SURGERY I – PAST QUESTIONS

(2007-2019)
(Compiled by Shahroze Ahmed, N-66,
Nishtar Medical University)

CONTENTS
SR # Unit Page #
1 Radiology 2
2 Pre-operative Evaluation & Management 6
3 Aseptic Techniques & Sterilization 6
4 Anesthesia & Analgesia 6
5 Post-Operative Complications 9
6 Advanced Trauma Life Support (ATLS) 9
7 Thoracic Trauma 11
8 Neurosurgical Trauma 11
9 Burn Injuries 11
10 Plastic Surgery 14
11 Acid-Base Disorders 14
12 Fluid Therapy 15
13 Hemorrhage & Shock 15
14 Blood Transfusion 17
15 Surgical Nutrition 18
16 Principles of Oncology 22
17 Skin Lesions 25
18 Cyst, Sinus, Fistula & Wounds 26
19 Surgical Infections 28
20 Arterial Disorders 32
21 Venous Disorders 34
22 Lymphatic Disorders 36
23 Surgical Anatomy 37
24 Miscellaneous 41

1
▪ RADIOLOGY
Ultrasonography
1. A 60-year-old patient with history of peripheral ischemic limb is referred to
ultrasonologist for Doppler study.
a) What is the principle of Doppler USG?
b) What are the advantages and disadvantages of USG? [Supple 2019 held in 2020]

2. A 20-year-old male is brought to emergency after road traffic accident with bruising
over the left lower chest.
a) What might be the diagnosis?
b) What is the role of ultrasonography in such emergency?
c) What are the strengths and weaknesses of ultrasonography use? [Annual 2019]

3. A 65-year-old person suffering peripheral ischemic disease is advised to have

Doppler ultrasound.
a) What is the basis of this investigation to finding the narrowing of a vessel?
b) What are the advantages of ultrasound?
c) What are the disadvantages of ultrasound? [Annual 2018]

4.
a) Name different contrast studies used to diagnose abdominal pathologies.
b) Tabulate advantages and limitations of Ultrasonography. [Annual 2016]

5. A 40-year-old obese female has been presented in surgery OPD with off and on
history of jaundice along with pain in the right hypochondrium.
a) Write down 1st line imaging investigation for her diagnosis.
b) Enlist the various diagnostic imaging techniques used to delineate pathology in
hepatobiliary tree.
c) Write down the advantages of ultrasonography as an imaging technique.
[Supple 2014 held in 2015]

6. A 45-year-old lady is suspected to have gallstones.

a) Which investigation is diagnostic in her case?
b) Give five advantages/strengths and two limitations/weaknesses of it.
[Supple 2013 held in 2014]

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7. A 60-year-old retired school teacher is diagnosed as suffering from carcinoma of the
esophagus. Surgeon advises endoscopic ultrasonography before operation.
a) What are the uses of endoscopic ultrasonography?
b) What are its advantages over conventional ultrasonography? [Annual 2007]

Conventional Radiographs (X-Rays)

1. A 50-year-old shopkeeper is complaining of pain on his chest after he was hit by a
speeding van an hour ago. On examination, his pulse is 90/min, his BP is 100/60 mm
Hg. He has soft crackling feeling on left side of the chest. He is dyspneic. After initial
resuscitation:
a) What is your 1st line of investigation of choice in this patient?
b) Compare and contrast your choice with two other imaging techniques available in
teaching hospital. [Annual 2011]

Mammography
1. A 45-year-old female has been recommended for breast screening to a medical
center. She is very apprehensive.
a) How will you counsel her for its utility and convince that she must undergo this
procedure?
b) Which are the malignant conditions for which screening can be carried out?
c) Name the imaging views that are taken during mammography.
[Supple 2016 held in 2017]

2. A 36-year-old female has presented with painful lump in the upper outer quadrant of
left breast. There is skin dimpling and history of bloody discharge from nipple. There
are also one or two mobile ipsilateral lymph nodes in axilla. She was advised
mammogram.
a) What views of mammogram are usually taken?
b) What is the dose of radiation in mammogram?
c) What are three advantages of ultrasound for breast? [Annual 2015]

3. A 36-year-old woman has presented with a 1 cm lump in the upper outer quadrant
of her right breast. She is nulliparous and does not have any family history of breast
cancer. There is no discharge from the nipple.
a) Apart from an ultrasound of her right breast, what other radiological
investigation you would request for this patient? Enumerate the steps involved in
this investigation technique.
b) Why is this safe radiological procedure?

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 c) Would you have requested for this investigation if the patient was 20-year-old
and why?

Computed Tomography (CT)

1. CT scan is widely in use in all kinds of health care related specialties for diagnosis.
Please answer the following questions in view of its characteristics.
a) What are the uses of three dimensional and multiplanar reconstruction CT scan?
b) Enumerate two common disadvantages of CT scan. [Annual 2017]

2. A 22-year-old first time pregnant lady has been advised CT scan of neck for smooth
swelling of 3x3 cm in size moving with swallowing. The consultant radiologist has
reservation for CT scan and suggests her another simple imaging technique for her
satisfaction.
a) Why did the radiologist disagree with a CT scan in her case?
b) What alternative imaging do you think he suggested and why?
[Supple 2011 held in 2012]

3. A twenty-six-year-old, three months pregnant lady presented in emergency after

road accident. She has altered sensorium with Glasgow coma scale of 7. On
examination, her BP was 180/100 mm Hg and pulse 60/min. X-ray skull showed
depressed fracture of left parental bone. She was advised CT scan brain.
a) What are the indications of CT in this patient?
b) What special precautions you will observe in this patient during scanning?
c) Which safe and non-invasive investigation can assess the fetal well-being?
[Supple 2008 held in 2009]

Magnetic Resonance Imaging (MRI)

1. An 80-year-old male has come with 5 days history of absolute constipation and
abdominal distension. He also has complaints of passage of blood mixed with stool
off and on.
a) Which radiological investigations are required in this case?
b) Describe the principle of MRI. [Supple 2016 held in 2017]

2. MRI is a very useful diagnostic modality. Keeping in view its principles:

a) Give two differences between T1 and T2 weight images.
b) Give two newer modifications of conventional MRI.
c) Give two absolute contraindications of MRI. [Annual 2014]

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3. A football player with traumatic injury to his right knee is advised an MRI.
a) Give the principle involved in this imaging technique.
b) What are its limitations? [Annual 2010]

Imaging in Acute Abdominal Conditions

1. A 30-year-old man presents in emergency with acute abdomen.
a) Enlist radiological investigations that can help you to reach the diagnosis.
b) Name the radiological investigation & pathological condition that exhibits ‘Claw
sign’. [Annual 2013]

2. 35-year-old male presents with 2 days history of colicky abdominal pain, vomiting &
constipation. There is history of laparotomy 2 years ago for typhoid perforation. On
examination patient is dehydrated, abdomen is distended with active bowel sounds
on auscultation.
a) Which is the most important radiological investigation for this patient in
emergency?
b) What positive findings do you expect to find on that investigation?
c) How can you differentiate radiologically between jejunum, ileum and colon?
[Supple 2010 held in 2011]

3. A patient with acute abdominal pain, distension and vomiting presents in emergency
department. What imaging techniques will be helpful in arriving at diagnosis?
[Annual 2009]

Nuclear Medicine
1.
a) What is radionuclide imaging?
b) Give four examples of its use in surgical practice.
c) Give four commonly used tumor markers and the tumors for which they are
utilized. [Supple 2017 held in 2018]

2. A 35-year-old housemaid is suffering from toxic nodular goiter for which thyroid scan
is advised.
a) Which other radionuclide scans are available in general?
b) Write two merits & two demerits of radionuclide scanning. [Annual 2008]

5
▪ PRE-OPERATIVE EVALUATION & MANAGEMENT
1. A 45-year-old female with gallstones & chronic cholecystitis is admitted from OPD.
She is known case of Diabetes Mellitus. She is planned for laparoscopic
cholecystectomy.
a) How will you evaluate her preoperatively?
b) What are the principles of creating pneumoperitoneum?
c) What type of intraoperative complications can occur in this operation?
[Annual 2015]

