Surgery; Final MBBS (Main) March 2021

(AL 2013) – Reviews by AL 2013 Colombo batch

1. Regarding Barret’s Oesophagus,
A) F - Anti-reflux surgery has not been proven to prevent high grade dysplasia .Treatment options for
high grade dysplasia are esophagectomy or endoscopic mucosal resection or ablation
B) T
C) T
D) T
E) T - low grade dysplasia is managed with annual observation with endoscopy or radiofrequency
ablation

2. A 50 yr. old previously healthy male presented with acute severe bleeding per rectum…………..

A) F
B) T
C) F
D) T
E) F

3. A 32 yr old female having POA of 10 weeks presents with ……………………

A) Acute Asthma – F
B) Acute Appendicitis - F
C) Ruptured ectopic pregnancy - T
D) Septic Abortion - T
E) .Threatened miscarriage – F

Answers (courtesy – Dr Medhawa Reg- Surgery)

FFTTF

4. A patient being prepared to undergo ERCP the following day……………………..

A) Blood transfusion - F
B) Fresh Frozen Plasma - T
C) IV Vitamin K - T
D) Oral Vitamin K - F
E) Tranexemic acid - F

Answers (courtesy – Dr Medhawa Reg- Surgery)

FTTFF
5.

A) F - hot cholecystectomy done with in 3 days of same admission

B) T
C) F - It is characteristic in cholangitis
D) T - acalculuous cholecystitis
E) T

Answers

FTFTT

2013/06

Regarding Fibroadenoma of the breast,

a. It’s a common condition among adolescent girls. – T

b. Diagnosis of Fibroadenoma doesn’t need a cytological evaluation-F
c. Large fibroadenomas increase the risk of malignancy- F
d. Will remain static or regress with time - T
e. Shrinks after Menopause - T

Answers (source 1 – B&L Pg.870, source 2 – Registrar Surgery)

TFFTT

Fibroadenomas are estrogen dependent and Shrink after Menopause.In about ¼ of all cases, multiple
fibroadenomas are found. Most fibroadenomas remain static in size after reaching a size of 2-3 cm.
Some will regress spontaneously. A very small amount will increase in size with time.
 2013/07

A 50 year old lady with a WHO grade 2 MNG came to the clinic. What is/are the investigations which
would support the diagnosis.

a. Thyroglobulin level -F
b. Thyroperoxidase antibodies -F
c. TSH - T
d. USS of the neck- T
e. X ray of the neck - F

Answers (Source – B & L Pg. 807 , Sanjeewa sir revision on zoom)

FFTTF Figure 1 Dr Sanjeewa Senevirathne Nov/2020
There seems to be a mistake in the stem.
The initial Investigations indicated in suspected multinodular goitre would be, just USS neck and TSH. CT Neck and thorax is
indicated if compressive symptoms or retrosternal extension is suspected. Thyroperoxidase antibodies are done to diagnose
Hashimoto’s thyroiditis (i.e. Chronic Lymphocytic thyroiditis). In Hashimoto’s thyroiditis the gland is Rubbery in consistency and
may even present with enlarged lymph nodes. In the initial phase of the disease patient has Hashitoxicosis and then he/she
gradually becomes hypothyroid.

