SURGERY – TEST & DISCUSIION

1. Which is the most common familial breast

cancer gene?
A. BRCA-1
B. BRCA-2 SELF MASTERED

C. p53
D. STK11
Answer- A
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Type of Breast Hereditary %
Cancer %
BRCA-1 45
Sporadic 65
BRCA-2 35
Familial 25
p53 1
Hereditary 10
Others <1

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2. A 25 year old female presents with green
discharge from nipple. What is the first differential
diagnosis-
A. Duct ectasia
B. Mastitis SELF MASTERED

C. Carcinoma
D. Pagets disease
Answer- A
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 Ductography- Dilated ducts
Periductal Mastitis

Healing by fibrosis

Duct becomes dilated & cannot

Contract- fibrosis replaces muscle
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Stagnation of secretions •Serous

Infection with bacteria •Green

•Blood stained
Abscess- pus •Black
•Purulent
Fistula formation
3. Which is the investigation done in a painful
breast lump in a lactating woman-
A. Mammography
B. USG
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C. MRI
D. FNAC
Answer-B
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Condition Investigation of Choice

Screening- normal risk X ray Mammography

Screening- high risk MRI
Age < 35 years USG Mammography
Patient with breast implants MRI
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Ductal carcinoma in situ X ray Mammography

Lobular carcinoma in situ MRI

Invasive Lobular Carcinoma
Recurrence after Surgery PET Scan/ MRI
4. Peau d’ orange appearance is seen with which
stage of breast cancer -
A. T4a
B. T4b SELF MASTERED
C. T2
D. T4d
Answer- B
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T stage Description
Tx Primary tumor cannot be assessed
T0 No e/o primary tumor
Tis Carcinoma in situ
T1 Tumor confined to breast tissue Tumor 2.0cm or less in greatest dimension
T2 Tumor confined to breast tissue Tumor between 2.0- 5.0cm in greatest dimension

T3 Tumor confined to breast tissue Tumor more than 5.0cm in greatest dimension
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T4 T4a- Extension to chest wall
T4b- Extension to skin
T4c- Extension to both chest wall and skin
T4d- Inflammatory Carcinoma
N status Mobile Side Node Groups
involved
Nx Nodal status cannot be assessed
N0 No e/o enlarged lymph node
N1 Mobile Ipsilateral Axillary Single
N2a Fixed Ipsilateral Axillary Single
N2b Clinically Ipsilateral Internal mammary Single
apparent SELF MASTERED
N3a - Ipsilateral Infraclavicular Single
- Ipsilateral Internal mammary + Multiple
Axillary
- Ipsilateral Supraclavicular Single

M0= no distant metastases M1= Distant metastases present

5. What is the most common quadrant for
carcinoma of breast-
A. Lower outer
B. lower inner SELF MASTERED

C. Upper outer
D. upper inner
Answer-C
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 Site Location
Upper outer quadrant 50%- MC
Central quadrant 20%
Upper inner quadrant 15%
Lower outer quadrant 10%
Lower inner quadrant 5%- LC

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 6. Which of these features suggest malignant tumor on mammography?

A. Spiculated margin

B. Comet tail appearance

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C. Wide halo

D. All of the above

Answer- D
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 Benign Malignant

Opacity Well defined margin •Irregular spiculated

margin
Margin •Comet tail appearance

Density Low density High density

Homogenous Homogenous Inhomogenous

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Halo Thin halo Wide halo

Calcification Macrocalcification Microcalcification

(>5mm diam.)
7. Popcorn calcification on mammogram is seen in-

A. Breast cancer

B. Fibroadenoma breast SELF MASTERED

C. Fat necrosis

D. Fibrocystic disease
Answer- B
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•Benign tumor of the breast tissue

•Highly mobile tumor- Called Breast Mouse

•Mammography shows – Pop Corn calcification

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8. Most common complication of modified radical mastectomy is-

A. Nerve Injury

B. Infection
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C. Seroma formation

D. Lymphedema
Answer- C
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Complications of Modified Radical Mastectomy-

• Nerve Injury-

•Wound Infection
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•Seroma- MC complication

•Edema- lymphedema

•Winging of scapula- injury to the nerve to the serratus anterior muscle.

Structures preserved in Modified Radical Mastectomy-
•Muscle- Pectoralis major muscle
•Axillary vessels
•Nerves—
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Nerve to Serratus anterior muscle
Thoraco-dorsal nerve. To latissimus dorsi

Structures removed in Modified Radical Mastectomy-

• Breast
•Axillary- Fat/ Fascia/ Lymph nodes
•Skin- part of the skin with nipple areola
•Pectoralis minor muscle
9. After thyroidectomy for medullary carcinoma of
thyroid, which is important for determining
recurrence of tumor:
a. Thyroglobulin
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b. TSH
c. Carcinoembryonic antigen
d. Thyroxine levels
Answer- C
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 MEDULLARY THYROID CARCINOMA

•Cancer arising from C cells or parafollicular cells. •FNAC- Amyloid stroma

•Associated with RET proto-oncogene on chromosome 10. •Not TSH dependant

•Most common presentation- diarrhea

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•Tumor marker for Medullary thyroid cancer- Serum Calcitonin.
•Investigation of choice- FNAC.
•Spreads by- 1. Lymph node metastases (early) and 2. Blood borne (late).

Treatment- Total thyroidectomy + Anterior compartment dissection

10. Psammoma bodies are seen in:
a. Papillary carcinoma of thyroid
b. Follicular carcinoma of thyroid
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c. Anaplastic carcinoma of thyroid
d. Lymphoma of thyroid
Answer- A
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 PAPILLARY THYROID CARCINOMA

•Most common thyroid malignancy- Papillary thyroid carcinoma.