2. A 35-year-old mother of eight children is brought from flood affected area of the
country. She has reducible swelling in area of her cesarean section scar. She is pale
looking and weighs 20% less weight for her age and height. The surgeon has
postponed the operation for one month to improve the final results.
a) Why did the doctor delay the operation? How should he assess the problem?
b) What advice should be given to patient to achieve his objectives? [Annual 2012]

▪ ASEPTIC TECHNIQUES & STERILIZATION

1.
a) What is the difference between sterilization and disinfection?
b) Enlist four common methods of sterilization with an example for each one of
them.
c) How disposable articles are sterilized? [Supple 2017 held in 2018]

▪ ANESTHESIA & ANALGESIA

Types of Anesthesia
1. A 20-year-old college student has to undergo right inguinal herniorrhaphy.
a) What anesthetic techniques can be employed in this case?
b) Write 1 merit & 1 demerit of each. [Supple 2008 held in 2009]
2. 65-year-old male presents with reducible RIH. He is hypertensive, well controlled on
medication. ECG is normal. There is history of diet control diabetes. He is planned for
repair of RIH.
a) What are various types of anesthetic techniques which can be used in this
patient?
b) Briefly discuss which one type of anesthesia is preferable for this patient.
[Supple 2010 held in 2011]

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General Anesthesia
1. What are techniques for maintaining airway during General Anesthesia?
[Supple 2016 held in 2017]

2. A 25-year-old school teacher is undergoing subtotal thyroidectomy for primary

thyrotoxicosis (Grave’s disease)
a) What type of anesthesia will be necessary for a safe surgical procedure?
b) What measures you will take to ensure the better outcome in the capacity of
anesthetist.
c) In five lines, give the steps you will take during the procedure. [Annual 2011]

3. A 40-year-old man with acute abdomen is planned for laparotomy.

a) What are objectives of the anesthetist to facilitate the surgery?
b) Give the advantages of general anesthesia in this patient. [Annual 2010]

Local Anesthesia
1. A 40-year-old woman presents with ganglion of right wrist. The surgeon decides to
operate her under Bier’s block.
a) Write a brief note on intravenous regional anesthesia (Bier’s block).
b) What are the common techniques for local anesthesia?
[Supple 2019 held in 2020]

2. A 25-year-old man is going to be operated for varicose veins of left lower limb under
spinal anesthesia.
a) What are the complications of this procedure and their treatment?
b) How does spinal anesthesia differ from epidural anesthesia? [Annual 2018]

3. A 30-year-old lady undergoing labor; she requests for epidural analgesia during
delivery.
a) Describe the method of giving epidural analgesia.
b) Mention its three complications. [Supple 2017 held in 2018]

4. What is spinal headache? [Supple 2016 held in 2017]

5. Mention three indications of Epidural Anesthesia. [Supple 2016 held in 2017]

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6.
a) Name different types of Regional Anesthesia.
b) Name three complications of Spinal Anesthesia.
c) Write the steps in the treatment of Spinal Headache. [Annual 2016]

7. A young female has presented with 2 cm x 2 cm swelling on the flexor aspect of her
right forearm. Surgical excision biopsy has been planned. She is reluctant to all types
of general anesthesia.
a) What is the most suitable regional anesthesia you will plan for this patient?
b) Name any two drugs frequently used for this anesthesia along with their
maximum safe dose in most cases.
c) Enlist atleast four complications of this form of anesthesia.
[Supple 2014 held in 2015]

8. A 35-year-old female is admitted with acute cholecystitis secondary to gallstones.

She is otherwise fit and early laparoscopic cholecystectomy is planned. Name the
layers through which spinal needle passes. [Annual 2014]

9. A 40-year-old lady who weighs 60 kg has come for removal of a lipoma on her right
forearm. You plan to remove it under local anesthesia.
a) Name two important local anesthetic agents and their doses which can be used in
her case.
b) Mention five important complications of local anesthetics.
[Supple 2013 held in 2014]

10. A 70-year-old man has to undergo right inguinal herniorrhaphy. He is not fit for
general anesthesia. Anesthetist decides that this procedure should be done under
regional anesthesia.
a) What do you mean by regional anesthesia? Mention its two advantages over GA.
b) Mention two of its types with their complications. [Annual 2013]

11. A 25-year-old man is planned for anorectal surgery under spinal anesthesia.
a) What is the most appropriate site for injection and why?
b) Enlist complications of spinal anesthesia. [Annual 2009]

12. A 20-year-old university student has to undergo left inguinal herniorrhaphy under
regional anesthesia.
a) What regional anesthesia techniques are available for this patient?

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 b) Describe any one of them. [Annual 2008]

Pain
1. What are the options for controlling severe pain in malignant disease? [Annual 2019]

2. A middle-aged lady presents with locally advanced carcinoma of right breast. Patient
is in agony because of severe intractable pain.
a) What is WHO ‘Pain step ladder’?
b) Which painkiller to be selected for this patient? [Annual 2017]

3. A 40-year-old male underwent radical gastrectomy for carcinoma stomach. In the

post-operative period, he was feeling severe pain for which the doctor advised
Patient Controlled Analgesia.
a) What is Patient Controlled Analgesia?
b) How is it administered? [Supple 2015 held in 2016]

▪ POST-OPERATIVE COMPLICATIONS
Wound Complications
1.
a) What is wound dehiscence?
b) Write the factors involved in this process.
c) What type of suture material is used to close the abdomen after laparotomy and
what is the rationale of tis use? [Annual 2016]

▪ ADVANCED TRAUMA LIFE SUPPORT (ATLS)

1. After a crossfire, a 30-year-old taxi driver is brought to emergency with bleeding
wound on left thigh. He is conscious.
a) What will be your first step at reception?
b) Give four steps of management.
c) Outline the final treatment. [Annual 2011]

2. A 17-year-old young man was brought to emergency with history of road traffic
accident (RTA) and injury to left arm. On examination, multiple lacerations of the
forearm and marked swelling of the hand and fingers were noted. Lacerations were

9
 soiled with mud and sand and he margins had some blackish discoloration. How will
you manage this patient? [Supple 2008 held in 2009]

3. A 15-year-old motorcyclist meets a road accident and presents to Accident &

Emergency Department with multiple injuries. He is dyspneic, tachypneic,
tachycardiac & hypotensive. How would you manage this patient using ATLS
approach? [Annual 2008]

4. In a suicide bomb attack 50 people died and 150 were injured, which were rushed to
local district hospital. Support you were medical officer on duty in emergency ward.
How would you manage these causalities? [Supple 2007 held in 2008]

5. A 54-year-old working woman got a penetrating wound on her right temporal region
which was bleeding profusely. On reaching Accident & Emergency Department 30
minutes later, she was not breathing, her pulse & BP were not recordable. Inspite of
all resuscitation efforts, she could not be revived. What pre-hospital management
could have saved her life? [Annual 2007]

Primary Survey & Resuscitation

1. A couple was brought in emergency room after Road Traffic Accident. The husband
was received dead while the wife had depressed conscious level. Primary &
Secondary surveys were done and she was managed conservatively.
a) Discuss Trimodal distribution of death along with the cause in each group.
b) Enlist four adjuncts to the primary survey. [Annual 2014]

2. The heart beat core of the ATLS system comprises of ABCDE of trauma care. What do
you understand by pneumonic ABCDE? [Annual 2017]

Definitive Care Plan (Tertiary Survey)

1.
a) What is FAST?
b) Write down its uses and limitations. [Supple 2015 held in 2016]

Triage
1. In a suicide bomb attack 50 people died and 150 were injured, which were rushed to
local district hospital. Support you were medical officer on duty in emergency ward.
How would you manage these causalities? [Supple 2007 held in 2008]

10
▪ THORACIC TRAUMA
Tension Pneumothorax
1. A 16-year-old boy is brought to surgical Emergency Room after a motor bike
accident. On primary survey and resuscitation, he has absent breath sounds on the
left side of the chest and hyperresonance on percussion. Trachea is deviated to right
side.
a) What is the diagnosis?
b) What measures would you take to deal with this emergency?
[Supple 2015 held in 2016]

▪ NEUROSURGICAL TRAUMA
Brain Injury
1. A 20-year-old motorcyclist is brought to Accident & Emergency department of
tertiary care hospital after a Road Traffic Accident. There is history of brief period of
unconsciousness. He has been resuscitated with ATLS protocol.
a) Write down the guidelines to obtain CT brain plain in patient with head injury.
b) Write down the specific management plan if this patient’s CT scan is showing an
acute extradural hematoma.
c) Write down motor response part of Glasgow Coma Scale.
[Supple 2014 held in 2015]

▪ BURN INJURIES
Classification of Burns
1. How would you classify burns on the basis of depth of burn wound?
[Annual 2016]

2. How will you classify burn wound on the basis of its depth?
[Supple 2013 held in 2014]

Assessment of Burns
1. A female patient of weight 70 kg had burns on both upper arm and front of chest.

