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Answers of last years cases " final exams - end round exams "


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#1
Dr. Islam

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هنجمع هنا بإذن الله إجابات الكاسيز
سواء الموجودة فى أمتحانات السنين اللى فاتت من 2008 .. و
end round cases  2011

.........
June 2008
Forensic
1) a young 18 years old male was found dead in his room with  an incised wound in the neck. huge amount of blood stains were seen on a  mirror and on the ventral aspect of his clothes. a razor was seen  nearby the body.

1- do you think this case was homicidal, suicidal or accidental ? and why ?
suicidal,
blood on the mirror indicates he was standing in front of it,
blood on ventral aspect of clothes,
a razor is found in place which is usually a character in suicidal cases

2- how could you confirm you suspicion through examination of the wound ?
site: up high above thyroid cartilage
number: single
hesitation mark: usually present
slanting

3- enumerate the causes of death from cut throat.
neurogenic shock, hge, venous air embolism, asphyxia or dealayed from glottic edema or pneumonia.

4- describe post-mortem findings which you could see in that case.
pale hypostasis , Internal and external signs of ashyxia and cadaveric spasm

5- how could you estimate the age of that male ?
by  X-ray on the head of femur & the lower ends of tibia and   fibula  .. If the epiphyses of these regions are united then he is 18 yrs   old  or more
X-ray  on the head of humerus and the lower ends of radius and ulna ..   if  the epiphyses of these regions are still not united then he is less    than 20 yrs of age ..

6- what is the MLI of the age of 18 years old in males ?
  first military service call, driving license, complete  criminal  responsibility, governmental employment & election voting  rights.
----------------------------
  A 21 years old girk with history of pschiatric disorders  was admitted to a hospital showing severe extensive burns involving the  face, chest, abdominal wall, arms & thighs. 2 old scars were seen at  the ventral aspect of her left wrist. she died within 6 hours after  being admitted to the hospital.

1- do you think this case was homicidal, suicidal or accidental ? and why ?
suicidal,history of pschiatric disorders
  multiple previous attempts for suicide

2- how would you confirm the AM nature oh such burns ?
  hypermia, vesicles filled with serum rich in albumin &  chloride,  soot in air passages, COHb in blood, hemoconcentration, signs  of  healing & sepsis are seen be NE or under microscope.

3- enumerate the possible causes of death in that case.
neurogenic shock, ashpyxia or injury of vital organs.

4- describe post-mortem findings which you could see in that case.
Evidence of AM burns of various degrees , Redness of the body " co HB in  blood " , soot in air passage , haemoconcentration and skull thermal  fracture may be seen

5- how could you estimate the age of that girl ?
by  X-ray on the iliac crest & proximal end of clavicle .. If  the  epiphyses of these regions are united then she is 21 yrs   old or  more

6- what is the MLI of the age of 21 years old in females ?
age of civil rights.

---------------------

Toxicology
  A 25 years old female with a history of epilepsy was admitted  to hospital after ingestion of 20 tablets of her drug therapy. on  examination, she was comatosed, pulse rate was 90/min. BP was 65/50  mm/Hg, respiration was slow deep & streturous, temprature was 36.3C  and pupils were dilated reactive.

1- what is your provisional diagnosis ?
barbiturates toxicity.


2- how could you confirm this diagnosis ?
routine tests & serum barbiturate level.

3- what are the proper lines of ttt of that case ?
Supportive (ABC)
GIT decontamination
Elimination of poison from blood

  


Edited by ISLAM Ali, 02 July 2011 - 07:20 AM.

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#2
Dr. Islam

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August 2008
Forensic
A 16 years-old male was involved  in a quarrel. He was admitted to  hospital with headache and vomiting.  On examination, he was confused  with scalp injury in the right  tempro-parietal region. Few hours later,  he passed into coma with  unequal pupil size and the heart rate was 55  beats /minute.

   1-What is your diagnosis?
Brain concussion followed by compression with lucid interval

2-What is the proper management of such case?(3 marks)
Must be hospitalized for few days with Measurement of  BP, pulse, respiration, temp., conscious, motor power,  reflexes &  pupils (size, equality & reactivity) every 15 min.
Decompression  operation is done if pulse falls below 60/min. with the  side of lesion detected by signs of lateralization , X-ray & CT not by scalp wound.

