Surgery Solved UHS Seqs

Solved University SEQ (General Surgery) for MBBS and BDS

SEQ.1 A 25 years old poultry form worker is brought with inability to open his mouth for

last three days. He had injury on his right foot ten days ago but kept working bare footed

in farm without treatment.

a) What is the diagnosis on high index of suspicion?

b) Outline the management plan with prognosis?

Key: 1

a) Tetanus

b) Management Plan: Isolation, quietness and comfort, drainage of pus and wound toilet

will be needed. Human anti-tetanus globulin is given intramuscularly to limit the effects of

free toxins and should be used in doses of 25—500 units to give cover throughout the period

of establishing active immunity by giving toxoid. A seriously ill patient, with dysphagia and

reflex spasm, will need to have a nasogastric tube passed and sedation continued. The diet,

the need for intravenous nutrition, the maintenance of balanced protein intake, and of renal

function and cardiac function will be priorities. A tracheostomy should be considered if the

patient has any difficulty in breathing. The meticulous care of the tracheostomy tube includes

suction and humidification

Prognosis 30-40 % mortality in moderate to severe disease

SEQ.2 A 15 years old school girl presents with 2x2 cm nodule on her left

supraclavicular region for the last four months. She is having sweats at night and her

sputum contains blood. She has lost about 10% of her body weight meanwhile.

a) What is the likely disease causing swelling in her neck?

b) How will you investigate her problem? Enumerate the necessary ones only.

c) Name three components of management?

Key: 2

a) Tuberculosis lymphadenitis (cold Abscess)

b) Sputum for AFB and malignant cell, X-Ray chest, FNAC or Excision biopsy swelling,

ESR, Base line Liver function test and ophthalmoscopy

d) confirmation of diseases, Nutrition and hygiene, Antituberculosis Drugs , Follow up to

see response and any side effects of drugs

SEQ. 3 A 40 years old garment factory worker reports with 1x1 cm ulcer on right side of

her oral cavity since two months. She is a habitual of pan eater. She also notices a 0 .5xo.5

cm nodule on upper part of neck on same side. The surgeon examines and advises.

a) What is his main suspicion

b) Why has he come to this conclusion

c) How should he proceed scientifically for the best results of treatment

Key: 3

a) Carcinoma of oral cavity

b) because the ulcer has enlarged neck node and she has risk factor of pan eating

c) Incisional biopsy of the ulcer, FNAC of cervical nodule, CT scans Head and Neck, MRI,

USG abdomen,

SEQ.4 Six days after exploratory laparotomy for perforated appendix, 50 years old

diabetic lady with moon face, looks toxic and has gangrene developing around her

abdominal wound. As attending surgeon

a) What is your main concern regarding the illness

b) Your diagnosis is further strengthened by the presence of which specific features

c) In few words outline the management

Key 4

a) Synergistic gangrene with septicemia

b) Diabetes mellitus, cushion syndrome, old age lady

c) Broad spectrum antibiotics (Benzyl penicillin, Metronidazole, Gentamycin )

Debridement of wound, control of blood sugar, monitoring of vital sign and intake and

Output charting, Blood transfusion, secondary wound closure or skin cover by grafting is

Only attempted after infection has been completely eradicated and health granulation

Tissue has formed.

SEQ.5 A 77 years old house wife presents with 5x5 cm swelling on right side of neck which

moves with deglutition .she has a normal voice and some difficulty in swallowing. Her pulse

is 78 per minutes. She is not using any drugs.

a) What investigations you will ask for in this patient

b) What diagnosis on one investigation can lead to suggestion of an operation

c) Name three complications which can result from operation for this problem

Key 5

a) Thyroid function test, FNAC, Indirect laryngoscopy, X-Rays thorax inlet

b) If FNAC swelling shows malignancy

C) Hypothyroidism, hypoparathyroidism, injury to recurrent laryngeal nerve, recurrence of

Disease, hemorrhage (primary or reactionary)

SEQ. 6 for reducing the infection rate in Operation Theater, the hospital infection control

committee has given six point instructions for all to observe. Please reproduce them here

Key 6

1) proper scrubbing

2) proper gowning and gloving

3) reduce inappropriate movement in theater and reduce too many people in theater

4) Reduce contaminations of instruments by unscrubbed persons.

5) ventilatory system should be laminar air flow

6) Proper skin preparation

7) 7) proper draping

8) 8) follow the universal precaution

SEQ. 7 A 35 years old school teacher comes to surgical outpatient department with a

uniform swelling of 6x6 cm in front of neck. She has prominent eyes. Her pulse is 120/min.

she is not using any medications.

a) Enumerate the clinical tests to complete your evaluation

b) Enlist the investigations in order of priority

c) Give immediate management in maximum of six lines

Key 7

a) Inspection of swelling, palpation of swelling, percussion and auscultation

Eye signs, pulse, tremor, reflexes

b) Thyroid function test, thyroid antibodies, Thyroid Scan

c) Tab propranolol

Tab Neomercazole

Lugol’s Iodine

SEQ. 8 A 12 years old school boy comes with a bluish swelling 2x2 cm in size lifting his

tongue upward and on left side. On examination it feels soft.

a) What is your likely diagnosis with closet differential diagnosis with some points

b) How will you treat this case

Key 8

a) Ranula. Differential diagnosis is hemangioma, lymphangioma (undersurface of tongue) as

Both are cystic and compressible, sublingual dermoid cyst, mucous retention cyst, tumor of

sublingual gland is firm in consistency

b) Excision of the sublingual gland or Marsupialization of the swelling

SEQ.9 A 35 year old shopkeeper’s presents with discharging point on his right cheek

a) What will be essential clinical examination in this case

b) How will you proceed with the most appropriate treatment

Key 9

a) The clinical examination consist of inspection (number, position, opening of sinus or fistula,

discharge and surrounding skin) palpation (tenderness, wall of sinus, mobility and lump)

examination with probe and examination of oral cavity and draining lymph nodes

b) First confirm the diagnosis by relevant investigation, cytology and culture of discharge,

sinogram or fistulogram, MRI Treatment according to the diagnosis, osteomyelitis, parotid

fistula, actinomycosis, sebaceous cyst, and tuberculosis sinus

SEQ.10 A 13 years old school boy brought after a highway traffic accident three hours

ago. He bears an abrasion and bruise on right upper quadrant of abdomen. He has a pulse

of 100/min and blood pressure of 100/60 mm Hg, complains of pain in abdomen. He

narrates the whole story of accident

a) What will you immediately do

b) What will be your next step

c) Outline the subsequent management plan

Key 10

a) Primary survey and resuscitation consists of assessment of airway with control of airway.

Assessment of breathing and maintenance of circulation with crystalloid fluid,

appropriate analgesia, antibiotics and tetanus toxoid. Intake and output charting by

indwelling folly’s catheter. Secondary survey and thorough examination of abdomen

b) Next step is if patient vitally stable then request for relevant investigations, USG

abdomen, Radiograph chest and abdomen, CT scan if needed, base line investigations,

screened cross matched blood

c) Management plan is according to the status of patient

Monitoring of the vital sign pulse, temperature, respiratory rate, blood pressure

Measurement of abdominal girth ½ hourly, serial examinations of abdomen for

Increasing tenderness or guarding or absence of bowel sounds and any signs of internal

Bleeding, Keep nil per oral, Pass Nasogastric tube for aspiration and folly’s catheter for

Urine output, intravenous fluids, analgesia and antibiotics. Local management of

Abrasion if response to conservative treatment then continues the treatment. If

Deterioration occurs then surgical intervention in the form of exploratory laparotomy i

Needed.

SEQ. 11 In May, A 20 year old student complains of pain in his right axilla for five days.

On examination his axilla shows redness and is tender over 3x3cm area.

a) What is your suspicion

b) Give a sketch to manage his problem

Key 11

a) Hydradenitis suppurativa

b) A course of metronidazole, prolonged course of Erythromycin, avoid deodorant in axilla

Keep axilla hygienically good, if the condition does not respond, then surgical excision is

necessary. If a wide area of skin needs to be removed, the wound needs to be covered by a split-

skin graft.

SEQ. 12 A 24 years old newlywed woman comes with a firm swelling on her left

supraclavicular fossa. She complains of numbness and weakness during washing of clothes.

On examination this side pulse is weaker than on right side. On x-Rays chest, surgeon has

discovered the cause of her problem and advised treatment.

a) what the surgeon has discovered on x-rays

b) What is the treatment advised and how should he proceed

Key 12

a) Cervical Rib on left side

b) Before surgery nerve conduction study, duplex scan subclavian artery or angiography

is needed. The rib should be excised with periosteum otherwise it will regenerate

Extraperiosteal excision of the cervical rib together with any bony prominence from the

first rib.