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 a) What is the rule of 9 to assess the size of a burnt area?
b) How will you assess the depth of burn wound? [Supple 2019 held in 2020]

2. A 30-year-old victim of fire incident has been brought to hospital. His burnt area
comprises whole of the front side of the chest, abdomen, perineum & 50% area of
involvement of both upper limbs. Some burnt patches over both lower limbs roughly
adding 5% to total burn area are also found.
a) Calculate the percentage of burn area using rule of 9.
b) Write down atleast four reasons under hospital admission criteria for the burn
patients or referral to burn center. [Supple 2014 held in 2015]

3. A patient weight 60 kg has sustained burns of face, scalp, upper chest front and both
upper limbs. What is the percentage of burn area? [Annual 2009]

Hospital Management
1. A female patient of weight 70 kg had burns on both upper arm and front of chest.
What is the fluid requirement in this patient? [Supple 2019 held in 2020]

2. A 45-year-old woman suffers burns of whole of front of chest, abdomen and whole
of right upper arm while cooking. She weighs 70 kg. the burns are partial thickness.
What will be initial plan of management of this patient? [Annual 2018]

3. A 10-year-old boy is seen in Emergency Room with high tension burns of right arm
about an hour ago. His arm is blue upto forearm and radial pulse is not palpable.
a) What is his initial management?
b) What is the surgical treatment of full thickness burn? [Annual 2015]

4. A 70-year-old male weight 60 kg suffers thermal burns following fire in his office. He
has deep facial burns posterior chest burns and full thickness circumferential burns
to both upper limbs with delayed capillary refill. He is cyanosed with change in voice,
stridor and respiratory difficulty.
a) What is the approximate percentage of burnt area and how much fluid should be
given in first 24 hours?
b) What measures should be done for his respiratory distress?
c) What surgical procedure should be done for his limb burn? [Annual 2014]

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5. A 25-year-old lady caught in a fire in the kitchen is brought to the emergency with
25% burns. Mention three important steps in the initial management.
[Supple 2013 held in 2014]

6. A 35-year-old male factory worker is brought to hospital with burns due to fire
breakout in chemical store.
a) Enumerate five important steps of management at reception.
b) How will you continue your effort for a successful outcome in surgical ward
thereafter?
c) Enlist the persons involved to bring the satisfactory end to this worker’s suffering.
[Annual 2011]

7. A 35-year female presents with 30% superficial burns. She weighs 60 kg. burnt area
involves neck chest and abdomen.
a) How would you calculate her fluid requirement in 1st 24 hours?
b) Calculate her fluid requirement. How would you administer the calculated
amount of fluid to this patient and which type of fluid you will use?
[Supple 2010 held in 2011]

8. A young man of 35 years was trapped in house which caught fire. This man was
brought to surgery department within one hour of incidence. He had burns of face,
front of chest trunk and right upper limb.
a) Describe the immediate steps to be taken by the attending doctor.
b) How would you manage inhalation burn? [Annual 2010]

9. A 25-year-old housewife (weight 60 kg) is brought to emergency ward 2 hours after

sustaining 30% burns on her abdomen and lower limbs. What is the general
management of this patient during 1st 24 hours? [Annual 2007]

10. A person weight 60 kg has sustained burns of face, scalp, upper chest front and both
upper limbs.
a) What is the calculation of fluid for the first 24 hours?
b) What is escharotomy? [Annual 2009]

Non-Thermal Burn Injuries

1. A 45-year-old lineman got electrocution while working on high tension chemical
lines. On examination, he has entry wound on hand and exit wound on foot.
a) What possible damage can occur?

13
 b) What is important during management of this patient? [Annual 2019]

Complications of Burns
1. What are acute and chronic complications of burns? [Annual 2016]

2. Enlist three late complications of burns. [Annual 2015]

3. A 35-year-old female presents with 30% superficial burns. She weighs 60 kg. burnt
area involves neck, chest and abdomen. What late complications of burn this patient
may develop? [Supple 2010 held in 2011]

▪ PLASTIC SURGERY
1. A 25-year-old stage actress has a 7x7 cm wound on left side of neck after excision of
full thickness acid burn. Please enlist five reconstruction options with one point of
preference in this case. [Annual 2012]

2. What are the various methods of skin cover? [Annual 2009]

▪ ACID-BASE DISORDERS
1. A 50-year-old woman has presented with gastric outlet obstruction. She is vomiting
profusely.
a) Name the fluid and electrolyte disturbance that can occur.
b) Name type of acid-base imbalance can be seen in her case.
c) What is paradoxical aciduria?
d) How will you correct it? [Supple 2014 held in 2015]

2. A 60-year-old lady presents in emergency with gastric outlet obstruction resulting in

repeated vomiting.
a) What is the electrolyte imbalance & give its physiological basis?
b) Mention two important fluids & one important investigation used to treat &
monitor this patient. [Annual 2013]

3. A four-week baby presented with non-bilious vomiting, distension of abdomen and

succussion splash positive.
a) Enlist the metabolic complications you will consider in this case.
b) How will you treat this child? [Supple 2008 held in 2009]

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▪ FLUID THERAPY
1. A 40-year-old woman is recovered from the debris of an earthquake in October, five
days after incident. She is semi-conscious, responding to loud verbal commands after
adequate airway control in a camp hospital.
a) What will be your fluid & electrolyte replacement strategy when there is not
obvious or concealed hemorrhage?
b) How will you monitor the efficacy of designed therapy?
c) How long will you continue with this fluid and electrolyte support? [Annual 2011]
▪ HEMORRHAGE & SHOCK
Hemorrhage and Its Management
1. A 45-year-old man underwent above knee amputation for gas gangrene of the lower
limb. On 7th postoperative day, massive bleeding started from the wound site.
a) What is this type of hemorrhage?
b) What are the factors responsible for bleeding?
c) What are the principles of management? [Annual 2019]

Shock and Its Classification

1. A 35-year-old person is brought to emergency with history of road side accident. On
examination, he is found to be in shock.
a) Define shock.
b) Classify shock. [Supple 2019 held in 2020]

2. Define and classify shock. [Supple 2010 held in 2011]

Severity of Shock
1. A 30-year-old patient was brought to Emergency with history of fall 4 hours. On
examination, he is well-oriented, there is deformity of right upper limb, cold
peripheries. Pulse 100/min, BP 110/70 mm Hg.
a) Is it compensated or decompensated shock?
b) Enumerate the factors to place the patient in the above category. [Annual 2017]

2. In a patient runover by a speeding truck, polytrauma has resulted in shock.

a) What are parameters of patient in the stage of severe shock?