  3-How can you diagnose the side of brain lesion?(2 marks)
from signs of lateralization , X-ray , CT scan and not by scalp wound

4-What are the possible sequelae of such case? (3 marks)
page 88

5-How can you verify that the age of the victim is 16 years? (2 marks)

X-ray :
- union of lateral epicondyle in the shaft
- union of upper end of ulna with the shaft

......................
Toxicology
  A farmer had repeated vomiting,  abdominal colic and diarrhea after taking his lunch which contains some  farm vegetables. The examination revealed constricted pupils, muscular  twitches, pulse was 60/minute, Bl.Pr. was 90/70 mm Hg., with sweating  and cripitations all over the chest.

1-  What is your provisional diagnosis and differential diagnosis?
organophosphorus compounds toxicity
DD >> morphine , carbolic acid , pontine hge

2-  What is the action of the suspected poison?
irreversible choline esterase inhibitor >> increase acetyl choline level peripherally & centrally.

3-  What is the proper treatment of such case?
* Prophylactic
* Curative (atropine sulphate, oximes, keep patent airway, GIT decontamination & gastric lavage).


Edited by ISLAM Ali, 01 July 2011 - 04:42 AM.

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#3
Dr. Islam

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June 2009
Forensic
an 18yrs old farmer was shot to death in his field . Two  suspects were arrested , one of them had a Ghaffir gun & the other  had a revolver . on examination , hypostasis was patchy &  intraocular pressure was Zero .
Thee was a central hole surrounded by smaller holes covering an area of 4 cm in the precordium and there were no exit wounds .

  a) how could you estimate the age of victim ?
by X-ray on the head of femur & the lower ends of tibia and  fibula .. If the epiphyses of these regions are united then he is 18 yrs  old or more
X-ray on the head of humerus and the lower ends of radius and ulna ..  if the epiphyses of these regions are still not united then he is less  than 20 yrs of age ..

  b ) mention the time passed since death ..
3 hours passed since death because ; hypostasis is patchy , intraoccular pressure is Zero .

c) who is the assailant ? how could you prove that his weapon was the causal object ?
the assailant is the one with the Ghaffir gun .( non-rifled weapon )

Prove : because the Inlet is caused by a non-rifled weapon ( shots )  showing a central hole with dispersion .. while the revolver is a rifled  weapon and will cause a single whole with no dispersion holes..

search for evidence of recent firing ( muzzle smell , swap )

compare the cartridge if present with the bore , type of the weapon ..

d) mention the distance of firing in this case ? what investigations should be done and what is it value ?
  * Distance of firing :
2 meters ( central hole + 4 cm dispersion )

* Investigations :
1/ examination of fire arm combustion residues ..found on the victim , thumb and index of the assailant

-visible residues : powder marks , grease marks ..
- Non-visible residues  :

  • nitrites , nitrates from gun powder , primer component ..
  • metal residues from the barrel ..
2/ X-ray : for

  • localization of shots
  • number of shots , dispersion .
  • documentation
3/ examination of clothes for : defects , firearm residues for estimation of distance , direction of firing

4/ Identification of the weapon

  • Examination of the weapon :
Fingerprints on the trigger

Full description of the weapon ( bore , type , license )

Muzzle smell , swap for recent firing

Compare the weapon with the cartridge , shots found in the scene ..

  
  • Examination of the cartridge :
compare the type , bore with the weapon . if it fits the weapon  experimental firing is done and the 2 cartridges are compared for :

preliminary marks :

           - striking needle grooves are compared for size , site , depth , shape

-Extractor hook marks

if they match then put them under comparison microscope and search  for confirmatory marks ( minute scratches near percussion cap ) if they  match then it's the causal weapon

  • Examination of the wound : central wound surrounded by 4 cm dispersion holes ..
-----------------------------------
  Toxicology
A female aged 16 yrs was brought to Kasr Al Aini poison  control center after attempting suicide by a drug . on examination , the  patient was confused with history of repeated vomiting with and attack  of hematemesis , temperature was 38 C , Bp was 100/80 , Pulse was  105/min . Resp rate was 32/min . Investigations revealed that ; PH 7.21 ,  HCO3 14ml Eq / L . prolonged prothrombin & bleeding time and on  X-ray . gastric concertion were noted .

