SURGERY SET

QUESTIONs

NAME :

ROLL :

SESSION :
 SURGERY Paper-I
BOARD-A
(GIT, Paediatric surgery, Operative Surgery)

1. How will you treat & Tell the clinical presentation of a case of carcinoma stomach. What single
investigation will be confirmed it?
Clinical feature of Ca stomach :
Symptoms :
a. Recent onset dyspepsia over age of 40 years or persistent dyspepsia of any age.
b. Epigastric pain not responds to treatment and no periodicity. 3) Early satiety, bloating, epigastric fullness
c. Anorexia
d. Vomiting with features of gastric outlet obstruction.
e. Dysphagia
f. Weight loss.
g. Lump in the epigastrium.
h. Haematemesis & melaena
i. Cough (if lung metastasis).
j. Generalized bone pain (if bone metastasis).
Signs :
1) Wasting/cachexia
2) Epigastric tenderness.
3) Epigastric mass
4) Anaemia due to chronic bleeding from carcinoma or lack of protein and iron in diet
5) Jaundice (due to secondary deposits in liver)
6) Abdomen may be scaphoid with wrinkled and inelastic skin or distended from ascites(due to carcinomatosis of
peritoneum).
7) Troisler's sign: A visible as well as a palpable mass of lymph nodes in left
8) Supraclavicular fossa (Virchow's gland)
9) Succussion splash if pyloric obstruction is present
10) Krukenberg's tumour - Metastasis in ovary.
11) DRE- Findings of metastatic deposits (Blumer's shelf)
12) Non-metastatic effects:
a. Trousseau's sign → Thrombophlebitis of the superficial veins of legs.
b. Deep vein thrombosis

Investigation to confirm : Upper GI endoscopy with 10 quadrant biopsy.

Treatment:
 Pre-operative operation:
 Correction of dehydration: I/V normal saline.
 Correction of electrolyte imbalance: IV normal saline supplementation of K+
 Correction of anaemia by BT.
 Correction of hypoproteinaemia by high protein diet, amino acid / human albumin infusion.
 Gastric lavage before each feed 4-5 days prior to surgery.
 Prophylactic antibiotic.
 Surgical treatment:
 Total gastrectomy
 Subtotal gastrectomy
 Palliative surgery
 Adjuvant therapy : Chemotherapy,Radiotherapy,Immunotherapy.

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2. Tell the name of incisions that you have seen in general surgery OT with indication.

Incision Indication
Upper midline incision Repair of perforation of gastric and duodenal ulcer
Suprapubic cystotomy & cystolithotomy
Prastatetectomy
Lower midline incision Burst appendix operation
Volvulus operation
Gynaecological operation
Upper paramedian incision Cholecystectotomy
Right : Choledocolithotomy
Whipples operation

Left : Vagotomy
Splenectomy
Appendicectomy
Lower paramedian incision
Cystolithotomy
Cholecystectomy
Choledocolithotomy
Subcostal incision
Choledocotomy
Right hepatic lobectomy
Grid iron incision Appendicectomy

3. A 6 months old male healthy baby has been passing red currant jelly for last 2days along with
screaming of vomiting
a. Tell the possible diagnosis?
Intussusception of intestines
b. What investigation will you do?
 Plain X-ray abdomen in erect posture .
 USG of whole abdomen
 Barium enema (claw sign)
 CT scan (target or sausage shape)
 CBC
 Bleeding time , Clotting time
 Serum electrolyte.
4. A young lady of 20 years present to you with pain in her right lower abdomen, nausea and low grade
fever for last 2 days
a. What is your possible diagnosis?
Acute appendicitis
b. What are the investigations do you suggest for diagnosis?
Still now in most of the cases it is diagnosed clinically.
A. Routine:
1) Complete blood count (FBC):
 Neutrophilic leukocytosis.
 Raised ESR.
2) Urine analysis.

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 B. Selected cases:
a) Pregnancy test.
b) Urea & electrolytes.
c) Supine abdominal radiograph.
d) USG of the abdomen / pelvis.( It is done in case of female where there is confusion of origin of
pain either from appendix or adnexa.)
e) Contrast enhanced CT scan of the abdomen.
5. Tell the steps of grid iron incision.
Steps of grid iron incision :
a) Skin
b) Superficial fascia
c) External oblique muscle
d) Internal oblique muscle
e) Transverse abdominis muscle
f) Transverse fascia
g) Parietal peritoneum
6. Tell indications & contraindications of circumcision.
Indications of circumcision :
A. In infants and young boys:
a) Religious purpose in Muslims & Jews.
b) Phimosis.
c) Paraphimosis.
d) Balanitis.
e) Balanoposthitis
f) Recurrent urinary tract infection with an abnormal upper urinary tract.
B. In adult:
1. Early carcinoma of prepuce or glans penis (both diagnostic & therapeutic).
2. Inability to retract the foreskin for intercourse.
3. For splitting of an abnormally tight frenulum.
4. For recurrent balanitis.
Contraindications:
A. Absolute :
a. Hypospadias.
b. Epispadias.
B. Relative : Bleeding disorder.

7. How will you differentiate anal fissure from haemorrhoid?

Traits Haemorrhoid Anal fissure

It is a longitudinal split in the anoderm of
Hemorrhoids are cushion of submucosal
the distal anal canal, which extends from
1) Definition tissue containing venules,arterioles,and
the anal verge proximally towards, but not
smooth muscle fiber.
beyond, the dentate line.
2) Sub types External & internal. Acute & chronic.
3) Pain Painless. Painful
4) Palpable Palpable. Not palpable.
5) D/R/E Indicated Contraindicated

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8. A young adult unmarried female patient with peri-umbilical colic pain, shifting to right iliac fossa for
2 days. On examination she is found to have a tender RIF lump overlying muscle rigidity and pyrexia.
a. Formulate clinical diagnosis.
Appendicular lump
b. Outline the treatment option.
Standard treatment is the conservative Ochsner- Sherren regimen. It is as follows-
1) Complete bed rest.
2) Temperature, blood pressure, pulse chart.
3) Marking the mass to identify the progression/regression.
4) Nothing by mouth until further order is given.
5) Nasogastric suction in each hour.
6) Intravenous fluid and electrolytes.
7) Broad spectrum parenteral antibiotics – Metronidazole with ampicillin or gentamicin or
cephalosporin.
8) Analgesics with H2 receptor blocker
 Tramadol hydrochloride.
 Pethidine.
 Antispasmodic - hyoscine-N-butyl bromide.
9) On complete recovery, the patient is discharged with advice for appendicectomy after 4 to 6
weeks (interval appendicectomy).
9. Tell some causes of neonatal intestinal obstruction.
Causes of neonatal obstruction :
a) Congenital atresia and stenosis of duodenum , jejunum,ileum.
b) Cystic fibrosis
c) Intestinal malrotation with midgut volvulus (Volvulus neonatorum)
d) Meconium ileus
e) Hirschsprung’s disease
10. Tell the causes of lump in the right lower abdomen.
Causes of lump in the right lower abdomen :
a. Appendicular mass
b. Appendicular abcess
c. Psoas abcess
d. Carcinoma of caecum
e. Chron’s disease
f. Ovarian tumour
g. Fibroid uterus

11. Described about right subcostal incision.

Kocher's incision/Right subcostal incision :
It is an oblique incision, which starts from midline 2 to 5 cm below the xiphoid process and runs
downwards, outwards and parallel to and about 2.5 cm below right costal margin.

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Steps of opening / Structures divided :
a) Skin.
b) Superficial fascia.
c) Medially :
 Anterior layer of rectus abdominis muscle.
 Rectus abdominis muscle.
 Posterior layer of Rectus abdominis muscle.
d) Laterally :
 External oblique muscle (downwards and medially) pockets directions.
 Internal oblique muscle (upwards and medially).
 Transversus abdominis muscle.
 Fascia transversalis - extraperitoneal tissue
 Parietal peritoneum.
Advantages: Good exposure for -
1. Gallbladder.
2. Common bile duct (CBD).
3. Hepatic duct.
4. Right lobe of liver.
Indication:
1. Cholecystectomy.
2. Choledochotomy or choledocholithotomy.
3. Right hepatic lobectomy.

12. A 60 years old man came to surgery ward with absolute constipation, gradual distension of the
abdomen for 4 days. Plain X-ray abdomen shows pneumatic tire like shadow arising from left lower
abdomen.
a) Tell your diagnosis?
Volvulus of sigmoid colon.
b) Tell the predisposing factors/causes of this condition.
Causes of sigmoid volvulus :
a) Bands/adhesions
b) Long pelvic mesocolon
c) Narrow attachment of pelvic mesocolon
d) Overloaded pelvic mesocolon
e) Constipation
f) High residual diet
c) Tell treatment plan of this condition.
Treatment:
Resuscitation followed by laparotomy and further treatment depends on peroperative
findings
 If the bowel is viable: Resection & fixation of the sigmoid colon to the posterior abdominal
wall and end to end anastomosis.
 If bowel is not viable:
 Hartmann's procedure (Sigmoid colectomy with anastomosis).
 Paul Mikulicz procedure.

Isfaqure rahman �� -5- tmc-9

13. How will you manage a patient of upper GIT bleeding with shock?
A. Immediate treatment (Resuscitation):
a) Immediate hospitalisation and bed rest.
b) Blood should send for grouping & Rh typing & cross matching.
c) Blood volume should be restored with colloid or crystalloid solution as well as blood.
d) Injection of H2 blocker (e.g. ranitidine) or proton pump inhibitor (e.g. pantoprazole).
e) Inhibitors of fibrinolysis (e.g. aminocaproic acid, tranexamic acid).
f) If intractable pain - Injection morphine.
g) O2 inhalation if the patient is in shock.
h) Close monitoring of -
 Pulse.
 Blood pressure.
 Central venous pressure.
 Urine output.
 Hematocrit value.
B. Further treatment:
 Transfer patient to intensive care unit (ICU).
 Antibiotics.
 Treatment of complications like sepsis, DIC, ARDS
C. Specific treatment: Open surgery (laparotomy) [one of the following procedure is done]
 Under running of the ulcer bed
 Ligation of gastroduodenal artery,gastrectomy,ligation of varices with devascularisation.
14. Tell the name of common incisions that usually made in surgery OT with indication.
Same as question no. 2
15. A 2 days old male baby brought to you with no passage of stool since birth. On examination his
abdomen is found relatively distended and has got no anal orifice.
a. Tell your clinical diagnosis?
Imperforated anus (Anorectal malformation)
b. What investigations do you suggest & why?
i. Prone crosstable lateral X ray view
ii. USG of whole abdomen
iii. Invertogram (to identify whether it is low variety or high variety )
 Low variety : Rectal pouch is distal to Stephen’s line (Pubococcygeal line)
Or
Distance between distal rectal gas shadow and opening of anus is < 1 cm.
 Intermediate variety : At the level of ischial spine (Kelly’s point)
 High variety : Proximal to Stephen’s Line (distance >1cm)
c. Tell the treatment options.
Mainly surgical :
 In low variety : Single stage reconstruction surgery under G/A.
 Anoplasty
 Anovestibuloplasty
 Anal dilatation
 In high variety : Transverse sigmoid colostomy

Isfaqure rahman �� -6- tmc-9

16. Tell the causes of per rectal bleeding in case of children & adult.
Causes of per rectal bleeding:

Children Adult Old age

 Rectal polyp (most common).  Haemorrhoids/piles.  Colorectal carcinoma.
 Intussusceptions.  Inflammatory bowel disease.  Diverticular disease.
 Meckel's diverticulum.  Colitis:  Colitis:
 Arterio-venous malformation  Infective colitis.  Ischemic colitis.
 Bleeding disorder  Radiational colitis.  Radiational colitis.
 Angiodysplasia.  Rectal ulcer.
 Carcinoma of rectum.

17. In the month of Ramadan, a fasting male of 40 years experienced- sudden excruciating pain in upper
abdomen at noon. On examination his abdomen is distended & rigid.
a. What might be the cause?
Perforation of gas containing hollow viscus
b. What investigation do you like to do for confirmation of your diagnosis?
Plain X ray of abdomen AP view in erect posture including both dome of the diaphragm.
c. How will manage the patient?
A. Immediate resuscitation (Bed side management):
a) Admission in the hospital.
b) Nothing by mouth.
c) Nasogastric suction.
d) Intravenous fluid administration (Ringers Lactate).
e) Parenteral antibiotic.
f) Parenteral H2 receptor blocker (e.g. ranitidine) or proton pump inhibitor (e.g. omeprazole,
pantoprazole).
g) Analgesics (e.g. tramadol hydrochloride, antispasmodic etc.).
h) Catheterization.
B. Surgery: Laparotomy with repair of perforation by intracorporeal suturing with omental patch
thorough peritoneal toileting (by NS – 2L).

18. Define colostomy. Tell the differences between colostomy & ileostomy.
A colostomy is an artificial opening made in the large bowel to divert faces and flatus to the exterior, where
it can be collected in an external appliance.

Colostomy Ileostomy
Large gut Small gut
Solid contents comes out Liquid contents comes out
Transverse ,sigmoid colon Ileum
Skin excoriation present Absent
Left iliac fossa Right iliac fossa

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19. Tell the cardinal features of acute intestinal obstruction. How will you differentiate small gut
obstruction from large gut obstruction?
Cardinal features of acute intestinal obstruction :
 Abdominal Pain
 Vomiting
 Distension
 Absolute constipation

Traits Small gut obstruction Large gut obstruction

Clinical :
1) Mode of onset Acute Chronic or acute on chronic.
Central severe colicky abdominal Start at lower abdomen, less severe
2) Pain
pain. colicky.
Late vomiting with smell of faces
3) Vomiting Early and profuse.
(faeculent)
4) Abdominal distension Central, minimal, late. Peripheral, pronounced, early.
5) Dehydration Rapid & marked due to vomiting. Often absent.
6) Absolute constipation Late Early.
7) Visible peristalsis Step ladder pattern in umbilical area. Peristalsis from right to left.
Multiple air fluid level present
Peripheral & shows haustral
Radiological centrally and lie transversely.
folds.
Jejunum - Valvulae conniventes.

20. What do you mean by herniotomy, herniorrhaphy & hernioplasty.

Herniotomy:
Dissecting out and opening the hernial sac, reducing any contents and then trans-fixing the neck of
the sac and removing the remainder.
Or
Cutting the hernial sac.

Herniorrhaphy:
It consists of the excision of the hernial sac plus repair of the stretched internal (deep) inguinal ring
and the transversals fascia and further reinforcement of the posterior wall of the inguinal canal.
Or
Repairing of hernia only by suture.

Hernioplasty:
If the gap in the posterior wall of inguinal canal is repaired by synthetic prolene meshwork, it is
called hernioplasty.
Or
Repairing of hernia by prolene mesh.

21. A baby of 4 weeks present with projectile, non-bilious vomiting after every feed
a) Tell your diagnosis.
Infantile hypertrophic pyloric stenosis
b) What investigation you need to confirm diagnosis?
USG of whole abdomen – shows Doughnut sign .

Isfaqure rahman �� -8- tmc-9

22. Classify hemorrhoids. How will you manage a case of 3° hemorrhoid?
Hemorrhoids are cushion of submucosal tissue containing venules, arterioles, and smooth muscle fiber.
Classification 1
a) External haemorrhoid
 Below the dentate line & covered by skin
b) Internal haemorrhoid
 Above the dentate line & covered by mucous membrane
c) Interno-external
 Together occurs & covered both mucous membrane & skin
Classification 2
A. Primary haemorrhoid
 located at 3,7,11 O’ clock position related to the branches of the superior haemorrhoids vessel
which divides on the right side into two ; left side it continue as one
B. Secondary haemorrhoid
 one which occurs between the primary sites
Classification 3
1) 1st degree: bleeds only , no prolapse (within rectum)
2) 2nd degree: prolapse but reduce spontaneously
3) 3rd degree: prolapse and have to be manually reduced
4) 4th degree: permanently prolapse (never goes inside)
Management of 3rd degree haemorrhoid :
Clinical feature :
Symptoms :
1) Patient may feel a large mass coming down through the anal canal which cannot be reduced
2) Severe, constant, unremitting pain
3) A mucoid discharge is usually present
4) Pruritus may be present following discharge
5) Per rectal bleeding during defecation
Signs :
1) A large haemorrhoid protruding from the anal orifice is seen
2) The pile shows gross odema and later ulceration
3) Oedema on anal margin may be present
4) Tenderness is present
5) D/R/E the thrombose part can be felt with the fingers
Treatment
a) Symptomatic treatment
1) Bed rest
2) Analgesic to relieve pain
3) Frequent hot hip bath
4) Warm saline compression with firm pressure usually cause the pile mass to shrink considerable
within 3-4days
5) Appropriate antibiotics to prevent infection
6) Steroid ointment reduce inflammation

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 b) Surgery
1) Longo operation
2) Ligation and excision of pile
3) Haemorrhoidectomy if necessary
23. Define hydrocele? How will you differentiate infantile hydrocele from inguinal hernia.
Hydrocele : Abnormal collection of serous fluid in a part of processus vaginalis usually the tunica vaginalis.

