MCQ YEAR 3,26TH JULY 1.

Differential diagnosis for a 45 year old man who presents to the emergency department with acute epigastric pain includes:A. Myocardial Infarction B. Acute Cholecystitis C. Splenic infarction D. Acute pancreatitis E. Hollow viscus perforation Answer A.TRUE, ECG should be evaluated for patient coming with epigastric pain. (Bailey and Love, Short practice of surgery, 25th edition, page 1011) B.FALSE, Pain is usually at right hypochondrium C.FALSE, Pain is at left hypochondrium. D. TRUE, Initially started at epigastrium but may localized to either left or right upper quadrant. (Bailey and Love, Short practice of surgery, 25th edition, page 1140) E.TRUE, only in case of perforated Peptic ulcer, which by definition means Gastric ulcer and duodenal ulcer. Other hollow viscus like small bowel or colon will not cause pain in the epigastrium. . ( Bailey and Love, Short practice of surgery, 25th edition, page 1062. Further reading on peptic ulcer, page 1054) *EXTRA INFORMATION Other causes of epigastric pain are:GERD, Reflux esophagitis, Mallory-weiss syndrome, hiatus hernia (both rolling and sliding), peptic ulcer, pancreatic endocrine tumor (Bailey, 25th Edition, page 835)

2.Anaesthesia preparation of patient in the Operation theater includes : A. Testing of anaesthetic machine B. Anaesthetic drugs check list

C. Removal of hearing aid D. Verification of consent form and premedication check list E. Clinical re-examination is not necessary Answers A.TRUE (All answers were given by an anesthetic doctor) B.TRUE C. FALSE D. TRUE E. FALSE. 3. Regarding imaging of the gastrointestinal tract: A. Left decubitus radiographs are performed to look for free intraperitoneal air in patients who are not able to stand up. B. Ultrasound has a low sensitivity rate in detecting bowel-related tumors. C. Enterocyclis (small bowel enema) provide better images of small bowel compare to barium follow through studies. D. Single contrast study of the colon is often performed to look for bowel tumors E. Bowel preparation is not required for patients undergoing barium swallow study. Answers A. TRUE. (Manipalmanual , 3rd Edition, page 408) B.TRUE. C. FALSE. Gastrointestinal Imaging and Intervention, 3rd edition, page 33. D. FALSE. Barium enema is helpful if there is stricture or obstruction due to bowel tumors. (SRB Manual of Surgery , 3rd Edition, page 839) E. FALSE. Bowel preparation includes low residue diet for 48hours prior to procedure.

`4. Pyogenic liver abscess : A. Has an increased incidence in diabetes B. Is associated with right upper quadrant discomfort C. Is caused by EntameobaHistolytica D. Is treated empirically with Metronidazole E. The most common organism that causes liver abscess is Escherichia Coli. Answers A. TRUE.Increase incidence in elderly, DM and immunosuppressed. (Bailey and Love, Short practice of surgery, 25th edition, page 1094) B.TRUE. Pain at Rt.hypochondrium(SRBS Manual of Surgery, 3rd Edition, page 537) C.FALSE. E.Histolytica cause Ameobic liver abscess. (SRBS Manual of Surgery, 3rd Edition, page 528) D.FALSE. Ameobic liver abscess is treated EMPERICALLY with Metronidazole. However, Pyogenic liver abscess is treated with penicillin, aminoglycoside and metronidazole (PAM) OR Metranidazole and cephalosporin. (Bailey and Love, Short practice of surgery, 25th edition, page 1095) E. TRUE.Most common organisms are E.coli and Streptococcus milleri.(SRBS Manual of Surgery, 3rd Edition, page 537 and Bailey and Love, Short practice of surgery, 25th edition, page 1095)

5. The following is true in Branchialcyst : A. Arises from 3rdBranchial cleft. B. Present as a swelling at the junction of upper and middle third of sternomastoid muscle. C. Ultrasound does not help in diagnosis. D. Passes backward upwards through the bifurcation of CCA