  طبعا السطر اللي وضحلنا الحل بتاع الكيس هو :
  prolonged prothrombin & bleeding time  = Aspirin

1) what is the aced - base disturbance in this case ?
  Metabolic Acidosis ( 7.21 )
N.B normal PH is 7.4

  2) what is your provisional diagnosis ? why ?
  Aspirin toxicity .. because : shows the clinical picture of aspirin toxicity ..
  • Prolonged prothrombin , bleeding time
  • Vomiting , hematemesis
  • increase respiratory rate .
  • Acidosis
  • Gastric concretion on X-ray caused by the large amounts of aspirin tablets .
  • Fever due to uncoupling of oxidative phosphorylation process by aspirin overdose .
3) Enumerate two other poisons that induce the same acid base disturbance ?
  Remember the causes of acidosis : MUD PILES

M : Methanol
U : Uremia
D : Diabetic ketoacidosis
P : Paraldehyde, Phenformine
I : Iron , Isoniazide
L : Lactic acidosis
E : Ethylene glycol
S : Salicylates

  4) What is the proper treatment of such case ?
1- Supportive treatment : ( ABC )
  • maintain the airway via nasal mask , entubation
  • maintain circulation and treat hypotension by Fluid infusion , Dopamine (5-15 mg/kg )
  • assess CNS functions ( the patient is awake )
2- prevent further exposure ( GIT decontamination ) :
  • Emesis by syrup of Ipecac
  • Gastric lavage by sodium bicarbonate  ( helps in the condition of acidosis )
  • Activated charcoal and MDAC
  • Cathartics
  • Whole bowel irrigation
3- Poison Elimination :
  • Diuresis : Forced alkaline diuresis ( NaHCO3 1-2 mg/kg )
  • Dialysis in severe intoxication .
4- Symptomatic :
  • Acidosis : NaHCo3 I.V
  • seizures : Diazepam
  • Hyperthermia : cold foments
  • GIT irritation : demulcents
  • Bleeding tendencies : Vit K or blood transfusion .
  • Dehydration : I.V fluids


Edited by ISLAM Ali, 01 July 2011 - 04:12 AM.

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#4
Dr. Islam

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August 2009
Forensic :

  A 23 yrs old female was found dead in a clinic . on  examination the body was pale and small fetus was found beside the  deceased whose length was 16 cm . at autopsy. the length of the uterus  was 6 inches . the obstetrician claimed that this was a case of  therapeutic abortion that has been complicated to death ...

a) How could you estimate the age of the victim ?
  on autopsy :
union of the epiphysis of the medial head of the clavicle , iliac crest = she is >21yrs
starting of the union of the parietal suture  so he is between 23-28 yrs
the medullary cavity doesn't reach the surgical neck of humerus .. so she is less than 28 yrs
   eruption of the wisdom tooth ( 3rd molar ) ..

  b ) is that fetus belongs to the victim ? why ?
yes ..
the length of the uterus is 6 inches so she was in the 4th month of gestation
  the length of the fetus is 16cm that means that it has been aborted after 4 months of gestation ..

c) what are the possible causes of death in this case ?
1- Neurogenic shock  ( symp , parasymp )
2- Haemorrhage ( 1ry  )
3- Embolism ( air , amniotic fluid )
  NB: we exclude late causes of death ..

d) what are the investigations requested by the medical examiner for this case ?
1- Details on the medical condition that needed the abortion to save the mother ..
2- The consent of the husband and the woman for the abortion
3- signs of pregnancy ( HCG , abdominal and breast changes )
4- signs of local violence :
Cervix : bruises , volsellum marks
vagina : remnants of abortion . etc...
5- Laboratory analysis for blood , urine , stools for any abortificient drugs
6 - examination of the fetus .. determining the age , macerated or not , precepitin test ..
7 - peritoneum for signs of Hge , sepsis, perforated uterus
8 - GIT : for inflamations by purgatives .
9 - uterus : size , contents , endomtetrium condition ..

e) Is there any medicolegal responsibility on the obstetrician ? why ?
Yes ..
because therapeutic abortion must be done in a well prepared hospital ..