Traits Inguinal hernia Hydrocele

Hernia is a protusion of viscus or part Abnormal collection of serous fluid

1) Definition of viscus through an abnormal opening in some part of processus vaginalis
in the walls of its containing cavity usually the tunica
2) Region /site Inguinoscrotal Scrotal
3) Get above the
Not possible Possible
swelling
4) Reducibility Present Absent
5) Consistency Variable Cystic
6) Transillumination Negative Positive

24. A 45 years old man presents with epigastric fullness & vomiting after meals. On examination he is ill
health & visible peristalsis is present from left to right across his upper abdomen.
a. What is your clinical diagnosis?
Gastric Outlet Obstruction due to pyloric stenosis
b. How will you investigate such a case?
1) Upper GI endoscopy with biopsy of the area around the pylorus to exclude the malignancy
2) Barium meal x-ray of the stomach and duodenum with the duodenal cap series:
 Absence of duodenal cap
 Dilated stomach where the greater curvature is below the level of iliac crest
 Mottled stomach
 Barium will not pass into duodenum
Routine investigation :
1) TC & DC of WBC , ESR, Hb%
2) Blood urea, serum creatinine
3) Blood sugar
4) Serum electrolytes
5) X-ray chest PA view
6) ECG
c. How will prepare the patient for surgery?
Preoperative preparation for surgery :
a) Correction of dehydration: IV normal saline
b) Correction of electrolyte imbalance : IV normal saline supplementation of K+
c) Correction of anaemia by BT
d) Correction of hypoproteinemia by high protein diet , amino acid / human albumin infusion
e) Gastric lavage before each feed 3 days prior to surgery :

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 Fluid , suction –> residual food particles wash out —> Normal
1st day saline 200ml –>wait for 10-15 mins then suction –> continue upto
clear fluid comes out
 Normal highly nutritious clear soup (low residual diet)
which will be given before 30 mins in each lavage as liquid
2nd day
food pass within 30mins
 Daily 3-4 times gastric lavage
 Day before operation NPO
3rd day
 Suction continues

Aims of stomach preparation before operation

1) Reduce the size of stomach
2) Increase the toxicity of stomach
3) Decrease the mucosal oedema
Operative procedure :
1) Bilateral truncal vagotomy with gastrojejunostomy
2) Highly selective vagotomy with gastrojejunostomy
3) Highly selective vagotomy with pyloric dilatation
4) Endoscopic treatment with ballon dilatation
5) Occasionally duodenal stent insertion will be considered in specialist center

25. Tell the common sites & complications of peptic ulcer disease.
Common sites of PUD :
1) Anterior wall of first part of duodenum {if post wall then gastroduodenal artery erosion occurs}
2) Stomach (lesser curvature)
3) In the lower oesophagus
4) Gastro jejunostomy stoma
5) Meckel’s diverticulum {Criteria – 2 % population, 2 inches in length, within 2 feet of ileocaecal valve}

Complication of PUD :
A. Acute :
 Perforation leads to peritonitis
 Bleeding : haematemesis or malena
B. Intermediate : Residual abscess
C. Chronic :
 Scaring , swelling & stenosis leads to Gastric Outlet Obstruction
o Pyloric stenosis
o Tea pot deformity (in gastric ulcer)
o Hour glass contracture (in gastric ulcer
 Penetration into surrounding viscera eg. Liver & pancreas
 Malignant transformation usually into adenocarcinoma of stomach
26. Define phimosis & paraphimosis. Tell the treatment options of them.
Phimosis : Inability to retract the prepucial foreskin due to narrowing of the prepucial orifice.
Paraphimosis : Inability to place back (cover) retracted prepucial skin over the glans penis .
Treatment :
 Ice bag, gentle manual compression and injection of a solution of hyaluronidase in normal saline
 Circumcision if careful manipulation fails
 A dorsal split of prepuce under local anesthesia in an emergency

Isfaqure rahman �� - 11 - tmc-9

27. Tell the advantages & disadvantages of minimal access surgery.
Advantages of MAS
1) Decrease in wound size
2) Reduction in wound infection , dehiscence, bleeding, herniation & nerve entrapment
3) Decrease in wound pain
4) Decrease wound trauma
5) Decrease heat loss
6) Improved mobility
7) Improved vision
Limitation of MAS
1) Reliance on remote vision and operating
2) Loss of tactile feedback
3) Dependence on hand eye movement
4) Difficulty with haemostasis
5) Reliance on new technique
6) Extraction of large specimens.

28. Tell the D/D of lump in epigastric region. What the clinical features of carcinoma of stomach?
D/D of epigastric lump :
1) Carcinoma of stomach
2) Carcinoma of head of pancreas
3) Enlarged left lobe of liver
4) Pancreatic pseudocyst
5) Colonic growth (transverse colon)
6) Enlarged lymph node

Clinical feature of Ca stomach :

Symptoms :
a) Recent onset dyspepsia over age of 40 years or persistent dyspepsia of any age.
b) Epigastric pain not responds to treatment and no periodicity. 3) Early satiety, bloating, epigastric
fullness
c) Anorexia
d) Vomiting with features of gastric outlet obstruction.
e) Dysphagia
f) Weight loss.
g) Lump in the epigastrium.
h) Haematemesis & melaena
i) Cough (if lung metastasis).
j) Generalized bone pain (if bone metastasis).
Signs :
1) Wasting/cachexia
2) Epigastric tenderness.
3) Epigastric mass
4) Anaemia (due to chronic bleeding from carcinoma or lack of protein and iron in diet)
5) Jaundice (due to secondary deposits in liver)
6) Abdomen may be scaphoid with wrinkled and inelastic skin or distended from ascites (due to
carcinomatosis of peritoneum).
7) Troisler's sign: A visible as well as a palpable mass of lymph nodes in left

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 8) Supraclavicular fossa (Virchow's gland)
9) Succussion splash if pyloric obstruction is present
10) Krukenberg's tumour - Metastasis in ovary.
11) DRE- Findings of metastatic deposits (Blumer's shelf)
12) Non-metastatic effects:
a) Trousseau's sign → Thrombophlebitis of the superficial veins of legs.
b) Deep vein thrombosis
29. How will you give preoperative order for elective major surgery?
Pre-operative order for elective major surgery :
 Nothing by mouth from 12 midnight today.
 Please take informed written consent.
 Please clean & shave the operative area.
 Please open an IV channel with infusion Hartsol (1000cc) @10-15 d/min.
 Please send the patient to OT at 8 AM tomorrow morning
 Please give Inj. Ceftriaxone (1 gm) IV before OT.

30. A 4th year university student got admitted into surgery ward with the complaints of pain on
defecation, bright red blood on stool, mucus discharge & constipation.
a) Tell the most likely diagnosis?
Acute anal fissure
b) Tell the treatment options of above condition.
A. Conservative treatment
1) Fiber rich diet (Vegetables,fruits, brown rice)
2) Stool softeners
3) Bulk forming agents (pytlum hink, bran).
4) Adequate water intake
5) Warm bath & topical local anaesthetics agents
6) Anal dilators (little effect).
7) Chemical sphincterotomy by Nitric oxide donors Schilefletch
 Topical nitroglycerine 0.2% appliot 2-3 times daily
 Diltiazem (2%) applied twice daily
 Botox (Botulinum toxin) 10-100units in either divided or single dose injected into the
internal sphincter

B. Operative measures (if conservative treatment fails & in chronic case) :

 Forceful manual (four or eight digit) sphincter dilatation under general or regional
anesthesia (is unpopular now).
 Lateral anal sphincterotomy (good for acute case).
 Anal advancement flap.
 Dorsal fissurectomy and sphincterotomy (good for chronic case)
31. Tell the early features of rectal diseases. What are the positions of D/R/E?
Main symptoms of rectal disease :
 Fresh blood per rectum.
 Altered bowel habit
 Mucus discharge.
 Tenesmus.
 Prolapse.
 Proctalgia (pain).

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Position of the patient
1) Left lateral position (common).
2) Right lateral position.
3) Dorsal position in ill patients.
4) Knee elbow position.
5) Lithotomy position.
32. Tell the common causes of neonatal intestinal obstruction. Tell the treatment options of
Hirschprung's disease.
Causes of neonatal intestinal obstruction:
1) Congenital atresia and stenosis of Duodenum, jejunum, ileum, ascending colon, or multiple sites
2) Cystic fibrosis.
3) Intestinal malrotation with midgut volvulus (Volvulus neonatorum)
4) Alimentary tract duplications.
5) Meconium ileus.
6) Hirschsprung's disease.
7) Anorectal malformations: Imperforated anus.
8) Necrotising enterocolitis.
9) An incarcerated inguinal hernia.
Treatment of Hirschprung’s disease :
a) Neonate : Laparotomy & biopsy
b) Child (1st Stage) : Transverse colostomy
c) After 6 months (2nd stage) : Ressection pull through
d) 3rd stage : Colostomy closure
Single stage treatment : Transanal Endorectal Pull Through (TEPT)
33. A young lady of 20 years presents to you with pain in her right lower abdomen, nausea & low grade
fever for last 20 hours.
a) Tell your possible diagnosis?
Acute pancreatitis
b. How will you differentiate acute appendicitis from ruptured ectopic pregnancy?
By – pregnancy test & hcG test
34. Tell the clinical features of perforated peptic ulcer disease.
Clinical feature of PUD :
Symptoms
1) Sudden onset severe upper abdominal pain in the epigestrium initially, later in the right side abdomen
and finally becomes generalized
2) Fever.
3) Nausea & vomiting may be present.
Signs :
 Patient is toxic, with tachycardia. hypotension & tachypnea
 Abdominal distension.
 Dehydration
 Shallow breathing (due to pain).
 Restricted abdominal movement (due to pain)
 Board-like rigidity of abdomen.
 Upper border of liver dullness is obliterated.
 Bowel sound is diminished or absent.

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Radiological findings perforated peptic ulcer: Free gas shadow under the right dome or both domes of the
diaphragm.
35. Tell the name of incisions for appendicectomy.
Incisions for appendicectomy :
1) Grid iron incision
2) Rutherford morrison muscle cutting incision
3) Lanz incision / transverse skin crease incision
4) Right lower paramedian incision
5) Lower midline incision

36. A middle aged male present with dysphagia which more to liquids, weight loss & regurgitation of
undigested foul-smelling foods. Barium swallow shows pencil tip lower oesophagus & absence of gastric
air bubble in upright position.
a) What is clinical diagnosis?
Achalasia cardia
b) Tell the name of gold standard diagnostic investigation.
Oesophageal manometry (gold standard)
c) Tell the treatment options
Treatment:
 Forcible dilatation:
o Plummer's pneumatic dilatation.
o Negus hydrostatic balloon dilatation.
 Surgery: Modified Heller's cardiomyotomy.
 Drugs:
o Botulinum toxin A.
o Nitroglycerine.
o Nifedipine.
37. Define acute abdomen. Tell common examples of it's that you had seen in surgery ward.
Acute abdomen is defined as sudden, severe, spontaneous, non traumatic disorder whose chief
manifestation is in the abdominal area and for which urgent operation may be necessary.
Common examples of acute abdomen :
a) Acute appendicitis
b) Acute cholecystitis
c) Acute pancreatitis
d) Peptic ulceration
e) Ulcerative colitis
f) A perforated gall bladder
38. Define & classify hypospadias. Tell the complications of its.
A hypospadias is a congenital malformation in which the external meatus opens on the underside of the
penis anywhere from just short of the normal site as far as back ot the perineum, while the ventral aspect of the
prepuce is poorly developed .
Classification :
a) Glandular hypospadias
b) Coronal hypospadias

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 c) Penile & penoscrotal hypospadias
d) Perineal hvpospadias
Complications:
1) Abnormal appearance of the penis.
2) Problems learning to use a toilet
3) Abnormal curvature of the penis with erection.
4) Problems with impaired ejaculation.
39. Name the incision that usually made in case of breast abscess. What herniorrhapy & hernioplasty?
Incision made on breast abscess – Radial incision
Herniorrhaphy – Repairing of hernia only by suture
Hernioplasty – Repairing of hernia by mesh.
40. A 30 years man with H/O PUD came to surgery ward with massive haematemesis and malaena. On
exam he is semiconscious with tachycardia & low BP. His abdomen exam was unremarkable
a) What immediate measures you will take to manage him?
Treatment of shock:
1) Stabilize the patient with initial resuscitation.
2) Maintenance of respiration.
3) Maintenance of circulation:
a. Plasma.
b. Normal saline.
c. Ringer's lactate.
d. Hartmann' solution.
4) Inotropic agents: Dopamine, dobutamine, nor-adrenaline.
5) Prevention of renal failure:
a. Catheterization of the patient & keeping urinary output above 50 ml / hour.
b. Diuretics if necessary.
6) Correction of acidosis (pH < 7.2) by 8.4% sodium bicarbonate solution.
7) Steroid is a life saving drug: 500-1000 mg of hydrocortisone can be given.
8) Antibiotics.
9) Treatment of underlying cause while resuscitation is underway.
10) Continuous monitoring of intra-arterial pressure, ECG, central venous pressure, cardiac output,
urine output, serial blood gases.
b) How will you monitor him?
Essential :
1) Pulse and blood pressure.
2) Urine output.
3) Pulse oximetry.
4) Electrocardiogram (ECG).
Additional :
1) Central venous pressure (CVP).
2) Invasive blood pressure.
3) Cardiac output.
4) Base deficit and serum lactate.

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41. Describe Kocher's incision.
It is an oblique incision, which begins in the midline below the xiphoid process and runs downwards and
laterally for 10 cm and 2.5 cm below and parallel to the right costal margin.
Steps of opening / Structures divided :
a) Skin.
b) Superficial fascia.
c) Medially :
 Anterior layer of rectus abdominis muscle.
 Rectus abdominis muscle.
 Posterior layer of Rectus abdominis muscle.
d) Laterally :
 External oblique muscle (downwards and medially) pockets directions.
 Internal oblique muscle (upwards and medially).
 Transversus abdominis muscle.
 Fascia transversalis - extraperitoneal tissue
 Parietal peritoneum.
Advantages: Good exposure for -
a) Gallbladder.
b) Common bile duct (CBD).
c) Hepatic duct.
d) Right lobe of liver.
Indication:
a) Cholecystectomy.
b) Choledochotomy or choledocholithotomy.
c) Right hepatic lobectomy.
42. A 2 years boy present with absence of right testis. He has also under developed right hemi scrotum.
a. Tell the sites to search for missing testis.
1) At the superficial inguinal ring.
2) In the perineum
3) At the root of the penis.
4) In the femoral triangle.
b. What complications may occur in future?
1) Infertility.
2) Malignancy: Seminoma.
3) Hernia: An associated indirect inguinal.
4) Testicular torsion.
5) Epididymo-orchitis.
43. Tell the common causes of intestinal obstruction in children & adult.
Common causes intestinal obstruction in children :
1. Congenital atresia and stenosis of- Duodenum, jejunum, ileum, ascending colon, or multiple sites.
2. Cystic fibrosis.
3. Intestinal malrotation with midgut volvulus (Volvulus neonatorum).
4. Alimentary tract duplications.
5. Meconium ileus.
6. Hirschsprung's disease.
7. Anorectal malformations: Imperforated anus

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 8. Necrotising enterocolitis.
9. An incarcerated inguinal hernia.
Common causes of intestinal obstruction in Adult :
A. Dynamic:
1) Intraluminal:
 Impaction.
 Foreign bodies.
 Bezoars.
 Gall stones.
2) Intramural:
 Stricture.
 Malignancy.
3) Extramural:
 Bands / adhesions.
 Hernia.
 Volvulus.
 Intussusception.
B. Adynamic :
1) Paralytic ileus.
2) Mesenteric vascular occlusion.
3) Pseudo-obstruction.
44. Tell the structure of an operation note after performing a major operation.
Operation note after appendicectomy/Major operation :
 Date of operation.
 Time of operation.
 Name of the doctor who conducted the operation.
 Name of the assistant (s).
 Name of the anaesthetist.
 Procedure of operation; With all aseptic precautions, appendicectomy was done. At first grid iron
incision is done. Then the abdomen is opened layer-by-layer. Then the base of the appendix is
identified. Base of the appendix and appendicular artery are ligated. Then the appendix is cut and
removed. After ensuring proper haemostasis, the abdomen is closed by layers.
45. A 30 years man with history of PUD came to surgery ward with massive hematemesis & malaena.
On examination he is semiconscious with tachycardia & low BP. His abdomen exam was unremarkable.
a) What immediate measures you will take to manage him?
Same as Q. No. 40
b) How will monitor him?
Same as Q. No. 40
46. Define & classify dysphagia.
Dysphagia is defined as difficulty in swallowing.
Types:
a) Oesophageal dysphagia
b) Oropharyngeal dysphagia

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47. Compare laparoscopic cholecystectomy with open cholecystectomy. Which one is superior & why?

48. A 60 years old female presented with bleeding per rectum, tenesmus & early morning diarrhea. On
D/R/E there was an ulcer 5 cm from the anal verge.
a) Tell your clinical diagnosis?
Ca rectum
b) How can you confirm your diagnosis?
Rigid sigmoidoscopy & biopsy (confirmatory)
c) Name the operation done for it.
 Upper 1/3rd : High Anterior resection
 Middle 1/3rd : Low anterior resection
 Lower 1/3rd : Abdominoperineal excision with permanent colostomy.

49. Define & classify fistula in ano. Tell the complications of perianal abscess.
A fistula in ano, or anal fistula, is a chronic abnormal communication, usually lined to some degree by
granulation tissue, which runs outwards from the anorectal lumen (the internal opening of fistula) to an external
opening on the skin of the perineum or buttock (or rarely, in women, to the vagina).
Types of fistula in ano:
A. Standard classification (Milligan Morgan )
1) Subcutaneous. (Commonest)
2) Low anal. (Common).
3) Submucous.
4) High anal.
5) Pelvi rectal.

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B. Park's classification:
1) Intersphincteric.
2) Transphincteric which may be high
3) Suprasphincteric.
4) Extrasphincteric.
C. Another classification:
1) Low level fistulas
2) High level fistulas
Complications of perianal abscess :
1) Resolution.
2) Recurrent abscess formation.
3) Horse shoe abscess.
4) Anal fistula.
5) Sinus formation.
6) Portal pyemia
50. Tell the difference between direct & indirect inguinal hernia.