•F:M= 2:1. Age= 20 to 40 years.
•Most common presentation- Painless thyroid nodule.
•Lateral aberrant thyroid is a presentation of papillary carcinoma of thyroid.
•Multifocal in same or both lobes.
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•Speads by lymphatics.
•Can be diagnosed by FNAC.
•Best prognosis in thyroid cancer- Papillary thyroid cancer.
•Cancer for which neck irradiation is a risk factor- Papillary thyroid cancer.
•Cancer arising in thyroglossal cyst- Papillary thyroid cancer.
•Thyroid cancer associated with dystrophic calcification- Papillary thyroid cancer
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Histological characteristics-
•Branching papillae of cuboidal cells.
•Presence of Psammoma bodies
•Orphan Annie eye cells-
• Intra-nuclear pseudo-inclusions
11. Most common cause of solitary thyroid
nodule is:
a. Physiological goiter
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b. Follicular adenoma
c. Colloid degenerations
d. Cysts
Answer- C
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 SOLITARY THYROID NODULE

•Presence of a single thyroid nodule.

•Most common cause of solitary thyroid nodule-
Colloid degeneration
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2nd MC- Follicular adenoma
•Investigation of choice in STN- FNAC
•Surgical procedure of choice in STN- Hemithyroidectomy.
 12. False statement for this condition is-

A. It is congenital

B. Can occur as a complication of thyroglossal cyst

C. Treatment is Sistrunk’s operation

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D. All are false
Answer- A
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 Thyroglossal cyst Treatment-

•Sistrunk’s Operation-
Infection of the cyst-
Due to associated lymph nodes •Excision of entire thyroglossal

Duct with part of hyoid bone

Abscess formation with pus
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Abscess drained- but no excision
Of Thyroglossal duct

Thyroglossal Fistula Formation

 THYROGLOSSAL CYST

•Most common location- Subhyoid (midline of neck). •Sistrunk in Surgery-

•Most common presentation- painless swelling in neck. •Operation-
•Moves on swallowing and protrusion of tongue. •Thyroglossal cyst
•Thyroglossal fistula
•Treatment of choice- Sistrunk’s operation
•Lymphedema-reduction
•Sistrunk’s operation- Thyroglossal cyst/ fistula
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Complications-
•Papillary Carcinoma
•Thyroglossal fistula
13. This female is following up in OPD for many years. She has refused surgery.
Now she comes with rapid growth of swelling. Malignancy is suspected. Which is
The likely malignancy in this condition:

A. Papillary thyroid carcinoma

B. Medullary thyroid carcinoma

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C. Follicular thyroid carcinoma

D. Anaplastic carcinoma
Answer- C
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 FOLLICULAR THYROID CARCINOMA

•Second most common thyroid malignancy- Follicular carcinoma of thyroid.

•F:M= 3:1.
•Age= > 50 years.
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•Blood borne metastases are more common.
•Long standing multinodular goiter is a risk factor.
•Cannot be diagnosed by FNAC- as FNAC cannot differentiate
between a follicular adenoma and a follicular carcinoma.
•Microscopically they show vascular invasion.
 ANAPLASTIC CARCINOMA OF THYROID

•Thyroid cancer with the worst prognosis- Anaplastic Carcinoma of thyroid.

•Spreads directly by local infiltration.
•Most common presentation- hard fixed mass in neck.
•In case of respiratory distress treatment is by isthmectomy

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 14. A 40 year old man has developed a parotid tumor. On Technicium pertechnate scan
- The following findings were seen. Identify the diagnosis-

A. Pleomorphic adenoma

B. Warthin’s tumor SELF MASTERED

C. Adenoid cystic carcinoma

D. Mucoepidermoid carcinoma
Answer- B
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•Benign tumor of the salivary gland.
•Second most common benign tumor of parotid gland
•Consists of epithelial and lymphoid elements= adenolymphoma
•Slow growing tumor.
•Usually lower end of parotid gland
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•M>F.
•Age: 5th -7th decade.
Warthin’s
•Associated with smoking.
Tumor
•Well encapsulated. Never turns malignant.
•Hot spot in 99Tc-pertechnate scan
15. Kidney stone whose development is
insensitive to pH is-
A. Calcium oxalate
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B. Triple phosphate
C. Uric acid
D. Cysteine
Answer-A
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Type Colour Surface •Other •Crystals
Oxalate Discoloured Irregular shaped •Monohydrate is • Dumbell shaped
+ projection hard and
•Envelope
radiodense
shaped
•pH insenstitive
Phosphate Dirty white Smooth •Alkaline urine •Coffin lid shaped

•Staghorn
Uric acid/ urate Yellow- reddish Smooth •Hard, multiple, •Multifaceted
brown radioluscent
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Cystine Pink, yellow turn •Contain sulphur, •Hexagonal
to greenish hard, radio-
opaque

•Acid urine
Xanthine Brick red Smooth, round •Lamellated
16. A 60 year old smoker male, presents with gross painless hematuria for 1
day. IVU shows 1.2cm filling defect in the bladder. Which is the best
investigation?

