the origin of bleeding if stool blood is dark red? (1 mark)

5) Mention the cause for stool mixed with blood and why? (1 mark)

6) Mention the cause for blood on the surface of stool and why? (1 mark)

7) What should be suspected if children present with bleeding per anum? (1 mark)

8) What is spurious diarrhea? (1 mark)

9) In which condition early morning bloody diarrhea seen? (1 mark)

ANSWER KEY:
1. Fissure in ano
– page no. 553 A manual of clinical surgery – S Das 13th edition
2. Haemorrhoids and carcinoma
– page no. 553 A manual of clinical surgery – S Das 13th edition
3. Rectum or anal canal
– page no. 553 A manual of clinical surgery – S Das 13th edition
4. Caecum, Ascending, transverse, descending or sigmoid colon
– page no. 553 A manual of clinical surgery – S Das 13th edition
5. Blood mixed with faeces means that the blood has come from bowel
higher than sigmoid colon where the softness of the stool remains giving
chance to the blood to mix with the faeces
– page no. 553 A manual of clinical surgery – S Das 13th edition
6. Blood on the surface of the faeces usually comes from the rectum or anal
canal
– page no. 553 A manual of clinical surgery – S Das 13th edition
7. Rectal Polyp
– page no. 553 A manual of clinical surgery – S Das 13th edition
8. The patient endeavour to empty the rectum several times a day, often with
the passage of flatus and a little blood stained mucus (bloody slime).
– page no. 1329 Bailey & Love ‘s short practice of surgery 27th edition
9. Carcinoma rectum
– page no. 1329 Bailey & Love ‘s short practice of surgery 27th edition
 Eye signs of Thyroid:

1) What is the condition shown in picture? (1 mark)

2) Mention the reason for identification? (1 mark)

3) Which disease manifests this condition? (1 mark)

4) What is lid lag and what is the sign called? (1 mark)

5) What is lid retraction? (1 mark)

6) Name the eye signs due to adrenergic overactivity? (2 marks)

7) Name an eye signs due to infiltrative ophthalmopathy? (1 mark)

8) What are the four important changes occur in eyes of thyrotoxicosis? (2 marks)
ANSWER KEY:
1. Exophthalmos – page no. 412, Hamilton bailey physical signs – 19th edition.
2. Both lids are moved away showing sclera below and above the iris, and visible goitre
– page no. 384, A manual of clinical surgery – S Das 13th edition.
3. Graves disease – page no. 1635, Schwartz’s principles of surgery, 11 th edition vol – 2.
4. The upper eyelid cannot keep pace with the eyeball when it looks down
following an examiner's finger moving downwards from above. Von Graefe's
sign – page no. 383, A manual of clinical surgery – S Das 13th edition.
5. When the upper eye lid is higher than normal due to overactivity of the involuntary
(smooth muscle) part of the levator palpebrae superioris muscle while the lower
eyelid is in normal position. - page no. 383, A manual of clinical surgery – S Das 13 th
edition.
6. Page no. 412, Hamilton bailey physical signs – 19th edition.

7. Page no. 412, Hamilton bailey physical signs – 19th edition.

8. Changes seen in eyes due to thyrotoxicosis are lid retraction, exophthalmus,

ophthalmoplegia, chemosis - page no. 383-384, A manual of clinical surgery – S
Das 13th edition.
Examination for DVT:

Answer the following: (10 Marks)

1) What is the test shown in picture? (1 Mark)

2) What is the pre-requisite to do this test? (1 Mark)
3) What is the inference (symptom & sign) examiner get from this test? (1 Mark)
4) What is the significance of this test? (1 Mark)
5) If this test is positive what should not be done? (1 Mark)
6) What are the other clinical test to diagnosis this test? (1 Mark)
7) What is Virchow’s triad? (1 Mark)
8) What criteria used to predict this disease? (1 Mark)
9) What is the management for this disease? (2 Marks)
ANSWER KEY:
1) Modified perthes’ test. - page no. 103, A manual of clinical surgery
– S Das 13th edition.
2) There should not be any perforator incompetence. - page no. 103,
A manual of clinical surgery – S Das 13th edition.
3) Symptoms - cramp like pain; signs - veins becoming prominent. -
page no. 103, A manual of clinical surgery – S Das 13th edition.
4) To find deep vein thrombosis of lower limbs. - page no. 103, A
manual of clinical surgery – S Das 13th edition.
5) Varicose vein treatment is contraindicated
6) Homans sign and Moses sign. - page no. 103, A manual of clinical
surgery – S Das 13th edition.
7) Endothelial injury, hypercoagulable state ( thrombophilia) and
stasis. page no. 986 Bailey & Love ‘s short practice of surgery 27 th
edition
8) Modified wells criteria. page no. 988 Bailey & Love ‘s short practice
of surgery 27th edition
9) Medical management – anticoagulation; surgical management –
thrombolysis, endovenous thrombectomy, and stenting. page no.
990 Bailey & Love ‘s short practice of surgery 27th edition
45 years old male came with complaints of swelling in his left lower limb
for the past 4 days which is associated with severe pain and fever. On
examination there is redness, local rise of temperature and tenderness
in the surrounding area.

