Surgery MCQs

All this data is obtained from this post by Ahmad Hassan Bhai.
https://www.facebook.com/media/set/?set=a.10204604474432210.1073742009.1845046617&type=3
S-1 Bailey
Multiple choice questions
• Homeostasis • Mediators
1. Which one of the following statements 4. Which of the following statements
about homeostasis is false? about mediators are true?
A It is defined as astable state of the A They consist of neural, endocrine and
normal body. inflammatory.
B The central nervous system, heart, lungs, B Every endocrine gland plays a part.
kidneys and spleen are the essential C They playan important role in the flow
organs that maintain normal homeostasis. phase.
C Elective surgery should cause little D These mediators are released over
disturbance to homeostasis. several days.
@ Emergency surgery shouldcause little E They playan important role in the
Q disturbance to homeostasis. recovery process.
E Return to normal homeostasis after an • Optimal perioperative care
insult (operation, injury, infection) would
5. Which of the following statements are
depend uponthe presence of comorbid true of optimal perioperative care?
conditions. A Surgery should be carried out by the use
• Stress response of adequate large incisions to give good
2. Neuroendoaine pathways of the
exposure.
stress response consist of the follow-
B Adequate pain relief is essential.
ing except: C arly mobilisation.
A Spinal cord D )I.void ongoing insults and secondary
B Thalamus trauma.
C Hypothalamus E Maintain good fluid load with several
D Pituitary litres of normal saline.
© Thyroid I' r- I .,.
6. The following statements are true
regarding Enhanced Recovery After
Surgery (ERAS) programmes except:
A It optimises rehabilitation following
maJor surgery.
B It reduces hospital stay.
~ Patient engagement is an integral part.
U It isonly used in colorectal surgery.
E Blocking afferent painful stimuli is
important in reducing stress response.
• •
• Pathophysiology of shock B In a patient with intestinal obstruction
1. Which of the following statements are with hypovolaemic shock, time should
true inthe pathophysiology of shock? be spent in optimising with adequate
@1nshock, cells switch from aerobicto fluid resuscitation.
anaerobic metabolism. C In hypovolaemia, inotropes must be
B The product of anaerobic respiration is started as soon as possible as first-line
carbon dioxide, resulting in respiratory therapy
acidosis. D The ideal fluid is colloid in hypovolaemia.
{8Hypoxia and acidosis generate oxygen E The shockstatus is best determined by
free radicals and cytokine release. an initial fluid challenge.
~ Renal ischaemia leads to decreased glo-
merular filtration (GFR), thus activating • Monitoring
the renin-aldosterone-angiotensin 4. Which of the following statements
system (RAAS). are true?
E Once shock has been treated and {A) CVPmonitoring is a dynamic reflection
circulation restored, the physiological on fluid challenge.
disturbances return to normal. @Measurement of cardiac output (CO)
Ir'! helps in distinguishing the type of shock.
• Severity of shock \tJMixed venous oxygen saturation is an
2. Which of the following statementjs indicator of systemic perfusion.
are false? D Pulmonary arterywedge pressure
A Incompensated shoe~ blood flow is main- (PAW'f"J measurement should be insti-
tained to the brain, lungs and kidneys. tn'.uted in all shocked patients in the ICU.
@ Loss of 151¾> of circulating blood volume \.::)t is mandatory to perform Allen's test
will overload the body's compensatory prior to insertion of an arterial line.
c-flechanisms.
V:apillary refill time is an accurate clinical • Haemorrhage
parameter in all types of shock. 5. The following statements are true
CD')Hypotension is an earlysign of shock. except:
t Prolonged systemic ischaemia and A Haemorrhage with hypovolaemic shock
results in a state of coagulopathy.
reperfusion injurycontribute to multi-
B Haemoglobin level is an accurate
organ failure. . ' . . , .' . ,'
G) In a patient with intestinal obstruction
with hypovolaemic shock, time should
be spent in optimising with adequate
• Severity of shock fluid resuscitation.
2. Which of the following statementjs C In hypovolaemia, inotropes must be
are false? started as soon as possible as first-line
A In compensatedshock, blood flow is main- therapy.
tained to the brain, lungs and kidneys D The ideal fluid is colloid in hypovolaemia.
0 Loss of 1soi1> of circulating blood volume
will overload the body's compensatory
& e shock status is best determined by
an initial fluid challenge.
mechanisms.
0 Capillary refill time is an accurate clinical • Haemorrhage
5. The followingstatements are true
parameter in all types of shock.
~ Hypotension is an earlysign of shock. except:
l"' Prolonged systemic ischaemia and A Haemorrhage with hypovolaemic shock
reperlusion injurycontribute to multi- results in a state of coagulopathy.
organ failure. e}Haemoglobin level is an accurate
indicator of the degree of haemorrhage.
• Resuscitation C The acid-base disturbance is metabolic
3. Which of the followingstatements acidosis.
are true? D Permissive hypotension is a strategy
©,na patient who is shocked from a to be followed until haemorrhage is
leaking abdominal aortic aneurysm or a controlled.
bleeding peptic ulcer, time should not ~ aemorrhagic shock can be classified
be wasted in instituting high-volume into three groups - mild, moderate and
fluid resuscitation. severe.
• Blood transfusion C The vast majority of the population is
6. Which of the following statements Rhesus negative.
D In coagulopathy packed red blood cells
0 are true?
Blood group 'O' is regarded as universal
donor.
/';.\should be transfused.
~ Fresh frozen plasma (FFP) has a shett
@ Blood group 'AB' isregarded as life of 2 years
universal recipient.
• Clinical scenarios
A A SO-year-old man is undergoing partial hepatectomy for secondary metastasis. The
operation proceeded smoothly for the first couple of hours, after which the surgical
team noticed unusual bleeding in the form of oozing from all the wound sites. The
patient has two intravenous cannula sites through one of which he is on his first unit of
blood. missed matched transfusion
B A fit 30-year-old woman while gardening suddenly became very short of breath, had intense
itching with rash and complained of a painful red spot on her arm. She has been brought to
the A&Edepartment and ishypotensive, hypoxic with warm peripheries.anaphylactic shock
C A fit 25-year-old man fell from aheight of 40 feet at a building site. He has been brought in
unconscious with a GCS of 13 and flaccid limbs. He has been immobilised in a spinal frame
and has an intravenous line. neurogeni c shock
D A70-year-old man of ASA anaesthetic category 3, underwent an emergency closure of a
perforated duodenal ulcer. The anaesthetic and operation were uneventful. On the first
postoperative day, he complained of feeflng very unwell with a systolic blood pressure of
80 mm Hg with no unusual signs in his abdomen; there wasimpaired conscious level and
peripheral vasoconstriction. Cardi ogeni c shock
E A 60-year-old man of ASA 1anaesthetic risk underwent a total gastrectomy for stomach
cancer. While in the ITU, 12 hours postoperatively, his BP has fallen to 80 mm Hg systolic,
he has not put out any urine over the past 3 hours and he is hypoxic with oxygen saturation
of 92%. hypovulemic shock
F A 60-year-old woman has been admitted as an emergency with a 4-day history of severeright
upper quadrant pain, vomiting, jaundice and intense pruritus and is very toxic - high tempera-
ture with rigors and hyperdynamic circulation. septic shock
G A 35-year-old woman isdue for a bilateral mastectomy. She has requested a bilateral breast
reconstruction at the same time. However, sheis a strict Jehovah's Witness and would under
no circumstances have a heterologous blood transfusion. autologous blood transfusion
• Normal wound healing C There is no role for tests for hepatitis
1. The following statements are true and HIVwhen managing wounds.
except: D Primary repair of all damaged
@rhe inflammatory phase of wound structures should be attempted in all
healing lasts for s to 7days. wounds.
B Platelet-rich blood clot and dilated vessels (!'.)Healing bytertiary intention should be
are typical of the inflammatory phase the choice in certain situations.
C Fibroblasticactivity is the main feature
of the proliferative phase. • Managing the acute wound
D In a tendon injury, fibrous adhesion 3. Which one of the following statements
between the tendon and its sheath is an f7:l is fal.se?
important mechanism of healing. \..J In case of severe uncontrollable
E In a fractured bone cortical structure bleeding, a soft clamp must be applied
and medullarycavity are restored in the immediately across the vessel in the
remodelling phase. wound.
B \l\founds should be classified as tidy
• Abnormal healing and untidy before deciding upon
2. Which of the following statements intervention.
are true? C Repair of all damaged structures can be
@ rhe aim in treatment of a wound attempted under certain situations.
is to reduce the inflammatory and D Pulsed jet lavage for saline irrigation is
proliferative responses. not always ideal for saline irrigation
(ID The mechanism of wounding influences E Alarge haematoma should be actively
the healing of a wound. treated.
A A72-year-old man, recovering from astroke, has developed an ulcer over hissacrum over a
week. There isalso apatch of necrotic skin over his heel. pressure sores
B A 54-year-old woman who is undergoing chemothera py for breast carcinoma underwent
an emergency appendectomy for acute perforated appendicitis 4 days ago. She complains
of severe pain in the wound, which shows erythema, oedema, skin blistering and
crepitus. necrotizing soft tissue infection
C A76-year-old woman complains of an ulcer in the region of her medial malleolus for 6
months. She has had a swollen leg for many years following a deep vein thrombosis, which
she suffered after childbirth. venous ulcer
D A28-year-old man while working on abuilding site sustained a fracture of his tibia and fibula
having fallen from a ladder. This was promptly treated by open reduction and internal fixation.
On the second postoperative day, he developed severe pain in his legexacerbated by passive
movement and sensory loss.compartment syndrome
E A62-year-old man underwent a coronary artery bypass grafting 8 months ago.
The longitudinal scar on hissternum has increased in width, is itchy and is cosmetically
unsightly keloid
F An 18-year-old man sustained an assault injury to his face and neck with a broken glass bottle.
This was sutured as an emergency and healed primarily. The scar is unsightly and he wishes
further surgery. hypertrophic scar
G A26-year-old woman sustained a burn to her upper limb, which straddled her cubital fossa.
This hashealed, leaving her with aflexion deformity contracture
,
• Incisions C It is essential that in end-to-end
1. Which of the followingstatements are anastomosis the bowel ends should
e .ue about skin incisions? match the diameter.
kin incisions are best made along D In vascular anastomosis, polypropylene
tension lines. is the suture material to be used.
@ incisions should avoid bony E Atransverse arteriotomy should always
prominences and skincreases. be used to prevent stenosis after closure.
C The 22-blade scalpel is ideal for all
inos1ons. • Drains
@ incisions should be made bearing in 4. Which of the following statements are
mind cosmesis. false?
(OTransverse abdominal incisions have @ Adrain is best inserted through the end
fewer respiratory complications. © of awound so as not to have another scar.
'When in doubt drain' should be the
• Wound closure motto.
2. The followingstatements are true C Drains are mandatory after a
except: thoracotomy.
A Mass closure technique is the usual D Drains are usually used following
method used for abdominal walL exploration of the common bile duct.
B Sutures lose SOC¾> of their tensile E During removal of a chest drain, the
@ strength at the knot patient should be asked to do aValsalva
Non-absorbable suture materialshould manoeuvre.
be used in the biliary and urinarytract.
D Synthetic suture materials elicit minimal • Principles of diathermy
tissue reaction. 5. Which of the following statements are
E Round-bodies needles are used in true?
intestinal surgery. A The two types of diathermyin use are
mnnnnnl,r anrl hinnt,r
• Principles of anastomosis • Principles of diathermy
3. Which of the following statements are 5. Which of the following statements are
true? true?
@ he current favoured technique of @rhe two types of diathermyin use are
bowel anastomosis is the one-layer monopolar and bipolar.
extramucosal interrupted method. B Monopolar diathermy is ideal for
B The bowel must be prepared prior to ~ 1icrosurgery and delicate procedures.
any anastomosis. \';;J'.ipolar diathermy is ideal for patients
€)11is essential that in end-to-end who have pacemakers.
anastomosis the bowel ends should (§}Accidental burns are more common
match the diameter. when monopolar diathermy is used.
@ 1n vascular anastomosis, polypropylene ~ pacitance coupling can occur when a
is the suture material to be used. metal port is used in laparoscopicsurgery.
E Atransverse arteriotomy should always
be used to prevent stenosis after closure.
1. Which of the following statements are ana picked up by the primary care doctors.
true? C Antibiotics should be started onlyonce
& icroorganisms are prevented from sensitivities are available.
causing infection by intact skin, chemi- D Extensive debridement is necessary in
cal, humoral and cellular factors. Meleney's synergisticgangrene.
@ Reduced resistance to infection may result E An infected wound is ideallytreated by
from metabolic problems, disseminated opening it up
disease and iatrogeniccauses.
© Colonisation and translocation in the
gastrointestinal tract is a risk factor
• Prophylaxis
for SIRS, MODS and wound infection except:
(surgical site infections, or SSls) A The blood and tissue levels of antibiotics
D When closing a skin incision, silkhas the should be maximal before contamina-
least chance of causing infection. tion occurs.
B In a long operation, under certain
© In reduced host resistance,
non-pathogenic microorganisms may conditions, antibiotics should be
behave as pathogens. repeated at 4-hourlyintervals.
0 Further doses of antibiotics post-
• Presentation operatively helps in reducing infection.
2. The following statements are true D Patients with cardiac valve disease or a
except: prosthesis should have prophylaxis
A Whether a wound becomes infected E Ideally, preoperative shaving should be
depends upon the host response. done in the operating theatre just before
@ All SSls are secondaryand due to HAI the operation.
(health-care-associated infection).
C Presence of antibiotics during the • Bacteria involved in
'decisive period' is crucial to the surgical infection
prevention of SSls. 5. Which of the following statements are
D Poor surgical technique is a recipe for SSls. true?
E Primary infection occurs when the A Streptococci are most often responsible
source of the pathogen is endogenous. 0
for cellulitis.
Tl. - _ __ _.., __ _ _ _ __ _ _____ . ___ · - __
B All SSls are secondary and due to HAI the operation.
(health-care-associated infection)
C Presence of antibiotics during the • Bacteria involved in
'decisive period' is crucial to the surgical infection
prevention of SSls. 5. Which of the following statements are
D Poor surgical technique is a recipe for SSls. true?
E Primary infection occurs when the Ci) Streptococci are most often responsible
source of the pathogen is endogenous. for cellulitis.
+ Treatment of surgical
G rhe most common organism inan
abscess is Staphylococci.
infection C Bacteroides are aerobicspore-bearing
3. Which of the following statements is organisms.
not true? () clostridium difficile causes
A Surgical incision through infected tissue pseudomembranous enterocolitis.
is best managed by delayed primary or (!!)staphylococcus epidermidis is a cause
secondary closure. of HAL
B SSls are usuallymissed by the surgical team
11'\~nd picked up by the primary care doctors.
v ntibiotics should be started onlyonce
sensitivities are available.
D Extensive debridement is necessary in
Meleney's synergisticgangrene.
E An infected wound is ideally treated by
opening it up.
• Principles of antimicrobial O minoglycosides may have ototoxicity
treatment and nephrotoxicity.
6. Which of the following statements is O carbapenems are effective against
Gram-positive and anaerobic
not true?
0A broad-spectrum antibiotic should be A organisms.
VI Quinolones havea limited role in
used to treat aknown sensitive infection.
B Combination of broad-spectrum treating surgical infections.
antibiotics is to be used while awaiting • Human immunodeficiency
sensitivities.
C Under certain circumstancesit may be
virus, AIDS and the surgeon
necessary to rotate antibiotics. 8. The following statementsare true
D Antibiotics should not beused instead of except:
surgical drainage. A In surgical practice, the risk of trans-
mission of theHIV virusis through
E In SIRS and MODSwhen there is no
responsewithin 3 to 4 days, one should needlestick injury.
revisit the clinical situation. B Those with thevirus havean increased
risk of neoplasms and opportunistic
• Antibiotics used in infections.
treatment and prophylaxis C Untreated HIVinfection proceeds to
AIDSwithin 2 yearsin 25%-35% of
of surgical infection ~ patients
7. Which of the following statements are \;/I In the early phases of infection, drug
e true?
Benzylpenicillin is the treatment of
choJCe against Gram-positive organisms.
treatment isnot required.
E Treatment after exposure should be
dictated by local policies
B Ampicillin and amoxicillin are
the antibioticsof choice against
Pseudomonas and Klebsiel/a.
Maten tne magnoses wnn me c.11rnca1scenarios tnat 10110w:
A A58-year-old cattle farmer normallya resident in the subcontinent, on a short visit to the
United Kingdom, was brought into the A&Edepartment with convulsions. The episode started
with lassitude, irritability, dysphagia and spasm of facial muscles. He showed generalised
tonic and clonic spasm. tetanus
B A68-year-old woman underwent anamputation of her right leg following severe crush injury.
Three days postoperatively she has pyrexia and tachycardia and looks toxic The amputation
site looks red and brawny with the limb swollen with crepitus in the intermuscular planes.
gas gangrene
C A75-year-old man underwent a low anterior resection. Five dayspostoperatively he became
toxic. A contrast CT scan showed an anastomotic leak. bacteremia & sepsis
D A38-year-old woman sustained a superficial wound of her thumb from a puncture while
gardening. Twenty-four hours later, her thumb became swollen and very painful, with red
inflamed streaks all along the skin up to the axilla. celluliti s & lymphangitis
E A 42-year-old woman underwent an emergency appendectomy for perforated suppurative
appendicitis. Three days postoperatively, her wound becamered and tender with gross
oedema; on removal of the sutures, the wound showed slough and ulceration.synergistic spreading gangrene
F A 25-year-old man presented with a tender lump in the right supraclavicular area of 3 days'
duration. The lump is red and fluctuant. Helooks unwell with pyrexia. Aweek before the
onset of this episode he had his right ear pierced, which became infected. abscess
Principles of /aparoscopic
and robotic surgery
CRSelvasekar

• Advantages of minimal ®;,. -
access surgery (M AS) ($}COl:lprorri~ a.iliac rei.-Jtn.
I. Which of the follCM'q stawnercs ate 5. Which of the lollc,,,Ylg statm!ENS
uue? are true regarding complications
@ oooease in. wourd size- associated Ytith mating
®Oeaease:I pompera!M pit'JI• pnaimoprioneum?
.C. Reduced operatrg time. A 81ee:1~
(g) Improved vision. B !listml~
E l«!doced opefi!lilll. ineat;e tmts. C ;,s disseai:ln in lhe abd:>rr.inal .,,'ill
0 ~ 10 ~ blood vessels.
• Um ttations o f MAS E ClmMllll tsrs.
2. Which of the lollCMirlg stiltfmeru a;e
lrue1 • Energy sources in MAS
ledri:.ilymoredema~ 6. Yi'hich ol the iollcr.wlg enfffY sources
lcss of lat.ti! foo:brl. are used in minimal acces-s si.rgery?
Extraction of lart:e specinens. ~orq,o&. d~Ulermy.
Dffiai':y wi1h h1emoua51S.. 89()1ardi!lh?tmy.
® s"i"Y tnllcMicg~-JS.,,,..,.
operaoon5. ""·
IJtms:luid eneli'f.
1/apcu ~asm,a COllgi.iltion (VP().
• ' Gas used in
p neumoperitoneum • Robotic surgery
7. The follo\'ling are the .ivantages ol
3. Which ol the follO'Ail8 .statemeru are
uue? robotic SUJiet)' euept
I! sholkl be ,1 ~patl.'r of combustion. A 3-0visio:t.
ltnt.Adbetii&fiy~ in bb:ld. 8 Attiokled i~runems a'low~ precise
C !1shot.Mbetapidtye:«medbyd,e disseaon
~.~
bod1 tr'Si~p le.rningOJM!.
Jl£e shoukl be b'Nrisl: ci ernbdwt
E Stifgi'l'Y can be perlom,ed in aco;f~d
It shm.A:I hM few dffusicn co-effici,ert.
"'1"-
• ComPkations of
8. What are the benefits of robotic
p neumoperitoneum surgery O't"l'r laparoSUJpic surgery?
4. Which of the lollCMYlg statemerts are er ergoo:im.ic.s:.
uue? tKeS fieneed Ji:. G..sistan!S.
A l!ypefthl,ms. se dissection ard roor.i:in sali11g.
®-amt atm{llmias.
~
Q. Shetter aper~ ti:ne.
(()Sh«ter learning~
9. What are the curreffl fb\\backs of 0 The injuries are miriot
/":\ roboticsurgecy? f. ll,jpola1 dia'!hemry is eq,Jal>(
\JY Sooeasedcon <il~
dfea~CUM.
Si?d operatq tf:'le. • SectrosurgicaJinjuries in
runic irn;t'ICi!ions. laparoscopic surgery
i-aare fea:md.. tl. \'Iha are the main causes of
• Bleeding in MAS dectrosu,sical injuries in Caparoscopic
SI.WgE<y!
10. How can b8eedingfrom lhe trocarsite lnadw.'tE':rri lilt.Xhingor~asping-of
be cortrolled? lis9R d1Jri-€ a~pk.tticn.
9y al);i'ting up.q::I and latml FfffiUte 8 Direct couping.
'llilh the trocar. C l~nbreal:s.
B 3)• usiig a ~OJtMeel.5 mooofil.!ment. 0 lndrect cou~illG,
S'U!Uteb:lp-. E P>s...,. at ek<lricily lronu eceni'f
C Sunr.ing, ~lla!ed tissue.
0 Ati~o.1 of Foley cat.'lel!r ballocn
0""""1y. -+ Natural orifice trans!uminal
• Risk of electrosurgery in MAS surgery (NOTES)
1I. Which ohhe Jollc,,wig s&aternerts 13. Vl!jcb of the foll~ing are used
ate true ii relatioo to the risks of
as access poin..s for n.atur.il orifice
elecuosuq:ery in milWnal access ,..._transtuminalsurgery (NOTES)?
SUflEl'Y?
""""""
~
Mapityof ~es <kXllt fol~Vlg lhe ~\'agina.
used mooopotlr :!ia:hermy. L Urrbiirus.
De irri:le~ is aboti ore ID 1v.o cases ®Imo.
pei: 1000 pr«edues. E Re"""'""""".
C Allthe iili,lnes are leel)i,ised a. the
~ 'Tie of SU~!)'.
All the past papers i had with me written here
PS: answers ko apni zimedari pe man'nain xD
S-1 MCQs made Simple

,,,,
MW, Date:
t¼rotrog
"'°" 1¥-%( ; ".'%\rm~ Tq :tu root
') Eil>rob'o$~ n:vm GJDurx;I Suhs¼tr§
G.-.,..,w-, o~ c..1-rnc.., ~ \.ooj'!,
•
ii. l>elaved "': ·

~ n:, C093:y t lo»uvc ;, \is l'lJ i colec,¼ f:oi: jleococc g I , S .
* Cool-Yo\ ble!d ,., 5c1\p 1<1ffYl'.11-,on • £,1.1e1r~ C'19l(9 9ecl'X'.\..l'(O~l'c~.

