Surgery-traumatology final exam experience

I had the final exam in surgery-traumatology on the 28th of October (13:00). Me and another student waited outside the room which was written on Neptun (5th floor of 400 bed, to the right when you exit the elevator. Eventually the examiner fetches us into the seminar room (the same where trauma/surgery seminars took place). We draw topics, one from each of three envelopes, and are given time to prepare if we wanted.

There are separate examiners for the surgery part and the traumatology part. There’s no patient examination. While I had my surgery topics, the other student had her traumatology topics. The surgery examiner was Dr. András Papp. I did not catch the name of the trauma examiner.

After a few minutes of preparing, the examiner asked me whether I would like to start without preparation time to get over with it, and I was like “why not”. I believe I remember most of their questions, so here they are.

A12: Abdominal ischemia

• Me: We can distinguish ischaemia of the large bowels and the small bowels
• Examiner: What is the blood supply of the small bowels?
• [damn anatomy]
• M: The coeliac trunk, SMA, and IMA?
• E: And the large bowel?
• M: The IMA, and the superior rectal?
• E: Nononono, the SMA and the IMA. What is the border between the two systems?
• M: The ligament of Treitz?
• E: Yeah. The median colic artery comes from the SMA but the left sided colic arteries come from the IMA. What are the symptoms if the patient has abdominal ischaemia?
• M: Severe abdominal pain, which ..
• E: At all time?
• M: Not always, but if it’s acute, then ..
• E: It’s always acute. Can you tell me the symptoms when it starts and as it’s going on, what starts to happen?
• [I had no idea what he’s going for here]
• M: It kind of depends on the etiology, if there is an embolism there’s a sudden, out-of-nowhere severe abdominal pain, which they say is “out of proportion to the physical findings”.
• E: Okay. And?
• M: They can also have haematochezia
• E: They can, yes. Is the pain constant?
• M: It gets more and more severe
• E: And then?
• M: Uhm..
• E: And then there’s no pain. After a while it starts again, and keeps going until death.
• M: Okay, I didn’t know that
• E: It’s really characteristic. The pain at first is really high, and then it gets better for a few hours, and when it becomes necrotic and reaches the point of no return the pain progresses again. What can you do when there is abdominal ischaemia of the small bowel but it’s only a few cm of the jejunum involved?
• M: You can surgically remove the necrotic part?
• E: Yeah. And then? What is very important in this operation? Can we do the resection and the anastomosis and the patient can go home?
• [no idea]
• M: We should also look for the cause of the ischaemia. We can do some interventional radiological methods like thrombolysis or thrombectomy to remove it.
• E: Thrombectomy is not radiological, it’s surgical. Yeah, we can do that also. We can also do a resection. But what I wanted was that the patient often needs a so-called “second look” operation, where we check again whether there is other necrotic parts.

That was the end of this topic. I got a 4 on it.

B34: Perianal abscesses and fistulae. Surgical management of hemorrhoids.

• M: Okay so perianal abscess is often primary, so there’s some clogging of the perianal glands which causes a subdermic [yes I said subdermic] abscess that’s visible as a bulging out of the skin which is red and very painful, especially during defecation.
• E: And what is the temperature of the patient?
• M: The patient has fever as well.
• E: Yes
• M: And there may be an internal fistula as well, from the anal canal to the abscess
• E: Yeah they almost always go together. We can say that an abscess is an incomplete fistula. In what kind of disease can we frequently find fistulas?
• M: Crohn’s disease
• E: Yes. What is Crohn’s disease?
• [this question is made for me]
• M: It’s one of the two inflammatory bowel diseases where we can have inflammation of the whole GI tract, most commonly the terminal ileum.
• E: Yes. What are the surgical treatments of Crohn’s disease?
• M: It’s mostly used for adhesions and in severe cases you might have to remove bowel which is inflamed and doesn’t respond to medical therapy.
• E: Yes. What is the big difference between the surgical treatment of Crohn’s and ulcerative colitis?
• M: For ulcerative colitis total colectomy is curative, but there’s no curative surgery for Crohn’s. Treatment for Crohn’s is mostly non-surgical.
• E: Yes, and if we need it we resect only the part which is inflamed.
• M: Yeah
• E: Okay. Surgical treatment of haemorrhoids
• M: So we classify internal haemorrhoids as 1, 2, 3, or 4, which …
• E: What does the grade 4 mean?
• M: It means that it’s not possible to retract it.
• E: Yes, so it’s an absolute indication for surgery
• M: Yes. So surgery is indicated for grade 4 and I think grade 3 as well
• E: Yes.
• M: The others are treated mostly conservatively. There are many options for surgical treatment, like sclerotherapy, banding, haemorrhoidectomy …
• E: What is actually a haemorrhoid?
• M: Haemorrhoids are pouches or pillows of dilated veins
• E: Yes, so it’s actually normal, but if they cause symptoms then it’s a problem. Okay, one more question for the 5. What is the Dixon operation?
• M: [after thinking] I don’t remember
• E: Okay, it’s an anterior resection of the rectum with a primary anastomosis.

