1

2
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Q-1 Surgical audit. ( MPMSU 21 Nov - 5 marks )

Ans. It is the systematic review of surgical practice with the objective of
recognizing deficiencies and improving standards of care. Like if a surgeon is
doing laparoscopic cholecystectomy and if he has to do open surgery in 10%
cases, while the national data so that only 3% of cases of lap
cholecystectomy need to be converted to open surgery, he needs to audit
what his reason of high failure rate.

STEPS OF AUDIT:-

1. Define the standard to be reviewed

2. Decide what data to be collected
3. Compare current practice with actual performance
data collected from the department
4. Recommend a change
5. Close the audit cycle.

Q-2 Metabolic response to injury.

Ans. It is sequential change in tissue energy during stress(injury). It is
physiological, immunologic & metabolic change in body due to injury.

Physiological (neuroendocrine) response :-

HORMONE FUNCTION
4

GH Protein synthesis, lypolysis,glycogenolysis, and anti insulin

effect
CORTISOL Gluconeogenesis, lipolysis, hyperglysemia, and anti
inflammatory effect
INSULIN Triglyseride synthesis, glucose absorption in muscle and fat,
glycogen synthesis
GLUCAGON Proteolysis , lipolysis, insulin resistance
ADH Water retention, sodium and water absorption from kidney
5

Injury

Nociceptive receptors

Spinal Cord

Thalamus

Hypothalamus

Pituitary Sympthetic system

GH ACTH
Adrenal Glucogen

Cortisol

2- Immunologic response :-

Innate immunity- it is natural, non specificand immediate mediated by

macrophages.

Adaptive immunity- it is highly specific for any pathogenic agent, acquired

and slow and mediated by B AND T Lymphocytes.

Response- can be both pro inflammatory and anti inflammatory.

Initial effect-

Pyrexia , proteolysis in skeletal muscle , production of acute phase reactants

in liver.
6

Usually both responses are balanced but pro inflammatory is unopposed

causes SIRS(systemic immune response syndrome)

Unopposed anti inflammatory response causes CARS(compensatory anti

inflammatory response syndrome)

Injury

Innate Immune System Adavtive immune response

Anti-Inflammatory Pro-Inflammatory
response response

IL-1 receptor antagonist TNF soluble

IL-1 , IL-6, IL-8, TNF-B
receptor IL-4, IL-5, IL-9, IL-13

CARS SIRS

3. Metabolic response

 Lipolysis/proteolysis
 The body stops deriving energy from glucose due to insulin deficiency
These phases of metabolic response
1. EBB phase: (decrease metabolic rate)
 48 hrs
 Hypotension, hypothesis, decreased using hydrogen excretion
2. FLOW PHASE: (catabolic phase)
 Adrenaline is the main hormone
3. breakdown of protein, lipid in muscle and fats.
4. RECOVERY PHASE:(absorption phase) Resynthesis of tissue occurs
7

EBB 48 Hypotension, hypothermia, lactic acidosis,

hrs increase catecholamines , cortisol aldosterone
RAAS activation, reduced BMR and cardiac
output
Flow 3-10 Increase adrenalin, energy production, fats
days and proteins are utilized as energy source,
insulin resistance , glucagon, ACTH,
catecholamine, corticosteroids, cytokines and
free redicals, BMR increases , increasew
cardiac outputs, body temperature
Recovery Few Restoration of body fat and proteins , it is
weeks anabolic phase
to
month

Q-3 Define shock pathophysiology of shock. c/f, investigate and treatment

of hypovolemic shock. ( MPMSU 19 june , 21 Nov - 20 marks )

Ans. It is acute failure of the regulatory system to supply blood in sufficient

quantity or under sufficient pressure to tissues causes severe
dysfunction of vital organs.

 Pathophysiology
Hypoperfusion

Release of catecholamines → increase

heart rate
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Vasoconstriction of peripheral vessel to

increase flow to vital organs

Restoration of blood pressure & flow

 In severe cases, these mechanisms may not be sufficient.

If required perfusion is not achieved

Deprivation
of o2 histamine, bradykinin, cytokine
release Lactic acidosis → inadequate
ATP → The cell loses integrity → cell
swells up

Cell death

TYPES (CHOD)- Caring HoD

1. Cordrogenic
2. Hypovolumic
3. Obstructive: pneumothorax, cardiac temponade, embolism
4. Distributive: septic, neurogenic, anaphylactic

 CIF (FiT3 DC2P)

1. Fast & flexible phase
2. Cold and calmy extremities
9

3. Thrist
4. Tachypnea
5. Tachycardia
6. Confusion (brain)
7. Decrease urine output (kidney)
8. Peripheral vasoconstriction

 INVESTIGATION :-
1. Mainly indications are made by clinical features.
2. Metabolic acidosis can be assessed by doing ABG analysis.
 Tx : :-
1. Assess ABC(airway, breathing and circulation)
2. Provide oxygen
3. Attach monitor to record vitals (HR, BP, RR, OS)
4. Obtain 2 large bore inter-nervous access(18 or 16 G)
5. Do rapid infusion of 500 ml to 1l of ringer lactate or isotonic normal
saline
6. PCV , FFP(Fresh Frozen Plasma) and platelets will be needed in
haemorrhagic shock.
7. Haemmorhagic shoch – restoration of adequate circulatory volume.
8. Septic and anaphylactic-iv fluid
9. Cardiogenic-vasopressors and inotropes.
10. In obstructive shock- needle thoracostomy pericardiocentesis

CAUSES OF HYPOVOLEMIC SHOCK

1. Loss of blood - haemorrhagic shock

2. Loss of plasma – burns
3. Loss of fluid– dehydration as in severe diarrhoea
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Q-4 Septic shock. (MPMSU 19 Feb , 21 April -20-marks)

Ans.

Sepsis is the response of the host to bacteremia and endotoxemia. It results

in persistent hypotension despite adequate fluid

Local inflammation and endotoxins activates neutrophils macrophages

monocytes causes releases of inflammatory mediators like interleukins, TNF
α, prostaglandins etc results in activation of coagulation cascades

SOFAS SCORE-

Sequential organ failure assessment.

Should be >/=2 + known foci of infection.

Parameters

SBP

Altered mental status

rr>22/min

etiology

mnemonic- SGH PIC

S- surgery

G- Genetic polymorphism in MHC, CYTOKINES, SNPs etc

H- Hospital factors

P- procedure

I-intrinsic Factor

C- community acquired
11

Pathophysiology-

Toxins/endotoxins from organisms like E. coli, Klebsiella, Pseudomonas and Proteus

Inflammation, cellular activation of macrophages, neutrophils, monocytes

Release of cytokines, free radicals ,l. Chemotaxis of cells, endothelial injury, altered coagulation cascade-
SIRS

Reversible hyperdynamic warm stage of septic shock with fever, tachycardia, tachypnoea

Severe circulatory failure with MODS (failure of lungs, kidneys, liver, heart) with DIC

Hypodynamic, irreversible cold stage of septic shock.

C/F

1. Peripheral vasodilatation
2. Tissue hypoperfusion may persist despite adequate fluid resuscitation
leades to cellular dysfunction lactic acidosis and ultimately multiorgan
failure.
3. Dry mucous membranes
4. Cold and calmmy skin.

Tx.

1. Removal of septic focus is the main

2. early empirical antibiotic therapy
3. IV fluids like ringer lactate administration
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4. Oxygen support
5. Vasoactive agents, like non-epinephrine to do vasoconstriction and to
raise systemic vascular resistance to normal, dopamine, dobutamine,or
adrenalin may be needed vasopressin is used in patients of refractory
shock.
13

- mnemonics- InDiA’S FaV Is Rajnikant , Bobby , Mahatma Gandhi,

Reached Delhi station
14

6. Initial resuscitation
7. Diagnosis
8. Antibiotic therapy
9. Source control
10. Fluid therapy
11. Vasopressor
12. Inotropics
13. Steroids
14. Recombinant human activated protein C
15. Blood product administrations
16. Mechanical ventilation
17. Glucose control
18. Renal replacement
19. DVT Prophyllaxis
20. Stress ulcers prophyllaxis

Q-5 Classify Wounds. Define about wounds healing & factors affecting
wound healing.( MPMSU 22 May - 20 marks)

Ans.-
Definition-a discontinuity and break in surface epithelium
CLASSIFICATION-
A- Simple vs Complex wound
 Simple Wounds: Involve oily Skin
 Complex Wounds: Involve underlying nerves, vessels and tendons

B- Open or closed wounds

1. Closed (HAC)
 Haematomas- Collection of blood
 Contusions-soft tissue injury without break in skin
15

 Abrasions – epidermis is scrapped it is painful due to free nerve

endings

2. Open- (LIC Parth)

 Penetrating
 Lacerated
 Incised
 Crushed

3. Acute vs Chronic wounds

 Acute
 Chronic

4. Tidy vs Untidy wounds

 Tidy
 Untidy
Types of wound healing

Primary healing-wound edges are approximated with sutures there is more

epithelial regeneration then fibrosis scar is linear and smooth

Secondary healing-wide scar, hypertrophied and contracted, re

epithelialisation occur from remaining dermal elements.

Tertiary healing- debridement and control of local infection is required then

sutured or skin grafts can be used.
16

Components of wound healing

1- Inflammatory {Lag} Phase

 Release of inflammatory mediators mainly histamine. This results
in increased capillary Permeability.
 In first 48 hours , Polymorphonuclear[PMN]leucocytes dominates
and play the role of scavengers
by removing dead tissue.

2- Proliferative {Collagen} Phase

 In days 3-5, PMN leucocytes diminish in number and monocytes

which play the role of scavenging increase.
 By day 5-6 fibroblasts appear, which give rise to protocollagen,
which is lateral converted collagen by protocollagen hydroxylase.
 Mucopolysaccharides and ground substance helps in the binding of
collagen fibres.
Protocollagen hydroxylase

Protocollagen Collagen
Hydroxylation
( Oxygen , , Fe++, vitamin C )
 Epithealisation occurs mainly from the edge of the wound through cell migration
and multiplication.

3- Remodelling {Maturation} Phase

 Brought by Myofibroblasts.
 Occurs between 5-14 days.
 They reduce the size of wounds to aid in wound healing.
 Wound contraction readily occurs in areas of loose skin like the back
and gluteal region.
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 Connective tissue formation- most important and fundamental step

in wound healing.

4- Phase of Scar formation

 Fibroplasia and Laying of collagen increases
 Vascularity reduces
 Epithelialisation Continues
 Ingrowth of lymphatics and nerve fibers.
 Remodeling of collagen takes place with cicatrisation resulting in scar.

FACTOR AFFECTING WOUND HEALING:-

1. Systematic –aiims d ki copy cat university

 Age
● Infection
 Icterus/ jaundice
 M- Malnutrition
 S-Systemic infection and inflammation
 D- Diabetes
 C- Corticosteroids
 C- Cytotoxic drugs
 U- Uremic patients

3. Local( PH increases in fat human)

 Local infections
● Poor blood supply.
● Hypoxia
 I- ionizing radiations
 F- foreign bodfy
 T- Tension
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 Haematomas

Q-6 Compartment syndrome?
Ans.- Serious condition characterized by increased pressure in one of the
compartments of the body (ex. lower limb in case of the fractured leg)
resulting in ischaemia of tissue.
Causes-
Tight dressing, increased content within the compartment due to trauma
like fracture, oedema, ischemic injury, haematoma, positioning after
trauma etc

Types:-
● Acute – trauma , fracture of leg
● Chronic- repeated exercise.

 C/F (Clinical features) :

1. Severe pain in the leg, disproportionate to the severity of injury.
2. Pain, pallor, pulselessness, Paraesthesia
3. Painful passive stretching of a limb in diagnostic feature
Note – severe progressive pain which increases by passive muscles
stretching is the diagnostic sign.

 Tx : (Treatment) :
1. Fasciotomy With two-incision technique
(lateral&medial) it is done when pressure is more
then 30 mmhg
2. Antibiotics
3. Catheterization
4. Mannitol ans diuresis
5. Hyperbaric oxygen
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6. Fresh blood transfusion

 Complications :
1. Infection
2. Gangrene

Q-7 Gas gagrene.( MPMSU 20 Feb - 5 marks )

Ans.- Highly fatal, rapidly spreading infection by clostridium organisms
carry myonecrosis.
Gas produced by organism consists of mainly nitrogen others are hydrogen,
oxygen carbon dioxide.

→Aetiology :
 Most commonly by clostridium perfingens(60%)
 Clostridium septicum
 Clostridium histolyticum
→C/F (Clinical features) have to PACK BFF
1. Pain
2. Thin brown fluid escapes which have a sickly sweet odour
3. Crepitus: crackling sound due to bones rubbing against each other
4. Skin khaki colored due to hemolysis
5. Anxious
6. Hypotension
7. Vomiting
8. Low grade fever
→Diagnosis :
1. Microscopy: Examine pus after Giemsa staining.

2. Naglers reaction: Clostridium produces lecithinase, positive for clostridium

steins.
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3.X-Ray , CT, MRI

→Tx : (Treatment)

1. Antibodies
 Injection crystalline penicillin 10-20 lakh units 4-6 th hourly should
be for for 7 days.
2. Surgery-emergency surgery
● Excision of dead muscles and necrotic tissue.
● In severely ill patient with hypotension and shock amputation is only
option left.
3. Hyperbaric oxygen therapy.
 It reduces toxin formation.(because the organisms are gram +ve
anaerobic)
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Q-8 Retro-mammary abscess. (MPMSU 20 Aug - 5 marks)

Ans. It is a collection of pus in retromammary space

Causes:

1) Haematoma with secondary infection

2) Tuberculosis of the ribs with cold abscess

3) Cold abscess arising from lymph node

4) Empyema necessitates: Empyema of lung, if left untreated, tracks out

and the pus collects in the subcu taneous plane posteriorly and
retromammary region anteriorly, thereby forming retromammary abscess.
There may be a tense, tender and cystic lump palpable which can be confused
with breast abscess.

Mx:

1) Chest X-ray

2) Treated by draining abscess by sub-mammary ( Gaillard Thomas )

incision.

Q.9 Flail chest.

Ans. Due to severe injury of the chest with fracture at two or more
consecutive ribs Ribs, with each ribs have to or more fracture sites
anteriorly and posteriorly so that certain ribs has no attachment to the
chest wall.
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Paradoxical respiration- These ribs become indrawn

due to intrathoracic negative pressure as the patient inhales and

is driven outwards on expiration producing instability.

Cause Hypoventilation,CO2 Retension, respiratory failure

Types :

1) Ant. Flail ---- Fracture of costochondral junction on both Sides of

sternum

2)Post. Flail ---- Ribs of post-chest wall fracture

3) Lateral Flail: Fracture shaft of ribs

Treatment-

Anterior flial- the flial segments are stabilized wirth metal plates and
screws to stabilize flial segment
Posterior flial- no treatment is required
Lateral flial- positive pressure ventilation reduction of dead space,
management of pulmonary contusion and pain control.
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Q-9 Fibroadenoma. (MPMSU 19 Feb - 5 marks)

Ans. It is a benign tumor in which the epithelial cells are arranged in a
fibrous stroma.

It is aberration in normal development of lobule of breast.

Itv is most common benign tumor of breast below 30 yrs of age.

Types:

gross

1) soft- common after 30 yrs more cellular

2) hard- common below 30 yrs , more fibrous

3) Giant- >5 cm in size, common in Africa.

Microscopic- I. Pericanalicular type- stroma with normal ducts

2. Intracanalicular type- stroma with distorted ducts.

C/F:
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1) Painless lump in one of the quadrant of the breast

2) Smooth, round-bordered,firm to hard in consistency.

3) Also called breast mouse

4) Peak age of incidence---- 20 yrs

Investigation:

1) Mammography- popcorn calcification on mammography.

2) FNAC

3) USG

Tx.

1) In pericanalicular type , the lump is superficial so removed by a

periareolar incision.

2) In the intracanalicular type , the lump is deep,so done by submammary

incision
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Fibroadenoma< 3cm / single / age <30 years can be left alone with regular
follow-up in 6 months.

Recent advances – cryotherapy, vacuum-assisted excision, high intensity

focused ultrasound.

Q-10 Phyllodes tumors. ( MPMSU 20 Aug - 5

marks)
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Ans. A) earliest known as cystisarcoma phylloides , it is not simply giant

fibroadenoma , it is composed of an epithelial and cellular stromal
component.

B) Can convert to the malignant tumor so it is considered as potentially

malignant tumor of the breast.

Types:

1) Benign 2) Borderlines 3) Malignant

C/F:

1) Usually unilateral 2) Grows rapidly

3) Stretched ,shiny skin 4) Red, dilated veins over the surface

5) Bosselated surface 6) Not fixed to skin or muscles or chest wall

7) Nipple retraction absent 8) Doesn’t involve lymph nodes.

9) Warm to touch 10)Dimpling of skin

Diagnosis-

1) USG
2) Tru cut biopsy
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2) FNAC

3) MAMMOGRAPHY

Tx.

 Wide excision with 1 cm margin or subcutaneous mastectomy.

 If malignant, total mastectomy with adjuvant chemotheraopy.

Q-11 Stages of cancer breast. ( MPMSU 20 Feb -

20 marks )
Ans. Primary tumor ( T)

TX :. – cannot be assessed

To. – no evidence of primary tumor

TIS. – carcinoma in situ i.e DCIS, LCIS,paget’s disease.

T1. – tumor <2cm in greatest dimension.

T2. – tumor 2-5 cm in greatest dimension.

T3. _ tumor> 5 cm in greatest dimension.