SEQ. 13 A 55 years old farmer comes with history of swelling around left ear for the last

ten years. It has recently increased in size up to 8x8 cm and he is unable to close his left eye

a) What is your spot diagnosis

b) What will you do to complete your clinical examination

c) Outline the management plan in six lines

Key 13

a) Carcinoma left parotid gland with facial nerve involvement

b) Examination of the whole parotid gland including inspection, bimanual palpation,

Bidigital examination of duct, examination of facial nerve, temporomandibular joins

And regional lymph nodes

C) Confirmation of the diagnosis by FNAC of swelling, CT scans Head, Neck and face,

MRI

X-Ray chest, USG abdomen, after counselling the patient and taking consent the

Radical parotidectomy with neck dissection is performed

SEQ. 14 In September there is new epidemic of disease characterized by patients

complaining of fever with rigors, headache and body aches. On examination, many patient

show hemorrhagic small spots on their body.

a) What is your most likely diagnosis

b) Name two pathogenic elements in spread of this illness

c) Suggest in few lines measures limit the spread of this disease

Key 14

a) Dengue fever

b) Aedes aegypti mosquitoes, ticks, infected blood products and organ transplantation,

mother to child

c) (1) Advocacy, social mobilization and legislation to ensure that public health bodies and

communities are strengthened,

(2) Collaboration between the health and other sectors (public and private),

(3) An integrated approach to disease control to maximize use of resources,

(4) evidence-based decision making to ensure any interventions is targeted

appropriately

(5) capacity-building to ensure an adequate response to the local situation

The primary method of controlling A. aegypti is by eliminating its habitats. This is

done

by emptying containers of water or by adding insecticides or biological control agents

to these areas Reducing open collections of water through environmental

modification is the preferred method of control; People can prevent mosquito bites by

wearing clothing that fully covers the skin, using mosquito netting while resting,

and/or the application of insect repellent

SEQ. 15 A 70 years old elder from tribal areas of Pakistan has a non-healing 1.5x1.5 cm

ulcer on his right cheek for the last one year. On examination, the ulcer has rolled up

margins with no evidence of any swelling in rest of his head and neck.

a) Name two main suspicions keeping a high index

b) Give management plan of diseases you favor with reference to any latest development in

this field

Key 15

a) Basal cell carcinoma, squamous cell carcinoma

b) wide local excision of lesion or Radiotherapy

Latest development is Mohs Micrographic surgery

SEQ.16 A 12 years old school boy is brought to emergency after a road traffic accident

twenty minutes earlier. He has a laceration on his forehead, bleeding. He is fully

conscience.

a) What will be your first step

b) In three lines give next plan

c) Enlist definite management plan

Key 16

a) Primary survey and resuscitation, airway, breathing and circulation. In this patient the

first step is to stop the bleeding by pressure dressing.

b) secondary survey , x-rays skull and neck to rule out skull fracture and cervical spine

injury, Primary suturing of laceration

c) appropriate analgesia and antibiotics , tetanus toxoid, primary suturing of lacerated

wound with proline under aseptic measures , monitoring of the patient with Glasgow

coma scale and follow up after 5 days for the examination of wound and stich removal

SEQ. 17 A six years old girl is in outpatient department with discharging sinus of right

side of neck just anterior to anterior border of sternocleidomastoid muscle since birth

a) What is the most likely diagnosis

b) Name most relevant investigation

c) Suggest appropriate definite treatment

Key 17

a) Branchial sinus / fistula

b) Sinogram / fistulogram, MRI

c) Complete excision of sinus/ fistula tract by more than one transverse incision in neck

under general anaesthesia

SEQ.18 A 60 years old farmer complains of non-healing ulcer on his lower lip for the last

four months. He has also observed 1x1 cm swelling on left side of neck.

a) What is the most likely diagnosis with high index of suspicion

b) Give two necessary investigation to reach diagnosis and design management

c) Enumerate management options

Key 18

a) Squamous cell carcinoma lower lip

b) incision biopsy of lip ulcer, FNAC neck swelling, CT scan Head neck and chest

c) Both surgery and radiotherapy are frequently employed and are highly effective methods of

treatment, each giving cure rates of about 90 per cent.

Small tumors: Up to one-third of the lower lip can be removed with a V or W-shaped excision

with primary closure this method is suitable for tumor up to 2 cm in diameter. The residual

defect is reconstructed by approximating and suturing the borders in three layers; mucosa,

muscle and skin. Particular attention should be paid to the correct alignment of the vermilion

junction. This simple procedure can readily be performed under local anaesthetic on an out-

patient basis. Initially the lip will appear tight, but this improves after about 3 months.

Intermediate Tumors: Larger tumors, which produce defects of between one-third and

Two-thirds the size of the lower lip, require local flaps for reconstruction. V or W excision will

result in microstomia. Large central defects are best managed using the Johansen step technique

This allows closure of the defect by symmetrical advancement of soft-tissue flaps, utilizing the

excess skin in the labio-mental grooves. Alternative techniques include the Bernard rotational

flap.

Total lip reconstruction

Extensive tumors of the lower lip, which invade adjacent tissues (T4), have a high incidence of

neck node metastasis. Patients with such advanced disease require surgery that may include Uni-

lateral or bilateral selective neck dissection and total excision of the lower lip and chin. The

lower lip defect is best reconstructed with a forearm flap

SEQ. 19 Give a brief account of risk factors which make a wound more prone to infection.

Key 19

Factors influencing healing of a wound

Site of the wound

Structures involved

Mechanism of wounding, Incision, Crush, Crush avulsion

Contamination (foreign bodies/bacteria)

Loss of tissue

other local factors, Vascular insufficiency (arterial or venous), Previous radiation,

Pressure

Systemic factors, Malnutrition or vitamin and mineral deficiencies, Disease (e.g. diabetes

mellitus), Medications (e.g. steroids), Immune deficiencies [e.g. chemotherapy, acquired

immunodeficiency syndrome (AIDS), Smoking

SEQ. 20 A 18 years old club cricketer is disturbed by slowing increasing swelling under his

tongue. On examination this looks blue and more prominent on right side and is fluctuant

with little displacement of his tongue. This problem is observed for the last six months.

a) What is the most likely diagnosis with one differential diagnosis

b) Give four lines on management options

Key 20

a) Ranula. Differential diagnosis is retention mucous cyst or tumor minor salivary gland

b) Marsupialization of cyst

Excision of cyst

Excision of cyst and underlying sublingual gland

Sometimes spontaneously disappear

Never perform incision and drainage as recurrence is common

SEQ. 21 A 25 years old house wife has noticed a 1x1.5 cm swelling on back of her neck for

last one week. This is painful to touch. She also complains of discomfort during combing of

her hair.

a) What is the diagnosis

b) How will you manage

Key 21

a) sebaceous cyst

b) excision of the cyst under local anaesthesia

if abscess has formed in cyst then first incision and drainage is performed then later

Excision of the cyst is performed.

SEQ. 22 A 70 years old diabetic lady has presented with swelling of her right arm after an

act of prolonged itching. Her arm is red and painful. She has fever with chills.


b) What are the components of management? Enumerate

Key 22

a) cellulitis of right arm

b) Appropriate Antibiotics

Proper analgesia

Rest of arm

Icing

Elevation of right limb

Compression with elastic bandage

SEQ. 23 A 30 years old motor mechanic is worried by weight loss for last ten months. He

has increased appetite, anxious and disturbed by hand tremors. On examination his pulse

is 115/min. There is visible prominence in front of neck with staring gaze.


b) Enlist necessary investigations

c) Give three management options

Key 23

a) Thyrotoxicosis

b) Thyroid function test (T3, T4, TSH), thyroid antibodies, Thyroid scan

c) Antithyroid drugs, Beta Blockers , Radioactive iodine , Thyroidectomy

SEQ. 24 After getting a multivitamin injection on her left upper arm, this 40 year old

house maid comes with painful swelling of left upper arm for last two weeks. She has fever

with rigors. The swelling is 8x8 cm red hot, tender and fluctuant.

a) What is the clinical diagnosis

b) Outline the best option to manage

c) Name important investigation which can bring complete resolution of problem

Key 24

a) Injection Abscess left arm

b) incision and drainage of abscess with secondary wound heeling

c) pus for culture and sensitivity, biopsy of wall of abscess cavity, x-rays left arm to rule

out osteomyelitis

SEQ. 25 A 25 years old office clerk complains of pain and fatigue of his right hand after a

prolonged desk work. On examination his right radial pulse is weaker than left. There is

firm prominence on right supraclavicular fossa.

a) What is the most likely clinical diagnosis

b) Which simple routine investigation can give support to your diagnosis

c) Outline the treatment

Key 25

a) symptomatic right cervical rib

b) X-Rays cervical spine and chest

c) Extraperiosteal excision of the cervical rib together with any bony prominence from the

first rib

SEQ. 26 A 60 years old shopkeeper comes to outpatient department with 10x10 cm

swelling of left side of face below and in front of left ear for last 15 years. There has been

recent increase in size.