1) What will be your surgical treatment of choice for the above condition?
(1 mark)

2) Most predominant organism isolated from pyogenic abscess? (1 mark)

3) Composition of pus? (2 marks)

4) Reason for pain in a patient with abscess? (2 marks)

5) Role of antibiotic therapy following surgical intervention in this patient?

(2 marks)

6) Time taken for abscess formation in a surgical wound? (1 mark)

7) Persistent chronic abscess can lead to formation of _________________?

(1 mark)
Answer key:

1) Incision and drainage

2) Staphylococcus aureus

3) Dead WBCs, predominantly neutrophils

4) Abscess contains hyperosmolar material which draws in fluid resulting in
increased pressure and pain

5) If the abscess cavity is left open no need of antibiotics and if abscess

cavity is closed, antibiotic is given

6) 7-10 days

7) Sinus or fistula formation

Reference: O’Connell PR, McCaskie AW, Sayers RD. Bailey & Love’s Short Practice
of Surgery. CRC Press; [Link] 5; p.56.
A 30-year-old male patient presented with a lump in right iliac
fossa for the last 5 days following an acute attack of pain in right
iliac fossa for which is associated with fever and vomiting. On
further evaluation he was diagnosed with appendicular mass.
1) What is the standard regimen used for treatment of appendicular mass
(2 marks)

2) What is the criteria to discontinue the above regimen (2 marks)

3) Write the parameters to be monitored in this regimen (2 marks)

4) What is the best radiological investigation of choice, for appendicular

mass (2 marks)

5) What will you do if the mass increases in size with worsening abdominal
pain? (1 mark)

6) Enumerate the investigation of choice for follow up? (1 mark)

Answer key:

1) Ochsner-Scherren regimen

2) Rising pulse rate, increasing or spreading abdominal pain, increasing

size of the mass

3) Temperature and pulse Q4h, fluid balance charting and size of the
mass

4) Contrast enhanced CT scan

5) Stop conservative management (Ochsner-Scherren regimen) and plan

for surgery

6) CT / MRI to ensure complete resolution

• Reference: O’Connell PR, McCaskie AW, Sayers RD. Bailey & Love’s
Short Practice of Surgery. CRC Press; [Link] 76; p.1343-44.
A 25-year-old Male was brought to casualty with alleged history of
RTA (2-wheeler vs 4-wheeler). On examination, Pulse: 120/min, BP:
80/60 mmhg & RR: 28/min. Physical examination showed deformed
and externally rotated left lower limb.

1) Identify the type of shock in the given clinical scenario and what will be
your immediate line of management (2 marks)
2) Name the 2 clinical parameters to undergo early derangement (2 marks)
3) Best clinical parameter for monitoring the progress of septic shock (2
marks)
4) What is the optimum urine output per hour to suggest adequate tissue
perfusion? (2 marks)
5) Type of shock associated with bradycardia? (2 marks)
Answer key:

1) Hypovolemic or hemorrhagic shock. Secure 2 wide bore cannula and

resuscitation with IV fluids
2) Pulse rate (tachycardia) and pulse pressure
3) Urine output
4) 0.5-1 ml/kg/hr
5) Neurogenic shock

Reference: Trauma AC of SurgeonsCO, Acs. Advanced Trauma Life Support:

Student Course Manual. [Link] 3;p 42-61.
Examination of Cervical Lymph Nodes:

1) What is the levels of cervical lymph node station (1 mark)

2) How will you examine cervical lymph nodes (1 mark)