A. Cystoscopy
B. Urine cytology
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C. USG abdomen
D. DMSA scan
Answer-A
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Type of carcinoma Incidence Characteristic MC genetic alteration-
Deletion of material
Transitional cell 90% Papillary or exophytic On chromosome 9
carcinoma lesions
Squamous cell 5- 10% Lateral bladder wall &
carcinoma dome
Adenocarcinoma <2% Urachal remnants –
risk factors

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 RISK FACTORS

TRANSITIONAL SQUAMOUS CELL ADENO-CARCINOMA

CELL CARCINOMA CARCINOMA

•Cigarette smoking- MC •Schistosoma hematobium Urachal Remnants

•Chemicals: Naphthylamine, •Chronic irritation
•Schistosoma hematobium- •Bladder diverticula
•Drugs: Phenacetin SELF MASTERED
•Cyclophosphamide CLINICAL FEATURE- GROSS PAINLESS HEMATURIA
•Pelvic irradiation
17. CA prostate commonly metastasizes to the
vertebrae:
a. Because valveless communication exist with
Batson’s periprostatic plexus
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b. Via drainage to sacral lymph node
c. Of direct spread
d. None of above
Answer-A
SELF MASTERED
Bone Metastases Imaging modalities-

•L= Lumbar vertebra •For prostate anatomy = MRI.

•P= Proximal femur •For pelvic lymph nodes = CT Scan

•P= Pelvis SELF MASTERED

Tumor Markers-
•T= Thoracic vertebra
•Prostate Specific Antigen
•R= Ribs
•Prostatic acid Phosphatase

•Alkaline phosphatase
18. A 70-years old man with prostate cancer was
given radiotherapy. The recurrence of the cancer is
monitored biochemically by:
a. Androgens only SELF MASTERED
b. Prostate specific antigen and carcinoembryonic
antigen
c. Prostate specific antigen only
d. ALP and CEA
Answer-C
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Prostate Specific Antigen-
•Also called gamma semino-protein or Kallikrein-3.
•Glycoprotein enzyme coded by KLK3 gene
•Function is dissolution of coagulum so that sperm can be liberated

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•Normal Range- 1-4ng/ml
•Forms- Free form and bound form
•Free form more important for screening

Best screening method- DRE + Serum PSA

19. Osteoblastic metastasis commonly arise
from:
a. Breasts SELF MASTERED
b. Prostate
c. Lung
d. RCC
Answer-B
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 PROSTATE CANCER

Increased Risk with- Bone Metastases

•MC cancer in males
•Advancing age L= Lumbar vertebra
•MC cause of bone secondaries.
•Increased fat intake P= Proximal femur
•Screening= PSA + DRE
•African American P= Pelvis
•Sentinel node= Obturator node.
•MC genetic alteration- T= Thoracic vertebra
•Bony Metastases= Osteoblastic
Chromosome 11 R= Ribs
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20. Circumcision is contraindicated in:
a. Paraphimosis
b. Meatal stenosis SELF MASTERED
c. Hypospadias
d. Phimosis
Answer-c
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 HYPOSPADIAS

•1: 200- 300 boys. •Ventral opening of urethral meatus Classification-

•Mc congenital mal- •Chordee •Glanular

formation of urethra •Hooded prepuce •Coronal

•Penile shaft
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•Best time for surgery of hypospadias is between 6-12 months of age. •Peno-scrotal
•Hypospadias is a contra-indication for circumcision. •Perineal

•Principles of Surgery in Hypospadias repair-

1.Glanuloplasty 2. Meatoplasty 3. Orthoplasty 4. Urethroplasty 5. Skin cover

21. Sentinel lymph node of carcinoma penis:
a. Cabana
b. Virchow SELF MASTERED

c. Delphian
d. Darwins
Answer-A
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 PENILE CANCER

•Poor hygiene – V.Imp

•Carcinoma in situ-
•Phimosis- associated 50% times.
•Erythroplasia of Queyrat- Red velvety plaques
•Important carcinogens-
over glans and prepuce.
•Smegma
•Bowen’s disease- Associated with HPV
•HPV- 16,18,31,33
SELF MASTERED •Sites-

•MC presentation- Lesion with foul smell. •Glans

•MC symptom of metastatic penile cancer- priapism •Sulcus

•MC cause of death- Erosion of femoral artery •Prepuce

•Shaft
Type of cancer Treatment

Confined to prepuce – non 5-FU

invasive
Nd-YAG laser

Radiotherapy + close follow

up
Involving glans or distal shaft Partial penectomy with 2cm
margin
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Involving proximal shaft or Total penectomy with
2cm margin not acheived perineal urethrostomy

Metastatic lymph nodes Bilateral inguinal lymph node

dissection
22. Identify the following condition given on CT Scan

A. Hepatomegaly
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B. Horse shoe kidney

C. Polycystic kidney

D. Pancreatitis
Answer- B
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Horse shoe Kidney-

•Most common renal fusion anomaly.

•Fusion at lower pole by parenchymatous or fibrous isthmus.

•IMA prevents full ascent. SELF MASTERED

•Pelvis and ureters are anteriorly placed.

•Rovsing sign- abdominal pain and nausea on hyperextension of spine.

23. What is the absolute contra-indication for this treatment modality

A. Hard calculus

B. Obesity SELF MASTERED

C. Bleeding disorders

D. Skeletal deformity
Answer- C
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Absolute Contra-indications-
Indications-
•Pregnancy
•Renal calculi less than 2cm in aggregate length.
•Obstructed system
•Proximal ureteric calculi
•Non functioning kidney
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•Bleeding disorder.
24. According to “rule of nines”, burns involving
perineum are:
a. 1% SELF MASTERED
b. 9%
c. 18%
d. 27%
Answer-A
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 Wallace’s Rule of 9
Body part %TBSA Body part %TBSA Total

Head/neck 9% Lower back 9%

R-UL 9% R- thigh 9%

L-UL 9% L-thigh 9%

Anterior chest 9% R- leg 9%

Upper back 9% L- leg 9%

Anterior abdomen 9% Genitals 1%

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Total 54% 46% 100%
25. Identify the type of burns?
a. Superficial first degree
b. Superficial second degree
c. Third degree SELF MASTERED
d. Fourth degree
Answer-B
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 First degree Second degree Third degree Fourth degree