/ ol,·rec.~ Dires.syrP. on 9,leedi~ £tj~l"~ (~ )
:Ji; Atter tk-w1•,1ort4'"c 51,,.,<,1:.. - > pl:,;il!!inr, 11:f>~ ~9tec\ t>g MY~">"." 1es
,c Bes.I- , ,v;,~ ~o M12m,ue t:1=:ilovk,'+ron ; B;e,.p fdld Jt,1ckne$s.
K Af k ,t A, $·,o:g•·cgl pYC( Pdure ( 'll'\e u l:o I op<,>~O.,-leJ;,
t£ :re N - ::'t JQ.W'IOJ2e 9 f~r- 3 Mo\'\41S ,LPT~ 9S?~90~td • R~t1(e

ft:!~ (oo k Qt: -
in '!->Ound ic~- at-1-f t:
' \..;<.c l To s Rs .
'e ~:-...._..________________!l~>a!!:le~:----=--=-
-1'< Tr \::ooyr,
+r!?lve J tQ Cl'i"i
• i I,'\ \19,M(?.y. ~ I ' ¼

,< ib~\.../g,\ ~•c_c.,,™ ¼ f9,l,':.S.
½11l¼..,->16<1i. i½S&-Joc.i\.l've_
• ctt: CJc.e14"1·c_,:J Co....,~i~\.-!0y,. £11.JQ\dfcl iv-.. 'o<J.,l.MJ.
t !'1£ ~Ir<;.\. 1,:....e i,. ~o, Bu,u,., .,_ I/v Li,.,., -¼ '- P.,.;,,., ;,, \,·<4 '
• ~ ¥-Oba<., So_1,:cwa.. is Nol' Yl:<o\,·o-re>,1's~-
• O{ r~\r~u)) T,, w/'!l -> e:,1,,v.,ew,e~ f~~ cv.. e i<: l}.:r.we ~ GxPd .
• ti' Rez-\. 'fu;. w- '"-'¥1. -) v>erir\tetrJ \Jruc,1 br_ du~e
tJe )scl:-,e,wo ot l,~.,,h Jtf¥,Y!,, :\:o I ac.); 0£ e~£:e,cl-n,e.
0£ ~ec \..um.
_::i
, 3 f
•
!C1-IM
--
-
P<2.hib,n,·+1s :::} (:\u,·d 1e1us.ti\-obari~ R.v.,"fA \o.c 6\-e ·
fl.
~ s.S: 'i /o f'l"QG\.a:!:hioa\ ~'-'lb ,.c\1S\.cn~r~~,·ri·~ ~'r A -
_ _o._'-'-¥-S - :=, f<V6 _\_V__I ~ 1 + s.xa-.. \- 1r~4 ~ u'tc<l::tl"M w I O ·91 ·
_ ·. M .
_ s_~
-
-- - -- -------
i:, iStamp _
I
Date:
M-Ph<.;se l:a
9S An
I ;$ 'i)O C. 6.c Y/o . I

Sf>f
ac a~e)'.q\:1'on unde~ Q , ?e~s.oo ei(pect•·eoces
\:x:od a c:be , R:vc.~ , ioahi\1'8j b £.leep, it•·~ d ue
!'I 4o Y/o .,..,·+t, l.' L.

•
clele..,,q • £c M c(laJ \/ e&Y'
t _ _e.9-.:\:_!:e~ecl:::!!.,·~n~a1--.=:::'t:z._..;S~u:!l~~*~Iq;;.u;;·au\_ ..:!,;.~'r~1'!S!O:::!,dw.J1'a~1=l--t'!tl::!.IW~ocl"~01.!!Y'oCll..!..?,!~.- - - - - - -
>< ~ ,' 1c. ~ ,·cw~ ~ f:\"'•t\cc..le "Y'>§\'\4,..,\.e. iv.~Vfq\. ,'vi. ~ ~oc..d,
• __c+:f:__!M~CJ,C_,_ _ T..Ull.29lt:OL::S.,..;tc.1U,c$:.!''20Qu.._ ____
_~Ll,,s.31"~\.z..J.J$L.>~a!.ll'-l{:>.Q.....,.- - - - - - -- - - - -- -
;t1.
· ----------- ------------
•-------------------------
•---------------------
.-------------------
. - - - - - - -- - - - - - - - - -
.• - - - - - -- -- - - -~
-: -
, - - ---==---
, 4 A,.,, •O 11\41• of \l'l.!HV h3, u1,1o\l,1•d: bli,ril h•\1f'I•• I 1 ,, t l4o'ttt ~•t1, U1 • ttN»1 111•4!1J 1, 1r 1
' -- - - ~ - hl!:JI \ •• c111(10•ntv .1111•t \111,1 , r11u, ,.._v"'J ••1
v'
n.
'2013 . Date:
- Booe
Trourpg
~ - Sold.·ea w,l Mi<,s.i!e iOjY!:'.j - c,t,an<,C
-4 · Me:\9h.ru:~ o \l;s+las: rs ooesno\: , o "sc <ll kQ \$'$,{S I
~go ro\ ,-,. T e ..,,rql(:
~ ~-'---8A'=iPl"''wA....;'t,,,.•,;___,i"'"' -"€"-"'"-i1,.,.0.,...._...::::2...a:
::} ?i,.,,"6"'' ~:z.Y½½=!t!=ia._._ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ __
- Blood ..,1, ti- +£•c
...
""'llt - &;x;leriodeS F•i~l(S , 'I' 5-SOS.)H"C 1:9 im\c!92<$<S ,
... - Ay,\i'oto~l' c "'-i',01"1 ~ { ,w, &· -.,_,.ct,~ cJc£CCYSl:t CfG!MY
\9.
i;;,. \\"'t' I •11, io 'IA'ves §YpeA S:rc cg1 1~m¢c,r..1·cs .
\e.ire.k .
_ !);:YMai,f .brosg,(<D!:lA ~lr])MJP<:6,u,6 • i"'¼J1ua-.e.,.. ~ 'l
- £01-I- ~i),.e. S,Ieu,.. ='1 Tq~ di: ~@IQ.M..Q

- I'\<: Q'f\A,\e - Sy•"-'-"~ ~•QM<>. m,. L/ L<p ="> o b!;<:ll' va l:-1 <211 •
,. ®r;io' i"' ¼lcgr => ooi M e,k,i~z.. \..e L N
Mt • IQ 4M ~ I h,,,:acie,I. <l,g 9~ '="=' I'" lM b,u<L 4 'Aoce • ex gse,
ov,d ""rp\'~ sk-- ~a£}- .
-- - c:::::'.===-- - --.- -- ~ - ~ - - : ,. ,_ _ _ __
Date:
• rc, ay ,le
• i,-T T •
• p:ce.rocd(cg-jon bc ~, e
o~crg\.i(l) • %ivea iO 11' Cil' ang,J+-e ~i'c. Yoom
.
ac L't !°phc dc roa ,s 9i l:\:i09 ,a oo',-u'l'e / ,o,\..,.09en,'c.
i * N½ fpd.1·c:a1-,-o,,. 4 u~Gi ~ \.,,_~\-,' "'c..li (>'e:sl§'-lY-.<Sl:½,
• ~ ""Wet tm ~! l S.Q ::lt =-1 ~e~ ~ M
gr j& LJce.. .
) CIC {g. ·
4
GO-J\ioe~&u·,
$~ o. 4 .
Cl Jt (.l ~ Yu..,,-,\ aj~ cr"'k.,. C...111\Jg\- ur e
'
c-: St :0~ 0 ffi £,h ,os o:c c"m g _,, ~gl\,·gl.iue
Uni I--> ho \-- dc .? • 9m py lqn on .
¥ S> M ==" ~ C.on~, ~ 'D.i ~ \Q<j fa t.¼Jr: I' a ", ouN;\ . n
£e.c;.,i fa n .
;. T'i> N ==> 1: L~ T$ - "'e-,(,i. c;.¼
f ~ • s,\-c~ Fg.t I "ed->ce f9. t co. n's::n\-s.
6£ W ¥ de£ecce.s \:c.l;e ':ib \-o bg msiliili?&i _
_ _ _ _ __
~ Pio" i,. i c sn c.u l 7;, m --"> O\JC.i.Q\\ 'l'Y'O\ +¢. \1 ¼) '> 1o· / •
it' Q.M e.M -.r9.i.,·ca.se \/c:.i·Ms =± ~a'-'-'~ c Te ;\- .
lL - \fgJN\uS ul ce r ~ · 0+0'<J.e Q.Mot.1"91e2 ¼ ;~ ( 'T 9.\ ,~ s
eo ui n~
,.. 2,l ac ,\; "'t ct¢ ¼· c ~\ .c. b V
oo l\ · ~a\\:s:lr alr c:4 i')C:\1'c.g\-bj
UeooUC;a 4\c e\- _. ., \=re.e... ~., ,,~ 1•c .g: .ci .i\_ ..1 ;\r )"- !:! :!~ ·u~ 'ji- --- ---
--
e,c \-\ k ===" Rs cc. 11,. ... ve.. •
Date:
_______
~:_ ___________
--:--____::.
-~- - - - - - - - - - - - - - - - - - -
...~===========~============
Maryam Baji S-1 points

GENERAL SURGERY IMP POINTS TO ATTEMPT
MCQS (by Maryam Malik- RMC}
REF= MCQs & EMQs in surgery bailey & love, Kaplan Suraery
Part 1= Principl
CHAPTER 1 = METABOLIC RESPONSE TO INJURY.
• Homeostasis l s lhe ormal phys,ol<>gical tat .of the humaq body - 1 \ ,,,,ev, a term coined
•
by f laude Bemard, 3
The vital organs - the brain. heart. lungs and kidney , and, to a lesser extent. lhe splee - play an
essentia~ in maintenance of Homeostasis '\.
• A return to normal physiology is always affec:Ced 6y lilt presem;e f ongo!ngh mplications or
secondary insults. such as ischem,a from l\ypotension~inadequate oxygenation from hY:S?°xia. or
1nfection and complications such as companment syndrome or dee venous rombosis.
• in iiii. This disturbance is directly
proportional to the degree of injury and inversely p rtional 01.the fitness of the patient prior to the
event.
• in s beeause lhe patient is optimised and
precautions taken against co- ,d
~ ilioos prior 10 an operation.
• Neuroendocrine pathway consist o aff nt nociceptive neurons. spinal cord, lhaJamus.
hypolhalamus, pitujtary.___ _""
• TheJ hyroid does not form a part of the neuro--endocrine athwa to the sttess response.
• The changes that 0<:c~li'ody meta ism in e stress response have been divided into the 'ebb ancl
• ses. a term Iha ir Da Id Culhbeitson first used.
• The initial (a ho d~ pattem)-~ hich lasts for a few hours(
is characterize lhe classical features of shock -
. The main role of ebb phase is to conserve bolh circulating
volume & e~tores for; ef overy & repair.
• The hormo~ s re ~ Ible '!Qyhe ebb phase are emtnee ,
• ebb phase, foll 1ng resuscitation. gives way to the now phase. This phase concentrates on
~ very-and [epair. The'8 is tissue edema fncreased basal metabolic rate, increased cardiac output
1ncreased bod_y temperatureJ...levkocytosis and gtuconeogenesiS.
!2!.'..
C8Use oflraos.ca ·ua leaka e seconds to increase in microvascular ermeabilit . olkMI
- • abiJciiiinal surgery e os mew , n '1 o 2,al!Y.
• The ~ phase Initially consists ol the cataboMc mas@ . which lasts up to da~II( • followed
by lhe anabolic !)base w • Iasis ks. Obviously the duration of lhese phases will depend upon
the severit of in'u .
Duotngca
• The two immune systems are he innate (mainly macrQehages) and the iadaptive· {T cells and B cells)
systems. These produce the mediators - interleukin -1 IL-1) IL-6. IL-8 and tumour necrosis factor
alpha (TNFu) in first 24 hrs. They act on the hypothalamus to cause pyrexia.
p ay a minor role
2 of 13
• Proinnammatory cytoklnes thus released result in systemic innammatoruesponse syndrome SIRS
Al lhis stage, endogenous cytokine anlagonists appear lo conlrol lhe prolnnammatory-9-toldnes, thus
keeping in check !he SIRS. If Iha response lo SIRS is inadequate, mulliple organ dysfunc110n,
syndrome (MOOS) occurs which is a step away from dea= l hc.·- .= ~-
• Avoidable factors to reduce the response lo inJury (and hence SIRS)=- continuous hemorrhage
J!Y.polherm1a. tissue edema tissue under perfusion, starvation. 1mmob11ity
• Majority of_J?atients {_exc~t possibly those with extensive bums) demonstrate energy expenditures app
5-25 % above redicted heallhy resting values.
• During calabolic phase major site of protein loss is 11eripheral skelelal muscle. Although nitrogen
losses also occurs in the respiratory muscles (predisposing to hypoventilation & Chest infections) & gut
(reducing gut motility), cardiac muscle Is mostly spared.
• Under extreme conditions of catabolism (e.g. major sepsis) uri:n:c.: ;.,a "'. ..,..=
f.Oglday; "'l':'ivalent to loss of 500g of skeletal musde per day
• :Adequale pain_, is - to raduce Ille slr8ss N19ponw
c-! s' = ow1n= g surg,ca
• Block01g afferent painful stimuli by epidlJral anal9'!S1a ls an officiant method of,l!!l!!tofl'!ratJ','.e R@l k
I • • · su!9!d. It has the advantage'i>I conlinu"\!~ nalgesia bylfl.f;Jt on
(or wilh ,e~tient_-<:0ntrol~ analgesia, P~~) through a calheter in ui,~ural s11,acq__f\ weak loca
'anaesthetic with op,gids e.g, fentanyl) ,s used This allows earty me_~~ilisar n, lhus~ lhe
incidence of deep vein thrombosis and chest complications. '\
• Minimal access surgery 1ns1ead of open surgical mcismnsls--well kno lo re lhe stress response
and return the ~tient to an eart sto rative normaf ~ tas·s.
• It is important to ~=~~~~
~ 10 hasten recove .
r!i!•lii\A!!!I (sal
• ~ h the concept of
- it Is h_ow used across all surgical specialties
• ERAS is an evidence-based innovative approa It-to t t i , : ~rative, traoperallve and postoperative
care of patlenls undergoing elective surgery. It i111Qroves palle ~ tcomes bUfleedlng osto erative
recove • thus reduci the stre~ response followl ng ur ery. concepl'Sp1rrnleea a
~ This lsac:hiev~ lhro"ilh .
• Main labile energy reserve in body Is fatL J
• Main lab1I r tein resetve in ~ • keletal muscl
CHAPTER 2= SHOC~ & BLOOD'TRANSFUSION

•
•
•
•
•
the blood now to the skin hence. cold skin in shock , muscles and gastrointestinal tract
• Capillary refill time Is as this ma not be affected in the earty
st~~,es: moreover, ·n septic shock the penpheries are warm w,th a brisk ca~
~ ..c;- efill
• hypotension is lhe~ igJUQ be affected_!~ - Fit and young patients maintain their blood
pressure by increasing the stroke volume and peripheral vasoconstriction. Elderly hypertensive
patients may show a misleading 'normal blood pressure' In the presence or shock just as a11ents on
beta blockers ay fail to show tachycardia.
W n compensated shock, adequate preload is maintained to the vilal 0<gans such as the brain, lungs,
heart and kidneys. This perfusion in the presence of adversilY. is also helped by the phenomenon of
autoregutation in the brain, heart and kidneys. Prolonged lschaemi from profound shock leads to cell
3 of 13
death. resulting ~'! myocardial depression that is unresponsive to volume expansion or inotropes. This,
coupled with reperfust0n injury. contributes to multipte organ dysfunction syndrome, a condition
defined by the failure of two or more or ans
• kfrth eye, one re'1! sh elie~d" u-l)Oll
- .lt Is a dynamic measuremen that assesses
res nse to fluid resuscitation. ree ae be• riea In CVP ol 2--5 cm Indicating a
responae ICi a whereas a
sustained rise denotes ftuid overload or cardiac failure
• ~asurement of CO helps In dis11n9uishin9_.bypovo1aemic. cardiogenic and d1stribulive shock
particula~y when they co-ex,st This Information is obtained b real-time monitoring by Dop !er
Ultrasound and pulse waveform analysis
• Mixed venous oxygen saturatton is an indicator of systemic perfusion. Mixed te~ us oxygen saturation
is obtained from blood from the right atrium with an accurately placed CVP tine ,Nbrmal levels are 50%
to 70% and are an indicator of oxygen delivery and extraciion by the tissues. Levels below 50% are .I
reflection of Insufficient oxygen delivery or lllCl'eased oxygen extracbon by the cells - a sltuation thar
OCCUI'$ • votemic nic s , tl'9 enous saturation is seen in disttibutlve shock, as 'n
SIS f;.";;i;,..;W,~ I\
• When _ is necessary. - lo,: com;n ~ blood P'J!SSUre
monitoring is advisable. Before inserting such a line. len·s test is mandatory 10 e s.u that the
coUateral circulation in the palm between the and tAnar arte,t is effi,cie l.
• PAWP measurement II largely_, su
jiiore sophislicaled end lesa '"".!!!!llli!l.lllmlli ~•Q(!!l>l),Of a Swan-Ganz catheter can
produc serious omplicalions.
• or a patient who is losin blood from a Jaiiidnjj1iiixicimiiai'
1181
lncre sJng the p d would make the patient lose alt
the infused fluid. Moreover, it would be dangB<OUS, because..it woul"-cause ,hypothermia, and dilute
coagulation factors increasing the chances of disseminated intravascular coagulation {DIC). [hi
klOOJJ!ll usl be lllmed o as as 1>9ssl
J>!i.e.Y surge')' Permissive hypotension is the key,
Arrest of hemorrhage should be the immediate ~
• On the other hand, a patient with intestinal obstruction W1ll have lost a large amount of fluid as a resul
of sequestration into the th,rd space.
ti !Ill monitored by an indWelhng urinary catheter and central
venous essure C P~J,in . 'iiii'si~
0~eii Fs:'1
• saelllng lhe slatus a where the response of the patient is
gauged by infusing _~O-liOO ml o f ~ o-15-30 ml . The response is gauged by the
patient's blood pressure. heart rate. CVP and urinary: output.
• lnotro2e administration Is in !!Ygo-volaem1a. It should never be used until
confirm~ Jhe presence or a adequate preload. An inotrope in the presence of inadequate pretoad
will redu~ C:,~5:tolic filling and cor.eoary perfusion with disastrous consequen_~c~e~s;..
- ----~
• Although coo ~ oV8 y contiJJues wffh regard to the ideal intravenous fluid, it is customary o se
crystalloids ere is less benefit from the use or colloids, which are more expensive
ave~ si e eff{CIS.
• jj!vel of em'19!oblnJS of the degree of hemorrhage. as it re resents a
:entratlon ~ not an absolute amountJmmediately after blood loss and In
fOOlinued blood loss, the hemoglobln level Is uncha~ as whole blood is losl. The hemoglobin level
will faRafter som 'e'lime When there is a fluid shift from the intracellular and interstitial spaces into the
vascu1a~ ar1men1.
, /-lemorrhaglc shock is Classified into four groups, 1 to 4 depending upon the estimated percentage of
= =
the total blood volume lost: 1 - <15%. 2 15%- 30%. 3 30%-40% and 4 >40%. =
• Hypovolemic shock from haemorrhage results in pcyte traumatic 99agufopath (ATC) along with
$Cldosis @Qd hypo!hermlli.
• The red blood cells have aggtutinogen a sugar) on the outer coat. ii.qitiiiiiiiii:l~
or the
population) is regarded as the liiiili:iiiiiiiQ&because it has neither 'A· nor ·s• agglutinogen to
provoke a reaction.
• Blood grou has agglutlnogen A
• up B has agglutinogen B
• p AB . has both agglulinogen A and B. Those belonging to blood
because they do not develop any agglutinins.
4 of 13
ANAPHYLACn c SHOCK;
• Anaphylactic shock. more common l~tients with asthma and eczema. is an acute medical
emergency.that can lollow insect bites. administration or drugs or vaccines and consumption' of
shellfish and many other foodstuffs.
- "'he patient presents with ~~ii'..:'iuirOcaiiciiiili'.:'liiioiic:lioiijiiiiiii".19i9i sp11piraii~
lofy di81J8Ss, na
• In this type or shock the antigen combines with immun lobulin (lg.E e a
basophils, releasing large amounts or (sl~ se-su axis).
These compounds cause the symptoms.
• ifhe mortality is about o•
• In the acute stage. the patient should be made to he down with elevation or the lower limb; The a,rwa~
hould be free: the patient is given oxygen and-venous I monitoring; in
severe hypoxia ventilation may be necessary.
• The atient is given the following: .6'"-..
1. 0.5 mt ol 1 in 1000 adrenahne intramuscular (0.5 mg)' to - b~e- repeated alter 5 minutes if shock persists
l - ,Anhhistam,ne chlor eoamine/chtor heniramme 10 mg bY,.SIO)'i,.lntravenousj njectio o be continued
lor 48 hours "-A...-.....: V
3. Intravenous hydrocortisone 100 mg
NEURogEN/C_SHQCK
• ln'~ llfogeni.C shock head or spinal in'u the cardiovascular res nse is sometimes referred lo as
distributive shock, lntanup6on
@'Xllll!li!betic:JIIIIXl.~ 111!1.IIIL!lll, This causes hypotension from loss or vasomotor tone with warm
extremities, 't!,adycardia. flacci<!i!)' and loss of reflexesc.;..~
• The sympal'F:°elic tone takes <l to 7 days to return to normal
• Fractures of the auas (C1 account for 5% of all cervical spine (c-spine) injuries. and 40% of these are
associated with a concomitant injury of the axis (C2). the most common fracture is a burst fracture
(Jetterso raclurei caused by axial loading. The treatment of C1 Injury is a halo jacket 3 months
Fractures of the axis aocount ror 18% of all C-spine injuries, and 60% of these Involve the odontoid
process. Fracture occurs in the posterior element called s and Is the most
dangerous. occurring In 20%. Confirmation is by x-ray folowid liyC The
mechanism of in·u is h erextension. in C2 in'u the treatment is
5 of 13
R• of NEUROGENIC SHOCK : The immediate management is to identify and exclude life-threatening
problems,
• Whilst intravenous access is obtained,
be indicated,
• th red'"n1
-i-s-ol~one
- is lld1111nl$tered lor 24
• Once resuscitated and stabilised. the patient is referred to the spinal Injuries centre
• The treatment is surgical expk>raUon to stop the bleedin .