Traits Indirect inguinal hernia Direct inguinal hernia

Any age, commonly infants and young
1. Age Elderly person
adults
2. Sex Male >>Female More in male
3. Side involved Unilateral Bilateral
4. Entry Through deep inguinal ring Through weak posterior wall
5. Exit Superficial inguinal ring Rarely superficial inguinal ring
6. Reducibility Gradually reduces Reduces immediately
7. Deep ring occlusion
Positive Negative
test
8. Obstruction &
Common Rare
strangulation

51. Define stoma. Name surgery where stoma is done. Tell the complications of stoma.
Stoma is an artificial opening or 'mouth like' to the exterior, the abdominal wall so as to drain the content
from the tubular structures inside, like bowel or ureter. It is done for diversion of urine or faecal matter in case
of malignancy, trauma, and sepsis or after surgery.
Surgery where stoma are done :
 Ileostomy
 Colostomy
 Vesicostomy
Complications of stoma:
a) Early complications:
 Stoma retraction.
 Stoma trauma.
 Mucocutaneous separation.
 Allergy to the appliance.
 Ischemia.
 Bleeding from the stoma edge

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 b) Late complications:
 Stoma prolapse.
 Stenosis and block.
 Paraostomal hernia.
 Skin excoriation.
 Infection either bacterial or candidial.
 Diarrhoea due to irritation.
 Leak due to improper fitting of the appliances, scar, irregularity of stoma,prolapse.
52. What do you mean by early & advance gastric carcinoma?
Early gastric cancer is defined as involvement of mucosa and/or submucosa only with or without involvement
of lymph nodes- T1+ any N.
Advanced gastric carcinoma is defined as involvement of muscularis and/or serosa with or without lymph
node involvement.
53. Define intussusception. Tell the aetiology & clinical features of its.
Invagination of one portion of the gut within an immediately adjacent segment is called intussusception.
Aetiological factors for intussusception:
a) Idiopathic.
b) Meckel's diverticulum
c) Polyp.
d) Duplication.
e) Henoch Schonlein purpura
f) Appendix.
g) Hyperplasia of Peyer's patches in the terminal ileum,
h) Peutz-Jeghers syndrome.
i) A submucosal lipoma or tumour.
Clinical feature of intussusception :
Symptoms:
1) Age : from 2 months to 2 years of age.
2) Episodes of screaming & drawing up of legs in a previously well male infant.
3) The attack lasts for few minutes and recurs repeatedly.
4) During attacks the child has facial pallor.
5) Between episodes the child may be listless.
6) Vomiting may or may not occur at the outset but becomes conspicuous & bile stained with time.
7) Initially, the passage of stool may be normal, whereas, later, blood and mucus are evacuated
(Redcurrant jelly) stool.
Signs :
1) Progressive dehydration.
2) Abdominal distension from small bowel obstruction will occur.
3) Palpable sausage-shaped mass in the right upper quadrant.
4) There may be an association of feeling of emptiness in the right iliac fossa
5) On rectal examination: Blood stained mucus may be found.
54. A 42 years old male on NSAID for knee joint pain, notice sudden, severe upper abdominal pain.
a. Tell the most common probable cause.
NSAID induced PUD.

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 b. How will you manage the case?

55. Tell the clinical features of intestinal obstruction.

Cardinal features of acute intestinal obstruction:
1) Severe colicky abdominal pain
2) Distension.
3) Vomiting.
4) Absolute constipation.
56. Tell the indications, advantages& disadvantages of upper midline incision.
Indications of upper midline incision: Operations done
1) Repair of perforation of gastric and duodenal ulcer.
2) Vagotomy with pyloroplasty.
3) Gastrojejunostomy.
4) Left hepatic-lobectomy.
5) Splenectemy.
6) Operation on the transverse colon, abdominal aorta or inferior vena cava
Advantages of upper midline incision:
a) Easy and quicker procedure.
b) This area is relatively less vascular. So bleeding is less.
c) Good and popular for emergency operation.
Disadvantages of upper midline incision:
a) Delayed healing.
b) Chance of wound dehiscence.
c) Post-operative incisional hernia is more.
57. How will you differentiate undescended testis from ectopic testis?

Undescended testis Ectopic testis

1) The testis is arrested in its normal path of descent 1) Testis deviates from its normal path of descent

2) Usually undeveloped testis 2) Fully developed testis

3) Shorter length of spermatic cord 3) Longer length of spermatic cord

4) Poor spermatogenesis 4) Spermatogenesis is perfect

5) Associated with indirect inguinal hernia 5) Not associated with indirect inguinal hernia.

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58. Tell the causes of lump in right iliac fossa. How will you manage such a case?
Causes of lump in right iliac fossa:
1) Appendicular mass.
2) Appendicular abscess.
3) Ileo-caecal tuberculosis.
4) Carcinoma of caecum.
5) Cohn's disease (terminal ileitis),
6) Iliac lymphadenopathy.
7) Iliac artery aneurysm.
8) Psoas abscess.
9) Chondrosarcoma or osteoma of the ilium.
10) Actinomycosis.
11) Spigelian hernia.
12) Ruptured epigastric artery.
13) Ectopic kidney.
14) Kidney transplant.
15) Retroperitoneal tumour.
Female :
1) Ovarian cyst/ tumour.
2) Fibroid.
Treatment of Appendicular lump : Standard treatment is the conservative Ochsner- Sherren regimen. It is
as follows-
1) Complete bed rest.
2) Temperature, blood pressure, pulse chart.
3) Marking the mass to identify the progression/regression.
4) Nothing by mouth until further order is given.
5) Nasogastric suction in each hour.
6) Intravenous fluid and electrolytes.
7) Broad spectrum parenteral antibiotics – Metronidazole with ampicillin or gentamicin or cephalosporin.
8) Analgesics with H2 receptor blocker
a. Tramadol hydrochloride.
b. Pethidine.
c. Antispasmodic - Hyoscine-N-butyl bromide.
9) On complete recovery, the patient is discharged with advice for appendicectomy after 4 to 6 weeks
(interval appendicectomy).

59. Define phimosis. Tell the complications of it's, if not treated properly.
Phimosis : Inability to retract the prepucial foreskin due to narrowing of the prepucial orifice.
Complications :
a) Balanitis
b) Posthitis
c) Paraphimosis
d) Penile carcinoma
e) Voiding dysfunction

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60. Tell the steps of SPC by pfannestiel incision with indications.
Pfannenstiel incision :
Steps of opening / Structures divided:
1) Skin.
2) Superficial fascia
3) Linea alba
4) Anterior layer of rectus sheath
5) Rectus abdominis muscle
6) Fascia transversalis.
7) Extraperitoneal tissues.
8) Parietal peritonetm.
Indications:
1) Operations on the urinary bladder.
2) Prostatectomy.
3) Caesarean section.
4) Abdominal hysterectomy
5) Operation on the ovaries and fallopian tubes.

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 Surgery Paper-I
Board A
(Principles of surgery, Vascular Diseases, Anesthesia, Radiology, Radiotherapy, Blood transfusion)

1. Define infusion & transfusion with examples.

Infusion :
It is the process by which fluids or derivation of non biological origin are administered into the
body.
Example : Isotonic Saline & Hypertonic Saline.

Transfusion :
It is the process or medical treatment to replace the blood or portion of the blood lost through
injury,surgery or disease.
Example ; Blood transfusion, plasma.

2. Tell the clinical features of acute lower limb ischemia. What are the investigations will you suggest
for the diagnosis of such case?
Clinical feature of Acute lower limb ischaemia :
 Pulselessness
 Pain
 Pallor
 Paraesthesia
 Paralysis
 Poikilothermic
Investigation :
a) General :
 Blood for TC,DC,Hb % , ESR.
 Serum lipid profile
 Blood & urine sugar.
 ECG .
b) Specific :
 Doppler USG
 Angiography
 Digital Subtraction Angiography
 MRI
 Biopsy
3. A 30 years old man following RTA got generalized abdominal distention & came to you rapid &
thready pulse & low blood pressure
a) What type of shock developed here?
Hypovolaemic Shock.
b) How will you resuscitate the patient?
The patient should be treated according to the ATLS protocol :
i. Primary survey & simultaneous resuscitation :
 Airway
 Breathing and control of spine
 Circulation and control of haemorrhage
 Neurological assessment
ii. Secondary survey
iii. Definitive care
But the main focus in such cases is the control of haemorrhage and body fluid replacement of the lost
blood.

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4. Define & classify fistula. Give example of some common acquired fistula.
Fistula is defined as a abnormal communication between two epithelial surface .
Classification :
A) Congenital fistula:
1. Tracheo-oesophageal fistula
2. Recto-vaginal fistula
3. Recto-urethral fistula
4. Patent ductus arteriosus
5. Pre-auricular fistula
6. Congenital fistula of lip
B) Acquired fistula :
1. Gastrocolic fistula
2. Colovesical fistula
3. Colocolic fistula
4. Faecal fistula
5. Urinary fistula
6. Pancreatic fistula
7. Biliary fistula
5. Define and classify burn. How to assess size of burn?
Burn is defined as the injuries resulting from the application of dry heat or chemical substances to the
external/internal surface.
Classification of burn :
A. According to depth :
a) Superficial partial thickness burn (epidermis + papillary dermis)
b) Deep partial thickness burn (epidermis + upto reticular dermis)
c) Full thickness burn (whole of dermis)
B. Traditionally :
a) 1st degree burn (only epidermis)
b) 2nd degree burn (Epidermis & part of dermis)
c) 3rd degree burn (whole thickness of skin)
C. On the basis of contact :
a) Scald burn
b) Fat burn
c) Flame burn
d) Chemical burn
e) Electrical burn
f) Cold injury
g) Frictional injury
Assessment of burn :
1) Head and Neck =9%
2) Front of Chest & Abdomen = 9 x 2 = 18%
3) Back of chest and Abdomen = 9 x 2 = 18%
4) Upper limb = 18 x 2 = 36 %
5) Lower limb = 18 x 2 = 36 %
6) Perineum =1%
Total = 100 %

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6. During blood transfusion, a patient notice fever with rigor, back pain & shortness of breath
a) What could be the underlying cause?
Mismatched blood transfusion .
b) How will you manage such case?
Management :
a) First immediately stop the blood transfusion
b) Check vital signs of patient
c) Inj. Hydrocortisone
d) Inj. Calcium gluconate
e) Maintain IV access
f) Give IV fluid.
g) Monitor urine output
7. What do you mean by intermittent claudication? How will you manage a case PVD due to Buerger's
disease?
Intermittent claudication occurs as a result of anaerobic muscle metabolism & is classically described as
debilitating cramp-like pain felt in the muscles that is -
a) Reliably brought on by walking.
b) Not present on taking first step.
c) Reliably relieved by rest both in the standing & sitting positions; usually within 5 minutes.
d) Most commonly felt in the calf but can affect the thigh or buttock.
Treatment of PVD due to Buerger’s disease :
A. General treatment:
a) Stop smoking.
b) Nutritious diet & vitamin supplements.
c) Care of limb / foot:
 Wearing soft shoes & socks.
 Keeping the feet dry.
 Careful pairing of toe nails.
d) Regular exercise within the limit of claudication pain.
e) Burger's exercise : Raise the limb for 2-3 minutes, then down for 5-10 minutes, and then flat
on the bed for 10 minutes. Exercise is done for 2-3 times in a day.
f) Drug treatment:
 Pentoxyphylline 400 mg twice daily; This has been claimed to improve microcirculation by
reducing the blood viscosity.
 Clistasole 100 mg twice daily; This is a phosphodiesterase inhibitor and improves micro
circulation.
 Analgesics: For rest pain NSAIDs like Aceclofenac (100 mg/day) may be given.
 Low dose aspirin; It may be given for its antithrombotic activity. But if surgical treatment
is contemplated aspirin should be withdrawn at least 72 hours before operation.
g) Broad spectrum antibiotic (if ulcer & gangrene).

B. Specific treatment: It depends on the situation.

1) Burger's disease with rest pain :
 Bilateral lumbar sympathectomy. If fails- Amputation.
2) Burger's disease with superficial ischaemic ulceration:
 Bilateral lumbar sympathectomy with local care of ulcer.
3) Burger's disease with gangrene in the great toe on foot:
 Bilateral lumber sympathectomy with below or above knee amputation.

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8. Define & classify haemorrhage. Tell some technique that controls haemorrhage during operation.
Haemorrhage is defined as the escape of blood from the blood vessels to the exterior.
Classification of haemorrhage :
A. According to duration :
 Primary haemorrhage
 Reactionary haemorrhage
 Secondary haemorrhage
B. According to source :
 Arterial
 Venous
 Capillary
C. According to visibility :
 External
 Internal
D. According to chronicity/mood :
 Acute
 Chronic
Techniques that controls haemorrhage during operation:
 Pressure bandage/packing
 Position and rest
 Holding the bleeding vessel by haemostatic forcep
 Ligature of bleeding vessels by suture material
 By diathermy.
9. Compare general anaesthesia with subarachnoid block. Which one is superior & why?

10. Define & classify haemorrhage. Tell some technique that controls haemorrhage during operation.
Repeat
11. Classify X-ray with example. Tell the importance of plain X-ray of abdomen in surgical practice.
Classification of x – ray :
a) Plain X –ray :
 Plain X ray of whole abdomen
 Plain X ray of KUB region
b) Contrast X – ray :
 Barium swallow (for oesophagus)
 Barium meal (for stomach)
 Barium follow through (for small intestine)
 Barium enema. ( for large intestine)

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Importance :
a) To diagnose/see the free gas shadow below diaphragm in case perforation of gas containing hollow
viscus.
b) To see multiple air fluid level in case of Intestinal Obstruction.
c) To see calcification.
12. What are the general anaesthetic triads? How long is routine pre-operative fasting time & why?
General anaesthetic triads :
 Amnesia (Unconsciousness)
 Analgesia (Pain relief)
 Adequate muscle relaxation.
Pre operative fasting time :
a) Below 1 year :
 No breast milk before (2-3) hours
 Clear fluid given 3 hours before surgery
b) Above 1 years :
 No feeding (6 hrs) before surgery
 Clear fluid 3 hours before surgery
c) Adult :
 Avoid solid diet 6 hours before surgery
 Fluid 4 hours before surgery.
Why??
To avoid Acid Aspiration Syndrome.
13. Define sterilization? Tell the common methods of sterilization. Tell the principles of autoclaving.
Sterilisation is the complete destruction of all viable micro-organism including spores, virus and
mycobacteria.
Method of sterilisation:
A) Physical method
 Heat :
 Dry heat(hot air oven, incineration)
 Moist heat(water bath,steaming,tyndallisation ,autoclave)
 Radiation: X ray,UV-ray,gamma ray
 Filtration
B) Chemical methods
 Phenol
 Cresol
 Dettol
 Acid and alkali
 Halogen
 Formaldehyde
 Gluteraldehyde
 Ethylene oxide
 Detergent
 Oxidising agent
Principles of autoclave:
1) At atmospheric pressure water boils at 100 o C.
2) With rise of the pressure, the boiling point of water also rises.
3) Steam under pressure unmixed with air has more temperature than that mixed with the air .

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 4) Steam under pressure has more penetratring power. This is due to the fact, that steam condenses to
water on contact with materials.
5) During condensation of steam water, a large amount latent heat is liberated thus increasing the efficacy
of sterilisation.
Temperature-121o C
Pressure-15 lb/sq inch
Time-15 minutes

14. What are the investigations will you advice for GA fitness of a 50 years Hypertensive male planned
for cholecystectomy?
Investigation for general fitness for General Anaesthesia :
 Complete blood count
TC/DC,ESR,Hb%
 Urine RME
 Blood sugar level
 Serum electrolyte
 Serum creatinine
 USG of abdomen
 Chest X ray
 ECG
15. Tell the transfusion order for a single unit of a blood.
Transfer of 1 unit of crossed-matched fresh human blood 5ml/min for first 10 minutes, wait for any
reaction,if there is no reaction continuous blood for 20 drops/min
If there is any reaction :
 Stop the transfusion immediately
 Compare patient profile with donor blood
 Call for the duty doctor
 For hypersensitivity
Rx: Inj dexamethasone
Inj chlorpheniramine
16. Define wounds. How will you manage a lacerated wound following RTA?
Wound is defined as breach in the (anatomical) continuity of any living tissue due to any trauma and violence.
Classification :
A) According to contamination:
 Clean/tidy wound
 Uncleaned/untidy wound
B) According to duration
 Acute – close, open,complex,injury to special tissue
 Chronic – ulceration,pressure sore
C) Surgically:
 Clean wound – Hernioplasty,Excision, Thyroidectomy
 Clean contaminated wound – Appendicectomy, Gastrojujenostomy
 Contaminated wound - Acute abdominal condition
 Dirty infected wound – Abcscess drainage,Perforated viscous with peritonitis, Faecal contamination.

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Management of lacerated wound following RTA :
a) Examine the whole patient according to ATLS principles.
b) The wound itself should be examined, taking into consideration the site & the possible structures
damaged.
c) A Bleeding wound should be elevated & a pressure pad applied. (Should not apply clamps blindly on
vessels).
d) Examination under adequate analgesia and / or anaesthesia (local, regional or general) is required
e) After proper assessment, cleansing.
f) Exploration and diagnosis.
g) Debridement.
h) Repair of structures.
i) Replacement of lost tissue where indicated.
j) Skin cover by flap or graft if required.
k) Skin closure without tension.
l) All the above measures should be taken with careful tissue handling and meticulous technique.
m) Proper antibiotic, anti-tetanus immunoglobulin and anti-gas gangrene serum if indicated.
17. What are the components of blood products? Tell some indications of blood transfusion in surgery.
Components of blood products :
1) Whole blood.
2) Blood components:
 Red cells.
 Platelets.
 White cells (buffy coat).
 Fresh frozen plasma.
 Cryoprecipitate.
3) Plasma products:
 Human albumin solution.
 Coagulation factor concentrate
 Immunoglobulin.
Indication of blood transfusion in surgery :
 Acute blood loss
 Perioprative anaemia
 Aplastic anaemia
 During major surgery like Abdiminoperineal surgery, Hepatobilliary surgery.
 Following severe burn
 ITP
 Acute leukaemia.
18. Compare FNAC with Trucut/corecut biopsy. Which one is superior & why?

Traits FNAC Truecut biopsy

1) Material Cells Tissue
2) Cost Minimal More exepensive
3) Anaesthesia No need Sometimes needed
4) Equipment Minimal Expensive
5) Sampling error Possible Rare
6) Scar Never Always

Truecut biopsy is better because hormone receptor status can be known, grading and differentiation of tumour
can be done.

Isfaqure rahman �� - 31 - tmc-9

19. Define ulcer. Tell the classification of ulcer according to edge with example.
An ulcer is a breach of continuity of covering epithelium (skin & mucus membrane) due to sloughing out of
necrotic tissue.
Classification according to edge:
 Slopping edge- non specific ulcer,healing ulcer (Arterial , Venous ulcer)
 Undermined edge- Tubercular ulcer
 Rolled out ulcer- Basal cell carcinoma(rodent ulcer)
 Punched-out edge- syphilitic ulcer,trophic ulcer
 Raised everted edge- squamous cell carcinoma, carcinomatous ulcer
20. What is Buerger's disease? How will you manage a case of limb ischaemia due to Buerger's disease?
It is one of the peripheral vascular disease characterised by the occlusion of small and medium sized arteries.
Clinical features:
 Thrombophlebitis of the deep and superficial vein
 Raynaud’s syndrome
 Intermittent claudication
 Rest pain
 Ulceration
 Gangrene
 Arterial pulsation absent
 Arterial bruit
 Slow capillary refilling
21. Define and classify anesthesia with examples.
General anaesthesia is defined as abolition of all sensation i.e pain, touch, temperature, posture with a state
of reversible loss of consciousness.
Local anaesthesia defined as the loss of sensation in a part or whole of the body without loss of consciousness.
Example-
 General anaesthesia –halothane
 Regional/local anaesthesia -
 Spinal anaesthesia (procaine , tetracain)
 Epidural anaesthesia(procaine)
 Surface/tropical anaesthesia(cocaine)
 Infiltrative anaesthesia (cocaine)
 Nerve block
Classification :
A. General anaesthesia-
 With controlled ventilation
 With spontaneous ventilation
B. Regional anaesthesia
 Central/Spinal neuronal block
 Epidural
 Subarachnoid
 Caudal
 Peripheral neuronal block
 Brachial plexus block

Isfaqure rahman �� - 32 - tmc-9

  Intercostal nerve block
 Pudendal block
 Local inflitrative

22. Define abscess. Tell the importance of pyogenic membrane in an abscess.

Abscess is defined as localised collection of pus caused by suppuration buried in a tissue, an organ or an
confined space.
Clinical features :
 Swelling
 Fever with chills and rigor
 Severe throbbing pain
 Redness
 Pointing tenderness
 Increase in local temperature

Importance of pyogenic membrane :

As the abscess expands, pyogenic membrane is rapidly replaced by granulation tissue which prevent systemic
invasion of bacteria.