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 b) What are consequences of irreversible shock? [Annual 2010]

Hypovolemic/Hemorrhagic Shock
1. A 40-year-old bank cashier is brought to emergency in shock. He had suffered from
high-grade fever, severe bone pain and hemorrhagic spots on his body since last 10
days. He has stayed at home and was using NSAIDs for symptomatic control. On
brushing of his teeth, he was bleeding but ignored.
a) What is your suspicion and enumerate three 1st line measures?
b) How will you subsequently manage him after initial one hour of admission?
[Supple 2011 held in 2012]

2. From the rural health center, a 45-year-old mother of six children is referred with the
diagnosis of Dengue Fever. She has a body temperature of 100 F, pulse rate 110/min.
She has a platelet count of 70 x 10^9. Enlist five management steps for her care in
our ward. [Annual 2011]

3. A 20-year-old college student sustains multiple injuries in a road traffic accident. His
pulse is 120/min & thready, blood pressure 90/60 mm Hg. He has difficult respiration
and sweat on his forehead.
a) What is the diagnosis?
b) How would you treat this case? [Supple 2007 held in 2008]

Septic Shock
1. What are the clinical features of septic shock? [Supple 2017 held in 2018]

2. A 50-year-old man after laparotomy for typhoid perforation develops tachycardia,

low blood pressure & oliguria on 3rd post-operative day. His Hb is 12 gm/dl &
leukocyte count is 22,000/dl.
a) What is the probable cause?
b) Outline the principles of management of the patient. [Annual 2013]

Obstructive Shock
1. A 50-year-old male was struck on right side of chest during a quarrel. He develops
rapidly progressing dyspnea. On examination, his extremities are cold and clumsy.
Pulse 110, Blood pressure 90/60. There is tracheal and apex beat shift to left side.
a) What type of shock this patient has developed and why?
b) What are other clinical conditions which can lead to same category of shock?
[Supple 2010 held in 2011]

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Shock Monitoring
1. A 35-year-old person is brought to emergency with history of road side accident. On
examination, he is found to be in shock. How will you monitor this patient who is in
shock? [Supple 2019 held in 2020]

2. A 21-year-old boy presents in Emergency Room with stab injury in right chest. On
examination, his pulse is 120/min, BP 90/60 mm Hg and pallor is positive. Two wide
bore I/V lines are taken & I/V crystalloids are administered. Half hour later, his pulse
becomes 96/min and BP 105/70 mm Hg.
a) What is dynamic fluid response and its interpretation?
b) How will you monitor the patient in shock for organ/system perfusion? Give four
points. [Annual 2014]

▪ BLOOD TRANSFUSION
Indications of Blood Transfusion
1. Give three indications of blood transfusion. [Supple 2015 held in 2016]

Complications of Transfusion
1. A 40-year-old male who has been operated for cholecystectomy is started blood
transfusion. You notice the mistake of mismatched or incompatible blood.
a) What will be the management of this patient?
b) What measures will you take to prevent the catastrophe in future?
[Annual 2018]

2. A 65-year-old carpenter with O positive blood group has to undergo Whipple’s

operation for which multiple blood transfusions would be required. What
complications of blood transfusion can occur in this patient?
[Supple 2015 held in 2016]

3. A 40-year-old male is brought to Emergency Room after multiple injuries. He is in

shock. Initial management has been done now he is in the ward. He is found to have
intra-abdominal bleeding. He was transfused with five pints of blood during and
after repair of liver injuries. Mention any three complications with single transfusion.
[Annual 2015]

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4. In a surgical ward, nurse on duty has called the duty doctor announcing ABO
incompatible blood transfusion to a young male patient due to clerical mistake and
told him only 10 ml blood was transfused when she stopped the transfusion. Patient
is shivering, running fever and complaining pain in loin area.
a) How would you deal with this condition in the immediate phase if you are the
attending doctor?
b) Enlist the infectious complications of blood transfusion.
[Supple 2014 held in 2015]

5. An 8-year-old male has been advised whole blood transfusion after a major
abdominal surgery. He complains of severe headache & develops fever & rapidly
appearing urticarial rash all over the body 5 minutes after initiation of transfusion.
a) What is the most likely diagnosis?
b) Enumerate initial treatment steps in management of this patient.
c) How can this complication be prevented? [Annual 2012]

6. A 65-year-old carpenter with O +ve blood group has to undergo Whipple operation
for which multiple blood transfusions would be required. Which infectious
complications of blood transfusion can occur in this patient? [Annual 2008]

Disseminated Intravascular Coagulation (DIC)

1. What treatment steps are suitable to treat coagulopathy after massive blood
transfusion? [Annual 2015]

▪ SURGICAL NUTRITION
Nutritional Assessment
1. A 60-year-old man is suffering from dysphagia and is not taking proper food. How
will you do nutritional assessment of this patient? [Supple 2019 held in 2020]

2. A 50-year-old female has been operated for a tuberculous perforation. Post-

operatively, she developed multiple enterocutaneous fistulae. She lost 10 kg weight
in the last one week.
a) What are the clinical parameters on which this patient has to be assessed for
malnutrition?
b) What type of nutritional therapy this patient needs and why? [Annual 2017]

18
3.
a) How will you calculate BMI?
b) How will you clinically assess the nutritional status of a surgical patient?
[Supple 2016 held in 2017]

4. A 50-year-old street bowler has been diagnosed as a case of unresectable carcinoma

of esophagus. He is emaciated with significant weight loss. How can you assess his
nutritional status? [Supple 2015 held in 2016]

5. A 20-year-old female had difficulty in swallowing after accidental ingestion of caustic

soda six months ago. She has lost about 20 kg weight and needs corrective surgery.
She is being admitted for surgery. Which baseline investigations are necessary to
evaluate her nutritional status? [Annual 2015]

6. A 16-year-old girl after corrosive intake presents with three months history of
dysphagia both for solids & liquids.
a) How will you assess her nutritional status?
b) What is the best method of replenishing her nutritional requirements?
[Annual 2013]

7. A 65-year-old man with dysphagia for six months is being prepared for a major
surgical procedure in next few days. He has lost about 20% of his body weight in this
period.
a) For a better result of surgical intervention, what is your point of focus at this
stage?
b) How will you execute your strategy? [Supple 2011 held in 2012]

8. A young man had a wide resection of his intestine and needs total parenteral
nutrition.
a) How would you administer TPN?
b) What are the complications of this method? [Supple 2008 held in 2009]

9. A 35-year-old housewife develops jejunal fistula after leakage of an anastomosis. She

is put on conservative treatment. How would you look after nutritional requirements
of this patient? [Supple 2007 held in 2008]

19
Calculation of Nutritional Requirement
1. A 20-year-old female had difficulty in swallowing after accidental ingestion of caustic
soda six months ago. She lost about 20 kg weight and needs corrective surgery. She
is being admitted for surgery. What is average amount of energy, carbohydrate, fat
and protein requirement for 24 hours? [Annual 2015]

Enteral Feeding
1.
a) Name various methods of enteral nutrition.
b) What are the complications of enteral nutrition? [Supple 2019 held in 2020]

2. A 20-year-old female got corrosive burns to esophagus. In emergency room,

resuscitation of patient is done. She is unable to take by mouth. Enteral nutrition is
planned.
a) What are common enteral nutrition techniques?
b) What metabolic and tube related complications can occur during enteral
nutrition? [Annual 2019]

3.
a) What is enteral nutrition?
b) What are various methods of enteral nutrition?
c) Enumerate the complications of enteral nutrition.
[Annual 2018]

4.
a) How will you define Enteral Nutrition?
b) Enlist different methods of Enteral Nutrition.
c) What are indications and contraindications of Enteral Nutrition? [Annual 2016]

5. A 50-year-old street bowler has been diagnosed as a case of unresectable carcinoma

of esophagus. He is emaciated with significant weight loss. Write down three
different ways to give him enteral nutrition. [Supple 2015 held in 2016]

6. Write down atleast three ways of entera nutrition. [Supple 2014 held in 2015]

7. A 60-year-old patient presented with dysphagia and significant weight loss. His upper
GI endoscopy showed a malignant stricture 35 cm from incisors. Investigations: Hb 9

20
 gm% & serum albumin was 2 gm%. CT scan showed growth which is not involving
adjacent structures. It was decided to improve his nutritional status before surgery.
a) Discuss how can he be provided with adequate nutrition enterally.
b) Enumerate 5 tube-related complications of enteral nutrition.
[Supple 2010 held in 2011]

8. A 70-year-old butler is suffering from advanced carcinoma of the esophagus for

which he has to be put on total enteral nutrition
a) Which methods of total enteral nutrition are available for this patient?
b) Write two merits and two demerits of total enteral nutrition. [Annual 2008]

Total Parenteral Nutrition

1. Enumerate the complications of Total Parenteral Nutrition.
[Supple 2017 held in 2018]

2. Give indications of Total Parenteral Nutrition. [Supple 2016 held in 2017]

3. A 34-year-old male from peripheral area presents after some abdominal operation
to a tertiary care hospital. He has been diagnosed as a case of high output intestinal
fistula.
a) Write down the ideal route of nutritional supplementation in this case.
b) Write down metabolic complications he can encounter with this supplementation
relating to feeding regimen. [Supple 2014 held in 2015]