T4. – any size with direct extension to chest wall and skin

t4a. – extension to chest wall , not including only pectoralis

major muscles.

t4b. – uleration of skin oedema including peau d’orange

t4c – both t4a. & t4b

t4d. – inflamantory carcinoma

Nodular investment (N)

Nx. – Cannot be assessed

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No. – No regional lymph node metastases

N1 – metastases to mobile ipsilateral axallery LN

N2a - metastases to ipsilateral axillary LN that are fixed to one

another(matted)

N2b – metastases only in ipsilateral internal Mammary LN not clinically

evident

N3a. – metastases to ipsilateral infraclavicular LN

N3b. – metastases in ipsilateral supraclavicular LN which is clinically evident

N3c – metastasis to ipsilateral supraclavicular lymphnode.

Distant metastases :

M0. – No metastasis

M1. -- distant metastases detected.

UICC STAGING :

Stage 0 : Tis No M0

Stage 1. : T1 No Mo

Stage 2 : T1N1Mo ,T2 N2Mo

Stage 3 : T3, T4 No - 3 Mo ]--LABC

Stage 4 : tany Nany M1 )—metastatic BC

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Q-12 Etiology , prognestic factors and Mx of

malignant carcinoma of breast. ( MPMSU 19 Feb -
20 marks)
Ans : Risk factors:

1- Non- modifiable Rf

a. Age

b. Sex-female

c. Early menarche

d. Late menopause

e. BRCA genes mutation

f. Race- highest in whites rare in Japanese and taiwanian populations.

2. Modefiable Rf – HIS SAD BONE

H- Harmone replacement therapy( post menopausal)

I- Ionizing radiations

s- smoking

s- saturated fats in diet

a-alcohol

d- decrease vitamin c, folate, beta carotene obesity increases risk in diet

b- breast feeding decreases risk

o- obesity

n- nulliparity
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e- early menarche and late menopause

Prognostic Factors:

1.LN status is most important.

 C/F

1.Lump in the breast is the most common presentation . Upper & outer
quadrant is mostly involved.

2. skin ulceration

3. peau d’ orange

4.Bleeding per nipple (uncommon)

5.Pain is late sign

6.Bony pains due to bony metastasis i.e bone fractures,quadriplegia ,para

plegia .

 Signs:

1.nipple may be elevated or retracted ,Centrally retracted nipple

2. Peau d’ orange

3.Lump is fixed to breast tissue .

4.In late stage ,lump can be fixed to pectoralis major (in both upper &
inner lower quadrant ) or serratus ant. (In outer lower quad.)

5.dimpling of skin

6.Odema of breast

 SPREAD :
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(1) Local spread :

a) 1.Infiltration to skin : Ulceration , bleeding , fungation, secondary

infections and foul smelling discharge
b) 2.Invade chest wall : Pectoralis minor & major muscles, serratus
anterior.

(2) Lymphatic spread :

a) Axillary group of LN – central, lateral, pectoral, subscapular

b) Internal mammary LN
c) Infraclavicular LN
d) Supraclavicular LN
e) Lymphetics from inner medial quadrants causes ascites, krukenberg’s
tumor, secondaries in liver.
f) Malignant pleural effusion is the common cause of death in breast
cancer.

(3) Blood spread

(a) Bony secondaries

(b) Lung parenchyma

(c)Brain causing headache, vomiting

(d)liver

 Diagnosis:

Triple Assessment which include :

1.Clinical Examination
32

2.Radiological imaging ( Mammography,USG)

3.Biopsy ( FNAC tru cut Biopsy)

 Tx.

1.Goal of Tx : is palliation ,prolong survival

(1) General Tx : -

(a) Hormonal Therapy ( ER +ve pt.) . Tamoxifen. [SERM] ---+ for

premenstrual.

Letrozole for postmenopausal

(b) Chemotherapy. (ER-ve pt.) .CAF regime ,CEF regime ,CMF ,TAC regime

2.Palliative Sx -

I. Simple mastectomy .
II. No axillary dissection required
III. Done in-

a) Bleeding b) Fungating tumor

c) Ulcerating tumors d) Pain

3) Pallative Radiotherapy -

a) 1.Whole breast irradiation

b) 2.Accelectrel partial breast ---- Partial breast × 5 dy --2 sitting
/day

4)Bisphosphonates inhibit osteoclast formation & decrease bone resorption .

Ex --Zolandronate

5) Supplement with calcium & vitamin D3

33

6)Headache ,ICT increases ----- radiotherapy & corticosteroid

Q-13 Classify Breast Cancer ( MPMSU 20 Feb -

20 marks)
Ans. Histological Classification

A.Non-invasive carcinoma

(1)DCIS

(2) LCIS

B.Invasive carcinoma

(1) Invasive carcinoma of no special type (NST) /Invasive ductal carcinoma .

{it is the most common sub-type}

(2) Invasive Lobular carcinoma

(3) Special histological type. ( M*2 TP ) .

 Medullary carcinoma
 Mucinoud carcinoma.
 Tubular carcinoma
 Paget’s disease of nipple.

Q–14.C/F spread of Invasive Ductal

Carcinoma.(MPMSU 20 Feb - 20 marks )
Ans. C/F

1. The most common type of Invasive carcinoma

2. Retraction of nipple
34

3. Dimpling of skin

4. Desmoplastic reaction in stroma scan

5. Hard lump seen

SPREAD : --- Same as carcinoma breast

Q-15 C/F & Mx of LABC / Stage III Carcinoma.

(MPMSU 21 April - 20 marks) 1 -Pain

2- Bleeding Per Nipple

Ans. C/F :
3- pathological fracture
 Tumor fixed
4- Ulceration of skin
 Fungating ulcer
 Odema 5- Peau d’ orange

 Peau d’ orange 6- Odema of Breast

Mx

Locally Advanced Breast Cancer

Operable LABC (T3

Inoperable LABC
N1 M0)

Neoadjuvant chemotheraphy

No response
Clinical response

Complete the entire 8 Second line chemotheraphy

cycles of NACT

Partial Pathological
Surgery MRM/BCS Surgery
response
MRM
35

Complete
Pathological
 Adjuvant chemotheraphy
response
 Hormonal theraphy
 Radiotheraphy
 Trastuzumab

A) Neo-Adjuvant Chemotherapy. ( Pre- operative)

1) TAC regime :

a) Taxans (eg Paclitaxel or decetaxel)

b) Adriamycin (Doxorubicin)
c) Cyclophosphamide

2) Surgery preferred

a) MRM is done, BCS can be done in selected cases.

3) Radiotherapy is mandatory

4) hormone Therapy:Letrozole or Tamoxipen.

Q.16. C/F & MX of stage III Carcinoma

Stage I ---- Early breast carcinoma
Ans. Same as LABC.
StageII------Early breast
1) Operable LABC : carcinoma

a) Stage III A b) T3N1Mo StageIII-----LABC

2) Inoperable LABC :
Stage IV-----Metastatic Breast
I. : StageIII A,B,C Carcinoma

Tx : of Early Breast Carcinoma

 36

EBC

BCS BCS
contraindication
s

MRM Post operative

hormonal therapy

Radiotherapy if ( if applicable) and

indicated, Mandatory in Mandatory

BCS Radiotherapy

Q.17- Classify Thyroid Swelling .( MPMSU 22 May - 20 marks )

Ans. (1) non toxic Goitre [PCM]

 Puberty goiter
 .Colloid goitre ( iodine deficiency goitre)
 .Multinodular goitre

(2) Toxic Goitre [GST]

 Graves disease
 Secondary Thyrotoxicosis
 Toxic nodular goitre

(3) Neoplastic goitre

 Benign
37

 borderline
 Malignant
(I) Primary : [PARTH FAM]
 Papillary .
 Follicular
 .Anaplastic .
 Medullary

(ii ) Secondary :

 Breast cancer ,
 Malignant melanoma,
 RCC Produce secondaries in thyroid

(4) Thyroiditis :

 Autoimmune thyroiditis .
 Granulomatous thyroiditis .
 Riedels thyroiditis

(5) Other causes : .

 Thyroid cyst .
 Thyroid abscess
 Amyloid goitre

Q18-Multinodular goitre. (MPMSU 22 May - 20

marks)
Ans.- End result of diffuse myplastic goitre Pathogens

Puberty Iodine Goitrogens

deficiency
38

Low levels of T3 & T4

TSH Stimulation

Diffuse hyperplasia

Later fluctuation of TSH Level

Mixed area of active & inactive lobe

Active lobe become more vascular & hypoplastic

Necrosis of Inactive lobe

Nodule formation - MNG

C/F

1) Common in females 2) Dyspnoea 3) Dysphagia 4) Nodular gland

5) Sudden increase in size & pain indicate haemorrhage in nodule

Mx:

Investigation:

1)USG :First investigation in thyroid swelling 2) CBC

3)X-ray of neck : To look for compression of tissue 4) FNAC

39

5)T3 , T4 ,TSH ,FT3;,FT4 .

Tx : :-

MNG

MNG with pressur Retrosternal

Early Case extension
symptoms ,
cosmetic worreis ,
Observe fear of malignancy
tab eltroxin 0.1mg/day

Surgery
If not injury

Total thydroidectory Sub-total thyroidectomy Dowhill procedure

• Avoids hypoparathyroidism & RLN •Lobectomy of one side &

•complete relief from
paralysis
symptoms sub - total resection on
• Reccurence <5%
other side
•Good if done by • Not preffered now a days
experienced hands • Parts of right and left lobes and •Some tissue is preserved

•Risk of RLN paralysis &

entire isthmus is emoved leaving •hypoparathyroidism &
behind a little tissue in
hypothyroidism is avoided
hypoparathyroidism tracheoesophageal groove to
protect RLN & parathroid gland

Q-19 graves Disease / Primary

Thyrotoxicosis.(MPMSU 21 Nov, 21 July – 20
marks )
Ans. ETIOLOGY :-

1) Autoimmune

2) Familial
40

3) Thyroid-stimulating immunoglobulins (TS1) & long-acting thyroid

stimulates ( LATS)

4) Female sex

C/F :-

1)Thyroid swelling

2) Thyrotoxicosis. TRIAD OF GRAVES

3) Exophthalmos

4)Tremors

5) Unexplained loss of weight

6)Sweating

7) Intolerable to heat

8) OLIGOMENORRHOEA

9)Tachycardia

10)Hyperkinetic movement

11) Prominent eyeballs

12)Thyrotoxic Myopathy----- weakness in muscle

13) Thyrotoxic Dermatopathy----Pretibial myxoedema

14) Irritability

15) insomnia

16) infertility
41

Mnemonic- WO DEKHO MP KI FIIISSH

W- WEIGHTLOSS

O- OLIGOMENORRHOEA

d- dermopathy

e- exophthalmos

k- malnutrition, myopathy

h- hyperkinetic movements

m-malnutrition

p- palpitation

f- fine tremors

I – irritability

I – insomnia

I – infertility

s- steatorrhoea

s- sweating palm

h- heat intolerance

Inv :-

1)CBB, Laryngoscopy & X-ray

2) USG
42

3)T3 ,T4,TSH

Treatment :-

1) Anti -Thyroid Drugs

A) Carbimazole ----5-10 Mg 8 hourly

B) Propylthiouracil

C) Propranolol

Advantages:-

1) Avoid surgery

2) Economical

Disadvantages :-

1)Prolong duration of treatment

2) Relapse common----50%

3)Agranulocytosis,, fever , and rash are common symptoms

4)Missed dose

(2). SURGERY:

A) Total thyroidectomy

B) Sub-total thyroidectomy → Both lobe & isthmus is removed leaving

tissue equivalent To the pulp of the finger is retained on both sides. It is
commonly done.

Advantages:

1)Rapid cure
43

2)Problem of Radioactive thyroidectomy Avoided

3)Better option to control ophthalmopathy

Disadvantages:

1) Morbidity & Mortality

2) Thyroid insufficiency

Radioactive Therapy

.It destroy the cells.

.I*131 is used ( emit Beta rays )

Advantages:

1)No medicine

2)No surgery

3)More cost effective

Disadvantage:

1) Contraindicated in lactating & pregnant women

2) Permanent hypothyroidism in 10-15% people.

44

Q-20 Single Thyroid Nodule.(MPMSU 19 Feb , 19

June-20 marks).
Ans. – a) Presence of single palpable nodule in thyroid .

b) M/C surgical disc of thyroid

Causes: AM CT scan

1) Adenoma 2) Multinodular goiter

3) Toxic Autonomous Nodule

4) Carcinoma 5) Cysts

6)Toxic Autonomous Nodule

Investigation:

1) T3,T4,TSH 2) USG. IOC 3) FNAC

4) Antibodies 5) Serum thyroglobulin level 6)

 45

Treatment:

Solitary Nodule Thyroid-Nontoxic

Papillary ca
Follicular neoplasm Medullary Ca Adenoma Colloid-goitre
thyroid

Total Total Total Lobectomy * Observe

yroidectomy thyroidectomy thyroidectomy (hemithyroide *Eitroxin
ctomy) 0.1mg/day
Solitary Nodule Thyroid-Toxic

Cyst-aspiration

Suggestive of Toxic nodule Toxic nodule

*Resolves – wait & watch.
MNG in young in elderly
*Fills – aspirate again – if
it refills , surgery
Total Lobectomy
Lobectomy
thyroidectomy or ablation *Fills + solid component-
surgery
46

Q-21. Thyroglossal cyst.

Ans. It is swelling occuring in the neck or in any part along the line of
Thyroglossal tract , it is due to failure of thyroglossal duct to obliterate
completely, there will be persistant duct at certain part forming cystic
swelling containing mucus fluid.

It is usually congenital

It is lined by pseudostratifed, ciliated columnar epithelium

C/F :

1) Swelling in midline 2) Moves with deglutition (tugging sensation)

3) Swelling is smooth,soft, non tender mobile and often transillumnate.

4) thyroid fossa is empty 5)it may form abscess , cyst wall contain
lymphatic tissue so infections are common

6) malignancy can develop-cyst will become harder, fixed with palpable nec
nodes

INV:

1) USG 2) FNAC 3) if biopsy show malignancy then

complete thyroidectomy is indicated 4) thyrod profile 5) radioisotope study

Tx.

1) Sistrunk operation-excision of cyst and full tract upto foramen

caecum is done along with removal of central part of hyoid bone

Q-22. Surgical anatomy of thyroid

Ans. A) Located in ant. Triangle of Neck

47

B) Located in space between oesophagus & trachea medially & carotid

sheath laterally .

C) Isthmus is connecting part .

Blood Supply :

1) Superior thyroid artery→ Branch of external carotid artery

2) Inferior thyroid arytery→ Branch of subclavian artery

3) Thyroid ima artery → Branch of Brachiocephalic Artery.

Venous Drainage :

1) Superior Thyroid vein 2) Middle Thyroid vein 3) Inferior

thyroid vein

Lymphatic:

1) Prelaryngeal 2) Paratracheal 3) Pretracheal

4) Perithyroidal nodes 5) Mediastinal nodes

Nerves in Relation to Thyroid :

1) Superior laryngeal nerve 2) Recurrent laryngeal nerve

Histology :

1) Divided into lobules 2) Each lobules have follicles

Q-23 Pleomorphic Adenoma of Parotid.(MPMSU 21 July - 5 marks)

Ans. It is M/C benign salivary gland neoplasm in aduts

C/ F : [Like Fibroadenoma ]
48

1) Middle age women commonly affected

2) Slow growing swelling

3) Painless

4) Curtain sign → swelling is confined to lower border of zygomatic bone .

5) Rubbery & firm

Investigation:

1) USG is the first investigation 2) FNAC of lymph node

3) X-ray
49

Tx.

1) Superficial parotidectomy
2) . Superficial lobe is removed
3) . Preserved the facial nerve
4) .Avoid rupture of gland
5) .Enucleation ( local dissection) should not be done as it cause tumor left
behind & recurrence.
 50

Q-24 Aetiology, Pathology,. C/F Mx. Of Buerger’s Disease. (MPMSU

19jun,20 Aug -20marks)

Ans. Thromboangits obliterans It is a peripheral arterial disease . It is

Progressive, segmental

,Occlusive, Non-atherosclerosis, inflammatory,

Almost starts from lower limb, it involve medium sized and distal vessels.

Often present as reynaud’s phenomenon.

II. Aetiology
1) Smoking & tobacco users
2) Male predominantly affected
3 genetic factors
51

Smokes contains co & nicotin acid

carboxyhaemoglobin

vasospasm and hyperplasia of intima

Thrombosis & obliteration of vessels

panartritis

Ischemia of limb

Collaterals open up

Compensatory PVD C- Cold feet

L-Limb elevation
As patient continue to smoke , collaterals
A-Altered sensation
are blocked eventually
U-Ulceration

Critical limb ischemia D- Dead toe gangrene

I-Intolerable pain
Rest Pain , ulceraton , Gangrene

C- Cracks

A-Arterial pulse
decreases
C/F {CLAUDICATION}
T-thrill present
1. Intermittent claudication in foot and Calf
I-Intermittent
2. Rest pain, ulceration and gangrene Claudication

3. Recurrent migratory superficial thrombophlebitis O-Oedema

N-Narrow calf muscle

girth
52

4. Feeble pulse 5. Raynaud’s phenomenon may be seen

Inv.

1. CT Angiogram -- Corkscrew appearance

Inverted tree/spider leg collaterals

Corrugated rippled artery

Tx :.

1. To relieve pain

 Analgesics :Paracetamol
 Burger’s exercise: by elevation and dependency of the foot by few
minutes
 Heel raise: by 2 cm, to decrease the workload on
calf muscles and improve Claudication
 To Arrest the Progression of Disease
# Stop smoking

3. MEDICAL MANAGEMENT

 Aspirin 75mg/day or clopidogrel 75mg/day reduce mortality.