E. Cystic hygroma is one of the differential diagnosis. Answer A. FALSE.It arises from the 2NDbranchial cleft. B. TRUE.(Bailey and Love, Short practice of surgery, 25th edition, page 727) C. FALSE.Ultrasound does help in aiding diagnosis, also with FNAC. D. TRUE. (Bailey and Love, Short practice of surgery, 25th edition, page 727) E. TRUE.(Bailey and Love, Short practice of surgery, 25th edition, page 727)

6. Fistula in Ano: A. Is a chronic abnormal communication lined by granulation tissue B. Goodsalls rule is use to indicate the likely position of internal opening according to the postion of external opening. C. Is usually classified as high and low fistula in ano depending in the risk of incontinence if laid open. D. All fistulas require surgical treatment E. Purulent discharge and pruritus ani are some of the clinical features the patients can present with. Answer: A. TRUE.(Bailey and Love, Short practice of surgery, 25th edition, page 1262) B. TRUE(Bailey and Love, Short practice of surgery, 25th edition, page 1262) C. TRUE (Bailey and Love, Short practice of surgery, 25th edition, page 1262) D. TRUE(Bailey and Love, Short practice of surgery, 25th edition, page 1262) E. FALSE.Pruritus ani is not a clinical features. However, patient come with intermittent purulent discharge (which may be bloody), and pain which increases until temporary relief occurs when the pus discharge.(Bailey and Love, Short practice Refer :Concise Textbook of surgery, 25th edition, page 1262) of surgery, S.Das, 7th Edition, Page 1073 http://depts.washington.e du/surgstus/VirtualPt/surg eryhtml/792detail.htm

This rule relates the location of internal opening based on external opening site. If the external opening is anterior to transverse anal line, the fistula runs directly straight anteriorly into anal canal. If the external opening is posterior to transverse line, the fistula track will curve so that the internal opening is in the MIDLINE of anal canal posteriorly. Exception, if external opening is ANTERIOR but is more than 3.75cm (1 ) away from anus, the track will curve posteriorly to the midline of anus.

7. Regarding breast imaging : A. Mammogram is routinely performed in women under 30 years of age. B. Patients are not allowed to used powder and deodorant on the day of mammogram examination. C. MRI is the investigation of choice to detect the implant rupture D. A mammographic feature of malignancy is the presence of mass with speculated or stellate margin. E. Galactography is one of the best imaging techniques Answer A. FALSE.Guidelines for mammography screening vary from country to country. In the United Kingdom, a national breast screening programme, screens women between the ages of 50 and 64 years at 3-yearly intervals. The American Cancer Society recommends mammography screening yearly from the age of 40 years. The American College of Radiology, the Society of Breast Imaging, the American College of Obstetricians and Gynecologists, American Society of Breast Disease all

recommend regular screening mammograms should begin at the age of 40 years.

In Malaysia, a nationwide screening programme has not been implemented yet. Currently women who are encouraged to go for screening normally have a higher risk profile than the general public, such as having a close family member with breast cancer. However, it is useful for screening women in the high-risk groups, such as those with a family history of breast cancer, or a previous history of benign breast disease, to detect early breast cancer. This may start from 30-35years onwards. Routine screening for ladies less than 40 years is normally not recommended as the dense breast tissue tends to obscure disease and active breast tissue may be more sensitive to radiation. There is no upper age limit for screening mammography, since the risk of breast cancer increases with age. (http://www.radiologymalaysia.org/breasthealth/BreastImaging/mammodebate2.htm) B. TRUE. You should not apply any talcum powder, perfume or deodorant to your upper body, and armpit areas. These may cast shadows on the mammogram, which may affect the interpretation of the mammogram by the radiologist. (http://www.radiologymalaysia.org/breasthealth/BreastImaging/diagnostic.htm) C. TRUE. MRI is the most accurate imaging examination for the evaluation of breast implant rupture.MRI's drawbacks include its cost and possible unavailability. Ultrasonography is fairly accurate and more available than MRI but is highly operator dependent and has a steep learning curve. (http://emedicine.medscape.com/article/345877-overview) Based on a study, USG had a sensitivity of 59% and specificity of 79%. CT had a sensitivity of 82% specificity of 88%. MRI had sensitivity of 95% and specificity 93%. (http://www.ajronline.org/doi/pdf/10.2214/ajr.163.1.8010248) D. TRUE. Findings of mammogram suggestive of CA are microcalcification, spiculations or stellate margin. (SRBs Manual of Surgery, 3rd Edition, page 456)