a) What is the clinical diagnosis

b) Which clinical examination is mandatory in this case

c) Give few line on management

Key 26

a) Pleomorphic adenoma left parotid gland probably malignant change has occurred

b) Facial Nerve examination, bimanual examination of parotid gland and examination of

neck lymph nodes

c) After the confirmation of diagnosis with FNAC and CT or MRI scan superficial left

parotidectomy with preservation of facial nerve if it is benign otherwise in case of

malignancy radical parotidectomy with resection of nerve trunk and radical neck

dissection accordingly

SEQ.27 A 65 years old bus accident victim is brought to emergency one week after the

accident. His initial care was done by family at home. He is toxic looking with temperature

101F. His injured right leg is swollen, tender and discolored. On examination a crepitus

is discovered.

a) What is your clinical diagnosis

b) Which simple investigation will clinch the diagnosis

c) Enlist the treatment options in three lines

Key 27

a) gas gangrene right leg

b) X-Rays right leg will show subcutaneus gas

c) Treatment, to be effective, requires immediate action:

Maximum doses of penicillin (up to 2.4 g 4-hourly) or clindamycin and metronidazole,

blood transfusion. Either exposure of all the affected muscle groups by long incisions or,

in the subcutaneous infections, multiple subcutaneous drainage and slough extraction by

incisions into the subcutaneous tissue. Hyperbaric oxygen where this is available. It is

said to be helpful in the postoperative period.

The use of antiserum used to be recommended, but clinical experience was variable

SEQ. 28 Grandfather of 75 years is losing weight over the past four months due to

increasing difficulty to swallow solid food. He has noticed a small 1x1cm firm swelling in

his left supraclavicular fossa.

a) What is your suspicion on priory and its basis

b) Which investigation specific to problem will be your choice? name three only

c) How will you counsel the patient and family about management options

Key 28

a) carcinoma esophagus as he has dysphagia, weight loss and supraclavicular lymph node

b) barium swallows, endoscopy , CT scan Neck chest and upper abdomen

c) the patient and the family will be counselled about the management according to the

stage of disease and operability, resectability of tumor and site of tumor. Surgery and

Radiotherapy is curative if tumor is in the upper or middle part of esophagus and it is not

metastasized distally. Palliation can be done by intubation of esophagus by different

tubes or stents, surgical resection of esophagus and transposition of defect with stomach

or colon or small intestine

SEQ. 29 A 14 years old swimmer attends clinic with headache, fever and nose block.

Headache is dull and changes with different postures

a) What is the likely diagnosis

b) Which imaging technique will be useful to support your diagnosis

c) Outline the management

Key 29

a) Maxillary sinusitis

b) X-Rays paranasal sinus, CT scan face, MRI face

c) Decongestant nasal spray, analgesia, antibiotics, Antral lavage under local or general

anaesthesia, Intranasal endoscopic operations permit the precise removal of diseased

mucosa with minimal trauma to adjacent tissues. Caldwell—Luc radical antrostomy.

SEQ. 30 Three days after tooth extraction this 50 years old teacher comes to emergency

with a swelling of floor of mouth displacing her tongue upward. She looks toxic and finding

difficulty in teaching due to voice limitation. Her breathing is also uncomfortable while she

lies in bed

a) What is your most likely suspicion

b) Which serious problem can occur if untreated

c) Give steps of management

Key 30

a) Ludwig angina

b) airway obstruction due to glottic edema

c) Broad-spectrum antibiotics such as amoxacillin or cefuroxime combined with

metronidazole to combat the anaerobes. In advanced cases where the swelling does not

subside rapidly with such treatment, a curved submental incision may be used to drain

both submandibular triangles. The mylohyoid muscle may be incised to decompress the

floor of the mouth. Simple but generous corrugated drains may be placed in the wound

which is then lightly sutured. This operation may be conducted under local anaesthesia

and on rare occasions an additional tracheostomy may be necessary.

SEQ. 31 A young female patients from low socioeconomic class presents with a pus

discharging sinus in the lower part of the posterior triangle of the neck. Chest X-Rays

reported tubercular lesion at the apex of right lung.

a) What other investigation are required to confirm the diagnosis

b) What is your plan of treatment in this case

Key 31

a) pus for culture sensitivity and AFB, sinus wall for histopathology, PCR, growth of

bacteria takes 6 weeks.

b) Good nutrition and hygienic living. Treatment with triple therapy consisting of

rifampicin 600 mg, isoniazid 300 mg and pyrazinamide 1500—2000 mg per day given

orally for at least 2—3 months is the standard chemotherapy at present, followed by 6

months of double therapy (rifampicin plus isoniazid).

Sensitivity testing is usually available at the end of the first period of triple therapy and, if

the source of the infection is with an organism that is resistant to one of these drugs,

appropriate changes can then be made. Ethambutol may be of use in resistant cases. In

cases of pulmonary tuberculosis, the sputum should be examined to assess progress

every month until the smears are negative, but should the number of acid-fast bacilli

increase or the cultures remain positive, the development of resistance or

noncompliance of the patient with treatment should be considered.

SEQ. 32 A 5 years old male child presents with soft cystic swelling about 12 cm in diameter

in the lower part of anterior triangle of neck. It has been present since birth and increasing

in size. on transillumination it is brilliantly translucent.

a) What is the differential diagnosis

b) What complication may arise if not treated now

c) What advise will you give to parents regarding treatment of this patient

Key 32

a) cystic hygroma, branchial cyst,

b) Respiratory difficulty, infections

c) complete excision of the cyst at an early stage. Injection of a sclerosing agent, for

example picibanil (OK-432), may reduce the size of the cyst; however, they are

commonly multicystic and if the injection is extracystic subsequent surgery may be more

difficult.

SEQ. 33 while eating food a young male gets severe colicky pain in the right

submandibular salivary gland which becomes enlarged and painful. Patient also gets fever

a) How will you investigate this problem

b) What is the treatment of this condition

c) What are the complications of stone in submandibular salivary gland duct

Key33

a) Lower occlusal X-Rays, Sialogram, ultrasound and CT scan

b) If the stone is lying within the submandibular duct in the floor of the mouth anterior to

the point at which the duct crosses the lin-gual nerve (second molar region), the stone can

be removed by incising longitudinally over the duct. Once the stone has been delivered,

the wall of the duct should be left open to promote free drainage of saliva.

Where the stone is proximal to the lingual nerve, i.e. at the hilum of the gland, stone

retrieval via an intraoral approach should be avoided as there is a high risk of damage to

the lingual nerve during exploration in the posterior lingual gutter. Treatment is by

simultaneous submandibular gland excision and removal of the stone and ligation of the

submandibular duct under direct vision.

C) infection, pain, stricture formations, recurrence of stone

SEQ. 34 A 50 years old lady who been eating betel (pan) for the last 15 years, develops a

painless ulcer in the middle of the right lateral border of her tongue. It is gradually

increasing in size and has everted margins and its base is hard to touch

a) Clinically what is your diagnosis

b) How will you investigate this case

c) What methods of treatment are available for this condition

Key 34

a) Carcinoma tongue

b) incisional biopsy to confirm the diagnosis , CT scan head neck and chest, MRI face ,

USG abdomen

c) Radiotherapy , chemotherapy and surgery ( hemiglossectomy with radical neck

dissection

SEQ. 35 a young boy of eighteen years met with an accident, while driving a motor cycle.

He sustained blunt injury to his abdomen. in the emergency room his blood pressure was

80mm Hg, and pulse rate was 120/minute, he was pale

a) Which is the most common solid intra-abdominal organ to rupture in blunt abdominal

trauma

b) What investigations are required to confirm the diagnosis

c) How will you resuscitate and prepare this patient for operation

Key 35

a) liver

b) Four quadrant aspiration , Diagnostic peritoneal lavage ( for hemoperitoneum ) USG

Abdomen , CT scan Abdomen ( for hemoperitoneum and rupture of solid organs )

c) Emergency resuscitation always starts with assessment of airway, breathing and

circulation. In this patient two wide bore intravenous cannulas are inserted and ringer

lactate fluid is given till blood is available, nasogastric tube is passed for aspiration.

Folly’s catheter for urin output measurement. Antibiotics and analgesia, arrangement of

cross matched blood. Informed consent of the patient

SEQ. 36 seven years old diabetic female patient developed right ischiorectal abscess. It was

rapidly enlarging in size and patient was very septic. At places the skin was gangrenous.

