PRINCIPLES OF SURGERY

Q.1 What mismatched blood transfusion? How do you manage such case?
Ans: Mismatched Bl. Transfusion: IMBDA transfusion of blood. Which is not cross
matched with the recipient. IMBDA administration of blood of the wrong blood type.
Management:
(a) Diagnosis: Pain at the site of transfusion, back & chest. Facial flushing Fever,
Respiratory distress, Hypotension. Tachycardia.
(b) Treatment: Transfusion should be stopped immediately.
A sample of the recipients blood drown and sent along with suspect unit to
the blood bank for comparison with the pre transfusion samples.
Urine output should be monitored
Adequate hydration maintained to prevent renal failure.

Q.2: How do you treat a case of tetanus? What are the causes of death in tetanu?
Ans: Treatment of tetanus: TTg 250-500 Units IM inj (Prophylaxis)
3000-10,000 units (for case)
Muscle relaxant, Sedatives
Penicillin
Wound debridement keep pt in noise free room.
Cause of death: Tomic spasm of resp. Muscles Respiratory failure.

Q.3 Define carbuncle. What investigantions will you do in an old patient e carbuncle?
How do you heat carbuncle?
Ans: Carbuncle: IMBDA a necrotizing infection of skin & subcutaencous tissues
composed of a culster of furuncles, usually due to staph, aureus with multiple
drainage sinuses.
Investigation: CBC, fasting blood glucose, Urine R/M/E,
Pus for microscopy and C/S.

Treatment of carbuncle:
1. Incision & drainage of pus & excision of all dead tissue.
2. Antibiotic-Flucloxacillin or cephradine or change after c/s report.
3. Protection with sterile dressing.
4. Control of diabetics (if present) and improvement of general condition
5. Large sloughing requirs excision & skin grafting.

Q.4 Name the important electrolytes in our body. How they contro the fluid
movement in different compartments?
Ans. Major electrolytes in body fluid-Na+, K+, Cl-, HCO3-
other electrolytes Ca, Mg, HPC4, SO4, Proteins, Organic Acid, etc.
The control of fluid movements in different compartments depends on
(i) Osmotic Presure, that depends on crystalloid and colloid
(ii) Permeability of membrane.
(iii) Ion channels & pumps.
(iv) The major electrolytes are crystalloids, small ions that can pass through
ion channels & pumps. In this way they cross a compartment & change
osmotic pressure. The incressed osmotic pressure drains fluid from other
compartment. In this way, the electrolytes control fluid movement.

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Q:5 Define gangrene. How do you diagnose & treat a case of gas gangrene
Ans: Gangrene: IMBDA necrosis or death of tissue, usually resulting from deficient or
absent blood supply followed by bacterial invasion and putrefaction.
Diagnosis of gas gangrene:
History: H/O contaminated wound
Pain & swelling wound
Fever
Sign: Tachycardia, Tachypnoea, Low BP, Delirium.
The extremity of wound shows tendernen, tissue swelling, crepitus present
and a serosanguineous discharge, Nearby skin soon become discoloured.

Investigation: CBC shows leukocytosis, low , low or normal Hb.

X-ray of infected site showns gas in muscle or fascial plane.
Treatment:
1. Penicilin (upto 2 ) 4 hourly.
2. AGS (anti-gas gangrene serum).
3. Treatment of shock. Blood transfusion usually required.
4. extensive surgery with removal of all the dead and infected tissue is
necessary.
5. Hyperbaric O2 therapy if available.

Q:6 What is transfusion? What is the difference between transfusion & infusion?
Name fluids those are used for transfusion.
Ans: Transfusion: IMBDA the introduction of whole blood or blood components
directly into the blood stream of aperson.
Infusion: IMBDA the therapeutic introduction of fluid other than blood into the blood
stream of a person.
Difference: The term Transfusion is used for blood & blood products The term
infusion is used for fluids other than blood.
Infusion fluids: Normal saline, Dextrose in aqua (5%, 10%, 25%), Dextrose in normal
saline, Cholera saline, Hartmanns solution, Ringer Lactate solution, Baby saline etc.

Q:7 Define burn, How do you calculate fluid requirements in a 45% burn patient?
Ans: Burn: IMBDA tissue injury resulting from exessive expossure to thermal,
chemical, electrical or readioactive agents.
Fluid requirments: According to Parkland formula,
4 mL (body wk in kg) (% of TBSA burnt)
So, (4mL 45)=180 mL/kg body wt.
Half of this fluid is infused during first 8 hour post injury rest half in next 16 hour.

Q. 8 How do you differentiate between partial and full thickness burn?

What are the difference in the treatment of two types?
Ans: The Differentiation is made clinically an examination.
10/ Superficial burn-0 painful erythematous but do not blister.
20/ Partial thickness burn Extemely painful e weeping & blister
30/ Full thickness burn-Hard p;ainless and non blanching.
Difference in treatment
Partial thickness burn- Good analgesic required. No skin graft needed
Full thickness burn: Analgesia may not be needed.

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Skin graft is required
Antibiotic dressing is required.
Q.9 Define shock. What are the clinical features of haemorrhagic shock? Enumerate
the principles of management of a patient with hemorrnage shock.
Ans: Shock: IMBDA a profound hemodynamic and metabolic disturbance due to
failure of the circulatory system to maintain adequeate perfusion of vital organs.
Management of hemorrhgic shock:
1. Confirm diagnosis by pulses, BP resp rate, capillary refill etc.
2. Assesment of patient-Urine output Source of bleeding etc.
3. Treatment principles:
(i) Resuscitation of the patient
* Supine, head down position
02 inhalation
IV fluid infusion and blood transfusion to restore circulatory volume.
(ii) Stop the hemomhage Presure, pack, Ligation, Diathermy
(iii) Treatment of complications-Acidosis, Renal failure etc.

Q. 10: What are the indications of blood transfusion? What are the rules you will
follow to start blood transfusion:
Ans:
1. Whole blood Acute blood loss leading to shock.
2. Red call concentrate- Severe anaemia (Hb <9 gm/dl)
3. Platelet concentrate-Thrombocytopenia
4. White cells concentrate-Overwhelming bacterial/fungal sepsis in neutropenic
patient.
5. Fresh frozen plasma-DIC, Plasma loss in Burn, Dengue etc.
6. Cryoprecipitate Haemophilia
7. Coagulation factor concentrate- Haemophilia.
8. Human albumin solution- Hypoalbuminaemia, Plasma replacement.
9. Immunoglobulin (Specific standard pool)
Rules to start blood transfusion:
1. Check-Name, age, sex, ward no, bed no, blood group, blood bank reference no. and
blood bag number.
2. Keep the blood bag of room temp for 15-20 min beface transfusion.
3. Open IV channel wide bore cannula.
4. Inj. Chlorphemiramine 25 mg IM 15 min before transfusion.
5. Transfuse blood at the rate of 30 drops per minute.
Observe for transfusion reactions chills, rigor, Sweating, Chest pain, Back pain, Resp,
distress, Confusion.

Q. 11 Define and classify ulcer. What at the macroscopic character of Malignant

ulcess.
Ans: Ulcer: IMBDA sloughing out of inflamuatory necrotic tissue from the surface of
an organ or tissue, Which is one of the sequence of inflammation.
Classification: An ulcer is a discontinuity/breach/break of continuity an epethcial
surface which occurs due to slough inflammatory necrotizing tissue.
1. Spreading Ulcer
2. Healing Ulcer
3. Callous Ulcer.

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6. Pathsiogical classification:
1. Specific ulcer-Tuberculer ulcer, Syphilitic ulcer.
2. Non-specific ulcer.
(i) Traumatic
(ii) Ischaemic ulcer.
(iii) venous ulcer.
(iv) Neurogenic/Trophic ulcer.
3. Malignant Ulcer:
(i) SCC, (ii) BCC, (iii) MM (Malignant melanoma squamous cell Basal cell.
Macroscopic Character of Malignant ulcer:
Squamous cell carcinoma Non-healing ulcer e everted edge. foul smelling discharge,
non tender bleeds on touch and indurated base.
Basal cell carcinoma Typical site is on face above angle of mouth, rolled up/ raised
edge, floor may be deep into muscles or bone, dilated blood vessels in skin.
Malignant Melanoma- Asymmetry Border irregular, (color irregular, diameter after>
0.5 cm, Elevation irregular (Remember, ABCD)

Q: 12: Define absecess, WHat are the climical feature of an abscess

Ans: Abscess IMBDA a localized collection of pus in any body part that resuths from
invasion of a pyogenic micro organisn
Clinical featurers
Symptoms: Local pain (Throbbing in character), Swelling, redned of the area, fever.
Signs: Fever, Local sings of inflammation heat redness, tenderess swelling, loss of
fuction, fluctuation text positive.

Q.13: What do you mean by sepsis? What is bacteremia & septicemia?

Ans: SIRS: Systemic inflammatory response syndrome consists of any two of the
following three point.
(i) Hyperthermia (> 38) or Hypothermia (<36c)
(ii) Tachycardia (>30/min & no B blocker) or Tachypnoea (>20/min)
(iii) TWBC count > 12 109/L 02 <4 109/L
Sepsis: IMBDA a SIRS with a documented infection.
Bacteremia: IMBDA presence of bacteria in blood.
Septicemia: IMBDA Systemic discase associated with the presence and persistence
of pothogenic micro organises in the blood / toxin / both.

Q: 14 WHat are the donor criteria for blood transfusion?

Ans: Donor criteria
1. Age > 18 years and <58 years.
2. Weight: Minimum 50 kg
3. Exclude pregnancy, location menstruation.
4. Haemoglobin >12 gld (80%)
5. Vital sings normal
6. H/O Hepatitis DM, MTN, Malaria Allergy.
HTN control nj blood w`Z cvie|
DM-OAD Lj blood w`Z cvie, wK insulin wbj cvoe bv|
7. H/O travelling, IV drug sbuse, sexual exposure
8. Major Operation within 6 months
Tooth extraction within 4 weeks.

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vaccination within 4 weeks.
9. Last date of blood donation (120 days gap)
10. KD hw` Blood receive Ki _vK Ze h 1 years Gi ga Donate Kie bv|
11. Donor for platelet nj RvbZ ne m aspirin Lvq wKbv|
12. If he/she is feeling well at present.

Q. 15: Define & Classify shock. How does septic shock develop?
Ans: Shock: IMBDA a profound hemodynamic & metabolic disturbance due to failure
of the circulatory system to maintain adequate perfusion of vital organs.
Classification:
1. Hypovolumic/Hacmorrhagic shock.
2. Traumatic shock.
3. Septic shock.
4. Cardiogenic shock.
5. Obstructive shock.
6. Neurogenic shock.
7. Anaphylatic shock.

Pathogenesis of septic shock:

Gram negative bacteria infection
Relase of Endotoxin (LPS)
High quantities of inflammatory mediators cause
Leukocytosis fever Raise of acute phase reactant
Low cardiac output, Low peripheral resistance.
Blood usual injury, Thrombosis, DIC, ARDS.

Q. 16: Mention at least four clinical signs of shock. what kind of fluid you will infuse
immediately to resuscitate with haemorrhagic shock?
Ans: 4. Clinical sings of shock:
Cold, clammy skin (hot in case of soptic shock),
Tachycardia
Tachypnoea
Decreased blood prossure.
Choice of fluid:
Whole blood is the best replacement for hemorrhagic shock.
But for immediate resuscitation, crystalloid solution is best choice
Such as, Ringers lactate solution, Hartmans solution, Normal saline.

Q: 17 describe the pathogenisis of shock in burn. Mention four clinical sings that
indicate adequate fluid replacement in hypovolumic shock.
Ans: Shock in Burn:
1. Immediately Anixety. Excessive sensory stimulus nerogenic shock.
2. Early Loss of plasma from Burnt area- Hypovolaemia Hypovolumic shock.
3. Late Secondary baterial infection septic shock.
Indicator of adequate replacement:
1. Blood pressure returns to normal range.
2. Pulse rate returns to normal range.
3. Capillary refilling time becomes normal.
4. Breathing rate returns to normal range.

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5. Urine output > 30 ml/hour.

Q: 18: Define burn, What is meant by 2nd degree burn? WHat percentage of the body
surface is involved in front the left lower limb is effected by bourn?
Ans: IMBDA tissue injury resulting for excessive exposure to thermal chemical,
electrical or radioactive agents.
Front of left lower limb his 9% of total body surface area.
Q: 19: How muchh fluid is required in 24 hours time in a 60 kg 30% of the body
surface is affected by superficial burn? is preferred for volume replacement in case
of burn.
Ans: Acord. to Parkland formula
Fluid requirement in first 24 hours= 4mL (body wt. in kg) (% of TBSA burent)
= 4 60 30 ml
= 7200 ml
Preferred fluid is rigners lactate solution
In absence of it, any other crystalloid ostonic solution coil.

Q. 20: Classify Burn. Would you need fluid infusion for 10% burn in children? mention
two clinical sings differentiating 2nd degree from 3rd degree burn.
Ans:
Actiolgocial classification
1. Thremal
(i) Flame burn
(ii) Contact burn
(iii) Scald
2. Electrical
3. Chemical
Clinical classification:
1. Superficial burn.
2. Partial thickness burn.
3. Full thickness burn.
Yes, in children, burn of 10% or more area requires fluid.
Clinical sign
1. Presence of pain
2. Blanching on prossure

Q: 21: what is the danger or the circumferential burn? what should be immediately in
case of circumferent burn of the limbs? What first aid measure should be taken late
in acid burn?
Ans: Tourniquet effect for cirumferential Oedematous burn eschar leads to
compartment syndrome.
If compartment syndrome statrs to develop exharotomy is done if no improvement,
then fasciotomy is done.
First aid measure for acid burn: Wash with copious amount of plain water.

Q: 22. What are the end results of 3rd degree burn if not treated adequately? What
surgical measures is undertaken in 3rd degree burn?
Ans: End result of 3rd degree burn,
Scar formation.

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Hypertrophic scar or keloid.
Scan contracture
Restriction of movement of nearby joint.
rd
Surgical measure in 3 degree burn:
After resucitation of patient, early excision and grafting done.
In large burn, serial excisions can be performed,
Split thickness skin autograft is done in most cases.
Q. 23 A lacerated wound in right hand has been sustained 2 hours earlier by a dirty
wire. Mention the steps you would undertake. what would you do if there was a
divided tendon? What would be your decision about closure of the wound.
Ans: The wound presented within 6 hours of injury. So, it is type III or
Contaminated wound
Management
1. Wound toileting and wound debridement.
2. Assessment of injury to deep structures, vessels and nerves.
3. Repair of the deep injuries.
4. Closure of the wound (Primary closure)
5. Sterile dressing
6. Broad spectrun antibiotic and tetanus prophylaxis
Divided tendon:
Early repair is recommended. But in case of bulky repair of flexor tendons, they can
be left for later reconstruction.

Q: 24 Name four facotrs contributing to surgical site infections (surgical wound)

Such Name two common organisms causing infection of the abdominal wound.
Ans: 4 factors contributing to surgical site infection:
1. Contaminated or clear contaminated surgery
2. Malnourised/Debilted/immunosuppressed patient.
3. Infected OT/instrument/staff
4. Foreign body material.
Commonest 2 Organizes are:
1. Escherichia coli (E.coli)
2. Staphylococcus aurcus.

Q. 25 Describe the principles of autoclaving. Mention two major advantage

autoclaving. How laparoscopic instruments are sterilized:
Ans: Principle of autoclaving:
1. Water boils of 1210C when pressure is increased 15 lb/in2 over atmospheric
pressure.
2. When this highly heated steam comes in contact with any object it relases huge
amount of latent heat. This heat can kill any micro organisms including spores.
3. After release of heat, steam becomes water and reduces in volume so, a vacumm
is formed which draws more steam to the object:
Advantage of autoclaving
1. It is a method of sterilization. It can kill spores.
2. It is cheap, suitable for hospital use. It can be used for most instruments in
hospital setting.
Laparoscopic instruments are sterilized with Gluteraldehyde 4-6 hours in 4.5%
w/w/Gluferaldehyde.

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Q: 26: Name two causes of fever after on abdominal operation on a 60 years old
man. Name two common post operative respiratory complications.
Ans: 2 Causes of fever (i) Wound infection (ii) Bronchopneumonia
2 respiratory complications: (i) Bronchopneumonia (ii) Atelectasis

Q: 27: Define sterilization. Name the methods of sterilization Name an ideal method
of sterilization. Why do you think it is ideal?
Ans: Sterilization: IMBDA the process that destroys all forms of micro organisms
including spores from an object.
Metholds of sterilization
Own writing:

Why autoclaving is ideal:

1. It can destroy all micro organisns including spores.
2. It can be applied for most of the surgical instrument execpt sharp and latex.
3. It takes shortest time than other heat method and chemical methods.
4. It can be used in hospital setting, which is not possible, for radition method.

Q: 28 What are the pricniples of autoclaving? Name two articles cannot be

autocloved.
Ans: (These answers are already written for previous questions) sharp instruments.

Q: 29: Why biling cannot be said to be a method of sterilization why the authocliving
is an effecient method of sterilization.
Ans: Boiling cannot kill spores so it cannot be said to be a method of sterilization.

Q: 30: What is the most common micro organization found in the skin. How do we
prepare the skin before incision is made for operation what is the purpose of
preparing the skin:
Ans: Commonest Organism in the skin: Staphylococcus epidermidis.
Skin preparation: 1. Before operation, the area should be washed with soap water.
2. Shaving may be necessary but not routinely recommended.
3. Before incision, the area is painted with povidone iodine for sepsis.
Purpose of preparing skin: It is a part of aseptic preced to reduce surgical site
infection.

Q. 31: Name the type of wounds. Mention chronologically the steps a contaminated
wound in leg.
ANs: Types of wound
(a) Closed wound
1. Burise
2. Ecchymosis
3. Hematoma
4. Contusion
Open wound:
1. Abrasion
2. Incised wound
3. Laceration

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4. peretrating / perforating wound.
5. Gun shot injury
6. Bomb blast injury.
(c) According to contamination:
1. Clean wound
2. Clean contaiminated wound
3. Contaminated wound.
4. Dirty wound.
(d) According to presence of infection:
1. Infected wound.
2. Non-infected wound.
Steps of management of contaminated wound in leg:
1. Wound toileting and wound debridement.
2. Assessment of injury to deep structures, vessels and nerves.
3. Repair of the deep; injuries.
4. Closure of the wound.
(i) If the case in presented within 6 hours then primary closure.
(ii) If the case is presented after 6 hours then delayed primary closure
5. Sterile dressing
6. Broad specturn antibiotic and tetanus prophylaxis.

Q. 32: Mention the conditions when you would consider primary sture of the wound.
What is delayed primary suture? What is its objective:
Primary suture of wound:
1. Clean wound.
2. Clean contaminated wound
3. Contaminated wound presenting within 6 hours.
4. The wound edges can be approximated.

Delayed Primary suture:

In case of grossly contaminated would after toileting and debridement the wound is
kept open under dressing for 4 to 6 days. If healing start without any sign of infection
then it is closed. This technique is called delayed primary.

Objective:
1. Reduce the chance of infection in grossly contaminated wound.
2. Regular observation and dressing eradicate development of infection.

Q.33: Name two general and two local factors affecting would healing what is by
second intention? Give on example. What is scar? Name two complication of scar.
Ans: General factors affecting would healing
(i) DM
(ii) Malnutition
Local factors: (i) Vascularity and tissue
(ii) Contamination/infection
Healing by second intention:
It is a process of healing which takes place when the wound edges and are not
brought together, When tehre is irreparable skin loss, when the wound becomes
injected, has to be laid open.

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Scar: IMBDA the resident visible mark of a wound after healing.
Complication of scar: (i) Contraction (ii) Keloid formation

Q. 34: Mention two indications of blood transfustion Name two blood component
need in surgical managements. Named two discases for which blood donor must be
screened for
Ans: 2 Indications: (i) He morrhagic shock.
(ii) Severe anaemia
2 blood components: (i) Fresh frozen plasma- Plamal loss in burn, DIC
(ii) Red cell concentrate- Severe anaemia.
2 discases must be screened (i) Hepatitis B, (ii) Hepatitisc.

Q 35: Name two immediate reactions you must watch in a patient just after starting
a blood transsfusion. What wil happen to the renal function in case of mismatched
transfusion? What will be the ill effect of whole blood transfusion to chronic anaemic
patient.
Ans: 2Immediate reactions: (i) Immediate hemolytic transfusion reaction
(ii) Allergic/anaphylatic reaction
Renal function in mismatched blood transfusion:
Due to hemotysis, free hemoglobin pass through kidney.
Hemoglobinuria occurs. If its amount is massive then the Hb block renal tubules
leading to acute renal shutdown.
Ill effect of whole blood transfusion to a chronically anemic patient:
Circulatory overload. May cause heart failure, pulmonary edema.

Q: 36: Name two effects of DM on surgical operations. How DM is managed during

operation? Why DM get worse with surgical trauma?
Ans: 2 effects of DM on surgery
(i) Increased risk of infection
(ii) Delayed healing

Management of DM during operation:

Controlled by diet-Monitor blood glucose 4 hourly.
Controlled by OAD-Omit morning medication. Give 10 unit insulin in 11.5% DA.
- Monitor blood glucose 1-2 hourly.
- Stop OAD when patient can eat normally
Insulin dependent
Stabilize DM before operation
Half doese of long acting insulin 24 hours before operation
One fourth dose of medium acting insulin at evening meal before operation.
Monitor blood glucose 1-2 hourly start OAD when patient can eat normally.
Omit normal dosage in the morning
Start 15 unit insulin in 1L 5% DA 2 hours before surgery.
Monitor blood glucose 1-2 hourly.
DM get worse in surgery:
Any trauma whether it is a surgery or an accident, in a stress. It causes release of
epinephrine, corticosterioid, grwoth hormone all these hormones counter the action
of insulin and increases blood glucose. So DM gets worse in surgical trauma.

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Q. 37: Define and classify hemorrhage give two causes of reactionany hemorhage
occuring after prostateclomy.
Ans: Hemorrhage: IMbDA the escape of blood from the vessels
Classification:
(a) According to relation with the exterior
(1) Internal H.
(2) External H.
(b) According to nature of vessel
(1) Anterial H.
(2) Venous H.
(3) Copillary H.
(c) According to time of hemorrhage related to surgery
(1) Primary H.
(2) Reactionary H.
(3) Secondary H.
2 Causes of Reactionary hemorrhage after prostatectomy:
(i) Incomplete hemostasis of blood vessels in prostate capsule
(ii) Re-operaing of blood vessels at the bladder neck.
Q. 38: Mention four climical signs of a concealed hemorrhrge after a blunt
abdominal trauma. Mention 2 course of traumatic hemo peritoneum.
Ans: Intra abdominal hemorhage is hard to diagnose only on clinical signs.
There may be substaintial amount of bleeding without my sign.
The sigm are
(i) Abdominal distention
(ii) Abdominal tenderness
(iii) Signs of peritionitis Rigidity, Rebound tenderness.
(iv) Cullens sign-Bluish discoloration around umbilicus.
2 Causes of traumatic hemo peritoneum:
1. Splenic rupture
2. Liver rupture

Q:39 What is secondary hemorrhage? Give two causes of secondary hemorrhage.

What is warning hemorrhage? Mention two measures you should take to prevent
reactionary hemomhage.
Ans: Secondary hemorrhage: Hemorrhage that occurs from would 24 hours after
surgery up to the healing.
Causes: (i) Infection (ii) Pressure necrosis of vessel wall.
Warning hemorrhage: Some episodes of small hemorrhage may occur before
rupture of a vessel or luminal organ that leads to large hemorrhage. Those
preceding episodes are called warning hemorrhage
eg: Warning hemorr hage before rupture of tubal pregnancy warning headache
before subarachnoid hemorrhage. Warming perineal pain before rupture aortic
aneurygm.
Prevention of ractionary hemorrhage:
1. Good surgical techinque for hemostasis during operation
2. control of BP during post operative/recovery period.

Q. 40: Mention four indications of blood transfusion in surgical words mention the
steps you must take to avoid a mismatched transfusion.

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 Ans: 4 indications of blood transfusion in surgical words:
1. Hemorrhagic shock.
2. Burn
3. Severe anaemia
4. DIC
To avoid mismatched transfusion:
1. Proper blood grouping and cross matching
2. Check patients name age, admission number, word a bed number with that
written in requisition from accompaying blood bag.
Q 41: Mention two immediate transfusion reactions? Mention four infection discases
that can spread through blood transfusion. What might happen if two units whole
blood is transfused to a case of chronic severe anaemia.
Ans: (i) Allergic reaction
(ii) Febrile reaction
(i) Hepatitis B, (ii) Hepatitis C (iii) HIV (iv) Malaria
Circulatory overload
Q 42: What is an abscess? Mention two clinical symptoms and two signs of an
abscess. Why do you treat an abscess by surgical drainage, not by antibiotic
Ans: Abscen IMBDA a localized collection of pus in any body part, that results from
invasion of a pyognic micro organism.
Symptom: (i) Fever.
(ii) Local pain (Throbbing in character)
Sign: (i) Signs of inflammation, Heat, Redness, Swelling, Tenderness
(ii) Fluctuation test positive
Abscess is treated by surgical drainage:
Because, most absecess has membranes that is impermeable to antibiotic. So,
antibiotic is useless against abscess. Some abscesses that may permeate autibiotic
will result in antibioma. Due to these reasons, surgical dranige in the treatment
option.

Q: 43 What in bacteremia? What is septicemia? Mention two common micro

organism responsible for septicemia.
Ans: Micro organism Esch coli, N. meningitidis.