E. TRUE. The most common use of galactography is to evaluate a woman who has a bloody or clear discharge from her breast nipple and an otherwise normal mammogram. Galactography is typically NOT called for in women with the following conditions:A discharge that is milky, yellow, green, black or gray is usually not a cause for concern, especially if it comes from multiple ducts in the breast.A discharge that is from both breasts in a woman who has not had children may indicate a side effect from a drug, or may be related to a pituitary problem located in the brain. (http://www.radiologyinfo.org/en/photocat/gallery3.cfm?pid=1&image=GalactoMovie.j pg&pg=galactogram)

8. Sigmoid volvulus has the following features A. Rotation occurs in clockwise direction B. Abdominal distension is an early and progressive sign C. The classic appearance in X-ray is a dilated loop of bowel running diagonally across the abdomen from right to left D. Surgery is required to prevent ischaemia E. Is the least common form of volvulus of the gastrointestinal tract

Answer A. FALSE; voluvulus usually occurs in anticlockwise direction (manipal manual page 604)

B.

TRUE enormous distension takes place due to diffusion of co2 (manipal manual page 604)

C.

FALSE classic x-ray sign is bent inner tube or omega sign(manipal manual page 604)

D.

TRUE; after successful nonoperative treatment is done, elective surgery is still done 7 days later. (manipal manual page 605)

E.

FALSE it is a common form of volvulus. (manipal manual page 603)

9. In acute intussusceptions A. There is twisting or axial rotation of a portion of the bowel over its mesentry B. It is common in children C. Colocolic is the commonest type in children D. Radiological reduction is indicated in most cases E. Early symptoms include moderate to severe cramping pain

Answer A. FALSE; it is an invagination of one segment of intestine into another (manipal manual page 612 )

B.

TRUE common in infants aged 6 to 18months (manipal manual page )

C.

FALSE; ileocolic is the commonest type (manipal manual page 612)

D.

FALSE hydrostatic reduction is successful 50-70% cases (manipal manual page 613)

E.

TRUE, (manipal manual page 613 )

10. The following are true regarding varicose veins A. Dilated, elongated tortuous veins are present B. More common in upper limbs C. Complicated by deep vein thrombosis D. Surgery is not indicated E. Varicosity is also found in esophagus

Answer A. TRUE; (manipal manual page 103)

B.

FALSE,(manipal manual page 104 )

C.

TRUE; (manipal manual page 110 )

D.

FALSE; Surgery is one of the treatment (manipal manual page 110 )

E.

TRUE

11. Regarding general anaesthesia A. Ketamine is an intravenous anaesthetic B. Naloxone is used to reverse respiratory depression caused by narcotics C. Thiopental is an ultra short acting barbiturate D. Sevoflurane is an inhaled anaesthetic that decreases methionine synthesis activity E. Propofol is a general anaesthetic belonging to inhalants.

Answer A. TRUE; Ketamine can be given intravenously as anaesthetic

B.

TRUE ; (http://quizlet.com/dictionary/naloxone-narcan/)

C.

TRUE; (http://en.wikipedia.org/wiki/Sodium_thiopental)

D.

FALSE; (not found )

E.

FALSE; known as milk of amnesia for its milk-like appearance, it is given intravenoulsy(wikipedia )

12. Primary thyrotoxicosis is associated with A. Abnormal thyroid stimulating antibodies B. Hashimotos disease C. Multinodular goitre D. Malignant exophthalmos E. Depression

Answer A. TRUE; abnormal antibodies stimulate thyrocytes to grow and produce excess hormone TRUE; Hashimotos disease can cause temporary thyrotoxicosis features

B.

C.

FALSE; Multinodular goitre is a cause of secondary thyrotoxicosis

D.

TRUE;

E.

