General Surgery & Ortho Cheats

Cheatsheet Content

### Breast Lump: Provisional Diagnosis & Investigations **Q1. A 50-year-old female patient presented in surgery OPD with a lump 3x3 cm in right breast, noticed 5 days back, which is non-tender, hard in consistency with irregular surface, margins ill-defined and fixed to the breast tissue.** #### a) Provisional Diagnosis and Favorable Points (2 marks) * **Provisional Diagnosis:** Carcinoma Breast (likely Invasive Ductal Carcinoma) * **Points in favour:** * Age (50 years old, increased risk) * Recent onset (5 days back) * Non-tender * Hard consistency * Irregular surface * Ill-defined margins * Fixed to breast tissue (suggests local invasion) #### b) Investigations to Confirm Diagnosis (3 marks) 1. **Clinical Breast Examination (CBE):** Detailed assessment of the lump and axillary lymph nodes. 2. **Radiological Examination (Imaging):** * **Mammography:** Essential for women >35-40 years, helps characterize the lump (e.g., spiculated margins, microcalcifications). * **Ultrasound (USG) Breast:** Useful for differentiating solid from cystic lesions, assessing density, and guiding biopsies. Also used for younger women ( ### Short Notes on Breast Conditions (5x2 marks) #### a) Fibroadenoma Breast * **Definition:** Most common benign solid tumor of the breast, typically seen in young women (20s-30s). * **Pathology:** Biphasic tumor composed of both epithelial and stromal components. * **Clinical Features:** * Painless, firm, rubbery, mobile (classic "breast mouse") lump. * Well-defined, smooth margins. * Usually solitary but can be multiple. * Does not typically change with menstrual cycle. * **Diagnosis:** Triple assessment (CBE, USG, FNAC/Core biopsy). USG shows well-circumscribed, oval hypoechoic mass. * **Management:** * Observation for small, asymptomatic, confirmed benign lesions. * Excision if large, growing, symptomatic, or patient preference/anxiety. #### b) Breast Abscess * **Definition:** Localized collection of pus within the breast tissue. * **Etiology:** Most commonly occurs in lactating women (puerperal mastitis) due to bacterial infection (Staphylococcus aureus) entering through cracked nipples. Non-puerperal abscesses can occur, often associated with periductal mastitis. * **Clinical Features:** * Painful, tender, hot, red, fluctuating lump in the breast. * Fever, chills, malaise. * Skin may be shiny and edematous. * Associated with nipple discharge if periductal. * **Diagnosis:** Clinical examination, USG (shows fluid collection). * **Management:** * **Antibiotics:** Broad-spectrum, covering S. aureus (e.g., Flucloxacillin). * **Drainage:** * **Needle aspiration:** Repeated aspiration under USG guidance is preferred. * **Incision and drainage:** For large or recurrent abscesses, usually reserved if needle aspiration fails. * Continue breastfeeding from the unaffected breast; may continue from the affected breast if not too painful and drainage is effective. #### c) Cystosarcoma Phyllodes * **Definition:** Rare fibroepithelial tumor of the breast, characterized by leaf-like projections into cystic spaces. Can be benign, borderline, or malignant. * **Epidemiology:** Occurs most commonly in women aged 40-50 years, slightly older than fibroadenomas. * **Clinical Features:** * Rapidly growing, large, firm, often painless breast mass. * Mobile, but can become fixed if very large. * Skin over the tumor may be stretched, thin, and shiny, with prominent veins. * **Pathology:** Characterized by hypercellular stromal overgrowth and leaf-like projections. Malignant phyllodes tumors can metastasize hematogenously (lungs, bone), but rarely to axillary lymph nodes. * **Diagnosis:** Core needle biopsy is essential, but often difficult to differentiate from fibroadenoma on FNAC or small core biopsies. Excisional biopsy is often required for definitive diagnosis. * **Management:** * **Wide local excision:** With a clear margin of healthy tissue (at least 1 cm) due to local recurrence risk. Mastectomy may be required for large tumors or positive margins. * Axillary lymph node dissection is generally not indicated unless there is clinical suspicion of nodal involvement, as lymphatic spread is rare. * Adjuvant radiotherapy or chemotherapy may be considered for high-grade or recurrent malignant phyllodes tumors, but their role is debated. ### Multiple Choice Questions: General Surgery (1x5 marks) i) **Blood stained nipple discharge is seen in** * c) Duct papilloma (Correct. Intraductal papilloma is the most common cause of blood-stained nipple discharge.) ii) **Best diagnostic method for breast lump** * c) Biopsy (Correct. While imaging aids in characterization, biopsy provides definitive histological diagnosis.) iii) **Carcinoma breast is most commonly seen in which quadrant of breast** * b) Upper outer quadrant (Correct. Approximately 50% of breast cancers occur here due to the largest amount of glandular tissue.) iv) **Triple assessment of breast includes** * d) Clinical breast examination, Radiological examination and pathological examination. (Correct. This is the standard diagnostic approach.) v) **BI-RADS stands for** * a) Breast imaging, reporting and data system (Correct. A standardized system for reporting mammography findings.) ### Charcot's Triad & Acute Cholecystitis (1 mark each) **Q8. Charcot's Triad has the following:** * iv) All are correct (Correct. Charcot's triad consists of Right upper quadrant pain, fever and chills, and jaundice, indicating cholangitis.) **Q9. Acute cholecystitis** * iv) Only i,ii are correct. (Correct. Murphy's sign is positive and HIDA scan is positive. Management is often initial conservative treatment followed by planned cholecystectomy, not *always* conservative.) ### Anesthesia Part-C: Multiple Choice Questions (1 mark each) 1. **The following are Induction Agents used in General Anaesthesia except** * d) Atracurium (Correct. Atracurium is a neuromuscular blocker, not an induction agent. Propofol, Thiopentone, Ketamine are induction agents.) 2. **What is the minimum fasting period (in hours) for clear fluids before surgery** * a) 2 hrs (Correct. Current guidelines recommend 2 hours for clear fluids.) 3. **The commonest drug used for Subarachnoid Block is** * c) Bupivacaine (Correct. Bupivacaine is a commonly used long-acting local anesthetic for spinal anesthesia.) 4. **The following drugs are used as Adjuvant agents in regional anaesthesia except** * c) N-SAIDS (Correct. NSAIDs are analgesics but not typically used as adjuvants *in* regional anesthesia to prolong block. Fentanyl, Sufentanyl, Clonidine are used as adjuvants.) 5. **Which of the following drug is discontinued before operation** * a) Beta-Blockers (Incorrect - Beta-blockers are often continued, especially for cardiac patients. The question implies a drug that *must* be discontinued. Anticoagulants (not listed) are a prime example. From the given options, if a choice must be made on discontinuation, it's context-dependent. However, Beta-blockers are generally continued. N-SAIDS are often discontinued due to bleeding risk. Let's assume the intent was for something like anticoagulants or NSAIDs due to bleeding risk.) * *Correction/Clarification*: Beta-blockers are generally continued perioperatively. NSAIDs are often discontinued due to increased bleeding risk. Statins are usually continued. Antihypertensives are generally continued. Given the options, and common practice, NSAIDs would be the most likely answer if a drug needs to be discontinued to prevent complications like bleeding. As NSAIDs are an option for 4, and not for 5, this question is slightly ambiguous with the provided choices without further context. If forced to choose the *most likely* to be discontinued for surgical risk (e.g., bleeding), NSAIDs would be a strong candidate. However, as it's not an option, and Beta-blockers are usually continued, the question might be flawed or looking for a very specific scenario. Without further context, it's hard to definitively answer among the given choices if one *must* be discontinued. Assuming the question implies a drug with *significant* perioperative risk that mandates discontinuation, and looking at the common practice, none of these are *always* discontinued. Let's re-evaluate based on potential exam intent: if it's about bleeding risk, NSAIDs would be the answer. If it's about a drug that could cause profound hypotension *if not managed correctly*, some antihypertensives could be temporarily held. However, Beta-blockers and Statins are usually continued. ### Anesthesia Short Questions 1. **What are the Absolute Contraindications of Central Neuraxial Blocks? (2 Marks)** * Patient refusal * Coagulopathy / Anticoagulation (risk of epidural hematoma) * Severe hypovolemia / shock (risk of profound hypotension) * Increased intracranial pressure (risk of brain herniation) * Local infection at the site of injection (risk of meningitis/abscess) * Sepsis / bacteremia (risk of meningitis/abscess) * Allergy to local anesthetics * Severe uncorrected anatomical abnormalities of the spine 2. **What is Mallampati Classification? (2 Marks)** * The Mallampati classification is a system used to assess the visibility of the soft palate, uvula, tonsillar pillars, and tongue when the patient opens their mouth and protrudes their tongue. It is a predictor of difficult endotracheal intubation. * **Class I:** Full visibility of soft palate, uvula, and tonsillar pillars. * **Class II:** Visibility of soft palate and uvula. * **Class III:** Visibility of soft palate and base of uvula. * **Class IV:** Only hard palate visible, no soft palate or uvula. * Higher classes (III and IV) indicate a higher likelihood of difficult intubation. ### Ortho: Acute Osteomyelitis (3+2+2 marks) **1. Describe the aetiopathogenesis, clinical features and treatment of acute osteomyelitis.** #### Aetiopathogenesis: * **Definition:** Acute osteomyelitis is an acute inflammatory process of the bone and bone marrow, usually caused by infection. * **Causative Organisms:** Most commonly *Staphylococcus aureus* (80-90%). Other organisms include *Streptococcus pyogenes*, Gram-negative bacteria (e.g., *E. coli*, *Pseudomonas*), and *Salmonella typhi* (especially in sickle cell disease). * **Routes of Infection:** * **Hematogenous spread (most common in children):** Bacteria enter the bloodstream from a distant focus (e.g., skin infection, tonsillitis) and lodge in the metaphyseal capillaries of long bones, particularly prone to infection due to sluggish blood flow. * **Direct inoculation:** Trauma (open fractures), surgery (internal fixation), puncture wounds. * **Contiguous spread:** From adjacent soft tissue infection (e.g., diabetic foot ulcers). * **Pathogenesis:** * Bacterial colonization leads to inflammation, edema, and pus formation within the rigid bone structure. * Increased intraosseous pressure compromises blood supply, leading to bone necrosis (sequestrum formation). * Periosteum may be lifted, forming a new bone sheath called involucrum. * Pus can track through the cortex to form subperiosteal abscesses or sinus tracts. #### Clinical Features: * **Systemic:** * High fever, chills, malaise. * Increased white blood cell count (leukocytosis), elevated ESR and CRP. * **Local:** * Severe, throbbing pain over the affected bone, often worse at night. * Swelling, redness, warmth, and tenderness over the affected area. * Reluctance to move the affected limb (pseudoparalysis in infants). * In children, metaphyseal involvement of long bones (femur, tibia, humerus) is common. #### Treatment: * **Antibiotics:** * **Empirical:** Start immediately after cultures are taken, typically broad-spectrum IV antibiotics covering *S. aureus* (e.g., Flucloxacillin, Cefazolin). * **Culture-guided:** Adjust antibiotics based on culture and sensitivity results. * **Duration:** Minimum 4-6 weeks, often longer for chronic cases, to ensure eradication of infection from bone. * **Surgical Debridement:** * Indicated if there is pus collection (subperiosteal or intraosseous abscess), sequestrum formation, or failure of antibiotic therapy. * Involves incision and drainage, removal of necrotic bone (sequestrectomy), and irrigation. * **Immobilization:** Splinting or casting to reduce pain and prevent pathological fractures. * **Supportive Care:** Pain management, hydration, nutritional support. ### Ortho: Short Notes (2+2 marks each) #### a) Classification of Open Fracture * **Definition:** An open (or compound) fracture is a fracture in which the skin and soft tissues overlying the bone are disrupted, exposing the fracture site to the external environment. * **Gustilo-Anderson Classification (most common):** * **Type I:** Wound 1 cm, moderate soft tissue damage, without extensive flap or avulsion, moderate comminution. * **Type III:** Extensive soft tissue damage, high-energy injury. * **IIIA:** Adequate soft tissue coverage of bone, severe comminution, high energy. * **IIIB:** Extensive soft tissue loss with periosteal stripping and bone exposure, massive contamination. Requires soft tissue reconstruction. * **IIIC:** Arterial injury requiring repair, regardless of soft tissue damage. #### b) Complication of Open Fracture * **Early Complications:** * **Infection:** Most common and serious complication (osteomyelitis, cellulitis, gas gangrene). Risk increases with Gustilo type. * **Hemorrhage and Shock:** Due to extensive soft tissue injury and bone bleeding. * **Neurovascular Injury:** Damage to nerves or blood vessels, especially in high-energy trauma. * **Compartment Syndrome:** Increased pressure within a muscle compartment, leading to ischemia. * **Tetanus and Gas Gangrene:** Due to contamination. * **Late Complications:** * **Non-union / Delayed Union:** Failure or delay of bone healing, often due to infection, soft tissue interposition, or inadequate fixation. * **Malunion:** Healing of the fracture in an anatomically unacceptable position. * **Chronic Osteomyelitis:** Persistent bone infection. * **Amputation:** May be necessary in severe, uncontrolled infection or limb-threatening neurovascular injury. #### c) Treatment of Fracture Neck of Femur * **Definition:** A fracture of the femoral neck, occurring in the region between the femoral head and the intertrochanteric line. Common in elderly patients (osteoporosis). * **Goals of Treatment:** Preserve life, restore function, prevent complications (avascular necrosis, non-union). * **Factors influencing treatment:** Patient's age, general health, fracture displacement, activity level. * **Non-operative:** Rarely used, only for non-ambulatory patients or those with prohibitive surgical risk. * **Operative Treatment (preferred):** * **Internal Fixation (e.g., Cannulated Screws, Dynamic Hip Screw):** * Indicated for younger patients ( ### Ortho: True or False (1 mark each) a) **Treatment of open fracture by internal fixation like plating, nailing etc.** * **False.** While internal fixation can be used, it's often delayed in contaminated open fractures. Initial management focuses on debridement, irrigation, stabilization (often external fixation), and antibiotics. Internal fixation may be done after the wound is clean. b) **Total duration of antibiotic in acute osteomyelitis is 10 days.** * **False.** The total duration of antibiotics in acute osteomyelitis is typically 4-6 weeks, sometimes longer. c) **Commonest organism in acute osteomyelitis is staphylococcus.** * **True.** *Staphylococcus aureus* is the most common causative organism. d) **Sickle-cell disease are prone to infection by salmonella typhia in acute osteomyelitis.** * **True.** Patients with sickle cell disease are particularly susceptible to *Salmonella* osteomyelitis. ### Ortho Part-B (15 marks) **Q1. Classify Fractures. Write the management of open fractures. (5 Marks)** #### Classification of Fractures: Fractures can be classified based on several criteria: 1. **Based on Etiology:** * **Traumatic:** Caused by sudden, excessive force (most common). * **Pathological:** Occurs through bone weakened by underlying disease (e.g., tumor, osteoporosis, infection). * **Stress/Fatigue:** Result of repetitive, submaximal stress on normal bone. 2. **Based on Communication with Exterior (Skin Integrity):** * **Closed (Simple):** Skin is intact. * **Open (Compound):** Skin and soft tissues are breached, exposing the fracture to the environment. 3. **Based on Displacement:** * **Undisplaced:** Fracture fragments are in anatomical alignment. * **Displaced:** Fragments are out of alignment (e.g., translated, angulated, rotated, distracted, overriding). 4. **Based on Fracture Pattern:** * **Transverse:** Fracture line perpendicular to the long axis of the bone. * **Oblique:** Fracture line at an angle to the long axis. * **Spiral:** Fracture line spirals around the bone (often due to torsional forces). * **Comminuted:** Bone broken into three or more fragments. * **Segmental:** Two or more complete fracture lines isolating a segment of bone. * **Greenstick (children):** Incomplete fracture, bone bends and breaks on one side. * **Avulsion:** Fragment of bone pulled off by a ligament or tendon. * **Impacted:** Fragments driven into each other. 5. **Based on Anatomical Location:** * Diaphyseal (shaft), Metaphyseal (end of shaft), Epiphyseal (growth plate/end of bone), Intra-articular (involving a joint surface). #### Management of Open Fractures: Open fractures are surgical emergencies due to the high risk of infection. The management aims to prevent infection, achieve fracture healing, and restore function. 1. **Initial Assessment & Resuscitation (ATLS Principles):** * Address life-threatening injuries first. * Control bleeding (direct pressure, tourniquet if necessary). * Assess neurovascular status of the limb. 2. **Wound Care & Antibiotics:** * **Sterile dressing:** Cover the wound with a sterile, moist dressing. Do NOT attempt to reduce the fracture in the field. * **Tetanus prophylaxis:** Administer if immunization status is unknown or incomplete. * **Broad-spectrum IV antibiotics:** Administer immediately (within 3 hours) to cover Gram-positive and Gram-negative bacteria (e.g., Cefazolin + Gentamicin, or Flucloxacillin + 3rd generation Cephalosporin). Duration typically 3-5 days post-closure/debridement. 3. **Surgical Debridement & Irrigation (within 6-8 hours):** * **Thorough debridement:** Remove all devitalized tissue, foreign bodies, and contaminated bone fragments. This is the most crucial step in preventing infection. * **High-pressure irrigation:** With copious amounts of saline. * **Wound excision:** Convert irregular, contaminated wound edges into clean, viable margins. 4. **Fracture Stabilization:** * **External Fixation:** Often preferred for initial stabilization, especially in Gustilo Type II and III fractures, as it allows access to the wound for dressings and future soft tissue procedures, and is less likely to become infected. * **Internal Fixation (ORIF - plates, screws, intramedullary nails):** May be considered for Type I fractures or after the wound is clean and healthy (delayed primary closure, or secondary closure) in more severe types. 5. **Soft Tissue Coverage:** * **Primary Closure:** Only for very clean Type I wounds if possible without tension. * **Delayed Primary Closure:** After 2-5 days, once the wound is clean and healthy. * **Flap Reconstruction:** For extensive soft tissue loss (Gustilo Type IIIB), requiring plastic surgery. 6. **Rehabilitation:** Early mobilization and physiotherapy as appropriate, once the fracture is stable and pain allows. **Q2. MCQ [2X5=10 Marks]** i) **Fracture in children is called as** * c. Greenstick Fracture (Correct. Greenstick fractures are incomplete fractures common in children due to their more flexible bones.) ii) **All of the following are true about primary bone union except** * a. Good amount of callus is formed (Correct. Primary bone union occurs with absolute stability and direct bone healing, with minimal or no visible callus formation. Callus is characteristic of secondary bone union.) iii) **All are true about type 3 open fractures except:** * b. Minimal contamination (Correct. Type III open fractures are characterized by extensive soft tissue damage and usually massive contamination, not minimal.) iv) **ORIF Stands for** * c. Open reduction and Internal fixation (Correct. A common surgical procedure for fracture management.) v) **The Surest sign of fracture is** * b. Crepitus (Correct. While pain, swelling, and deformity are strong indicators, crepitus (a grating sound/sensation) on palpation is considered a definitive clinical sign of fracture due to bone fragments rubbing together.) ### General Surgery Part-A: Breast Swelling (10 marks) **Q1. A 20yrs old unmarried girl came to surgery OPD with chief complaints of swelling in left breast, noticed while taking bath which is painless. On examination a freely mobile solitary lump of about 3X2 cm in the outer and lower quadrant of left breast present. No tenderness.** #### A. What is your diagnosis? (1 mark) * **Diagnosis:** Fibroadenoma Breast #### B. What make you come to this diagnosis and what is the other name of this disease? (3 marks) * **Points in favour of diagnosis:** * **Age:** 20 years old (common age for fibroadenomas). * **Sex:** Female. * **Nature of lump:** Painless, freely mobile, solitary lump. * **Consistency:** Implied to be firm/rubbery (typical for fibroadenoma, though not explicitly stated as hard like in carcinoma). * **No tenderness:** Suggests benign nature. * **Other name of this disease:** Breast mouse, Adenofibroma. #### C. Enumerate the investigation to confirm you diagnosis? (2 marks) 1. **Ultrasound (USG) Breast:** Preferred imaging for young women, shows a well-circumscribed, oval, hypoechoic mass. 2. **Fine Needle Aspiration Cytology (FNAC) or Core Needle Biopsy (CNB):** To obtain cellular/tissue diagnosis and confirm benign nature. 3. **Clinical Breast Examination (CBE):** As already performed, it guides further investigation. * *Note: Mammography is generally not indicated in this age group unless USG and biopsy are inconclusive, due to breast density and radiation exposure.* #### D. What will be your treatment? (4 marks) * **Conservative Management / Observation:** * For small, asymptomatic, and unequivocally benign lesions confirmed by triple assessment (CBE, USG, and FNAC/CNB). * Regular follow-up (e.g., 6-12 months) with clinical examination and USG to monitor for changes in size or characteristics. * **Surgical Excision:** * Indicated if: * The lump is large (>3-4 cm) or rapidly growing. * Patient preference or significant anxiety. * Pain or discomfort. * Diagnosis is equivocal or suspicious for phyllodes tumor on biopsy. * Cosmetic concerns. * The procedure is typically a lumpectomy or excisional biopsy, performed under local or general anesthesia. ### Thyroid Gland: Blood Supply, Carcinoma Types, Pre-op Management & Post-op Complications (2+1+2+2 marks) **Q2. Illustrate the Blood supply of thyroid Gland. Mention the types of Carcinoma of thyroid. Discuss the Pre-operative management of a patient with thyroid carcinoma presenting with hyperthyroid features. Enumerate the Post-operative complications after total Thyroidectomy.** #### Blood Supply of Thyroid Gland (2 marks) * **Superior Thyroid Artery:** First branch of the external carotid artery. Supplies the upper pole and anterior surface. Accompanied by the external laryngeal nerve (close to the superior pole). * **Inferior Thyroid Artery:** Branch of the thyrocervical trunk (from the subclavian artery). Supplies the lower pole and posterior surface. Closely associated with the recurrent laryngeal nerve (often runs posterior or through its branches). * **Thyroid Ima Artery (variable):** May arise directly from the brachiocephalic artery or arch of aorta, supplying the isthmus. * **Venous Drainage:** * **Superior Thyroid Vein:** Drains to the internal jugular vein. * **Middle Thyroid Vein:** Drains to the internal jugular vein. * **Inferior Thyroid Vein:** Drains into the brachiocephalic (innominate) veins. #### Types of Carcinoma of Thyroid (1 mark) 1. **Differentiated Thyroid Carcinomas (DTC):** (Most common, good prognosis) * **Papillary Thyroid Carcinoma (PTC):** Most common (80%), often multifocal, lymphatic spread. * **Follicular Thyroid Carcinoma (FTC):** Second most common (10-15%), hematogenous spread. * **Hurthle Cell Carcinoma:** A variant of FTC, more aggressive. 2. **Medullary Thyroid Carcinoma (MTC):** (5-10%), arises from parafollicular C cells, produces calcitonin, associated with MEN 2 syndrome. 3. **Anaplastic (Undifferentiated) Thyroid Carcinoma (ATC):** (1-2%), highly aggressive, poor prognosis. 4. **Lymphoma of Thyroid:** Rare. #### Pre-operative Management of Thyroid Carcinoma with Hyperthyroid Features (2 marks) * This refers to a patient with thyroid cancer who also has thyrotoxicosis (e.g., Graves' disease coexisting with a nodule, or a toxic nodule which is cancerous). It's crucial to achieve euthyroid state before surgery to prevent "thyroid storm." 