Depth Superficial epidermis Sup- partial Deep partial Epidermis + Full Skin + Other tissue
thickness dermis

Colour Red Red, maybe Pink-white White, black or Variable

blistered bullae or moist brown

Skin texture N Edematous, dry to Thick Leathery, dry Variable

small blisters SELF MASTERED inelastic

Capillary refill Yes Yes Possibly No No

Pin prick sensation Yes Yes Possibly No No

Healing 5-10 days. No scar 7-14 days. NO OR 25-60 days. No spontaneous No spontaneous
minimal scar Dense scar healing healing
26. In burns management,in adult, which of the
following is the fluid of choice?
a. Dextrose 5% SELF MASTERED
b. Normal saline
c. Ringer lactate
d. Isolyte-M
Answer-C
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 FLUID RESUSCITATION IN BURNS

Children Adults

When to give >10% TBSA >15% TBSA

What fluid to give Dextrose saline Ringer Lactate

Which formula Galveston Parkland

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End point- Urine output of 0.5-1ml/kg/hr

When to give After 24 hours

colloids

Which colloids Dextran/ Albumin

27. Tensile strength of wound becomes normal
after:
a. 6 weeks SELF MASTERED
b. Never
c. 4 months
d. 6 months
Answer-B
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 Inflammatory Proliferative Phase Remodelling Phase
phase

Timing after 2-3 days 3rd day- 3rd week After 3rd week
wound

Major Processes •Bleeding •Fibroblast activity •Maturation of

taking place •Vasoconstriction •Angiogenesis collagen
•Thrombus •Re-epithelialization •Decreased wound
formation •Wound contraction vascularity
SELF MASTERED •Wound contraction
Collagen type & - Mostly type III •Type I:III= 4:1
Wound strength Collagen •Gains 80% strength.
•Never 100%
28. Keloid Scar is made up of-
A. Dense collagen
B. Loose fibrous tissue
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C. Granulomatous tissue
D. Loose areolar tissue
Answer-A
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 KELOID

•Excessive scar tissue. Treatment-

•Extends beyond boundaries of original wound. •Silicone + Pressure garment

•Etiology- Unknown •Intralesional steroid

•Predisposing factors- Deeply pigmented skin •Excision + Radiotherapy

• Elevated growth factors SELF MASTERED

•Common areas- Clavicle, upper extremity, sternum

•Micro- Excess collagen & Hypervascularity
 Hypertrophic Scar Keloid
Genetic Not familial Familial
Race No Dark skinned +
Age/ Sex Children. F=M 10-30 years. F>M
Border Within original wound Spreads beyond wound
Course Subsides with time Keeps growing
Etiology Tension on wound SELF MASTERED Unknown
Time of Starts within 4 weeks of wound 3 months to year after trauma
development
Histology Parallel orientation of collagen Thick wavy collagen fibers in
fibers random orientation
29. Identify the following instrument-
A. Towel clip
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B. Sponge holder
C. Kelly’s Hemostat
D. Cheatle Forceps
Answer-B
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 Indications- Sponge holding Forceps
• With sponge-
• Preparation of the part
for operation.
• Blunt dissection.
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• Hemostasis
• To dry the operative field
 Indications- Sponge holding Forceps
• Without sponge-
• To hold tongue
• To retract bowel.
• To hold bowel or SELF MASTERED
stomach.
• To hold gallbladder
 Kelly’s Hemostat
Towel Clip

SELF MASTERED

Cheatle Forcep
30. Most common site for carcinoma esophagus
in India is-
A. Upper 1/3 SELF MASTERED

B. Middle 1/3
C. Lower 1/3
D. GE junction
Answer- B
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 CARCINOMA OF ESOPHAGUS

•Squamous cell carcinoma- •Adenocarcinoma-

•Most common in India. •Increasing incidence in Western countries
•Most common location- •Usually lower third of esophagus.
middle one third of esophagus •H. Pylori is not a risk factor
•H. pylori is a risk factor SELF MASTERED
•No role for RT/ CT
•RT/ CT is useful
Investigation of choice- Endoscopy + biopsy

MC symptom- Dysphagia
31. A 9 month child presents with excessive cry,
right iliac fossa sausage shaped lump and blood in
stools. What is the best treatment?
• IV fluids + Antibiotics +
A. NG tube SELF MASTERED

B. Air enema
C. Barium enema
D. Saline enema
Answer- B
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 INTUSSUSSCEPTION
•Peak incidence between 5 – 10 months of age.
•Most common lead point is Meckel’s diverticulum. •Types of intussusception-
•Ileocolic- 77%-MC
•Sudden crampy abdominal pain.
•Ileo-ileo-colic- 12%
•Vomitting, red current jelly stools
•Ileoileal
•Sausage shaped mass
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•Colocolic-MC in adults
•Empty Right iliac fossa- Dance sign

•Treatment-
•Hydrostatic reduction by contrast enema or air enema.
•Failure of reduction requires operative intervention.
SELF MASTERED
35. Gastric outlet obstruction leads to-
A. Hypochloremic metabolic alkalosis.
B. Hyperchloremic metabolic acidosis
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C. Hypernatremic metabolic alkalosis
D. Hyponatremic metabolic acidosis
Answer- A
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 CONGENITAL HYPERTROPHIC PYLORIC STENOSIS

•1 IN 4000 live births Hypokalemic, Hypochloremic Alkalosis

with Paradoxical Aciduria
•M:F= 4:1
•Manifests at 4 weeks •Non bilious projectile vomiting Surgery-
•Of life (3-6 weeks) Ramstead
•Palpable pylorus
pyloro-myotomy
•Associations- •Peristaltic wave seen
H- Hirschprung disease SELF MASTERED
A- Esophageal atresia USG-

R- Anorectal malformation •Pyloric wall thickness of at least 4 mm.