Not found

13. Carcinoma of breast; A. High incidence in multiparous women B. Inflammatory carcinoma is staged as T and D in TNM staging C. Early menarche and late menopause are not risk factors D. Treatment includes multimodality regime E. Is associated with Pagets disease of the nipple

Answer A. FALSE; Risk factors include lack of child bearing (wikipedia)

B.

TRUE ; T4d Inflammatory carcinamatosa (manipal manual page 347)

C.

TRUE; These factors cause a lower risk to developing breast cancer (http://www.cbcf.org/central/AboutBreastHealth/PreventionRiskReduction/risk_f actors/Pages/menarch_meno.aspx)

D.

TRUE; A multidisciplinary approach is preferable (wikipedia)

E.

TRUE; It is an intraductal carcinoma involving excretory ducts.

14. Following about dysphagia are true A. Oesophageal malignancy presents mainly as dysphagia to solids progressing to liquids B. Paraesophageal hernia mainly presents as splenic herniation recognised by CXR C. Smooth termination with massive proximal esophageal dilation in a barium swallow in 40/yo female is characteristic of esophageal malignancy D. Patterson Kelly syndrome mainly affects men. E. Barrets esophagus is a premalignant condition

Answer A. TRUE; (wikipedia )

B.

Not found

C.

FALSE; it is found in man over 60 years old (manipal manual page 376)

D.

FALSE It is more common in women (wikipedia )

E.

TRUE; (wikipdia )

15. In acute pancreatitis A. Antibiotics are mandatory B. Serum blood lipase is elevated C. Treatment is conservative D. Laparatomy is always indicated E. Rise in serum amylase is diagnostic

Answer A. FALSE In acute edematous pancreatitis no antibiotics are required (manipal manual page 507 )

B.

TRUE ; Lipase is only secreted by pancreas (manipal manual page 505 )

C.

TRUE; Treatment is almost always conservative (manipal manual page 506 )

D.

FALSE; See above (manipal manual page 506 )

E.

FALSE; There are many other causes for elevated serum amylase (http://wiki.answers.com/Q/What_causes_high_amylase_levels )

16. Following are true regarding wound healing

A. Healing of 2ndary intention is suturing of clean wound over face within 4 hours of injury B. Best example of regeneration is shown by liver C. Remodeling phase is seen by 3rd day to 3rd week following injury D. Old age is inversely proportional to wound healing E. Fetal wound healing occurs without formation of scar

Answer A. FALSE; Healing by secondary intention refers to a wound which is infected, discharging pus, or wound with skin loss (manipal manual page 2 )

B.

TRUE; The liver is the only human internal organ capable of natural regeneration of lost tissue; as little as 25% of a liver can regenerate into a whole liver (wikipedia) TRUE; Its start after 4th day and completed by 14th day (manipal manual page 3)

C.

D.

TRUE

E.

FALSE; only fetal skin wounds heal without scar (manipal manual page )

15. In Acute pancreatitis:

A. Antibiotics are mandatory. B. Serum blood lipase is elevated. C. Treatment is conservative. D. Laparatomy is always indicated.

E. A rise in serum amylase is diagnostic.

Answers: A. FALSE Antibiotics are not indicated. (BAILEY & LOVE 25th edition page 1141)

B. TRUE If the serum lipase level can be checked, it will increase and provide a slightly more sensitive and specific test than amylase. (BAILEY & LOVE 25 th edition page 1140).

C. TRUE If after initial assessment a patient is considered to have a mild attack of pancreatitis, a conservative approach is indicated with intravenous fluid administration and frequent but, non-invasive observation. ( BAILEY & LOVE 25th edition page 1141).

D. FALSE Laparotomy is indicated when there is complication to pancreatitis; sepsis. (BAILEY & LOVE 25th edition page 1143).

E. TRUE The diagnosis of acute pancreatitis is made on the basis of the clinical presentation and an elevated serum amylase level. (BAILEY & LOVE 25th edition page 1140)

16. The following are TRUE regarding wound healing :

A. Healing by secondary intention is suturing of clean wound over the face within 4 hours of injury. B. The best example of regeneration is shown by liver. C. Remodelling phase is seen by 3rd day upto 3 weeks following injury. D. Old age is inversely proportional to wound healing. E. Fetal wound healing occurs without formation of scars.