 Prostacyclins, ticlopidine,
 Cilostazol-DOC → Decrease Intermitent Claudication
 Low molecular dextrans
 Gene therapy-i /m injection of VEGF

4. SURGICAL MANAGEMENT:

 (A)Lumbar Sympathectomy .It causes vasodilation, hence improve

blood circulation and promote healing of ulcers.
53

 (B)Amputations .Below knee amputation in the last resort .Indicated

in severe rest pain.
 OMENTOPLASTY- to revasclarise the effected limb
 Profndoplasty- dne for blocage in profnda femoris artery

Q-25 Surgical Anatomy, Pathophysiology of Varicose Vein .(MPMSU 21 july

, 21 April-20 marks)

Ans. Permanently elongated, dilated tortuous vein

Classification-

long/ great saphenous veins

short/small saphenous veins

varicose veins de to perforators incompetance

Risk factors:

1.Female sex/ Pregnancy 2.Prolong standing

3.Raised intra abdominal pressure like sports , tight clothing ,pregnancy .

4.Chronic constipation 5) high heels 6) atered estrogen progesterone ratio

Surgical Anatomy:

It has 3 Parts:-

1.Superficial Venous system 2.Deep venous system 3.Perforations

Superficial veins:

1.LSV is main vein here 2.Short Saphenous Vein

Tributaries:
54

 Tributaries at its termination

 Superficial circumflex iliac vein
 Superficial epigastric vein
 Superficial external pudendal vein

Tributaries in Lower Thigh :

 Lateral superficial femoral vein

 Medial superficial femoral vein
 Transverse suprapatellar Vein.
 Transverse infrapatellar vein

Tributaries in leg.

 Anterior vein of leg

 Posterior arch vein

Perforations :

1.Leg perforations 2.Knee perforations 3.Thigh perforations.

Deep Veins :

It has femoral vein and popliteal vein which is formed from

1)Anterior tibial vein 2)Posterior tibial vein

3)Peroneal Vein 4)Soleal venous sinus

 Symptoms: mnemonic- SUBI DD

1) swelling in legs 2)ulcerations 3) bleeding 4) itching 5) dragging pain
5) dermatitis
signs-mnemonics- TAPS
1. tortuous and dilated vein
55

2. Trandelenberg test
3. Ankle flare- group of reticular vein near medial malleolus
4. Pigmentations- due to subcutaneous microangiopathies
5. Sephena Varix----- large varicosities in groin
6. Schwarts test
 INV:-
1. Venous doppler
2. Duplex scan
3. plathesmography
4. ambualatory venous pressure
5. arm-foot venous pressure
6. venography
7. varicographyl
 TX.
Pharmacotherapy
1. Diosmin , hesperidin
2. Calcim dobisilate 2. Benzopyrones, saponins ruscus,
coumarins

They prolong vasoconstriction effect of norepinephrine on vein wall.

Non-Surgical TX :
1. Elastic Compression stockings
2. Elevation of limbs
3. Unna boots-
4. Pneumatic compression
Adv .
1. Require minimal patient involvement
2. Provide Topical Therapy
56

Disadvantage-
1. Ulcers cannot be monitored
2. Dermatitis
3. Uncomfortable

2) Compression sclerotherapy

1. 3 % sodium tetradecyl sulphate is injected in column of vein.

2. It irritate the endothelium causing sclerosis.

Adv.

1.Relatively easy method 2. Can be used for veins for veins <3mm.

Dis.

1. cannot be for veins > 3mm veins. 2.can cause deep vein thrombosis

3) Radiofrequency Ablation (RFA).

o For veins <12 mm diameter

o A bipolar catheter is inserted with alternating radiofrequency which
leads to venous spasm , collagen shrinage and constriction.

C. (Surgery)

1)Trendelenburg’s operation:
57

Inaugural incision is made

LSV is identified

3 tributaries are ligated

LSV is divided from femoral vein&ligated

Incision on medial side of upper part of leg

Long saphenous vein isolated

metalllic head is introduced->Inguinal incison stured →tght crepe appled→limb

elevated

2) Subfascial ligation of cockett & Dodd.

3) Subfacial endoscopic perforator surgery { SEPS }.

Q-26 DVT.

Ans. It is semisolid clot in vein which has high tendency to develop

pulmonary embolism and sudden death.

Causes: [THROMBOSIS]
58

Deep Vein Thrombosis

T – Trauma

H – Harmones (OCP’s)

R – Road traffic accidents

O – Orthopedic surgery

M – Malignancy

B – Blood disorders

O – Obesity / old age

S – serious illness

I – Immobilization

S - Splenectomy

CIF

1)Fever→ earliest symptom

2)Pain & swelling in thigh, calf & thigh .

3)(+)ve Homan’s sign:. Forcible Dorsiflexion of foot cause severe pain in calf

4) Mose’s test: Gentle squeezing of calf side to side is painful(gentleness is

important otherwise thrombus will dislodge to form embolus)

INV. :

1)Venous Doppler 2)Duplex scanning

Treatment:
59

1) Bedrest and limb elevation

2)Anticoagulant: Heparin/ low molecular weght heparin, Warfarin .Inj.

Heparin 10,000 units IV bolus given for 7 days. .Warfarin started---
continue for 6-12 months

Prevention of DVT:

1)Decrease obesity

2)Stop smoking

3)Pressure bandage on legs during major surgeries

4)Low dense heparin--- 5,000 units 2 hrs before surgery

5) Stockings, Pneumatic compression given

6)Aspirin.

Q.27 Volksmann ischemic contracture.(MPMSU 19 feb , 23feb - 5 marks)

Ans. Vascular injury Leading to muscle infarction and subsequent

contracture

Causes :

1. Burns 2. Chemotherapy 3. Tight plaster

4. supracondylar fracture of humerus 5. closed forearm crush injuries

Pathogenesis :
60

Injury to brachial artery

Results in infarction of forearm flexor muscles.

Aseptic muscles necrosis

Fibrosis

Contracture

C|f:

1. Pain 2. Pallor 3. Deformity

Tx :

1. In active phase :

● Correction of fracture ● Exposre of brachial artery ● Sutne of arterial tear

If prevent

2. in late phase :

● Max - page operation – release of flexor muscles from their orgin from
bone

● Physiotherphy

Q-28 Blood transfusion

Ans. Complication of blood transfusion :

 Mnemonic-- FHATI CT
 Febrile Rxn
 Heamolytic reaction – major or minor incompatibility Reaction
61

 Allergic r×n
 Transfusion –related acute lung injury (TRALI)
 congestive cardiac failure
 transfusion related graft versus host disease.

1. Febrile Rxn :

● Most common ● Fever , cills rigor , tachycardia seen

2. Haemolytc r×n :

● Major IR ● Remlt of mismatched blood transform

C/F :

1. Fever, chills , rigor 2. Haematuria 3. oliguria

Tx.

1. Stop transfusion

2. Fluid therapy

3. Inj hydrocortisone / dexamethasone

4. Furosemde Iv to flsh kidneys

5. TRALI

● Breathlessness ,saturation drop

5. TGVH:

● seen in immuncompromised patients

● Donor lymphocyte reaction against host tissues

6. CCF :

● if large quantities of blood is infused.

62

Trauma
Q.29 Defination, Clarification, pathophysiology m of 40% thermal burn ,rule
of 9.( MPMSU 20 Feb - 20 marks)

Ans. Injury to skin or organic tissue by chemical ,heat ,radiation ,electricity

, friction

Classification :

1. Based on causative agent: [ REC2T]

 Radiation
 Electrical
 Chemical
 Cold
 Thermal --moist heat , dry heat

2. Based on depth of wound

● First degree –involve only epidermis

● Second stage – involve epidermis + varying degree of dermis

● Third degree – Epidermis +dermis + subcutaneous tissue

● Fourth degree – all tissue including bone, muscles, fascia.

Pathophysiology :

Heat causes coagulative necrosis

Release of vasoactive peptides

Altered capillary permeability

63

severe hypovolemia

Decreased cardiac output Decreased renal perfusion

Altered pulmonary resistance causing Oliguria

pulmonary edema

Infection

SIRS

MODS
64

Mx:. ( FSLN ---- फ़िसलन. )

1) First Aid
.Stop burning process
.Cool area with tap water

2) Definitive Treatment:
.ABC maintain
.Assess % , degree & type of burn

3)Fluid resuscitation:

(A) Parkland’s Regime :

For First 24hrs ,total fluid Needed = 4ml × body weight × % of

TBSA(Total body surface area burnt) .
Half of the volume is given in the first 8 hrs . Rest half is given in the
next 16 hrs
Only crystalloids are given in the first 24 hrs like Ringer Lactate.
After 24 hrs , colloids shall be given to Compensate plasma loss.
Human albumin is an ideal Colloid.

(4) Local management:

.Dressing under general anesthesia.

.Open method --- silver sulphadiazine without any dressings
.Closed method ---- Done to protect the wound.

(5) Surgery:

Wound excision and covered with allograft or autograft .

Debridement
When wound is large , meshed skin graft can be used.
65

(6) Nutritional support:

.High carbohydrate & protein did :-

Curreri formula : 25 × weight + 40 kcal × %BSA Mx of 40% burns

patient

: By using Parkland’s Regime

: 4×60×40 = 9600ml = 9.6 L fluid needs to be administered if patient

is 60 kg.

Rule of 9-

It was given by Wallace- it is used to find body surface area involved in

burn
66

GIT
Q-30 Barrett's esophagus. (MPMSU 21 Nov - 5 marks)
Ans. Metaplasia of squamous cells to columnar cells in the lower oesophagus.

Risk factors-

Age> 50 yrs

Smoking

Obesity

Male sex

Pathogenesis:

Repeated reflux causes damage- As a protective mechanism squamous

epithelium changes to columnar epithelium

It commonly affects lower esophagus

Intestinal metaplasia s seen- goblet cells are present

Histologically- columnar epithelium lined esophagus(CELO) and intestinal

metaplasia present

This columnar epithelim is seen endoscopically.

Clincal features-

GERD, Haemetmesis, dysphagia

Common in man, common in whites

Complications- dysphagia bleeding, perforation, adenocarcinomas of OG

junctions
67

Inv:

1) Endoscopy- salmon pink color

2) Biopsy

TX.

1) High dose PPI for 8 weeks 2) Radiofrequency ablation

3) Laser photodynamic therapy 4) Laparoscopic anti reflex surgery

5) Oesophagectomy in severe cases

Q-31 Achalasia cardia.(MPMSU 22 May - 5 marks)

Ans. A)It is an Oesophageal motility disorder characterized by a spasm of
circular muscle fibers at the end of the esophagus.

Failure of relaxation of OG junction

B) It is a pre- cancerous condition for carcinoma oesophagus

Aetiopathology :

1) Idiopathic: Absence or degeneration of Auerbach’s plexus also called

myenteric plexus.

2) Acquired: caused by Trypanosoma cruzi It Destroys ganglion cells in

Auerbach’s plexus.

3)Stress & emotional factors.

3) vit B1 deficiency

4) infection- trypanosoma cruzi

68

5) idiopathic

C/F: mnemonic- HR becomes High When Female DO Catwalk

1) Dysphagia

2) Regurgitation triad

3) Weight loss

4) Recurrent Respiratory infection like pneumonia

5) Halitosis

6) common in females

7) chest pain

8) heartburn

9) odynophagia

INV:

1] Barium Swallow

 Bird beak appearance – uniformly dilated esophagus above with

tapering segment below
 Oesophageal Manometry

2] X-ray

3} Oesophogoscopy:
69

 Dialated sac containing stagnant food and fluid.

4} USG

Tx : :

→MX - CCB , Nitrates, nitroglycerine, sildenafil

→Endoscopic MX - NOTES { natural orifice transluminal endoscopic

surgery}

1. Modified laparoscopic Heller's cardiomyotomy

2. per oral endoscopic myotomy [ POEM]

3.Pnenmatic dilatation:

● A balloon is positioned in LOS

● Rapidly inflated to widen the passage

● Most effective non-surgical option

4. botulinum toxic injection

5. Drugs sublingual nifedipine CCB to short-term relief.

6. resection of OG jnction

Q-32 Trache- oesophageal fistula

Ans. ● It happens in newborn

● Lower end of esophsgus commncates wth trachea and upper end is blind
- M/C type

C/F :-

● Continuous poring of saliva is a diagnostic feature.

70

● newborn regurgitates all food

● Cough

● Cyanosis

Inv :-

Obstruction seen while praising nasogastric tube .

Tx : :-
Right thoracotomy

Fistula is ligated

Lower segment is anastomosed with upper segment

Colonic or gastric transposition required in long

atretic segment

Q-33 PUD - Etiopath, Type , C/F , MX , complications .

Ans. Acid peptic digestion of alimentary mucosa resulting in a uLcer is

called PUD.

Etiopath:

Can occurs due to increased damage or impaired defense

A) Increased damage

1. H.Pylori infection - Most important primary cause of PUD

2. Alcohol
71

3. Cigeratte smoking

4. NSAIDS – some prostaglandins are protective in nature but NSAID’S

destroy them

5. Zollinger-ellison syndrome-gastric acid hypersecretions, severe PUD, non

islet cell tumors of pancreas, hypergastrin secretions

B). Impaired defense

● Ischemia

● Shock

● Delayed gastric emptying

TYPES( depending on the sites)

A) chronic duodenal ulcer: Occur in the first inch of first part of the
duodenum.

B) Chronic gastric ulcer: Occurs in lesser curvature

C) Combined: Gastric ulcer type 2- gastric ulcer with duodenal ulcer

D) Anastomotic ulcer-

C/F { SHIV weds parvati} 1. SITE

2. Haematmesis
1.Chronic gastric ulcer
3. Incdence : less
 Weight loss 4. Vomiting

 Pain on taking food 5. Weight loss

 Vomiting frequent 6. Pain- burning

 happen on lesser curvature 7. Pain on taking

food
 less common
 burning pain
72

 haematemeiss more common

B) chronic duodenal ulcer

● Weight gain

● Pain 1- 2 hrs after taking food

● Vomiting absent

● Happens in 1st part of duodenum

● Common

● Burning pain

● Melena more common

Mx:

Inv.

● esophagus gastroduodenoscopy (OGD)

● barium meal study (obsolete now)

TX : — of CDU

A)Surgical line of MX indicated in frequent relapse , haemorrhage,

gastric outlet obstructions

1. highly selective vagotomy (HSV ) also called as parietal cell vagotomy

Advantages:

1. No drainage is required

2. Nerve supply to gall bladder & liver is not distrbed

3. No diarrhea
73

Disadvantage:

1. Complicated Procedure — need experienced surgeon

. Recurrence high

2. TV with gastrojejunostomy of mayo

● Most popular & most commonly done operation for PUD

● Transaction of both vagal trunks at Oesphageal hiatus denervated

acid-producing fundus of stomach

● It also denervates vagal supply to the liver, gall bladder, pancreas,

intestine etc.

B) Medical MX

● pantoprazole 40 mg/ day for 4 weeks

 ranitidine
 sucralfate

● Stop smoking, alcohol, spicy food, coffee

● Eradication therapy if positive — helicobacter pylori

● Avoid NSAIDS

TX : OF CGU :

A) Mcdical MX

● ranitidine or omeprazole

● Stop smocking, alcohol, NSAIDS

74

B) Surgery

1. billroth 1 gastrectomy- gastrodeudenostomy

● parital gastrectomy including removal of ucler followed by

gastroduodenal anastomosis

2.Billroth 2nd gastrectomy

● Indication — Gastric ulcer is on lesser curvature

● Remanant of stomach is anastomose with a jejunal loop

3 HSV with excision of ulcer

complications —BP²M

1. Bleeding — Hematemasis or melena

2. Perforation

3. Pyloric obstruction(Gastric outlet obstruction)

4. Malignant transformation

5. Teapot determity

6. Hourglass contracture of the stomach

Q-33 Pathophysiology & C/F & MX of acute perforation of duodenal ulcer

with generalized peritonitis. (MPMSU 20 Aug - 20 marks)
Ans. 1) Stages of perforation:

1. Stages of chemical peritonitis

● Stomach content escapes the peritoneal cavity

● Acid causes severe pain in the epigastric region.

● Vomiting
75

● Guarding

● Rigidity

● On percussion, liver dullness is obliterated because of the collection of air

under the right diaphragm

2. Stage of reaction:

● peritoneum secretes lots of fluid to neutralize the escaped content

. ● Pain reduces and patient feel better ,this last for 2-4 hrs

Hypertension ,Dehydration

3.Stages of diffuse becterial peritonitis :

● Bacteria from gut migrates to site of perforation causing diffuse

peritonitis

● After 6 hrs

● Hippocratic facies — Bright eyes , dry tongue , toxic look

C/F:

1. severe persistent pain in the epigastric region later to the right side of
abdomen and finally becomes generalised .

2. Rebound tenderness ( Blumberg sign) 3. Fever , vomiting, dehydration

4. Grading & rigidity 5. Obliteration of liver dullness

6. oiguria, septicima, shock in letter stages

7. Silent abdomen & absence of bowel sounds.

Inv:

● Chest x-ray with abdomen in erect posture: show gas under diaphragm
76

● USG

● CT scan

Tx : (ABCDEF)

1. Aspiration of stomach content with ryle’s tube

2. Blood grouping

3. Charts : temperature,pulses,bp ,respiration,urinary output

4. Drugs :

● Inj cephalosporine 1g of IV start and 12 hrly against gram +ve organism

● Inj gentamicin – for gram -ve organism

● Ing metronidazole – for anaerobes

5. Exploratory laprotomy through mid line incision

•peforation is closed with interputed non absoebable sillk suture

• omental patch placed before suturing called grahms patch

6. Fluids – Ringer lactate normal saline , dextrose saline.

Q-34 C/F ,Inv. ,Mx of Gastric outlet obstruction.(MPMSU 22 May - 20

marks)
Ans. C/F ( Stomach that you feel & hear )

Symptoms:

1) Classic hunger pain of duodenal ulcer disappear.

2) Dull aching pain or colicky pain due to hyperperistalsis of stomach

77

3) Vomiting is profuse ,foul smelling.