3) What is cold abscess (1 mark)

4) What is virchow’s node (1 mark)

5) Differential diagnosis of chronic cervical lymph nodes (1 mark)

6) What are the investigations for cervical lymph nodes (1 mark)

7) What are the treatment for tubercular lymph nodes (2 marks)

8) Differentiate inflammatory from malignant lymph node (1 mark)

9) What is the difference between Hodgkins and Non-Hodgkins

lymphoma (1 mark)
Per Rectal Examination:

1) What are the positions of per rectum examination (1 mark)

2) What is the diagnosis for painful bleeding per rectal examination (1 mark)

3) What is Goodsall’s rule (1 mark)

4) What are the positions of primary haemorrhoids (1 mark)

5) What are the grades of haemorrhoids (1 mark)

6) Write the treatment of perianal abscess (2 marks)

7) What are the types of fistula in ano (2 marks)

8) Write the management of haemorrhoids (1 mark)

 Examination of Xray:

1) What is this radiological appearance (1 mark)

2) Surgical Cause of this radiological appearance (2 marks)
3) What clinical signs will be there in this condition (2 marks)
4) Initial steps in management (2 marks)
5) Surgical management (2 marks)
6) When will you remove ICD (1 mark)
A 55 year old male, following RTA presented to casualty with

severe breathing difficulty secondary to chest trauma.

1) What is the implication of first rib fracture? (1 mark)

2) What are the implications of lower rib fractures? (1 mark)

3) What is Flail chest (1 mark)

4) Treatment of isolated rib fracture? (1 mark)

5) What is the most common source of bleeding in traumatic haemothorax? (1 mark)

6) What is the treatment of tension pneumothorax in children and adults? (1 mark)

7) Mention 2 indications of thoracotomy following traumatic haemothorax? (1 mark)

8) What is Beck’s triad and seen in which condition? (1mark)

9) What is sucking chest wound? (1 mark)

10) How will you manage sucking wound of the chest? (1 mark)
ANSWERS:

1. What is the implication of first rib fracture? Severe violence; associated vascular or brachial

plexus injury.

2. What are the implications of lower rib fractures? Rule out liver, spleen or kidney injury.

3. What is Flail chest? 2 or more ribs fractured at 2 or more places; Types - Central and lateral

(Central- fracture of ribs on either side of sternum resulting in flail segment of sternum;

Lateral- fracture of multiple ribs on one side resulting in flail segment on one side of the

chest)

4. Treatment of isolated rib fracture? Analgesics, respiratory physiotherapy and incentive

spirometry.

5. What is the most common source of bleeding in traumatic hemothorax? Intercostal vessels

6. What is the treatment of tension pneumothorax in children and adults? Children- wide bore

needle at 2nd Intercostal space at midclavicular line; Adults- Intercostal tube at 5th

intercostal space mid- axillary line

7. Mention 2 indications of thoracotomy following traumatic hemothorax? Massive bleeding >

1 litre on ICD ; Bleeding > 200ml/hour over 3 hours; Associated tracheobronchial injury,

oesophageal injury, great vessel injury.

8. What is Beck’s triad and seen in which condition? Muffled heart sounds, Increased JVP,

Hypotension; Cardiac tamponade

9. What is sucking chest wound? Penetrating injury in chest wall through the pleura; air moves

in and out of the wound during inspiration and expiration respectively leads to inadequate

ventilation

10. How will you manage sucking wound of the chest? 3 way occlusive dressing; wound is

repaired and ICD is placed beside the wound.

A 60 year old patient presents with pain abdomen, vomiting, distention

and constipation for 5 day; obstipation since 1 day. He had abdominal

surgery 1 year ago.

1) Which loop of bowel is seen? (2 marks)

2) What is the most likely diagnosis? (2 marks)

3) What is the cause? (2 marks)

4) What are the signs of the above mentioned diagnosis in the x-ray? (2 marks)

5) How will you manage the same? (2 marks)

ANSWER:
1. Which loop of bowel is seen? The given clinical scenario and X-ray suggest

intestinal obstruction where the involved segment is the jejunum. The

obstructed bowel loops are central in location and show valvulae conniventes

(mucosal folds that cross the entire diameter of the bowel)

2. What is the most likely diagnosis? Intestinal obstruction

3. What is the cause? Adhesion

4. What are the signs of the above-mentioned diagnosis in the x-ray? Dilated

bowel loops ([Link] rule- 3cm for small bowel, 6cm for large bowel and 9cm

for caecum), Multiple air fluid levels in erect film

5. How will you manage the same? NPO, Iv fluids, Ryle's tube let to drain +/-

Antibiotics; If conservative management failed, Laparotomy and adhesiolysis.

