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UNIVERSITY OF IBADAN – COLLEGE OF MEDICINE

BDS PART III EXAMINATION JULY 2025 - COMPREHENSIVE ANSWERS

SECTION A

Question 1: 45-year-old farmer with puncture wound

a) Most likely diagnosis (1 mark): Tetanus (Clostridium tetani infection)

b) Four features indicating poor prognosis (4 marks):

  1. Short incubation period (less than 7 days from injury to first symptom)
  2. Short onset period (less than 48 hours from first symptom to first spasm)
  3. Generalized tetanus with severe muscle spasms
  4. Autonomic dysfunction (cardiovascular instability, hyperthermia)

c) Principles of management (5 marks):

  1. Wound care: Thorough debridement and cleaning of the puncture wound
  2. Neutralization of toxin: Human Tetanus Immunoglobulin (TIG) 3000-5000 IU intramuscularly
  3. Prevention of further toxin production: Metronidazole 500mg IV 8-hourly or Penicillin G 2-4 million units IV 6-hourly
  4. Control of muscle spasms: Diazepam 10-40mg IV, muscle relaxants, consider neuromuscular blocking agents in severe cases
  5. Supportive care: Airway management, mechanical ventilation if needed, nutritional support, prevention of complications

Question 2: Kidney Biopsy

Indications for kidney biopsy (4):

  1. Unexplained acute kidney injury with suspected glomerulonephritis
  2. Nephrotic syndrome in adults (except diabetic nephropathy)
  3. Rapidly progressive glomerulonephritis
  4. Systemic diseases affecting kidneys (SLE, vasculitis)

Contraindications (4):

  1. Bleeding disorders or coagulopathy
  2. Severe hypertension (>180/110 mmHg)
  3. Single functioning kidney
  4. Severe chronic kidney disease with small kidneys

Complications (4):

  1. Bleeding (hematuria, perinephric hematoma)
  2. Arteriovenous fistula formation
  3. Infection at biopsy site
  4. Pneumothorax (rare)

Procedural steps:

  1. Pre-procedure: Obtain informed consent, check coagulation studies, blood grouping
  2. Patient positioning: Prone position with pillow under abdomen
  3. Ultrasound guidance: Identify kidney location and biopsy site
  4. Local anesthesia: Lidocaine infiltration
  5. Biopsy: Use automated biopsy gun, obtain 2-3 cores
  6. Post-procedure: Pressure, bed rest, monitor vital signs and urine

Question 3: Diabetic patient with oral manifestations

a) Four oral manifestations of poorly controlled diabetes (2 marks):

  1. Periodontal disease (gingivitis and periodontitis)
  2. Delayed wound healing
  3. Increased susceptibility to oral infections (candidiasis)
  4. Xerostomia (dry mouth)

b) Two pathophysiologic mechanisms (2 marks):

  1. Impaired immune function: Hyperglycemia impairs neutrophil function and reduces resistance to bacterial infections
  2. Microangiopathy: Diabetes causes small vessel disease leading to poor tissue perfusion and delayed healing

c) Three important laboratory investigations (3 marks):

  1. HbA1c (glycated hemoglobin) - assesses long-term glycemic control
  2. Fasting blood glucose - current glycemic status
  3. Complete blood count - assess for infections or complications

d) Three precautions for dentists (3 marks):

  1. Schedule appointments in the morning when blood glucose is most stable
  2. Ensure patient has eaten before treatment to prevent hypoglycemia
  3. Monitor for signs of hypoglycemia during procedures

e) Hand hygiene importance and 5 moments: Importance: Hand hygiene is the most effective measure to prevent healthcare-associated infections, protecting both patients and healthcare workers.

5 moments of hand hygiene:

  1. Before patient contact
  2. Before aseptic procedures
  3. After body fluid exposure risk
  4. After patient contact
  5. After contact with patient surroundings

Question 4: 50-year-old with rectal bleeding

a) Eight pertinent history questions (8 marks):

  1. Character of bleeding (bright red vs dark blood, mixed with stool or separate)
  2. Quantity of bleeding (amount, frequency)
  3. Associated symptoms (pain, tenesmus, change in bowel habits)
  4. Duration and progression of symptoms
  5. Previous similar episodes
  6. Associated constitutional symptoms (weight loss, fever, fatigue)
  7. Family history of colorectal cancer or inflammatory bowel disease
  8. Medications (anticoagulants, NSAIDs)

b) Eight causes of hematochezia (2 marks):