23. Tell the classification of wound closure and healing with characteristics features.
Classification :
A) Wound closure :
 Primary: within 6 hours
 Normal
 Minimal scar
 Delayed primary: 48 hours-10 days of surgery
 Increase inflammation
 Proliferation
 Wound initially left open until healing condition favourable
 Secondary :10-14 days
 Wound left open
 Poor scar
B) Wound healing:
 Primary :
 Normal
 Minimal scar
 Delayed primary :
 Increase inflammation
 Proliferation
 Wound initially left open until healing condition favourable
 Secondary :
 Wound left open
 Poor scar

Isfaqure rahman �� - 33 - tmc-9

24. Tell the treatment modalities of malignant diseases. What do you mean by adjuvant and neo-
adjuvant therapy?
Treatment modalities of malignant disease :
 Surgery
 Chemotherapy: Adjuvant, Neoadjuvant
 Radiotherapy
 Immunotherapy
 Hormonal therapy
 Combined therapy
Neoadjuvant therapy:
Chemotherapy given to a cancer patient before the surgery in order to decrease the tumour size & invasion
for the aid of better surgery .
Adjuvant therapy:
Chemotherapy given to the cancer patient after the surgery in order to improve the outcome and decrease the
risk tumour relapse.
25. Define and classify fistula with examples.
Same as question no. 5
26. Classify suture materials with examples.
Classification of suture materials :
A) According to the source
 Natural –Silk, Catgut, Linen
 Synthetic –Prolene,Vicryl ,Vexon,PDS (Polydiaxanone suture )
B) According to absorbility:
 Absorbility: Catgut, Vicryl,Dexon, PDS
 Non absorbable: Prolene,Silk,Polythene
C) According to number of filament
 Monofilament :Prolene,PDS,Catgut
 Polyfilament :Silk,Vicryl,Dexon
D) According to relation with needle:
 Atraumatic
 Traumatic
27. A 25 years old girl developed septic abdomen following perforation of gangrene appendix &
emergency laparotomy was done
a) What type of surgical wound was here?
Dirty infected wound
b) Tell the possible complications of this patient.
Early :
 Wound infection
 Wound abscess
Late :
 Bacteraemia
 Septicaemia
 Shock

Isfaqure rahman �� - 34 - tmc-9

28. Tell average daily requirement of water & electrolytes of a healthy adult.
Water intake Water Output
Water from beverage = 1200 ml From urine = 1500 ml
Water from food = 1000 ml Insensible loss from skin and lung = 900 ml
Water from oxidation = 300 ml From faeces = 100 ml
Total = 2500 ml Total = 2500 ml

29. Define bed sore. Tell the risk factors & common sites of bed sore. Tell the types of anesthesia
practiced in your hospital with examples.
Bed sore is defined as tissue necrosis & ulceration due to prolonged pressure. It is the trophic ulcer with
bone at the base.
Common site :
 Occiput
 Scapula
 Over the shoulder
 Olecranon process
 Paravertebral area
 Ischium
 Sacrum
 Malleolus
 Heel
Risk factor : Patient commonly affected :
a) Old age
 Anaemia b) Bed ridden
 Injury c) Paraplegic
 Malnutrition d) Unconscious patient
 Moisture e) Hypotensive
 Pressure f) Patient with PVD
g) Immunocompromised

Pathophysiology :
Prolong weight bearing & pressure acts on bony prominence
↓
When this pressure exceeds normal capillary perfusion pressure (32 mm Hg)
↓
Occlusion and tearing of small blood vessel
↓
Reduced tissue perfusion
↓
Ischaemic necrosis
↓
Pressure sore

Isfaqure rahman �� - 35 - tmc-9

Types of anaesthesia practiced in our hospitals are :
 General anaesthesia –Halothane
 Regional/local anaesthesia -
 Spinal anaesthesia (procaine , tetracain)
 Epidural anaesthesia(procaine)
 Surface/tropical anaesthesia(cocaine)
 Infiltrative anaesthesia (cocaine)
 Nerve block

30. Tell comomon antiseptic solution used in general surgical practice.

Common antiseptic solution used in surgery are :
 Acid and alkali
 Formaldehyde
 Gluteryldehyde
 Bleaching powder
 Phenol
31. Tell the advantages of SAB over G/A.
Advantage of SAB over GA :
a) Patient remains conscious
b) Profound muscle relaxation (Adequate)
c) No chance of post-operative complication (Respiratory complication )
d) More reliable technique for below umbilical surgeries (lower abdomen and lower extremity)
e) Less operative haemorrhage
f) Economical.
32. A 45 years old diabetic lady presents a small painless swelling in her back for six months, which is
marble in shape, soft & adherent to skin pin-hole black spot at the centre of the swelling
a) What is your diagnosis?
Sebaceous cyst
b) How will you manage this condition?
Management :
 Incision and avulsion of the cyst content , cyst wall and all adjacent dead tissues.
 Control of DM.
 Proper antibiotic therapy after culture and sensitivity of pus.
 Regular dressing of the wound.
c) What precaution you will take during surgery?
a) Test for blood sugar level
b) Send the pus for C/S.
33. Tell indications of blood transfusion in surgical practice.
a) Acute blood loss
b) Preoperative anaemia
c) Symptomatic chronic transfusion
d) Exchange transfusion
e) Severe burn
f) ITP
g) Acute leukemia

Isfaqure rahman �� - 36 - tmc-9

34. What is Marjolin's ulcer? Tell the factors for persistence of a fistula or sinus.
Marjolin ulcer is defined as an aggressive type of squamous cell carcinoma presenting in a area of
previously traumatised chronically inflamed or scarred skin.
Factors for persistence of fistula and sinus :

Local Factors : Systemic Factors

a) Presence of foreign body or necrotic tissue a) Immunosuppression
b) Absence of rest b) Diabetes mellitus
c) Non dependent drainage or inadequate drainage c) Malnutrition
of pus. d) Drugs – Steroids, Cytotoxics
d) When the tract becomes epithelialised.
e) When a specific chronic infection is the cause.
f) Dense fibrous tissue around the wall of cavity and
tract preventing their collapse.

35. A 60 years old diabetic man presented with a painful swelling of the nape of the neck with foul
smelling multiple discharging sinus
a) What is your diagnosis?
Carbuncle
b) Tell the factors responsible for this.
 DM
 Obesity
 Poor hygiene
 Immunocompromised patient
 Chronic illness
 Age > 40 years
 Male usually
c) How will you treat the condition?
a) Incision and drainage of pus by cruciate incision and excision of all the dead tissue.
b) Control of the DM
c) Antibiotics
d) Regular wound dressing
e) If require, skin grafting.

36. Tell aetiology, common sites & management of cold abscess.

Aetiology of cold abscess :
 Staphylococcus
 Streptococcus
 Pneumococcus
 Haemophilus
 Mycobacterium tuberculosis
Common site of cold abscess:
 Axilla
 Intercostal space
 Groin
 Pott’s disease (Tb of spine)

Isfaqure rahman �� - 37 - tmc-9

Management of cold abscess :
a) General treatment :
 Anti-tubercular therapy
 Vitamins and minerals supplementation
b) Local treatment :
 If abscess is small ; subsides with general conservative treatment.
 If abscess is large ; aspirate
 If associated with glandular enlargement ; excision of whole lymph nodes

37. Tell the name of common operations that can be done under SAB.
Operations done under SAB :
1. Abdominal and vaginal hysterectomy
2. Caesarean section
3. Inguinal Herniotomy, Hernioplasty, Herniorrhaphy .
4. Haemorrhoidectomy
5. Prostatectomy
6. Appendicectomy
7. Lateral sphincterotomy
8. Perianal abscess drainage
9. Nephrolithotomy
38. A 26 years old lady of 60 Kg came to burn unit with the complaints of 30% flame burn 2 hours back
a) How will you resuscitate the patient by fluid?
By administrating body fluid (Parkland Regimen)
Total body fluid need = (4 x 60kg x 30%)
= 7200 ml
1st 8 hour = ½ of total = 3600 ml
2nd 8 hour = ¼ of total = 1800 ml
3rd 8 hour = ¼ of total = 1800 ml
c) Which burn patient needs hospitalization?
 Deep Partial Thickness Burn.
 Full Thickness Burn.
39. Define & classify shock with example.
Shock is defined as a systemic state of low tissue perfusion which is inadequate for normal cellular
respiration .
Classification :-
A. Hypovolaemic shock
 Haemorrhage
 Excessive body fluid loss (Diarrhoea, Burn, etc.)
B. Cardiogenic shock
 Myocardial Infarction
 Valvular Heart Disease
C. Obstructive shock
 Tension Pneumothorax
 Air Embolism
D. Distributive shock

Isfaqure rahman �� - 38 - tmc-9

  Septic shock
E. Anaphylactic shock
 Hypersensitivity reaction
40. Tell the causes of peripheral vascular diseases.
Causes of PVD :
a) Arterial stenosis & occlusion.
b) Embolism.
c) Aneurysm.
d) Burger's disease.
e) Raynaud's disease.
f) Raynaud syndrome.
g) Systemic causes of small vessel disease e.g. PAN, SLE.
h) Thrombosis:
 Superficial vein thrombosis (thrombophlebitis).
 Deep vein thrombosis (phlebothrombosis).
i) Varicose vein.
j) Arteriovenous fistula.
41. A 50 years old male underwent right hemicolectomy for carcinoma caecum. On 5th post operative
day he developed fever.
a) Tell probable cause of this condition.
Surgical site infection (It is a 2nd most complications following surgical procedure due to virulent
bacterial entry, altered wound environment and change in host defence.)
b) How will you examine the patient?
General:
 Ill looking and toxic
 Pulse, Temperature, Blood Pressure, Urine output
Systemic:
o Inspection : Abdomen is distended
o Palpation: tenderness present
o Percussion : Percussion note is tympanic
o Auscultation: bowel sound absent
43. Tell the surgical causes of shock. How will you monitor a shock patient?
Surgical causes of shock :
 Hypovolemia
 Cardiac failure
 Sepsis
Monitor of shock patient :
A. Essential :
 Pulse
 Blood pressure
 Urine output
 O2 saturation
 ECG
B. Additional :
 Central venous pressure
 Cardiac output
 Serum lactate

Isfaqure rahman �� - 39 - tmc-9

44. Define & classify cyst with examples .Tell the complications of sebaceous cyst.
Cyst is defined as collection of fluid in sac lined by epithelium and endothelium.
Classify:
A. Acc. to lining epithelium
a. True cyst :
 Sebaceous cyst
 Dermoid cyst
b. False cyst : Pancreatic Pseudocyst

B. Acc. to development
a. Congenital :
 Thyroglossal cyst
 Branchial cyst
b. Acquired :
 Hydatid cyst
 Epidermoid cyst
Complication of sebaceous cyst :
a. Infection  Abscess Ulcer Sinus
b. Haemorrhage
c. Torsion
d. Compression of adjacent structure
e. Obstruction
f. Calcification
45. Tell the features that give you clues about wound infection. Tell the risk factors for wound infection.
Features of wound infection :
1. Fever
2. Erythema (redness)
3. Oedema (swelling)
4. Increased pain
5. Loss of appetite
6. Malaise
7. Discharge pus from wound
8. Delayed wound healing
Risk factors of wound infection :
1. Poor circulation .
2. DM
3. Obesity
4. Immunosuppression by any disease or drugs
5. Malnutrition
6. Poor hygiene
46. Tell commonly used I/V fluid in surgery ward with indications.
Commonly used :
 Normal saline
 5% DA
 5% DNS
 Hartmann solution / Ringers lactate
 Cholera saline

Isfaqure rahman �� - 40 - tmc-9

Indications :
A. Normal saline
 Replacement of sodium in vomiting
 Post-operative daily supplement of Na+
B. 5% DA
 Shock
 Early post operative period
C. 5% DNS
 Correction of volume in hypovolemic shock
D. Hartmann solution
 Replacement of plasma loss
 Correction of hypovolaemia
47. Define & classify sinus with example. Tell the differences between sinus & fistula.
Sinus : It is defined as blind ending tract that connects a cavity lined with granulation tissue with an epithelial
surface .
Classification:
A. Anatomical sinus :-
 Paranasal sinus
 Cavernous sinus
B. Pathological sinus :-
1. Congenital :
 Pre-auricular sinus
 Post auricular sinus
 Urachal
 Coccygeal
 Sacral
2. Acquired :
 Pilonidal sinus
 Suture
 Actinomycosis
 Tuberculosis
 Chronic osteomyelitis
 Median mental sinus

Sl.
Criteria Sinus Fistula
no.
It is blind ending tract that connects a
An abnormal communication between
1. Definition cavity lined with granulation tissue with
two epithelial lined surface
an epithelial surface.
2. Tract Closed Open
3. Opening One opening Two openings

48. How will you prepare a diabetic patient for elective major surgery?
1. If controlled by diet :
o Measure blood glucose level 4 hourly .
o If blood glucose > 12 mmol/L start
 Glucose K+ insulin regimen .
2. If controlled by oral hypoglycaemic agents :
a) Admit patient (24 – 48) hours prior to surgery .

Isfaqure rahman �� - 41 - tmc-9

 b) Omit oral anti-diabetic drugs such as Metformin (24 hours) prior to surgery .
c) Monitor blood glucose (1-2 ) hourly .
d) If blood glucose >12 mmol/L  Glucose-Potassium Insulin regimen .
e) Operation should be scheduled at first operation in the morning .
f) Oral hypoglycaemic drugs resumed when eating post operatively .
3. If controlled by insulin :
a) Admit patient (24 - 48) hours prior to surgery.
b) Stop long acting insulin and start short acting insulin.
c) Operation should be scheduled first in the morning (Should not fast for long).
d) When NPO – IV infusion of insulin with dextrose is given.
e) On morning operation start Glucose K+ insulin regimen and continues upto 1st light meal
post-operatively .
f) Check CBC and S. Electrolytes regularly.
49. Tell the ideal time for stitch removal in different parts of the body.
Ideal time for stitch removal :
a) Face. = 2-3 days
b) Scalp. = 5 days
c) Neck. = 7 days
d) Upper limb = 7-10 days
e) Abdomen = 10 days
f) Groin = 7-10 days
g) Lower limb =14 days
50. Tell common tumors of skin. How will you clinically differentiate between BCC & SCC.
Common tumour of skin :
A. Epithelial :-
a. Benign : Papilloma, seborrheic keratosis.
b. Malignant : SCC, BCC
B. Melanocyte :-
a. Benign : Navei
b. Malignant : Melanoma
C. Skin adnexal tumor :-
a. Benign : Syringoma, Sebaceous adenoma
b. Malignant : Sebaceous carcinoma
D. Dermal tumor :-
 Fibroma, Neurofibroma, Hemangioma, Lymphangioma, Lymphoma

Sl. Criteria Squamous Cell Carcinoma Basal Cell Carcinoma

1. Site Skin of any site of body Upper part of face
2. Shape Irregular Circular
3. Lymphatic metastasis Occurs in 2% cases Rare
4. Rate of growth Slow growing Comparatively rapid
5. Radiotherapy Radio-resistant Radio-sensitive

51. Tell the steps of management of a lacerated wound following RTA.

Steps of management of a lacerated wound following RTA :
1. Examine the whole patient according to ATLS protocol .
2. Examine the wound itself, taking into consideration the site and possible structures damaged .
3. Bleeding wound should be elevated and a pressure pad should be applied.
4. If require examine/treat under anaesthesia.

Isfaqure rahman �� - 42 - tmc-9

 5. After proper assessment , clean the wound area.
6. Exploration and diagnosis.
7. Debridement of repair of damage structures.
8. If indicated replace lost tissue, skin cover by flap or graft.
9. Skin closure without tension.
10. If indicated proper antibiotic, anti-tetanus Ig & antigas gangrene is given.
52. Define cellulitis & boil. Tell the commonest organism responsible for cellulitis & boils.
Cellulitis is defined as the non suppurative inflammation of the skin and the soft tissue underneath.
Boil is defined as the acute staphylococcal infection of the hair follicles resulting in the localised
accumulation of pus and dead tissues.
Organism responsible are :
 Staphylococcus aureus
 Group A haemolytic streptococcus
53. Tell some important electrolytes present in body with normal value.
Electrolytes Normal value (mmol/L)
Na+ 135 - 145
K+ 3.5 - 5
Ca2+ 2 - 2.6
HCO3- 23 - 28
Cl- 98 - 106
Phosphate 36 - 92 IU/L

54. A young boy of 5 years underwent circumcision 4 hours back. Now, his parents bring him for profuse
bleeding from circumcision site
a) Tell your diagnosis?
Reactionary haemorrhage
b) How will you manage him?
First, carefully examine the operative site and access the anaemia, RR and other vital signs.
Then,
 Remove the dressings
 Open the layer of wound to relieve the tension.
 Taken to operation table.
 Evacuate the haematoma
 Secure the bleeding points
 Steroid to reduce oedema.
55. Tell the complications of burn.
Complications of burn :
A. Immediate :
 Shock
 Renal failure
 ARDS (Acute Respiratory Distress Syndrome)
 Pneumonia
 Hypothermia

Isfaqure rahman �� - 43 - tmc-9

 B. Delayed :
 Wound infection
 Septicaemia
 Cerebral damage
C. Late :
 Hypertrophied scar
 Keloid
 Marjolin’s ulcer
56. How will you prepare a patient for general anaesthesia?
Patient preparation for General Anaesthesia:
a) Assessment of patient; by taking history, examination and investigation.
b) Taking informed written consent.
c) Nothing per oral for 6 hours.
d) Opening and maintenance of IV channel.
e) Maintain fluid/electrolyte balance.
f) Clean and shave the operative area.
57. Tell the name of some contrast X-ray used in surgery. How will you prepare a patient for IVU?
Contrast X-ray used in surgery are :
i. Barium X-ray :
 Barium swallow x-ray
 Barium meal x-ray
 Barium meal follow through
 Barium enema
ii. Intravenous Urography
iii. Intravenous Pyelogram
Preparation of patient for IVU :
a) Low residue diet for 3 days
b) Tab. Ultra carbon; 2 tabs 3 times a day after meal for 3 days
c) Laxative 2 tab daily at bed time for 2 days
d) Tab promethazine HCl 1 tab twice daily for 3 days
e) Patient is sent for X ray on 4th day morning with
 Inj. Conray 45% 2 ampule
 Inj. Chlorpheniramine
 Inj. Dexamethasone
 Inj. Hydrocortisone
58. Tell the name of investigations that must be necessary for anaesthetic fitness.
Investigation for anaesthetic fitness :
a) Blood for TC,DC,Hb%, ESR
b) Blood sugar level
c) Serum creatinine
d) Urine R/M/E
e) Chest X ray
f) Electrocardiogram (ECG)
g) Echocardiogram
h) BT/CT.