When the cause may be due to traumatic rupture of a I • such as the liver.
kidney or spleen. and the patient is stable, a should be performed. r the diagnosis Is
confirmed, ~iiii~m out H arterial . red,
•
t either surgically or by the interventional
na
•
• A haemoglot,;n level or less than
It is t : l ,ted when haemoglobin level (g/dL is the following:

1- Jii( ~ · there is l!.0
2- 6-8, transfusion Is \Jnlikely to be beneficial in the bsence o bleed' g
3- < 6, wtll benefit from lrans1us·
MISSED MATCHED TRANSFUSION

Although .rare the complication of ABO-incompatibility is alwa)"s due to human error. It arises from mtstakes
that can occur at various levels. such as in taking the blood labelling the sample, collecting the wrong blood
6 of 13
from the blood bank refrigerator and, finally. Inadequate or hurried checking prior to transfust0n,
t=.i-:i~~
Table 2.1 Complications of blood transfusion
General Massive transfusion
• Oise- transmission • Hypothermia
- Bacterial
-Parasitic
- Viral
• Dilutional coagulopathy
• DIC
• Add-base disturbance
•
• Transfusion reactions • Hypoc.alcaemia
• Mismatched transfusion
· TRALI
• lmmunosuppression
• Hypomagnesaemia
• Hyperi(alaemia V
~
CHAPTER 3-WOUNDS, TISSUE REPAI , & S RS
• The ~ Jlhn!i or wound healing ID 3 day1j.
Normal wound healing occurs in lhree phases lhe inflammatory phase lasts for lhe first 2 to 3 days
.__,.,
the proMeratNe phase lasts for 3 days to 3 weeks llridl-flnal , the remode I maJ\Jfatoon LP.has last
•
l rom the end of the third week to
The
~••rs
also ?.lied the • has ' It
consisls of vascular, cellular "11?•~ mallc pro"f.:ses. result of lhe wound. bleeding.
vasoconslriction and thrombus f~llon oc;,,:'rs. Plalelets tick lo lhe damaged vessel endothelium,
releasing adenosine dlphospha19-f/lOP.f'cvt;;tnes, serotonin, prostaglandins and hislamlne, This
causes vascular pe ~ility, re ln.ihe
g migration of Inflammatory cells and macrophages, the
lallerremoving de i ~ · ue a ic:IO<liflli!nisms. Flbrlnogen produces fibrin, which forms the
fmmewor1< for lhe fi • · · ·ch l!> second phase.
• The phM8 - from 3 ~ IO Ille end '1e The nnc1pal feature of this IS
Eb<oblast,c acll~ with the eroductlon of collagen and new cap,llanes (ang,ogenesis) and ',';;.;;.,--
eprtheltalisalJOn. this Is calleil gra,"Jllllllll.!ls•ue. This !11C1'88sed COl!!9!lll!IV8SJ/M!~und ~
- 0!!9lnal I strength
~ e third Qha e V emodelling con titutes re-arran ment and cross-lmktn of c~lagen fibres·. which
can 90 on for ye<1rs•? hile tt'l, ound regains
ound he~ f'Q in s~ ·a1 sit( lations such as tendon, consists of Intrinsic and extrinsic mechanisms. the
~ depending upon fibrous adhesions between the tendon and llS sheath In fractured bonti in Lh
1nal phase of f9ffl0delllng, res1ora11on of corucal bone and the medullary ca"'!)! occ.,,i:_
TIie This can occ.,r by reducing the
infta~ lory an roliferative responses. By doing so. healing occurs by first or primary intention
when th t..iund es are aocurale a sed, leavl minimal scarring.
" For example, a ciean-cut incision
in an elective operation wm heal well with the least promment scar. On the other hand a I or
one following burns will take a long lime lo heal and do so ndary nlllnUon with ugly 11011111nd!'
n certeln 111Ualion1 1Uch aa eme,vency ebclclmrlal IUflllllY fecal pen- - Ille wound-'
- ,. - _...y contarn.-d.lt 1s prudent 10 leave 1he abdominal wall open after clo6ing the pentoneu
Delayed cJosure of the wound Is earned out when the 1nftarrwnatory and prol1feralive phases ol
re well established Th,s Is refened to as closure "
There is a role for tesbng hepauus and HIV v,n,ses when multiple victims rrom the same sit (lerr,Q~ I,
related ,J]iunes or bus crashest h ave been brought in because these wiU carry the risk of Ussue and-
viral contamination
7 of 13
~ e uc s. ne. tendon. soft tissue. nerve and vessels
- Such re~ should be carried _put only In a Udy wu,nd,
Sta ed ocedures should be attem ted in untid wounds such as explosionf.
because nerves ~ be
~ r•bl~ damag!!!!, The bleeding wound should be elevaled and a pressure pad applied until the
wound can be property examined under adequate analgesia or anaesthesia (local, regional, or
general), When appropriate, this examination is carried out under the use of :::.a.;;
tou
= mccicq;,.u:.;e:;,;t;.,
. ---~
• Wounds are classified as 'tidy' and ·untidy' to h"!f.> in their management. [tidy wwnds are those "111\ a
......,,,,......_
Clean Incision on heafthy nssue wilhout any ussue'losi'__Jlnicly woliiCli are '
• ~ i r of au damaged struetures may be attempted m a tidy wound. V: a

sels ; ;es and tendons are
repaired, magnlfcation being used whenever necessary.
Wound Irrigation with large amounts of saline is carried out as a part of d emenl. rrigation b
pulsed tat lavage , because the procedure can push the din further dee mlo
tissue planes.
• large
but the latter is not atways successful because the clOt
COMPARTMENT SYNDROME:
ompartment s ndrome usuall occurs in lhe limb, oil
Ul98 O ec:utely lsellemtc
• The patient complains of severe pam oul of propo<tion to the Injury or operation; the pain is
e)(ac erb;:Hed by pass:vc movement -: nd associated rlh sensory dis1urbance and loss o( two-point
piscnm1na1ion.
• The cal1 muscles fe~ tense and tender and 1n 1a1e stag~ P
_™:,_!!!U ulses not be ~ b l
• In w lnerable(unconsclous only) palients, compail~ 'l,I_ press~ y be measured by a catheler
~-~_ced in lhe muscle ~ , tor throu h use of-. e,ssure monitor. Normal pressure 1n the calf ,s
up10 10 mm Hg Piiif tllrll a nwn has to lit
~ 'Oeco111>ression ol lhe lower limbs Is earned oul by two lnctslons lale<al 10 1he
~neoU$ l>Ordef or lhe · 11\us "'9 access lo the two posleoor compartmenls onea\
CONTRACTUR
• s • ints, causing defOffl"lty resulting in compromise of mobility.
, causes disabill and
!ollowed by Intensive
• (unplanned
keloid is an exuberant scar, which is the resuJ1 of
• 11 Is associated wilh '.[a,sed levels or growth lac10

occurs more oommonly in pigmented skin and has an inherited tendency.
• Certain areas of lhe body are more susceptible. such as ear lobe and the area bounded by the two
shOulde:r bps and the x1plustemum.
• Hislologically, the dermis is markedly thickened with broad and irregular hyalinised collagen bundles
and an excess of capHlaries and fib<oblasts than seen in normal scar tissue.
8 of 13
recurrence is common
Steroid injection into the lesion and excision with postoperative radiation or steroid injection flas been
tried with limited success.
ULCER
An ulcer is defined as a break in epithelial continuity
Leg ulcers can be caused by vascular disease (arterial or venous, or a combination of both) and
autoimmune diseases such as rheumatoid arthritis causing arteritis. trauma chroni ·nrection
inflammatory bowel disease. haematological disorders and skin cancers.
One of the moslJommon ..,... of lag .-111 fs post.phlebltic syndromiwith venous hypertension.
An Indolent ulcer unresponsive to the usual methods of conservative treatment should be · Pili
ciud s a squ ous cha e · venou~
An arterial component [lschaemia) should always be excluded by Doppler sound.
The mainstay of management is to treat the underlying cause.
Localty conservative regime of hygiene, rest elevation and compression
supervision of a district nurse is the key.
NECROTIZING SOFT TISSUE INFECTION
PRESSURE SORE
Also called pressure sores are chronic wounds that
result in tissue necrosis
0 , tthough Qreventable, sue
Prevention
• most lmportan is is achieved by good skin care. special pressure dispersion
cushions, ~08"'\_8Q_d beds; Jnl>tioo ous nursing of the bed-bound patient who should be turned at
regular inte~ ls ~ $ nual._gverall management should be a multi-disciplinary approach and surgery
~ be CO\"'lmpl only after very careful and detailed assessment.
A welf:'m otivat.,S clinic •stable patient with good nutrition should be considered for surgery by graft
)ae CO~J;!li_\should be preceded by optimum preparation of the wound by debridement and
va ~ Sl~ sure (VAC) also called negative J)<essure wound closure.
CHAPTE ~ BASIC SURGICAL SKILLS & ANASTAMOSIS

Skin Incisions are best made along Lan ers· lines (tension lines which represent the direction of
dermal colla en fibres. Therefore, incisions made arallel to these lines resuH in a ood scar.
tient cou hs much better J)<ooucin less res 'rato

The . It•
,11115-blade is for minor procedures and an 11 •blade is for arteriotom
a!, should • as they would
act as a nidus for a stone. Absolbable sutures should always be used when closing the common 6ue
duCl0£ placing sutuies an~ere lrom_tne renal P!!lviS down to tile urina~
9 of 13
:::::,n closure of lhe atxfon,lnal wall, mass closure te<:hn1qu is the usual method. In this large bites are
laken In shO<t steps using ~Ion or pol 'P!9P_x!ene non-absorbable) o, pojyd,axanone (POS. slOwl
:absor:t,ablel._sutures.
• The length of suture material used should be at least four times 1he sength of the mc,s,on 10 be lose J
this is to minimise the risk of wound dehiscence or inc:isionat hemia.
,;_.,Knot tying. ooe of the most basic of surgical te<:hniques. should be lhoroughly mastered as utures
lose 50% of the,r suength at the knot.
• Sutures from ~IC8f or t e IIBSUe reacuon 'Cl8ble lhe,I'
peha11110<1"
• e bodies of noodles are round. triangular, or Oat Round-bodied needles graduaJIY. taper to a point
and are desi ned to separate tissue fibres s m intestinal a d cardiovascular suj ~
Trtangul,irneecl have cutting edges and are used when tough or dense e such as
. . lobe
.~ e brought ut thr end o
an 1oc1s1on. because lh1s leads to an increased chance of wound infecbon.
•
IIIWU.dol.f)""• -· TNa dictum,-• ~
The use al drains depends upon a surgeon's nd1v1dual,._ereference and type o s3 rge~. E In. afte< the
same ope<ation one surgeoo might drain whilst another might not. "'J:Ol"~ ts · drains
re<nove collectioos wfthln a wound or peritoneal cavil: t might indicate ~ tive emorrhago;
those not In favour al drains clai m that they Increase · once al nd . Ions. abdominal pain
and hospital stays, and that they reduce pulm0<1al)' fu ~
The current favoured techni ue of bowel a.nastomos,s ,s one-layer exttamucosal s e because it
causes the least tissue necrosis and luminal ·
• The suture must lnciode the svbmucos!, of its "'liin..ccoUagen content, Is the most
stable suture la r.
• In l!O!I~ 811i181omosii, encls.muat be ol slmler ihmeie Following resectoon for
intestinal obstruction when e bowel ends to be anastomos re: ual a side•to•slde or end•to-
side anastomost.S 1s done. " ..ih .. '-.'-.
In case the discrepancy Is minlw , nd-to-en~.!)8Stomii ·scan be carried out by making a cut into
the anll-m0$ente<lc border 1111"!1,li>I of distal collapsed lumen to bring the diameter Into line
with that of the xlmal bowel.
• In when pr e t10$ erial or graft ls used, the anastomosis will never be
int~rated into the ~ sues. Tha,te{ore, uture line needs to be permanent. Hence.
~c;.,lon( as it ,s,'iio t.oileQradil!)le. is to
• When making an artenotomy, particula~ I embolectomy .
although it wttl not stenos-eon closure, ~ s It may not give adequate access A
!Q!!gltudlnal art&riotomy 1s preferable and is closed with a vein patch In arterial anast~ the
needle SltQu.kN dways go from wt.no to without on the downstream edge of the vessel to prevent
eteaU I adis on and fe< anv pl lque.
• _ ...... ....,,to
Acc1dentaJ burns ,s more common 1n monopofar diathermy rOf the following reasons: the Indifferent
ele<:trode may be lncorrecUy applied with inadequate conlact, the patient being earthed by metal
contact 0<1 the operating lable, there may be faulty insulation of the diathermy leads and accidental
contact of the active electrode '!E!Y occur with other metal instrument,,,
s::.
ln:.;u.,,s"'e"-._ _ _ _ __
• Capacitance coupling 1s the cause of a ccldentat bum mj..ry to intrall<'nloneal suuctures durlfl9
taparoscO!l'< surg_!!}',. For exampie, when an insulated diathermy hook is passed through a metal
taparoscopic port, HFAC is transferred from the Insulated Instrument to the molal port. which. tt In
conlact with an intra-abdominal organ, r0$ulls in burning the organ. say a pa,1 of the bowel. This
da er is avoided b usin entire! astic rts.
s
10 of 13
CHAPTER 5= SURGICAL INFECTION
Infection by microorganisms is normally prevented by intact epithelial surfaces. such as skin, chemical
factors such as the low pH of gastric acid, humoral factors such as antibodies, and cellular factors
such as phagocytic cells. macrophages. polymorphonuclear cells and killer lymphocytes.
The organism gains the uwer hand when resistance to infection is com rornised in situations such as
metabOlic - diabetes'. m"'alnutrilion and obesity, jaundice, chronic renal a1lure· disseminated 1sease -
matignancy, AIDS: iatrogenic - radiothera2)'. ste<oids, chemothera2Y,
• When a patient's immunity is depressed as in cancer. sepsis and shock. bacteria. particularly aerobic
Gram-negative bacilli, tend to colonise the upper gastrointestinal llact. They then transtocate to the
mesenteric lymph nodes causing release of endotoxins, which may then go on to produce SIRS,
MOOS and SSis.
• In a situation of compromised host resistance, harmless mietoorganisms su as fungi become
pathogenic, producing opportunistic infections much more so when proj id, and changi ng antibiotic
r~imes have been in place.
~~
• Silk as a suture material acts as a nidus for infection and encourages the invasion of bactena, tausing
suture abscesses. Hence, it should not be used,__ _ _ __ ~
• Not all SSls are secondary and of health-car&-essoc,ated ongin. The ong,n of an SSI can be pnm
when it ls endogenous in ongin and present In the host, such as in faecal peritonlHs from perforate
dive<ticulllls or acute petforated aPI)!! lcltls secondary or XQ9eoouyllll!n ealthcCat
associated or nosooomia•intecMon- ~
Host response Is a very i mponant factor that will determine ethet' a w~ d bee mes infected.
After trauma or surgery it takes hours or host s{nl~mm• IQ{Y• ~umoral and cellular
defence mechanisms to be in place. This is-~err ~ as the d~~ive perioa· during which time the
causative organisms become established in~ host. if!jerefore, ~cpncentration of antibiotics must
reach its peak during this period so that the a* olio ~et in the tiss,iil should reach above the
.---..
minimum lnhlblto concentration for the likel pa ns.
surgical lec:hnlque. such as leaving e deed space. or tscfleemjc and neaolle traaue end
haemalomlla~im!1ll.i~!!\l\for "I"'-""'~
~
There is no evidence that extra ~ e5,!)11 n: blotics postoperatively are of any value in the prevention
or infection. Such extra doses cao,.~tJa~e harmful as the rocess can cause antibiotic resistance.
Prophylactic antibiodcs'are ideally ~~en in ~ when local wound defences are
minimal and before~ • nation ~ rs.
In long operations or in I l l ·~ "or-excess ve blood loss as in vascular surgery, or in unexpected
contamination, antibiotics repea al 4-hourly intervals during operation as tissue levels fall faster
than ser:~ vels.
• Patientf wi~ tvular disease b(,! e heart and those with prosthesis should have prophylactic
antibiotics"la ~ nt bacteraemia-.when undergoing any form of surgical intervention. such as dental
wol1< or ur~hf S!!_Ument@li<tn,
ll)Jl'eoperattye prel!8(atlon:'-sWaving of the skin should be done just before the operation in the theatre,
as SSI rate a dean'wound surg doubles if it is done the night before.
cause it takes two to three days for the answer to be available. Empirical treatment
should be sta ed. when there is swingi~ rexia, s reading infection. ceUulitis and bacteraemia.
~rapy-
. . . . staned; this is obviously modified once the results are available.
• As most pa ,ents have a shon hospital stay after surgery and wound Infections take up to 10 days to
develop, SUJQiCal teams miss most SSls; they are managed in primary care.
In necrotizing fascilt,s or the abdominal wall (Meie~ ·s s~nerglstic gangrenaj. extensive debride.ment
should be carried out: all necrotic tissue i s excised and affected areas laid open, which will require skin
grafting later.
,---.~•.hen there is infected postoperative wound with evidence of underlying pus, the wound should be laid;
open ~ removal of the sutures and wound curettage to drain the et.JS.
• In severely contaminated wounds. such as a laparotomy for faecal peritonitis, it is prudent to leave the
wound open to be closed by delayed primary or secondary closure.
11 of 13
Streptococci are Gram-positive organisms Group A Streptococcus (S. pyogenes) is the most
pathogenic. with the ability to spread, and causes cellulilis and tissue destruction by releasing the
streptolysin. slreptokinase and streptodomase enzymes. The organism is sensitive to penicillin and
erythromycin,
Staphylococci are Gram-positive organisms normally present in the nasopharynx of up to 15% of the
population.
Staphyk>Coccus aureus is the most important pathogen that causes an abscess. Most of these strai~
are P-lactamase producers resistant to penicillin (MRSA) but sensitive to fluctoxacillln, vancomycin,
amin~I osides. some ce halos rins and fusidic acid.
) 8
• Bacteroides are non•spo,e-beanng anaerobes found In lhe large bowel, vagina and oropharynx
cteroKIBs tragilis ts the main Ofgamsm that acts 10 concert with aerobic Gram negative bacllh lo
se SSls after coforectal and ynaecok)gical suf9!1<Y, Such o~anisms are sens I
tronidazole and cefotaxlme
Cloalndia are Gram,poettive a
This is caused by the inJ!,aiclc!,us use o ~ entibiotics
sequentiaU . and the elderl and immunocompromised re rtlculai1 vul~ ble.
, For instance wh~ ~ •~sofa,ied, it shljlld be treated by

specific antibiotics such as vancomycin and teicoptanin, !ii,'- , .,.\
A combination of b; oad:spectrum antibiotics such as amp,ciHin or mezlocillin (penicillins). gentam 1
(am1noglycoside} and metromdazoJe is used whilst awaiting sensillvities.
'" situations where commensals such as Pseudomonas and Klebsiella (Gram.negative species)
become resident opportunist pathogens. it ma.Y. l>e prudent to rotate antipseudomonal and anti-Gram-
~ ga1,ve therapy. (
Antibiotics should never be used f S a substitute for ~ surgica technique and surgicaJ drainage:
wherever pus is present, it ne~ o be let out.A , ,
In SIRS and MODS with antibioti ~atment ·(the patierrt'has not improved, the surgical team should
revisit the_diagnosis and methods ofl~glng 1Gidentify the source.
Benzyfpeni£!1!jrl is the antibiotic oil oi~ ainst Gram-positive organisms such as streptococci,
clostri<fia and stap i l ) t ~at do po,t pr~uce Plactamase. II is effective against Actlnomyces. a
pathogen causing ch~ ~d inf(lCtlon in d§ireloplng countries and very potent In gas gangrene, II
is effeclive against spre di119
thera2r,". '- ~
":Sl~occaf infections and also used as a component of multiple
Amin~lycosides (gentamic,n ~ tobra ycin}. effective against Gram-negative Enterobacteriaceae

and Psi¥l_Qf!>Qnas, may cause tpxicily and nephrotoxicity at sustained high levels, Therefore,
serum le~ s'shbuld be monitore 4ll hours after commencing treatment and the dosage modified to
satisfy pea en<! l!'o<!gh lev!!&.,.
Aminoglyco~des \g~ lamiclft-5nd tobramycin), effective against Gram-negative Enterobacteriaceae
~ Ps~ ~ •s, ~ cause olotoxicily and nephrotoxicity at sustained high levels. Therefore,
~ m •~ stidvld be monitored 48 hours after commencing treatment and the dosage modifted to
satisfy pea Id tl~ugh levels.
Ouinolones (clp.,,lloxacin) have a limited role in surgical infections because or the development of
resistanl,;!lf£1ins.
Ampicillln~ amoxicillin are not effective against Pseudomonas and Klebsiella These are Jl,-lactam
penicHlins that can be used orally and parenterally but are rarely used now as there are more erreclive
alternatives.
HIV INFECTION
In HIV. In the early phases of treatment. drug treatment is most effective. Htghly active anti-retroviral
therapy (HAART) acts by inhibiting reverse-transcriptase and protease synthesis, which are the main
mechanisms through which HIV progresses.
Needlestick injury during operations is the most common risk of transmission of the disease.
In general this retrovirus virus is transmitted by body nuids, especially blood.
• On exposure, the virus binds to CD4 receptors with toss of CD4- cells, T-helper cells and other cells
involved in cell-mediated immunity and ant.ibody production. herefore. the chances of o~ortunistic
12 of 13
Infections (Pneumocystis carinii pneumonia. tuberculosis and cytomegalovirus) and neoplasms
(Kapos.-s sarcoma and lymphoma) are enhanced.
Untreate HIV infection lead to AIDS in 25% to 35% or patients within 2 ~ears,
Contamination most often occurs due lo needlestick injury on the nondominant index finger during an
operation.
• An abscess is a cavity lined by granulation tissue containing pus. The organism is most likely lo be
Staphylococcus aureus. Aerobic Gram-negative bacilli are usually responsible for bacteraemia and
sepsis from anastomotic breakdown (deep space SSI). The patient needs vigorous resuscitation
followed by laparolomy. The procedure should be lo dismantle the anastomosis. bring lhe proximal
end out as an end colostomy and close off lhe distal rectum. This should be followed by copious warm
salfne washouts. The abdominal wall may be left open to be closed by delay~ p(!mary closure. If on
imaging the leak looks small and contained, a decision may be made to drain:el eak by inlervenlional
radiology. -~ /
• S ner9istic SP!eading~an ren is caused by a group of organisms actin9) concert. The group
includes coliforms, staphylococci. Bacteroides species and anaerobic streP..t~ccl. When it occurs on
the abdominal wall It is called Meleney's synergistic hospital gang/'ene; whe~.ft,f ffecls the s§/\,tum ll is
referred to as f ournier's gangrene. Contaminated wounds are ~ il!~Yc to be affected. causing
severe wound pain and signs of spreading inflammation with crepif~~ cf ul-sme llng-dtsch"arge. The
patient is treated with broad-spectrum antibiotics with circulatory suPS?Of ~ s combined with
aggressive excision of local necrotic tissue, which ma to be rePI! led. patient once
recovered will require extensive skin grafting.
CHAPTER 7= PRINCIRllES OF PAROSCOPIC SURGERY