M- Malrotation of gut •Channel length of at least 17 mm.

33. Which is the rarest position of the appendix?
A. Retro-cecal
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B. Post ileal
C. Pelvic
D. Para- cecal
Answer-B
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SELF MASTERED
34. Which is the best way to diagnose lower
small intestinal obstruction?
A. Pain in the abdomen SELF MASTERED
B. Multiple air fluid levels on Xray
C. Profuse biliary vomiting
D. Feculant vomiting
Answer- B
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Signs of small bowel obstruction- Clinical Features-
•Multiple air fluid level. •Inability to pass stools
•Bowel dilatation proximal to obstruction •Inability to pass flatus
•Paucity of large bowel gas. •Distension of abdomen
•Ground glass appearance- intraluminal fluid •Colicky pain
•Step ladder pattern of air fluid levels •Vomitting
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 IOC:
•Adults- CT Scan
•Children : USG

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35. What is incorrect about Zenker’s
diverticulum?
A. Regurgitation of previous days food.
B. Halitosis SELF MASTERED

C. Located at Killian’s triangle

D. Metabolic alkalosis
Answer- D
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 ZENKER’S DIVERTICULUM

•Killian’s dehiscence- lies between oblique and horizontal (cricopharyngeus)

fibres of inferior pharyngeal constrictor.
•Zenker’s diverticulum Protrudes posteriorly above cricopharyngeal sphincter
through natural weak point (killian’s dehiscence).
•It lies posteriorly in midline of the neck.
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•Dysphagia, IOC- Barium swallow •Complications-

•Halitosis •Aspiration pneumonitis
•Regurgitation •Lung abscess
36. Investigationof choice for hiatus hernia

A. MRI

B. CT Scan SELF MASTERED

C. USG

D. Plain Xray
Answer‐ B
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Type of Hiatus Other name Position of Gastro- Position of Fundus
Hernia esophageal junction of stomach

Type I Sliding type Displaced upwards Normal

Type II Rolling type- True Normal Displaced upwards

Para-esophageal
Type III Mixed Displaced upwards Displaced upwards

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 37. Graham’s omental patch repair is done for which complication of peptic ulcer

A. Perforation

B. Bleeding SELF MASTERED

C. Obstruction

D. Cancer
 Answer‐ A
Perforation
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Perforated Peptic Ulcer-
Most commonly at first part of Duodenum- anterior wall.
Clinical Features-
•Pain in abdomen
•Tachycardia, Hypotension, Tachypnea
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•Board like rigidity of abdominal wall
Investigation-
•X ray abdomen/ chest- Free gas under diaphragm
•Better investigation- CT Scan
Treatment-
•IV Fluids to manage fluid and electrolyte imbalance
•Exploratory Laparotomy + Graham Patch repair
38. Commonest type of Gallstone is:
a. Cholesterol stone
b. Pigment SELF MASTERED

c. Mixed
d. All are equally common
Answer- C
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 TYPES OF GALLSTONES

•Cholesterol stone- cholesterol content is 51-99%

•MCtype of gallstones= Mixed
•Pigment Stones- cholesterol content< 30%.
•MC type in USA/ Europe=
•Mixed stones
SELF MASTERED Mixed / cholesterol stones
Black Pigment Stones Brown Pigment Stones •MC type in Asia/India=
Risk Factor- Risk Factor-
pigmented
Hemolysis -Infection- β-
glucuronidase •(Source- Bailey Love 26th ed)
- Stasis
39. Initial investigation of choice for biliary
obstruction:
a. CT Abdomen
b. ERCP SELF MASTERED

c. MRCP
d. USG
Answer- D
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Condition Investigation of Choice
Initial investigation of choice – Biliary obstruction USG
Initial investigation of choice- Acute Cholecystitis USG
Gold Standard investigation- Acute Cholecystitis HIDA Scan

Cholelithiasis- Gallstone USG

Chronic Cholecystitis SELF MASTERED USG

Bile duct injury MRCP

Carcinoma Gallbladder CECT

Cholangiocarcinoma MRCP
Condition Investigation of Choice
Liver Infections USG / CECT
Liver Tumours CECT
Acute Pancreatitis CECT
Pancreatic necrosis CECT
Pancreatic abscess CECT
Chronic Pancreatitis SELF MASTERED ERCP
Pancreatic Cancer CECT
40. Investigation of choice for hydatid disease is:
a. CT scan
b. Elisa SELF MASTERED

c. Biopsy
d. USG
Answer- A
SELF MASTERED
 HYDATID CYST

•Dogs are definitive hosts. •USG •ELISA

•Sheep are the usual intermediate hosts. •CT •Immunoblot
•Man is accidental intermediate host. •MRI •IHA
SELF MASTERED
•Echinococcus granulosus •Complications-
•E multilocularis •Intra- biliary rupture
•Rupture into bronchial tree
•Free rupture into peritoneal,
Preferred treatment is PAIR •pleural or pericardial cavity
41. “Chain of lakes” appearance seen in:
a. Acute pancreatitis
SELF MASTERED
b. Chronic pancreatitis
c. Carcinoma pancreas
d. Strawberry gallbladder
Answer-B
SELF MASTERED
SELF MASTERED
 Investigation of Choice :ERCP
Most Common cause- Alcohol
•Causes- Part of Pancreas affected Surgery
T= Toxic/ metabolic
Dilated duct + Obstruction Lateral pancreatico-
I= Idiopathic jejunostomy
G= Genetic Head of pancreas Pancreatico-
SELF MASTERED duodenectomy
A= Autoimmune
Body + Tail of pancreas Distal pancreatectomy
R= Recurrent attacks
Entire pancreas Total pancreatectomy
O= Obstructive
42. Balthazar scoring system is used for?
a. Acute pancreatitis
b. Acute appendicitis SELF MASTERED
c. Acute cholecystitis
d. Cholangitis
Answer-A
SELF MASTERED
Scoring of Severity of Acute Pancreatitis-