This was also a 4.

B7: Foot fractures and dislocations. Achilles-tendon injuries.

• I was given some extra time to prepare for the trauma topic. After a few minutes the trauma examiner asks me if I’m ready
• M: I think I’m okay with achilles tendon injuries, but I find foot fractures and dislocations a bit difficult, but we can start.
• E: Actually I think the achilles tendon injuries are the most important anyway. So you can start with this
• M: Okay. So the achilles tendon is the largest tendon and injury of it is common in sports
• E: Which types of sport?
• M: For example sports where you have rapid turning and acceleration, like basketball, football, sprinting, volleyball, etc.
• E: Yes
• M: The patient often feels like someone “kicks” them at the tendon when it snaps. And they lose the plantarflexion, which we can examine with the Thompson test.
• E: What is the Thompson test?
• M: It’s when you have the patient prone, you compress the calf, and you see whether the foot is plantarflexing or not. If it doesn’t, it indicates achilles tendon injury.
• E: Yes
• M: So it’s controversial whether it should be treated surgically or conservatively …
• E: Actually let’s talk about diagnosis. Which modality is good?
• M: Ultrasound, or MRI.
• E: Yes. Usually the ultrasound is enough.
• M: You can also palpate a gap in the tendon itself
• E: Yes. So treatment?
• M: So like I said, it’s kind of controversial whether surgical or conservative is the best.
• E: What do you think, which is better?
• [he’s a surgeon so the answer is obvious]
• M: I think surgery
• E: Yes
• M: Yes, probably because the recovery is quicker. It involves repairing the tendon, sometimes you might need a graft.
• E: If the injury is fresh then you can just suture it. What can we do after the surgery?
• M: Proper rehabilitation is important
• E: Yes, very important. In which position is the rehabilitation?
• M: What do you mean by which position?
• E: Like, which leg position.
• [guessing time]
• M: In plantarflexion
• E: Yes, usually in the first 3 weeks. And after that?
• [no idea]
• M: Probably mobilisation and physiotherapy?
• E: Yes, but in which position?
• [guessing time 2]
• M: Dorsiflexion?
• E: Yes. And after 6 weeks?
• [I’d run out of ankle positions so idk]
• M: I’m not sure
• E: After 6 weeks the patient can take off the brace and start to walk. Okay, please give me some words from the foot fractures.
• M: Okay, so the most common is the talus and calcaneus fracture.
• E: Okay, yeah [hesitating a bit]
• [instant anxiety due to the examiner’s hesitation]
• M: They can be due to high energy trauma like car accident, or falling from a height. So they can sometimes be bilateral. There is local pain, and there can be plantar ecchymosis.
• E: What can you see if somebody has foot fractures?
• M: You could see a deformity of the foot, and the patient cannot walk on it.
• E: Perhaps a haematoma?
• M: Yes, and swelling.
• E: Okay. Diagnosis?
• M: X-ray, maybe sometimes CT as well.
• E: Okay. Could you tell me something about the toe fracture? I think those are more frequent fractures.
• M: There are some named fractures, I’m trying to remember. Is Jones fracture on of them?
• E: No, Jones is a 5th metatarsal fracture. Tell me about the toe fractures.
• [I’d thought that toe fractures include metatarsal fractures but apparently not]
• M: So they can be due to direct trauma. The patient will experience pain, difficulty walking …
• E: And the treatment?
• [idk]
• M: I would say it probably depends on if there’s dislocation or not and how severe the fracture is. If not dislocated and not severe then we can do conservative, if not then maybe we need surgery.
• E: Actually only when the 1st toe is dislocated is when we use the surgery. In other cases it’s conservative, no matter the dislocation.

And that was it. 4 here as well.

Done

So that was it, a 4 in total. It took probably 10 – 15 minutes excluding prep time. They both had calm, non-confrontational voices, and at no point did I feel like I was close to failing, which was nice.

I’m still annoyed, though. Most questions were simple and straightforward, but some were explained as a single sentence in a single presentation in one of the three surgery subjects we’ve had (second-look operation), hidden among a wall of text on lecture (characteristic pattern of mesenteric ischaemia), or never written in lectures at all (the position and timing of casting after achilles tendon rupture, fractures of the toes). I’m annoyed because I put so much time and effort and went through so much stress to prepare for this and write notes, only to have an exam which was relatively non-difficult but still being asked questions I could probably never be prepared for. But that’s not new here, unfortunately.