• Advantages of minimal access surl/ery (IMS) are decreased wound size, reduced post operative pain,
improved vision.Th' "'!'!<-.it vanlage'I. are lllduced wound pain and wound-related complications such
as infection. bleeding~ '&~ ne , [entrapnt.
i In the long-term there is possibility of decreased
adhesions and lnclsionaLhernia ~
• Um11a11ons of MAS : Tecl \ ~y mo de anding, loss of tactile feedback, extraction of large
specim~ urgery following"ro:!._Olliple ope alions. reliance on remote vision and operating and
depend nee OQ hand eye coorij~)i~on. The set-up costs and operating theatre costs can be high.
However, .th'li,overall hos ital cosls are less.
• gas usedfor creating pneurnoperitcinm ~y . ly e
. should not be combuatlble o, suppor11\ie of combuallon, because this can cause~J!l&lll!!l.-!>.l!!!R
dialhenny II should haw a high dillUslon coellldent to minimise the risk of ambol
• Compllcabons of pneumoperitoneum: acidosis, cardiac atrhY1!Jmias comP[!!rruse<i cardiac
embolism, hypothermie and referred shoulder•bp pain
• :[he procedure to create poeumopentoneum can be assoaated with major rls1<s like bleedi!lll~viSC!trl!I
J!.IIYl!!!..gas issecli the abd all n Y!Y. to blood essels la ea .
• In MAS follgSying energy sources are used :
1) Monopolar aiathermy Is the common energy source used but Bipolar energy devices are safer to use.
2) Laser
3) ultrasound
4) Argon plasma ooagulation (APC) is used lo augment the coagulation effect of the diathermy, but there
Is a potential for lateral spread and care should be exercised in Its use.
• Bleeding from the trocar site can be controlled by
1) Applying upward & lateral pressure with the trocar
2) By using percutaneous monofilament suture loop
3) Suturing
4) Application of foley catheter balloon.
13 of 13
5) Diathermy
LOS ED TECHNIQUE (Vl!RRESS NEEDLE) The use of a click sound os,oc1otcd w11h the ,pnngmg forward of the blunt style
s recommended 10 deLcnnme when 10 stop advancing the needle. Diffimml me1hod-!. are reported m lncraturc 10 improve 1h
fety, for CXt'lmpfo 1he palpation of aona l J), the angling of the . or
..IDLfJ.J. lhS sein?I p$£:dl£ ISSl (
• n CT ond MRI and the dir«lm<aMlfin of the distw1c
TRAUMA
• ANTERIOR CORO SYNDROME: associated commonly with burst fracture of vertebrae. There is totaJ loss of motor
function below the level of the lesion & loss of PAIN & TEMPERATURE on both sides below the level of the lesion. Oest
investigation to study e)(tent of neurological damage= MRI ~
• CENTRAL CORO SYNDROME : commonly seen in elderly secondafy to forced hyperexte~oniype inju(Y to the nee:k .
Burning pain & paralysis in upper extremities with relative sparing of lower extremir , sf
• BROWN SEQUARO SYNDROME : acute hemis~tion of the cord, lpsilateral motor an
conttalateral pain loss below the level of the lesion.
• ACUTE DISK PROLAPSE : severe radicular pain w ith positive straight leg rai\ n1,-test
• CAUDA EQUINA SYNDROME : paraplegia, variable sensory loss, urinary & fe al n tinen
•
S-1 Bailey Points

8 Facebook •• •• o ~ 4 :26 PM ~ 27% l >
Cancel Final Year Nu gg et s fo r M CQ s
~ 1,111 fil. •%,~,~ (Bf\ll.£.Y Al-lll. ll>VE~~
@ -li d. ~ , , -m v= ;j "\ M
!:!:.\tit_ ' Ali' ~~~ l'ru'\l.'l\j,,. \'lik•~C .-{ \d», '""- 'i
@ l\l::.\ Cot- kt :\ .i ~-iabc.. M
@ 11h , i,'t:e\kt\ ..tJ ~ u:\:-1 V,:,:e,. ~\ \

-...~CPCI!<. __jl~ ~iU 1. _ _ _ _ ~-~
~£.,J. /~ ho ur
®IY·:bl.\tJ Ju. m-J.!l~ ~t ~1~we wx_

@-fut eec ,n. c\ df - f'1:1;"
"lbuv, (.\l~l
:, o.rl~k ~
-~ - -·
___ __ _ir. ... !hcch.. 1~
~'· "I,
@ St:-ro;;. 4_ ~ 1 d. .t"al a\ ,-6U--•p=:J:• !<lvllo.d

r-. ·il b.cl!\:w hdl'lltl,l_...:\c.0\h <a-
® lm d uro£,/J f, _it l
@- \ah.d \S J~cfut- u:\\ Ult~ ~ 1 . ..f.W~~ •k , l

- . ~W -f 21 c1 i'J L !S. >":t! /!'.ftI\lj
®. s~d \~ L W(d b1 9¾11,1.J:,, j .L.... .tvl"ltl 11
~ Mu ha m m ad Yasir
"g Gen.S ur ge ry 1
er 2015 •
Final Year Nuggets for MCQs · 11 Novemb
View full size · More options
rt Facebook ··••O9 4 :26 PM ~ 27% 1 •
Cancel Final Year Nuggets for MCQs
€) SJL 1'1, t ..& tr ml: IBrr,tl\(, °ft"P:nx:- ~\~.A.cir ~ - -

- - t-j- - ---~
--©- $k,fot(~ ~·'t~rol mi j_Jk'1:l Ob Jc& 't.d..

@}, Vu> wttk A.::11<t\ I\. 11.l<1l°for~' i.,,.ib _l.•F.lJLd ti\,.
(n>a ~Ill, ~ 1»f'-e. l _c.11i,"~
@~~Jq\,_ 11,.l~ f.'-'J~ oo ~111.

-rtM.. t 1:Jt ~~
_ .sln\l.b:'l... kl •.Joh-J, -drc~• i f ~ J{lj, I 1 .0:~4~!/.w 11je-el-t :q
@. C,os uw\ ~ _kiittL \kur.x,pcik'1l'0 in ( C~
@ - -
J.\l.Cllu.t: 4-- 'fGUf@l\. lJ~ JtL-1oc\l2i\,.aot,.j 11
----
roMsut<l ly, C~ _(~ -------
_@ . Midi:£ c(t)'{fl it> t< ~ l ~ 't:rio,¥·®~--1s 8:r,J-gte tA
-@ \11,ed:: f*.:@. ,,,~fu c&~ulltk ci ~o'r,.,«dih.Jor: 1,ri v31'.

elf® q, tY® ¢, n:rull~ I11dr+1,r0 nvt9
Muhammad Yasir
u Gen.Surgery 2
Final Year Nuggets for MCQs · 11 November 2015 ·
View fu ll size · More options

8 Facebook •• •• ~ 9 4 :2 6 PM ~ 27% 1_ _ J
Cancel Final Year N ug ge ts for M C Q s
fcitl½tl -frp. Ct r\:al ...b. "Do'lf'rcth

@1ckxcal I J l t ..fuidure. ~r .l;
- lk!rl, (®\,illi.i,
@ r~ ~~ r,.lo\Jl!lll .alln tni,.,. ~
hw t at i;~ J',rM r:CStn,\b«'ll 1lMi-. Sor®tX1.

@ Ir ul~•:d:
@ -, ,, [) ~ ~ ~ : Is. ~ . ~l llO l. h - : ;
-\i..p--lc)'/uw.,_(1\l~h mJ~=es_ _
~
==--
-~~~wVl_cbo-c.-.~l~ u
6~ ~ _.J lb " d~ \)l e,
@ , Sw ~""'~ h:.,,,ro 1k \o:k:00..;. ¥ .~ ~ V L 1 lt )
® C.h_ &ii~c.zJ ~ ,b l)~ a«c'16, k ~ ~ df~l'3<c.

-\.~t:.. ~ t t..-~\im ~\ ,,tt:o
@) , ft1o± - ©•J:~V\ :Cu~J_ j, \<(Ib!\ l\"I 1
~ M uh am m ad Yasir
'U1 Gen.Surgery 3
mb er 20 15 .
Final Year Nu gg ets for MCQs · 11 No ve
View ful l size · Mo re op tio ns
a Facebook ··••O~ 4 :26 PM ~ 27% 1 •
-
~ l\ic. 2ccl.. cLScni:..
®+ Sou,-d.. lll!?f~ ~ -m. JJ\\fo•00td I:
@;. ~~ IA!cl. .c:ctb:o~ ~ h ltl'-l '
@- ~Lita ~ k _ ~ i ! i l . ~ ~ ~ ..&· ~ =
~~ - aM._woMe.11. 1,,1\&.. .O.e€~ ¥&,._ -!wctY1b:-r.h,
~i-,i\la)_ ~ t ~a:oo.:_
c,, . E~ ~~ oWLYIJiMl .M£11~~ ~!fit!~

~_o±ki_ • rlti\lo.l..l~ Ct~11:clr), !C~
®-l)clqdfio\ ~ ..tPrt arui %et ~ .eiefYllL

~ l)CJO -ukwbw ~ ce.l211ktu I1fllP1•oeu" . . fuE.....,.eo:--
@-jMtl~ J- c\y,\e h rBl'c\i:J.. htu\Ll\.~\'"i.. ~
@- foheve w\fu 0.>,r

_venoea. JYL-_lnl_~
..o.tl.
..o1i((\
<;k1w\\riMm1,
Jr,·r1»1,.,,,
\~ ~~
tr,-, ~lliW'..
@ Med coMCfl 0Cft11;::cd~ l ~ l

@-kfoW _ct'l N~A1D... , pte ~tlfe. ~90£1.lll1.._k1
_k'i!h. ~ C'~t 1 ••hl\u 2,l:t_dnif M:i:Otl' A.t l
~ Muhammad Yasir
,U, Gen.Surgery 4

a Facebook ··••O9' 4 :26 PM -f 26% I •
(½\ ,IA~ £l ~•, r .hfntl WJ clL. Li~ k,_ JIM, "1li
~ km: , l~ I\ llp .t
~ c~· oJol i I tr"

\Lil l ½
'\
I
,lll( 1
I
~ fil.l t'l ll'.lluho\'" \,
~ Muhammad Yasir
'U Gen.Surgery 5
Final Year Nuggets for MCQs · 11 November 2015 •

rt Facebook ··••O9 4 :26 PM ~ 26% 1 •
-fP-)- C~c.w,~ -4 trA o\R'it.u:.. ,..u,11irA ,c~CY°I ;.,.,

- UV'.ib((,~.iLJrl.cl c,~ ~ '5: :J,D.'t:
~ V
~ eet '\'f'n. k &\u1t;,a\J,,, J.. ~ ®F-
( ~'lie!. • Y.c4 ~ 'h_t.a ((dr,
@) t~~~i\:v:. ,1iJJ.clk. ():(~ mt.j; ~tle1l. ..uMetL
.~l!f.0. ~ i,ll~ .od.:.!.A/.aL !!f:. lJL~ 01 t.ilk
-G 1¾ ~ .(~;)a. ~et \n\~ ~)g_ s~~

€). ~ ~-a\u'nauoo ~ :r<ia~ar:e~i'o...?-J~~-
~ me. ~MQ ~wor,1e\l:CJJiJ.U11 ha-
- -
® fuM ~MCL'li --1n1~ ~ I L - -
~'c;-.f j~(1\tl'"4iMn:1.. _. toocl·K&s. ~
~ tt d~-- r4f~-~~ ~®es\w~o._ _ __
- ~ - dtv~-4- ..010\ce W. ~~-~b. G~.l\11.f.

_@ M<M. (DY)l)'.MY) 1/J, 4, Wuh c:R- s.ra\ ll)).~ ~ I J\£!Xol•
-€,· ~>'I -\\u,_ jk:,\ '1\h ~~ ) \{~ ~\ ~~

_.....,.... i i'6"- ~!,Sur:~~iau ~ (.\'l\c1. \/t'"-'_
_ -;,....--- -
~ Muhammad Yasir
'U Gen.Surgery 6

••••o Ufone ::a- 4 :26 PM -f 26% I •
'oda\c
... 1
' I\ \'{>J:1:it!w r ~- \ \
r\ I • ., \\ ,. \ I •
l\ r:lr,ls
I.• •( i;,00\ -. ,J\,;\I()!), ,
i. (lt1/11'.C:IS -
(n Mclnbli t -• ,\k<JMI.S-
~ Muhammad Yasir
'U1 Gen.Surgery 7
••••o Ufone ::a- 4 :27 PM -f 26% I •
@ ,. ... .1 u
(tr. ., I fV,L ,. I
~.\ ,J,
f,\••I
'·· Ml" rt
'
l -I p • iO
;\'~¥! .•
t, ,•• ~ cl, 1' ~-WU , rti
Gu. I! ui ~ ni'ctl..~ J 1:,.<t.o J. ~ft~. ~\'"

~ra. c~o.\'Klllo) \ Ja ~ hll;t.\.lMi '-'-t t'4'.h .!>. Jr·~} ciro.
~\ k,l ~"-\uhnlO'l. ~ ha•, ~ ~ 1'.\CO.\e... Is. ~$i:)'.)
llli ~l,tp- p•e;..,l'i!I. 1A ./:llllS. Cl\ i\•~ ~
~~(ntl W<ef,
~j x.f !AOVrr , dt,...,r.<t \lb ulol ·~st
@ ~00,~ er Ii k dtt:~~c.. ot f; cm.\ 1,¼ill_fuidcrt.
@f :liJ1~ ts £0\1 1b_ ~ ~e ~ '~) "-~'- ~ <.i
~ Muhammad Yasir
'lif1 Gen.Surgery 8
Final Year Nuggets for MCQs • 11 November 2015 •

••••o Ufone ::a- 4 :27 PM -f 26% I •
b'(&
'rr.rnal di. b:ai~~ M. \"' 1pretl w!n".m£trol dJsc.
I l lllt''t·\«I
l' ~ ~ \
e~ \11\' ~1lie1l
't\, l ~W\
t
\'
11•~\ Vt"' \ v)·I \,,
,•
61 (Q'l'IIT,\QV\!:tt <'?\l"CtY '\>\ \ ~'l'l'&O '-!:ill
~ co.~~ \J'no.\. Ilk& r , -f,NI\

1hr 0T Jl"\.'. fl\ \~
@ 1J.,dto,\ \'I'\. tes'Al. \.1<1rl~!l.,.\. t°'\1!!\'l la.~~ 'Oj (i f:/

~ f-l~t J,.~tl_ rmhl~~ 1'in C;,1o.r.. W.t~~(h'}. ill\\ t)
(§) ~lled. ~ >lie.. foll.YA II\ ~'0~1\ ccil C<h!lr-tiro
@). ~ t Cofl'.M~\. s1\:~ .n~ \\.:f1bo\~!c.. icms ] ~ ~}1,.J
@. ~rtt ve\-r. \t» (lf\:oW. ~ ~ ~ tfjl~, $i ~ !l.-aM. ~

-@ l%t (Qm,r,-,0~ ( Qalf 4-- .Ml~~'\: \?J°Ofl~()~~
?oro JlDI \O-~"\\\.o.\'l..n.
~ Muhammad Yasir
'1.11 Gen.Surgery 9
View full size · More options

••••o Ufone ::a- 4 :27 PM -1 26% I •
q_~ f'l\;.rut.\~«-. 1:1t,...~1i\\:. ~ rut flt>:!Oi?Cl 't:<

Oil (W~M 'j
~l'Y\) h\.d1Jtn\vn\ 1
'Jc1 t O.tP.J()\~M !l.. ""'\1r&_.-,_d_ v-/,,e'r\
h:w,,~..r<
~) \ t<:\: db.~· \Ti C( ,,1,..~,.a<~ ooi~;r.-. I

@ ~± (O '1' fill'\\ 'f>t"'I~ \1 t.' ~md Ol~tt
$JI\ \f!)~ C
~ \· .,Jt
~l ~s\: k \m.,,S '<!l.•v ,._iol\l~ cC. \_,-, \
® 111 .161
1
,,'().y\tE:1 \~1 ~ ll'a•,~' f, \

S-2 MCQs made simple

C
0
H
D
w
feMO""O I T,
l.ll int ... ~ ".illa,nine ,
~ L'J'.:,~, Qf" '3 ;t'\1"'\.C!: ,Ol ni\.hi~e. 0Y'Sp
)ysp
~one_s ? -:. c~s\o,ine
+o +1, , 1ve , fe v«-'r , e 1oo0 i"' n al)-~ , T<!l'\d,l "'4!1~
~O \!>Q\.cd " "e pl-t•ob\Q.S+om.::t ,

'li U.ine i nconl.; ,.,ent.e_ in l=eroalt ---. in Vt i\-i ~ c:i.h-d • C.~<;\:Qt\">tif.!{,
>I< M C ~ym p¼-rn 0 i;: e,10ddeY C.A o ~ei:r,Cll.l~'<- tQ .

i< 7~ y /.o , ~c.'r. ~alt-,, ('.ro.<3'3~ ?'os~\e. -:: M_e'\,q~.\,'c... -f>Y06\.ak C.A ·
Y ._~.,,, S "I,: c:A f"<OS.¼l.e- :. ~e.~ ~ ',,.e~Q\ ~ne..
,y ..1::i< :.C.tna.1 1,,1 'r, "°' ~j l'Y',f'Q+u, ofs.p \o.c.ed IY"> !je\J'Ol'J;¾ ~n
'il\ar,;; .., ""5.~iokcl ...,..,·1.1-i c..h<:>~de~ .
~ · IAYC..\-h<a\ vo.\ve. • "IO c.. • MC. u C::i.
It 1'/1 /o , 1tr i1<'.lbLl,L i ~ \I.IL. T~kJ.>lal" 6..u~\\1h9 c \ ~ 'l\~ :-~e;c 1
c:nlo.rqe_cl Ter.de_1- i'e':.-ti5 L't~c\ 1 ~m'ie,,o .ir_ n i_+1'1l,.es •
lcu¥-oc..t\\.cs 1n \.l'tlc:ie. :,. C.f"'d,c:l.~m~-<.)rc.h'1\.is.
~ Ha..i.½itr10\.o l'n~oiq i\.1·~ :,. ~-£'' 1\o.~ ~ c.~.
-.k.. Mc. f> re5..c.oltctlriol"l fli rc")A'.l ~ ~ "i', ti ~ Re.no.\ Su~-
~ E,c.u~ ieWC..U~"I' \<.\'4.'(>I'\ --.:0, S t.Ld.O.e.n e'lC--c..{UC. i0.~\.l""'J'.3
Te~·Ho.i.~o..r ~1 11 qnO ,e..nd..~~

<owe__\\tng.
-)( ~~m~?\.,:~ ~oeMtn,a -., M. C. ~0.\~o.ty ~ IC\_l"\d. w~
~ \o 'I l o , S"'le\\i"-<;i th nee. \c:: , °'e ~u,-9 ,\-o,\ldl-, ~1·~\o~ ~ ,
(o14t\.. •!Yl,?~~c -t>Je , 1' o.~~'r C!<i\.-~i • t>\-.a..,-y"'~Q..1

,"(' u c..'n i.-z.e.o ~ e. l 1s)
~ - ~u'totcjde. (YQl:.Y> • B? Si~· -...C\"l. J ?:. 1.10, Tro<:.bec:i.
de..'l~\ca , Y'.l.o l?.S. oY'> ~ ~ • ~ Ide ..,. 1 _,. nc._ec:\ le d ~~'tCM1'..
'7' \cmc\ "Tu.d•"l"(CAKI It:'-\ ~ µ~,?U'<o1@ro10. ~ Nc:i
on \.\ • C.'nes,- •
S.,.$ Ond. ~u\\ ~t>tC.U~'\~ v--e\.-~ CN- \..\.· '!.1~.e 4 rv\ CV)) ive
µa_t.mO~'t ~'( ,
il. c.x R • Mall t;JYN kt • 0....,- ~k.,.·J le.u~ • i ..c : M ~
r,o roo-1 ,.'_\n®'"j • t• ~ ~c, >.J , ~
{
.
vo +Q \-, , c,r., I
lnj uy '1 \-o ~ fi e x.1 ·or , +
* M cn ,-. .cu s du e.
q,x i MC
l
,-.,...,.;.c.l(?
* \ec ;.l on O. 'ri~ e 'l'- ,om S~ .
~~
e.('.\?ec.1.- ci._,1c1.t!"\ \.. eo .d ,l"t C.' t:.. , ,,.. ,n' <: ., \,m b~ •
Rho\x:lo,.,-,ya':A r(4 Mq .
fQ ''" _. , c\1"-.loco..-kc:1 .
" ~... ~~ ?l o. Ye t_ <;. ,..0 1.1 \de .r
on 1 , ~c.ht 'rn IC co n\. rc, c.. \.u ,e • <:...>~,c..c.e.~lo.\,
~ \/o \c m !.
µ. ~e \ I.IS ~ .. 0c ..\ .u \e .
~ 1~"~ ~' O" .:f h ur"J\\::. 11'<:. llS •
-+<. 4 'f /o =l te d'- >< ih 1e
1.t m' o\i co \ he ll nr<11
i( IC C. ~ m rY'-Ut t' ho i ~ -= ~oc..-hls C.Q4) ~
'if lm pe • rcr ..-o.k QY )U' o ~ di ,id ed ,,_'r.c, \.+•~h
t"U +- • eQ.\- •
I-Ii rsv- pt un9 • D )( \I'" \
el "'l em o. .
l~ A • Coloh_ic.. C.A ·
o~ \-1,'p
A ~n d1'c.,~1·s -" ' fe:,~ ~ e> <. kr ;~ '<S h
t•e "-r oc oe .co l)
Ye c:. ~ I (.f\ "? s ~ t . -- , ~h du l ur oih C\ \ us. <:i '(e_c_ l- ll. i"r\ .

"'
°'"'°-f
l--e. le. ir>'-'Ql"e.dl. f6"\ Sf> Y ~d .
* ~i IQr,c:ic;.t''i, ~
1'0 \I.
~ M i la , '1 ~f~Q..Gl~c. : ~m ,'l
;"-oo..- Q~ 'f~ !.ll :S h _. , Q c.. uk \j\"
W'\p~o.~'31·1-,s_ )
w \r,~ _e c~ d
+ c.,..J-lru...te 'C"cJ4... .
·1V\ use.& w / e'I.Ak- ~ Q )'
~ 1h< am pe .~ re .
" 11 er -c \lc .n bC .li °T e!.+- ~ ~~ ~~ ,Q
~~ Im ~ \.e lo w ,n' :!\ J ~ \ ) •~ q( YQ .Y )i
~ 'R.\. , ':) ru in \oh.)~!--i
1- e C..jsl--,c.. 4 Sc;>heno... \Jo..1-11 .
~
(: bi n- ') \eo.<i..\-
\p ( ~ h'\c,z.\ij \-o _
~ C..\.i..-oniL.. '- I'-
~f e' I 'r.,. B'\oc.'f.- / 'r) ~~" e.
c.0w1po-e.M • ~ (? )
__ ciJe...,':. ) r:ier-:> ~ . i'\C-l•'--•
~ Ph\0-9 fT) C.' :>' "" o-..\bo
I
t
.,. I"E.C.hemi'q o~ 1,·=b __,. lcic l:. o~ c('..~ec.-1- c've
'
C: i'l'c u \o_\.t:11 .
"' ~es I... pqlh a\.. l"\f 9nl. • f=oo.\- ,po,J'n ~ '-l: t ' •
pe•if>h~,o\ vci<..c.u l0r c\1'-;.l!'oS~.