Answers:

A. FALSEHealing by secondary infection is when wound left open, heals by granulation, contraction and epithelialisation. Increased inflammation and profileration and poor scar. (BAILEY &LOVE 25th edition page 25).

B. TRUE The liver is the only human internal organ capable of natural regeneration of lost tissue; as little as 25% of a liver can regenerate into a whole liver. http://en.wikipedia.org/wiki/Liver#Regeneration C. FALSE Proliferative phase lasts from the 3rd day to the 3rd weeks. Remodelling phase occurs after that. (BAILEY & LOVE 25th edition page 24)

D. TRUE Old age is inversely proportional to wound healing as the production of collagen and ground substance ( glycosaminoglycans and proteoglycans) (BAILEY & LOVE 25th edition page 25).

E. TRUE In utero, early in fetal life, wounds heal by regeneration instead of repair. This scarless fetal wound healing occurs across species, but it is age dependentthat is, at a certain time point in embryonic development, a switch is flipped that triggers scarring. In humans, this transition occurs in the last trimester of pregnancy . http://www.nature.com/jid/journal/v132/n2/full/jid2011444a.html

17. In skin tumours:

A. Basal cells cancers occurs mainly in whites. B. Keloid is a variety of skin malignancy. C. Marjolins ulcer spreads early via lymphatics. D. Prognosis of malignant melanoma is dependent on Breslows thickness. E. Malignant melanoma is highly radiosensitive.

Answers:

A. TRUE White skinned people are almost exclusively affected in basal cell carcinoma. (BAILEY & LOVE 25th edition page 609)

B.FALSE Keloid is not one of skin malignancy. It is one type of abnormal scar. (BAILEY & LOVE 25th edition page 598)

C.FALSE Lymphatic metastasis is unusual as the lymphatic are already destroyed or occluded by previous chronic lesion of the skin. (DAS Manual on Clinical Surgery page 53)

D. TRUE The Breslow thickness of a melanoma (measured to nearest 0.1 mm from the granular layer to base of the tumor) is the most important prognostic indicator in the absence of lymph node metastasis. (BAILEY & LOVE 25th edition page 615)

E. TRUE Malignant melanomas caused largely by exposure by UVB (BAILEY & LOVE 25th edition page 612)

18. Regarding Medullary carcinoma of thyroid.

A. Tumour cells are derived from para follicular cells. B. High levels of carcinoembryonic antigen are serum indicators. C. Is the commonest form of thyroid carcinoma. D. Associated with MEN-2A E. Most likely to be caused by radiation therapy to the neck given to treat other cancers during childhood.

Answers:

A. TRUE Medullary carcinoma of thyroid are tumours of the parafollicular cells (C cells) (BAILEY & LOVE 25th edition page 797).

B. TRUE High levels of serum calcitonin and carcinoembryonic antigen are produced by many medullary tumours. (BAILEY & LOVE 25th edition page 797).

C. FALSE The most commonest form of thyroid carcinoma is papillary carcinoma with relative incidence of 60% (BAILEY & LOVE 25th edition page 792).

D. TRUE Medullary carcinoma may occur in combination with adrenal phaeochromocytoma and hyperthyroidism (usually due to hyperplasia) in MEN-2A (BAILEY & LOVE 25th edition page 798).

E. FALSE The single most important aetiological factor in differentiated thyroid carcinoma particularly papillary carcinoma, is irradiation of the thyroid under 5 years of age. (BAILEY & LOVE 25th edition page 792).

19. The following statements regarding parotid masses are TRUE:

A. Pleomorphic adenoma is best treated by removal of 0.5 cms of adjoining tissue to the growth and leaving the rest of parotid tissue behind. B. Warthins tumour primarily affects smokers and can affect bilaterally. C. Freys syndrome is caused by division of great auricular nerve during parotid surgery. D. Parotid fistulas in superficial parotidectomy is usually self limiting. E. Parotid malignancy is characterized by facial nerve involvement.