4) Epigastric fullness

Signs:

(1) Visible gastric peristaltis

 Wave of contraction of stomach starts from left hypochondrium, runs

across the umbilicus and ends in right hypochondrium .
 Stomach that you feel

(2) Succussion splash :

 Residual fluid in stomach gives splashing sound which can be heared

with/ without stethoscope.

Inv. :

(1) Barium meal X-ray

 Hugely dilated stomach
 Mosaic appearance ----Barium do not enter duodenum ,it mix with
food to give rise to mosaic appearance .
(2) Gastroscopy :
 The scope will not enter duodenum.

Tx.
1) Aspiration with Ryle’s tube
2) Blood arrangement for surgery
3) Charts ---- Recording of vitals --- BP, sugar, temp ,pulse
4) Drugs ---- Antibiotics for surgery
5) Exploratory laproscopy: .Vagotomy followed by GJ is done
78

6) Fluids correction . Normal saliva initially then ringer lactate

Q-35 Early gastric cancer. (MPMSU 21 April - 5 marks)

Ans. It is Adenocarcinoma limited to mucosa & submucosa of Stomach ,
regardess of lymph node status .

Etiology

(1) Environmental factors-

 H pylori infection
(1) Solid tumor
(2) Dietary factors -
(2) Obstruction
 Nitrites
(3) Melena
 Smoked food
(4) Anaemia
 Spicy food
 Alcohol (5) Cachexia ---Weight
loss
C/F STOMACH :
(6) Haemetemasis
1) Early satity 2) Flatulence

3) Discomfort

4) Pain in upper abdomen

5) Obstruction at pylorous –visible gastric

Peristaltis.

SOLID :

1) Silent in growth but menifests as secondaries in liver, ascites, krukenberg

tumor
79

2) Obstruction at pylorous with vomiting with or without blood, visible

gastric peristalsis , obstruction at cardioesophageal junction produces
obstruction

3) Lump in abdomen which is hard and irregular

4) Insidious in onset

5) Dyspepsia in man of > 40 yrs

INV.

1) CBC 2) USG 3) RBS, LFT RFT, ECG, 4)

Esophagogastroduodenoscopy 5) CECT 6) CEA-carcinoembryonic antigen
7) barium meal xray

Tx.

1) Surgery is main modality .

2) Operable mass cure is possible by doing radical surgery .

3) Inoperable mass no chances of cure but growth may be resectable .

4) adjuvant che4motherapy- in few patients it’s benificial

Q-36 Bariatric Surgery. ( MPMSU 21 Nov - 5 marks)

Ans. It is surgical management of obesity if trial of lifestyle modification is

failed.

BMI>/= 35 KG/M2 with comorbidities

Types

1) Restrictive procedures
 Laproscopic adjustable gastric banding (LAGB)
 Laproscopic sleeve gastrectomy (LSG) widely practiced
80

 This largely decreases food intake

(2)Restrictive procedures with some malabsorption:
 Roux-en-Y gastric bypass (RYGB) this restricts food intake and
cause some malabsorptions
(3)Malabsorptive procedures with some restriction:
 Biliopancreatic diversion (BPD)
 Duodenal switch
 Rarely done

Indications:

1) BMI >40 Kg/M*2 2) BMI> 35 Kg/ m*2 with associated comorbidities

3) Failed dietary therapy 4) Psychiatrically stable

Contradiction:

1- Medical :
 cirrhosis
 Inflammatory Bowel Disease (IBD)
 POOR fitness for general anaesthesia
 Autoimmune CTD (Connective Tissue Disorder)

2- Surgical
 Inability to ambulate.
 Parder willi syndrome

Complication :

 Staple line / anastomotic leaks.

 DVT
81

 Nutitional deficiency

Q-37 C/F & MX of carcinoma stomach. (MPMSU 19Jun, 21Nov-20marks)

Ans. C/F
S → Solid

T → Tumor

O → Obstruction

M → Melena

A → Anaemia

C → Cachexia - marked
weight loss & muscle loss

H → Haematemesis

Mx:

 Surgery is main modality

 Treatment depend on stage of cancer .
 In case of growth in pylorous ,lower radical gastrectomy ( subtotal
gastrectomy) with removal or greater omentum lesser omentum
,lymph nodes etc
 In case of growth in OG junction ,, upper radical gastrectomy along
with other removal.
 In case of entire stomach involvement (i.e stage 4 or linitis plastics)
total gastrectomy with oesophageojejunal anastomosis.

Group 1 → 1, 2,3,4,5,6 , Group 2 → 7,8,9,10,11

82

 D1 Gastrectomy →when gastrectomy is done with Group 1 Lymph

node dissection. (1 to 6)
Indicated → When lymph node are not enlarged.(N0)
 D2 Gastrectomy → Gastrectomy+ Group 1 + Group 11 LN dissection.

Indication :

Lymph node Group 1 level are enlarged (N1) so one step higher are
cleared .

Surgery of lymph node :

1) Right Pericardial 2) Left Pericardial 3) Lesser curvature

4) Greater curvature 5) Suprapyloric 6) Infrapyloric

7) Left gastric vessel 8) Common hepatic 9) Celiac

10) Splenic hilum 11) Splenic artery

83

Chemotherapy:

5FU ,Cisplatin

Chemo ---- 5FU , Cisplatin

Q-38 Aetiology ,C/F ,Inv. Mx of Gallstone.(MPMSU 21 July, 21 Nov- 20

marks)

Ans.

Aetiology mnemonic- mehnati boys in hostel- m- metabolic b- bile stasis i-

infections h-hemolytic anaemia

1) Infection .
i. M/C cause
ii. cause of 80% of Gallstone
iii. E.coli ,protes involved
Organism reach gall bladder wall and make foci around which
cholesterol and bile salts gets precipitated
2) Metabolic causes
i. Cholesterol is usually released with bile salts in 25:1 ratio ( bile
salts: cholesterol)
ii. If this ratio goes below 13:1 , it results in precipitation of
cholesterol.
iii. Obesity ,high calorie diet etc results in this .

3) Bile stasis & decreased bile Acid pool .

i. pregnancy ,estrogen , following vagotomy can cause this.
84

4) Haemolytic Anaemia :

Calcium
Increase increased Unconjugat bilirubinate
RBC unconjugat ed bilirubin stone
breakdown ed bilirubin + Ca*2+ (pigment
stones)

5) Saint’s Triad :

Hiatus Hernia

Diverticulosis of colon Gallstone

6) Age>40

7) Diabetes
FEMALE , FORTY , FERTILE ,FATTY
8) Obesity

9) Female sex
85

Types:
 Empyema-----pus collection

1) Cholesterol stones -----10% in a pre-existing cavity

 Abscess--------Pus collection
2) Brown pigment stones
in a newly formed cavity
3) Mixed stones ---80%

4) black Pigment stones ----5%

C/F : mnemonic- ACE Inhibitor lene se aadmi MC, Pagal aur Gadha ho
jaata h

A- Acute cholecystitis

C-Chronic cholecystitis

E- EMPYMA

A- Acute pancreatitis

M-Mucocele

C-Cancer

P- Perforation
G- Gall stone colic

In Gallbladder :

1) Acute cholecystitis 2) CHRONIC Cholecystitis

3) mucocele- enlarged gallbladder with mucocele

4) Gallstone colic ( pain when a gallstone is being passed)

5) Emphysema Gallbladder 6) Perforation

1-In Bile Duct :

86

a) Obstructive Jaundice b) Cholangitis

2- In intestine :

a) Acute intestinal Obstruction

Investigation :

1) USG Abdomen : seen as posterior acoustic shadowing ioc

2) CT scan abdomen

Tx.

1) laparoscopic cholecystectomy ideal

2) Open cholecystectomy

Q-39 Acute Cholecystitis Paths ,C/F ,Mx.( MPMSU 20 Aug - 20 marks)

Ans. Acute bacterial inflammation of gallbladder with or without stone .

Types:

1) Calculous: Obstructive cholecystitis ,commonest variety

2) Acalculous : Non- Obstructive cholecystitis

87

Pathogenesis:

obstruction at
hartmann's pouch
or cyst duct due to
stone.

Stasis ,odema
of wall

Collection of bile

Mucosal erosion due to

stone

Necrosis and
perforation of
gallbladder

peritonitis

C/F : ( Fatty , Fertile ,Female ,Forty)

1) Sudden onset of pain in right hypochondrium.

2) Tenderness

3) Rigidity

4) Guarding
88

5) Jaundice

6) Tachycardia

7) Nausea & vomiting

8) Boas sign : Area of hyperaesthesia bt 9th & 11th ribs part on right side .

9) Murphy’s sign: pain on palpation when hold deep breath

10)Right shoulder pain

Inv.

1) Total WBC is raised.

2) USG abdomen---- very useful reveal presence or absence of Gallstone

3) CT Scan : when USG finding are not clear

4) X-Ray : Radioactive stone in right hypochondrium.

Tx-

1) Hospitalisation

2) Conservative TX : (95%)

3) Nasogastric Aspiration------- Ryle’s tube

4) Antispasmodics ------ Inj. Tramadol 50 mg IV/ IM

5) ANTIBIOTICS : broad spectrum are given :

o Ceftriaxone
o Cefoperazone
o Ceftazidime .
o Observation
o Follow up
89

3)later 3 to 6 week elective internal cholecystectomy by open or

Laproscopic method.

Q-40 Courvoisier's law.

Ans. In a patient with Jaundice if there is palpable gallbladder,it is not Due

to stones. Because stones wall give rise to chronic inflammation and
Subsequently fibrosis of gallbladder..

Q-41 Surgical Jaundice / Obstructive Jaundice

Ans. Jaundice due to biliary obstruction

C/F :

1) Severe Jaundice 2) Pruritus ------ Itching

3) Pain in rigid hypochondrium 4) Steatorrhoea (fatty stool)

5) Loss of weight

Investigation:

1) Serum bilirubin Conjugated bilirubin is increased

2) Total leucocyte count raised with neutrophilia Due to inflammatory colon

3) Endoscopy 4) MRI 5) CT SCAN

6) ERCP ( Endoscopic retrograde cholangiopancreatography ) 7) CA 19-9

Tx.

1) CBD stones ----- ERCP Stone removal

2) Carcinoma head of pancreas ------Whipples operation

3) Klatskin tumor --------Radial resection

4) Biliary striture--------Stenting
90

Q-42 Patho, C/F ,Diagnosis of Acute pancreatitis. (MPMSU-21April,

21Nov-20marks)
I GET SMASHED
Ans. Actiology

1) Alcohol abuse ------- Major cause

I - Idiopathic
2) Gallstone -------Major cause in western countries
G- Gallstones
3) Collagen vascular disorders ------Autoimmune disorder
E- Ethanol
4) Drugs ------ Corticosteroids , tetracycline
T-Trauma
5) Hyperparathyroidism
S-Stents

6) Hyperlipidemia
M- murphy‘s

7) Injection A - Autoimmune

8) Idiopathic S- Scapian bite

H - Hyperlipidemia

E- ERCP

D-------Drugs

Pathogens :

Biary gallstones caue Alcohol cause toxicity & injury

pancreatic obstruction by release of free radicals
OR
Free radicals

Spasm of sphincter of Oddi

or increased release of
pancreatic enzymes
91

Typsinogen activate into trypsin

and Activate other enzymes

Lipase Elastase Lysolecithinase

Acts on fats digestive elastic Membrane

fibres of BV damage
fatty acide
& gycerol
Necrosis
Pseudoaneurysm
Fatty
acid+Ca2+
Necrotising
Calcium Haemorrhage Pancreatitis
soap

Infective
Fat nerosis Death
necrosis

lots of fluid get collected leading to hypovolmic shock & renal failure

C/ F :

1) Severe epigastric pain ------Relieved on bending forwards

2) Vomiting

3) Fever
92

4) Hemaetemesis and melena

Signs:

1) Cullen’s sign: Bluish ecchymotic discoloration seen around umbilicus

2) Grey Turner’s Sign: Bluish discoloration in flanks

3)Fox’s sign ------ Bluish discoloration on inguinal ligament

3) Cynosis : Improper perfusion to lungs

4) Feature of shock ---- Tachycardia, Tachypnea, thrist, feeble pulse

,hypotension, cold extrimities (pale .. fat , CAD )

5)Tenderness

6) rigidity and guarding

INV:

1) Haemogram

2) Serum amylase > 1000 are diagnostic of acute pancreatitis.

3) USG

4) CT Scan

Mx: ABCDEF

1) A-----Aspiration with Ryle’s tube

2) B------Blood transfusion if required

3)C- Charts -take the vitals BP, PR, RR, HR, Temp.

4) D- Drugs-imipenem is DOC
93

5)E- Exploratory laprotomy

6)F- Fluids – Ringer lactate is fluid of choice

Q-43 Pseudocyst of Pancreas.

Ans. Collection of amylase rich fluid in lesser sac due to pancreatic

pathology .

. Fluid collection in first 4 weeks is an active fluid collection and late

become active Pseudocyst.

C/ F :

1) Swelling in epigastric region

2) Not moving with respiration ( because retroperitoneal )

3) Baid Test: If Ryle’s tube is pressed it will be felt over the abdomen as
stomach is stretched towards abdominal wall

Inv.

1) USG 2) CT

3) MRCP ( Magnetic Resonance Cholangio pancreatography )

4) ERCP ( Endoscopic retrograde cholangiopancreatography)

5) Barium meal

Tx.

1) Conservative line of treatment:

 Majority of Pseudocysts following acute pancreatitis resolve

spontaneously.
2) Surgery
94

 Cystogastrostomy

Indications : Pseudocyst in relation to body and head of pancreas size >6 cm

Procedure:

1) Anterior & posterior wall of stomach is opened

2) Brownish fluid is aspirated

3) Thick capsule of Pseudocyst is opened

4) All fluid with necrotic material are sucked.

3). Laproscopic Cystogastrostomy is becoming popular

Actiology :

1) ACUTE PANCREATITIS 2) CHRONIC PANCREATITIS

3) BLUNT INJURY OF ABDOMEN

Q-44 MRCP .

Ans. - Magnetic Resonance cholangio pancreatography

 Non- invasive diagnostic test

 T1 weighted images are used for pancreas
 T2 weighted images for biliary tree.

Adv. :

1) Equal or better imaging than ERCP.

Disadv :

1)Only diagnostic ( Not both theraputic & diagnostic like ERCP )

Q-45 Annular Pancreas.( MPMSU 19 Jun - 5 marks)

95

Ans. Due to failure of complete rotation of ventral bud of pancreas ,so the
ring of pancreas encircle the 2nd part of duodenum causing obstruction.

Types:

1)Neonatal type: produce symptoms of intestinal obstruction

2) Adult type: present with features of duodenal ulcer & billious vomiting.

Inv.:

1) X-rays - double bubble appearance 2) ERCP

3) Barium meal obstruction

Tx :

1)Duodenoduodenostomy—TOC 2)Duodenojejunostomy

C/F:

1)Intestinal obstruction 2) Vomiting 3) Inability to take food

Q-46 Amoebic liver abscess.( MPMSU 20 Aug - 5 marks)

Ans. Most common extraintestinal manifestations amoebiasis.

Pathogenesis:
 96

Portal vein
Superior
mesentri
c vein
Inferior mesentric vein

Sigmoid colon
Caecum
Dysentery
Typhlitis

Typhlitis Dysentery

Infection of caecum Infection from sigmoid

(commonly)
colon
OR

Travel through SMv Travel through IMA

Right lobe gets infected( Posterior

surface ) - as it is bare area

Trophozoites destroy hepatocytes by

releasing Histolysin

Amoebic hepatitis & multiple

microabscess formation

Liquefactive Necrosis
C/F :

Anchovy sauce pus

97

Symptoms :

1) Severe pain in right hypochondrium

2) Fever, chills , rigor

Signs :

1) Anaemia 2) Emaciation 3) Jaundice

4) Liver is enlarged in right hypochondrium.

5) Intercoastal tenderness -- Imp. Sign

Inv.:

1) WBC increased 2) USG abdomen 3) CT Scan

Tx :

DRUGS-

(1) Metronidazole 800 mg 3 times a day for 7 days

OR

Tinidazole. 2g orally

(2) Us guided Aspiration & Pigtail drainage

 Before Aspiration , bleeding profile (BT ,CT,PT) Should be normal .

 Anchovy sauce pus collect

(3)Surgery:

Indication:

1)Failure of US guided Aspiration

2) Ruptured Amoebic abscess with abdominal ,Peritonitis

98

3) Laparotomy is done

4) Malecot’s catheter ( any tube drainage) is introduced in abscess cavity &

connected to a bay .

Q-47 Hydatid cyst of Liver.(MPMSU 22May, 21 April-20 marks)

Ans. Disease caused by Echinococcus granulosus, transmitted by dog and

man is the intermediate host. Layers :

1) Pseudocyst: .Fibrous layer derived from liver tissue .Adherent to liver &
cannot be separated.

2) ECTOCYST: .White & elastic AND prodced by endocyst

3) Endocyst: .Which contains the hydatid fluid .

Brood capsules develop in which scolices of Echinococcus granulosus develop.

C/F:

1) Dragging pain in the upper abdomen.

2) Liver is enlarged---- Hepatomegaly 3) Asymptomatic

4) Typical hydatid thrill 5) May Present as anaphylactic shock

Inv. :

1) USG 2) CT: Cart wheel appearance 3) ERCP

4) ELISA 5) X-Ray : calcification in X-ray

Tx.