1. **Antithyroid Drugs (ATDs):** Propylthiouracil (PTU) or Methimazole to block thyroid hormone synthesis. 2. **Iodine (Lugol's iodine or Saturated Solution of Potassium Iodide - SSKI):** Given for 7-10 days pre-operatively. Decreases thyroid vascularity and gland size, and inhibits hormone release (Wolff-Chaikoff effect). 3. **Beta-blockers (e.g., Propranolol):** To control adrenergic symptoms of hyperthyroidism (tachycardia, tremors, anxiety). 4. **Monitor Thyroid Function Tests:** Ensure patient is euthyroid before surgery. #### Post-operative Complications after Total Thyroidectomy (2 marks) 1. **Hypocalcemia:** Due to inadvertent removal or damage to the parathyroid glands, leading to parathyroid insufficiency. Can be transient or permanent. 2. **Recurrent Laryngeal Nerve (RLN) Injury:** * **Unilateral:** Hoarseness, dysphonia (vocal cord paralysis). * **Bilateral:** Aphonia, airway obstruction (stridor, respiratory distress), requiring tracheostomy. 3. **Hemorrhage / Hematoma:** Can cause airway compression, a surgical emergency. 4. **Infection:** Wound infection. 5. **Thyroid Storm:** Rare, but life-threatening, if hyperthyroidism was not adequately controlled pre-operatively. 6. **Tracheal Injury:** Rare. 7. **Hypothyroidism:** Inevitable after total thyroidectomy, requiring lifelong thyroid hormone replacement (levothyroxine). ### Right Upper Abdomen Pain, Fever, Chills, Rigor, Jaundice (10 marks) **Q3. A female patient of 45 years attended in the surgery OPD with the history of pain in the Right Upper abdomen & with fever, chills and rigor for last 2 days. She give the history of jaundice one month ago with similar attack.** #### 1. What will be the possible diagnosis? (1 mark) * **Possible Diagnosis:** Acute Cholangitis (likely due to Common Bile Duct (CBD) stones, given the history of jaundice and recurrent attacks). #### 2. How to investigate to get a final diagnosis? (2 marks) 1. **Blood Tests:** * **Complete Blood Count (CBC):** Leukocytosis with left shift (suggests infection). * **Liver Function Tests (LFTs):** Elevated bilirubin (direct predominant), elevated alkaline phosphatase (ALP), gamma-glutamyl transferase (GGT) (suggests cholestasis). * **Amylase/Lipase:** To rule out pancreatitis. * **Blood Cultures:** To identify causative organism and guide antibiotic therapy. * **Coagulation Profile (PT/INR):** Important before any invasive procedure. 2. **Imaging Studies:** * **Abdominal Ultrasound (USG):** First-line, can show dilated bile ducts, gallstones, CBD stones (if visible), gallbladder wall thickening. * **Magnetic Resonance Cholangiopancreatography (MRCP):** Non-invasive, highly sensitive for detecting CBD stones and assessing the biliary tree. * **Computed Tomography (CT) Scan Abdomen:** Useful for assessing complications, ruling out other pathologies, and in severe cases. * **Endoscopic Ultrasound (EUS):** Very sensitive for small CBD stones. 3. **Therapeutic/Diagnostic Procedure:** * **Endoscopic Retrograde Cholangiopancreatography (ERCP):** Gold standard for both diagnosis and treatment of CBD stones (sphincterotomy, stone extraction, stenting). #### 3. Describe the possible complications and treatment options for common bile duct stones. (3+4 = 7 marks, total 10 for Q3) ##### Possible Complications of Common Bile Duct Stones: 1. **Acute Cholangitis:** Infection of the bile ducts (as in this patient), can lead to sepsis and liver abscess. Charcot's triad (RUQ pain, fever, jaundice) or Reynold's pentad (Charcot's triad + hypotension + altered mental status) indicate severity. 2. **Acute Pancreatitis:** If the stone obstructs the ampulla of Vater, causing reflux of bile into the pancreatic duct or obstruction of the pancreatic duct. 3. **Obstructive Jaundice:** Persistent blockage of bile flow, leading to hyperbilirubinemia, pruritus, and fat malabsorption. 4. **Secondary Biliary Cirrhosis:** Chronic, untreated obstruction can lead to irreversible liver damage. 5. **Gallstone Ileus:** Rare, when a large gallstone erodes through the gallbladder wall into the bowel, causing intestinal obstruction. 6. **Mirizzi Syndrome:** External compression of the common hepatic duct by a stone impacted in the cystic duct or gallbladder neck. 7. **Choledocholithiasis without symptoms:** Can be asymptomatic for a long time before complications arise. ##### Treatment Options for Common Bile Duct Stones: 1. **Endoscopic Retrograde Cholangiopancreatography (ERCP):** * **Most common and preferred method.** * Involves passing an endoscope into the duodenum, cannulating the ampulla of Vater. * **Endoscopic Sphincterotomy:** Incision of the sphincter of Oddi. * **Stone Extraction:** Using a balloon or basket. * **Biliary Stenting:** Placement of a stent to ensure bile flow if stones cannot be removed or in cases of stricture/malignancy. * **Indicated for acute cholangitis:** Urgent ERCP with biliary drainage is life-saving. 2. **Laparoscopic Common Bile Duct Exploration (LCBDE):** * Performed surgically, usually at the time of laparoscopic cholecystectomy. * The CBD is opened (choledochotomy), and stones are extracted directly. 3. **Open Common Bile Duct Exploration:** * Rarely performed now, reserved for complex cases, failed ERCP/LCBDE, or when other open surgery is required. 4. **Medical Management:** * **Dissolution therapy (e.g., Ursodeoxycholic acid):** Only for small, cholesterol stones, very slow, and high recurrence rate. Not suitable for symptomatic patients or pigmented stones. 5. **Cholecystectomy:** Removal of the gallbladder (usually laparoscopic) is performed after CBD stones are cleared to prevent recurrence, as the gallbladder is typically the source of the stones. ### Short Note on: (5x4=20 marks) #### a) DVT (Deep Vein Thrombosis) * **Definition:** Formation of a blood clot (thrombus) in a deep vein, most commonly in the legs or pelvis. * **Etiology/Risk Factors (Virchow's Triad):** * **Venous Stasis:** Immobility (surgery, prolonged travel, paralysis), heart failure, obesity, old age. * **Endothelial Injury:** Trauma, surgery, central venous catheters, previous DVT. * **Hypercoagulability:** Malignancy, pregnancy, oral contraceptives, inherited thrombophilias (Factor V Leiden), inflammatory bowel disease. * **Clinical Features:** * Unilateral leg swelling (pitting edema). * Pain or tenderness, especially in the calf or thigh. * Warmth and erythema of the affected limb. * Homan's sign (pain on dorsiflexion of foot) is unreliable. * May be asymptomatic. * **Complications:** * **Pulmonary Embolism (PE):** Most serious, life-threatening complication, when a part of the thrombus dislodges and travels to the lungs. * **Post-thrombotic Syndrome:** Chronic leg pain, swelling, skin changes, and ulceration due to venous valve damage. * **Diagnosis:** * **D-dimer:** Elevated in DVT, but non-specific. Useful for ruling out DVT in low-probability patients. * **Duplex Ultrasonography:** Gold standard, non-invasive, visualizes the thrombus and assesses venous flow. * **Venography:** Invasive, rarely used now. * **Treatment:** * **Anticoagulation:** * Initial: Low molecular weight heparin (LMWH) or unfractionated heparin (UFH). * Long-term: Oral anticoagulants (e.g., Warfarin, DOACs like Rivaroxaban, Apixaban) for 3-6 months (or longer depending on risk factors). * **Thrombolysis:** For massive DVT with limb-threatening ischemia, or for extensive PE. * **Inferior Vena Cava (IVC) Filter:** For patients with contraindications to anticoagulation or recurrent PE despite adequate anticoagulation. * **Compression Stockings:** To reduce swelling and prevent post-thrombotic syndrome. * **Prevention:** Early mobilization, prophylactic anticoagulation (LMWH), graduated compression stockings, intermittent pneumatic compression devices in high-risk patients (e.g., post-surgery). #### b) Buerger's disease (Thromboangiitis Obliterans - TAO) * **Definition:** A rare, non-atherosclerotic, segmental inflammatory vasculitis affecting small and medium-sized arteries and veins of the extremities, leading to thrombosis and occlusion. * **Etiology:** Strongly associated with heavy tobacco use (smoking or chewing). Exact cause unknown, but genetic predisposition and autoimmune factors are implicated. * **Epidemiology:** Primarily affects young to middle-aged males (20-45 years). * **Clinical Features:** * **Claudication:** Pain in the feet or hands during exercise, relieved by rest. * **Rest Pain:** Severe pain in the affected extremity, even at rest, especially at night. * **Ischemic Ulcers/Gangrene:** Develop on digits (toes, fingers) due to severe ischemia, often very painful. * **Raynaud's Phenomenon:** Spasm of blood vessels, causing color changes in digits (white, blue, red). * **Phlebitis:** Superficial migratory thrombophlebitis (inflammation of superficial veins). * **Diminished/Absent Pulses:** In affected extremities. * **Diagnosis:** * Clinical presentation (young smoker with distal ischemia). * **Angiography:** Shows segmental occlusions, "corkscrew" collaterals, and normal proximal vessels. * Biopsy of affected vessels (rarely done) shows inflammatory changes. * Rule out other causes of vasculitis or thromboembolism. * **Treatment:** * **Absolute Cessation of Tobacco Use:** This is the most critical and often the only effective treatment to halt disease progression. * **Pain Management:** Analgesics, sympathetic blocks. * **Vasodilators:** Prostacyclin analogues (e.g., Iloprost) can improve symptoms and promote ulcer healing. * **Wound Care:** For ulcers. * **Amputation:** For non-healing ulcers or gangrene. * **Bypass Surgery:** Rarely feasible due to small vessel involvement. * **Spinal Cord Stimulation:** May be considered for severe rest pain. #### c) Mention five risk factor for Ischemic heart disease. 1. **Smoking:** Damages endothelium, promotes atherosclerosis, increases thrombosis. 2. **Hypertension (High Blood Pressure):** Increases workload on heart, damages arterial walls. 3. **Hyperlipidemia (High Cholesterol):** High LDL contributes to plaque formation. 4. **Diabetes Mellitus:** Accelerates atherosclerosis, increases inflammation and endothelial dysfunction. 5. **Obesity / Physical Inactivity:** Contributes to other risk factors like hypertension, diabetes, dyslipidemia. 6. **Family History:** Genetic predisposition. 7. **Age:** Risk increases with age. 8. **Male Sex:** Men generally have higher risk than premenopausal women. #### d) Compare the advantage and disadvantage of Valve repair and Valve replacement surgery in valvular diseases of the heart. ##### Valve Repair (Valvuloplasty): * **Advantages:** * Preserves the native valve, often resulting in better long-term ventricular function. * Avoids the need for lifelong anticoagulation (if mechanical valve replacement is avoided). * Lower risk of valve-related complications (thromboembolism, endocarditis) compared to prosthetic valves. * Better durability in some cases (e.g., mitral valve repair). * Lower mortality and morbidity in some studies. * **Disadvantages:** * Not applicable to all valve diseases or all patients (e.g., severely calcified or destroyed valves). * Requires a skilled cardiac surgeon. * Risk of residual regurgitation or stenosis, potentially requiring re-operation. * Durability can be an issue for some repaired valves (e.g., aortic valve repair is less durable than mitral). ##### Valve Replacement: * **Advantages:** * Applicable to a wider range of severely diseased or damaged valves. * Predictable hemodynamic results. * **Mechanical Valves:** Highly durable, suitable for younger patients. * **Bioprosthetic (Tissue) Valves:** Do not typically require lifelong anticoagulation (unless other indications exist), suitable for older patients or those with contraindications to anticoagulation. * **Disadvantages:** * **Mechanical Valves:** Require lifelong anticoagulation (Warfarin) to prevent thromboembolism, with associated risks of bleeding and regular INR monitoring. Audible clicking sound. * **Bioprosthetic Valves:** Limited durability (typically 10-15 years), prone to degeneration, often requiring re-operation (re-replacement). Higher risk of structural valve deterioration. * Increased risk of prosthetic valve endocarditis compared to native valves. * Higher risk of perioperative stroke compared to repair. * May result in less optimal ventricular function compared to native valve preservation. ### Very Short Note (2 marks each) #### a) Elaborate the pathogenesis of development of Multinodular Goitre. * **Pathogenesis:** Multinodular goiter (MNG) is thought to develop due to a combination of factors, primarily **iodine deficiency** (historical, but still relevant in some areas) and **genetic predisposition**. * **Thyroid cell heterogeneity:** Thyroid follicular cells are not uniform; some have inherent growth advantages. * **TSH stimulation:** Chronic, fluctuating TSH stimulation (due to relative iodine deficiency or intrinsic defects) leads to cycles of hyperplasia (growth) and involution (regression) in different areas of the gland. * **Clonal expansion:** Cells with growth advantage (e.g., activating mutations in TSH receptor or Gs-alpha protein) proliferate preferentially, forming nodules. * **Autonomy:** Over time, some nodules become functionally autonomous, producing thyroid hormone independent of TSH, which can lead to hyperthyroidism (toxic MNG). * **Fibrosis and degeneration:** Repeated cycles of growth and involution lead to areas of hemorrhage, cystic degeneration, and fibrosis, contributing to the multinodular appearance. #### b) Discuss the Eye signs associated with primary Thyrotoxicosis. * **Primary Thyrotoxicosis (Graves' Disease):** * **Lid Retraction (Dalrymple's sign):** Upper eyelid is pulled up, giving a "staring" appearance (due to sympathetic overactivity). * **Lid Lag (von Graefe's sign):** Upper eyelid lags behind the globe on downward gaze. * **Exophthalmos/Proptosis:** Protrusion of the eyeballs (due to retro-orbital inflammation, edema, and fat/muscle deposition). This is specific to Graves' ophthalmopathy and not just sympathetic overactivity. * **Periorbital Edema:** Swelling around the eyes. * **Chemosis:** Conjunctival edema. * **Diplopia:** Double vision (due to extraocular muscle involvement). * **Ophthalmoplegia:** Weakness or paralysis of eye muscles. * **Corneal Ulceration:** Due to exposure from severe exophthalmos and lid retraction. * **Loss of vision:** Due to optic nerve compression (rare, severe cases). * *Note: Lid retraction and lag can occur in any cause of thyrotoxicosis due to sympathetic overactivity, but true exophthalmos and other severe orbital signs are characteristic of Graves' ophthalmopathy.* ### MCQs: write down the correct answer. (1 mark each) **Q1. Name of the Lymph node present between the pectorals major and minor** * i) Rotter's Nodes (Correct. Also known as interpectoral nodes, located between the pectoralis major and minor muscles.) **Q2. What is the % of Ca. Breast arising from upper and outer quadrant** * iii) 50% (Correct. The upper outer quadrant contains the most glandular tissue and is the most common site for breast cancer.) **Q3. Which thyroid cancer arise from Neuroendocrine cell.** * iv) Medullary (Correct. Medullary thyroid carcinoma arises from the parafollicular C cells, which are neuroendocrine in origin and produce calcitonin.) **Q4. Most sensitive test for characterization of thyroid nodules.** * ii) USG (Correct. Ultrasound is highly sensitive for detecting thyroid nodules, assessing their characteristics (solid/cystic, calcifications, margins), and guiding biopsy.) * *Note: While FNAC gives a definitive diagnosis, USG is the most sensitive for initial detection and characterization before biopsy.* **Q5. Most important gene associated with Medullary Thyroid Carcinoma is** * iii) RET (Correct. Mutations in the RET proto-oncogene are strongly associated with both sporadic and hereditary forms of Medullary Thyroid Carcinoma.) **Q6. Caroli disease is...........** * ii) Multiple cysts on both the intrahepatic and extrahepatic bile ducts (Correct. Caroli disease is a rare congenital disorder characterized by segmental saccular or fusiform dilatation of the intrahepatic bile ducts. Caroli syndrome includes renal cystic disease and congenital hepatic fibrosis. Option ii seems to describe a broader or more severe form.) * *Self-correction: Caroli disease predominantly affects intrahepatic ducts. Option ii suggesting "both intrahepatic and extrahepatic bile ducts" might be including Caroli syndrome or a broader definition. However, among the given options, it's the closest description of a cystic dilatation of bile ducts. Option "It is Type IV choledochal cyst" is incorrect, as Type IV choledochal cysts involve both intrahepatic and extrahepatic ducts, but Caroli disease is primarily intrahepatic. Let's assume Option ii is the intended answer for a general description of multiple cystic dilatations associated with this condition.* **Q7. Hepatocellular Carcinoma treatment includes Trans Arterial Chemo embolization)** * iv) all the above. (Correct. TACE, Liver resection, and Liver Transplant are all established treatment modalities for Hepatocellular Carcinoma, depending on tumor stage and liver function.) ### Urology: Testicular Tumour (10 marks) **Q1. Describe classification, clinical features, investigations and principles of management of testicular tumour.** #### Classification: Testicular tumors are primarily classified into germ cell tumors and non-germ cell tumors. 1. **Germ Cell Tumors (GCTs) (90-95%):** Arise from germ cells of the testis. * **Seminoma:** * Classic (most common, 40-50%). * Anaplastic (more aggressive). * Spermatocytic (occurs in older men, good prognosis). * **Non-seminomatous Germ Cell Tumors (NSGCTs):** * Embryonal Carcinoma (aggressive, often mixed with other types). * Yolk Sac Tumor (Endodermal Sinus Tumor) (most common in children). * Choriocarcinoma (highly malignant, early hematogenous spread). * Teratoma (mature or immature). * Mixed Germ Cell Tumors (common, often containing elements of multiple types). 2. **Non-Germ Cell Tumors (5-10%):** * **Sex Cord-Stromal Tumors:** * Leydig Cell Tumor (can produce androgens or estrogens). * Sertoli Cell Tumor. * **Lymphoma:** Most common testicular tumor in men over 60. * **Metastatic Tumors:** Rare (e.g., prostate, kidney, lung). #### Clinical Features: 1. **Painless Scrotal Swelling/Lump:** Most common presentation. The lump is typically firm, non-tender, and does not transilluminate. 2. **Sensation of Heaviness:** In the scrotum. 3. **Dull Ache/Pain:** In the lower abdomen, groin, or scrotum (less common, usually indicates advanced disease or hemorrhage into the tumor). 4. **Hydrocele:** May be present in some cases, obscuring palpation of the tumor. 5. **Symptoms of Metastasis (advanced disease):** * **Retroperitoneal Lymph Nodes:** Back pain, abdominal mass. * **Lungs:** Cough, dyspnea, hemoptysis. * **Liver:** Abdominal pain, jaundice. * **Brain:** Headaches, neurological symptoms. * **Hormonal Symptoms (rare):** Gynecomastia (due to increased hCG or estrogen from some tumors), precocious puberty (in children with Leydig cell or Yolk sac tumors). #### Investigations: 1. **Clinical Examination:** Palpation of the scrotal contents, abdominal examination for masses, supraclavicular nodes. 2. **Scrotal Ultrasound (USG):** Gold standard for initial imaging. Confirms testicular origin of mass, differentiates solid from cystic, and assesses tumor characteristics. 3. **Tumor Markers (Blood Tests):** * **Alpha-fetoprotein (AFP):** Elevated in NSGCTs (Yolk sac, embryonal, teratoma). Not elevated in pure seminoma. * **Beta-human Chorionic Gonadotropin (β-hCG):** Elevated in choriocarcinoma, some embryonal carcinoma, and 10-20% of seminomas. * **Lactate Dehydrogenase (LDH):** Non-specific, elevated in bulky disease or high tumor burden. 4. **Staging Imaging:** * **CT Scan Abdomen/Pelvis:** To assess retroperitoneal lymph node involvement. * **CT Scan Chest:** To rule out lung metastases. * **MRI Brain:** If neurological symptoms or high-risk histology (choriocarcinoma). 5. **Biopsy:** Not usually performed due to risk of tumor spillage. Diagnosis is made after radical inguinal orchidectomy. #### Principles of Management: 1. **Radical Inguinal Orchidectomy:** * Initial diagnostic and therapeutic step. * Surgical removal of the entire testis, epididymis, and spermatic cord via an inguinal incision (to prevent scrotal contamination and ensure complete lymphatic drainage). * Pathological examination confirms diagnosis and histology. 2. **Staging:** Based on TNM (Tumor, Node, Metastasis) system and tumor markers. 3. **Adjuvant Therapy (post-orchidectomy, based on stage and histology):** * **Surveillance:** For low-stage seminoma and NSGCTs, with regular clinical exams, tumor markers, and imaging. * **Radiotherapy:** Highly effective for localized seminoma (retroperitoneal lymph node fields). * **Chemotherapy:** * **Platinum-based regimens (e.g., BEP - Bleomycin, Etoposide, Cisplatin):** Standard for advanced GCTs (both seminoma and NSGCTs). * Adjuvant chemotherapy for high-risk Stage I NSGCTs. * **Retroperitoneal Lymph Node Dissection (RPLND):** * May be performed for residual disease after chemotherapy in NSGCTs or for primary staging in selected Stage I NSGCTs. 4. **Sperm Banking:** Offered to patients before chemotherapy or radiation due to potential infertility. 5. **Prosthesis:** Testicular prosthesis can be offered for cosmetic reasons. 6. **Follow-up:** Long-term follow-up is crucial due to potential for recurrence. ### Urology: Short Notes (5x2 = 10 marks) #### a. Benign Prostatic Hyperplasia (BPH) * **Definition:** Non-malignant enlargement of the prostate gland, common in aging men, leading to lower urinary tract symptoms (LUTS). * **Etiology/Pathogenesis:** Age-related increase in androgen-to-estrogen ratio, dihydrotestosterone (DHT) stimulation of stromal and epithelial growth, and genetic predisposition. * **Clinical Features (LUTS):** * **Obstructive Symptoms:** Hesitancy, weak/intermittent stream, straining to void, feeling of incomplete emptying, post-void dribbling. * **Irritative Symptoms:** Frequency, urgency, nocturia. * **Complications:** Acute urinary retention, recurrent UTIs, bladder stones, hematuria, hydronephrosis, renal impairment. * **Diagnosis:** * **Digital Rectal Examination (DRE):** Enlarged, smooth, firm prostate. * **Urinalysis:** Rule out UTI, hematuria. * **Serum PSA:** To screen for prostate cancer (elevated in BPH, but also in cancer). * **Uroflowmetry and Post-void Residual (PVR) Volume:** Assess bladder emptying. * **Urodynamic studies:** If diagnosis is unclear. * **Management:** * **Watchful Waiting:** For mild symptoms. * **Medical Therapy:** * **Alpha-1 Adrenergic Blockers (e.g., Tamsulosin):** Relax smooth muscle in prostate and bladder neck, rapid symptom relief. * **5-alpha Reductase Inhibitors (e.g., Finasteride):** Shrink prostate by blocking DHT, takes longer to act, reduces PSA. * Combination therapy. * **Surgical Therapy (for moderate-severe symptoms, complications, or failed medical therapy):** * **Transurethral Resection of the Prostate (TURP):** Gold standard, endoscopic removal of prostatic tissue. * **Laser Prostatectomy:** Various laser techniques (e.g., HoLEP, GreenLight). * **Open Prostatectomy:** For very large glands. * Newer minimally invasive procedures (e.g., UroLift). #### b. Vaginal Hydrocele * **Definition:** A collection of serous fluid within the tunica vaginalis (the serous membrane surrounding the testis and epididymis). * **Types:** * **Congenital (Communicating):** Due to a persistent processus vaginalis, allowing peritoneal fluid to enter the scrotum. Common in infants and children. Fluid volume changes with position/activity. * **Acquired (Non-communicating):** Most common in adults. * **Primary (Idiopathic):** No identifiable cause. * **Secondary:** Due to inflammation/infection (epididymo-orchitis), trauma, testicular torsion, testicular tumor, filariasis, or post-surgery. * **Clinical Features:** * Painless, soft, smooth, elastic swelling in the scrotum. * Does not reduce spontaneously (unless communicating). * **Transilluminates:** (Distinguishes from solid masses like tumors). * Testis may be difficult to palpate. * Size may vary (communicating). * **Diagnosis:** * Clinical examination (transillumination test). * Scrotal Ultrasound: Confirms fluid collection, rules out underlying testicular pathology (especially for secondary hydroceles). * **Management:** * **Infants/Children (Congenital):** Often resolves spontaneously by 1-2 years of age. Surgical repair (ligation of processus vaginalis) if persistent beyond 1 year or symptomatic. * **Adults (Acquired):** * **Observation:** For small, asymptomatic hydroceles. * **Aspiration:** Temporary relief, but high recurrence rate. Risk of infection. * **Surgical Excision (Hydrocelectomy):** Definitive treatment for symptomatic or large hydroceles. Techniques include eversion of the sac (Jaboulay's) or excision of the sac (Lord's plication, Winkelmann's). * Treat underlying cause if secondary. #### c. Undescended testis (Cryptorchidism) * **Definition:** Failure of one or both testes to descend into the scrotum. The testis may be located anywhere along the normal path of descent (inguinal canal, abdomen) or be ectopic (outside the normal path). * **Epidemiology:** Affects about 3-5% of full-term male infants, but most descend spontaneously by 3-6 months. Persistent cryptorchidism affects ~1% of infants at 1 year. * **Etiology:** Multifactorial – hormonal (androgen deficiency), mechanical (abnormal gubernaculum), genetic. * **Types:** * **Palpable:** Inguinal canal, high scrotal. * **Non-palpable:** Abdominal, peeping (at internal ring), or absent (vanishing testis). * **Complications:** * **Infertility:** Impaired spermatogenesis due to higher temperature in abdomen/inguinal canal. Risk increases with bilateral or prolonged undescended testis. * **Malignancy:** Increased risk of testicular cancer (seminoma), even if surgically corrected, but orchidopexy allows for easier surveillance. * **Inguinal Hernia:** Often associated with a patent processus vaginalis. * **Testicular Torsion:** Increased risk due to abnormal fixation. * **Psychological Impact:** Empty scrotum. * **Diagnosis:** * Clinical examination: Palpation of scrotum, inguinal canal. * Imaging (for non-palpable testis): USG (limited for high testes), MRI, Laparoscopy (diagnostic and therapeutic). * **Management:** * **Observation:** Until 6 months of age (up to 1 year max) for spontaneous descent. * **Orchidopexy (surgical correction):** * Recommended between 6-12 months of age. * Involves bringing the testis down into the scrotum and fixing it. * For non-palpable testes, laparoscopy is often used to locate and then perform orchidopexy (single or two-stage). * **Orchidectomy:** If the testis is severely dysplastic or if found in an adult (to remove cancer risk). * **Hormonal therapy (hCG):** Rarely used, less effective than surgery. ### Urology: Short Notes (any five) (2x5 = 10 marks) #### a. Risk factors of carcinoma urinary bladder 1. **Smoking:** Most significant risk factor (aromatic amines). 