Q: 44 Mention four steps you should take to prevent infection in a lacerated wound,
How a wound is irrigated.
Ans: Prevent infection
1. Wound toileting: Wash the wound with normal saline, remove foreign bodies, wash
with H2O2.
2. Would debridement: Excise necrotic tisues
3. Cover the wound: Close the wound. Sterile dressing
4. Prophylaclic antibiotic
Irrigation of wound: Two techniques
(i) Copious saline irrigation
(ii) Plused Jet lavage

Q: 45 What type of wound in favourable for contacting tetanus? Mention two early
signs of tetanus. What is the tetanus immunization schedule?
Ans: Tetanus may occur:

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(i) Soil contaminated wound
(ii) Contaminated punctured wound
(iii) Contaminated wound aging 6 hours more before wound toileting.
Early Sign of tetenus: No early sign, only symptoms
Wound pain, restlessness. Unexplained sweating
Lock jaw, Dysphagia
Tetnus imminization:
Intramuscular Tetament toxoid injection 0.5 ml
at 0, 6 wk, 1 Year
Booster dose at 5 years internal

Q: 46: What is gas gangrene? What type of wound is favourable for gas gangrene to
develop? Mention two clinical sign indicating gas gangrene in a leg wound.
Ans: Gas Gangrene: IMBDA an actue severe, painful condition in which the muscles
and subcutaneous tissues become filled with gas and a serosanguioneous exudate,
due to infection of wounds by anaerobic bacteria among which are various species
of clostridium.
Favourable for gas gangrene:
1. Contaminated wound especially with soil or feces.
2. Crushing injury
3. Missile injury
4. High voltage electical injury.
Sign: Swelling serosagenous discharge Brown discoloration of skin (later blue biach)
soft tissue crepitus

Q-47: A 50 year old diabetic and hypertensive lady was scheduled for an admonial
operation at 9 am. She is on oral hypoglycemic and anti HTN dugs and having good
control of both conditions. What would you do with the morning medication of
hypertension and diabetes. How blood bugar is managed during operation and post
operative period?
Ans: Morning medication:
Patient remains Nothing by mouth.
For HTN-Morning dose of anti-HTN drug is taken orally with small amount of
water.
For DM-Omit morning medication Give 10 unit insulin in 12 5% DA.
Management of blood glucose:
Monitor blood glucose 1-2 harly until statble. Then 6 hourly.
Give IV insulin by infusion pump piggybacked into 5% DA as follows-
Blood glucose soluble insulin
<4 mmol/L---------0.5 Units/hour
4-15----------2 units/L
15-20 -----------4 units/L
20 -------- 6 Units/h (ask help form diabetologist)
Adust dose after patient starts eating. Then stop insulin, start OAD.

Q: 48 Mention the fluid electrolyte and acid base imbalances occurring from
repeated vomiting due to gastic outlet obstruction. Infusion of which fluid would
correct the imbalances and how?
Ans: Dehydration with hyponatraemia. Hypochloraemia, hypokalemia and metabolic

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alkalosis.
Treatment: IV normal saline potassion supplementation.
How: If we can replace the water, sodium, chloride and potassium then the kidneys
will correct the alkalosis.

Q: 48: A man had a crushed lower limb from a road traffic accident. Mention two
factors responsible for the development of gas gengrene.
Two features suggesting gas gangrene. Mention two life saving measure.
Ans: Two factors:
1. Necrotic tissue that creates an anaerobic environment.
2. Contamination of would so the spores are brought.
Two life saving measure: 1. Large dose of penicillin injection
2. Anti Gas gangrene surum (AGS) inject.

Q. 49: What is triage? Mention two life saving measures for a severely injured patient
from RTA. Mention two clinical features of internal concealed haemorrhage in
abdomen.
Ans: Triage: IMBDA the screening and classification of sick, wounded or injured
persons during war or other disasters to determine priority of need and proper place
of treatment for the efficient use of medical and nursing personel, equipment and
facilities.
2 Life saving measures:
1. Clear airway and establish breathing
2. Control hemorrhage and resuscitate.

Q: 50 You are going to manage a contanninated lacerated wound in the foot. HOw
would you deal with the divided tendon or nerve and What would be your plan
regarding wound closure.
Ans: Mangement of contaminated lacerated wound:
1. Irrigation and wound toileting.
2. Anesthesia or analgesia
3. Wound debridement and wound examination
In this way the untidy would is converted into a tidy wound.
4. Repair of tendon and nerve. Cover the tendon or nerve with some vascularized
tissue.
5. Womd closure:
(i) If the wound presented within 6 hours Primary closure
(ii) If the wound presented after 6 hours Delayed primary closure.
6. Sterile dressing:
7. Oral antibiotic and anagestic.

Q: 51 A man had a long standing right inguinal hermia, Suddenly it became very
painful, What complication has develped? Mention two clinical signs in favor of it,
What surgical intervention is urgently necessary and why?
Ans: Complication: Strangulation of hermia
Signs in favor: (i) Hernia is tender
(ii) Cough impulse is lost.
Surgical intervention: Herniotomy and herniorrhaphy.
Cause: If surgical intervention is not done urgently, the stangulated organ will die and

14
necrose and cause SIRS or sepsis.

Q.52: What would you do immediately to stop an obvious bleeding in a limb that is
occuring from road traffic accident? what are the method of haemostasis usually
applied for hemostasis during surgical operations:
Ans: Bleeding limb: Elveation and pressure are usually adequate. A tightly
compressed bandage.
If proffuse bleeding from a large area, tourniquent may be applied, but it must be
released in every 10-15 min for 1 min.
Hemostasis during surgery (i) Pressure, (ii) pack (iii) Ligation (iv) Dirthermy
coagulation.

Q: 53: what are the types of hemorrhage according to the time of occurance after
trauma? What are the causes of a reactionary hemorrhage what should you do to
prevent reactionary hemorrhage in post operation period after a thyroidectomy
operation?
Ans: Types of hemourhage: (i) Primary (ii) reactionary (iii) Secondary
Causes of reactionary hemorahage:
(i) Rolling/Skipping of a ligature
(ii) Dislodgement of a clot
(iii) Rise of BP and refilling of venous system on recovery from shock.
(iv) Restlessness coughing and vomiting which raise venous pressure.
After thyroidectory:
(i) Pethidine to prevent restlessness and coughing
(ii) Antiemetic to prevent vomiting.
Q.54: What is concealed hemarrhage? Mention two examples when do your suspect
concealed hemorrhage after a fall from height?
Ans: Concealed hemorrhage. When hemorrhage occurs within a body cavity and
does not come out so cannot be seen, it is called concealed/internal hemorrhage.
Example: Hemothorax, Hemoperitioneum.
When to suspect concealed hemorrhage?
1. Hemodynamic instability-4 pulse, BP, cold and claming skin.
2. Chest Dyspnoea, stony dull on percussion, Breath sound.
3. Adomen-Distension Muscle guard, Peritonitis cullens sign.
4. Cranium-Severe headache, incresed ICP, cushing triad , stroke like feature GCS.
5. Limbs-Fracture of long bones or pelvis.

Q.55: How would you define shock? Mention the types of shock. HOw septic shock
develops:
Ans: [See Ans. of Q.15]

Q:56 What is the effect of shock on kidneys? What are the effects of shock on
respiratory system:
Ans: Effect of shock on Kidneys: Oliguria, Anuria , Acute renal failure, Acute ischemic
tubular necrosis.
Effect of shock on resp system: Tachypnoea, Pulmonaryoedema, ARDS shocks lung
(old name of ARDS).

Q 57: How would you clincially recognize the state of shock in a patient having

15
abdominal pain? Mention the steps you must take to resuscitate a patient from
shock.
Ans: Signs of shock: Cold clammy skin, Restlessness agitation
Rapid thready pulse BP, Capillary refill time, Oliguria/Anusia.
Steps of resuscitation:
1. Prevent hypothermia
2. Open two wide bore IV channel
3. Send blood for grouping cross matching and necessary investigations. Requisition
for blood.
4. Start IV fluid 500 mL in 10 min and observe CVS response.
(i) Responder-Keep monitoring and slower fluid sesuscitation.
(ii) Trasient responden Search and stop ongoing hemorrhage
(iii) Non responder search and stop ongoing hemorrhage start missive honsfusion
protocol.
5. Do urinary catheterization and m onitor urinary output

Q: 58 What is septic shock? Describe the C.V.S changes that occur in septic shock.
Mention the treatment guideline of septic shock.
Ans: Septic shock: It is a type of shock which occurs due to sepsis. CVS changes in
septic shock.
1. Vasodilatation in response to several inflammatory mediators.
2. Later, increased capillary permeability and fluid loss in interest
3. Lastly, myocordial depression due to acidosis and baterial.
Treatment guideline
1. Recognize severe sepisis/septic shock.
2. Measure arterial serum lactate
3. Resuscitation
A- Airway: If patient is obtunded, consider intubation for Protection
B-Breathing High flow (> 40%) Oxygen
C- Circulation: Keep CVP 8-12 mm Hg, MAp> 65 mmHg and write output > 0.5
ml/kg/hour.
4. Microbiology, Specimen of blood sputum urine wound pus.
5. Antibiotic: early emperical.
6. Source identification and untist (Surgical and/or radiological)
7. Consider adjuvants: steriods, Activiated Protein C.

Q: 59 A boy having bleeding from his circumcision wound 6 hours after Leaving
hospital. How would you control the bleeding? If the bleeding continues in spite of all
measures, What would be your next step to get the bleeding controlled.
Ans: Control of bleeding:
1. Pressure on bleeding area for 10 minutes.
2. Take blood and send for CBC, coagulation profile, blood grouping and cross
matching in requisition of 1 unit Fresh blood or FFP or cryoprecipitate
3. Re-assess bleeding
(i) Capillary bleeding: Most probably coagulation defect. Transfuse Fresh blood or
FFP or cryoprecipitate.
(ii) Venous or arterial bleeding: Close with suturing or bipolar diatprmy.

Q: 60: Mention major indication of whole blood transfusion in surgical practice

16
Mention the blood components that are transfused in surgical practice with are
examples for each one.
Ans: [See Ans. of Q. 10]

Q: 61: Mention chronologically the steps for arranging blood transfusion in surgical
practice. Mention chronologically the steps for transfusion one unit of whole blood
to a patient once you have received it in the ward.
Ans: [See ons. of Q:10]

Q: 62: What is safe blood transfusion? What are the immediate blood transfusion
reactions? What are the diseases that might be transmitted through blood
transfusion?
Ans: Safe Blood transfusion: Provision of Universal access to safe, quality of
efficacious blood and blood produces for transfusion, their safe of appropriate use,
and also ensuring blood donor and patient safety.
Immediate reactions:
1. Immediate hemolytic transfusion reaction
2. Febrile reaction
3. Allergic reaction
4. Anaphylactic reaction
5. Alloimmunication
6. Circulatory overload
Transfusion Transmitted Disease:
HIV, HCV, HIV, CMV, EBV
Malaria, Filaria, Leishmania
Syphilis.

Q: 63 What is mismatched blood transfusion? How would you recognization

transfusion clinically? How would you manage a case of mismatched transfusion?
Ans: See Ans. of Q: 1
Q. 64: What is cellulites? What micro organism cause it? What are the clinical signs
of cellulites? How could you treat cellulites at right leg developed after minor injury
to a 60 years old man?
Ans: Cellulites: IMBDA inflammation of the soft/connective tissue in which a thin,
watery exudate spreads through the cleavage planes of interstitial and tissue
spaces, it may lead to ulceration and abscess.
Organim: Streptococcus pyogenes.
Signs: Swelled, shiny skin, redness tenderness, itching then may be local gangrene.
Treatment of given case:
1. Rest, elevation of leg
2. Antibiotic Flucloxacillin or Cephradine
3. Diabetes, if present should be treated.
Q: 65. What is carbuncle? How would you recognize it clinically? Mention the general
and specific measures needed for the management of carbuncle:
Ans: Carbuncle: IMBDA a necrolizing infection of skin and subcutances tissues
composed of a cluster of furuncles, usually due to staphylococcus aurus with
multiple drainage sinuses.
Clinical signs: Usually in nape of the neck or upper part of the back.
Skin is red, inflamed, painful, indurated, multiple discharging sinuses present there

17
may be sloughing out of skin. There may be fever.
General measures:
1. Anti pyretic for fever
2. Control of DM
Specific measures:
1. Incision and drainage of pus and excision of all dead tissue
2. Protection e sterite during
3. Antibiotic
Q: 66: Define an abscess What are the symptoms and physical sign of an abuscess
why surgical drainage must be done to treat an abscess?
Ans: {See ans of Q: 12 and 42}

Q: 67: Name the micro organisms causing gas gangreme. What are the factors that
increase the likelihood of the development of gas gangrene in a limb crushed under
the wheel of a car?
Ans: Organisms: Clostridium Perfringess (90%)
Cl. Sordellii. Cl. novyi, Cl. histolyticum, Cl. Septicum.
[See ans. of Q. 46 and 48]

Q: 68 Mention one general and two local signs that suggest the onset of gas
gangrene. How radiological confirmation can be done for a gas gangrene affected
limb?
Ans: Radiolgoical confirmation X-ray can show gas in muscle or fascial plane.

Q: 69: Mention the aetiological agent factors of gas gargrene when do you clinically
suspect the develpment of gas gangrene in a grossly injured limb?
Ans: [See ans. Q. 67]

Q: 70: What kind os surgical wound is likely to casue the devleopment tetanus?
Mention the early features of tetanus. What are the principles of treating a case of
tetanus?
Ans: [See ans. of Q:45]
Principles of treating tetanus
1. Assisted ventilation of patient
2. treat convusion Mascle relaxant, sedation
3. Neutralize toxin- very large dose of antitoxin.
4. Surgical debridement of wound.
5. Antibiotic Penicillin.
6. Immunization of patient for future by TT.

Q 71: What are the systemic factors increase the likelihood of surgical site
infection? Mention the local factors responsible for surgical site infection.
Ans:
Systemic Factors Local Factors

1. Malnutrition (Obesity, wt. loss) 1. Contamination and potential pathological

2. Mtabolic disease (DM, Uremia, 2. Foreign body material

Jaundice)
3. Local ischimia

18
3. Immunosuppression (Cancer, AIDS, 4. Devitalized tisue
steriod, chemotherapy, radio therapy.
5. Oedema/Pressure/Consiriction
4. Cigarrate smoking, Alocholism.
6. Poor surgical technique (dead space,
5. Shock hematoma)

6. Extremes of Age

Urology

Q: 72: What are the causes of secondary hydrocele? Describe the clinical features
and treatment of tubercular epididymo orchitis?
Ans: Causes of secondary hydrocle:
1. Acute or chronic epidiymo orchitis
2. Torsion of the testis
3. Some testicular tumour
4. Filarial hydrocele
5. Post herriorrhaphy hydrocele
C/F of tube rular epididymo orchitis:
Typically, there is firm discrete swelling of the lawer pole of the epididymis, which
aches a little. The disequse preogresses until the whole epididymis in firm and
craggy behind a normal feeling tests. There is a lax secondary hydrocele in 30%
case. A characteristic beading of the vas may be apparent. The seminal vesicle feel
indurated and swollen. In neglceted cases, a cold abscess forms, which may
discharge.
Treatment :
1. Anti tubercular chemotherapy (as for Renal TB)
2. If resolution does not occur within 2 months, epididymectomy or orchidectomy is
advisable.
Q. 73: Describe the effects of chronic prostatic enlargement what are the
complications of bening hyperphasia of prostate?
Effect:
(a) Irritative symptoms: Frequency Nocturia, Urgency, Urge incontinence
Nonctural in confience (Enuresis) Involuntary uniation by children at night.
(b) Obstructive Symptoms: Hesitancy poor flow, Intermittent stream, Dribbling
sensation of poor bladder emptying.
(c) Lenghtening of Urethra, hypertroploy of detrusor muscle, trabeculation, Low
urinary flow rate, High voiding pressure.
Complications
(a) At prostatic level- Acute retention, Chronic retention, Hematuria.
(b) At bladder level Diverticula, Urinary infection, Stone formation.
(c) At ureter and kidney level- Hydronephrosis, Hydroureter, pylorephritis, Renal
failure.
(d) Effect of straining Hemorrhoids, Hernia, REctal Prolapse.

Q: 74: Define anuria. Enumerate the causes of anuria. How can you clinically
differentation between anuria and acute retention of urine?
Ans: Anuria: IMBDA the complete absence of urine production (for 12 hour or more)
Causes of anuria

19
(a) Pre-remal (b) Renal (c) Post renal

1. Hypovolemia 1. Drugs 1. Calculi

2. Blood loss 2. Poisons 2. Pelvic Malignancy

3. Sepsis 3. Contrast media 3. Surgery

4. Cardiogenic shock 4. Eclampsia 4. retroperitoneal fibrosis

5. Anaesthesia 5. Myoglobinuria 5. Bilharzia

6. Hypoxia 6. Incompatible blood 6. Crystallunia

transfusion

7. DIC

The following features are in favour of Acute retention of urine:

History: Suprapubic pain Intense desire to micturate.
On Exam-Urinary bladder is distended, as evident by palpation and dull on
percussion.

Q: 75 Define and Classify vaginal hydrocele What are the C/F of vaginal hydrocele?
How do you treat vaginal hydrocele?
Ans: Vaginal hydrocele: IMBDA an a bnormal collection of serous fluid in a part of the
processes vaginalis usually the tunica.
Classification
(a) Congenital hydrocile (b) Acquired hydrocele

1. Vaginal hydrocele 1. Primary or idiopathic

2. Infantile hydrocele 2. Secondary to testicular discase.

3. Hydrocles of the cord 3. Treatment is missing

4. Congenital hydrocele

Q. 76 Enumerate the causes of urolithiasis. What are the complication of uretiric

obstruction
Ans: Causes of Urolithiasis
1. Increased dietary oxalate and less calcium (after gastric bypass)
2. Vitamin A deficiency
3. Inflammatroy bowel disease
4. Altered urinary solutes and colloids (as in dehydzaiton)
5. Decreased urinary citrate
6. Renal infection
7. Inadequate urinary drainage and urinagy statsis
8. prolonged immobilization
9. Hyperparathyroidism
10. Gout

20
11. Sarcoidosis
Complications of Ureteric Obstruction:
1. Hydronephrosis
2. Pyelonephritis
3. Stone formation
4. Chronic renal failure (Actue, if bilateral)
5. Uremia
6. Secondary HTN
7. Traumatic rupture

Q. 77: Classify testicular neoplasm, Describe the clinical presentation of seminoma

testis
Ans: Classification
1. Seminoma (40%)
2. Teratoma (32%)
3. Combined Seminoma ....... teratoma (14%)
4. Interstitial tumours (1.5%)
5. Lymphoma (7%)
6. Other tumours (5.5%)
C/F of seminoma:
1. A testicular lump usually painless, 30% case of painful.
2. A sensation of heaviness occurs when the testis is 2-3 times its normal size.
3. On exam, the testis is enlarged smooth firm and heavy 10% case have a lax
secondary hydrocle.

Q. 78: Describe the clinical presentations of Ca-prostate. How do you investgate a

suspected case of ca-prostate to confirm diagnosis?
Ans: C/F of CA-prostate
1. Like BEP Fequency, nocturia Urgency urge incontineuce, nocturnal incontinence,
histency poor flow, intermittent stream dribbling, sensation of poor bladder emptying
.
2. Acute urinary retention
3. Occasionally, alternation in bowel habbit, hematuria, pelvic pain.
4. On PR exam irregular induration characteristically stony hard in part or in the
whole of the prostate. Obliteration of the median sulcus.
5. S/S of metastasis back pain weight loss, anaemia, ureteric obstrcution and renal
failure.
Confirmation: Prostate specific antigen
(> 10 nmol/ml is suggestive)
(> 35 nmol/ml is diagnostic)

Q: 79 What are the causes of unitateral hydronephrosis? How do you investigate and
treal such a case:
Ans: Causes of unilateral hydronephrosis:
(a) Extramural Tumour of cervix prostate, rectum colon, cecum, Idiopathic
retroperitoneal fibrosis.
Retrocaval water.
(b) Intramural- Pelviureteric Junction stenosis
Inflammatory sticture of ureter following operation or TB.

21
 Ureterocele and congenital small ureteric orifice.
Tumour of ureter or tumour of bladder near ureteric orifice.
(c) Intraluminal Urcteric stone
sloughed papilla in papillary necrosis
Investigation
1. USG
2. Plain X-ray KUB.
3. Excretion Urography
4. Renography
5. Retrograde Urography
Q. 80: What are the cause of scrotal hematoma? Describe the C/F and treatment of
scrotal hematoma
Ans: Causes of scrotal hematoma
1. Local trauma to scrotum
2. Trauma to perineum
3. Rupture of bulbar urethra
4. 1-2 days after injury to kidney and ureter
5. Bleeding disorder or on anti coagulant .
C/F: A well circumscribed bluish dome shaped lump under the scrotal skin. Scrotal
skin is lax, so not much pain but tender.

Treatment: If not much pain no need to drain the trematoma will resolve in 2-3
weeks. Treat the cause (possible injury)

Q.81: Define phimosis and para phimosis. How do you diagnose and treat
paraphimosis? What may happen if you do not treat paraphinosis?
Ans: Phimosis: IMBDA consitriction of the orifice of the prepure se that it cannot be
drawn back over the glass.
Para phimosis : IMBDA strangulation of the glans penis due to retraction of a
narrowed or inflamed foreskin
Diagnosis of Paraphimosis: Pain engorgement and oedema of the glans. thight band
of foreskin can be seen proximal to glans.
Treatment of paraphimosis:
Incebag and gentle mainpulation. It may be possible to compress the glass and draw
the foreskin forward. If this fails, the tight band must be incised under general
anaesthesia, later, elective circumcision is advocated.
If no treatment: Death and necrosis of glans penis.

Q. 82: What do you mean by varicocele? Describe the clinical features and treatment
of varicocele?
Ans: Varicocele: IMBDA enlargement of the veins of the spermatic cord.
C/F of varicocele: Small varicoces remain symptomless.
Large varicole may cause a vague, dragging sensation and aching pain in the axeiry
scrotum or groin. On palpation, if feels like a bag of wooms varicocele disappear in
lying position.
Treatment: 1. Laparoscopic Ligation of testicular vein above ingunal irgament.
2. Embolisation of testicular vein under radiographic control.

Q. 83: What investigations will you do in a case of suspected bladder neoploysm?

22
How do you treat a case of papillary ca. of bladder?
Investigations:
1. Urine should be cultured and examined cytologically formalignant cells.
2. Blood: Hb, U&E.
3. Invtravenous urography IVU
4. Ultrasonography
5. Cross Sectional imaging
6. Cystourethroscopy
7. Bimanual examination

Treatment:
1. Transurethral resection of tunnour (TURT)
2. Immunotheraphy- Intravesical BCG injection
3. Intravesical chemotherapy- Mitomycin C, Doxorubicin.
4. Surgery Cystectomy
Q: 84 : Enumerate the causes of prostatic enlargement. Pescribe the clinical
presentation of a patient bening hyperphlina of prostate
Ans: Causes of prostate enlargement:
1. Nodular hyperplasia of prostate
2. Carcinoma of prostate
3. Prostatic calculi
4. TB of prostate
5. Chronic prostatitis.
6. Granulamatous prostatitis
C/F of BHP: [see ans. Q. 73 ]

Q.85: What are the clinical presentations of rapture urethra? How do you manage a
case of rupture of bulbar urethra
Ans: Clinical Presentation of rupture urethra
1. H/O trauma
2. Retention of Urine
3. Perineal haematoma
4. Bleeding from the external urethral meatus
5. Displaced high prostate (repute of membrane urethra)

Management:
1. Give analgesia. Discourage to micturition
2. If patient had already passed urine and no extravasation, the rupture, partial and
catheter not needed
3. If the bladder is full, a simple percutancous suprapubic puncture should be
performed and catheter inserted to drain it.
If such facilities is unavailable, one attempt to pass a soft small calibre uretheral
catheter without force is permissible.
4. Administer and cruses of prophyfactic antibiotic
5. Treat other major truma if present.
6. Definitive treatment Repair operation

23
Q: 86 Define epididymo orchitis Describe the clinical features and treatment of tuber
cular epideidymo orchitis:
Ans: Epididymoorchitis Inflammation of the epididymis and testis
[See ans. of Q: 72]

Q. 87: How renal carcinoma metastasizes? Outline the Mx of renal cell carcinoma.
Ans: Metastasis of renual carcinoma:
1. Hematogenous Lung (CAnonball secondary) Bones (Long bones)
2. Lymphatic Para aortic lymph nodes and beyond.
Treatment:
1. Nephrectomy e removal of the perinephric fat.
2. Removal of tumour extension along renal vein, inferior venacava.
3. Cytokine IL-2
4. Radiotherapy and chemotherapy has poor response.

Q: 88 How do you investigate case of renal stone? What are the treatment options
available for treatment of multiple stones in the kidney?
Investigation: 1. Use of urinary tract.
2. X-ray of KUB region
3. Contrast enhanced CT of urinary system.
4. Intravenous urography
Treatment options:
1. USG of Urinary Tract
2. X ray of KUB region
3. Contrast enhanced CT of Urinary system
4. Intravenous urography

Treatment options:
1. Stone < 5mm size may pass spontaneously with high fluid intake
2. Extracorporeal shock wave lithotripsy
3. Percutaneous nephrolithotomy
4. Open surgery (i) pyelolithotomy
(ii) extended pyelolithotomy
iii) Nephrolithtomy

Q. 89: Describe ureteric colic what are the clinical features of stone impocted at pelvi
ureteric junction?
Ans: Description: (You better ask!!
Colic starts when stones leave their anchorage and reach the ureters. Pain starts
suddenly and grows with 15-30 minutes to a increasing and unbearable pain, which
is accompanied by nausea and vomiting . This pain, which is accompanied by
nausea & vomiting. This pain, which is first localized to the region of the renal bed,
radiates caudally (Loin to Groin) e the passage of the through the ureter and leads,
shortly before the passage of the concernment into the bladder, to tenesmus and
occasionally to violent pain in scrotum and testis, glans of penis or labia. When the
stone reaches the uterovescal junction, dysuria and urge can occur. Upon entry of
the stone into the bladder, the renal colic disappears spontaneously.

Impaction:

24
Colic pain turns into a more consistent dull pain after iliac fossa. The pain may be
increased by exercise and lessened by rest. distension of pelvis causes pain and
discomfort in the loin sever renal pain subsiding after a day or so suggests complete
obstruction.