The wound was foul smelling. It was clinically diagnosed as synergistic gangrene

(necrotizing fascitis)

a) Which micro bacteria are involved in this infection

b) What other investigations are to be carried out in this case

c) What is the treatment of this condition

Key 36

a) A mixed pattern of organisms is responsible: coliforms, staphylococci, Bacteroides spp.,

anaerobic streptococci and Pepto streptococci have all been implicated, acting in synergy.

b) Pus for culture and sensitivity , MRI ischiorectal area, CT scan abdomen , Endoluminal

USG

c) broad spectrum antibiotics, inotropic sport , blood sugar control, serial extensive

debridements , later graft on defects

SEQ. 37 Fifty five years old patient had a soft, compressible swelling on the left side of neck

for the last 8 years, it was gradually increasing in size and would further enlarge with

taking food and reduce in size after regurgitation of food, he also complained of difficulty

in swallowing

a) Describe the investigations to confirm the diagnosis

b) What plan would you suggest for treatment

Key 37

a) video fluoroscopic swallowing study. Barium swallow ,

b) Preoperative physiotherapy and attention to the respiratory, cardiovascular and

nutritional aspects of the patient are important. Preoperative chest physiotherapy and

perioperative antibiotics are recommended. Surgical excision of the pouch through neck

approach.

SEQ. 38 twenty five years old male patient sustained open wound to his right thigh in a

factory. The wound was heavily contaminated with dirt. on third day of injury he

developed full-blown tetanus

a) How will you manage this case

b) What is the prognosis

Key 38

a) Isolation, quietness and comfort, drainage of pus and wound toilet will be needed.

Human anti-tetanus globulin is given intramuscularly to limit the effects of free toxins

and should be used in doses of 25—500 units to give cover throughout the period of

establishing active immunity by giving toxoid (tetanus vaccine, adsorbed) im.

Antibiotics, including penicillin and metronidazole, are indicated along with measures to

protect the lungs. In dangerously ill patients, a major cyanotic convulsion will require

curarization. Intermittent positive-pressure respiration should be provided, and intensive

nursing care with increasing sedation would be needed

b) the death rate can be reduced to approximately 15 per cent. 30 % mortality in severe

cases

SEQ. 39 A 60 years old man presents with progressive dysphagia for solids. He gives

history of weight loss. He has been smoking for the last 30 years .on examination he looks

wasted. Barium swallow study showed stricture at the mid esophagus.

a) How will you assess the nutrition status of this patient?

b) What is the next step to confirm the diagnosis?

c) How will you treat this patient?

Key 39

a) Body weight ,Anthropometry (skin fold thickness, mid arm

circumference), Lymphocyte count, Serum albumin

b) Esophagoscopy and taking biopsy

c) Confirmation of the diagnosis by endoscopy

Assessing and improving the nutrition

CT chest and abdomen to assess the extent of tumor

Staging the diseases

Preparation of the patient for surgery including fitness for general anesthesia

Assessment of pulmonary function

Surgical management (curative or palliative) according the stage of disease

Follow up of the patient for complications and recurrence of diseases

SEQ. 40 A 25 years old female presented with multiple swellings in front of neck. She gives

history of palpation, weight loss and disturbance of menses. On examination, the swellings

are firm in consistency and move with swallowing. Radiograph neck shows deviation of

trachea.

a) What is the most likely diagnosis?

b) How will you confirm the diagnosis?

c) How will you manage this case?

Key 40

a) Toxic Multinodular goiter

b) Thyroid Function Test (T3 ,T4 & TSH ), Ultrasound Thyroid Gland , Thyroid Scan

c) Confirmation of the diseases

Anti-thyroid drugs and beta-blocker to control the hyperthyroid status before

definitive surgery

When patient becomes Euthyroid, plan for total thyroidectomy

Preparation of patient includes informed consent and counseling regarding total

thyroidectomy especially explain the nature of disease, complications of procedure

and use of thyroxin for whole life indirect laryngoscopy, stop antithyroid drug at

night and give beta blocker in the morning with sips of water

SEQ.41 A 60 years old male smoker presented with non-healing ulcer on the left lateral

side of tongue. On examination, 2x2 cm ulcer present over the posterior third part of the

left lateral side of tongue. Submandibular lymph node hard in consistency is also palpable.

a) What are differential diagnoses

b) How will confirm your diagnosis

c) What are the principles of management

Key 41

a) Tuberculous ulcer

Dental ulcer

Syphilitic ulcer

Malignant ulcer (squamous cell carcinoma)

b) Incisional biopsy.

c) Confirmation of the disease

Staging of the diseases with MRI or CT Head, Neck & Chest

Radiotherapy or Surgical treatment according to the stage of disease

Up to 30% of patients with a T1 (<2cm diameter) tumor have occult metastasis at

presentation and should undergo simultaneous treatment of the neck by either selective

neck dissection or radiotherapy. When performing surgical excision of the primary tumor,

a 2-cm margin in all planes should be achieved to ensure a wide, complete excision.

In Advanced tumors (T3 andT4), a major resection of the tongue and floor of the mouth

and mandible is required.

T4 tumors of the oral tongue often cross the midline, for which total glossectomy is the

only option to achieve adequate tumor clearance.

SEQ. 42 A 20 years old male got trauma to face in road traffic accident. He complains of

pain neck. On examination the left cheek is depressed and there is parasthesia over the

cheek

a) How will you assess the patient in emergency room?

b) What is le Fort classification?

c) What is the possibly of neck pain in the patient?

Key 42

a) Primary survey and resuscitation

Airway with care of neck spine

Breathing

Circulation

Deformity

Exposure

Secondary survey head to toe examination

Radiograph Head, Neck and Chest

OPG (Orthopantomograph)

CT scans Head and Neck.

b) Le Fort classified the Fracture of Maxilla in to three groups

Le Fort I Separates the alveolus and palate from the facial skeleton above.

Fracture line runs from the nasal pyriform aperture to lateral &medial walls of maxillary

antrum posteriorly to include the lower part of the pterygoid plates

Le Fort II Pyramidal in shape .Runs through the bridge of the nose & ethmoid to

medial part of the infraorbital rim & infraorbital foramen to posteriorly through the

lateral wall of the maxillary antrum at a higher level than Le Fort. I to the pterygoid

plates at the back cribriform plate may be fractured. CSF rhinorrhea

Le Fort III effectively separates facial skeleton from the base of the skull to nasal

bridge, septum & ethmoid. Irregularly through the bones of orbit to frontozygomatic

suture to lateral wall of the maxillary sinus at a higher level & the pterygoid plates

.Cribriform plate fracture leading to CSF rhinorrhea

c) Neck pain may be due to cervical spine injury

SEQ. 43 A 35 years old male presented with submandibular swelling which increase in

size after meal. He also complains of pain in the swelling after taking lemon drinks. On

examination, the swelling is bimanually palpable.


b) How will you investigate this case?


Key 43

a) Calculus in submandibular gland

b) Radiograph floor of mouth as majority stones are radiopaque

Sialogram to see the level of obstruction in submandibular duct.

c) If the stone is lying within the submandibular duct in the floor of the mouth anterior to

the point at which the duct crosses the lingual nerve (second molar region), the stone

can be removed by incising longitudinally over the duct. Once the stone has been

delivered, the wall of the duct should be left open to promote free drainage of saliva.

Suturing the duct will lead to stricture formation and the recurrence of obstructive

symptoms. Where the stone is proximal to the lingual nerve, i.e. at the hilum of the gland,

stone retrieval via an intraoral approach should be avoided, as there is a high risk of

damage to the lingual nerve during exploration in the posterior lingual gutter. Treatment

is by simultaneous submandibular gland excision and removal of the stone and ligation of

the submandibular duct under direct vision.

SEQ. 44 A 20 years old female presented with swelling in the right side of neck. She also

gives history of low-grade fever and weight loss. On examination, the swelling is soft,

nontender and fluctuant. Her ESR is 90 mm/HG.

a) Give three differential diagnoses.

b) How will you investigate this patient?


Key 44

a) cold abscess

Branchial cyst

Cystic hygroma

b) Thorough history and examination of neck along with swelling

Fine Needle Aspiration Cytology

Culture and sensitivity of aspirate

Excision biopsy

c) If it is cold abscess repeated aspirations and give antituberculosis drugs for 9 months.

Follow the patient for response and see the side effects of drugs.

If it is Branchial cyst then it is excised

If it is cystic hygroma then it is also excised

SEQ. 45 A 30 years old man got blunt trauma abdomen in road traffic accident. In the

emergency room, he is received in semiconscious stat. His pulse is 120/min and blood

pressure is 90/60 mm/Hg. His abdomen is gradually distending.

a) What is the possible cause of hypotension

b) What is this type of shock?

c) How will you manage this patient

Key 45

a) internal bleeding my due to liver laceration, splenic laceration and injury to mesentery

b) Hypovolemic shock

c) Primary Survey and resuscitation

Pass nasogastric tube

Pass Foleys catheter for urine output measurements

Give antibiotics

Arrange cross-matched blood

Take informed consent for exploratory laparotomy and Shift the patient to Operation Theater

for exploratory laparotomy If liver trauma then manage it according to the grade of injury If

spleen is injured then then splenectomy If mesentery is lacerated then repair it.