1) Conservative treatment

Calcified & dead cyst are left alone

2) Medical treatment
99

 Albendazole or 400 mg BD given for 21 days , for 2 weeks

 If no improvement, maximum 3 such cycles can be given .
3) Surgery
Indication:
1) Symptomatic cyst
2) Asymptomatic cyst >5 cm , Non- Calcified
3) Injected cyst

Procedure:

1) Laproscopy and isolation of cyst

2) Aspire contents & inject Scolicidal agents like SAVLON

3) Peel off ECTOCYST

4) All endocyst ,ectoctst should be removed

Precautions:

1)Albendazole given before surgery

2) spillage to be avoid to avoid peritoneal hydatid

3) Injection hydrocortisone to avoid anaphylactic shock

4) Percutaneous drainage

Also called PAIR ---- Puncture, Aspiration, Injection, and Reaspiration.

100

C/F:

Extrahepatic Intrahepatic
1) Females ( more) 1) Males (more)
2) Splenomegaly (-ve) 2) Splenomegaly (+ve)
3) Jaundice (-ve) 3) Jaundice (+ve)
4) Liver failure (-ve) 4) Liver failure (+ve)
5) Ascitis (-ve) 5) Ascitis test (+ve)
6) Encephalopathy (-ve) 6) Encephalopathy test (+ve)

Q-48 Portal Hypertension -- Etio/ C/F.(MPMSU 19feb, 22May-20 marks).

Ans. When portal Venous pressure> 10 -12 mmHg. It is portal

hypertension.

Aeitology :

 Liver Cirrhosis

 Budd Chiari Syndrome

 Portal vein thrombosis

1)Prehepatic :

 Spleen vein thrombosis

 Portal vein Thrombosis

2) Hepatic :

 Cirrhosis,

 Schistosomiasis
101

3) Post Hepatic :

 Tricuspid incompetancy

 Constrictive pericarditis

 Budd Chaiari Syndrome

Pathophysiology:

Oesophageal
varices
Portal
systemic
anastomosis
Collaterals
develop
open up

HTN

Extrahepatic----
Jaundice X , Big
C/F: Splenomegaly, Ascites
X Liver failure X ,
1) Bleeding gastroesophageal varices.
Encephalopathy X
Inv.
Intrahepatic----
1) CBC : Anaemia due to bleeding Jaundice✓, Moderate

2) LFT : Albumin low, SGOT & SGPT raised Splenomegaly, Ascites

✓ ,LF✓
3) Oesophagogastroduodenoscopy (OGD) To confirm
102

Oesophageal varices

Tx.

Resuscitate ABC

 Aspiration of stomach content from Ryle’s tube

 Blood transfusion if needed

 Charts monitor vitals

(2) Pharmacotherapy:

 Non selective Beta blockers Propranolol ( Reduce portal pressure)

(3) Endoscopic Sclerotherapy: To control esophageal varices (3.2 variceal

banding) 2% ethanolamine oleate injection

(4)Balloon tamponade:

 Sengstaken’s tube is used

 Cannot be kept more than 24 hrs as it can cause pressure Necrosis.

(5) TIPSS: Transjugular Intrahepatic Portosystemic Stent Shunt

(6) Surgical Shunts:

 End-to-side portacaval shunt

 End of portal vein to side OF IV C

 Side to side portacaval shunt : Side anastomosis of Portal vein & IV C

 Splenorenal Shunt.

Q-49 Budd – Chiari Syndrome.

Ans. Due to Obstruction of hepatic vein.

Causes :
103

1) Congenital---- Web exists in suprahepatic portion of IVC

2) Clotting disorder---- Polycythemia

3) Contraceptive pills

4) Cancer ---- cancer infiltration of hepatic veins ( Hepatocellular

carcinoma)

C/ F:

1) Hepatomegaly

TX.

1)Peritoneovenous shunt as an alternate method to drain ascitic fluid .

Peritoneovenous :- Shunt between portal

vein & IVC.

Q-50 Splenic trauma.( MPMSU 21 July - 5 marks)

Ans. Causes

1) BLUNT INJURY abdomen

2) Penetrating injuries

3) Spontaneous rupture of spleen → Ex.Malaria , Infectious mononucleosis

4) Iatrogenic

C/P: ( Clinical Presentation)

1) Tearing of Splenic vessels .

 Result in severe Haemorrhage

 Shock

 May cause death

104

2) Slow developing haemorrhage shock.

 Intraperitoneal bleeding

 Due to capsular tear

 Anaemia

 Tachycardia.

 BP- low.

 Cold ,clammy extremities.

 Guarding & rigidity Shock .

 Kehr’s sign ------Pain is referred to shoulder

 Ballance’s sign.

Inv.:

1) Hb% estimation 2) USG: can revea splenic tear

3) CT Scan 4) Plain X-ray Abdomen

TX.

1) Emergency Splenectomy .Haemodynamic instability is main indication

<90mmHg,130/mm

2) Partial Splenectomy

3) Conservative Treatment (ABCDEF)

Q-51 Generalised Peritonitis . (MPMSU 20 Aug - 20 marks)

Ans. Inflammation of Peritoneum

Pathogenesis :
105

Perforation , Postinflammatory, Postoperative

Multiplication of bacteria in peritoneal cavity --- E.coli etc

Endotoxin Peritoneal
illustrate

Septic shock Exudate collect 3 rd space Loss

hypovolemic shock

MOF

Death

C/F:

1) Severe abdominal pain 2) Guarding & rigidity

3) Rebound tenderness 4) Persistent vomiting

5) High grade fever 6) Hippocratic facies----In end stage

106

Inv:

1) CBC ------- Increased ( Neutrophils)

2) X-Ray

 Gas under diaphragm ---- perforation

 Ground glass appearance---Smooth homogeneous appearance due to
accumulation of fluid.

TX.

1) Aspiration: Nasogastric aspiration with Ryle’s Tube

2) Blood arranged for surgery

3) Charts : Temp., BP , PULSE , RR

4) Drugs : against gram +ve ,gram -ve & anaerobic organisms

5) Exploratory laparotomy

6) Fluids: Ringer lactate solution is an ideal replacement

Q-52 Abdominal Tuberculosis--- Types, C/F , Mx.

Ans. Types:

1) Tuberculous peritonitis

2) Tuberculous mesenteric lymphadenitis

3) Intestinal Tuberculosis

4) Tuberculosis of solid organs like liver & spleen

107

Inv.

1) CBC Haemoglobin may be low .

2) ESR increases

3) Sputum AFB : Demonstrated by ZN stain

4) Chest X- ray

5) Ultrasound

TX.

1) HR2E --- 2 months then HRE --- 4 months

Q-53 Intestinal TB - C/ F & Mx.(MPMSU 21 April, 22 May-20marks)

Ans. C/ F ( FC. SBH. NVAW)

Symptoms:

1) Abdominal pain : .can be dull , vague pain or colicky pain which increase

after taking food or relieved by vomiting.

2) Diarrhoea .

3) Abdominal distension

4) Weight loss common , Anorexia .Noisy Abdomen , every rise in

temperature.

Signs:

1) Malnourished ✓ 2) Visible intestinal peristaltis ✓

3) Distended bowel loops X 4) Doughy Abdomen ✓

INVESTI:

1) Caseating Necrosis in granulomas is hallmark of TB 2) CBNAAT

108

Mx:

1) No evidence of Intestinal Obstruction: Anti – TB treatment

2) With Obstruction

1. Solitary stricture:

 Best treated by Stricturoplasty

2. Multiple strictures at long interval .

 Stricturoplasty is ideal treatment

3. Multiple stricture at short interval

 Resection is ideal treatment.

Q-54 Meckel's diverticulum .( MPMSU 20 Feb - 5 marks)

Ans. Congenital diverticulum arising from terminal ileum and was a part of

proximal portion of vitellointestinal duct.

 2% common .

 2 feet proximal from ileocecal valve .

 Length ---- 2 inches

C/F:

1) Asymptomatic 2) Painless rectal bleeding ---M/C symptomatic

3) Internal Obstruction 4) Volvulus

5) Intussusception 6) Diverticulitis
109

Diagnosis :

1) Technetium (T*99) radioisotope scan .

2) CT scan

TX.

1) If symptomatic , it is surgically resected .

Q-55 Gastrointestinal fistula ( enterocutaneous fistula)

Ans. An abdominal communication between mucosal epithelium of intestine

and skin surface .

Aetiology :

F -- Foreign body

R—Radiation

I- IBD

E—Epithelization

N-----Neoplasm

D--Distal Obstruction

S--Steroids
110

C/F:

1) SKIN Excoriation ( Excoriation-abrading of skin )

2) Severe malnutrition

3) Recurrent sepsis

4) Pellagra ----- Niacin deficiency

5) Osteomalacia ---- Vit. D deficiency

6) Zinc deficiency

TX. ABCDEF region :

1) Resuscitation with crystalloids & colloids

2) Sepsis control with antibiotics

3) Medications :

 Slow bowels ( Loperamide , diphenoxylate ) .

 Decrease Intestinal secretion ( octreotide)

 Decrease stomach secretion ( PPI 8)

1)Etiology 2) Stabilisation 3) Nutrition

4) Investigation 5) defect Mx

Q-56 Hirschsprung's disease.( MPMSU 20 Feb - 5 marks)

Ans. It is a congenital condition in which nerve cells of the myenteric plexus
are absent in distal bowl & rectum .

C/F:

1) Abdominal pain & distention 2) Vomiting 3) Constipation

4) Delay passing meconium 5) Poor weight gain

111

6) Failure to pass meconium

7) Acute Intestinal Obstruction----Due to loss of peristaltis.

DIAGNOSIS:

1) ABDOMINAL X-RAY

2) Rectal biopsy--- with slow absence of ganglion cells.

TX.

1) Fluid resuscitation 2) IV antibiotics

Definitive TX.

1) Surgical Removal of aganglionic section of bowel

2)Continuity maintained by coloanal Anastomosis

3)Closure of colostomy

Common procedures:

1) Modified Duhamel operation

2)swenson’s operation.

Q-57 Carcinoma colon management.(MPMSU 19 Jun - 20 marks)

Ans. Surgery depending on location:

1) Right side early growth: Cancer in Caecum.

 Right radical hemicolectomy with Ileotransverse anastomosis is done.

 Structure removed are :

112

(A) Terminal 10-12 cm of ileus

(B) Caecum ,Iliocecal junction

(C) Ascending colon

(D) Right bunch of middle colic artery , right colic and ileocolic artery

(E) Hepatic flexure.

(2) Transverse colon growth : Cancer in ascending colon / hepatic I/

transverse colon growth

 Extended right hemicolectomy anastomoting terminal ileus with

proximal part of descending colon.

Structure removed :

 10*-12 cm of terminal ileus

 Caecum , Ileocecal junction,Hepatic flexure.

 Appendix

 Ascending colon

 Transverse colon , Splenic flexure ,

113

 While MCA , Ileocolic & right colic artery.

(3) Left sided early growth ( Ca is Splenic flexure/ descend colon )

 Left radical hemicolectomy

(4) Structure removed :

 Transverse colon beyond left MCA

 Descending colon

 Splenic flexure

 Inferior mesenteric artery

(5) Tumor in sigmoid colon :

 Sigmoid colectomy with coloanal anastomosis

Structure removed :

 Sigmoid colon

 Rectunm

Coloanal anastomosis using a circular stapler , ( Patient remains continent).

Chemotherapy:

5-FU with folinic acid ,oxaliplatin ---FILFOX

Indication ---- LN(+) , T3 ,T4 stages ,Metastasis

Investigation:

1) CBC ---- Hb% decreases 2) Colonoscopy ---for biopsy

3) USG : First baseline investigation 4) CT scan

5) Carcinoembryonic antigen (CEA)

114

Foetal glycoprotein not present in normal humans.

Q-58 Enumerate causes of acute Interstitial Obstruction. C/F & MX of

intussusception in an infant .

Ans. (1)In lumen of gut-

 Gallstone ileus
 Meconium ileus
 Food bolus Obstruction
 Roundworm bars

(2) In wall of gut-

 Stricture eg.TB
 Crohn's disease
 Adhesions
 Atresia
 Carcinoma

(3) Outside the wall of gut

 Intussusception
 Volvolus
 Meckel’s diverticulum with a band .
 Obstructed hernia.

Intussusception :

Invagination of one segment of intestine into another is called

intussusception.
115

C/F:

Symptoms:

1) Child screams with Abdominal pain.

2) Red current jelly stool ( only in infant)

3) Vomiting

Signs:

1) Emptiness in light iliac fossa

2) Visible stepladder peristaltis

3) Rectal examination- blood stained mucus .

Inv.:

1) USG : Donut sign/ Target sign ( in child) 2) Pseudokidney sign ( in adult)

(2) CT Scan : Sausage shaped mass scan.

TX.

1) Conservative Tx :---

 Hydrostatic reduction : Saline is introduced through the rectum

which push the intestine to take their normal shape .

2) An Contrast enema.

(3) Surgery:

Laparotomy & reduction of Intussusception.

Intussusception is reduced by squeezing the colon in opposite direction.

Q-59 Staging of Carcinoma Rectum.( MPMSU 21 July - 5 marks)

Ans.
116

C/F : ( ABCDEF)

1) Altered Bowel habits 2) Bleeding per rectum 3) Constipation

4) Incomplete defecation 5) Early morning spurious diarrhoea

6) Fatigue

Q-60 C/F & MX of Haemorrhoids.

Ans. Dilated plexus of superior haemorrhoidal Veins in relation to anal

canal.

C/F:

1) Bleeding per rectum 2) Usually painless 3) Constipation

117

Grades of Haemorrhoids:

Grade I :Only bleed ,don’t prolapse

Grade II : Bleeding , prolapse but return is normal after defecation.

Grade III: Bleeding , prolapse and need to be pushed back digitally.

Grade IV: Bleeding ,pain , discomfort, permanently prolapsed.

Mx:

Grade I TX.

Non- operative treatment---

Grade 2 Tx.
F- Fibre in diet
Grade I Tx : + Sclerotherapy/Banding
I--Increase fluid intake
Sclerotherapy:
B----Bulk purgatives

 Sclerosant agents is injected in pile mass . eg.isabgol husk

R--. In toilet discouraged.

Aseptic Thrombosis E--Encourage to lose weight

S---Sitz bath

Pile mass is pulled up

 It should be given above dentate line.

Ex of Sclerosants:

1) Sodium tetradecyl sulphate (m/c) 2) Phenol in almond oil.

118

Banding :

 Band is put at base of Haemorrhoids above dentate line.

 After few days it Slough off .

Grade 3 Tx.

Mx of Grade 2 ---- if no response--- Surgery

Grade 4 TX.

Surgery for all.

Surgical options :

1) Open haemorrhoidectomy

2) Close haemorrhoidectomy

3) Stapler haemorrhoidopexy

4) Doppler Guided haemorrhoideal art. , ligation.

Open haemorrhoidectomy :

1) Stretch the sphincter

2) Mark the positions of pile mass

3) Dissect upto the base

4) Excision of piles with skin

5) Wound packed with roller gauze

Close haemorrhoidectomy :

1) Same as open ,just the cut mucosa & skin edges are sutured.
119

Stapler haemorrhoidopexy

1) Circular anal dilater is inserted.

2) After reduction of prolapsed piles, sting suture is appl Applied.

3) By maintaining traction in tails of suture, the stapler is Fully fired.

Adv.

1) Less operative time

2) Less post operative pain

3) earlier return to normal activity

Q-61 Fistula in Ano.

Ans. Abnormal communication between anal canal and Rectum with

exterior ( perianal skin) is called fistula in Anus.

Aetiology pathogenes

Rupture inside &

Due to persistent anal Result in
outside resulting
gland infection anorectal abscess
in fistula

C/F :

1) Persistent Seropurulent discharge

2) External opening in paranal region.

3) If patient passed flatus/ faeces ,it means internal opening is In rectum.

4) Goodsall’s rules

Diagnostic:

MRI
120

TX.

1) Fistulotomy - Indicated in low fistula

2) Fistulectomy - All chronic fistulae are treated by fistulectomy.

3) Use of Seton or medicated thread :

 Medicated thread passed through entire tract & both ends are tied

and tightened Once a week .So by 6 weeks it cuts through.

4 ) Video-assisted anal fistula treatment (VAAFT).

Q-62 Goodsall’s Rule.

Ans.

A fistula with an external opening in the anterior half of anus within 3.75
cm tend to be direct type .

And in posterior half, indirect type or curved area sometimes horseshoe

type .It may communicate with opposite side.

So, if ant. an external opening at 1° clock position will correspond to a

internal opening at 1° clock. While in post. ,any opening correspond to
internal opening at 6° clock position.
121

Q-63 C/F & Mx of Caecum Anal Canal . ( PM ke BAP ko UTI )

Ans. C/F 1) Pain 2) Mass 3) Bleeding 4)

Advanced faecal incontinence 5)
1) Ulceration Pruritus 6) Ulceration

2) Bleeding 7) Tenderness in anal canal 8)

Anovaginal fistula in female .
3) Pain, Pruritis

4) Discharge
( PMT - खून के आं सू )

5) Irregular indrrated mass

1-Pain 2-Mass 3- Tenders

6) Faecal incontinence 4- Bleeding

7) Anovaginal fistula in females

8) Constipation

Mx:

1) Biopsy from anal region

TX.

1) Wide excision of lesion with 3-5 cm decrease and illioinguinal lymph

node dissection.

2) Followed by radiotherapy---given as per Nigro regime.

3) Chemoradiation ---- 5FU ,Adriamycin

Vincristine Cisplatin Fulguration ---

Destruction of
Q-64 Causes of Bleeding per rectum and its MX.
tissue with help
(MPMSU 21 Nov - 20 marks). of electric
Ans. Causes: current.
122

1) Angiodysplasia 2) Diverticular disease

3) Ulcerative colitis , Crohn’s Disease

4) Anarectal dis. - Haemorrhoids , fissure in anal

5) Colorectal cancer 6) Tumor from colon or small bowel.

7) Meckel’s diverticulum 8) Intussusception

9) Rectal carcinomas 10)Infective colitis

TX :- ( ABCDEF) , VASOPRESSIN ,EMBOLISATION.