  1. Hemorrhoids
  2. Anal fissure
  3. Colorectal cancer
  4. Diverticular disease
  5. Inflammatory bowel disease (ulcerative colitis, Crohn's disease)
  6. Angiodysplasia
  7. Ischemic colitis
  8. Infectious colitis

c) Four necessary investigations (4 marks):

  1. Complete blood count (assess for anemia)
  2. Coagulation studies (PT/INR, APTT)
  3. Flexible sigmoidoscopy or colonoscopy
  4. Stool examination (microscopy, culture, occult blood)

SECTION C

Question 8: Short Notes

a) Glasgow Coma Scale (GCS)

Definition: A neurological scale used to assess level of consciousness in patients with head injuries or altered mental status.

Components:

  • Eye opening (E): 4 - spontaneous, 3 - to voice, 2 - to pain, 1 - none
  • Verbal response (V): 5 - oriented, 4 - confused, 3 - inappropriate words, 2 - incomprehensible sounds, 1 - none
  • Motor response (M): 6 - obeys commands, 5 - localizes pain, 4 - withdraws to pain, 3 - abnormal flexion, 2 - abnormal extension, 1 - none

Scoring: Total score ranges from 3-15 (E + V + M)

  • 13-15: Mild injury
  • 9-12: Moderate injury
  • 3-8: Severe injury

Usefulness:

  • Standardized assessment tool
  • Prognostic indicator
  • Communication tool between healthcare providers
  • Monitors changes in neurological status

Limitations:

  • Not applicable in intubated patients (verbal component)
  • Cultural and language barriers
  • Influenced by alcohol, drugs, or metabolic disorders
  • Poor inter-rater reliability in some cases

b) Nuclear Bone Scan

Definition: A nuclear medicine imaging technique using radioactive tracers to detect bone abnormalities.

Procedure:

  • Injection of Technetium-99m labeled phosphate compounds
  • Uptake period of 2-4 hours
  • Imaging with gamma camera

Indications:

  • Detect bone metastases
  • Evaluate unexplained bone pain
  • Assess fractures (especially stress fractures)
  • Monitor response to treatment

Advantages:

  • High sensitivity for bone abnormalities
  • Whole-body imaging capability
  • Relatively low radiation exposure

Limitations:

  • Low specificity (many conditions show increased uptake)
  • Cannot distinguish between different pathologies
  • Poor spatial resolution compared to CT/MRI

c) Ocular conditions diagnosed with Pen Torch

Examination technique: Direct illumination and inspection of external eye structures.

Conditions diagnosable:

  1. Conjunctivitis: Redness, discharge, injection of conjunctival vessels
  2. Corneal abrasions: Irregular light reflection, patient discomfort with light
  3. Pupillary abnormalities: Anisocoria, poor light response
  4. Pterygium: Triangular growth extending onto cornea
  5. Stye/Chalazion: Eyelid swelling and inflammation
  6. Cataracts: Opacity of lens visible through pupil
  7. Subconjunctival hemorrhage: Bright red blood under conjunctiva
  8. Foreign bodies: Visible particles on conjunctiva or cornea

Limitations: Cannot assess posterior segment, intraocular pressure, or detailed fundus examination.

d) Dysphagia

Definition: Difficulty or discomfort in swallowing.

Classification:

  1. Oropharyngeal dysphagia: Difficulty initiating swallowing
  2. Esophageal dysphagia: Difficulty with food passage through esophagus

Causes: Oropharyngeal:

  • Neurological: Stroke, Parkinson's disease, multiple sclerosis
  • Muscular: Myasthenia gravis, muscular dystrophy
  • Structural: Tumors, inflammation

Esophageal:

  • Mechanical: Strictures, tumors, rings
  • Motility disorders: Achalasia, esophageal spasm

Clinical presentation:

  • Difficulty swallowing solids and/or liquids
  • Choking or coughing during swallowing
  • Regurgitation
  • Weight loss
  • Aspiration pneumonia

Investigation:

  • Barium swallow study
  • Upper endoscopy
  • Esophageal manometry
  • Video fluoroscopy (modified barium swallow)

Management:

  • Treat underlying cause
  • Dietary modifications
  • Swallowing therapy
  • Surgical interventions when indicated

SURGERY BDS PART IIIA EXAMINATION ANSWERS

Question 1: Local Anesthetics

a) Mechanism of action: Local anesthetics work by blocking voltage-gated sodium channels in nerve cell membranes, preventing the generation and propagation of action potentials. They bind to the intracellular aspect of sodium channels in their ionized form, stabilizing the channel in its inactive state.

