Surgery Answers Review – 2024

01. Regarding Barret’s oesophagus,

A. Achalasia cardia is a predisposing factor
B. Barium swallow shows bird’s beak appearance
C. Histology shows intesAnal metaplasia
D. It is a malignant condiAon of lower oesophagus
E. Radio frequency ablaAon is a treatment opAon

Answer - F F T F F
A. Barret esophagus is a metaplasAc change in the lining mucosa of the esophagus in response to
chronic gastroesophageal reflux (IntesAnal metaplasia). The risk of transformaAon to
adenocarcinoma is about 0.5% per paAent per year.
Achalasia cardia is a predisposing factor to squamous cell carcinoma of the esophagus.
B. Barium swallow shows bird’s peak appearance in achalasia cardia because of abnormal contracAon
in the esophagial body and a tapering stricture in the distal esophagus.
D. PaAents who are found to have BarreQ’s esophagus undergo regular surveillance endoscopy with
mulAple biopsies at 2 years intervals to idenAfy dysplasia or in situ cancer. The relaAve risk of cancer
rises with increasing length of BarreQ’s segment.
When BarreQ oesophagus is idenAfied treatment is for underlying GORD with PPI + anAreflux
surgery.
E. Treatment of established high-grade dysplasia includes endoluminal therapy (endoscopic mucosal
resecAon, radiofrequency ablaAon or photodynamic therapy) or an oesophagogastrectomy.

02. Treatment modaliAes of achalasia cardia,

A. Botulinum toxin injecBon
B. Heller's myotomy
C. Nissen fundoplicaBon
D. Oesophageal dilataBon
E. Peroral endoscopic myotomy
TTFTT
Achalasia cardia
• It is due to impaired peristalsis in the esophageal body and increased lower esophageal
• sphincter tone May have recurrent regurgitaAon, retro sternal discomfort, halitosis, recurrent
aspiraAon with cough.
. Gold standard Ix - esophageal manometry which will show impaired peristalsis and Aght sphincter. If
that is not available barium swallow is done. The characterisAc finding is a bird’s beak appearance.
In CA esophagus rat tail appearance is seen.
Mx opAons of achalasia
1. InjecAon of botulinum toxin
2. DilataAon of the sphincter
3. Heller’s cardiomyotomy
4. POEM(Peroral endoscopic myotomy) – a Newer technique for the management of achalasia it is
the endoscopic equivalent for surgical mayotomy
Nissen fundoplicaAon is used to treat for GORD when symptoms resistant to medical Mx

03. Regarding diverBcular disease of the colon,

A. Majority are asymptomaBc
B. Predisposes to colonic cancer
C. Causes colo-vesical fistula
D. Associated with massive PR bleeding
E. Complicated with colonic strictures
TFTTT
DiverAcular disease –
When a paAent present with fever, abdominal pain and vomiAng inflammatory pathologies affecAng
the gut always consider this.
Since there is a mass in the lea iliac fossa the affected part is the sigmoid colon area.
– Usually tumors in the lea side tend to grow into the lumen and can obstruct. Rectal tumors are
usually non obstrucAve. UlceraAve coliAs always affects the rectum and the paAent should have
blood and mucous diarrhea, tenesmus, urgency and frequency if it was the diagnosis. - On the other
hand, diverAcular disease commonly affects the elderly and commonly involves the sigmoid colon.
- With diverAculiAs the paAent can develop fever and abdominal pain.
- ConsApaAon is a risk factor for diverAcular disease. - That might be the reason there is a past history
of altered bowel habits.
- With diverAculiAs there may be localized abscess formaAon.
- On the long run diverAcular disease can result in strictures, adhesions, perforaAons and fistula
formaAon.
- It can present with PR bleeding and can someAmes give rise to massive bleeding
- It never affects the rectum.
- In the Asian populaAon it commonly affects the right side and the caecum.
- Gold standard for diagnosis is the colonoscopy. - In the acute sedng if a colonoscopy is done it may
result in perforaAon. Usually done 6 weeks later. - So in the acute sedng with inflammaAon CECT is
the best.
- Acute diverAculiAs is managed with I.V. fluids, analgaesics, anAbioAcs etc. - Chronic disease is
managed with high fiber diet, fluids and laxaAves or stool soaeners.
- DiverAcular disease will not increase malignancy risk.

04. Regarding large bowel obstrucAon,

A. Erect abdominal X-ray is used to detect the site of obstrucAon -F

Erect abdominal films are no longer rouAnely obtained and the radiological diagnosis is based on a
supine abdominal film.(ref-Bailey &love)
In erect X-ray it will show presence of air fluid levels suggesAng an intesAnal obstrucAon but cannot
be used to detect the site of obstrucAon.
Whereas in supine X-ray you could see dilated bowel loops proximal to the site of obstrucAon
B. Barium enema is contraindicated -F
A barium enema which is inserted through rectum is not contraindicated in case of large bowel
obstrucAon except when perforaAon is a possibility.
A barium follow-through(barium swallow) is contraindicated in the presence of acute obstrucAon and
may be life-threatening.

C. Tenderness in the right iliac fossa is suggesAve of impending perforaAon - T

Localised tenderness indicates impending or established ischaemia.In cases of large bowel
obstrucAon, it is important to elicit these findings in the right iliac fossa as the caecum is most
vulnerable to ischaemia & perforaAon (Bailey& love)

D. Colonic stenAng can be used to relieve obstrucAon -T

Decompression of the obstructed lea colon using endoscopically placed stents oaen as a bridge to
surgery has been widely reported.(Bailey & love)

E. Hartmann’s procedure can be used in treatment-T

A Hartmann’s procedure involves colectomy with end colostomy formaAon. Typically performed as
an emergency procedure in case of bowel obstrucAon
In a Hartmann’s procedure, a descending colon end colostomy is formed and the residual rectal
stump is closed

05. Treatment of the following condiAons is facilitated by a defuncAoning stoma,

A. 3rd degree vaginal tear
B. High fistula-in-ano
C. Prolapsed thrombosed haemorrhoids
D. Grade 4 sacral pressure sore
E. Perineal necroAsing fasciiAs

FFFTT
A. 3rd degree- injury to perineum involving the anal sphincter complex.
IIIa-<50% of external anal sphincter torn.
IIIb- >50% of external anal sphincter torn.
IIIc- both external and internal sphincters torn
In situaAons in which there is a discrete disrupAon of the sphincters, the ends of the divided muscle
are found and reunited by a double overlap repair. It is performed under regional or general
anaesthesia.

B. Fistula tract is idenAfied by probing and, if low, laid open under GA, so that it heals by
granulaAon Assue from the base. With high fistulae or pelvirectal fistulae there is a danger to
puborectalis when opening the tract. InconAnence may result. Therefore, first line treatment for
high/complex fistula is the placement of a seton in the tract. This prevents the tract closing and
further perianal sepsis recurring. There are many ways to deal with high fistulae including plugs, glue
and anal advancement flaps.

C. StrangulaAon, thrombosis and gangrene treatment

If adequate anAbioAc cover is given from the start, immediate surgery can be done. But there is a risk
of postoperaAve stenosis. Therefore, can approach conservaAvely and later go for
haemorrhoidectomy if necessary. ConservaAve measures such as pain relief, bed rest with frequent
hot baths and warm or cold saline compresses with firm pressure usually cause the pile mass to
shrink considerably in 3-4 days.

1st /2nd degree piles- symptomaAc management. If symptoms are not improved by conservaAve
measures, submucosal injecAon of 5% phenol in arachis oil or almond oil can be used. Procedure is
repeated for each pile and paAent is reassed aaer 8 weeks. If necessary, injecAons are repeated. For
more bulky piles, banding can be done. Haemorrhoidectomy is done for the 2nd degree piles which
are not cured by non-operaAve treatments.
3rd /4th degree piles- haemorrhoidectomy
Transanal haemorrhoidal dearterializaAon (THD) or haemorrhoid artery ligate operaAon (HALO) is
done for 2nd and 3rd degree haemoorrhoids.

D. Staging of pressure sores.

I – Non blanchable erythema without a breach in the epidermis.
II- ParAal thickness skin loss involving the epidermis and dermis.
III – Full thickness skin loss extending into the subcutaneous Assue, but not through underlying fascia.
IV- Full thickness skin loss through fascia with extensive Assue destrucAon, maybe involving muscle,
bone, tendon or joint.

Primary treatment involves relieving pressure, opAmising nutriAon, correcAng anaemia, prevenAng
infecAon and dressing.
Surgical management of pressure sores follows the same principles involved in acute wound
treatment. PreoperaAve management of the pressure sore involves adequate debridement, and the
use of vacuum-assisted closure (VAC) may help to provide a suitable wound for surgical closure.

E. NecroAsing fasciiAs of the perineal region is known as Fournier’s gangrene. Although it can
occur in conjuncAon with sepsis of the tesAs, epididymis or perianal region, an obvious cause is
absent in over half the cases. It can arise following minor injuries or procedures in the perineal area,
such as a bruise, scratch, urethral dilataAon, injecAon of haemorrhoids or opening of a periurethral
abscess.
Treatment - This is a surgical emergency. IniAal management involves intravenous fluid resuscitaAon
and early use of broad-spectrum intravenous anAbioAcs. Urgent wide surgical excision of the dead
and infected Assue is essenAal, and the extent of the internal necrosis is typically much greater than
the external appearances suggest, such that extensive debridement is oaen necessary. Urinary and
faecal diversion may be necessary. SupporAve care is essenAal, because the paAents oaen become
severely sepAc. Early review of the wounds is helpful to confirm that all dead Assue has been
removed, and when the infecAon has been controlled, vacuum-assisted dressing is helpful, if it is
available. If the paAent survives the acute episode, skin graaing is oaen necessary.