4. A patient presented in Surgical Emergency with signs and symptoms of acute

abdomen. His exploratory laparotomy was done. Almost whole of small gut was
found to be gangrenous and it was resected. Only 20 cm of jejunum was left behind,
a) Which route of nutrition will you chose in this patient?
b) What are the effects of resection of small intestine on him?
c) Name four complications of parenteral nutrition. [Annual 2014]

5. A 25-year-old boy presents with high output enteric fistula after laparotomy for
typhoid perforation.
a) Name nutritional fluids that should be given to him with their caloric values.
b) Enumerate ten complications of parenteral nutrition. [Supple 2013 held in 2014]

21
6. A young lady attempted suicide by drinking a corrosive solution. She developed
ulceration and scarring of the esophagus and stomach due to which she is unable to
tolerate orally. She is advised total parenteral nutrition.
a) What are the routes available for this procedure?
b) What are its complications? [Annual 2010]

7. A patient with advanced carcinoma of esophagus with severe malnourishment has

been planned for esophagectomy.
a) What combinations of fluids will you use to improve nutrition of this patient prior
to surgery by parenteral nutrition?
b) Enumerate the complications of parenteral nutrition. [Annual 2009]

8. A 35-year-old clerk develops jejunal fistula due to leakage of anastomosis. He is put

on total parenteral nutrition through a central venous line. How would you perform
biochemical monitoring of this case? [Annual 2007]

▪ PRINCIPLES OF ONCOLOGY
Screening
1. Carcinoma breast is common in Pakistan. Many patients report late. You are asked
to design a program of screening. Witte a brief note about criteria for screening of
this disease. [Supple 2019 held in 2020]

2.
a) Define screening test.
b) What is the criteria for selection of screening test? [Annual 2017]

3.
a) What is screening for cancer?
b) Name three important cancers in which screening can be helpful.
c) Give three criteria which are requirements of a good screening test for
malignant disease. [Annual 2013]

Tumor Markers
1.
a) What is tumor marker? How they are useful in clinical practice?
b) Give four examples of commonly used tumor markers and tumor for which they
are utilized? [Supple 2017 held in 2018]
22
Principles of Cancer Surgery
1. Write down the five roles of surgery in the treatment of cancer with examples.
[Supple 2015 held in 2016]

Principles of Chemotherapy
1. A 55-year-old female is planned for adjuvant chemo-radiotherapy after modified
radical mastectomy for invasive ductal carcinoma of breast.
a) What do you know about adjuvant chemo-radiotherapy?
b) What are the basic principles of combined therapy? [Annual 2019]

2. A 50-year-old woman is diagnosed as a case of Carcinoma Breast. The doctor advised

adjuvant therapy.
a) What is meant by neoadjuvant therapy?
b) What is mean by adjuvant therapy?
c) What are the principles of administration of chemotherapy in cancer patients?
[Annual 2018]

3.
a) What is adjuvant and Neo-adjuvant Chemotherapy?
b) Enlist common complications of Chemotherapy. [Annual 2016]

4.
a) Name three firsts generation chemotherapy drugs sued after mastectomy for
cancer.
b) What are basic principles of combined chemotherapy? [Annual 2015]

5. A 40-year-old female underwent breast surgery with axillary clearance followed by

radiotherapy for left sided carcinoma of the breast. What is the mechanism of action
of 5-fouruouracil? [Supple 2014 held in 2015]

6.
a) What is neoadjuvant chemotherapy? Give two examples.
b) Mention three basic principles of combined chemotherapy for cancer patient.
[Supple 2013 held in 2014]

7. A 12-year-old villager boy has been diagnosed with lymphoma after an excision
biopsy of his cervical swelling. He also has few similar swellings in his inguinal region.

23
 a) Enumerate treatment options available to you for this boy.
b) Give your choice with atleast three points for preference.
[Supple 2011 held in 2012]

8. A 45-year-old lady with carcinoma breast has undergone modified radical

mastectomy in right side and has been advised chemotherapy treatment.
a) What is the broad classification of chemotherapeutic agents?
b) What are the complications of chemotherapy? [Annual 2009]

9. A 45-year-old receptionist presents with locally advanced carcinoma in her left

breast. Chemotherapy with CMF regiment is planned. What complications of
chemotherapy can occur in this patient? [Supple 2007 held in 2008]

Principles of Radiotherapy
1. What are different types of radiotherapy? [Annual 2016]

2. What is the indication for radiotherapy for breast cancer? [Annual 2015]

3. Give five points of concern i.e., ‘Rs’ while designing the radiotherapy regiment for
cancer patient. [Annual 2011]

4. Surgical excision of malignancy is considered the best option. Enumerate the various
malignant diseases where radiotherapy is considered a better option.
[Annual 2010]

5. In a cancer patient, cure and palliation can be achieved with the help of
radiotherapy.
a) What are the methods available for giving radiation to the disease tissue?
b) What are the complications of radiotherapy for cancer?
[Supple 2008 held in 2009]

6. A 50-year-old peasant suffering from carcinoma of tongue is being treated by

brachy-radiotherapy.
a) What brachy-radiotherapy techniques are available in general?
b) Write two merits and two demerits of brachy-radiotherapy. [Annual 2008]

24
7. A 65-year-old retired nuclear scientist is diagnosed as suffering from the carcinoma
of prostate, for which radiotherapy is planned. What complications of radiotherapy
can occur in him? [Annual 2007]

Principles of Immunotherapy
1. A 40-year-old female underwent breast surgery with axillary clearance followed by
radiotherapy for left sided carcinoma of the breast. Name the monoclonal antibody
used in breast cancer. [Supple 2014 held in 2015]

Principles of Hormonal Therapy

1. A 40-year-old female underwent breast surgery with axillary clearance followed by
radiotherapy for left sided carcinoma of the breast. What are different options of
hormonal therapy in breast cancer? Name the monoclonal antibody used in breast
cancer? [Supple 2014 held in 2015]

Tumor Board
1. Enlist six members of the multi-professional team in the management of cancer
(tumor board). Give three-point advantages and three-point disadvantages of
making such a team from different disciplines. [Annual 2012]

▪ SKIN LESIONS
Basal Cell Carcinoma
1. A 60-year-old farmer presents with 1 cm sized oval shaped, slowly growing ulcer just
over his right zygomatic area for last six months. It is painless. On examination, there
is crusting but no exudates & the margins are rounded & elevated. The lymph nodes
draining the area are not palpable.
a) What is the most probable diagnosis?
b) Mention three of its types and give three predisposing factors of this condition.
[Annual 2013]

2. A 70-year-old frail lady presents with ulcer on her right cheek below the right lower
eyelid. Ulcer has been there for 4 months and has not healed. On examination, there
is 2x2 cm ulcer with necrotic base and raised edges.
a) What is the most probable diagnosis? Give one alternative diagnosis as well.
b) What are treatment options and which is suitable for this lady?
[Supple 2010 held in 2011]

25
3. A 30-year-old housewife presents with an ulcer no medial canthus of her right eye
for last one year. It started as a small nodule, which later ulcerated. Examination
reveals that the ulcer has rolled edges.
a) What is the likely diagnosis?
b) How would you treat this patient? [Annual 2008]

Squamous Cell Carcinoma

1. A 70-year-old peasant presents with non-healing ulcer on his lower lip for last 6
months. Examination reveals that the ulcer has everted edges. What is your
diagnosis? How would you treat this case? [Supple 2007 held in 2008]

▪ CYSTS, SINUS, FISTULA & WOUNDS

Sinus
1. A 25-year-old van driver is disturbed by discharging point on his back b/w his
buttocks. The driver is of thick built and very hairy. On examination, the doctor
noticed pus coming out from a point at natal cleft.
a) What is your diagnosis and advice?
b) What is your suggestion for complete resolution from this problem?
[Supple 2011 held in 2012]

2. A 60-year-old truck driver with bristly hair has come with discharging sinus in
between the buttock and tuft of hair protruding out of this sinus.
a) What is the possible diagnosis?
b) What is the principle of treatment?
c) How will you prevent recurrence? [Annual 2009]