  -------------------------------
  Toxicology
  a young girl was admitted to the poisoning control center  after she has ingested 50 tablets prescribed for her mother's cardiac  condition . the girl had repeated vomiting with abdominal pain .on  examination she was unconscious but responding to pain , pulse was  60/min , BP 90/60 and the respiratory rate was 12/min . ECG showed A-V  block and serum K+ was 6 mEq/L ..

1) what is the electrolyte disturbance in this case ? Mention the mechanism
Hyperkalemia.. mechanism:
Inhibition of the Na/K ATPase leading to retention of sodium inside the cells and potassium outside ( Hyperkalemia )

  2)What is your provisional diagnosis and Investigations needed to verify your diagnosis?state her coma stage ?
* Digitalis toxicity
* Investigations needed :

  • Serum digoxin level
  • Electrolytes level K+, Ca++
  • ECG for arrhythmias .
  • Kidney functions
* Coma stage 1 .. according to Reed coma scale

3) What is the proper treatment of such case ?
1-Supprotive :
ABC +
> Treat the electrolyte imbalance:
insulin with 5% glaucose for hyperkalemia
-disodium EDTA for hypercalcemia

>Antiarrhythmics :

  • Atropine for the A-V block
  • Lidocaine
  • Phenytoin
2- prevent further exposure  ..
charcoal , cholestyramine ( to stop the enetro hepatic circulation )

REMEMBER : Drugs with enterohepatic circulation  :
Bile To Deodnum


B
: Barbiturates

T: TCA
D: Digitalis .

3 - Physiological antidote
Digibind .... ( check the book for details )


Edited by ISLAM Ali, 01 July 2011 - 04:24 AM.

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#5
Dr. Islam

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June 2010
Forensic

A 21 years-old man was found dead in his bathroom  , lying on his left  side .
There was blood beneath his head  , associated with a laceration to  the posterior  scalp together with multiple linear contusions allover  the body. On examination  , His body shows patchy hypostasis and rigor  mortis of the face and neck . Autopsy showed a large wedge shaped  intra-cerebral hemorrhage tapered deep into the brain substance. Same  red stain was found on the bed sheet & bathroom. Serology  investigations revealed that the blood stain from the bathroom belongs  to the deceased , while the stain on the bed was not blood.

1) Prove the alleged age of the deceased by an X-ray(one site)? 1 mark
On x- ray , The lower end of femur  units with shaft
The upper ends of tibia and fibula unit with their shafts
Hence, The patient is about  21 years-old

2)Describe characteristics of the given injuries and possible causal instrument? 3 marks
There was a laceration on the posterior scalp , multiple linear contusions.
* Laceration on the posterior scalp is characterized by being often  linear due to convexity of the underlying skull  simulating cut wounds   "severe bleeding, regular edges".
* There is also multiple linear contusions which are superficial  raised above the surface of the skin and being linear as they take the  shape of the causal object
… So the possible causal instrument is stick

3)   How could the expert confirm that the stain on the bed was  not blood and the blood from the bathroom belongs to the deceased? 4  marks
A - The expert confirmed that the stain on the bed was not blood  after preliminary and confirmatory tests  ( write all in detail if  possible )

* Preliminary tests " oxidase tests" :
Guaiacum test-Benzidine test-Kastle –Meyer  test

* Confirmatory tests
Microscopical examination " fresh stains" - Microchemical tests " dried stains " - Spectroscopic examination

B – He confirmed that the blood from the bathroom belongs to the deceased
by genetic markers of the blood ( RBCs , Plasma " serum " , WBCs )
- The RBCs surface antigen system " A,B,Rh,M,N,…"
- The red cell isozymes " Phosphoglucomutase PGM "
- The serum proteins polymorphism " Hp,GM,GC protein "
- The histocompitapility antigen of WBCs " HLA "
- The DNA finger prints
.. Genetic markers of that blood were matched with that of the deceased

4)   What is the possible cause of death in this case ? 2 marks
intra-cerebral hemorrhage tapered deep into the brain substance causing brain laceration

5)   Verify the postmortem interval in such case ? 2 marks
Rigor mortis in head and neck indicates at least more than 2 hours after death
& patchy hypostasis on the body indicates 3 hours after death
.. the postmortem interval is mostly 3 hours.