So Y/o - J"'l,,.., 1'>101e o"' F<\- , ~<e 1-a
{ kh~ ,
'has doubled ,n '» 1'2.<? ii-,, \0~1-- (. "Y>O h!Ji'- + ei:, 1·'=>Cl de
o~ e.ieeditig =- S-f~rf-tc.1q \ ~~Y~Qd ~ M~k.f\411-TG>J.
~ , ,·b,ol Froc\-un? • f=,•rsl. f''" ,· n f>'<O;,. ~,r,c,\ ,,·b1'.:)\,

SeCev>d I cq"e ...,,..,... , "' M~d ,o \ \.. o
.\-1,,,c,u~\.,_ CC\
l qk.u::,J d,•re c~fG.11\ :;i.s c.m S..u,p. 1,-ov..,O,Yc.\<;l -r.. es

Clt u.:Q,':I ~r om I, e.e \ ~ C..ho.h&.e. ~ d.o, Y'r'I Q <:J e
cl~ pel'Ol\E'Cl \ ne , \lC2._ - ...-_.,
~
.....
.......
.....
....
....
•..
•-
..
• -------------,..=== I I
{:
I
2.o l;i . I
'-'?~.,. ,-e,I( , ~nc:1e:r ,l''r<>~YudtQ in'to am&~ k)\" A , Qi.\>°w·alr fol°1 .I
. 1'
Ya\lC-.l t ' I'"'" li l<.e ~\U(c:l ~ \!irClh<.hlQ\ <:.ye.Ir •
,., c~~~ o\Ta in ,r-.,ey~f<I" ~ '!i..-, 1.c.~ on\-&'rlO>- +a_ mJdsi1la't~ line . 3. Dys
• Acc. id t ~ - te,p . • l1+•t•• ..,, I..\ . C.',,es+ \)Qin , cl ,,i.enci&d Ch~ ,,l, CliY I. Dy,,,
t Ml':I on L~· s,-cla , ~~ 100 ,,~ , ~..~e \\C , 8~ 20/~I ~'ien,oJ'on

Pnt1.1trOl holQX' ,
1
• l.ln,ommd"I ~-.ea~ L...n~ d\: ~o.~n0.uc !1 'iivoch-arne .
'k MC "'M • ....-ttcl lasMnwm T ...mQ\ = n-.~~mQ/f\ell11:ilgc.nlt. .f~rr,q{1)
.._ ~11-e.!J'i =o.Q~cwn..!:l ,. ~iv,d.e ?e.c.\.o ra.\1'• ~not-.
'tk (~\:olilQrcom~ f h'GllodtS 11"1 @)'{eq~ ~ w (de I~~\ e.,t~IICIV' l'l~
Yim oi n<1tn-.::il ,,·ssl.le..

-11 ~rtrner,o~I w.ome.n ""' \~ o tsc.Yek ~~ ~ \1.1n;p •
,,.,,nisl-i l'j~llo- \: \'-41'.:l on O.~~,q1t,.-, + l'lO 'olood , \'t~
~l's~f)p8:ltS -, C.~~lt-/c. c:4t._CA~
~ • ~, Yl o- ,·,.i:1e1"'u\ o.reolQ , r.o ~m\\~ t+lo &rACt~ C~ , no ~,.~111014..,
.... b""~'-~ ~ro ~lami , i,a'raf,l~ 1.1 ltl'l! 1.tcai- ~ ,1,.60Jt- Q~ l.(nQt.r\~(""9
.... MQ'll'iL .. ~ti-4'rt... o~ ~1&,d'rit ~ ~'l'C~'e~ \l~~.
-. * fttj II~~~ l'Wf ~, ,o..,e.a ,~~'f(O'r ~o 'Te."~~ M.ino'r . ~ _
... ~ t)JC1..b&~' " \ol\t&.r Foolt- ....- No ie~~~ ➔ ~'~q~~ .
OI'\
~ru Clbdo tn 1 +o.O'l'::i~ti:lt'c__, h.~tc:1~1'1£ lv& 1 OL~!Je.nci(A:f
. . II'-
..
.. 9' ~ Q./._r,
i.n 11~'!'
l'\tu. 11t-tn~ , ~ ,,._ &01.1~,
11"' tc:tl{ '- ~ti.,.., F 1'l"S~
Ql~~Cl.lll- "6_ ~~A.~ •
®I.a. \-o ~~\le a,c ~rd-. 1 n•.w onl~
"t
ic.o.rO(Ql "VtrnfOM.£\e .
• 60 ~cu·cil~ " lr,le,l'l'\i~"~ Cl•i.ldi~li-(oi, .

• 'y# tro~~$~ ~mth• o;. \..ol"I, e°"'e A Sf 'P"~~ IS •
• ii r,o,~ll'(e 41h'~w, yQcli~ w/ c:l (,1"11 ~.\-1'01"1 ~ i l"\~\'loY Y~ro.•
• W.-.c:a'r
• ~ ?oi\-c.:CfOY
J'p1'n._ :. Colle '.5
~1,loco.\.,'on •~ 14 ~-p ~ C\tlle.~ e ~ec:,1
: l(~e>-iO,... '" &P-. \.l \ I~ ~,uW~ ,
•_____________________r!im
'll)at c:
.
"' c,c..s ~ ~, ve~ Ji-a o.••es, o~C'.olll£ c,.riol ~yo~ ~~ts. rh Q.
pl- • .... i\.h ~ inj'-'Y~ .
iL' ~~he~"°""'Y • c,~r, ~oc:e..:lu.'<"e. , invo\~ts ,ll~ i'So\4n o1 ~vofd
i S¼-nmu1i Clnd '1&.t~lcoJ ~nc.,'s lon ~/u.i. 1{' - ,~ ,;Q<.nea.l
.,, 1... ~ .
-°'f MC rno,. 1!5nQl'l'!:j ol!- bone. :. os NeO (.Qi',omQ .
-+ t-euri 1n p,~. 1-,~t-tl ....\--,ilc ....,,-;i 1n!:I , ~11,.., } Lc. ~ ocl~I~ o.., po~.,_ ,
qc.~e c:.1- o ~ u.t is~ -:, Gi~"'a\l"'~-
..., A pi,~on ~q\1$ 0;er,cl~ ove«- Cjl')<:'t\.ern\c.o. f s" I I ~
n ~ . 14qtic:l I
b0.1- • )( - -.-°''4 • ~ re,.~,~ • ~ 1 _,. gcq~'r'tClfc:l .

'<¥ Ale.A ho_lrc - 111-, \:,in Cl& q\lMing - Vair,(~ fr"ICJ CIC C:f'S( 11,c..\~ - $1.1~ tc.c. I
c.rn~\.-i':i SQ.~ •~ n&.~ __. 9ot.'ChQQ~ 1& SyrA,~~
..i,, ~kme!?.ls of !='rt.I-I ~Jc:.~, ~ i~~+,, fC ~ i" 1 ~ CII.\Ci.~ , !Joi,,~ln':1,
f>- 1<>9. 1 ~I' ll o / \o ~c.x R.a.u- ~clcu c!. 1'q ~~..II)
.,'1~tt.d /pe~ ~TQ~~ ~?~c. ~,~ .. '
1t 01. Fe~\'Qfe tn ~ ~~t.d ,·n ' @>~¼\' '-A'·
,Jr \j~ e_y ~op~y c.11 i '~c~cl,-eo ~rr,w1e/arrci '
'K ~(c.tct•n~ , \.IJ~ ~.nc\~ti,e•, •~t ~bdo'f't'ltn, ,.QCb~ CA/"di'CI , .
hi;~n• r~, I),:.L. • ~loccl S+a~.., R-.p_h u:ec:l SjS,~n .
)t (1'fcrn.lilc "'~pet~r~l~i, ~o'rl, Eitenosl', • 'Jotni~ll") 8 S4o.Y~ a.~
a•
It w I(,'.
·~ Al cahel1•~ • c,,•i~~~"- lic.r-c\.tt~ -4 ht._m~~ (_~e,'n +
C.01> lo~~) - ~11\t_t. \10 &~ 10 •/~o • Vo..~ I iCe'-) ~ (j)
"'!""41• -it po•+ t.p~~re.c.-1-on,y • ~\ee.l'\tc.~my SC!f>''' f)t..~rn-i«:l ~(Jr
---• 'l-e.1l"ICll~t·'-oJ. "~~ 1n o.. 1:1oun9 ~e

u ,, NO't f\'\a_ l b ;,. cor,..~ t'/\$ !)r\OC ~G \,·pre! .
1-' * "11 'I Jo • Ru~ ~n ~ ~ \p,ct'olc. ~'r MOSS + r-e11eJ.
.,
~ - .. bnpj~l'I\ C\ Gi ~ .
--
1
" Ac.ul.e. ~a..,.vlQ!I\I~ .... Mod i\:lc-4 C- 105'3°"" C:.vi-lftf ~ • (:il'-ICO~ .
lit Jo.-.nd(u, W4• 1of.a , P«t!'4'blt. ~e. 11"1 ~UQ , 'tBill ru\) (n, ,1' AL.e '
....,.icl":i ~ !11,i -4 C.CI. µc..d of ~Yeci$ . 8. Oyspt
0 l Ovspl
..,_ ~ 1"'9
•eA\-\n3 l)'l'1CIJ~th:i~"m, ~., l>'l!o\.l~\., l"l !ll- ~
c
~ I " ~II <~) T-...o cl,,._ ,e'-~~11+- have b~~ no~d,
Qld dl'QE' ~ !)e\'~
~ ~WY'OOf'C"l'll-ol'\c11m .,,. To.chYCAYcl 1Q .
., lt y/o , c. 1rc.ull"C)t o.l p1ia~n',c,,\.tcw. , f'o\1 ~ ''C' £o\Qh • ~ctmQv"tomC( $ .
"'- MI , Lf#> clct~ _ Ab~ol'\11'/'A I ~ 11"1 , .i.. ~p 1 $ i..,,, ,~h bci1.o1,el IY'IQII •,
S~ool +•L i:-- a tood ,. ~~n I-ct i C. \sc.Mm~ -
~~- ~mi co le c.4arny • V 00,1-u,....:4 + A-~dovfi \'\~ .L.:s~\.1'4:11,.,\ -+
No ~~ • f'q'l"q\Yt•· c. t: \~~
,It 4 Mon~ o\Q , .;iti l-1~4r l't/O f;~ ®.l"O:t l"IO.\ •
,i@jE B A.\' ~~~t'Q'fl
"'""" 1'4 rng , ~I:- 'D\oo~ ?cs ~c:.~~ :::_ 'In\.<.I "'-lt.c:...p~•·c),J
/Jr l.lrekYo,t61'()0(do5\omy ) Me~l00 ,,~ ~c. ~Si'-.
I( Oye ,,,dij'-~'~ + ~MGN\' IQ • T'!O.nAt'~ro,,Q\ lell r..imc;:ir e1~
...._ StQ.dole• ,
~ ~ _H,.ne~ ~ n ---+ tio.u~~, \otl"I ~ ii"\ , 9'4ll"l~u\ rv,t(.~r i -Hon, _.
... FL11s\ocQ_ 1 ,ti'ldlZr if"\ A.It · L.o\'I•, , ~~'ffl.~~'or, i'~~ ~114M • U'T~
... ,t 1:)11\- 111~ ,~~~ -~ S,tvQ~U.l4t~ ~l\[t'.I , ~QC C)~"L<d
... T,:,y ..~ At- ~ ~ 1 , ~ l)S .
,. #I U>t,c. C\c..id ~1-cr1e ~ (..o..l,)~ • Tho.-z.\&. c::\il.)Ye.\-rcs.
,. ""~i~'~ i-< •'~\e.. p\\os.~~ -
c._.,,.\c:u\ i' •
• .._ iq 1/0 1'!1(:11"1 _ Peiin ~1f -I" f=lc. \ f>"''de '<ecil.ut-lb)IIL m4S~ 1
• W t : t ~ ~ ~ ) ' C:U, ~,w.ll ~ __,.o.fre.CA-- !'f'\,l.( ine,.Q

• ~Y1 1't>.
,
• ft 0$:.½t121'r-SY(?'(ron ~1't"l'\4.Ji-a ~ ~\~AJ.. ~ -
••
l21 I
o,.
l)y .
•I, n
o,,,
• C.ltcav- e,\,'a r, hcQ
1
lqrie Sertlle pol j f • Vitlous O\c::lenotrA Mo,
* ~ C..\-a\ CA ~o.9i~ • YI! Ch=<\ e,-)ciO!'.O"'°t°~~ , Tx I
• .l'i "f i e ""an , ~ d.c,y 1110 Tendei- s.....eli1~ 'il'l "~~I <l<ef~ 8 l>y,ph,
o , , ... 1 M ,·..ii,nc pili-5 ....·,Ith i::.1,.,c~uCII')\ ~,·tll/!'lS' 1"Q ~\. · 8-ov,oh•
o~ l"IC!~I C::14~4 _. p c ~io.nq\ ab-S.«-'.U

~ ~PIPc.....,le~ • lo ~y~ lo.~~ • 'Tem?, 1iwil'l3 .. '\ ~ ~C. ~i.a~
~ ,;,e-s i"°"H-,·~ ... CA.Aise.~ • ~~tc:: ~<~ .
• ~Srt . ~flt~1-G1 -...~~ ""~\itt'd b'::i _. ,~~<c c.vs~~in
;c .le l'Y\Cth'C' i Q ~ c~~ o~ M It.~ , A~ ~ ~ QOQ,t.Y' \c.1~l' ,
~ \.lr, ,St.'(Otc.lM ~~ ~ C..4:!\..o~c.\-\,~• S.M • - -
ltC 1l. Y/o , we~ lo- \lt/o ~i,. · ~icl.eA ~~ ~o\-Q\ ~w&l\ing ,
1
...,. ~ F(~.... 'o~ \ ll't.~Y , ~ \\(~ o-,..~,t. ~ Si.L..~Ntr\ I
--,. ~l\-lcu.lAI ~~'°'"'~ )

T&1>\-1u.Jo..- Tu.AM~ .
... ~ ~\~ ~~~. ) (('M+-i,,.. C.Wl4- c...l\~~o.t- w:».\le.
~ ~ ~ ~~ ½ 'Alolcl«.t
._ ,, 4o 'I/O - ~~6 >"elu,s - '~\.ewd..: '\ - ~~~~~
9 O~t.-v: A..
•* M~ N l!A... 1 luwt i'II ~'Y Yo1·~ -c4 l't:l,f{l\-.eA- , ~ Q i ~ . _
t Toln:::..l ~y'°"·~ ~ ,. ....w~ '-"~ • M~,, l l ~~
It 'llC ~C:.VQ...Uv.V\~ +OY- c..A ~~ •
~'('C:.t \.Q~ a O
• *,6 v ,6 _ MAJ~ -L\JiS __ e.M\a...tr 'oiAJdt..1 -1o..i.¥
: Sk~ Si.4J. \ ~ 1 4 , \ • f'(MSJ-e.~ l ~p ~ •
I
______________________(
~ =! , a" m
A must do as it contains classic scenarios that may appear in exam
Bailey EMQs made simple