Q:90: Enumerate the causes of Urolithiasis. What are the effects of long standing
ureteric obstruction?
Ans: Hey, this is same Q: 76

Q: 91 Enumerate the causes of scrotal swelling. How do you differente between

scrotal and inguino scrotal swelling.
Ans: Causes of scrotal swelling Differentiate between
1. Oedema of scrotum
2. Hydrocle
Scrotal and inguino
3. cyst of epididymis and spermatocele.
Swelling by
4. Acute epididmo oxchitis
5. TB epididyrno onchitis
6. Syphilis of testis
7. Testicular tumour
8. Varicocele
9. Old clotted hematocele
10. Inguino scrotal hermia.

Q. 92: Classify bladder carcinoma. Describe the clinical presentations papillary

carcinoma of urinary bladder.
Ans: Classification
1. Urothelial ttomour
(i) Invested papilloma
(ii) Papilloma
(iii) Urothelial tumour of low malignant
(iv) Papillary urothelial ca
(v) Carcinoma
Q. Squarman cell caricnoms
3. Mixed carcinoma
4. Adenocarcinoma
5. Small cell carcinoma
6. Sarcoma

Clincial presentation:
1. Early-Painless gross heamaturia
2. Extravesical spread-Constant pian in the petuis.
3. Frequency and discomport associated with urination
4. Ureteric obstruction Pain in the or pyelonephitis
5. Nerve invloveent pain refereed to superapublic region, groins, perineum, anus and
into the things.

Q: 93 What do you mean by primary and secondary vesical calculus? How do you
that a case of versical calculus.
Ans: Primary venical calculus: A primary bladder stone in one that develops in sterile

25
Vrine, it often originate in the kidney.
Secondary vesical calculus is secondary bladder stone occurs in the presence of
infection, outflow obstruction, impaired bladder emptying or a foreign body.
Treatment:
(a) Litholopaxy- Ultrasound lithotripsy, Otical lithotrite,
Electro hydraulic lithortite, Holmium laser lithotrite
(b) Percutaneous supraputic litholapaxy
(c) Treatment of underlying cause.

..............................................

Q. 94: Describe the clinical feature and treatment of wilms tumour

Ans: C/F: An abdominal tumour grows rapidly while the general well-being of the
child deteriorates the mass may be enormous compared with the tiny patient. Some
patients rehypertensive. Hematuria denotes. extension of the tumor into the renal
pelvis.

Q. 95: Treatment: 1. Ureteroscopic stone removal

2. Ureterolithotomy

Q. 96: A 30 yrs old man had an operation for hemorrhoids at 11 am. A 5 pm he

developed lower abdominal pain and was unable to pass urine. Why this condition
developed? What measures should become taken to facilitate mictuction? What
should be done next and how? taken to facilate mictuction? What should be done
next and how?
Ans: Cause: 1. Anal pain (hemorrhsidectomy)
2. Intensive postoperative analgesic treatment
3. Spinal anesthesia

Treatment: Urinary catheterization.

Next: Bladder retraiing & removal of catheter.

Q. 97: A 65 years old man complins of dribbing of urine for severe weeks waht would
you suspect if he had a lower abdominal swelling without a traceable lower limit?
Name tow common causes for this condition. Mention two findings you expect in a
digital rectal examination.
Ans: Provisinal Diagnosis: Chronic urinary retention with overflow incontinence.
Common Cause: Benign prostatic hypertrophy, Ca- prostate Urethral stricture.
DRE. findings
1. Prostate gland/nodular.
2. A fluctuating swelling above prostate (Residual Urine)

Q.98: A 5 year old boy presented e sudden severe pain in his stratum without any
significant trauma metition two common causes for this condition. Mention an
urgent investigation to find the starts of circulation to testis. Do you feel that
immediate surgical exploration is justified? What important information you must
convey to the parents before operation?
Ans: Cause: 1. Torsion of the testis
2. Acute epididymo orchitis.

26
Inustigation: Color Doppler ultrasound.
Immediate surgical exploration: Justified. To save testis.
Counseling: 1. If the testis is found non viable, it will be removed.
2. Fertility should be assessed by semen analysis before marriage.

Q. 99: A 25 yrs old man sustained a trauma to the perineum from a ship over a
bamboo bridge. Since then he could not pass urine but noticed few drops of blood at
the tip of his penis. What do you suspect in this case? Would you try catheterization?
What would be the next step of management?
Ans: Ruptured Urethra.
Catheterization-Tried once [See ans. of Q. 85]
Percutaneous suprapubic puncture.

Q: 100: Name one surgical operation for primary vaginal hydrocele. What is done to
the tumica vaginalis? Why re accumulation of the fluid does not occur?
Ans: Surgery: Jaboulays procedure.
What in done: The hydrocel sac is everted and anchored and sutures.
Reaccumuation: Does not occur because the sae is everted.
Q: 101: Mention two causes of hematuria from the diseases of the kidney. What are
the commonest malignant tumour of kidney in adults and children? Mention two
imaging investigation good at detecting the kidney.
Ans: Hematuria (i) Renal tumour (ii) Renal stone
Adult Grautizs tumour
Children- Wilms tumour
Imaging: (i) USG (ii) UCT e enhancement, (iii) IVU.

Q: 102: What is hydronephrosis? Mention two causes of unilateral hydro less

mention two investigation for assessing hyronephrosis.
Ans: Hydronephrosis is an aseptic dilatation of the kidney caused obstruction to the
outflow of urine.
Cause: PUJ abstraction/Stenosis, Renal or ureteric stone.
Investigation: USG, Excretion urography

Q: 103: Mention two major types of urinary calculus based on other communication
how can you find a ureteric calculus in plain radiogram?
Ans: Oxalate calculus (calcium oxalate)
Phosphate calculus (calcium phosphate after e ammonium phosphate
On x-ray of KUB: An opacity that maintains its postive relative to the urinary tract
during respiration is like be a calculus.

Q: 104 What would you suspect if a 50 years old man presents painless, profuse and
paroxysmal hematuria? What is TURBT? what cystoscopic finding you expect in such
a situation.
Ans: Suspect: Urinary blader carcinoma.
TURBT: Trans urethral resection of bladder tumor.
Cystos copy: (i) Inflamed mucosa (ii) Papilla (iii) exophytic growth.

Q. 105: Mention two effects of BEP on urinary bladder. What is post voidal residual
urine? How can you measure it?

27
Ans: Effects of BEP: 1. Hypertrhy of detrusor muscle.
2. Trabeculation of muscle layers.
Post voidal residual urine in the amount of urine remain is urinary bladder
immediately after micturition Normally it should be zero. It is measured by USG.

Q. 106: Mention two digital rectal examination findings that given the suspicion of
carcinoma of re prostate. Mention are method of prostatic biopsy. What is the tumor
marker of ca prostate?
Ans: DRE finding: Irregular induration characteristically story hard in part of in the
whole of the gland obliteration of the median sulcus.
Biopsy: Transrectal biopsy using an automated gun is recommended TURP.
Tumor marker: Prostate specific antigen.

Q: 107 Mention two complications of BEP. Mention there DRE findings of BEP. Name
of commonest operation done for BEP.
Ans: Complication Acute urinary retention chronic urinary retention.
DRE findings (i) Posterior surface of prostate is smooth, convex and typically elastic
but may be firm in consistency.
(ii) Rectal mucosa moves over prostate.
(iii) Median sulcus present.
Operation- Transurethral resection of prostate (TURP)

Q: 108 Mention two causes of severe pain of urinary tract origin Mention two causes
of retention of urine in children.
Ans: Severe pain: 1. Renal and ureteric colic (Uro lithiasis)
2. Acute urinary retention.
Acute retention in children- Phinmosis posterior urethral valve.

Q: 109: Mention two causes of painless scrotal swellings. What is varicocle which
group of 1ymph nodes you should examine for nodal metastasis in suspected case
of testicular tumor? Mention two commonest varieties of testicular tumours.
Mention two effects of cryptorchism. What is the ideal age for the correction of it in
and why?

Painless scrotal swelling:

1. Hydrocele,
2. Testicular tumour.

Nodal metastasis: Para aortic lymph nodes and beyond.

Varsities of testicular tumor: Seminoma 2. Teratoma

Effect of Cryptorchism:
1. In bilateal case, sterility
2. Torsion
3. Malignancy

Ideal age: 6 months to 1 years age, not more than? Years

Reason: Under ended testis may descend down in 3 months for term infant and later
in pre-term infant.

28
So, 6 months waiting will decrease unnecessary operation.
But after 2 years the chance of fertility is reduced
So, the operation should be done before 2 years age.
TRAUMA & NEUROSURGERY

Q.110: What are the basis steps in examining a head injury patient? What are the
steps of management of head injury.
Ans: Exam of head injury:
1. Primary survey and resuscitation.
2. Papillary size and reactivity
3. GCS
4. Focal neurological signs
5. Secondary survey full exam of head neek and peripheral nerve.
Management: 1. Primary survey and resuscitation.
2. CT scan (please see indication from book)
3. If indication of surgery it is done
4. Monitoring and supportive treatment.

Q. 111: What do you mean by potts disease? How TB of spine occurs?

Ans: Tuberculour lesion of spine is called potts discase TB of spine is secondary TB
due to hemotogenous spread the primary site is usually fung.
Q.112: How do you diagonse a cse of TB spine?
Ans Symptoms: 1. Mild backache, limitation o joint movement, kyphosis of spine
2. Gradual weight poss, Night fever e sweating
3. Due to primary focus in long. Cough crest pain, hemoptysis
Signs: 1. Early Tenderness percussion and limitation of movement
2. Late: Kyphosis is seen, ABscessin in groin or ankle.
Investigation: 1. Blood: HB lymphoyctosis, ESR
2. Mantoux test positve
3. X-ray spine Disc space narrow, osteolytic lesion Abscess shadow may be seen.
4. CXR for primary to cus.

Q: 113 Name two organs that could be ruptured from blunt traunma to the abdomen.
Mention two clinical features of hemo peritoneum. How canyou make a bedside
diagnosis of hemo peritoneum.
Ans: [See ans. to the Q:38]
Bed side test (i) Focused abdominal sonar for trauma (FAST)
(ii) Diagnostic peritoneallavage (DPL)
Q: 114 A 25 years old man had a trauma to his head from motorcyle accident. He
was brought to the emergency room in an unconsicious state. Mention four clinical
signs suggesting extradural intracranial hemorrhage in what position should an
unconsicous patient should be placed on bed.
Ans: Signs in a classic presentation
1. Rapid deterioration after a Lucid interval
2. Ipsilateral pupillary ditatation.
3. Contralateral hemipllegia.
4. Reduced conscious level.
5. Cusling triad due to PICP.
Postion: Head up 200-300 [Reverse trendelenburg postion]

29
Q.115: A50 years old man had road haffic accident. He was brought to the
emergency room in an unconscious state with multiple injuries all over his body.
How world you measure the level of his consciousness? Name one significant sign
in pupil of the eye. Name two sites of profuse internal hemorrhage resulting from
bone fractures.
Ans:
Glasgow coma scale
Dilated pupil
Fracture of femur, pelvis

Q.116: 25 years old man was brought to the Emergency room in an unconscious
state. He has history of fall from a height. Mention two clinical signs suggesting
increasing intracranial hematoma. If the patient was grossly anemic and in a state of
shock, give two possible causes.
Ans: Increasing intracranial hematoma: GCS, PULSE< BP
Possible cause of shock: Hem thorax, Hem peritoneum, Multiple fracture.

Q.117: Why does he scalp wound bleeds excessively? How can you tartest it
immediately? In which layer of scalp, hematoma may develop? How for it can
extend?
Ans:
Because scalp has rich blood supply and the vessels are held open at dense
fibrous tissue.
4th layer or layer of loose areoler tissue.
Up to upper eye lid margin.

Q: 118 What is cerebral concussion? What kind of trauma can cause it? How do you
evaluate the level of consciousness of a patient?
Ans: Cerebral concussion: IMBDA temporary neuronal dysfunction following non
penetrating head trauma.
Trauma: Non penetrating head trauma, usually low energy trauma.
Level of consciousness Glasgow coma scale.

Q: 119: How the traumatic intra criminal hematoma is classified? Name the source
of bleeding in each type of intra cranial hematoma.
Ans: 1. Extra Dural hematoma Middle meningeal artery.
2. Sub Dural Disruption of cortical vessel or brain
3. Sub-arachnoids- Aneurysm rupture.

Q. 120: What is extra dural hematoma? How it can develop? What kind of history
gives a strong suspicion of extra Dural hemorrhage?
Ans: Extra dural hematoma: EDH is collection of blood in the space between skull
bone and dura mater.
How: Due to tearing of a meningeal artery.
Classical History: Head injury followed by a lucid interved when the patient
camplains of a headache but is fully alert and oriented with no focal deficit after
minutes or hours, a rapid deterioration occurs, with controlateral hemi paresis,
reduced conscious level and ispsilateral papillary dilatation as a result of brain

30
compression and herniation.

Q: 121 Mention the changes in pupil, pulse, BP and motor function a left is extra
Dural hemorrhage. What is lucid interval of a patient who sustained a head hyinry.
Ans: Left pupil dilated and non reacting
Pulse, BP
Right hemiparesis
Lucid interval: It is brief period of consicuousness between 2 periods of
unconsciouness following head injury.

Q.122: Mention the intra cranial space occupying lesions. Mention two symptoms
and two physical signs suggesting ICSOL.
Ans: 1. Newroepthelial tumour
(i) Gliomas-Astrocytoma oligodendroglioma. Ependymoma
(ii) Pineal tumor
(iii) Neuronal tumor Ganglioglioma,Ganglicytoma, New
(iv) Medulloblastoma
2. Nerve sheath tumour-Vestibular Schwannoma
3. Menigeal tumour-Meningioma
4. Pituitary tumor
5. Germ Cell tumors-Germinoma, Tratoma
6. Lymphoma
7. Tumour like malformation-Crassiopharyngioma, Epidermoid tomour, Dermoid
tumor
8. Metastatic tumour
9. Contiguous extension from regional tumous, eg: Glomvs tumors
Symptom: Morning headache and vomiting
Sign: Papilloedema, Focal neurological deficit.

Q.123: What is hydrocephalus? Mention characteristic features of hydrocephalus.

Name the surgical procedure to treat hydrocephalus.
Ans: Hydrocephalus: It is a condition in which there is disequilibrium between CSF
production and absorption, leading to raised ICP and is after associated with dilated
ventricles.
C/F:
(a) In infant-Progressive macrocephaly, Sun-setting eyes,
Bulging anterior fostanelle, Dilated scalp veins.
(B) In Adult (after infancy)
6th nerve palsy, Impaired up gaze, Focal neurological defect
Impaired counsicious level.

Treatment:
1. Removing a causative man lesion.
2. Venticulopemitional (V-P) shurt
3. Endoscopic third ventriculstomy

PAEDIATRIC SURGERY

Q. 124: What is the problem if congenital diaphragmatic hernia is not treated in

31
time? Name the types of congenital diaphragmatic hernia.
Ans: Problems:
1. Large defect course immediate problem- Respiratory distress.
Pulmonary hypertension, Cardio respiratory failure.
2. Small defect may present in later childhood with respiratory or gastrointestinal
symptoms
Types:
1. Bochdalek hernia
2. Esophageal hernia
3. Para-sternal hernia

Q: 125: What is rectal polyp? What are the causes of prolapsed rectum in children?
Ans: Rectal polyp: An abnormal growth from mucous. membrane of rectum.
Cause of rectal prolapsed in children.
1. Constipation
2. Diarrhea
3. Fibrocystic disease
4. Neurological cause
5. Maldevelopment of pelvis

Q. 126: How can you classify intestinal obstruction in childhood? What will be the
presentation of intestinal obstruction in childhood.
Ans: Int. Obs. in childhood:
1. Proximal obstruction
2. Distal obstruction
C/F
1. Bilious vomiting
2. Abdominal distension
3. Constipation
Q. 127: What problem will occur if torsion of testis is not treated in time? what are
the cause of acute scrotum?
Ans: If torsion of testis is not treated in time, the testis will die and necroses. there
will be immunological reaction and chance of future infertility.
Causes of a cute scrotum:
1. Torsion of testis
2. Torsion of testicular appendages.
3. Acute epididymo-orchitis.
4. Trauma

Q. 128: ?

Club foot is associate with: Arthrogcyposis, Myelomeningocele.

Q.129: What are the presenting symptoms of hypertrophic pyloric stenosis of the
newborn Mention one significant clinical sign on palpation of the abdomen?
Ans: Presenting Symptom: Projectile vomiting between 2 and 8 weeks of age the
body feeds hungrily and vomits non bilious milk curd towards the end of a feed.
Sign: Thickened pylorus is palpable as an Olive in the epigastria or right upper
quadrant.

32
Q.130: Name to common causes of neonatal intestinal obstruction. What would
suspect if a body fails to pass meconium with anus being normal rectal exam.
Ans: Causes: 1. Anorectual malformation
2. Hirsch rung disease.
If anus is normal:
1. Hirschsprungs disease
2. Meconiumileus.

Q. 131: What is congenitally deficient is Hirsch rungs disease? what happens to the
gut in Hirsch rungs disease? How diagnosis of Hirsch rungs disease is confirmed?
Ans:
Deficiency of ganglion cells in my enteric plexus of color.
The gut remains peristaltic constricted, fail to dilate.
Diagnosis is confirmed by histopathology after biopsy.

Q. 132: What are the high varieties of imperforate anus? How can you diagnose the
high variety of imperforate anus by radiological method what additional abnormal
congenital anomaly may be associated with high variety of imperforate anus?
Ans: High varieties of Imperforate anus:
1. Rectovesical fistula
2. Recto urethral prostatic fistula
3. Recto urethral bulbar fistula
4. recto vestibular fistula
5. cloacal malformation.
Radiology: Lateral abdominal radiograph with a radio opaque marker on the
perineum.
Associated malyormations
1. Urinary treat defect
2. Skeletel defect, eps. seacrum
3. Tethered cord
4. Oesophageal atresia
5. Cardiac anomaly

Q.133: How imperforate anus is classified? How plain radiograph can help in this
regard? How intestinal obstruction is overcome in high variety of imperforate anus?
Ans: Classification (i) High (ii) Low
Plain radiograph: Can show distance between rectal gas and primal skin?
High variety treatment: Temporary colostomy, then reconstructive surgery
(anorectoptasty).

Q: 134 Name two common causes of intestinal obstruction in 1 year old child what
would you suspect if a child presents with maroon colored diarrhea along with
abdominal distention and vomiting.
Ans: Cause: Intussception, Volvulus
Suspect: Intussusceptions

Q. 135: What is intussusceptions? Name two significant abdominal signs suggesting

ileo cercal intussusceptions in a child? How ileocecucal infuses usception can be

33
diagnosed by radiology?
Ans: Intussusceptions: IMBDA telescopic projection of one part of the intestine into
the lumen of an immediately adjacent part.
Abdominal signs: 1. Sign of Dance feeling of emptiness ring iliac fassa.
2. A palpable sausage shaped mass in the right upper quadrans.
Confirmatory radiology:
1. ................USG
2. Claw sign in Barium enema X ray

Q. 136: A 5 years old boy developed sudden severe pain scrotum without significant
trauma. Name the most probable cause. Mention the physical that can rule out the
possibility of a strangulated inguinal hernia. What are the steps you must undertake
to avoid servious complications.
Ans: Probable cause: Torsion of testis
Differentiate: Get above the swelling is positive if it is testicular forsion.
Step: Exploration of scrotum.

Q.137: What are clinical features that suggest the torsion of the testis? How can you
confirm the ischemia of the testis? What is the surgical treatment you torsion testis?
Ans: C/F of torsion of testis: The patient usually a teenager present with sudden
onset of testicular pain and swelling. On exam there in a red, swollen hemiscrotum
that is usually too tender to palpate elevation of testis increases pain.
Confirm: (i) Doppler ultrasound test
(ii) surgical exploration and check viability.
Surgical treatment:
A totally infracted testis should be removed
1. If viable untwist. If dead excise and remove the testis.
2. Bilateral orchiopexy.

Q. 138: What anatomical abnormality leads to congenital hydrocle? Mention two

physical signs that suggest a congenital hydrocele. Name the surgical operation for
this condition.
Ans: Abuormality patent processvs virginals
Physical signs 1. Pressure on hydroule empties it, (not always)
2. Hydrocele fluid drain in peritoneal cavity iahen child is lying down.
Treatment: Herniotomy

Q. 139: Name two causes of scrotal swelling occurring in children. Name two
testicular tumors that can develop in children. What congenital abnormality would
lead to a complete indirect inguinal hernia in children?
Ans: Cause: 1. Hydrecele, 2. Inguino scrotal hernia.
Tumom: 1. Anaplastic teratoma, 2. Interstital tumour
Abnormality: Patent processus vaginals.

Q. 140: What is crypto orphism or undescentded testis? Where could you find the
testis if it was not in the scrotum? Name two complications related to under ended
testis.
Ans: Cryptoorchism: IMBDA failure of one or both testes to descend into the
scrotum.

34
It may be palpable at the neck of the scrotum or in the groin or impalpable if it is in
the abdomen.
Complications: 1. Torsion, 2. Infertility

Q. 141 A 1 month old boy cries and vomits after each breast feeding. He is
dehydrated and there is a visible peristalsis in upper abdomen. What would be your
clinical diagnosis if you find a hard mass in epigastria region?
Ans: Clinical diagnosis: IHPS (infantile hypertrophic pyloric stenosis)
Investigation: USG to determine thickens of pylorus.

Q. 142: Name two causes of recurrent UTI in children. What is vesico ureteric reflux?
Name two causes of retention urine occurring in children.
Ans:
Vesico-Ureteric reflux, posterior urethral valve.
Back flow of urine from bladder into ureter during maturation
Congenital urethral valve/stenosis, phimosis

Q. 143: A 5 years boy presents with hematuria and enlargement of abdomen. Name
the most likely diagnosis if you find a slid abdominal mass name three common
childhood malignant tumors.
Ans: * Wilms tumor
Nephroblastoma, Hepatoblastoma, Retionablastoma

Q. 144: A 7 yrs old girl presented acute pain at right knee and high grade fever for
one day. Her knee joint movements are slightly painful but otherwise free. What
investigations you think would be useful in this case? What treatment would you
suggest initially?
Ans: Rheumatic fever
Inv. CBC, ESR, CRP, ASO tire
Intial treatment: Aspirin and Ranitidine
Q: 145 Name two childhood primary bone tumors. Mention two common fractures
occurring in childhood. How the fractures of childhood do differ from those of
adulthood?
Ans: Osteoid osteoma, Chordroblastoma, Ewings sarcoma
* Supra condylor and of humerous, clavicle
* Growth plate may be facured . Green stick occurs, Healing and remodeling perfect.

ORTHOPAEDICS

Q. 146 Classify dislocation of hips. How do you manage central dislocation of hip?
Ans: Dislocation of hip: 1. Posterior, 2. Anterior 3. Central Management.
1. X ray of pelvis AP, lateral oblique view. Or CT scans
2. Assessment of fracture.
3. If the displacement of is minimul or if the acetubular floor is highly fragmented,
the injury may be treated conservatively with traction for 6 weeks.
4. If the main weight carrying part of the acetabulum is intact but the femoral head
displaced, and if the disruption of the acetabulum is such that reduction and fixation
of the main fragments is likely to be techincally feasible, then surgical reconstruction
and iternal fixation are indicated.

35
5. Severely damaged hip-Total hip arthroplasty.

Q. 147: What are the common fractures of childhood? How do you treat traclure of
clavicle is 8 years old boy?
Ans: Common in children: Supra condylar H, Clavicle, H, Monteggia H, Greenstick H,
Hair line H.
Treatment: Triangular sling e elbow bag support for 3 weeks
Analgesic
Physiotherapy

Q. 148: A patient has fracture of idle third of humerus. What are the possible
complication that may occur?
Ans: Median nerve injury, Radial nerve injury.
Brachial artery injury, Non- Union.

Q. 149: What kind of trauma occurs supracondylar fracture? What are the
complications of this fracture?
Ans: Trauma: FAll on outstreched hand e slightly flexed clbow.
Complication: Brachial artery injury . Volkmanns ischemic contracture maluvinon,
Nonunion, Joint stiffness, Tardy nerve palsy.

Q. 150: What are the usual X-ray findings in supracondylar fracture? Describe the
management of such a case
Ans: X-ray finding
1. Fracture line is detectable in AP and lateral view
2. In AP view there is often medial or laternal shift of epiphysial compex
3. In lateral view, the distal fragment is backward displaced or tilted.

Management
Closed reduction under G/A followed by immobilizaiton by long arm back slab for 6
weeks.

Q. 151: Define fracture. How do you classify factures. A 10 years old boy has a
fracture of radius and ulna in the middle third. Describe the management:
And: Fracture: IMBDA a soft tissue injury where bone happens to be broken IMBDA
loss of continuity in the substance of a bone.
Classification:
(a) Clinical (1) Closed 2. Open 3. Complicated
(b) Aetiological (1) traumatic (2) Pathological
(c) Radiological
1. Transverse 2. Oblique 3. spiral 4. Comminute 5. Wedge 6. Depressed 7. Avulsion
8. Greenstick 10. Buckle fracture (i) AO classification
AO classification
Management: Closed reduction immobilization by long arm brack slab for 6 weeks.