06. Painful perianal condi ons include,

A. 2nd degree haemorrhoids
B. Acute fissure-in ano
C. Perianal abscess
D. Anal warts
E. Perianal haematoma

Answer :-
A. False - only strangulated 4th degree haemorrhoids are painful
B. True
C. True
D. True - many are asymptomaAc, but pruritus, discharge, bleeding and pain are usual presenAng
complains of anal warts
E. True - acute pain with straining + lump at anus

Anal condiAons :-
Lump at anus - haemorrhoids, rectal prolapse
Pain at anus - perianal abscess, fissure in ano, pilonidal sinus
Discharge - fistula in ano

07. Causes for high swinging fever, right upper quadrant pain and tenderness include,
A. Biliary colic
B. Acute cholangiAs
C. Liver abscess
D. Mucocele of the gall bladder
E. Right renal abscess
F T T F ?T
Biliary colic - It is produced by impacAon of a stone in the neck of the gallbladder or in the cysAc duct.
The stone may either fall back into the gallbladder or pass through the cysAc duct into the CBD.
This is described as a severe right upper quadrant pain which ebbs and flows, associated with nausea
and vomiAng. Pain may radiate to the chest. The pain is usually severe and may last for minutes or
even several hours. Jaundice may result if the stone migrates from the gallbladder and obstructs the
common bile duct.
When the symptoms do not resolve but progress to con9nued pain with fever and leukocytosis, the
diagnosis of acute cholecysAAs should be considered. Biliary colic itself is not associated with high
swinging fever.
Acute cholangiAs - The paAent presents with clinical jaundice, fever with rigors and a tender right
upper quadrant with pain (Charcot’s triad). It's a medical emergency, and delay in appropriate
treatment results in mulAorgan failure secondary to sepAcaemia.
The diagnosis is confirmed by the finding of dilated bile ducts on ultrasound, an obstruc9ve picture of
liver func9on tests and the isola9on of an organism from the blood on culture. Once the diagnosis
has been confirmed, the paAent should be commenced on a first-line broad spectrum anAbioAc and
rehydrated, and arrangements should be made for urgent endoscopic or percutaneous transhepaAc
drainage of the biliary tree.
Liver abscess - This could be a pyogenic liver abscess or an amoebic liver abscess. The paAent usually
presents with anorexia, fever with rigors and malaise, accompanied by right upper quadrant
discomfort. Tender hepatomegaly can be evident in examinaAon.
Mucocele - This may follow an aQack of biliary colic. When the stone impacts in the neck of
gallbladder and Bile started to get absorbed. But mucus secreAon conAnues.
The paAent present with previous history of biliary colic, and RUQ discomfort. Occasionally this can
be felt as a Large, tense globular mass in RUQ. This is not associated with high swinging fever.
Renal abscess - The paAent usually presents with fever, back or abdominal pain and costovertebral
tenderness. They may have no urinary symptoms or findings if the abscess does not communicate
with the collecAng system of the kidney.

8) chronic pancreaAAs is a progressive inflammatory disease in which there is irreversible destrucAon

of pancreaAc Assue.

A)T-weight loss is common because paAent does not feel like eaAng. Pain,nausea ,vomiAng also csn
cause fear of food ingesAon.

B)T -loss of exocrine funcAon leads to steatorrhoea and it cause malnutriAon & weight loss.

C)T- PancreaAc stones block the biliary ducts and causing insufficient enzyme secreAon from
pancreas.It leads to low amount of enzymes which needed A digest nutrients leading to weight loss
and malnutriAon,malabsorpAon.

D)T- chtonic pancreaAAs is one of majior risk factor for pancreaAc cancer and cancer per se cause
cancer cachexia ;which causing weight loss & wasAng.

E)T- loss of endocrine funcAon(insulin) and development of Diabete is common.

9)LactaAonal masAAs,
Occur during breasveeding, due to cracked nipple.InfecAon spread from babies' mouth ,usually
unilateral.IniAally a generalised celluliAs if lea untreated end in abscess formaAon.
A)T
B)F
Breasveeding from both breasts encouraged 2hrly,followed by emptying the breast. Breast support
garments, cold compression,analgesia for symptom relief.
C)F
Ultrasound guided aspiraAon done.It gives beQer cosmeAc outcomes, high success rate,won't hinder
breast feeding further I&d can cause non healing milk fistula.
D)F
Commonest-Staphylococcus aureus
E)T
Ab-Flucloxacilin, coamoxiclav
10) Fibroadenomas usually arise in fully developed breast between age 15-25yrs and arise from
hyperplasia of a single lobule.

A)? Has low malignant potenAal

B)F- occasionally they occur in much older women(menopaused women) size increase.....
C)T- triple assesment;Hx &Ex,Imaging,Cytology
D)T
E)T-A fibroadenoma doesn't require excision unless asdociated with suspicious cytology,It becomes
very large or paAent's desire to remove.

11)A)T
Thyroglobulin is a tumor marker produced by normal thyroid cells and most differenAatedthyroid CA.
This is an extremely accurate method of following paAents post operaAvely.
Following lobectomy the level will not be undetectable but trends can be used to monitor recurrence.
Following total thyroidectomy aim is to have an undetectable thyroglobulin.
B)T
Malignant tumors of thyroid were thought of as differenAated( papillary, follicular, hürthle cell) &
undifferenAated( anaplasAc)
The prognosis of differenAated thyroid CA is generally excellent.
C) T
Papillary CA is known for its propensity for lymph node metastasis. It is common in younger paAents,
in whom they do not affect the otherwise excellent survival. Usually there is no blood spread.
D)F
papillary CA is confirmed with psammoma bodies and Orphan Annie nuclei.
E)T
When medullary CA is diagnosed, staging of the neck and chest should be performed. If the disease
confined to the thyroid, total thyroidectomy to remove all the C cells. In addiAon, elecAve dissecAon
of the central neck nodes is performed to opAmize the chance of cure.
It is not TSH dependent, so no use of radiotherapy.

12)A)F
Graves' disease, a diffuse vascular goitre appearing at the same Ame as hyperthyroidism.
B)T
The usual cause of thyroid eye disease is Graves' disease.Thyroid eye disease causes inflammaAon of
the eyes and the Assues around the eyes, oaen results in chemosis.
C)F
Graves' disease is an autoimmune process. Serum IgG anAbodies bind to TSH receptors in the thyroid,
sAmulaAng thyroid hormone producAon that is, they behave like TSH. These TSH receptor
anAbodies(TSHR-Ab) are specific for Graves' disease.
D)F
E)T
Toxic mulAnodular goitre- drugs alone will never result in complete remission over a long period of
Ame. Always need total thyroidectomy or Radio iodine therapy if small goitre.
In Graves' iniAal treatment with carbimazole should be given for 18-24m. Then once the paAent is
euthyroid can stop and monitor.
If recurs need to give radioiodine with anAthyroid drugs. If sAll persistent need thyroidectomy.
13) I° for CT within 1hr,
GCS <13 at any point
GCS <15 at 2hrs
Focal neurological deficit
Suspected,open,depressed or basal skull #
>1 episode of vomiAng
Post traumaAc seizure
A)T PaAent’s gcs is 11(2+4+5),so CT indicated
B)T
C)T
D)F

14) A)F
Head to toe examinaAon to idenAfy all injuries.
Front &sides
Limbs
Complete neurological examinaAon including GCS
Log roll
PR( current ATLS guidelines - not mandatory)
B) neurogenic shock
This presents with hypotension, a normal heart rate, or bradycardia & warm peripheries.
This is due to unopposed vagal tone resulAng from cervical spine cord injury at or above the level of
sympatheAc ouvlow(T1/T5)
It should be treated with ionotropic support, and care should be taken to avoid fluid overload.
C)F
Diaphragm is supplied by phrenic nerve -C3,4,5. So hypovenAlaAon occurs above these level
D)T
spinal shock is characterized by paralysis, reduced tone and hyporeflexia. Once it has resolved the
bulbocavernous reflex returns.
E)

15. Regarding injuries to extremiAes,

A) Severed finger needs to be transported in a 0.9% saline soluAon
B) IV broad-spectrum anAbioAcs should be started as soon as possible in an open fracture
C) Supracondylar fracture with an absent radial pulse requires emergency closed reducAon
D) Gas gangrene is a complicaAon of primarily sutured farm injury
E) Palpable pedal pulse excludes compartment syndrome in a Abial shaa fracture

FTTTF

A) First Aid - Amputated Finger or Toe - Transport

Briefly rinse amputated part with water. Place amputated part in plasAc bag. Place plasAc bag
containing the part in a container of ice. Take paAent and amputated part to emergency department
immediately.
B) The use of anAbioAcs in the iniAal treatment of open fractures of the extremiAes is almost
universal in all high-income countries, where benefits are assumed to outweigh potenAal risks.

C) Neurovascular injury at the Ame of a supracondylar fracture is not uncommon. Careful aQenAon
should be paid to the neurovascular status of the limb. The white pulseless hand is a surgical
emergency and requires emergent reducAon. If the pulse does not return with reducAon, then the
vessels should be explored by appropriately trained surgeons.
The pink pulseless hand is more controversial and requires early senior decision making. If there is
saAsfactory perfusion of the limb, no suggesAon of compartment syndrome and no neurological
injury, then reducAon and stabilisaAon of the fracture is warranted and a more expectant approach
to the vascular injury can be taken. Oaen the pulse will return within 24–48 hours.

D) Gas gangrene; Caused by Clostridium perfringens. Spores are present in the soil. Thrives in
anaerobic condiAons and produces many exotoxins. Treat with radical and regular surgical excision.
Give oxygen and penicillin. Early amputaAon may be life-saving

E) Compartment syndrome is a clinical diagnosis characterized by pain out of proporAon, increasing

pain and pain on passive stretch. Paralysis, paraesthesia and pallor are late signs and pulselessness is
an extremely late sign.

16. ComplicaAons of unilateral undescended tesAs,

A) ErecAle dysfuncAon
B) InferAlity
C) Inguinal hernia
D) Malignancy
E) TesAcular torsion

FTTTT

Undescended testes can result in potenAal long-term complicaAons, such as ferAlity issues, tesAcular
cancer, tesAcular torsion, inguinal hernias, and psychological issues, if lea untreated.

17. Regarding paroAd gland,

A) Malignant neoplasms are commoner than benign ones
B) Mumps cause bilateral paroAAs
C) Calculi disease is commoner than in submandibular gland
D) Duct opens into floor of mouth
E) Pleomorphic adenomas have a risk of malignant transformaAon

FTTFT

A) 80–90% of tumors of the paroAd gland are benign, the most common being pleomorphic adenoma
B) Mumps is the most common cause of acute painful paroAd swelling and predominantly affects
children. It is spread via airborne droplets of infected saliva. The disease starts with a prodromal
period of 1–2 days, during which the paAent experiences fever, nausea and headache. This is
followed by pain and swelling in one or both paroAd glands. ParoAd pain can be very severe and
exacerbated by eaAng and drinking. Symptoms resolve within 5–10 days. The diagnosis is based on
history and clinical examinaAon; recent contact with an infected paAent with a painful paroAd
swelling is oaen sufficient to lead to a diagnosis. Atypical viral paroAAs does occur and may present
with predominantly unilateral swelling or even submandibular involvement.

C) The most common cause of obstrucAon within the submandibular gland is stone formaAon
(sialolithiasis) within the gland and its associated duct system. Eighty per cent of all salivary stones
occur in the submandibular glands because their secreAons are relaAvely viscous. Eighty per cent of
submandibular stones are radio-opaque and can be idenAfied on plain radiography.

D) The secreAons of the paroAd gland are transported to the oral cavity by the Stensen duct. It arises
from the anterior surface of the gland, traversing the masseter muscle. The duct then pierces the
buccinator, moving medially. It opens out into the oral cavity near the second upper molar.

E) Pleomorphic adenomas harbor a small risk of malignant transformaAon. The malignant potenAal is
proporAonal to the Ame the lesion is in situ (1.5% in the first five years, 9.5% aaer 15 years).