SEQ. 46. A 25-year-old female presented with swelling in front of neck, palpitation and

tremor of hands. On examination the swelling is diffuse, non-tender and moves with

swallowing .USG neck shows no nodularity.

a) Justify your diagnosis.

b) Write three appropriate investigations, which are helpful in making diagnosis.

c) Write three options to treat this patient

Key 46

a. Diffuse toxic goiter as swelling is diffuse in consistency and there are more CNS signs

b) Thyroid function test, Thyroid scan and thyroid antibodies

c) Antithyroid drugs

Radioactive iodine

Thyroidectomy

SEQ. 47. A 60-year-old farmer presented with non- healing ulcer on the right cheek. On

examination, it has pearly rolled edge and telangiectatic vessels. No cervical lymph node

palpable.

A) What is the most probable diagnosis?

B) How will you confirm your diagnosis?

C) Enlist the treatment options in this patient

Key 47

a) Basal cell carcinoma

b) Wide local excision and histopathology

c) Mohs’ micrographic surgery

Radiotherapy

Surgical excision and closure of wound

SEQ. 48. A 50-year-old male presented with non-healing ulcer on the right lateral side of

tongue. On examination, the edge of ulcer is everted and base is indurated. A 3cm hard

lymph node is palpable in right side of neck.

a) How will you confirm the diagnosis?

b) How will you treat this patient?

c) Name the different types of neck dissections

Key 48

a) incisional biopsy

b) After confirmation of diseases stage the diseases

Up to 30% of patients with a T1 (<2cm diameter) tumor have occult metastasis at

presentation and should undergo simultaneous treatment .Advanced tumors (T3

andT4) often encroach upon the floor of the mouth and, occasionally, the mandible. In

these circumstances, a major resection of the tongue and floor of the mouth and

mandible is required of the neck by either selective neck dissection or radiotherapy.

T4 tumors of the oral tongue often cross the midline, for which total glossectomy is

the only option to achieve adequate tumor clearance.

c) Classical radical neck dissection involves resection of the cervical lymphatics, the

lymph nodes and those structures closely associated such as the internal jugular vein, the

accessory nerve, the submandibular gland and the sternomastoid muscle. These structures

are all removed en bloc and in continuity with the primary disease if possible. The main

disability that follows the operation is the drooping of the shoulder due to paralysis of the

trapezius muscle as a consequence of excision of the accessory nerve.

Modified radical neck dissection — in selected cases one or more of the three following

structures are preserved, the accessory nerve, the sternocleidomastoid muscle or

the internal jugular vein, but otherwise all major lymph node groups and lymphatics

are excised.

Selective neck dissection — in this type of dissection one or more of the major lymph

node groups is preserved along with sternomastoid muscle, accessory nerve and internal jugular

vein. Under these circumstances, the exact groups of nodes excised must be documented.

SEQ. 49 Bomb Blast occurred near your hospital and you are expected to receive 20

casualties.

a) What is the common scheme of assessment for these patients?

b) What are the commonest steps of ATLS (Advanced Trauma Life Support)?

Key 49

a) A common scheme of assessment is presented below.

• Triage sieve — a quick survey is made to separate the dead and the walking from the

injured.

• Triage sort — remaining casualties are now assessed and allocated to three or four

groups according to local protocols:

category 1 — critical and cannot wait. Airway obstruction and catastrophic

Hemorrhage are examples;

category 2 — urgent. Serious injury but can wait a short time, 30 minutes in most

systems;

category 3 — less serious injuries. Not endangered by delay

category 4 — expectant. Severe multisystem injury. Survival not likely;

(optional) — heavy manpower demands.

b) ATLS component steps

Primary survey — identify what is killing the patient

Resuscitation — treat what is killing the patient

Secondary survey — proceed to identify all other injuries

Definitive care — develop a definitive management plan

Primary survey and resuscitation must be concurrent.

SEQ. 50 An elderly man had a hard lymph node palpable in the upper part of the right side

of the neck, anterior to the sternomastoid muscle. FNAC confirmed metastatic carcinoma,

probably from a primary in the oropharynx.

a) Where would you look for the primary focus

b) What other investigations would you do for management of the case

Key 50

a) tongue , lip, pharynx, larynx, buccal cavity

b) CT scan, MRI, USG Abdomen, Laryngoscopy, if primary found then incisional biopsy of

lesion.

SEQ. 51 A 45 years old female patient from Gilgit had multinodular goiter for the last 15

years. One year ago she developed tachycardia, weight loss, tremors in hands and sweating

of palms


b) What investigations are required to confirm the diagnosis

Key 51

a) Toxic multinodular goiter

b) Thyroid Function Test ( T3, T4, THS ) Thyroid Scan

SEQ. 52 A thirty five years old female patient had history of recurrent stone in both

kidneys for which she lithotripsy done in Past. Now she had developed another stone in the

right kidney. She also suffers from peptic ulcer diseases and radiological examination

reveals multiple cysts in the limb bones.

a) Clinically what is your diagnosis

b) What investigations are required for confirmation

c) How will you manage this case

Key 53

a) primary hyperparathyroidism

b) raised level of S/Ca, low level of phosphate , raised level of parathyroid hormone( PTH )

USG Neck, MIBG scan

c) after taking the detail history of patient, performing relevant physical and systemic

examination, confirmation of the diagnosis by specific investigation and localisation of

the parathyroid adenoma before definite surgical management. if it is parathyroid

adenoma or malignancy then parathyroidectomy of respective gland is performed by

carefully preserving the recurrent laryngeal nerve. if it is hyperplasia of glands then all

the four glands are removed and small pieces of gland are implanted in the

sternocleidomastoid muscle or brachioradialis muscle in the arm.

SEQ. 53 A 45 years old patient developed an ulcerating lesion 1cm in diameter on the neck

just below her right eye. The biopsy of the ulcer revealed basal cell carcinoma.

a) Clinically how does basal cell carcinoma present

b) What are the different types of treatment available? In your opinion what is the best

treatment

Key 53

a) Clinically it is slowly growing locally malignant carcinoma skin. Its margins are pearly

white and rolled up. No lymph node enlargement occurs.

b) wide local excision with reconstruction of defect, Mohs’ micrographic surgery. Local

application of 5-fluorouracil, imiquimod, cryosurgery , radiotherapy

In my opinion in this patient Mohs’ micrographic surgery is best as lesion is around the eye

SEQ. 54 A dentist notices a shaggy white mass in gingivobuccal recess of a 68 years old

man. It has been increasing in size and bleeds occasionally.

a) What investigations for the confirmation of diagnosis and plan of treatment are required

b) What treatment would you suggest if it turns out to be cancerous

Key 54

a) incisional biopsy of the mass , CT scan Head , Face , Neck and Chest, MRI face , USG

abdomen

b) if the tumor is small size (T1, T2) the wide local excision including the underlying

muscle or bone. if node positive then supraomohyoid neck dissection. if the tumor large

in size (T3, T4) then approach is lip-splitting technique, wide excision of the tumor with

segment resection of involved bone. Reconstruction of the defect by radial artery forearm

flap or temporalis muscle flap

SEQ. 55 Mother of five years old child brought her son to you with complaint of that her

son has a midline painless, cystic swelling in front of neck just below the hyoid bone. It has

recently become red, painful and child has fever.


b) How will you confirm the diagnosis

c) What is the treatment of this condition

Key 55

a) infected thyroglossal cyst , acute infection in previously cold abscess, infected sebaceous

cyst

b) Aspiration of cyst and culture of material , USG of Cyst

c) The treatment depends on the diagnosis. if infected thyroglossal cyst give antibiotics to settle

the acute infection followed by complete excision of cyst with central core of hyoid bone

(Sistrunk operation). If the diagnosis is cold abscess then give specific treatment

(antituberculosis drugs). if infected sebaceous cyst then first do incision and drainage and

later when infection is settled total excision of cyst wall.