•Ranson’s Score- Based on clinical parameters

•Acute Physiological And Chronic Health Evaluation-

APACHE- Based on clinical parameters
SELF MASTERED
•Balthazar Score- Based on CT scan
43. Most common organism causing this condition

A. Klebsiella

B. Clostridium welchii
SELF MASTERED
C. Pseudomonas

D. Staphylococcus
Answer‐ B Clostridium welchii
SELF MASTERED
Organisms:
•Cl. Welchii, IOC : USG
•E. coli
Treatment:
Risk Factors:
•Immuno-compromised condition Cholecystectomy
•Diabetes

Features: SELF MASTERED

•Gas in GB lumen
•Gas in GB wall
•Gas in peri-cholecystic region
 Classification system used in this condition is

A. Glasgow coma scale

B. DeMeester Score
SELF MASTERED
C. TIGAR-O

D. Gleason Score
Answer‐ C TIGAR‐O
SELF MASTERED
45. Which of the following liver tumors always
merit surgery?
a. Hemangioma SELF MASTERED
b. Hepatic adenoma
c. Focal nodular hyperplasia
d. All of the above
Answer- B
SELF MASTERED
 Hemangioma FNH Adenoma
Most common 2nd most
common
Diagnosis CT scan Sulfur colloid CT with angio
scan
Special features -Giant -Central scar Risk of
hemangioma - Functional -Rupture
- Kassabach hepatic cells take - HCC
Merritt up sulfur colloid
Syndrome
SELF MASTERED
Treatment Surgery only if Surgery only if Always surgery
symptomatic symptomatic
46. Which of the following structures is a
content of Calot’sTriangle?

A. Cystic duct

B. Common hepatic duct

C. Inferior edge of liver SELF MASTERED

D. Lymph node of Lund

Answer‐ D
SELF MASTERED
 Calot’s
Triangle
Contents-
Boundaries-
• Cystic Artery
• Cystic duct

Common hepatic duct • Lymph node of Lund

•
SELF MASTERED
• Inferior edge of liver
Lymph node of Lund-

• Also called as Mascagni’s Lymph node

• Sentine node for carcinoma of gallbladder

47. Which is the most common site of peripheral
aneurysm-
A. Femoral artery SELF MASTERED
B. Radial artery
C. Popliteal artery
D. Brachial artery
Answer-C
SELF MASTERED
•Most common artery to have aneurysm- Abdominal Aorta

•Most common Peripheral artery to develop aneurysm- Popliteal Artery

•Most common visceral artery to develop aneurysm- Splenic Artery

•Most common artery to have pseudo-aneurysm- Femoral Artery

SELF MASTERED
•Most common site for Dissecting aneurysm- Right lateral wall of ascending aorta

•Most common site for Mycotic aneurysm- 1.Femoral artery 2. Aorta

Most common organism causing mycotic aneurysm- Staphylococcus

48. Drug used for sclerotherapy of varicose veins
are the following except:
a. Ethanolamine oleate
b. Polidocanol SELF MASTERED

c. Ethanol
d. Sodium tetradecyl sulfate
Answer-C
SELF MASTERED
Drugs used for Sclerotherapy-
Indications for Sclerotherapy-
•Polidochonol
•Reticular Veins
•Sodium tetradecyl sulfate
•Telengiectasias
•Sodium morrhoate SELF MASTERED
•Small AV malformations
•Ethanolamine oleate
•Small residual veins after Surgery
•5% Phenol in almond oil
49. A 35 year old male, chronic smoker, presented with gangrene of the
toes. An angiogram of the lower limb revealed the following
appearance. The most likely diagnosis is-

A. Atherosclerosis
SELF MASTERED
B. Aneurysm

C. A-V Fistula

D. Thrombo-angiitis obliterans
Answer‐ D Thrombo‐angiitis obliterans
SELF MASTERED
 THROMBO-ANGIITIS OBLITERANS

• Young men Vessels affected- Infra-popliteal- Small & Medium sized

• Below 40 years. Triad of-

Associated with
• Cigarrette smoking and
• Low socio- economic groups.
• Intermittent claudication.
• Raynaud’s phenomenon
SELF MASTERED
• Migratory superficial thrombophlebitis
Angiography-
• Segmental lesions= skip lesions

• Extensive collateralization= Cork Screw

collaterals
 50. Which of the following changes are seen in AV fistula:

A. Arterialization of vein

B. Varicose veins SELF MASTERED

C. Left ventricular hypertrophy

D. All of the above

 Answer‐ D
All of the above
SELF MASTERED
 ARTERIO-VENOUS FISTULA
Structural changes Function Effect
Veins become dilated, tortuous and thick Pulse pressure Increased
walled (arterialised). Venous return Increased
Heart rate Increased
• Most common type of AV fistula=
Congenital Cardiac output Increased
• Most common cause of acquired AV Left ventricle Enlarged
fistula= penetrating trauma. Later left ventricular failure
SELF MASTERED
Investigation • Pulsatile swelling
• Duplex scan • Machinary murmur Treatment-
• Angiography • Branham’s/ Nicoladini’s sign • Embolisation
 Proximal pressure resultsin-
Nicolidini’s
• Decrease in size ofswelling
Sign
Branham’s Sign • Thrill or bruit to cease