2. **Occupational Exposure:** Aromatic amines (dyes, rubber, chemicals), petroleum products (e.g., painters, hairdressers). 3. **Chronic Bladder Inflammation/Infection:** * Schistosomiasis (Squamous Cell Carcinoma). * Recurrent UTIs, chronic catheter use. 4. **Previous Radiation Therapy:** To the pelvis. 5. **Certain Medications:** Cyclophosphamide (chemotherapy). 6. **Genetic Factors:** Family history. 7. **Age and Gender:** More common in older males. #### b. Phimosis * **Definition:** A condition where the foreskin (prepuce) of the penis cannot be fully retracted over the glans penis. * **Types:** * **Physiological Phimosis:** Normal in infants and young boys, foreskin gradually separates. Usually resolves by age 5-7. * **Pathological Phimosis:** Due to scarring from inflammation, infection, or trauma, causing the foreskin to become tight and non-retractile. * **Clinical Features:** Difficulty with hygiene, pain during erection, ballooning of foreskin during urination, recurrent balanitis (inflammation of glans). * **Complications:** Paraphimosis (foreskin trapped behind glans), UTIs, balanitis. * **Management:** * **Conservative:** Topical steroid creams (e.g., betamethasone) to stretch the foreskin (for physiological phimosis). * **Surgical:** Circumcision (definitive treatment) or preputioplasty (foreskin-sparing surgery) for pathological phimosis or failed conservative treatment. #### c. Etiology of urinary stones * **Multifactorial, often related to supersaturation of urine with stone-forming minerals.** 1. **Low Urine Volume/Dehydration:** Concentrates urine. 2. **Dietary Factors:** High intake of sodium, animal protein, oxalates (spinach, rhubarb), low calcium intake (paradoxically). 3. **Metabolic Disorders:** * **Hypercalciuria:** (Idiopathic, hyperparathyroidism). * **Hyperoxaluria:** (Dietary, malabsorption). * **Hyperuricosuria:** (Gout, high purine diet). * **Cystinuria:** Genetic disorder. 4. **Urinary Tract Infections (UTIs):** Urease-producing bacteria (e.g., Proteus) lead to struvite (magnesium ammonium phosphate) stones. 5. **Anatomical Abnormalities:** Urinary stasis (e.g., horseshoe kidney, UPJ obstruction, strictures). 6. **Medications:** Loop diuretics, some antacids, topiramate. 7. **Genetic Predisposition:** Family history. #### d. Horseshoe kidney * **Definition:** A congenital anomaly where the kidneys are fused at their lower poles (in ~90% of cases) across the midline, typically anterior to the aorta. * **Incidence:** ~1 in 400-800 live births. * **Clinical Significance:** * Often asymptomatic and discovered incidentally. * **Increased risk of complications due to abnormal anatomy and drainage:** * **Hydronephrosis:** Often due to ureteropelvic junction (UPJ) obstruction, as the ureters cross anterior to the isthmus. * **Urinary Tract Infections (UTIs):** Due to stasis. * **Kidney Stones:** Increased incidence. * **Renal Cell Carcinoma / Wilms' Tumor:** Slightly increased risk. * Vulnerable to trauma due to anterior position and lack of rib protection. * Associated with other congenital anomalies (e.g., Turner's syndrome). * **Diagnosis:** Imaging (USG, CT, IVU). #### e. Wilms' tumour (Nephroblastoma) * **Definition:** The most common renal malignancy in children, arising from primitive metanephric blastema. * **Epidemiology:** Peak incidence between 2-5 years of age. * **Clinical Features:** * **Asymptomatic Abdominal Mass:** Most common presentation, often discovered by parents during bathing. Firm, smooth, non-tender, rarely crosses the midline. * Abdominal pain, hematuria (10-20%), hypertension (due to renin secretion). * Fever, malaise, anorexia. * **Associated Syndromes:** WAGR syndrome (Wilms' tumor, Aniridia, Genitourinary anomalies, intellectual disability), Denys-Drash syndrome, Beckwith-Wiedemann syndrome. * **Diagnosis:** * **Abdominal Ultrasound:** Initial imaging, confirms renal origin. * **CT Scan Abdomen/Chest:** For staging, assesses extent of tumor, contralateral kidney, and lung metastases. * **Urinalysis:** For hematuria. * **Biopsy:** Not routinely performed pre-operatively as it can cause tumor spillage; diagnosis is usually confirmed after nephrectomy. * **Management:** * **Surgery (Nephrectomy):** Primary treatment, often followed by chemotherapy. * **Chemotherapy:** Pre-operative (neoadjuvant) to shrink large tumors, and post-operative (adjuvant) based on stage and histology. * **Radiotherapy:** For advanced stages or unfavorable histology. * Excellent prognosis with modern multidisciplinary treatment. #### f. Hematuria * **Definition:** Presence of blood in the urine. * **Types:** * **Gross Hematuria (Macroscopic):** Visible to the naked eye (red, pink, cola-colored urine). * **Microscopic Hematuria:** Not visible, detected on urinalysis (≥3 red blood cells per high-power field). * **Causes:** * **Urinary Tract Infections (UTIs):** Common, especially in women. * **Urinary Calculi (Stones):** Renal, ureteric, bladder stones. * **Trauma:** To kidneys, bladder, urethra. * **Glomerular Disease:** Nephritis, IgA nephropathy (typically microscopic hematuria, dysmorphic RBCs). * **Urological Malignancies:** Kidney cancer, bladder cancer, prostate cancer. *Any unexplained hematuria, especially in adults >40-50, must be investigated for malignancy.* * **Benign Prostatic Hyperplasia (BPH):** In older men. * **Medications:** Anticoagulants, NSAIDs. * **Renal Disease:** Polycystic kidney disease. * **Vascular Abnormalities:** Arteriovenous malformation. * **Investigation:** * Urinalysis, urine culture. * Blood tests (renal function, coagulation). * Imaging: Renal USG, CT Urography. * Cystoscopy (for bladder/urethral causes). * Nephrology referral for suspected glomerular disease. ### Orthopaedic: Supracondylar Fractures of Humerus in Children (8 marks) **Q1. Describe the mechanism of Injury, Classification, Clinical features, Treatment and Complications of Supracondylar fractures of humerus in children.** #### Mechanism of Injury (1 mark) * **Extension Type (most common, ~95%):** Fall onto an outstretched hand with the elbow hyperextended. The olecranon is driven into the olecranon fossa, causing the distal humerus to fracture just above the condyles. * **Flexion Type (rare, ~5%):** Fall onto the flexed elbow. #### Classification (1 mark) * **Gartland Classification (based on lateral X-ray):** * **Type I:** Undisplaced or minimally displaced fracture. Anterior humeral line (drawn along the anterior cortex of the humerus) passes through the middle third of the capitellum. * **Type II:** Displaced fracture with intact posterior cortex. Anterior humeral line passes *anterior* to the capitellum. Can be further subdivided: * IIA: Posterior cortex intact, good periosteal hinge. * IIB: Posterior cortex intact, periosteal hinge disrupted (rotational deformity). * **Type III:** Completely displaced fracture. No cortical contact, distal fragment is typically displaced posteriorly and often rotated. Anterior humeral line is completely anterior to the capitellum. * IIIA: No rotational deformity. * IIIB: Rotational deformity present. #### Clinical Features (2 marks) 1. **Pain:** Severe pain around the elbow. 2. **Swelling:** Rapid and significant swelling around the elbow, often extending into the forearm. 3. **Deformity:** Visible deformity (e.g., S-shaped elbow in extension type). 4. **Loss of Function:** Inability to move the elbow. 5. **Tenderness:** Localized tenderness over the supracondylar region. 6. **Neurovascular Assessment (CRITICAL):** * **Pulses:** Radial and ulnar pulses (check for absent or diminished pulses, indicating vascular compromise). * **Capillary Refill:** Prolonged refill suggests ischemia. * **Nerve Function:** Assess motor and sensory function of median, ulnar, and radial nerves. * Median nerve: "OK" sign (flexion of thumb and index finger). * Ulnar nerve: Finger abduction/adduction. * Radial nerve: Wrist extension, thumb extension. #### Treatment (2 marks) * **Goal:** Restore anatomical alignment, maintain reduction, and prevent complications. 1. **Type I (Undisplaced):** * **Immobilization:** Long arm cast or splint with the elbow in 90 degrees flexion for 3-4 weeks. 2. **Type II (Displaced, intact posterior cortex):** * **Closed Reduction and Percutaneous Pinning (CRPP):** Attempt closed reduction under fluoroscopy, then stabilize with K-wires (pins) inserted across the fracture fragments. Pins are typically removed in 3-4 weeks. * **Closed Reduction and Cast:** May be attempted for Type IIA with stable reduction, but CRPP is generally preferred to maintain reduction and allow for earlier mobilization. 3. **Type III (Completely Displaced):** * **Urgent Closed Reduction and Percutaneous Pinning (CRPP):** This is the standard treatment. Reduction is achieved by traction, flexion, and correction of rotation, then fixed with K-wires (medial and lateral pinning is common). * **Open Reduction and Internal Fixation (ORIF):** If closed reduction fails, for open fractures, or in cases of severe vascular compromise (especially if irreducible). * **Post-reduction:** Neurovascular status must be re-assessed immediately. #### Complications (2 marks) 1. **Vascular Injury:** * **Brachial Artery Injury:** Can lead to Volkmann's ischemic contracture (a severe forearm muscle contracture due to ischemia). Requires urgent reduction and often exploration/repair. * Compartment Syndrome: Can develop due to swelling or arterial injury. 2. **Nerve Injury:** * **Median Nerve:** Most commonly involved. * **Anterior Interosseous Nerve (AIN):** Branch of median nerve, often injured. * **Radial Nerve, Ulnar Nerve:** Less commonly involved. * Usually neurapraxia (temporary), but can be axonotmesis or neurotmesis (requiring repair). 3. **Malunion:** * **Cubitus Varus (Gunstock Deformity):** Most common malunion, elbow points inwards. Primarily cosmetic, but can lead to functional impairment. * Cubitus Valgus (less common). 4. **Non-union:** Rare. 5. **Stiffness:** Due to prolonged immobilization or heterotopic ossification. 6. **Infection:** With open fractures or pin-site infections. ### Orthopaedic: Short Notes (Any Three) (2x3 = 6 marks) #### i) P.I.V.D (Prolapsed Intervertebral Disc) * **Definition:** Displacement or herniation of the nucleus pulposus (inner gelatinous core) of an intervertebral disc through a tear in the annulus fibrosus (outer fibrous ring), often impinging on nerve roots or the spinal cord. * **Etiology:** Degenerative changes (age-related), trauma, heavy lifting, poor posture. Most common in lumbar spine (L4-5, L5-S1) and cervical spine (C5-6, C6-7). * **Clinical Features:** * **Back/Neck Pain:** Localized pain, often radiating. * **Radicular Pain (Sciatica or Brachialgia):** Sharp, shooting pain radiating along the dermatome of the compressed nerve root (e.g., down the leg in sciatica). * **Neurological Deficits:** Numbness, tingling (paresthesia), muscle weakness, diminished reflexes in the affected dermatome/myotome. * Exacerbated by coughing, sneezing, straining. * **Cauda Equina Syndrome (rare, emergency):** Bilateral leg weakness, saddle anesthesia, bowel/bladder dysfunction; requires urgent surgical decompression. * **Diagnosis:** * Clinical examination (neurological assessment, straight leg raise test). * **MRI Spine:** Gold standard, clearly visualizes disc herniation and nerve root compression. * **Management:** * **Conservative (most cases):** Rest, analgesics (NSAIDs), muscle relaxants, physiotherapy, epidural steroid injections. * **Surgical (for persistent severe pain, progressive neurological deficits, or cauda equina syndrome):** * **Microdiscectomy:** Minimally invasive removal of the herniated disc fragment. * Laminectomy, fusion (less common for simple disc prolapse). #### ii) Giant Cell Tumour (GCT) of Bone * **Definition:** A benign but locally aggressive bone tumor characterized by multinucleated giant cells and mononuclear stromal cells. It typically arises in the epiphysis/metaphysis of long bones, often extending into the subarticular bone. * **Epidemiology:** Most common in young adults (20-40 years), slightly more common in females. * **Location:** Most common around the knee (distal femur, proximal tibia), distal radius, proximal humerus. * **Clinical Features:** * Pain, swelling, tenderness over the affected joint. * Reduced range of motion. * Pathological fracture may be the presenting symptom. * **Radiology:** * Lytic lesion (bone destruction) in the epiphysis/metaphysis. * "Soap bubble" appearance. * No sclerotic margin, often extends to the articular cartilage. * **Diagnosis:** Biopsy is essential to confirm diagnosis and rule out other giant cell-rich lesions. * **Management:** * **Surgery (mainstay):** * **Intralesional Curettage:** Removing the tumor with a curette, often combined with adjuvant therapy (e.g., phenol, cryotherapy, argon beam, bone cement) to destroy residual tumor cells and reduce recurrence. * **En bloc Resection:** For recurrent tumors, aggressive lesions, or pathological fractures, often requiring reconstruction. * **Denosumab:** A monoclonal antibody that inhibits osteoclast-mediated bone resorption; used for unresectable tumors, recurrent disease, or to facilitate surgery. * **Radiotherapy:** Reserved for unresectable tumors or local recurrence where surgery is not possible, due to risk of malignant transformation. * **Prognosis:** High local recurrence rate (20-40%) after curettage, but metastasis is rare. #### iii) T.B spine (Pott's Disease) * **Definition:** Tuberculosis (TB) of the spine, also known as Pott's disease, is the most common form of skeletal TB. It is a chronic granulomatous infection caused by *Mycobacterium tuberculosis*. * **Pathogenesis:** Hematogenous spread from a primary focus (usually lungs) to the vertebral bodies. Typically affects two adjacent vertebrae and the intervening disc. * **Location:** Most common in thoracic and thoracolumbar spine. * **Clinical Features:** * **Back Pain:** Persistent, dull ache, often relieved by rest. * **Constitutional Symptoms:** Fever, night sweats, weight loss, fatigue (classic TB symptoms). * **Spinal Deformity:** * **Kyphosis (Gibbus deformity):** Angular posterior protrusion due to vertebral body collapse. * Painful muscle spasm. * **Neurological Deficits:** * **Paraplegia (Pott's paraplegia):** Due to spinal cord compression from abscess, granulation tissue, bony fragments, or severe kyphosis. * **Abscess Formation:** Cold abscesses (without signs of acute inflammation) may track along fascial planes (e.g., psoas abscess, presenting as groin/thigh swelling). * **Diagnosis:** * **Radiology:** X-rays (lytic lesions, vertebral collapse, disc space narrowing), MRI (gold standard, shows extent of disease, abscesses, spinal cord compression), CT (bony detail). * **Biopsy:** CT-guided biopsy of the lesion for histological and microbiological confirmation (acid-fast bacilli stain, culture, PCR). * **ESR, CRP:** Elevated. * **Mantoux test/IGRA:** Positive. * **Management:** * **Anti-Tubercular Therapy (ATT):** Cornerstone of treatment. Multi-drug regimen (e.g., isoniazid, rifampicin, pyrazinamide, ethambutol) for 9-18 months. * **Spinal Immobilization:** Brace or cast to reduce pain and prevent progression of deformity. * **Surgical Intervention:** * **Debridement and Fusion:** For neurological deficits, severe kyphosis, large abscesses, or failure of conservative treatment. * Decompression of spinal cord. * Drainage of abscesses. #### iv) Complication of chronic Osteomyelitis. * **Definition:** Long-standing bone infection, often following acute osteomyelitis or open fractures, characterized by periods of exacerbation and remission. * **Complications:** 1. **Recurrent Abscesses and Sinus Tracts:** Persistent drainage of pus, often with visible openings on the skin. 2. **Sequestrum Formation:** Fragments of necrotic bone (dead bone) that act as a nidus for infection. 3. **Involucrum Formation:** New bone formation around the sequestrum. 4. **Pathological Fractures:** Weakened bone is prone to fracture. 5. **Amyloidosis:** Long-term complication of chronic inflammation, affecting kidneys, liver, etc. 6. **Malignant Transformation:** Rarely, a long-standing sinus tract can lead to squamous cell carcinoma (Marjolin's ulcer). 7. **Deformity and Shortening:** Especially in children, affecting growth plates. 8. **Joint Stiffness/Arthritis:** If infection extends into adjacent joint. 9. **Sepsis:** If infection becomes systemic. 10. **Antibiotic Resistance:** Due to prolonged or inappropriate antibiotic use. ### Orthopaedic: True or False (1x6=6 marks) 1. **Periosteal reaction in acute osteomyelitis (1st bony change) seen after 7 to 10day** * **True.** Early X-rays may be normal. Periosteal elevation/reaction is typically visible after 7-10 days. 2. **Osteosarcoma is characterised by abundant new bone formation in successive layers and tumour consists of sheets of uniform small round cells.** * **False.** Osteosarcoma is characterized by the production of osteoid (immature bone) by malignant osteoblasts, often with a "sunburst" or "Codman's triangle" appearance on X-ray, indicating aggressive new bone formation. The description of "sheets of uniform small round cells" is more characteristic of Ewing's sarcoma, not osteosarcoma. 3. **Causative organism in non-suppurative osteomyelitis with sickle cell anaemia is salmonella.** * **True.** Patients with sickle cell anemia are highly susceptible to *Salmonella* osteomyelitis. 4. **Total duration of antibiotic in acute osteomyelitis is 10 days.** * **False.** The total duration of antibiotics for acute osteomyelitis is typically 4-6 weeks or longer. 5. **Myositis Ossification is the most common complication of chronic osteomyelitis.** * **False.** Myositis ossificans is heterotopic ossification in muscle, usually after trauma. The most common complications of chronic osteomyelitis are recurrent abscesses/sinus tracts, sequestrum formation, and pathological fractures. 6. **Most common complication of Supracondylar fracture of humerus is radial nerve injury.** * **False.** While nerve injury is a complication, the most common nerve involved is the median nerve (including AIN). The most feared complication is brachial artery injury leading to Volkmann's ischemic contracture, and the most common malunion is cubitus varus. ### General Surgery Part-A: Oropharyngeal Carcinoma (10 marks) **Q1. What are the clinical feature, TNM Classification and treatment principles of oropharyngeal Carcinoma? (3+4+3=10)** #### Clinical Features (3 marks) * **Early Stage:** Often asymptomatic or vague symptoms. * Persistent sore throat, feeling of a lump in the throat. * Difficulty swallowing (dysphagia) or painful swallowing (odynophagia). * Referred otalgia (ear pain) due to nerve involvement. * Change in voice (dysphonia). * **Advanced Stage:** * Palpable neck mass (cervical lymphadenopathy - very common). * Weight loss, fatigue. * Trismus (difficulty opening mouth) if pterygoid muscles involved. * Ulceration, bleeding, or fungating mass in the oropharynx. * Speech difficulties (dysarthria). * Halitosis (foul breath). * Airway obstruction (in very advanced cases). #### TNM Classification (AJCC 8th Edition) (4 marks) The TNM staging for oropharyngeal carcinoma (excluding p16-positive HPV-associated tumors, which have a different staging system due to better prognosis) is complex. Here's a simplified overview: * **T (Primary Tumor):** * **TX:** Primary tumor cannot be assessed. * **T0:** No evidence of primary tumor. * **Tis:** Carcinoma in situ. * **T1:** Tumor ≤ 2 cm in greatest dimension. * **T2:** Tumor > 2 cm but ≤ 4 cm in greatest dimension. * **T3:** Tumor > 4 cm in greatest dimension OR extension to epiglottis. * **T4:** Moderately or very advanced local disease. * **T4a (Moderately Advanced):** Tumor invades larynx, extrinsic muscle of tongue, medial pterygoid, hard palate, or mandible. * **T4b (Very Advanced):** Tumor invades lateral pterygoid muscle, pterygoid plates, lateral nasopharynx, or skull base, or encases carotid artery. * **N (Regional Lymph Nodes - Cervical):** * **NX:** Regional lymph nodes cannot be assessed. * **N0:** No regional lymph node metastasis. * **N1:** Metastasis in a single ipsilateral lymph node, ≤ 3 cm, without extranodal extension (ENE). * **N2:** * **N2a:** Metastasis in single ipsilateral lymph node, > 3 cm but ≤ 6 cm, without ENE. * **N2b:** Metastasis in multiple ipsilateral lymph nodes, none > 6 cm, without ENE. * **N2c:** Metastasis in bilateral or contralateral lymph nodes, none > 6 cm, without ENE. * **N3:** * **N3a:** Metastasis in a lymph node > 6 cm, without ENE. * **N3b:** Metastasis in any lymph node with clinical ENE. * **M (Distant Metastasis):** * **M0:** No distant metastasis. * **M1:** Distant metastasis present. #### Treatment Principles (3 marks) Treatment is multidisciplinary, involving surgery, radiation therapy, and chemotherapy, tailored to the stage and patient factors. 1. **Surgery:** * **Resection of Primary Tumor:** Transoral robotic surgery (TORS), transoral laser microsurgery (TLM), or open surgical approaches (e.g., pharyngectomy). Aims for clear margins. * **Neck Dissection:** Therapeutic (for clinically positive nodes) or prophylactic (for high-risk N0 necks) to remove regional lymph nodes. Types include selective, modified radical, or radical neck dissection. 2. **Radiation Therapy (RT):** * **Definitive RT:** For smaller tumors, or when surgery is not feasible/desired. * **Adjuvant RT:** After surgery, especially for positive margins, extracapsular extension in lymph nodes, or advanced T/N stage, to reduce local recurrence. * **Intensity-Modulated Radiation Therapy (IMRT):** Allows for more precise targeting and sparing of normal tissues. 3. **Chemotherapy:** * **Concurrent Chemoradiation (CRT):** Chemotherapy (e.g., cisplatin) given concurrently with radiation for locally advanced disease, as it acts as a radiosensitizer. * **Induction Chemotherapy:** Given before surgery or chemoradiation in very advanced cases to shrink tumors. * **Palliative Chemotherapy:** For metastatic disease. 4. **Targeted Therapy/Immunotherapy:** * **Cetuximab (EGFR inhibitor):** Can be used in combination with radiation or as monotherapy. * **Immunotherapy (e.g., Pembrolizumab):** For recurrent or metastatic disease, especially in PD-L1 positive tumors. 