Q-65 Pathogenesis, Etiology, C/F , Mx of acute Obstructive appendicitis.

(MPMSU 20 Aug - 20 marks)
Ans. Aetiology :

1) Luminal Obstruction due to :

a.Faecolith b.Ascariasis

c .Food particle d. Carcinoid tumor

2)Non- Obstructive:

Due to bacterias such as :

a. E.coli b .Pseudomonads

c. Klebsiella d . Proteus

(3) Diet: .Diet rich in fiber protect while rich in meat precipitates
appendicitis.

(4) Socioeconomic status – Rich > Poor

(5) Familial susceptibility.

123

Pathogenesis:

Luminal Obstruction
Mucus of Inflammatory fluid collect inside the Lumen
Increasal interluminal pressure
Blockage of Lymphatics & venous Drainage
Odema of mucosa
Mucosal ulceration and ischemia
Bacterial translocation
Acute Obstructive appendicitis
Thrombosis of Appendicular Art
Necrosis
Perforation
Peritonitis

C/F ( Clinical Presentation)

Symptoms:

1) Common in children & teenagers.

2) Pain - severe , colicky .

 Pain is initially In the periumbilical region due to distension of

appendix .It is visceral pain.

 Lateral it migrate to right iliac fossa ,it is due inflammation of

parietal Peritoneum which is more sensitive & give localised pain .

3) Nausea & Vomiting.

4) Anorexia (loss of appetite).

124

Signs:

1) Rebound tenderness –McBurney’s Point

Sign of Peritonitis
2) Guarding & Rigidity

3)Pointing sign : Patient point towards the side of Maximum tenderness.(

Right iliac fossa)

4)Rovsing sign, Palpation at left iliac region Produce pain at right iliac
region .It happens due To shifting of bowel or gaseous distension.

5)Psoas sign: Hyperextension of hip causes pain In right iliac fossa.

6)Obturator sign: Plexion & internal rotation of hip Pain in right iliac fossa .

Inv:

1)CBC : WBC Increased

2)CECT:Inv.of choice

3)USG

Mx: ABCDEF Drugs ----Gentamycin and metronidazole

1)Lap.emergency appendicectomy

2) lap.appendectomy.
125

Q-66 Ochsner–Sherren regime .

Ans. Appendicular mass is treated with OSR.

1) Aspiration of content with Ryle’s Tube ,only if vomiting in present.

2) Charts : Temp, BP, Pulse Rate , RR, TLC COUNT , SIZE OF LUMP , PAIN
.

3) DRUGS: For gram positive ,gram negative and anaerobics

4) Fluids to prevent dehydration

5) Nil-per oral for 2days .

After 6-8 weeks ,patient is advised Electric Appendicectomy.

Q-67 Mesenteric cyst .( MPMSU 20 Feb - 5 marks)

Ans. Congenital cyst located in umbilical region mass right angle to
mesentry.

Types:
126

1)Chylolymphatic cyst

2)Enterogenous cyst

1) Chylolymphatic:

a.Chyle filled b . separate blood supply

c.thin walled d . Tx. Excision

2) Enterogenous:

a.Thick wall

b.For diverticulous of intestine

c.TX. Excision of cyst with bowel segment.

Q-68 ARM ( Ano-rectal malformation) .(MPMSU 22 May - 5 marks)

Ans. Risk factors :

1)Maternal infection 2)Chromosomal abnormalities.

Types :

1(Persistent anal membrane ---Anal canal Covered with greenish

membrane

2)Anal stenosis

3)Anal agenesis –Imperforated anus

4)Rectal agenesis

Inv:

1)Invertogram - at 24 hr 2(MRI –IOC

C/F :
127

a.Meconium don’t pass.

b.Greenish in recto-vesical fistula.

c.Membrane present on anal opening –Dimple seen.

Tx.-

1) Colostomy is done
2) PSARP- POST. Sagitta anorectal plasty
3) Closure

Low level ano rectomalformation

- posterior sagittal anorectoplasty

High level ano rectomalformation- posterior sagittal

anorectoplasty

UROLOGY
Q-69 Intravenous urography.( MPMSU 21 Nov - 5 marks)
Ans. Aim

1) To study renal functions ( Physiology)

2) To detect Pathology of Kidney ,ureter or bladder

3) To study anatomical variation of renal system ( Anatomy).

Procedure:

1) Fat free non residue diet is given for 2-3 days prior to procedure to
avoid Intestinal gas shadows.
128

2) Dimol 2 tablets TDS given 2-3 days prior to procedure to expel gas.

3) Patient should not take oral fluids 6 hrs before procedure.

4) Radiological contrast dye ---45% sodium Diatrizoate 20-40 ml

injected through median cubital vein .

Contraindication for IVU :

1) Iodine sensitivity 2) Renal failure

3) Multiple Myeloma 4) Hyperuricemia

Uses of IVU:

TO DIAGNOSE:

1) Congenital abnormalities

 . Horse shoe kidney

 .Polycystic kidney

 .Single Kidney

 .Multiple Kidney & ureters

2) Hydronephrosis , Hydroureter

3) Renal ,uretric ,bladder stones

4) Renal TB , tumors.

Radiology:

1) Early film after 2-5 min: Kidney outline.

2) 5 min later : Pelvicalyceal system visualised.

3) 15-20 min : Ureter & Bladder visualised.

129

Q-70 Renal Stone - causes , Et. Types ,Inv. ,Tx : , MX.

Ans. Aetiopathogenes :

1) Infection: Proteus , Pseudomonas, Klebsiella .

2) Hot climate : It Causes dehydration result in precipitation of calcium

oxalate stone .

3) Dietary factors: Red meat ,eggs ,fish ( purine rich diet result in uric acid
stone ) .

4) Metabolic causes : Hyperparathyroidism, Gout .

5) Immobility :causes bone resorption & increased Calcium levels.

6) Decrease urinary citrate : Citric acid keeps pH low , acts as a stone

inhibiting substance.

7) Urinary stasis: Due to resistance to urinary flow ( horse -shoe kidney

,ectopic kidney ).

Types :

Calcium oxalate stone .

 M/C (85%) of urinary calculi .

 Radioopaque

 Thorny surface can abrade the skin & causes hematuria , which

impart brownish hue to these stones.

 Spiky stone causes intense pain

 Citrate deficiency is often found in patients.

(2) Uric acid stone .

 seen in 5-10% of all .

130

 Pure uric acid stone are radioluscent.

 Acidic pH and dehydration favour their formation.

(3) Phosphate stone .

 Usually occurs as triple phosphate stones ( Calcium , Magnesium

,ammonia )

 Alkaline urine facilitates their formation ( infections due to urea –

splitting bacteria Hance called infection stones .)

 They fill the collecting system Hance called Staghorn calculus.

(4) Cystic calculus Cystinuria is inborn error of metabolism.

Colicy: Sharp localised pain

C/F :

1) Renal Pain : From dull aching to pricking type of pain Is present

Posteriorly in renal angle .

2) Ureteric colic : When stone is impacted in the pelviureteric junction or

anywhere is ureter , caused severe colicy pain.

3) Haematuria

4) Recurrent UTI

5) Guarding & Rigidity : of the back & abdominal muscles during severe
pain.

Inv.

1) Blood urea & creatinine: To rule out renal failure.

2) X-Ray : 90% of renal stone are radiopaque..

3) USG 4) CT Scan : Gold standard 5) Intravenous pylogram

131

C/F :-

1) DICH crisis : Stone at pelvis can block the urine from draining into

the ureter causing urine to accumulate in the kidney .

 This cause distension of kidney .

 Patient have pain at rectal angle and palpable swelling. .

 Patient prodces large volume of urine and swelling subside .

Mx:

1) 1) For stage <5 mm ----Drink copious amount of fluid

with forced diuresis( IV hydration +IV furosemide)

2) For stone >5 mm and<2cm---- ESWL (Extracorporeal shock

wave lithotripsy)

ESWL :

1) Ultrasonic waves targeted at stone shatter it to smaller pieces.

2) Patient has to lie very still.

3) Shock waves generated by electromagnetic, piezoelectric method

4) Stone is located & observed through ultrasound or fluroscopy.

Complications:

1) Pain 2) Haematuria

Contraindication:

1) Pacemaker presence 2) Pregnancy

3) Hard stones like calcium oxalate or cystine.

132

4) If ESWL contraindicated other option is ---- PCNL ( Percutaneous

nephrolithotomy) ----URS / RiRS ----Retrograde intravenal (Uteroscopy
surgery).

PCNL :

i. >2 cm size

ii. Small 1 cm incision in the loin ,PCNL needle is passed.

iii. Gridwire inserted.

iv. Nephoscope is inserted and stone is shattered.

Complications:

1) Injury to colon

2) Urinary leak

3) Injury to blood vessels.

 URS:Ureteroscopic removal of stone .

 RiRS: Retrograde intrarenal surgery .

 Dormia basket used to retrieve stone.

Q-71 Ureteric Stone .

Ans. C/F

1) Pain in loin

2) Haematuria

3) Guarding & Rigidity of Abdominal wall

Inv. Same as renal stone.

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Tx.

1) Flushing Therapy : About 2L of IV fluid with 20-40 mg if Inj.

Furosemide.

2) Stone in upper ureter :ESWL is ideal TX :.

3) Stone in middle ureter :

(a) ESWL REMOVAL (b) Ureteroscopy basketing (c) Ureterolithotomy

4)Stone in lower ureter.

(1) Uteroscopic removal (2) Ureterolithotomy (3) Flushing Therapy.

Q-72 RCC.

Ans. Etiology

1)DM 2) HTN
3) SMOKING 4) Asbestosis
5) Tobacco 6) Obesity

C/F:

a) Traids of abdominal mass ,haematuria & pain seen in only 10% of causes.

Abdominal mass

Pain Haematuria
134

 Pain : Dragging or intermittent colic due to blood Clot blocking the

ureter.
 Mass: Hard : Balloon sac ,moves with respiration.

2) Bony manifestations: Fracture ,secondaries ,pain

3) Haematological :

 Anaemia

 Polycythemia

 Hyperglobulinemia

(4) Endaural :

 Hypertension.

 Hypercalcemia.

Inv:

1)CECT : IOC for staging

2)Urine examination: Haematuria, urine cytology-ve

3)X-ray KUB : Enlarged kidney shadow

4)IVP: Distortion of calyces

5)USG : ENLARGED KIDNEY.

TX.

Surgery is the main treatment as they are chemo and radiopersistent.

Main surgeries are:

1) Partial nephrectomy 2) Radical nephrectomy

135

Partial Nephrectomy indications:

1) Tumor< 4cm

2) B/L tumor

3) RCC Is solitary functioning kidney

4) RCC in a kidney where other kidney is affected by stones or

hydronephrosis.

Radical Nephrectomy:

Removal of kidney with Gerota’s fascia , paracolic lymph Nodes ,ureteric

removal upto pelvic brim

( Ipsilateral adrenal gland ( in T4 tumors) (Only remove if tumor move

upper pole of kidney)

Other surgeries:

1) Therapeutic embolization:

 Given pre-operatively to reduced size of tumor .

 Block lumen of vessels

2) Immunotherapy: IL-2 improve survival.

Q-73 Wilms tumor. (MPMSU 19 Jun - 5 marks)

Ans. M/C pediatric renal malignancy

Etiology

1)Most(90%) of Wilms tumor is sporadic

2)Is asserted with in 3 congenital syndrome

a.WAGR Syndrome b.Beckwith-Wiedemann syndrome

c.Denys-Drash syndrome
136

C/F:

1) Abdominal mass 2) Haematuria 3) Fever

Inv:

1) CECT:IOC 2) USG 3) IUP 4) FNAC

TX.

1)Tumor confined to renal capsule : Stage I

 Radial nephrectomy + Chemotherapy ( Actinomycin D & Vincristine

for 6 months )

2)Tumor extend beyond renal capsule : Stage II

Nephrectomy + Radiotherapy+ Chemotherapy

Chemo---- Actinomycin D + Vincristine for 15 months

3)Tumor is unresectable : Stage III

 .Chemo & Radio given pre-operatively

 . Nephrectomy done .

 .Chemo postoperatively --- ActinomycinD+

Vincristine + Doxorubicin

3) Bilateral Wilms Tumor : Stage IV

 .Radial nephrectomy is one kidney + partial Nephrectomy in Kidney

with smaller tumor.

 .Tumor free margin should be there .

 Post op chemo & radio.

137

Q-74 Causes of Haematuria.(MPMSU 21 April, 21 July- 20 marks).

Ans. 1) Polycystic Kidney Disease 2)Renal Stone

3)Ureteric Stone 4) RCC

5) Wilms tumor 6) Renal TB

7)Renal infection

Q-75 Vesical calculs ( Bladder stone ) . (MPMSU 21 April - 5 marks)

Ans. Types:

1) 1° Bladder stone ---- Formed in the bladder in noninfected urine.

 .Mixed urate stone seen

2) 2° bladder stone :

 2° to renal stone ,infected urine ,bladder outlet Obstruction.

 Phosphate stone.

 IOC : NCCT.
Types: 1) Calcium oxalate : Mulberry shaped 2)
Mx: Uric Acid : M/C type of urinary bladder . 3)
Triple phosphate 4) Cystine
 1st line is perurethral cystolithotomy .
 When C/I , suprapubic cystolithotomy is used

C/I :

1) Urethral stricture

2) STONE on a bladder diverticulae

3) Failed perurethral cystolithotomy stone .

138

C/F :

1) Pain at end of micturition

2) Frequency of micturition increases 3) Haematuria
4) Retention of urine.

Q-76 Actiopathogenesis , C/F , MX of BPH.(MPMSU 21 july, 21April, 21

Aug-20 marks)

Ans. Actiopathogenesis : -

1) Hormonal Theory :

stimulate leydig Release Release 5x

Hypothalamus .Release LH Reaches Postate convert to DHT
cells testosterone reductase

As the person get old ,the testosterone level falls down but oestrogen fall
less ,so prostrate enlarges.

Prostrate maintain its ability to respond to androgen through life .

As age advanced level of androgen Decreases.

Increased in oestrogen which stimulate prostate gland .

BPH.

C/F:

1) Triad of BPH : Frequency , Urgency , Hesitancy

139

Frequency

Urgency Hesitancy.

Irritative Symptoms (FUN).

 Frequency.

 Urgency.

 Nocturia.

Obstructive Symptoms ( PISS)

1) POOR stream 2) Intermittency 3) Straining

4) Sense of incomplete emptying.

Inv:

1) Blood urea & creatinine

2) Uroflowmetry – Normal peak flow : >15 ml/sec Doubtful peak

obstruction: 10-15 ml/sec Definitive peak obstruction: < 10 ml/sec

3) USG

Mx: 1) Medical MX:

A) Finasteride acetate 5mg daily for 6 month .

It is a 5 alpha reductase inhibitor

B) Alpha adrenergic blockers:

a)Relax internal sphincter For better bladder drainage.

b)Tamsulosin, Terazosin, Alfuzosin, Silodosin . c) Combination therapy.
140

2) Surgical MX:

1) Transurethral resection of prostate (TURP)

o .Most popular & Gold standard

o .Rectoscope is passed through urethra and under vision with contrast

irrigation with water & glycerine , prostate is resected into multiple

pieces

o .Haemostasis obtained from Cauterization.

Complications:

a. Retrograde ejaculate ( M/C )

b. Incontinence
c. Bladder neck contracture.

2) Holmium laser

 Best laser for patients >/= 100g prostate or in patients with

increased bleeding .

3) Transvesical Suprretropubic prostatectomy.

4) Retropubic prostatectomy.

Q-77 Paraphimosis.

Ans. Retracted skin of gland penis cannot be pulled forward .

C/F:

1) Severe pain in glans penis 2) Swelling in retracted prepucial skin

3) Odema in distal glans penis

TX.
141

Conservative - Glycerine

1) SEDATION

2) INJ. Hyaluronidase

Complication :

1)Ulcer of gland 2)Gangrene of glans.

Q-78 Phimosis.

Ans. Inability to retract prepuce.

Causes:

1) Congenital ( M/C)

2) Secondary to chronic balanitis

3) Carcinoma of Penis

C/F:

1) Inability to retract prepuce. 2) balanitis Because inability to clean

glans .

Tx. - 1) Circumcision

Q-79 Premalignant condition of penile Carcinoma. (MPMSU 19 Jun - 5

marks)
Ans. (1) Erythroplasia of Queyrat or Paget’s disease of Penis.

 A persistent red, rash , precancerous lesion.

(2) Bowman’s disease:

 A small eczematous plaque that may develop Carcinoma in situ.

142

(3) Genital warts :

 . Buschke-Löwenstein tumour is a giant penile Condyloma that

resembles squamous cell Carcinoma.

(4) Leukoplakia:

 . Persistent Non- specific patch in the glans or Prepcial skin.

 .They are not white in penis.

# Premalignant condition penile area :

1) Leukoplakia
Leukoplakia
2) Erythroplakia Paget’s
3) Lordosis Bowman’s
Genital
4) EBV

Q-80 Hydrocele. (MPMSU 19 Feb - 5 marks)

Ans. A collection of fluid in tunica vaginalis.

Types:

(1) Congenital Hydrocele

(a) Vaginal Hydrocele

(b) Infantile Hydrocele

(c) Hydrocele of cord

(2) Acquired hydrocele

a) Primary Hydrocele
143

b) Secondary Hydrocele

Primary Hydrocele:

a)Due to defective absorption of fluid .

C/F:

1) Tense swelling 2) Testis not palpable

3) Clear fluid : Brilliant Transilluminant.

Secondary Hydrocele:

a) Due to increased secretion of fluid .

C/F :

1) LAX swelling 2) Testis palpable

3) Turbid fluid : No Transillumination.

MX:

1) Lord's plication:

 Indicated few small Hydrocoeles.