18. Regarding parathyroid adenoma,

A) Serum phosphate is low in primary hyperparathyroidism
B) Serum calcium is high in secondary hyperparathyroidism
C) Adenoma is commoner than carcinoma
D) Osteoporosis is common in primary hyperparathyroidism
E) Hungry bone syndrome is a complicaAon following removal of parathyroid adenoma

TFTFT

C) The underlying aeAology of primary hyperparathyroidism is usually a solitary parathyroid adenoma

D) Bone disease in severe primary hyperparathyroidism is described classically as osteiAs fibrosa

cysAca (OFC). Bone pain, skeletal deformiAes and pathological fractures are features of OFC. Bone
mineral density is usually extremely low in OFC, but it is reversible aaer surgical cure.

E) Hungry bone syndrome is a state of profound hypocalcemia that can persist for prolonged periods,
most notably aaer parathyroidectomy and thyroidectomy.
Hungry bone syndrome occurs in the postoperaAve period aaer parathyroidectomy for primary or
secondary hyperparathyroidism aaer total thyroidectomy for thyrotoxicosis, and it can also occur in
the case of metastaAc prostate cancer. HBS in postsurgical cases occurs aaer prolonged exposure to
parathyroid hormone (PTH) or thyrotoxicosis that leads to high bone turnover rates with net bone
resorpAon that then has a sudden marked shia towards osteoblasAc acAvity aaer the removal of the
hormone excess takes place. It can also present in men with increased osteoblasAc acAvity in
metastaAc prostate cancer, leading to increased use of mineral building blocks for excess bone
formaAon.

19. Regarding skin cancers,

A) AcAnic keratosis is premalignant
B) Basal cell cancer has a poor prognosis
C) Human papilloma virus (HPV) is an aeAological factor
D) SenAnel node biopsy is indicated in malignant melanoma
E) UV radiaAon is a risk factor

TFTTT

A) AcAnic keratoses are premalignant cutaneous lesions that may progress to squamous cell
carcinoma. These lesions commonly appear on sun-exposed areas of the skin in individuals with a
history of cumulaAve sun exposure.

B) Basal cell carcinoma is a nonmelanocyAc skin cancer that arises from basal cells (small, round cells
found in the lower layer of the epidermis). The prognosis for paAents with BCC is excellent, but if the
disease is allowed to progress, it can cause significant morbidity.

C) A high prevalence of human papillomavirus (HPV) DNA, parAcularly in squamous cell skin
carcinoma of immunosuppressed but also of immunocompetent paAents, has renewed great interest
in a possible eAologic role of HPV in nonmelanoma skin cancer.

D & E)
Malignant melanoma
l Rising incidence
l Cutaneous melanoma is caused by exposure to UVR
l GeneAc and acquired risk factors
l Superficial spreading form the most common
l Breslow thickness most important prognosAc indicator
l SenAnel node biopsy useful for staging

20. Regarding hernia management,

A) Herniotomy done in indirect inguinal hernia
B) Genitofemoral nerve damage is a complicaAon
C) Right sided sliding hernia contains caecum
D) Laparoscopic repair is contraindicated in recurrence
E) Mesh repair is done in infants
TTTFF

C) Sliding hernia is an acquired hernia due to weakening of the abdominal wall, but occurs at the
deep inguinal ring lateral to the inferior epigastric vessels. Retroperitoneal faQy Assue is pushed
downwards along the inguinal canal. As more Assue enters the hernia, peritoneum is pulled with it,
thus creaAng a sac. However, the sac has formed secondarily, disAnguishing it from a classic indirect
hernia. On the lea side, sigmoid colon may be pulled into a sliding hernia and on the right side the
caecum.

D) Laparoscopic surgery is of parAcular benefit in bilateral cases and in paAents with hernia
recurrence aaer open surgery.

E) Inguinal hernias in children

l More common in premature boys (right > lea)
l 15% bilateral
l Indirect with a patent processus vaginalis
l Groin lump that appears on straining or crying
l Incarcerated inguinal hernias can usually be reduced with gentle pressure
l In infants they can transilluminate like a hydrocoele, making the test redundant when the
disAncAon is difficult
l If reducAon is impossible emergency surgery is needed
l In infants: repaired promptly to prevent the risk of strangulaAon
l The hernial sac is isolated, ligated and divided

21. ComplicaAons of chronic suppuraAve oAAs media,

A) Facial nerve palsy
B) Ramsay Hunt syndrome
C) Intracranial abscess
D) Hearing loss
E) Maxillary sinusiAs

TFTTT

If lea untreated, chronic suppuraAve oAAs media can lead to severe complicaAons, including polyps,
sclerosis, tympanosclerosis, labyrinthiAs, epidural, subdural, or brain abscesses, and conducAve or
sensorineural hearing loss affecAng the child's performance in school.

AOM: ComplicaAons are rare, but can be categorised as: intratemporal – oAAs media with effusion,
chronic oAAs media, mastoidiAs, facial palsy and labyrinthiAs; extratemporal
extradural such as abscess; extratemporal intradural such as meningiAs, intracranial abcess and
sigmoid sinus thrombosis. The most common complicaAon is mastoidiAs because the mastoid air
cells connect freely with the middle ear space.
COM: Permenant abnormality of the tympanic membrane from previous recurrent AOM and/or
OME. It is classified as acAve (i.e. inflamaAon and pus present) or inacAve. AcAve and passive are
then further subclassified as mucosal or squamous.
22. CharacterisAc features of graves eye disease,
A. Diplopia F
B. Pterygium F
C. Lid lag F
D. Chemosis F
E. Proptosis F
Answer:
• Lid retracAon & lid lag are a result of increased catecholamines sensiAvity of elevator
palpabre superioris and occur in any form of hyperthyroidism.
• Pterygium is fleshy overgrowth of conjuncAva
• Lid lag is mostly seen in thyroid eye disease, but may also occur with cicatrical(scar Assue)
changes to eye lid or congenital ptosis.
• Chemosis is seen in conjuncAviAs, allergy, infecAon
• Proptosis is seen in thyroid eye disease as well as orbital celluliAs, neoplasms, inflammatory
condiAons
Exophthalmos and opthalmoplegia are pathognomic to thyroid eye disease . They are direct effects of
retro – orbital inflammaAon, whereas chemosis, light lag & corneal scarring are secondary to
proptosis and lack of eye cover. Eye manifestaAons may appear before or aaer the onset of
hyperthyroidism.

23. Following disease condiAons compared with image modality of choice,

A.Gallstones - x-ray F
B.Hydronephrosis.- Ultrasound scan T
C. Renal scarring - DTPA F
D.PUV - MicturaAng cystourethrogram T
E.Renal Calculi - Non- contrast CT T

Answers:
• A- Plain xray will show only 10% of gallstones( radio opaque), USS abdomen will show
intensely echo- penic foci which cast a clear acousAc shadow beyond them
• B – Hydroureter and hydronephrosis are clearly seen in USS.
• C- DMSA is used to detect renal scarring (gold standard). Also can be used to detect
ectopic kidneys and confirming non – funcAon.
DTPA is used to assess the renal blood flow and to idenAfy site of obstrucAon.
• D- MCUG to detect anatomical and funcAonal abnormaliAes of the bladder and
urethra ( gold standard for VU reflux and PU valve.
• E-Non-contrast CT is gold standard in invesAgaAng renal calculi
24. Spinal anesthesia is used for,
A. Abdominoperineal resecAon F
B. LigaAon of processes vaginalis T
C. Haemorroidectomy T
D. Varicose vein surgery T
E. Inguinal hernia repair T

Answers:
• APR is done under GA as there is a midline laparotomy scar extending
from xiphisternum to pubic symphysis.
Epidural catheter for post-op pain management.

25. AnAbioAc prophylaxis given in,

A. Right hemicolectomy T
B. Inguinal hernia mesh repair T
C. Total hip replacement T
D. Cardiac surgery T
E. Excision of breast lump T
26.Which of the following are corr aectly matched with regards to the suture removal Ame
of a healthy adult

A. Carpal tunnel surgery – 5 days F

B. Facial laceraAon - 3 days T
C. Fibroadenoma removal of breast - 7 days T
D. Midline laparatomy incision- 10 days T
E. Scalp lump excision – 5 days T

27. In obstrucAve jaundice coagulopathy is due to,

A. Abnormality in common pathway T
B. Abnormality in extrinsic pathway T
C. Abnormality in intrinsic pathway T
D. Thrombasthenia T
E. Thrombocytopenia T
Answer:
Biliary obstrucAon --- defecAve absorpAon of fat soluble vitamin – Reduced Vit K --- defecAve gamma
carboxylaAon of clodng factor 2, 7, 9,10—defecAve extrinsic pathway
Low grade DIC --- increased fibrinolysis – affects common pathway
Low grade DIC- affects- intrinsic, extrinsic and common pathways
Endotoxin induced damage to platelets – thrombasthenia
Thrombocytopenia from hyperspleenism

28. An 8 year old boy presented with joint swelling , erythema and fever. Regarding sepAc arthriAs
A. High ESR confirms the diagnosis F
B. Knee joint is the comments affected joint T
C. Staphylococcus aureus is responsible T
D. Irreversible joint destrucAon occurs T
E. Joint washout should be done T

Answers:
• A- USS guided aspiraAon of joint fluid should be done and sent for cell
counts gram stain and culture. FBC, CRP & blood culture should also be
done.
 • B- Knee joint is commonest in Children & adults, hip joint is commonest in
neonates. Haematogenous spread is commonest.
• C- Staphylococcus aureus is the commonest organism, Streptococci & E-
coli can also cause.
• D- Inadequate clearance may lead to chronic infecAon & joint destrucAon.
• E- Arthrotomy & drainage or arthroscopic drainage is a must .Medical
treatment alone is rarely indicated. IV Flucloxacillin, Gentamycin or
Cephalosporins are suitable anAbioAcs.

29) Regarding abdominal aorAc aneurysm,

A. Severe backache due to retroperitoneal bleeding
B. Anteroposterior diameter of 6cm is an indicaAon for intervenAon
C. Ischemic coliAs is a known complicaAon
D. Mostly seen in aorAc segments below the renal artery
E. Commonest eAology is atheroscleroAc disease
TTTTT

• Abdominal aorAc aneurysms are the most common type of large vessel aneurysm
• 95% occur below the renal arteries
• Atherosclerosis is the main risk factor.
• Aneurysm -Increase in vessel wall diameter >50 % from original size.
• Most cases asymptomaAc and detected during an USS abdomen done for another reason.
• If large can present with a pulsaAle epigastric lump.
• Large ones can erode the bone and cause back pain.
• Ureteric obstrucAon with loin pain can occur.
• Rarely can cause duodenal obstrucAon.
• It can act as a source of distal emboli and cause acute LL ischaemia.
• It can present suddenly with severe shock if bleeding occurs.
• Usually intraperitoneal bleeds result in rapid hypotension and death whereas retroperitoneal
ones can be amenable to Sx as it results in a tamponadic effect and less bleeding.
• SomeAmes rupture may occur into the duodenum and give rise to severe haematemesis or
malaena. SomeAme an aortocaval fistula can form causing acute HF.