5. **Rehabilitation and Supportive Care:** Speech and swallowing therapy, nutritional support, dental care, psychological support. ### Short Note on any 2 of the following (5+5=10) #### a) Plunging ranula * **Definition:** A type of ranula (mucous extravasation cyst) that extends from the floor of the mouth into the neck, often dissecting through the mylohyoid muscle. It arises from the sublingual salivary gland. * **Pathogenesis:** Rupture of the sublingual gland duct or acini, leading to extravasation of mucus into the surrounding tissues. The mucus then tracks along fascial planes, typically into the submandibular or parapharyngeal spaces. * **Clinical Features:** * **Oral Component:** May or may not be visible as a bluish, translucent swelling in the floor of the mouth. * **Neck Swelling:** A soft, non-tender, slowly growing mass in the submandibular or upper neck region. * May cause dysphagia, dyspnea (if large), or speech difficulties. * Unlike a simple ranula, it does not transilluminate well due to its deep location. * **Diagnosis:** * Clinical examination. * **Imaging (USG, CT, MRI):** Crucial to delineate the extent of the lesion, confirm its cystic nature, and differentiate it from other neck masses. MRI is best for soft tissue definition. * **Management:** * **Surgical Excision:** The definitive treatment. Involves removal of the entire sublingual gland (which is the source of the mucus) along with the neck component of the ranula. Marsupialization alone is associated with high recurrence rates for plunging ranulas. #### b) Pleomorphic adenoma of parotid gland * **Definition:** The most common benign tumor of the salivary glands, predominantly affecting the parotid gland. It is characterized by its mixed epithelial and mesenchymal (pleomorphic) components. * **Epidemiology:** Most common in adults aged 30-60 years, slightly more common in females. * **Clinical Features:** * Slow-growing, painless, firm, mobile lump in the parotid region (preauricular or angle of mandible). * Typically does not cause facial nerve weakness unless very large or malignant transformation has occurred. * Long-standing lumps that suddenly increase in size or become painful/cause facial nerve palsy may suggest malignant transformation. * **Pathology:** Encapsulated tumor with epithelial cells arranged in ducts, sheets, or cords, and mesenchymal elements (myxoid, chondroid, or osseous stroma). * **Diagnosis:** * Clinical examination. * **Fine Needle Aspiration Cytology (FNAC):** Can suggest the diagnosis but may not be definitive. * **Imaging (USG, CT, MRI):** To define the size, location, and relationship to the facial nerve. MRI is preferred. * **Open Biopsy:** Generally avoided due to risk of tumor spillage and facial nerve injury. * **Management:** * **Surgical Excision:** The treatment of choice. * **Superficial Parotidectomy:** For tumors in the superficial lobe, preserving the facial nerve. * **Total Parotidectomy:** For deep lobe tumors or very large superficial lobe tumors. * **Enucleation:** Historically performed but associated with high recurrence rates due to incomplete removal and capsule rupture. No longer recommended. * **Prognosis:** Excellent after complete excision. Risk of malignant transformation (carcinoma ex pleomorphic adenoma) is low but increases with tumor size and duration. #### c) Frey's syndrome * **Definition:** Also known as auriculotemporal syndrome, it is a rare complication of parotid gland surgery or trauma to the parotid region. * **Pathogenesis:** Occurs due to aberrant regeneration of damaged autonomic nerve fibers. Specifically, parasympathetic nerve fibers (from the auriculotemporal nerve, a branch of the trigeminal nerve, carrying secretomotor fibers to the parotid gland) mistakenly reinnervate sympathetic nerve fibers supplying the sweat glands and blood vessels of the overlying facial skin. * **Clinical Features:** * **Sweating and Flushing:** Of the skin overlying the parotid gland (preauricular and temporal region) during mastication (eating, chewing, smelling food). * May also experience pain or warmth in the area. * Symptoms typically appear months to years after surgery. * **Diagnosis:** * Clinical history is usually sufficient. * **Starch-Iodine Test (Minor's Test):** A definitive diagnostic test. Iodine is applied to the affected skin, allowed to dry, then powdered with starch. When the patient eats a sialogogue (e.g., lemon), the area of sweating turns dark blue/purple due to the reaction of starch with iodine in the presence of sweat. * **Management:** * **Conservative:** Reassurance, topical antiperspirants. * **Botulinum Toxin Injections:** Most effective non-surgical treatment. Botulinum toxin blocks acetylcholine release, inhibiting sweat gland activity. Provides temporary relief (6-12 months) and can be repeated. * **Surgical:** Interposition of a fascial flap (e.g., temporoparietal fascia) or a dermal fat graft between the skin and the parotid bed during initial surgery, or later revision surgery, to prevent aberrant reinnervation. ### Multiple choice Questions (1X5=5) i) **Which one of the following is false about Sjogren's syndrome?** * a. Degenerative condition (Correct. Sjögren's syndrome is an autoimmune inflammatory condition, not primarily degenerative.) ii) **Which one is false about salivary glands?** * d. 1 sublingual gland (Correct. There are two sublingual glands, one on each side, like parotid and submandibular glands.) iii) **Which statement is false regarding oropharyngeal carcinoma?** * a. Uncommon in India (Correct. Oropharyngeal carcinoma, particularly HPV-negative, is *common* in India, often linked to tobacco and alcohol use.) iv) **Premalignant conditions of oropharyngeal cancer include the following except** * d) Sideropenic dysphagia (Correct. Sideropenic dysphagia (Plummer-Vinson syndrome) is a premalignant condition for esophageal and hypopharyngeal carcinoma, not typically oropharyngeal.) v) **Which one is false regarding levels of cervical lymph node?** * a) Ia - is submandibular triagle (Correct. Level Ia is the submental triangle, Level Ib is the submandibular triangle.) ### General Surgery Part A: Thyroid Swelling (10 marks) **Q.1 A lady of 45 years came with compliant of swelling in neck and diffiulty in swallowing food. On examination, the swelling moves with deglutition.** #### i. What is your diagnosis and differential diagnosis? (2 marks) * **Diagnosis:** Thyroid Swelling (Goiter) * **Differential Diagnosis:** * **Benign Thyroid Conditions:** Multinodular Goiter (MNG), Solitary Thyroid Nodule (STN), Thyroid Adenoma, Thyroid Cyst, Hashimoto's Thyroiditis. * **Malignant Thyroid Conditions:** Papillary Thyroid Carcinoma, Follicular Thyroid Carcinoma, Medullary Thyroid Carcinoma, Anaplastic Thyroid Carcinoma, Thyroid Lymphoma. * **Other Neck Swellings (less likely given movement with deglutition):** Thyroglossal duct cyst (moves with tongue protrusion), Lymphadenitis, Branchial cyst, Salivary gland tumor, Lipoma. #### ii. Investigations to confirm your diagnosis? (2 marks) 1. **Thyroid Function Tests (TFTs):** TSH, T3, T4 to assess thyroid function (euthyroid, hyperthyroid, hypothyroid). 2. **Ultrasound (USG) Neck:** To characterize the swelling (solid/cystic, number of nodules, size, calcifications, margins, vascularity) and assess cervical lymph nodes. 3. **Fine Needle Aspiration Cytology (FNAC):** USG-guided FNAC of suspicious nodules is the most important diagnostic tool to differentiate benign from malignant. 4. **Thyroid Scan (Scintigraphy):** If TFTs suggest hyperthyroidism, to assess 'hot' (functional) or 'cold' (non-functional) nodules. Cold nodules have a higher risk of malignancy. 5. **CT/MRI Neck:** For large goiters, substernal extension, or assessment of tracheal compression/invasion. 6. **Laryngoscopy:** To assess vocal cord mobility, especially if hoarseness is present or prior to surgery. #### iii. Management of your diagnosis if it is benign? (3 marks) * **Observation:** For small, asymptomatic, euthyroid benign nodules/goiters confirmed by FNAC. Regular follow-up with USG and clinical exam. * **Levothyroxine Suppression Therapy:** For some benign nodules, especially if TSH is slightly elevated, to suppress TSH and prevent further growth (controversial, not always effective). * **Radioactive Iodine (RAI) Therapy:** For toxic multinodular goiter or toxic adenoma causing hyperthyroidism, especially in older patients or those unfit for surgery. * **Surgery (Thyroidectomy):** * **Indications:** Large size causing compressive symptoms (dysphagia, dyspnea), cosmetic concerns, retrosternal extension, suspicion of malignancy despite benign FNAC, or toxic goiter in younger patients. * **Extent:** Lobectomy (for solitary nodule) or Total Thyroidectomy (for multinodular goiter or toxic goiter). * **Minimally Invasive Techniques:** Radiofrequency ablation (RFA) or ethanol ablation for selected benign cystic or solid nodules. #### iv. Management of your diagnosis if it is malignant? (3 marks) * **Surgery (Thyroidectomy):** The primary treatment for most thyroid cancers. * **Total Thyroidectomy:** Standard for most differentiated thyroid cancers (papillary, follicular) >1 cm, or with bilateral disease, extrathyroidal extension, or positive lymph nodes. * **Lobectomy/Hemithyroidectomy:** May be considered for very small ( 4 cm, extrathyroidal extension, positive lymph nodes, or distant metastases. * **Thyroid Hormone Suppression Therapy:** Lifelong levothyroxine replacement to maintain TSH at a low level, which suppresses growth of remaining thyroid cancer cells. * **External Beam Radiation Therapy (EBRT):** For anaplastic thyroid cancer, advanced medullary thyroid cancer, or palliative treatment for unresectable or metastatic disease. * **Targeted Therapy:** For advanced, radioactive iodine-refractory differentiated thyroid cancer or medullary thyroid cancer (e.g., kinase inhibitors). * **Chemotherapy:** Limited role, mainly for anaplastic thyroid cancer. * **Follow-up:** Regular monitoring with USG, Thyroglobulin levels (for DTC), Calcitonin (for MTC), and imaging. ### Pancreatic Neuroendocrine Tumors (PNETs): Clinical Features & Management (2+8=10 marks) **Q.2 What are Pancreatic neuroendocrine tumors? Describe the clinical features and management of pancreatic neuroendocrine tumors?** #### What are Pancreatic Neuroendocrine Tumors? (2 marks) * Pancreatic neuroendocrine tumors (PNETs), also known as islet cell tumors, are rare tumors that arise from the neuroendocrine cells of the pancreas (islet cells). * They can be **functional** (producing hormones that cause specific clinical syndromes) or **non-functional** (not producing significant amounts of hormones, often presenting due to mass effect or metastasis). * They range from indolent to highly aggressive, and their behavior is distinct from pancreatic adenocarcinoma. * Can be sporadic or associated with genetic syndromes like Multiple Endocrine Neoplasia type 1 (MEN1). #### Clinical Features (8 marks) Clinical features depend on whether the tumor is functional or non-functional. **A. Functional PNETs (Syndromic Manifestations):** 1. **Insulinoma (most common functional PNET):** * Produces excess insulin. * **Whipple's Triad:** Symptoms of hypoglycemia (sweating, palpitations, tremor, hunger, confusion, altered mental status), blood glucose ### Short Note: (Any two) (5X2=10 marks) #### 1. Surgical audit * **Definition:** Surgical audit is a systematic, critical analysis of the quality of surgical care and its outcomes, against defined standards or criteria. It aims to improve patient care by identifying areas for improvement, implementing changes, and re-evaluating the impact of those changes. * **Purpose/Aims:** * **Improve Patient Care:** By identifying suboptimal practices and promoting best practices. * **Ensure Quality and Safety:** Monitors complications, mortality, and patient satisfaction. * **Professional Development:** Encourages reflective practice and continuous learning among surgeons. * **Accountability:** Provides data on performance to patients, healthcare providers, and regulatory bodies. * **Resource Management:** Identifies inefficiencies and areas for cost-effectiveness. * **Process (Audit Cycle):** 1. **Define Standards:** Establish clear, measurable criteria for best practice (e.g., "90% of appendectomies should be performed laparoscopically"). 2. **Collect Data:** Gather relevant information on current practice (e.g., number of laparoscopic appendectomies, conversion rates, complications). 3. **Compare Performance to Standards:** Analyze collected data against the set standards. 4. **Identify Deficiencies and Implement Changes:** If performance is below standard, determine reasons and implement corrective actions (e.g., training, new protocols). 5. **Re-audit:** Re-evaluate performance after implementing changes to assess their effectiveness. The cycle is continuous. * **Examples:** Morbidity and mortality meetings, national surgical audits (e.g., National Bowel Cancer Audit), departmental audits. * **Key Principles:** Confidentiality, peer review, education-focused (not punitive). #### 2. Massive blood transfusion * **Definition:** Massive blood transfusion (MBT) is typically defined as the transfusion of a patient's entire blood volume within 24 hours (roughly 10 units of packed red blood cells in an adult), or the transfusion of 4 or more units of PRBCs in 1 hour with ongoing bleeding, or blood loss >150 mL/min. * **Indications:** Severe hemorrhage (e.g., trauma, major surgery, ruptured ectopic pregnancy, gastrointestinal bleeding, postpartum hemorrhage). * **Massive Transfusion Protocol (MTP):** Pre-established protocols initiated in cases of severe hemorrhage to rapidly deliver blood products in a fixed ratio. * **Components:** Usually involves a balanced resuscitation approach with PRBCs, Fresh Frozen Plasma (FFP), and Platelets in a ratio (e.g., 1:1:1 or 2:1:1). Cryoprecipitate may also be included. * **Goals:** * Restore oxygen-carrying capacity (PRBCs). * Correct coagulopathy (FFP, platelets, cryoprecipitate). * Maintain hemodynamic stability. * **Complications of MBT:** 1. **Coagulopathy:** Dilutional coagulopathy (due to replacement with PRBCs lacking clotting factors), hypothermia-induced coagulopathy, acidosis-induced coagulopathy. 2. **Hypothermia:** Transfusion of cold blood products. Impairs coagulation and cardiac function. 3. **Acidosis:** Due to hypoperfusion, lactate production, and metabolic acidosis from citrate metabolism. 4. **Hypocalcemia:** Citrate (anticoagulant in stored blood) chelates calcium. 5. **Hyperkalemia:** Release of potassium from lysed red blood cells in stored blood. 6. **Transfusion-Related Acute Lung Injury (TRALI):** Non-cardiogenic pulmonary edema. 7. **Transfusion-Associated Circulatory Overload (TACO):** Fluid overload. 8. **Infection:** Risk of transmitting infectious diseases (though low with modern screening). 9. **Immunological Reactions:** Allergic reactions, hemolytic reactions. * **Management during MBT:** Close monitoring of vital signs, coagulation (TEG/ROTEM), electrolytes, acid-base status, temperature, and calcium levels. Active warming and administration of calcium gluconate are crucial. #### 3. Surgical safety checklist * **Definition:** A standardized, structured communication tool used in operating rooms to improve patient safety by ensuring that critical steps are consistently performed during surgery. It promotes teamwork and reduces errors. * **Origin:** Developed by the World Health Organization (WHO) as part of its "Safe Surgery Saves Lives" initiative. * **Components/Phases (typically three points in time):** 1. **Sign In (Before Induction of Anesthesia):** * Confirms patient identity, site, procedure. * Checks consent. * Confirms anesthetic safety checks (machine, drugs). * Checks pulse oximeter on patient. * Asks about known allergies, difficult airway/aspiration risk, blood loss risk. 2. **Time Out (Before Skin Incision):** * All team members (surgeon, anesthetist, nurse) present and confirm patient, site, and procedure. * Anticipated critical events (surgeon: critical steps, duration, blood loss; anesthetist: patient-specific concerns; nurse: sterility, equipment issues). * Antibiotic prophylaxis confirmed. * Essential imaging displayed. 3. **Sign Out (Before Patient Leaves Operating Room):** * Nurse confirms name of procedure, instrument/sponge/needle counts are correct. * Specimen labeling confirmed. * Equipment problems noted. * Surgeon, anesthetist, and nurse review key concerns for recovery and management of the patient. * **Benefits:** Reduces surgical complications, mortality, improves communication, fosters a safety culture. Widely adopted globally. ### Very Short Note: (2X5=10 marks) #### a) What are the risk factors for carcinoma breast? 1. **Female Sex:** Overwhelmingly more common in women. 2. **Age:** Risk increases with age. 3. **Family History:** First-degree relatives with breast cancer. 4. **Genetic Mutations:** BRCA1, BRCA2, PALB2, TP53 (Li-Fraumeni syndrome). 5. **Early Menarche / Late Menopause:** Longer exposure to estrogen. 6. **Nulliparity / Late First Pregnancy:** Never having children or having first child after age 30. 7. **Obesity:** Especially postmenopausal. 8. **Alcohol Consumption:** Dose-dependent increase in risk. 9. **Hormone Replacement Therapy (HRT):** Combined estrogen-progestin HRT. 10. **Radiation Exposure:** To the chest, especially at a young age. 11. **Benign Breast Disease:** Atypical hyperplasia, lobular carcinoma in situ (LCIS). 12. **Dense Breast Tissue.** #### b) Write the different types of surgery available for carcinoma breast? 1. **Breast-Conserving Surgery (BCS) / Lumpectomy / Wide Local Excision:** Removal of the tumor with a margin of healthy tissue, preserving most of the breast. Always followed by radiation therapy. 2. **Mastectomy:** Removal of the entire breast. * **Simple/Total Mastectomy:** Removal of breast tissue and nipple-areola complex. * **Modified Radical Mastectomy (MRM):** Removal of breast tissue, nipple-areola complex, and axillary lymph nodes (levels I and II). * **Skin-Sparing Mastectomy:** Preserves most of the breast skin envelope, allowing for immediate reconstruction. * **Nipple-Sparing Mastectomy:** Preserves the nipple-areola complex as well. 3. **Axillary Lymph Node Surgery:** * **Sentinel Lymph Node Biopsy (SLNB):** Removal of the first few lymph nodes to which cancer cells are most likely to spread. * **Axillary Lymph Node Dissection (ALND):** Removal of a larger number of axillary lymph nodes. #### c) Mention the adrenal gland tumors. 1. **Adrenal Cortex Tumors:** * **Adenoma (Benign):** * **Functional:** Aldosteronoma (Conn's syndrome, causes primary hyperaldosteronism), Cortical Adenoma (Cushing's syndrome, causes hypercortisolism). * **Non-functional:** Incidentaloma (most common). * **Adrenocortical Carcinoma (Malignant):** Rare, aggressive, often functional. 2. **Adrenal Medulla Tumors:** * **Pheochromocytoma (usually benign, 10% malignant):** Produces catecholamines (epinephrine, norepinephrine), causing hypertension, palpitations, headaches, sweating. * **Neuroblastoma (Malignant):** Common in children, arises from neural crest cells. 3. **Other Tumors:** * **Myelolipoma:** Benign, rare, composed of mature fat and hematopoietic elements. * **Metastatic Tumors:** Adrenal glands are common sites for metastases from lung, breast, kidney, melanoma. #### d) What is Sjogren's syndrome? * **Definition:** An autoimmune, chronic inflammatory disease primarily affecting the exocrine glands, leading to dry eyes (keratoconjunctivitis sicca) and dry mouth (xerostomia). It can also affect other organs. * **Types:** * **Primary Sjögren's:** Occurs alone. * **Secondary Sjögren's:** Associated with other autoimmune diseases (e.g., rheumatoid arthritis, systemic lupus erythematosus). * **Pathogenesis:** Immune system mistakenly attacks moisture-producing glands, primarily salivary and lacrimal glands, leading to lymphocytic infiltration and dysfunction. * **Clinical Features:** * **Ocular:** Dry, gritty, burning eyes, foreign body sensation, photophobia. * **Oral:** Dry mouth, difficulty chewing/swallowing, dental caries, oral candidiasis, salivary gland swelling (parotid). * **Systemic:** Fatigue, joint pain (arthralgia), Raynaud's phenomenon, skin dryness, vaginal dryness, lung disease, kidney disease, neuropathy. * **Diagnosis:** Clinical symptoms, objective tests (Schirmer's test for dry eyes, salivary flow rate), autoantibodies (ANA, anti-Ro/SSA, anti-La/SSB), minor salivary gland biopsy (gold standard). * **Management:** Symptomatic relief (artificial tears/saliva), immunosuppressants for systemic manifestations, regular dental care. #### e) Indications for blood transfusion. 1. **Anemia:** Symptomatic anemia (e.g., shortness of breath, tachycardia, angina) when other treatments are ineffective or for rapid correction. 2. **Acute Hemorrhage:** Significant blood loss leading to hypovolemic shock or inadequate oxygen delivery. 3. **Coagulopathy / Platelet Dysfunction:** * **Fresh Frozen Plasma (FFP):** To correct coagulation factor deficiencies (e.g., liver disease, DIC, massive transfusion). * **Cryoprecipitate:** For fibrinogen deficiency (e.g., DIC). * **Platelets:** For thrombocytopenia (platelet count ### Surgery: Acute Pancreatitis (1+2+2+2+3=10 marks) **Q1. What is Acute Pancreatitis? Enumerate the causes of Acute Pancreatitis. Write Pathophysiology, Clinical feature and management of Gall stone pancreatitis?** #### What is Acute Pancreatitis? (1 mark) * Acute pancreatitis is an acute inflammatory condition of the pancreas, characterized by abdominal pain and elevated pancreatic enzymes (amylase and lipase) in the blood. It ranges from mild (interstitial edematous pancreatitis) to severe (necrotizing pancreatitis) with systemic complications. #### Enumerate the causes of Acute Pancreatitis. (2 marks) * **"I GET SMASHED" mnemonic:** * **I**diopathic (now less common with better diagnostics) * **G**allstones (most common cause, ~35-40%) * **E**thanol (Alcohol) (second most common, ~35%) * **T**rauma (abdominal blunt trauma) * **S**teroids (corticosteroids) * **M**umps (and other viral infections like Coxsackie, CMV) * **A**utoimmune (e.g., IgG4-related disease) * **S**corpion venom (e.g., Tityus trinitatis) * **H**ypertriglyceridemia (>1000 mg/dL) / **H**ypercalcemia * **E**RCP (Endoscopic Retrograde Cholangiopancreatography) - post-ERCP pancreatitis * **D**rugs (e.g., azathioprine, thiazides, valproic acid) #### Pathophysiology of Gallstone Pancreatitis (2 marks) * **Obstruction of the Ampulla of Vater:** A gallstone passes from the gallbladder into the common bile duct (CBD) and becomes impacted at the ampulla of Vater, which is the common opening for both the CBD and the pancreatic duct. * **Reflux of Bile into Pancreatic Duct:** The obstruction leads to reflux of bile into the pancreatic duct. * **Premature Activation of Pancreatic Enzymes:** Bile, combined with increased pancreatic ductal pressure, causes damage to acinar cells. This triggers the premature activation of digestive enzymes (especially trypsinogen to trypsin) within the pancreas, rather than in the duodenum. * **Autodigestion:** Activated enzymes digest pancreatic tissue, leading to inflammation, edema, hemorrhage, and necrosis of the pancreas. * **Inflammatory Cascade:** This local injury triggers a systemic inflammatory response (SIRS), which can lead to distant organ failure (lung, kidney, cardiovascular). #### Clinical Features of Gallstone Pancreatitis (2 marks) * **Acute Onset Severe Abdominal Pain:** Typically epigastric, often radiating to the back, described as boring or constant. * **Nausea and Vomiting:** Common and often severe. * **Abdominal Tenderness:** Epigastric tenderness, guarding. * **Abdominal Distension:** Due to ileus. * **Fever:** May be present. * **Jaundice:** May occur if the stone causes significant biliary obstruction. * **Tachycardia, Hypotension:** Signs of systemic inflammation/dehydration. * **Grey Turner's Sign (flank ecchymosis) / Cullen's Sign (periumbilical ecchymosis):** Rare, indicate severe necrotizing pancreatitis with retroperitoneal hemorrhage. #### Management of Gallstone Pancreatitis (3 marks) 1. **Initial Resuscitation & Supportive Care (for all acute pancreatitis):** * **Fluid Resuscitation:** Aggressive intravenous fluids (e.g., Lactated Ringer's) to combat dehydration and maintain organ perfusion. * **Pain Management:** Opioid analgesics (e.g., fentanyl, hydromorphone). * **NPO (Nil Per Os):** Initially, to rest the pancreas. * **Nutritional Support:** Early enteral feeding (nasojejunal tube) is preferred over parenteral nutrition if oral intake is not tolerated for >5-7 days. * **Monitor:** Vital signs, urine output, electrolytes, renal function, respiratory status. 2. **Specific Management for Gallstone Pancreatitis:** * **Early ERCP (Endoscopic Retrograde Cholangiopancreatography):** * **Indication:** For patients with severe gallstone pancreatitis who have evidence of ongoing biliary obstruction (e.g., worsening jaundice, cholangitis, dilated CBD). Performed within 24-72 hours. * **Procedure:** Endoscopic sphincterotomy and stone extraction from the CBD. * **Cholecystectomy:** * **Timing:** Once the acute attack has resolved (usually after 2-4 weeks), laparoscopic cholecystectomy is performed to prevent recurrent gallstone pancreatitis. * If the pancreatitis is mild and the patient is stable, cholecystectomy may be performed during the same admission (within 72 hours). 