Q. 152: A boy complains of severe pain in fingers after reduction and plaster for
supra condoler fracture. How do you examine him and manage this case:
Ans: Examine: Remove plaster
Observe excessive swelling and bruising

36
Color (pallor) Temperature (Coldness) Sensation (Parenthesis)
Movement (pain on active movement)
Pulse.
Management: 1. If pulse is absent Remanipulation
2. If excessive swelling-Do not plaster until swelling subside
3. Analysis

Q. 153: Classify fracture neck femur. What are the treatment options available for
this condition?
Ans: Fracture neck femur: 1. Intracapsular (i) Sub capital (ii) Tran cervical
2. Extracpsular (i) Intertroctanteric (ii) Subtrochanteric
Treatment Option
(a) Intracapsular- Conservative measure (if surgery impossible)
Closed reduction and internal fixation
Hemiarthroplasty or bipolar arthroplasty
Total hip replacement.
(b) Extra capsular H-Closed reduction and internal fixation
Hip spica (in children)
conservative measure (If surgery impossible)

Q. 154: What is the difference between compound and complicated fracture? What
are the risks of compound fracture ?
Ans: Compound H is that when the bone communicate with exterior. Complicated H
is that involving the vessels, waves or other organs during initial injury.
Risk of compound it : Hemorrhage, shock wound infection, Tetanus Gas gangrene,
Osteomyclitis, Sepsis

Q. 155: What is osteomyelitis? How can you classify it? How do you class bone
tumor? What are the bening bone tumors?
Ans: Osteonmyelitis: IMBDA infection of bone and bone manow
Classification
(a) Clinical Acute, Sub acutest, Chronic
(b) Aetiological Bacterial, Tubercular, Fungal
(c) Source of Organism Post traumatic, Hematogenous, Contiguous
Bone tumor
Classification
1. Bone forming tumour Bening

2. Cartilage forming tumour Ostema

3. Fat forming fumor chondroma

4. Fibrous tumor Osteochondroma

5. Vascular tumor Giant cell tumor

6. Giant cell tumor

7. Marrow tumor

37
8. Other

Q. 156: What are the estimated blood losses caused by different fractures? Why
fracture of the shaft of humorous is dangerous?
Ans: Pelvis 2-3L, Femur 1-5-2L, Tibia 1-1.5L.
Humorous 500-750 ML, Radius Ulna 250-500 ML
Fracture shaft of homeruns is bound to be displaced, so there is great risk of radial
revere palsy open fracture.
The reason is , upper part of hummers is pulled by pectoralis in and the lower part is
in pulled by deltoid muscle in opposite directions.

Q. 157: A 60 years old day had a fall in the toilet and was unable to get up and walk
name two clinical signs suggesting a fracture neck of the femur. What type of
femoral neck fracture would lead to the vascular necrosis of the head of the femur?
What is recommended in such a situation?
Ans: Sings:
1. External rotation of the limb
2. Pain is produced by rotation of the hip.
Avosular necrosis: May occur in case of intracapsular fracture,
Which is slightly or completely displaced.
In this we recommend total hip replacement situation.

Q: 158 A 50 years old man sustained a direct blow to his right lower leg. He had a
lacerated wound in front of his right leg and bone fragments were visible in it. How
would you clean the wound? What should you do if you find laceration of muscles?
How you would immobilize the fracture?
Ans: Clearing: Removal of foreign material and excision of all non-viable tissues. A
through lavage, first a saline then e a solution of antibiotic.
Lacerated muscle is tested for Viability and derided properly
It should be repaired during delayed closure of the wound.
Immobilization: (i) Solid intramedullary noil
(iii) It grossly contaminated, external fixation.

Q. 159: A. 8 years old boy was brought to you with high grade fever and pain in his
right knee for one day. Mention two possible causes. You found the right knee joint
moved with little pain and upper end of the right tibia was externally tender. What is
your clinical diagnosis?
Ans: (i) Acute ostemoyelitis, septic arthritis.
(ii) Acute osteomyelitis of right tibia.

Q: 160: Mention three important signs of fracture. Mention three important steps for
the management of a compound fracture.
Ans: Sign of fracture: 1. Position of the limb is abnormal
2. Impaired active movement 3. Swelling and tenderness
Management Steps:
1. Resuscitation
2. Clean and deride the wound. Cover the wound e sterile dressing
3. Give Antibiotic, Anti tetanus prophylaxis

38
4. Immobilize the fracture.
5. Send to patient where there is provision of orthopedic surgery.
6. Open reduction and external fixation
7. Repair of other injuries

Q.161 Mention the stages of facture healing. Name two improtant complications of
celles fracture.
Ans: Stages 1. Hematoma 2. Sub periosteal & end steal cellular proliferation 3. Callus
formation 4. Consolidation 5. Remodeling.

Complications:
1. Malunion, 2. Sudecks atrophy 3. Deloyed rupture of tender 4. Carpal tunnel
syndrome. (ext. Pollicis longus).

Q. 162: Define Compound fracture and mention two complication. Mention two
possible fractures that can occur if a 6 years old boy falls with an auto retched hand.
Ans: Compound fracture is a type of fracture which communicates with external
environment.
Complication: Osteomyelitis, Wound infection
Fall on out stretched hand: Supracondylar fracture, colles Monteggia

Q. 163 What is a compound fracture? Mention two late complication of fracture.

Mention two deformities of spine.
Ans: Late complication. Malunion, Non Union Growth disturbance, Osteoarthritis
Deformities of spine: Kyphosis, Lordosis, Scoliosis.

Q. 164: A 5 years old boy had sudden onset of pain in his right leg with persistent
high fever and restricted movement. On examination, there was localized tenderness
and increased warmth over the upper end of the tibia. His mother informed that he
had toothache one week earlier. What is your provisional diagnosis? Name two
investigations that will help to confirm your diagnosis Mention two radiological
feature that indicate a malignant tumor.
Ans: A cute osteomyelitis.
Inv: CBC ae ESR, Blood culture, X ray after I week.
X-ray of malignant tumour: Osteolytic lesion, Sun ray appearcence Codmans
triangle.

Q: 165: A 30 years old man presented e recurrent pain, swelling and discharge
sinuses in his left leg. He had a fracture of left tibia 6 months back what is your
provisional diagnosis? Mention two radiological features supporting your diagnosis
Name one common congenital anomaly of lower limb.
Ans: Chronic phylogenic osteomylitis e sinuses in left leg.
X-ray finding (i) Sequester (ii) Sub per steal reaction
Congenital anomaly: Talipes equimovqurs.

Q. 166: Mention two common primary sites of metastatic bone tumor. Mention two
malignant tumors of soft tissue. Name two common types of non infective arthritis.
Ans: Primary site Prostate Breast, Lung cancer
Malignant soft tissue tumor Firbrosarcoma, Rhabdomyos

39
 Non infective arthritis rheumatoid arthritis, Gout.
Q: 167: What is pathological fracture? Mention two causes of pathology fracture In
the treatment of fracture, reduction of always necessary- is this statement correct?
Justify your answer.
Ans: Pathological fracture: A pathological fracture is one which has occurred in a
bone which is abnormal or diseased.
Case: 1. Osteoporosis
2. Bone tumors & Cysts
The Statement is not correct.
If the fracture is not displaced, it does not need reduction.
eg: Hair line fracture
On the other hand, some fracture may heal excellent without proper reduction, eg:
Clavicle facture.

Q: 168: A lady of post menopausal age had a fall on her outstretched hand and
developed a painful swelling in her left wrist. She had a dinner fork deformity of her
left wrist with tenderness around it. What is your clinical diagnosis? Mention two
complications of this case. Mention the most important investigation for the
confirmation of bone tumor.
Ans: Colles fracture of left fore arm
Attrition rupture, Sundecks atrophy
Confirmatory investigation: Biopsy and histopathology

Q: 169 What is streets or fatigue fracture? Give an example. Mention two common
fractures of elderly female?
Ans: Stress fracture: A type of facture that is caused by unusual or repeated stress
on a bone.
e.g. Fracture of talus after military parade
Common it in elderly female: Fracture neck of femur colles fracture.

Q. 170: Define sequestrum. Mention two important complication of supra condoler

fracture of the hummers.
Ans: Sequetrum: IMBDA a piece of dead bone separated from the surrounding sound
bone in the process of necrosis.
Complications: Injury to m edian or ulnar nerve or brachial artery.

Q 171: Name the commonest organism of acuter dosteomyelitis. Which part of long
bone is first to be involved in infection? and why? Mention two common
complications of acuter ostemoyelptis. Staphylococcus queues.
Ans: Metaphysic of long bone
Because hair pin bend/ Copse of blood vessel in this region.
Complications Chronic ostemoyelits, Pathological facture, Limb
shorting/lengthening.

Q. 172: Mention two common fractures of childhood. Mention two complications of

prolonged immobilization.
Ans: Supraconyler H of hummers, Montego H, Clavicle H.
Joint stiffness, Muscle atrophy, Asthenia.

40
Q. 173: After a fall from chair the X-ray of the forearm of a 4 years old boy shows
slight bending only, no separation of bones. will you call it a fracture? Why this
happens?
Ans: Green stick facture
Cause-Bones of children are less brittle so these may bend.
Q. 174: Mention two differential diagnosis of a cystic/osteolytic lesion at the lower
end of the femour in a 17 years old boy. What is the surgical treatment of chronic
Ostemyelitis.
Ans: Aneurismal bone cysts , Unicameral bone cyst.
Treatment of Chronic Ostemoyelitis:
Surgical clearance of all dead and contaminated tissues,
bone de roofing, cauterization, intramedullary reaming and intravenous antibiotic.

Q. 175: Define comminuted fracture. What is the commonest site of the fracture
shaft of clavicle. How factored clavicle is treated?
Ans: Comminuted Fracture: IMBDA a fracture in which he bones is broken or
splintered into pieces.
* At the junction of middle and lateral third of clavicle.
* Triangular sling elbow bag support for 3 weeks.
Q. 176: Left supracondylor fracture of the hummers of a boy was treated by closed
reduction and long full plaster in an evening. At night he developed severe pain and
was unable to move his left finings what do you guess happened to him? What
action you must take immediately?
Ans: Compartment Syndrome
Remove plaster cost and support with back slab.

Q.177: Enumerate two common indications of amputation of limbs Mention two

complications of amputation.
Ans: Indication: 1. Gangrene 2. Osteosarcoma / Other malignant tumor.
Complications: 1. Bone Spur 2. Phantom limb.

Q. 178: Define Colles Fracture from the position of the lower limb, how can you
differentiate fracture neck of the femur from the posterior dislocation of the hip joint.
Ans: Colles fracture: Fracture of the lower end of radius one inch above the lower
articular surface of the radius. It may be associates with fracture of stolid process of
ulna and dislocation of inferior radioulnar joint.
Limb position:
1. IN posterior dislocation- Hip is flexed, adducted and internally rotated
2. In facture neck of femur-Lower limb is adducted and extenrally rotated.

Q: 179 How colles plaster is applied? Mention two reasons why plaster of Paris is an
ideal splint.
Ans: Colles plaster: The skin is protected e wool roll. The wet slab is fettled over the
anterior, lateral and posterior aspects of the radios tucking the tongue into the plan.
The slab is secured with two wetted 10 cm open weave bandages.
Plaster of Paris is ideal, because
1. Cheap
2. Can be applied both as a slab and a cost.
3. Can be molded to any part, giving particularly good support.

41
Q. 180: Mention two causes of chronic discharging sins in thing. How does
osteomyelitis develop?
Ans: (i) Chronic osteomyetlits (ii) Osteosarcoma.
Source of infection: Hematogenous (Usually) from other site like lung, skin, Even
minor cut or prick may interdict infection. Other potential cause is open fracture and
surgery.
Q. 181: Mention two local signs of osteosarcoma. How the diagnosis of
osteosarcoma is made confirmed.
Ans: * Pain, Swelling, Restriction of joint movement.
* Biopsy and histopathology
Operating Surgery and Anesthesia

Q. 182: Define upper midline incision along with indications. What are the
advantages and disadvantages of this incision?
Ans: UMLI: A verified incision made in midline of anterior abdominal wall between
the lower level of xiphisternum and the upper level of the umbilicus.
Indications: 1. Gastrojejunostomy
2. Vagotomy
3. Pyleroplasty
4. Crastrectomy Partial or total
5. Repair of perforated duodenal ulcer.
6. Cholecystectomy or other biliary tree operation.

Wanlage:
1. Easy to perform
2. Rapid method of gaining entrance to abdomen.
3. Minimal bleeding
4. Does not damage muscles, nerves, major blood vessels
5. It may be extended downward or in T shape for greater access.

Disadvantage:
1. In some people may reveal abundant and well vascular zed fat , particularly in the
falciform ligament.
2. Because of relatively poor blood supply, the linea alba may undergo necrosis and
subsequent degeneration after incision if its edges are not aligned properly during
closure
3. Incision hernia may occur.

Q. 183: What are the indications of circumcision? What are the complications after
circumcision?
Ans: Indications
1. Phimosis
2. Paraphimosis
3. Recurrent balanoposthitis
4.Carcinoma affecting prepuce
5. Religious reason
Complication :
1. Bleeding

42
2. Infection
3. External urethral meatus stenosis

Q. 184: What are the complications of general anesthesia? What are the causes of
cyanosis after induction of general anaestheis?
Ans: Complications of general anesthesia:
(a) Per operative
1. Intubation problem- Trauma to teeth, Oral cavity larynx etc. Accident intubation
into esophagus either bronchus.
2. Vomting and aspiration
3. Hypotension
4. Cardiac arrhythmia
5. Cardiac arrest
6. MI.
7. Hypothermia
8. Drug allergy
(6) Post Operative
1. Vomiting
2. Atelecless Prenomia, Acute brondchits Lungabscess
3. CO2 retention
4. Deep vein thrombosis of leg
5. Post operative pain
6. Delayed toxic effect of durgs
7. Tracheal stenosis

Causes of Cyanosis/Hypoxia:
1. Undetected respiratory obstrcution, Kinked or displaced emotenced bute.
2. Vagal stimulation (rarely)
3. Wrong gas or wrong connection
4. Tension penumo thorax during positive pressure ventilation
5. Chemical peritonitis due to gastirc acid aspiration
6. Cardiac arrest
7. Cardiac arrhythmia
8. Undetected hypotension

Q. 185: What do you mean by cardiac arrest? What are the causes of cardiac or rest?
How do you manage such a case?
Ans: Cardiac arrest cardiac arrest describes the sudden and complete loss of
cardiac output due to asystole, ventricular tachycardia or ventricular fibrillation, or
loss of mechanical contraction (pulselen electrical activity).
Cases:
1. Ventricular fibrillation (this may be due to MI)
2. Cardiac asystole (this may be due to MI, general anesthesia)
3. Pulse less electrical activity (due to hypovolemia cardiac tampondadc tension
pheumothorax, pulmonary embolism.

Management:
1. Shout for help
2. Basic life support Cardio pulmonary resuscitaiton

43
3. Early defibrillation
4. Advanced life support

Q. 186: Define and describe curiae incision. Describe how you will drain a perional
abscess.
Ans: Cruciate incision: It is cross shaped incision made over the most fluctuant part
of an abscess, followed by excision of the four dermal flaps, Leading to formation of
a diamond shaped skin defect/gap.
Drain perianal abscess:
1. Spinal anesthesia/General anesthesia
2. Lithotomy position
3. Painting, Draping
4. Circuited incision is made over the most fluctuant part of abscess.
5. Pus in collected in Kidney dish
6. Gloved finger is inserted into abscess cavity to break any septum present.
7. After complete draining and homeostasis, the cavity is washed with antiseptic
8. Antiseptic soaked ribbon gauze is packed into the cavity

Q.187: What are the steps of operation in repairing an acute duodenal ulcer
perforation.
Ans: 1. The abdomen is opened through upper midline incision and quick survey in
made of confirms diagnosis.
2. The intraperitonal collections are soaked out, mopped out as for as practicable.
3. The liver is retracted and the assistant holds the stomach away, Thus the proximal
part of the duodenum is stretched and fixed.
4. The perforation is repaired is used by atraubratic chromic catgut no vo 2/0 with
interrupted suture omental patch laid over the suture line and fixed with stitch for
reinforcement.
5. Though surgical toileting of abdomen is carried out.
6. Any bleeding is checked and abdomen is closed in layers.
Q. 188: Define and describe appendectomy
Ans: appendectomy : IMBDA surgical excursion and removal of vermiform appendix.
Description:
Skin and subcutaneous tissue are cut in the same line of incision (Gird iron incision
or lanz incision). The external oblige and transverses abdomens are splits along its
fiber directions and retracted. Fascia transversals, extraperitnneal fat and
peritoneum together are held and but as a single layer in the same line of incision
then peritoneal cavity is opened, which is extended upwards and down words as for
a necessary by fine cursed scissions. A quick but careful survey is carried out and
the cecum is identified along with the base of the appendix. The ceucl along woth
apendix and part of the terminal ilum are pulled out through the opening. The
meroappendix is identified and the appendix is made from it by lighting and cutting
the meaoapendix in between pairs of forceps. A purse string suture with atraumatic
catgut no. 2/0 is inserted on the cecum arouind the base of the appendix to 1 inch
away from the base. The appendix is crushed at the base with a straight haemostatic
forceps which in removed and reapplied to the appendix just 1 can distal to first
crush and kept in stin. A ligature is applied to the first crush near the cecum with
catgut or silk and tied to occulude the lumer of appendix totally. The appendix is
excised and removed just proximal to the forceps by BP knife. The appendix stumps

44
is touched with iodine and sprit and then iveirginated to the cecum by plain
classecting forceps and purse string suture is tied thus burying the appendix
stumps. Any bleeding in checked. Abdomen is closed in layers as would.

Q. 189: What do you mean by herniorrhaphy? What are the indications of inguinal
hermoorrhaphy? describe the steps of the operations
Ans: Herniorrahaphy: It means repair of the stretched inguinal ring and strengthening
of the posterior wall of the inguinal canal.
Indications:
1. Used along with herriotmy in indirect inguinal hernia in adult.
2. Recurrent inguinal hernia
3. Only hermorhaphy is done in case of direct inguinal hernia.
Readies are requested to read description of incisions and operations from book
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Q. 190: Define vaginal hydrosol. Describe the operations for vaginal hydrocele.
Ans: Vaginal Hydrocele: IMBDA an abnormal collection of serous fluid in a part of the
procenus vaginally hydroce, Usually the tunica.
Treatment: Lords operation Jaboulay procedure.
Description: See Textbook.

Q. 191: Define herniorrhaphy and hernioplasty. Describe the indications and

difference between herniotomy and hernioplasty.
Ans: Herniorrhaphy. It means repair of the stretched inguinal ring and strengthening
of the posterior wall of the inguinal canal.
Hernioplasty: It is same as herrniorrhaphy but this is made by some other things
such as fasica lata wire, Dacron, mesh.
Indication: (See ans to Q. 185)

Q. 192: Define URPMI along with indications for hepatobiliary pathologies. Describe
the incision.
Ans: URPMI: It is vertical incision made over the anterior abdominal wall about 1 inch
right and parallel to midline, extending between the right costal margin and the over
of umbilicus.
Indications for hepatobiliary pathologies
1. Chole cystectomy
2. Choledocolithotomy
3. Cholecystoenterostomy
Description: See text book.

Q.193: Describe the procedure of draining an ischio rectal abscess How do you
confirm the presence of pus in the lesion?
Ans: See ans. of Q. 186
Confirm presence of pus Insert a needle not recession and aspirate fluid. If pus
comes out, it is confirmatory.

Q.194: What do you mean by vasectomy? Describe the operative procedures of

vasectomy. What are the complications of vasectomy?
Ans: Vasectomy: IMBDA excision of a segment of the Vas deference with ligation of

45
the ends.
Description: See textbook
Complications:
1. Pain scrotal hematoma
2. Local infection
3. Sperm granules
4. spontaneous recanalization
5. Spontaneous recanalizaiotn.
5. Autoimmune response
6. Psychological depression

Q. 195: Define circumcision Describe the procedure of cicussicion

Ans: Circumcision: IMBDA surgical excision and removal of prepuce of penis.
Description: See Textbook.

Q.196: What do you mean by Suprapubic cystostomy? Describe the steps of the
procedure:
Ans: Suprapublic Cystostomy: Drainage of urinary bladder supra publically e retaining
catheter by operative technique.
Description: See Textbook.

Q. 197 Name 4 incisions for appendectomy. Describe steps of Mcburneys incision.

Ans: Invasions
1. Grid iron incision/Mc Burneys incision.
2. Lanz incision
3. Rutherford Morision incision
4. Lower right paramedian incision.
Description: See Textbook.

Q. 198: Mention 2 indications of circumcision other than religious reasons. What is

the most prominent bleeding source during circumcision. How do you deal with that?
Mention two early complication of circumcision.
Ans: Indication Phimosis, Recurrent balamitis.
Most prominent bleeding source? An artery in frenulum.
Complication- Degloving injury. Amputation of penis. Hemorrhage. A four point
hemostatic stitch is given.

Q: 199 Mention two types of regional anesthesia. In spinal anesthesia What drug is
injected at which space? Name two complications of spinal anesthesia.
Ans: Regional anesthesia (i) Nerve block (ii) Plexus block
Spinal anesthesia: Lidocaine or Bupivacane
Injected in Epidural or subarachnoid space.
Complication: (i) Headache (ii) Hypotension

Q. 200: Mention two different anesthetic options for circumicna Mention one
contraindication of circumcision. What should be the immediate management of
reactionary hemorrhage after circumcision.
Ans: Anesthesia, G/A, L/A,
Contraindication: Relative contra indication in bleeding disorder.

46
Management of hemorrhage- Ligation, Diathermy
Q. 201; Define right upper Para median incision. Mention Separation where right
upper Para median incision is chosen what is done to the rectus muscle in this
incision:
URPMI: It is a vertically straight incision made over the anterior abdominal wall,
about 1 inch right and parallel to the mid line between the right costal margin and the
level of umbilicus.
Operation: 1. Cholecystectomy
2. Choledocholithotomy
The retunes muscle is retracted laterally.

Q. 202: Describe the surface marking of the upper midline incision. Mention 2
operations where upper midline incision is chosen. How peritoneum is opened
safely?
Ans: UMLI it is made the midline, between the lower level f xiphiod process and the
upper level of the umbilicus.
Operation: Gastrectumy, Gastrojecjunostomy.
Peritoneum Opening: The pperitoneum is holded with two artery forceps and
elevated. Thus a text is formed. The peritoneum is now palpated to pxclude any
structure in between the tent A small incision in made over the peritneum and it is
extended above and down word with scissers.

Q. 203 Why suprapubic cystomsmoy in performed? How the Urinary bladder is

opened safely? What is clone to the peritoneum while performing Supraputic
cystostomy?
Ans: Indication
1. Acute retention of urine when catheterization in failed
2. Rupture urethra
3. Unyielding urethral stricture
4. As a part of trans vesicle prostatectomy.

Open bladder Safely

1. The peritoneum is separated from bladder by blunt dissection.
2. Two stay sutures are placed on the bladder. bladder is lifted up with these sutures.
3. Bladder is stubbed by BP knife vertically. The opening is extended upward and
down word.
Peritoneum: the personal sac as a whole is reflected from the bladder by blunt
dissection and retracted upwards to expose anterior surface of the bladder.

Q. 204: What is Hiltons safe method of draining an abscess? Mention two sites
where Hiltons method and drainage of abscess is mandatory. Mention two steps in
drainage of a breast abscess.
Ans: Hiltons safe method after incision over the most fluctuant part of analoscen a
finger is introduced info he abscess cavity and rotated to break any locale then all
pus comes out easily.
Two site: Breast abscess
Ischisdrectal abscess.
Steps: Please see Textbook.

47
Q. 205: Describe the surface marking of gird iron incision. What is the basic
difference between grid iron incision and Lanz incision? Mention two situations
where right lower paramedian is chosen for appendectomy.
Ans: GII is an oblique incision 2-3 inch in length make at MCBurneys point
rd
perpendicular to the right spino umbilocial ine, with 2/3 above and 1/3 rd below the
line.
Basic difference: GII is not along skin crease.
Lanz incision is made along skin crease lines.
Situation 1. Diagnosis is not sure
2. Ruptured/Burst appendix.

Q. 206 Name two indications of vasectomy. Name two complications of vasectomy.

Mention the advice to patient about contraception after vasectomy.
Ans: Indication :
1. Family planning
2. As a preventive measure before prostatectomy to avoid post operative
epideidymorehitis.
Complications:
1. Sperm granule
2. Spontaneous recanalization.
Contraception: Use other temporary method of contraception for at least 30
ejaculations after vasectomy.

HEPATOBILIARY SYSTEM AND PANCREAS

Q: 207 Enumerate the types of hepatic neoplasm. What are teh primary sites that
metalize in liver?
Ans: Hepatic neoplasm:
1. Benign 1. Hemangioma
2. Hepatic adenoma
3. Focal nodular hyperplasia
(b) Malignant 1. Hepatocellular carcinoma
2. Hepatoblastoma
3. Cholangio carcinoma
Secondary: From colorectal carcinoma and other.
Primary site: Colorectal cancer other cancer
Breast cancer Real cancer.

Q. 208: What is pseudo pancreatic cyst? Describe clinical features and treatment of
pseduopancreatic cyst.
Ans: A pseudo cyst is a collection of amylase rich fluid enclosed in a wall of fibrous
or granulation tissue pancreatitis inflammatory axudate secretion.
C/F:
1. H/O acute pancreatitis 4 or more weeks ago
2. Small Asymptomatic, detected by USG>
3. Large Persistent or intermittent abdominal discomfort
4. Very large Vomiting obstructive jaundice palpable mass even visible.
Treatment
(a) Conservative- For small cyst
(b) Surgical for cyst larger than cm, and age > 12 weeks

48
 (i) Cystogastrostomy
(ii) Endoscpicdringage
(iii) Pecutaneous transgastic cystagstrostomy.

Q. 209: Name the type of Gall stones. Describe the cause and character of each of
them. Name the complications of gall stone. What do you mean by gall stone ileus.

Ans:
Type Cuase d Character

1. Cholesterol stone 1. super saturation of chol 1. Usually single large with

in bile smooth surface whitish yellow.
2. Pigment store
2. Long standing 2. Small, brittle, sometimes
3. Mixed stone
hemolytic anemia speculated multiple stones.
Black or brown in color.
3. Chronic cholecystitis
3. Usually multiple, of variable
size, hard or soft, mulberry
shaped, faceted or irregular,
whitish yellow and green to
black in cooler.