Management

• USS abdomen is the 1st most important Ix.

• Usually, ones less than 4.5cm in diameter and asymptomaAc can be observed with yearly
USS. Ones from 4.5-5.5 cm need scans 6 monthly.
• Ones >5.5cm regardless of symptoms need Sx repair as there is a high risk of rupture.
• All symptomaAc ones need Sx repair.
• Accurate size should be esAmated before Sx using CT abdomen.
• Endovascular or open Sx methods can be used to repair the aneurysm.
PostoperaAve complicaAons

• The most common complicaAons aaer open repair are cardiac (ischaemia and infarcAon) and
respiratory (atelectasis and lower lobe consolidaAon). A degree of colonic ischaemiaunAl
cross-matched blood is available but surgery should commence immediately if
haemodynamic instability develops.

• Femoral aneurysms – Most are asymptomaAc. Usually does not lead to distal embolizaAon.
No Sx needed.

• Popliteal aneurysms- Can be asymptomaAc. Large ones can present with a pulsaAle mass in
the popliteal fossa or with acute ischaemic limb due to distal embolizaAon. May need Sx if >
20mm or if a thrombus is seen. Rupture is uncommon. Always look for concomitant AAA.

30) 50-year-old male smoker presented with intermiQent claudicaAon and a claudicaAon
distance of 150m. Regarding management of this paAent,
a) DSA is indicated to idenAfy the occulusion
b) Hb needed to opAmized
c) StaAn is indicated
d) Aspirin is effecAve in increasing claudicaAon distance
e) Graded exercise should be encouraged.

ANSWER= FFTFT
A) Whether paAent needs invasive management or not depend on Fontaine classificaAon.
Fontaine 1 - asymptomaAc
Fontaine 2 – 2a=intermiQent claudicaAon with a distance >200m
2b= distance <200m
Fontaine 3 - rest pain
Fontaine 4 – Assue loss
.
Fontaine 1 and 2A and 2B ca managed conservaAvely unless they hv disabling claudicaAon. If so need
intervenAon.
Fontaine 3 and 4 needs intervenAon
this paAent is belongs to -Stage iib which is claudicaAon distance less than 200m. but the quesAon
details not enough to idenAfy he is disabling or not. If we plan intervenAons only arrange DSA as
invesAgaAon. So ans A wrong
b) if undergo intervenAon need to opAmize Hb.
c) all paAents should be on dual anAplatelets which aspirin and clopidogrel to prevent cardiovascular
events. otherwise these drugs not improve the claudicaAon distance.
CILOSTAZOL is a drug that improve the claudicaAon distance.
d) as above
e) life style modificaAon is the best way in early stages which are cessaAon of smoking and alcohol,
graded exercise, weight reducAon and glycemic control.
31. 35 years old man is presented to the A & E with one episode of haematemesis preceded by
several bouts of vomitng. What is the mostly likely diagnosis?
A. GORD
B. Mallory Weiss syndrome
C. Oesophageal carcinoma
D. Oesophageal varices
E. OesophagiAs

1.GORD – Retrosternal chest pain of burning sensaAon, regurgitaAon, acid taste in mouth, nocturnal
cough and can mimic angina

2. Mallory weiss syndrome – Forceful vomiAng may lead to a tear at the OGJ, mostly immediately
below the squamocolumnar juncAon. PaAents present with haematemesis. Bleeding is rarely severe,
and the diagnosis is readily made with endoscopy. Endoscopically the bleeding can be stopped by
adrenaline (epinephrine) injecAon or endoscopic clips to stop bleeding and close the mucosal defect.

3.oesophageal carciinoma- progressive dysphagia iniAally for solids, LOW but i iniAally normal
appeAte, hoarseness of voice due to recurrent laryngeal nerve involvement, cough few seconds aaer
swallowing due to tracheo- esophageal fistula later LOA due to liver mets or spread to stomach

4.Oesophageal varices
Oesophageal varices usually present with sudden, large-volume haematemesis secondary to portal
hypertension, which is most commonly due to hepaAc cirrhosis.

5.oesophagiAs- EOO is believed to commence with food anAgen iniAaAon of cytokine-mediated

signals that lead to eosinophilia, infammaAon and subsequent remodelling by ~rosis. It is a
progressive disease; thus, in infants or toddlers, it may present with irritability, food aversion and
failure to thrive. In young children vomiAng and regurgitaAon predominate. In older
Children or early adolescents, it may present with heartburn and dyspepAc symptoms, while in adults
dysphagia and food impacAon become the most common symptoms. The peak age of presentaAon is
around 20–30 years. There is a clear associaAon with other atopic disorders such as asthma, atopic
rhiniAs or dermaAAs and food allergies.

Answer B- Mallory weiss syndrome

32) A 60 y old woman is on treatment for rheumatoid arthriAs presents with sudden severe
abdominal pain. She looks ill, is tachycardic and has generalized abdominal tenderness and guarding.
Which is the most possible clinical diagnosis?
A) acute cholecysAAs
B) acute diverAculiAs
C) acute pancreaAAs
D) perforated pepAc ulcer
E) ruptuted aorAc aneurysm
Answer=perforated pepAc ulcer

This paAent is an elderly lady who is on treatment for rheumatoid arthriAs, most probably steroids
and NSAIDS. These medicaAons result in pepAc ulcers as a side effect. Hence with background risk
factors for pepAc ulcer disease, the most brobable clinical diagnosis for this presentaAon of sudden
onset acute abdominal pain is perforated pepAc ulcer.
Typical presentaAon of acute cholecysAAs is right hypochondial pain with posiAve murphys sign in
abdominal examinaAon.
Acute diverAculiAs the pain is usually localized to lea lower quadrant and can be associated with PR
bleeding.
In acute pancreaAAs pain radiates to back and is relieved with bending forward.
Ruptured aorAc aneurysm causes severe tearing type central chest pain.

33) Non bilious vomiAng and visible peristalsis with succussion splash are suggesAve of gastric outlet
obstrucAon. Metabolic derangements that occur in gastric outlet obstrucAon are,

-Hypochloremic metabolic alkalosis causes by prolong vomiAng leading to loss of hydrochloric acid
and as a result increase in bicarbonate in plasma to compensate for the lost chlorides.

_Hypokalemic Hypochloremic metabolic alkalosis causes by increasing renal excreAon of potassium in

order to preserve sodium.This happens with conAnuous vomiAng. The adrenocorAcal response to
hypovolemia intensifies the exchange of potassium for sodium at the distal tubule, with subsequent
aggravaAon of the hypokalemia.

So the answer is D.

34)A 35 year old man presented with intermiQent loose stools with blood and mucus for 12 months
duraAon.He had lose of weight and a lower back pain. Abdominal examinaAon is unremarkable.
What is the most likely diagnosis?
A.UlceraAve coliAs
B.Rectal cancer
C.Solitary rectal ulcer
D.DiverAculiAs
E.Benign rectal polyp

Answer-A

A)UlceraAve coliAs
Commonly diagnosed in 20-40yrs age group .Male=Female in <40yrs and M>F in >40 yrs
Clinical Fx;
1.Rectal discharge- blood stained/mucous/purulent
2.Extra intesAnal manifestaAons
-ArthriAs
-Skin- erythema nodosum
-IriAs
-Sclerosing cholangiAs
-Cholangio carcinoma
3.Systemic manifestaAons- fever, hypalbuminaemia, Loss of weight

B)Rectal carcinoma
M:F – 3:1
Common age at presentaAon 45-65 yrs
Clinical features-
- Bleeding-earliest and commonest
- Tenesmus
- Altered bowel habits (early morning bloody discharge)
- Pain ( late symptom)

C)Solitary rectal ulcer

Clinical features compaAble with rectal carcinoma.
D)DiverAculiAs
A clinical feature of diverAcular disease.
DiverAcular disease
-common in elderly
-90% in elderly
- clinical features
• Persistent lower abdominal pain
• Fever,malaise, leukocytosis
• DRE- tender mass
• Fx of IBD- distenAon,flatulence

E)Benign rectal polyp

Clinical features-
• AsymptomaAc (in most cases)
• Bleeding
• Mucous discharge
• Prolapse

In this quesAon given informaAons are compAble with inflammatory bowel disease.35 years old man
with hx of blood and mucous diarrhoea.DuraAon is 12 months and fairly a longer duraAon.And also
having extraintesinal manifestaAons such as lower back pin suggesAve of sacroiliAs(arthriAs)
Therefore the most likely answer is (A)

35) Management of a DiverAcular Abscess

DiverAcular abscess is one of the possible complicaAons of diverAculosis. Commonly occurs in the
sigmoid colon. Other complicaAons of DiverAcular disease include diverAculiAs, peritoniAs, intesAnal
obstrucAon, hemorrhage and fistulaAon.
In many cases of uncomplicated diverAculosis, conservaAve management is sufficient. Even when
complicated with a DiverAcular abscess, given that the abscess is sufficiently small (<5cm - although
this cutoff is not definite), conservaAve management may be aQempted. However, the given scenario
depicts a large abscess coupled with deranged hematology indicaAng possible sepsis, which requires
acAve intervenAon to prevent further complicaAons. Drainage of the abscess is the goal.

The opAons at this point include,

A) Open Drainage
B) Percutaneous Drainage
C) Hartmann’s Procedure + De-funcAoning Colostomy

Laparotomy for DiverAcular disease in the acute sedng has considerable risk of mortality.
Hartmann’s procedure is generally used in perforated diverAculosis. Therefore the next step in the
management of the given paAent is percutaneous drain with USS guidance, which is relaAvely less
invasive than other opAons.