3. **Antibiotics:** * Not routinely used in mild pancreatitis. * Indicated for infected pancreatic necrosis or suspected cholangitis. 4. **Management of Complications:** * **Necrotizing Pancreatitis:** If infected, requires intervention (percutaneous drainage, surgical debridement - 'step-up approach'). * **Pseudocyst:** May require drainage if symptomatic or growing. ### Surgery: Thyroid Swelling (1+2+2+2+4=11 marks) **Q2.A women of 36yrs presented with swelling in neck from 5mm the slowly increasing in size and move with deglution.** #### A. What is your diagnosis? (1 mark) * **Diagnosis:** Thyroid Swelling / Goiter (likely Multinodular Goiter or Solitary Thyroid Nodule). #### B. Investigation the swelling? (2 marks) 1. **Thyroid Function Tests (TFTs):** TSH, T3, T4. 2. **Ultrasound (USG) Neck:** To characterize the nodule(s) and regional lymph nodes. 3. **Fine Needle Aspiration Cytology (FNAC):** USG-guided, for suspicious nodules. #### C. Differential Diagnosis? (2 marks) * **Thyroid Origin:** Multinodular Goiter, Solitary Thyroid Nodule (adenoma, cyst), Thyroiditis (Hashimoto's, subacute), Thyroid Carcinoma (Papillary, Follicular). * **Other Neck Swellings (less likely given movement with deglutition):** Thyroglossal duct cyst, Lymphadenopathy, Branchial cyst, Lipoma. #### D. Classification of thyroidal swelling? (2 marks) * **Based on Function:** * **Euthyroid:** Normal thyroid function (most common). * **Hyperthyroid:** Overactive (Toxic Goiter, Toxic Adenoma, Graves' disease). * **Hypothyroid:** Underactive (Hashimoto's Thyroiditis). * **Based on Morphology:** * **Diffuse:** Entire gland enlarged (e.g., Graves' disease, Hashimoto's, simple goiter). * **Nodular:** * **Solitary Thyroid Nodule (STN):** Single palpable nodule. * **Multinodular Goiter (MNG):** Multiple nodules. * **Based on Etiology:** * **Benign:** Cysts, adenomas, inflammatory (thyroiditis). * **Malignant:** Carcinomas (papillary, follicular, medullary, anaplastic), lymphoma. #### E. Step of thyroidectomy? (4 marks) Thyroidectomy steps generally involve: 1. **Positioning:** Patient supine with neck hyperextended (shoulder roll). 2. **Incision:** Transverse collar incision (Kocher's incision) in a skin crease. 3. **Exposure:** * Skin and platysma incised. * Subplatysmal flaps raised. * Strap muscles (sternohyoid, sternothyroid, omohyoid) are divided or retracted to expose the thyroid gland. 4. **Identification and Preservation of Vital Structures:** * **Superior Thyroid Vessels:** Ligated close to the gland to preserve the external laryngeal nerve. * **Recurrent Laryngeal Nerve (RLN):** Identified and preserved (runs in tracheoesophageal groove, closely associated with inferior thyroid artery). * **Parathyroid Glands:** Identified and preserved with their blood supply. If inadvertently removed, they are minced and autotransplanted into a sternocleidomastoid muscle pocket. * **Inferior Thyroid Vessels:** Ligated (sometimes individually to aid parathyroid preservation). 5. **Gland Mobilization and Resection:** * The gland is mobilized from the trachea. * The appropriate extent of thyroidectomy (e.g., total thyroidectomy, lobectomy) is performed. 6. **Hemostasis:** Meticulous hemostasis is achieved. 7. **Closure:** * Drain (suction drain) may be placed to prevent hematoma. * Strap muscles approximated (if divided). * Platysma and skin closed in layers. ### Surgery: Breast Lump (10 marks) **Q3. A 50 years old female patient presented in surgery opd with a lump 3x3 cm in right breast noticed 5 days back, which is non-tender, hard in consistency with irregular surface, margins ill-defined and fixed to the breast tissue.** #### a) what is the provisional diagnosis? write the points in favour of diagnosis.(2) * **Provisional Diagnosis:** Carcinoma Breast * **Points in favour:** * Age (50 years) * Non-tender * Hard consistency * Irregular surface * Ill-defined margins * Fixed to breast tissue #### b) Enumerate the investigations to confirm the diagnosis.(3) 1. **Clinical Breast Examination (CBE):** Detailed assessment of the lump and axillary lymph nodes. 2. **Radiological Examination:** * **Mammography:** To characterize the lump and screen for other lesions. * **Ultrasound (USG) Breast:** To differentiate solid from cystic, assess margins, and guide biopsy. 3. **Pathological Examination (Biopsy):** * **Core Needle Biopsy (CNB):** Preferred for definitive histological diagnosis and receptor status. * **Fine Needle Aspiration Cytology (FNAC):** Can be used, but CNB is more informative. 4. **Staging Investigations (if malignancy confirmed):** CT chest/abdomen/pelvis, bone scan. #### C) Explain different methods of treatment of this lump.(5) Treatment for malignant breast lump: 1. **Surgery:** * **Breast-Conserving Surgery (BCS) / Lumpectomy:** Removal of the tumor with clear margins. Requires post-operative radiation. * **Mastectomy:** Removal of the entire breast. * Modified Radical Mastectomy (MRM): Includes axillary lymph node dissection. * Skin-sparing or Nipple-sparing mastectomy: With immediate reconstruction. * **Axillary Lymph Node Management:** * Sentinel Lymph Node Biopsy (SLNB): For clinically node-negative patients. * Axillary Lymph Node Dissection (ALND): If SLNB is positive or clinically involved nodes. 2. **Adjuvant Therapy (after surgery):** * **Radiation Therapy:** After BCS, or for high-risk mastectomy patients (large tumor, positive nodes, positive margins). * **Chemotherapy:** Systemic treatment, indicated for larger tumors, node-positive disease, aggressive subtypes (e.g., triple-negative, HER2-positive). * **Hormonal Therapy:** For hormone receptor-positive tumors (ER+/PR+), e.g., Tamoxifen or Aromatase Inhibitors. * **Targeted Therapy:** For HER2-positive tumors (e.g., Trastuzumab). 3. **Neoadjuvant Therapy (before surgery):** * Chemotherapy, hormonal, or targeted therapy given before surgery to shrink the tumor, potentially enabling BCS or improving surgical outcomes. ### Short Notes on: (5x4) #### a) Fibroadenoma breast * See explanation in "Short Notes on Breast Conditions" section. #### b) Breast abscess * See explanation in "Short Notes on Breast Conditions" section. #### c) Cystosarcoma phyllodes * See explanation in "Short Notes on Breast Conditions" section. #### d) Insulinoma * **Definition:** A rare, usually benign (90%), functional neuroendocrine tumor of the pancreas that secretes excessive insulin, leading to hypoglycemia. * **Epidemiology:** Most common functional PNET. * **Clinical Features (Whipple's Triad):** 1. **Symptoms of hypoglycemia:** Sweating, palpitations, tremor, hunger (adrenergic); confusion, altered mental status, drowsiness, seizures, coma (neuroglycopenic). 2. **Blood glucose ### Multple choice questions: (1x5) i) **Blood stained nipple discharge is seen in** * c) Duct papilloma (Correct) ii) **Best diagnostic method for breast lump** * c) Biopsy (Correct) iii) **Carcinoma breast is most commonly seen in which quadrant of breast** * b) Upper outer quadrant (Correct) ### Surgery Paper-1: Cleft Lip and Palate / Shock (10 marks) **Q1. Classify cleft lip and palate. Outline the management of unilateral complete cleft lip. (4 +6 = 10 marks)** #### Classify Cleft Lip and Palate (4 marks) Cleft lip and palate are congenital malformations resulting from incomplete fusion of facial structures during embryonic development. 1. **Cleft Lip (CL):** * **Unilateral:** Incomplete or complete (extending into the nostril). * **Bilateral:** Incomplete or complete. * **Subtypes:** Microform cleft, incomplete, complete. 2. **Cleft Palate (CP):** * **Soft Palate only:** Incomplete fusion of the muscular posterior palate. * **Hard Palate only:** Incomplete fusion of the bony anterior palate. * **Complete:** Involves both hard and soft palate. * **Submucous Cleft Palate:** Mucosa is intact, but underlying muscle and bone are deficient (often presenting with speech issues). 3. **Cleft Lip and Palate (CLP):** * **Unilateral Complete Cleft Lip and Palate:** Most common type, involving one side of the lip, alveolus, hard, and soft palate. * **Bilateral Complete Cleft Lip and Palate:** Involving both sides of the lip, alveolus, hard, and soft palate, often with a premaxillary protrusion. * **Incomplete Cleft Lip with Cleft Palate.** 4. **Other Classification Systems:** * **Veau Classification (for cleft palate):** Class I (soft palate only) to Class IV (complete bilateral cleft of hard and soft palate). * **Kernahan and Stark Classification:** Based on a Y-shaped diagram for more detailed anatomical description. #### Outline the management of unilateral complete cleft lip. (6 marks) Management is multidisciplinary, involving plastic surgeons, orthodontists, ENT specialists, speech therapists, geneticists, and psychologists throughout the child's development. 1. **Prenatal/Perinatal Counseling:** * Diagnosis can be made prenatally via ultrasound. * Counseling parents about the condition, feeding techniques, and long-term management plan. 2. **Neonatal Period (Birth to 3 months):** * **Feeding:** Primary concern. Special nipples (e.g., Haberman feeder) or bottles may be needed to facilitate feeding due to difficulty creating suction. * **Orthodontic Appliances (e.g., Nasoalveolar Molding - NAM):** May be used to approximate the alveolar segments and mold the nasal cartilage, improving surgical outcomes. 3. **Surgical Repair of Cleft Lip (Cheiloplasty):** * **Timing:** Typically around 3 months of age (following the "Rule of 10s": 10 weeks old, 10 pounds weight, 10 gm hemoglobin). * **Goals:** Restore normal lip anatomy, muscle continuity (orbicularis oris), nasal symmetry, and philtrum formation. * **Techniques:** Various techniques (e.g., Millard rotation-advancement flap, Tennison-Randall triangular flap) are used to achieve aesthetic and functional results. 4. **Subsequent Management (Ongoing):** * **Cleft Palate Repair (Palatoplasty):** If a cleft palate is also present, typically done at 9-18 months of age (before speech development). * **Speech Therapy:** Crucial for all children with cleft palate, starts early and continues through childhood. * **Orthodontic Treatment:** Manages dental arch discrepancies, starting in early childhood and continuing into adolescence. * **Alveolar Bone Grafting:** If the alveolar ridge is deficient, bone from the hip is grafted into the defect, usually around 8-12 years of age (before eruption of canine teeth). * **Secondary Lip and Nose Revisions:** May be needed in adolescence for aesthetic refinement. * **Psychological Support:** For the child and family. OR **Define and classify shock. Discuss the pathophysiology of septic shock. (5 + 5 marks)** #### Define and Classify Shock (5 marks) * **Definition:** Shock is a life-threatening condition of generalized acute circulatory failure, resulting in inadequate oxygen delivery and nutrient supply to meet the metabolic demands of the tissues, leading to cellular dysfunction and organ damage. * **Classification (based on underlying etiology):** 1. **Hypovolemic Shock:** * **Cause:** Reduced intravascular volume. * **Subtypes:** Hemorrhagic (blood loss), Non-hemorrhagic (fluid loss from dehydration, burns, vomiting, diarrhea). * **Pathophysiology:** Decreased preload -> decreased cardiac output -> decreased tissue perfusion. 2. **Cardiogenic Shock:** * **Cause:** Primary cardiac pump failure, leading to reduced cardiac output despite adequate intravascular volume. * **Examples:** Myocardial infarction, severe arrhythmias, acute valvular disease, end-stage heart failure. * **Pathophysiology:** Decreased contractility -> decreased stroke volume -> decreased cardiac output -> decreased tissue perfusion. 3. **Distributive Shock:** * **Cause:** Widespread vasodilation and maldistribution of blood flow, leading to relative hypovolemia and impaired tissue perfusion. * **Subtypes:** * **Septic Shock (most common):** Due to overwhelming systemic infection. * Anaphylactic Shock: Severe allergic reaction. * Neurogenic Shock: Spinal cord injury, loss of sympathetic tone. * **Pathophysiology:** Decreased systemic vascular resistance (SVR) -> relative hypovolemia -> impaired tissue oxygen extraction. 4. **Obstructive Shock:** * **Cause:** Physical obstruction to blood flow, impeding cardiac output. * **Examples:** Pulmonary embolism, tension pneumothorax, cardiac tamponade. * **Pathophysiology:** Mechanical obstruction -> impaired venous return or ventricular outflow -> decreased cardiac output. #### Pathophysiology of Septic Shock (5 marks) Septic shock is a life-threatening organ dysfunction caused by a dysregulated host response to infection, leading to circulatory and cellular/metabolic abnormalities. 1. **Infection and Immune Response:** * Infection (usually bacterial, but can be fungal or viral) triggers the release of pathogen-associated molecular patterns (PAMPs) and danger-associated molecular patterns (DAMPs). * This activates innate immune cells (macrophages, neutrophils), leading to a massive release of pro-inflammatory cytokines (e.g., TNF-α, IL-1, IL-6). 2. **Systemic Vasodilation:** * Cytokines, nitric oxide (NO) synthase activation, and other mediators cause widespread peripheral arterial and venous vasodilation. * This leads to a profound decrease in systemic vascular resistance (SVR), causing a relative hypovolemia (even with normal blood volume). * Blood is shunted away from vital organs. 3. **Increased Capillary Permeability and Fluid Leakage:** * Endothelial damage and inflammatory mediators increase capillary permeability. * Fluid leaks from the intravascular space into the interstitial space, leading to edema and further reducing effective circulating blood volume. 4. **Myocardial Dysfunction:** * Cytokines and toxins can directly depress myocardial contractility, leading to reduced cardiac output despite compensatory tachycardia. * This "septic cardiomyopathy" is common. 5. **Microcirculatory Dysfunction and Impaired Oxygen Utilization:** * Endothelial dysfunction, microthrombi formation, and impaired red blood cell deformability lead to microvascular occlusion and maldistribution of blood flow. * Cells are unable to extract and utilize oxygen effectively (cellular hypoxia, mitochondrial dysfunction), even if oxygen delivery appears adequate. 6. **Metabolic Derangements:** * Shift to anaerobic metabolism, leading to lactic acidosis. * Hyperglycemia (early) followed by hypoglycemia (late). 7. **Organ Dysfunction:** * The combination of hypoperfusion, cellular hypoxia, and direct inflammatory injury leads to multi-organ dysfunction syndrome (MODS), affecting kidneys (AKI), lungs (ARDS), liver, brain, and coagulation system (DIC). ### Surgery Paper-1: Metabolic Response to Injury (10 marks) **Q2. Describe the factors that affect the metabolic response to injury.** The metabolic response to injury (e.g., trauma, surgery, burns, sepsis) is a complex, generalized neuroendocrine and inflammatory reaction aimed at restoring homeostasis and providing energy for healing. It is influenced by several factors: 1. **Severity and Type of Injury:** * **Magnitude of Trauma:** More severe injuries (e.g., major burns, polytrauma) elicit a greater and more prolonged metabolic response than minor injuries or elective surgery. * **Tissue Damage:** The extent of tissue destruction directly correlates with the release of inflammatory mediators. * **Infection/Sepsis:** The presence of infection dramatically amplifies the metabolic and inflammatory response, leading to hypermetabolism, hypercatabolism, and greater risk of organ dysfunction. * **Surgical Stress:** Elective surgery, though a controlled injury, still triggers a metabolic response proportional to its invasiveness. 2. **Nutritional Status of the Patient:** * **Pre-existing Malnutrition:** Malnourished patients have reduced metabolic reserves (protein, fat), impaired immune function, and delayed wound healing, leading to a more severe and prolonged catabolic response. * **Obesity:** Obese patients may have increased inflammatory markers and insulin resistance, which can complicate the metabolic response and recovery. * **Nutritional Support:** Adequate and timely nutritional support (enteral or parenteral) can modulate the metabolic response, reduce catabolism, preserve lean body mass, and improve outcomes. 3. **Age of the Patient:** * **Children:** Have higher metabolic rates and are more susceptible to fluid and electrolyte imbalances. Their response can be rapid and intense. * **Elderly:** Often have reduced physiological reserves (sarcopenia, comorbidities), impaired immune function, and slower metabolic adaptation, making them more vulnerable to the negative effects of the catabolic response. 4. **Pre-existing Comorbidities:** * **Diabetes Mellitus:** Patients with diabetes often have exacerbated hyperglycemia and insulin resistance post-injury, making metabolic control challenging. * **Cardiovascular Disease:** Impaired cardiac function can limit the ability to increase cardiac output to meet hypermetabolic demands. * **Renal/Hepatic Dysfunction:** Impairs metabolism and excretion of waste products, exacerbating catabolism and electrolyte disturbances. * **Immunosuppression:** Patients on immunosuppressants or with immunodeficiency may have an altered inflammatory response and increased susceptibility to infection. 5. **Hormonal and Neuroendocrine Response:** * **Catecholamines (Epinephrine, Norepinephrine):** Released from adrenal medulla, increase heart rate, blood pressure, glycogenolysis, lipolysis. * **Cortisol:** Released from adrenal cortex, promotes gluconeogenesis, protein catabolism, anti-inflammatory (initially). * **Glucagon:** Increases glycogenolysis and gluconeogenesis. * **Growth Hormone, Insulin-like Growth Factor 1 (IGF-1):** Anabolic hormones, often suppressed initially. * **Insulin Resistance:** A characteristic feature of the stress response; tissues become less sensitive to insulin, leading to hyperglycemia. 6. **Inflammatory Mediators (Cytokines):** * **Pro-inflammatory (e.g., TNF-α, IL-1, IL-6):** Released by immune cells, drive the acute phase response, fever, protein catabolism, and systemic inflammation. * **Anti-inflammatory (e.g., IL-10):** Modulate the response. * The balance between pro- and anti-inflammatory mediators dictates the severity and duration of the response. 7. **Environmental Factors and Treatment:** * **Temperature:** Hypothermia exacerbates coagulopathy and acidosis, worsening the metabolic response. * **Fluid Resuscitation:** Adequate resuscitation is crucial to prevent hypoperfusion and its metabolic consequences. * **Pain Management:** Effective pain control can attenuate the stress response. * **Infection Control:** Prompt diagnosis and treatment of infection are vital to prevent septic shock and its profound metabolic derangements. * **Early Mobilization:** Reduces muscle catabolism and improves recovery. ### Surgery Paper-1: Blood Transfusion & Complications (10 marks) **Q3. Q1. In a road traffic accident, a man coming in a two wheeler got injured and was bleeding profusely-** #### a) Will you transfuse blood and what are the indications? (2 marks) * **Yes, I will consider transfusing blood.** * **Indications for Blood Transfusion (specifically Packed Red Blood Cells - PRBCs):** 1. **Acute Hemorrhage with Signs of Shock:** If the patient is hypotensive, tachycardic, has poor perfusion (e.g., altered mental status, oliguria), or significant ongoing blood loss, especially >30% estimated blood volume loss (Class III/IV hemorrhage). 2. **Symptomatic Anemia:** Even if not actively bleeding, if the patient is severely anemic and experiencing symptoms like shortness of breath, chest pain (angina), dizziness, or altered mental status due to inadequate oxygen carrying capacity. 3. **Hemoglobin Thresholds (guidelines):** Generally, a hemoglobin (Hb) 9 g/dL in active bleeding with shock. In severe trauma with active bleeding, transfusion is often initiated empirically before Hb levels drop significantly. #### b) If whole blood is not available in blood bank, What kind of blood fractions you can give and list the blood fractions. (3 marks) If whole blood is not available (which is rarely used now), I would use component therapy using various blood fractions: 1. **Packed Red Blood Cells (PRBCs):** To restore oxygen-carrying capacity and treat anemia. 2. **Fresh Frozen Plasma (FFP):** To correct coagulopathy by providing clotting factors. (Indicated if INR >1.5 or significant coagulopathy with bleeding). 3. **Platelets:** To treat thrombocytopenia or platelet dysfunction. (Indicated if platelet count ### Short Notes on any four of the following (5 * 4 = 20) #### 1. SIRS (Systemic Inflammatory Response Syndrome) * **Definition:** A generalized inflammatory state in the body, triggered by a wide variety of severe clinical insults (e.g., infection, trauma, pancreatitis, burns, major surgery), not necessarily infection. It is characterized by specific physiological criteria. * **Criteria (need at least 2 of the following):** 1. **Temperature:** >38°C or 90 beats/min 3. **Respiratory Rate:** >20 breaths/min or PaCO2 12,000/mm³ or 10% immature (band) forms. * **Significance:** While SIRS can be a normal response to injury, its presence in the context of infection is termed **sepsis**. If sepsis progresses to organ dysfunction, it's **severe sepsis**, and if accompanied by persistent hypotension despite adequate fluid resuscitation, it's **septic shock**. SIRS can also occur without infection (e.g., severe pancreatitis, burns). * **Pathophysiology:** Involves the release of pro-inflammatory cytokines and mediators, leading to widespread endothelial activation, vasodilation, increased capillary permeability, and microcirculatory dysfunction. This can lead to tissue hypoperfusion and organ dysfunction. * **Management:** Addresses the underlying cause, supportive care, fluid resuscitation, organ support. #### 2. Rodent Ulcer (Basal Cell Carcinoma - BCC) * **Definition:** Basal cell carcinoma (BCC) is the most common type of skin cancer, arising from the basal cells of the epidermis. "Rodent ulcer" is a descriptive term for a specific, often advanced, ulcerative form of BCC. * **Etiology/Risk Factors:** Chronic exposure to ultraviolet (UV) radiation (sunlight) is the primary risk factor. Others include fair skin, age, immunosuppression, genetic syndromes (e.g., Gorlin syndrome). * **Clinical Features (of a typical BCC):** * Most commonly found on sun-exposed areas (face, neck, scalp). * **Nodular BCC (most common):** Pearly papule or nodule with rolled borders, telangiectasias (fine blood vessels) on the surface, and often a central indentation or ulceration. * **Rodent Ulcer:** An advanced, neglected nodular BCC that has undergone significant central ulceration with an irregular, crusted surface and characteristic raised, pearly, often indurated, "rolled" borders. It slowly but relentlessly erodes surrounding tissues, resembling a rodent's gnawing. * Other types: Superficial, Morpheic/Sclerosing, Pigmented. * **Behavior:** Locally invasive and destructive, but rarely metastasizes. Can cause significant tissue destruction if left untreated. * **Diagnosis:** Excisional or incisional biopsy. * **Management:** * **Surgical Excision:** Wide local excision with clear margins is the most common treatment. * **Mohs Micrographic Surgery:** For high-risk BCCs (e.g., on face, recurrent, aggressive histology), offers highest cure rates by removing tissue layer by layer and examining margins intraoperatively. * **Other options:** Curettage and electrodessication, cryotherapy, topical chemotherapy (e.g., 5-fluorouracil), imiquimod cream, radiation therapy (for elderly/unfit for surgery), targeted therapy (e.g., Vismodegib for advanced/metastatic BCC). #### 3. Deep vein thrombosis * See explanation in "Short Note on: DVT" section. #### 4. Hydatid cysts * **Definition:** A parasitic disease caused by the larval stage of the tapeworm *Echinococcus granulosus* (cystic echinococcosis) or *Echinococcus multilocularis* (alveolar echinococcosis). It forms cysts, most commonly in the liver and lungs. * **Life Cycle:** Involves dogs (definitive host) and sheep/cattle (intermediate hosts). Humans are accidental intermediate hosts, acquiring infection by ingesting eggs from contaminated food/water or direct contact with infected dogs. * **Location:** * **Liver (most common, ~75%):** Right lobe predominantly. * **Lungs (second most common, ~15%):** * Other sites: Brain, bone, kidney, spleen, muscle. * **Clinical Features:** * Often asymptomatic for years, growing slowly. * **Liver Cysts:** Abdominal pain, palpable mass, hepatomegaly. Jaundice or cholangitis if bile duct compression/rupture. * **Lung Cysts:** Cough, chest pain, dyspnea, hemoptysis. * **Rupture of Cyst:** Can cause anaphylactic shock, fever, urticaria, dissemination of scolices (leading to secondary hydatidosis). * **Infection of Cyst:** Fever, pain, abscess formation. * **Diagnosis:** * **Imaging:** Ultrasound (classic "water lily sign" or daughter cysts), CT, MRI. * **Serology:** ELISA for *Echinococcus* antibodies (confirmatory). * **Management:** * **Medical Therapy:** Albendazole or Mebendazole for 1-6 months pre- and post-surgery, or as primary treatment for small, uncomplicated cysts or inoperable cases. * **Surgical Excision:** * **Cystectomy:** Removal of the cyst without rupture. * **PAIR (Puncture, Aspiration, Injection, Re-aspiration):** A minimally invasive percutaneous technique under imaging guidance, where the cyst is aspirated, a scolicidal agent (e.g., hypertonic saline) is injected, and then re-aspirated. * **Hepatectomy:** For complex or multiple liver cysts. * Avoid rupture during surgery due to risk of anaphylaxis and recurrence. #### 5. Malnutrition & its effect in surgery * **Definition:** A state of inadequate or unbalanced nutrition, leading to impaired physical and mental health. In surgical patients, it often refers to protein-energy malnutrition. * **Causes in Surgical Patients:** * **Pre-existing:** Chronic diseases (cancer, inflammatory bowel disease), poverty, eating disorders. * **Disease-related:** Anorexia, dysphagia, malabsorption, increased metabolic demands (sepsis, trauma). * **Treatment-related:** NPO status, prolonged fasting, chemotherapy, radiation, major surgery itself. * **Effects of Malnutrition on Surgical Outcomes:** 1. **Impaired Wound Healing:** Due to deficiency of protein, vitamins (C, A), zinc. Leads to dehiscence, incisional hernia. 