2013/08
A 60 yr old patient has fallen from a height and sustained a spinal injury. He is conscious and rational, BP
is 80/60 mmHg, Heart rate is 60bpm, and he is unable to move all 4 limbs. He also has persisitent penile
erection. T/F regarding this?
a. Atropine is required - T
b. Complete cord traction is present – T (Presence of priapism indicate a complete or nearly
complete cord damage)
c. He has sustained a high cervical spine injury - T (Inability to move upper limbs indicate a lesion
at or above C5C6 level.)
d. Reduction of blood pressure is due to hypovolaemic shock.- F (The patient has bradycardia)
e. Vasopressors are indicated - T
Answers = TTTFT
Source 2 – ATLS 10th edition pg 144
➢ Those with neurogenic shock classically have bradycardia. If the
patient’s blood pressure does not improve after a fluid challenge,
and no sites of occult hemorrhage are found, the judicious use of
vasopressors may be indicated after moderate volume
replacement. Phenylephrine hydrochloride, dopamine, or
norepinephrine is recommended. Atropine may be used to
counteract hemodynamically
significant bradycardia. Overzealous fluid administration can
cause pulmonary edema in patients with neurogenic shock. If the
patient’s fluid status is uncertain, ultrasound estimation of volume
status or invasive monitoring may be helpful. Insert a urinary
catheter to monitor urinary output and prevent bladder
distention .
➢ Priapism is a strong predictor of severe
cord injury even in intubated patients
Source = B&L 27th pg 332, 352
2013/09
A 40 year old man met with a head on collision with a vehicle. He is complaining of L/S chest pain. Pulse
rate is 130/min and blood pressure is 90/80 mmHg. There is abdominal tenderness. What is/are the
probable causes for the above presentation?
a. Cardiac tamponade – T – this patient can have cardiac tamponade because he has hypotension,
tachycardia and chest pain. Other signs should be looked for
b. Diaphragmatic injury- T – Diaphragmatic injuries can present with many nonspecific features
c. Massive Haemothorax - T - high velocity trauma, chest pain with haemorrhagic shock supports
Massive haemothorax. Further signs should be looked for.
d. Splenic rupture – T – can be there because he has abdominal tenderness and harmorrhagic
shock.
e. Tension pneumothorax – F – unlikely, A tension pneumothorax severe enough to produce
hypotension should have a marked respiratory symptoms , which are not mentioned.

Answers (source= Dr Arul, Surgery Registrar)

TTTTF
a. Cardiac tamponade is characterized by Beck’s triad; Hypotension, Elevated JVP, Muffled heart
sounds. Pulsus paradoxus, tachycardia and chest pain may also occur. (source – Praveen )
b. Diaphragmatic injuries are almost always occurred in left side. In diaphragmatic rupture
Abdominal contents herniate to the thoracic cavity. Symptoms and signs of Diaphragmatic
injuries are very nonspecific and high index of suspicion is needed. (source B&L Pg. 370)
c. Massive Haemothorax Presentation is with haemorrhagic shock, flat neck veins, unilateral
absence of breath sounds and dullness to percussion. The initial treatment consists of correcting
the hypovolaemic shock, insertion of an intercostal drain and, in some cases, intubation. Initial
drainage of more than 1500 mL of blood or ongoing haemorrhage of more than 200 mL/h over
3–4 hours is generally considered an indication for urgent thoracotomy.
d. Splenic rupture can produce haemorrhagic shock, and abdominal tenderness.
e. Tension Pneumothorax The clinical presentation is dramatic. The patient is increasingly restless
with tachypnoea, dyspnoea and distended neck veins (similar to pericardial tamponade). Clinical
examination may reveal tracheal deviation; this is a late finding and is not necessary to clinically
confirm diagnosis. There will also be hyper-resonance and decreased or absent breath sounds
over the affected hemithorax
2013/10
Bone Pathology and Related Anatomical site,
a. Acute osteomyelitis in children – Diaphysis – F
b. Ewing’s sarcoma – Metaphysis- F
c. Giant cell tumour – Epiphysis - T
d. Osteosarcoma – Metaphysis - T
e. Pott’s disease – Lumbar spine - T
Answers ( source = Robbins Basic pathology 9th edition)
FFTTT
a. Acute pyogenic osteomyelitis site of origin in bone;
i. Neonates→ Metaphysis of long bones +/- Epiphysis
ii. Children → Metaphysis of long bones
iii. Adults → Metaphysis + Epiphysis

In Neonates and Adults (elderly) septic arteritis secondary to osteomyelitis is more likely than in
children.