36. 35-year-old male presented to the A & E following one episode of hematemesis aaer several
bouts of vomiAng. What is the most probable diagnosis?
A. Gastro oesophageal reflux disease
B. Mallory-Weiss syndrome
C. Oesophageal carcinoma
D. Oesophageal varices
E. OesophagiAs

Answer B
The suggested theory of Mallory Weiss syndrome is that when the intraabdominal pressure suddenly
and severely increases (as in cases of forceful retching and vomiAng), the gastric contents rush
proximally under pressure into the esophagus. This excess pressure from the gastric contents results
in longitudinal mucosal tears which may reach deep into the submucosal arteries and veins, resulAng
in upper GI bleeding. These tears tend to be longitudinal, and not circumferenAal, possibly because
of the cylindrical shape of the esophagus and stomach

37. Which of the following is the invesAgaAon modality for loco-regional staging in cancer of distal
rectum?
A. CT scan
B. Endoscopic US
C. MRI scan
D. PET scan
E. USS abdomen & pelvis

Answer C - MRI scan

InvesAgaAons for assessing spread in rectal carcinoma
• Lung - Chest X-ray, CECT scan
• Liver - LFT, USS, CECT scan
• Pelvic metastasis - CECT scan
• Local pelvic spread - Transrectal USS, MRI
• Bone - X-ray, Bone scan
• Brain - CECT scan
• Peritoneal metastasis - Laparoscopy

Although endoscopic ultrasound has been the tradiAonal technique for determining the depth of
tumour invasion, over the last decade magneAc resonance imaging (MRI) has emerged as a very
effecAve tool for accurate T-staging.
(hQps://www.ncbi.nlm.nih.gov/pmc/arAcles/PMC3463019/)

38. A 20-year-old boy presented with first episode of painless fresh PR bleeding. There were drops of
blood at the end of defecaAon. No lumps. DRE normal.
A. Haemorrhoidectomy
B. Life style modificaAon
C. Sclerotherapy
D. Banding
E. Sigmoidoscopy
Answer B
It’s a young boy presenAng with painless PR bleeding at the end of defecaAon, with normal DRE.
Diagnosis is haemorrhoids. As there is no lump and only PR bleeding, it’s grade 1. For assessment we
can perform proctoscopy. Flexible sigmoidoscopy should be done to exclude malignancy in elderly.
IniAally can be manage conservaAvely, by giving dietary advices, stool soaners and bulkers, increase
fiber intake. If conservaAve management is failed can manage with sclerotherapy and banding.
Haemorrhoidectomy is indicated for grade 3 and 4 haemorroids and grade 2 haemorrhoids that can’t
be cured by non-operaAve management.
• Haemorrhoids are dilated anal cushions due to increased venous pressure within them.
• Common in elderly due to consApaAon and straining
• Usually situated at 3,7,11O’ clock posiAons.
• Types are primary and secondary
• Primary – consApaAon, profuse diarrhea, pregnancy, obesity
• Secondary – portal hypertension, rectal cancer, pelvic tumor
A.
39. 58-year-old male smoker has had 2 episodes of upper extremity weakness which was resolved
within 10 to 15mins. He was undergone CT brain which was normal but angiogram revealed 75%
stenosis in lea caroAd artery. What is the most appropriate intervenAon?

A. AnAplatelets
B. CaroAd artery bypass
C. CaroAd endarterectomy
D. Manage conservaAvely and life style modificaAons
E. Oral anAcoagulant

Answer: C
40. A 40-year-old female presented with right hypochondriac pain and fever for 3 days. What is the
most important fact to differenAate cholecysAAs from cholangiAs?
A. family Hx of hemolyAc anemia
B. LOA
C. tea color urine
D. d)past Hx of biliary colic
E. pain radiaAng to back

Answer- C
• Acute cholecysAAs- InflammaAon of the gallbladder
B. Clinical features of acute cholecysAAs
A. Fever
B. Right hypochondriac pain
C. Murphy’s sign
D. CholangiAs- InflammaAon of the common bile duct
E. Clinical features of cholangiAs (charcot’s triad)
F. Fever with chills and rigors
G. Right hypochondriac pain
H. ObstrucAve jaundice
C.
D. Features of obstrucAve jaundice
E. Pruritus
F. Tea color urine
G. Pale stools
H. So in acute cholecysAAs, there are no any features of obstrucAve jaundice

41. 75 yr old man presented with painless obstrucAve jaundice associated with anorexia and LOW for
one month duraAon. Ultrasound scan shows gallstones and dilaAon of intrahepaAc and extrahepaAc
duct down to the ampulla. What is the next invesAgaAon?
A) CECT
B) MRCP
C) ERCP
D) Endoscopic USS
E) Percutaneous transhepaAc cholangiogram

Answer B

Given the paAent’s presentaAon with painless obstrucAve jaundice, anorexia, and weight loss, along
with ultrasound findings of gallstones and ductal dilaAon, the primary concern is to further evaluate
the cause of the obstrucAon. The most appropriate next step is an imaging study that provides
detailed views of the biliary and pancreaAc ducts.B) MRCP (MagneAc Resonance
Cholangiopancreatography) is the next best invesAgaAon.
MRCP is a non-invasive imaging technique that provides detailed images of the biliary and pancreaAc
ducts. It is parAcularly useful for visualizing ductal dilataAon and idenAfying the level and cause of
obstrucAon without the risks associated with invasive procedures. It is a good choice in this scenario
because it can help disAnguish between benign and malignant causes of obstrucAon.
RaAonale for other opAons:A) CECT (Contrast-Enhanced CT): While CECT can provide detailed
anatomical informaAon and idenAfy masses or tumors, MRCP is more specific for evaluaAng the
biliary tree and pancreas in the context of obstrucAve jaundice.
C) ERCP (Endoscopic Retrograde Cholangiopancreatography): ERCP is both diagnosAc and therapeuAc
but is invasive and associated with complicaAons such as pancreaAAs. It is usually reserved for cases
where intervenAon is planned.
D) Endoscopic Ultrasound (EUS): EUS is excellent for detailed imaging and fine-needle aspiraAon of
pancreaAc masses but is also invasive. It is oaen used following iniAal non-invasive imaging.
E) Percutaneous TranshepaAc Cholangiogram: This is an invasive procedure typically reserved for
cases where ERCP is not possible or unsuccessful. It carries a risk of complicaAons and is not the first
choice for iniAal invesAgaAon.
Thus, MRCP is the most appropriate next step for detailed and non-invasive evaluaAon of the biliary
and pancreaAc ducts in this paAent.

42. 45-year-old female presented with scaly lesion over the Right-side nipple areolar complex for 3
months duraAon. That is not respond to the treatment. Rest of the examinaAon is normal. What is
the most probable diagnosis?
A. Fungal infecAon
B. Eczema
C. Invasive ductal carcinoma
D. Paget's disease of the breast
E. Periductal masAAs

Answer D
• Most common fungal infecAon of the breast is candida infecAon & usually present as burning
pain of the nipple/areola, sore nipples, stabbing pain of the breast, and nonstabbing pain of
the breast.common in post partum mothers. Canbe unilateral / bilateral (madscape)
• Eczema of the nipple is a rare condiAon which is oaen bilateral and usually associaAon with
eczma in the eleswhere in the body. Treated with 0.5% hydrocorAsone.
• Paget's disease of the nipple is superficial manifestaAon of an underlying breast CA. Presents
as an eczema like condiAon of the nipple areola which persists despite local treatments.
Unilateral and non-itchy. Paget's disease of the nipple. The nipple is eroded slowly and
eventually disappears. If lea, the underlying carcinoma will sooner or later become clinically
evident. Nipple eczema should be biopsied if there is any doubt about its cause.
Microscopically, Paget's disease is characterized by the presence of large, ovoid cells with
abundant, clear, pale-staining cytoplasm in the Malpighian layer of the epidermis.
• Paget's disease • Eczema
I. Superficial manifestaAon of an underlying J. Affects only the areola. Not the nipple
breast carcinoma. Eczema like condiAon of
the nipple & areola
K. Unilateral L. Bilateral
M. Not itchy N. Itchy
O. Underlying lump is present (may or may not) P. No underlying lump
• •
Periductal masAAs also known as duct ectasia is a dilataAon of the breast ducts & oaen
associated with periductal inflammaAon. Common in smokers. Clinical features - nipple
 discharge of any colour, subareolar mass, abscess, mammary duct fistula and/ or nipple
retracAon
Common type of breast Ca. Usually (76%) present with underlying lump( hard, irregular ,
painless & immobile). Here rest of the Ex are normal.
Q. Answer: Paget's disease of breast
R. Ref: B & L

43. 50-year-old woman presented with 3cm right side breast lump for one month duraAon. Lump was
in upper outer quadrant of breast. What is the next step in management?
A. Core needle biopsy
B. FNAC
C. Mammogram and MRI scans
D. USS and mammogram
E. USS and MRI

Answer D

USS+ FNAC + Core biopsy confirm the breast ca. But sAll need mammogram. Why?
1. Mammogram is not to diagnose but to idenAfy spread. Mammogram will tell whether focal
lesion or mulAfocal lesion.
2. Mammogram will asses the state of opposite breast.
• Ideally mammogram should be done before the FNAC/ Core biopsy otherwise we
can't take accurate size of tumour due to structural distorAon by those procedures).
Also those structural lesions can be misinterpret as tumour lesions.
• Mammogram changes in breast ca- structural distorAon , spiculaAon, microscopic
calcificaAon, Intradermal oedema.
Mammogram +FNAC+ Core biopsy done. SAll need USS. Why?
• To see axillary lymph nodes

"Shankar sir discussion "

44. 29-year-old pregnant women in 20 weeks of POA with toxic adenoma who is clinically and
biochemically hyperthyroid. What is the best management?
A. Carbimazole
B. Methimazole
C. PTU
D. RadioacAve iodine
E. Lugol’s iodine

Answer C
1.Carbimazole /Methimazole - acAve form of carbimazole
Block thyroid hormone synthesis
Not use in pregnancy
2.PTU
Block peripheral conversion of T4 toT3
Gives in children and pregnancy.
3.RadioacAve iodine is absolute contraindicated during pregnancy ,breast feeding ,desire for
pregnancy within 6 month.

45. 38 years old lady present with pupillary thyroid cancer confined to only for gland
What is the next step in management aaer thyroidectomy?
A. RadioacAve iodine
B. TSH monitoring
C. Cervical block dissecAon
D. High dose thyroxine to suppress TSH
E. Chemotherapy

Answer – D

A. RouAne ablaAon of residual thyroid Assue with I131 is controversial if no nodal or metastaAc
disease is demonstrable.
Tumours larger than 1cm should have radioiodine therapy. Pregnant and lactaAng mothers have to be
excluded.
(Ref - NaAonal Guidelines CSSL 2007/ Management of goitre)

RadioacAve iodine is given to deliver tumoricidal doses of radioacAvity to thyroid Assue. Here it
states the cancer is confined only to the gland but sAll may be considered to ablate undiscovered
microscopic metastases.