SEQ. 56 A diabetic patients developed multiple discharging sinus on the right side of the

neck near the right angle of mandible with fever. Pus was sent for culture and it reported

as actinomycosis


b) What are the complications of this infection if not treated in time

c) What is the best treatment for this condition

Key 56

a) carbuncle , Actinomycosis , osteomyelitis of mandible , cold abscess

b) it will burst out and spread in to tissue planes , gums can become indurate and bony

swelling occur , sinus formation can occur , in chronic wounds malignancy can occur

c) benzyl penicillin , lincomycin , tetracycline

SEQ. 57 A 26 years old psychiatric patient presents with brawny swelling in the right

submandibular region and odynophagia. Examination reveals trismus, edema of the tongue

and floor of mouth along with putrid halitosis.


b) What are various complications of the untreated condition

c) Outline a treatment plan for this patient

Key 57

a) Ludwig angina

b) dysphagia , painful obstruction of the airway, glottic edema

c) Antibiotics , curved submental incisions to drain out both submandibular triangles under

local anaesthesia , Rarely tracheostomy may be needed

SEQ. 58 A 28 years old male presented with enlarged cervical lymph nodes. Enumerates

various causes of cervical lymphadenopathy

Key 58

Causes of cervical lymphadenopathy

Inflammatory, Reactive hyperplasia

Infective, Viral (infectious mononucleosis, HIV)

Bacterial (Streptococcus, Staphylococcus, Actinomycosis, Tuberculosis, Brucellosis

Protozoan, Toxoplasmosis

Neoplastic, Malignant

Primary, e.g. lymphoma

Secondary, e.g. squamous cell carcinoma

Known primary

Occult primary

SEQ. 59 A 35 years old female presents with non-healing ulcerative lesion in the right

submandibular region following the extraction of a carious tooth. On examination there is

brawny edema and purulent discharge from the lesion which contains yellowish granules


b) What is the causative organism of this condition

c) How will you confirm the diagnosis

d) What is the treatment of this condition

Key 59

a) actinomycosis

b) actinomycosis Israelii

c) Diagnosis depends on finding the organism in pus or in tissue section. Pus should be

collected in a sterile tube (a swab is usually insufficient) and inspected in a good light for

the presence of pinhead-sized ‘sulphur granules’. On microscopy, the granules are seen to

consist of Gram-positive branching bacilli. The peripheral filaments radiate4 from the

central part of the granule and may be surrounded by Gram-negative tissue clubs

d) benzyl penicillin, tetracycline , lincomycin

SEQ. 60 A 38 years laborer presents with a painless swelling in the left cervical region.

There is history of evening rise of fever and generalized malaise. the swelling is 3x4 cm,

soft, nontender and fluctuant with normal local temperature. there are matted cervical

lymph nodes on the same side.


b) What investigations will you suggest to reach the diagnosis

c) Briefly outline the treatment of this condition

Key 60

a) cold abscess ( tuberculosis lymphadenitis )

b) ESR, Pus for Culture and AFB, FNAC from matted lymphonods , excision biopsy lymph

node , Mycodott

c) Multiple Aspirations of cold abscess, good nutrition and hygiene condition, Anti

tuberculosis therapy for 9 months (rifampicin, ethambutol, isoniazid, pyrazinamide)

according to the weight of patient. Now DOTT ( directly observed treatment therapy )

method adopted to insure the compliance of patient

SEQ. 61

a) Define the terms “ cellulitis “ and “Lymphangitis “

b) What are the common organisms responsible for these lesions

c) What is the clinical presentation of these conditions

Key 61

a) cellulitis is the nonsuppurative invasive infection of tissues. In addition to the cardinal signs

of inflammation, there is poor localisation .lymphangitis is inflammation of the lymphatics

b) Beta-hemolytics streptococci, staphylococci and C. perfringens.

c) Lymphangitis is caused by similar processes but presents as painful red streaks in affected

lymphatics. Cellulitis is usually located at the point of injury and subsequent tissue infection.

Lymphangitis is often accompanied by painful lymph node groups in the rebated drainage

area.

SEQ. 62 A 47 years old intravenous drug abuser who is suspected to have HIV infection

presented with right sided parotid abscess requiring incision and drainage. as a surgeon,

what precautions will you take to protect yourself during parotid surgery

Key 62

wear goggles for eye protection

Wear double gloves and long shows

carry out the procedure in an orderly manner.

Surgical assistants should be kept to a minimum

should be instructed not to move while the operation is proceeding. If the assistants’

position is to be adjusted then the operating surgeon should stop operating while changes

are being made. This should avoid the risk of the operating surgeon injuring an assistant’s

hand while it is being moved across the operative field.

The operation should proceed in a slow and methodical manner with meticulous

attention to hemostasis, taking care to avoid unexpected rapid bleeding which

changes the tempo of the procedure and increases the risk of inadvertent injury to the

operators.

No sharp instruments or scalpels should be passed across the operative field from hand

to hand.

All instruments are passed from the scrub nurse to the surgeon and back to the scrub

nurse in a dish, thereby reducing the risk of injury while passing instruments.

SEQ. 63 A 46 years old man presents with an irregular bright red lesion on the mucosal

aspect of right cheek, diagnosed as “ Erythroplakia “

a) Define Erythroplakia

b) Enumerate the pathological features of this lesion

c) Outline the treatment of this lesion

Key 63

a) Erythroplakia is defined as any lesion of the oral mucosa that presents as a bright red plaque

which cannot be characterized clinically or pathologically as any other recognizable

condition.

b) The lesions are irregular in outline and separated from adjacent normal mucosa. The

surfaces may be nodular. These lesions occasionally coexist with leukoplakia.

c) As the incidence of malignant change in Erythroplakia is 17-fold higher than in leukoplakia.

In every case of Erythroplakia there are areas of epithelial dysplasia, carcinoma in situ or

invasive carcinoma. Clearly, all Erythroplakia areas must be completely excised either

surgically or with a carbon dioxide laser, and the specimens submitted for careful

pathological examination.

SEQ. 64 enumerates various lesions and conditions of oral mucosa associated with

increased risk of malignancy

Key 64

Conditions associated with malignant transformation

High-risk lesions

Erythroplakia

Speckled Erythroplakia

Chronic hyperplastic candidiasis

Medium-risk lesions

Oral submucous fibrosis

Syphilitic glossitis

Sideropenic dysphagia (Paterson–Kelly syndrome)

Low-risk/equivocal-risk lesions

Oral lichen planus

Discoid lupus erythematosus

Discoid keratosis congenita

SEQ. 65 An eight year old child has presented with delayed eruption of primary teeth.

a) Enumerate the local factors related to delayed eruption

b) Enumerate the systemic factors related to delayed eruption

Key 65

a) Local factors

• loss of space/overcrowding

• additional teeth

• dentigerous cysts

• retention of deciduous tooth.

b) Systemic factors

• metabolic diseases – cretinism and rickets;

• osteodystrophies – cleidocranial dysostosis and fibrous dysplasia;

• hereditary gingival fibromatosis.

SEQ. 66 A 45 years old female has been diagnosed as a case of “Sjogren Syndrome “

a) What is “ Sjogren Syndrome”

b) How will you diagnose this condition

c) How will you treat this patient

Key 66

a) Sjögren’s syndrome is an autoimmune condition causing progressive destruction of salivary

and lacrimal glands.

b) The characteristic pathological feature of Sjögren’s syndrome is the progressive

lymphocytic infiltration, acinar cell destruction and proliferation of duct epithelium in all

salivary and lacrimal gland tissue. The diagnosis is based on the history as no single lab-

oratory investigation is pathognomonic of either primary or secondary Sjögren’s syndrome

c) Management of Sjögren’s syndrome remains symptomatic. No known treatment modifies

or improves the xerostomia or keratoconjunctivitis sicca.

An ophthalmological assessment is important, and artificial tears are essential to preserve

corneal function. For dry mouth, various artificial salivary substitutes are available, but

patients often consume large volumes of water, carrying a bottle of water with them at all

times. In the dentate patient, the use of salivary substitutes with fluoride is important to

counter the risk of accelerating dental caries. Other oral complications include oral

candidosis and accelerated periodontal disease.

SEQ. 67 A 35 years old female presents with an enlarged thyroid gland. while considering

the appropriate management of this patient, how are various thyroid swelling classified

Key 67

Simple goitre (euthyroid)

Diffuse hyperplastic (Physiological, Pubertal, and Pregnancy)

Multinodular goitre

Toxic:

Diffuse, Graves’ disease

Multinodular, Toxic adenoma

Neoplastic, Benign, Malignant

Inflammatory

Autoimmune

Chronic lymphocytic thyroiditis

Hashimoto’s disease

Granulomatous

De Quervain’s thyroiditis

Fibrosing

Riedel’s thyroiditis

Infective

Acute (bacterial thyroiditis, viral thyroiditis, ‘subacute thyroiditis’)

Chronic (tuberculous, syphilitic)

Other, Amyloid

SEQ. 68 A 40 years old male presents with history of upper abdominal pain aches and pain

various bones, frequent passage of gravels in the urine and variable mode changes during

the past 2 years. Clinical examination is unremarkable. His serum calcium is 3 mmol/L and

BUN and creatinine are within normal range.


b) Enumerate various investigations to confirm the diagnosis

c) Enumerate various investigations to localize the causative lesion

d) What is the treatment of this condition

Key 68

a) Hyperthyroidism

b) Raised level of serum calcium and parathyroid hormone , low level of phosphate in serum ,

high level of urinary calcium

c) USG Neck , MIBG scan , MRI Neck, CT scan Neck , selective angiography and selective

venous sampling

d) Parathyroidectomy where adenoma present. if there is hyperplasia then all the four glands

are removed with transplantation of small pieces in the sternocleidomastoid muscle or

brachioradialis muscle

SEQ. 69 A mother brings her 3 months old son with complains of gradually enlarging

swelling on the right upper neck which increases in size when the child cries. on

examination the swelling is 6x8 cm in size, non-tender, soft to cystic and brilliantly trans

illuminant. The temperature overlying skin is normal and fluctuation test is positive


b) What is the pathology of this lesion

c) What are the various complications if the condition is left untreated

d) What is the treatment

Key 69

a) cystic hygroma neck

b) The cysts are filled with clear lymph and lined by single layer of epithelium with a mosaic

appearance.

c) respiratory problem , rupture , infection , obstruct the labor

d) Definitive treatment is complete excision of the cyst at an early stage. Injection of a

sclerosing agent, for example picibanil (OK-432), may reduce the size of the cyst;

however, they are commonly multicystic and if the injection is extracystic subsequent

surgery may be more difficult.