Wound Healing
1. What is the difference between healing by primary intention and healing by
secondary intention? [Supple 2019 held in 2020]

2. Which factors are responsible for poor wound healing in a patient?

[Supple 2017 held in 2018]
3.
a) What factors delay wound healing?
b) Which organisms cause wound infection after appendectomy? Name any two.
[Supple 2016 held in 2017]

26
4. A 6 cm long medium sternotomy wound after cardiac bypass has been left open
resulting in a scar.
a) What is the type & cause of this abnormal healing process?
b) Classify types of wound healing & give examples. [Annual 2013]

Wound Management/Excision and Debridement

1. A woman while working in the kitchen suffers from a wound on the anterior surface
of left arm. She is brought to Emergency Department. How will you manage this
wound? [Supple 2019 held in 2020]

2. A 20-year-old man got rollover injury by motor vehicle over the lower limb. On
examination, his pulse is 90/minute and blood pressure is 140/85 mm Hg. Local
examination revealed the skin is lifted from the bed and distal pulses are palpable.
a) What is the type of wound?
b) What is the most likely danger in this wound?
c) How will you manage this wound? [Annual 2019]

3. A housewife presents with a wound on the left arm which is self-inflicted following a
fight with her husband. Discuss the management of this patient. [Annual 2018]

Scars
1.
a) What is the difference between a keloid and hypertrophic scar?
b) Which surgical procedure can be done to improve a complicated scar?
[Supple 2017 held in 2018]

Chronic Leg Ulcers (CLU)

1. A fifty-year-old diabetic lady noticed a non-healing ulcer on her right foot. Give the
principles of management of ulcer in this patient. [Supple 2008 held in 2009]

2. An 80-year-old lady became bed-ridden after having history of fall in toilet. Nursing
care was provided by attendants but she developed a bed sore on her right
trochanteric area.
a) Enumerate the preventive measures against bed sores development for such
patients.
b) What are the various ways to cover the defect, which has been left after carrying
out multiple debridement of this bed sore?

27
▪ SURGICAL INFECTIONS
Surgical Site Infections (SSIs)
1. A 30-year-old male has been operated for open cholecystectomy on elective list. He
is not a diabetic, hypertensive or on any drug. On 4th post-operative day, patient
develops severe induration and pus started pouring out of wound. Wound was
opened and multiple debridement were carried out on wound.
a) Can you enumerate the scientific name of such infection?
b) Name the simple steps to avoid such infections. [Annual 2017]

2. In surgical practice various methods are used to avoid wound infection.

a) Classify wounds according to the risk of infection.
b) Also give example of each type of wound as well as risk of infection with or
without antibiotics prophylaxis. [Supple 2016 held in 2017]

3.
a) Name the factors that determine whether a wound will get infected or not.
b) How will you treat a 20-year-old boy who has developed wound infection after
appendectomy? [Supple 2016 held in 2017]

4.
a) What are different factors that increase the risk of Surgical Site Infections?
b) What pre-operative measures should be taken to minimize Surgical Site
Infections? [Annual 2016]

5. What scoring system/systems are used for wound infection classification?

[Annual 2015]

6.
a) Define Surgical Site Infection (SSI).
b) Write four ways to avoid SSI. [Annual 2014]

7. A 15-year-old boy has undergone appendectomy. On 5th post-operation day, he

develops wound infection.
a) What type of wound is it?
b) Classify the surgical wounds and give examples. [Supple 2013 held in 2014]

28
8. On fourth day of operation done for perforated appendix, the 30-year-old man is
complaining of increased pain at wound site. On examination, the doctor finds
redness and swelling at wound. Patient has pulse of 100/min and temperature 100 F.
his BP is 130/70 mm Hg.
a) What should be the doctor’s first step in this case with suspected diagnosis?
b) How should he subsequently manage this patient? [Annual 2012]

9. On fourth day of open cholecystectomy, a 40 years diabetic housewife has

developed redness, swelling and increased pain at the site of her wound. Her body
temperature is 100 F and BP is 120/80 mm Hg.
a) What immediate steps surgeon should take in this case by identifying the
complications?
b) How will he ensure complete resolution of this problem? [Annual 2011]

10. Classify wound according to the risk of infection. [Supple 2010 held in 2011]

11. A patient has undergone right hemicolectomy for carcinoma of cecum & stated
having temperature on 4th post-operative day. Wound shows redness & induration.
a) What is the possible cause for this condition?
b) What organisms are usually involved?
c) What preventive measures should be taken to avoid this complication?
[Annual 2009]

Abscess
1. A 30-year-old female who is lactating mother presents in surgical emergency room
with complaints of fever and pain in her left breast. On examination, her left breast
was swollen, red hot and tender. She is diagnosed as a case of breast abscess.
a) What is the composition of an abscess?
b) What are two different ways to treat an abscess? [Supple 2015 held in 2016]

Necrotizing Fasciitis
1. A 40-year-old diabetic female underwent abdominoplasty about a week ago. She
presented with fever and restlessness. On examination she is looking toxic.
Abdominal wound is showing discolored margins which are turning black. There is
some pus oozing out from the wound.
a) What is the most likely diagnosis?
b) What kind of bacterial flora in involved in the causation of this condition?

29
 c) What appropriate steps should be taken to treat this potentially fatal condition?
[Annual 2015]

2. A 50-year-old known diabetic developed acute spreading cellulitis on her right thigh
one week after draining of her perianal abscess. She became ill with rigors and fever.
The affected skin appears reddish, swollen and blistered.
a) What is the likely diagnosis?
b) Name the microorganisms responsible for this condition.
c) Outline the stepwise treatment plan. [Supple 2014 held in 2015]

Gas Gangrene
1. A farmer was working in the field when he had a wound on his right leg. He did not
care and when the condition worsened, he was brought to emergency and
diagnosed as gas gangrene.
a) What is gas gangrene?
b) What are the clinical features of a patient suffering from gas gangrene?
c) How will you manage this case of gas gangrene? [Supple 2019 held in 2020]

2. A 30-year-old industrial worker undergoes above elbow amputation for crush injury
in his left arm. Three days later he becomes toxic, thin, brown, foul smelling,
discharge starts coming out of the wound. Crepitus is also detected around wound.
a) What is your diagnosis?
b) How would you treat this case? [Annual 2007]

Skin Infections
1. A 50-year-old male who had injured his right foot 2 weeks ago presents with redness
and painful swelling of foot and leg. He is running with chills and rigors.
a) What is the likely diagnosis?
b) What are causative organisms that are usually present in this infection?

2. A 30-year-old lady has presented with history of multiple discharging sinuses in her
right axilla for last five years. She gives history of similar symptoms in one of her
siblings. The discharge is creamy and foul smelling.
a) What is the most likely diagnosis?
b) What are the common bacteria involved in this disease and name the surgical
procedure to treat it? [Supple 2013 held in 2014]

30
Ingrowing Toe Nail
1. A 15-year-old school girl came to hospital for an operation for in growing toe nail of
her right big toe. She had a full breakfast and insists to be operated early as she was
promised by the doctors in OPD. How will you achieve pain free environment with
precautions for a smooth procedure? [Annual 2012]

Madura Foot (Mycetoma)

1. A 45-year-old farmer presented with an irregular, painless nodule on tip of right big
toe. Later, the nodule developed ulceration and blackish discoloration. Right inguinal
lymph nodes were enlarged, firm and non-tender.
a) What is your diagnosis?
b) Name two other sites where this pathology can be found.
c) What is the best mode of treatment of this pathology? [Annual 2014]

Tetanus
1. A 25-year-old poultry farm worker is brought with inability to open his mouth from
last three days. He had injury on his right foot ten days ago but kept working bare
footed in farm without treatment.
a) What is the diagnosis on high index of suspicion?
b) Which organism is responsible?
c) Outline the management plan. [Annual 2019]

2. A 35-year-old farmer suffers from a cut on his left big toe. He ignores it and
continues to work. After a few days, he notices jaw stiffness and difficulty in
respiration.
a) What is the diagnosis?
b) How will you treat this patient?
c) How will you prevent this disease in his fellow workers? [Annual 2018]

3. A 30-year-old farmer presents with jaw stiffness, dysphagia and convulsions one
week after sustaining minor injury in the fields.
a) What is your diagnosis?
b) How would you treat him? [Supple 2007 held in 2008]

31
Human Immunodeficiency Virus (HIV)
1. A 25-year-old HIV positive patient has to undergo cervical lymph node biopsy under
local infiltration anesthesia. What precautions would you take to minimize the risk of
cross-infection? [Annual 2008]

2. It is Saturday afternoon and a HIV positive patient has been referred to you for a
diagnostic lymph node biopsy. All his laboratory investigations are complete. At the
time of surgery, enlist 5 precautions you would take to minimize the risk of cross-
infection.