Isfaqure rahman �� - 44 - tmc-9

59. Define burn. Tell the ABCDEF management of burn.
Burn is defined as the thermal injury resulting from the application of dry heat or chemical substances to
the external/internal surface of the body.
A – Airway control
B – Breathing and ventilation
C - Circulation
D - Disability and assessment of neurological status
E - Exposure and environmental control.
F – Fluid resuscitation
60. A 43 years old man got admitted with inability to swallow & to open mouth. He had history of
contaminated lacerated injuries in his left leg from RTA 10 days back
a) Tell your diagnosis with justification.
Tetanus
C/F :
 Dysphagia (inability to swallow due to muscle rigidity)
 Unable to open mouth due to locked jaw & Risus sardonicus
 H/O of RTA & contaminated lacerated wound, favourable for tetani spore to grow.
b) How will you treat the patient?
Treatment:
a) Isolation of the patient in quite calm & dark room.
b) Sedatives and muscle relaxants
c) Neutralising of circulating Ag by Ig (3000-5000) IU.
d) Antibiotics (Penicillin)
e) Local wound management :- debridement & cleaning of dead tissues.
f) Active or passive immunisation by Tetanus toxoid.

Isfaqure rahman �� - 45 - tmc-9

 SURGERY Paper-I
BOARD-B
(HBS & pancreas, Urology, Breast, Endocrine)
1. Classify gallstone. Tell the effects & complications of gallstone.
Classification of gall stone :
a) Cholesterol stone
b) Pigment stone :
 Black
 Brown
c) Mixed stone
Effects and complication of gallstone :
a) Biliary colic
b) Acute cholecystitis
c) Chronic cholecystitis
d) Biliary obstruction
e) Empyema of gallbladder
f) Mucocele of gallbladder
g) Gangrene
h) Carcinoma of gallbladder
2. Tell the treatment options of carcinoma breast. How will you council a patient for mastectomy?
Treatment options of carcinoma breast :
a) Stage I : Lumpectomy with 2 cm normal tissue. (wide local excision)
b) Stage II First do biopsy + 4 operations:
1. Lumpectomy + axillary lymph nodes dissection preserving pectorals major.
2. Simple mastectomy + axillary lymph nodes dissection preserving pectoralis major.
3. Patey's mastectomy (Conservative radical mastectomy).
4. Lumpectomy / simple mastectomy combined with radiotherapy (best treatment)
c) Stage IIII + IV: Palliative surgery- Simple mastectomy + Hormone therapy / chemotherapy.
Counselling of patient for mastectomy :
1. About the disease & its fate.
2. Proposed treatment.
3. Alternative & potential treatment.
4. Expected side effects of the treatment.
5. Management of the side effects.
6. Post-operative follow-up.
7. About post-operative radiotherapy/chemotherapy.
8. Prognosis of the treatment.
9. Consequences of no treatment at all.
10. Consent from the husband / authorised guardian.
3. A 16 years old girl presented with a firm nodule on left lobe of thyroid gland
a) How will you assess clinically?
 First of all, history taking of the patient
 Then clinical examination of the patient mainly the deglutination and tongue protrusion test &
look for the sign symptoms associated with thyroid disease.
 Lastly, we go for certain investigation

Isfaqure rahman �� - 46 - tmc-9

 b) What investigations do you suggest for her?
Investigations :
 Thyroid function test ; TSH, FT3, FT4 .
 USG of the thyroid gland.
 Thyroid antibody test.
 Thyroid scan.
 FNAC of the thyroid gland.
4. Tell types of renal stone. What are the clinical features of renal stone?
Classification of renal stone :
A. According to the composition :
a) Oxalate stone
b) Phosphate stone
c) Uric acid stone
d) Cystine stone
e) Xanthine stone
B. According to radiology :
 Radiopaque stone
 Radiolucent stone
Clinical feature of renal stone :
Symptoms :
 Asymptomatic
 Pain
 Hematuria
 Pyuria
Signs :
 Rigidity of lateral abdomen muscles during attack
 Renal angle tenderness
 Kidneys may be ballotable.
5. Define surgical jaundice. Tell the causes of surgical jaundice. What are the treatment options of
choledocholithiasis?
Surgical jaundice is defined as the jaundice due to the mechanical obstruction to the biliary tree usually the
common bile duct which can be corrected surgically.
Causes of surgical jaundice :

1) Biliary atresia
Conginetal
2) Choledochal cyst
1) Ascending cholangitis
Inflammatory
2) Sclerosing cholangitis
1) CBD stone
Obstructive 2) Biliary stricture
3) Parasitic infestation
1) Ca head of pancreas
Neoplastic 2) Periampullary carcinoma
3) Cholangiocarcinoma
Extrinsic Compression of CBD by lymph nodes or tumours

Isfaqure rahman �� - 47 - tmc-9

Definitive treatment of choledocholithiasis :
a) If size of CBD stone < 10 mm :
 ERCP along with endoscopic sphincterotomy & stone retrieval by Dormia basket. (Gold standard
for diagnosis).
b) If size of CBD stone > 10 mm :
 Cholecystectomy with Choledocholithotomy with T' tube drainage.
 Cholecystectomy with Roux-en-Ycholedochojejunostomy.
 If facilities are available: Endoscopic sphincterotomy & bile duct extraction by a Dormia basket
catheter introduced through the endoscope followed by laparoscopic cholecystectomy.
6. A woman aged 55 years presented with right sided breast lump which is hard & non tender
a) Tell the most probable diagnosis?
Carcinoma of breast (right sided)
b) How will you confirm it?
Confirmed by truecut biopsy followed by histopathology.
c) What investigations will you do to stage it?
Investigation :
a) Chest X ray / Mammogram
b) Serum alkaline phosphatase
c) glutamine transferase
d) Liver ultrasound
e) Isotope bone scan
7. Tell the clinical features of acute pancreatitis.
Clinical feature of acute pancreatitis :
Symptoms :
Signs :
a) Sudden severe pain in epigastric that radiates to back
b) Nausea a) Tachycardia
c) Vomiting b) Tachypnoea
d) Retching c) Hypotension
e) Fever d) Grey turner syndrome
f) Hiccup e) Cullen sign
f) Abdominal distension

8. Tell the effects of enlarge prostate if not treated properly.

Effects of enlarge prostate if not treated properly are :
 Retention of urine
 Incontinence of urine
 Haematuria
 Recurrent UTI
 Stone formation
 Renal impairement
 Retrograde ejection
 Impotence
 Urethral stricture

Isfaqure rahman �� - 48 - tmc-9

9. A lactating mother presented with fever & painful swelling of her right breast for 3 days
a) What could be the possible diagnosis?
Breast abscess on right breast.
b) How will you treat her?
Treatment of breast abscess :
 Immediate surgical drainage of abscess under GA
 Pus sent for C/S
 Antibiotic according to C/S
 Analgesic
 Bed rest and support to the breast
 Lactation should be withheld, but the healthy breast may be used
 Regular dressing of wound.
c) How will you counsel her?
Counselling :
a) Reassurance of the patient
b) Bed rest & support of breast
c) Supportive treatment
d) Lactation from healthy breast only.
10. Tell the causes of midline neck swelling.
Causes of midline neck swelling :
a) Thyroglossal cyst
b) Dermoid cyst
c) Sebaceous cyst
d) Ranula
e) Subhyoid bursa
f) Pharyngeal pouch

11. Tell the clinical features of empyema of gallbladder.

Clinical feature of empyema of gallbladder :
Symptoms :
a) H/O of acute biliary colic
b) Dull aching pain in right hypochondrium
c) Swinging fever
d) Nausea
e) Vomiting
Signs :
a) Toxic appearance
b) Temperature raised
c) Localised tenderness with muscle guarding of right hypochondrium area
d) Lump in the right upper abdomen

Isfaqure rahman �� - 49 - tmc-9

12. A middle aged man unable to pass urine following trauma to his perineum. On examination there
was blood in urethral meatus & perineal haematoma
a) Tell your diagnosis.
Acute retention of urine due to rupture urethra.
b) Tell in brief the immediate management of this patient.
Immediate management :
a) Immediate hospitalisation
b) Resuscitation of patient
c) Blood transfusion if needed
d) Suprapubic catheterisation by sheldinger technique
e) Aspiration of perineal hematoma
f) Delayed urethroplasty
g) Antibiotic
h) Analgesic
i) Discourage to pass urine
j) No catheterisation per urethra.
13. Tell the predisposing factors of gall stone formation.
Predisposing factors of gall stone :
a) Impaired gallbladder function
b) Supersaturated bile
c) Cholesterol nucleating factors
d) Absorption/enterohepatic circulation of bile acids.
14. What do you mean by triple assessment of breast lump?

Triple assesment

Clinical Imaging Pathology

Age Examination USG Mammography FNAC Corecut

Confident diagnosis in 99.9 % of cases

15. A 62 years old male patient presented with acute urinary retention. He had history of difficulty in
voiding for last one year
a) What is most likely diagnosis?
Benign enlargement of prostate (BEP)
b) What may be other possibilities?
Other possibilities are :
 Carcinoma of prostate
 Bladder neck contraction

Isfaqure rahman �� - 50 - tmc-9

  Urethral stricture
 Neurogenic bladder
 Bladder carcinoma
c) Tell relevant investigations in the scenario.
Investigations :
a) USG of whole abdomen special attention to KUB region with post voidal residue.
b) X-ray KUB region
c) Routine investigation :
 Urine R/M/E
 Blood urea
 Serum creatinine
 Hb %
 Serum electrolyte
 Serum acid phosphatase
 Serum prostate specific antigen
d) Cystourethroscopy
e) Uroflowmetry
16. Define acute scrotum with examples.
Acute scrotum is defined as sudden and severe pain with swelling in the scrotum.
Examples :
 Acute epididymo-orchitis
 Torsion of the testis
 Trauma
 Acute haematocele
 Strangulated inguinal hernia
17. Tell the causes of nipple discharge. How will you diagnosis such a case?
Causes of nipple discharge :
a) Discharge from surface:
 Paget’s disease
 Skin disease (Eczema, Psoriasis)
b) Discharge from single duct
 Duct Ectasia
 Intraduct carcinoma
 Intraduct papilloma
 Fibrocystic disease
c) Discharge from more than one duct
 Carcinoma of breast
 Fibrocystic disease
 Infection
 Lactation
Investigation :
 Examination of discharge : colour
 USG
 Mammography
 FNAC

Isfaqure rahman �� - 51 - tmc-9

18. A middle aged fatty lady present with upper abdominal pain & dyspepsia for the last 24 hours. On
examination she has tachycardia, mild fever & tenderness at right hypochondriac region.
a) Tell the most probable diagnosis.
Acute Cholecystitis
b) Suggest the investigations for diagnosis.
o Complete blood count
o USG of the whole abdomen special attention to hepatobilliary system.
o Liver function test
o Plain X ray of abdomen.

c) What are the treatment options?

A. Conservative :
 Hospitalisation
 Bed rest
 Free fat diet
 IV fluid
 Antibiotics
 Analgesics
 Antispasmodic
 Antiulcerant
B. Surgical : After 6 weeks of conservative treatment
 Open or laparoscopic cholecystectomy .
19. Define & classify haematuria with examples.
Presence of blood in urine is known as hematuria.
Classification of hematuria :
1) According to visibility
a) Macroscopic : Stone, neoplasm, trauma .
b) Microscopic : AGN, black water fever .
2) According to pain
a. Painful : UTI, Stone, obstruction, trauma .
b. Painless : Glomerulonephritis, TB, Polycystic Kidney Disease .
20. What are the complications of multinodular goiter.
Complications of multinodular goiter
1. Secondary thyrotoxicosis
2. Follicular carcinoma of thyroid
3. Haemorrhage
4. Infection
5. Cystic degeneration
6. Tracheal compression
7. Tracheal obstruction
8. Tracheal calcification
9. Cosmetic problem

Isfaqure rahman �� - 52 - tmc-9

21. A 40 years old female present with right upper abdominal pain & jaundice. On she has scratch marks
over the hands, feet & gallbladder is not palpable.
a) What is your most possible diagnosis?
Obstructive jaundice due to stone is CBD
b) How will you investigate the patient?
 USG of abdomen special attention of hepatobilliary system
 CBC
 Serum bilirubin
 Cholangiography
 Liver Function Test
 MRCP
 ERCP
 Urine
 Stool
c) How will you prepare the patient for surgery?
Pre-operative management / Preparation for operation:
i. Correction of dehydration & fluid electrolyte imbalance:
 A high intake of glucose
 Ideal fluid 5% DA or 10% D.A but we use 5% DNS to increase glycogen in liver.
 Replacement of K+ by Rule of 40 .
Urine output atleast 40 ml/hr not > 40 mmol/L and not faster than 40 mmol/hr.
ii. Improvement of nutritional status & hypoalbuminaemia:
 Regular high protein diet.
 Fresh frozen plasma
iii. Correction of prothrombin time & other clotting factors;
 Vitamin K+ supplementation
 If not corrected -› Fresh Frozen Plasma .
iv. Prevention of Hepato renal syndrome (HRS):
 Correction of dehydration.
 Inj Mannitol 10% 500 ml with catheter before and during operation
 Broad spectrum systemic antibiotic.
 If urine output decreases -› Inj Mannitol 10% 200 ml IV bolus then Inj Frusemide
 If not improved Dialysis.
22. Tell the treatment modalities of nephrolithiasis.
Treatment modalities of nephrolithiasis :
 Conservative
 Bed rest
 Analgesics
 Sedatives
 IV fluid
 Antibiotics
 If stone is < 0.5 cm,
 It may be passed out through urine spontaneous.
 Drink plenty of water.
 Followed by an X-ray of KUB every 6-8 weeks

Isfaqure rahman �� - 53 - tmc-9

  If stone is large then :
 0.5 to 2 cm :
 Extracorporeal Shockwave Lithotripsy (ESWL)
 > 2 cm :
 Percutaneous nephrolithotomy (PCNL)
 Pyelolithotomy
 Nephrolithotomy
 Partial nephrectomy
 Total nephrectomy
23. Define & classify mastalgia.
Painful condition of breast is called mastalgia .
Types :
 Cyclical
 Acyclical
 Chest wall pain

24. An alcoholic man 45 years notice epigastric mass of 4 weeks after attack of severe abdominal pain.
a) Tell the possible diagnosis.
Pancreatic pseudocyst.
b) What investigations will you suggest?
1) USG of whole abdomen
2) CT scan
3) MRCP
4) ERCP
5) Barium meal
6) LFT
7) Endoscopic ultrasound guided aspiration and analysis of fluid for amylase & CEA.
c) How can you treat the patient?
A. Conservative :
 Observation, follow up using repeat USG. 50% cases are resolved spontaneously.
B. Interventional :
 ERCP
 USG guided drainage ;
 Transpapillary
 Transmural
 Percutaneous
C. Surgical : Open or laparoscopic method.

25. Tell the clinical features of acute cholecystitis.

Clinical features of Acute cholecystitis :
Symptoms :
a) Pain in the upper right quadrant sometime refered to right shoulder tip
b) H/O of biliary colic
c) Nausea
d) Vomiting
e) Fever

Isfaqure rahman �� - 54 - tmc-9

Signs :
a) ↑ Temperature
b) Tachycardia
c) Mildly icteric
d) Tenderness of right hypochondrium
e) Murphy’s sign positive
f) Gallbladder not palpable
26. Tell the treatment modalities of enlarge prostate.
A. Conservative :
 Acute retention – catheterization if fails suprapubic cystostomy
 Chronic retention –
 No need of catheterization
 If uremic urgent catheterization
 IV fluid
 Blood transfusion
B. Drugs :
 α - blocker : Prazosine, terazosine
 5-α reductase inhibitors (if prostate is large)
C. Surgery :
 Trans – uretheral resection of prostate (TURP)
 Transvesical prostatectomy
 Retropubic prostatectomy

27. A patient 2 hours after subtotal thyroidectomy suddenly developed respiratory difficulty. On
examination operative area is swollen & skin is tense.
a) What is the most probable cause of difficulty respiration?
Respiratory obstruction due to laryngeal oedema due to tension hematoma due to reactionary
haemorrhage.
b) Tell your management plan.
 Removal of dressing
 Open the layer of wound to relief tension
 Evacuate hematoma
 Secure the bleeding point
 Ligation of bleeding vessel
 An endotracheal tube is left in place for several days if releasing hematoma doesn’t immediately
relief airway obstruction
 Steroid to reduce edema

28. Define goiter. Mention some causes of iatrogenic goiter.

Goiter is defined as enlargement of thyroid gland.
Classification :
 Simple
 Toxic
 Inflammatory
 Neoplastic

Isfaqure rahman �� - 55 - tmc-9

 Causes of iatrogenic goiter :
 Thyroidectomy


29. Tell the fates of acute cholecystitis. How mucocele of gallbladder is formed?
Fates of acute cholecystitis :
 Complete resolution with /without treatment
 Chronic cholecystitis
 Mucocele of gall bladder
 Empyema of gall bladder
 Perforation of gall bladder.