Answers:

A. TRUE When in the minor salivary glands, a 5 mm margin should be obtained. These tumours do not invade into periosteum, thus bone need not be resected. http://radiopaedia.org/articles/pleomorphic_adenoma

B. TRUE ts etiology is unknown, but there is a strong association with cigarette smoking. In 514% of cases, Warthin's tumor is bilateral, but the two masses usually are at different times. http://en.wikipedia.org/wiki/Warthin's_tumor

C. TRUE Frey's syndrome often results as a side effect of surgeries of or near the parotid gland or due to injury to the auriculotemporal nerve, which passes through the parotid gland in the early part of its course. http://en.wikipedia.org/wiki/Frey's_syndrome

D. FALSE Anticholinergics, irradiation, denervation of the gland, duct ligation are done to reduce saliva production. (SRB Manual of Surgery 3rd edition page 364)

E. TRUE General features of malignant salivary tumours is nerve involvement in which; facial nerve in parotid gland tumour (SRB Manual of Surgery 3 rd edition page 370)

20. The following statements related to Common Bile Duct stone:

A. Most common cause of Common Bile Duct stones are those that have slipped from gallbladder. B. Mostly are associated with raised alkaline phosphate. C. They are often associated with palpable distended gall bladder. D. They cause high levels of unconjugated bilirubin. E. Best modality of treatment is by Endoscopic Retrograde Cholangiopancreatography (ERCP).

Answers:

A. TRUE About 15% of people with gallstones will develop stones in the common bile duct, the small tube that carries bile from the gallbladder to the intestine. http://www.nlm.nih.gov/medlineplus/ency/article/000274.htm

B. TRUE Alkaline phosphatase (AP) is often raised in this setting, but the pattern of liver enzyme abnormalities should be interpreted with caution, because elevated alanine transferase (ALT) levels can be seen in acute biliary obstruction and many parenchymal liver diseases can give rise to a high AP secondary to intrahepatic cholestasis. http://www.gponline.com/Clinical/article/1151937/Clinical-Review---Commonbile-duct-stones/

C. FALSE In common bile duct obstruction with stone, the gall bladder as a rule is impalpable. Most patients with jaundice due to stones have a shriveled, fibrotic, non-distenible gall bladder, and hence gall bladder will not be palpable. [Courvoisiers law](BAILEY & LOVE 25th edition)

D. FALSE Common bile duct stone causes obstructive jaundice. Hence, it causes high levels of conjugated bilirubin.

E. TRUE The gold standard, endoscopic retrograde cholangiopancreatography (ERCP), is generally reserved for therapeutic intervention. http://www.gponline.com/Clinical/article/1151937/ClinicalReview---Common-bile-duct-stones/

21. With regard to kidney transplantation:

A. It is offered only to patients aged below 50 years. B. The transplant is placed extraperitoneally. C. Urine output is monitored to detect rejection. D. Immunosuppression is required. E. A urinary tract infection is a contraindication.

Answers:

A. FALSE There is no absolute upper age limit to transplantation but, inevitably, older patients (>65 years) are less likely to be considered because of major comorbidity. (BAILEY & LOVE page 1422)

B. FALSE The transplant kidney is placed in the iliac fossa in retroperitoneal position leaving the native kidney in situ. (BAILEY & LOVE 25th edition page 1422)

C.TRUE As a first step in the management of early graft dysfunction, the urinary catheter should be irrigated in case it is occluded by clot. ( BAILEY & LOVE 25th edition page 1423)

D. FALSE Immunosuppressive therapy increases the risk of infection and malignancy after transplantation. ( BAILEY & LOVE 25th edition page 1422)

E. FALSE It is important to ensure that their urinary tract is functional and that there is no need for corrective urological surgery.

22. The following points are related to abdominal pain:

A. The visceral component of duodenal pain is perceived in the umbilical area. B. Patients with renal colic tend to lie very still. C. Shoulder tip pain is very characteristic of perforated peptic ulcer. D. Mesentric thrombosis is associated with colicky pain abdomen. E. Parietal pain is usually after the visceral pain.