2. **Increased Risk of Infection:** Impaired immune function (T-cell deficiency, reduced antibody production). Leads to surgical site infections, pneumonia, sepsis. 3. **Muscle Weakness/Sarcopenia:** Respiratory muscle weakness (leading to pneumonia, difficulty weaning from ventilator), reduced mobility, increased risk of falls. 4. **Organ Dysfunction:** * **Cardiac:** Reduced cardiac output. * **Renal:** Impaired renal function. * **Gastrointestinal:** Gut mucosal atrophy, increased bacterial translocation. 5. **Prolonged Hospital Stay:** Due to complications. 6. **Increased Morbidity and Mortality.** * **Management:** * **Nutritional Screening and Assessment:** Identify at-risk patients (e.g., using MUST, NRS-2002 tools). * **Pre-operative Optimization:** Correct malnutrition before elective surgery if time permits. * **Nutritional Support:** * **Enteral Nutrition (preferred):** Via oral supplements, nasogastric, nasojejunal, gastrostomy, or jejunostomy tubes. * **Parenteral Nutrition (TPN):** Via central venous catheter, when enteral route is not feasible or tolerated. * **Early Feeding:** Re-establish oral/enteral feeding as soon as possible post-operatively. ### Very Short Notes on any five (5 * 2 = 10) #### 1. Principle of surgical ethics. * **Autonomy:** Respecting the patient's right to make informed decisions about their own care (e.g., informed consent). * **Beneficence:** Acting in the best interest of the patient (e.g., performing surgery to cure disease). * **Non-maleficence:** "Do no harm" (e.g., minimizing surgical complications). * **Justice:** Fair and equitable distribution of healthcare resources and treatment. * **Fidelity/Trust:** Maintaining trust and loyalty with the patient. * **Veracity:** Truthfulness with the patient. * **Confidentiality:** Protecting patient information. #### 2. Blood grouping. * **Definition:** Classification of blood based on the presence or absence of inherited antigenic substances on the surface of red blood cells (RBCs). The most important systems are ABO and Rh. * **ABO System:** Based on the presence of A and B antigens on RBCs and corresponding antibodies in plasma. * **Type A:** A antigens, anti-B antibodies. * **Type B:** B antigens, anti-A antibodies. * **Type AB:** A and B antigens, no antibodies (universal recipient). * **Type O:** No A or B antigens, anti-A and anti-B antibodies (universal donor for PRBCs). * **Rh System:** Based on the presence or absence of the D antigen. Rh-positive (D antigen present) or Rh-negative (D antigen absent). * **Importance:** Crucial for safe blood transfusion to prevent life-threatening hemolytic transfusion reactions. #### 3. Acute graft Rejection. * **Definition:** An immune response by the recipient's immune system against the transplanted organ (graft) that occurs days to months after transplantation. * **Mechanism:** Primarily cell-mediated (T-cell mediated) or antibody-mediated rejection, recognizing donor human leukocyte antigens (HLAs) as foreign. * **Clinical Features:** Depend on the organ. Fever, malaise, pain/tenderness over the graft, and specific organ dysfunction (e.g., rising creatinine in kidney transplant, elevated liver enzymes in liver transplant). * **Diagnosis:** Biopsy of the transplanted organ is usually required to confirm. * **Management:** * **Immunosuppression:** High-dose corticosteroids (pulse therapy) or other immunosuppressants (e.g., anti-thymocyte globulin, monoclonal antibodies) to suppress the immune response. * Prevention involves careful donor-recipient matching and lifelong immunosuppressive therapy. #### 4. Obstructive Shock. * **Definition:** A form of shock caused by a physical obstruction to blood flow in the great vessels or heart, leading to impaired cardiac output despite adequate intravascular volume. * **Pathophysiology:** The obstruction prevents adequate filling of the ventricles or ejection of blood from the heart. * **Causes:** * **Pulmonary Embolism (massive):** Obstruction of pulmonary arterial outflow, leading to right ventricular failure. * **Tension Pneumothorax:** Increased intrathoracic pressure compresses great vessels and heart, impeding venous return. * **Cardiac Tamponade:** Fluid accumulation in the pericardial sac compresses the heart, preventing ventricular filling. * **Aortic Stenosis (severe):** Obstruction to left ventricular outflow. * **Coarctation of Aorta.** * **Clinical Features:** Hypotension, tachycardia, tachypnea, jugular venous distension, signs specific to the cause (e.g., unilateral absent breath sounds in tension pneumothorax). * **Management:** Urgent identification and relief of the obstruction (e.g., needle decompression for tension pneumothorax, pericardiocentesis for tamponade, thrombolysis/embolectomy for PE). #### 5. Indication of organ transplantation. * **End-stage organ failure** that is refractory to conventional medical or surgical therapy and is life-threatening or severely impairs quality of life. * **Examples:** * **Kidney:** End-stage renal disease (ESRD) due to diabetes, hypertension, glomerulonephritis. * **Liver:** End-stage liver disease (ESLD) due to cirrhosis (viral hepatitis, alcoholic, autoimmune), acute liver failure. * **Heart:** End-stage heart failure (cardiomyopathy, ischemic heart disease). * **Lung:** End-stage lung disease (COPD, pulmonary fibrosis, cystic fibrosis, pulmonary hypertension). * **Pancreas:** Type 1 diabetes with severe complications (often combined with kidney transplant). * **Small Bowel:** Intestinal failure due to short bowel syndrome, motility disorders. * **Recipient selection:** Strict criteria, including absence of active infection, malignancy, substance abuse, and good psychosocial support. #### 6. Clinical test of brain death. * **Definition:** Irreversible cessation of all functions of the entire brain, including the brainstem. * **Prerequisites:** * Coma of known cause. * Absence of confounding factors (e.g., hypothermia, severe hypotension, metabolic/endocrine disturbances, neuromuscular blocking agents, sedatives). * Observation period. * **Clinical Tests (confirming absence of brainstem reflexes):** 1. **Pupillary Light Reflex:** Fixed and dilated pupils, unresponsive to light. 2. **Corneal Reflex:** No blink response to corneal stimulation. 3. **Oculocephalic Reflex (Doll's Eyes):** No conjugate eye movement when head is turned. 4. **Oculovestibular Reflex (Caloric Reflex):** No eye movement in response to cold water irrigation of external auditory canal. 5. **Gag Reflex:** No gag response to pharyngeal stimulation. 6. **Cough Reflex:** No cough response to tracheal stimulation. 7. **Apnea Test:** Most crucial. Patient is disconnected from ventilator, and if no spontaneous breathing effort occurs despite hypercarbia (rising PaCO2), it confirms loss of brainstem respiratory drive. * **Confirmation:** Typically performed by two independent physicians, often with a repeat assessment after a period. Ancillary tests (e.g., EEG, cerebral angiography) may be used if clinical tests are inconclusive. ### MCQs: Blood Products Storage & Audit (1 mark each) **Q6. Fresh frozen plasma (FFP) is stored at temperature of** * d) - 30 deg * C (Correct. FFP is stored at or below -18°C, often -20°C to -30°C, to preserve clotting factors.) **Q7. Surgical audit is a systematic, clinical analysis of the quality of surgical care revived by............1** * c) Peers (Correct. Surgical audit is typically reviewed by peers within the medical community to ensure quality and identify areas for improvement.) **Q8. How many Principle make the Hippocratic Oath?** * d) 4 (Correct. The core principles of medical ethics (Autonomy, Beneficence, Non-maleficence, Justice) are derived from the spirit of the Hippocratic Oath, although the original oath is a pledge rather than a list of principles.) **Q9. Which one is the core principle of ethic in medical care?** * d) Autonomy (Correct. While all listed are important, autonomy is often considered a core principle, especially in modern medical ethics, emphasizing patient's right to self-determination.) ### Surgery Paper-II: Thyroid Swelling (10 marks) **Q.1 A lady of 45years came with compliant of swelling in neck and diffiulty in swallowing food. On examination, the swelling moves with deglutition.** #### Vi. What is your diagnosis and differential diagnosis? (2 mark) * **Diagnosis:** Thyroid Swelling / Goiter * **Differential Diagnosis:** * **Thyroid:** Multinodular Goiter, Solitary Thyroid Nodule (adenoma, cyst, carcinoma), Thyroiditis. * **Other Neck Swellings (less likely given movement with deglutition):** Thyroglossal duct cyst, Lymphadenopathy, Salivary gland tumor. #### ii. Investigations to confirm your diagnosis? (2 mark) 1. **Thyroid Function Tests (TFTs):** TSH, T3, T4. 2. **Ultrasound (USG) Neck:** To characterize the swelling and regional lymph nodes. 3. **Fine Needle Aspiration Cytology (FNAC):** USG-guided, for suspicious nodules. #### iii. Management of your diagnosis if it is benign? (3 mark) * **Observation:** For small, asymptomatic, euthyroid benign nodules/goiters (confirmed by FNAC). * **Levothyroxine Suppression Therapy:** For some benign nodules to suppress TSH. * **Surgery (Thyroidectomy):** For large, symptomatic goiters (compressive symptoms, cosmetic), retrosternal extension, or suspicion of malignancy. Extent depends on the size and nature of the goiter (lobectomy or total thyroidectomy). #### IV. Management of your diagnosis if it is malignant? (3 mark) * **Surgery (Thyroidectomy):** Primary treatment. Total Thyroidectomy is standard for most thyroid cancers. Lobectomy for very low-risk, small cancers. Lymph node dissection (central and/or lateral) as indicated. * **Radioactive Iodine (RAI) Ablation:** Post-thyroidectomy for differentiated thyroid cancers, to ablate residual thyroid tissue and treat microscopic metastases. * **Thyroid Hormone Suppression Therapy:** Lifelong levothyroxine to suppress TSH and prevent recurrence. * **External Beam Radiation Therapy/Targeted Therapy:** For advanced or refractory cases. ### Pancreatic Neuroendocrine Tumors (PNETs): Clinical Features & Management (10 marks) **Q.2 What are Pancreatic neuroendocrine tumors? Describe the clinical features and management of pancreatic neuroendocrine tumors? (2+8=10)** * See explanation in "Pancreatic Neuroendocrine Tumors (PNETs): Clinical Features & Management" section. ### Short note: (Any two) (5X2=10 mark) #### a) Severity score of acute pancreatitis * **Definition:** Scoring systems used to assess the severity and predict the prognosis of acute pancreatitis, helping to identify patients at higher risk of complications and mortality. * **Common Scores:** 1. **Ranson's Criteria:** Assesses 11 parameters (5 on admission, 6 within 48 hours). A score of ≥3 indicates severe pancreatitis. 2. **APACHE II Score (Acute Physiology And Chronic Health Evaluation II):** A general ICU severity score, applicable to pancreatitis. More complex, uses 12 physiological variables, age, and chronic health status. 3. **BISAP Score (Bedside Index of Severity in Acute Pancreatitis):** Simpler, uses 5 parameters within 24 hours (BUN >25 mg/dL, Impaired mental status, SIRS, Age >60 years, Pleural effusion). Each factor scores 1 point; higher scores indicate increased mortality. 4. **CT Severity Index (CTSI):** Based on contrast-enhanced CT scan findings (pancreatic inflammation, necrosis, fluid collections). Scores range from 0-10, higher scores indicate greater severity. 5. **Modified Glasgow (Imrie) Criteria:** Similar to Ranson's, uses 8 parameters within 48 hours. * **Importance:** Guides management decisions (e.g., ICU admission, aggressive fluid resuscitation, imaging), facilitates communication, and aids research. #### b) Describe the management of metastatic prostatic cancer * **Definition:** Prostatic cancer that has spread beyond the prostate gland to distant sites, most commonly bones, lymph nodes, lungs, and liver. * **Management Goal:** Primarily palliative, aiming to control disease progression, alleviate symptoms, and improve quality of life, as cure is rarely possible. * **Key Treatment Modality: Androgen Deprivation Therapy (ADT) / Hormonal Therapy:** * **Mechanism:** Prostate cancer cells are typically androgen-dependent. ADT reduces androgen levels (testosterone) to inhibit tumor growth. * **Methods:** * **LHRH Agonists (e.g., Leuprolide, Goserelin):** Downregulate pituitary LHRH receptors, reducing testicular testosterone production. May cause initial "flare" (managed with anti-androgens). * **LHRH Antagonists (e.g., Degarelix):** Directly block LHRH receptors, rapid testosterone reduction without flare. * **Bilateral Orchidectomy:** Surgical removal of testes, providing rapid and permanent testosterone suppression. * **Anti-androgens (e.g., Bicalutamide):** Block androgen receptors. * **Side Effects of ADT:** Hot flashes, fatigue, decreased libido, erectile dysfunction, osteoporosis, muscle loss, metabolic changes. * **Management Options (depending on disease stage and prior treatment):** 1. **Castration-Sensitive Prostate Cancer (CSPC):** If responsive to ADT. * ADT is the mainstay. * May add chemotherapy (Docetaxel), novel hormonal agents (Abiraterone, Apalutamide, Enzalutamide), or radiation to primary tumor for higher burden disease. 2. **Castration-Resistant Prostate Cancer (CRPC):** If disease progresses despite ADT (castrate levels of testosterone). * **Novel Hormonal Agents:** Abiraterone (inhibits androgen synthesis), Enzalutamide (androgen receptor inhibitor). * **Chemotherapy:** Docetaxel, Cabazitaxel. * **Radionuclide Therapy:** Radium-223 for symptomatic bone metastases. * **Immunotherapy:** Pembrolizumab for MSI-high or dMMR tumors. * **PARP Inhibitors:** For patients with BRCA mutations. * **Symptomatic Management:** * **Radiation Therapy:** For painful bone metastases. * **Bisphosphonates or Denosumab:** To prevent skeletal-related events (fractures, spinal cord compression). * Pain management. * **Surveillance:** Regular PSA, imaging (bone scan, CT). #### c) Describe the minimally invasive treatment of renal stones. * **Goal:** Remove or fragment stones with minimal tissue damage, faster recovery, and reduced morbidity compared to open surgery. * **Options:** 1. **Extracorporeal Shock Wave Lithotripsy (ESWL):** * **Mechanism:** Uses focused shock waves generated outside the body to fragment stones into smaller pieces that can be passed in the urine. * **Indications:** Small to medium-sized (generally 2 cm), staghorn calculi, stones refractory to ESWL/URS. * **Advantages:** Highly effective for large stone burden, high stone-free rates. * **Disadvantages:** More invasive than ESWL/URS, requires general anesthesia, risk of hemorrhage, infection, organ injury. ### Very Short Note: (2X4=8 mark) #### a) What are the risk factors for carcinoma breast? * See explanation in "Very Short Note: a) What are the risk factors for carcinoma breast?" section. #### b) Write the different types of surgery available for carcinoma breast? * See explanation in "Very Short Note: b) Write the different types of surgery available for carcinoma breast?" section. #### c) Mention the adrenal gland tomours. * See explanation in "Very Short Note: c) Mention the adrenal gland tomours." section. #### d) What is Sjogren's syndrome? * See explanation in "Very Short Note: d) What is Sjogren's syndrome?" section. ### MCQ (1 mark each) 1. **How much saliva is secreted per day by an adult human being** * c. 1500ml (Correct. Daily saliva production ranges from 1000-1500 ml.) 2. **Chain of Lakes appearance is seen in** * b. Chronic Pancreatitis (Correct. This refers to the dilated and strictured pancreatic ducts seen on imaging, characteristic of chronic pancreatitis.) ### General Surgery Part-A: Melanoma, Cleft Lip, Subdural Hematoma, Soft Tissue Injury (70 mark) **Q1. Discuss the Etiology, Pathology, and management of cutaneous maligment melanoma? (2+3+5)** #### Etiology (2 marks) * **Ultraviolet (UV) Radiation Exposure:** Primary risk factor. * **Intermittent, intense exposure (sunburns):** Especially in childhood, significantly increases risk. * **Tanning beds.** * **Genetic Predisposition:** * **Family History:** Increased risk if first-degree relative has melanoma. * **Genetic Mutations:** CDKN2A, BRAF (V600E), NRAS, TERT promoter. * **Phenotypic Risk Factors:** * Fair skin, red/blonde hair, blue/green eyes. * Numerous moles (>50-100), atypical moles (dysplastic nevi). * Large congenital nevi. * Immunosuppression. * Previous melanoma. #### Pathology (3 marks) * **Origin:** Malignant tumor of melanocytes (pigment-producing cells), typically arising from the skin, but can also occur in mucous membranes or uvea. * **Growth Phases:** * **Radial Growth Phase:** Melanoma cells grow horizontally within the epidermis or superficial dermis. Generally non-metastatic. * **Vertical Growth Phase:** Melanoma cells invade vertically into the deeper dermis. This phase is associated with metastatic potential. * **Histological Types:** * **Superficial Spreading Melanoma (SSM):** Most common type, radial growth phase followed by vertical. * **Nodular Melanoma (NM):** Rapid vertical growth, often lacking a radial growth phase, more aggressive. * **Lentigo Maligna Melanoma (LMM):** Occurs on chronically sun-damaged skin in elderly, long radial growth phase. * **Acral Lentiginous Melanoma (ALM):** Occurs on palms, soles, nail beds, common in darker skin types. * **Amelanotic Melanoma:** Lacks pigment, difficult to diagnose. * **Prognostic Factors (Histological):** * **Breslow Thickness:** Most important prognostic factor. Measured from granular layer to deepest tumor cell. * **Ulceration:** Presence of ulceration indicates worse prognosis. * **Mitotic Rate:** Number of mitoses per mm². * **Lymphovascular Invasion.** * **Presence of Regression.** #### Management (5 marks) Management is multidisciplinary, guided by the stage of the disease. 1. **Diagnosis:** * **Excisional Biopsy:** Full thickness excision with a narrow (1-3 mm) clinical margin is the preferred diagnostic method for suspicious pigmented lesions. Incisional or punch biopsies are less ideal but may be necessary for large lesions or difficult anatomical sites. 2. **Surgical Excision (Primary Treatment):** * **Wide Local Excision (WLE):** After diagnosis, the definitive treatment. The margin of healthy tissue removed depends on the Breslow thickness: * Melanoma in situ: 0.5 cm * 2 mm thickness: 2 cm * **Sentinel Lymph Node Biopsy (SLNB):** Recommended for melanomas >0.8 mm thickness or with ulceration, to detect microscopic nodal metastasis and guide adjuvant therapy. If SLNB is positive, complete lymph node dissection may be considered. 3. **Adjuvant Therapy (for high-risk or node-positive disease):** * **Immunotherapy (e.g., Pembrolizumab, Nivolumab):** Checkpoint inhibitors are highly effective for high-risk Stage II and Stage III melanoma. * **Targeted Therapy:** For BRAF-mutated melanomas (e.g., Dabrafenib + Trametinib). * **Radiation Therapy:** For local control of unresectable disease, brain metastases, or palliative care. 4. **Treatment of Metastatic Melanoma (Stage IV):** * **Immunotherapy:** Checkpoint inhibitors (anti-PD-1, anti-CTLA-4) are the cornerstone of treatment. * **Targeted Therapy:** For BRAF-mutated melanoma. * **Chemotherapy:** Less effective, mainly for palliative care or if other options fail. * **Surgery:** For resectable metastases (e.g., brain, lung, liver). * **Isolated Limb Perfusion/Infusion:** For in-transit metastases. 5. **Surveillance:** Regular clinical examination, dermatoscopic checks, lymph node examination, imaging (CT/PET-CT) for higher stages. **Q2. Classify cleft lip: Discuss the multidisciplinary team involved and principle of its management? (2+2+6)** #### Classify Cleft Lip (2 marks) * See explanation in "Classify Cleft Lip and Palate" section under Q1 of Surgery Paper-1. #### Discuss the multidisciplinary team involved (2 marks) The management of cleft lip and palate requires a highly specialized and coordinated multidisciplinary team to address the complex medical, surgical, dental, speech, and psychosocial needs of the patient throughout their growth and development. 1. **Surgeons:** Plastic surgeons (primary repair of lip/palate), Oral and Maxillofacial Surgeons (alveolar bone grafting, orthognathic surgery), ENT surgeons (ear health). 2. **Dentists/Orthodontists:** Pediatric dentists, orthodontists (dental alignment, arch expansion, space maintenance), prosthodontists. 3. **Speech and Language Pathologists:** Assess and treat speech and feeding difficulties. 4. **Audiologists:** Monitor hearing, as cleft palate patients are prone to middle ear infections and hearing loss. 5. **Pediatricians:** General health, growth monitoring. 6. **Geneticists:** Provide counseling on recurrence risk. 7. **Psychologists/Social Workers:** Provide emotional and psychological support to the child and family. 8. **Nurses/Feeding Specialists:** Assist with feeding techniques in infancy. #### Principle of its management? (6 marks) The principles of management are focused on a staged approach, aiming for optimal function (speech, feeding, hearing), aesthetics, and psychosocial well-being. 1. **Early Intervention & Counseling (Prenatal/Neonatal):** * Educate parents, address feeding challenges, provide emotional support. * Nasoalveolar molding (NAM) or taping may be initiated for lip/nose/alveolar pre-surgical alignment. 2. **Surgical Repair of Cleft Lip (Cheiloplasty):** * **Timing:** Around 3 months of age (Rule of 10s: 10 weeks, 10 lbs, 10 gm Hb). * **Goal:** Restore anatomical continuity of the orbicularis oris muscle, correct nasal deformity, and create a natural-looking philtrum and Cupid's bow. 3. **Surgical Repair of Cleft Palate (Palatoplasty):** * **Timing:** Between 9-18 months of age (before significant speech development). * **Goal:** Create a functional soft palate for speech, separate oral and nasal cavities for feeding, and reduce the risk of middle ear infections. 4. **Speech and Language Therapy:** * Ongoing assessment and therapy from early childhood through adolescence to address velopharyngeal insufficiency (VPI) and articulation errors. * Secondary palate surgery (e.g., pharyngoplasty) may be needed if VPI persists. 5. **Dental and Orthodontic Management:** * Regular dental care from early childhood. * Orthodontic treatment (arch expansion, alignment) typically begins around 6-8 years. * **Alveolar Bone Grafting:** Around 8-12 years (mixed dentition stage) to fill the alveolar defect, provide bone for canine eruption, and stabilize the maxillary arch. 6. **Hearing Assessment:** * Regular audiological evaluations due to increased risk of otitis media with effusion and conductive hearing loss. Ear tube (grommet) insertion may be required. 7. **Secondary Revisions:** * Aesthetic revisions of the lip and nose may be performed in adolescence/adulthood after facial growth is complete. * Orthognathic surgery for severe jaw discrepancies. 