Common types:

  • Esters: Procaine, chloroprocaine (metabolized by plasma cholinesterases)
  • Amides: Lidocaine, bupivacaine (metabolized by liver enzymes)

b) Complications:

  1. Local complications:
    • Tissue irritation and inflammation
    • Nerve damage (rare)
    • Hematoma formation
    • Infection at injection site
  2. Systemic complications:
    • CNS toxicity: Seizures, altered mental status
    • Cardiovascular toxicity: Arrhythmias, hypotension, cardiac arrest
    • Allergic reactions (more common with esters)
    • Methemoglobinemia (with prilocaine)

Question 2: Elderly patient with urinary symptoms

Clinical presentation analysis:

  • Age: 64 years (high risk for prostate pathology)
  • Symptoms: Frequency, nocturia, poor stream, weight loss
  • PSA: 24ng/mL (significantly elevated, normal <4ng/mL)
  • Anemia: PCV 35% (suggests chronic disease)
  • Diabetes: HbA1c 7.0% (controlled)
  • UTI: Positive leucocytes and nitrites

Management approach:

Immediate assessment:

  1. Complete history and physical examination including digital rectal examination
  2. Assessment of bladder emptying (post-void residual)
  3. Urinalysis and culture
  4. Renal function tests

Staging investigations:

  1. Transrectal ultrasound and biopsy (high PSA warrants tissue diagnosis)
  2. Imaging: CT abdomen/pelvis, bone scan if cancer suspected
  3. Chest X-ray

Treatment plan:

  1. If benign prostatic hyperplasia:
    • Alpha-blockers (tamsulosin)
    • 5-alpha reductase inhibitors (finasteride)
    • Surgical options if medical therapy fails
  2. If prostate cancer:
    • Multidisciplinary team approach
    • Staging complete before treatment decision
    • Options: Active surveillance, radical prostatectomy, radiotherapy

Supportive care:

  • Treat UTI with appropriate antibiotics
  • Diabetes management continuation
  • Nutritional support for weight loss

Question 3: Foreign body in nose (5-year-old)

a) Likely complications:

  1. Immediate:
    • Mucosal trauma and bleeding
    • Further impaction with manipulation
    • Aspiration if object dislodged posteriorly
  2. Delayed:
    • Secondary bacterial infection
    • Rhinolith formation (calcification around object)
    • Septal perforation
    • Chronic rhinosinusitis

b) Management:

  1. Assessment:
    • Calm reassurance of child and parents
    • History: Type of object, time of insertion
    • Examination: Anterior rhinoscopy, assess for bleeding
  2. Removal techniques:
    • First attempt: Positive pressure (parent occludes opposite nostril, blows into child's mouth)
    • Medical removal: Nasal speculum, forceps, or suction under direct visualization
    • Topical anesthesia: Lidocaine spray if needed
  3. Precautions:
    • Adequate restraint and positioning
    • Good lighting and visualization
    • Avoid pushing object further back
    • Maximum 2-3 attempts before referral
  4. Post-removal:
    • Inspect for retained fragments
    • Antibiotic drops if mucosal trauma
    • Follow-up if symptoms persist

Question 4: Hypercalcemia and post-thyroidectomy management

Blood sample collection for hypercalcemia:

  1. Timing: Early morning, fasting state
  2. Technique: Venipuncture without tourniquet (prolonged use can increase calcium)
  3. Sample: Serum or plasma in appropriate tubes
  4. Storage: Rapid processing to prevent hemolysis
  5. Additional tests: Ionized calcium, parathyroid hormone, albumin, phosphate

Immediate treatment of post-thyroidectomy hypercalcemia:

Note: Post-thyroidectomy typically causes hypocalcemia due to inadvertent parathyroid gland removal or devascularization. Hypercalcemia post-thyroidectomy would be unusual but could occur due to:

  • Parathyroid hormone surge before gland failure
  • Bone release of calcium
  • Medication effects

Management:

  1. Confirm diagnosis: Repeat calcium levels, check ionized calcium
  2. Immediate measures:
    • IV normal saline hydration
    • Bisphosphonates (pamidronate or zoledronic acid)
    • Calcitonin for rapid effect
    • Corticosteroids if vitamin D mediated
  3. Monitoring:
    • Cardiac monitoring (risk of arrhythmias)
    • Neurological assessment
    • Fluid balance
    • Electrolyte monitoring

Question 5: Collapse in dental chair

i) Likely diagnoses:

  1. Vasovagal syncope (most common in dental settings)
  2. Local anesthetic toxicity
  3. Anaphylactic reaction
  4. Myocardial infarction
  5. Hypoglycemia
  6. Adrenal insufficiency

ii) First action:

  1. Stop procedure immediately
  2. Assess airway, breathing, circulation (ABC)
  3. Position patient supine with legs elevated
  4. Ensure patent airway
  5. Administer high-flow oxygen

iii) Further management:

  1. Monitoring:
    • Continuous vital signs
    • Cardiac monitoring if available
    • Blood glucose check
  2. Specific interventions:
    • If vasovagal: Trendelenburg position, IV fluids
    • If anaphylaxis: Epinephrine 1:1000, 0.3-0.5mL IM, IV steroids, antihistamines
    • If local anesthetic toxicity: Supportive care, lipid emulsion therapy
    • If hypoglycemia: IV glucose or glucagon
  3. Disposition:
    • Stabilize before transport
    • Call emergency services if severe
    • Hospital evaluation for unexplained collapse

Question 6: Cancer chemotherapy

a) Classification of chemotherapeutic drugs:

  1. Alkylating agents: Cyclophosphamide, cisplatin, carboplatin
  2. Antimetabolites: Methotrexate, 5-fluorouracil, gemcitabine
  3. Plant alkaloids: Vincristine, vinblastine, paclitaxel
  4. Antitumor antibiotics: Doxorubicin, bleomycin, mitomycin
  5. Topoisomerase inhibitors: Etoposide, irinotecan
  6. Hormonal agents: Tamoxifen, letrozole, leuprolide
  7. Targeted therapy: Imatinib, trastuzumab, rituximab
  8. Immunotherapy: Checkpoint inhibitors, CAR-T cells

b) Common complications and management:

Hematological toxicity:

  • Neutropenia: Monitor CBC, use G-CSF, prophylactic antibiotics
  • Thrombocytopenia: Platelet transfusion if severe bleeding
  • Anemia: Iron supplementation, erythropoietin, transfusion

Gastrointestinal toxicity:

  • Nausea/vomiting: Antiemetics (ondansetron, dexamethasone)
  • Mucositis: Mouth care, topical anesthetics, nutritional support
  • Diarrhea: Loperamide, fluid replacement

Organ-specific toxicity:

  • Cardiotoxicity: Baseline and monitoring echocardiograms
  • Nephrotoxicity: Hydration, monitor creatinine
  • Neurotoxicity: Dose modification, supportive care

Secondary malignancies:

  • Long-term surveillance
  • Risk-benefit assessment

Question 7: Major burns

Criteria for major burns:

  1. Adults:
    • Partial thickness burns >25% TBSA
    • Full thickness burns >10% TBSA
    • Burns involving face, hands, feet, genitalia, perineum, major joints
    • Electrical burns
    • Chemical burns
    • Inhalation injury
    • Burns with concomitant trauma
  2. Children:
    • Partial thickness burns >20% TBSA
    • Full thickness burns >5% TBSA

Initial resuscitation of 45-year-old female with petrol explosion burns:

Primary survey (ABCDE):

  1. Airway: Assess for inhalation injury, consider early intubation
  2. Breathing: High-flow oxygen, assess for pneumothorax
  3. Circulation: Large bore IV access, fluid resuscitation
  4. Disability: Neurological assessment
  5. Exposure: Remove burning clothing, prevent hypothermia

Secondary assessment:

  1. Burn assessment: Calculate TBSA using Rule of Nines
  2. Depth assessment: Superficial, partial, or full thickness
  3. Circumferential burns: Assess for compartment syndrome

Fluid resuscitation (Parkland formula):

  • First 24 hours: 4mL × weight(kg) × %TBSA burned
  • First 8 hours: Give half of calculated volume
  • Next 16 hours: Give remaining half
  • Monitor: Urine output (0.5-1mL/kg/hr), vital signs

Specific considerations for petrol burns:

  • Inhalation injury: High suspicion due to enclosed space
  • Chemical component: Potential systemic toxicity
  • Extent: Often extensive due to ignition properties

Wound care:

  • Cool compresses for small areas
  • Tetanus prophylaxis
  • Topical antimicrobials
  • Early debridement if indicated

Pain management:

  • IV morphine titrated to effect
  • Avoid IM injections in shock

Nutritional support:

  • High protein, high calorie diet
  • Consider enteral feeding

Psychological support:

  • Early intervention
  • Family counseling
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