144

Sac
opened

Cut edges
plicated to
tunica albuginea

Sac get
crumpled

Testicular
secretion get
absorbed

2) Jaboulay’s procedure:

 Indicated in large Hydrocoeles

 M/C procedure done.

Scrotal
incision made
Separate
sac
Receptive sac
& drain fluid
Event sac & suture
with scrotal wall
Deposit
testis back

Closure

Complications:

1) Hematocele 2) Hernia of hydrocele sac

Q-81 Undescended Testis .

Ans. When the testis is not able to descent to the Scrotum.

145

Development:

1) Testis develop in retroperitoneum.

2) Guided to scrotum by gubernaculum .

3) By 7 month --- Reaches deep inguinal ring .

By 8th month ---Reaches inguinal canal .

By 9 th month ---Reaches superficial inguinal pouch .

By full term ---- Scrotum.

Causes :

1) Muscular Hypotonia : Decreased abdominal contractions .

2) Gubernaculum dysfunction

3) Deficiency of HCG in pregnancy

4) Retroperitoneal adhesions.

C/F:

1) Right side is more often involved.

2) Cryptorchidism : Bilateral Undescended Testis

3) Retractile testis : Testis is palpable at floor of scrotum.

Harmless & get spontaneously collected.

Tx.

1) Orchidopexy

 Can be done by open method or laproscopy

146

2-Types:

1) Fowler-Stephens technique:

 Step 1: High ligation of testicular vessels and position testis in

inguinal canal.

 Step 2: Place testis into scrotum after collateral blood supply develop.

(2) Silber’s procedure:

 Testicular vessels cut .

 Testis placed in scrotum .

 Microvascular anastomosis of testicular vessels.

(2) Orchidectomy .

 Done after age of 14 yes because of Malignant potential.

Q-82 Classify Testicular tumor & It’s Mx .(MPMSU 19 jun, 20Feb-

20marks)

Ans. WHO Classification

1) Germ Cell tumors. (95%)

A) Seminoma --- Classical , Anaplastic ,Spermatocytic

B) Non- seminomatus GCT

a)Choriocarcinoma b)Embryonal cancer c)Teratoma d)Yolk sac tumor.

(2) Stomal tumors

a)Leydig cell tumors. b) Sertoli cell tumors.

C/F:
147

1) Painless testicular mass ( M/C presentation)

2) Abdominal lump: Due to enlargement of retroperitoneal lymph nodes.

3) Infertility 4) Gynecomastia.

Typical presentation:

1) Hurricane varicity : Tumor grow rapidly with pulmonary metastasis &

patient die in few days .

2) Mimicking acute epididymo-orchitis: .Severe pain with testicular

swelling.

Inv:

1) USG 2) Chest X-Ray --- To rule out cannonball secondaries.

3) Abd.USG 4) MRI 5) CT.

TX.

a) .Radical inguinal Orchidectomy is treatment of choice for all testicular

tumor irrespective of Histological type & stage to stop spread .

b) .After Orchidectomy, following are done.

148

Mx of seminomatous GCT:

Stage I Stage II

Good prognosis Bad prognosis 1) radiotherapy to

If :. Tumor markers If: retroperitneal lymph node

2) Chemotherapy for

Not raised or. Tumor markers residual lymph node

Well differentiated Or poor

Mx: Surulbene. differentiation., Mx:Carboplatin

Stage III
1)Seminoma :
Metastasis seen
Stage-I -II A ------Radiotherapy
Chemotherapy:
Stage IIB-III ------Radical
Orchidectomy Chemo BEC.
B- Bleomycin PVB regimen- Cisplatin ,vincristne
Bleomycin
E- Etoposide

C-Cisplatin

Radiotherapy if needed.

Mx for Non- seminomatus GCT :

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Stage I Stage II Stage III

. Chemotherapy Chemotherapy
Chemotherapy

1) Bleomycin tumor markers/LN/

2) Etoposide Tumor markers /LN still present. Metastasis +

.If tumor markers/ CN /

3) Cisplatin
Metastasis+ve

.RPLND (Retroperitoneal lymph 2nd line

node dissection.) chemotherapy

2nd line Chemotherapy

if LN still+

1)Non- seminomatus GCT :

If LN (+) still RPLND Stage I-II A---ROrch + RPLND RPLND

Stage IIB-III----R.orchidectomy+
Chemotherapy

Q-83 Seminoma Testis.( MPMSU 21 July - 5 marks)

Ans.Seminoma is most common GCT .

Malignant GCT

TYPES:
150

1)Classical (M/CType)

2) Anaplastic: High mitotic index ,poor prognosis

3) Spermatocytic: Slow growing ,rarely spread , good Prognosis

Aetiology:

1) Undescended Testis 2) Klinefelter syndrome

C/F:

1) Testicular swelling 2) Loss of sensation

TX.

1)Radial Inguinal Orchidectomy

2) Then use of Radiation and chemo as in previous page .

I-IIA------Radiotherapy

IIA-III-----(RO) + Chemotherapy.

Q-84 Causes of Haematuria.

Ans. 1)In the Kidney (IIT)

A) INFECTION:

 Acute Glomerulonephritis
 Tuberculosis

B) Infection:.

 SBE(subacte bacterial endocarditis) with emboli causing infarction .

 Mismatched blood transfusion

C) Injury:
151

 Stab injury

D) Tumors .

 Wilms tumor
 RCC

2)In Ureter

 .Stones

3) In bladder:

 Stones
 Carcinoma bladder
 Carcinoma prostate
 BPH
 Cystitis
 Tuberculosis

4)In Urethra : Stone.

Q-85 Spinal Anaesthesia.

Ans. Injection of local anaesthetic around spinal cord to do Reversible block

of impulses done in sub-archnoid space.

Indication:

1) Lower abdominal surgery 2) Lower limb surgery

3) Cesarean section 4) Prostate surgery

Approach :

a) Midline approach : Lumbar puncture needle is inserted in midline.

 Needle pass the following structures:

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1)Skin 2)Subcutaneous tissue

3)supraspinous ligament 4)Interspinous ligament
5)Ligamentum flavum 6)Dura & arachnoid

b) )Paramedian approach :

Complications:

1)Major ---Meningitis ,Cauda -Equina Syndrome

2)Minor--- .

a) Hypotension b).Bradycardia c) .Post dural puncture headache (PDPH) d)

Respiratory depression.

Q-86 Epidual Anaesthesia.

Ans. Local Anaesthesia is injected in space over dura

Technique:

1) Puncture done through 16 or 18 guaze needle .

2) Inserted midline or paramidline approach .

Complications:

1) PDPH ---Post dural puncture headache

2) Total spinal block

3) Meningitis

4) Cauda equina syndrome

5) Urinary Retention.

Q-87 Torsian Testis , When rotation of testicles .

Ans. - Causes :
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1)Inversion of testis -----M/C cause

2) High investment of Tunica vaginalis Bell clapper testis

3) Undescended Testis

C/F:

1)Young male (10-25 yrs)

2)Acute scrotal pain

3) Swelling

4)Prehn Sign:When testis lifted up , pain increase

5)Deming’s sign: Affected site lies at higher level

6) Angell’s sign: Transversely placed testis in torsion .

Mx:

 .Scrotal Doppler to confirm diagnosis:

 .If viable , Orchidopexy with derotation.

 .If Non- viable , Orchidectomy.

Q-88 Fournier’s gangrene

Ans. Necrotising fascitis involving perineal region.

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C/F

1)Pain 2)Fever 3)Shock

4)Foul smelling odour 5) Swelling

Mx:

1) Aggressive debridement & dressing 2) IV fluids 3) Shock

management 4) Analgesics 5) Antibiotics.

Q-89 Incisional Hernia &Postoperative hernia . ( MPMSU 19 Feb - 5 marks)

Ans. Causes :

1) Infection 2) Obesity with weak muscle tone

3) Faulty technique of closure

4) Wrongly placed incisions 5) Ascites , postoperative cough

6) Postoperative weight lifting

C/F:

1) Swelling in relation to the scar 2) Reducibility present

3) Expensible cough

TX. ( Refer Notes)

1)Mesh Repair .
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Sac opened
Greater omentum excised
Content reduced
Closure of Peritoneum
Prolene Mesh placed .
Non- absorbable suture repairs done

2)Laproscopic mesh repair

 Procedure of choice

 Minimum scars ,pain & early recovery.

ORTHOPAEDIC
Q-90 Classification of fractures , MX of open fracture.

Ans. It can be done on the basis of ( AbC DEF P)

1) Etiology 2) Complexity 3) Pattern

4) Displacement 5) Communication with external environment

6) Quantum of force.

1) Etiology:

• Trauma fracture – Due to trauma

• Pathological fracture --- Due to underlying pathology ,non-union is

common

• Stress fracture:
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 Due to repeated. Stress

 Difficult to diagnose as not visible X-rays

 Pain is seen.

(2) Complexity :

• Simple fracture ---- 1) Fracture into 2 pieces

2)Easy to treat

• Complex fracture----1) Fracture into multiple pieces 2)Hard to

treat

(3) Pattern ( COST). ( SCO4T’S) :-

 comminuted fracture: Fracture with multiple fragments

 Oblique : Fracture line oblique

 Spiral

 Segmental

 Transverse.

(4) Communication with external environment .

a) Closed Fracture

 Skin is not breached

 c).Fracture lies inside.

b) Open fracture
 Skin & subcutaneous tissue in damaged and fracture come out of it .

 Prone to infections.

(5)Displacement .Undisplaced .shift: Angulated , Rotated.

Mx of open fracture:
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(1) Emergency care :

1) Bleeding from
wound is stopped
2) Wound is washed
with clean tap water
3) Fracture is
splinted
4)Prophylactic
antibiotics:
Cephalexin
5)Tetanus
prophylaxis
6) Analgesics

7) X-rays

(2) Definitive Care:

1) Wound care

(a) wound debridement – It is needed in all cases .

 SKIN Should be excised as little as possible while muscle & fascia can

be excised literally.

(2) Definitive Wound Management

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Wound

Small puncture wound Non-infective wound Doubtful wound healing by

Infected wound secondary

intention

leave as it is Primary Closure Wait for 2-3 days

No infection Infection

Delayed primary closure Secondary intention

Fracture MX :-

Fracture

Undisplaced Closed reduction Displaced

 Manipulation open reduction and internal

Immobilisation* Traction fixation

physiotherapy

Physiotherapy Acceptable Unacceptable.

posture posture

physiotherapy physiotherapy

(3) Phase -III Rehabilitation

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• Joint immobilisation • Muscle exercise during immobilisation

Q-91 Compartment syndrome .

Ans.- Serious condition characterized by increased pressure in one of the

compartments of the body (ex. lower limb in case of the fractured leg)
resulting in ischaemia of tissue.
Causes-
Tight dressing, increased content within the compartment due to trauma
like fracture, oedema, ischemic injury, haematoma, positioning after
trauma etc

Types:-
● Acute – trauma , fracture of leg
● Chronic- repeated exercise.

 C/F (Clinical features) :

1. Severe pain in the leg, disproportionate to the severity of injury.
2. Pain, pallor, pulselessness, Paraesthesia
3. Painful passive stretching of a limb in diagnostic feature
Note – severe progressive pain which increases by passive muscles
stretching is the diagnostic sign.

 Tx : (Treatment) :
7. Fasciotomy With two-incision technique
(lateral&medial) it is done when pressure is more
then 30 mmhg
8. Antibiotics
9. Catheterization
10. Mannitol ans diuresis
11. Hyperbaric oxygen
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12. Fresh blood transfusion

 Complications :
1. Infection
2. Gangrene

Q-92 S/N on non -union of fractures.

Ans. When the two ends of the fracture do not unite ,it is called non-union.
Causes :

1)Old Age

2) Malignancy

3) Muscle or gravity pulling

the fragments
4) Bone loss at time of
fracture
5) Infection

6) Inadequate reduction &

immobilisation.

Type :

1) Atrophic : Callus absent 2) Hypertrophic : Callus

present

C/F :

1) Persistent pain 2) Pain on stretching the fracture

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3) Mobility 4) Increasing deformity at fracture

site.

TX.

1)Open reduction , internal fixation & bone grafting:

 .Most common Operation for non-union .

2)Excision of fragments 3)ilizarov’s method

Diagnosis:

1) Radiology--- 1) Fracture line visible 2) Little

bridging callus.

Q-93 Supracondylar fracture of Humerus .

Ans. Mechanism

1) Fall on an outstretched hand .

1)It can be of 2 types:

1)Flexion type 2) Extension type

 Extension type is more common .

 In it ,the distal fragment is extended in relation to the Proximal

fragment.

C/F:

Symptoms:

1)Pain 2)Swelling 3)Deformity

4) Inability to move defected elbow.
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Signs:

1) Unusual posterior prominence of point of Elbow ----because of

backward tilt of distal fragments.

Inv:

1)Radiological findings :

Wide Displacement seen on X-ray

Tx.

1)Undisplaced fracture ---Immobilisation by an above elbow plaster slab

with elbow in 90° flexion.

2) Displaced fractures -

I)Closed reduction with Percutaneous wire fixation

II) Open reduction with K-wire fixation : . DONE when it is not possible to
achieve good position by closed methods .

Complications:

A. Immediate complications:

(1) Injury to brachial artery :

 Injured by sharp edge of proximal Fragment.

(2) Injury to nerves :

 Median nerve is most commonly injured .

B Early Complications:

1. Volkmann’s Ischemia:
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• Ischemic injury to muscles and nerves of flexor compartment of firearm.

• Caused due to occlusion of brachial artery.

• Treatment: Fasciotomy of deep fascia.

(C) Late complications:

1) Malunion :

• M/C complication

• Gun shot Deformity also called cubitus varus .

2)Myositis ossificans.

 Ectopic new bone formation around elbow joint resulting in stiffness.

3)Volkmann’s Ischemic contracture (VIC) .

 ISCHEMIA muscle are replaced by fibrous tissue result in flexion.

OSTEO---BONE
MYELUS----BONE
MARROW

Q-94 Define Chronic osteomyelitis . Discuss C/F & MX.

Ans. Infection of bone & bone marrow by micro-organisms is called

osteomyelitis.

It most commonly happen secondary to active osteomyelitis.

Types:

1)Garre's osteomyelitis
164

2)Brodie's osteomyelitis

3) chronic osteomyelitis

Etiology :

1) Delayed and inadequate treatment.

2) High virulence of organism : Staph aureus .

3) Reduced host resistance--- AIDS , Tuberculosis.

C/F:

1)Chronic discharging sinus :

I. M/C presenting symptoms & characteristics of chronic osteomyelitis.

II. May heal but reappear in acute exacerbations

III. Discharge may be Seropurulent to thick .

IV. Sinus is fixed to bone .

2) Persistent pain .

i. Minimal but aggravated on exacerbations.

3) Sequestrum formation. 4) Involucrum overlying the sequestrum.

5) Thickened irregular bone. 6) Tenderness. 7) Stiff adjacent joints.

MX:

Inv .

1)X-rays : Hallmarks of diagnosing chronic osteomyelitis .

 Bone cavity .

 Sequestrum .

 Involucrum & cloacae may be.

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2)CT scan : Better modality .

3) Sinogram : Indicated when there is extensive involvement of bone .

Tx.

Aim of treatment:

1)Removal of dead bone

2) Elimination of dead space of cavities

3) Removal of infected granulation tissue

4) Excision of sinuses.

Operative Procedures:

1)Sequestrectomy : Sequestrum is removed.

2)Saucerization :

• A bone is not collapsing cavity.

• Always some amount of pus remains in the bone resulting in recurrent

infection.

• Walls are removed which result in free drainage of infected material.

3)Excision of infected Bone .

 If it doesn’t impair function ex. Fibula

4)Curretage

5) Amputations: Rarely done .

 After surgery ,wound is closed over a continuous suction irrigation

system.
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Q-95 Etiopathogeneses, C/F , Diagnosis , Radiological feature ,MX of

Osteosarcoma.

Ans. Highly malignant bone tumor characterised by formation of bone

matrix or osteoid by Malignant tumor cells.

Etiopathogeneses:

A. Primary Osteosarcoma

I) Due to mutation in Tumor supressor gene :

a)RB gene b)TP53 gene

B) Secondary Osteosarcoma-

Due to

a) Paget disease of bone b) Radiation exposure.

C/F:

1)Pain

2)Swelling :

a)Skin over swelling is shiny with prominent veins

b) Swelling is warm & tender

c) Movement of adjacent joint may be limited due to swelling

(3) Abnormal osteoid & matrix .

4) Micrometastasis to lungs .

5)Common sites -

1)Lower end of femur 2)Upper end of tibia.

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Inv:

1)X-rays show:

 .Area of irregular destruction of metaphysis .

 Periosteal reaction

 .Codman’s triangle : Bone formation under the elevated periosteum.

 .Sun-ray appearance : Calcification of Sharpey's fibres.

2)Biopsy : Standard method to confirm diagnosis.

Tx.

1)Neoadjuvant chemotherapy: .

 Chemotherapy given before surgery to control metastasis.

2)Surgical ablation:

I. Limb-sparing :

a)Wide excision of tumor with a cuff of normal tissue all around.

b) Defect reconstructed by graft :

I. Amputations: Done in severe areas

3)Adjuvant. Chemotherapy:

I. To prevent Recurrence.

Chemotherapatic agents :

A multi drug combination of two or three drug is used.

Drugs --+ Multi -day combination 2or 3 day

used.
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1)High dose Methotrexate 2)Ifosfamide

3)Cisplatin 4)Adriamycin (Doxorubicin)

These are main drugs .

(4) Radiotherapy have almost no effect on osteosarcoma.

Q-96 Ewing's sarcoma.

Ans. Highly malignant tumor occurs between age 10-20 yrs.

C/F ( FCSBH, DSP)

1)Pain

2) Swelling:located in diaphysis

3) Associated fever & malaise may be present.