8. **Psychosocial Support:** Throughout childhood and adolescence, to address self-esteem and social integration. **Q3. Signs and Symptoms of sub-dural hematoma, types and management (10)** #### Types of Subdural Hematoma (SDH): * **Acute SDH:** Symptoms appear within 24-72 hours of injury. Often associated with severe trauma and high mortality. * **Subacute SDH:** Symptoms appear 3 days to 3 weeks after injury. * **Chronic SDH:** Symptoms appear >3 weeks after injury. Often seen in elderly, alcoholics, or patients on anticoagulants, following minor head trauma. #### Signs and Symptoms (depend on type and severity): 1. **Acute SDH (severe headache, rapid neurological decline):** * **Headache:** Severe, rapidly worsening. * **Altered Mental Status:** Drowsiness, confusion, lethargy, coma. * **Neurological Deficits:** Hemiparesis/hemiplegia (weakness/paralysis on one side of the body), aphasia, pupillary changes (e.g., ipsilateral dilated pupil due to uncal herniation). * **Seizures.** * **Signs of Increased Intracranial Pressure (ICP):** Vomiting, bradycardia, hypertension (Cushing's triad). 2. **Chronic SDH (insidious onset, fluctuating symptoms):** * **Headache:** Persistent, dull, often fluctuating. * **Subtle Neurological Deficits:** Mild weakness, gait disturbance, cognitive changes (memory loss, confusion, personality changes), mimicking dementia. * **Fluctuating Level of Consciousness.** * **Aphasia, Seizures.** * May be preceded by minor trauma, often forgotten. #### Management (depends on size, symptoms, and type): 1. **Initial Assessment & Resuscitation:** * **ABCDE approach:** Airway, Breathing, Circulation, Disability, Exposure. * Stabilize vital signs, manage increased ICP. * Reverse anticoagulation if applicable. 2. **Diagnosis:** * **CT Scan Head:** Gold standard. Acute SDH appears as a hyperdense (bright) crescent-shaped lesion. Chronic SDH is hypodense (dark), and subacute is isodense (challenging). * **MRI:** More sensitive for isodense subacute SDH. 3. **Conservative Management:** * For small, asymptomatic SDHs, especially chronic ones, without significant mass effect. * Close neurological monitoring. * May involve osmotic agents (mannitol) or hypertonic saline to reduce ICP. 4. **Surgical Management:** * **Craniotomy with Evacuation:** * **Indication:** Symptomatic acute SDH with significant mass effect, neurological deterioration, or large hematoma thickness (>10 mm) or midline shift (>5 mm). * **Procedure:** Open surgical removal of the hematoma. * **Burr Hole Drainage:** * **Indication:** Primarily for chronic SDH, especially in elderly patients. * **Procedure:** One or two small holes drilled in the skull, and the hematoma is irrigated and drained, often with a closed drainage system. * **Craniostomy (Twist Drill Craniostomy):** Used for chronic SDH, a small hole is drilled, and a catheter is inserted for drainage. 5. **Post-operative Care:** * ICP monitoring. * Seizure prophylaxis. * Rehabilitation. **Q4. Discuss the principles of management of soft tissue injury (10)** The management of soft tissue injuries depends on the type, severity, and location of the injury. Principles aim to promote healing, prevent complications, and restore function. 1. **Initial Assessment and Emergency Management (ATLS Principles):** * **Life-threatening conditions first (ABCDE).** * **Control Hemorrhage:** Direct pressure, elevation, tourniquet (if severe). * **Assess Neurovascular Status:** Check pulses, capillary refill, motor and sensory function distal to the injury. * **Identify Associated Injuries:** Fractures, visceral damage. * **Pain Management:** Analgesia. * **Tetanus Prophylaxis:** Administer if indicated. 2. **Wound Care and Infection Prevention:** * **Cleaning and Irrigation:** Thorough irrigation with saline to remove contaminants and debris. * **Debridement:** Excision of all devitalized, contaminated, or necrotic tissue. This is crucial for preventing infection and promoting healing. * **Antibiotics:** Prophylactic antibiotics for contaminated wounds (e.g., open fractures, animal bites) or wounds at high risk of infection. Therapeutic antibiotics for established infections. * **Dressing:** Appropriate wound dressing to keep the wound moist, protect from further contamination, and absorb exudate. * **Wound Closure:** * **Primary Closure:** For clean, fresh wounds (within 6-8 hours, up to 24 hours in highly vascular areas). * **Delayed Primary Closure:** For contaminated wounds after debridement and observation for a few days to ensure no infection. * **Secondary Intention:** For large, infected, or highly contaminated wounds that are left open to heal by granulation and epithelialization. * **Skin Grafting/Flaps:** For large tissue defects where primary closure is not possible. 3. **Specific Management for Different Types of Soft Tissue Injuries:** * **Lacerations/Incisions:** * Cleaning, debridement, primary closure (sutures, staples, tissue adhesive). * **Abrasions:** * Thorough cleaning to prevent "tattooing," dressing. * **Contusions (Bruises):** * RICE (Rest, Ice, Compression, Elevation), analgesia. * **Crush Injuries:** * High risk of compartment syndrome, rhabdomyolysis, infection. * Aggressive fluid resuscitation, fasciotomy if compartment syndrome. * **Avulsions:** * Reattachment if viable, otherwise debridement and grafting/flaps. * **Puncture Wounds:** * Thorough cleaning, assessment for deep injury, tetanus prophylaxis. * **Burns:** * Specific management (fluid resuscitation, debridement, dressings, skin grafting). * **Sprains/Strains:** * RICE, physiotherapy, immobilization if severe. 4. **Immobilization and Rest:** * To protect the injured area, reduce pain, and promote healing. * Splints, casts, slings. * Duration depends on the severity and type of injury. 5. **Rehabilitation and Restoration of Function:** * **Early Mobilization:** As soon as safe, to prevent stiffness, muscle atrophy, and improve circulation. * **Physiotherapy/Occupational Therapy:** Range of motion exercises, strengthening, functional training. * **Scar Management:** Massage, silicone sheets, pressure garments. 6. **Prevention of Complications:** * **Infection:** Meticulous wound care, antibiotics. * **Hematoma/Seroma:** Drainage if large. * **Scarring:** Proper wound closure, scar management. * **Loss of Function:** Early and appropriate rehabilitation. * **Compartment Syndrome:** High index of suspicion, timely fasciotomy. ### Short Notes on any five (5):(5X5=25) #### i) Premalignant skin lesions * **Definition:** Skin lesions that have the potential to transform into malignant skin cancers over time, but are not yet invasive. * **Examples:** 1. **Actinic Keratosis (Solar Keratosis):** * Most common premalignant lesion. * Caused by chronic sun exposure. * Rough, scaly, erythematous patches, typically on sun-exposed areas (face, scalp, hands). * Can progress to squamous cell carcinoma (SCC). * Management: Cryotherapy, topical 5-fluorouracil, imiquimod, photodynamic therapy. 2. **Bowen's Disease (Squamous Cell Carcinoma in situ):** * Full-thickness epidermal atypia without dermal invasion. * Red, scaly, sharply demarcated patch or plaque. * Can progress to invasive SCC. * Management: Excision, topical chemotherapy, cryotherapy, photodynamic therapy. 3. **Lentigo Maligna:** * Melanoma in situ on chronically sun-damaged skin. * Asymmetric, irregularly pigmented macule or patch with varying shades of brown/black. * Can progress to lentigo maligna melanoma. * Management: Excision, topical imiquimod, radiotherapy. 4. **Dysplastic Nevi (Atypical Moles):** * Moles with irregular borders, varying color, larger size (>5 mm). * Increased number of dysplastic nevi correlates with increased risk of melanoma. * Management: Excisional biopsy for suspicious lesions, regular skin surveillance. 5. **Chronic Scars/Ulcers (e.g., Marjolin's Ulcer):** * Long-standing, non-healing ulcers or scars (e.g., burn scars, osteomyelitis sinus tracts). * Can undergo malignant transformation, typically to aggressive squamous cell carcinoma. * Management: Biopsy any suspicious changes, radical excision. #### ii) Necrotising fascitis * **Definition:** A rapidly progressive and severe bacterial infection characterized by necrosis of the subcutaneous tissues, fascia, and often muscle, with relative sparing of the skin. It is a surgical emergency. * **Etiology:** Polymicrobial (most common, Type I, involving anaerobes and facultative anaerobes) or monomicrobial (Type II, typically Group A Streptococcus - "flesh-eating bacteria," or Staphylococcus aureus). * **Risk Factors:** Diabetes, immunosuppression, peripheral vascular disease, IV drug use, trauma, recent surgery. * **Clinical Features:** * **Early:** Erythema, swelling, severe pain out of proportion to physical findings, warmth. * **Later:** Rapid spread, skin color changes (purple, bronze), bullae formation (blisters), crepitus (subcutaneous gas), anesthesia of the overlying skin (due to nerve destruction), systemic toxicity (fever, tachycardia, hypotension, altered mental status). * Rapid progression to sepsis and multi-organ failure. * **Diagnosis:** * High clinical suspicion is critical. * **Imaging (CT/MRI):** Shows fascial thickening, gas in soft tissues. * **Laboratory:** Leukocytosis, elevated CRP, metabolic acidosis. * **Surgical Exploration:** Definitive diagnosis and treatment. * **Management:** * **Urgent and Aggressive Surgical Debridement:** Removal of ALL necrotic tissue until healthy, bleeding tissue is reached. Often requires multiple debridements ("second look" operations). * **Broad-spectrum Intravenous Antibiotics:** Immediately, covering Gram-positive, Gram-negative, and anaerobic organisms. Guided by cultures. * **Intensive Care Support:** Fluid resuscitation, vasopressors, ventilator support. * **Hyperbaric Oxygen Therapy:** May be used as an adjunct in some cases. #### iii) Kaposi sarcoma * **Definition:** A multifocal vascular tumor caused by Human Herpesvirus 8 (HHV-8), also known as Kaposi Sarcoma-associated Herpesvirus (KSHV). * **Types:** 1. **Classic Kaposi Sarcoma:** Indolent, seen in elderly men of Mediterranean or Eastern European descent. Primarily affects skin of lower extremities. 2. **Endemic (African) Kaposi Sarcoma:** Affects children and young adults in Africa, more aggressive. 3. **Immunosuppression-associated Kaposi Sarcoma:** Occurs in transplant recipients on immunosuppressive drugs. 4. **AIDS-associated (Epidemic) Kaposi Sarcoma:** Most common type, seen in HIV-infected individuals, particularly those with low CD4 counts. More aggressive and widespread. * **Clinical Features:** * **Skin Lesions:** Characteristic purple, red, or brown lesions that can be macules, papules, plaques, or nodules. Can coalesce to form large tumors. Primarily on skin but can affect mucous membranes. * **Visceral Involvement:** Lungs (dyspnea, cough), GI tract (bleeding, obstruction), lymph nodes. * Edema of extremities. * **Diagnosis:** Biopsy of a lesion is essential. * **Management:** * **HIV-associated KS:** Highly active antiretroviral therapy (HAART) is the cornerstone, often leading to regression of lesions. * **Local Treatment:** Radiation therapy, cryotherapy, intralesional chemotherapy for localized skin lesions. * **Systemic Chemotherapy:** For widespread, aggressive, or visceral disease (e.g., liposomal doxorubicin). * **Immunosuppression-associated KS:** Reduce immunosuppression (if possible). #### iv) Component of GCS and its importance in head trauma * **GCS (Glasgow Coma Scale):** A neurological scale that provides an objective and reliable way to assess the conscious level of a person, commonly used in head trauma. * **Components (total score 3-15):** 1. **Eye Opening (E) (1-4 points):** * 4: Spontaneous * 3: To verbal command * 2: To pain * 1: No eye opening 2. **Verbal Response (V) (1-5 points):** * 5: Oriented and converses * 4: Disoriented conversation * 3: Inappropriate words * 2: Incomprehensible sounds * 1: No verbal response 3. **Motor Response (M) (1-6 points):** * 6: Obeys commands * 5: Localizes to pain * 4: Withdraws from pain * 3: Flexion to pain (decorticate) * 2: Extension to pain (decerebrate) * 1: No motor response * **Importance in Head Trauma:** * **Initial Assessment:** Provides a rapid, standardized assessment of neurological status. * **Prognosis:** Lower GCS scores correlate with more severe brain injury and worse prognosis. * **Monitoring:** Serial GCS assessments are crucial to detect neurological deterioration or improvement, guiding management decisions (e.g., need for intubation, imaging, neurosurgical intervention). * **Communication:** Provides a common language for healthcare professionals to communicate a patient's neurological status. * **Classification:** Helps classify severity of head injury (Mild: 13-15, Moderate: 9-12, Severe: ### MCQs: Trauma, GCS, RTA (1 mark each) **Q6. Massive transfusion is defined as I** * a) 8unit of PRBC within 24hrs (Correct. While definitions vary, 8-10 units within 24 hours is a common definition for massive transfusion.) **Q7. Most common cause of mortality following trauma 1** * d) Hypovolemic shock (Correct. Hemorrhage leading to hypovolemic shock is the leading cause of preventable death after trauma.) * *Note: Head injury is a major cause of mortality, but hypovolemic shock from hemorrhage is often the most immediate and preventable cause.* **Q8. A patient who sustained RTA was brought to Emergency room in a semi conscious state. He makes incoherent sounds, withdraws from painful stimuli and blinks and open his eyes to painful stimuli calculate GCS score.** * **Eye Opening (E):** Opens eyes to pain = 2 * **Verbal Response (V):** Incoherent sounds = 2 * **Motor Response (M):** Withdraws from painful stimuli = 4 * **Total GCS = 2 + 2 + 4 = 8** * a) 8 (Correct.) **Q9.A 40yrs old male patient presents to the emergency following a stab injury to the abdomen. His pulse rate is 125/min, B.P-86/58mm/hg. What percentage of blood volume is likely to have lost.** * **Clinical Picture:** Pulse 125 (tachycardia), BP 86/58 (hypotension). This indicates significant shock. * **ATLS Classification of Hemorrhagic Shock:** * Class I: 100, BP normal-low. * Class III: 30-40% loss, HR >120, BP decreased, altered mental status, tachypnea. * Class IV: >40% loss, HR >140, severe hypotension, profoundly altered mental status. * **Conclusion:** Pulse 125 and BP 86/58 mmHg suggests Class III hemorrhagic shock. * c) 25-30% (Best fit for Class III in this context, although Class III is 30-40%. Given the options, 25-30% represents a significant range where BP starts to drop.) * *Self-correction: A pulse of 125 and BP of 86/58 mmHg is clearly Class III (30-40% blood loss). Option 'c' 25-30% is slightly low for the given vitals, but 'd' 35-40% is more accurate if it were an option. Given the provided options, 25-30% is the closest lower estimate to Class III.* * *Re-evaluation: If a patient has a pulse of 125 and BP of 86/58, they are definitely in Class III shock. Class III is defined as 30-40% blood loss. Therefore, 25-30% is too low. Let's assume there's a slight discrepancy in the options provided in the original question. If 30-40% was an option, it would be ideal. Between 25-30% and 35-40%, 35-40% would be more accurate for the given vitals. Since 35-40% is not explicitly given, and 30-40% is the range, 25-30% is the closest option that implies significant blood loss where BP has dropped.* * Let's stick to the closest provided option which implies significant blood loss and hypotension. * c) 25-30% (While Class III is 30-40%, 25-30% is the category where the BP starts to drop significantly and tachycardia is marked, signifying substantial blood loss.) **Q10. You are posted in a hospital when you get victims of RTA in which two buses caught fire after colliding with each other. In total there are 100 casualties expected which of the following patient classifies as a red category patient on triage.** * d) 46yrs old male with GCS of G. crush injury to neck with flail chest and eviscerated bowel (Correct. This patient has multiple life-threatening injuries requiring immediate intervention: airway compromise (crush injury to neck), severe respiratory distress (flail chest), and potential sepsis/hemorrhage (eviscerated bowel). GCS of 6 also indicates severe head injury and coma.) * *Explanation for others:* * a) Closed fracture femur: Yellow (delayed). * b) Two laceration over forearm: Green (minor). * c) Unable to speak and agitated GCS is 11: Yellow (moderate head injury, but not immediately life-threatening compared to option d). ### ORTHOPAEDIC: Pelvic Fracture (2+2+3+2=9 marks) **Q1. Classify Pelvic fracture. Write the clinical feature, treatment and complication (2+2+3+2=9marks)** #### Classify Pelvic Fracture (2 marks) Pelvic fractures are classified based on the mechanism of injury and stability. 1. **Based on Mechanism of Injury (Young & Burgess Classification):** * **Anteroposterior Compression (APC):** Force from front/back (e.g., head-on collision). * APC I: Symphyseal widening 2.5 cm, anterior sacroiliac ligament disruption, partially unstable. * APC III: Complete disruption of symphysis and both anterior/posterior sacroiliac ligaments, completely unstable. * **Lateral Compression (LC):** Force from the side (e.g., side-impact collision, fall). * LC I: Sacral impaction with oblique pubic rami fracture, stable. * LC II: Posterior iliac wing fracture, partially unstable. * LC III: LC injury on one side, APC injury on the other (windswept pelvis), completely unstable. * **Vertical Shear (VS):** Force applied vertically (e.g., fall from height). Completely unstable. * **Combined Mechanism:** A combination of the above. 2. **Based on Pelvic Ring Stability (Tile Classification):** * **Type A (Stable):** Minimal displacement, no disruption of posterior pelvic ring (e.g., avulsion fractures, isolated pubic rami fractures). * **Type B (Rotationally Unstable, Vertically Stable):** Disruption of anterior and partial disruption of posterior pelvic ring (e.g., APC II, LC II). * **Type C (Rotationally and Vertically Unstable):** Complete disruption of both anterior and posterior pelvic ring (e.g., APC III, LC III, VS). #### Clinical Features (2 marks) 1. **Pain:** Severe pain in the groin, lower back, or hip, exacerbated by movement. 2. **Deformity:** May be visible if severe displacement (e.g., leg length discrepancy, rotational deformity). 3. **Tenderness:** Over the pubic symphysis, iliac wings, or sacrum on palpation. 4. **Instability on Pelvic Rocking:** (Perform gently once only, if suspected unstable fracture). 5. **Associated Injuries (Crucial):** * **Hemorrhage:** Massive retroperitoneal hemorrhage is common and life-threatening. * **Urogenital Injury:** Bladder rupture (suprapubic pain, hematuria, inability to void), urethral injury (blood at meatus, high-riding prostate in males). * **Neurological Injury:** Sciatic nerve injury. * **Gastrointestinal Injury:** Rectal laceration. #### Treatment (3 marks) Treatment focuses on hemorrhage control, fracture stabilization, and management of associated injuries. 1. **Emergency Resuscitation (ATLS Principles):** * **Hemorrhage Control:** * **Pelvic Binder/Sheet:** Applied immediately to reduce pelvic volume and tamponade bleeding. * **Fluid Resuscitation:** IV fluids, blood products. * **Angiography and Embolization:** For ongoing arterial bleeding. * **External Fixation:** Rapid stabilization of the pelvic ring to reduce bleeding. 2. **Definitive Fracture Stabilization:** * **Non-operative:** For stable (Type A) fractures, involves rest, pain management, and early mobilization. * **Operative (for unstable Type B and C fractures):** * **External Fixation:** For temporary stabilization and hemorrhage control. Can be definitive for some B-type fractures. * **Open Reduction and Internal Fixation (ORIF):** For definitive stabilization of the anterior (plate fixation of symphysis) and posterior (screws across SI joint or plates) pelvic ring. 3. **Management of Associated Injuries:** * **Urethral Injury:** Suprapubic catheter, delayed repair. * **Bladder Rupture:** Surgical repair. * **Rectal Laceration:** Colostomy. #### Complication (2 marks) 1. **Hemorrhage and Hypovolemic Shock:** Most common cause of death. 2. **Urogenital Injuries:** Urethral rupture, bladder rupture, vaginal/rectal lacerations. 3. **Neurological Injuries:** Sciatic nerve injury (especially in posterior displacement). 4. **Infection:** Pelvic abscess, wound infection. 5. **Thromboembolic Events:** DVT, PE (high risk due to trauma and immobility). 6. **Malunion/Nonunion:** Can lead to chronic pain, gait disturbance, limb length discrepancy. 7. **Sexual Dysfunction, Chronic Pain.** ### ORTHOPAEDIC: Short Notes (Any Three) (2X3=6 marks) #### i) Fracture Clavicle * **Definition:** A break in the collarbone, a common fracture, especially in children and young adults. * **Mechanism of Injury:** Direct fall onto the shoulder, direct blow to the clavicle, or fall onto an outstretched hand. * **Location:** Most commonly in the middle third (80%), followed by distal third (15%) and medial third (5%). * **Clinical Features:** * Pain over the clavicle, worse with arm movement. * Swelling, tenderness, deformity (sagging shoulder, palpable step-off). * Patient often supports the injured arm. * Neurovascular examination is crucial to rule out brachial plexus or subclavian vessel injury. * **Classification (Allman Classification):** Group I (middle third), Group II (distal third), Group III (medial third). * **Management:** * **Non-operative (most common):** For most middle-third fractures. * **Arm Sling or Figure-of-Eight Bandage:** For comfort and immobilization (figure-of-eight is controversial for outcomes). * Pain relief, early range of motion of elbow/wrist/hand, gradual return to activity. * **Operative (Open Reduction Internal Fixation - ORIF):** * **Indications:** Significant displacement (>2 cm), severe shortening (>2 cm), tenting of skin, open fracture, neurovascular compromise, nonunion, floating shoulder (clavicle and scapular neck fracture). * Fixation with plates and screws or intramedullary nails. * **Complications:** Malunion (common, often asymptomatic), nonunion, neurovascular injury (rare), post-traumatic arthritis (distal end). #### ii) CTEV (Congenital Talipes Equinovarus) / Clubfoot * **Definition:** A congenital deformity of the foot and ankle characterized by a combination of four deformities: 1. **Cavus:** High arch. 2. **Adductus:** Forefoot adduction (medial deviation). 3. **Varus:** Hindfoot varus (inversion). 4. **Equinus:** Ankle plantarflexion (foot points downwards). * **Etiology:** Multifactorial, genetic and environmental factors. Arrested fetal development, uterine crowding, neurological factors. * **Clinical Features:** * Foot appears small, short, and rotated inwards at the ankle. * The heel is drawn up and inwards. * Unable to correct the deformity passively. * Calf muscle atrophy. * May be unilateral or bilateral. * **Diagnosis:** Clinical examination at birth. X-rays confirm bony deformities. * **Management (Ponseti Method - Gold Standard):** * **Serial Casting:** Weekly gentle manipulation and application of long leg plaster casts to gradually correct the deformities. Typically for 5-7 weeks. * **Percutaneous Tenotomy of Achilles Tendon:** Performed after casting to correct residual equinus. * **Foot Abduction Brace (FAS):** Worn full-time for 3 months, then during naps and night for 3-4 years, to prevent recurrence. * **Surgical Correction (Posteromedial Release):** Reserved for complex or recurrent cases where Ponseti method fails, involving extensive soft tissue release. * **Prognosis:** Excellent with early and consistent Ponseti method, leading to a functional, pain-free foot. #### iii) Meniscus Injury * **Definition:** Damage to one of the two C-shaped cartilaginous structures (medial and lateral menisci) in the knee joint, which act as shock absorbers and provide joint stability. * **Mechanism of Injury:** * **Traumatic (younger patients):** Twisting injury to the knee while the foot is planted and the knee is flexed (e.g., sports injuries). Medial meniscus injured more often. * **Degenerative (older patients):** Minor trauma or even normal activities can cause tears due to age-related degeneration. * **Clinical Features:** * **Pain:** Localized to the joint line (medial or lateral). * **Swelling:** May be delayed (effusion). * **Clicking, Popping, Catching:** Sensation within the knee. * **Locking:** Inability to fully extend the knee due to a torn meniscus fragment getting caught in the joint. * Tenderness on palpation along the joint line. * Positive meniscal tests (McMurray's test, Apley's grind test). * **Diagnosis:** * Clinical examination. * **MRI Knee:** Gold standard for visualizing meniscal tears. * **Management:** * **Conservative (for small, stable, peripheral tears, or degenerative tears with mild symptoms):** RICE, NSAIDs, physiotherapy (strengthening, range of motion). * **Surgical (Arthroscopy - minimally invasive):** * **Meniscal Repair:** For peripheral tears in vascularized zones (red-red or red-white zone), especially in younger patients. Aims to preserve meniscus. * **Partial Meniscectomy:** Removal of the torn, unstable portion of the meniscus. More common, but increases risk of osteoarthritis. * **Total Meniscectomy:** Rarely performed due to high risk of early osteoarthritis. * **Complications:** Persistent pain, locking, progression to osteoarthritis, re-tear. #### iv) Open Fracture * See explanation in "a) Classification of Open Fracture" and "b) Complication of Open Fracture" sections under Ortho Short Notes. ### General Surgery Part-A: Blood Transfusion, Audit, Ethics (70 Mark) **Q1. In a road traffic accident, a man coming in a two wheeler got injured and was bleeding profusely-** #### a) Will you transfuse blood and what are the indications? (2) * See explanation in "Blood Transfusion & Complications" section. #### b) If whole blood is not available in blood bank, What kind of blood fractions you can give and list the blood fractions. (3) * See explanation in "Blood Transfusion & Complications" section. #### c) Complications of blood transfusion? (5) * See explanation in "Blood Transfusion & Complications" section. **Q2. In an institute, 5 person got blind after doing cataract surgery** #### a) Is surgical audit helpful in this case? (2) * **Yes, surgical audit is extremely helpful in this case.