C. Cervical block dissecAon is done in papillary thyroid cancer if there are lymph node metastases.

D. High doses of thyroxine is used to obtain maximum TSH suppression without making the paAent
hyperthyroid because growth of differenAated thyroid cancer cells is TSH dependent, thereby has less
risk of primary thyroid gland or deposited metastaAc thyroid Assues to grow.
46. 45-year women presented with right side thyroid nodule; USS shows 2cm solitary thyroid nodule
with no suspicious features. There is no family History of thyroid cancer.
Which of the following is best recommended management?
A. Core biopsy
B. Follow up USS
C. Right hemithyroidectomy
D. Total Thyroidectomy
E. USS guided FNAC

Answer B

In euthyroid solitary nodules

If <4cm no need of FNAC, do a repeat USS in 6 months
If>4cm do a FNAC

l Majority of the solitary nodules are not palpable. 3-4% of adult populaAon have
palpable nodule
More common in females- F:M= 4:1
l 2 types of presentaAons
Isolated or solitary thyroid nodule (70%)- No other abnormality in the gland
Dominant nodule of a mulAnodular goitre (30%)- abnormality in the gland
l 15% of solitary nodules are proven to be malignant
l 30-40% of solitary nodules are follicular adenomas
l Rest- colloid degeneraAon, thyroidiAs or cysts
l The incidence of malignancy or follicular adenoma in dominant nodules are half of
solitary nodules.
InvesAgaAons usually done
Thyroid funcAon
USS- Gold standard invesAgaAonn
Isotope scan- done in solitary nodule with toxicity
FNAC- ideal with ultrasound guided. Highly specific and sensiAve invesAgaAon.
Radiology
X-ray neck- used for tracheal deviaAon and tracheal compression
CT neck and chest- useful to assist surgical planning and to aassess superior mediasAnum and lungs.
Flexible laryngoscopy- preferred over the indirect
laryngoscope. Unilateral vocal cord palsy with ipsilateral thyroid nodule is usually diagnosAc of
malignant disease.

Sonographic classificaAon of thyroid lesions

U1 Normal thyroid
U2 Benign- do not require FNAC unless risk of malignancy
U3 Equivocal
U4 Suspicious-Need FNAC
U5 Malignant
47. 45-year-old man is brought to the A&E aaer a high velocity road traffic accident. He is in a spinal
board with a semi-rigid collar. He is restless, breathless and his breathing is noisy. His SaO2 is 88%. His
blood pressure is 80/50 mmHg and pulse rate 136/min. His GCS is 8. The most appropriate method to
secure his airway?
A. Bag mask venAlaAon
B. Cricothyroidotomy
C. Et tube
D. Laryngeal mask airway
E. Oropharyngeal airway

Answer B
Here the paAent fulfils the criteria for a definiAve airway (GCS 8, Stridor, breathless, combaAveness,
reduced spO2)
Criteria for establishing a definiAve airway

• A DefiniAve airway is a tube placed in the trachea with the cuff inflated below the vocal
cords, the tube connected to oxygen enriched assisted venAlaAon, and the airway secured in
place with an appropriate stabilizing method. There are 3 types of definiAve airways.
1. Orotracheal tube (ET tube)
2. Nasotracheal tube
3. Surgical airway (Cricothyroidotomy and tracheostomy)
• So can exclude the answers Bag mask venAlaAon, Laryngeal Mask Airway and Oropharyngeal
Airway.
• Here, the paAent has undergone high velocity injury, so spinal cord injury can be suspected.
• And the paAent is having noisy breathing which indicates an airway obstrucAon.
• Because of these 2 reasons ET tube would not be suitable here. So, the answer is
cricothyroidotomy which is a surgical airway.
• IndicaAons for surgical airway
 1. Inability to intubate the trachea.
2. Presence of oedema of the glods
3. Fracture of larynx
4. Severe oropharyngeal haemorrhage that obstructs the airway (This pt is having noisy
breathing)
5. Inability to place an ET tube through vocal cords.

• There are 2 types of cricothyroidotomy.

1. Needle cricothyroidotomy - inserAon of a needle through the cricothyroid membrane
into the trachea in an emergency, unAl a definiAve airway can be placed.
2. Surgical cricothyroidotomy - making a skin incision that extend through the
cricothyroid membrane.

48. Farmer sustained an injury during working in the field. Aaer local infiltraAon of anaesthesia,
inspecAon revealed, superficial skin laceraAon in Abial area.
What is the best soluAon to clean?
A. 0.9% saline
B. 10% povidone iodine
C. 2% chlorhexidine
D. 70% ethanol
E. Hydrogen peroxidase

Answer - A
Copious wound irrigaAon with normal saline or tap water 3 washes away foreign maQer and dilutes
the bacterial concentraAon to decrease post-repair infecAon. Warmed irrigaAon soluAon is more
comfortable for the paAent.4 Povidone-iodine soluAon, hydrogen peroxide, and detergents should
not be used because their toxicity to fibroblasts impedes healing.

References
hQps://www.aafp.org/pubs/afp/issues/2008/1015/p945.html#:~:text=Saline%20or%20tap%20water
%20may,hydrogen%20peroxide%20should%20be%20avoided.&text=The%20sAng%20from%20a%20l
ocal,administraAon%20and

49. 60-year-old man following a mid-shaa fracture with radial nerve injury undergone screw and
plate reducAon. What is the best orthopaedic support?
A. Below elbow palmar back slab
B. Below elbow dorsal back slab
C. Collar and cuff
D. Dynamic wrist splint
E. U slab

Answer D

Reasons for Choosing a Dynamic Wrist Splint:

Radial Nerve Injury Management: A dynamic wrist splint is specifically designed to address the
consequences of radial nerve injury, such as wrist drop. It maintains the wrist in a funcAonal posiAon,
typically in slight extension, which helps prevent flexion contractures and facilitates hand funcAon.
Post-Surgical ApplicaAon: Following surgical fixaAon of the humerus, the dynamic wrist splint can
complement the internal fixaAon by providing support to the wrist and hand, ensuring the hand
remains in an opAmal posiAon for healing and funcAon.
Why Not the Other OpAons:
Below Elbow Palmer Backslab and Below Elbow Dorsal Backslab: These splints primarily immobilize
the wrist and forearm but do not specifically address the posiAoning required for radial nerve palsy.
They are also less appropriate for the humerus fracture stabilizaAon.
Collar and Cuff: This is typically used for simple humerus fractures without significant nerve injury
and does not provide the necessary support for managing radial nerve palsy.
U Slab: This is usually used for forearm or wrist fractures and is not designed to manage the
consequences of a radial nerve injury specifically.
Using a dynamic wrist splint in combinaAon with the stable surgical fixaAon of the humerus provides
an effecAve soluAon for addressing both the fracture and the nerve injury.

50. 35-year-old motorcyclist met with a high-speed road traffic accident. She is on spinal board and
shouAng in pain. SPO2 98% on air. There is a rapid pulsaAle bleed from her right distal thigh. What is
the most appropriate iniAal method that should be applied to arrest haemorrhage?
A. Clamping and haemostat
B. Direct compression
C. Packing with gauze
D. Tourniquet applicaAon
E. TracAon splint

Answer B
51. A front seat passenger involves in a head on collision during an RTA. He was stable aaer the iniAal
assessment and management. 2 hours later his lea leg was noAced to be shortened, internally
rotated with a foot drop. What would be the Most likely diagnosis?

A. VerAcal shear pelvic fracture

B. Femoral shaa fracture
C. Supracondylar femoral fracture
D. Posterior dislocaAon of the hip joint
E. Intra capsular fracture of the femoral head

Answer D

A
s
s
o
c
i
a
t
i
 Ø A motor vehicle crash associated with a point of impact of the knee joint of the driver on the
dashboard of the car could induce a fracture dislocaAon and hip joint due to transmission of
force from the knee joint to the hip socket by indirect blunt mechanism.
Ø Posterior dislocaAon of the hip joint is the commonest hip dislocaAon that associated with
road traffic accidents.
Ø Clinical features are,
• Short, internally rotated limb
• AdducAon
• Slightly flexed
Ø ComplicaAons of posterior dislocaAon of the hip joint
• Fractured acetabulum
• Fractured femoral head
• SciaAc nerve injury
• Avascular necrosis
• OsteoarthriAs
v SciaAc nerve compression/injury result in foot drop and sensory loss over most of lower leg &
foot
Ø Management of posterior dislocaAon of the hip joint
• ReducAon under anaesthesia
• TracAon for 3 weeks
52. 19-year-old boy presented with Nocturnal pain and swelling around right knee for one month
duraAon. He AQribute it to twisAng injury happened 2 months ago. Xray shows bone destrucAon and
new bone formaAon in right upper Abia. What is the most likely diagnosis?

A. Chronic osteomyeliAs
B. Hemarthrosis of knee
C. Osteosarcoma
D. Osteochondroma
E. Hemarthrosis
Answer A

PaAent is 19 year old, so bleeding disorders presenAng as hemarthrosis is somewhat uncommon at

this age as it could have manifested at young ages.

PaAent has presented with bone swelling and pain at knee over an one month duraAon which are
much common manifestaAons of bone infecAon rather than bone tumor.
Osteosarcomas also common at this age (10-20 years) but Xray usually should have shown sunburst
appearance.
New bone formaAon (involucrum) and bone destrucAon (sequestrum) are typical manifestaAons of
osteomyeliAs. As paAent had develop condiAon over a month period this should be chronic
osteomyeliAs at knee joint.

53. 23-year-old male presented with lea scrotal swelling for 1 month. On examinaAon there is a hard
irregular lump. What is the next invesAgaAon in aid of diagnosis?
A. FNAC
B. Serum alfa feto-protein level
 C. Serum beta HCG level
D. TesAcular core biopsy
E. USS of tesAs

Answer E

54. 60-year Male presented with Dysuria, frequency and poor stream. On examinaAon Prostate is
clinically benign. His UFR shows 10-15 pus cells and PSA elevated 8 (normal <4) WOF most important
next step in the management?
A. MRI of prostate
B. Tamsulosin for 2 weeks and repeat PSA
C. Trans rectal USS guided biopsy of prostate
D. Urine culture followed by anAbioAc and repeat PSA
E. Watchful waiAng and PSA repeated in 3 months
Answer D

PSA level is elevated with evidence of lower urinary tract symptoms in this paAent.
Elevated PSA seen in;
Benign prostaAc hyperplasia
Prostate massage
Prostate cancer
ProstaAAs
UTI
Recent ejaculaAon
DRE
PSA normal value should be less than 4ng/ml.
1-4 ng/ml- 20% chance of prostate cancer
4-10ng/ml- Gray zone- 25% chance of prostate cancer
10ng/ml- >67% chance of prostate cancer
35ng/ml- Almost diagnosAc of advanced prostate
As his UFR shows 10-15 pus cells along with dysuria, frequency, poor stream the most important next
step of management is to perform urine culture followed by anAbioAcs as this coukd be prostaAAs.
ProstaAAs is a disorder of the prostate gland usually associated with inflammaAon. ProstaAAs oaen
causes painful or difficult urinaAon, as well as pain in the groin, pelvic area or genitals. PSA can be
repeated aaer treaAng prostaAAs in this paAent. And also as this is menAoned that it was clinically
Benign we couldn't reject prostate CA because its symptoms appears more lately.
The DRE findings of enlarged prostate due to CA
1. Hard
2. Irregular
3. ObliteraAon of median
4. Fixed overlying mucosa

55. A healthy man is diagnosed with 1cm stone in renal pelvis. He has episodic pain and haematuria.
Renal funcAon is normal and infarcAon density is 900 HC on CT. What is the treatment opAon of this
paAent?