Elderly patient presents with abdominal pain and constipation.

1) What is the radiological sign seen? (2 marks)

2) What is the diagnosis? (2 marks)

3) First therapeutic procedure done in casualty? (2 marks)

4) What is the definitive treatment? (2 marks)

5) What happens if definitive treatment is not given? (2 marks)

How will you counsel a patient for management of peritonitis?

(10marks)
ANSWER:

How will you counsel a patient for management of peritonitis?

[Link] Yes/no

1. Self introduction

2. Diagnosis explanation; why/ how it happened

3. What are the different modalities of management

4. Preparation of patient for ot (ryles, foleys, iv fluids, written

consent, antibiotics)

5. Anaesthesia procedure risks and complications

6. Perioperative complications and expected duration of

procedure

7. Procedure to be done (stomach- omental patch / bowel

perforation- resection and stoma)

8. Post op icu stay, ventilator requirement, ionotropes

requirement

9. Post operative expected outcome

10. Overall prognosis and reassurance at the end

Each explanation carries 1 mark

How will you counsel the patient for amputation?

(10 Marks)
CHECK LIST / ANSWER:

[Link] Observation Satisfactory Unsatisfactory

1 Introduction Tell your name 1 0

Did Candidate give his / her name Ask pt. name
Did candidate ask name of the patient
2 Diagnosis Gangrene of foot 2 0
Did the candidate explain about the diagnosis of Infection
the pt condition Carcinoma
Trauma

3 Choice of treatment Level of 2 0

Did the candidate explain about the procedure amputation
and alternative treatment and anaesthesia Wound
debridement
Antibiotics
Anticoagulation
Type of anesthesia
- GA /SA/BLOCK
4 Complication and risk Post op 2 0
Did the candidate explain about the possible complication
complication of the procedure Bleeding
Per operative Infection
Post operative Phantom limb
Risk of higher level
of amputation
General
complication
Death
5 Post operative follow up Days of stay- 5-7 2 0
Did the pt explain about post operative period days
Drugs given Drugs - iv
diet antibiotics ,
Post operative care analgesics , anti
Stay in hospital coagulation ,
Follow up regular medication
Physiotherapy and
exercise
Prosthesis
6 Open questions to finish 1 0
Did the candidate ascertain whether the pt
understood the procedure
Did the candidate encourage to ask doubts from
patient
How will you counsel the patient for thyroidectomy?

(10 Marks)
CHECK LIST / ANSWER:

[Link] Observation Satisfactory Unsatisfactory

1 Introduction Tell your name 1 0

Did Candidate give his / her name Ask pt. name
Did candidate ask name of the patient

2 Diagnosis Carcinoma thyroid 2 0

Did the candidate explain about the diagnosis of the pt Multinodular goiter
condition Solitary nodular goiter
Thyrotoxicosis

3 Choice of treatment Hemithyroidectomy 2 0

Did the candidate explain about the procedure and Subtotal thyroidectomy
alternative treatment and anaesthesia Total thyroidectomy

4 Complication and risk Post op complication 2 0

Did the candidate explain about the possible complication Bleeding
of the procedure Respiratory distress
Per operative Nerve injury –
Post operative hoarsness of voice
Loss of voice
Stridor and
tracheostomy
Wound infection
Hypothyroid
Hypoparathyroid
Thyroid crisis
5 Post operative follow up Days of stay- 5-7 days 2 0
Did the pt explain about post operative period Drugs - iv antibiotics ,
Drugs given analgesics , , regular
diet medication
Post operative care Chest Physiotherapy
Stay in hospital Thyroid function test
Follow up Follow up for
malignancy

6 Open questions to finish 1 0

Did the candidate ascertain whether the pt understood
the procedure
Did the candidate encourage to ask doubts from patient
How will you counsel the patient for Mastectomy?