** It is precisely for identifying and investigating such adverse events that surgical audit systems are designed. It would allow for a systematic, critical review of the entire process to understand the root cause and prevent recurrence. #### b) Components of audit and how will you do? (3+3=6) * **Components of Audit:** 1. **Standards/Criteria:** What is the expected outcome (e.g., rate of blindness after cataract surgery should be 4-6 weeks). * **Formula Selection:** Standard polymeric, semi-elemental, or elemental formulas, disease-specific formulas (e.g., for diabetes, renal failure). * **Timing:** Early EN (within 24-48 hours post-injury/surgery) is beneficial for critical illness. 3. **Parenteral Nutrition (PN) / Total Parenteral Nutrition (TPN):** * **Indication:** Patients with a non-functional GI tract, severe malabsorption, prolonged ileus, severe pancreatitis, short bowel syndrome, or when EN is contraindicated or insufficient. * **Method:** Administration of nutrients (carbohydrates, amino acids, lipids, vitamins, minerals, trace elements) directly into the bloodstream, usually via a central venous catheter. * **Advantages:** Provides complete nutrition when gut cannot be used. * **Disadvantages:** More invasive, higher risk of complications (catheter-related bloodstream infections, metabolic complications like refeeding syndrome, liver dysfunction, hyperglycemia, electrolyte imbalances). * **Timing:** Start when EN is not feasible for >5-7 days in critically ill, or earlier in severely malnourished patients. 4. **Special Considerations:** * **Refeeding Syndrome:** Occurs when severely malnourished patients are rapidly refed. Characterized by severe electrolyte shifts (hypophosphatemia, hypokalemia, hypomagnesemia). Requires slow refeeding, electrolyte monitoring, and supplementation. * **Immunonutrition:** Use of specific nutrients (e.g., glutamine, arginine, omega-3 fatty acids) to modulate the immune response in critically ill patients. * **Glycemic Control:** Strict blood glucose management is essential in all surgical patients, especially those on nutritional support. **Q7. Differentiate - Enteral nutrition & Parenteral nutrition. (8)** | Feature | Enteral Nutrition (EN) | Parenteral Nutrition (PN) | | :--------------------- | :---------------------------------------------------- | :------------------------------------------------------ | | **Definition** | Delivery of nutrients via the gastrointestinal tract. | Delivery of nutrients directly into the bloodstream. | | **Route of Delivery** | Oral, nasogastric, nasojejunal, gastrostomy, jejunostomy. | Central venous catheter (PICC, CVC) or peripheral IV (for PPN). | | **Gut Function** | Requires a functional or partially functional GI tract. | Used when the GI tract is non-functional or inaccessible. | | **Physiological** | More physiological; uses normal digestive/absorptive pathways. | Less physiological; bypasses the GI tract. | | **Complications** | **Mechanical:** Tube dislodgement, obstruction. | **Catheter-related:** Infection (CRBSI), pneumothorax, thrombosis. | | | **Gastrointestinal:** Nausea, vomiting, diarrhea, constipation, aspiration. | **Metabolic:** Refeeding syndrome, hyperglycemia, electrolyte imbalances, liver dysfunction, gallstones. | | | **Infectious:** Lower risk of infection. | **Infectious:** Higher risk of catheter-related bloodstream infections. | | **Cost** | Generally less expensive. | Generally more expensive. | | **Impact on Gut** | Maintains gut mucosal integrity, prevents bacterial translocation. | Can lead to gut mucosal atrophy and increased bacterial translocation. | | **Nutrient Delivery** | Formulas (polymeric, elemental, disease-specific). | Solutions containing glucose, amino acids, lipids, vitamins, electrolytes, trace elements. | | **Monitoring** | Fluid balance, bowel function, electrolytes. | Extensive monitoring: fluid balance, electrolytes, glucose, liver function, renal function, coagulation, infection markers. | | **Timing/Duration** | Can be short-term or long-term. | Can be short-term or long-term, often initiated after 5-7 days of inadequate EN. | | **Immune Response** | Better preservation of immune function. | May have a negative impact on immune function. | **Q8. Short notes** #### i) Autotransfusion (5) * **Definition:** Autotransfusion, or cell salvage, is a medical procedure where a patient's own blood is collected, processed (washed), and then reinfused back into the same patient. It is primarily used during surgery to recover shed blood from the surgical field. * **Mechanism:** Blood is collected from the surgical site, anticoagulated, then processed by a cell saver machine that washes and concentrates the red blood cells. The concentrated RBCs are then reinfused. * **Indications:** * Major surgical procedures with anticipated significant blood loss (e.g., cardiac, orthopedic, vascular, major abdominal surgery). * Patients with rare blood types or multiple antibodies, making allogeneic blood difficult to obtain. * Patients who refuse allogeneic (donor) blood (e.g., Jehovah's Witnesses). * To reduce exposure to allogeneic blood products and their associated risks. * **Advantages:** * Eliminates risks of allogeneic transfusion (transfusion reactions, infectious disease transmission, immunomodulation). * Readily available blood, reducing demand on blood banks. * Cost-effective in high-volume procedures. * **Disadvantages/Contraindications:** * **Contamination:** Cannot be used if blood is contaminated with bacteria (e.g., bowel surgery), amniotic fluid, or malignant cells. * **Cost:** Initial equipment cost. * **Complications:** Air embolism, coagulopathy (if not adequately washed or if cell-free plasma is not replaced), hemolysis. * Not suitable for replacing plasma and clotting factors. #### ii) Blood grouping and Cross - Matching (5) * **Blood Grouping:** * **Definition:** Determination of a person's blood type based on the presence or absence of specific antigens on the surface of red blood cells (RBCs), primarily ABO and Rh systems. * **Method:** Done by mixing patient's RBCs with known antibodies (forward typing) and patient's plasma with known RBCs (reverse typing) to detect agglutination. Rh typing determines D antigen presence. * **Importance:** Essential first step for safe transfusion. * **Cross-Matching (Compatibility Testing):** * **Definition:** A laboratory procedure performed before blood transfusion to confirm compatibility between donor and recipient blood, ensuring that the recipient does not have antibodies that will react against the donor's RBCs. * **Types:** * **Major Crossmatch:** Recipient's serum is mixed with donor's RBCs. Detects antibodies in recipient that would react with donor cells. * **Minor Crossmatch (rarely done now):** Donor's serum with recipient's RBCs. * **Method:** Involves an immediate spin phase, incubation at 37°C, and an antiglobulin phase (Coombs test) to detect incomplete antibodies. * **Importance:** It is the final safety check before transfusion, detecting ABO incompatibility and other clinically significant antibodies that could cause a hemolytic transfusion reaction. Without a compatible crossmatch, only O-negative blood can be given in emergencies. **Q9. What is the amount of CPD (Citrate phosphate dextrose) required for collection of lunit of blood. (2)** * a) 50ml (Correct. Typically 63 ml of CPD anticoagulant is used for 450 ml of whole blood, but 50ml is the closest and most common answer in MCQs.) **Q10. Fresh frozen plasma (FFP) is stored at temperature of (2)** * d) -30°C (Correct. FFP is stored at -18°C or colder, often -30°C, to preserve labile clotting factors.) **Q11. Surgical audit is a systematic, clinical analysis of the quality of surgical care reviewed by.......... (2)** * c) Peers (Correct. See explanation in "Surgical audit" section.) **Q12. How many Principle make the Hippocratic Oath? (2)** * d) 4 (Correct. Referring to the four core principles of medical ethics derived from it.) **Q13. Which one is the core principle of ethic in medical care? (2)** * d) Autonomy (Correct. While all are important, autonomy is often highlighted as a foundational principle in modern ethics.) ### Ortho Part-B (15 Mark) **Q1. Define fracture. Write the classification of fractures according to their aetiology. (5)** #### Define fracture: * A fracture is a break in the continuity of a bone or cartilage. #### Classification of fractures according to their aetiology: 1. **Traumatic Fracture:** * **Definition:** Occurs when a sudden, excessive force (e.g., direct impact, indirect rotational force, bending force) is applied to a bone, exceeding its structural integrity. * **Characteristics:** Usually involves healthy bone. * **Examples:** Fractures from falls, sports injuries, motor vehicle accidents. 2. **Pathological Fracture:** * **Definition:** A fracture that occurs through bone that has been weakened by an underlying disease process, often from minimal or no trauma that would not normally cause a fracture in healthy bone. * **Causes:** * **Tumors:** Primary bone tumors (e.g., osteosarcoma), metastatic bone disease (e.g., from breast, lung, prostate cancer), multiple myeloma. * **Infections:** Osteomyelitis. * **Metabolic Bone Disease:** Osteoporosis, osteomalacia, Paget's disease. * **Genetic Disorders:** Osteogenesis imperfecta. * **Characteristics:** Bone is inherently weak. 3. **Stress (Fatigue) Fracture:** * **Definition:** A fracture that results from repetitive, submaximal stress or cyclical loading on otherwise normal bone, where the bone's remodeling capacity is exceeded by the rate of microdamage accumulation. * **Causes:** Sudden increase in activity, repetitive impact (e.g., long-distance running, marching in military recruits). * **Location:** Commonly affects weight-bearing bones (e.g., tibia, fibula, metatarsals, femoral neck). * **Characteristics:** Often subtle, can be difficult to detect on initial X-rays. **Q2. Describe stages of fracture healing. (5)** Fracture healing is a complex biological process that restores the bone's integrity, shape, and mechanical strength. It typically involves two main types: **indirect (secondary) healing** with callus formation (most common) and **direct (primary) healing** with absolute stability. The stages described below refer mainly to indirect healing. 1. **Stage of Hematoma Formation (Inflammation):** * **Timing:** Immediately after fracture (first few hours to days). * **Process:** Blood vessels are ruptured, forming a hematoma (clot) at the fracture site. This hematoma provides a scaffold for healing. Inflammatory cells (neutrophils, macrophages) infiltrate the area, removing debris and releasing cytokines and growth factors that initiate the healing cascade. 2. **Stage of Granulation Tissue Formation (Soft Callus Formation):** * **Timing:** Days to 2-3 weeks post-fracture. * **Process:** Fibroblasts and capillaries proliferate, forming granulation tissue within the hematoma. Osteoclasts resorb dead bone ends. Chondroblasts differentiate and produce hyaline cartilage, forming a soft callus that bridges the fracture gap but is not yet rigid. 3. **Stage of Callus Consolidation (Hard Callus Formation):** * **Timing:** 3-4 weeks to 3-4 months post-fracture. * **Process:** The soft callus is gradually replaced by woven bone through endochondral ossification (where cartilage is replaced by bone) and intramembranous ossification (direct bone formation). This forms a hard, visible callus that provides structural rigidity, uniting the fracture fragments. Clinically, the fracture becomes "sticky" and stable. 4. **Stage of Remodeling:** * **Timing:** Months to several years. * **Process:** The woven bone of the hard callus is slowly replaced by stronger, lamellar bone. Osteoblasts and osteoclasts work together to reshape the bone, restoring its original anatomical contour and medullary canal. The bone adapts to mechanical stresses according to Wolff's Law. This stage continues until the bone's original strength is restored. **Q3. Define non-union. What are the causes of non union. (5)** #### Define non-union: * Non-union is a condition where a fractured bone fails to heal completely within a reasonable and expected time frame for that particular fracture site and type, and the healing process has ceased. There is no radiographic evidence of progression towards union and often a persistent fracture gap. #### Causes of non-union: Non-union typically results from a combination of biological (healing potential) and mechanical (stability) factors. 1. **Inadequate Immobilization / Instability:** * **Excessive motion at the fracture site:** Prevents the formation of a stable callus and disrupts the vascular supply. This is the most common mechanical cause. * Inadequate fixation (e.g., loose plates, external fixators). 2. **Inadequate Blood Supply:** * **Devascularization of fragments:** Severe soft tissue damage, extensive periosteal stripping during surgery, or certain anatomical sites (e.g., femoral neck, scaphoid, talus) that have a precarious blood supply. * Smoking, diabetes, peripheral vascular disease. 3. **Infection:** * **Osteomyelitis:** The presence of infection at the fracture site inhibits callus formation, promotes bone resorption, and leads to tissue necrosis. This is a common cause in open fractures. 4. **Soft Tissue Interposition:** * Muscle, fascia, or periosteum trapped between the fracture fragments can prevent bone-to-bone contact and healing. 5. **Bone Loss / Gap at Fracture Site:** * Significant loss of bone substance (e.g., high-energy trauma, segmental fractures) creating a large gap that cannot be bridged by normal healing processes. 6. **Systemic Factors:** * **Malnutrition:** Deficiencies in protein, vitamins (C, D), minerals (calcium, phosphorus, zinc). * **Systemic Diseases:** Diabetes mellitus, chronic kidney disease, severe anemia. * **Medications:** NSAIDs (especially chronic high-dose), corticosteroids, chemotherapy. * **Smoking:** Impairs microcirculation and osteoblast activity. * **Advanced Age:** Slower healing rates. 7. **Local Factors:** * **High-energy trauma:** Associated with severe soft tissue and bone damage. * **Comminuted fractures:** Multiple fragments make stable fixation difficult. * **Type of bone:** Cortical bone heals slower than cancellous bone. * **Distraction:** If fragments are pulled apart. ### MCQs (1 mark each) **10. Name of the Lymph node present between the pectorals major and minor** * i) Rotter's Nodes (Correct) **11. What is the % of Ca. Breast arising from upper and outer quadrant** * iii) 50% (Correct) **12. Which thyroid cancer arise from Neuroendocrine cell.** * iv) Medullary (Correct) **13. Hepatocellular Carcinoma treatment includes** * iv) all the above. (Correct) **14. Charcoat's Traid has the following:** * iv) All are correct (Correct) **15. Acute cholecystitis.........** * iv) Only i,ii are correct. (Correct) ### ORTHOPEADIC: Supracondylar Fracture of Humerus (10 marks) **Q1. Describe the mechanism, Pathoanatomy, Clinical feature, modalities of treatment of supracondylar fracture of humerus in children. (2+2+2+4=10)** #### Mechanism (2 marks) * **Extension Type (Most Common, ~95%):** Occurs from a fall onto an outstretched hand with the elbow in hyperextension. The olecranon is driven into the olecranon fossa, causing the distal humerus to fracture just above the condyles. The distal fragment is typically displaced posteriorly. * **Flexion Type (Rare, ~5%):** Occurs from a fall directly onto a flexed elbow. The distal fragment is displaced anteriorly. #### Pathoanatomy (2 marks) * Fracture occurs through the supracondylar region of the humerus, above the epicondyles. * **Extension type:** The distal fragment is typically displaced posteriorly, often proximally, and may be medially or laterally rotated. The sharp proximal fragment can injure the brachial artery or median nerve. * **Flexion type:** The distal fragment is displaced anteriorly. * **Gartland Classification (based on displacement):** * Type I: Undisplaced or minimally displaced. * Type II: Displaced with intact posterior cortex (periosteal hinge). * Type III: Completely displaced with no cortical contact. * High risk of neurovascular compromise due to close proximity of brachial artery and median nerve to the fracture site. #### Clinical Features (2 marks) 1. **Severe Pain:** In and around the elbow. 2. **Swelling:** Rapidly developing and often significant. 3. **Deformity:** Visible S-shaped deformity of the elbow (in extension type). 4. **Tenderness:** Localized over the supracondylar region. 5. **Limited Range of Motion:** Inability or reluctance to move the elbow. 6. **Crucial Neurovascular Assessment:** * **Vascular:** Check radial and ulnar pulses, capillary refill, skin color and temperature of the hand. Absent pulse indicates urgent attention. * **Neurological:** Assess motor and sensory function of the median, ulnar, and radial nerves (e.g., "OK" sign for median/AIN, finger abduction for ulnar, wrist extension for radial). #### Modalities of Treatment (4 marks) Treatment aims to achieve anatomical reduction and stable fixation to prevent complications. 1. **Type I (Undisplaced):** * **Immobilization:** Long arm cast or splint with the elbow at 90 degrees flexion for 3-4 weeks. Close monitoring for displacement. 2. **Type II (Displaced with intact posterior cortex):** * **Closed Reduction and Percutaneous Pinning (CRPP):** Preferred method. Under general anesthesia and fluoroscopic guidance, the fracture is reduced, and K-wires are inserted percutaneously (usually cross-pinning or lateral pinning) to provide stable internal fixation. * **Closed Reduction and Cast:** May be used for very stable Type IIA fractures if reduction is easily maintained, but CRPP is generally safer. 3. **Type III (Completely Displaced):** * **Urgent Closed Reduction and Percutaneous Pinning (CRPP):** This is the standard of care. Requires careful reduction maneuver (traction, flexion, correction of rotation) followed by K-wire fixation. * **Open Reduction and Internal Fixation (ORIF):** Indicated if: * Closed reduction fails. * Open fracture (skin breach). * Evidence of severe vascular compromise (absent pulse, signs of ischemia) that does not improve after closed reduction, requiring vessel exploration. * Nerve entrapment. * **Post-reduction:** Neurovascular status must be re-assessed immediately. Pins are typically removed in 3-4 weeks, followed by gentle physiotherapy. ### ORTHOPEADIC: Short notes on any 5(five) (5X4=20) #### I. Define fracture. Classify fracture on basis of pattern. (4 marks) * **Define fracture:** A fracture is a break in the continuity of a bone or cartilage. * **Classification of fracture on basis of pattern:** 1. **Transverse:** Fracture line is perpendicular to the long axis of the bone. 2. **Oblique:** Fracture line is diagonal or at an angle to the long axis of the bone. 3. **Spiral:** Fracture line wraps around the bone like a spiral, often caused by twisting forces. 4. **Comminuted:** Bone is broken into three or more fragments. 5. **Segmental:** A type of comminuted fracture where a segment of bone is isolated by two distinct fracture lines. 6. **Greenstick (Incomplete):** Bone bends and breaks only on one side, common in children. 7. **Impacted:** One fragment of bone is driven into another. 8. **Avulsion:** A fragment of bone is pulled off by a tendon or ligament. #### II. What are the clinical features of a fractured bone? (4 marks) 1. **Pain:** Severe, localized pain, often sharp and aggravated by movement or weight-bearing. 2. **Swelling:** Rapid onset of localized edema due to hemorrhage and inflammation. 3. **Deformity:** Visible alteration in the normal contour or alignment of the limb (e.g., angulation, shortening, rotation). 4. **Loss of Function:** Inability or extreme reluctance to use the injured body part. 5. **Tenderness:** Localized tenderness on palpation over the fracture site. 6. **Crepitus:** A grating sensation or sound felt/heard when the fractured bone ends rub against each other (should be elicited gently, if at all). 7. **Ecchymosis (Bruising):** Discoloration of the skin due to extravasated blood, often appearing hours to days after injury. 8. **Abnormal Mobility:** Movement at a site where no joint exists. #### III. Define compound fractures. Classify them. (4 marks) * **Define compound fracture:** A compound fracture, also known as an open fracture, is a fracture in which there is a break in the skin and soft tissue, leading to communication between the fracture site and the external environment. This exposes the bone to potential contamination and infection. * **Classification (Gustilo-Anderson Classification):** 1. **Type I:** Wound 1 cm, moderate soft tissue damage, without extensive flap or avulsion, moderate comminution. 3. **Type III:** Extensive soft tissue damage, high-energy injury. * **IIIA:** Extensive soft tissue laceration, adequate soft tissue coverage of bone, severe comminution, high energy. * **IIIB:** Extensive soft tissue loss with periosteal stripping and bone exposure, massive contamination. Requires soft tissue reconstruction. * **IIIC:** Arterial injury requiring repair, regardless of soft tissue damage. #### IV. What in brief different stages of fracture healing? (4 marks) * See explanation in "Q2. Describe stages of fracture healing." section under Ortho Part-B. #### V. Classify femoral neck fractures. (4 marks) Femoral neck fractures are classified based on their anatomical location and displacement, both of which are critical for prognosis and treatment. 1. **Based on Anatomical Location (Pauwel's Classification - less common now, but historically important for angle of fracture line):** * **Subcapital:** Fracture just below the femoral head (most common, highest risk of AVN). * **Transcervical:** Fracture through the middle of the femoral neck. * **Basicervical:** Fracture at the base of the femoral neck, just above the intertrochanteric line. 2. **Based on Displacement (Garden's Classification - most commonly used, correlates with blood supply disruption):** * **Garden I (Incomplete):** Incomplete fracture, often impacted in valgus. Undisplaced. * **Garden II (Complete Undisplaced):** Complete fracture line, but fragments are not displaced. * **Garden III (Complete Partially Displaced):** Complete fracture with partial displacement, usually varus deformity. * **Garden IV (Complete Fully Displaced):** Complete fracture with full displacement, no contact between fragments, head is rotated. * *Note: Garden I and II fractures are considered undisplaced, while Garden III and IV are displaced. Displaced fractures have a higher risk of complications like avascular necrosis.* #### VI. Common cause of back pain (4 marks) 1. **Musculoskeletal:** * **Mechanical Low Back Pain:** Most common cause (muscle strain, ligament sprain, poor posture). * **Degenerative Disc Disease:** Age-related wear and tear of intervertebral discs. * **Herniated Disc (PIVD):** Disc prolapse compressing nerve roots (sciatica). * **Spinal Stenosis:** Narrowing of the spinal canal, compressing nerves. * **Spondylolisthesis:** Forward slippage of one vertebra over another. * **Spondylolysis:** Stress fracture of the pars interarticularis. * **Osteoarthritis:** Of facet joints. * **Fibromyalgia.** 2. **Inflammatory:** * **Ankylosing Spondylitis:** Chronic inflammatory disease affecting spine and SI joints. 3. **Infectious:** * **Osteomyelitis:** Vertebral bone infection. * **Discitis:** Disc space infection. * **Pott's Disease (TB spine).** 4. **Malignancy:** * **Metastatic Cancer:** (Common from prostate, breast, lung, kidney, thyroid). * **Primary Spinal Tumors.** * **Multiple Myeloma.** 5. **Visceral Referred Pain:** * Kidney stones, pyelonephritis, pancreatitis, aortic aneurysm. 6. **Psychogenic.** #### VII. CTEV (4 marks) * See explanation in "ii) CTEV (Congenital Talipes Equinovarus) / Clubfoot" section under Orthopaedic Short Notes (Q2, 2025).