Formation of mucocele of gallbladder:

Obstruction of cystic duct due to stone / neoplasm
↓
Failure of drainage of bile through cystic duct
↓
Collection of bile in gall bladder
↓
Absorption of water and water soluble contents of bile and hypersecretion of mucus
↓
Accumulation of mucus within gall bladder
↓
Distention of gall bladder
↓
Mucocele

30. Tell the causes of radio-opaque shadow in right lumber region. What investigation will you advice to
differentiate gallstone from right renal stone.
Causes of radiopaque shadow in right lumber region :
 Renal stone
 Gall stone
 Foreign body
 Faecolith
 Calcified mesenteric lymph node
 Calcified adrenal gland
 Ossified tip of 12th rib
 Calcified TB lesion in kidney
 Phleboliths
Investigation :
Plain X ray of abdomen lateral view :
 Gall stone : Radiopaque shodows present in front of lumber vertebrae .
 Renal stone : Radiopaque shadows present within the lumber vertebrae or back of the vertebrae.

Isfaqure rahman �� - 56 - tmc-9

31. Tell causes of acute pancreatitis.
 Gall stone
 Alcoholism
 Post ERCP
 Viral infection
 Abdominal trauma
 Drug induced (corticosteroids,thiazide)
 Hyperparathyroidism
 Hypercalcemia
 Malnutrition
 Idiopathic
32. How will you differentiate torsion of testis from acute epididymo-orchitis?
S.No Torsion of testis Acute epididymo-orchitis
1. Twisting of spermatic cord Inflammation of epididymis
2. Young age usually Any age
3. Sudden onset Gradual onset
4. H/O of UTI absent Present
5. Position of testes – high up Normal
6. Unilateral Bilateral
7. On lifting scrotum, pain aggravates Relief / Decreases
8. Surgical treatment Conservative treatment

33. How will you prepare a thyrotoxic patient for surgery? Tell the complications of thyroidectomy.
Pre-operative preparation for thyrotoxic patient :
 The aim is to make the patient euthyroid or near euthyroid at operation.
 Carbimazole 30-40 mg a day is the drug of choice for preparation taken in divided doses at 6 -8 hourly
intervals
 When euthyroid after 8-12 weeks – the dose may be reduced to 5 mg 8 hourly and the addition of
thyroxine may facilitate maintenance of the euthyroid state.
 Last dose of Carbimazole should be given on the evening before surgery.
 Iodides may be given with Carbimazole for 10-14 days immediately before operation .
 An alternative method is beta blocking drug.
Complication of thyroidectomy :
a) Haemorrhage
b) Injury to recurrent laryngeal nerve
Intraoperative c) Injury to superior laryngeal nerve
d) Injury to trachea.
a) Haematoma
b) Laryngeal oedema
Immediate c) Respiratory obstruction
d) Parathyroid insufficiency
e) Recurrent laryngeal nerve paralysis
a) Hypothyroidism
b) Hypocalcaemia
Rare c) Thyrotoxic storm
d) Wound infection
e) Hypertrophic scar.

Isfaqure rahman �� - 57 - tmc-9

34. Define pyelonephritis. Tell the clinical features of pyelonephritis.
Pyelonephritis is defined as the inflammation of the kidney and renal pelvis due to any infection usually
bacterial.
Clinical feature :
Mild : Low grade fever with or without low back pain.
Severe :
 High fever
 Burning sensation
 Frequent urination
 Loin pain
 Nausea
 Vomiting
35. Tell the causes of cervical lymphadenopathy.
Causes of cervical lymphadenopathy :
 Infection
 Inflammation
 Tuberculosis
 Lymphoma
 Metastatic area.
 Reactive hyperplasia
36. A young boy was admitted with it upper abdominal pain & shock following history of RTA.
a) What are the probable diagnosis?
Hypovolemic shock due to intra-abdominal injury most probably splenic rupture.
b) Tell your treatment plan.
A. Conservative treatment :
 Immediate hospitalisation
 NPO
 IV channel open
 Blood for grouping, Rh – typing & crossmatching
 Catheterisation
 Antibiotics
 Monitoring of the vital signs
B. Surgically :
 Laparotomy
 Splenectomy :
 When blunt splenic trauma
 Continuous blood loss despite resuscitation
37. Tell the risk factors of developing carcinoma of breast.
Risk factor of Ca of breast :
 Early age
 Genetic predisposition
 Positive family history
 Early menarche & late menopause
 Nulliparity

Isfaqure rahman �� - 58 - tmc-9

  Obesity
 High fat diet
 Alcohol and smoking
 Previous history of breast carcinoma in opposite breast.
38. Tell different types thyroid surgery with indication.
Types of thyroid surgery:
a) Total thyroidectomy : Toxic goitre, Non – toxic multinodular goitre.
b) Subtotal thyroidectomy : Follicular carcinoma of thyroid and medullary carcinoma of thyroid.

39. A 40 years old male presents with right upper abdominal pain, fever & intermittent jaundice for last
1 month.
a) Tell your most likely diagnosis?
Obstructed jaundice due to stone in CBD.
b) How will you prepare a jaundice patient for surgery?
Prepare of jaundice patient for surgery :
1. Correction of dehydration & fluid electrolyte imbalance:
 A high intake of glucose
 Ideal fluid 5% DA or 10% D.A but we use 5% DNS to increase glycogen in liver.
 Replacement of K+ by Rule of 40 :
Urine output atleast 40 ml/hr not > 40 mmol/L and not faster than 40 mmol/hr.
2. Improvement of nutritional status & hypoalbuminaemia:
 Regular high protein diet.
 Fresh frozen plasma
3. Correction of prothrombin time & other clotting factors;
 Vitamin K+ supplementation
 If not corrected -› Fresh Frozen Plasma .
4. Prevention of Hepato renal syndrome (HIRS):
 Correction of dehydration.
 Inj. Mannitol 10% 500 ml with catheter before and during operation
 Broad spectrum systemic antibiotic.
 If urine output decreases -› Inj Mannitol 10% 200 ml IV bolus then Inj Frusemide
 If not improved — Dialysis.

40. Define hydronephrosis. Tell the causes of bilateral hydronephrosis.

Hydronephrosis is defined as the aseptic dilation of kidney caused by obstruction to outflow of urine.
Bilateral causes of hydronephrosis :
a) Congenital :
 Congenital stricture of external urethral meatus or pinhole meatus.
 Congenital posterior urethral valve.
b) Acquired :
 Benign enlargement of prostate (BEP)
 Prostate carcinoma

Isfaqure rahman �� - 59 - tmc-9

  Phimosis
 Ca cervix
 Bladder carcinoma
 Inflammatory or traumatic urethral stricture
 Post operative bladder neck swelling.
41. Tell the differences between mucocele of gallbladder &empyema of gallbladder.

Sl No. Mucocele of gallbladder Empyema of gall bladder

1. Distension of gallbladder by a clear watery Inflamed, obstructive gallbladder filled with
mucinous secretion due to total obstruction of creamy pus like substance.
cystic duct.
2. Usually asymptomatic Symptomatic
3. Painless Painful
4. Non tender lump Tender lump
5. No fever High fever
6. No vomiting Vomiting

42. A young lady of 20 years presents with painless mobile lump in her left breast. O/E lump is found
well circumscribed, non-tender & firm in consistency
a) What is the most likely diagnosis?
Fibroadenoma of breast (left sided)
b) How will you confirm your diagnosis?
By truecut biopsy
Treatment :
i. Reassurance
ii. Enucleation ( Removal of adenomatous tissue without capsule)
iii. Excision ( Removal of both capsule and adenomatous tissues)
43. Tell the clinical features of urinary bladder stone.
Ans : C/F of urinary bladder stone :
a) Asymptomatic
b) Frequency of urine
c) Retention of urine
d) Sensation of incomplete bladder emptying
e) Pain in suprapubic region
f) Haematuria
g) Recurrent UTI

44. Tell the precautions taken before doing splenectomy.

 Blood sample of the patient should be taken and send for Blood grouping and Rh typing ,cross matching
and coagulation profile to prepare blood during or after surgery.
 Then vaccination against pneumococcus, meningococcus and haemophilus influenza should be given 2-
3 weeks before surgery.

Isfaqure rahman �� - 60 - tmc-9

45. A young boy presents with single nodule on his right lobe of thyroid gland with a hard enlarged
lymph node in right cervical region
a) What is your diagnosis?
Carcinoma of thyroid gland.
b) How will you investigate such patient?
 Thyroid function Test (TSH,FT3,FT4 )
 FNAC of thyroid followed by histopathology (Confirmatory, if negative then truecut biopsy
or Frozen section biopsy)
 Thyroid autoantibody
 USG of the thyroid gland
 X-ray of neck.
c) Name the treatment of this patient.
Total thyroidectomy with neck dissection + thyroxine replacement.
46. Mention the methods of prostatectomy. Tell the major complications of prostatectomy.
Methods of prostatectomy :
a) Transurethral resection of prostate (TURP).
Best method due to –
 Abdomen need not to open
 Fewer complications
 Short recovery time
 Cost effective
 Ideal for elderly patient
b) Transvesical prostatectomy
c) Retropubic prostatectomy
Complications of prostatectomy :
a) Haemorrhage
b) Clot retention
c) Perforation
d) Sepsis
e) Urinary incontinence
f) Urethral stricture
g) Retrograde ejaculation
h) Impotence
47. Tell the causes of lateral neck swelling. How will you differentiate clinically thyroglossal cyst from
thyroid swelling.
Causes of lateral neck swelling :
 Cervical lymph node enlargement
 Branchial cyst
 Cystic hygroma
 Dermoid cyst
 Thyroid gland swelling
 Ranula
 Carotid body tumours
 Carotid artery aneurysm
Clinically, on protrusion of tongue thyroglosal duct cyst moves upward but not the thyroid swelling.

Isfaqure rahman �� - 61 - tmc-9

48. What do you mean by ERCP & MRCP. Tell the complications of ERCP.
ERCP (Endoscopic Retrograde Cholangiopancreatography)
It is invasive procedure in which an endoscope is introduced into the 2nd part of the duodenum and a cannula
is introduced through the endoscope into the ampulla.
 Iodine containing dye is introduced through the cannula and screening is done radiologically.
 It is done under C-ARM guidance and sedation like midazolam or propofol anaesthesia.
 Patient is placed in prone position with the head turned towards right.
MRCP (Magnetic Resonance Cholangiopancreatography)
It is a non-contrast, non-invasive diagnostic method using magnetic field and energy as resonance, better
then ERCP as diagnostic tool in biliary & pancreatic disease.
 T1 weighted images are used for pancreas.
 T2 weighted images are used for biliary tree.
 Both images are used to see invasion and adjacent structures.
Complication of ERCP :
 Pancreatitis
 Gut perforation
 Haemorrhage
 Infection like cholangitis, cholecystitis
 Post ERCP
 Duodenal injury
 Papilla stenosis
49. What do you mean by Courvoisier's law & Charcot's triad.
Courvoisier’s law : In a patient with jaundice if there is palpable gall bladder, it is not due to stones, it is due
to neoplastic obstruction in common bile duct.
Charcot’s triad : It is a triad of
i. Pain
ii. Fever
iii. Jaundice
50. How will you manage a case of retention of urine following trauma to perineum?
Management of case of retention of urine due to perineum trauma :
a) Immediate hospitalisation
b) Resuscitation of patient
c) Blood transfusion if needed
d) Suprapubic catheterisation by sheldinger technique
e) Aspiration of perineal hematoma
f) Delayed urethroplasty
g) Antibiotic
h) Analgesic
i) Discourage to pass urine
j) No catheterisation per urethra.

Isfaqure rahman �� - 62 - tmc-9

51. A 25 years old woman presents with recent swelling in the neck & weight loss. She looks very anxious
& her palms are very moist, patient giving history of weight loss, despite increased appetite.
a) What is your clinical diagnosis?
Hyperthyroidism
b) How will you assess thyroid function status?
Thyroid function test : ↑ T3 & T4 ; ↓ TSH.

52. How will you manage a case of benign breast lump?

Treatment :
i. Reassurance
ii. Enucleation ( Removal of adenomatous tissue without capsule)
iii. Excision ( Removal of both capsule and adenomatous tissues)
53. By D/R/E how can you differentiate enlarge prostate from carcinoma of prostate.

Traits BEP Ca Prostate

Symmetry of enlargement Symmetrically enlarged. Asymmetrically enlarged.
Surface Smooth Irregular.
Consistency Firm Hard.
Medial sulcus Prominent Obliterated.
Rectal mucosa. Free. May be fixed.
Examining finger Not blood stained. May be blood stained.

54. A 40 years female reveal gallstone disease on routine check-up.

a) Tell sonographic findings of chronic calculus cholecystitis.
USG findings :
 Single or multiple echogenic structure with posterior acoustic shadow
 Gallbladder is thick, fibrous and contracted.
b) What type of surgical approach can be done? Which one is the best & why?
Surgical approach :
1. Open cholecystectomy
2. Laparoscopic cholecystectomy
Laparoscopic cholecystectomy is best because :
a) Less post-operative pain.
b) Decrease in wound size.
c) Reduction in wound infection, dehiscence, bleeding, herniation and nerve entrapment.
d) Decreased wound trauma.
e) Improved vision.
f) Better cosmesis
g) Improved mobility.
h) Decreased heat loss.
i) Shorter hospital stay.
j) Earlier return of normal physiological life.

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55. Tell stone forming organs in the body. Tell the problems of surgery in a jaundice patient.
Stone forming organs :
 Salivary gland
 Pancreas
 Gall bladder
 Urinary bladder
 Kidney
 Prostate
Problems of surgery in a jaundice patient :
 Obstruction
 Sepsis
 Clotting
 Dehydration
 Hypokalaemia
 Anaemia
 Renal failure
 Hepatic failure
 Coagulation disorder
56. What are the hormones secreted from adrenal gland.
A. Mineralocorticoid: Aldosterone (Zona glomeerulosa)
B. Glucocorticoid: Cortisol (Zona fasciculate)
C. Adrenal androgens: Dehydroepiandrosterone, Testosterone (Zona reticularis)
57. A middle aged man presented with left sided loin pain with haematuria.
i. Tell common causes of this condition.
a) Stone in ureter
b) UTI (Upper)
c) Trauma
d) Loin pain hematuria syndrome

ii. Suggest investigations for him.

a) USG of whole abdomen special attention to KUB region
b) Plain x – ray of KUB region
c) CBC
d) Urine R/M/E
e) Serum creatinine
f) IVU
g) CT-Scan
h) Cystoscopy
i) Retrograde ureteroscopy
j) Renal function test
58. Tell the common causes of Bladder outlet obstruction (BOO).
i. Benign Prostate Hyperplasia (BPH)
ii. Bladder neck stricture
iii. Prostate carcinoma
iv. Urethral stricture

Isfaqure rahman �� - 64 - tmc-9

59. Define gynaecomastia. How will you manage a young patient of unilateral gynaecomastia?
Abnormal enlargement of glandular tissue of the breast in male is called gynaecomastia.
Causes :
a. Idiopathic
b. Hormonal teratoma of testis
c. Drug induced
d. Liver disease
e. Klinefelter syndrome
Treatment :
 Reassurance
 Withdraw any drug causing gynaecomastia.
 If not, mastectomy with preservation of the areola & nipple can be done.

60. A patient underwent cholecystectomy with choledocholithotomy. Tell about management of post
operative T-TUBE.
 Maintaining position of T-Tube
 Drainage of the bile through T-Tube upto 7th POD
 Progressive clamping of the T-Tube from 7th POD
 Observing the patient during clamping tube
 Daily observation of bile flow
 Post operative cholangiography is done on 11TH POD
 Removal of the tube on 12th / 13th POD by slow sustained traction.

Isfaqure rahman �� - 65 - tmc-9

 DEPARTMENT OF SURGERY (BOARD-B BOX-1)
(TRAUMA & ORTHOPAEDICS)

SET -1
1. What is fracture? Classify it.
 Structural break in the normal continuity of bone which may be complete or incomplete fracture.
( TARIKUL SIR)
 It is defined as a soft tissue trauma or injury which bone happen to be broken . ( Recent )
 Break down of structural continuity of the bone is called fracture. (old)
Classification :
A. Clinical Classification –
 Closed fracture (Simple fracture)
 When a fracture fragment does not communicate with environment
 Open fracture (compound fracture)
 When fracture fragment communicate with environment through the wound of skin and
soft tissue.
 Complicated fracture. If Tarikul sir ask all 3 points , others first 2
 Fracture associated with other organ system injury
B. Radiological / Morphological types : ( force of direction)
a. Complete fracture (Both cortex and both periosteum are separated)
 Transverse fracture : (avulsion force)
 Oblique fracture : (direct force)
 Spiral fracture : (twisting force)
 Segmental fracture.
 Comminuted fracture :
 More than 2 fragment will be present i.e. proximal and distal fragment
 Impacted fracture
b. Incomplete fracture:
 Greenstick fracture
 Torous Fracture
 Burst fracture
C. Aetiological /Etiological ( Cause):
 Traumatic fracture
 High velocity trauma: RTA, fall from height
 Low velocity trauma: Trival fall
 Pathological fracture
 Infective
 Neoplastic
 Metabolic
 Cystic
 Stress fracture / (March)
 Congenital fracture. If Tarikul Sir ask
Classification :-
Gustilo classification of open fractures
1. Type I
Wound is usually a small, clean puncture through which a bone spike has protruded
Criteria-

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  Wound size less than 1 cm
 Contamination less or absent
 Minimal soft tissue injury with no crushing and fracture is not comminuted
 Low energy trauma

2. Type II
Criteria :
 Wound size 1 cm to 10 cm
 Contamination – moderate
 Moderate tissue injury and no more than moderate crushing or comminution of fracture
 Moderate crush trauma

3. Type III
Criteria :
 Extensive soft tissue injury, large laceration
 Severe crushing
 Severe contamination
 Severely comminuted fracture with extensively periosteal stripping.
 High energy trauma

a) Type III A :
Exposed bone can be covered with adequate surrounding soft tissue despite laceration,
fracture pattern (multiprogmentary,segmental) or bone loss irrespective of the size of the skin
wound
b) Type III B :
There is extensive periosteal stripping
Exposed bone cannot be covered with surrounding soft tissue without distal flap coverage.
c) Type III C
Major arterial injury must be repaired.
In this case size does not matter

2. What is osteomyelitis? Treatment of acute osteomyelitis.

Inflammation of bone and bone marrow caused by pyogenic micro-organism.