A. Extracorporeal shock wave lithotripsy

B. Medical dissoluAon therapy
C. Medical expulsion therapy
D. Percutaneous nephrolithotomy
E. Pyelolithotomy

Answer A
56. 60-year-old man has drooping mouth aaer submandibular sialoadenectomy. Which is the most
likely nerve injury?
A. Glossopharyngeal nerve
B. Hypoglossal nerve
C. Lingual nerve
D. Marginal branch of the trigeminal nerve
E. Marginal mandibular branch of the facial nerve

Answer E

The most likely nerve injury aaer submandibular sialoadenectomy (removal of the submandibular
gland) that results in a drooping mouth is the marginal mandibular branch of the facial nerve. This
branch innervates the muscles responsible for lip movement,the orbicularis oris muscle, which
controls the corner of the mouth. Damage to this nerve can lead to a slightly crooked smile or
weakness of the lower lip

A. Glossopharyngeal nerve - involved in swallowing and taste sensaAon

B. Hypoglossal nerve - controls tongue movement.
C. Lingual nerve - sensaAon in the anterior two-thirds of the tongue
D. Marginal branch of the trigeminal nerve - The trigeminal nerve primarily innervates the face

57. 23 years old girl presented with right side thyroid nodule and firm to hard, 5×4 cm in size
supraclavicular mass with fluctuaAons in some regions. What is the most probable diagnosis?
A. Branchial cyst
B. Glandular fever
C. Lymphoma
D. MetastaAc deposit of carcinoma
E. Tuberculosis lymphadeniAs

58. 43-year-old female presented with hyperpigmented skin rash in lower limb. On examinaAon it has
irregular margin and 1cm in diameter. What is the most appropriate management opAon?
A. Excision and flap cover
B. Immunotherapy
C. Neoadjuvant chemotherapy and wide local excision
D. Systemic chemotherapy
E. Wide local excision
Answer E

MALIGNANT MELANOMA
• Arises from epidermal melanocytes
• Involve the skin and mucous membrane
• Female > Male
• Common age of presentaAon- 20-39years
• Risk factors – Female, Fair skin, Family history, Sun burn, Reddish blonde hair
• 4 Types
1. Superficial spreading Commonest (64%) From previous nevus Occurs in any part of the body
Male-back, Female - Leg
2. Nodular Most malignant Occurs mainly in legs and trunks AmelanoAc Decreased or no
pigmentaAon
3. LenAgo malignant
4. Acral lenAginous
• Spread
Direct- Satellite lesion
LymphaAc- In transit lesion and LN involvement
Blood- Liver, lung, brain, bone and skin
• Assessed with Breslow thickness Clark’s level
• InvesAgaAon - Biopsy
• Treatment – Medical, Interferon, Bevacizumab, Chemotherapy
Surgery - Excision, Lymph node staging, SenAnel lymph node biopsy, Block dissecAon

59. 60-year-old man presents with pain, erythema, swelling around the surgical site aaer inguinal
hernia mesh repair. There is neither fluctuaAon nor discharge. He has DM and on oral hypoglycaemics
drugs. What is the most appropriate management opAon?

A. Start anAbioAc
B. Change to insulin
C. Remove suture
D. Remove mesh
E. USS of groin
Answer - A

In surgical site;
• If there is only erythema → IV anAbioAcs
• If there is pus discharge → 1st remove sutures → 2nd IV anAbioAcs → If not responding →
Suspect sepsis and uncontrolled DM → Remove mesh
Pain, erythema and swelling in the surgical site indicated that this paAent is having an ongoing
inflammaAon. But sAll not having a bacterial infecAon. Nevertheless he is more prone to develop an
infecAon due to risk factors like site (groin), age and diabetes mellitus.
A. So beQer to start AnAbioAcs to prevent infecAon.
B. Glycemic control is a must. So need to achieve glycemic control. But it can be achieved by oral
drugs. No need to rush in to insulin. With age there is a high risk of developing hypoglycemia
too if started insulin.
C & D. No fluctuaAons and discharge indicates no pus formaAon. O no need to go for suture removal
or mesh removal.
E. If we are suspecAng abscess formaAon beQer to do USS. But here the paAent is less likely to have
an abscess as he does not have fever or discharges.
60. 40-year-old woman presented with a 4cm defect of para umbilical hernia. She complains
intermiQent pain and no other associaAons. What is the likely content to be in her hernia sac?
A. Jejunum
B. Omentum
C. Peritoneal fluid
D. Preperitoneal fat
E. Transverse colon
Answer: B

PARAUMBILICAL HERNIA
1. Occurs commonly in adults
2. Common in obese females. ( M:F =1:5) 3. HerniaAon occurs through the linea alba, just above or
below the umbilicus. The defect is rounded with a well-defined fibrous margin
3.. Small umbilical hernias oaen contain extra peritoneal fat or omentum. Larger hernias can contain
small or large bowel but, even when very large, the neck of the sac is narrow compared with the
volume of its contents. As a result, in adults, umbilical hernias that include bowel are prone to
become irreducible, obstructed and strangulated.
4. Most paAents complain of pain due to Assue tension or symptoms of intermiQent bowel
obstrucAon. In large hernias, the overlying skin may become thinned, stretched and develop
dermaAAs.
5. ComplicaAons
• Adhesions
• Irreducibility
• ObstrucAon
• StrangulaAon
6. Treatment- always surgery
• Anatomical repair
• Mayo’s repair
• Mesh repair

This paAent only complains intermiQent pain with no other symptoms of bowel obstrucAon such as
vomiAng, consApaAon, abdominal distension. So bowel contents are unlikely.

▪Answer: B- omentum
C-False (contain extra peritoneal fat )
D- False (contain extra peritoneal fat )

61. A 40-year-old male who undergone anterior resecAon develop sudden-onset SOB on post-op day
five. He was conscious with RR 32/min, BP 100/70 mmHg, PR 120 bpm. His SpO2 was 88% despite on
100% O2. What is the most appropriate next step in the management?
A. CT chest and abdomen
B. Blood culture and give anAbioAcs
C. Fluid resuscitaAon
D. Laparotomy repair
E. VenAlatory support
Answers- A?
Causes for SOB in post op day 5 can be Due to Pulmonary embolism, anastomoAc leakage, infecAon
like pneumonia
Here the pt developed sudden onset sob with respiratory compromise and tachycardia more likely be
due to Pulmonary embolism. So most appropriate next step in mx is CT pulmonary angiogram, but
from the opAons given in the quesAon CT chest and abdomen can be taken as the answer

62. 42 years old male following major trauma admiQed to ICU. He is restless, tachypnoeic and SpO2 is
88% on room air. Which of the following best indicates ARDS?
A. RR>32
B. P/F <100
C. PaO2 60mmHg on room air
D. mid zone opacity in chest x ray
E. SpO2 - 88%
Answer B

63. 65-year-old male admiQed to ICU with sepsis aaer a laparotomy fie gangrenous bowel. No
improvement of MAP or CVP aaer 3 boluses of 20ml/kg crystalloid. What is the next best fluid?
A. 0.9% NaCl
B. 3% NaCl
C. Albumin
D. Hartmann
E. Tetrastarch

Answer C

In a criAcally ill paAent with sepsis who has not responded to iniAal fluid resuscitaAon with
crystalloids, the next best step oaen involves considering a different type of fluid to improve
hemodynamic status.

A. 0.9% NaCl (Normal Saline) is another crystalloid, which may not be beneficial if the paAent has
already received significant amounts without improvement.
B. 3% NaCl (Hypertonic Saline) is used for specific indicaAons like severe hyponatremia or elevated
intracranial pressure, not typically for general fluid resuscitaAon in sepsis.
C. Albumin is a colloid soluAon that can be considered in cases of severe sepsis or sepAc shock,
especially if the paAent has not responded to crystalloids.
D. Hartmann's soluAon (Lactated Ringer's) is another balanced crystalloid, similar to Normal Saline,
and may not provide addiAonal benefits if the paAent has not improved with previous crystalloid
boluses.
E. Tetrastarch is a syntheAc colloid, but there is evidence suggesAng it might be associated with
adverse outcomes in criAcally ill paAents, parAcularly those with sepsis.

Considering these points, the best answer would be:

C. Albumin.

This opAon is supported by guidelines suggesAng the use of albumin in paAents with sepAc shock
who do not respond adequately to iniAal crystalloids
hQps://journals.lww.com/ccmjournal/fulltext/2021/11000/surviving_sepsis_campaign__internaAon
al.21.aspx

64. Newly developed COVID 19 anAgen test was assessed by comparing its performance against viral
culture (gold standard) using specimen from 300 paAents.

Culture (+) Culture (-) Total

AnAgen (+) 79 11 90
AnAgen (-) 21 189 210
Total 100 200 300

What is the sensiAvity and specificity of new anAgen test?

A. 79% and 80%
B. 79% and 94.5%
C. 87% and 94.5%
D. 87% and 90%
E. 94% and 87.8%

Answer B

SensiAvity = 79/79+21 = 0.79

Specificity = 189/189+11 = 0.945
65. Following paAents are prepared for tomorrow surgery list.

35y old man - wound debridement

4y old child - herniotomy
45y old woman – thyroidectomy

What is the order you would take them into the theatre?
A. A B C
B. A C B
C. B A C
D. B C A
E. C A B

Answer- D

• B (4-year-old child - herniotomy): Pediatric paAents, especially young children, may become
more anxious or irritable if their surgery is delayed. AddiAonally, maintaining the child's
fasAng status, which is required for general anesthesia, may become challenging if the
surgery is postponed. PrioriAzing the child's surgery can help minimize these issues.

• C (45-year-old woman - thyroidectomy): Thyroidectomy is a surgical procedure that requires

careful assessment and experAse, as well as preparaAon for general anesthesia. By scheduling
the thyroidectomy as the second surgery, the paAent can be adequately prepared, and any
fasAng requirements can be maintained.

• A (35-year-old man - wound debridement): Wound debridement, parAcularly if performed

under local anesthesia, may be less Ame-sensiAve compared to the other surgeries listed.
This procedure could be scheduled as the last surgery without significantly impacAng paAent
care.

66. 3 old boy admiQed to the A & E department with 3 episodes of PR bleeding for 6 months
duraAon, Not associated with diarrhoea, consApaAon or abdominal pain. His platelet count is 250000
with Hb 10g/dL. What is the most likely diagnosis?
A. Acute anal fissure
B. HaemolyAc Uremic Syndrome
C. IntussuscepAon
D. DiverAcular disease
E. UlceraAve coliAs

Answer - D

A. Anal fissures - arise due to trauma caused by strained evacuaAon of a hard stool or less
commonly from repeated passage of diarrheoa. Anterior anal fissures are more common in
females arise following vaginal delivery.
 Clinical features - severe localized pain which is sharp (knife like) in the anus during
defecaAon associated with fresh per rectal bleeding. Streaks of blood in the stools.
Associated with consApaAon.