b. Ewing Sarcoma – A malignant tuour. M>F. Most common in 10-20 yrs of age. Medullary cavity of
Diaphysis of bones; especially in Femur, Tibia and pelvic bones.
c. Giant Cell tumour (Osteoclastoma) – Benign locally aggressive tumour. Can Metastasize to lung.
Soap bubble appearance. F>M 20-40 years. Epiphysis of long bones, especially Distal femur,
proximal Tibia.
d. Osteosarcoma – Malignant. 2 types; Primary and secondary. Primary osteosarcoma M>F, 10-25
yrs olds, Haematogenous spread, Medullary cavity of Metaphysis and proximal diaphysis of long
bones, distal femur, proximal tibia, hip, proximal humerus.
e. Pott’s Disease – Spinal tuberculosis, Synovium of the intervertebral joints is initially affected
(Reason , Tb is an aerophilic organism ). Usually involve upper lumbar and lower thoracic regions
of the vertebral column.
2013/11.

Regarding chronic urinary retention,

a. Seen with high prostate volume -T

b. It should be treated by immediate catheterization -F
c. Patient is unable to pass urine - F (can pass, but cant empty completely.)
d. Residual volume is more than 300ml -T
e. Usually signifies detrusor muscle failure -T

Answer (oshan ayya )

TFFTT
Very good question and please remember this answer for rest of your life since most of the doctors are
not aware of this.. After caterization, you need to measure the initial output which was retained. When
it's more than 1 liter, usually due to chronic retention...
problems of sudden decompression are
1. Post decompression haematuria
2.Post obstructive diuresis
For Tx
1.haematuria.. now there is no evidence to support gradual decompression and need to observe and if
haematuria is not settling... insert a 3way catheter and irrigate...
2. Post obstructive diuresis
Measure hourly UOP
If it's >200cc per hr, need to replace half of the volume OF previous hour by IV
Monitor creatinine and electrolytes- imbalance can occur...

2013/12.
A 60 year old male presented with dysuria, hesitancy and poor urine flow. On examination prostate
enlargement was noted. Which of the following is/are true regarding management of this patient?
a. Alpha adrenergic receptor antagonist – T- Has an immediate reaction
b. Cystoscopy - T
c. Elective catheterization - F
d. Transurethral prostatectomy - F
e. USS KUB – T - to exclude complications like hydronephrosis or hydroureter)
Answers
TTFFT
2013/13.
Regarding parotid gland tumors,
a. Enucleation is done for benign tumors - F
b. Facial nerve palsy is suggestive of pleomorphic adenoma - F
c. Gustatory sweating is a feature of malignancy - T
d. Incisional biopsy is contraindicated - T
e. Mucoepidermoid carcinoma is the commonest type of parotid gland tumor - F

Answers (Oshan aiya :)

FFTTF

a. F; not indicated due to risk of capsular damage,superficial conservative parotidectomy is done

for pleomorphic adenomas since most arises from superficial lobe.
b. F; ( pleomorphic adenoma is the commonest benign tumour, muco epidermoid carcinoma is the
commonest malignant tumour)
c. T
d. T , to avoid seeding of tumour cells.
e. F; (in parotid gland , benign ones are commoner than malignant ones)

2013/14.
Regarding hernia,
a. Direct inguinal hernia occurs due to weakness of the transversalis fascia - T
b. Femoral hernia is situated below and lateral to the pubic tubercle -T - inguinal hernia above and
medial
c. Indirect inguinal hernia can be controlled by applying pressure on the deep inguinal ring - T
d. Mesh repair is the treatment of choice in open hernia repair - T
e. Strangulation is rare in femoral hernia -F - highest because femoral hernia has the narrowest
neck)
Answers
TTTTF