Answers:

A. FALSEThe visceral component of duodenal pain is perceived in

B. FALSE In colic, the patient is either tossing on the bed, doubled up or rolls in agony seeking in vain a position of comfort.(DAS Manual on Clinical Surgery page 340)

C. TRUE The pain may be reffered to the tip of right shoulder due to irritation of the under surface of the diaphragm. (DAS Manual on Clinical Surgery page 354)

D. TRUE Pronounced shock, colicky pain (which is quite severe), distension and frequent vomiting are the usual symptoms. (DAS Manual on Clinical Surgery page 356)

E. TRUE That is because once it got inflamed it started irritating the PARIETAL peritoneum, which causes somatic or localized pain. http://theclinicaljournal.wordpress.com/2012/04/12/abdominal-pain-the-basicsfrom-a-clinical-perspective/

22. The following are related to abdominal pain A. The visceral component of duodenal pain is perceived in the umbilical are B. Patient with renal colic tend to lie very still C. Shoulder tip pain is very characteristic of perforated peptic ulcer D. Mesenteric thrombosis is associated with colicky pain abdomen E. parietal pain is usually after the visceral pain Answer A. FALSE. Duodenal pain is referred at epigastrium. At the umbilical area, pain is referred from the appendix and ileum (Das Clinical, 436) B. FALSE. In colic pain, patient is either tossing on bed, doubled up or rolls in agony seeking in vain a position to comfort (Das Clinical, 438) C. TRUE. Irritation to the diaphragm by gastric content or blood or bile give rise to referred pain to the corresponding ahoulder (Das Clinical, 454) D. TRUE. Pronounced shock, colicky pain,distension and frequent vomiting are the usual symptoms and mimic appendicitis (Das Clinical,454) E.TRUE. The first pain is visceral pain, followed by parietal pain, due to inflammation of the peritoneum covering the organ, this pain is more localized (Das Clinical, 449)

23. In patients with acute cholecystitis A. Gallstone are always present B. Diagnosis is confirmed by oral cholecystogram C. Pericholecystic abcess is the ususal complication D. Complications are more likely if diabetis is present E. Cholecystoduodenal fistula is essential for gallstone ileus Answer A. FALSE. In about 90% of the cases of gallbladder inflammation are associated with calculi. Other causes could be chemical irritation, bacterial infection, pancreatic reflux (Das Textbook, 864) B.FALSE. Oral cholecystogram is contraindicated (Das Clinical,450) C. TRUE. Complications of acute cholecystitis include,true perforation, pericholecystic abcess and internal fistula, from gallbladder into GIT. (Das textbook,864) D. TRUE. Emphysematous cholecystitis which is one of the complicated cholecystitis, common in diabetic patient (Google) E. TRUE. Through the fistula, large gallstone may be impacted in the terminal ileum cause gallstone ileus ( Das Textbook, 864)

24. The following related to burns A. Parkland formula is ringer lactate 4ml x body surface of burns x wt. In kgs given over 24 hours B. Children have higher body surface area of the head

C. The rules of nine is based upon the fact that the surface area of the following parts of an adult body each correspond to approximately 9% of total D. Blister scalds relate to superficial burns E. Majority of deaths in burns within hours caused by septicaemia Answer A. TRUE. Parkland formula is amount of resuscitation fluid needed by burn victim in 24 hours = (4x pt weight (kg) x percent body of the surface area) (Wikipedia) B. TRUE. Example, in 1 year old child, head represent 19% compared as adult 7%, and for each lower extremity represent on 13% of total body surface area ( Das Textbook, 64) C. TRUE. (Das Textbook,63) D. TRUE. Vesiculation is the hallmark of second degree burn (superficial) (das Textbook,63) E. FALSE. Bacterimia and bacteremic shock are the second commonest cause of death in burn following oligaemic shock. This usually occur between 2 nd and 3rd weeks (Das Textbook, 64)

25. The level of amylase in serum is typically raised in patient with A. Acute pancreatitis B. Acute appendicitis C. Renal failure D. Perforated peptic ulcer E. Acute cholecystitis Answer A. TRUE. Answer for A,B,C,D,and E are at the page 921,Das Textbook)