▪ ARTERIAL DISORDERS
Chronic Lower Limb Ischemia
1. A 60-year-old man presents with history of intermittent claudication in his right leg
for the last one year. He is a smoker for the last 20 years. On examination, his blood
pressure is 170/100 mm Hg.
a) What is intermittent claudication?
b) How will you investigate this patient?
c) What is the management? [Annual 2018]

2. A 38-year-old man presented with chronic lower limb ischemia.

a) What sign and symptoms would you look for?
b) Enlist three specific investigations to reach a diagnosis.
[Supple 2017 held in 2018]

3. A 70-year-old man who is smoker comes to OPD with history of carrying pain in his
right calf which comes on walking for less than half a kilometer. It is relieved on
stopping.
a) What is he suffering from?
b) How will you investigate him?
c) What is conservative treatment of this patient? [Supple 2016 held in 2017]

4. A 55-year-old salesman complains that he gets pain in right calf after walking a
distance of 1 km. the pain settles after resting, then recurs. His femoral pulses are
normal on palpation, but right popliteal, tibial and dorsalis pedis pulses are absent.
a) Name the symptom he is describing.
b) What is the probable cause?

32
 c) How will you investigate the patient? [Supple 2015 held in 2016]

5. A 50-year-old male, known smoker and hypertensive presented in surgical OPD with
2 years history of intermittent claudication. Now for last 1 week, he developed
continuous pain in right leg which becomes severe at night and he has to sleep in
chair to relieve the pain.
a) What is your clinical diagnosis?
b) How Ankle Brachial Pressure Index (ABPI) is determined?
c) How will you investigate? [Annual 2014]

6. A 65-year-old retired man suddenly notices that he develops pain in his right calf
after walking half a kilometer. He has to take rest to restart his walk. On clinical
examination, his right femoral artery is palpable with the distal pulses including right
popliteal impalpable.
a) What is he suffering from?
b) What is the likely site of disease process?
c) Name three important investigations & surgical procedure that can help him.
[Supple 2013 held in 2014]

Acute Arterial Occlusion/Acute Limb Ischemia

1.
a) What are two common causes of acute arterial ischemia?
b) Mention steps of embolectomy. [Annual 2015]

2. A 30-year-old young man develops sudden attack of atrial fibrillation.

a) Give three important causes leading to this condition.
b) Mention three examples where an arterial embolus can lodge and clinical effects
it will produce. [Annual 2013]

3. 30-year-old school teacher while being treated for cardiac arrythmias complains of
severe pain in right arm for one hour. On examination, her arm is pale, numb and
pulseless. She is unable to move fingers of her right hand.
a) What is your diagnosis with a relevant investigation to reach this diagnosis?
b) How will you arrange for a cure form this new development?
[Supple 2011 held in 2012]

33
4. A 40-year-old butcher presents with a stab wound on front of upper part of his right
thigh which is already dressed. On removal of dressing, red blood spurts with force.
Right dorsalis pedis and posterior tibial pulses are absent.
a) What is your diagnosis?
b) How would you treat this case? [Supple 2007 held in 2008]

5. A 50-year-old professional woman with previous history of myocardial infarction

presents with sudden severe pain in her right lower limb. On examination, limb is
cold and pale, with areas of blue and white discoloration.
a) What is your diagnosis?
b) How would you treat this case? [Annual 2007]

Compartment Syndrome
1. A 24-year-old male sustained an injury on the right leg during a motor bike accident
and brought to Emergency Room. He was crying due to severe pain in the right calf.
On examination, there was tightness of the muscles of the right calf with pain on
passive movement of the limb and distal pulses of the right leg were absent.
a) What is the most probable diagnosis?
b) How will you manage this patient? [Supple 2015 held in 2016]

Gangrene
1. A 45-year-old smoker attended OPD for pain in lower leg and foot. On examination,
there is dark discoloration of two toes and they are cold. Dorsalis pedis pulse is not
palpable. What is the most likely diagnosis? [Annual 2015]

▪ VENOUS DISORDERS
Varicose Veins
1. A 25-year-old female presents with heaviness in her right lower limb after working in
kitchen for long hours. On physical examination, dilated tortuous veins are noted on
the medial side. It is diagnosed as varicose veins.
a) What are other signs commonly found in varicose veins?
b) What are the investigations you will do in this patient?
c) What are the methods of treatment of varicose veins?
[Supple 2019 held in 2020]

34
2. A 30-year-old male presented in OPD with a complaint of heaviness on right lower
limb. On examination, there were dilated and tortuous veins on the medial aspect of
leg up to the knee joint.
a) What is the most likely diagnosis?
b) Name the clinical tests which will help to diagnose the patient.
c) Name different treatment options. [Annual 2016]

3. A 45-year-old security guard has presented with tortuous soft prominence from
above the right knee up to his right angle. This has resulted in pain and discomfort at
work since three years.
a) Based on clinical tests what is your diagnosis? Enlist atleast three clinical tests.
b) Give two relevant useful investigations for diagnosis and management.
c) Enumerate the management options with your recommendation of one with
point for reference. [Annual 2011]

4. A 55-year-old lady with long history of varicose veins had developed an ulceration
above the medial malleolus of her left ankle.
a) What is your provisional diagnosis?
b) What are the causes of this ulcer?
c) How it can be managed? [Annual 2010]

5. A 45-year-old barber presents with aching discomfort in his left lower limb, along
with tortuous dilated veins.
a) What is the diagnosis?
b) How would you treat this patient? [Annual 2008]

Deep Vein Thrombosis (DVT)

1. A 30-year-old whitewasher presented with swelling of the dominant arm for two
hours. On examination, the distal pulse is palpable. The arm is swollen and painful.
a) What is possible clinical diagnosis?
b) What are the predisposing factors?
c) What is the emergency imaging study and treatment? [Annual 2019]

2. A 65-year-old obese lady underwent laparotomy for perforated appendix. On second

post-operative day, house officer noticed swelling of her left leg. There is tenderness
on compression of left calf area.
a) What has happened?
b) How would you prevent this complication?

35
 c) Outline the stepwise treatment plan. [Supple 2014 held in 2015]

3. 65-year-old male underwent left radical hemicolectomy for CA colon. On 3rd

postoperative day he developed swelling on right leg. On examination, his right calf
is swollen & tense with mild tenderness.
a) What complication this patient has developed?
b) What are further sequelae of this complication?
c) How can you prevent this complication? [Supple 2010 held in 2011]

4. A 50-year-old obese woman underwent total abdominal hysterectomy with bilateral

salpingo-oopherectomy for carcinoma of the cervix. Five days later, she developed
painful swelling of her right calf. On examination, her right calf was tender.
a) What is the most likely diagnosis?
b) How would you treat this patient?