• Pulsation to fall

• Normalization of pulse pressure

SELF MASTERED
Name of Fistula Artery Vein
Brescia- Cimino Fistula Radial artery Cephalic vein
Snuffbox fistula Posterior branch of Cephalic vein
Radial artery
Feinberg Fistula Radial artery Basilic vein
 51. Identify the catheter used forembolectomy‐

A. Foley’s catheter

B. Malecoth catheter
SELF MASTERED
C. Fogarty catheter

D. Pig tail catheter

Answer‐ C Fogarty catheter
SELF MASTERED
 Embolectomy

SELF MASTERED
 Pig‐tail
catheter
Malecoth Catheter

SELF MASTERED
52. Which of the following vessels is involved in
extradural hematoma?
• a. Middle meningeal artery
• b. Venous sinuses SELF MASTERED
• c. Bridging veins
• d. Middle cerebral artery
Answer-A
SELF MASTERED
 EXTRADURAL HEMATOMA

•85%- Middle meningeal artery bleed

•Lucid interval
SELF MASTERED
•CT scan-
•Biconvex appearance
•Lentiform appearance

•Treatment-
•Surgical evacuation
53. Chronic subdural hematoma refers to
collection present for a period of:
a. 7 days
SELF MASTERED
b. 6 months
c. 1 year
d. 21 days
Answer-D
SELF MASTERED
 SUBDURAL HEMATOMA

Bleeding from diploic veins

•CT scan-
Nomenclature Time •Sickle shaped

Acute SDH <3 days SELF MASTERED

Treatment No mass Mass effect

Subacute SDH 4 – 21 days effect
<1cm Conserve Surgery
Chronic SDH > 21 days >1cm Surgery Surgery
54. GCS of a brain dead person is-
A. 0
B. 3 SELF MASTERED

C. 9
D. 15
Answer-B
SELF MASTERED
Score Motor Verbal Eye Opening

6 Obeys - -
command

5 Localises Oriented -

4 Withdraws Confused Spontaneous

SELF MASTERED
3 Flexion Inappropriate To command
words

2 Extension Incomprehensib To pain

le sounds

1 No response No response No response

55. A patient with head injury opens eyes to painful
stimulus, uses inappropriate words, and localizes
pain, what is his GCS score?
a. 8 SELF MASTERED
b. 10
c. 12
d. 14
Answer-B
E2V3M5
SELF MASTERED
Score Motor Verbal Eye Opening

6 Obeys - -
command

5 Localises Oriented -

4 Withdraws Confused Spontaneous

SELF MASTERED
3 Flexion Inappropriate To command
words

2 Extension Incomprehensib To pain

le sounds

1 No response No response No response

56.A patient presents with blunt abdominal trauma.
Pulse= 120 bpm; B.p= 90/60 mmHg. What is the
investigation of choice in this patient?
A. CT Scan with contrast
B. USG SELF MASTERED

C. MRI
D. Plain X ray Abdomen
Answer- B
SELF MASTERED
Blunt Abdominal Trauma- 4 Areas Scanned- e- FAST –
Extended FAST
•IOC- Stable patient- CECT P= Pericardial
•IOC- Unstable patient- P= Perihepatic 4 Ps of FAST +
B/L Thoracic cavity
FAST- Focused Abdominal P= Perisplenic
Sonography for Trauma P= Pelvic
SELF MASTERED
Upto 100cc blood can be diagnosed by FAST
57. A 40 year old patient was operated for a direct
inguinal hernia. During the Surgery 2 sacs were
seen. The diagnosis is-
A. Pantaloon hernia
SELF MASTERED
B. Richter hernia
C. Amyand’s hernia
D. Littre hernia
Answer- A
SELF MASTERED
Name of the Hernia Content/ Peculiarity
Pantaloon Hernia Direct + Indirect sac
Richter’s hernia Part of circumference of intestine
Amyand’s Hernia Appendix- content
Littre’s Hernia Meckel’s Diverticulum- content
Maydl’s Hernia ‘W’ shaped loop of intestine- content
Omentocele Omentum- Content
Enterocele Intestine- content
Sliding hernia Content forms a part of the sac of hernia
SELF MASTERED
58. Congenital Hydrocele in a child is best
managed by-
A. Plication of sac
SELF MASTERED
B. Herniotomy
C. Eversion of Sac
D. Partial excision of sac
Answer- B
SELF MASTERED
Type of Connection with Fluid in front of Fluid in front of
Hydrocele peritoneal cavity spermatic cord testis

Congenital + + +
Hydrocele

Infantile - + +
Hydrocele SELF MASTERED
Funicular - + -
Hydrocele

Hydrocele of - - +
Tunica Vaginalis
Encysted Hydrocele fluid is in a very small portion opposite
Hydrocele of spermatic cord- in form of a cyst
cord
59. Which of the hernia has highest chance of
strangulation-
A. Direct inguinal hernia SELF MASTERED
B. Indirect inguinal hernia
C. Femoral hernia
D. Incisional hernia
Answer- C
SELF MASTERED
 FEMORAL HERNIA

•More common in females than males Approach Name

•More common in multi-parous females High approach McEvardy’s
•40% present as strangulation Inguinal approach Lothessein’s
•MC Hernia to present as Richter’s hernia Low approach- Lockwood’s
Scrotal
SELF MASTERED

Strangulation is more common because-

•Femoral ring is a rigid ring
•Path of the hernia is not straight
60. Which type of hernia is shown in the figure?