SEQ. 70 What do you understand by the term “ Radical Neck Dissection “ enumerate

various types of radical neck dissections mentioning the various structures removed in

every type

Key 70

this means removal of all the cervical lymph enbloc with other surrounding tissue along

the primary tumor

Types of neck dissections

Classical radical neck dissection (Crile) — the classic operation involves resection of the

cervical lymphatics, the lymph nodes and those structures closely associated such as the internal

jugular vein, the accessory nerve, the submandibular gland and the sternomastoid muscle. These

structures are all removed en bloc and in continuity with the primary disease if possible. The

main disability that follows the operation is the drooping of the shoulder due to paralysis of the

trapezius muscle as a consequence of excision of the accessory nerve.

Modified radical neck dissection — in selected cases one or more of the three following

structures are preserved, the accessory nerve, the sternocleidomastoid muscle or the internal

jugular vein, but otherwise all major lymph node groups and lymphatics are excised.

Selective neck dissection — in this type of dissection one or more of the major lymph node

groups is preserved along with sternomastoid muscle, accessory nerve and internal jugular vein.

Under these circumstances the exact groups of nodes excised must be documented.

SEQ. 71 A 35 years old motorcyclist met a road traffic accident and sustained abrasions

and lacerations of the face. A deep lacerations on the right side causes complete transection

of ipsilateral facial nerve and parotid duct

a) Enumerate the basic steps while examine a patient for faciomaxillary trauma

b) Outline the principles of management of facial soft tissue injuries

c) What is the treatment of transected facial nerve

d) What is the treatment of transected parotid duct

Key 71

a) Commence with lacerations and soft-tissue injuries

■ Systematically examine bones including the occiput and cranial vault

■ Check dental occlusion and palpate the mouth

■ Check cranial nerves

■ Photographs are useful

b) Facial soft tissues have an excellent blood supply and heal well. They should be sutured

as soon as possible following the injury after careful exploration, debridement and cleaning,

particularly where foreign bodies may be embedded. Many lacerations may be closed using local

anaesthesia, injecting into the edges of the wound. If the patient is due to have a general

anaesthetic and there is a delay, the wounds should be temporarily closed in advance, using local

anaesthesia. Tissue sufficiently traumatized to have lost its blood supply should be removed with

a sharp scalpel, and the edge to which it is to be apposed trimmed to fit as appropriate. Great care

should be taken to replace tissues accurately, particularly in cosmetically important landmarks

such as the vermilion border of the lips, the eyelids and nasal contours. Hemostasis is important.

Muscle and underlying tissues should be brought together with absorbable sutures so that the

edges of the wound lie passively within 2 mm of their final position. Then fine monofilament

sutures (5/0 or 6/0) are used to bring the wound edges together Sutures should be placed so as to

avoid compromising the blood supply of the apices of small flaps. Vacuum drains are used where

there is concern over dead space beneath the wounds. The lacerations should be covered with

antibiotic ointment two or three times per day, and broad-spectrum antibiotics should be

prescribed. Ideally, alternate sutures should be removed from the third day with the remaining

sutures removed on the fifth day. Intraoral lacerations require careful debridement, and closure in

layers with resorbable suture materials. Lacerations to mobile structures such as the tongue and

soft palate can often be under estimated in terms of their depth. Failure to close the deeper layers

of intraoral lacerations may predispose to later dehiscence,

c) Primary repair is the most appropriate treatment

d) Cannulate from the mouth and anastomose over the stent

SEQ. 72 35 years old lady presents with solitary nodule in front of neck which moves on

deglutition with recent change in voice

A) What is the diagnosis

B) What important relevant investigations are required

C) What are the treatment options in papillary carcinoma

Key 72

a) Thyroid Carcinoma

b) thyroid scan , FNAC solitary nodule , Thyroid function test( T3,T4, THS), CT Neck and

chest , USG neck and abdomen

c) Total thyroidectomy with neck dissection, radioactive iodine therapy and thyroxin in

suppressive doses.

SEQ. 73 Painful red looking swelling in right submandibular region in 20 years old boy

with following findings and complaints, difficulty on swallowing, throbbing pain, tender

and fluctuant swelling

a) What are the possible diagnosis

b) What is the treatment

Key 73

a) Ludwig angina , sialadenitis , abscess

b) if Ludwig angina then first try antibiotics if do not respond then make incision over the

swelling and decompress the submandibular triangle.

if submandibular abscess then incision and drainage done along with appropriate antibiotics

SEQ. 74

a) define bacteremia and septicemia

b) what precaution would you take in extraction of tooth in a patient who has mitral valve

replacement

Key 74

a) Bacteremia means just presence of bacteria in the blood and septicemia mean when these

organism multiplying and producing toxins in the blood

b) the patient should get prophylactic antibiotics before extraction of tooth

SEQ. 75 what do you know by term

a) healing by first intention

b) healing by second intention

give two examples of each

Key 75

a) Where wound edges are apposed healing proceeds rapidly to closure; this is known as

healing by first intention or primary healing; eg surgical wounds closed primarily ,

thyroidectomy , parotidectomy or traumatic laceration on face sutured primarily heal by

first intention

b) Where the wound edges are apart, such as when there has been tissue loss, the same

biological processes occur, but rapid closure is not possible. Angiogenesis and fibroblast

proliferation result in the formation of granulation tissue. These contracts to reduce wound

area and allow epithelialization across its surface to achieve wound closure. This is known

as healing by second intention. all wound after debridement kept open for healing by second

intention or wound after incision and drainage also heal by second intention

SEQ. 76 A patients has undergone subtotal thyroidectomy for toxic goitre

a) enumerate various post-operative complications

b) how will you manage postoperative hemorrhage in such case

Key 77

a) hypoparathyroidism , primary and reactionary hemorrhage, injury to recurrent laryngeal

nerve , injury to superior laryngeal nerve , thyrotoxicosis crises , keloid scar, seroma

formation

b) if postoperative hemorrhage occurs within 24 hours it is called reactionary hemorrhage if

airway is compromised in the ward open the stiches to relieve the pressure of hematoma and

pack the wound. Inform the theater staff anesthetics and surgeon about the shift of patient.

in theater control bleeding points under anesthesia and put suction drains in the wound.

Replace blood loss and monitor the vital signs

SEQ. 77 A 60 years old man presents with I cm ulcer on lateral side of tongue with rolled

margins and a lymph node in submandibular region

a) what is the diagnosis

b) what investigations are required to confirm the diagnosis

c) what are the treatment options

Key 77

a) carcinoma tongue

b) incisional biopsy , FNAC submandibular lymph node , CT scan Neck and oral cavity, MRI

oral cavity , USG abdomen

c) surgery and radical neck dissection followed by radiotherapy or chemotherapy if required,

only radiotherapy. carbon dioxide laser may be used for the partial glossectomy

SEQ. 78 A young patients has been brought to emergency room with facial trauma and

difficulty in breathing:

a) what steps you will take to restore breathing

b) what is the cricothyroidotomy

Key 78

a) remove the blood or any other material in the oral cavity and immediately

cricothyroidotomy

b) it is the emergency procedure to maintain the airway patent by making incision in the

cricothyroid membrane and putting mini tube in the trachea to restore airway

SEQ. 79

a) what is the classification of maxillofacial injury

b) What is management of LeFort 1 type of fracture

Key 79

a) soft tissue injury , facial skeletal injuries (upper third ,middle third and lower third )

Injury to facial nerve, injury to parotid duct, blow out fracture of orbit, nasal bone

fractures

b) The lower part of the maxilla is approached through a gingival sulcus incision above the

maxillary teeth as far back as the second molar. Fractures may be identified with ease

through this route and fixed with plates or wires. The dental arch is restored to its original

shape as far as possible so that it matches the pre-morbid occlusion with the mandibular

arch. To achieve accurate location, dental arch bars or eyelet wires may need to be applied.