▪ LYMPHATIC DISORDERS
Lymphedema
1. A young man of 20 years presents with isolated swelling of right foot which has now
progressed up to knee. This swelling is present since birth. On and off skin
excoriation occurs. Initially pitting was there but now it is non-pitting. He has to
undertake antifungal and antibacterial treatment on many occasions. This swelling
increases with passage of time. Duplex for arterial and venous system is normal.
a) What is the most likely diagnosis?
b) Enumerate the specific tests for this disease.
c) Enumerate the treatment modalities. [Annual 2017]

2. A 40-year-old fruit merchant is anxious about the increasing girth of his left leg over
the past seven years. Initially he ignored but now it has become heavy and off and
on becomes red and tender. On examination, the swelling involved the foot and
extends to mid-thigh. The skin shows cracks and does not pit on pressure. What is
the diagnosis and how will you advise this worried person? [Annual 2012]

Filariasis
1. A young man has noticed gradual swelling of his lower limb and scrotum starting
with episodes of fever and headache after mosquito bite.
a) What is the probable diagnosis?
b) Give the outline of management. [Supple 2008 held in 2009]
36
Tuberculous Lymphadenitis
1. A 20-year-old boy presented with multiple enlarged matted lymph nodes in left
posterior triangle of neck. There is also a history of low-grade fever for the last one
month. His weight is 60 kg.
a) What is the most probable diagnosis?
b) How will you further investigate this patient to reach a diagnosis?
c) Name the common drugs, their dosage and one common important side effect.
[Annual 2016]

▪ SURGICAL ANATOMY
Submandibular Gland
1. A surgeon has to operate on a right submandibular gland. Excision of gland for
benign disease is planned.
a) What are important anatomical relationships of submandibular gland?
b) To what group of lymph nodes, the submandibular gland drains? [Annual 2017]

Thyroid Gland
1. A 30-year-old office secretary is undergoing thyroidectomy for multinodular goiter.
a) Name the anatomical structure the surgeon will incise/retract/dissect to expose
the thyroid gland with precision with start.
b) Enlist five structures required to be saved during thyroid gland dissection.
[Supple 2011 held in 2012]

2. 45 years of female presented with large multinodular goiter for 10 years. She
underwent bilateral subtotal thyroidectomy. During surgery, Kocher collar incision
was made. Upper & lower skin flaps were raised, cervical fascia incised radically in
midline. For adequate exposure of each lobe of thyroid, surgeon decided to divide
the muscle covering thyroid lobes.
a) Name the muscle covering thyroid lobes.
b) Surgeon should divide these muscles in lower part of neck near manubrium sterni
or in upper part of neck and why?
c) Name the nerve supplying these muscles. [Supple 2010 held in 2011]

3. A 40-year-old housewife presents with a swelling in front of neck, which on

examination is found to be of thyroid gland. Diagnosis of multi-nodular goiter is

37
 made, and total thyroidectomy is planned through collar incision. What anatomical
structures would be encountered in this incision before reaching thyroid gland?
[Annual 2007]

4. A 35-year-old woman suffering from multi-nodular goiter is undergoing total

thyroidectomy.
a) Enumerate the arteries that need to be divided in order to free the lobes of
thyroid gland.
b) Name one nerve, one large artery and one associated gland that need to be
preserved.

Breast
1.
a) Describe the lymphatic drainage of breast.
b) What are ligaments of Cooper?
c) What is the significance of these ligaments? [Annual 2018]

2. During modified radical mastectomy, the surgeon approaches the patient’s axilla by
lifting the fiber of a thick muscle anteriorly.
a) Which is this muscle and its function?
b) Which other structure the surgeon has divided deeper to the lifted muscle to
expose axillary lymph nodes with importance of tis relations?
c) What are the structures that the surgeon will preserve while working in axilla?
Name atleast three. [Annual 2012]

3. A lady 40-year-old diagnosed as a case of carcinoma left breast involving upper outer
quadrant is planned for modified radical mastectomy.
a) Give the lymphatic drainage of this area and important structures encountered in
axillary dissection.
b) What is sentinel lymph node? [Annual 2009]

Abdomen
1.
a) Draw and label the surface anatomy of anterior abdomen into nine regions.
b) Name two horizontal and two vertical imaginary lines responsible for this
division. [Supple 2014 held in 2015]

38
Stomach
1.
a) Which arteries supply the stomach, also name the parent arteries from which
these arise.
b) Give four posterior relations of stomach. [Supple 2016 held in 2017]

2. A young man with dyspeptic syndrome was found to have carcinoma of body and
antrum of stomach on endoscopy and biopsy for surgical treatment. He has to
undergo subtotal gastrectomy and gastro-jejunostomy.
a) What blood vessels have to be divided during this operation?
b) What group of lymph nodes should be looked for in this patient? [Annual 2010]

3. In a patient with carcinoma of stomach, total gastrectomy is being performed. Name

the arteries which need to be ligated during this operation. [Supple 2008 held in
2009]

Hepatobiliary System
1.
a) Draw and label surgical anatomy of Gallbladder with special reference to Calot’s
triangle.
b) Name four important structures in relation of Common Bile Duct. [Annual 2016]

2. A surgeon has planned a laparoscopic cholecystectomy of a patient with

cholelithiasis. After insertion of the ports, he has to do dissection in the Callot’s
triangle.
a) What is the Calot’s triangle?
b) Why is it important during laparoscopic cholecystectomy?
[Supple 2015 held in 2016]

3.
a) Draw and label the anatomy of gallbladder and Calot’s triangle.
b) Name four anatomical parts of common bile duct (CBD).
[Supple 2013 held in 2014]

4. A 40-year-old Qaria is diagnosed as s suffering from chronic cholecystitis and has to

undergo cholecystectomy through subcostal incision. Which anatomical structures

39
 would be encountered in this incision before reaching the gallbladder? [Annual
2008]

Appendix
1. A 20-year-old college girl diagnosed to have acute appendicitis.
a) While selecting a more appropriate incision what should be surgeon’s selection
criteria based on anatomical facts?
b) Enumerate with precision the structures incised and/or retracted to reach
inflamed appendix in retrocecal position. [Annual 2011]

Kidneys
1. A 25-year-old laborer presented with pain in his left lumbar region. Excretory
urography reveals left pyelolithiasis. Pyelolithotomy is planned through left lumbar
subcostal incision. Which structure will be encountered in this incision before
reaching kidney? [Supple 2007 held in 2008]

Inguinal Hernia
1. A 25-year-old person presents with a swelling in the right inguinoscrotal region. The
provisional diagnosis is right inguinal hernia.
a) Describe the surgical anatomy of inguinal canal.
b) Describe three differences between direct & indirect inguinal hernia to confirm
the diagnosis. [Supple 2019 held in 2020]

2. Describe the boundaries of inguinal canal. How do you clinically locate the deep
inguinal ring? [Supple 2017 held in 2018]
3.
a) Draw and label the anatomy of inguinal canal and Hesselbach’s triangle.
b) Name four contents in inguinal canal in male. [Annual 2015]

4. A patient presents with history of right sided reducible swelling in groin which
reappears on coughing. The diagnosis of indirect inguinal hernia is made and inguinal
mesh hernioplasty is planned.
a) Give the boundaries of inguinal canal.
b) Name the structures being cut from outside in, till you reach the contents of the
sac.
c) Name one nerve that is at risk of injury during hernia surgery. [Annual 2014]

40
Femoral Hernia
1. A 60-year-old female presented with swelling and severe pain in the left inguinal
region for one hour. On clinical examination, it is suspected strangulated femoral
hernia.
a) Name the anatomical boundaries occupied by this hernia.
b) Which structure impedes the reduction of hernia?
c) Which vessel is prone to injury during procedure? [Annual 2019]

Blood Vessels
1.
a) What are the anatomical relations of right femoral vein?
b) Draw and label the anatomy of the termination of long saphenous vein in the
right groin. [Annual 2013]

▪ MISCELLANEUS
1. A 25-year-old business man was brought to hospital with blunt injury abdomen
sustained during a road side accident. After initial resuscitation in emergency, he was
transferred to surgical ward. On 3rd day, he developed severe abdominal pain with
pulse 110/min, temperature 101 F and toxic look. Plain X-ray abdomen revealed air
under the diaphragm.
a) What is immediate suspicion of his problem?
b) Give 8 steps/components of management for cure in view of your diagnosis.
[Annual 2012]
2. A 60-year-old housemaid had a fall from stairs. She is complaining of severe pain in
her back. She is conscious, can walk few steps with pain and has normal vitals.
a) What is the most reliable investigation to confirm her injury?
b) Enlist five steps of management after the most likely diagnosis with important
precautionary measures. [Supple 2011 held in 2012]
3. Hospital infection control team is concerned about increased incidence of infection
in main operation theatre. They have asked for your recommendation based on
scientific knowledge. Enlist 10 points of your concern. [Supple 2011 held in 2012]
4. A 60-year-old retired clerk has undergone laparotomy for perforated duodenal ulcer
under general anesthesia. On 5th post-operative day, he develops fever and
tachypnea. Examination reveals a healthy wound. What are the differential
diagnoses in this case? [Supple 2007 held in 2008]

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