Complications:
1. Acute cholecystitis 6. Carcinoma of GB

2. Gangrene 7. Obstructive jaundice

3. Perforation 8. Cholangtis

4. Empyema 9. Acture pancreatistis

5. Mucocele 10. Gallstone ileus.

Gall stone ileus: Intestinal obstruction due to impaction of multiple gall stones.

Q. 210: What are the causes of common bile duct obstruction? How do you diagnose
and treat perampullary carcinoma?
Ans: (a) In: The Lumen: Gall stones, Round worm, Broken T-tube
(c) In the wall Congenital artesia- Traumatic stricture
(d) Cholngitis, Tumor of the bile duct.
(d) Outside the wall ca head of pancreas, ca-ampulla of vater pancreatitis.
Enlarge lymph mode at part hepatic.
Periampullary carcinoma:
Patient Presents with factures of obstructive jaundice.
Gall bladder is usually palpable (Courvoisiers law)
Investigation- USG. Contrast enhanced CT. MRCP, ERCP.
Treatment: If respectable: Whales operation
If not resettable: Palliative care.

49
Q: 211: Enumerate the type of hepatic nepotism. What are the primary sites that
metastasize in Liver?
Ans: (See ans to Q. 207)

Q. 212: What are the primary liver cancer? What are the etiologies of HCC?

Q. 213: What investigations will you do for diagnosis?

Ans: Primary liver concert: 1. Hepotocelluar carcinoma
2. Hepatoblastoma
3. Cholangio carcinoma
4. Angio Sarcoma
Aetiology: 1. Chronic livered is case
2. Virus-HBV, HCV
3. Toxin-Aflatoxin
4. Unknown
Investigations:
1. Liver funciton test (LFT) protein
2. Secrum alfa feto
3. CT scan Adomen and thorax
4. USG
5. MRI
6. FNAC
7. Needle bispsy forhistolocial confirmation.

Q. 214: Define acute pancreatitis. Describe the clinical features of acute pancreatitis.
What investigations will you do for diagnosis?
Acute pancreatitis: Acute inflammation of pancreases epigastria
C/F:
1. Constant severe or agonizing pain in the epigastria with radiation through to the
back. Nausea, vomiting and retching are after marked.
2. Examination often reveals much less tenderness guarding and rigidity than
expected from symptom.
3. Shock is often present in severe pancreatitis.
Investigation
1. Serum analyze and lipase
2. USG
3. ERCP

Q.215: How do you clinically differentiate between emphysema and mucocele of gall
bladder? How do you treat empyema of GB?
Ans: In case of empyema there is signs of infection, fever, tenderness on palpation.
Mucocele is usually non tender.
Treatment of emphysema: Drainage of pus and systemic antibiotic.
Later cholecystectomy

Q. 216: Describe the management of a case of acute pancreases what are the
complications of acute pancreatitis?
Ans: Management:

50
1. Nothing by month.
2. Open IV channel Analgesic, Antiemetic and correction of dehydration.
3. If severe attack-Antibiotic and treatment of shock.
4. Aprotinin (favorite of shahid sir, clinical trial shows no extra benefit.
5. ERCP (diagnostic and therapeutic)
6. Early return to eternal feeding. It is better to me jejunal feeding tube.
7. Treatment of complication.

Complications:
(a) Systemic-Shock, arrhythmia, ARDS, renal failure, Hypcalcmina Hyperglycemia,
Hyperlipidemia, Ileus, DIC, confusion, Irritability, Encephalopathy, Visual
disturbane, Arthralgia.
(i) Local-Acute fluid retention, siderite pancreatic necrosis, Infected pancreatic
necrosis pancreatic abscess, pseudo cyst pancreatic as cites, pleural effusion,
portal/splenic vein thrombosis.

Q.227: Name the tumors arising from pancreas. How do you treat a case of ca head
if pancreas.
Ans: Tumors: 1. Ducal adenocarcinoma (most common 85%(
2. Ampullary adeno carinoma
3. Serous cystedenoma
4. Mucinus cystic neoposm
5. Mucinus cystic neoplosm
6. Intraductul papillary mutinous neopllasm
7. Lymphone pathetical cyst.
8. Iymphangioma
9. Dermoid cyst.
10. Intestinal duplication cyst.
11. Adenoma of ampoule of vater.
12. Solid psendopapillery tumour.
13. Characinoid tumor.
14. Neure endocrire careinoma.
Treatment: Whiplles operation

Q. 218: A paitent is admitted in the hospital with deep jaundice due to malignant
stricture. How do you prepare the patient for surgery?
Ans: 1. Correction of anemia and malnutrition.
2. Correction of coagulopathy- vitk injection
3. An IV infusion should be started on the night before surgery Glucose 5% should be
infused at a rate of 100 mL/h. Also mannitol 20g should be given just before the
indnction of anaesthesia.

219. What is the pathogenesis of amoebic liver abscess? How do you treat amoebic
liver abscess?
Ans: Pathogenesis: Amoebic cyst is ingested with contaminated food or by
contaminated finger. If develops in trophozoite form in the color. It invades color wall
and a posses to liver via the portal circulation. Liver abscess occurs due to necrotic
effect of toxins released by ameba and also toxins released by leukocytes to kill it.
Treatment:

51
(a) Conservative-Metronidazole 750 mg tds for 10 days if do no respond.
(b) Surgical-USG guided needle aspiration of abscess.

220. Classify hepatic cyst. What investigations are done in these cased how do you
treat hydrated cyst of liver?
Ans: Hepatic cysts:
1. Primary:
(i) Congenital Congenital cyst of liver
(ii) Developmental-Caroles disease
(iii) Genetic- Polycystic liver disease
(iv) Billiard cyst adenoma
2. Secondary- (i) Trumatic-Seroma, Biloma
(ii) Infection-Pyogenic, Parasitic (eg: Hydatid cyst)
(iii) Neoplastic
Investigation- USG CT scan, Serology for hydatid disease FNAC in suspected
malignancy:
Treatment of hydrated cyst
(i) Medical- Alberdazole or Meberdazole.
(ii) Minimally invasive-PAIR therapy (Percuteneous aspiration, injection,
respiration)
(iii) Surgery-DC-rooting, Local excision of cyst Partial liver resection.

Q. 221: Describe the clinical features of acute cholecystitis. How do you manage
suck a case:
Ans: C/F: Right upper quadrant or epigastria pain, which may radiate to the back.
This may be colicky but more after dull and constant. dyspepsia, flatulence, food
intolerance (fatty food) On exam, Murphys sign is positive.
Conservative treatment followed by cholectystectomy:
1. Nil per month and IV fluid administration.
2. Anal genies.
3. Antibiotics (cefazolin/cefuroxime/gentamicin)
4. Observe- If pain and tenderness increase on other complication arise, emergency
operation is done
5. Routine operation is done 6 weeks later.

Q. 222: A 60 years old man presented with progressive deep jaunties for one month.
Name two probable surgically important causes in this case what clinical sign would
suggestiory destruction? He has markedly elevated S. bilirubin. Moderately elevated
ALT, markedly elevated S. alkaline phosphates and protestation of prothrombin
time. Mention two further investigations for diagnosis.
Ans: Probable cause Ca-head of pancreas cholangiocarcinoma
Clinical sign- Scratch mark indicates prorates that occurs in biliary obstruction.
Further investigation-USG, ERCP.

Q: 223: Mention two common presentations of cholelitons. Name tow causes of

non-tender palpable gall bladder. What abdominal physical sign you might expect if
there was an espuma of gall bladder.
Ans: Common presentations: 1. Acute cholelithisnsis 2. Obstructive jaundice
-Non tender palpable sell bladder

52
1. Mucocele of GB. 2. obstruction of common file duct other than stone.
Empyema: Focal tenderness and guarding are usually present in the right upper
quadrant. A mass is occasionally palpable, however guarding my prevent this.

Q.224: Name two ultrasonographic features of chole docolithies. Mention two

ensuewuence of impacted stores at the neck of the gall bladder and in the common
bile duct.
Ans: Small stones in the common bile duct frequently get lodged at in distal end of it,
behind the duodenum, and are, therefore, difficult to detect. A dilated common bile
duct and small stones in the gallbladder indicates stone in bile duct.
A large stone is acoustically dense and produces acoustic shadow.
Impacted stone in neck of GB cause (i) Actuate cholecystitis (ii) Mirizzi syndrome
Impacted sone in CBD Causes (i) Cholangitis (ii) Pancreatitis.

Q. 225: Name two ultrosonographic features of choledo colithiosis what in the

reason behind the prolongation of prothrombin time in obstruction jaundice and how
you can correct that before any surgical intervention?
Ans: Choledocolitiasis: See previous answer.
PT: due to decreased vit K.
Vit K. is fact soluble vitamin and its also option dempends on bile. In obstructive
joundice threre is no bile so vitk cannot be absorbed. So, production of prothrombin
is reduced.
Correction: Vit K 10 mg IM ing daily for 3 days before operation
Q: 226: Name 4 Liver function tests. Mention their changes in obstructive jaundice
What is ERCP?
LFT Normal value obstructive Jaundice

1. Secom biliration 5-17 umol/L- Moderately elevated

2. AST 5-40 IU/L

3. ALT 5-40 IU/L

4. S. ALP 35-150 IU/L

5. Prothmbin time 12-16 SEc

ERCP: (i) Old elaboration-Endoscopic fetrograde cholnigo pancreatgraphy

(ii) New elaboration-Endoscopic Retrograde cannulation of vater.

Q. 227: Name two etiological factors of acute pancreatitis Mention two abdominal
complications of acuter pancreatiols. Mention two systemic effects of acute
pancreatitis.
* Choledocholithasis, Post-ERCP.
* Pancreatic necrosis (infected/sterile) Pseudo cyst, Ileus.
* Shock, ARDS.
Q.228: What are the complications that may develop if a calculus gets impacted at
the neck of the gall bladder? What would you suggest a 30 years old lady who has
calculus in gall bladder but no symptom related to that?
Ans: Impacted store

53
1. Acuter cholecystitis Mucocele, empyema, Necrosis Fistula formation Gall
stone ileus
2. Mucocele
3. Compression over CBD-obstructive jaundice
4. Mirizzi syndrome.
No intervention is needed unless she is diatctic or has congenital hemolytic anemia
or salmonella carrier or about to undergo bariatric surgery.

Q.229: Describe the typical pain due to acute cholecystitis. Mention clinical signs
that suggest the presence of acute cholescystitis.
Ans: Biliary colic: A severe right upper quadrant pain that obs and flows associated
with nausea and vomiting. Pain may radiate to back or chest. Last for several hours,
even minutes.
Signs: 1. Murphys sign positive
2. Tenderness and guarding in the right hypochondria.

Q:230: How acute cholecystitis develops? Mention two USG feature suggesting
acute cholecystitis. Mention two common complications of laparoscopic
cholecystitis. Mention two common complications of laparoscopic cholecystectmy.
Ans: In most of the cases, a gallstone impacted in Hartmanns pouch or obstructing
the cystic duct leads to acute cholecystitis. Other causes may be bacterial infection
or non specific inflammation during recovery from major surgery.
USG features: distended GB, e thick walls, perichole cystic fluid, stones (if present).
Complication: 1. Access complications-Visceral injury
2. Bile duct injuries.

Q: 231 What is mucocele of the gall bladder? How it develops? What is empyema of
the gall bladder? How it develops?
Ans: Mucocele; IMBDA distended GB filled with mucus.
Pathogenesis: Mucocele results from complete obstructions of the cystic duct with
readsorpiton of the intraluminal bile salts and secretion of uninfected muws by GB
epithelium.
Hmpyena of GB: IMBDA distended GB filled with pus.
Pathogenesis (i) As a consequence of acute cholecystitis.
(ii) Infection of mucocele of GB.

Q. 232: What are the consequences of the presence of calculus in common bile
duct? Mention two methods for the removal of the calculus from the CBD.
Ans: Consequences: 1. Obstructive jaundice
2. cholangitis
3. Liver abscess from aseending cholangitis.
4. Pancreatitis.
Methods: 1. Endoscopie removal (ERCP)
2. Choled Ocholithtomy/Choledochotomy

Q. 233: What is the pathological change that occurs in case of acute pancreatitis?
Mention two important factors strongly implicated to the development of acute
pancreatitis?
Ans: The main pathology is obstruction to pancreatic secretion. This may be due to

54
biliary calculi, alcoholism or idiopathic. There may be back flow of bile and activated
pancreatic enzymes due to obstruction. Or, due to obstruction, accumulated
secreted enzymes may activate within pancreas. This leads to inflammation.
Factors: Biloary Calculi, Alcohol.

Q.234 What are the complications of acute pancreatitis in abdomen and respiratory
system? What are the investigations that help diagnosing the acute pancreatitis?
Ans: See ans to the Q. 216 and 214.

Q. 235 Mention presenting symptoms and abdominal sign: Suggesting acute

pancreatitis as clinical diagnosis. What do you expect in serum amylase level and
USG of the abdomen it your clinical diagnosis is acute pancreatitis?
Ans: Severe constant pain developing quickly within minutes, localized in epigastria
or either upper quadrant and radiates to back (in 50% ases) Pain persist for hours or
days.
Abdominal sign:
Grey Turner sign, culler sign (However less severe tenderness than pain in more)
common lack of sign.
S. Amylase: Elevated (Generally > 100 U/L)
Three times of upper limit of normal level (100 IU/L) suggest acute pancreatitis.
USG: May reveal swelling of the passcreas with peripancreatic fluid collection and
oedema and may detect gall stones.

Q. 236: Mention 2 common surgical causes of obstructive jaundice. Mention two

symptoums or two physical signs suggesting obstructive jaundice.
Ans: Causes: 1. choledocholithiasis
2. Periampullary carcinouma
Symptoms: 1. Yellow coloration of urine but pole stool.
2. Pruritus.
Signs: 1. Jaundice
2. Presence of pain or lump in right hypochondria (There may be 4 combination
pain/Painless Lump/ No lump)

Q.237: A 60 years old man is suffering from deep jaundice and he has a palpable gall
bladder. Mention the most probable cause of this situation. What are the imaging
investigations useful for the diagnosis?
Ans: Cause: Ca-head of pancreases cholongio carcinoma
Investigations: USG, ERCP.

Q. 238 What are the biochemical liver function tests? In obstructive jaundice
prothrombin time gets prolonged. Explain it. How can you correct it? Mention the
biochemical liver function test profile of obstructive jaundice?
Ans: LFT: S. bilrubin S. AST. ALT, ALP, GGT.
S. total protein, Albumin, A/G ratio
Prothrombin time.
See Ans. of Q. 225 and 226

Q. 239 What are the informations you can gather form an USG of hepato biliary
system? What are the suggestive features of choledoclolithiasis in an USG?

55
Ans: Information
1. If the gall bladder is distended.
2. If the gall bladder wall is thickened.
3. If there is peri cholecystic fluid.
4. If there is gall stone.
5. If the extrhepatic biliary tract is dilated.
6. If there is stone in common bile duct (alo worm)
See ans Of Q. 224

Q. 240: Name the causes of liver abscess. Mention two physical signs suggesting
the presence of liver abscess. How would you confirm your diagnosis of liver
abscess.
Ans: Causes of liver abscess
1. Pyogenic bacteria Esch, coli, strep. mill, Entamoeba histolytica.
Signs: 1. Tender hepatomegaly
2. Intercostal tenderness over liver.
Confirmation: By USG guided needle aspiration of pus. followed by microscopy and
C/S.

Q. 241: How a patient with liver abscess does present to you? How USG help
diagnosing a liver abscess? What in the treatment guideline of an amoebic liver
abscess.
C/F. 1. Fever 2. Anorexia. 3. Abdominal pain.
USG: (i) It shows cystic/hypoacoustic shadow in liver
(ii) It helps in USG guided needle aspiration.
Treatment
1. Metronidazole 750 mg tds for 10 days.
2. If large abscess or impending rupture or no response then USG guided aspiration.
Q.242: What are the surgical causes of hepatic enlargement?
How can you detect metastatic carcinoma in the liver?
Causes: 1. Cystic diseases of liver
2. Liver abscess.
3. Neoplastic HCC secondarys.
4. Primary bilary cirrhosis, Macronodular cirrhosis.
Mestastic carcinoma: H/O primary cancer
Liver is hard and nodular, no bruit
and fetopretion is normal
ALAP 4, Carcinoembroynic antigen increased.

Gastrointestinal Tract

Q.243 What is the difference between vomiting and regurgitation? Name some
conditions where regurgitation in common.
Ans:
Vomiting Regurgitation

1. It mean expulsion of gastric content 1. It means back ward flow

through month.
2. This term is used both for food and for

56
2. This term is specific for intestinal blood (aortic regurgitation).
content.
3. Occurs due to in competency of
3. There is active contraction of stomach value/sphincter.
in backward wave.

Regurgitation-1. In infant when lower esophageal sphincter mechanism is not well

developed.
2. GERD
3. Achalasia Cardia
4. Ca-oesophagus.

Q. 244: Describe the clinical features of acute duodenal ulcer perforation reporting
within 4 hours. Describe the management of a case of acute peptic ulcer perforation.
Ans: C/F: The patient, who may have a history of duodenal ulceration, develops
sudden onset, severe, generalized abdominal pain. The patient may be shocked with
a tachycardia. The abdomen exhibits a board like rigidity and the patient is
disinclined to move because of the pain. The abdomen does not move with
respiration.
Treatment:
1. Resuscitation
2. Analgesic
3. Antibiotic PPI
4. Surgery-Thorough peritoneal toilet.
Close the ulcer in a transverse direction.
If massive perforation, Billroth and operation.
5. Post operative care.
6. Triple therapy for H. Pylori eradication.

Q. 245: A patient is admitted with severe hematemesis and shock. How do you
manage this case?
Ans:
1. Hospitalization
2. Open two wide bore IV channel. Send blood for grouping cross matching and other
investigation.
3. Start resuscitation with crystalloid fluid. Transfusion later.
4. Urinary catheterization and monitor urine output.
5. Upper GI endoscopy by experienced endoscopist as soon as possible (within 24
hours)
6. If bleeding cannot be controlled by endoscopic procedure then surgery is done.
Bleeding vessel is sutured.
PPI for suspected peptic ulcer. Octrcotide for suspected bleeding uarices.

Q. 246: What do you mean by volvulus? How a case of pelvic colon presents?
Describe the management of a case of Vovulus of sigmoid colon.
Ans: Vovulus: A Vovulus is a twisting or axial rotation of a portion of bowel about its
mesentery.
C/F: The symptoms are large bowel obstruction, which may initially be intermittent

57
followed by the passage of large quantities of flatus and faces. Presentation varies
in severity and acuteness. With younger patients appearing to develop the more
acute form. Abdominal distension is an early and progressive sign, which may be
associated with hiccough and retching, vomiting occurs late. Constipation is
absolute. In the elderly, a more chronic form may be seen.

Management: Vovulus is tried to be untwisted by sigmoidoscope / clonoscope. a

flatus tube is inserted to allow deflation of the gut
If successful, resuscitate patient and then do surgery
If unsuccessful, go for emergency surgery untwisting of the loop and per anus
decompression. When the bowel is viable, shorting or fixation to posterior wall is
done. If bowel is necrosed, Paul- Mikuliez procedure or Hartmanns procedure is
done, later reanastomosis.
Q. 247: What are the complication s of heamatemesis? How do you treat prolapsed
thrombosed hemorrhoid?
Ans: Complication: Shock and its complications.
Treatment: Analgesia, bed rest, frequent hot bath, warm or cold salin compress with
firm pressure over piles. Later, hemorrhoid.

Q. 248: Describe acute anal fissure Describe the clinical feature and treatment of
acute and fissure.
Ans: An annual fissure is a longitudinal split in endoderm of the distal anal canal,
which extends from the anal average proximally towards, but not beyond, the dentate
line.
C/F: Severe and pain associated with defecation, which usually resolves
spontaneously after a variable time only to recur to the next evacuation as well as
the passage of fresh blood, striating over stool or on the tissue after wiping.
Treatment:
1. Fiber in diet adequate water and Stoll softener.
2. Warm both and topical local anesthetic
3. 0.2% Glycerol trinitrate applied to anal margin four times daily.
4. 2% Diltiazen applied to anal margin twice daily.

Q.249 What are the management of a case of antral carcinoma of stomach? What
are the criteria for curative resection?
Ans: Management
1. Prepare the patient for surgery, est correct anemia, malnutrition
2. Staging
3. If surgery is possible (as a case of antral carcinoma) subtotal gastrectomy with
reconstruction (Polya type or Roux en Y)
Criteria for causative resection:
1. All margins are cleared of tumor cells, do frozen section study.
2. Grossly 5cm beyond margin is desirable.
2. Lymph nodes D1 resection and D2 resection (It is still debatable)

Q.250: How a patient presents with early ca stomach? What investigations will you
do to confirm the diagnosis?
Symptom of early stomach cancer:
Asymptomatic or mild symptom of indigestion, dyspepsia or flatulence.

58
Confirmation: Upper G1 endoscopy, biopsy of any suspicious lesion and
histopathology. BYPS
nd
Q. 251: Define hemorrhoids describe the clinical features and treatment of 2 degree
hemorrhoids.
Hemorrhoid: IMBDA prolapse of anal cushion (internal H.) or a mass of dilated
tortuous veins in the ano-rectum involving the Venous plexus of that area (external
H.)
C/F of 20H: Lump appears at the anal orifice during defecation and returns
spontaneously after wards.
Treatment:
(a) Non-operative-Sclerotherapy: Banding.
(b) Operative-Hemorrhoidectomy.

Q.252: What is cardiac achalasia? How do you differentiate if from malignant

stricture of lower and of esophagus clinically?
Achalasia cardia: Failure to relax of the smooth muscles of lower esophageal
sphincter, due to degeneration of ganglion cells in the wall of the organ.
Clinical Diferentation
Achalasia Cardia Ca-esophagus

1. Slowly progressive dysphagia 1. Rapidly progressive dysphogia

2. Retrosternal pain present initially, 2. There may be long H/O heartburn

not later.
3. Anorexia, anemia present.
3. No anorexia anemia
4. Hoarseness of
4. No feature of invasion or voice/Dyspnoea/Horner
metastasis. syndrome/Palpable supra clavicular
lymph nodes.

Q.253: What are the complications of partial gastrectomy? How do you treat anemia
in such cases?
Ans: Complications: 1. Recurrent ulceration, 2. Small stomach Syndrome.
3. Bile vomiting, 4. Early and late dumping, 5. Post vagotomy diarrhea 6. Malignant
transformation, 7. Nutritional consequence, Anemia (iron, Vit B12 deficiency)
Osteoporosis .
Treat anemia: Iron supplementation (Usually oral is adequate) Parenteral vit B12
supplementation.

Q. 254: What are the medical treatment of early peptic ulcer? What are the
indications of surgery in chronic duodenal ulcer?
Ans: Medical treatment: 1. Ranitidine 150mg 12 hourly for 8 weeks.
2. Omeprazole 20mg daily for 4 weeks
3. Triple therapy
Indication: 1. Pyloric stenosis, 2. Perforation 3. Bleeding 4. Intractability or non
healing.

59
Q. 255: What is intussusceptions? What are the clinical presentations of such a
case?
Ans: Intussusceptions: IMBDA telescopic projection or prolapsed of one part of the
intestine into the lumen of an immediately adjacent part.
C/F: Usually a male infant of weaning period . Episodes of screaming and drawing up
of the legs. The attacks best for few minutes of recur repeatedly. Later bile stained
vomiting. Red arrant jelly stool. On exam, emptiness of right iliac fossa. A lump may
be palpable in right lumbar or right hy pochondrium region. On DRE, blood stained
mucus may be found. Even there may be prolapsed of intussusceptions.

Q. 256: A 50 year old man was brought to emergency room with heamtemesis
mention 2 common causes of heamatemesis what immediate, measures you would
undertake to resuscitabe the patient from shock due to hematemenis after
stabilizing the patient, What procedure is recommended for diagnosis and arrest of
bleeding.
Ans: Cases: 1. Bleeding peptic ulcer, 2. Oesophageal varies management See ans of
Q. 245. Uper G1 endoscopy.

Q. 257: A 50 years lady presented with sudden severe upper abdominal pain with
vomiting shehad no significant previous illness whatsoever. She was found in a state
of schok. Her abdomen had marked tenderness and rigidity in epigastria right
hypochondriac and umbilical region. Liver dullness was present in usual position but
bowel sound was absent. Mention two differential diagnosis. Plain X-ray shows no
gas shadows under the domes of the diaphragm, total WBC count was 15000/cu
mm, polymorphs 85% serum amylase was markedly raised. Give your interpretation.
Ans: D/D-1. Petic ulcer perforation 2. Acute pancreatitis.
Interpretation 1. X-ray indicates absence of preumoperitioneum.
2. Neutrophilic leukocytosis indicates acute inflammations
3. Markely raised s. amylase is in favour of acute pancreatitis.

Q. 258: A 65 years old man was presented with an epigastria lump 3 possible cause.
Mention 3 general and two local signs suggesting carcinoma of stomach.
Ans: Possible causes-Gastric Causes, clon cancer, Hepatomegaly, Pancreation
cancer/pseudocyst, Aortic aneurysm.
Signs: General: Anemia, Virchows gland, Asthenia
Abdomen: Epigastria tenderness
Epigastric mass- hard, irregular, dull.

Q. 259: A 1 year old boy presented with colicky abdominal pain and blood mixed
mucus diarrhea for one day. If a sausage shaped lump was felt around umbilicus,
what would you suspect? How per rectal examination would help assessing this
case? What further investigation would you ask for a diagnosis? What further
investigation would you ask for a diagnosis?
Ans; Intussusceptions
PR finding is blood stained mucus, Apex of intussusceptions may be palpable.
Investigation-USG, BA enema X ray.

Q. 260: A 60 years old man complaining, bleeding during defecation for 6 months.

60
Name two general physical signs and two signs on DRE suggesting CA-rectum. How
can you confirm the diagnosis of ca rectum?
Ans: General Physical sign:
1. Anemia (due to chromic bleeding)
2. Palpable lymph node: Virchow, gland, Inguinal
3. Hepatomegaly, Ascies (due to metastasis)
DRE signs:
1. An indurated nodule or ulcer bulging into lumen of rectum. It is hard, edge is
usually everted, base irregular and friable.
2. Mesorectal lymph mode may be palpable.
3. After with drawing finger, blood stain is seen.
Confirmation: Signoidoscopic biopsy and histopathology.