(Both upper and lower git)
ANUS ANDANAL CANAL
Choose and matth the torrect diagnos~ with each or the scenarios given below:
I A68-year-old male presents with bright red painless bleeding. He has an as-sociated history ol
recent change in bowels and a sensation of inromplete defaec,ition. RECTAL CARCINOMA
2 A32-year-old female romplains ol fresh blood per rectum and some discomfo,t following a
recent pr~ancy. She mentions a tendency towards constipation. HEMMORRHOIDS
3 A28-year-old male is referred with a history of severe anal pain associated with defaecation. He
also has s1reaks of fresh blood per ree1um. He has a long histo,y of hard stools and straining. ANAL FISSURE
4 An 82-year-old male who has had three previous myocarcfial infarctions and a recent
abdominal aortic aneurysm (MA) repa~ complains of abdominal pain and darkish rectal
bleeding. lschaemic colitis
D: 90-year-old female with a long history oftonstipation r.,~bred to the hospital with lower
abdominal pain on and off and painless dart< blood pe., :ectunn. Diverticulitis
6 An 18-year-old student who has just returnP.d fro,1; travelling in his gap year presenlS with
bloody diarrhoea and tolicky abdomin,I~ ir.. Infective colitis
7 A24-year-old female presents witi; a 6-month history of diarrhoea along 1,i\h blood and
mucus. She has lost a stone in weight She= that her mother has also had chronic bov.>el
problems and presently has a stoma. Ulcerative colitis
8 A: 3()-year-old r,.a:~ presents with a 2-week history ofsevere tenesmus and fresh blood per
rectum. Ke ~ known to be HIV-positive.
Proctitis
ANAL CANAL
Choose and match the correct investigations with each of the scenarios give.n below:
I A 70-year--Old male is referred with a histo,y of recent change in bowels and weight los~ Colonoscopy
2 A 36-year-old male is referred with a history or recurrent anal listulae needing several
operation~ (MRI)
3 A 26-year-old female is referred with fresh blood per rectum followi11g a recent pregnancy. Her
bowels are n°'mal and she has no abdominal symptom~ Rigid sigmoidoscopy
4 A28-year-old male presents v,ilh severe anal pain persisting despite local medic.itions. Clinical Examinat ion unde r
el<ilmination reveals anal sphincter spasm and hence funher exarr,i11~:ion is not possible. anaesthesia
5 A 58-year-old female presents with urge incontinence prc~rt!'.::,:vety getting worse r,;er the last
2 years. She has had a perinea! tear during a previou, <i,:livery several yeari ago.
Anorectal physiology
6 A 65-year-old male is referred with histo,y o! ~ irrnp in the anus. E>aminatioo reveals a 1.5 cm
hard lump at lhe anal verge. Biopsy
7 A 30-year-old male presents 11ilh history or dart-coloured rec1al bleeding associated wilh
diarrhoea and left-sided ab<lominal pain.
Flexible
sigmoidoscopy
ANAL CANAL
Choose and match the correct ooeration with each or the conditions given below:
1 Rectal prolapse Altemeier's procedure
2 Primary treaunent of anal f1SSUre Glyceryl trinitr e
3 Anal polyp Excision biopsy
4 Anal fissure resistant to medical thetapy Lateral in rnal sphincterotom y
S High anal fistula Lay open / seton insertion
6 Grade 3 piles Stapled anopexy
ANAL CANAL
Choose and match the correct diagnos~ with each of the descriptions given below:
I This is essentially due to failure of supports of the rectum usually compounded by strainin& Rectal prolapse
2 The most common cause is an ocrult obstetric sphincter injlJI'/. Urge incontinence
3 AIN and HPV infection virus can predispose to thi~ Anal sec
4 This is usually caused by the failure ol relaxation of the puborecu 1;1 muscle during defaecation. Anis mus
5 This is evidence of straining during defaecation v,ith an in,,~rnal intussusception in most cases. Solitary rectal ulcer syndrome
6 This is caused by a hypertonic anal sphincter •·iL\ resultant mucosa! ischaemia. Anal fissure
7 This is associated with dilatation and prolapse of the anal vascular rushions usually due to
strainin& Haemorrhoids
8 The cause is usually cryptogc11;c and associated with sepsis in the terminal pan of the anal
glaod~ Alldl fistula
rectum
Cilai®sie anti match diie ·foltowing diagnoS<is wilir. ea iI:h cf tile·seenarl o<S g;rven t.ie1ow
1 A 4~',--e.:ir-old male c0mpl ains (J)f 1 muoous dis:cr.a:rge fr,nnm lll"le- re mum far several rrnonths.
IRerenltif llhis has.l:iecome prafiLtSe- .and has. IT'l!ade lh iliLI ·Eeel vef!,' 'lve.ak On ,examination Ile has.
lost. some 'IY.eigi'lt .and on r,ec:ta'I e,:anninatioc, lher,e is a f.ror:icied Iarge 8ro wth that is. p.i~ble.
He has .a serum 1poraS&ium of 2 2 mmolj L Villous adenoma-PROFUSE MUCOID DISCHARGE RICH IN k
2 A 35-'\•e.ar-old male ca:impl ains (J)f lb leeding ·per !fem um .a-nd cenesflil l.i!'i. Oil e:xamina00<n ltier~ is
1nod'ling t,o 1indl in the abdo_rnen. 0 11 reaal iexamiAcMion, <'I lk:shy nna. 1i.s. ie1t in the 1mid-reaum.
On sigmotdosctli,p-y lhere- is a mass v.ilih, a:r1 ulcerated s.urfax.e. A bicipsy has been take 11. A ~"ea r
a;go he retumed to Bliitain after lrnn11 in 11,e F&r tt'asit fot .a fe.v ye.3rs Amoebic granuloma
or
3 A 5mu;•e.3r-olC!I female oom;plains; l)l~ di ng from the 1rooum ~ 11'.li:ate-d wi th defaeaitriorL
During :a rnotio11 stie-pa~ llatus, m ucus.and bood ari d very !il'JJE·fi~ea.-'I rnaUN. Gn,if'M al
era m.ination tl1 ere iis bloollll on th,e fing,e r; :s.igrnoldosrnpy shov.,,;. inflamed r,ecta1 muoosa lllfl lo
a;boot 15 cm m~ithout any ulcera;ti011_
Proct itis
4 A 4u,;•ear-old r-emale com;p,La:ins al ree1al b'leeding and pass.age ,}1 murui. tor se,.,era1 mont11:s
\'ffllh o cra:sional iricootinsnce_ Du.ri11g this limie stie lh-3s lb.em cqisri,p,ated andl rfeels a lump
1p,otru cli11g: fr,oon her anu:s v.•hicn she can reduo.e: herselfi. l.,r, examin;alio:n she has a parti_al r;ectal
[Pr 0~21 pse. 10 n si~moidoseapy at a bwl 7•0 o(ffl, di ere ;s. an u leer o:n 11:hie at11 terior wa•. A bill)psy I-es
!been tale 11. Solitary rectal ulcer
5 A 55'·\•e-;ar -o1d female ,m mpl.iitis ,of a luimliJ i:r~biud ing tmf'll het an us fo:r alm'OOI: liJi rmo11Chs.. SJie,
lha:s to r.wusth the mum(l) ,bad Bl ut [1 r.:iap~21rs ,'M'h eri :she [P,,ISSes: a lll'IOtio n,. oni examination stie
Illas .a 5 cm IE'fl gd, of rectum OLll:sid e fllhe ,i3nus, a11dl wh en il is; pu:s.he:cll baa: k ilt red uc.es 'I.Yith1ai
gurgle:. Rectal prolapse
6 A 55-'l'e.ar-old m al:e c.o ~!-'1.:iins Glf ea rty mo:rni ng di.aJrrti oe.i for the l-:1s1: 4! 1111 o nths. lie has. urtienc.y
01 defaec.alioo ar,d <'I f~ ling of insa:rfficiem e'M'acw t ion of ll'ii!i reaum with tenesrinus_IHe p,asse:s
lbtood and mua J ~' Jn his :stools. Ow'I abdominal oexa iimination lh.-.e hi:as il'lc:lenmll>Ie mi'iSSe:s in his; IEl't
1iloc fo:.sa. Ci.~ ~eelal examin~tion there is ,c} hard indurated l'll8SS wh k.h ira:n be seen at .a. <ni) con
sig,rn-oi d''t,~py. A bic:)psy has lbeen lilken. Carcinoma of rectum
APPENDIX
Choose and match the correct diagnoses with each of the scenarios given below:
1 A 25-year-old female complains of sei.-ere pain in her certra1 lower abdomen of 4 h duration.
It started with some initial discomfort around her suprapubic area. She feels faint and is v,ry
thirsty. She is not sure abou1 her last menstrual period and is on the oral cootraceptr<e pill
(OCP). On examination she is in agony, looks pale and is cold, clammy and s"""l'f• She is
apyrexial and has marked tenderness, rigidity and rebound teodemess over her entire lo\'I«
abdomen. She has some discoloration around her umbilicus. Ruptured ectopic pregnancy
2 A 35-year-old female complains of colidy pain in the right iliac fossa for the last 6 h. In
between the attad:s she is left with a dull ache. She has vomited a few times and feels feverish.
Inthe past she has had diarrhoea on and off for almost a ~ar. On e,camination she has a
temperature of 38'C, is in discomfort from her pain and has tenderness. rigidity and minimal
rebound tendaness in the right aiac Iossa. Crohn' s disease
3 A 40-year-old male complains of pain in his right liac Iossa aver the last 2 days. His pain in
the right iliac Iossa was prece<le<I by a bout of sudden-onset severe epigastric and right 14>P"
quadrant pain 3 days ago that la~ed for a few hour. This innial pain subsided with some
antacids which he has been taking on and off for 'indigestion' for almost 18 months. On
examination he is pyre>ial (39°Q and very tender and rigid over the right iliac Iossa. Pe rfo rated pe
4 An t8-year-old female complains of generalised colicky abdominal pain for abou1 6 h. She fee~
or
unweD, has vomned a couple times and is anorexi~ The pain has shifted to the right liac
Iossa. On examination she has pyrexia of 38'C, is tender over the right iliac Iossa \\ith rigidity
and has rebound tenderness. Acute appendicitis
S A 28-year-old female complains of sudden onset of severe right-sid,d ab.bs;,1al pain ~hich he
is unable to loca,se. He is in agony, writhing around and cannot '2'ld :, lJ!Tifortable position in
v.ti.ich to get arr( relief from his pain. Hehas some strangury. ·~'11 ,>!;.•mination he is tender all
over the right side of his abdomenwith some rigjd.ity •1A..' ~ ri."()uund. On perOJSsion trere is a
tympanitic note. Right ureteric ~,~Ii.
6 A22--iear-old female patient complains ol pain in the right iliac fossa. The pain ~rted
:-,a..'-!nly and has spread all o.-er the lower abdomen. Her last menstrual period was 2 weeks
5
i
,,go. On wmination she lool:s slightly pale, apyrexial and is tender \\ith rigidity and rebound
tenderness in the right !iac Iossa. Mittelschmerz ..t
7 A60-(ear-old male patient complains of pain in his right iliac fossa or 24 h duration. The pain i
has been cons1antly in the right iliac fassa. He has felt unwel for a few months, being unduly
shon of breath during his normal actilities. On examination he looks pale and is tender \\ith
rigidity and rebound tenderness in the right !iac fossa.
Carcinoma of caecum "'
• PALE DUE TO ANEMIA!! ~
I
A I •
INTESTINAL OBSTRUCTION
Choose and match the correct diagnosis with each of the scenarios given below:
A70-year-old male is brought to the A&E with a listO!)' of abdominal pain. distension and
absolute oonstipation. He had noticed increasing constipation over the ~st 3 months and had
lost a ~one in weight Clinical examination re\-eafs a tense and tympanic abdomen. Abdominal
X~;/f shows a c!Aated caecum and pra<im~ colon up to the splenic lle,ure. Primary colonic tumo
2 A 42-year-old female presenrs with a 4-<lay histOJY of abdominal pain. cfstension and vomiting.
She had an operation for an ovarian malignancy 2 years ago and has recently received
chemotherapy. Recurrence of malignancy
3 A :Ill-year-old male presents ~•h on-and-olf abdominal pain and vomiting o,.r the previous
weel He has been managing to pass small amount of stools occasionaUy. He has been
admitted to lhe hospital four times with similar symptoms aher his laparOlomy for a perforated
appendix S years ago.
Adhesions
4 An 86-year-old female presenrs wilh increasing aboominal distension and vomiting for lhe past
3 days. Abdominal examination reveals signs of small-bol,.i obstruction. A 2 cm tender and
irreducible lump is palpable over the medial aspect of her right g(Oin I d I .
Strnngu ate ext erna hernia
5 A 90·','ear-old demented female has been bro~ t ~om her "'"'"'t :t0me. Her carer says lhat
she seems to have abdominal dscomfort She has beffl ha ;,Tl~ Jiarrhoea and incontinence for
seve<al days. Ginical examination r....,.ls a cfistend..t t:oomen with multiple palpable masses
in her colon. Pe< rectal examination reveals that~-• r.aum is fuD of soft stools. Faecal impaction
6 A t0-year-o1d boy is brought 1o the h"'!>~ Y<!.h recurrent episodes of abdominal pain ever
since he was young. This episode hac; bt'!n more severe and associated with vomiting and
abdominal distension. Chest X-r~y 1a 1eals dextrocardia . I I .
Congemta ma rotation
7 You are called to see a 70-year-old man ~t.o underwent coronary artery b\'l)aSS graft {CABG)
2 weeks previously. He has not opened his bol,.is for more than a week and has developed
massive abdo:oi.ial distension Clinically the abdomen is very di&ended and tympanic. Bowel
sound< ae -1usenl Abdominal X~ey reveals massively cllated large bowel up to lhe rectum
~~ n,allt-off. Pseudo obstruction
8 A68..,...r-old fernale with chronic constipation is brought with a history of rapid distension of
lhe abdomen and constipation. She has had praious simi~r episodes ~tlich have been treated
conserwtii.•cly. Abdominal X·riff re...eals 'coffee bean' sign.
Sigmoid volvulus
.,.. o! ™
2 Bcw,'el perforation
3 lntussusception
4 Sigmoid volvulu.s
Choose and match the correct interven~on v.ith each of the diagnoses below:
1 Sigmoid i.ooulus : Flatus 1ube insertion
2 Irreducible inguinal hernia Urgent e,p!oranon
'
3 Obstructing left colonic carciooma Colonic ste'11ing
4 Adlieli\•e small-bcw,~I obstruction
. .
Trial v,ith conservative maragement
S Faecal impaction Manual disunoact1on
···-· ·-:;,- ···- ··· -
SMALL ANO LARGE INTESTINES
Choose and match the rorred diagnoses with each of the S<enarios giv,n below. E
"
1 A 60-year-old woman complains of feeling tired while doing her usual household \\OO. Ol'ef
the la~ 3 months. She has been short of breath climbing one flight of ~irs at home. Her Glronoma ol the caecum
haemoglobin is 8.5 &'L Abdominal examination revea~ a mob!e mass in the right iliac fassa.
2 A 45-year-<>ld male patient complains of diarrhoea with mucus and blood. He has three 10
foursuch motions a day, 'Mlich are associated v-.fth <ldl aching in his lower abdomen. He has- Ukera-tive colitis
had these symptoms for !he past 4 months dlling ""1ich time he has lost about IO pounds
inwaght Abdommal examination reveals some vague tenderness. Rectal examination sho-1>~
blood and mucus, and sigmoidoscopy shows hyperaemic mucosa, ~hich bleeds easily.
3 A 60-year-old male patient complains of frequency ol micturition, discomfort while passing
urine which is very fou1 smeOing aOO sometimes contaiM brown material On questioning re Diverticular disease
admits to passing air bubbles in his urine and recently has been con~1liJa?ed. Clo examination
of his abdomen there is nothing to find Urine examination '''""" heavy growth of E coli.
4 A55-year-<>ld male has presented as an emergency ',\01, 0,1 arute perianal abscess. He has had
frequent loose motions occasionally mixed ~ith •'ood on and off for many months. He also Ctohn's disease
suffers from colicky abdominal pain. He has a feeling of heavines.s in his right iliac fossa. On
examination he has an acute perianaJ abscess aOO a mass in the right iJiac fossa.
5 A70,,year-o\d man complains cf :..oitstlpation for 4 months. He has to 1a.ke increasing amourv.s
of laxatives to h3\oe a bow,:aoiion. FoUowing a ba••I acion, he is left ~•h a feeling of C.rcioom• of the descending colon
insufficient evacuatior•. On straining at stools. he passes blood from his anus. On examination
there is nothifl<: •o :iid except some evid,nce of weight loss. as seen by his loose tro.,;ei;
requiring .>r: ~ tra notch in his beh.
0
• _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Cmose and mat<h the correct clagnosis mlh each of the scenarios P-en below:
I A65","Mf-old man comp1ains of irtense ildiing and jiurxlice of 6 weels' durati:11\ He fl.is
I.W(.'f abdomml discorrdoo and has notud of late !hat his urwle is deep yellow in cotii. Cartinomaof the bead of tne pancren
and his g,~ are pale. He has some ....-eight bss. 0, er.amire'i:>n he is deept, ~n<ked 'i\it.i
scr~di malts all wet tiis body; abdoninal e.x.ariiation tevei!k a gl00Ula1lisae.te mass in the
rii.fit upper qua<l'dnl
2 A k).ye111-old bott' prl'Senl'i Wti uppet abdomnal pain of 2....ffl'S' dura!ion. This is associate:!
wilh upper .i>dominal di~ensioo, nauSM, in1ermitten! \t1miting &id some "'•t loss, whih
he ptjS cb,n to his: loss ci appetie. 0, abdominal exami~iCWI he looki oowel, wilh a PseudO()~Iof the pancreas
~ mass SI his epig,istrilm whih is tense and d015 nol 1110\~ \,11h ,esl)rati:lll. There is
lmiising owr tie slin of lhe e ~iooi and,. "hen questioned about i he says ii yes 1he
resu~ of his falliwig off his bike and lhe ha11dleb!r Slicking into his lummy.
J A45_,,udi woman. Ylflo is oo lhe~g list ford laparoscq,ic cholecystedomy, presents as
an emergency ~h sewre epig,istric: pain r,1diating to !ht back and the rest cl l!'.e abdomen of
3 h duratiol\ She has nausea, fl.ts 110m~ed a few tines and has retdii& 1Jn examnation she kule parmeatitis
isladiypnoeic. has tadiyc«dia 411d 4 bbxj psessu1e of Il(V60 n.-ll!1&- She is sliglit,, ictf'OC
ftbdominal exarnin.1.ion fe"•'t.ats a CtA!n's S9), exlrem! lend >rn,ss all 0\•er the abdomen Wfti
rebouOO and rigidify.
4 Ass..,udl man mmplains of iriermittent jaL·~ici: associated wilh itching. This 6 dSSOOdted
wth dncwre-xia, we~1t loss and l4lP'f abcbnir,111discomlort On examiM!ion the patient is 1eriamptAlry c.arc:inoma
anaemic, has set.Itch r'l'WIRS °'"'
his body, is ~at,, jal.fldiced aid has a gall bladder thal is
jist "''"'bl,.
5 ASO-)'tar-okl male pdlio?:t r1l'Sen1S 'i\11h 0011 aching p,wl St his epig.astri.im and t.m>ilic.al areas
radiati,g to die bat.,. i."c ihe last 6 months. He has ep~ of E'Xlla!lbabOn of lhis pain \Ulidi
Im for a dav ',r ~:.o. This is associated di nausea and occasi:inal YOn'li!ing and ciarrhw CJ.or« panaei!titis
n'lCQ d.v:. :--.~ has lost some weight 0'lef this period. Two moolhs ago he was diagrit6ed
w~h 1.1\.'t 2 diabetes ¥id is on cnl medic.a!ion. He adrri;s to nXlfe than .r.~rage akohol
,'t."hllnptia,. Ci\iail e,:·,millMie(i ShcM"$1'1t'i atwi:orrm:lfy ~!pl kw ~is?d ~ i
GALL BLADDER AND BILE DUCTS
Choose and match lhe cone.ct dagnosis Ylilh each of lhe scenarios gh-en below:
I A30-yea:-dd lem.1le p:esents \\llh., 2-<iay IE!ory or constant pai, OYer the rigl1 upper
q.1act«1t (RUQ} as.socialed \\ith VOl'lllDng, She 6 febrile vih apmii:;.-e Mt.rpl'r(s sign.
2 A S6-)'ear«I malep,esetn 'Mth aweek-long history of se.'e'e upper .i>dom~1al pail. He
is my oowdl 'Mlh spiting fe-.u . He has sigr,s of rigli upper quadrant peri!ooism with oo Em~-ema of lhe gall bladder
imeit,;ng. \'c!gud,palpaWe, t.ender limp. Blood testuM<'ll a n ~ white at toolll.
3 A60-)'eai-dd ITll!le preseiws v,lh a 6 h hislOty of severe and constant generalised abdonital
C11I blooder perfora60,vbili111v perf.ooitis
pail. On examina!ion he is wry urwd aOO in shock. l'he abdomen is disteOOOO wtfi
generalised guardiig and rebourd tendsness.
4 A38-yeaf~ female presents "llh a 6 h history or colid:y .,1x10111inal p,wl 011er the RUQ. this
radiates to lhe b«:k and right shoulder. On examina!ioo she 6 aftlxile v.ih i :;o!: abdomen.
S A40-year-dd ft'l'll,E bei11g •es.ed fc. acute dioleq,stitis is obseN~ t~ :.a-.~ a noll-leilder
p,1\)al:.! g4 bttdde1. She is afd>file a,d systemically ,,.,4 '.;al bl,,dder mucocele
6 AJS.year~d female v.ith knoml gaistolWS t01 se-.ml )~""··pesMIS ,,,i}i te1trdl tolidy
abdomiM pain «id vomiting, ~e hM '50 been amtip,ted for the past few days. CJriiul Calstor.e ileus
er.amirefun 1'\-eais a ~ abdomen with iootased bowl'! sounch.
7 A4.2-year4d mtsle presenb wth a Str..:len ol&'l ot severe e~ic. pain r.)(!iating IO !tie back. P..incrmilii
This is a~ ated wilh repeated '°"ling aOO retdiing, tie is ,,ery unromforlable and in shod..
Cfriical e:•c1rnin111io:! 1evei!II~~\Y,Jt!f abdominal te00emes5 "itJi scme gwrding.
8 A601yea1-dd male , ,t.'krts with a hi~ory cd epfaodic abdominal p,IISI, ~nd"ce and lever 'Mth Cholangilis
!hills.
fypes of bilia,y stones
They are USt.l?I( sciiaiy and p,ale and O\'Oid in appear~1ce. Obesity, hi&fl<ak::tt diets and Cholesteu::f stones
crrtain meditations iooease tne risk or these r.ooes.
'. Bie: ~s and intetted bilt predispose to lhese stones. fllis ~one l'orrMtion is rel&ed to Bro\\n pigment stool'S
decol'f,lgation of ~inlJin digloo.ironide by bacteria. These-are also associate:! wAh the
preseoce o f ~ oodies SWl as er1doptosthl'Sis 01 parasites.
These are the commonest variety aixl are usu,dly nwltiyle «id faceted. lhey have a aystaline Mixed Slones
strudtl'e on aoss-s«tion.
• these aie usually~phous arid contain ~ 1 insduble bilirut.i polymer. They a,e associated lkk pigment stones
with haemo~·lic a::,ndi!il'X'IS sudi as sitlle eel anaemia .wid hereditary spher0C)1(M.
GB AND BILE DUCTS
A79-year-old female v.ith a long history al gal~tones presents \\ith central colidy abdominal
pain and vom4ing. She has also been constipated for the past few days. Clinical examinanon
re.ea~ a distended ab<bmen v.ilh increased bowel sounds. Abdominal X-ray confinns features taparotomy - enterotomy aOO remov.aJ of stone
of small-bowel obstruaion with pneumobilia.
• •
2 A92-year-dd female wilh multiple co-morbid"Jlies is found ID have incidental gal~IDnes on No active treatmert
abdominal ultrasound.
3 A•~ar-old female has been having episodes of colicky RUQ pain for the past 3 months. The laparoscopic cholecy,teaomy
pain radiates to herback and is associaled with dyspeptic S)•mptoms. Ultrasound scan confirms
gall bladder stones v.ith normal b!e ducts. Blood tests show normal liver functions.
4 A60-,,>ear-old male presents 111ith progressive painless jaundice. Examination rM-als a palpable ERCP- steriting
non-tender gall bladder. Ultrasound and CTscans show adilated ble ruct w4h a pancreatic
head tumour v.bich is not resecrable.
5 A59"',>ear-old female presenlS with progreffl!e painless jaundice.. Examination reveals a
palpable non-tender gall bladder. Ultrasound and CT scans show a cilatedl>ile dua ,'4h ,. V\.'tupple'soperation
small, malignant-baking tumour at the ampulla. Biopsies confirm maJignancy ;:irta 1hP tumour
is considered to be resectable with ·no evidence of spread
6 A•~ar-old female has been having episodes of colicky RUQ pain :o: &.e past 3 months.
The pain radiates to her back and is aiSOOated \\ith dyspeptic syn:ptoms. Ultrasound scan ERCP - stone extraction followed by chofecy,tectomy
confirms gall bladder stones and dilaled bile ducts \\ilh stones. Blood tests showabnormal liver
functions.
7 A76-year-okl male presents with progressNe ~11\iess jaund.ice. Examination reveals a palpable
Percutaneous transhepaticcholangiography (PTQ and antegrade stenting
terrler U\1er. Ultrasound arxf CT scans she\\· rJated intrahepatic bile ducts with a mass at
the hwm. Acontraaed gall bladd<'I ...~ normal bile duct are seen. Attempts at ERCP are
unsuccessful in stenting the str'o.ll,:<c
8 A53-year-old man ha, , :"•:ited with an acute abdomen and has been diagnosed ID ha,e an Cholecystostomy
empyema of the ~ ~:adder. Percutaneous draina~ is unsuccessful and hence it is decided to'-----------:---=--.
GB AND BILE DUCTS
A79-year-old female v.ith a long history al gal~tones presents \\ith central colidy abdominal
pain and vomiting. She has also been constipated for the past few days. Clinical examinanon
re.ea~ a distended ab<bmen v.ilh increased bowel sounds. Abdominal X-ray confinns features taparotomy - enterotomy aOO removal of stone
of small-bowel obstruaion with pneumobilia.
2 A 92-year-dd female wilh multiple co-morbid"Jlies is found ID have incidental gal~IDnes on
' .
No active treatment
abdominal ultrasound.
3 A •~ar-old female has been having episodes of colicky RUQ pain for the past 3 months. The laparoscopic cholecystectomy
pain radiates to her back and is associaled with dyspeptic S)•mptoms. Ultrasound scan confirms
gall bladder stones v.ith normal b!e ducts. Blood tests show normal liver functions.
4 A 60-,,>ear-old male presents 111ith progressive painless jaundice. Examination r~ls a palpable ERCP - steriting
non-tender gall bladder. Ultrasound and CTscans show adilated ble ciJct w4h a pancreatic
head tumour v.bich is not resecrable.
5 A 59"',>ear-old female presenlS with progreffl!e painless jaundice. Examination reveals a
palpable non-tender gall bladder. Ultrasound and CT scans show a dlated bile dua ,'4h a Wt11pple's opera.non
small, malignant-loolcing tumour at the ampulla. Biopsies confirm malignancy and the tumour
is considered to be resectable with ·no evidence of spread.
6 A •~ar-old female has been having episodes of colicky RUQ pain for the past 3 months.
The pain radiates to her back and is associated with dyspeptic symptoms Ultrasound scan ERCP - stone extraction followed by cholecystectomy
confirms gall bladder stones and dilated bile ducts \\;lh stones. Blood tests show abnormal liver
functions.
7 A76-year-md male presents with progressNe pain1es.s jaundice. Examination reveals a pa1pat'ile
P<rcutaneous transhepatic cholangiography (PTQ and antegrade stenting
tender INer. Ultrasound and CT scans show d!ated intrahepatic bile duas 11ith a mass at
the hwm. Aconuaaed gall bladder and normal bile duct are seen. Attempts at EM' are
unsuccessful in stenting the stricture.
8 A 53-year-old man has presented \\ith an acute abdomen and has been diag;.:se: to ha,e an Cholecystostomy
empyema of the gal bladder. Percutaneous drainage is unsucces...ful .~~:' hence it is decided to
operate on him. Al operation the gal bladder is rense and dis<cnd,u. ~ ~:,orion reveals hank pt.G.
There are densevasrular adhesions around lhe gall bladder W1110 , r,ates dissection very diffiru11.
9 A 58-year-old male v.as admitted for an elective laparoscopic cholecystectomy. Al operation.