Management of Acute osteomyelitis:

A. Antibiotic therapy
B. Supportive therapy
C. Give rest to the affected part
D. Surgery

A. Several principles of antibiotic therapy:

 Rx should be given on an emergency basis
 Empirical antibiotic therapy should be started
1) Intensive phase
2) Maintenance phase
1) Intensive phase :

Isfaqure rahman �� - 67 - tmc-9

  Dose: Double the usual dose
 Route of administration: I/V
 Choice of antibiotic: Broad spectrum, bactericidal
 Duration: Till the symptomatic improvement, usually 1 week.
2) Maintenance phase
 Dose: Usual dose
 Route of administration: Orally
 Duration: 4-6 weeks

B. Supportive therapy :
 Pain – Analgesics
 Fever – Anti-pyretic
 Unable to feed – NG feeding

C. Rest of the affected limb :

By splint, surface traction, casting/plaster (back slab)

D. Operative intervention/Surgery :
If there is no favourable response in intensive phase, then we do operative Rx.
Favourable responses:
 Pus ↓
 Pain ↓
 Fever ↓
 ESR ↓
 D/C WBC ↓
 Neutrophilic leukocytosis ↓
Operative procedures
 Periosteum opening → incision and drainage of pus.
 If no pus then multiple drilling.
 Regular X-ray to monitor the patient.

3. Treatment modalities of giant cell tumour.

Rx option Recurrence rate

1) Only curettage 85%

2) Curettage + Bone graft 40%

3) Curettage + Chemical cauterization (5% phenol + 70% alcohol) + Bone graft 14%

4) Curettage + Chemical cauterization + Bone cement 1%.

5) Wide excision + Passive allograft radiotherapy 50%

6) Amputation (Rehabilitation) 0%

Isfaqure rahman �� - 68 - tmc-9

 SET -2
1. What are the causes of acute & chronic osteomyelitis.
Causative organism of acute osteomyelitis
1. Staphylococcus aureus (Mostly penicillinase producing - 90%)
2. Streptococcus pyogens
3. Pneumococcus
4. Pseudomonas (Green Pus) in AIDS patient
5. E. coli
6. Hemophylus influenza – Under 4 years children
7. Group B Hemolytic Streptococci & E. coli – Neonate
8. Hemophylus influenza, Pseudomonas, Proteus, Bacteroids - Children

Causes of chronic osteomyelitis :

 Inadequate treatment of Acute Osteomyelitis
 Bacteriology :
 M. Tuberculosis
 Treponema pallidum
 Fungal osteomyelitis
 Parasitic osteomyelitis

2. Classify bone tumour.

Classification of Bone Tumour
1) A/C to tissue origin –

Tissue origin Benign tumour Malignant tumour

• Osteoblastoma
a) Osteogenic tumour • Osteoid osteoma • Osteosarcoma
• Osteoma
• Chondroma
b) Chondrogenic tumour • Chondrosarcoma
• Chondroblastoma
c) Fibrogenic tumour • Fibroma • Fibrosarcoma
d) Giant cell rich tumour • Giant cell tumour • Malignant giant cell tumor
e) Myogenic tumour • Leomyoma • Leomyosarcoma
f) Lipogenic tumour • Lipoma • Liposarcoma
g) Vascular tumour • Hemangioma • Angiosarcoma
h) Notochordal tumour • Benign notochordal tumour • Chordoma
i) Undifferentiated tumour • Fibrous dysplasia • Ewing’s sarcoma

2) A/C to location -
a) Diaphyseal
 Osteoid osteoma
 Fibrous dysplasia
 Eosinophilic granuloma
 Ewing's sarcoma
 Adomartinoma

Isfaqure rahman �� - 69 - tmc-9

b) Metaphyseal
 Most of bone tumours
 Osteosarcoma
c) Epiphyseal
 Chondroblastoma
 Intra articular osteoid
 Giant cell tumour
 Clear cell chondrosarcoma

3. What is ALTS? Describe the components of ALTS.

ATLS (Advanced Trauma Life Support )
It is a treatment protocol for severely injured patients

Components of ATLS :

 Primary survey with simultaneous resuscitations

 Secondary survey
 Definitive treatment care
Primary Survey with simultaneous resuscitations
 A — Airway maintenance and control/ protection of cervical spine.

Airway
 Patent by chin lift or jaw thrust maneuver
 Foreign body removed by suction
 Tongue falls — airway tube/oropharyngeal tube
 Stabilize cervical spine with neck brace, sand bag (in neutral position)and lock roll technique

B — Breathing and ventilation

Assessment:
 Cyanosis
 Rate and depth of respiration
 Any abnormality in chest wall movement
 Check for pneumothorax, hemothorax
If unable to take respiration then
 CPR/Mouth to mouth breathing
 02 inhalation
 Ambu bag
 Endotracheal intubation (if needed)
 Tracheostomy (if needed)
Management according to causes:
 If tension pneumothorax then open seal drainage
 If cardiac tamponade then Pericardiocentesis
 C — Circulation and control of hemorrhage
 Wide bore IV channel open
 Blood withdraw and sent for blood grouping, Rh typing and cross matching for arrangement of
blood transfusion

Isfaqure rahman �� - 70 - tmc-9

  IV fluid :- ( colloid on one side & crystalloid on other side)
 Hartmann’s Solution (1st priority)
 0.9% NaCl ( Normal Saline)
 5% DNS
 Dextrose in aqua
 Ringer's lactate upto Resuscitation.
 Urinary catheterization to see input-output balance
 Vital sign :
 Pulse
 BP
 Urine output (1 ml/min) at interval of 30 mins or 60 mins
 02 saturation by Pulse oximetry
Assessment:
 Identify site of bleeding
 Vital signs

 D — Disability or assessment of neurological status ( GCS scale)

Glasgow Coma Scale

Injuries Glassgow Coma Scale Score

Mild (80%) 13 - 15

Moderate (10%) 9 - 12

Severe (10%) 3-8

Score 7-13  Hospital

Score < 7  ICU

 E — Exposure and environment

 Environment -Prevention of hypothermia
 Exposure -Undress the patient and look for any associated injury

Secondary Survey
 Head to toe - examination to detect associated injury
 Investigation - all .

Definitive treatment care

 Treatment according to investigation
 Confirmed diagnosis:
 Femur fracture- Orthopedics Dept.
 Head injury – Neurosurgery Dept.
 Abdominal lump- Surgery Dept.

Isfaqure rahman �� - 71 - tmc-9

 SET-3
1. What are the complications of fracture?
Complication of fracture :
A. Immediate (at the time of injury)
 Neurovascular injury
B. Early :
 Hemorrhage
 Shock
 Infection
 Thromboembolism
 Fat Embolism
 ARDS
C. Late / Delayed :
 Non union
 Delayed Union
 Malunion ( does not occur in normal position)
 Stiffness of joint
 Compartment syndrome
 Osteoarthritis
 Complex regional pain syndrome(CRPS)
 Plaster sore (inappropriate application of plaster)
 Bed Sore
 Amputation
 Stiffness
 Dystrophy

2. How will u treat a case of Osteosarcoma in 17yrs old boy.

Stage Treatment

Stage IA
(mild intracompartmental) Wide excision with or without chemotherapy.
Neoadjuvant Chemotherapy (NAC)
Stage IIA Wide excision
(high grade intracompartmental ) Adjuvant chemotherapy (AC)

Neoadjuvant Chemotherapy (NAC)

Stage I B + II B Radiological resection or amputation
Adjuvant chemotherapy (AC)
Neoadjuvant Chemotherapy (NAC)
Palliative surgery or amputation
Stage III
Adjuvant chemotherapy (AC)

3. What is triage? Types & importance of it.

Triage is a system of medical sorting to identify casualties in an order of priority for evaluation and treatment.
It is the medical sorting process of the patients based on their need for treatment and the resources available
to provide that treatment during mass causality events

Isfaqure rahman �� - 72 - tmc-9

Types :
 Triage sieve:
A quick and uncomplicated system based on simple clinical observation of a casualties like ability to
walk, breath and maintain peripheral perfusion

 Triage sort
Requires a degree of clinical and uses physiological measures to score casualties and place them into
priority group
Importance triage-
 Triage identify those who need immediate medical care to save life or limb.
 The separation of minor from severe injuries allows for the reduction of the urgent burden on medical
facilities and organizations.
 Triage enables equitable and rational distribution of casualties among the available hospitals .

Isfaqure rahman �� - 73 - tmc-9

 SET-4
1. Tell the principles of Rx of fracture.
Treatment of Fracture(5R)
1) Resuscitation of the patient according to ATLS procedure if needed.
2) Recognition of fracture
3) Reduction :
 Closed reduction
 Reduction without opening fracture site
 Open reduction
 Reduction with opening fracture site
4) Retention /Rest /immobilization
a) Plaster:-
 Half plaster/ back slab
b) Traction:- ( any site of femur)
 Surface Traction
 Non invasive
 usually children and elderly person
 Skeletal / Pin Traction ( 2 cm below tibial tuberosity)
 Adult person
c) Fixator
 Internal ( Definitive)
 Plate, screw, intramedullary nail, K nail, Surgical wire
 External- ( Supportive)
 Uniaxial; multiaxial (ring fixator), simple fixator , ilizarov external fixator
d) Gravity :
 Hanging cast ( if shaft of humerus is fractured)
e) Functional bracing
5) Rehabilitation:
Physiotherapy, movements to prevent stiffness and diffuse atrophy.

2. What are the features of acute osteomyelitis?

Clinical Features of Acute Osteomyelitis
a) Severe pain, swelling
b) High fever
c) Dehydrated
d) Very much toxic
e) Unwilling to take food
f) Unwilling to use affected limb [Muscle is replaced by fibrous tissue]
g) Movement is restricted
h) Tenderness in affected joint
i) Local temperature raised
j) Not let to touch his limb.

3. What is damage control surgery?

It is the minimal surgery for stabilisation of patient condition until physiological dearrangement are corrected.

Isfaqure rahman �� - 74 - tmc-9

 SET-5
1. What are the causes of non-union & delayed union of fracture?
Causes of non union and delayed union:
A. Local Causes
 Inadequate fraction reduction
 Insecured / poor fixation
 Inter position of soft tissue between 2 fragments
 Infection
 Comminuted fracture
 Excessive movement of fracture site.
B. General Causes :
 Malnutrition
 Anaemia
 Diabetes
 Poor nutritional status
 Immunosuppressive drug e.g steroids

2. What is sequestrum & involucrum etc.

Sequestrum: Dead piece of bone, separated from the living bone by the process of inflammation
Involucrum: Formation of new bone around the dead bone.

3. How will you manage a case of polytrauma?

Treatment – Done according to ATLS procedure and treatment of injured organ if present

Isfaqure rahman �� - 75 - tmc-9

 SET-6
1. What are the deficiency diseases of bone?
 Rickets
 Osteomalacia

2. What are the steps of Rx of trauma due to RTA?

3. Tell the clinical features & Rx of Ewing's sarcoma.(70)

 C/F →
 Local throbbing pain
 Swelling
 Pain aggravated at night.
 Intermittent fever
 Pathological fracture
Treatment :
1. Combined radiotherapy & chemotherapy + surgery
2. For accessible site:
→ NAC + Surgery (wide local excision) + AC for 1 year
3. For inaccessible site:
→ Neoadjuvant radiotherapy + Surgery + Adjuvant chemotherapy for 1 year.

Isfaqure rahman �� - 76 - tmc-9

 SET-7
1. What is dislocation? Mention the commonest type of joint dislocation & why? Complications of hip
dislocation.
Total loss of contact between two articular surface is called dislocation.
Some common dislocation :
 Shoulder joint dislocation (commonest – ant. dislocation)
 Hip joint dislocation
 Elbow dislocation
 Ankle dislocation
 Knee dislocation
 MCP (Metacarpo phalangeal joint) dislocation
Because :
 Shallowness of glenoid socket
 Ligamentous laxicity
 Glenoid dysplasia

Complications of Hip dislocation

 Avascular necrosis of head of femur
 Sciatic Nerve Palsy
 Stiffness
 Delayed union
 Recurrent dislocation
 Osteoarthritis
 Myositis ossificans

2. How will you manage a case of open fracture of tibia?

Treatment:-
a) Conservative Treatment:
 Simply immobilize by long leg back slab
 Close monitoring
 After 7-14 days when swelling subside definitive plaster is given i.e. long leg full plaster for 6
weeks ( No mobilisation)
 After 6 week, follow up— remove previous plaster and give walking cast for next 6 weeks
 Then follow up again and take a X-Ray if union has occurred then no plaster needed.
b) Surgical Treatment:-
 Open reduction with internal fixation

3. Classify bone tumour according to the sites of long bone.

Diaphyseal Metaphyseal Epiphyseal

 Osteoid osteoma  Most of bone tumours  Chondroblastoma
 Fibrous dysplasia  Osteosarcoma  Intra articular osteoid
 Eosinophilic granuloma  Giant cell tumour
 Ewing's sarcoma  Clear cell chondrosarcoma
 Adamantinoma

Isfaqure rahman �� - 77 - tmc-9

 SET -8
1. Define amputation. What are the indications of it?
Surgical removal of limb through the part of bone (T.Sir)
Cause/Indication:
1. Dead/Dying
 Peripheral vascular disease
 Severe trauma
 Burn
 Frost bite
2. Deadly/ Dangerous :
 Malignant tumour
 Lethal Sepsis
 Crush injury(Renal failure)
3. Dead loss/Damn Nuisance:
 Severe rest Pain
 Gross malformation
 Recurrent sepsis
 Loss of function/Paralysis

2. What is pathological fracture? Causes of pathological fracture.

It is defined as when the bone is weaken by some pathological condition or disease and fracture occurs due
to minor trauma or event spontaneously .
Causes/ Types :
 Metabolic bone disease :-
 Osteoporosis
 Rickets
 Osteomalacia
 Paget’s disease of bone
 Infection:
 Chronic osteomyelitis
 Tubercular osteomyelitis
 Bone tumors/ Neoplastic
 Benign bone tumor
 Osteochondroma
 Giant cell tumour .
 Enchondroma
 Malignant bone tumors
 Primary :
 Osteosarcoma
 Ewing‘s sarcoma.
 Secondary :
 Metastatic bone tumour (from thyroid, breast,lungs,kidney,prostate)
 Cystic :
 Aneurysmal bone cyst
 Simple bone cyst
 Congenital : ( According to TARIKUL SIR , included in etiological classification)
 Osteogenesis imperfecta

Isfaqure rahman �� - 78 - tmc-9

  Here, collagen type – I increases, decreased mineral deposition ,so bone become soft
 Osteopetrosis
 Increased mineral deposition, medullary cavity obliteration, hardening of bones

3. Which type of malignant bone tumour is common? Common sites of secondary bone tumour.
Secondary/ Metastatic Bone tumour
Common Site of Secondary Bone Tumours :
1) Breast (35%)
2) Lungs (30%)
3) Prostate (25%) (OSTEOLYTIC lesion → 1, 2, 4, 5 & OSTEOBLASTIC lesion → 3 )
4) Kidney (5%)
5) Thyroid (2%)

Isfaqure rahman �� - 79 - tmc-9

 SET-9
1. How will you treat a case of NOF of a 65yrs old women?
Treatment of Neck of Femur fracture in 65 yrs old :
A. Intracapsular femoral neck fracture:
 Undisplaced fracture; Internal fixation by
 Hip screw (Adult).
 Knowles (Children).
 Displaced fracture:
 If patient is young: Close reduction and internal fixation with cannulated screws or dynamic hip
screw.
 If the patient is older:
 Excision of head and replacement by prosthesis.
 Arthroplasty of the proximal femur may take the form of hemi- arthroplasty or total hip
replacement.
B. Extracapsular femoral neck fracture:
a) Intertrochanteric fractures:
Traction in bed until there is sufficient reduction of pain.
Internal fixation by sliding screw in conjunction with either a plate or intramedullary nail.
b) Reverse oblique fractures: Reduction by-
 Intramedullary device.
 Dynamic hip screw.
c) Subtrochanteric fractures: Most commonly treated with intramedullary devices with one or two
screws into the femoral neck and head.

2. What are the common primary malignant bone tumours?

5 Primary Malignant Bone Tumour :
1) Osteosarcoma
2) Giant cell tumour
3) Ewing's sarcoma
4) Chondrosarcoma
5) Fibrosarcoma

3. Which area of bone is most commonly affected in acute osteomyelitis & why?
Metaphysis is commonly affected.
Reason : Blood flows slowly through a hairpin turn in metaphyseal region, so lodgement of bacteria occurs.

Isfaqure rahman �� - 80 - tmc-9

 SET-10
A 60yrs old women presented to you with pain, swelling & dinner fork deformity of her Rt wrist after
fall on outstretch hand.
a) What is your diagnosis?
Colle’s fracture
b) What are its complications?
Complication :
a) Neurovascular injury :
 Radial artery
 Median nerve injury
b) Injury to Extensor Pollicis Longus tendon
c) Stiffness of wrist and finger ( more common)
d) Carpal Tunnel Syndrome
e) Osteoarthritis
f) Malunion
g) Shoulder Hand Syndrome/ Complex regional pain syndrome

c) Why old women are prone to such type of fracture?

Due to decrease oestrogen & progesterone level in post menopausal women.

Isfaqure rahman �� - 81 - tmc-9

 SET-11
1. Common causes of acute osteomyelitis in older children. Name the sequels of acute suppurative
arthritis.
Causative organism of acute osteomyelitis
1. Staphylococcus aureus (Mostly penicillinase producing - 90%)
2. Streptococcus pyogens
3. Pneumococcus
4. Pseudomonas (Green Pus) ind AIDS patient
5. E. coli
6. Hemophylus influenza – Under 4 years children
7. Group B Hemolytic Streptococci & E. coli – Neonate
8. Hemophylus influenza, Pseudomonas, Proteus, Bacteroids - Children

Sequels of acute supporative arthritis :

A. Immediate :
a) Dislocation and subluxation of hip joint.
b) Damage to epiphyseal plate leads to growth disturbance
B. Late :
a) Growth failure
b) Deformity
c) Articular dysplasia

2. How will you manage a case of penetrating abdominal trauma?

Laparotomy

3. Tell the radiological findings of Ewing's sarcoma.(70)

Findings of Ewing’s sarcoma :
 Onion peal/ skin appearance
 In mid diaphysis new bone formation may extend along the shaft and sometimes it appears as
fusiform layer of bone around the lesion – the so called onion peel effect.
 Often the tumour extends into surrounding soft tissues.
 Widening of the shaft
 Cortex is thinned & ballooned
 Pathological fracture

Isfaqure rahman �� - 82 - tmc-9

 SET-12
A 7 years old boy presented to you with pain swelling & S - shaped deformity of his Lt Elbow due to
fall.
a) What is your diagnosis?
Supracondylar fracture
b) Name 1 early & 2 late important complications.
1 early complications : Compartment syndrome
2 late complications : Malunion , Stiffness of elbow joint
c) Describes the Rx Protocol in such type of fracture.
Treatment :
A. Type I fracture -
 Immobilization with long arm back slab with elbow 90°. Forearm neutral position (mid-prone)
for 3 weeks.
B. Type IIA - (posterior cortex intact)
 Close reduction under G.A followed by long Arm back Slab with elbow 900 with forearm neutral
position.
 If fracture is unstable then open reduction under G.A. and internal fixation with per cutaneous
crossed K – wire for 3 to 4 weeks
C. Type II B; Type III; Type IV
 Open reduction and internal fixation by per cutaneous crossed K – wire for 3 to 4 weeks.

