Year 5 Surgery End-Of-Posting SAMPLE Questions

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National University Hospital (NUH), Singapore
National University of Singapore
Final Year (Year 5) Surgical Revision Posting
Class of 2001

Essay Paper
2 Questions
Total Time: 1 hour

Question 1
51 year old man presents with a sudden headache, and is comatose on admission. His blood pressure is 220/140 mmHg. Discuss your management.

Question 2
50 year old man has had gross haematuria with clots for 1 month. On examination, he is pale and there is a left flank mass as well as a Grade 3 varicocele on the left. How would you manage this patient?

Model Answer 1
1)Recognize emergency
2)ABCDE [Intubate, hyperventilate, i/v access, GCS score, focal neurological signs]
3)History and Physical
  a)AMPLE history
  b)Assess etiology [Signs and symptoms of a bleed, Risk factors]
  c)Assess severity [Signs of raised ICP (esp papilloedema), Cushing's reflex]
4)Working diagnosis - Intracranial bleed w/ raised ICP. Unlikely CSF obstruction, brain tumor.
  a)Immediate: Treat ICP [Head up, hyperventilate (PC02=30-40), i/v mannitol]
  b)Urgent CT Scan head [Looking for bleed, site, size, mass effect]
  c)Urgent neurosurgical referal [Indications for op]
  d)Future treatment [Rehabilitation, Prevention]

Model Answer 2
1)Resuscitate if unstable
2)Differential diagnoses:
  a)Renal cell carcinoma of left kidney
  b)Transitional cell carcinoma of left renal pelvis
  c)Stone with hydronephrosis
3)Clinical examination (Hx and PE: Signs and symptoms, Risk factors)
  a)RCC: Mass + pain + painless haematuria. Weight loss, loss of appetite, smoking.
  b)TCC: Mass + pain + painless haematuria. Wt loss, anorexia, smoking, anilene dye exposure.
  c)Stone: Past history, ureteric colic, obstructive symptoms.
  d)Mention: Renal vein invasion causing varicocele. Clot colic.
  a)For effect and severity: FBC, U/E/Cr, UFeme and cytology
  b)Diagnostic: Ultrasound (U/S), IVU, Retrograde Pyelourethrogram (RPG) with biopsy
  c)Staging: CT scan, U/S for IVC extension, Chest Xray
   (i)RCC - Radical nephrectomy with lymph node dissection. (kiv partial nephrectomy)
   (ii)TCC - Nephrouretectomy
  b)Palliative:RCC - Radiotherapy, embolization
  c)Stones: Percutaneous nephrostomy to relieve obstruction. Treat stones.
  d)Follow up: UFeme, Cystoscopy, U/S.

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