(10 Marks)
CHECK LIST / ANSWER:

[Link] Observation Satisfactory Unsatisfactory

1 Introduction Tell your name 1 0

Did Candidate give his / her name Ask pt. name
Did candidate ask name of the patient

2 Diagnosis Carcinoma breast and 2 0

Did the candidate explain about the diagnosis of the pt staging of the disease
condition Prognosis of the
disease
3 Choice of treatment All modalities of 2 0
Did the candidate explain about the procedure and treatment depending
alternative treatment and anaesthesia on staging
Surgery
Chemotherapy
Radiotherapy
Hormone therapy
Breast reconstruction
Psychotherapy
4 Complication and risk Post op complication 2 0
Did the candidate explain about the possible complication For surgery – seroma ,
of the procedure wound infection, injury
Per operative to serratus anterior ,
Post operative recurrence
For chemotherapy -
hair loss , cardiac
toxicity …
For radiotherapy

5 Post operative follow up Days of stay- 5-7 days 2 0

Did the pt explain about post operative period Drugs - iv antibiotics ,
Drugs given analgesics , , regular
diet medication
Post operative care Chest Physiotherapy
Stay in hospital Post op chemo
Follow up /radiotherapy /
hormone therapy .

6 Open questions to finish 1 0

Did the candidate ascertain whether the pt understood
the procedure
Did the candidate encourage to ask doubts from patient
1) What is the test shown above?

2) How is it performed?

3) Why is it performed?

4) How do you interpret the result?

5) What is positive deep ring occlusion test?

6) What is negative deep ring occlusion test?

7) What is deep inguinal ring?

8) What is the landmark of deep inguinal ring?

9) What is the size of deep inguinal ring?

10) Other names for deep inguinal ring?

ANSWER:
1) Deep ring occlusion test
- page no. 49 Bedside clinics in surgery – Makhan Lal Saha 12th edition
2) This test is performed in standing position and the hernia must be reduced first. Since
an indirect (oblique) hernia comes out through the deep inguinal ring and a direct
hernia medial lo the ring, pressure over the deep inguinal ring will occlude the
indirect hernia but not the direct hernia. A thumb is pressed on the deep inguinal ring
.The patient is asked to cough.
- page no. 601 A manual of clinical surgery – S Das 13th edition
3) This is a confirmatory test to differentiate an indirect inguinal hernia from a direct
inguinal hernia.
- page no. 601 A manual of clinical surgery – S Das 13th edition
4) A direct hernia will show a bulge medial to the occluding finger but an indirect hernia
will not find access.
- page no. 601 A manual of clinical surgery – S Das 13th edition
5) On occlusion of deep ring and asking patient to cough—no expansile impulse on
cough is seen medial to deep ring, suggesting this to be an indirect inguinal hernia.
This is described as deep ring occlusion test is positive.
- page no.49 Bedside clinics in surgery – Makhan Lal Saha 12th edition
6) On occlusion of the deep ring and asking patient to cough—expansile impulse on
cough is seen medial to the deep ring suggesting this to be direct inguinal hernia.
This is described as deep ring occlusion test is negative.
- page no.49 Bedside clinics in surgery – Makhan Lal Saha 12th edition
7) Deep inguinal ring is a U-shaped condensation of the transversalis fascia.
- page no. 751 SRB manual of surgery 5th edition
8) ½ inch above the mid-point between the anterior superior iliac spine and the
symphysis pubis.
- page no. 601 A manual of clinical surgery – S Das 13th edition
9) 1 cm in diameter.
10) Internal inguinal ring, Abdominal inguinal ring.
Examination of Peripheral Pulses: 10 x 1 marks

1) What are all the peripheral pulses that can be felt?

2) What is the anatomical landmark of dorsalis pedis artery?

3) What is the anatomical landmark of anterior tibial artery?

4) What is the anatomical landmark of femoral artery?

5) What is the anatomical landmark of radial artery?

6) What is the anatomical landmark of popliteal artery?

7) What is the anatomical landmark of common carotid artery?

8) What are the causes of limb ischaemia?

9) What are the types of gangrene?

10) What is ABPI?

ANSWER:

1) Dorsalis pedis artery, Posterior tibial artery, Anterior tibial artery, Popliteal artery, Femoral

artery, Radial artery, Ulnar artery, Brachial artery, Axillary artery, Subclavian artery, Facial

artery, Common carotid artery, Superficial temporal artery.

2) Dorsalis pedis artery is felt just lateral to the tendon of the extensor hallucis longus.