2013/15.
Regarding exposure to chronic ionizing radiation,
a. Breast has more malignant transformation potential than the thyroid gland – F- (ionizing
radiation is a known risk factor for papillary cancer)
b. Cataract occur due to occupational exposure - T
c. Localised radiotherapy causes more damage than scattered radiotherapy – F - localized
therapies such as brachytherapy are preferred to minimize adjacent tissue damage.
d. Causes lymphoma - T
e. Causes subfertility - T
Answers
FTFTT
16. Regarding drains in surgical procedures,
a. Under water seal bottle is used to drain pleural cavity - T - it allows air to leave pleural cavity
but can not be drawn back in by the negative pressure created in the intrathoracic cavity

b. Expedites wound healing - T - adequate fluid drainage prevents development of cavities or

spaces that may delay wound healing

c. Used to detect postoperative blood loss - T - as a signal of postoperative haemorrhage or

anastomotic leakage

d. Used to identify anastomotic leakage – T

e. When removing, negative pressure should be maintained throughout the procedure - F -

suction should be taken off prior to removal

Answers (Source - Bailey and love : Drains page 99-101, 27th edition)
TTTTF

17. A 45 year old woman waiting for emergency laparotomy for peritonitis due to perforated bowel.
What is/are true regarding the anesthetic mx of this patient,
a. Extubation is safer in lateral position than in supine position - T
b. Intubation with a non-depolarizing muscle relaxant - F?
c. Laryngeal mask airway is appropriate -F
d. Rapid sequence induction can be carried out - T
e. Six hours fasting ensures gastric emptying- F
Answers (source, Anaesthesia handbook)
T_FTF
a) T - When with full stomach extubate awake with bucking on ett in left lateral position
b) F? - Intubation with non depolarising muscle relaxant for predicted easy airway
c) LMA is contraindicated in full stomach as aspiration may occur.
d) T - RSI using a predetermined dose of iv anaesthetic agent with rapidly acting muscle relaxant
is used for those with high risk for regurgitation to secure airway quickly and commonly for
emergencies and in non emergent situations For those with delayed gastric emptying
e) F - with delayed gastric emptying this won't happen
18. Regarding sepsis,
a. Colloid is the fluid of choice - F
b. Empirical antibiotics should be started before the blood culture - F
c. It is a systemic inflammatory reaction involving multi organ system dysfunction due to
exaggerated host response - T
d. Noradrenaline is the vasoconstrictor of choice - T
e. qSOFA is used for early recognition of sepsis – T

Answer (Source - Vihara madam's article)

FFTTT

a) F- guideline recommends an initial fluid bolus of crystalloids such as 0.9% normal saline 30ml/kg as
the initial fluid of choice in the resuscitation of severe sepsis and septic shock. If excessive fliud is
needed albumin can be considered during resuscitation

b) F- Cultures must be obtained prior to commencing antibiotic therapy, provided that there is no
significant delay (> 45 minutes) in the start of antimicrobials

c) T- Sepsis was re-defined in 2016 as a life threatening organ dysfunction due to a dysregulated host
response to infection. Organ dysfunction is defined as an increase (an acute change of 2 points or
greater) in the sequential organ failure assessment (SOFA) score

d) T - Norepinephrine is considered to be the vasopressor of choice in septic shock.

e) T - quick SOFA comprising of three variables to enable clinicians to identify patients with suspected
infection who are been treated outside critical care units and likely to develop complications of
sepsis.This index can be used to “track and trigger”, similar to the early warning score.

19. A 30 year old female presented with iliofemoral DVT one week after C-section. Regarding her
management?
a. Breastfeeding is not recommended - F - warfarin is safe during breastfeeding
b. Early mobilization is not recommended - F - mobilization is recommended
c. Long term aspirin is recommended - F - long term anticoagulation
d. Commence treatment with heparin - T - Initial management with lmwh or ufh
e. Warfarin therapy must be continued for at least 3 months - T - postevent warfarin is for at
least 3 months
Answers (Source - Oxford gyn n obs and Bailey)
FFFTT
20. A medical officer plans a study to assess the cosmetic outcome of the non-absorbable subcuticular
suture compared to absorbable suture. With regard to this research
a. Blinding the assessor is not feasible - F
b. Ethical review is not mandatory - F
c. Verbal consent is adequate - F
d. Retrospective study is better than prospective study - F
e. Sample size is calculated before doing the surgery. - T
Answers ( Dr Ashan Pathirana – Reg– Community medicine)
FFFFT