B. TRUE C. TRUE D. TRUE E. TRUE

26. A hydrocele A. Is premalignant B. Occurs after repair of hernia C. Occurs in processus vaginalis D. Causes infertility E. Is reducible Answer A FALSE. Hydrocele are not cancerous nor will they become cancerous (HydroceleFAQ-Houston Metro Urology) B. TRUE. Herniorrhaphy can cause hydrocele (post herniorraphy hydrocele),(Das Textbook,1324) C. TRUE. Abnormal collection of serous fluid can occur within tunica vaginalis or some part of the processus vaginalis ( Das Textbook, 1324) D. TRUE. It can cause testicular atrophy which can lead to infertility (Das Textbook, 1321) E. FALSE. Hydrocele irreducible( Das Textbook,1321)

27. A peptic ulcer A. Occurs only in stomach B. give rise to hemorrhage C. causes obstruction in duodenum D. Always associated with stress E. Is associated with hyperparathyroidism Answer A. FALSE. It can occur at the duodenum (common), stomach, esophagus,Meckels diverticulum (Bailey,1036) B. TRUE. An peptic ulcer ay bleed. The bleeding may be chronic and presentation with anemia is not uncommon (Bailey,1039) C. TRUE. Stenosis or obstruction of the duodenum can occur, and it can cause vomiting in peptic ulcer patient (Bailey 1039) D.FALSE. Most peptic ulcer are caused by H. Pylori or NSAIDS (Bailey, 1036) E. TRUE. Hypercalcemia caused by hyperparathyroidism can lead to peptic ulcer and acute pancreatitis (Wikipedia)

28. The following are true about esophgeal perforation management A. Boerhaves syndrome is managed surgically B. Perforation with a flexible endoscope with an empty stomach in elective setting is managed by immediate operation C. The principles of esophageal perforations conservative management is hyperailimenatation, nasogastric tube and broad spectrum antibiotics

D. Mediastinal contamination with hydropneomothorax calls for operative Management E. Perforation of esophageal malignancy in debilitated patient call for immediate surgery

Answer A. TRUE. Survival without surgery, the mortality of untreated Berhaave syndrome is nearly 100%. (Wikipedia) B.TRUE. Boerhaave syndrome,without surgery can lead to death (Wikipedia) C.TRUE. These line of management can help to minimise peritonitis and septicaemia (Das textbook, management of perforation) D.TRUE. hydropneumothorax is one of the indication for operation in esophageal perforation (Wikipedia) E.TRUE. Esophageal perforationis treated by operation, otherwise, the mortality rate is almost 100% (Wikipedia)

29. The following statement are TRUE regarding Acute Appendicitis A. Tenderness is felt at the Mac Burneys point B. Rovsings sign is pain on sudden release of pressure on the right iliac fossa C. Psoas sign is right lower quadrant pain produced by the passive extension of the patient right hip D. Obturator sign is pain in the hypogastrium on flexing and internal rotation of the hip E. Appendicular mass is contraindication for immediate surgery Answer

A. TRUE. Tenderness at the Mac Burneys point is the parietal pain, occur due to inflammation of the peritoneum covering the inflamed appendix (Das Textbook,1008) B.FALSE Rovsings sign is the pain felt at the right iliac fossa on pressing the left iliac fossa (Das Textbook,1008) C.FALSE : Psoas sign can be elicited by flexing the leg, not by passive extension. (Das Textbook,1008) D. TRUE. Obturator sign is pain in the hypogastrium on flexing and internal rotation of the hip (das Textbook, 1008) E.TRUE : Due to adhesions, risk of ruptured mass and dangerous of forming fistulas (Das Textbook,1008)

30. The following are TRUE statement(s) about indirect inguinal hernia A. 25% are bilateral B. in children, if inguinal (indirect) hernia is present in one side, then processus is intact on the another C. In bubonocele, sac lies in the inguinal canal D. Equal incidence in males and females E. Placing trough external obstruction aponcusos behind the cord is acceptable Answer A. FALSE : 12% (Bailey 971) B. TRUE : (Bailey 971) C.TRUE. In bubonocele, sac lies in the inguinal canal (Bailey, 971) D.FALSE Males are 20 times more commonly affected than females (Bailey 971) E.TRUE. (Bailey 971)