------------------------------------
Toxicology
A 30 years-old  female under psychiatric  treatment  was  admitted to the poison control center with restlessness, upward  deviation of the eyes, torticollis , abnormal movement  of the tongue  and tachyarrhythmia . Bp was 80/50 mmHg . Pupils were dilated , ECG  revealed supraventricular  tachyarrhythmia .

A) What `s your provisional diagnosis ? 1 mark
Phenothiazine toxicity

b ) Discuss the mechanism of action of the drug ? 2 marks
a.Receptor blockade :
- Dopamine blockage in limbic system & basal ganglia
- Anticholinergic
- Alpha 1 adrenergic blockade
- Serotonergic & histaminic blockade

b.Quinidine – like action : Na channel blocker

C) Mention other CNS manifestations of the consumed drug ? 3 marks
* Depression of CTZ
*Coma
*Respiratory failure " RC depression "
*Extrapyramidal manifestations " Dopamine blockage "
- Dystonic reaction
- Akathesia
- Parkinsonism
- Tardive dyskinesia
- Neuroleptic Malignant syndrome

D) How can you treat such case ? 2 marks
   - Supportive "ABCs"

- GIT decontamination " lavage , activated charcoal , MDAC "
but avoid emetics " (-)CTZ , (-) gag reflex , dystonic reaction >> aspiration & compromise airway"

- Elimination of poison from blood " Diuresis , Hemoperfusion & plasma pharesis "
Haemodialysis is not recommended since antipsychotic is highly lipophilic wth large Vd

- management of the complications: p.105


Edited by ISLAM Ali, 01 July 2011 - 04:55 AM.

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#6
AkramYassin

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View PostISLAM Ali, on 01 July 2011 - 04:51 AM, said:

Nice Work ya Eslam .. thx a lot :)



#7
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#8
Dr. Islam

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First end round exam 2011
In medico-legal report , the forensic examiner stated that "  forensic examination of the corpse recovered from the river . How can the forensic expert reach these conclusion ?

A – cause of death is not drowning .
The examiner don't found this signs of drowning :
  1 – Air passages :
  contain froth finely beaten & foreign bodies from water (sand, weeds)
  2 – stomach :
             Contain unpalatable water and foreign bodies .
3 – Planktones :
  They pass into the circulation to all organs  and can be detected in the liver, brain  or bone marrow .

   B – he died since 3 weeks ."
      Adipocere is formed after 3 weeks in water , it's a waxy  yellow greasy material with characteristic odor that found in fatty  areas of corpse .


Edited by ISLAM Ali, 01 July 2011 - 01:29 PM.

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#9
Dr. Islam

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second end round exam 2011
A man was hit in his right arm by a fass during a quarrel  that lead to compound fracture . describe findings of examination of his  skin and bone after 1 week, 3 weeks & 3 months . considering that  there were no septic complication .

Healing of bone fructure :
   After 1 week : organization of the blood clot in between the 2 fragments .
   After 3 weeks : 1ry callus is formed in the organized clot .
     After 3 months : complete healing with a firm callus .

Skin show cut wound :
After 1 week : new vessels start to grow towards the skin surface .
After 3 weeks : the scar is red .
After 3 months : the scar is coppery brown


Edited by ISLAM Ali, 01 July 2011 - 01:32 PM.

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#10
Dr. Islam

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Third end round exam 2011
In medico-legal report the forensic examiner stated that "  the victim's examination and investigation revealed that she is 6-year  old died from carbon monoxide toxicity , 12 hours ago " discuss how can  he reach such conclusion

- She is 6-year old :
eruption of first permanent molars .

  - Died from carbon monoxide toxicity :
p.m.p
-brain edema & congestion
-int.& ext. signs of asphyxia
-Lung , brain & heart complications ( necrosis & degeneration )

- 12 hours:
( rigor mortis and P.M. cooling )


Edited by ISLAM Ali, 01 July 2011 - 01:36 PM.

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