dense adhesions were preserl in the C.lo(s triangle and hence had 10 be converted to an SUBTOTAL
open operation. Afundus-fim technique is used but it is still dilfiicult ID dis.sect the Calot's
triangle and reliably identify the structures CHOLECYSTECTOMY
10 A46,year-old male ha< i,_,.., having episodes of colicky RUQpain for the past 8 months.
The pain rad.ites :o I.'< 1,ack and is associated 11;th dyspeptic s,omptoms. Uhrasound scan Cholecystectomy and
corlirms , ~• ~ao,!-,; stones and dilated b!e ducts with s1ones. B1ood tesis showabnormal liver choledocholithotomy
functior; ..'-"- ,,pts at ERCP to remove the b!e duct stones are unsuccessful.
11 :.. 'i.'-Vf"~ar-old ma1e presents v,ith prog:-ressive painless jaundice. He also has vomiting and is
c•~ble to tolerate orally. Examination r..eals a palpable non4ender gal bladder and features E Surgery - palliative
Jf gastric outlet obstruaiOfl Ultrasound and CT scans showa dilated b!e duct v.ith apancreatic
head tm'lourwhich is not resectable. ERCP is unsuccessful bypass
SPLEEN
Amale patient of 55 yeaJS. knovm 1o suffer from myelofibrosis, presents v.ith onset of
<-• ~fl ,nn"'f nuM~ ;inti dmulrll>f tin n;ain nf A h dur;i,tinn nn JW;:imirutinn Iv> ~ t ;:i
temperature and marked tenderness O\'er an enlarged spleen. Acontrast-enhanced computed Splenk infarction
tomography scan (CEO) sha•s a perfusion defect in an enlarged spleen.
2 An l~-old male present< wlh intermittent generalised abdominal l)ain, mid jaundice and
aoorexia. On ecaminaoon he has palor, jaundice and splenornegaly. An ultrasound ol hi< alxbnen Hereditary spherocytosis
SOOHS multiple small ljilllstones and confirms splenomegaly.
3 A30,year-old female patient Pfesenls \\.ti petechial haemorrhagic spols in her skin. She
suffers from menonhagia. Abdominal examination shows no organomegaly tr..~ many ar&JS ldopathic thrombocytopenic purpura (Ill')
of skin ecchymose< The coagulation and bleeding times are nom,al. The b!ood tem show
anaemia and lowplatelet counl Bone marrow revea~ large number cf ;Jatelet-producing
megakaryocytes.
4 A25"!"ar-old male was kicked in tis abdomen accide~·.,llile playing football He got up
and continued to play for another few minutes; but :hen he felt dozy ~ith intense pain in his
left upper abdomen. In hospi~I he complained of pain in his left shoulder tip and had rigidity Splenic rupture
and rebound tenderness in his left IY,'!)O(hondriiun. Until the age of t8 years he li,,ed in a
tropical country v.ben he had suffel";:i b·om malaria.
S A30-(ear-old woman cbin!i !>1 ultrasound for pregnancy'"" found 1o have a calcified 1 an mass Splenic artery aneorysm
in the epigastrium. Aor:i., '" "' heard in the epigastric region. She does not ha,e any symptoms.
A30-year-dd patient has a history of recurrent attacks of feYEr with rigors, right upper quadrant caroli's dise.ase
pain and jaundice v.ith itching. Biochemistry m,~ a jaundice of obstrlletM' nature. CT scan
shows intrahepalic ductal mlatation with si.ones.
2 A 40-year-old female presenlS with recurrent episodes of right upper quacl-ant pain v.i!h
jaundice. Biochemist,y shows an obstructi-.,e pattern of the jaundice. foe years ago she
undeM'fflt a panproctocolectorrry forulcerative colitis and hi:6 been well since, euept forthese PnmaN sderos1ni cholans?ltls
attacks. Enooscopic retrograde cholangiopancreatography (tRCP) shows irregular narroa-ed
intra- and extrahepatic bile duas.
3 ASO-year-old female complains of general malaise, lethargy, pruritus and jaundice, the latter
being present over the last 3 months. The LFTs show a rise in btlirubin, the transaminases and Prima"( bilia"( cirihosis
prothrombin time. She has had recurrent small haematemesis and has ascites.
4 A30-year-dd female complains of abdominal discomfort and distension. st., ~.as had
3 episodes of sman haematemesis in the past 6 mont.t5. On examinatit:q ~he has Budd-Chiari syndrome
hepatomega}y and ascites. All the lFTs are deranged. CT scan of {i..,e ::ver shCfflS a large . . .
congested lr.-er.
S A fitlooking SQ-year-old male comp~ins of recent or.set cf dull, a<hing. right upper quacl-ant
pain of 3-4 months' duration. Examination shows oo abnormal:ity. liver function tests are Simple cystic disease
normal, as is an upper gastrointestinal eOOOSCOpy. M ultrasound of the li\-er shCM~ a 6 cm
solitary cystic lesion. I
A30-year-dd patient has a history of recurrent attacks of feYEr with rigors, right upper quadrant caroli's dise.ase
pain and jaundice v.ith itching. Biochemistry m,~ a jaundice of obstrlletM' nature. CT scan
shows intrahepalic ductal mlatation with si.ones.
2 A 40-year-old female presenlS with recurrent episodes of right upper quacl-ant pain v.i!h
jaundice. Biochemist,y shows an obstructi-.,e pattern of the jaundice. foe years ago she
undeM'fflt a panproctocolectorrry forulcerative colitis and hi:6 been well since, euept forthese PnmaN sderos1ni cholans?ltls
attacks. Enooscopic retrograde cholangiopancreatography (tRCP) shows irregular narroa-ed
intra- and extrahepatic bile duas.
3 ASO-year-old female complains of general malaise, lethargy, pruritus and jaundice, the latter
being present over the last 3 months. The LFTs show a rise in btlirubin, the transaminases and Prima"( bilia"( cirihosis
prothrombin time. She has had recurrent small haematemesis and has ascites.
4 A30-year-dd female complains of abdominal discomfort and distension. st., ~.as had
3 episodes of sman haematemesis in the past 6 mont.t5. On examinatit:q ~he has Budd-Chiari syndrome
hepatomega}y and ascites. All the lFTs are deranged. CT scan of {i..,e ::ver shCfflS a large . . .
congested lr.-er.
S A fitlooking SQ-year-old male comp~ins of recent or.set cf dull, a<hing. right upper quacl-ant
pain of 3-4 months' duration. Examination shows oo abnormal:ity. liver function tests are Simple cystic disease
normal, as is an upper gastrointestinal eOOOSCOpy. M ultrasound of the li\-er shCM~ a 6 cm
solitary cystic lesion. I
1 A25-year-old male complains of generaly feeong w".U with fever and weight loss. He
has had bloodsLlined motions on and off for the last 6 weeks afier he returned from the
subcontinent where he was working for 6 months. On wmination he has a tender right ~er Amoebicliver abscess
quadrant ~•h hepatomegaly. US shows a hypoechoic cdfy in the right lobe with ii-defined
borde<s.
2 ASQ-year-old female patient has rud rea.rrrern attaclrs of colidry right upper qu,drant and
epigastric pain wilh jaundice. high temperature ~•h rigoo and itching, Ten months '$0 she Ascending cholanglllS
uooet'Weri an uneventfu1 laparoscopic cholecystectomy. On examination she is jaundiced with
scratch marks all aeer her boot and hepalomegaly. She has raised serum bilin.i>in and the ALP
is 1100 IIJ/L US shows a dfated common ble duct vnth stones.
3 A35-year-old male patient presents v.ih general !, health, weigh! loss. a.•,r.•xia and malaise for
several weeks. He has d.,.loped jaundice for the last 2 weeks; he l>a, no pruritus. Abdominal V,al hepatitis
examination sho\'5 a tender hepatomegaly. l.i\,er function tests s;"low raised bilirubin and
transaminases.
4 A 75-year-old male diabetic patient complains of a.nr.ir.!;:ia. fever, malaise and right upper
quadrant discomfort. On examina>on there is v.,ight loss and lender hepatomegaly. US shows Pvo.l?enic ~ absces.s
a mu11iloculated cystic mass. a finding confumed on CT scan.
S ASQ-year-old male patien, a nati\·, d Cyprus, presents with a painful mass in the right upper
quadrant The pain is a coritin:,ous dull ache and has the features of a mass arising from the Hydatid li\oer disease
right lobe of the liver. Th> ~iood count shows raised eosinophi~. The CT scan sho\,s a smooth
· lr,s;r;:-. with multi le s ta within it
LIVER TUMORS
A 35-\'l!ar-old woman v.t.o is on the contraceptive pill presents v.tth right upper quad-ant
aching pain. She is In v.ithout arry physical findings. Her Lffs and oth3 blood teslS are oormal.
US ol the liver shol>< a single v.ell-demarcated hyperechoic mass and er scan demonstrates a
welkircumscribed vascular solid tumour.
2 A4o-v,ar-old male patient presen5 \\M dull, persistent upper abdominal pain, weakness.
\\~gtlt loss and occasional fever. He had one episode of haematemesis.. Abdomina1 Hepator:elular carcinoma (HCQ
examination shm\S an enlarged liver with a mas.s in the right lobe. l iver function tests show
elevation of the lransaminases and much raised alph..fetoprotein (AFP).
3 A60-year-old male patient presents v.ith dragging pain in the rw,t •,pper qui!<lrant for
3 months and weight loss. On examination he is slightly jaun<lced. He has an enlarged liver.
Three years ago he under/1--ent a rigtt hemicolectomy for o ncer of the caecum. lfTs show
elevation of all lhe parameters. US shcw,s a solid rr~ss in the right lobe and a CECT conf11T11s
the mass with lad: of enhancement.
4 In a 30-\~ar-old female patiem, during laparoscopic cholecystectomy, the surgeon noticed that
the under-51.Uface of the lfver M" several lesions which are blue in colour.
S A45-year-old female pati:,nt underwent an USfo, suspeaed biliary pain. The USof the .biliary
tract We£ normal b1f. ~'1o\ved a solid lesion in the rrter. Therefore she had a CECT scan which
showed a vaso~~· lesion surroLnding a sol.id mass with central scarring,
STOMACH ANO DUODENUM
1 A63-year-old male presenis with repeated non-biliousvomiting containing ingested food.
He has upper abdominal fullness and has lost 3 s10nes in weighL He is found to be pale and
c.ichectic.
2 A42-year-old executive presents with upper abdominal discomfort and heartburn. Smoking
and stress seem 10 make it wo~e. Clinical examination reveals him 10 be oveiweight but
otherwise nonnal.
3 A40-year-old male presents with right upper quadrant pain radiating to the bad It is episodk,
burning in nature and aggravated by spicy food. He mentions that h1s s~iois are sometimes
black.
4 A 52-year-old female presents with a history of slowly pme,rssive dyspha~a. She tends to
regurgitate ingested food aher a few hou~. She has c~Gl,iooally woken up v.ith a choking A<:halasia cardia
sensation. She is also concerned about her pe~isient halitosis.
5 A 78-year-old female presents with uppe! Gi bleed and melaena. She has been on long-term p.stritis
NSAIDs for her arthritis.
6 A63-year-old male presen~. wilh rapidly progressive dysphagia and profound weightloss. He is :arcinoma of.the oesophagus
..
pale and cachectic.
STOMACH AND
DUODENUM
I A48-year-old male who has had p<e<fous gastric resection for his peptic ulcer presents with
tremor,.faintness and prostration 1.5 h after eating. Th~ lasts for 30 min and is relieved by food late dumpin
and aggravated by exercise.
2 ASO-year-old male with a p<evious operation to, a duodenal ulcer was fully relieved of his
sympto,ns for a few years but now presents with similar sympto,ns as be/ore. He has upper
abdominal pain which is burning in nature. This is episodic and aggravated by alcohol.
3 A54-year-old male who has had a previous total gastrectomy presents with anaemia and
tingling in his ar,ns and legs. He is found to have maaocytic anaemi~oo blood tests.
4 A58-year-old male who has had previous gastric resection f,, h:s peptic ulcer presents with
epigastric fullness, sweating, light-headedness and dia~oca almoSI immediately after eating.
The attack last for halt an hour and is relieved by lying down and aggravated by more food. Early dumping syndrome
5 A46-year-old male who has had a previous operation for peptic ulcer presents with severe and
explosive diarrhoea. This is associated ,,_,:ii urgency and not responding to usual antidiarrhoeal Postvagoiomy diarrhoea
medications.
6 A70-year-old male who ,:;,d ~t a partial gastrectomy 30 years ago presents with recent- Malignancy
Gastric conditions
Choose and match lhe correCI a,agnos,s wnn eacn 01 me descriptions given below:
1 It is a rare cause of upper GI bleed and is essentially a gastric arteriovenous malformation
which is covered by normal mucosa.
2 This is a longitudinal tear below the gastro-oesophageal junction induced by repetitive and
strenuous vomiting.
3 The most common type of this condition is the metaplaslic type, which is associated wilh
H. py/(){i infection. The other types indude inflammatory and fundk gland type. The true
adenoma type has a malignant potential.
4 These are p<incipally of two types - intestinal and diffuse. H. wtori infection, pemkious Gasuic cancer
anaemia and gastric atrophy are some of the predisposing factors.
5 These are associated v.ith a muialion in the tyrosine kinase c-kit cr.cciiene and commonly GIST
ocrur in the stomach and duodenum. Their biological behavi,,cr is difficult to predict
6 They arise from the MALT and are more prevalent in L~e sixth decade. Bleeding and perforation
are two common complkations after chemotr.e:20'j.
7 Thiscauses Zollinger-Blison syndrome. Th.se may be spo<adic °'apart of multiple endocrine
neoplasia (MEN) type I S\'f)drome. These are usually found in the duodenal loop or lhe
pancreas.
8 These are unusual and al,~.ost exdusil'ely found in young female psychiatric patients. This can Trichobezoar
lead 10 ulceration, pc,ioration, bleeding and obstruction.
9 This is oo~~.:,se of upper abdominal pain, vom~ing and diffirulty in eating. This isol lwO
types: ~rianoaxial and mesenteroaxial. It is commonly assooated v.ith a diaphragmatic..delect.
GASTRIC PROCEDURES
Choose and match the correct operations v.nh each of the desaiptions given below:
I This has the best long·lelm resulls for morbid obesi!y. l can be done laparoscopically and is becom-
ing a standard procedure for the morbidly obese. The operalive mortality is around 2 per cEfl..
2 This involves resection of part ol the stomadl followed by closure of the duod,nal stump. The
continuity is restored by doing an anastomosis with the jejunum.
3 This is a non-seled:Ne operation used previously fct peptic u1cers. Gastric stasis is a common
po~operative problem and hence tns was combined with a drainage procedure.
4 The was a common gastric drainage procedure used in peptic ulcer surgery and is presentty-
more often used as a palfiative procedure in malignaocies. tt can be anterioror posterior and
isoperistaltic or antiperistaltic. oiarrmea is a common postoperati-.'e sequela
5 The 101,, r half of the ~omach is resected and lhe gastric remnant~ Gi:tctiy ana~omosed to
the fim part of the duodenum. This has a higher rate of anast£'1'lttic leat
6 This procedll'e selectively denervates the parieral rell 11"= , .1d has a low irri<lence of side-
effeds and acreptable rate of recurrence.
7 This is a popular procedure for morbid obes'~1 v.uh a mortality rate ol less than I per cenl
Slippage and dysphagia are two common compficatior5. LAP BA
8 This is an operation to treat d!-t.."'tic pancreatic pseudocysts and imolves creating a wide and
direct communication be~\''"-"' the posterior wall of the stomach and the cyst
9 This is a complex r.'lcJUf operation usually done for malignancies. Continuation is restored by a
Roux-en-Ylo"f' •l i 1ejunum. 'vitamin B12 injections are necessary after this operation to pra•ent
deficier.;,:\'. ?at,ents are advised to eat small amounlS a! a time after this surgery.
TOTAT Gl-iSTRfCTOMY
Dysphagia
1 A SO-year-old patient complains of chest pain on swallowing. This is usually episodic. He has
had these symptoms for many years but recently they have become more frequent and severe.
2 A45-year-old male patient complains of dysphagia of 2 years duration. He seems to have
greater diffirulty swallowing liquids than solids. Recently he has noticed that at night he is Achalasia
woken up by coughing. He has lost about 7- 8 kg in weight in 6 months.
3 A35-year-old female complains of occasional dysphagia w~h food sticking in the lower .
Schatzl<i's ring
retrosternal region. She has had occasional heartburn for many year...
4 A65-year-old male, a heavy smoker, complains of dysphagia to solid food of 2 months
duration. At present he can only take fluids. He has quite severe co:1gh when he tries
to swallow any food or fluids. He feels this is different to his ·srnuke(s cough' which he has Carcinoma
suffered for many year... He has lost about 10 kg in we;~nt since the onset of lhese symptoms.
5 A65-year-old male patient complains of dysphagia, with food sticking in the lower retrostemal
region. He has suffered from heartburn all his life and occasionally has a sour and bitter taste in
his mouth with waterbrash. He also h:,; cough on occasions. He has not lost any weight.
6 A60-year-old male complair.~ of quite a severe cough which occurs when he lies in bed. At
times he is woken up b~1.,.;se of incessant cough when food material seems to project oul He
is embarrassed by h,d breath. He also has some dysphagia. His doctor has been treating him
for chest infectio~s.
Intra-abdominal infect ion
1 A72-year-old patient underwent an emergency right hemicotectorny and ileotransverse
anastomosis for carcinoma of the caecum presenting as acute intestinal obstruction. He Postoperative peritonitis
progressed satisfactorily until the fifth postoperative day when he developed pyrexia,
generalised abdominal tenderness and rigidity with rebound tenderness.
2 ASO-year-old patient underwent a laparoscopic dosure of a perforated duodenal ulcer. On the Subphrenic abscess
fourth postoperative day, he developed pyrexia, looked toxic, complained of pain in his right
shoulder tip and was tender and rigid over his right upper quadrant.
3 Follo1\ing emergency appendicectomy for acute perforated append;ciL;.,, a 30-year-old
female patient progressed well for about 6 days. After that she ft!\ unwell, was pyrexial and Pelllic abscess
complained of tenesmus and foul-smelling vaginal discmree.
4 A 14-year-old boy has been brought w~h right ui:?er r,uadrant pain of 3 days' duration. He is 3asal pneumonia
pYfexial, tachypnoeic and tender in the right upper quadrant. There is reduced air entry in the
right lower diest which is dull on percussion.
5 After an uneventlul laparoscopic L~1Jiecystectomy, a 35-year-old female patient was sent home
on the first postoperative <i«f While at home the same evening she developed sudden onset of Bile peritonitis
severe right upper abdt•minal pain and pain in the right shoulder tip. On examination she had . .
a tinge of jaundirc ~r,d was extremely tender in the right upper quadrant with guarding and
rebound ter.d,1 ,,ess.
Ascites
1 A70-year-old woman, who is known to have had a myocardial infarct in the past, complains of ..
shortness of breath and abdominal distension. She has a raised jugular venous pressure. Congestive cardiac failure
2 ASO-year-old patient who is an alcoholic complains of abdominal distension. He has distended
veins around his umbilicus (caput medusa), palmar erythema and spider naevi. He is slightly
jaundiced.
3 A60-year-old male patient complains of feeling genm ily unwell for 3-4 months. During this
period he has felt gradual distension of his abdomen, weight loss and generalised malaise. He
has recently returned from the subcontinent after living there for 2 years.
4 A70-year-old female patient has had weight loss, abdominal distension, malaise and anorexia
fOf almost 4 months. Abdomir.il examination shows massive ascites. US shows solid bilateral
ovarian masses.
mesentery
Choose and match the correct diagnosis with each of the scenarios given below
1 A55-year-otd female patient presents with vague abdominal and back pain for 3 months. She
feels her abdomen is enlarging and is constipated. On examination there is a large mass in the
lelt loin, smooth in consistency, tender and bimanually palpable.
2 A20-year-old male patient presents with recurrent attacks of petiumbilical abdominal pain and
intermittent vomiting. Abdominal examination reveals a 5-6 cm fluctuant mass in the umbilical
region which is mobile in an oblique plane.
3 A30-year-old male patient has been brought in after a road tr.ific accident complaining of
abdominal pain. He was a front-seat passenger wearin3 a seatbelt In the accident thete was a
sudden deceleration and a head-on collision. In the .i.ilE department, on assessmen~ he had
no injuries except for abdominal wall bruising from the seatbelt. He has marked abdominal SEAT BE
tenderness, rigidity and rebound tenderness.
4 A SO-year-old obese man has beff, brought in as an etnergency complaining of sudden onset
of severe periumbilical abcbrnmal pain. On examination he is writhing around in pain and very
tender in the umbiliczl ,~gion with rigidity•~
. --------------
------- ---- ----- - --- ---------..---~ ------ ---- -- ---- --------- ... ----
HERNIAS
I A6-month-okl infllnl is brougli by tiis molhe, wilh a history or l!Jl1) M'I' the bell'{-W!lon,
wijch iooeasesin size""""the babr •avi~ Umbilical hernia
2 A26-ys-dd buillh p!'l'SeOISwilh a 1001) O'lt'f his left groin whKh has been there for the • • • •
lastl yea!'$. Examination r ~ c01Jgh fll)Ulseand a reducible he,ria over the left groin Indirect 1ngu1nal hernia
exleflding lo the scrOltJn. lnltmal ring occlusion lesl is positive.
3 A60-year-old obese woman is: referred Mlha history of paintlf l001><1rouod her wiiilirus. Paraumbilkal hernia
Examination reottak an i m:locible limp just abcue lhe r ilicus.
4 A78-'!-es-dd ....om,m is referred to yocJr dinic: with a ~ k history of suspected enlarged
left g,oin l)frc>h node. Examination reveal$ a 2 an hard and irredum>le 1001> oo.w the me!M Fem O r a I hernia
aspect of lhe left g,oin. Thereis no cough imp~.
i A40-year-dd w:>mdfl is 1e!er1ed lo '(Ot# d nicwilh a his:lely cl a &raduallyincrNSing lump

om the kl\~ abdomel\. She has had three caesarean sed:iorls in lhe past Clnir.sl fl).a.niM!ion I ncisio nal hernia
raeals a f'fannenstil'I scat. fliere is col¥! impulse and .i 1educi,le lu~ om t!-e ~~ 11~ml
asped of this sea, extending to the ri~t groit
; A76-ye,)r-old main is rele,red to you ,'111tu 2,yea, history of limps ever bcdl his groirn. lll!Se Direct inguinal hernia
are o..,_ c.ausi,g lim mir'Wnal discankrt Oinical examinatic-., .:"1t.rm 1edooble hernias o.ier
l:cth bis groins. Intern.al ring ocdusioo t~ is n~li.~
r ASO.ye:<11-d,d man presenlS Vlilh a h.1np belc,,y the uJ'li>ilicus and l11teral to the reel.ls. Acol.WI I
fflpulse is fell O\•er tht 11re11 ~ d tht ltJnp rM!ceswith diffmty. Spige ian hernia
l A22..,'e:olll-dd. fit male presents wilh,;i: epig.astric bul&e. This becOOll?i pwominent \\hile
e,iercisint st tht gym. • is 01hen,i:'t: asymplOmali::. Clnical er.«niltd!ion ""-eats a micline Diva ri cation of re ct i
gutta: in the t1ppe1 abdo,«:.t'l.
) AJO.>,'e&-c&I k"·Mic. ~ IS \\ilh 6 IOCi!li-.ed sharp pain i, tile upper &>domm Oif'IK'ill
tanira!ion :,•.~'s a butoo-lle soft swelng eqt.idistant bttween the xiptiistemum and the Epig a st ric he r nia
tmbiliC"- ~ i :teft is no coud, fll)Ulseand lhe limp is not redocible.
Complications of·nernia
Choose and match the correct a1agnos1s w1tn eacn or tne scenarios given below:
1 A 70-year-old male is referred to your clinic with a long-standing left inguinal hernia. He has not
noticed any recent changes in his hernia and his bowels have been normal. On examination (ADHESIONS B
you see a giant inguinoscrotal hernia which is not completely reducible. ANDSURROU
2 A 40-year-old male is referred with irreducibility and increasing pain over his right inguinal hernia
over the past 8 h. On examination the hernia is extremely tender with signs of peritonitis.
3 A 60-year-old female is referred with a history of increasing abdominal pain and distension over
the past 2 days. She has been vomiting repeatedly over this period. Clinic-'ji examination reveals
a right groin lump which is not reducible and abdominal examinatior, reveals a distended but
soft abdomen with increased bowel sounds.
4 A 50-year-old male is referred with irreducibility and discoh11ort over his right inguinal hernia
over the past 3 h. His bowels have been normal. An irreducible hernia is confirmed on
examination. The abdomen is soft, non-tender and not distended.
5 A 90-year-old woman with a long-staridiCTg history of incisional hernia presents to the
emergency with faeculant discharg~ from the hernia site. Examination reveals excoriated and
ulcerated skin over the incarcerated long-standing hernia.
--"----'"---------------
HERNIA REPAIR
lC
1 Primary unilateral inguinal hernia Open mesh repair
There are no significant advantages in doing a laparoscopic repair for an unilateral inguinal hernia
2 Primary bilateral inguinal hernia Total extraperitoneal (TEP)/TAPP repair and hence the present guidelines still recommend an open operation. Alaparoscopic repair may,
however, still be appropriate in selective patients.
3 Recurrent inguinal hernia - post-open repair Total extraperitoneal (TEP)/TAPP repair
2F
The morbidity and time off work are less compared with a bilateral open repair and hence this
4 Infantile umbilical hernia Wait and watch
should be the technique of choice.
5 Recurrent inguinal hernia - post-laparoscopic repair Transabdominal preperitoneal (TAPP) r 3F
Adhesions due to previous open operation make this a suitable case for laparoscopic repair
6 Divarication of recti Non-surgical through avirgin territory,
7 lncisional hernia Open/laparoseopic mesh repair 4A
Ninety-five per cent of these spontaneously resolve. Hence a conservative approach is advised up
8 Epigastric hernia Open suture repair to 2 years of age.
5B
9 Paraumbilical hernia Mavo repair
ATEP rep:;ir is difficult as the planes are obliterated.
,;·
.t
.
Arepair is unnecessary. An associated discrete hernia, if definitely confirmed, will need to be
repaired.
7D
Use of mesh in primary repair is recommended in view of the increased incidence of recurrence.
8H
The defect is usually small and only requires a couple of sutures. Mesh is rarely required.
9G
Amesh repair is considered in big defects, recurrent cases and in the presence of predisposing
factors.
Sources of abdominal pain
Match the following sources of pain to the site of radiation:
1 Back Pancreas
2 Umbilicus Appendicitis
3 Lower angle of scapula C.llolecystrtis
4 Loin Testicu!a: pain
5 Groin Ureteric colic
6 Left shoulder tip Splenic rupture
https://web.facebook.com/media/set/?set=a.10206202862150904.1073742121.1845046617&type=3
Points from Dr. Nadeem MCQ book

https://web.facebook.com/media/set/?set=a.10205910351278315.1073742089.1845046617&type=3
Obs MCQs made simple