B. HaemolyAc uraemic syndrome - characterized by intra vascular haemolysis with red cell
fragmentaAon, thrombocytopaenia and AKI due to thrombosis in small arteries and
arterioles.
Clinical features - oaen follows a febrile illness, diarrhoea associated with E.coli, notably strain O157.

C. IntussuscepAon - most occurs in between 2 months to 2 years (5 - 10 months of age). Males

has higher predominance than females.
Clinical features - sudden onset pain, abdominal distension, vomiAng and diarrhoea in 10% of
paAents, red current jelly stool, sausage shaped mass around umbilicus and empty RIF.

D. DiverAcular disease - can be either congenital or acquired

Congenital - all coats of the bowel are present in the wall of diverAcula (Meckel’s dicerAcular
disease)
Acquired - there is no muscularis layer present in the diverAculum.

E. UlceraAve coliAs - is a disease of rectum and colon with extra intesAnal manifestaAons. Most
commonly diagnosed in the ages 20 to 40 years.
Clinical features
ProcAAs - per rectal bleeding, tenesmus and mucous discharge
ColiAs - bloody diarrhoea and urgency. Severe or extensive coliAs is associated with anaemia,
hypoproteinaemia and electrolyte imbalances, malaise, LOA and fever.
And also associated with extra intesAnal manifestaAons like arthriAs, sclerosing colangiAs,
skin manifestaAons like erythema nodosum and pyoderma gangrenosum and eye condiAons
like uveiAs and episcleriAs.

PAEDIATRIC RECTAL BLEEDING

Newborns - malrotaAon and necroAsing enterocoliAs
Older infants and children - intussescepAon, anal fissures, juvenile polyps and certain
gasteroenteriAdes (Campylobacter infecAon).
Meckel’s diverAculum (may be complicated by an obstrucAng band between the diverAculum and the
umbilicus, diverAculiAs, intussiscepAon, intesAnal volvulus or perforaAon.
ü With the given clinical scenario, the most suitable answers will be
- UlceraAve coliAs
- DiverAcular disease
So, if Meckel’s diverAculum is considered, D. DiverAcular disease can be taken as the answer because
it is a more common cause of painless rectal bleeding in young children and matches the chronic
nature of the bleeding described without associated pain, diarrhea, or consApaAon.
IntussuscepAon is also a probable differenAal diagnosis for the above scenario with the given age, but
it typically presents with acute, episodic abdominal pain, which is oaen severe and can be
intermiQent. Children might draw their legs up towards the abdomen during episodes of pain. It can
also present with "red currant jelly" stools, which are a mixture of mucus and blood.
It typically presents as an acute condAon rather than a chronic history present in the given clinical
scenario.
67. 20 year-old female diagnosed paAent with rheumaAc heart disease presented acute severe right
side lower limb pain for 3 hours. On examinaAon, limb was cold and there were absent pedal and
popliteal pulses. Toe movement is intact. What is the most appropriate definiAve management?

A. DSA and thrombolyAc therapy

B. Femoropopliteal bypass surgery
C. 4-compartment fasciotomy
D. Intravenous heparin
E. Transfemoral embolectomy

Answer- E

Sudden onset LL pain- ALI/ Compartment syndrome- in this scenario, ALI is more likely.
Therefore,
Managent of ALI
1. Start with IV Heparin 5000IU
2. Forgarty Embolectomy- DefiniAve management
3. ProphylacAc fasiciotomy to prevent compartment Xn

Other revascularizaAon opAon- transasterial thrombolysis- if ischemia is not severe

Reference: Bailey and Love’s Short PracAce of Surgery- 28th EdiAon (P 1011)

68. 50-year-old DM paAent present with non-healing planter ulcer. He is afebrile. Pedal pulses are
absent and there is numbness at feet. What is most appropriate opAon
 A. AnAbioAc with revascularizaAon
B. AnAbioAc with wound off load
C. Wound off load and revascularizaAon
D. Wound excision and anAbioAcs
E. Wound excision and revascularizaAon

Answer C

Broad principles of management of the diabeAc foot ulcer are control of infecAon, metabolic control
and treatment of comorbidity, restoraAon of skin perfusion (treatment of PAD), local wound care,
relief of pressure and protecAon of the ulcer (off- loading), educaAon and prevenAon of recurrence.
AnAbioAcs are not needed in this paAent signs no signs infecAon (afebrile)

Reference:
hQps://www.sciencedirect.com/science/arAcle/abs/pii/S026393191930256X#:~:text=rights%20and%
20content-,Abstract,oaen%20the%20pathology%20precipitaAng%20presentaAon.

69. 58-year-old male smoker has had 2 episodes of upper extremity weakness which was resolved
within 10 to 15mins. He was undergone CT brain which was normal but angiogram revealed 75%
stenosis in lea coronary artery. What is the most appropriate intervenAon?

A. AnAplatelets
B. CaroAd artery bypass
C. CaroAd endarterectomy
D. Manage conservaAvely and life style modificaAons
E. Oral anAcoagulant
Best answer C
Answer A
64. AnAplatelets are used for secondary prevenAon of Stroke
65. Dual anAplatelets for NIHSS <3 for 3 weeks (Aspirin 75g and Clopidogrel 75mg) then
Clopidogrel alone life long
66. If not Aspirin for 1 month, then Clopidogrel life long

Answer B
Direct reconstrucAon of the cervical caroAd artery by means of a surgical bypass may be indicated in
situaAons where revascularizaAon via endarterectomy and primary patch closure cannot be
performed.

IndicaAons
IndicaAons for caroAd bypass and reconstrucAon are as follows:
Long-segment atheroscleroAc stenosis or occlusion
Aneurysmal disease [9, 10, 11]
InfecAon of a previously placed prostheAc caroAd patch
Malignant invasion [12]
RadiaAon arteriAs
Recurrent stenosis aaer a previous endarterectomy that is not amenable to endovascular therapy
[13, 14] ; a study by Spinelli et al suggested that caroAd bypass may be superior to caroAd
angioplasty and stenAng (CAS) or redo CEA for post-CEA restenosis or for intrastent restenosis aaer
CAS for post-CEA restenosis [15]
ElecAve debranching (revascularizaAon) of an arch vessel in lieu of aorAc arch stenAng or surgery

ContraindicaAons
ContraindicaAons for caroAd bypass and reconstrucAon are as follows:
Debilitated paAent with severe comorbidiAes
Lack of an appropriate distal target for revascularizaAon (intracranial extension)
Unaddressed inflow disease

According to above explanaAon caroAd bypass is inferior than caroAd endarterectomy.

Answer C
In Aght caroAd stenosis (>70%) is detected, caroAd endarterectomy should be offered.
IndicaAons for caroAd endarterectomy in symptomaAc paAents
70% or greater caroAd stenosis and:
● Ipsilateral amaurosis fugax or monocular blindness
● Contralateral facial paralysis or paraesthesia
● Arm/leg paralysis or paraesthesia
● Hemianopia
● Dysphasia (if dominant hemisphere)
● Sensory or visual inaQenAon/neglect
So the answer is C
Answer D
There is an increased risk of cardiovascular events following TIA , parAcularly in paAents with
extensive atherosclerosis. In this context, arterial hypertension, diabetes, dyslipidemia, and smoking
are the leading modifiable atherogenic risk factors for cerebrovascular and coronary insufficiency. It is
essenAal that clinicians address these modifiable factors with an emphasis on important core health
behaviors (i.e., smoking cessaAon, physical acAvity, proper dietary paQerns, and weight control) and
monitoring health-related metrics (i.e., lipid profiles, BP, and glucose control).
But in this PaAent main causaAve factor for TIA is 75% stenosis of lea coronary artery.so we have to
prioraAzed the management of stenosis rather than management of risk factors.So answer D is not
possible for appropriate intervenAon.

Answer E
Oral anAcoagulant
In secondary prevenAon of stroke in paAents with AF warfarin or direct oral anAcoagulants are used.
AnA coagulaAon for AF is commenced 2 weeks aaer ischemic stroke.
There is no evidence of AF in this paAent therefore E statement is false.

70. 40-year-old women is being followed up aaer successful renal transplantaAon 6 month ago. Her
serum creaAnine level is found to be rising in her recent clinic visit. Which is the most likely cause for
this condiAon?
A. Drug toxicity
B. Graa rejecAon
C. Malignancy
D. Technical problem with the vascular anastomosis
E. Technical problem with the ureteric implant

Answer is B
ExplanaAon
A) Drug toxicity may occur when a person has consumed a dose of a drug that is too high for them to
handle. It may also occur when the person's liver and kidneys are unable to funcAon properly and get
the drug out of the bloodstream. This can cause it to build up over Ame unAl it starts to cause
problems. Here even though paAent underwent successful kidney transplantaAon there is no enough
informaAon to take it as a drug toxicity.

C) Increased serum creaAnine that is not explained by dehydraAon, urinary obstrucAon, high
calcineurin inhibitor levels or the apparent cause is most likely due to an intra-graa process, such as
acute rejecAon, chronic allograa injury, drug toxicity, recurrent or de novo kidney disease.
Following renal transplant, the overall cancer development is high. The most common types however,
are renal cell carcinoma, and post transplant lymphoproliferaAve disorder. This is because the
suppression of the immune system, which increases the risk of cancer. Hence with the occurrence of
RCC, the renal funcAons could be affected leading to a rise in the serum creaAnine levels.
However, in post transplant paAents, post transplant malignancies is not the most probable cause for
the rise of serum creaAnine levels.

D) One of the commonest reasons for graa rejecAon is vascular anastomoAc problems
leading to necrosis. But here the problem has raised aaer 6 months from the
procedure. Therefore it is due to chronic graa rejecAon
E) The Aming of technical problems related to ureteric implantaAon aaer kidney transplantaAon can
vary, but they typically occur withining the first few days to weeks post-transplantaAon. It's essenAal
for paAents to be closely monitored during this period to detect and address any issues promptly.

A) Graa rejecAon 3types.

Hyper acute rejecAon – rejecAon occur within minutes to hours aaer transplant. AnAbody mediated,
Kidney become dusky in color, Scr increase
UOP nil
Can prevent but cannot suppress
No treatment as it is irreversible
Can prevent by ABO CompaAbility
Less volumes of AnA donor HLA anA bodies.

Acute rejecAon – rejecAon up-to 6 months of transplant.

2 types
Cell mediated – macrophages, CD 8 ,T cells , neutrophils
AnAbody mediated – AnA donor AB produce by B cells.
Treatment is immunosuppression by steroids or methyl prednisolone

Chronic rejecAon – rejecAon occur aaer 6months of transplant.

2types
Cell mediated
AnAbody mediated
Treatment – Immunosuppression for prolong period. for 1 year is not enouControl other long term
risk such as BP, lipids, smoking