Q.261: A 15 years old boy from rural area presented with a painful lump on his right
lower abdomen. What would you suspect/ What kind of treatment would you
recommend first? Mention two physical signs that demand a surgical intervention.

Ans:
* Appendicular lump
* Conservative treatment
1. Increasing/Spreding abdominal pain
2. Increasing size of the lump.

Q. 262: Mention two major complications of chronic duodenal ulcer that could lead
the patient to a state of shock. Mention two radiological features and two systemic
effects of gastric out let obstruction due to chronic duodenal ulcer.
Ans: Complication 1. Massive bleeding, 2. Perforation 3. Severe vomiting due to
pyloric stenosis.
Barium meal X-ray- 1. Dilation of stomach with/without peristalsis narrowing of
pylorus.
2. No transit of food even after 4 hours.
Systemic effect of Goo
1. Malnutrition
2. Chronic dehydration electrolyte and acid base disturbance.

Q. 263: Mention the types of vagotomy why vagotomy is done for the treatment of
chronic duodenal ulcer? Name two operative procedures that must be combined
with truncal vagotomy.
Ans: (i) Truncal vagotomy (ii) Selective V, (iii) Highly selective V.
To reduce gastric acid secretion
(i) Gastrojejunostomy, or (ii) Pyloroplasty.

Q. 264: What is hiatus hernia? Name two types of hiatus hernia? Name a contrast
radiological investigation that can detect hiatus hernia of the stomach.
Ans: Hiatus hernia: The protrusion of the stomach upward into the mediastinal,
cavity through the oesophageal hiatus of the diaphragm.
Types: 1. Sliding type 2. Rolling type
Radiology: Barium meal X-ray.

61
Q. 265: What is gastro oesophageal reflux disease/ Name wo important causes of it/
What happens to the oesophagus as its consequence?
Ans: GERD: Backward flow of gasric content into lower esophagus.
Causes:
1. Increased episodes of treatment lower oesophageal sphincter relaxation.
2. Sliding hiatus hernia.
Consequence: 1. Oesophagitis, 2. Stricture formation, 3. Oesophageal stortening. 4.
Barretts oesophagus.

Q. 266: 60 years old lady presents with difficulty in swallowing. Name two possilde
causes. What is the significance of dysphagia with solid food not the liquid? Name
two investigations for the diagnosis?
Ans: 1. Oesophageal cancer, Achalasia Cardia
2. It signifies mechanical obstruction in oesophagus.
3. Investigations- Ba-Swallow X-ray, Upper gI endoscopy.

Q. 267: Name two major causes of gastro duodenal bleeding? Describe step of the
management in the emergency room to resuscitate the patient.
Ans: Causes. 1. Ulcer (60%) 2. Erosion (26%) See ans of Q. 245

Q. 268: Mention symptoms and signs suggesting ca stomach. Mention two

morphological features of a gastric ulcer suggesting Ca-stomach. How its diagnosis
is confirmed?
Ans: Symptoms: 1. Early-Dyspepsia
2. Late-Anorexia, Asthmia, Anemia Early satity, bloating, Epgastric fullness, Vomiting.
Signs: 1. Epigastric tenderness
2. Epigastirc mass may be palpable
3. Ascites may be present
4. Virchows gland.
Morphological feature: Raised everted edge, Neerotic tissue in base surrounding
infiltration.
Confirm: Upper GI endoscopy, biopsy and histopathology.

Q. 269: Mention two local signs differentiation acute pancreatitis from the
perforation of duodenal ulcer, Name two biochemical investigations suggesting
acute pancreatitis and mention two of its complications.
Ans: Local signs: Perforated Du shows signs of peritonitis
No movement of abdomen-board like rigidity.
Perforated Du resulting in pneumoperitoneum causes
Obliteration of liver dullness.
Investigations: 1. S. Amylase 2. S. Lipase
Complications: Shock Pseudocyst formation

Q. 270: See Q. 262 and its answer

Q. 271: See Q. 263 and its answer.

Q. 272: A 10 month old boy is crying having a history of repeated vomiting and
reddish loose Stoll for two days and there is an elongated mass in umbilical region.

62
Mention the most likely diagnosis. What radiological investigation you want to
undertake for diagnosis? What is the surgical treatment of this condition?
Ans; Intussusceptions
Inv: BA-enema X-ray
Treatment: Reduction is achieved by gently compressing the most distal part of the
intussusceptions toward its origin, making sure not to pull.

Q. 273: Name two causes of small gut obstruction and two causes of large gut
obstruction. Name two important investigations that you will suggest in this
condition.
Ans; Small gut obstruction: Band/Adhesion, Obstruction hernia
Large gut obstruction: Colon cancer, Volvulus.
Inv: 1. Plain X-ray of abdomen.
2. For large gut, Ba enema X-ray
3. USG.

Q. 274: What is paralytic ileus? Name one local and one systemic cause of paralytic
ileus. Mention the radiological features of paralytic ileus.
Paralytic ileus: IMBDA a state in which there is failure of transmission of peristaltic
waves secondary to neuromuscular failure.
Cause: Local-Abdominal operation, Intra abdominal sepsis
Systemic hypokalemia, Uremia.
Radiology: The abdomen shows gas filled loops of intestine with multiple thid levels.

Q. 275: What is strangulated intestinal obstruction? Give an example of strangulated

obstruction. What is volvulus of sigmoid colon? What is the danger of volvulus of the
sigmoid colon?
When a portion of intestine become strangulated there is obviously obstruction and
the condition is strangulated intestinal obstruction:
Example: Strangulated inguinal heania.
Strangulated Sigmoid volvulus.
Volvulus of sigmoid colon: Twisting or axial rotation of sigmoid colon about an axis
passing through the highest point of convexity of the twisted portion and the
midpoint of its mesentery.
Danger: Strangulation-Gangrene-perforation-Peritonitis-sepsis-Shock.

Q. 276: Mention four clinical feature of intestinal obstruction you could discover with
digital rectal examination? If you find a tender swelling in inguinal region, What would
you suspect?
Ans: 4 classical features: Pain, Vomiting Abdominal distension, Constipation.
DRE findings in intestinal obstruction
1. Empty rectum
2. Ballooning of rectum beyond finger.
3. Ca-rectum may be felt
4. Impacted inspissated feces may be felt.
5. Apex of an intussusception may be felt.
6. Blood stained mucus is found in intussusceptions.
Tender swelling in inguinal region:
strangulated inguinal hernia

63
Q. 277: Mention three mechanisms of loosing fluid and electrolytes in case of
intestinal obstruction. What type of fluid you would infuse to correct fluid deficit?
Name two reasons when patient with intestinal obstruction needs laparotomy.
Ans: Loss of fluid and electrolyte:
1. Loss as a result of vomiting
2. Defective intestinal absorption.
3. Sequestration in bowel lumen.
4. Reduced oral intake.
Fluid: Normal saline, Later 5/DA.
Reason you laparotomy: 1. Strangulated hernia 2. Sigmoid volvulus.

Q.278: Mention two important symptoms and one-abdominal sign strongly

suggesting ileo caceal tuberculosis. What radiological study might suggest
existence of ileo cacal tuberculosis. How diagnostic Laparoscopy can help confirm
the diagnosis?
Symptoms 1. Alternation of bowel habit or intermittent diarrhea.
2. Weight loss, Evening rise of temperature
Sign: -1. Mass in right iliac fossa
Radiology-Ba-meal and follow through or small bowel enema
Laparoscopy:
If shows tubercles on bowel serosa, multiple stricture, areas of caseation,
enlarged lymph nodes.
Biopsy can be taken for histopathology.

Q. 279: Name two common causes of generalized peritonitis. Mention 2 general and
2 abdominal features of generalized peritonitis.
Ans:
* Perforated PUD, Burst appendix.
* Pulse, Temperature
* Board like rigidity, tenderness

Q. 280: Mention two symptoms of pelvic residual abscess. What you would feel
while performing DRE? How is it treated?
Ans: * Fever e chills and rigor. Abdominal/pelvic pain, Diarrhea.
* Bulging of anterior rectal wall which becomes soft cystic when ripe.
* Drainage of abscess through rectal wall or in female, vagina fornix Antibiotic,
Antipyretic, Analgesic.

Q. 281: Mention one common cause of rectal bleeding in children and one in elderly
people. How small amount of bleeding from GIT can be detected and what in the
most useful investigation for the diagnosis of rectal bleeding?
Ans: In children-Rectal polyp, Vascular malformation, Intussusceptions.
In adult: Ca rectum, Hemorrhoid, Anal fissure
* Occult Blood Test (OBT)
* Sigmoidoscopy

Q. 282: Name two complications of acute appendicitis. What is an appendicular

lump? Name two clinical signs that suggest appendicular lump turned into an

64
appendicular abscess.
Ans: Complications: Appendicular lump, Appendicular abscess.
Appendicular lump: It is an intra abdominal mass formed by inflamed appendix,
surrounded by omentuss, iteum cecum, as a sequaelae of acute appendicitis.
Appendicular abscess:
symptom: increased Pain, sign: increased Pulse, increased Temperature.

Q. 283: Name two etiological factors of acute appendicitis, Why V. appendix become,
gangrenous in some cases of acute appendicitis? What would happen if a
gangrenous V. appendix gets perforated?
Ans: Factor: infections, fecolith, Round worm, Decreased dietary fiber and increased
refined carbohydrate.
Gangrene: When the cause of appendicits is luminal obstruction it may become
gangrenous.
Obstruction Increased intraluminal pressure- Decreased venous return-Ischemic
necrosis-
Superadded infection by colonic bacteria-Gangrene.
Perforation: This leads to bacterial peritonitis.

Q. 284: If a patient had a perforated V. appendix, where the patient would feel pain?
What would be the general feature of the patient Mention two abdominal signs what
incision would be chosen for laparatomy and why?
Ans: Pain: Generalized abdominal pain.
General feature: Hippocratic face, disinclined to move
Shallow rapid breathing, No movement of abdomen,
Tachycardia, Increased Temperature.
Abdominal Sings: Tenderness, Board like rigidity.
Incision: Lower right paramedian incision
Because there is perforation of appendix, more area is needed for operation, which
cannot be obtained by GII or Lanz-incision.

Q. 285 How hemorrhoids are formed? What is 2nd degree hemorrhoid. Name two
treatment options of 1st and 2nd degree hemorrhoids name two locations of peri-anal
abscess. What is the principle of treating the perianal abscess? How fistula-in-ano is
formed?
Ans: Pathogenesis of hemorrhoid: Shearing forces acting on the anus (for a variety
of reasons) Lead to caudal displacement of the anal cushions & mucosal trauma.
With tissue fragmentation of the supporting structures (a normal consequence of
ageing but perhaps accelerated in those with hemorrhoids) leads to loss elasticity of
the cushions such that they no longer retract following defecation.

2. Hemorrhoid: Lumps that appear at the anal orifice during defecation & which
return spontaneously after wards.

Treatment option:
(i) Conservative-Stool softener & bulking agent.
Practice minimal strain defecation.
(ii) Minimal invasive- Sclerosis, Banding
Locations: 1. Marginal Abscess, 2. Ischiorectal abscess, 3. pararectal abscess.

65
Principle of treatment:

1. Drainage of abscess & deroofing of abscess cavity.

2. Healing by secondary intention.
3. Antibiotic therapy.
Formation fistula in ano: Infection of intersphincteric anal gland formation of
abscess the abscess opens into both directions, anal mucosa & skin-Fistula is
formed.

Q. 286: What is the most significant symptom of anal fissure? How do you find a
chronic anal fissure & how it looks like? How chronic anal fissure is treated
surgically?

Ans: Symptom: Tearing pain with defecation and blood on the toilet paper. A
sensation of intense & painful anal spasm lasting for several hours after defecation.

On exam: The fissure is often seen by gently separating the buttocks. patient is often
too tender to allow DRE. Chronic fissures develop ulceration & heaped-up edge with
the white fibres of internal anal sphincter visible at the base of-ulcer. There is often
an associated external skin tag and / or a hypertrophied anal papilla internally.

Surgical treatment: Lateral internal sphincterotomy.

CARDIO-THORACIC SURGERY
Q. 287: What are the clinical features of lung cancer? Outline the principles of
management of lung cancer.
Ans: symptoms: Cough, Hemoptysis, Breathlessness, Fever, Weight loss, chest pain,
Anorexia, Bone pain etc. Symptoms of paraneoplastic syndrom.
Sign: (a) General-Anemia, Clubbing, Cachexia, Supraclavicular or axillary
lymphadenopathy.
(b) Chest There may be feature of
(i) COPD, (ii) Pneumonia, (iii) Pleural effusion,
(iii) Collapse, (v) Mixed, (vi) Consolidation.
(c) Invasion & Metastasis- Horners syndrome, Bone pain,
Hepatomegaly, Stroke like feature.

Outline of principle a management:

1. Confirmation of diagnosis: Biopsy with the help of bronchoscopy or CT guided,
then histopathology.
2. Staging
3. If it is operable Lobectomy or Pneumonectomy is done
4. In operable-Radio therapy, Chemotherapy, Pleurodesis.

Q. 288: Waht do you mean by tension pneumothorax? How do you treat such a case?
What is the danger if you do not treat such a case?
Ans: Tension Pneumothorax: It means air is accumulating in the pleural space with
high tension (due to flap value machanism), causing shift of mediastinum and

66
hemodynamic instability.
Treatment:
1. Emergency relief of tension by inserting a wide bore neelde in second
intercostal space along mid clavicular line,
2. Then tube thoracostomy and water seal drainage.
Danger of no treatment
Meditational shifting causes kinking of great vessels Increased tension decreases
venous return. Both leads to obstructive shock, then cardiac arrest Death will occur.

Q. 289: Classify primary lung cancer. Online the management of primary lung cancer.
Classification:
1. Small cell carcinoma
2. Non-small cell carcinoma
(i) Squamous cell carcinoma
(ii) Adenocarcinoma
(iii) Large cell carcinoma
iv) Broncho alveolar carcinoma.
See ans. of Q. 287

Q. 290: What is hemothrax? Enumerte the cause of hemothorax. How do you treat
such a case of hemothorax?
Hemothorax: IMBDA presence of blood or bloody fluid in the pleural cavity.
Cavses: 1. Ca-lung, 2. TB, 3. Pneumonia, 4. Trauma 5. Iatrogenic.

Treatment:
(i) Tube throacostomy
(ii) If continued bleeding or massive bleeding or cake hemothorax then thoroctossy,
ligation of bleeding vessel and evacuation of blood.

Q. 291. Describe how emphysema thoracic may develop. ow do you diagnose and
treat this condition:
Ans: How empyema develops:
Empyema is the end stage of any bacterial infection of the pleural cavity. If may
occur as follows.
Contamination from a source contisuous to the pleural space
(i) Lung eg, as in pneumonia, lung abscess
(ii) Mediastinm, Deep cervical area, chaest wall and spine.
(iii) Subphrenic area eg, Liver abscess.

2. Direct inoculation of the pleural space

(i) Minor thoracic intervention eg, treatment of pleural effusions pneumothorax,
hemothorax.
(ii) Postoperative infection.
(iii) Penetrating chest injury eg. infection of hemthorax.
Diagnosis:
Symptom- High fever, Breathlessness, H/O underlying cause.
Sign- Chest signs oas in pleural effusion.
Pleurocentesis-The finding of grossly purulent, foul smelling pleural fluid make, the
diagnosis obvious at bedside.

67
Treatment:
1. Tube thoracostomy e waterseal drainage
2. Broad spectum antibiotic. It will be charged according to C/S result of pus.
3. Antipyretic and other symptomatic treatment.
4. If pus become loculated, USG guided or thoracoscopic drainage.
5. If pleura become hardered, lung decortications may be necessary.

Q. 292: A patient is admitted with multiple rib fracture due to blunt trauma. What are
the clinical features? Describe the management of this patient.
Ans: C/F: 1. H/O blunt trauma to chest
2. Chest pain sharp localized aggravated by breathing.
3. Dyspnoea.
Management:
1. Primary survey and resucitation
* There may be lung injury, hemothorax that require ventilation and circulatory
stabilization.
* There may be spelinc on liner hemorrhage that require circulatory stablization.
2. Secondary survey
3. Definitive treatment:
(i) Adequate analgenia
(ii) Bed rest O2 inhalation
(iii) Tube thoracostomy if hemothorax or phenumothorax present.
(iv) Antibiotic if pneumothorax present.
(v) If extensive flail chest segment or markedly displaced rib fractures open
reduction and internal fixation.

Q. 293: What are the clinical findings of a case of DVT? What are the clincial feaures
of a case of pneumothorax?
Ans: C/F and DVT
Sudden onest of pain & swelling of calf or whole leg.
Swelling of leg is usually unilateral. Involved muscle is hard and tender. Superficial
vessels are dilated, so skin is hot.
C/F of Pneumothorax.
1. Usually a H/O COPD or pulmonary TB or chest truuma.
2. Sudden onest of breathlessness.
3. Chest exam-Movement is restricted on that side
Percussion note hyper resonant,
Vocal fremitus and vocal resonance decreased.
:Decreased or absent breath sound.
If trachea, apex beat shifted or hypotension
is found then it is tension pneumothorax.
Q. 294: In examining a vascular patient, What are the questions youll ask in taking
history? What are the chest radiographic findings in pneumothorax?
Ans: History: If limb pain develops in muscle?
If pain develops during work and relieved by rest?
If there is a claudicating distance? How long?
Numbness, coldness, Parenthesis?
Smoking history
Occupation.

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CXR: Hyper translucent lung field with a collapsed/pushed lung border with/without
tracheal shift.

Q. 295: What are the anatomical landmarks of popliteal artery? How do you examine
it?
Ans: Surface marking: Poplitical artery starts at the level of junction of middle and
lower third of thigh, 2.5 cm medial to the midline of posterior surface of thigh. It
passes through the midline of popliteal fossa (back of knee) and ends on the midline
of back of leg at the level of tibial tuberosity.
Examination technique (According to Shahid Sir)
Patient is in supile position, Knee is bent to 1350. Examiner approximates all fingers
of both hand (except thumb as shown in the figure).
With the pulp of these finger he/she palpate poplitcal fossa obliquely. Pulsation
suggests popliteal artery.

Q. 296: What aetiological factors are associated with varicose vein? What is the
importance of pain relief in a case of thoracic injury.
Ans: Factor: (i) Idiopathic (ii) Familial predisposition (iii) Prolonged standing (iv)
Decreased venous drainage due to various obstruction/tumor (v) Damage of
perforator veins (vi) Incompetence of venous value.
Pain relief: Thoracic injury may cause rib fracture which is very painful. We cannot
immobilize chest to relieve this pain, Also the pain causes patient to stop breathing
movement, leading to respiratory failure. So, adequate pain relief by analgesics is
very important.

Q. 297: How lumber sympathectomy helps in the treatment of Buergers disease?

What investigations are performed to diagnose a case of DVT?
Ans: In Buergers disease, arterial narrowing occurs, We know, sympathetic, activity
causes vasoconstriction. So, lumbar sympathetomy results in vasodilatation of that
limb, which relieves symptom.

Q. 298: What are the plain X-ray findings of hemothorax in erect posture? How do
you treat a case of surgical pneumothorax?
Ans: CXR: A dense homogenous opacity in the affected lung with curvilinear upper
border, obliteration of costophrenic and cardiophrenic angles. Rib fractures may be
seen.
Treatment : Tube thracostomy. Clousre of wound.

Q. 299: What is the medical management of varicose vein? what is stove in chest?
How does it occur?
Ans: Medical management of varicose vein:
1. Avoid prolonged standing.
2. Contract calf muscle intermittently during standing.
3. Use of elastic compression stocking during working time.
4. Injection sclerotherapy
Stove in chest (Flail chest): If 3 or more adjecent ribs fracture at two points, the
segment becomes detached from chest wall and moves paradoxically (sucked in
during inspiration and driven out during expiration). This condition is called stove in
chest.

69
Q. 300: What are the contraindications of CABG? What are the causes of airway
obstruction?
Ans: Contraindications of coronary Artery Bypass Graft:
1. Small, diffusely diseased arteaies
2. Diffuse disease and heart failure.
3. Acute myocardial infarction over 6 hours old.
4. Moribund patient after resuscitation.
5. Significant cerebrovascular disease require modification Union of surgical
strategy.
Causes of Airway obstruction:
1. Traumatic- Denture teeth section blood in airway Bilateral mandibular fracture.
* Expanding neck hematoma
* Tongue fall back.
* Thyroid or cricoids fracture, Tracheal injury.
2. Comatose patient tongue fall back. Aspiration of vomited material.
3. Foreign body in airway.
4. Neurological Vocalcord paralysis Tetany
5. Anaphylaxis Larayngeal oedema
6. infection-Acute epiglottises, croup, Diphtheria
7. Obstructive airway disease.

Q. 301: What do you mean by vaso occlusive disease? What do you mean by
intermittent claudicating? When does rest pain occur in peripheral vaso occlusive
disorder does it indicate?
Ans: Vaso occulusive disorder. Means a disease process which occuldes the lumen
of blood vessel, mainly arteries.
Intermittent claudicating: Means a cramp like pain in a muscle which appears during
exercise. Rest pain occurs: When the vaso occlusive disorder has progressed much,
usually after several months or years.
Indicates: Rest pain indicates onest of critical limb ischemia.

Q. 302: What is flait chest? What do you mean by paradoxical chest movement?
Which dome of the diaphragm commonly rupture in blunt trauma and why?
Ans: Fee Ans of Q. 299
Left dome is usually ruptured
Because right dome is supported by the liver.
Q. 303: What is the auscultator differentiating point between cardiac tamponade and
tension pneumsmothorax? What is the treatment of tension pneumothorax?
Ans:
Cardica Tamponade Tension Pneumothorax

Heart Sound Muffled (coming from distance) Displaced/Shifted also muffled

Breath sound present Absent.

Treatment of tension pneumthorax: See ans of Q. 288

Q. 304: What are the indications of chest tube drainage (Tube thracostomy) Tell me

70
the management of sucking chest wound.
Ans: Indications: (i) Pneumothorax, (ii) Hemothrax (iii) Pleural effusion (iv) Empyema
(v) Post operative to lung surgery.
Management:
(a). Initial 1. Cover the defect with sterile occulsive pastic dressing taped on 3 sieds
to act as a flutter valve.
2. A Cest tube is inserted as soon as possible in a site remote from the wound.
3. Definitive: Fromal debridement and closure of wound.

Q. 305: Waht is mediastinum? Classfy mediastinum. Enumerate two life threatening

chest conditons following blunt chest trauma.
Ans: Mediastinum: IMBDA mass of time situated at the centre of thoracic cavity,
surrounded by sternum in front, vertebral columns in back , pleural sacs on both
sides and the diaphragm below.
Classification: 1. Superior 2. Inferior -* Anterior * Middle * Posterior
Life threateming: Tension pneumothorax, Massive hemothorax.

Q. 306: What do you mean by open heart surgery and give one example. Tell the
boundary of Triangle of safety for chest tube drainage (tube thoracostomy).
Ans: Open Heart Surgery: Surgery involving direct visualization of the exposed heart
eg: Heart valve replacement surgery.
Boundary of triangle of safety:
Anterior to the mid axillary line
Above the level of the nipple.
Below and lateral to the pectoralis major muscle.

Q. 307: What are the clinical and radiological differencing points between
ca-esophagus and achalasia cardia? What is pathological difference between
achalisia cardia and mega colon?
Ans: Clinical difference-see ans of Q. 252.
Radiolgocial difference.
1. Ca-oesophagus: A filling defect or ulcer may be seen. There is abrupt narrowing of
lusner. (shouldering)
2. Achalasia Cardia: Proximal dilatation of esophagus and tapering narrowing of
lower end like a birds beak.
Pathological Different Between Mega esophagus and Mega colon ganglion cells.
Achalasia cardia- Degeneration of nerve plexus / Ganglion cells (it is acquired)
Hirschsprung disease Absence of ganglion cells/nerve plexus (it is
congenital)
But other forms of mega colon are acquired.

308. What do you mean by pneumonectory? What are the treatment modalities of
lung cancer?
Pneumonectomy means surgical excision and removal of a lung.
Treatment modalities:
1. Surgery- Lobectomy, Pneumonectomy
2. Radiotherapy
3. Chemotherapy
4. Pallilative therapy

71
Q. 309: What do you mean by DVT? Tell two clinical features of DVT and two
prophylactic measures to prevent DVT. Mention name of two operations for lung
cancer (see previous ans.)
Ans: DVT: It means thrombus formation in deep veins.
C/F of DVT: see ans. of Q. 293.
Prophylactic measure. Early mobilization (Avoid prolong bed rest). fise compenssion
stocking.
Subcutaneous Heparin inj. in at risk patient.

Q. 310: What is flail chest? What in the danger of flail chest? How flail chest is
treated?
Ans: See ans. of Q. 292, 296 and 299.
Danger: Hypoxemia, Hypercapnia, Acidosis.

Q. 311: Mention two life threatening condition of pulmonary origin after a penetrating
injury to thorax. Mention two signs of traumatic tension pneumothorax, How can you
save the patient from the fatality of tension pneumothorax?
Ans: See ans Q. 305, 293, 288.

Q. 312: Waht is flail chest? What are the cause of severe hypoxin in flail chest? What
is the treatment of flail chest?
Ans: See ans of Q. 299
Causes: Flail chest Paradoxical movement-inefective Ventilation-also decreased
breathing due to pain-Severe hypoxia.
See ans of Q. 292

Q. 313: Mention two clinical signs of traumatic hemo throax. Mention two
investingative procedures to diagnose hemothorax. When would you consider
surgical intervention?
Ans: Signs: 1. Trauma-Bruise, Laceration or Puncture seen.
2. Chest finding are similar to pleural effusion.
Investigation:
1. CXR
2. Pleurocentesis
Surgical Intervention 1. Massive hemothorax and patient is unstable.
2. Ongoing hemorrhage, not stopping
3. Cake hemothorax.