(is main DO keep membrane intact
ni hona chiye??)
Paeds MCQ guideline1
(Jitna muje andaaza hai aur jitna mujhay yaad hai =p)
1) Growth aur nutrition waghaira wale jo chap k tables hain wo atau hain
2) Head circumferrence height waghaira
3) Aik question devp milestone ka ata hai mcq jis min btaana hota kid age min hainbacha
4) Doses nahin ati bilkul bhi
5) Ari,malnutrition,sorethroat aur diarrhea k jo imci tables hain wo mcq min puch saktay k classify
karo
Aur saath saath dehydration k abc plans jo hain detail main
6) Neonatal resuscitation min jo values hain wo puch saktay hain
Hypocalcemia hypercalcemia waghaira ki jo values hain k kis se uper kis se neche kia hu ga wo
puch sakte mcqs main
7) Apgar score calculation Jata hai
ur ye yaad rakhna k wo 1 aur 5 min pe check kartay
8) Epi ki doses waghaira bhi aur konsi vaccine kahan pe lagatay (kab laganay wala mcq rare hai
kiun k wo epi ka seq hi aajata hai)
9) Aik adh mcq meningitis ka pakka hota hai csf findings di hoti hain btana huta hai k konsa
meningitis hai
10) Coagulation studies wali chezain b inp hain fiagnosis ani chahye on basis of lb results of pt aptt
bt
11) Aik mcq tb drugs kay side effect ka kafi imp hai
12) Aur measles ki complications ka mcq is common too esp ye b us min vit A detay hain
13) Is kay ilawa normal values of respiration pata honi chahyein age group k lehaaz say
14) Aik mcq lazmi syndromes se ata hai must know how to differentiate between down patau and
edward syndrome
15) aik hypothyroidism ka b almost done hai mcq jis min umblical hernia ya prolonged jaundice is
the buzz word you must knoe
16) Haan CVS tu pura hi imp hai for Mcqs
17) Pertusis ka b inp mcq hai jis main diagnose karna hota hai aur sath DTap vaccine b yaad rakhni
uski aur ye k usmin neurologic aur myocarditis hota hai
18) Differential diagnosis of rash wala jo portion hai us kin se aik ajata hai (Yaad rakhna measles min
koplik spots b hotay hain)
19) aik mcq torch infections se b ajata hota hai jis min in sb k farak features pata honay chahyein so
that u can select the option with confidence
20) aik jo cheez farak hai k is min kabhi kabhi death rates puch letay hain neonatology walay
21) pneumonia aur meningitis k organisms puch letay hain according to age
22) Aik Mcq hepatitis se ata hai us min b mostly woi jo hep b k markers hain medicine walay woi
yaad hain tu chal jae ga
23) Haan energy requirement b puch letay hain bachay ki jo aik table hai book min us se andaza
hubtu banda kar leta hai wo bhi
24) Aik Mcq DKa ka pakka huta hai , need to diagnose it well aur is ka treatment woi
KFIA(pottasium,fluids,insulin,acidosis treatment)
25) Rickets ka b a jata hai aksar jis min vit d dependent pochtay hain ziada tar
26) Down edwar aur patau in teenon syndrome se b ajata hai , features a jatay hotay hain aur kehtay
hain k kia hai isay ya downs ki condition puch letay hain jo cvs ki associated hoti hai
27) MVP hota hai marfan's main ye b a jaata hai
1
Link to MCQ guidelines: https://www.facebook.com/wardmate/posts/537141553327782
MCQs Points
..
n,
N
= =-~=~P!)J11.~~s~ -1?~/j$~lb-dM~&:c.~Q~s=-=;~:::::::
•
I(
._1,.;o..1. '4-h h.u•'""1QlS:)l:.J\'0
.!a,_.:t
,.._ ll-lu ~•Q;uCQS.;!;=,.u
is>..., _
Je I T OE :._ Spe..L\:o..!._ _..,.a~~ ""'wi ,>= -.i.
lie I Mi:\:.l[Ql B.t.~1.a~, (>g,1M'1s\:diic. m lWIALL\- •

'
a
-a
: Ic~::Cwl
_ _,._-+-'""
de
""' S>\:s:!Oo»~ ;
f'.!1.....·!:.l""'ml B•~ni.- '{ei,u;rir:•.)AA ' t , ~o~'tt·
~mm , ,)l(i,:\::k.i.$"(SS. A £e!'C:3,l,f>~
t , ~ ., ~ ' ? ( ~\
I)ipb\be~ia Mcrn'o , _ qyo':i .\-\~ \'l oehe:uoi.- \:hair h\ccds
e
r;
* •
----.- II 01'\ 11t!l)OV9,)
• ,<.h\oa-(de C 01'\h;n t 66 oi'.S

ro t9,, h i eo I
II., :t lo
lie Po':i , ~glemc~ . ~~ • S:10 \:k.f91dr'e$JI~ ,·
- - - ~ l@:,;;,J...isl5l:~ILtt..nc.-meJ:}c;;u.'d - Pc3c~j\'T N.
# I
(;),Rd 'hld , fcsl'" fu<\::n::rw'~C . ~ \i'GIJ.'d AA'(fS.1'<2. H'IJ)A:: SCQ¾.
s. e;i ,c)o,s ~ ci.< ~ · C.PIM \ ~ \-o V\t'AlO~.h:-i~ Sac.iz1 Yf
a,. I Sc:xeen,oe Foir t>trm = C.ua\-ibinc.. ?no.r.pboklcd:>e 0~~1---

*, YQ \1'0 .. \/cn'rxsa\ \:\aY6 6 ~ir:-A \ Co:t9. -
• , Yac.c.ioPttd ~ - 2, ?\• .. Fron:- H.Bs&.g .

'¥ Deoq,ue. tic.mm. fe.'\lel ; leµ~tpiO I lbxAm'M+~tnta J 1: Hee
!k / i't. l iOA\:o\ f)c.) icx\ :. .;l,21 Wte.x,.<;, Cacs-~1'cn • 3: aqy!;. cie\tr ~IL~
- 1t • .a~u~\ cWoq, Ccr41p,:t\1U1 ,coe,.Y<;C ~'-lt~, wS~- 8=-..Q:r.,...;.•_ __

_ ___,
1
nxqr<11e , d{-'Jcndu\
-1F::..,;o..,._.... a.~n , ..u::o.'o}W ~nl°g , NQ
CU>X>.01.mCU- foso'1~ _ Q~ ~1.rfu \.\1._--:a,_~~~01'cliS.m. (do T'l 1Jsll'
' l)T ~ lo~ ~,,r:e ~l"\.a \jl''Qn f~Cb'OOQ C)f.~\Q.~ ~ - " w
-
l, iStamp
~-----
I
- -'--l-~- ----------=-..,.,-==-===---~-=~3,fid
- - "--r-8\oir-1'.A~ -~• r ec:L-S.~c I, L ~eutt le.n~ ~i.'.l.u., "'!('"'':i )'e.d ..~,du _ , fr0
'I~!~ on t:\e.c...):,, :!r _ia';ie.f>--:. f\~--i.,'Q_-~\.,Qn~~{,q._,_ _ I),
n,
- -~ t Mo~e~ ToQ'\\~~em<o. ~x_rie..l"~ .. ~'> ·/ • <.hcln<.e s
-
- ~
-
*-Vi.t:9.tnin D~
1
io ~ ------
~ f'O~?o - ~,,ci.-ron_ ~':i ye.a j_~~\e<o .
- • ·, l)Pi\11 ?'{aicio 'lle.~ui11e.'('Q()'.)T ' ""' C.h.i}g_; ~ I "1~--
* · ~~"ro1'g ...., r-t\u"-c.\e. ~ e ...________ J
• % I ~ w~ · ~aio I>1ei- ~OO-A<;. ~ ~eAl , : . 3Y--~\½ W,c i~\- ;
,, , ,, ,, _,1 _ 11 & Moo\:b» • ~ i> 11 //
ts . Di Ge0 l<y! Synd10me ::::t -} c,g1-l-_=-•,_ Ne.ol'.'s':9\ · :T~n':1 _ _
~c. S.c.~...rrcs ,·!:!. 1-l~ - S!-\\!)T\.e.. ~ i.L~e_s L'S'.A.:/_·J
Ne :raoic - CJ.rn1·c. ~ed't.\.l~ if"'I t:lr:on~\<.~. _ _ __
·* ' EYII Jc.am ~Id , w~ . ::~~ .. • _f ) ~ { § ~ ~ e . ~
-t: I E1~[d "~ 1 itcroc.ot ,n ..~-ema'ruie~'Q~~ ..............:J-¼:beLllfi,. __ __
i daij ;... 60 - 2,l!S m9. / ~ I da~.
- ,f!!)===
y iStamp
-
3
\ "'do
,.,.
gu
• ' .., Loh~~ P.nc.umon ,'o. •>'l 1>.. L10 ='I'. '.;)+~~, J ..(1-l'MC:.t'\ {~!:... ..
m
h
"' . .f'~\:o Ii< ---ct ~~.t~ Y{.ll.. - Ir
,. '
,,, £..
. (a~yl~,-o.._\ _d.e.n't jr,,. _gYQ,ul\- ± fti_\,el"d-~~e._g_~~ SC4>'1J;HIA~ l-.0
h•
',, . _cJ,,..., o - ~ e . . -:- - - - ------
I
-~... __t'\CC... ~ ~ ) ~ . ?-
Q
111 -
_ ;,:___µ<. e.1ypl<-4. l-4l-~ , Cm'6J ,·10i .1!~ 9'> 1· '" MC½,..-"u ~·_ _ __
I • 11
' ' I< a~
·1 ..
'OI
• . I• t,
• 11
- -- --1 ~ 1 ., /D 1¼
C
- -,'
ti' ,
• • •' .,
.;L ~ Y/D
t-- I UTI,
)<'.. l id
---
n.!,i
y iStamp
/
lnltttlo1>s OI$
I
I
•I
'
- ,Ayt. w~ · ¥ "' ,·o ?> l\1cv.!:los I i'\E. I w.1;_. -=:.. ~ !f!ll:l. ____
I Be--¼-Ax:e s.~wr, /MPU \&~ Ca t-2. CL, p C k. 31YC<35'!2 .
- ~ 1 \bj~toD1A =- Ce releP.JJgr d;.;eaJI!
* I Har10e1's ::::'l: M 1osrs ,, P>-:cn.c...------=-~---------
k I' ~~\xjle. se lz.Y Yf: . "'
~ C¢n9"nib, I P,k,u $.!:rro s 5 --='l 2 w~ · 0.f!./e.< bt&/.b ,

~ nskM1"C. o~se t "!_RI). • 'Hf y¥7tZ'Sf0l½c::.·
,.,=l,\,O"""'"f""'J""-:l- - - - - - -
•
·------- ----
l, iSuunp -
-
Random Points
Chap 1 complete
Chap 2 complete
Chap 3 complete
Chap 4 IMCI tables
Chap 5 skip it
Chap 6 Nutrition, Malnutrition
Chap 7 Skip it
Chap 8 complete
Chap 9 Acute
Diarrhea,polio,tetanus,Measles umps,Chickenp
ox!Typhoid,Rheumatic Fever,c t ,a of unknown
or1g1n
Chap 10 complete
Chap 11 chronic Diarrhea, hacr; Disease
Chap 12 complete G
Chap 13 pyogenic meningitl§, uberculous
meningitis,encephalitis.L1alaria,febrile
convulsions,epileps~tattffi
epilepticus,hydro~ a ,CP
Chap 14 DMD,Myasth':e}Jia gravis,GBS
Chap 15 microcy t~ anemia , Sickle cell anemia ,
macrocytic ane a , atelet disorders ,
thallasemia
Chap 16 wilm
Chap 17 skipj
Chap 18 co · te
Chap 19 glY.' 09en storage diseases for mcqs
Chap ~ R:A.71rlSP,Kawasaki
Chap 21 cn'tomosomal abn
Chap Q ematuria,APSGN,Nephrotic
syndrom , ARS
Chap 23 diaper dermatitis
Chap 24 hernia , PS , hirschprung, clubfoot ,
biliary atresia
Chap 25 general management
->IOP
.Anterior fontanelle closes at 18 months

So if ant fontanelle is not fused then we pal at
it to assess iop
Signs that help to find that iop is raise
->Febrile fits:
Fever and fits with abse.........e of any ens infection
Some children have s ch i s
6months to 6 yearS! 9 1n some )
Family history is import At
->if a child of less ba two years presents with

fits always exclufet·o...meningitis
-Csf
-Cells are s han 5/mm3. All are lymphocytes

-Glucose p rox. Two-thirds of normal blood
glucos~ ;;::,
Decrea"'-=·1n bacterial of tubercular
-proteins ,Q-50 mg 12:43 PM .././
- > Normal respiratory rates:
First 2 months .. less than /equal to 69
2 months to 1 year less than/ equal 5,
1 year to 5 years. Less than / eq I o•~ O
->Respiratory rate normal and c est indrawing

--- cough n cold
drawing ---
pneumonia
Resp rate high and cmeS:t indrawing --- severe
•
pneumonia
Normal Heart
- > heart rate .

Adult - 6 t 00
Norma I · ·s higher in children
In chiletren For every 1 degree temp heart rate

increases by 10 beats/ minute
Fits history
Preictal
Change in behaviour before fJ1s 1!!ura)
Family history
Ic ta I .,,..,,,_
Onset ~
Duration rt:i
Type (tonic/clonic/botl;;i·
Generalized/localiz@,
Time b/w two epis Etes
Uprolling of eye01: I
Urinary/fecal ineo tinence
Biting of tong -
Frothing of o
Fall/trauma
Fever
Conscioesness
Weakness/Paralysis
Change in Feeding habits
Sleep 11:1A Ct.A J
Xrays imp in neonatology
Rds
Necrotizing enterocolitis (pneumonitis
intestinalis)
Sick baby + bleeding : septicemia
Pulse oximeter - c: eeks oxygen saturation

( partial pressu e fi oxygen )
Normal 92-9 ,
If 100% eyes e rolental fibroplasia-blind) and
lungs ( br· nc opulmunary dysplasia- chronic
lung d. a~ damaged
60-80 respiratory rate in 0-2 months (normal is

60) we stop feeding and use NG Tube
If baby's weight is given , check 10%
If equal to 10% or above : exchange transfusion
If less than 10% : phototherapy
Preterm ki pie
What can be complications ?
Developmental delay
ROP
Chronic lung disease
Poor growth
Preterm ki pie :-
What can be Corl}) ·ca ions ?
Developmenta1~ elar
ROP
Ther=~,are never generalized seizures in

neonate , they are always focal since myleination
completes by 4-6 months 11 :33 AM ✓
Causes of neonatal thrombocytopenia
Serotonin
Sepsis
Autoimmune ( maternal antibodies dest(®
babies platelets)
Preeclampsia
Drugs
TORCH infections
Maternal ITP
SYNDROME ( sk abn + thromboc topenia +
common protein allergy)
Congenital amegakaryocyti - t
Types of van willibrand : 5

Type 4 is platelet type~ ~
Type 2 has further ty e
Autosomal dominant otfe of inheritance
Neonatal meniQgi i (LES)

Listeria
Ecoli
Streptococci
C8 nge ital Cyanotic Heart Diseases ( 3 Ts)

Tr ·n position of great vessels
Tetr logy of Fallot
Tricuspid Atresia

Surgery MCQs

Uploaded by

Document Information

Original Description:

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Surgery MCQs

Uploaded by

Copyright:

Available Formats

All this data is obtained from this post by Ahmad Hassan Bhai.

Multiple choice questions

S-1 MCQs made Simple

ii. l>elaved "': ·

* Cool-Yo\ ble!d ,., 5c1\p 1<1ffYl'.11-,on • £,1.1e1r~ C'19l(9 9ecl'X'.\..l'(O~l'c~.

t£ :re N - ::'t JQ.W'IOJ2e 9 f~r- 3 Mo\'\41S ,LPT~ 9S?~90~td • R~t1(e

• i I,'\ \19,M(?.y. ~ I ' ¼

I ;$ 'i)O C. 6.c Y/o . I

!'I 4o Y/o .,..,·+t, l.' L.

~ - Sold.·ea w,l Mi<,s.i!e iOjY!:'.j - c,t,an<,C

-4 · Me:\9h.ru:~ o \l;s+las: rs ooesno\: , o "sc <ll kQ \$'$,{S I

~go ro\ ,-,. T e ..,,rql(:

- Blood ..,1, ti- +£•c

- £01-I- ~i),.e. S,Ieu,.. ='1 Tq~ di: ~@IQ.M..Q

Maryam Baji S-1 points

CHAPTER 2= SHOC~ & BLOOD'TRANSFUSION

• The treatment is surgical expk>raUon to stop the bleedin .

It is t : l ,ted when haemoglobin level (g/dL is the following:

MISSED MATCHED TRANSFUSION

• ~ i r of au damaged struetures may be attempted m a tidy wound. V: a

keloid is an exuberant scar, which is the resuJ1 of

• 11 Is associated wilh '.[a,sed levels or growth lac10

NECROTIZING SOFT TISSUE INFECTION

CHAPTE ~ BASIC SURGICAL SKILLS & ANASTAMOSIS

tient cou hs much better J)<ooucin less res 'rato

, For instance wh~ ~ •~sofa,ied, it shljlld be treated by

Amin~lycosides (gentamic,n ~ tobra ycin}. effective against Gram-negative Enterobacteriaceae

CHAPTER 7= PRINCIRllES OF PAROSCOPIC SURGERY

S-1 Bailey Points

Cancel Final Year Nu gg et s fo r M CQ s

~ 1,111 fil. •%,~,~ (Bf\ll.£.Y Al-lll. ll>VE~~

@ l\l::.\ Cot- kt :\ .i ~-iabc.. M

@ 11h , i,'t:e\kt\ ..tJ ~ u:\:-1 V,:,:e,. ~\ \

®IY·:bl.\tJ Ju. m-J.!l~ ~t ~1~we wx_

@ St:-ro;;. 4_ ~ 1 d. .t"al a\ ,-6U--•p=:J:• !<lvllo.d

@- \ah.d \S J~cfut- u:\\ Ult~ ~ 1 . ..f.W~~ •k , l

®. s~d \~ L W(d b1 9¾11,1.J:,, j .L.... .tvl"ltl 11

Cancel Final Year Nuggets for MCQs

€) SJL 1'1, t ..& tr ml: IBrr,tl\(, °ft"P:nx:- ~\~.A.cir ~ - -

--©- $k,fot(~ ~·'t~rol mi j_Jk'1:l Ob Jc& 't.d..

@~~Jq\,_ 11,.l~ f.'-'J~ oo ~111.

@. C,os uw\ ~ _kiittL \kur.x,pcik'1l'0 in ( C~

_@ . Midi:£ c(t)'{fl it> t< ~ l ~ 't:rio,¥·®~--1s 8:r,J-gte tA

-@ \11,ed:: f*.:@. ,,,~fu c&~ulltk ci ~o'r,.,«dih.Jor: 1,ri v31'.

View fu ll size · More options

Cancel Final Year N ug ge ts for M C Q s

fcitl½tl -frp. Ct r\:al ...b. "Do'lf'rcth

hw t at i;~ J',rM r:CStn,\b«'ll 1lMi-. Sor®tX1.

@ , Sw ~""'~ h:.,,,ro 1k \o:k:00..;. ¥ .~ ~ V L 1 lt )

® C.h_ &ii~c.zJ ~ ,b l)~ a«c'16, k ~ ~ df~l'3<c.

Cancel Final Year Nuggets for MCQs

@;. ~~ IA!cl. .c:ctb:o~ ~ h ltl'-l '

c,, . E~ ~~ oWLYIJiMl .M£11~~ ~!fit!~

®-l)clqdfio\ ~ ..tPrt arui %et ~ .eiefYllL

@- foheve w\fu 0.>,r

@ Med coMCfl 0Cft11;::cd~ l ~ l

View fu ll size · More options

Cancel Final Year Nuggets for MCQs

(½\ ,IA~ £l ~•, r .hfntl WJ clL. Li~ k,_ JIM, "1li

~ c~· oJol i I tr"

~ fil.l t'l ll'.lluho\'" \,

View fu ll size · More options

Cancel Final Year Nuggets for MCQs

c,, . E~ oWLYIJiMl .M£11 ~!fit!~

(o14t\.. •!Yl,?c -t>Je , 1' o.'r C!<i\.-~i • t>\-.a..,-y"'~Q..1