A. Inguinal hernia

B. Umbilical hernia
SELF MASTERED
C. Lumbar hernia

D. Spigelian hernia
Answer‐ C Lumbar Hernia
SELF MASTERED
 Grynfellt’s Triangle
• 12th rib
• Paraspinal muscles

• Inferior oblique muscle

Petit’s Triangle-
SELF MASTERED
• Iliac crest
• External oblique muscle

• Latissimus dorsii muscle

 LUMBAR HERNIA

• Lumbar hernias can be either congenital (20%) or acquired (80%)

• Occur in the lumbar region of the posterior abdominal wall

• More common on left side, in men

SELF MASTERED

Treatment- Surgery- Dowd’s

Operation
61. Which of the following structure is found in the triangle of Doom‐

A. External iliac vessels

B. Vas deferens SELF MASTERED

C. Inferior epigastric vessel

D. Lateral cutaneous nerve

Answer‐ A External iliac vessels
SELF MASTERED
 TRIANGLE OF DOOM
• Space bounded by
vas deferens &
testicular vessels
SELF MASTERED

29
 TRIANGLE OF DOOM

Contains
• External iliacvessels,
• Deep circumflex iliacveins,
SELF MASTERED
• Genital branch of genitofemoralnerve

30
62. External hemorrhoids below the dentate line
are:
a. Painful SELF MASTERED

b. Ligation is done as management

c. Skin tag is not seen in these cases
d. May turn malignant
Answer- A
SELF MASTERED
External Hemorrhoids- •Internal Hemorrhoids-

•Located distal to dentate line •Located proximal to dentate line

•Painful, •Not painful

SELF MASTERED
•Not ligated. Excision is done •Present with bleeding

•Repeated thrombosis leads to semi-ripe black & mucosal prolapse.

current appearance •Can be ligated or excised

63. Best investigation to diagnose piles/
hemorrhoids is:
a. Sigmoidoscopy SELF MASTERED
b. Barium enema
c. Ultrasound
d. Proctoscopy
Answer- D
SELF MASTERED
Grade Bleeding Prolapse Remarks
I + - Diagnosis only on proctoscopy
II + On exertion Spontaneous reduction
III + On exertion Require manual reduction
IV + Spontaneous Unable to reduce
SELF MASTERED
64. Which of the following
procedures is shown in this figure-
A. Pile banding SELF MASTERED
B. Injection sclerotherapy
C. Open hemorrhoidectomy
D. Closed hemorrhoidectomy
Answer- A
SELF MASTERED
Treatment Grade I Grade II Grade III Grade IV
Medical Treatment + + - -
Injection Sclerotherapy + + + -
Pile banding + + + -
Operative treatment - - + +
SELF MASTERED
SELF MASTERED
65. Most common anorectal fistula:
a. Intersphincteric
SELF MASTERED
b. Transsphincteric
c. Suprasphincteric
d. Extrasphincteric
Answer- A
SELF MASTERED
Causes:
Type % Features
•Ano-rectal abscess Inter-sphincteric 45 Runs in intersphinteric space
•Crohn’s disease, Trans-sphincteric 30 Extends through both internal
•Tuberculosis, SELF MASTERED and external sphincters
Supra-sphincteric 20 Originates in the Intersphincteric
•Foreign body
plane and tracks up and around
•Malignancy the entire external sphincter
Extra-sphincteric 5 Originates in the rectal wall and
tracks lateral to both sphincters
SELF MASTERED
•Investigation of Choice: MRI
Treatment options-
•Fistulotomy,
•Fistulectomy, SELF MASTERED
•Setons,
•Advancement flaps
•Glues
Point Relation to Distance Tract Internal opening
imaginary line from anal
verge
A Anterior Within 3 cm Straight Corresponding pt
B Anterior Beyond 3 cm Curved Posterior midline
C Posterior Within 3 cm Curved Posterior midline
D Posterior Beyond 3 cm Curved Posterior midline
SELF MASTERED

GOODSALL’s RULE
66. High or low fistula in ano is termed
according to its internal opening present with
reference to:
a. Anal canal SELF MASTERED

b. Dentate line
c. Anorectal ring
d. Sacral promontory
Answer-C
SELF MASTERED
SELF MASTERED
SELF MASTERED
67. Most common site of chronic fissure in ano:
a. Anterior
b. Posterior SELF MASTERED

c. Lateral
d. Antero-lateral
Answer- B
SELF MASTERED
•Longitudinal split in the Anoderm

•Most common site: Posterior midline

•Most common symptom: Pain

•Anterior anal fissures- more often seen in women after vaginal delivery

SELF MASTERED
68. Anal fissure best diagnosed by:
a. Anoscopy
b. History and superficial clinical examination
SELF MASTERED
c. PR examination
d. USG
Answer- B
SELF MASTERED
Acute Fissure- Chronic Fissure-

•Painful defecation •Canoe shaped ulcer

•Passage of fresh blood •Hypertrophied papilla

SELF MASTERED •Sentinel tag

Diagnosis- History +
Clinical examination
•Chemical sphincterotomy: Nitroglycerine (0.2%) or diltiazem (2%)
• Lord’s procedure: Dilatation of sphincter under GA.
•Lateral sphincterotomy: Surgical procedure of choice for anal fissure

SELF MASTERED

• Anal advancement flap:

An inverted U-shaped flap of perianal skin is carefully mobilized on its blood supply
and advanced without tension to cover the fissure, and then sutured with
interrupted absorbable sutures.
69. Emergency management for tension
pneumothorax is:
a. Thoracotomy SELF MASTERED
b. Insertion of a chest tube
c. Needle decompression
d. Tracheostomy
Answer-C
SELF MASTERED
 Features- Lung injury
•Breathlessness
•Distended neck veins Flap like mechanism

•Absent breath sounds on affected side

•Shift of mediastinum Air trapped in pleural cavity
SELF MASTERED
Lung collapse +
•IOC : Chest Xray Mediastinal shift
Treatment-
•Emergency – Needle thoracotomy in 2nd Intercostal space
•Definitive- Tube thoracostomy- Intercostal drain
Tension pneumothorax

SELF MASTERED