3) Anterior tibial artery is felt anteriorly in the midway between the two malleoli against the lower

end of tibia just above the ankle joint, lateral to extensor hallucis longus tendon.

4) Femoral artery in the groin is felt just below the inguinal ligament midway between

anterosuperior iliac spine and pubic symphysis.

5) Radial artery is felt at the wrist on the lateral aspect against lower end of the front of radius.

6) Popliteal artery is difficult to feel. It is palpated better in prone position with knee flexed about

40–50°, to relax the popliteal fascia. It is felt in the lower part of the fossa over the flat posterior

surface of upper end of tibia.

7) Common carotid artery is felt in the carotid triangle just in front of sterno-mastoid muscle

against the carotid tubercle of the sixth cervical vertebra.

8) Atherosclerosis (Chronic), Buerger's disease, Embolism (Acute), Raynaud's disease, Embolism,

Diabetes, Scleroderma, Physical Agents — Trauma, Radiation, Electric burns, Pressure necrosis.

9) Dry gangrene and Wet gangrene.

10) Ankle brachial pressure index (ABPI).

Ultrasonography: Each question carries 1 Mark.

1) What is the investigation shown?

2) What is the diagnosis?

3) What is the USG finding in case of gallstones?

4) What are the types of gallstones?

5) What are the complications of gallstones?

6) What is murphy's sign?

7) What is saint’ triad?

8) How many percent of gallstones are radio-opaque?

9) What is silent gallstone?

10) What is Mirizzi syndrome?

ANSWER:

1) Ultra-sound abdomen showing Gall bladder.

2) Cholelithiasis.

3) Highly reflective echogenic focus within gallbladder lumen with post-acoustic

shadowing.

4) Cholesterol stones, Mixed stones and Pigment stones.

5) Acute cholecystitis, Chronic cholecystitis, Empyema gallbladder, Perforation causing

biliary peritonitis or pericholecystitic abscess, Mucocele of gallbladder, Limey

gallbladder, Carcinoma gallbladder.

6) It is elicited by asking the patient to breath deeply while exerting moderate pressure

with the left hand such that thumb lies over the fundus of the gallbladder.

7) Gallstones,™ Diverticulosis of the colon , Hiatus hernia.

8) 10% of gallstones are radio-opaque.

9) Asymptomatic gallstones.

10) Compression of CHD/CBD by stone from cystic duct or cholecysto-choledochal fistula.

 Each question carries 1-mark.

1) What is hematemesis?

2) What are the common causes of hematemesis?

3) How is hematemesis different from hematochezia?

4) What are the signs and symptoms associated with hematemesis?

5) How is the source of bleeding identified in a patient with hematemesis?

6) How would you manage a patient presenting with severe hematemesis?

7) What is the role of pharmacotherapy in the management of hematemesis?

8) What is the significance of the Glasgow-Blatchford score in patients with

hematemesis?

9) How can the recurrence of hematemesis be prevented?

10) What are the potential complications associated with hematemesis?

ANSWER:
1) Hematemesis refers to the vomiting of blood that originates from the upper gastrointestinal
tract, typically from the esophagus, stomach, or the initial part of the small intestine.
2) Common causes of hematemesis include peptic ulcers, esophageal varices, gastritis, Mallory-
Weiss tears, and malignancies such as gastric or esophageal cancer.
3) Hematemesis refers to vomiting blood, while hematochezia refers to the passage of fresh blood
through the rectum. Hematemesis originates from the upper gastrointestinal tract, while
hematochezia originates from the lower gastrointestinal tract.
4) In addition to vomiting blood, individuals with hematemesis may experience symptoms such as
dizziness, lightheadedness, abdominal pain, black, tarry stools (melena), and signs of shock in
severe cases.
5) Diagnostic procedures used to identify the source of bleeding in a patient with hematemesis may
include an upper gastrointestinal endoscopy, angiography, or imaging studies such as a CT scan
or an upper gastrointestinal series.
6) Initial management of severe hematemesis involves ensuring the patient's airway, breathing,
and circulation. Intravenous access should be established, and blood transfusion may be
necessary. Consultation with a gastroenterologist or surgeon for possible endoscopy or surgical
intervention is essential.
7) Pharmacotherapy for hematemesis includes the use of medications such as proton pump
inhibitors (PPIs) to reduce gastric acid secretion, vasoactive drugs like octreotide to constrict
blood vessels and decrease bleeding, and antibiotics in certain cases to prevent infection.
8) The Glasgow-Blatchford score is a clinical scoring system used to assess the risk of clinical
interventions and the need for hospitalization in patients with upper gastrointestinal bleeding. It
helps identify patients who may require early intervention or can be safely managed as
outpatients.
9) Prevention of recurrent hematemesis involves addressing the underlying cause. This may include
lifestyle modifications, such as avoiding alcohol and nonsteroidal anti-inflammatory drugs
(NSAIDs), treating Helicobacter pylori infection, or performing endoscopic procedures to control
bleeding or remove the source.
10) Complications of hematemesis include severe blood loss leading to hypovolemic shock, anemia,
aspiration pneumonia, and organ dysfunction. In cases of persistent or massive bleeding, surgical
intervention may be necessary to control the bleeding source.
 Each question carries 2-marks.