Inv .

X-ray - 1)Onion peel appearance seen

2) Destructive lytic lesions

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TX.

1)Multi agent Chemotherapy (VCA)

a)Vincristine b) Adriamycin
c) Cisplatin.

Alternating with :

a) Ifosfamide b) Etoposide

1) In 14 cycles over 9-10 months.

2)Limb salvage surgery after 3 months of Chemotherapy.

3) Radiotherapy can also be done as they are highly radiosensitive.

Q-97 Discuss C/F , Pathogenesis ,Stage and management of Tubercular

Arthritis of hip.

Ans. Pathogenesis:
Position of ease ---
1)The lesion usually began in the base and Filexiom , Abduction
,External Rotation
then spread to joint .

2)Caused by M T.B.
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T.B infection in any

organ (mostly lungs)
Spread Hematogenously
to hip bone
Chronic granulomatous inflammation
with caseating Necrosis in hip bone
Erosion
of bone
Granulation tissue & pus go into
Subperiosteal and soft tissue
.Cold abscess
formation
Burst to form sinuses
, pathological fracture

Joint involvement :-

Granulomatous tissue (which

contains the bacilli) , Reach
joint & erode articular cartilage

Synovial effusion

Pannus formation which

extended over the joint

Cartilage destroyed completely

& joint fill with pus &
granulation tissue.

Cold abscess formation in joint

. Chronic discharging sinuses

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C/F : Symptoms :

1)Fever

2)Malaise Constitutional symptoms

3)Night pain

4) Evening rise of temperature

5)Stiffness of hip

6)Pain

7)Night cries - caused by rubbing of 2 disease surface as a result of

muscle relaxation during sleep .

Signs : GAITS :

1)Unable to walk correctly : stiff hip gait

2)Lumber lordosis while walking

3)Child take the weight off the affected side due to pain

4)Muscle wasting : Thigh & gluteal muscles

5) Discharging sinuses

6) Shortening : True Shortening seen in stage III

7) Movement limitation.

Stages : 1)Stage I : Stage of synovitis .

 Excessive Synovial fluid secretion causes distension of capsule & pain .

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 Patient keep hip in position of ease ,i.e flexion , abduction & external

rotation .

 Affected limb appear longer , however they are actually of Same

length .

 Flexion & abduction deformities are slight and compensated by tilting

of pelvis .

2)Stage II : Stage of arthritis .

 Spasm of the powerful muscle around hip .

 As flexors and adductors are stronger muscles hip takes attitude of

flexion ,adduction & internal rotation.

 Affected limb appear shorter , however there is no true Shortening.

3)Stage II : Stage of erosion .

Cartilage is destroyed & acetabulum is crowded.

Dislocation of hip .

Attitude - Fkexion , adduction & internal rotation.

True Shortening --- Due to destruction of bone.

Inv.:

A)X-ray :

a)Haziness around hip joint : earliest sign b) Lytic lesions

c) Reduction of joint space

d)Irregular outline of articular ends e) Wandering acetabulum

f) Pestle & mortar deformity :Head of femur move Freely in acetabulum.

TX. Conservative:-
173

1)ATT 2)Rest

3) Immobilisation : using below knee skin traction , it correct Deformity &

relief from pain.

Operative Tx :

1)Joint debridement:

a) Joint opened using posterior approach b)Pus , nectrotic tissue ,dead

cartilage removed

c) Cavities in acetabulum are created

d) Joint washed through saline , traction given moblised after healing .

2)Girdlestone arthroplasty:

 Joint opened using posterior approach .

 Head & neck of femur excised .

 Dead & granulation tissue excised.

 Bilateral skeletal traction for 4weeks .

 Mobilisation.

3)Arthrodesis:

 If stiff hip with stability is desired over movement.

 Surgical knocking out of the joint.

4)Corrective osteotomy:

 Places where bone ankylosis of the hip has occured in an unacceptable

position.
174

5)Total hip replacement.

TB of hip

ATT+ below knee skin traction

Repeat X-ray

No minimal irregularity Severe joint destruction

Mobilise the joint Normal function not possible

If movement desirable if stability deairable

Girdlestone Arthroplasty Hip spica or

arthrodesis

Q-98 Describe in detail pathogenesis & MX of Pott’s spine .

Ans. M/C site of bone & joint TB always secondary.

A)Types:
175

1)Paradiscal : .M/C

Disc + Contiguous ½ vertebrae above & below are involved (as they develop
from one common somite)

2)Central :Body of single vertebrae affected

3) Anterior: Infection localised to anterior part of vertebral Body.

4)Posterior : Posterior Part affected

Pathogenesis:

MTB infection

Spread
Hematogenously to
spine

Chronic granulomatous
inflammation. With
casecting Necrosis

Erosion of margins of
vertebrae

Collapse of vertebrae
& disc degeneration.

cold abscess formation

C/F :

Symptoms :

1)Fever 2)Malaise 3)Night pains

4)Pain

5) Stiffness:Paraspinal muscle spasm 6)Cold abscess

7) Deformity: Vertebral destruction leads to collapse of Vertebrae.

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Knuckle : Spinous process prominence

Gibbus :2-3

Kyphosis :>3 7) Paraplegia.

Signs:. 1) - Gait :

 .Walk with short steps to avoid jerks

 .Very cautious while attempting to lie

 .To see sideways instead of neck

2) Attitude : Stiff ,straight neck 3)

Paravertebral swelling.

Inv :

1)X-ray :

a) Reduction of disc space due to destruction. And Desiccation.

b) Destruction of vertebral body . c) Evidence of cold abscess

I)Paravertebral abscess

II)Retropharyngeal abscess

III)Psoas abscess.

(2) MRI :IOC

(3) Biopsy.

Tx :

1)Rest

2) Mobilisation
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3) Treatment of cold abscess : I) Aspiration Ii) Evacuation.

Q-99 Classification,C/F , MX of fracture neck of femur.

Ans. Classification

1) Anatomical Classification

a)Subcapital - a fracture just below head

b) Transcervical -fracture in middle of neck

c) Basal -Fracture of base of neck

 More proximally the fracture ,worse is the prognosis

2)Pauwell’s Classification:

 Based on angle of inclination of fracture w.r.t horizontal plane.

 Type I ----30°

 Type 2---30-50°

 Type 3---->50º

 More the angle , worse the prognosis.

3)Garden’s classification:

I)Based on degree of displacement of fracture

II)Stage 1:

 Fracture incomplete .

 Head tilted postolateral direction .

 There is obtuse angle laterally at Tubercular stream

III)Stage 2:

 Fracture complete but undisplaced.

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 Break in trabecular stream.

IV) Stage 3:

 Fracture complete & partially displaced .

 Trabecular stream is broken .

 Alignment bt. Acetabulum and head also lost due to rotation

V)Stage 4:

 Fracture complete & fully displaced .

 Total loss of contact between head & neck trabeculae .

 Head & acetabulum normally alligned.

C/F :

1) Inability to walk 2) Pain in groin 3) External

rotation of leg

4) Shortening of leg 5) Straight leg raising not possible.

Mx:

Inv :

1) X-ray .

 External Rotation of femur .

 Lesser trochanter appear more prominent .

 Overriding of greater trochanter.

 Break in trabecular stream.

 Break in Shenton’s line.

Tx.
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1) Impacted Fracture (Undisplaced) .

 These are undisplaced fractures.

 Splinting done to immobilise

 Children --- Multiple pilus + Hip splica

 Adult : Fixation with Multiple Cannulated cancellous screws

2) Displaced fractures :

Age of patient

Physiological age<60 Physiological age <60.

< 3 weeks > 3 weeks

Closed reduction & Internal

Fixation with cannulated MRI VIable

cancellous Screw’s or

DHS {DHS- Dynamic H.P Screw} Non – Viable

IF + MEYER’s procedure IF+ osteotomy

Mc myrray

a) Meyer's procedure: pauwells

 Fracture is reduced , fixed with multiple screw and supplemented

with vascularised muscle pedicle bone graft .Ex: Quadriceps femoris

is taken from its insertion & recolated to head of femur .

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b) Hemiarthoplasty: .Head of femur is excised & replaced by a prosthesis.

Types :

1) Unipolar - Has one piece head , ex: Austin moore

2) Bipolar - Movement occur in 2 places hence mechanically superior.

Q-100 Classify Epiphyseal Injury & Mx.

Ans. Group of injuries which are seen in a growing skeleton .

Salter-Harris classification:

1) Type I : Epiphyseal slip

 seperation through the physis

 TX. Closed radiation

 Prognosis: Good

 EX: Radial neck epiphysis separation

2)Type II:

 fracture through a part of physis that extends through the

metaphysis TX. --- Closed reduction . Prognosis---Good

 Ex-.Lower end radius epiphysis.

3)Type III .

 Fracture through part of physis which extend through epiphysis

,often involve joint space .

 TX. open reduction can occur .

 Prognosis: Growth disturbance can occur.

 EX: Medial Malleolus epiphysis.

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4)Type IV:

 Fracture through physis , metaphysis & epiphysis

 TX open reduction

 Prognosis: Growth disturbance can occur

 EX: Lateral condyle of Humerus

5)Type V:

 Crush injury of physis

 TX. Conservative

 Prognosis: Growth disturbance always

 EX:lower tibial Epiphyseal Injury.

Mx:

Diagnosis:

1) Often missed due to

 child can’t communicate

 parents trying to hide a injury

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TX.

1)Most by non-operative method:

 Plaster immobilisation

 Traction

 Sling

2) Operative :

 Needed in following fractures .

 Displaced fracture of neck of femur

 Displaced fracture of lateral condyle of Humerus

 Fracture of shaft of femur.

Q-101 DDH ---Developmental dysplasia of the hip .

Ans. Dislocation of hip occuring before drug , during and shortly After birth
.

Etiology:

1) Hereditary

2) Hormone induced ---more common in females

3) Biceps malposition

C/F:

1)Common in females 2)Short limb

3)Widened perineum 4) Limitation of movement of affected limb.

5)Click when limb is moved 6) Asymmetry of crease of groin.

INV:-

1- MRI : IOC 2- X-Ray 3-Barlow test 4- Ortolani test.

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TX..

A) Reduction by :

 Closed reduction .

 Traction followed by closed reduction

 Open reduction

B) Maintenance of Reduction by Immobilisation

 Plaster cast :By frog leg and Bachelor’s cast

 Splint : Von Rosen’s splint

C) Acetabular reconstruction surgery:

 Salter osteotomy

 Chiari’s osteotomy

 Pemberton’s osteotomy

Q-102 Ortolani’s test .

Ans. It is done to diagnose CDH .

 HIPS & knees are held in flexed position & gradually abducted.

 .A check of entrance will be felt as the femoral head slips into the

acetabulum from position of dislocation.

Q-103 CTEV OR CLUB FOOT.

Ans. Congenital Talipes Equino varus

Etiology:

1) Idiopathic

2) Secondary club foot :

184

a) Neurogenic Disorders b)arthrogryposis multiplex congenita

Pathogenesis :

Small Tubes

Dislocation of talonavicular joint

Tendo Achilles Tibialis posterior

Plaster flexion Invasion

Eqinus varus

CTEV

DIAGNOSIS:

If the toe is touching anterior aspect of shin on dorsiflexion then foot is

normal .(If touch in infants)

Tx.

A) Non-operative

1)Ponseti Technique—

 Serial manipulation & POP casting for 1 year

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 According to Ponseti ,the calcaneo-cuboid navicular complex is

internally rotated in the Deformity under the planterfixed talus. .

 Hence to correect it thumb pressure is put over talus head

 By doing this the calcaneo-cuboid navicular complex is externally

rotated under talar head.

B) Operative:

 Posterior medial soft tissue release .

 Limited soft time release.

 Tendon transfer .

 Triple artheodesis.

Q-103 Colles fracture.

Ans. A) Fracture at distal end of radius at cortico-cancellous Junction.

B) Been more in post menopausal women .

Causes :

Due to fall on an outstretched hand with wrist extension.

Displacements:

a) Dorsal displacement b) Dorsal tilt c) Lateral displacement

d). Lateral tilt

C/F :

1)Pain 2)Swelling 3) Deformity

4) Tenderness 5) Irregularity of lower end of radius.

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Diagnosis:

Dinner fork deformity

TX.

1)For undisplaced :- Immobilisation in a below elbow plaster cast

2)For displaced :-

1) CR + Immobilisation in Colles cast

2)CRIF with K-wiles 3)ORIF with plates.

Q-104 Galezzi Fracture ( Fracture of necessity) .

Ans. a) Fracture of lower 1/3rd.of radius with dislocation of distal Radio-

ulnar joint .

b) Due to fall on an outstretched hand

TX.- 1) ORIF WITH plate

Q-105 Monteggia.

Ans. a) Fracture of upper 1/3rd of ulna with dislocation of head of radius.

b) By fall of an outstretched hand.

c)Types: Extension & Flexion type

TX.

ORIF with plate.

Q-106 Frozen Shoulder.

Ans. i) Glenohumeral joint become painful and stiff because of Loss of

resilience of joint capsule, possibly with adhesions Between it’s folds.
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ii)More common in diabetes.

C/F :

1) Pain of stiffness in shoulder

2) Early stage -- Stiffness only at abduction & internal rotation

3) Later stage ----- Pain present all time .

TX.

1 )Analgesics 2)Hot fomentation 3) Physiotherapy

4) Hydrocortisone (intra articular)

5)Mobilising exercises.

Q-107 Tardy nerve palsy .

Ans. Palsy of ulnar nerve due to frictional rub at the medial condyle
everytime elbow is flexed and extended.

Mx of Breast Cancer :

1) Hormonal therapy (given in all BP Patient)

 Tamoxifen20mg daily ----Premenopausal (SERM –Tamoxifen)

 .Letrozole-----------------In postmenopausal

 Others -----Trastuzumab (Monoclonal antibodies) In HER 2 nEu +

PATIENTS

2) CHEMOTHERAPY

a) TAC regime -----Paclitaxel + Adriamycin +Cyclophosphamide, 4

cycles of AC every 21 days followed by 4 cycles of Paclitaxel every 21
days ( total 8 cycles)

b) CAF regime -+-- Cyclo +Adriamycin. + 5- Fluorouracil

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c) CMF regime ----- Cyclo +Metho + 5-Fluorouracil

d) CEF regime ------Cyclo+ Epirubicin +5-Fluorouracil

.Adriamycin is cardiotoxic.

3)Surgical MX :

a) Radical Mastectomy:

 Removal of Breast + Nipple Areolar Complex (NAC) + Pectoralis

major + Pectoralis minor +;Level 1,2,3 ALN

b) MRM :

 Breast +NAC + Pectoralis fascia + pectoralis minor + Level 1,2 LN.

C) Simple mastectomy:

 Breast +NAC + Pectoralis fascia .

4)Radiotherapy:

a)Radiation field aft.BCS

1)Whole breast radiation (WBRT)----- .

 Whole breast + Internal Mammary LN.

 For 25 days with 1 fraction/day

2)Accelerated partial breast irritation:

 Partial breast X 5 days .

 2 sitting /day.
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Q-108 Flial Chest.

Ans. Due to severe injury of the chest with fracture at two or more
consecutive ribs Ribs, with each ribs have to or more fracture sites
anteriorly and posteriorly so that certain ribs has no attachment to the
chest wall.

Paradoxical respiration- These ribs become indrawn

due to intrathoracic negative pressure as the patient inhales and

is driven outwards on expiration producing instability.

Cause Hypoventilation,CO2 Retension, respiratory failure

Types :

1) Ant. Flail ---- Fracture of costochondral junction on both Sides of

sternum

2)Post. Flail ---- Ribs of post-chest wall fracture

3) Lateral Flail: Fracture shaft of ribs

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Treatment-

Anterior flial- the flial segments are stabilized wirth metal plates and
screws to stabilize flial segment
Posterior flial- no treatment is required
Lateral flial- positive pressure ventilation reduction of dead space,
management of pulmonary contusion and pain control.

Q-109 Premalignant lesion of oral cavity .

Ans. 1) Leucoplastia

Causes by :

a)Smoking b)Spices c)Poor oral hygiene d) Syphilis.

2)Erythroplakia : Red , valvety lesion

3)Chronic hyperplastic Candidiasis

4) Submucuous fibrosis: Due to paan masala

5)Sideropenic dysphagia : Plummer-Vinson syndrome Iron deficiency occur

in absence of anaemia.

6) Papilloma of tongue or cheek

7) DLE

8)Dyskeratosis congenita

9)Syphilitic Glossitis: Tertiary symphilis cause Carcinoma of tongue

10)HPV injection.
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Q-110 Tensor pneumothorax.

Ans : a) It is an emergency condition in which there is one way valve

formation which result in entering of air in thoraic cavity but not Exiting
from it .

b) This result in accumulation of air in thoraic cavity at each breath.

.Increase in thoraic
.Aur leak to thoracic
Injury to lungs cavity pressure due
cavity
to air accumulation

.Lung compression
.Hypoxia & cardiac
& Decreased venous
failure
return to heart

TX.

1) Emergency needle thoracocentesis in 2nd IC space in mid clavicular line.

2) Followed by urgent tube thoracocentesis by inserting intercoastal tube.

C/F:

1) Tachycardia 2) Tachypnea
3) JVP decreases

Signs:

1) Percussion----Hyperresonant 2) Auscultation ---No

heart. Sound 3) SBP Decreas

Q-111 Basal cell carcinoma.

Ans. Most common malignant skin tumor also called rodent ulcer.
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Causes:

1)UV rays 2)Fair skin vulnerable

C/F :

1)Ulcer never heals 2)Ulcer has raised & beaded edges

3)Bleeds on touch

4)Painless 5)Firm ,nodule

Tx.

1)Surgery.

 Factor affected WH

 3% Na tetradecyl SO4

 Na C