Where this is anticipated, the necessary wiring is undertaken before the main part of the

operation is commenced.

SEQ. 80 A patients with hepatitis C infection has come to you for dental treatment

a) What precautions you will take to avoid transmission to other patients and yourself

b) How will you sterilize, used instruments

c) What is the rout of infection in hepatitis C

Key 80

a) there should be careful protocols for the handling of blood and body fluids in order to

reduce the risk of auto-infection and cross-infection, for hepatitis B and C viruses such

precautions are of particular importance in patients who have pre-existing infection or who

are immunosuppressed.

General measures include:

• education of staff so that they are fully aware that there is a full vaccination Programme for

hepatitis B;

• the availability of advice for staff in the event of injury.

practical measures include:

identifying high-risk patients

• reduction of the number of staff in the theatres to cover essential roles only

• removal of all extraneous equipment from the theatre;

• Staff should avoid contact with contaminated body fluids, especially blood, and in this respect

abrasions should be covered. If the member suffers from eczema, he or she should be excluded

from the theatres and if contamination does occur rapid washing should be undertaken.

• When handling potentially contaminated blood or body fluids, scrub staff should use non

permeable gowns and masks with eye protection and should double glove.

Circulating personnel should use plastic aprons and wear gloves.

• Spills should be dealt with by staff wearing gloves and using absorbent disposable clothes;

hypochlorite 1 per cent solution may be applied to blood spilt on the floor.

• Particular care should be taken with the handling of sharps, which should always be kept in

receivers.

• Swabs should be counted but not left exposed, as for routine operations on a spike rack; they

should be placed in deep ‘swab pockets’ on plastic racks.

• Disposable equipment should be placed in yellow bags at the earliest possible time, then

sealed and double bagged with a hazard label attached.

• Soiled linen should be placed in special alginate bags and sent to the laundry clearly marked.

At the end of the case all surfaces should be cleaned with detergents and the Domestic Officer

informed.

b) high level of disinfection and cleaning of instrument then sterilization of instrument

c) This may follow blood transfusion, plasma infusion and, rarely, the administration of sera,

infection resembling infective hepatitis except that the incubation period is about 12 weeks.

Transmission by plasma has been reduced by avoiding the pooling of plasma from a large

number of donors. Transmission by syringes is prevented if all syringes are disposable. It occurs

amongst those who are drug addicts and possibly after tattooing or ear piercing. There is an

extremely high rate among certain homosexual communities. In certain centers more than 50 per

cent of male homosexual patients have antibody indicating exposure and about 5 per cent have

active disease. In Athens, a group of prostitutes was found to have a rate 20 times that of married

pregnant women, possibly due to more frequent coitus near the period or to other sexually

transmitted diseases, producing bleeding that transmits the infection.

SEQ. 81 A 60 KG patient with 30% burn and coughing has been admitted in the ward

a) What are the important steps in treatment

b) What is his fluid requirement

c) How would you assess percentage of burn and depth of burn

Key 81

a) admit the patient , primary survey and resuscitation of patient ( airway, breathing and

circulation ) proper analgesia ,

b) The simplest formula (for adults) is: 3—4 ml/kg body weight/% burn/in the first 24 hours.

Half of this volume is given in the first 8 hours and the rest in the next 16 hours. Total fluid

requirement will be 7200ml in 24 hours

c) rule of nine , Burn depth depends, in thermal injury, upon:

• the temperature of the burning agent;

• the mode of transmission of heat;

• the duration of the contact.

SEQ. 82 A fifty years old man presents with gradual dysphagia to solid

a) What are the relevant investigations

b) What is the most probable diagnosis

Key 82

a) Barium swallow , Endoscopy , Endoluminal USG, CT scan Neck, chest and upper abdomen

b) carcinoma esophagus

SEQ. 83 A patients presents with painless swelling in lateral side of neck, firm consistency,

six month duration

a) What are the important points in history that you will ask

b) What investigations are required to make diagnosis

c) What is FNAC

Key 83

a) progression of swelling , associated symptoms , any history of ear discharge or nose problem

, any lesion on the scalp and oral cavity , any history of contact with tuberculosis patient

b) FNAC swelling, Excision biopsy , USG neck, CT scan , MRI , X-Ray Chest , ESR,

c) It is fine needle aspiration cytology

SEQ. 84

a) what are the various varieties of shock

b) Enumerate the clinical features of hypovolemic shock

c) Attendant of patient, while witnessing a dental procedure collapse with following

finding

Pulse 50/ minute, thready

Blood pressure 70/40 mmHg

Beads of sweat on forehead

(what type of shock she has suffered)

Key 84

a) Hypovolemic , cardiogenic , septic , vasovagal , anaphylactic, burn shock, neurogenic

shock

b) low volume pulse, tachy cardia , low blood pressure, clod clammy extremities , sweating ,

decreased urin output, low CVP

c) psychogenic or vasovagal shock

SEQ. 85 A child five months old has presented with unilateral cleft lip and palate

a) How would you classify his deformity? what is your management plan

b) Pre-operative preparation

c) Timing of surgery

d) Objectives of good repair

Key 85

a) classification is the LAHSHAL system, which is able to describe site, size and extent, as

well as type of cleft

b) consent and counselling of parents , base line investigation , arrangement of blood and other

item necessary for surgery

c) Cleft lip repair is commonly performed between 3 and 6 months of age, whereas cleft palate

repair is frequently performed between 6 and 18 months.

d) The ultimate goal in cleft lip and palate management is a patient with a normal appearance

of lip, nose and face, whose speech is normal, and whose dentition and facial growth fall

within the range of normal development. Surgical techniques are aimed at restoring normal

anatomy. With the exception of rare conditions such as holoprosencephaly, there is no true

hypoplasia of the tissues involved on either side of the cleft. There is, however,

displacement, deformation and underdevelopment of the muscles and facial skeleton.

Emphasis is placed on muscular reconstruction of the lip, nose and face as well as muscles

of the soft palate. Normal or near-normal

SEQ. 86 A 20 years old female underwent appendectomy for perforated acute appendicitis.

On 5th post-operative day she complains of diarrhoea and passage of mucous discharge per

rectum. Rectal examination revealed bulging of the anterior rectal wall.


b) How will you confirm the diagnosis?

c) What are the treatment options?

Key 86

a) Pelvic abscess

b) USG abdomen and CT scan abdomen

c) Drainage of abscess through rectum

USG or CT guided aspiration of abscess

SEQ. 87 A 30 years old married female presented with pain abdomen and vomiting. Pain

is worsened by movement or breathing. She also gives history of vaginal discharge. On

examination, her pulse is 100/min and temperature is 102F. There is tenderness and

guarding in the abdomen. On vaginal examination she has tenderness on the movement of

cervix.

A) What is the differential diagnosis?

B) How will you investigate this patient?

C) How will you treat this patient?

Key 87

a) Pelvic inflammatory diseases

Perforated appendix

Ruptured ectopic pregnancy

b) Thorough history is taken regarding the pain and vomiting ,last menstrual period

Detailed general physical and abdominal examination including rectal and vaginal

examination. pregnancy test, BHCG, USG abdomen, Full Blood Count, urin complete

examination

c) Admit the patient, Keep Nil per oral, pass folly’s catheter, appropriate antibiotic, prepare

for exploratory laparotomy if perforated appendix or pelvic peritonitis or ruptured ectopic

pregnancy. during exploration manage according to the diagnosis

SEQ. 88 A 40-year-old bankers is suffering from duodenal ulcer for last 10 years. He is not

properly taking medication for this problem. He presented with projectile non-bilious

vomiting. On examination, he looks dehydrate and peristalsis is visible in the upper

abdomen.

A) What is the most likely diagnosis?

B) How will you confirm your diagnosis?

C) How will you manage this patient?

Key 88

a) Gastric outlet obstruction due to complication of long standing ulcer

b) Barium meal study , Endoscopy to assess the ulcer and take biopsy from suspicious area

c) After confirming the diagnosis and ruling out the malignancy gastrojejunostomy and

vagotomy is performed

SEQ. 89 A 60 years old man presented with mass in the upper abdomen. There is history

of anorexia, dyspepsia and weight loss. He is chain smoker for last 30 years. On

examination, he is wasted and looks pale .A hard mass palpable in the epigastrium.

Hematology investigation shows iron deficiency anaemia

a) what investigations are required to make diagnosis?

b) What are the principles of treatment in this patient?

Key 89

a) CT Scan abdomen with oral and I/V contrast , USG abdomen , Endoscopy and Punch

biopsy,

Surgery Solved UHS Seqs

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