1) What is the Glasgow Coma Scale (GCS), and how is it used in assessing

head injury?

2) How would you initially manage a patient with a suspected head injury?

3) What are the signs and symptoms of a severe head injury?

4) What is the role of imaging studies in evaluating head injuries?

5) What are the indications for performing a neurosurgical consultation in

a patient with a head injury?

ANSWER:

1) The Glasgow Coma Scale is a neurological scale used to assess the level of

consciousness in patients with head injuries. It evaluates three parameters: eye-

opening response, verbal response, and motor response. The scores range from 3

to 15, with lower scores indicating a more severe injury.

2) Initial management of a patient with a suspected head injury involves ensuring a

clear airway, adequate oxygenation, and stabilization of the cervical spine. Vital

signs should be monitored, and intravenous access should be established. The

patient should be assessed for signs of increased intracranial pressure, and a head

CT scan may be ordered based on the clinical presentation.

3) Signs and symptoms of a severe head injury include altered level of consciousness,

persistent vomiting, focal neurological deficits, seizures, clear fluid or blood

drainage from the ears or nose, and unequal pupil size or reactivity.

4) Imaging studies, such as a non-contrast head CT scan, are essential in evaluating

head injuries. CT scans can detect brain hemorrhages, skull fractures, and other

intracranial abnormalities that require immediate intervention.

5) Indications for neurosurgical consultation in a patient with a head injury include

significant intracranial bleeding, depressed skull fractures, signs of increased

intracranial pressure, deteriorating neurological status, or the need for surgical

intervention to evacuate hematoma or repair skull fractures.

 Each question carries 2-marks

1) How would you differentiate between visceral and parietal abdominal pain?

2) What are the clinical features of acute appendicitis?

3) How would you assess a patient with acute abdominal pain?

4) What is the significance of Murphy's sign in cholecystitis?

5) How would you manage a patient with suspected bowel obstruction?

6) What are the key features of acute pancreatitis?

7) What are the 5 common causes of acute abdominal pain?

ANSWER:

1) Common causes of acute abdominal pain include peptic ulcer disease ,appendicitis,

cholecystitis, pancreatitis, and bowel obstruction.

2) Visceral pain is typically dull and poorly localized, originating from the internal organs.

Parietal pain, on the other hand, is more intense, sharp, and well-localized, often

originating from the peritoneum.

3) Clinical features of acute appendicitis include right lower quadrant pain, localized

tenderness, rebound tenderness, and guarding. Nausea, vomiting, and low-grade fever

may also be present.

4) Assessment of a patient with acute abdominal pain involves taking a detailed history,

performing a thorough physical examination, ordering relevant investigations (such as

blood tests, imaging studies), and considering differential diagnoses based on the

findings.

5) Murphy's sign is elicited by palpating the right upper quadrant while the patient takes a

deep breath. A positive sign is indicated by the patient abruptly stopping inspiration due

to pain, suggesting inflammation of the gallbladder (cholecystitis).

6) Management of a patient with suspected bowel obstruction involves initial resuscitation,

correction of electrolyte imbalances, placement of a nasogastric tube for decompression,

and close monitoring. Surgical consultation may be necessary for definitive

management.

7) Key features of acute pancreatitis include severe epigastric pain that radiates to the

back, nausea, vomiting, and elevated serum amylase and lipase levels. Patients may also

present with abdominal distention, fever, and signs of systemic inflammation.