Isfaqure rahman �� - 83 - tmc-9

 SET-13
1. What is stress fracture? Where does it occur? Tell its management.
When the fracture occurs due to repeated event of minor trauma in a normal bone is called stress fracture.
Common Site :
 2nd metatarsal bone
 Shin of tibia
 Neck of Femur

Treatment :
 General
 Rest the affected part by immobilization
 Analgesic with anti inflammatory drug
 Elevation of affected area
 At first diagnosis can not be done so X- Ray is repeated after 2 weeks.
 Specific :
 Cast is given after diagnosis

2. Name 5 primary malignancies which give metastasis to bone.

5 Primary Malignant Bone Tumour :
1) Osteosarcoma
2) Giant cell tumour
3) Ewing's sarcoma
4) Chondrosarcoma
5) Fibrosarcoma

3. What are principles of Rx of open fracture?

Principle of treatment of open fracture
 Open fracture should be treated as orthopedic emergency.
 Resuscitation of the patient according to ATLS procedure .
 Antibiotic prophylaxis.
 Tetanus prophylaxis
 Urgent wound and fracture deprivement :-
 Remove all dead devitalized tissue and foreign material through surgical toileting with normal
saline(6-20L)
 Stabilization of the fracture :
 If gustilo type I and some case of gustilo type II & where there is no chance of infection —
Internal fixation (Rod/plate)
 If gustilo typeIII and some case of gustilo type lI & where there is chance of infection —
external fixation .
 Definitive wound care :
 Plaster
 Graft
 Cast
 Fixator

Isfaqure rahman �� - 84 - tmc-9

 SET-14
1. What is septic arthritis? Clinical features of acute suppurative arthritis. How will you confirm it?
Inflammation of joint & cartilage caused by pyogenic organism is called septic arthritis.
Clinical feature
 Infant :
 Septicaemia
 Irritability
 Refuse to eat
 Fails to thrive
 High fever
 Adult :
 Severe pain
 Fever
 Increase pulse
 Pain during movement ( wrist, ankle, hip — most affected )
 Signs
 Look
 Red, swelling
 Feel
 ↑temp, tender
 Movement
 Restricted, painful

Confirmed by Aspiration of joint fluid or pus and microbial examination.

2. What is frozen shoulder? Rx of frozen shoulder.
It may be defined as global restriction of shoulder joint, characterized by progressive pain & stiffness of
the shoulder which usually resolves spontaneously after about 18 months.

Treatment :
1) Surgical –
The main indication is prolonged & disabling restriction of movement which fails to respond to conservative
treatment
→ Arthroscopic capsular release.
2) Conservative -
 Analgesic (NSAID)
 Anti-inflammatory drugs
 Exercises are encouraged, the most valuable being pendulum exercises
If not improved,
Intra articular steroid injection
→ Methylprednisolone + Lignocaine

3. What is ALTS & Avascular necrosis? Mention the common sites of avascular necrosis.

ATLS (Advanced Trauma Life Support ) It is a treatment protocol for severely injured patients
Avascular necrosis : It is the ischemic necrosis of the part of the bone due to decrease blood supply following
fracture.
Site : Scaphoid,Neck of femur,Tallus,Humerus .

Isfaqure rahman �� - 85 - tmc-9

 SET-15
1. What are the common deformities of fracture?
Common deformity of fracture are :
a) S shaped deformity – Supracondylar fracture of humerus
b) Dinner fork deformity – Colles fracture
c) Gunstock deformity –Distal humerus
2. Define non-union & delayed union. Rx & causes of non-union.
" When a minimum 9 months has elapsed since injury and the fracture shows no progressive sign of healing
for consecutive 3 months” is called NON UNION.
Fracture site takes longer time and union process still continuous is called DELAYED UNION.
Causes of Non union :
A. Local Causes
 Inadequate fraction reduction
 Insecured / poor fixation
 Inter position of soft tissue between 2 fragments
 Infection
 Comminuted fracture
 Excessive movement of fracture site.
B. General Causes :
 Malnutrition
 Anaemia
 Diabetes
 Poor nutritional status
 Immunosuppressive drug e.g steroids
Treatment of non-union :
A. Conservative treatment
 Electrical and electromagnetic stimulation
 Ultrasound stimulation.
 BMP(Bone morphologic protein)
B. Surgical Treatment
a) Refreshening of the fracture end followed by
a. Bone grafting
b. Internal fixating system
c. Ilizarov external fixator.
b) Close apposition
c) Rigid internal fixation
3. Tell the radiological findings of Osteosarcoma (68) & non-union.
Radiological findings of Osteosarcoma :
 Sun Ray /burst appearance
 Codman's triangle
 Hazy osteolytic area
Radiological findings of Non union :
 Fracture line is present /seen without buzzing callus.
 Tapering of fracture .
 Obliteration of medullary cavity.
 Bony end sclerosis

Isfaqure rahman �� - 86 - tmc-9

 SET-16
1. How will you classify fracture clinically & radiologically?
A. Clinical Classification –
 Closed fracture (Simple fracture)
 When a fracture fragment does not communicate with environment
 Open fracture (compound fracture)
 When fracture fragment communicate with environment through the wound of skin and
soft tissue.
 Complicated fracture. If Tarikul sir ask all 3 points , others first 2
 Fracture associated with other organ system injury
B. Radiological / Morphological types : ( force of direction)
a. Complete fracture (Both cortex and both periosteum are separated)
 Transverse fracture : (avulsion force)
 Oblique fracture : (direct force)
 Spiral fracture : (twisting force)
 Segmental fracture.
 Comminuted fracture :
 More than 2 fragment will be present i.e. proximal and distal fragment
 Impacted fracture
b. Incomplete fracture:
 Greenstick fracture
 Torous Fracture
 Burst fracture

2. Name the stages of fracture healing.

Stage of fracture Healing :
o Stage 1 : Tissue destruction and hematoma formation
o Stage 2 : Stage of inflammation
o Stage 3 : Stage of callus formation
o Stage 4 : Stage of consolidation.
o Stage 5: Stage of remodeling.

3. What are the complications of acute osteomyelitis?(32)

Complications of acute osteomyelitis :
A. General Complications :
a) Chronic osteomyelitis
b) Pyogenic / septic arthritis
c) Septicemia
d) Pyemia
e) Metastatic abscess

B. Local Complications
a) Pathological fracture
b) Growth disturbance
c) Deformity
d) Septic arthritis

C. Long Term Complication :

 Malignant transformation

Isfaqure rahman �� - 87 - tmc-9

 SET-17
1. Name the common sites of secondary bone tumour.(8)
Common Site of Secondary Bone Tumours :
1) Breast (35%)
2) Lungs (30%)
3) Prostate (25%) (OSTEOLYTIC lesion → 1, 2, 4, 5 & OSTEOBLASTIC lesion → 3 )
4) Kidney (5%)
5) Thyroid (2%)

2. How will you manage a case of acute suppurative arthritis?

Treatment :
 General supportive treatment :
 I/V fluid for dehydration
 Analgesic for pain
 Blood transfusion for correction of anaemia
 High nourishing diet
 Antibiotic ( I/V : 4 – 7 days & Oral : 3 weeks)
 Neonates / infants : upto 6 months
 Flucloxacillin + 3rd generation cephalosporin
 6 months to puberty :
 Flucloxacillin + Cefuroxime
 Teenager/Old/Adult :
 Flucloxacillin + Fusidic Acid
 Operative treatment :
 Arthotomy with joint clearance under GA with through irrigation by normal saline and
gentamicin.
 Indication for operation
 If initial aspiration found frank pus
 Failure of conservative treatment after 48 hours of Antibiotic therapy
 In very young infant

3. Classify fracture healing. What are the factors that influence it?
Fracture healing :
a) Primary
b) Secondary
Factors influencing it :
a) Blood supply
b) Infection
c) Joint stability
d) Mobility

Isfaqure rahman �� - 88 - tmc-9

 SET-18
1. Classify osteomyelitis. How will you manage a case of chronic pyogenic osteomyelitis?
Classification:
According to clinical course:
1. Acute osteomyelitis (<3weeks)
 Hematogenous Acute Osteomyelitis
 Acute osteomyelitis complicating open fracture or surgical wound or penetrating injury
2. Sub-acute osteomyelitis (3 weeks)
3. Chronic osteomyelitis (>3weeks)
a) Specific
 Tuberculosis
 Syphilis
 Actinomycosis
b) Non-Specific: Caused by –
 Staphylococcus, Streptococcus, Pneumococcus, Salmonella, E. coli etc.

According to etiology :
1. Bacterial osteomyelitis
 Pyogenic osteomyelitis
 Tubercular osteomyelitis
 Skeletal Syphilis
2. Viral osteomyelitis
3. Fungal osteomyelitis
4. Parasitic osteomyelitis

According to route of entry

1. Hematogenous osteomyelitis
2. Post- traumatic osteomyelitis
3. Contiguous osteomyelitis (From neighbouring tissue – Diabetic Foot Ulcer)

Rx of Chronic osteomyelitis :
1. Main Rx is operative
 Saucerization
 Curettage
 Sequestrectomy
 Antibiotic irrigation
 Bone grafting
2. Antibiotic therapy
Aim :
a) It prevents acute flare up
b) It prevents spreading of infection to the normal tissue

2. Tell the radiological finding of GCT.

Radiological findings of Giant cell tumour / Osteoclastoma :
 An osteolytic area is seen in epiphysis which is eccentric & expansile
 Soap bubble appearance
 Tumour extends towards metaphysis

Isfaqure rahman �� - 89 - tmc-9

3. How will you manage a compound of tibia in 20 years old boy?
Treatment of tibia fracture :-
c) Conservative Treatment:
 Simply immobilize by long leg back slab
 Close monitoring
 After 7-14 days when swelling subside definitive plaster is given i.e. long leg full plaster for 6
weeks ( No mobilisation)
 After 6 week, follow up— remove previous plaster and give walking cast for next 6 weeks
 Then follow up again and take a X-Ray if union has occurred then no plaster needed.
d) Surgical Treatment:-
 Open reduction with internal fixation

Isfaqure rahman �� - 90 - tmc-9

 SET-19
1. Describes the management policy of S/C fracture of humerus of 9 years old boy.
Treatment of Supracondylar fracture :
A. Type I fracture -
 Immobilization with long arm back slab with elbow 90°. Forearm neutral position (mid-
prone) for 3 weeks.
B. Type IIA - (posterior cortex intact)
 Close reduction under G.A followed by long Arm back Slab with elbow 900 with forearm
neutral position.
 If fracture is unstable then open reduction under G.A. and internal fixation with per cutaneous
crossed K – wire for 3 to 4 weeks
C. Type II B; Type III; Type IV
 Open reduction and internal fixation by per cutaneous crossed K – wire for 3 to 4 weeks.

2. Name the types of hip dislocation. Which 1 is common? Mention the complications.
Types of Hip Dislocation:
 Postero-superior (most common)
 Antero-inferior
 Central

Complications of hip dislocation :

 Avascular necrosis of head of femur
 Sciatic Nerve Palsy
 Stiffness
 Delayed union
 Recurrent dislocation
 Osteoarthritis
 Myositis ossificans

3. Tell the important D/D of acute osteomyelitis.

Differential Diagnosis of Acute Osteomyelitis
 Acute septic arthritis
 Rheumatoid Arthritis
 Scurvy
 Ewing’s Sarcoma
 Hemarthrosis

Isfaqure rahman �� - 91 - tmc-9

 SET-20
1. Describes the Rx Protocol of CTEV in different age groups.
Treatment of CTEV :
1. Conservative -
a) Normal stretching by mother
b) Strapping
c) Light plaster cast
d) Ponseti technique
Serial corrective plaster (upto 2 ½ years)
 Weekly interval for 4 weeks → 4 plaster
 2 weekly interval for 4 weeks → 2 plaster
 4 weekly interval for 4 weeks → 1 plaster
e) NITOR protocol
 0-3 weeks → Manual stretching
 3 weeks to 3 months → Serial plaster
 3 months to 3 years → Posteromedial release
 3 years to 5 years → PMR + Dillwyn Evans (cuboid de-cancellation)
 5 years to 9 years → PMR+ Dillwyn
 9 years to 12 years → Wait & observe
 12 years → Triple arthrodesis

2. Surgical : Posteromedial release (PMR)

2. Mention 2 important radiological findings of Osteosarcoma. Which area of long bone is commonly
affected? What is the most common age of its onset?
Radiological findings of Osteosarcoma :
 Hazy osteolytic area may alternate with osteoplastic area
 Sun Ray /burst appearance
 Codman's triangle

Affected area of long nome : Metaphysis

Age group : 30-40 years of age

Isfaqure rahman �� - 92 - tmc-9

 SET-21
1. Tell the cardinal signs of Osteoarthritis.
Cardinal signs of Osteoarthritis :
a) Progressive cartilage destruction
b) Sub articular cyst formation
c) Sclerosis of the surrounding bone
d) Osteophyte formation
e) Capsular fibrosis.

2. Mention the common congenital deformities of foot & hand.

Common congenital deformities of hand are :
a) Syndactyly
b) Polydactyly
c) Club hand
d) Cleft hand
Common congenital deformities of foot are :
a) Club foot
b) Syndactyly
c) Polydactyly

3. Describes the principles of Rx of fracture.

Principles of treatment of fracture :
1) Resuscitation of the patient according to ATLS procedure if needed.
2) Recognition of fracture
3) Reduction :
 Closed reduction
 Reduction without opening fracture site
 Open reduction
 Reduction with opening fracture site
4) Retention /Rest /immobilization
a) Plaster:-
 Half plaster/ back slab
b) Traction:- ( any site of femur)
 Surface Traction
 Non invasive
 usually children and elderly person
 Skeletal / Pin Traction ( 2 cm below tibial tuberosity)
 Adult person
c) Fixator
 Internal ( Definitive)
 Plate, screw, intramedullary nail, K nail, Surgical wire
 External- ( Supportive)
 Uniaxial; multiaxial (ring fixator), simple fixator , ilizarov external fixator
d) Gravity :
 Hanging cast ( if shaft of humerus is fractured)
e) Functional bracing
5) Rehabilitation:
Physiotherapy, movements to prevent stiffness and diffuse atrophy.

Isfaqure rahman �� - 93 - tmc-9

 SET-22
1. Name the types of shoulder dislocation. Which 1 is common? Mention the complications of it.
Types of shoulder joint dislocation
 Anterior dislocation ( most common )
 Posterior dislocation
 Inferior dislocation

Complications of Shoulder Dislocation :

A. Immediate
 Neurovascular injury :-
 Axillary nerve injury
 Axillary artery injury
 Brachial plexus injury
B. Late:
 Osteoarthritis
 Stiffness of joint
 Avascular necrosis

2. Name the fractures when fall on the outstretch hand.

Fractures when fall on the outstretched hand are :
a) Supracondylar fracture
b) Colle’s fracture
c) Clavicular fracture
d) Smith fracture

3. Define triage with its importance.

Triage is a system of medical sorting to identify casualties in an order of priority for evaluation and treatment.
Or
It is the medical sorting process of the patients based on their need for treatment and the resources available
to provide that treatment during mass causality events
Importance triage-
 Triage identify those who need immediate medical care to save life or limb.
 The separation of minor from severe injuries allows for the reduction of the urgent burden on medical
facilities and organizations.
 Triage enables equitable and rational distribution of casualties among the available hospitals .

Isfaqure rahman �� - 94 - tmc-9

 SET-23
1. What are the clinical features of fracture?
Clinical feature of fracture :
a) Pain
b) Swelling
c) Restricted movement

2. Define neoplasm. Name 5 primary malignancies which give metastasis to bone

It is an abnormal mass g of tissue the growth which exceeds & is un-coordinated with that of normal tissue &
persist in the same excessive manner after the cessation of the stimuli, which evoked the change .

5 Primary Malignant Bone Tumour :

1) Multiple myeloma
2) Osteosarcoma
3) Ewing's sarcoma
4) Chondrosarcoma
5) Fibrosarcoma

3. Mention the radiological pictures of chronic osteomyelitis.

Radiological findings of chronic osteomyelitis : Clear lucent area/zone of demarcation.
 Soft tissue swelling
 Sub periosteal reaction
 Bone destruction

Isfaqure rahman �� - 95 - tmc-9

 SET-24
1. Define compound fracture. What is the most important clinical significance of an open fracture?
When fracture fragment communicate with environment through the wound of skin and soft tissue is called
compounds or open fracture.

2. Name the D/D of cystic lesions of bone.

DD of Cystic lesions of bone are :
 Non osteogenic fibroma
 Fibrous dysplasia
 Benign cartilage tumour.

3. What is compartment syndrome? Mention it's sign & management.

Compartment syndrome may be defined as elevation of interstitial pressure in a osteofascial compartment that
results in microvascular compromised and may cause irreversible damage and to the content of the space.
Clinical feature :
 Pain
 Pallor
 Anesthesia
 Paralysis
 Pulselessness
 Positive passive stressing state

Treatment :
A. Conservative: (within 4 hours pressure decrease by 30.)
 Rest and immobilization
 Elevation of affected Iimb
 Proper analgesic and anti in inflammatory
 Antibiotic
 General management
B. Operative:
 Decompression surgery
 Release of osseofascial compartment / fasciotomy.(urgent within 6 hours)
Surest Sign :
 By measuring the intra compartmental pressure
 If diastolic and compartmental pressure difference is less than 30 mmHg then it is the
surest sign or indicate compartment syndrome

Isfaqure rahman �� - 96 - tmc-9