Q. 314: What is water seal drainage? Give two examples where water seal drainage is
essential. What is the right place for insertion of a chest drain?
Ans: Water seal drainage: It is a type of drainage system where the external end of
drain tube is immersed under water, making is air tight, preventing atmospheric air to
enter through it.
Use: Pneumothorax, Hemothorax.
Right place: Triangle of safety (see and of Q. 306)

Q. 315. What is empyma thoracis? Mention two casues of empymatherocis. Contion

two clincial signs that indicate the possibility of empgema thoracis.
Empyema: IMBDA presence of pus in the pleural covity see ans. of Q. 291.

72
BREAST, THYROID AND ENDOCRINE SYSTEM
1. How staging for breast carcioma is done? How staging helps in planning
treatment of breast carcinoma?
Ans: Ca-Breast staging is done according to TNM system, by
1. Physcial exam of skin, breast tissue, regional lymphoid, liver, lung and bony
tenderness.
2. Mammography, Chest radiography.
3. Sentinel lymph node biopsy
4. Intra operative finding of tumour size, chestwall invasion.
Planning of treatment:
Staging helps in predicting current status of disease process, its extent progrnosis
and best possible theorapy
stage O- Lumpectomy or simple mastectomy
Stage-I, II- modified radical mostectomy
Stage-III- Neo-adjuvant chemotherapy and radical mastectomy.
Stage IV- Palliative surgery, Hormonal therapy.

Q. 317: What are the post operative complications of partial thyroidectomy? How do
you manage them?
Ans: 1. Haemarrhage: A tension hematome deep to the cervical fascia is usually due
to reactionary hemorrhage from one of the thyroid arteries, thyroid veins or thyroid
remnant. Treat by urgent decompression by opening the layers of the wounds (not
only skin closure), then urgent transfer to OT and secure the bleeding vessel.
2. Rerpiratory obstrcution: Do endotracheal intubation.
3. Recurrent laryngeal nerve palsy and voice change.
4. Thyroid insufficiency: Give thyroxine supplement.
5. Thyroid storm: Cooling, IV fluid, Carbimazole, Sodium iopdate, Propranolol.
6. Parathyroid insufficiency. Cat tt+ and Vit D.
7. Wound infection
8. Hypertrophic or keloid scar.
9. Stitch granuloma.

Q. 318: What do you mean by lumpy breast? Describe the clinical features and
treatment of such a case.
Ans: Lumpy breast means fibrocystic changes of breast synonym-Fibroadenosis,
ANDI (Aberration of normal development and involution.)
C/F : A bening discrete lump in the breast is commonly a cyst or fibroadenoma.
-Lumpiness may be bilateral, commonly in upper outer quadrant
-Lumpiness and tenderness may be cyclical, both increase before menstruation.
-Non-Cyclical tenderness is more common in peri and post menopausal women.
Treatment: Firm Reassurance.

Q. 319: Waht hormone is produced by parathroid glands? Describe the clinical

manifestations of hyperparathyroidism.
Ans: Parathormone.
C/F: [Bones, Stones, Abdominal groans, (Abdominal pain), Psychic moans]
Bone pain, osteopenia, fracture, renal stone,
Peptic ulcer, constipation, Urinary frequency,
Irritability.

73
Q. 320: What is TNM staging? Describe how do you do this staging?
Ans: TNM staging is a system of mapping out extent of solid malignancy, as
recommended by the international union against cancer (UICC).
Here. T. denotes extent greatest dimension of tumor.
N. denotes involvement of regional lymph nodes.
M denotes presence of metastasis.
All these are assessed by physical examination, investigation and some intra
operative findings. Thus TNM staging is done.

Q. 321: Classify Breast tumor. What are the clinical feature of inflammatory
carcinoma? How do you differentiate it from acute mastitis?
Ans: Classification: (Histopathologial classification)
(a) Epithelial tumor:
1. Non-proliferative Breast changes (lumpy breast)
(i) Cyst, (ii) Fibrosis (iii) Adenosis
2. Proliferative changes without atypia
(i) Epithetial hyperplaisa, (ii) Sclerosing adenosis (iii) Complex sclerosing lesion (iv)
Papilloma

3. Proliferative changes with atypia

(i) Atypical ductal hyperplasia
(ii) Atypical lobular hyperplasia
4. Carcinoma in situ.
(i) Ductal carcionoma in situ (Includes pagets discase)
(ii) Lobular carcinoma in situ.
5. Invasive carcinoma knx` mvi wewfb fvM Kib
(i) Invasive ductal carcionoma * Congasintal/Acquired
(ii) Invasive lobular carrcinoma * Limitaternal/Bilaeral
(iii) Tubular carcinoma * Solitary/Multiple
(iv) Medullary carcinoma * Small/Large
(v) Mucinous carcinoma etc. * Cystic/soft/Hard
* Inflammatory/Non-inflammatory
(B) Stromal tumour:
1. Fibroadenoma
2. Phyllodes tumor (Cystosarcoma Phyllodes)
3. Sarcoma
C/F of inflammatory carcinoma: Patient presents with painful swollen breast, which
is warm e cutoneous oedema.
No lump is palpable.
Inflammatory carcinoma Acute bacterial mastitis

1. No specific time of ocurrance 1. Occus during first month of lacation.

2. Skin may appear as peaud orange. 2. No such change

3. Usually involves 1/3rd of breast. 3. Starts from a small segment then

spread like cellulitis or localize as breast
4. Looks like abscess but no fluctuation abscess

74
point. 4. Breast abscess has a fluctuation point

5. Fever unlikely 5. Fever is present.

Q. 322: A 40 years old lady has a goiter since her childhood. Recently there was a
rapid increase in size and she was not feeling well. Name two possible reasons.
None 4 clinical features and suggesting thyrotoxicosis. What would you expect in
plain radiogram of neck.
Ans: Reasons: 1. Carcinomatous change in pre-existing goitre.
2. De Quervains thyroiditis in pre existing goiter
C/F: Heat intolerance, Weight loss, palpitation, Diarrhoea.
X-ray- Tracheal deviation, compression
Retro sternal extension
Calcification.

Q. 323: A 25 years old lactating mother complains of fever and localized painful lump
in her right breast. Mention two clinical signs suggesting a breast abscess. What
would happen if it is treated by antibiotic in stead of surgical drainage? What would
you advise the patient about nursing her baby:
Ans: Sings: Red, hot, tender, wedge shaped swelling.
Fluctuation test positive
Axillary hymph node enlarged, tender.
If amtibiotic given
1. No response. Worsening of condition.
2. Antibiotic resistance may develop.
3. Abscess may rupture.
4. Occasionally, antibioma may form.
Advice:
1. Feed baby from healthy breast.
2. Empty the disease breast regularly using breast pump or manually.

Q. 324: Mention one physical sign indicating that a midline neck swelling could be a
thyroglossal cyst. A thyroid scan is wise to be done before removing a thyroglossal
cyst. Why? Where do the internal opening of the thyroglssal fistula opens?
Ans: Tug/Elevation of swelling with protrusion of tongue.
Because, the thyroglossal cyst may be the only thyroid tissue present. This
will determine post operative treatment.
Foramen cecum of tongue.

Q.325: Name two congenital lateral neck swellings. Mention two diseases could
manifest as cystic lateral neck swelling. If you find palpable left supraclavicular
nodes. Mention two diseases you will look for.
Congenital: Cystic hygroma: Branchial cyst.
Cystic lateral neck swelling: Retention Cyst of salivary gland.
Phenging ranula.
Thyroid swelling (Sometimes cystic).
Left Supraclavicular node: Ca-stomach, CA-lung
Testicular Ca.

75
Q.326: Mention two clinical presentations of cervical nodal tuberculosis. How can
you confirm your diagnosis without an open biopsy? When surgical excision of the
nodes are considered for cervical nodal tuberculosis?
Ans: Clinical Presentation: 1. Tubercular lymphadenitis 2. Tubercular abscess. 3.
Discharging sinus.
Confirm: By FNAC
Surgical excision:
1. If abscess does not resolve with anti TB drugs.
2. If the abscess is large enough to produce symptom due to its size.

Q. 327: Why thyroid gland of a girl starts enlarging in northern Bangladesh during
puberty? Mention two macroscopic feature of multinodular goiter and two
complicaitons of multinadular goiter other than pressure effects.
Ans: During puberty there is increased, production/demand of thyroid hormone, so
thyroid gland enlarges. But concomitantly, northern Bangladesh is an endemic region
of goiter due to iodine deficiency. That may be a contributing factor.
Multinodular goiter. Multiple nodule, variable size, firm consistency, there may be
cystic degeneration, hemorrhage ints nodule.
Complications: Secondary thyrotoxicosis.
Cystic degeneration, Hemorrhage into nodule, Infection,
Calcification of nodule.

Q. 328: What are the thyroid function test/ How the isotope thyroid scan in
interpreted? How ultasonogram can help evaluating a thyroid nodule.
Ans: Thyroid Function Tests.
USG: S. TSH, FT3, FTA

1. Helps to determine solid and cystic Anti TPO antibody, Anti Tgb antibody
nodes.
USG of thyroid
2. Indentify parathyroid adenoma
X-ray of neck and thoracic inlet
3. Helps in targeted biopsy
CT, MRI, PET

Thyroid scan

RAIU

FNAC

Interpretation of thyroid scan: Cold spot/nodule, warm spot/nodule.

Q. 329: What are the complications of a multinodular goiter? What kind treatment is
needed for multinadular goiter?
Ans: Complications:
1. Tracheal obstruction
2. Acute respiratory obstruction following hemorrhage into a nodule impacted in
thoracic inlet.

76
3. Secondary thyrotoxicosis.
4. Carcinoma.
Treatment:
1. In asymptomatic patient without complicaiton
-Thyroxine 0.15-0.2 mg daily for few months.
-Surgery may be done for cosmetic purpose or to alleviate patients anxiety.
2. In symptomatic or complicate case or retrosternal goiter. Total/Partial
thyroidectomy with thyroxine supplementation.

Q. 330: What are the toxic goiters? Name the types. what are the treatment options
for thyrotoxicosis. What are the advantages of treating thyrotoxicosis by surgical
operation?
Ans: Toxic goiter: Goiter that produces thyrotoxicosis is called toxic goiter.
Type: 1. Diffuse toxic goiter (Graves disease).
2. Toxic multinadular goiter.
3. Toxic nodule.
Advantage: The goiter is removed
Cure is rapid
Curerate is high if surgery has been adequate.
Q. 331: A 25 years old lady presented with a palpable nodule in the right lobe of her
thyroid gland. She is clinically eutheroid. What are the possible causes? What
relevant investigations are adviced to evaluated the nodule? What procedure might
be needed to have a confirmed diagnosis?
Ans: Causes: Colloid nodule, Thyroid cyst, Follicular adenoma, Carcinoma.
Investigations: USG, RAIU and turnover, Thyroid scan
Confirmatory: FNAC or core cut biopsy

Q. 332: What are the types of malignant thyroid tumor? Mention the treatment
options of carcinoma of thyroid gland.
Ans: Malignant thyroid tumor:
(a) Primary
(1) Follicular cell origin (i) Follicular Ca. (ii) Papillary CA. (iii) Anaplastic Ca.
2. Parafollicular cell origin-Medullary Ca.
3. Lymphoid cell origin-Lymphoma.
(b) Secondary
1. Metastic
2. Local infiltration
Treatment Options:
Papillary Ca-Total thyroidectomy with Radioactive iodine ablation
Follicular Ca-Total thyroidectomy with Radioactive iodeneablation.
Medullary Ca- Total thyroidectomy with removal of affected cervical lymph nodes
Anaplastic Ca & Lymphoma-Radiotherapy+Chemotherapy.
In every case, thyroxine supplementation is needed later.

Q. 333: What pre-operative preparation is needed for thyroidectomy for a toxic

multinadular goiter? Name the common immediate and late complicaitons of
thyroidectomy operations?
Ans: Preparation: Make the patient euthyroid and shrink the size of goiter by iodine
therapy.

77
Complications: See ans of Q. 317

Q. 334: What happens if a parathyroid gland goes into hyper function. What happens
if all the parathyroid glands are removed in a total thyroidectomy operation? How
would you treat it?
Ans:
Hyperparathyroidism (See ans. of Q. 313)
Hypoparathyroidism Hypocalcemia tetany.
Treatment:
(i) Acute-20 ML of 10% calcium gluconate IV injection.
(ii) Chronic-Ca++ and vit-D supplementation.

Q. 335: Classify goitre. How can you screen thyroid dysfunction by a single
investigation?
Ans: (i) Diffuse goitre (ii) Nodular goitre (iii) Multinodular goitre (iv) Simple goitre (v)
Inflammatory Goitre (vi) Neoplastic goiture (vii) Toxic goitre
Single test: Serum TSH.

Q. 336: Name the major arteries need to be secured during thyroid surgery and name
the nerves that might be injured at that stage. What are the thyroid hormones? How
can you have an accurate serum level of those?
Ans: (i) Superior thyroid artery-External branch of superior laryngeal nerve.
(ii) Inferior thyroid artery-Recurrent laryngeal nerve.
(iii) Arteria thyroidia ima.
Thyroid hormones: Thyroxine, Tri-idothyronine, Calcitonin.
Measuremtn method: Immunochemiluminometric assay.
mviiv Kb GB ck `q/ gb co hvq Dipyllobothrium. evbvb Ki)

Q.337: Name two non malignant causes of a breast lump in a 45 years old woman.
Name two causes of pain in breast.
Ans: Lump: Fibrocystic changes, Fibroadenoma, fat necrosis.
Pain: Fibrocystic changes, Mastitis, Abscess.

Q. 338: What are the macroscopic pathological changes that occur in fibrocystic
disease of the breast? Mention two causes of retraction of breast.
Ans: * Cyst, Fibrosis, Epithelial hyperplasia, Adenosis.
* Ca-breast, Ductal ectasia.

Q. 339: Name two common varieties of carcinoma of thyroid gland. What is the usual
interpretation of radio active iodine scan in cases of carcinoma of thyroid gland?
What is the effect of TSH on thyroid. Carcinoma? How can you suspect this effect?
Ans: * Follicular, Papillary, Anaplastic
* Interpretation-Hot nodule, Cold nodule
* TSH has trophic (growth stimulus) effect on differentiated thyroid carcinoma.
* To suppress this effect, after total or total thyroidectomy, Ta is supplemented to
keep the patient euthyroid.

Q. 340 Name three non-malignant conditions of the breast what is antibioma? Name
one investigation which is used for breast cancer screening in > 40 population.

78
Ans: * Fibrocystic chnages, Fibroadenoma, Mastitis.
* Mammography.

Q.341: What are the two important features of malignant breast lump classified as
T3. What is a sentine lymph node of a breast tumor and how can it identified?
Ans: T3-Size> 5cm, Not fiexed to skin or underlying structure.
Sentinel lymph node of breast: It is the first ymph node among the regional lymph
nodes which drain the lymphatics from that breast tumour.
Identification: The sentiment node is localised per operatively by the injeciton of
patent blue dye and radio isotope labelled albumin in the breast (in sbdermal plexus
around nipple). Then the sentinel node is identified visually and with a hard held
gamma camera.

Q. 342: Mention two classical symptoms of fibroadenosis/fibrocystic disease of the

breast mention two causes of nipple discharge. What is the Pagets disease of the
nipple?
Ans: * Lumpness and Tnderness
(i) Duct ectosia-Greeen or brown disechare
(ii) Duct papilloma Bloody discharge.
Pagets discase of the nipple is a superficial manifestation of an underlying breast
carcinoma. It presents as an eczema-like condition of the nipple and areola, which
persists despite local treatment. The nipple is eroded slowly and eventually
disappear. The underlying carcinoma will become clinically evident sooner or later.
Q.343: How loco regional control of the carcinoma of the breast, done by surgery?
How the bone metastasis from carcinoma of the breast is identified? How bromine
sensitivity of the carcinoma of the breast is determined.
Ans: * Local control-Excision and removal of tumor (Mastectomy)
Reginal control-Excision and removal of lymph nodes (Axillary clearance)
* Isotope bone scan
* Measurement of presence of estrogen receptor of progesterone receptor in biopsy
materioal by immunohistochemistry method.

Q.344: Mention method of detecting early breast cancer you should advice to women
population. What are the criteria for Manchester breast tumor staging? What N2
implies in TNM classification of carcinoma of the breast.
Ans: Screening: Self breast examination 3 monthly, clinical examination by physician,
yearly. Mammography. 1-2 yearly.
Manchester Staging:
Stage Mobile Fixed lump Mobile Matted or Metastasis
lump Oxillery fiexed to opposite
Gode axillary breast,
hode opposite
oxilla, bone,
lung, liver.

ii

79
iii e pectorals

iv e skin

N2 implies fixed axillary nodes.

So, the criteria of Manchester staging are
* Presence of breast lump, its mobility and fixity.
* Presence of axillary lymph nodes, their mobility and fixity.
* Presence of metastasis.

80
 Case Scenario
ENDOCRINE AND BERAST
C.1 A patient presented with a painless parotid swelling for 7 months duration.
Explain on which criteria you confiner it malignant?
Malignant parotid swelling:
1. rapidly growing (not need to be big, but growing rapid).
2. Persistently painful
3. Skin is red and hot.
4. Signs of facial nerve paralysis.

C.2: A patient has a painless parotid swelling for 5 years duration. Mention five
differential diagnosis. How can you asses that it is benign?
Ans: 5 D/D:
1. Pleomorphic adenoma (Mixed tumor).
2. Cystadenolymphoma (wasthins tumour)
3. Sjogren Syndozome
4. Tuberculosis
5. Sarcoidosis (Mikuliczs syndrome)
Bening: 1. Slow growing 2. Painless 3. overlying skin normal 4. Facial nerve intact.

C.3 A middle aged man has a painful parotid swelling for 3 months duration. What
are the importance of examining oral cavity in such a case.
Ans: Oral cavity findings may be
1. Dry mouth.
2. Red, inflamed Stensens duct.
3. Thickened or lump in stonsens duct.

C.4: A 15 years girl complaints of a lump in her right breast. Mention three
possibilities. How will you confirm the nature of the lump?
Ans:
* Fibroadenoma, Sarcoma, Carcinoma.
* Confirmatory test-FNAC or core cut biopsy.

C.5: A 38 years old lady presented with a lump in her left breast. Mention three
important criteria to assess this patient. (Triple assement)
Ans: Triple assenment:
1. Clinical (i) History (age of pt), (ii) Examination
2. Imaging- (i) USG, (ii) Mammography
3. Histopathology- (i) FNAC (ii) Core cut biopsy

C.6: A 35 year old lady presented with a lumpinher left breast it is 6 cm in highest
diameter, and freely mobile and only a single lymph node in palpable in left axilla. No
secondary metertasim was found. Tell the TNM staging of this patient.
Ans: T3, N1, MO
So, the stage is III A

C: 7: A woman with oliagnosis of fibrocystic disease of breast wants to get rid from
her tension of inelegancy. What you will do?
Ans:

81
1. Firm reassurance
2. Do an USG or Mammography to support diagnosis.
3. Re-examine after 6 weeks.
C. 8: Prognostic factors:
1. Histological grade of the tumor.
2. Hormone receptor status.
3. Measures of tumor proliferation eg: S-phase fraction.
4. Growth factor analysis
5. Oncogene or ascogonia product measurements.
No Hingham prognositc index: This is a prognosis index of breast cancer patients,
that combine the prognostic factors (described above) to allow sub-division of
patients into discrete prognostic groups.

C.9: A middle age man has a nodule in right lobe. What information would you obtain
from FNAC in this case of solitary thyroid ndule?
Ans: FNAC can tell the histologic type of the thyroid nodule. If there is normal colloid
or neoplasia, such as, follicular cells, papillary cells, medullary cells, anaplastic cells.
FNAC can differentiate adenomas and carcinomas except follicular adenoma from
follicular carcinoma.
C.10: A patient had thyroidectomy at 9:00 AM in the morning. In post operative ward
the patient complaints of respiratiory difficulty of 11:00 AM. What are the causes?
What you would do?
Ans:
Cause Management

1. Tension hematoma 1. Open all layers of the wound the

secure bleeding vessel.
2. Respiratory obstruction
2. Endotracheal intubation.

C. 11: A young female patient of 37 years presented with a swelling in front of neck
which moves with deglutition. iodine uptake after oral dose of 5 yrs. RAI uptake is an
followed.
4 hours-15%
24 hours -75%
48 hours-30%
How do you interpret the findings? What investigations do you advice?
Ans: Interpretation: High uptake and High turnover/Rapid turnover suggesting, the
pathology may be a toxic nodule.
Advice: FNAC (if the sweeling is a nodul)
Thyroid scan/scintigraphy (this will differentiate toxic adenoma) Toxic MNG, Gravis.
TRAB (in suspected Graves disease)
TSH, FT4, FT3 (to know thyroid status)

C.12: An elderly female patient presented with a diffuse swelling in front of neck
which moves with deglution. iodine uptake after oral dose of 5 uci RAI uptake is as
follows.
4 hours-12%

82
24 hours-45%
48 hours-41%
How do you interpret the findings? What is your diagnosis?
Ans: Interpretation: Normal uptake and slow turnover.
Diagnosis: Hashimotos thyroiditis.
hw` case nZ High uptake slow turnover Zvnj Iodine deficiency.
C.13: A young female presented with a nodule in the right lobe of thyroid. The
swelling is firm, nontender and mobile. What are the possiblities? What investigation
do you suggest?
Ans: Possibility (i) Thyroid adenoma (ii) Thyroid Cyst (iii) Carcinoma
Investigations: USG & FNAC

C. 14: A young boy has been growing rapidly for about a year and has become taller
than elder brother. What is the causes of increased growth? How do you confirm you
diagnosis?
Ans: Cause: Excess growth hormone (Gigantism)
Confirm: MRI scan of pituitary region.
PRINCIPLES OF SURGERY

C. 15: A patient complaints of a swelling in the thigh for 4 days. The swelling is
painful and skin is red. What is your diagnosis? What is the treatment?
Ans:
* Cellulitis of thigh
* Leg elevation, IV antibiotic (flucloxacillin and benzyl penicillin)
DVT prophylaxis.

C 16: A 30 year old man had a swelling for 5 days. The swelling was painful, became
soft, discharged pus on pressure. On examination there is a tender swelling e pus
discharge from one point.
How will you treat the patient?
Ans: Drainage of pus. Antibiotic

C. 17: A diabetic patient presented with a painful swelling on the posterior aspect of
neck. There is a diffuse swelling with dark skin color and pus discharge from
multiple points. What is your diagnosis? What is the treatment? What test would be
helpful?
Ans: * Carbuncle
See ans. of Q. 3.

C. 18: A school boy had injury of the elbow during playing cricket which is not healing
for 3-4 weeks. That might be the cause that this wound is not healing despite
different antibiotics and repeated dressing?
Ans: Causes
1. Foreign body
2. Wrong antibiotic
3. Drug resistant organism.
4. Movement of elbow causing repeated hauma.

Q. 19: A severely anemic patient needs a major surgery, his Hb is 4 gm% calculate

83
amount of blood that will be required for this patient before, operation.
Ans: Target Hb is 10 gm%
So, (10-4)= 6 Unit of Red cell concentrate or whole blood is required
It is recommended to give RCC in severe anemia.

Q. 20: After three days following laparotomy patient developed swinging rise of
temperature. Mention four possibilities.
Ans: Possibilities: 1. Intra abdominal abscess.
2. Wound abscess
3. Liver abscess
4. Lung absecess.

Q. 21: Mention four organs where transplantation is currently possible.

Ans: 1. Skin, 2. Cornea 3. Kidney 4. Liver.

Q. 22: At accident and Emergency dept. a patient came with stab injury of abdomen.
what will you do in next 5 minutes?
Ans: 1. Cherk the hemodynamic status of patient.
2. Start resuscitation, Unresponsive patient is sent for laparotomy.
3. Observe the site of stab wound.
(i) Anterior abdominal stab wound.
(ii) Thoracoabdominal stab wound- Chance of diaphragm injury.
(iii) Right upper quadrant stab wound- Chance of liver injury.
(iv) Back and flank stab wound-Chance of injury to color, duodenum or urinary tract.
4. Explore the wound under local anesthesia to see if fascia is penetrated.
* If not, then the wound did not enter abdominal cavity.
* If violated, then do a Diagnostic pertinent Lavage (DPL).
Send patient to some investigation after making stable.
CXR
Plain AXR
For (iii) do CT scan of abdomen
For (iv) do triple contrst CT scan of abdomen.

Q. 23: What are your options it you fail to set IV cannula at dorsum on both hands of
a child?
Ans: Options: 1. Long Saphenous vien, at the ankle.
2. Femoral vein
3. External jugular vein.
4. Scalp vein (in infant)
5. Intra osseous infusion (in children <6 years age)
6. Central venous access (by expert).

Q. 24: Following intravenous convolution, after 3 days the hand is painful swollen,
oedematous. How do you explain it? How will you manage it.
Ans: Phlebitis/Thrombophlebitis.
Explanation: If an IV cannula i-f kept for more than 72 hours then there is high risk of
cannula related infection.
Management: Remove chanula and send it for C/S
Re-cannulation of other hand

84
Antibiotic.

Q. 25: A patient of carcinoma stomach has Hb only 5 gm% How much blood has to
be transfused o raise the Hb to 10 gm%?
Ans 5 Unit.

Q. 26: After stating blood transfusion patient complaints of feeling of cold and start
shivering. Explain cause of chill and rigor. What will you do?
Ans: Cause: Febrile reaction
Presence of HLA antibody (in recipient) bind with HLA on
WBC of donr WBC release pyrogenic substances to cause fever. But, we should be
careful, because there is chill and rigger another life threatening cause may be
bacterial contamination of transfused blood. Check pulse and BP and exclude septic
shock.

Management:
Slow the rate of transfusion
Paracetamol.
Reason of chill and Rigor: Rapid rising of temperature by activity of muscle produce
rigor. Cutaneous vasconstriction causes a feeling of chill.

Q. 27: One hour after starting an infusion a patient complaints of breathless and
starts congaing. What is the cause? What would you do immediately?
Ans: Cause: TRALI (transfusion related acute lung injury)
Management: Stop the transfusion.
Propped up position, 02 inhalation,
Inj. luydrocortisow.
Diuretics.
[ck ejv nqQ, infusion m Diagnosis-Plumonary oedema]

Q.28: A patient of hemophilia was given a IM injection. What will be the problem?
Ans: Hematoma formation

Q. 29: A patient has developed pain in the index finger two days after a thorm prick.
Now the index is swollen, is painful during flexion or extension.
What is the diagnosis? What is the treatment?
Ans: * Flex or tensynovitis.
Treatment: 1. Empiric IV antibiotic
2. If no improvement within 24 hours, then surgical drainage of pus.
OPERATIVE SURGERY

C. 30: A 40 years old lady needs cholecystectomy. What four systems should be
assessed pre operatively? What is your plan to exclude those.
Ans:
1. C.V.S Plan

2. Resp. System (a) History

3. Liver/Hepatobiliary system (b) Clinical exam

85
4. Blood (c) Inv-Blood, CBC, FBS, BT, CT, PT, CXR,
ECG, Liver function test, USG.

C.31: A 40 years old mate after herniosplasty under spinal anesthesia developed
retention of urine. What are the steps of management?
Ans: Urinary catheterization
Bladder retraining.
Removal of catheter.

C.32: After partial gastrectomy a patient developed fever on fifth POD What might be
the cause? How will you investigate such a case.
Ans: Causes:
Superficial and deep wound infection,
Chest infection, UTI.
Thrombophlebitis, Infection of cannula,
Intra abdominal abscess
Investigations: CBC, Blood culture
Urine R/M/E and C/S
Sputum C/S
CXR.

C. 33: A 75 year male under went TURP and developed retention of urine after 6
hours. Mention four causes.
Ans: 1. Blood clot obstructing the catheter.
2.
3.
4.

C.34: How will you infiltrate local anesthesia in case of circumcision? In what
concentration and how much?
Ans: Local anesthesia is infiltrated subcutaneously at the proximal portion of penis.
The needle is introduced at midline of dorsum of pesis and the anesthetic is
infiltrated on both sides.
Concentration: Plain Lidocaine/Adrenaline Free Lidocaine 1% solution.
Maximum dose: 3 mL/kg So, if a boy of 10 kg has come for circumcision, maximum
30 mL can be used.

C.35: Mention four indications for transferring the patient to ICU after surgery.
Ans: Indications of ICU: (Both in surgery and medical practice)
1. Patient requires endotracheal intubation and invasive mechanical ventilatory
support. (eg. Neurosurgery case)
2. Patient requiring support of two or more organ systems.
3. Patient who already had a chronic improvement of one/more system, now require
acute support of another organ system.
4. Patient who require frequent, detailed observation or monitoring (eg: after CABG,
Phaeochrormocytoma operation).

C.36: A patient had gastrojejunostomy. Two hours post operatively there was

86
profuse blood in the nasogastric tube. What parameters would you assess before
reporting to concerned surgeon?
Ans: Pulse, BP, Capillary refill, Respiratory rate, Temperature.
Amount of bleeding, Ongoing bleeding, Urine output.
C.37: Clear the airway immediately: There may be blood or vomit. The patient is
placed in recovery position. If immediate relief is not achieved, then airway is cleared
with suction, or with gloved finger. Then airway is protected with a oropharyngeal
tube. Then O2 supply is given.

C.38: A patient has developed retention of urine post operatively. Although he was
catheterized before. What may be the cause? What you will do?
Ans: Cause: The catheter is blocked, usually by blood clot or by stone, or by
aggregation of sloughed epithelium or edema of bladder neck may have compressed
the catheter.
Treatment: Flush the catheter with normal saline. This usually removes the
obstruction. Otherwise, the catheter should be changed.
GIT

Q.39: A 38 years old man presented with pain and swelling on one side of anal canal.
He also has fever. What is your probable diagnosis? What micro Organism may be
involved?

Ans: * Perianal abscess.

* Organism: Staph aureous, E Coli, Proteus, Streptococcus etc.

Q. 40: A 5 years old patient presented with a lump in epigastric region and vomiting
after meals for last 3 months. What is your probable diagnosis? What investigations
do you suggest?
Ans: * Gastric Carcinoma with gastric outlet obstruction.
Inv: Upper GI endoscopy, biopsy and histopathology
USG of whole abdomen.
CBC

Q. 41: A 45 years old patient complaints of vomiting for last 6 months. Vomitus
contain undigested food particles. He also gives history of induced vomiting as it
relieves him of his discomfort. What are two most possible diagnosis? How can you
confirm diagnosis?
Ans: Q/D: Chronic duodental ulcer with ps with GOO.
Gastric Cancer with GOO.
Confirm: Upper G1 endoscopy, biopsy and histopathology

Q. 42: A young female presents with sever epigastric pain and vomiting. She gives
history of some drugs for headache. On the previous day. What may be the cause of
pain? What should be your advice? What other drugs may cause such problem?
Ans: Cause Gastrictis/Drug induced gastritis/Erosion.
Advice:
Tab Ranitidine 150 mg, 12 hourly for 6 weeks.
In future, the following rule should be followed for taking any painkiller- Take a
raintidine hour before meal take pain killer of the end of the meal.

87
Drugs- NSAID, Steroid, Iron.

Q. 43: A midlle aged man, diabetic for 7 years complaints of pian in epigastrium off
and on which passes to the back and is relieved when he becomes prone. waht is he
cause of pain? What investigations do you suggest?
Ans: Chronic pancreatitis.
Inv: Plain AXR (CT scan is better)
ERCP
Endoscopic Ultra Sound (EUS)

c44. how can you differentiate gastric outlet obstrcution due to pyloric stenosis and
ca stomach? What are the electrotlytes, abnormalities in a case of long standing
obstrcution?

Ans:
Pyloric sTenosis Ca-stomach

1. Long H/O Peptic ulcer pain patient has 1. Short H/O abdominal pain or no pain
appetite. at all. Patients Anorexic.

2. On exam, patient may be anemic 2. On exam, patient is anemic, usually a

lump in epigastrium.
but no lump in epigastrium.
3. USG shows a tumor arising from
3. USG shows increased thickness of
stomach.
first part of duodenum.
4. Endoscopic biopsy show carcinoma.
4. Endoscopy shows norrowing of first
part of doudenum.

* Hyponatremia, Hypokalemia, Hypochloremia, Alkalosis.

C.45: A patient has an opening in left lower quadrants of abdomen crated of

abdominal trauma. HOw would you identify whether this is anitcosting 02 colostomy:
Ans: Ileostomy colostomy

1. Site 1. Right lower quadrant 1. Left lower quadrant

2. Nearbyskin 2. May be excoriated 2. Normal

3. Stoma 3. spout, Narrower 3. Flushed wider

4. Effluent 4. Liquid 4. Semisolid.

C. 46: A patient has a stoma in left lower quadrant with only one opening. What
operation was done?
Ans: Possible operations: 1. Hartmanns procedure.
2. Posterior resection of rectal carcinoma. (Abdominal perineal resection)

88
Q. 47: During appendicetomy if you find appendix is normal looking, what four other
structure you have to search for?
Ans: 1. Terminal ileum.
2. Search for Meckels diverticulum.
3. Cecum
4. In female, right ovary and fallopian tube.

Q. 48: A patient complaints of constipation for years. Mention four surgical problems
he might develop as a consequence of constipation.
Ans:
1. Haemorrhoid
2. Anal fissure
3. Acute diverticulitis.
4. Large bowel obstruction due to fecal impaction.

C. 49: A middle aged female allowed to brust her perineal abscess, spontaneously.
What might be the consequences?
Ans: Fistula in ano.

C. 50: A middle aged man with performation of duodenum did not agree to
operation. Five days after be developed fever and abdominal distension. What are
the causes? Mention four sites where yhou might get pus at operation?
Ans: Causes: 1. Generalized peritonitis.
2. Intraperitoneal abscess.
3. Peritonitis with paralytic ileus.
Pus site:
1. Right subphrenic space
2. Righ subhepatic space
3. Left subphrenic space
4. Left subhepatic space/Lesser sac.

C. 51: There are continous foul smelling discharge from umbilicus. What are the
causes:
Ans:
1. Patent vitellointestinal duct.
2. Patent urachus.
3. Umbilical fistula.

C: 52: A 35 years old man complaints of a swelling in upper abdomen. On

examination, there is a small 1.5 cm rounded swelling in midline that protrudes on
coughing What is the diagnosis?
Ans: Epigastric hernia.

CARDIO THORACIC SURGERY

C. 53: A patient had a stab injury on the left side of chest Examinaiton revealed air
comes out on coughing. Patient is gradually becoming breathless. What is your
interpretation? What will you do immediately?

89
Ans: Open pneumothorax
Treatment: Cover the wound with three sided bandage (keep one side open)
Take the patient to OT. DO tube thoracostomy
Clsoe the wound.

C. 54: A patient was struck by moving vehicle. He developed pain chest and was
breathless. A segment of chest was moving in and out with inspiration and
expiration. Expalin the pattern of chest wall movement.
Paradoxical movement.

Q. 55: A Patient developed hemothroax due to injury. A chest drain tube was
introduced. How do you monitor the patient clinically? How would you assess
whether chest drain is functioning
Ans: Monitor: Vital signs, Pulse, BP, Respiratory rate , Temperature chest exam,
Drain: Measure volume of drained blood every hour.
Drain in functioning: If fluid in the two moves with respiration.

Q. 56: A middle aged man was been admitted for pain in left leg for 2 years and
blackening of great toe. what is probable cause? How do you confirm clinically?
Ans: Cause: Arterial stenosis and occlusion.
Clincial confirmation: Absent pulsation of dorsalis pedis artery.
Coldness. Numbness , Paresthenia, in adjacent.
area of grangrene. Buergers test positive
Dry gangrene itself is a sign.

Q. 57 A patient complains of pain in lower limb specially in the evening. He also

complaints of swelling of leg and foot that disappears in the morning. What is the
probable cause?
Ans: Varicose Vein

C. 58: After road traffic accident a victim has developed a wound in his chest through
which large amount of air is pasing in and out and lungs can be seen. What will you
do immediately?
Ans: See cons of C. 53.

C. 59: A check X ray after introduction of a chest drain show the tube is bent and
almost close. What you will do?
Ans: I will replace the tube under local anesthesia then another check X-ray.
Hepatobilary System and Pancreas

C. 60: See. Q. and Ans. of C. 43

C.61: A young female complaints of upper abdominal pain. USG. revealed a single
stone is gall bladder. On endoscopic examination she also has duodenal ulcer. How
you will treat the case.
Ans: 1. Medical management of doudenal ulcer.
Triple therapy than omeprazole of 4 weeks
[ Even if it is cholecystitis, conservative treatment is indicated]
2.When Du is healed, reassessement is done and if indicated cholecystecoty is done

90
C. 62: A patient aged 30 years, presented with M/O upper abdominal pain fever and
vomiting for 4 days. On examationation she was a mass in right upper abdomen,
tender and moves with respiration. What is your diagnosis? How do you monage
this patient?
Ans: Liver abscess.
Management:
1. USG guided aspiration, mircoscopy and C/S.
2. If USG shows single abscess and aspirate in like anchovy sauce start
Metronidazole 750mg tds.
3. If USG shows multiple abscess start ceftriaxone+Gentamicin.

C. 63: A patient of obstrcutive jaundice has LFT report as follows s. biliraub in 7.5
mmol/L, SGOT 35 IU, SGPT 40 IU. ALP 578 unit.
Expalin each of them.
S. blirauin is increased because bilirubin excretion is obstrcuted. SGOT and SGPT are
normal, because hepatocytes are not affected.
ALP is increased because of injury to lining epithelium of biliary tract.

C. 64: At USG report, it was found that there is a worm is CBD. What is that worm?
What will be the after effect if not removed.
* Round worm.
* If not removed Obstructive Jaundice Acute pancreatitis.

S.65: A 34 years old male jaundice for about two months in the hospital 3 days after
admission, it was diagnosed to be obstructive jaundice due to stone. How will you
prepare this patient for surgery?
Ans See ans. of Q. 218.

C.66: What are the differentiating points between empyema is mucocele of Gall
bladder
Ans: See ans. of Q. 215.
C. 67: A patient of pancreatitis discharged three days after adminssion as pain
subsided weeks after that the patient was admitted with a tense swelling in
epiyastrium. what is the most probable cause? What imaging you will advice?
Ans: Pancreatic pseudocyst
USG of upper bdomen.

C. 68: A known case of the thallasemia has splenomegaly and gall stones. What is
the relationship between two?
Ans: Thalassemia: Excesshemolysis sptenomegaly for he molysis purpose.
Pipment stone in G.B. gue to- Excess bilirubin due to excess hemolysis.

Q. 69: A pateind had spime tomy for truma. What prophylaiss will he need.
Ans: Vaccination for ......Menigococcus. Haemophilus, Injucery
Phemoxymethylpesicillan 250 mg bd. for long term.

Q. 70: A patient e obstructive jaudice had exploartion of CBD. CBD was closed
keeping a t tute. Post operatively no bile was collected in the drain bag. What are the

91
possible causes.
Ans: CAuses: 1. Accidental ligation of CBD, above T-tube.
2. Biliary leak, the bile in leading from above t-tube.
3. Unrecognised remaining stone blocked the T-tube.
4. T-tube is displaced.

Q. 71: A patient had a T-tube drain after exploration of CBD. Next morning you find
that the tube has been clamped by someone. What will you do immediately? What
will you check in this patient?
1. Will remove the clamp
I will check jaundice, signess of peritonitis.

Q. 72: You have been instructed to remove a T-tube. As you by to pull the tube you
find that it is not coming out. What will you do?
Ans: T tube needs to be removed by laparotomy.

UROLOGY

q. 73: Father of a boy of three months requestsyou perform circumcison of the boy.
you find that external genitalia is not well developed what will do?
I will dicuss this with him and persuadic him that the operation should be done later.

C.74: Father of a boy of three years request to perform circumcisions of the boy.
What would you assess? What investigations will be required?
Exam: Fully clincial exam.
Specially anemia hepatosplenomegaly.
Local exam-epispadias, Hypospadias,
Local infection, Nappy rash.
Investigation-CBC, BT, CT, Blood grouping

C. 75: During circumcision you find that prepuce in not retracting, What will you do?
Ans: I will introduce a probe between prepuce and glans and divide it over the probe.
Then it will be easy to separate it from glans.

C. 76: A 7 year old boy developed painful tender scrotum for 4 hours. Mention 4
possibilities.
Ans:
1. Torsion of testis.
2. Torsion of testicular appendiages.
3. Acute epidiadymo or chitis
4. Scrotal cellulitis.

C. 77: A young man complains of excruciating pain in left loin for two hours. What in
the possiblity? How you will confirm the diagnosis?
Ans: * Ureteric stone
Confirmatory: USG of urinary treat.

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C. 78: A patient of 12 years presented with a painless swelling is left loing. The
swelling sometimes become soft and impalpable. What in your diagnosis?
Ans: Intermittent hydronephrosis of left kidney. (But it is painful) .

.Q 79: 40 years male presents with hematuria after taking some drugs. Mention
three causes.

Ans: * True hematuria-Anti coagulant (Warfarin, Dicoumarol)

* False hematuria Phenindione, Phenazopynidine,
Nitrofurantion.

Q. 80. A patient had urethral catheter during a prolonged operation. Three days after ,
patient compliants of burning pain in the urethra and discharge. What in the cause?
What wuld you do?
Ans: Urethritis.
Treatment: 1. Send discharge for C/S.
3. Start broad sprectrum antibiotic with anti psendomonal activity.

Q. 81: A patient admitted with acute urnary retention due to BEP. Patient refuses
operation. what are the consequencess of untreated BHP?
Ans: See ans. of Q. 73.

PAEDIATRIC SURGERY

C. 82: A 7 years boy underwent circumcision four hours earlier developed bleeding.
Mention four causes. Waht you will do immediately?
Ans: Causes 1. Dislodgement of a clot.
2. Slipping of blood vessel under suture.
3. Vosodilation
4. Trauma.
Management: See ans. of Q. 59.

C. 83: A 7 months baby developed pain,k vomiting, abdominal distension and attered
coloured stool. What is your first suspicion. What will be your probable finding in
abdomen?
Ans: * Intussesception
Sign of Dance.

C: 84: A child of 2 years just swallowed a two take con. Her parent warried. What will
you do?
Ans: Check the airway and breathing
If the child is stable It has gone into oesophagus problem
If breathing problem- It has gone into trachea.
If stable, we can do a X-ray of neck AP and Lateral view. then take measure
(bronchoscopy or upper GI endosocopy).
In emergency situation bronchoscopy and removal of the coin.

C. 85: Mother of a 8 years boy noticed two ascaris came with vomiting yesterday.

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She is warried. Explain it consequences.
Ans: Severe ascairos may result in-
Intusssessption: Intestinal obstrcution, obstrcutive janudice, Pancrealitis,
Malnutrition, Appendicitis.

Ans: 86: A boy of 6 years presented with a painful swelling in the upper part of neck.
He gives a history of pain during swelling 5-6 days back. On examination there is a
tender mbile swelling along anterior border of sternoclidomostoid above the level of
hyoid bone. What is the probable swelling? What is the treatment

Q. 86: A bag of 6 years presented with a painful swelling in the upper part of neck.
He gives a history of pain during swealliwing 5-6 days back. On examination there is
a tender mobile sweling along anterior border of sternoceidomastoid above the level
of hyoid bone. What is the probable swelling? What is the treatment?
Ans: Probable swelling: Lymph node.
Treatment: As treatment of sore throat.
paracetumol.
Amoxiycillin.

C. 87: A young patient of 5 years has been admitted for intestinal obstrcution. During
operation about 2 literes of small gut fluid content was removed after anterotomy.
What will be the appropriate formulation of flid for such a case?
Ans: Appropriate for mulation: Cholera Saline.
C. 88: What will be the rate of IV fluid administra if you want 3 liters of fluid to be
infused in 24 hour.
Ans: There are two easy formula for calculation.
(a) This formula is applicable for 24 hour total time.
(Number of drops per minute)= (Volume in Litre that we want to infuse in 24
hour)11
eg: No. of drops/min=311
=33
(a) This formula is for caluclation for any time period.
Volume in mL
(b) Number of drips per minute=
4 (hour)
3000
eg: No. of drops/min= 31 . 25
4 24
In practice, usually 30 drops/min is infused for 3L/24 hour.

C. 89: A baby aed 6 months has a swelling in the check the appeared soon after
bisth. This is red and can be compressed to some extent. What is your diagnosis?
Ans: Haemangioma.

C: 90: A boy of 6 years has a swelling in the neck since birth. The swelling is soft and
non-tender. What is your diagnosis?
Ans: Cystic hygroma.

C. 91: A 3 year old child cannot protrude tendgue and cannot speak clearly. What is
your diagnosis?

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Ans: Ankyloglossia (Gongue tie)

C. 92: A boy was brought to you by his parents as the boy has both his feet bent
inwards. What is the condition? What can be done for the boy?
Ans: Talipes equinovarus.
Treatment:
1. Trial of correction by orthoses.
2. Reconstructive surgery.

C. 93: A girl of 3 year has two fingers of left hand joined from birth. What will you
suggest.
Ans: Separation of digits with/without skin grafting for fluncitonal or cosmetic
purpose.

C.94: A boy of two years preented with repeated vomiting after meals. What may be
the diagnosis? What clincial sign will support your diagnosis?
Ans: ?? 2 year bv nq 2 week nj ejZvg 1HPS.

C.95: A 5 year old male child has a small swelling in front of neck above the hyoid
bone. This moves with deglution. What is yhour diagnocis? What else you would look
for in this patient?
Ans: Thyroglossal cyst.
I want to look if the swelling moves with tongue protrvesion.

NEUROSURGERY

C. 96: A patient had a accident. You are suspecting cervical spine injury. How will you
take case of cervical spine.
Ans: Immobilize the cavical spine with a hard collar.
If unavailable, a hard boned is placed behind (from head to thorax), two saline bangs
are placed on each side of neck and tied around using a cloth.

C. 97: A patient of car accident has continous leakage of CSF. How do you explain
this situation?
Ans: CSF leak due to dura injury usually in case of deprensed skill valut H or skill
base H.
C. 98: A patient of head injury has bleeding from right eaz. What does it indicate?
Ans: Skill base fracture with perforation of right tympania memberane.

C. 99: A Victim of RTA cannon move lower limbs and also failed to pass urine. On
examination the patient had no sensation below umbilicus. What is the cause? What
is the level of lesion?
Ans: Transection of spinal cord at the level of T10 spinal segment, corretponding to T7
vertebra.

C. 100: A young man was admitted with head injury and was consicious. 2 hours
after admission patient has become drowsy and feeling weakness of right side of

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body. What is the probable cause?
Ans: Extra dural heamtoma on left side.

C. 101: A neonate has been admitted for swelling on the back of head. This is soft
and bulges when baby cries. What is your diagnosis? What you must not do?
Ans: Meningocele/Meningomyelocele.
I must not injuree the swelling. So,avoid palpation.

Q. 102: A small child has been amitted as is head was growing larger than his age.
What is the diagnosis/ What is the treatment.
Ans: Hydrocephalus.
Treatment
1. Ventriculperitoneal shurt
2. Endoscopic 3rd ventriculostomy.

Q. 103: A boy of two years has been admitted because he can not stand. On
examination there is a swelling on the back in the midline which is soft. What is your
diagnosis?
Ans: Meningmyelocele. e paraplegia.
Trauma and Orthopaedies

C. 104: A patient, 23 years old, male attends emergency department following a

tumuma to right hand at his home. He is holding his hand down with other hand and
bleeding profusely. How would you manage this patient?
Ans:
1. Put a tourniquet over right arm.
2. Wash the wound and debride
3. Release the tourniquet in every 15 min for 1 min
4. Identify bleeding artery/vein
5. Repair the artery/vein and repair other injury
6. Close the wound.
7. Check circulatory status and manage accordingly.
C: 105 A boy of 15 attends emergency room after a deep cut injury of right forearm
and cannot move the finger. What is your diagnosis? What is the treatment if the
patient comes within 4 hours.
Ans: Incised wound in right fore arm e injury to flexor digitorum muscle.
Treatment: If patient comes early the wound is debrided and primary repair is done.

Q. 106: A 27 years old housewife had a cut injury of left 3 days back by a kitchen
knife. She managed hereself by putting an aintement and deressing by a peice of
clean cloth. Now she has developed pain and swelling of chole of index and cannot
move the finger. What is your diagnosis? Now could you prevent this?
Ans: Flexor tenosynovitis
Prevention: By proper wound toileting and dressing by sterile bandage. Prphyaxis
amitbiotic

Q. 107: A 10 years old boy got a small cut injury in the leg 3 days back which he
ignored. Now he has developed pain in left leg and the area is red and swollen and is
increasing what is your diagnosis?

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* Cellulitis.

Q. 108: A patient after road traffic accident with open wound came to you. HOw will
you take care regarding telanus.
Ans:
1. Wound toileting and debridement.
2. TIg injeciton
3. Penicillin
Q. 109: A patient after RTA e oepn wound came to you. Flow will you take care
regarding wound infection:
Ans: See ans of C: 108.

C.110: A 10 year old boy fell from a tree 30feet heigh What are the possible sites of
fracture?
Ans: According to site of impact the following bomes may fracture- Calcaneus,
Tibia-Fibula, Femur, Scaphoid, Radio-ulna, Humerus, Clavicle.

C.111: What do you mean by the term AMPLE? Why history of meal is important in
case of road traffic accident?
Ans: AMPLE is a mnemonic to remember importnat his take during recondary
survery of trauma patient.
A-Allergy
M- Medication including telanus status.
P- Past medical history
L- Last meal.
E- Events of incident.
Last meal is iportant to assess riok of aspiration of gastric content and for giving
G/A.

C.112: A 70 years old lady suddently fall in her rosman developed fracture neck of
femur. What is the pathogness.
Ans: 70 years old lady definitely have osteoporosis.
Her bones one weak due to osteoporosis In this setting, even her own weight may
fracture the bone. It is well said that Scuh a lady actually gets facture then fall.

Q. 113: A student had a gunshot injury and some pallets are in his thigh. Otherwise
have is stable and okay. How will you remove the pellets?
Ans: ?? ACT scan e 3D reconstrcution may guide the surgeron. (I dont know) Do I
need to remove?

Q. 114: After 3 days following road traffic accident a patient developed hematuria.
Mention three possibilities.
Ans: 1. Kidney injury (A clot becoming dislodged after 3 days)
2. Fracture of pubic rami, which has now injured bladder.
3. Hemorrhageic cystitis.

Q. 115: A young man had a stab injury and was admitted with protruding lonps of
bowel. What will you do with gut loops?
Ans: If the gut lsop is viable, I will reposition them into abdomen, after washing with

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warm saline. Then check the abdomen for other injuries. Then peritional toileting.
Then close the abdomen in layers.

Q.116: A young man had complee severed lower limb above knee. What can be
done? What will you do if you are helf an hour away from a tertiary hospital?
Ans: 1. Stop the bleeding by a tourniquet take him to hospital.
2. If this is a erush injury, the limb is dead loss.
3. If the severed limb is intact, it may be taken to hospital along with patient.
(i) Textbook says, it may be possible to replant a limb within 4 hours (well, it was
done index fingure)
(ii) Even if it is not possible, then some skin or myocutaneous flaps can be use.
My opnion is to left the dead loss limb:
A replantation surgery is a dream.
It will only cause reperfusion injury
Also, a severed limb is contaminated already.
You better rescue the patient in hurry.
If you dont want him to hury.
What can be done: Resuscitate, Wound deleridement, Hoemostaiss, Shape the
wound so that an artificia limb can be worm later.

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